A major public health crisis in our county jails

Reports from the field document the large and growing presence of persons with mental health and substance use conditions in our county jail and juvenile detention facilities. Conservatively estimated, at least three-quarters of all adults currently incarcerated have a mental health condition, a substance use condition, or both.  Further, at least one to two of every 10 have a serious mental illness, including schizophrenia. Unfortunately, the numbers are almost as large for our children and youth in juvenile detention.

The very sad fact is the vast majority of these persons should never be incarcerated in our county facilities.

Then, why are they there? Many reasons can be put forward: the inadequate capacity of county mental health and addiction care systems; lack of crisis intervention and diversion training for police; absence of local mental health and drug courts; little or inadequate behavioral healthcare in our county detention facilities; and non-existent or inadequate re-entry care as people leave these facilities. Re-incarceration is the rule rather than the exception.

The litany of problems dictates the type of solution we will need to craft. Clearly, any effective solution will need to be systemic, and it will need to engage all related components of county government. Below, I outline the key elements of a systematic approach to this current public health crisis.

Building a Strategic Partnership and Plan. A fundamental initial step is to engage key county leaders in a joint conversation at a common table. At a minimum, participants must include county health, mental health, substance use,  public health, and social service directors; the county sheriff and municipal police officials; county elected officials who oversee there programs; and local representatives of the mental health and substance use consumer communities. These leaders will need to craft a county strategic plan that includes the elements described below.

Prevalence Assessment. This will involve the development and implementation of an ongoing data collection system to identify the number of persons with different behavioral health conditions in pre- and post-adjudication status in county facilities. These data will need to include basic socio-demographic, socio-economic, and residential address or specification that the person is homeless, as well as health insurance information, including Medicaid coverage, and health care provided while in jail. Collected on a continuous basis, these data will permit specification of turnover rates, as well as recidivism rates, in addition to overall prevalence.

Identification of Entry and Exit Patterns. Through focus groups and personal stories, the Committee will need to identify the most common patterns of entry and exit from the county facilities for both adults and juveniles. Who, how, and why are key factors to be identified.

Development of a Countywide Service Plan. The essential goal of this plan will be to reduce the prevalence of adults and juveniles with these problems in county detention facilities. This plan must include:

• Prevention: A strategy for behavioral health case management and peer support to prevent incarceration from occurring.
• Diversion: A strategy for police training in crisis intervention and the introduction of a diversion care center in lieu of jail entry. Over the longer term, the county also could develop mental health and drug courts to facilitate diversion.
• In-Jail Care. Whenever possible, good, in-jail behavioral health care should be provided by county mental health and substance use programs, not by a newly developed jail healthcare program. This approach will promote needed continuity of care.
• Care upon Community Re-entry: Community re-entry care is just as important as front end jail diversion care to reduce recidivism. Essential features must include immediate case management, continuation of medication therapy, and needed social wrap around services.

Budgeting for These Services. The Affordable Care Act (ACA) and its Medicaid expansion provisions can provide new resources for developing and implementing these services. The only services currently excluded from Medicaid payment are those actually provided in the county detention facilities. In addition, ACA Section 2703 also can provide 90% federal funding for health homes for two years. Health homes could be configured for populations at risk of incarceration. Finally, state and county funds supplanted by federal ACA funds could be dedicated to these services.

The very high prevalence of persons with mental health and substance use conditions in our county detention facilities is a current public health crisis that demands our immediate attention. We call for well executed county action to address this crisis.

(Author’s Note: On December 9, the National Association of Counties and the Council of State Governments will announce a major initiative to reduce the prevalence of behavioral health conditions in our county detention facilities. NACBHDD will be a partner in this important initiative.)