Correctional mental health administration

Abstract

Mental health administrators in correctional facilities have the complex task of balancing the clinical needs of incarcerated individuals and the safety and security missions of the facilities. This article describes the various structures of mental health administration within correctional facilities, the tasks commonly required of these professionals, and the skills necessary to be effective in this role. This editorial discusses the legal framework for mental healthcare in jails and prisons, staffing, cost containment, quality assurance and quality improvement, accreditation, peer review, morbidity and mortality reviews, utilization management, medication formularies, electronic health records, and innovative strategies as they apply to administrators of mental health services in correctional facilities. Throughout this article, practices are also included that have been found to be of value for managing a correctional mental health system.

Keywords:

• Mental health administration
• jail
• prison
• quality assurance
• quality improvement
• accreditation
• peer review
• utilization management
• medication formularies
• electronic health records

Administrators of jails and prisons are responsible for the safe and orderly running of facilities designed to manage persons involved with the criminal justice system. The rate of serious mental illness in these correctional facilities is estimated to range from 9–20% (Scott & Falls, 2015). While many in society consider the primary reason for incarceration for those found guilty of a crime to be punishment, rehabilitation is another important goal (Scott, 2010). Consistent with the goal of rehabilitation, the American Psychiatric Association’s (APA, 2016) practice guideline for psychiatric services in jails and prisons calls for inmate patients to be provided with the same level of mental health treatment that should be available in the community. This is no simple matter. The purpose of this article is to describe the basis, structure, tasks, best practices, and challenges for administrators of correctional mental health services in the US.

Whether convicted of a crime or not, persons in correctional facilities have a constitutional right to necessary and adequate healthcare (Bell v. Wolfish, 1979; Estelle v. Gamble, 1976), including mental healthcare (Bowring v. Godwin, 1977). Unlike in community systems, jails and prisons may be held liable not only for the negligence of those working in the facilities, but also for civil rights violations when policies and procedures amount to at least the appearance of deliberate indifference to legitimate healthcare needs (Estelle v. Gamble, 1976). The subsequent tripling of lawsuits by inmates with only 2% going to trial and finding in favor of inmates (Scalta, 1997) led to Congress passing the Prison Litigation Reform Act of 1995. Though this law has reduced the incidence of class-action litigation against correctional agencies, some are or have been subject to consent decrees, private settlement agreements, or memoranda of understanding that mandate resources to provide for an adequate mental health system. Under the Civil Rights of Institutionalized Persons Act, institutions found to be depriving persons of constitutional rights (e.g. healthcare) may be subject to oversight by the US Department of Justice (Roskes & Vanderpool, 2015). Whether or not any of these situations apply, these organizations are motivated to avoid the substantial costs of litigation and monitoring (Metzner & Appelbaum, 2015). Thus, correctional agencies must provide healthcare services to inmates, although they are also held accountable for safety, security, and the responsible use of public funds.

The structure of mental health administration in prisons and larger jail systems is typically comprised of two levels: the administrative structure present within the correctional agency (usually state or county government), and the administration of the organization providing mental healthcare services. Administrators in correctional agencies often have law enforcement (rather than clinical) backgrounds. The actual providers of mental health services may be directly employed by the correctional agency. More often, the agency contracts with another entity such as a medical school, a not-for-profit organization (Delaware and the District of Columbia being current examples), or a for-profit company (Appelbaum, Manning, & Noonan, 2002; Trestman, 2015) for these services. Sometimes, correctional agencies may use non-contracted providers in the community (Metzner & Appelbaum, 2015). Thus, providers may be government workers, employees of a for-profit or a not-for-profit organization, a subsidy of an academic centre, or independent practitioners, accounting for highly variable models of administration at an organizational level.

When mental health services are not provided by professionals who work directly for the government, it is often the case that those correctional agencies directly employ clinically-trained professionals for the purpose of oversight of a vendor of mental healthcare services. In such an arrangement, there may be parallel administrations: one in the correctional agency, and another in the organization directly supervising the provision of healthcare services to inmates. The agency’s healthcare authority could be a non-physician administrator, another government agency (e.g. a health department), or a third-party health organization (as is the case in the Texas Department of Criminal Justice). When the healthcare authority is not a physician, the responsibility for medical judgement ultimately rests upon the licensed attending physician (Metzner, 1997). For the purpose of this article, correctional mental health administrator refers to any person with oversight responsibility for the mental healthcare services, although we acknowledge that to whom this refers will differ between systems.

An effective mental health administrator will first and foremost provide leadership, with a well-understood and articulated mission for inmate services, and will hold staff accountable to this mission (Patterson, 2015). What separates them from contemporaries in the community is that administrators working in these settings must understand and work within the correctional ‘culture’. While often unique to each facility and system (Gage, 2015), common themes include mutual respect amongst professionals, understanding the hierarchy of the correctional agency, and valuing input. Correctional mental health administrators must appreciate the need to find a balance between security concerns and treatment concerns, and effective leaders will maintain open lines of communication with decision-makers within the correctional agency (Patterson, 2015).

Responsibilities placed upon a correctional mental health administrator are numerous, and may include both duties specific to the internal healthcare process, as well as duties outside of the correctional agency. Duties internal to the agency’s healthcare process include:

• staffing and credentialing;

• supervising and training of mental healthcare staff;

• reviewing and revising mental health related policies and procedures;

• for governmental mental health administrators, monitoring the contractual compliance of the mental healthcare vendor;

• participating in committees such as Pharmacy and Therapeutics (P&T);

• developing, overseeing, and following-up of projects to monitor and improve the quality of services;

• consulting on difficult clinical and administrative issues; and

• conducting morbidity and mortality (M&M) reviews.

Duties external to the correctional agency may include:

• reviewing pending legislation relevant to the correctional agency,

• co-ordinating current inmate services with other state agencies,

• attending and co-ordinating meetings with other state agencies relative to new initiatives,

• attending Governor-sponsored task force meetings on behalf of the agency’s Commissioner,

• visiting other correctional settings across the nation,

• reviewing outside policies and practices which could affect the healthcare status of offenders or the delivery of healthcare, and

• taking part in developing and/or reviewing healthcare and correctional research activities and presenting findings on behalf of the correctional agency at various national conferences.

Considering the breadth of these tasks and the essential interface with clinical work, the ideal correctional mental health administrator is clinically experienced and savvy, stays abreast of developments in the field, and directly interacts with line staff to remain connected to clinical and operational problems.

Furthermore, it is critical that the correctional mental health administrator be capable of effective communication and engagement with key personnel at all levels, including custody and administrative professionals without clinical backgrounds. This is especially challenging when custody, organizational, and healthcare objectives conflict. Examples include access to inmate patients for the purpose of evaluation and treatment, sharing of custody information of relevance to mental health (such as drug screening results), and difficult-to-manage cases. In our experience, regular meetings including administrators from both the correctional agency and the mental health providers can be of value for addressing operational matters than would otherwise be a barrier for necessary mental healthcare.

Conflicts between the goals of custody administrators and mental healthcare administrators health is perhaps most often evident in matters related to cost-containment. The expenses associated with prison systems typically comprise 2.5–2.9% of a state’s budget, with 9–25% of this devoted to healthcare for inmates (Trestman, 2015). Budgetary considerations are, thus, high-profile and unavoidable when making strategic healthcare decisions. Obtaining specialized healthcare services outside of the facility (such as a specialist consultation, outside hospitalization, or electroconvulsive therapy) are costly and require co-ordination with custody for appropriate security measures. This apparent conflict can be mitigated by utilizing cost-containment strategies used in prison and large jail systems, such as negotiating rates and fees with hospitals and pharmaceutical suppliers (NCCHC, 2001). Regardless of how these conflicts are managed, correctional healthcare administrators must carefully consider how to provide necessary and appropriate healthcare services in a cost-effective manner.

As mental healthcare cannot happen without mental health staff, correctional mental health administrators must ensure that the staffing needs of the institution or system are met by recruiting, credentialing, placing, and supervising psychiatrists, psychologists, clinical social works, and other professionals. Generally, offering salaries modestly higher than those available in the community for comparable work is required to effectively attract qualified candidates. Candidates may perceive jails and prisons to be more dangerous places to work. While comparative literature on this subject is sparse, one study found the lowest rates of reported physical violence against staff occurred in the prison and probation services (compared with traditional psychiatry settings, eldercare, and special education schools), even though these individuals were more likely to report these incidents (Rasmussen, Hogh, & Andersen, 2013). In our experience, those with prior correctional experience are more likely to succeed in these settings. Regardless, orientation to the safety and security focus of the institution is critical for new employees. Promoting mutual respect between correction officers and the mental health personnel is important for the retention of quality staff.

Quality improvement (QI) is a critical task for administrators in any healthcare system, although the need for QI may be more explicit in correctional settings. A QI programme may be required by agency policies, state regulations and statutes, the terms of consent decrees or other litigation, and standards from accrediting agencies such as the NCCHC or the American Correctional Association (ACA). Quality indicators may also be defined in contracts with mental health vendors (Trestman, 2015).

Ruiz v. Estelle (1980) described the most basic framework for quality mental healthcare in these settings by listing the following essential elements:

• systematic screening and evaluation;

• treatment that is more than mere seclusion or close supervision;

• participation by trained mental health professionals;

• accurate, complete, and confidential records;

• safeguards against psychotropic medication prescribed in dangerous amounts, without adequate supervision, or otherwise inappropriately administered; and

• a suicide prevention programme.

Since this landmark decision, agencies such as the NCCHC and the ACA have developed and published evolving national standards that comport with and go far beyond these essential elements, with a goal to have correctional practice reflect community practice as much as possible (Penn, 2015). It is worth stating that, despite accreditation and following the standards of accrediting agencies being voluntary, correctional agencies have increasingly sought accreditation, as certified compliance with national standards is expected to reduce the risk of successful litigation. As of 2014, ∼500 correctional facilities, in 47 states and the District of Columbia, were accredited by the NCCHC (2014). Correctional mental health administrators are often charged with planning, preparing, and training staff for the accreditation process, which can also be described as an external peer review. Examples of NCCHC standards for mental healthcare include access to care, health-related policies and procedures, communication of healthcare needs and privacy, and grievance mechanisms to address patient complaints (Penn, 2015).

Correctional agencies are required by the NCCHC to have a quality improvement (QI) programme for accreditation (Joint Commission Resources 2015). Quality assurance (QA), while a component of a QI programme, is not sufficient as to be the entire QI programme, as QA comprises only the monitoring of a process. A fully developed QI Programme incorporates QI projects which take the information obtained in QA, and has goals to improve the process (e.g. how medication is delivered to inmate patients) or the outcome (e.g. clinical improvements related to medication), and both kinds should be undertaken (Metzner, 2015). A QI programme may be facilitated by a QI committee that is typically responsible for monitoring quality, identifying problems, and developing action plans to address them. Avenues for staff feedback about quality issues, such as an e-mail or physical ‘suggestion box’ or an open-door policy, may be valuable sources of information. Some quality problems may be improved simply through education and training; others may involve modification of existing practices and may be codified in policies, procedures, and workflows. Even better, line staff can be trained and encouraged to participate in local QI projects. A local QI team should involve staff at a specific work site with direct knowledge of the process issues that may impact upon quality. Following a QI model, local QI teams can be empowered to proactively initiate, plan, monitor, and report on a QI project. An example of a QI model used in healthcare is Deming’s Plan-Do-Study-Act (Deming, 2000):

• identify the problem, form a PI team, and collect baseline data;

• brainstorm solutions and implement changes;

• collect follow-up data; and

• if improvement occurs, act on and report findings.

Such an approach greatly extends the reach of a correctional mental health administrator, opens opportunities for application of best practices elsewhere in a system, and promotes staff investment in quality clinical care. To promote a culture of quality improvement, since 2005 in the New Jersey Department of Corrections, an annual fair has been held to share and celebrate dozens of projects conducted by line staff from around the state (DeBilio & Steefel, 2016).

In 2007, the Prisoner Re-entry Institute of John Jay College of Criminal Justice convened a panel of experts on correctional psychiatry to define a set of performance measures, any of which may be appropriate targets for QI (Hoge, Greifinger, Lundquist, & Mellow, 2009). A summary of these recommendations include:

• adherence to psychopharmacology treatment will be documented on the medication administration record, and that incidents of significant non-adherence will be communicated to the prescriber;

• for patients prescribed antipsychotic medication, the psychiatrist will document monitoring for abnormal involuntary movements using a standardized tool such as the AIMS at baseline and every 6 months;

• especially for patients prescribed second-generation antipsychotic medications, there will be baseline and periodic routine monitoring documented for weight, body mass index, lipids, and glucose;

• patients on higher-risk mood stabilizers (e.g. lithium and valproic acid) will have pre-treatment workup, with serum levels checked after implementation, after changes in dosage, and with routine periodic monitoring;

• all inmates will be screened for suicide risk upon entry to the facility, using an empirically validated measure, with positive screens referred for mental health evaluation;

• all correctional staff will be trained in suicide risk management;

• all inmates on the mental health case load will have an individualized treatment plan with multidisciplinary input and periodic updating; and

• pharmacotherapy for insomnia should be limited to cases in which a clear diagnosis warrants treatment, and that long-term treatment should be rare with clear documentation for the rationale.

We might suggest other important quality indicators, such as:

• staffing and caseload levels;

• direct assessment of symptom change using an instrument such as the BASIS-24;

• patient participation in services outlined in the individualized treatment plan;

• disciplinary charges for those with serious mental illness;

• incidents of self-injury;

• incidents of healthcare-directed seclusion and restraint;

• continuity of care (e.g. chart reviews following intra- or extra-facility transfer);

• timeliness and completeness of various mental health evaluations and follow-up documentation;

• averse medication reactions;

• appropriate prescribing of medications, especially those at high risk for misuse;

• polypharmacy, especially for high-risk medications such as antipsychotics; and

• quality of discharge planning.

Sometimes innovative QI strategies may effect positive changes in terms of healthcare quality. While few guidelines to date have been published for providing care in these settings, correctional mental health administrators can develop recommendations for treatment based on existing and applied community guidelines, published research, and knowledge of best practices as they apply to the applicable system, as long as these are periodically reviewed and are flexible enough to allow for clinical judgement. Reeves (2012) noted a QA result of a high level of prescribing benzodiazepines and low-dose quetiapine off-label for insomnia in a prison system. Both of these practices are considered higher risk for misuse, abuse, and diversion in correctional settings (Tamburello, 2015). The prison system employed a QI strategy to provide staff education using a guideline discouraging this practice. Furthermore, Reeves (2012) used an innovative peer comparison intervention wherein he distributed a chart comparing the prescribing habits of psychiatrists in the system, with each knowing their own position but blinded to that of their peers. On follow-up monitoring, the prescribing of benzodiazepines and low-dose quetiapine were reduced by 38% and 59%, respectively. Other examples of innovative QI strategies include: benchmarking quality indicators with other comparable correctional systems, developing integrative care models (i.e. joint medical–mental health teams) to prevent or improve chronic medical illnesses, and obtaining and monitoring patient satisfaction ratings.

Closely related to QI is peer review, which is another NCCHC standard (NCCHC 2008). While, by definition, peer review is conducted by professional line staff amongst peers in an informal manner, peer review in a correctional setting is typically designed, implemented, monitored, interpreted, and followed-up by correctional mental health administrators in a robust, formal manner. Thus, peer review in these settings may be used to indirectly or directly educate staff about expected clinical care, and to identify problems with the quality of care provided. Professionals may find feedback from peers to be less threatening, and participating in peer review may be used for maintenance of board certification (ABPN, 2016), making this a particularly useful tool for correctional mental health administrators. Potential peer review subjects are myriad, and may include quality of mental health evaluations; compliance with agency guidelines, policies, or procedures; and the appropriateness of diagnosis, treatment, and follow-up of psychiatric disorders. Examples of peer reviews we have used to good effect in the New Jersey Department of Corrections include monitoring metabolic indices for inmate patients prescribed second-generation antipsychotic medications, adherence to organizational guidelines for the prescription of antidepressant and antipsychotic medications, the appropriate use of medication for the treatment of insomnia, and the quality of psychiatric evaluations.

Suicide risk management is an important quality issue for correctional mental health administrators. Besides the obvious human costs, suicide in these settings is a common source of litigation (Gage, 2015). It has been shown that reforms including better screening and monitoring have greatly reduced the incidence of suicides in jails and prisons (Hanson, 2010). Unfortunately, suicides in corrections remain a common occurrence, with a rate of 15 per 100,000 in prisons, and 47 per 100,000 in jails (Hanson, 2010), despite living in an environment with an increased level of supervision while in custody. While pro-active approaches are critically important, a thorough morbidity and mortality (M&M) review is necessary whenever a completed suicide or a serious suicide attempt occurs in these settings (Hoge et al., 2009). Such reviews should be led by a correctional mental health administrator, and should gather information and report on:

• mental health screenings, diagnostic work-up, treatment planning, and co-ordination of treatment;

• relevant circumstances leading up to, during, and immediately following the incident;

• relevant policies and procedures and how they were applied or deviated from in this situation;

• limited resources (e.g. staffing, facilities, available programming);

• issues related to staff training or orientation;

• inmate non-adherence, or partial adherence with treatment;

• co-morbid substance-use or medical conditions;

• documentation deficiency; and

• any other factors that may have been contributory.

While an adverse outcome is never desired, an M&M may be a unique opportunity to identify systemic issues (such as staff training, policy, physical plant, or clinical or operational procedures) for the purposes of quality improvement (Hughes & Metzner, 2015). These reviews may reveal patterns of risk, such as single-cell disciplinary housing (Reeves & Tamburello, 2014). Another benefit of this process is the opportunity for dialogue amongst staff and administrators regarding quality clinical care, and also to posit recommendations for the larger correctional system to consider making improvements which have a bearing on healthcare delivery and outcomes.

In some healthcare settings, M&Ms have evolved into Root Cause Analysis (RCA). An RCA is a comprehensive process by which system vulnerabilities are identified for the purpose of eliminating or mitigating their associated risks (National Patient Safety Foundation, 2016) and includes the participation of all individuals needed to study the process of the event of concern. Thus, in a correctional setting, non-healthcare administrators, internal affairs, and custody staff may be required to effectively review factors such as operations, the physical environment, policies and procedures, and orientation and training of non-healthcare staff. The sensitive nature of these issues makes this level of participation challenging. Some systems address such concerns by conducting parallel reviews at the clinical, operational, and administrative levels to optimize self-disclosure and self-correction. We expect that setting a goal to improve collaboration between mental healthcare and custody administration would better approximate an RCA, which may provide better information to strategically reduce risk.

Utilization management (UM) differs from QI in that the former is focused on avoiding costly and unnecessary care. Especially in fee-for-service models with mental health vendors, UM is more likely to be managed by administrators under the direct employ of the correctional agency or a third-party organization (Trestman, 2015). In the ideal situation, the goals of UM and QI should not conflict but work together to improve the efficiency and effectiveness of a healthcare process. UM may result in cost containment over a shorter time frame, although it is less focused on long-term systemic improvements, so correctional administrators must consider these factors in deciding which approach to take. While this same issue may be present in the community, budgetary matters ubiquitous in correctional settings make this a particular challenge.

The most common example of UM in correctional psychiatry is a medication formulary, which is a list of medications approved for use within the facility or system. The majority of US state prisons and large jail systems use a medication formulary as a cost-management tool (NCCHC, 2001). A correctional agency’s medication formulary is most often managed by the P&T Committee, on which typically sits representatives from the agency, mental health administrators, and pharmacists. While immediate cost-control is an important consideration for determining the contents of the formulary, thoughtful P&T formulary decisions may also consider safety issues or the need for involvement of specialists (Greifinger, 2006). These safety issues, such as medical risks in overdose, can result in long-term costs that are not reflected in the short-term medication wholesale price. Medications not available on the formulary should be made available through a UM process, by which the prescriber documents that formulary options are unavailable or inappropriate for this particular inmate patient. Such a request process is typically reviewed by a psychiatrist administrator, and is best suited as justification for treatment rather than a burden to the prescriber in an effort to block or dissuade access to care.

Electronic health records (EHRs), when available, greatly enhance the capacity of correctional systems to track quality and utilization management data (Metzner, 1992). An EHR is also a powerful mechanism to provide evidence of the delivery of mental healthcare if involved in litigation or court monitoring. The expanded use of EHRs has put pressure on jails and prisons without EHRs to develop manual tracking systems (e.g. spreadsheets) to make such systemic administrative oversight possible (Metzner, 2015). These manual tracking systems can be viewed as an intermediary step towards EHR implementation. Correctional MH administrators have come to learn that manual tracking systems cannot produce data mining results as robust as EHRs. In some ways, expanded EHR usage has encouraged administrators to directly adopt this technology.

Correctional mental health administrators must remain aware of the changing landscape of correctional healthcare. Evolving clinical standards based on research in community or institutional settings may inform and guide changes in practice in jails and prisons. Legal decisions may also better define necessary healthcare. An example of this is the treatment of gender dysphoria in prison (Osborne & Lawrence, 2016), although a full discussion of this subject is beyond the scope of this article. If guidelines or other direction is used by administrators for QI or UM, it is appropriate that these be regularly updated to reflect changes in recommended practice.

While most of this article is of greater relevance to mental health administration in prisons and larger jail systems, smaller jails are just as (or more) often called upon to address the healthcare needs of the seriously mentally ill (Race, Yousefian, Lambert, & Hartley, 2010). Jails usually rely upon funds from county resources (Trestman, 2015). As such, resources in these settings are usually more limited, including physical plant, staffing, and access to psychiatric services (Race et al., 2010). Such limitations may put strain on these facilities, which typically have higher turnover and, thus, conduct more new evaluations (Dvoskin & Brown, 2015). Some jails contract out to mental health providers in the community, although access to these services and transportation are consistent challenges (Metzner & Appelbaum, 2015; NCCHC, 2001; Race et al., 2010). When mental health providers are employed by the jail and available in-house, they may answer directly to custody or jail administration. According to eight larger jail systems responding to a 1999 survey by the National Commission on Correctional Health Care (NCCHC), two systems were run by a physician, with the remaining overseen by a non-physician administrator reporting either to a sheriff, another custody professional, a county health department official, or another county administrator (NCCHC, 2001).

In summary, the task of correctional mental health administrators is complex. These individuals must balance the legitimate clinical, custodial, and budgetary needs of a facility or system while providing leadership, direction, and accountability for staff. Correctional mental health administrators need to understand how to communicate at multiple staff levels and how to navigate the correctional culture. They are responsible for ensuring quality through setting expectations for the facility and system, staff recruitment and training, a QI process to ensure compliance with local and national standards, utilization management, and comprehensively reviewing serious adverse events. Effectively meeting these challenges can contribute to quality psychiatric care that may save lives, relieve suffering, improve patient functioning, improve staff safety, and promote continuity of treatment in the community.

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.