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.
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.
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 firstname.lastname@example.org.) 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.