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SHERIDAN — Parallel to the medical care process, Title 25 also initiates a legal process designed to allow judicial review of a patient’s involuntary hospitalization.

According to Deputy Sheridan County and Prosecuting Attorney Clint Beaver, however, that legal process has considerable flaws and no one entity has the time or resources necessary to effectively overhaul the law’s procedure.

When law enforcement or medical personnel impose a Title 25 hold on a patient, a clock starts ticking. Statute requires the state to prove — sometimes repeatedly — it is necessary for the titled individual to be in emergency care for more than 72 hours, Beaver said.

If the patient is stabilized and discharged before those 72 hours run out, there is no hearing at all. No paperwork is filed in 4th Judicial District Court. No additional follow-up is required, Beaver said. Many titled patients are released before the 72-hour deadline expires.

When a patient should be held longer, the first venue in which the state must prove this is called a 109 hearing, Mahoney said, in reference to the name of the statute authorizing initial emergency detention, Wyoming Statute 25-10-109.

If, as the 72-hour deadline approaches, hospital staff determine the patient requires longer hospitalization, it notifies Beaver. In response, Beaver opens a case file, captioning the case “In the interest of” the patient and preparing to proceed to a hearing ahead of the 72-hour mark.

During the 109 hearing, Beaver said he appears — as usual — on behalf of the state and seeks court orders for treatment in the best interest of the patient. An attorney chosen from a handful in Sheridan County who perform Title 25 hearings and paid by the county also appears to represent the patient.

A 4th Judicial District Court judge and court reporter also appear for the 109 hearing. Beaver said Sheridan County is unique in that district court judges almost always hear the cases personally, which is not the case in other jurisdictions across Wyoming.

In an extreme scheduling bind, district court commissioners may serve in the judges’ place, Beaver explained, which happens in roughly one in 100 hearings.

During the 109 hearing, the burden of proof is on the state to prove that more likely than not the patient should remain in emergency care because he or she is mentally ill and a danger to him or herself or others. Beaver said he presents testimony from licensed clinical social workers, licensed professional counselors and other mental health professionals to explain the patient’s diagnosed mental illnesses and symptoms related to those diagnoses.

The judge can order up to 10 days of additional emergency detention during a 109 hearing, and the order will specify where that care should take place, whether at a secure facility like Wyoming Behavioral Institute in Casper or an unsecured facility like Sheridan Memorial Hospital.

After the 109 hearing, the clock starts again, this time for 10 days.

A patient who is stabilized at any point in the 10-day period can be released from care, Mahoney said.

If the patient’s status does improve, statute requires a second hearing — called a 110 hearing — be held to evaluate the patient’s stabilization progress within 10 calendar days of the 109 hearing.

During this hearing, attorneys for the state and titled person as well as the judge and court reporter gather to present evidence and hear arguments.

The 110 hearing is similar to the 109 hearing with two notable exceptions.

First, the 110 hearing involves a higher burden of proof for the state, Beaver said.

The state must prove by clear and convincing evidence — or substantially more likely than not — that the hospitalized person requires additional care. To do this, Beaver typically solicits testimony from licensed physicians, including psychiatrists and medical doctors.

Second, during the 110 hearing, the court has the authority to commit patients to the Wyoming State Hospital.

Commitment to the state hospital is indefinite. Although state hospital practitioners must report the patient’s progression to the court after the first 90 days of treatment and every six months after that, the court cannot set an end date for treatment at the hospital. The patient could spend years in the state hospital as a result of the hearing, Beaver said.

At the 110 hearing, the judge once again determines what level of care is appropriate for the patient, ranging from just a few more days in an inpatient setting to an indeterminate amount of time in the state hospital. Beaver said his office continues managing Title 25 cases until the patient is discharged or committed to long-term inpatient treatment.

During either a 109 or a 110 hearing, the court may order “directed outpatient treatment,” or require outpatient treatment with a mental health provider in the community.

For several decades, Beaver said public policy has trended toward favoring community-based, outpatient treatment. Sheridan County judges, in contrast to some others in the state, tend to favor this treatment method.

Of those Title 25 cases that proceed to a hearing, about one in 10 result in directed outpatient treatment.

According to statute, directed outpatient treatment plans can include taking medication; restrictions on travel and drug or alcohol consumption; temporary inpatient, group home or residential treatment; and other treatment options.

In Sheridan, much of the directed outpatient treatment is provided by Northern Wyoming Mental Health Center, Beaver said.

The problem is, Beaver said, these requirements can be difficult to enforce.

“The section is very specific as to what remedies there are if a patient does not comply with that order, and they’re of questionable effectiveness,” he said.

The court can revoke or modify a directed outpatient commitment — effectively eliminating or changing the treatment plan originally recommended by the judge — and continue to a 110 hearing.

However, Beaver said many titled people ordered to outpatient treatment do not meet the threshold required for commitment to the state hospital, so there are few options for enforcing the outpatient treatment.

For this reason, Beaver said, many Wyoming counties do not entertain the option of outpatient treatment.

While this process — hold, hearing, treatment — seems streamlined, the statutorily-defined process often turns procedurally messy.

Title 25 has been in Wyoming’s statutes for years and amended several times by different committees listening to different stakeholders, Beaver said. The result is a muddled law.

One particularly challenging element of the law, Beaver explained, is the section delegating financial responsibility for titled patients. Although the bill seemingly splits costs cleanly — requiring counties to pick up the tab for an uninsured patient’s first 72 hours of care while the state pays for any additional care required — many counties are unable to pay these costs. Sheridan County, for instance, would not be able to afford to pay medical providers the full cost of this care, Sheridan Memorial Hospital Chief Financial Officer Nathan Stutte said.

Difficulty in enforcing directed outpatient treatment, too, is a legislative challenge, Beaver said. The law would need to be changed to realistically enforce those treatment regimens.

Beaver has spent the past two legislative interim periods lobbying for changes to the law on behalf of the Wyoming County and Prosecuting Attorneys Association. The association, in conjunction with other essential stakeholders like medical providers, proposed rewriting Wyoming’s involuntary commitment law from a clean slate, using what has been learned from the current Title 25 process.

“We can change this process and make it easier for everybody to use,” Beaver said.

The challenge with an overhaul on this scale, however, is that it can’t be shoehorned into any one legislative committee.

As Beaver lobbied the Legislature during the most recent interim, for example, the proposed bill ultimately failed because the issue related to the division of funding crept into what was supposed to be a purely procedural bill.

The discussion, Beaver said, tends to grind to a halt when issues overlap, from the Joint Judiciary Committee to the Joint Committee on Labor, Health and Social Services.

The judiciary committee will not continue to discuss Title 25 during the 2022 legislative interim.

The labor and health committee, meanwhile, will discuss Wyoming’s behavioral health systems as its No. 2 priority this interim, with the possibility of supporting bills establishing interstate compacts for mental health workers, including licensed professional counselors, social workers and psychologists.

Beaver is optimistic the law can be improved while he’s still working on Title 25 cases.

“I’m hopeful,” he said.

This story was published on Sept. 21, 2022.

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