By Taylor Knopf

Several hundred county commissioners, sheriffs, court officials and mental health providers from across North Carolina will meet in Raleigh on Tuesday to discuss a new initiative to reduce mental illness in jails.

County jails are the largest provider of residential mental health care in the United States, said Richard Cho, director of Behavioral Health at the Council of State Governments Justice Center. This fact would surprise people 20 years ago, he added.

“But we have reached a point where that no longer shocks people. It’s become accepted,” Cho explained. “We realized we have to take a different approach. The crisis of people with mental illness in jail is bigger than ever.”

The CSG Justice Center along with National Association of Counties and American Psychiatric Association Foundation launched an initiative called Stepping Up, a data-driven plan to reduce mental illness in jails.

North Carolina has 41 counties participating in the program, the most in the U.S. That means 41 county boards of commissioners signed resolutions to use Stepping Up.

The state Department of Health and Human Services’ division of Mental Health Developmental Disabilities and Substance Abuse Services is hosting the Stepping Up Summit in Raleigh on Tuesday so county representatives can share their stories about treating mental health and learn from others.

“Many counties sign a resolution, it’s logged in the minutes and sits in the clerk’s office,” said Robin Huffman, executive director of the N.C. Psychiatric Association, who helped organize the event.

“The conference goal is to inspire them to do something, show them how to get the community around the table and start work.”

What is Stepping Up?

The Stepping Up initiative is a data-based program that encourages counties to track outcomes on the people with mental illnesses coming in and out of their jail system. The idea is that when there is actual data, counties will be able to determine what programs and changes provide real results.

“It’s a different approach that doesn’t just focus on a nice pilot project,” Cho said. “We are using data to drive where we should focus on the various reforms.”

Cho explained that many counties have put funds toward different responses to mental illness in jails with different programs, reentry services, community-based treatment and police mental health training.

“What we are saying is all those things are important and things that need to be considered. The truth is the counties have been doing a lot of those things, but not to scale,” Cho said.

“Do we need to do more in terms of law enforcement and police practices? Court processing? Is it diversion at the pre-trial stage that we need to focus on? Or is it a lack of community-based mental health services and treatment that’s the obstacle here?”

Cho and others with the Stepping Up Initiative believe the only way to know for sure is to track the data.

“Our big emphasis is we need to quantify what is the number of people in jail today and how are we actually going to show that is different tomorrow,” Cho said. “Having data can drive our decision making and the development of strategies.”

Stepping Up provides tools and questions county leaders should be asking themselves about mental health services. Counties can apply for federal grants to assist with the data tracking. Cho said his organization is also doing some “hand holding” with a few counties each year to help get their data tracking and analysis systems up and running.

Alamance County leading the way

One North Carolina county leading the way on the Stepping Up Initiative is Alamance.

Once a month, more than a dozen community agency officials — including the sheriff and some deputies, the health director, the social services director and a county commissioner —  meet at the Sheriff’s department to track data and talk about solutions. This team will be presenting at the summit this week.

The group started meeting in September 2015, and every police chief in the county attended the first meeting, said the Psychiatric Association’s Huffman, who is a member of the Alamance Stepping Up team.

“It’s been great to see how the Stepping Up effort has been working in a real, hands-on kind of way,” she said. “A lot of counties joined after they were doing some things already. Alamance hadn’t. We are really the county that used the Stepping Up Initiative to jumpstart our work.”

At the March meeting, the team members went over the mental health data collected during the past two months from the jail, EMS, the regional behavioral health provider and the county emergency department.

For example, 12 percent of people coming into the Alamance jail screened positive for mental illness. About 11 percent of the jail’s daily population receives psychiatric medication, and 3 percent are on suicide watch. The jail’s daily population averages 467 people. In those two months, about 80 staff hours were used for mental health transportation. The total cost of serving inmates with mental illness for those two months came to $220,312.

Bringing the community to the table

March’s meeting included the presentation of graphs tracking the last six months of mental health emergency department visits, as well as who brought the patients in and what time of day they arrived.

The discussion continued with brainstorming over what could be done to improve the numbers.

Bob Byrd, Alamance County Commissioner, said the local hospital is interested in helping because treating mental health in the emergency department is difficult. “It’s a morale buster among the staff,” he added.

The group talked about the issue of jail inmates receiving proper medications.

“Just because you are taking medications outside of jail, doesn’t mean you are getting them while locked up,” said Susan Osborn, Alamance County department of social services director.

The group also discussed what other statistics the county could track. Art Springer from National Alliance for Mental Illness North Carolina wanted to look into how long it takes to get a psychiatric bed in the county. Meanwhile, Stacie Saunders, Alamance County health director, brought up the issue of inmates with mental illness that is missed at the intake screening.

“Who catches those later?” she asked. “We should find a way to track those numbers.”

She added that some inmates will screen negative for mental illness during intake, not show symptoms, but develop them later from simply being jailed.

Chief Sheriff Deputy Tim Britt said the jail also needs a better way to handle inmates on suicide watch. The jail doesn’t have an assessment tool to take them off the watch.

He added that the local behavioral health provider has given the jail a social worker for 10 hours a week, and he plans to reclass another job position to put one more social worker in the jail.

“I’m so impressed by all the non-mental health people in our community that are so gung-ho about this,” said psychiatrist Jim Ryan after listening to an hour of the discussion. “People have not always been excited about mental health.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...

2 replies on “Reducing mental illness in jails with evidence”

  1. It’s good to see this initiative. It’s similar to the work I did in Orange County working with people who were homeless. In 2012, Jamie Rohe recruited me to co-chair the 100K Homes Task Force, focused on housing the most vulnerable persons experiencing homelessness in Orange County. We saw an increasing number of people with complex needs — untreated mental illness, addiction, physical health issues, poverty — and they often intersected with criminal justice involvement. There is a whole lot we could be doing on the side of prevention. That will require a robust mental health and substance abuse services system, and all the things that go along with that — housing and jobs and healthcare.

  2. On behalf of the Anxiety and Depression Association of America, we wanted to laud the effort and learn more about the initiative. You may want to submit a session abstract for our April 2018 conference in DC that convenes 1,300 experts in the mental health field. Submissions open June 12. I know our members would love to hear about your initiative.

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