Regionalism may be a civil’ solution to the thorny detention dilemma
States joining hands to combine resources
Tuberculosis controllers around the nation, armed with tough new laws to help them lock up persistently recalcitrant patients, now find themselves facing another civil detention dilemma: Where, exactly, do they put detained patients?
Into a regional facility, say some state officials. The solution’s appeal is the way it matches "haves" with "have-nots." Instead of consigning recalcitrant patients to jails or to expensive acute-care hospitals, states can transport them to long-term care facilities across state lines, to places happy to have paying patients filling their empty beds.
One key to such agreements are interstate compacts. The arrangements are aimed at bridging the thickets of legal hurdles that spring out of the bewildering variety of detention criteria that exist among states, and often, within various jurisdictions in the same state. The pacts also run interference with the financial and political obstacles that arise at such times.
"Part of the movement toward regionalization comes out of systems thinking and reflects the bigger overall effort to collaborate and form partnerships," says Missouri’s TB controller Vic Tomlinson. "These patients are crossing borders all the time anyway. So when we serve others, we’re serving ourselves."
David Ashkin, MD, Florida’s TB controller and the medical director of the A.G. Holley Tuberculosis Hospital in Lantana, agrees. "It’s very important for us to maximize our limited resources," he says. "We all share the same problem."
NTCA looking at regionalization
To explore the idea of regionalization from a national perspective, the National Tuberculosis Controllers Association (NTCA) has created a subcommittee, chaired by Ashkin, to study the subject. At the Division of Tuberculosis Elimination at the Centers for Disease Control and Prevention in Atlanta, director Ken Castro, MD, is only lukewarm about the concept. "Do we need a lot more of these regional facilities? As we continue to reduce the number of cases, I think the answer is probably not."
In any case, many states have already begun to meet and talk about regionalization or in some cases, explore other ways to solve their detention problems.
In New England, after a year’s worth of hard politicking, Rhode Island has become the first state in the area to sign off on an interstate compact. It enables the state to send the occasional detainee to the Lemuel Shattuck Hospital in Boston. Other states expected to approve the compact include Connecticut, Maine, Massachusetts, New Hampshire, and Vermont. (For details on the Shattuck facility, see story, p. 111.)
In Missouri, all eight contiguous states were scheduled to meet in late September to discuss a similar plan. The idea in this instance is to designate Missouri Rehabilitation Center in Mount Vernon, near Springfield, as a shared regional facility, says Tomlinson. Though some of Missouri’s neighbors say they’ve already made other arrangements, all of them were "very receptive" to the idea and say they’ve been struggling hard to find solutions to the civil detention problem, says Tomlinson.
"Some of the states say they’ve actually tried to find ways to send these patients to National Jewish Hospital," the elite Denver facility usually reserved for only the most complicated medical and surgical cases, says Tomlinson.
In Florida, the A. G. Holley Tuberculosis Hospital is also enthusiastic about the idea of going regional, although Ashkin says it would be "awkward" for him to disclose details.
Sometimes decentralization can work
California and Texas have a different kind of problem. With large geographic areas, whopping caseloads, and a paucity of beds for civil detention, they are considering scattering smaller, decentralized detention facilities across their states.
The California legislature recently approved $2.9 million in the 1997-1998 budget for that purpose. The money, says Sarah Royce, MD, state TB controller, will provide housing for homeless TB patients and fund construction of civil detention units. Plans for the first facility in the San Francisco area are being firmed up now, adds Royce.
In Texas, the need for more civil detention beds may have run aground due to immigration problems. At the very least, the state’s 45-year-old civil detention facility in San Antonio needs repairs. But lawmakers have asked to see a state-wide, long-range plan for the entire process before they hand over any money, says James Elkins, FACHE, hospital director of the Texas Center for Infectious Disease in San Antonio, and director of the South Texas Hospital in Harlingen.
The fear is that providing more beds for TB patients might provoke "seeking behavior." Building more sanitoria (often referred to as sans) for Texans might provoke a flood of sick patients seeking care from south of the border.
Reciprocal arrangements offer benefits
In most places, the equation isn’t so lopsided, and reciprocal arrangements promise mutual advantages. For states with an existing long-term care TB facility, regional agreements offer patients benefits that are paid for by other states. To states lacking a facility, the agreements provide options other than putting TB patients up in costly acute-care hospitals, or even worse, in the county jail. (Jails are almost never equipped to care for civil-detention patients, but that’s where many wind up. In California, a recent study found most of the state’s civil detainees wound up in jail; their average length of stay was 83 days.) 1
Adding to the dilemma is new evidence that recalcitrant patients may cause much more trouble than was previously assumed.
When San Francisco epidemiologists conducted molecular fingerprinting studies on their cases several years ago, a striking finding was that just three patients were responsible for three big case clusters, says William Burman, MD, attending physician at Denver Public Health Department. If the totals from each cluster are tallied together, they add up to 14% of all cases, Burman adds all because of three patients. Similarly, the largest case cluster ever identified in Denver has been traced to a single recalcitrant patient, he adds.
"We really dance around the I-word’ the issue of incarceration," he says. "In some ways, it’s been the dirty little secret of TB control. But I think it’s time we started paying these really bad actors more attention."
Being able to follow through on the threat to incarcerate someone may actually motivate some patients to shape up, Burman adds. "We firmly believe, although we can’t prove it, that demonstrated willingness to use incarceration decreases the need for its use," he says.
"I’m not certain it’s a little like arguments about capital punishment, and whether the death penalty deters people from killing each other," says Paula Fujiwara, MD, TB controller of New York City. "But yes, I think having the ability to detain someone probably does have a deterrent effect."
Reference
1. Oscherwitz T, Tulsky JP, Roger S, et al. Detention of persistently nonadherent patients with tuberculosis. JAMA 1997; 278:843-846.
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