The state's local and regional jails are currently not equipped to provide the services that their mentally ill inmates would receive in a community setting, according to the Office of the State Inspector General's 2013 report, "A Review of Mental Health Services in Local and Regional Jails."
In a letter accompanying the report to the governor and legislature earlier this week, Inspector General Michael Morehart wrote that according to the Compensation Board's annual report, "one in four inmates in local and regional jails was known, or suspected, to be mentally ill -- making Virginia's jails one of the Commonwealth's largest providers of mental health services for persons with mental illness."
More than 6,322 people diagnosed with a mental illness are being held in Virginia's jails, he noted. Of those, more than 3,000 are deemed to have a serious mental illness, such as bipolar disorder, schizophrenia or severe depression, a 30 percent increase in five years.
Based on those findings, the Office of the State Inspector General has issued a series of recommendations for changes in the way Virginia treats the mentally ill who are incarcerated — from coordinating care better with community services boards to incentivizing the building of specialized mental health wings. To that end, state Sen. Ryan T. McDougle, R-Mechanicsville, has introduced a bill, SB301, providing "that the Commonwealth will reimburse 50 percent of the cost of constructing, enlarging, or renovating a jail or regional jail to provide mental health beds and 100 percent of the cost of treating personnel." Currently those costs, once borne largely by the state and its hospital system, are borne primarily by localities.
One of the OSIG's primary recommendations addresses the need for parity in funding within jails and the community. "The state should develop a strategy for funding mental health treatment for individuals in local and regional jails that is proportional with the Commonwealth's investment in support services for the same population in the community," it reported. In FY2012 Virginia appropriated $762 million to support community-based mental health treatment, but no comparable funds for treatment in jails. The state's per-person investment in the community was $1,625; an equivalent investment for individuals in jail would amount to $10.3 million.
That "money follows the person" strategy would make a big difference, according to Dave Simons, head of Hampton Roads Regional Jail in Portsmouth that serves four cities, including Hampton and Newport News, and houses several hundred inmates diagnosed with a mental illness. By downsizing the state hospitals — Eastern State in James City County lost about half its capacity since 2008 — and making jail the de facto place of treatment, the state simultaneously shifted the cost of treatment to localities. According to the Compensation Board's FY2011 Jail Cost Report, the state provided 35.1 percent of jail operations costs, but no dedicated funds for mental health.
The cost of serving individuals with mental illness in jail in the board's 2012 report was estimated at $13.2 million, deemed a low estimate as it didn't include the staff cost of providing one-on-one supervision; transportation costs; and associated medical care for injuries resulting from inmate-on-staff aggression. "If the money followed the patient, whoever provided the services — whether jails or community services boards, CSBs — there would be better continuity of care," said Simons.
Not only does the state not allot any funds to mental health care in jail, but when individuals are incarcerated, they lose their Medicaid entitlement (which can then take from weeks to months to reinstate on release). That, in turn, is a disincentive for CSBs to provide services, as they typically rely on Medicaid reimbursement to underwrite mental health care. Consequently, the report found, the role of private providers has grown to provide 40 percent of in-jail care. The OIG report further noted that because inmates are "denied equal access to treatment," it leads to an overreliance on medication. "Control of symptoms through medication is often the only intervention available to jails," it reported.
Costs of psychotropic medications are second only to the cost of AIDS drugs, according to Sheriff Gabe Morgan in Newport News. "Some reimbursement and funding needs to come back," he said. Jails, which unlike state hospitals are unable to medicate over objection, emphasize medication cost containment. OSIG reviewers found formulary restrictions at eight jails and policies prioritizing generics at eight. Also, it determined, CSB staff may delay transfer to state hospitals for treatment because jail is considered a "safe" environment. On release, the supply of medication provided to individuals ranged from three to 30 days.
The OSIG report also called for a separate review of suicides and attempted suicides among the mentally ill in jail. Suicide is the number one cause of death for inmates in jails. The review found that policies on segregation or isolation based on suicide concerns was used at all facilities, but that 64 percent didn't have any guidance on it and that the focus was on "control and safety" and not treatment of the mental illness.