Recommendations for Implementation

A growing body of clinical evidence shows the benefits of widespread access to the newer generation of medications (see Policy Statement 35: Evidence-Based Practices). Fewer people taking these medications require hospitalization or rehospitalization, yielding substantial cost savings.  More people taking them are able to enter the workforce and reduce their dependency on a wide array of social services.  As the benefits of the newer medications have become more widely recognized the demand has increased, allaying concerns about higher costs.

Newer medications, which are considerably more expensive than older medications, are not used as frequently in prisons and in jails as they are in the general community.  Using these newer medications in many instances, however, is in fact cost-effective; their ability to increase the likelihood that the inmate will adhere to his treatment plan may offset, at least in the long term, the difference in cost between the two generations of medications.

Correctional officials usually require that licensed staff in the jail or prison pharmacy fill prescriptions, including those for psychotropic medications, in accordance with a departmentally prescribed formulary.  Policies should define procedures that ensure a balance between the higher cost and the more desirable results, including the lesser side effects of many of these new medications.  At a minimum, pharmacies should maintain adequate stocks of the most commonly prescribed psychotropic medications. These should not be limited to the least expensive and generic brands.  Sufficient supplies of newer medications that have been prescribed by the psychiatrist for individual patients should also be kept on hand.

Furthermore, regardless of whether a particular medication is on the jail or prison formulary, there should be provision for obtaining any medication that a physician deems appropriate to prescribe.  If the medication is not on the formulary, the physician should be able to order it as a special request and receive it in a timely manner.[1]

In order to ensure consistency in the application of psychotropic medications, and to manage pharmacy costs, state correctional agency officials should work with leaders in the mental health system to develop and adopt jointly standardized clinical decision protocols (i.e., algorithms) that are based upon research conducted on a national level.

Example:  National Formulary, Federal Bureau of Prisons

In an effort to deliver consistent and cost-effective medical care, the Pharmacy and Therapeutics Committee of the Federal Bureau of Prisons established the National Formulary for the Bureau of Prisons. The committee's objectives are to ensure that inmate medical care will be delivered consistently and cost-effectively as a result of the formulary's implementation.

Implementation of the formulary includes review of evidence-based scientific literature for new and existing drugs and to determine their appropriate role in the Bureau's pharmacotherapeutic armamentarium.  It is the committee's role, through the formulary, to stay current with BOP clinical treatment guidelines for medical and mental health conditions, as well as reflect the generally accepted professional practices of the medical community at large.

The committee meets and conducts reviews annually and is composed of pharmacists and clinicians from the bureau and other institutions and includes the chief physician and chief psychiatrist; it is chaired by the chief pharmacist.  Responsibilities include reviewing the formulary and updating it to be in line with evidence-based medicine; new drugs are reviewed by conducting literature searches and cost/benefit analyses to determine whether the side effect of a given drug is worth the benefit of administering it.

Example:  University of Texas Medical Branch, Texas Department of Criminal Justice

Beginning in 1995, the Texas Department of Criminal Justice (TDCJ) developed policy and guidelines for facility-level providers to obtain nonformulary drugs for offenders in the custody of the Texas Department of Corrections.  TDCJ has incorporated the procedure for obtaining nonformulary drugs for inmates as part of the Pharmacy Policy and Procedure Manual.  The prescribing physician must provide documentation in the offender's health record about what role the desired drug will have in the offender's treatment plan (e.g., diagnosis, special considerations) and also provide documentation confirming that no acceptable substitute is available on the formulary.

Procedures and a flowchart have been developed to show the protocols for what happens when such a request is made. Requests for nonformulary medication are made to the clinical pharmacist assigned, who, in turn, evaluates the request by a review of information provided by the prescribing physician/psychiatrist and/or a review of other relevant information including the target disease, previous medications used for the indication, dosages, compliance allergies, diagnostic procedure, TDCJ Disease Management guidelines, national standards and guidelines, and applicable scientific literature.

The Texas Department of Criminal Justice has evaluated the program through continued monitoring of nonformulary requests and denials.  The initiative is funded through a contract with the University of Texas Medical Branch/Correctional Managed Care to provide mental health services for offenders in the TDCJ through the Correctional Managed Care Advisory Committee.

Much progress has been made in the area of clinical informatics as a result of managed care initiatives that have moved into pharmacy services.

Example:  The Texas Medication Algorithm Project, Texas Department of Mental Health and Mental Retardation

The Texas Medical Algorithm Project (TMAP) is a public and academic collaborative effort headed by the Texas Department of Mental Health and Mental Retardation.  TMAP is designed to improve the quality of care and achieve the best possible patient outcome by establishing a treatment philosophy for medication management. TMAP developed and instituted a set of algorithms to illustrate the order and method in which to use various psychotropic medications.  The TMAP algorithms have been adopted by the Texas Department of Criminal Justice for use in the state's prisons.

The ultimate goal of TMAP is to optimize patient outcomes with the underlying assumption that resources will be most optimally utilized.  It is intended to develop and continuously update treatment algorithms and to train systems to apply these methods to minimize emotional, physical, and financial burdens of mental disorders for clients, families, and health care systems.

TMAP consists of four phases.  During Phase 1, guidelines were developed through scientific evidence and expert clinical consensus, resulting in the development of algorithms for use of various psychotropic medications for three major psychiatric disorders: schizophrenia, major depressive disorder, and bipolar disorder.  Phase 2 was the feasibility trial of the project and evaluated the suitability, applicability, and costs of the algorithms.  The third phase was a comparison of the clinical outcomes and economic costs of using these medication guidelines vs. traditional treatment/medication methods. The fourth and final phase is the implementation of TMAP throughout clinics and hospitals of the Texas Department of Mental Health and Mental Retardation and is known as the Texas Implementation of Medication Algorithms (TIMA).  Collaboration for this project included public sector and academic partners, parent and family representatives, and mental health advocacy groups.[2]

In order to ensure quality and objectivity, correctional agencies should enlist the services of a licensed pharmacist to review policies and procedures, and to assist in a review of the use of medications in the facilities.  For example, there may be some instances when physicians prescribe the newer, more expensive medications even though the older medications may achieve the same desired clinical outcome.  If replacement medications are considered, prescribing physicians should keep in mind the potential impact of side effects associated with switching medications.  Checks and balances must be established and enforced to ensure that physicians are not overprescribing medications that yield little additional salutary effect.

To ensure that mental health and correctional facilities staff members do not become overly dependent on medications alone to modify or to control inmate behavior, mental health services should include an array of interventions designed to meet the unique needs of inmates with mental illness.  When interdisciplinary teams work together to develop a treatment plan, the services delivered are more likely to be balanced and tailored to the specific needs of the inmate

Interventions that have proven to be effective in a correctional setting include the following:

• cognitive-behavioral therapy, particularly those interventions that improve basic problem-solving skills and reduce maladaptive (criminal) thinking
• individual and group therapy that is skill acquisition oriented
• independent living-skills training
medication self-management
• relapse prevention
• physical exercise programs

Example:  Behavior Modification Treatment Level System, West Virginia Division of Corrections

The West Virginia Division of Corrections has implemented a Behavior Modification Treatment Level System at the Mount Olive Correctional Complex.  Mental health staff at the facility put this system in place to facilitate effective inmate management and to provide an incentive for inmates placed in the Mental Health Unit (MHU) to achieve an appropriate functioning level.

Programming is offered at various levels for some inmates who used to be locked down in their cells for 23 hours a day.  Since the program has started there has been only one four-point restraint utilization, no cell extractions, and inmates that used to be housed in single cells are now stabilized and socialized to be double bunked.  To increase success, the warden was asked to forgo disciplinary infractions for inmates receiving mental health treatment on the unit.  This approach has empowered mental health staff to implement programming without having punitive restrictions. Critical to this approach is the ability to select staff who are philosophically aligned with a habilitation model as opposed to a punitive model.

At most institutions, correctional staff members provide general case management services.  When inmates have a mental illness, however, they should be assigned to case managers specially trained to understand the distinct service needs of this population (see Policy Statement 30: Training for Corrections Personnel).

All programs for inmates with mental illness should also address inmates with co-occurring substance abuse disorders.  Over the past decade, virtually every state department of corrections has implemented residential substance abuse treatment programs within their prisons.  Some of these programs specialize in treating the dually diagnosed - those with co-occurring substance abuse and mental health problems.  These programs generally serve inmates whose primary problem is substance abuse, and whose mental health problems tend to be less severe but there are clearly examples of offenders with co-occurring disorders whose mental illness is the primary concern.   Some of these residential programs are specifically designed for women - a large percentage of whom are dually diagnosed - with depression as the primary psychiatric diagnosis.[3]

Key program components for co-occurring disorders include the following: an extended assessment period; orientation/motivational activities; psychoeducational groups; cognitive-behavioral interventions, such as restructuring of "criminal thinking errors"; self-help groups; medication monitoring; relapse prevention; and transition into institution or community-based aftercare facilities.  Many programs use therapeutic community approaches that are modified to provide greater individual counseling and support, less confrontation, smaller staff caseloads, and cross-training of staff.^[4]  (See Policy Statement 37: Co-Occurring Disorders.)

Example:  Co-occurring Disorder Programs, Columbia River Correctional Institution (OR)

In 1998, the Oregon DOC combined state and federal grant resources to create a system of four co-occurring disorder programs at a single institution (the Columbia River Correctional Institution).  Two of these programs are for men, and two for women.  One program for each gender is targeted at inmates whose problems are more heavily weighted toward addiction and criminality, but who also have some mental health problems (the Turning Point programs, which are profiled elsewhere in this report).  Another two programs (again, one for each gender) are designed to address the needs of offenders with serious and significant mental health problems who also have problems with addiction.  Mental health and substance abuse treatment in all four programs is provided in an integrated manner, with much cross-pollination of ideas and information among supervisors and staff of all four.

Qualified, licensed mental health staff can be hard to come by in jails and prisons located in remote, rural areas.  As a result, some jurisdictions, including some in Texas, have resorted to electronic communications as a means of providing professional, clinical services to such institutions. (See Policy Statement Section 41: Workforce)

Example:  Telemedicine, Texas Department of Criminal Justice

Texas Tech University Health Sciences Center (TTUHSC) is responsible for providing medical care in the western portion of Texas to inmates in the Texas Department of Criminal Justice and to juveniles in five Texas Youth Commission facilities.  In 1994, TTUHSC began delivering health services to inmates via telemedicine. As of 2002, TTUHSC conducts approximately 2,000 prison telemedicine consultations a year for the 33,000 inmates that are housed in the 26 prison units for which TTUHSC is under contract.  Approximately one-third of all telemedicine consultations are in telepsychiatry and telepsychology.   This expansion has significantly reduced the amount of time clinicians spend driving to distant prison sites.

Psychotropic medications should be prescribed by, or in consultation with, a psychiatrist or other licensed mental health professional having training in psychotropic medications and authority to prescribe them as determined by the state. Given the shortage of psychiatrists, doctors who provide general health care, but who are not credentialed in psychiatry, are allowed to prescribe psychotropic medications for inmates with serious mental illness.  It is essential that physicians who specialize in psychiatric medicine oversee mental health treatment, in addition to psychotropic medication prescription, administration, and monitoring.

Like their counterparts in the community, mental health professionals working in correctional settings have access to a growing body of research documenting the effectiveness of certain interventions and the promise of others.  Similarly, researchers have demonstrated that various service models have little or no impact on the behavior or health of a person with mental illness.  To ensure provision of the most effective possible services to people with mental illnesses in prisons and jails, correctional mental health officials should stay abreast of the work of research efforts on evidence-based practices such as those conducted at the New Hampshire Dartmouth Psychiatric Research Center and at the National Association of State Mental Health Program Directors (NASMHPD) Research Institute.[5]  Researchers affiliated with these organizations have identified services that have been shown in a variety of settings to provide treatments and supports that will enhance the ability of a person with mental illness to live successfully in the community.  (See Policy Statement 35: Evidence-Based Practices.)

As stated earlier in this chapter, the majority of people incarcerated in the United States are African American or Latino.  In some states, people of color make up nearly 80 percent of the prison population.  Cultural competency has generally been shown to improve client receptiveness to services and counselor effectiveness (see Policy Statement 40: Cultural Competency). Mental health services in correctional settings should recognize the effects of culture on all aspects of mental illness and, in order to treat inmates effectively, should organize and design their approaches accordingly.  In particular, clinicians and other correctional staff who are in routine contact with inmates with mental illness should receive training to enhance their "cultural competency" and their ability to recognize and respond to the needs of people from different cultural backgrounds who come under their care or control.

Male and female inmates may have similar mental illnesses and custody levels, but their treatment plans, housing situations, and programming needs will be distinct.   For example, the Bureau of Justice Statistics has found that histories of trauma and abuse are particularly high among females in prison and jail:  more than 78 percent of female state prison inmates and more than 72 percent of the female population in jail reported such histories.[6]

In response, a growing number of jurisdictions have instituted programs intended to identify women who are victims of past abuse and to offer interventions that meet their specific needs. These programs provide training that helps correctional administrators and officers to understand the high prevalence of trauma history among their inmates as well as the relationship between abuse, substance abuse, mental illness, and criminal behavior.  The programs also include interventions that help inmates with histories of abuse to better understand their own situations, often through group meetings.

Example:  The TAMAR Project, Maryland Mental Hygiene Administration, Division of Special Populations

The TAMAR (Trauma, Addictions, Mental health, And Recovery) Project was initially piloted in one rural and two suburban counties in Maryland and has now spread to a number of counties in the state. Its goal is to provide integrated services for women who typically have interrelated trauma, substance abuse, and mental illness issues. Meeting in groups, the women are encouraged to share their stories with one another and to engage in therapeutic activities such as art therapy and journal writing. Once released from jail, women in TAMAR are able to continue to meet in groups in the community that provide continuing support.

Prisons have increasing numbers of inmates with mental illness who also are elderly, developmentally disabled, or sex offenders.  The clinical needs, treatment approaches, strengths and deficits, and general goals of programs for inmates in these groups differ significantly. Correctional administrators should ensure that mental health programs and services provided to these special populations are distinct from programs and services provided to other inmates with mental illness

Some program approaches that serve sex offenders and those with developmental disabilities may provide useful guidance for approaches for offenders with co-occurring disorders.

Example:  Program for Inmates with Developmental Disabilities, Texas Department of Criminal Justice

This program was established to minimize the negative effects of incarceration on offenders who have developmental disabilities and to maximize the likelihood of their successful reintegration into the community. An Interdisciplinary Team (IDT) includes a physician or registered nurse, licensed or certified psychologist, social caseworker, vocational supervisor, social work supervisor, and rehabilitation aide.  Occupational therapists and speech pathologists are included as necessary.  The IDT performs a needs assessment to determine what services are best suited to meet the needs of the individual.  A vocational evaluation is completed, which takes into account the inmate's assets and limitations.  Offenders with developmental disabilities are housed in the least restrictive environment appropriate to their habilitation, treatment, and safety and security needs. Available services include: medical care; psychiatric services; educational programming; occupational therapy; substance abuse treatment; treatment planning and monitoring; and continuity of care (transitional planning).

Example:  ASEND Program,Utah Department of Correction

Since 1986, the Utah Department of Corrections has been operating the Advantage Program at the Utah State Prison to address the needs of offenders with an IQ below 70.  In 1999, space was designated at the prison and new policies and procedures were implemented for an expanded program, called ASEND, operating in a segregated living unit.

The ASEND Program provides programming for those inmates lacking the skills and knowledge to meet the standards of self‑sufficiency and acceptable social responsibilities, not only in society but also within this institutional environment. The goal of the ASEND Program is to assist inmates to live successfully in the prison population and to prepare for their eventual release to the community.

The program comprises the following components: 1) a written individual habilitative plan; 2) an education program component; 3) a cognitive programming component; 4) an employment job readiness component; 5) modified behavior privilege matrix; 6) additional services coordination for inmates who have a mental illness, or who have sexual or drug abuse histories; 7) recreation and physical activities; 8) aftercare services; and 9) appropriate training and habilitative specialist status for block officers.

Example:  Sexual Offender Accountability and Responsibility (SOAR) Program, North Carolina Department of Corrections

SOAR is a voluntary day treatment program for incarcerated sexual offenders referred by psychological staff from state prisons. Two program sessions are held each year, with a total of 72 offenders participating.  Inmates are housed in a segregated unit while participating.  Group therapy conducted by a program staff psychologist is the primary mode of treatment.  The program, which has been in existence since 1991, is relatively inexpensive to operate ($7.16 per day per inmate) and has been demonstrated to be reasonably effective. The latest outcome study reported that by April 2000, 302 of a total of 501 participants who had completed the program had been released to the community.  Of these 302 men, only 7, or 2.3 percent, had been returned to prison for a new sexual offense charge.  This compares very favorably with the return rate of general population inmates in North Carolina.  According to a 1996 study, 47 percent of all inmates leaving North Carolina prisons are reconvicted within three years.  A youth SOAR program designed to serve offenders between the ages of 16 and 21 is planned.

Example:  Sexual Offender Residential Treatment (SORT) Program, Virginia Department of Corrections

SORT provides comprehensive assessment and treatment services for inmates who are a moderate to high risk for reoffense. The program operates in five phases:  orientation; assessment; treatment readiness; treatment; and release planning.  The program begins with the development of an individualized treatment plan, then progresses through the participation by offenders in various psychoeducational groups, and, finally, in a program of treatment having the Trans-theoretical Model and Cognitive Behavioral Techniques as its basis. The release planning phase, which includes the participation of the offender's community supervision officer and family members, includes an evaluation of future needs and the identification of programs and providers to address such needs.

Beyond general population beds, correctional administrators usually have few housing options, especially in overcrowded facilities, for inmates with mental illness.  In those units, staff members generally are not trained adequately to address these inmates' needs.  Inmates suffering from severe mental illness who are housed in general population, especially when their illness is undiagnosed or untreated, often decompensate more quickly than they would in housing designed and operated for inmates with mental illness.  When inmates with mental illness in general housing decompensate they are likely to incur disciplinary infractions, which in turn prompts their reassignment to segregation cells, where their mental health is likely to deteriorate still further and more rapidly.

Centralized and noncentralized approaches to housing inmates with mental illness each have benefits and drawbacks.  Generally, it is more cost-efficient to hold people with significant problems in specialized units at a central facility.  On the other hand, decentralizing services provides greater administrative flexibility.  Furthermore, "mainstreaming" inmates who can safely be housed in the general population reduces the stigma associated with mental illness.

An ideal approach to this issue is to have both options available.  Depending upon the size of the system and facilities, correctional administrators should provide separate residential services to inmates with serious mental illness, as well as a range of counseling activities in day and outpatient levels of care.  Several states have developed multilevel housing systems for inmates with serious mental illness.  These include maximum-security medical units, step-down, post-acute housing, and transitional housing units.

In order to make the most appropriate housing assignment for an inmate with mental illness, staff should first take into account the medical requirements of the inmate, including concurrent nonpsychiatric conditions (e.g., HIV, TB, etc.).  For example, inmates whose medical needs are within reasonable limits, are medication compliant, and are responsive to supervision could likely be assigned appropriately to general population units.  Cross-discipline participation on panels and committees that make decisions regarding the handling of inmates with mental illness should be a standard practice.

Correctional staff should reevaluate the housing assignments of inmates with mental illness routinely to ensure the assignment is properly serving their changing needs.  Inmates assigned to a specific unit because of their mental illness should be evaluated regularly for changes in their mental health needs.

Custody and program staff, whether they are assigned to special housing units or to general population, should receive training in basic mental health issues.  In order to have an impact on problem inmates with mental illness receiving disciplinary actions due to their illness, it is recommended that hearing officers, and others involved in the work of disciplinary committees, also receive this training.  These officers should have discretion to consider the presence of mental illness as a mitigating factor in imposing sanctions (see Policy Statement 30: Training for Corrections Personnel).

When inmates are transferred to a new institution, it is critical that information regarding their mental illness and treatment history accompany them.  When this information does not follow the transferred inmate, the receiving facility must undertake the inefficient and expensive step of conducting another evaluation.

Service delivery between the two institutions should also be seamless.  Without continuity of care, an inmate's condition can worsen.

Employing one of three mechanisms will enable corrections administrators to ensure that an inmate's mental health information will be forwarded to a receiving institution whenever he or she is transferred:

Establish a central, computerized tracking system, which alerts the mental health case manager at the receiving institution that an inmate with mental health needs will be arriving at the facility; or

Send with the inmate a summary form that alerts the mental health case manager at the receiving institution.  When mental health information is not maintained in a system-wide database, staff will need to include in this form a clinical summary of assessment results and a brief description of treatment and services received at the previous institution;  or

In jurisdictions that do not have a central computerized tracking system, the mental health record should accompany the inmates at the time of their transfer.

Example:  Wisconsin's Health Transfer Summary

Wisconsin's Health Transfer Summary, a form and protocol used to ensure continuity of care when inmates are transferred from one correctional facility to another, pertains to transfers between county jails, between state prisons, and between county jails and state prisons.  In particular, the summary provides necessary information to health care providers and custodial staff at correctional facilities to ensure their proper care - such as current health and mental health status; medications in use; and treatments - while maintaining the confidentiality of inmate health care information in compliance with state law. At the time of a transfer, the Health Transfer Summary is prepared by a facility health care professional and delivered along with the inmate by the transportation officer assigned to transport the inmate to the receiving facility. If the transfer is completed at a time when the health care professional is not available, the form is prepared and dispatched with alternative means within 24 hours.

Once received, a health care professional at the receiving facility logs in the summary, notifies the sending facility that it has been received, and makes follow-up assessments, investigations, and requests for information concerning the inmate's health care status or condition as required.  The summary is maintained in the inmate's medical files as a confidential record following guidelines set forth in Wisconsin law.  According to the statute, inmate consent for the transfer of his or her health care information between correctional facilities is not required.  The statute also authorizes the sharing of the inmate's complete health record, but specifically excludes the mental health information from being included when that complete record is shared.  The exclusion can be waived only with the inmate's consent.

Confidentiality regulations designed to protect the privacy and rights of those receiving treatment for mental illness and substance abuse are often misinterpreted, and, in some cases, such regulations unnecessarily impede the flow of information needed to ensure the quality and continuity of care for offenders who are transferred between facilities.  Mechanisms can be used that enable correctional agencies to share important and relevant information while maintaining an appropriate level of confidentiality for the inmate.  Information sharing should be understood here as sharing between clinical treating providers at two different sites, and not as sharing with administrative or other correctional staff.  Clinical files (whatever form they take) should be sealed and opened only by qualified personnel who have appropriate training in confidentiality issues.  Inmates who receive services for their mental illness should be encouraged to provide written consent in order for agencies to release treatment records to another program.  Even when a statute allows sharing without consent, it is still a good idea to obtain it.

It is particularly important to facilitate the transfer of records from jails and other facilities that are not operated by the state correctional agency.  Similarly, state corrections directors should also consider developing memoranda of agreement between state agencies, such as the agency for mental health services, to ensure the transfer of patient records when an individual who is being served in a state institution is transferred to a correctional facility.

Corrections administrators and their counsel often have a difficult task in determining how federal and state statutes regarding the confidentiality of inmate mental health information applies to inmates.  State statues - or administrative regulations - should be established to clarify how the information of this distinct population can be used.

In addition, states should consider establishing statutes or administrative regulations that require the transfer of inmate mental health records between facilities under the purview of the state correctional agency.  In Arizona, this statute requires transfer of records either prior to or at the time of the transfer; it also authorizes the records to be transferred between county and state facilities.

Example:  Duty to Deliver Medical Records, Arizona State Law

Arizona state law requires the transfer of a prisoner's "medical record file, including the prisoner's mental health file or a standardized medical record."  The file must be transferred prior to or at the same time as transfer of the prisoner.  This requirement applies to all transfers between jail and state department of correction facilities.

Louisiana takes this process a step further, allowing the correctional agency to obtain information from other state agencies, as necessary, while ensuring reasonable confidentiality protection.

Example:  Access to Records, Louisiana State Law

Louisiana state statute gives the department of corrections access to "information and records under the control of any state or local agency which are reasonably related to the rehabilitation of the individual."  Access to such information may be obtained "during the course of any investigation which the department of corrections is authorized by law to conduct or any investigation necessary to the rehabilitation of persons in the custody of the department of corrections."  The statute also requires that all information obtained under this provision "be held as confidential and not be disclosed directly or indirectly to anyone except" when required by statute.

These examples illustrate how a state essentially can define the department, and/or the state as a whole, as a unified system of care, thus enabling mental health information to be freely passed between facilities and departments as though they were part of a provider enterprise, as occurs in community health systems.  Confidentiality assurances can be established simply through policies and procedures that are consistent with statutes.

In cases where statutes do not provide for transfers across agencies, one solution would be for the agencies to enter into memoranda of agreement that include Qualified Services Agreements (QSA).  QSA's are agreements between providers that allow for the release of confidential information between the agencies, while transferring responsibility for adherence to federal and state confidentiality regulations.

Departmental policies and procedures should define what specific information is required at intake, who is responsible for reviewing and following up on obtaining complete mental health records, and what immediate services are to be provided.  Time frames for conducting clinical review and approval of medications should be specified throughout the intake process.  Lastly, the procedures should specify a protocol for interinstitutional communication when proper documentation does not accompany the inmate at the time of intake.

Example:  Statewide Weekly Mental Health Staff Teleconference, Arizona Department of Corrections

By administrative order, the facility health services administrators and other relevant mental health professionals at the Department of Corrections' (DOC) Alhambra Behavioral Health Treatment Facility, and all other correctional complexes and facilities teleconference every week to discuss the mental health treatment needs and issues of inmates being referred to or from the Alhambra complex and other Arizona DOC facilities and provide a forum for peer consultation on difficult cases.

Several jurisdictions have developed electronic data systems to improve records management and facilitate the instant flow of clinical records.  To ensure a successful records transfer, electronic communication should be used in conjunction with the personal transfer of information between clinicians at the institutions.  Officials should be mindful that most confidentiality regulations apply equally to paper and electronic records (HIPAA regulations specifically cover electronic records), and thus develop their electronic information protocols accordingly.

Example:  Mental Health Record and Referral/Evaluation Systems, Michigan Department of Corrections

The Health Management Information System (HMIS) is a computer-based management system, which contains health care data for persons incarcerated in Michigan correctional institutions. Two mental health-related components of HMIS are the mental health record system and the referral/evaluation system.  Staff from DOC Psychological Services and DCH Corrections Mental Health Program use these components. The Mental Health Record system enables mental health care services providers to systematically identify and track prisoners with mental illness at different levels and units within the correctional system. The referral and evaluation system ensures the identification and tracking of prisoner referrals for evaluations as well as the evaluation outcomes.

Example:  Process of Transmitting Mental Health Treatment Histories of Inmates When Transferred to Other Facilities, New Jersey Department of Corrections

The New Jersey Department of Corrections uses an electronic medical record system that allows any professional health care practitioner within the Department to view any inmate's health record at any time.  When an inmate is transferred from one facility to another, mental health professionals send an e-mail stating that the inmate has been transferred and the health record can be immediately accessed.  Case conferences occur on the more difficult management cases.

Example:  Interagency Case Conferencing, New Jersey Department of Corrections

When the New Jersey Department of Corrections participates in interagency transfers (e.g., between correctional and mental health agencies), it often organizes case conferences, in conjunction with the electronic transfer of data between the agencies, to enable clinicians from both sending and receiving institutions to meet to discuss and develop individual treatment plans.

State mental health agencies recognize the benefits to be gained from the development of an integrated and automated patient records systems that is operated system wide.  The establishment of such a system is expensive, however, and the work on such systems in most states is far from complete.  Indeed, implementation of electronic patient record systems is inconsistent across local agencies, making it impossible for state mental health authorities to gather complete information or to realize the gains that could be reaped from a statewide system.  Additionally, seemingly simple problems such as the incorrect spelling of a patient's name or an inaccurate social security number can create significant headaches for staff.  In some states, efforts are under way to include state correctional agencies in the development of electronic patient/inmate record systems.