Clients Receiving
Mental Health Services in Jail:
A Report for San Diego County
Mental Health Services
Fiscal Year 2006‐2007
Data Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG) Date Revised: 4/2/2009 1
Table of Contents
Title
Page
Table of Contents
1
Introduction
2
Overview and Key Findings
4
Summary
6
References
7
AOAMHS Services Provided FY06‐07 to Clients Who Received Jail Services
8
AOAMHS Services Provided to Clients Who Received Jail Services in FY06‐07
9
Clients with 30 Days of more Jail Inpatient Services FY06‐07
10
The goal of this report is to explore the use of community‐based (i.e. non‐jail) mental health services among adults who receive mental health services in jail for planning purposes for new programs and new collaborative efforts. As shown in Figure 1, 9,768 adults utilized jail based mental health services at some point during FY 06‐07.1
Introduction
The implementation of the Mental Health Services Act (MHSA) created an opportunity to transform our public mental health system of care into a wide‐ranging and inclusive planning process that fosters inter‐agency cooperation throughout San Diego County. One area of focus has been the development and provision of effective and efficient programs and policies to serve our residents involved in the forensic system and
protect public safety. One of our County’s MHSA initial Community Services and Supports programs built upon the demonstrated successes of the earlier Mentally Ill Offender Crime Reduction (MIOCR) programs provided by the San Diego County Sheriff’s Department and the San Diego County Probation Department. This program demonstrated the efficacy and importance of intensive case management to divert mentally ill consumers from the Criminal Justice System and decrease both recidivism and associated costs. Adults Who Received Mental Health Services (38,124) Adults Admitted to San Diego County Jails (71,914)
Jail and Mental Health Services (9,768)
Figure 1. Adults using both Jail and Mental Health Services
Agencies throughout the United States have begun to address the growing awareness of the importance of establishing comprehensive jail diversion and other related programs that result in the “right care” at the “right time” in the “right place.” Many have developed creative and integrated programs that provide mentally ill consumers appropriate services, lessening their involvement
In fiscal year 06‐07, 9,768
individuals received mental
health services in jail,
representing 25.6% of the
38,124 adults who received
mental health services and
13.6% of those in jail during the
year.
Data Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG)
Date Revised: 4/2/2009
3
with emergency and public safety agencies and decreasing overall costs. As a result of these trends, public policy experts have encouraged the implementation of jail diversion programs to minimize the number of individuals with serious mental illness who are arrested as a primary consequence of their mental illness.
The problem of unserved or underserved mentally ill citizens cuts across multiple jurisdictions, multiple municipalities and multiple agencies. Public Safety and Emergency Services throughout the County are impacted, resulting in less than optimal care and inappropriate use of public safety and emergency resources. At its inception, the MHSA recognized these issues and among the key tenets of the Act is a focus on transforming mental health services n California, thus accomplishing a
lessening of e of the
mentally ill in the Criminal Justice System. i th involvement ritical to the development of an appropriate response to this problem is having rele
In order to explore the overlap between clients of MHS and those incarcerated thro
C
vant and accurate data upon which to base policy and program decisions. The purposes of this collaborative effort includes augmenting decision making, accurately identifying needs and potential outcomes, documenting the system impact and cost savings, and directing the development of a centralized, collaborative exchange of information.
Overview
ugh the justice system (see Figure 1), we identified individuals receiving public mental health services in San Diego County jails in fiscal year 2006‐07 (FY0607), and summarized their use of mental health services, both in jail and outside of jail, and costs, in FY0506, FY0607, and FY0708. We conducted a similar analysis of services for 30 days pre booking and 30 days post release for individuals receiving services for 30 days or more in a forensics inpatient unit.
Key Findings
Type of Service Use in Jail Of the 9,768 individuals described above and referred to in Figure 1, 346 (4%) received services in a forensics inpatient unit, 5,235 (54%) received outpatient (but not inpatient) services in jail, and 4,187 (43%) received only an assessment or forensic evaluation in jail (see highlighted cells, Table 1). Use of Community Based Outpatient Services In FY 06‐07, 84% of those who received a mental health service in jail did not receive any outpatient mental health service in the community (16% received outpatient services while outside of jail; see highlighted cell, Table 2). Similarly few individuals received outpatient services in the years prior to or following their jail‐related services (13% and 16% respectively, see highlighted cells, Table 2). Even among those with more serious conditions requiring inpatient services in jail, over 60% did not receive any outpatient mental health services outside of jail (38% received outpatient services in FY 06‐07) with a similar pattern seen for other fiscal years (see highlighted cells Table 2). The data show that persons receiving services in jail do not transition to community‐based outpatient services when they are released from jail.84% of those who received a
mental health service in jail
did not receive any outpatient
mental health service in the
community.
A Revolving Door: Repeat Usage of Jail Mental Health Services Individuals who use mental health services in jail are often repeat users of these services. Nearly one‐third of individuals who received mental health services in jail in FY 06‐07 also received services in jail in the year prior and year after (32% in FY0506 and 32% in FY0708, see highlighted cells, Table 2). Costs of Mental Health Services for Shared Clients Total costs for mental health services among persons receiving services in jails were $24.6 million in FY0607. The largest component of costs was community based inpatient mental health services. A similar pattern seen in the year prior and year after (see highlighted cells Table 2). These data suggest that inpatient expenditures might beData Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG)
Date Revised: 4/2/2009 5
reduced if persons exiting jail were more successfully transitioned to community based outpatient services. Patterns of High Usage Jail Mental Health Services Users One of the purposes of this report is to explore use of community‐based mental health services among those who are the most severely ill in the jail system. For the purposes of this report, we defined a this group as
those receiving 30 or more consecutive days of services from the forensic inpatient unit during FY 06‐07.
Among the 53 we identified, 31 (59%) received a mental health service while in a separate jail stay during the 3 months prior to being admitted to the forensic inpatient unit. In the 3 months post release from jail, 8 or 15% were back in jail for a separate stay and received at least one mental health service. Although our sample size is small, the fact that 31 of 53
individuals were not new to the jail system when they received 30 or more days of services from the forensic inpatient unit, and that 8 of the 53 were back in jail and utilizing forensic mental health services within 30 days post release suggests a cyclic pattern of repeat usage that may be costly. Total cost for mental health services were over $206,000 in the 30 days pre booking and over $242,000 in the 30 days post release (see highlighted cells, Table 3). This translates to $2.7 million in annual expenditure, or $51,000 per client per year.
31 of 53 individuals were not new to the jail system when they received
30 or more days of services from the forensic inpatient unit.
This report examined the use of community‐based mental health services among individuals who received mental health services in jail. This report has two main findings:
(1) very few individuals who receive services in jail ever receive services in the community, and (2) individuals who receive services in jail are often repeat users of these services.
The concept of a revolving door for justice system services is well known. Baillargeon and colleagues (2009) found that prison inmates with major psychiatric disorders (major depressive disorder, bipolar disorders, schizophrenia, and nonschizophrenic psychotic disorders) had substantially increased risks of multiple incarcerations during a 6‐year period. The greatest increase in risk was observed among inmates with bipolar disorders, who were 3.3 times more likely to have had four or more previous incarcerations compared with inmates who had no major psychiatric disorder.
Prisons and jails also serve as treatment settings for inmates with mental illness. In a nationwide study of the health and health care of inmates, Wilper and colleagues (2009) found that among inmates in local jails who had ever been treated with a psychiatric medication, only 39% were taking psychiatric medication at the time of admission, but that 46% were restarted on medication as part of their treatment while in jail. Thus, incarceration often results in the resumption of psychiatric treatment.
Summary
Very few individuals who receive services in
jail ever receive services in the community.
Individuals who
receive services in jail
are often repeat users
of these services.
The revolving door of incarceration of individual who are mentally ill, combined with the treatment capacity of prisons and jails, result in a missed opportunities for engagement and retention in treatment. Baillargeon and colleagues (2009) recommend interventions to reduce recidivism among mentally ill inmates, such as continuity of care reentry programs to help mentally ill inmates, as well as a greater role for mental health courts and other diversion strategies. Wilper and colleagues (2009) suggest improvements in correctional health care and in community mental health services that might prevent crime and incarceration. A dual approach would employ transition teams to assist individuals with mental illness as they are being released from jail, as well as prevention efforts aimed at those with a high risk or history of incarceration. In summary, although the current use of community‐based mental health services is low, and recidivism is high among individuals who receive services in jail, there are also great opportunities for engagement in treatment through a strengthening of current forensic services, increased prevention efforts, and improved linkages to community based services.
Data Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG) Date Revised: 4/2/2009 7 REFERENCES J Baillargeon, IA Binswanger, JV Penn, BA Williams, and OJ Murray. “Psychiatric Disorders and Repeat Incarcerations: The Revolving Prison Door. Am J Psychiatry 2009 166: 103‐ 109.
A Wilper, S Woolhandler, JW Boyd, KE Lasser, D McCormick, DH Bor, DU Himmelstein. The Health and Health Care of US Prisoners: Results of a Nationwide Survey. Am J Public Health. 2009 Jan 15.
TABLE 1: AOAMHS Services Provided FY06‐07 to Clients Who Received Jail Services
*Unique Clients: Inpatient = 346 Outpatient = 5,235 Assess/Eval = 4,187 Overall = 9,768 % of Clients who received any non‐jail service = 28.2%
Total Visits Total Clients Percent Users
Mean Visits Among Users
Outpatient Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Case Management 727 2,569 3,397 6,693 29 67 121 217 8.4% 1.3% 2.9% 2.2% 25.1 38.3 28.1 30.8 Outpatient Programs 503 4,706 4,102 9,311 57 549 385 991 16.5% 10.5% 9.2% 10.1% 8.8 8.6 10.7 9.4
Fee for Service 861 2,669 3,192 6,722 49 260 213 522 14.2% 5.0% 5.1% 5.3% 17.6 10.3 15.0 12.9 Full Service Partnership 1,603 1,658 1,295 4,556 42 65 51 158 12.1% 1.2% 1.2% 1.6% 38.2 25.5 25.4 28.8
Total Visits Total Clients Percent Users
Mean Visits Among Users
Emergency Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall EPU 422 2,009 985 3,416 183 1,074 531 1,788 52.9% 20.5% 12.7% 18.3% 2.3 1.9 1.9 1.9
PERT 45 155 91 291 34 121 79 234 9.8% 2.3% 1.9% 2.4% 1.3 1.3 1.2 1.2
Total Days Total Clients Percent Users
Mean Days Among Users
Forensic Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Jail 14,490 24,416 6,118 45,024 346 5,235 4,187 9,768 100.0% 100.0% 100.0% 100.0% 41.9 4.7 1.5 4.6
Total Admissions Total Clients Percent Users
Mean Admissions Among Users
Inpatient Admissions Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
County Hospital 46 105 58 209 33 75 46 154 9.5% 1.4% 1.1% 1.6% 1.4 1.4 1.3 1.4 FFS Hospitals 77 281 242 600 39 148 116 303 11.3% 2.8% 2.8% 3.1% 2.0 1.9 2.1 2.0 15.0 Crisis Residential 228 2,590 2,557 5,375 27 190 141 358 7.8% 3.6% 3.4% 3.7% 8.4 13.6 18.1
Data Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG) Date Revised: 2/6/2009 9
TABLE 2: AOAMHS Services Provided to Clients Who Received Jail Services in FY06‐07
*Unique Clients FY06‐07 Inpatient = 346 Outpatient = 5,235 Assess/Eval = 4,187 Overall = 9,768
FY0506 Percent Users FY0607 Percent Users FY0708 Percent Users
Outpatient Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
Case Management 7.8% 1.2% 2.6% 2.0% 8.4% 1.3% 2.9% 2.2% 6.9% 1.5% 2.8% 2.2% Outpatient Programs 16.5% 8.5% 7.9% 8.5% 16.5% 10.5% 9.2% 10.1% 11.3% 10.6% 9.0% 9.9% Fee for Service 14.7% 5.2% 5.1% 5.5% 14.2% 5.0% 5.1% 5.3% 12.7% 4.3% 4.8% 4.8% Full Service Partnership 0.0% 0.0% 0.0% 0.0% 12.1% 1.2% 1.2% 1.6% 17.6% 1.9% 1.8% 2.4% Any Outpatient Services 28.9% 12.5% 13.0% 13.3% 38.2% 14.8% 14.8% 15.6% 39.0% 15.1% 14.9% 15.9%
Emergency Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
EPU 36.4% 11.7% 9.8% 11.8% 52.9% 20.5% 12.7% 18.3% 25.7% 11.7% 9.1% 11.1%
PERT 13.9% 3.2% 2.2% 3.2% 9.8% 2.3% 1.9% 2.4% 9.2% 2.1% 2.2% 2.4%
Any Emergency Services 39.0% 13.4% 10.9% 13.2% 54.9% 21.5% 13.5% 19.3% 29.2% 12.8% 10.2% 12.3%
Forensic Services Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
Jail 49.7% 38.8% 23.0% 32.4% 100.0% 100.0% 100.0% 100.0% 51.7% 35.2% 25.7% 31.7%
Inpatient Admissions Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
County Hospital 6.1% 1.1% 0.9% 1.2% 9.5% 1.4% 1.1% 1.6% 7.2% 1.1% 0.9% 1.2%
FFS Hospitals 11.6% 2.7% 2.8% 3.0% 11.3% 2.8% 2.8% 3.1% 9.0% 2.1% 1.8% 2.3%
Crisis Residential 6.4% 3.0% 2.5% 2.9% 7.8% 3.6% 3.4% 3.7% 5.5% 3.0% 2.6% 2.9%
Any Inpatient Admissions 20.8% 5.4% 4.8% 5.7% 24.0% 6.4% 5.8% 6.8% 18.2% 5.1% 4.3% 5.2%
FY0506 Costs FY0607 Costs FY0708 Costs
Service Type Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall Inpatient Outpatient Assess/Eval Overall
Outpatient Services $324,632 $1,341,473 $1,522,566 $3,188,670 $488,621 $1,746,887 $1,753,750 $3,989,258 $730,036 $2,549,680 $2,035,837 $5,315,553 Emergency Services $476,462 $1,867,182 $945,742 $3,289,385 $619,756 $2,083,353 $1,157,476 $3,860,584 $288,173 $1,182,153 $840,382 $2,310,708 Inpatient Admissions $1,134,343 $2,557,519 $2,618,933 $6,310,795 $1,766,324 $3,677,304 $3,191,879 $8,635,507 $1,394,840 $3,018,958 $2,289,098 $6,702,896 Subtotal Non‐Jail $1,935,436 $5,766,174 $5,087,240 $12,788,850 $2,874,701 $7,507,544 $6,103,105 $16,485,350 $2,413,049 $6,750,791 $5,165,317 $14,329,157 Jail $1,319,897 $1,634,591 $653,637 $3,608,126 $4,961,390 $2,232,002 $985,737 $8,179,129 $800,592 $1,432,465 $2,028,852 $4,261,909 Grand Total $3,255,333 $7,400,765 $5,740,877 $16,396,976 $7,836,091 $9,739,546 $7,088,841 $24,664,479 $3,213,641 $8,183,256 $7,194,169 $18,591,066
Data Sources: UBH (1/2007, 1/2008, & 7/2008 download) Source: HSRC (AS, BL, JC, ST, TG)
TABLE 3: Clients with 30 Days or more Jail Inpatient Services FY06‐07
Unique Clients 53 3 months Pre Booking 3 months Post ReleaseOutpatient Services Total Visits Total Clients Percent Users
Mean Visits
Among Users Total Visits Total Clients Percent Users
Mean Visits Among Users Case Management 46 6 11.3% 7.7 40 6 11.3% 6.7 Outpatient Programs 13 3 5.7% 4.3 12 3 5.7% 4.0 Fee for Service 33 7 13.2% 4.7 11 3 5.7% 3.7 Full Service Partnership 0 0 0.0% 0.0 255 7 13.2% 36.4
Emergency Services Total Visits Total Clients Percent Users
Mean Visits
Among Users Total Visits Total Clients Percent Users
Mean Visits Among Users
EPU 21 12 22.6% 1.8 9 8 15.1% 1.1
PERT 5 4 7.5% 1.3 3 2 3.8% 1.5
Forensic Services Total Days Total Clients Percent Users
Mean Visits
Among Users Total Days Total Clients Percent Users
Mean Visits Among Users
Jail 139 31 58.5% 4.5 56 8 15.1% 7.0
Inpatient Admissions Total Admissions Total Clients Percent Users
Mean Visits
Among Users Total Admissions Total Clients Percent Users
Mean Visits Among Users County Hospital 6 5 9.4% 1.2 2 2 3.8% 1.0 FFS Hospitals 5 4 7.5% 1.3 2 2 3.8% 1.0 Crisis Residential 0 0 0.0% 0.0 2 2 3.8% 1.0
Service Type 3 months Pre Booking Costs 3 months Post Release Costs
Outpatient Services $9,540 $49,788 Emergency Services $45,134 $10,353 Inpatient Admissions $109,330 $166,453 Subtotal Non‐Jail $164,004 $226,594 Jail $42,129 $15,807 Grand Total $206,133 $242,401
