Calling for help

It has become axiomatic that local jails are the front line in many communities for the assessment of acute mental illness. According to the U.S. Department of Justice, serious mental illness affects up to 16% of the incarcerated population.1 Jails often become the de facto venue for initial assessment and treatment of individuals with serious mental illness, some of whom are arrested multiple times over a short period.

For jails, housing this population increases costs, particularly in taking steps to prevent suicides. Jails are required to provide safe management often without adequate mental health consultation or intervention. For individuals with mental illnesses, these safe management techniques may result in long periods of suffering in solitary confinement.

Across the nation, good solutions to these problems have been limited. In Kentucky, an innovative program, the Kentucky Jail Mental Health Crisis Network, provides all jails in the state with access to a system of care that identifies mental health and suicide risk and offers 24/7 mental health consultation and intervention. Since this program is fully funded through the state legislature, detention centers may use this program without incurring additional costs. More importantly, data suggest that the program has resulted in an 80% reduction in deaths of inmates in custody.

Program Development

In February 2002, a series in the Louisville Courier-Journal revealed that 17 individuals had committed suicide while in custody in the previous 30-month period, and two others had died while in restraints.2 The Kentucky legislature responded by passing legislation that required four hours of mental health training for all detention center personnel. However, it soon became clear that services, not simply more training, were required.

Through Bluegrass Regional Mental Health-Mental Retardation Board, Inc., a large community mental health center (CMHC) in central Kentucky, the authors developed a comprehensive program to address the greater needs of the state's detention centers. The main objective was to offer immediate access to mental health consultation. In 2003, using Bluegrass's emergency and assessment call center, a Telephonic Triage program was developed and piloted with five jails. Using a toll-free telephone number with 24/7 access to licensed mental health professionals, the Telephonic Triage program uses standardized protocols to guide a mental health triage risk assessment. The identified risk level corresponds to clearly delineated best-practice jail risk-management protocols.

Based on positive responses from the pilot program jails, the Telephonic Triage program became the focal point for the development of other service components that would enhance and unify the state jails' response to people with mental illness. Standardized screening forms were developed to ensure identification of risk when someone enters a jail. Additional face-to-face services were organized through the Department of Mental Health's 14 community mental health-mental retardation regional boards to ensure the safety of and appropriate response to people with mental illness. Finally, a telephonic and electronic infrastructure was developed to create an integrated network between jails and mental health centers that centralizes the flow and collection of data.

In 2004, a funding proposal for the newly created Kentucky Jail Mental Health Crisis Network was presented to the Kentucky legislature. With the leadership of State Senate Majority Leader Dan Kelly, the program received designated funding through a $5 increase in court costs. Participation is voluntary, and 90% of the state's 86 detention facilities are enrolled in the program with others interested in joining.

Program Components

The Kentucky Jail Mental Health Crisis Network's components are based on the tenants of proper inmate classification and the recommendations of Lindsay M. Hayes, a project director at the National Center of Institutions and Alternatives, for the reduction of suicide in jails.3 The program includes four components:

Standardized screening instruments

The use of standardized screening instruments is the foundation for assessing risk and need in most detention centers and is integral to this program's success. Two instruments have been developed, one for the arresting officer and one given to the arrestee by the booking/screening officer. The instruments, each with no more than 20 yes/no questions, have standard risk assessment questions, including those related to behavioral indicators of suicide, history of psychiatric hospitalization and mental illness, acquired brain injury, mental retardation, and reaction to the charge. (For more information on the instruments, e-mail milligan0806@behavioral.net.) A yes to any of the mental health questions triggers an automatic call to the Telephonic Triage line.

In addition to the two screening instruments, jail personnel are trained to observe mental health problems, keep mental health risk alerts from previous incarcerations, and respond to the individual's and family members' requests for mental health services. Any indication of risk or request for services triggers a call to the Telephonic Triage line.

Telephonic Triage

Telephonic Triage provides jails with 24/7 access to a licensed mental health professional, who uses a research-based assessment instrument to identify and scale an inmate's mental health risk. Telephonic Triage involves a guided telephonic interview between the mental health professional and the deputy (and, when possible, the inmate) to determine the level of risk related to four potential risk categories: (1) the charge, (2) suicide, (3) potential substance abuse withdrawal, and (4) symptoms of mental illness in four diagnostic categories. Information also is obtained on history of treatment, hospitalization, and medications.

A final summary level of risk—critical, high, moderate, or low—is assigned based on the constellation of risk variables. The mental health professional also will determine if the risk level's acuity warrants treatment or diversion, and he/she will arrange follow-up services. Diversion options include civil commitment to a psychiatric facility, referral for a competency evaluation, or working with the courts to have charges dropped. The completed Telephonic Triage form is e-mailed or faxed to the jail and to the corresponding CMHC when follow-up is indicated.

Jail risk management protocols

The summary risk level determined through Tele-phonic Triage corresponds to a level of jail risk management protocols that represent the industry's best practice standards. These recommended safe management techniques guide jail personnel on interventions with housing, supervision, property, clothing, and food.

These protocols' goal is to enhance the safe and humane treatment of persons with mental illness in detention facilities. The program seeks to reduce the unnecessary use of restraints and to ensure that isolation and suicide watch protocols are implemented safely on a time-limited basis. At any time, additional Telephonic Triage calls can be conducted to reassess an inmate's level of functioning and need for intervention.

Follow-up with mental health services

The final component is face-to-face follow-up services provided by the state's CMHCs. Local mental health professionals are trained and available to respond to requests for follow-up made by the Telephonic Triage clinician within specified time frames. Each risk level has a required time frame, from three hours to the next business day, for follow-up response to ensure that this service is implemented consistently across the state.

Follow-up services include a face-to-face evaluation with the inmate to provide crisis counseling and consultation to the jail. An assessment is made to determine if the risk level and jail management protocols seem appropriate and if additional services are indicated. If the inmate can be diverted from the facility to other care or have the charges dropped, the local clinician makes those arrangements. Documentation of the follow-up is sent to Bluegrass for data collection and to the jail for the inmate's file.

Results

Since the program's implementation in fall 2004, 90% of jails in the state participate in the Kentucky Jail Mental Health Crisis Network. More than 11,000 Telephonic Triages have been conducted. There has been an 80% reduction in suicides in participating jails and a 100% reduction in deaths in restraints.

Analyses of data generated by Telephonic Triage interviews reveal that 65% of people being booked in Kentucky jails have some risk related to suicide, 30% have had a psychiatric hospitalization in the past year, 38% of those triaged have substance abuse–related risk, and a staggering 77% have at least one symptom of a mental illness.

This program has been a win-win situation for everyone involved. It offers jails much needed mental health consultation, intervention, and risk reduction with no increased cost. It provides CMHCs with funding for this service and the opportunity to develop expertise with a population that traditionally has fallen through the service delivery cracks. And most importantly, people with mental illness in detention facilities now have options for services and diversion that did not exist previously.

Connie Milligan, LCSW, is the Regional Director of Intake and Emergency Services for the Bluegrass Regional Mental Health-Mental Retardation Board, Inc., and Director of the Kentucky Jail Mental Health Crisis Network.
Ray Sabbatine, MA, is a jail consultant to the Kentucky Jail Mental Health Crisis Network.

References

1. Ditton PM. Mental Health and Treatment of Inmates and Probationers. BJS Special Reports. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics; July 1999. Available at: https://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf.
2. Adams J, Shipley S. Locked in suffering: Kentucky's jails and the mentally ill. Four-part series. Courier- Journal [Louisville, Kentucky]. Feb. 24-Mar. 3, 2002.
3. Hayes LM. Jail suicide prevention and liability reduction. National Center on Institutions and Alterna-tives.