Health and Justice Outcomes:
An Investment Strategy for Offenders with Mental Health Problems
in New Jersey
by Nancy Wolff, Ph.D.
January 9, 2003
Investing in Health
and Justice Outcomes:
An Investment Strategy for Offenders with Mental Health Problems in
Mental illness is over-represented in the
2 As incarcerated populations grow in size and in their
representation of mental illness, state and local officials are
looking for ways to respond that comply with constitutional
requirements and legal mandates, fit the contours of a fragmented
public system, which relies increasingly on the private sector, and
are affordable. Their affordability is perhaps the most limiting and
vexing challenge, especially in contemporary times of huge budget
shortfalls. The needs of mentally disordered offenders are complex
and multi-dimensional, often including addiction problems, HIV/AIDS,
and some form of personality disorder, and they are expensive if
managed comprehensively. It is unlikely that there will ever be
enough public funding, even in more prosperous times, to meet all
their needs. For this reason, it is vital that policy makers
carefully invest available funds in responses that are most likely
to address needs that produce health and justice outcomes most
valued by society.
This paper argues that the most sensible way to respond to the needs
of offenders with mental illness is to treat their needs as an
investment, and to evaluate alternative responses to their needs in
terms of the health and justice outcomes they produce. States and
local governments that seek to get the most out of their investment
dollars need to consider what outcomes are produced by their
investments and whether these outcomes are protected from loss. For
example, it makes no social or economic sense to invest public
dollars in stabilizing chronic mental health problems of inmates and
then lose the "outcome" by gaps in treatment when the person moves
from prison or jail to the community. Framing social problems as
investment opportunities changes the point of reference and
lengthens the time frame. Here the challenge facing public officials
is not mental illness in correctional or community settings but
rather how to use scarce public dollars to produce and protect
mental health and prosocial behavior.
This paper has three parts. The first part describes the prevalence
of mental health and addiction problems among inmates in New Jersey
jails and prisons. These rates are contrasted with those for the
nation and are used to identify the scope and nature of the state's
investment opportunity. The next part describes the "investment"
responses by New Jersey prisons and jails. The third part discusses
obstacles to "protecting" investments in health and justice outcomes
and recommends an investment strategy and operational changes that
might minimize the loss and maximize the return on the public's
I. Behavioral Health Problems Among New Jersey Inmates: An
Federal statistics show that approximately 16 percent of jail and
prison inmates have some type of mental health problem.1 A recent
report prepared by the National Commission on Correctional
Healthcare estimates higher rates of mental illness, especially
among women.2 It is also known that inmates with mental health
problems are likely to have co-occurring addiction problems.
According to federal statistics, roughly 60 percent of state prison
inmates with mental health problems were under the influence of
drugs or alcohol at the time of their index arrest.1 This estimate
is consistent with epidemiologic evidence on the co-morbidity
between mental illness and addiction problems.3-5
Combined together, these estimates suggest that mental illness is
over-represented in the incarcerated population, and it ranges in
its severity and persistence. But these are rather "soft" estimates,
lacking the detail and specificity required for informed policy
making and planning, in part because state and local correctional
authorities do not routinely collect mental health statistics, and
those numbers that are collected are typically not published.
Prevalence Estimates of Behavioral Health Problems in New
Jersey Prisons. The estimates presented here are drawn from a study
on reentry planning that was commissioned by the New Jersey
Department of Corrections (NJDOC) and Division of Mental Health
The prevalence estimates are based on the universe of inmates housed
at nine (adult) New Jersey correctional institutions. Of the
approximately 19,000 inmates at these facilities, roughly 3,200
inmates (or 17 percent) were classified as special needs inmates.
These are individuals who need or receive "mental health treatment
of some type" while in prison.7
Prison mental health staff determines whether an individual has
symptoms requiring mental health treatment. An inmate may be placed
on the special needs roster during the intake process or at any time
during incarceration. Special needs inmates in New Jersey prisons
are most likely to be male (68 percent), African American (48
percent), and between the ages of 25 and 44 (68 percent).
Table 1 shows the distribution of the most serious psychiatric
diagnoses within the special needs population. The pattern of
diagnoses differs among male and female offenders.f Schizophrenia,
psychotic disorders, and dementia are more common disorders among
male than female inmates. Rates of major depression, bipolar, major
mood disorder, and borderline personality are higher for female than
for male inmates.
Table 1. Most serious Axis I diagnosis of special needs inmates
in New Jersey prisons by gender, August 2002.
Table 2. Other behavioral health problems of special needs
in New Jersey prisons by gender, August 2002.
* All gender
differences reported in this section are significant at the 1
These inmates also differ by criminal history (Table 3). Overall,
special need inmates were more likely to be serving their first
prison sentence (77 percent) but the length of their sentences and
the type of offense varied by gender. Compared to female inmates, a
larger proportion of male inmates was serving sentences longer than
5 years and for crimes involving violence. But, the females inmates
were more likely to be rearrested on parole/probation violations
than their male counterparts.
Table 3. Criminal history of special needs inmates
in New Jersey prisons by gender, August 2002.
Speaking nationally, this is the most comprehensive portrait of a
special needs population in a prison system that is currently
available. Its availability is due in part to the electronic
management information systems developed by the NJDOC and in part to
the Commissioner's willingness to make the data available to
researchers. Both are necessary if we are to move past the sketchy
impressions of the present to a more fact-based future.
Prevalence Estimates of Behavioral Health Problems in New
Jersey Jails. Estimates reported here are based on responses
from health services administrators from 17 jails participating in
the Correctional Health Care Study.8-9
In 2000, all participating jails were using standardized screens at
booking to identify behavioral health problems in inmates. These
screens included questions about mental health problems, as well as
substance and alcohol use and abuse. Medical histories were
conducted within four hours and physical examinations within 48 to
72 hours of booking. The rates of behavioral health problems
identified through screening are shown in Table 4. Approximately
16 percent of jail inmates were reported to have a mental illness.
Psychotropic medications are also commonly used at these facilities.
On any given day, roughly 20 percent of inmates in New Jersey jails
is receiving psychotropic medications. Again, the rates of inmates
receiving these medications varied considerably among jails.
Table 4. Rates of Behavioral Health Problems
in New Jersey Jails, 2000
These rates should be interpreted with caution because they are
based on the best estimates of respondents. In most cases,
respondents did not have access to or collect behavioral health
statistics. Most medical units of New Jersey jails did not, at the
time of the study, have a medical information system, nor did they
have the capacity to integrate health data across behavioral health
and medical divisions. Considerable amounts of information were
being lost between the cracks of health care units operated by
different private contractors. Most of the jails were contracting
with private companies for health services, and many jails had
different private contractors for medical, mental health, and
substance abuse services. Although the private contractors had
automated record keeping systems, the staff at the jail relied on
medical records stored as paper files at the facility.
II. Intervention Investments that Yield Health and Justice
On average, rates of mental illness and substance abuse reported
above for inmates in New Jersey prisons and jails are consistent
with federal estimates for state prison and local jail populations.
They suggest the following investment opportunity for the State
of New Jersey: On any given day, 16 percent of New Jersey jail and
prison inmates -- approximately 5400 people --- have a mental health
problem. But, as described above, there is considerable
diversity among the special needs population. There is not one type
of special needs inmate, just like there is not one type of person
with mental illness in the community. These individuals vary in
their behavioral health problems (e.g., severe versus non-severe
mental illness; the presence of addiction problems or personality
disorder) and criminal histories (e.g., violent versus non-violent)
and, as a consequence, they require different types of investments.
Standards for mental health care have been defined by the National
Commission on Correctional Health Care10,11
and the American Psychiatric Association.12
Typically, these standards include, but are not limited to,
screening, evaluation, crisis intervention, suicide prevention,
psychiatric medications, case management, therapy/counseling,
special programs and housing units, and reentry planning. In
addition to constitutional mandates and professional standards, the
public expects that, through the incarceration experience, these
individuals will be readied for community living. Public funding of
corrections is intended to protect the public's welfare in the
short-term by isolating offenders from the community and in the
longer term by restoring them. The public's expectations are
affirmed in the NJDOCs' mission statement, which states "that all
persons committed to the state correctional institutions are
confined with the level of custody necessary to protect the public
and that they are provided with the care, discipline, training, and
treatment needed to prepare them for reintegration into the
The challenge here is not understanding the intent of the court, the
standards for treatment, or the public's expectations but to fund
their implications. In general, there is very little information
available on correctional health care spending, and even less on its
appropriateness relative to need and public expectations. The
estimates that are available pertain to prisons in large measure
because prisons are centrally funded by the state, whereas jails
rely on local funding sources.
Correctional Health Care Spending by Prisons. In
aggregate, the prison systems for the 50 states spent approximately
$2.5 billion on prisoner medical and dental care in fiscal year
1996, which represented approximately 12 percent of total prison
operating expenditure. States vary in their spending on correctional
health care. For example, correctional health care spending as a
percentage of total prison operation expenditures is estimated at
approximately 20 percent for New Hampshire, Nevada, and Wyoming,
compared to 5 to 6 percent for Nebraska, Iowa, and Oregon. The
prison system in New Jersey reportedly spent 7.5 percent of its
annual operating budget, or $62 million, on correctional health care
in fiscal year 1996. This translates into roughly $2,300 per inmate
per year, or $6.30 per day.14
Correctional health care spending has increased in New Jersey in
recent years. In 2002, approximately $97 million, or 11 percent
of the prison's operating budget, was spent on medical and mental
health care, equaling about $4,000 per inmate per year.15
Metzner reports data on mental health spending by 16 state prison
systems. These states spent, on average, 17 percent of their
correctional health care budget on mental health services, with a
range among states from 5.4 percent (Minnesota) to 42.7 percent
Mental health spending represented roughly 18 percent of the
correctional health care budget for New Jersey prisons in 2002.15
The NJDOC's spending on behavioral health has increased in recent
year as a result of the consent decree associated with the C.F. v.
Terhune class action suit brought against the NJDOC on behalf
of prisoners with mental health problems confined in New Jersey
prisons. As part of the settlement, the NJDOC was required to build
a comprehensive psychiatric capacity inside its prisons, and to
coordinate mental health treatment post release.17
The New Jersey prison system now provides comprehensive mental
health treatment to special needs inmates in five locations: a
forensic psychiatric hospital, stabilization units, residential
treatment units, transitional care units, and outpatient care for
those in the general population. A complete description of the New
Jersey prison system of care can be found in Cevasco and Moratti.7
Having complied with the first part of the consent decree, the NJDOC
is now developing a plan for a reentry program.
Correctional Health Care Spending by Jails. It is very
difficult to determine the level of spending on correctional health
care in jails in part because spending is determined locally and by
a county budgetary process. All counties set total correctional
budgets but vary in the discretion and proportions granted to
correctional officials. Some counties grant lead correctional
officials full discretion over the total corrections budget, while
others target a portion of the total budget for health care. In some
cases, health budgets are carved out and the freeholders either
negotiate directly with private contractors or assign this
responsibility to another county agency. Counties choosing the
carve-out approach frequently do not involve local correctional
officials in the negotiation process. Given the complexity
associated with budgeting and the variation among counties in New
Jersey, it is not surprising that correctional officials are unaware
of correctional health care spending levels there. Those few
respondents in the Correctional Health Care Study who were aware of
fiscal arrangements in New Jersey jails reported that health care
spending represented about 10 percent of their operating budgets.
How adequate this spending is relative to the size of the needed
investment is unclear. The majority of jails reportedly have written
guidelines for serious mental illness (50 percent), suicide
prevention (60 percent), and detoxification (75 percent). Clinical
guidelines for the treatment and management of serious mental
illness were available at half the reporting facilities and these
facilities reportedly have sufficient resources to meet these
standards of care. The other half reported no clinical guidelines,
and the majority of them (83%) reported that the resources that were
available were inadequate to provide appropriate mental health care.
To meet standards for appropriate care, more behavioral health
professionals, including psychologists, social workers, and
substance abuse counselors, would be needed to develop special
programs and manage the level of need within the inmate population.
Physical space was also needed to conduct group therapy and for
special units (e.g., MICA program, residential substance abuse
treatment program, and residential mental health program).
The typical treatment plan for serious mental illness at the
reporting jails always included medications. These plans also
included other components but these varied among facilities. In
general, inmates with serious mental illness had access to
individual therapy at a majority (60 percent) of jails, while few
jails offered these inmates group therapy (33 percent), case
management (25 percent), or support groups (13 percent). The
majority (80 percent) of respondents reported little or no
difficulty getting inmates with acute psychiatric problems evaluated
by a psychiatric crisis evaluator or admitted to a hospital.
However, some facilities had problems getting crisis evaluations
conducted on or off site and extreme difficulty gaining admission to
a hospital bed because of changing hospital admission criteria and
Inmates with substance and alcohol problems were typically
detoxified and offered access to support groups, such as narcotics
or alcoholics anonymous. Inmates are usually treated symptomatically
during the detoxification process, with careful monitoring of blood
pressure. Most respondents reported that no active pharmacological
treatment was offered to inmates during the withdrawal phase (the
first 72 hours of admission) in an effort to prevent the
substitution of legal drugs for illegal drugs. Substance abuse
counselors provide individual or group therapy at roughly half of
the jails. Several facilities reported having special drug treatment
units, therapeutic communities, or boot camp programs.
II. Structural and Systemic Investments that Preserve Health and
As inmates move from correctional settings to the community, their
behavioral health problems move with them and require continuous
treatment. Reentry planning is the mechanism by which treatment is
coordinated and continued after incarceration. It is also the way in
which the public's investment in health is protected. Such planning
typically includes an individualized written post-release plan,
provision of a temporary supply of medications for those inmates
receiving medication, referrals and linkages to appropriate
community mental health care providers, and assistance in obtaining
necessary financial benefits and housing.12
A. The State of Reentry Planning in New Jersey Prisons and Jails
This section summarizes how correctional facilities in New Jersey
are working with special needs inmates and community providers to
protect the public's investment in mental health.
Reentry Planning by New Jersey Prisons. In an
average year, roughly 600 special needs inmates are released from
New Jersey prisons. According to the settlement, the NJDOC is
required to provide reentry planning for special needs inmates that
includes, at a minimum, an appointment with a community provider,
two weeks of medications, and county-specific information necessary
for the reestablishment of public benefits. The NJDOC is also
required to develop connections with community based providers and
provide treatment information at the request of community providers
and in accordance with patient consent.18
In accordance with the settlement, The NJDOC and the Division of
Mental Health Services jointly commissioned a study to estimate the
need for and cost of reentry planning for New Jersey prison inmates
with mental health problems.6 Here we describe the plan proposed by
that study. The proposed plan calls for classifying special needs
inmates into three need-risk groups that correspond to reentry tiers
offering different levels of coordination effort. The program tiers
are matched to three need-risk risk levels (high, moderate, and low)
identified within the special needs population. The program tiers
- Tier 3: Intensive Case
Coordination. 18 months of specialized coordination by mental
health professional with forensic experience, beginning 6 months
- Tier 2: Intermediate Case
Coordination. 6 months of specialized coordination by a mental
health professional with forensic experience, beginning 3 months
- Tier 1: Limited Appointment
Coordination. 4 weeks of engagement by a mental health
professional with forensic experience, beginning 2 weeks before
discharge. Responsibility is limited to scheduling an appointment
with an outside mental health provider and following up on any
This program is designed to respond to the need-risk clusters of
inmates with particular types of mental health, addiction, and
criminal problems. It is estimated that the percentage of special
needs inmates assigned to the high, medium, and low reentry tiers
would be 27, 52, and 21, respectively. The reentry study estimated
the cost of a three-tiered reentry program with a caseload of 600
special needs inmates at approximately $930,000 annually, with 47
percent of the cost allocated to the highest need-risk group (tier
3). The estimates of need and cost for this program do not include
the cost of community-based care. The success of this program, or
any reentry program, depends in large measure on the availability of
appropriate services in the community, and the willingness of
service providers there to treat persons with mental health problems
who also have criminal histories, personality disorders, and
Reentry Planning by New Jersey Jails. One of the
primary objectives of the Correctional Health Care Study was to
evaluate the state of reentry planning in New Jersey jails. The
central finding of this study was the near universal opinion among
the medical staff that reentry planning is critically important for
inmates with mental health problems but that in practice it was not
part of the treatment plan at most facilities.9 This is not to say
that New Jersey jails do nothing to assist inmates with behavioral
health problems connect with community providers post release. But
what is done can be reasonably considered "minimal," and the minimal
effort varies by facility and type of problem. Some type of reentry
planning was reported for inmates with serious mental illness by 73
percent of respondents and 53 percent for substance abuse. But, for
each type of behavioral health problem, less than 10 percent of
inmates with a behavioral health were released from these facilities
with reentry plans. Reentry planning for particular behavioral
health problems was most common and complete in facilities with
special treatment programs (e.g., drug treatment programs, special
mental health unit). In such cases, the reentry planning was
particular to the program, not to the entire facility.
Reentry planning, if it existed, most often consisted of a
connection to community resources or a family member. The most
typical reentry plan involved giving the inmate a telephone number
of a provider, treatment center, or clinic. Other forms of reentry
planning were more idiosyncratic, and may include the occasional
telephone call to an outside agency to give them a "heads up," or
scheduling an appointment for the person with a community provider.
Some facilities reportedly provide a summary of the inmate's
clinical record or treatment plan to community providers but this
was a fairly uncommon practice.
Most facilities have a policy against releasing inmates with their
medications. However, some facilities reportedly release inmates
with medications or a prescription for medications if they have a
serious mental illness, although this is not a common practice among
facilities. Facilities tend to shy away from releasing inmates with
medications because they are concerned that inmates will sell the
medications instead of using them as prescribed. Doctors also prefer
not to release inmates with prescriptions because it implies that
the prescribing doctor is responsible for follow-up care in the
B. Obstacles to Protecting the Public's Investment in the Mental
Health of Offenders
Connecting offenders with mental illness to community mental health
services is critically important according to the position statement
on post-release planning issued by the American Association of
and the Task Force of the American Psychiatric Association.12 Yet
while important, these standards have not made their way into
practice in New Jersey. Approximately 16 percent of New Jersey
inmates is identified as having mental health problems. Most of
these inmates are released without effective linkages to medications
or psychiatric services, both of which are essential for maintaining
their mental health. The situation in New Jersey is consistent
with anecdotal reports from other states. Delivering seamless care
to individuals who move between corrections and the community
requires communication, coordination, and cooperation among
correctional health care, the court, and community services. This
section begins by focusing on obstacles -- the reasons, as described
by correctional health care staff and the broader literature, for
why the public's investments in inmate mental health are lost or not
maximized. The concluding section develops a set of recommendations
for guiding and protecting the public's investments .
Obstacles Related to Coordination. Obstacles here
center directly on the lack of coordination and communication within
the criminal justice system.
Obstacle #1: Uncoordinated Release
People are released from correctional settings without medical
clearance and without advance notice.
Jails in New Jersey screen for mental health problems within the
first four to 72 hours of detention but detainees may be released at
any point during their adjudication -- at arraignment, during the
trial, or at sentencing. As a result, these individuals are released
from the jail at all hours of the day and night. Most
detainees/inmates are released before the medical unit is informed
of their disposition. Issues of timing and lack of coordination are
more problematic for jails than prisons, which generally have more
advanced notice of release dates (except in times of severe budget
shortfalls, when release dates become less predictable).
Obstacle #2: Insufficient Case Management
There are too few behavioral staff to deliver services, and most do
not have case management responsibilities.
Most jails lack the professional staff to offer mental health or
substance abuse services to inmates and what staff they have focus
on screening first and then treating, leaving little or no time for
reentry planning. Case management is not a responsibility typically
assigned to medical units. While case management may be the
responsibility of other service units within or affiliated with the
correctional setting, the medical staff typically functions separate
from social service units, as well as probation and parole. For this
reason, they are ill-prepared for service coordination activities,
and isolated enough to be ineffective at this task. Understaffing
and informational deficiencies are also problems for prisons. Prison
inmates may be housed in prisons that are hundreds of miles away
from the communities where they will eventually live upon release.
Social workers at the host facility may be unaware of resources in
those local communities, and unconnected to their counterparts at
prisons located closer to these communities.
Obstacles Related to Information Sharing and Eligibility.
Obstacles to reentry planning for inmates with behavioral health
problems expand past the gates of jails and prisons.
Obstacle #3: Information Gaps
Information bottlenecks exist which limit the clinical information
available to correctional and community providers treating the same
patient at different times.
One of the most common and persistent obstacles concerns the chasm
between correctional and community settings. Inmates, as well as
correctional health staff, are isolated from the community in ways
that limit their contact and communication with community providers,
creating information gaps. Very little effort is extended on either
side of the gate to bridge the information gaps that lead to
discontinuities in treatment. Failure to provide information to
correctional or community health care staff can result in the
substitution of medication or treatment approaches that are less
effective, while failure to make treatment plans available can
result in treatment discontinuities and symptom decompensation.
Obstacle #4: Treatment Eligibility
Treatment histories in correctional settings imperfectly translate
into eligibility requirements for community treatment.
All counties in New Jersey have community-based programs in
operation that could serve as a bridge between correctional and
community treatment settings. These special community-based
programs, referred to as programs of assertive community treatment
or intensive case management services (ICMS), are designed for
persons with severe mental illness who tend to be treatment
resistant. Eligibility for these programs require either prior
hospitalization or failure to thrive in a previous intensive
outpatient program, usually within the past 18 months. Most inmates
do not meet these eligibility criteria. Without recent evidence of
treatment failure in the community, most inmates fail the
eligibility test for intensive community-based treatment, even
though it may be equivalent to the treatment they received while
incarcerated or prior to their incarceration. Yet, even when inmates
with serious mental illness meet these criteria, there are often no
Obstacle #5: Public Funding Eligibility
People released from prison and jail are without public benefits and
re-qualifying for them takes months.
Funding issues, however, further complicate the individual's ability
to connect with treatment resources in the community. It is
remarkably easy to process the paperwork to terminate public
entitlements, such as Medicare, Medicaid, and welfare, but
extraordinarily cumbersome to reactivate them. Re-qualifying for
Medicaid or Medicare takes time and requires a community address. As
a consequence, most people are released from jail and prison without
any health care insurance coverage. Without a means to pay for
treatment, community providers may be unwilling to deliver services
and prescribe medications. In the interim, the public's investment
in the inmate's mental health depreciates, as effective treatments
are withheld until funding is determined, eligibility criteria are
satisfied, and treatment slots become available.
C. An Investment Strategy for Restoring and Protecting the Mental
Health of Offenders
Restoring mental health begins and continues with effective
treatment. Research evidence has shown that there are effective
programs available for people with mental illness, including
assertive community treatment, supportive employment programs,
programs for the mentally ill, chemical abusers, as well as
medications management regimes.21-25
In addition, programs are developing that respond to the special
needs of people with mental illness and criminal histories.26-30
The issue is not whether effective treatment exists but whether it
is consistently available to the people who need it, and whether
these individuals continuously avail themselves of treatment. The
public's investment in the mental health of its citizens must be
consistent and continuous to yield health and justice outcomes that
Investments in Mental Health and Prosocial Outcomes.
The public (or the state as its agent) cannot afford to fully meet
the needs of this population, but there is some level of care that
is within the public's budget. The level of care to be provided will
be determined in large measure by the size of the investment budget,
which depends on how much the public is willing to spend on a
standard of care for this population. But, once the investment
budget is determined, an investment strategy is needed. The three
recommendations presented here are intended to set the foundation
for the state's investment strategy. These recommendations require
deliberative effort and consensus building, which will take time and
the active involvement of policy makers, system officials, and the
public. The strategic recommendations include: treatment parity,
treatment capacity, and need-treatment matching. Fiscal politics and
administrative dynamics will undoubtedly shape the standards for
parity, the extent of treatment specialization, and the
sophistication of needs-treatment matching. Nonetheless, the state
can take the lead to guide the process and assure some reasonable
baseline for all three.
Strategic Recommendation #1: Treatment
Standards of care and treatment opportunities must be equivalent
between correctional and community settings.
Whatever treatment opportunities exist on one side of the gate must
exist on the other side if treatment is to be consistent and
continuous. Treatment must follow the person, and it cannot follow
if the capacity is absent or changes with residency. National
standards for correctional health care may make clinical sense in an
abstract social context but they are not socially useful if they are
not paired with equivalent service standards in the community.
Strategic Recommendation #2: Treatment
The degree of specialization within the treatment capacity must fit
the case mix of the population.
The complexity and diversity of the treatment capacity is determined
in large measure by the variation in need within the special needs
population. A "one size fits all" treatment approach is not likely
to fit the case mix within the special needs population, which
includes people with severe mental illness combined with HIV/AIDS,
addiction problems, and personality disorders, those with mild forms
of acute depression, and everyone else in between. An array of
services contoured to the multi-dimensional nature of the problems
within the population will most likely be needed, especially in
areas with high concentrations of HIV/AIDS and addiction problems.
Strategic Recommendation #3:
Screening and assessment must be comprehensive and used to guide the
assignment of treatment intensity.
Matching people with mental health problems to appropriate treatment
services is critical. It requires accurate screening for mental
health problems and a comprehensive accounting of co-occurring
conditions and risk factors. Without this information, people may be
assigned to services that are more or less intensive than what they
need, which is wasteful and inconsistent with clinical standards.
Preserving and Protecting the Public's Investments in Mental
Health. Mental health is lost when treatment is disrupted or
discontinued against clinical advice. Even if the strategic
recommendations are adopted, treatment may still lapse if the
obstacles described above are not eliminated or, at least, managed
effectively. The recommendations here are operational in nature and
require administrative changes and/or additional funding. Many are
amendable to immediate responses, while others may require more
Coordination Obstacles. People are typically released from
prisons and jails in an uncoordinated way. Often there is little or
no coordination within the correctional facility (obstacle #1) or
between corrections and the community (obstacle #2). The first two
recommendations are intended to facilitate coordination inside the
gate. They are:
Operations Recommendation #1:
Cross Train Provide correctional and medical staff with
opportunities to learn each other's jobs, train specialty
correctional staff for special mental health units, and establish
protocols that guide access to treatment, which are respectful of
and consistent with security and therapeutic concerns.
Operations Recommendation #2:
Coordinate Release Develop protocols for release that include
clearance by the medical unit and the provision of two weeks of
medication as "personal property."
Fragmentation exists between the medical and correctional staff. The
professional philosophy of these two groups is different in focus
and objective, each seeing the inmate and his/her needs differently.
These differences can lead to frequent disagreements regarding when
and if inmates need access to treatment and how treatment will be
delivered. Serious gaps in communication also exist between the
correctional staff in charge of release and the medical staff. The
lack of communication here can begin the cycle of relapse for
inmates who are chronically ill and need medications and continued
treatment to maintain their health.
The next recommendation is intended to coordinate treatment
activities between correctional and community providers (obstacle
Operations Recommendation #3: Agency
Assign one public agent with the responsibility to coordinate
treatment between the correctional and community settings and fund
Treatment is disrupted upon release from prison and jail because no
public agent has responsibility for coordinating treatment between
the correctional setting and the community. In the breach, no one
accepts responsibility and the public's investment in inmate health
is placed at risk. To protect the public's investment, some public
system must become the responsible agent, and to act responsibly the
agent must be adequately funded and provided with the information
necessary to make the treatment connections inside and outside the
Information Obstacle. Timely and complete medical information
is required to efficiently and effectively respond to inmate health
problems. The goal here is to remove information bottlenecks
(obstacle #3) that impede the flow of clinically appropriate
information to providers.
Operations Recommendation #4: Automate
Invest in interactive, integrated information management systems
that combine clinical information on health, mental health,
substance abuse problems.
Operations Recommendation #5: Integrate
Integrate health information between health care settings to improve
detection and treatment engagement.
Having access to more complete historical information at booking,
saves money on testing and screening (which can be very expensive),
and frees up staff and resources for treatment, yielding more
treatment and health per correctional health care dollar. These
records also could be used to identify so-called "frequent flyers"
and engage them in treatment. Automated systems also facilitate the
construction of health profiles that document the level of illness
among inmates and how illness patterns are changing over time.
Operations Recommendation #6: Regulate
Develop protocols for sharing health information that are consistent
with federal and state protections on privacy and applicable to
public and private providers.
Idiosyncratic interpretations of federal and state regulations on
confidentiality typically limit information sharing between health
providers treating the same person in different settings.
Information barriers can impair clinical decision-making and create
unnecessary disruptions in treatment.
Eligibility Obstacles. There are two types of eligibility
obstacles. The first obstacle concerns the difficulty of matching
offenders' treatment histories to the eligibility requirements for
community-based services (obstacle #4).
Operations Recommendation #7: Eligibility
Develop a way to identify case equivalents between community and
correctional setting and protocols for assuring equal access for
those in equal need.
Eligibility for intensive treatment in the community requires a
severe mental illness and evidence of extreme treatment
noncompliance during the past 18 months. While these criteria are
designed to restrict access to those who are most in need of
intensive treatment, they are not compatible with the treatment and
confinement experience of inmates. While in prison, some inmates may
be receiving treatment equivalent to that provided by PACT or ICMS,
and their mental health status may depend on receiving that level of
treatment. Barring them from appropriate community care because they
were incarcerated is not inconsistent with the clinical intent of
these programs or the public's investment in them.
The second eligibility obstacle concerns access to public benefits,
especially Medicaid (obstacle #5). Access to treatment depends
critically on the ability to pay. Federal and state entitlements,
including health benefits, are typically suspended or terminated if
a person is incarcerated for more than a month. The next
recommendation addresses access to public entitlements.
Operations Recommendation #8: Eligibility
Create a mechanism by which inmates can reactivate their Medicaid
eligibility prior to release.
Termination or suspension of benefits has serious consequences for
reentry planning. It can take up to six months to get Medicaid and
SSI benefits reinstated (after release) but in the interim these
individuals need medical care and housing, which are tied to the
having public support and Medicaid. Establishing benefits that cover
medical services is vital for this population.
The strategic and operational recommendations suggested here are not
exhaustive. They are intended to be illustrative of the types of
investments that are necessary to produce and protect health and
justice outcomes. Outcomes that are consistent with society's
preferences and willingness to pay. These recommendations also serve
to move corrections-and community-based services closer together.
Closing this gap reduces the likelihood of treatment
discontinuities, which wastes the public's money and places the
public at undue risk. But, to move the state's investment strategy
more in keeping with that outlined here, there must be the political
will to change systems, remove structural barriers, and regulate
performance. It is not clear that the proposed investment strategy
will cost the public more, but it is clear is that the public dollar
would be invested differently and more purposefully.
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