It has taken a while for the criminal justice and the behavioral health systems to really understand that they are partners, says Patrick J. Fleming, director of the Salt Lake County Division of Behavioral Health Services.
What unites them is the fact that county governments in 23 states bear the costs of behavioral healthcare not only within the criminal justice and jail systems, but also in the larger community. “Those are also the states where you see the counties taking an active role in setting up alternatives to incarceration,” he said. “The best safety valve for keeping this under control is community behavioral health.”
One major source of counties’ pain involves the Medicaid “inmate exception,” a federal law that prohibits Medicaid expenditures on people who are incarcerated—even those awaiting trial that retain a presumption of innocence. Fleming is one of many county leaders who are working with the National Association of Counties (NACo) in an ongoing effort to end the inmate exception, at least for inmates who are still awaiting trial.
Fleming says that diverting non-violent offenders who have mental illness and substance use disorders (SUDs) away from jail and into treatment enables counties like Salt Lake to access Medicaid dollars for their treatment. He adds that the proposed Medicaid expansion under the Affordable Care Act will be one of the best ways to help uninsured people with behavioral health problems to get services that help keep them out of jail.
“I pay for the largest residential treatment program for substance use disorders, and it’s in the Salt Lake County jail,” said Fleming. Many of these inmates are not currently eligible for Medicaid, or are in or out of jail, but under the expansion – which includes single men without children – they will be. “If we can get them enrolled in Medicaid, judges are more likely to let them out of jail” because they will be receiving treatment, says Fleming.
More jails or more treatment
Though the war on drugs has increased the pressure on correctional facilities – county jails and state prisons alike – there just aren’t many cells available in Salt Lake County, Fleming says. “There are a lot of people locked up who aren’t dangerous. This has driven local elected officials to realize they have to do something different, or they have to build more jail and prison cells.”
The county jail has only 2,300 beds, he said, noting that the county population is 1 million. But the county elected officials, including the sheriff, are not ready to build more jail cells, says Fleming. So, they want to keep the jail cells for “the people we’re scared of” – violent criminals. Fleming says that desire, combined with the fact that Utah as only one psychiatric hospital in the state, demonstrates that “we prefer to do more community based-services in this state.”
But even then, Fleming explains that there are barriers to removing people from jail, even if they belong in treatment instead. “Sometimes a judge doesn’t want to let someone with mental illness or addiction out of jail if that person already failed in community-based treatment.”
And behavioral health treatment is only one of many types of care required by the county’s justice-involved population. At present, the county sheriff pays $4 million for inpatient services for people who are in his custody but need medical care – dialysis, cancer treatment, and so on, says Fleming. Thus, if NACo is able to get the federal government to change the Medicaid exception for jail inmates, “it could be a big deal for us.” For example, of the 2,300 people in the county jail, 500 are women, and many come in pregnant, he says. “We want to take them to the hospital to have the delivery.”
Partnering with police
Jeannie Edens, health policy planner with the Salt Lake County Division of Behavioral Health Services, explained that the county uses a “sequential intercept model” in which mobile crisis outreach teams and CIT (crisis intervention trained) officers will extend help even in people’s homes to help prevent arrests and incarcerations. “One of our biggest partners is the Salt Lake City police department,” she says.
There is a “23-hour” receiving center located at the local university, where people can walk in or where a police officer or a family member can bring a person in crisis. For people not in crisis, the county offers a wellness resource recovery center. In addition to the crisis hot line, which has been in existence for a long time, there is now a warm line for those who need support to prevent a possible crisis (See sidebar).
Those reentering the community from county jail or state prison also receive support. On release, they can be transported by van to the mental health agency, where they can set up at-home services. And when they are home on probation, mobile crisis outreach teams can visit them and ensure they are getting their medications and other essentials, said Edens. “They’ll transport them to court, or help them buy groceries too.”
It’s important to keep channels of communication – and coordination – open between behavioral health and criminal justice. “We meet on a monthly basis with the courts, the district attorney, county behavioral health services, legislative people, and the state department of corrections,” said Edens, adding that as far as she knows, Salt Lake County is the only county in the state to offer such a comprehensive web of treatment.