Recommendations for Implementation

This recommendation calls for screening to be conducted on all detainees, regardless of their known history of mental illness and their presenting appearance.   (See Policy Statement 17: Intake at Correctional Facility for Sentenced Inmates, for a more thorough discussion of screening procedures.)  

In the majority of jails, staff immediately screen new admissions for basic issues that might affect housing assignment and safety, but many of these screens fail to address mental health issues.  The screening should occur at the point of intake, before placement in a housing area.   The screening should be done using a standardized instrument developed under the direction of a qualified mental health professional.  Booking staff should receive training in how to use the instrument and interpret the results.  Several states, including Colorado and Montana, have statutes that require administrators of detention facilities to mandate screening for mental illness at the time of intake.  In Montana, the screening is intended to identify misdemeanants who could be diverted from the detention facility into mental health services. 

When the screen shows possible indications of mental illness, the screening officer should arrange for a more thorough examination by a qualified mental health professional.  Some jurisdictions have developed a multitiered approach to identifying people with mental illness.

Example:  Screening, Summit County (OH) Jail

The Summit County, jail has a three-tiered approach that includes the initial screening by the booking officer, a cognitive function examination by a mental health worker, followed by an evaluation by a clinical psychologist.   

Jails should also ensure that the screening protocol includes identification of suicide risk.  Given the high rates of suicide in jail when compared to those occurring in the general population, it is important that great care be taken in identifying those at risk of suicide.

Example:  Suicide Screening Initiative, Montgomery County (MD) Detention Center

In Montgomery County, detained inmates are screened at three points of intake using the same set of seven questions: at central processing, upon institutional intake, and as part of medical screening.  When an inmate is first processed through the Central Processing Unit, an officer completes the Suicide Screening Form, comprising seven items relating to current suicidal ideation and past history of suicidal/self-destructive behavior.  There are specific questions regarding mental health history and current psychiatric treatment.  When inmates are processed through intake, the same form is completed a second time.  Inmates answer the questions a third time when nurses at medical intake use the same questionnaire.  The document first used at Central Processing follows the inmate throughout this process.  If an inmate answers affirmatively to any of the questions at any point along this three-part process, a referral is generated to mental health services, who then conduct an assessment. 

Example:  Suicide Prevention Screening Guidelines Tool (SPSG), New York State

New York State has developed a Suicide Prevention Screening Guidelines (SPSG) tool  that is used in all local lockups, county jails, and state prisons throughout the state.  SPSG was developed and approved by the New York Commission of Correction and the Office of Mental Health and has been validated through numerous research projects.  It consists of a structured interview conducted during the booking process by booking officers, and examines risk factors from past behavior, the inmate's current situation, and mental status.  If there are indications that the inmate may be suicidal, the booking officer contacts the shift commander for immediate intervention, who arranges for increased supervision of the individual.  

When resources do not allow for a timely, comprehensive, in-house follow-up assessment to a screen, such as may be the case in rural or remote settings and small facilities, creative alternatives should be found.  These might include contracting for services with community mental health, or making provision for interns at local universities who might be available to conduct assessments on site on a part-time basis. Another option is telepsychiatry, where a qualified mental health professional is able to interview and examine the detainee through the use of telephone or closed-circuit television.   (See Policy Statement 18: Development of Treatment Plans, Assignment to Programs, and Classification / Housing Decisions, for examples of telepsychiatry and electronic communication arrangements in use in Texas and Alaska.)  When a delay in providing a follow-up assessment in unavoidable, jail personnel must provide adequate supervision to ensure the physical safety of an inmate at risk of suicide until professional mental health services can be provided.

Individuals admitted to jail facilities may be withdrawing from a psychoactive drug, including both illicit substances and psychotropic medication.  It is important that an observation period extend through the first 72 hours of detention and that the screening protocol be repeated if the detainee's behavior indicates the possibility of post-acute withdrawal or mental decompensation.  Jail medical staff should also keep in mind that many psychotropic medications, particularly ones that are used in injectible forms, can take several weeks to clear a patient's system.  Intake screeners and anyone reviewing medical records should look for indications of such long-lasting drugs and take steps to ensure that suicide screening and prevention measures are extended over several weeks in appropriate circumstances.  This is particularly important in jails that have a limited pharmacy and may change the type of drug or form of administration.    

The admission of an individual with mental illness into a county or municipal detention facility presents an opportunity to determine whether continued involvement with the criminal justice system is the most appropriate strategy to address that individual's situation.  Once a detainee has been identified as having a mental illness, corrections officials can work with pretrial service programs, mental health service providers, and other partners to determine whether the detainee may be eligible for programs that provide an alternative to further detention.   Some states, such as Montana, have passed legislation requiring jail administrators to divert certain detainees to mental health services, either in the community or to inpatient hospitals.   

Many programs use detention facilities as the first point of contact to identify a person with mental illness who may be eligible for diversion.  Jail administrators who work closely with such programs will help individuals who would be better served by diversion from the criminal justice system while at the same time freeing jail beds for more appropriate purposes.  It is essential that programs providing alternatives to further involvement with the criminal justice system for individuals with mental illness consider the multiple needs of these individuals, especially the need for adequate housing (see Policy Statement 38: Housing).

Example:  Thresholds Psychiatric Rehabilitation Centers Jail Program, Cook County (IL)

The Thresholds Psychiatric Rehabilitation Centers Jail Program in Cook County provides intensive case management for individuals with mental illness who have become involved in the criminal justice system.  Thresholds case managers work with individuals while they are still in jail, even accompanying them to court and often helping secure their early release.  Once released, the case manager helps the individuals access mental health services, find employment, and locate housing.   Threshold Jail Program members, as the program's clients are called, are usually housed in single-occupancy rooms in local hotels.  Thresholds has developed relationships with landlords, guarantees the rent payment, and provides 24-hour on-call case managers in case of a crisis situation.  Though Thresholds owns some 30 group homes and ten apartment houses, community and local government opposition prevents them from using these resources to house most individuals with mental illness who have been released from jail.      

While important in identifying people who might have a mental illness, a screen conducted at booking depends exclusively upon inmate self-reporting.  Yet detainees, and particularly those with mental illness, are often unreliable reporters of factual information.  It is important, therefore, to obtain information about a detainee that can shed light on his or her mental health history and help the facility to make appropriate decisions regarding classification and to ensure that those currently in treatment continue to receive it while in custody.  In many instances the arresting officers may have input into classification decisions.

Several jails have also developed ways to alert the mental health community when a mental health client has been arrested so that mental health can respond immediately to the situation.

Example:  Cook County (IL) Jail

Through an automated information system, the Cook County Jail electronically transfers its jail census on a daily basis to mental health clinics in the Chicago area.  Clinic staff review the lists to see if they can identify any of their clients.  The goal is to notify these clinics when one of their clients is in custody to aid in the continuation of treatment while in custody.

Example:  Montgomery County (MD) County Detention Center

The county detention center in Montgomery County each day posts the names of detainees who have entered the facility in the previous 24 hours, ensuring that a copy of the list is available to local mental health providers. Providers recognizing names of current or past clients on the detention center list may then, without breaching confidentiality, contact mental health staff at the detention center with information, including diagnosis and medication, that might help the detention center provide appropriate services or make decisions regarding placement or diversion. (See also Maricopa County Data Link Project, Policy Statement 11: Pretrial Release / Detention Hearing.)

Another way to facilitate the release of mental health information is to encourage individuals who are at risk of being arrested to provide their clinician with prior consent to discuss their mental health needs with jail officials if an arrest and detention occurs. (See Policy Statement 25: Sharing Information.)

Families can also provide more comprehensive information about the mental health history of a jail detainee.  They should be encouraged to share any information that will result in delivery of appropriate mental health treatment in the jail setting.

People arriving at a jail may be in an active psychotic state or may decompensate to such a condition during the period of confinement.  Jail staff must have the resources that they need to intervene effectively with detainees experiencing a crisis.  The American Psychiatric Association has offered the following recommendations regarding crisis intervention in jails:

• Training of jail staff to recognize crisis situations;
• Around-the-clock availability of mental health professionals to provide evaluations
• A special housing area for those requiring medical supervision; and
• Around-the-clock availability of a psychiatrist to prescribe emergency medications.

Example:  Summit County (OH) Jail

At the jail in Summit County one corrections officer is designated as the crisis intervention specialist and receives 40 hours of training each year from the jail's mental health coordinator.

The capability must also exist to meet the treatment needs of detainees.  In larger jails, separate mental health units may be available.  Often, however, there can be waiting periods to get into such a unit.  In smaller jails, such units are typically not available, and the most severely ill inmates may need to be transferred to a state hospital or other secure facility.  Regardless of where the individual is housed, there can be great benefit to ensuring that the clinician who was attending the individual before arrest continues to monitor the person's treatment while in custody. 

Inmates are usually prohibited from bringing their own medications into jail.  Owing to formulary restrictions, prohibitive costs, limited inventories, or a combination of these factors, however, correctional health officials are often unable to fill a prescription prepared by a doctor outside the facility.  Accordingly, the effect of the medications that detainees are taking at the time of their incarceration is likely to wear off soon after their arrival at the jail. The detainee's condition is thus likely to deteriorate, and he or she may commit disciplinary infractions that will lengthen his or her stay in jail. 

Increasingly, offenders with mental illness are brought to jails with prescriptions for the newer, and considerably more expensive, psychotropic medications.  In many cases, when facilities provide for the continuation of treatment, they substitute the medications the inmate has been taking with one on their formulary and readily available in their own pharmacy.

In some states, correctional health officials are required to adhere to the formulary, even if it is limited.  Such policies can have negative consequences for inmates for whom medications on the formulary are either ineffective or cause harmful side effects.  When a particular medication prescribed by a psychiatrist is not on an institution's formulary, corrections administrators should ensure that a mechanism is in place to enable access to the medication within 24 hours.[2]  

Jail officials should understand that although there are often several medications that can be prescribed for the same diagnosed illness, the effectiveness and medical risks of different medications often varies considerably.  The practice of switching medications can be particularly ineffective because many psychiatric medications take weeks to build up to therapeutic levels.  Common drug interactions between different medications prescribed for the same problem can exacerbate the delay before the new medication becomes effective and can create serious medical risks for patients, and potential problems for the jail staff, if both medications are present in a patient's system at the same time.

Community mental health programs and service providers should be involved in medication issues for recently arrested and detained defendants.  They can serve as a resource for detention-based health care officials in determining detainee medication needs, possibly assisting facilities with limited formularies to obtain and share the costs for less commonly prescribed and more expensive medications, if they are required for the detainee's well-being.  

Enrolling a person who is eligible for Medicaid in this federal benefit program is a time-consuming process.   Reinstating someone in Medicaid after their benefits have been terminated can take anywhere from 14 to 45 days (and sometimes longer), depending on the state.[4]    Accordingly, when a detainee with mental illness enters jail, and he or she is already enrolled in Medicaid, staff should do everything possible to maintain that person's enrollment in the program.  Suspending, instead of terminating, the detainee's enrollment in Medicaid enables staff to effect the reinstatement of the benefits immediately upon release, guaranteeing the individual access to the treatment and medications likely to keep him or her from coming into contact with the criminal justice system again.

A myth in many corrections, mental health, and public health agencies is that federal regulations require states to terminate a person's enrollment in Medicaid once he or she is incarcerated.  In fact, federal law does not require states to terminate inmates' eligibility, and inmates may remain on the Medicaid rolls even though the services provided in jail are not covered.  According to the US Secretary of Health and Human Services, "Federal policy permits, but does not require states to use administrative measures that include temporary suspending an eligible individual." [5]   Thus, determining when a detainee's enrollment in Medicaid should be terminated is, in some important respects, at the discretion of the state.[6] 

Given these parameters, jail administrators should work with appropriate state and local social security administrators and state Medicaid administrators to develop policies and procedures to prevent the unnecessary termination of detainees who enter the facility on Medicaid.    Ideally, for those detainees eligible for Medicaid by virtue of their enrollment in the Supplemental Security Income (SSI) program, authorities should terminate a detainee's Medicaid coverage only when SSI eligibility is terminated.  (This occurs after 12 consecutive months of SSI suspension.)

Example:  Interim Incarceration Disenrollment Policy, Lane County (OR)

Officials in Lane County have confronted the barriers and disruption in continuity of care for people detained for a short time in jails.  At the behest of the county, the state adopted the Interim Incarceration Disenrollment Policy.  This policy specifies that individuals cannot be disenrolled from their health plan during their first 14 days of incarceration, during which the state makes the Medicaid payments.  In addition, Lane County officials developed a relationship with the local application-processing agency for Medicaid and Social Security Insurance.  Now, the application process for those individuals who did not have benefits prior to incarceration or whose incarceration period lasts longer than 14 days can begin while the detainee is still in custody.

When a detainee whose participation in Medicaid has been suspended, corrections administrators should work with health officials to authorize immediate coverage of the detainee upon his or her release.  While the confirmation of a released detainee's qualification of Medicaid is pending, federal rules permit the reinstatement of the benefits for six months.  (This reinstatement may be terminated before six months have expired if state officials determine beforehand that the individual is no longer eligible for Medicaid).  In those cases where a released detainee's benefits are reinstated, and the person's qualification for Medicaid is subsequently confirmed, officials should ensure that services already delivered are billed, retroactively, to the federal government. 

One reality for jail staff attempting to address the mental health needs of pretrial detainees is that a detainee may be released at any time with little or no warning to jail staff -  the detainee may post the bail or plead guilty and be sentenced to time served, or the prosecutor may dismiss the charges.  Given this situation, it is of little surprise that recidivism rates among people with mental illness released from jail are exceptionally high.[7]  Thus, it is important that planning for the ultimate discharge of the individual be an ongoing process during the time the individual is detained.  Such planning should include arranging for services immediately upon release; ensuring that there is no disruption in medications made available to the individual; and assisting with other needs, such as housing, food, clothing, and transportation. 

Example:  Discharge Training, Fairfax County (VA) Jail

Discharge planning at the Fairfax County Jail is the responsibility of Offender Aid and Restoration (OAR), a nonprofit organization.  OAR staff conduct weekly meetings with the jail's psychiatrist to set plans for release for all inmates with serious mental illness, and provide emergency services for those released before a plan is completed.  Staff of OAR carry caseloads, and the same case manager works with an inmate with mental illness from the time of booking through discharge.

Example:  Case Management Services for Pretrial and Sentenced Offenders, Hampshire County (MA) Jail

At the Hampshire County jail, all inmates, regardless of whether they have a mental illness, are assigned case managers, who have a typical caseload of approximately thirty detainees.  Inmate treatment needs are assessed at intake, and the case manager then provides individual counseling, meets with the family, and makes referrals to appropriate resources both inside and outside the facility.  Assignment of sentenced and pretrial inmates to a case manager facilitates the process from intake through discharge planning (and reentry, if applicable).  A high level of contact between the client and the case manager ensures that inmates have access to services and that they do not slip through the cracks.^[8]

One of the most pressing problems facing individuals with mental illness who have become involved in the criminal justice system is the lack of affordable housing.  Housing for people with mental illness should be directly linked to other services, including mental health and substance abuse treatment, life skills, and job training.  This model of  "supportive housing" has been shown to have significantly higher retention rates than housing alone or housing that is not directly linked to services.[9]  Long-term housing is crucial for helping individuals with mental illness maintain stability and avoid involvement in the criminal justice system. (See Policy Statement 38: Housing.)   

Example:  Maryland Community Criminal Justice Treatment Program (MCCJTP)

Through the Maryland Community Criminal Justice Treatment Program, staff in jails throughout the state work to provide treatment and aftercare plans for inmates with mental illness, and then provide community follow-up after their release.  The MCCJTP has been widely recognized for impressive cross-system collaboration, focus on co-occurring disorders, transitional case management services, and attention to long-term housing needs.  A $5.5 million grant from the U.S. Department of Housing and Urban Development, complemented by matching local funds, allows MCCJTP case managers to help offenders with mental illness who qualify as homeless to become eligible for Shelter Care Plus housing funds.[10]  Local service providers participating in MCCJTP support  Shelter Care Plus recipients with vocational training, substance abuse treatment, and life-skills training to ensure that these individuals have access to meaningful daytime activity.

Example:  Conditional Community Release Program, Maricopa County (AZ) Adult Probation Department

The Maricopa County Adult Probation Department has instituted a program called the Conditional Community Release Program, which is geared toward early jail release of offenders with mental health issues and provides appropriate treatment in the community at a reduced cost. This program utilizes a contract psychiatrist, probation officer, surveillance officer, and intake specialist to identify, diagnose, and supervise offenders with mental illness. Once referred, the inmate is evaluated within 72 hours by an intake specialist. If appropriate, the inmate is admitted to the program and jail release planning is undertaken. The psychiatrist will see the person in jail in order to ensure continuity of care once released, and the probation officer will see the client to complete all necessary paperwork.

Once released, the probationer may be placed in a housing facility funded by Adult Probation, or released to their home if appropriate. While in the community, the client is supervised by the probation officer and surveillance officer, and seen by the psychiatrist for follow‑up treatment if not enrolled in community treatment. Using contracts with a local medical services agency, medication is provided at a reduced cost and necessary psychological testing is performed.

The program is 45 days in length, at which time the client is transferred back to his or her original probation officer, or referred to a specialized mental health caseload. In the event the client is not stabilized psychiatrically, the county will continue to serve the client until this is accomplished.