What About Data?

Lack of comprehensive national data makes overall mental health picture hard to view 

While this Hot Topics contains much information about the issues related to individuals with mental illnesses in jails, one important piece is missing: the current number of people with mental illnesses in county jails across the country. Is the number getting smaller? Is it getting bigger? The answer is this: On a national level, we just don’t know.

 

National Data… Or Lack Thereof

The most recent national data from the Department of Justice indicate that 64 percent of the jail population has a mental health problem. These data are based on personal interviews with 6,982 local jail inmates in 2002  — 15 years ago — where mental health problems were defined by a recent history or any symptoms of a mental health problem that occurred within the 12 months prior to the interview.  This national number is used widely, but does not reliably measure the number of individuals in jail who have been diagnosed as having a mental illness by a health professional such as a psychiatrist.

Learn More

Both the Stepping Up initiative and the Data-Driven Justice initiative, focused on promoting data-driven strategies through peer sharing and discussion, have resources available to help counties jumpstart or enhance their efforts to collect, use and share accurate data on individuals with mental illnesses in their community and their jail. Find out more:

Stepping Up Resources Toolkit

Data-Driven Justice Initiative

The federal government recognizes the intersection of incarceration and health and has an interest in better understanding the social determinants of health. While the Justice Department does not systematically collect health data in inmate surveys or conduct annual surveys of inmates, many national health surveys are conducted with regular frequency. In March of 2016, the Department of Health and Human Services convened a steering committee on improving the collection of data on justice-system involvement in population health-data programs.

The major challenge in attempting to include justice-system involvement questions in health surveys is developing a consistent definition of such involvement. For example, in the annual National Survey of Drug Use and Health, criminal justice involvement is defined to include an arrest and booking at any time, but does not distinguish between individuals who were released shortly after booking — sometimes within a few hours — and individuals who were detained for longer periods of time and make up the population of individuals in a jail. Additionally, because the survey asks whether the respondent was ever arrested and booked, it does not reliably provide information on the most recent profile of the jail population.

Outside of the federal government, several academic studies have been completed to try to better understand the scope of the problem with various definitions and groups. One study from 2007 found that over two-thirds of individuals in jails met criteria for a lifetime psychiatric disorder. Another from 2009 estimated that the rate of serious mental illness (SMI) was 14.5 percent for males in jail and 31 percent for females. While these studies can give a more reliable estimate, they also are from several years ago and use various definitions of mental illness, making it difficult to extrapolate to today’s general population or to identify national trends.

As a result of the lack of national data, we often rely on other measures for identifying trends in the national jail population. For example, the Treatment Advocacy Center (TAC) conducts regular surveys of key stakeholders to help nail down some of the challenges.

In a 2011 survey of 230 sheriffs’ departments that operated jail facilities or detention centers in 39 states, three quarters of jails reported seeing more or far more numbers of seriously mentally ill inmates, compared to five to 10 years ago. This was particularly true in medium and large jails. More than half of the jails responding to TAC’s survey had implemented housing or staffing changes as a result of supervising seriously mentally ill inmates. This trend was more pronounced in larger jails, where 86 percent had made changes due to the prevalence of serious mental illnesses in the population.

What About Local Data?

One of the biggest challenges counties face when trying to develop or enhance a plan to reduce the number of people with mental illnesses in their jails is collecting, sharing and using data. Counties can use and share data on individuals who enter jail to effectively respond to a person’s needs. For planning and budgeting purposes, the effective use of data can help counties to understand who is in their jail and trends in the jail population, identify potential policy or practice changes and track progress of their reform efforts.

Counties face several challenges when trying to accurately collect and share this data:

Lack of a system-wide definition of mental illness. Each state has its own definition of mental illness that is used to determine eligibility for state-funded treatment and services, and in many counties —but not all — the county health department uses this definition to determine service-delivery options. Health providers in the jail may use their own definition or use a definition based on screening tools used to identify a mental illness. Without one agreed-upon definition, it can be difficult for counties to accurately identify and share information on the mental health needs of individuals who come into the jail.

Inability to identify individuals with mental illnesses and collect and store information. While mental health screening and assessment tools are becoming more prevalent, many counties still do not have a system in place to objectively identify a person with a mental illness or substance use disorder in their jail. Screening and assessment processes vary from county to county, with some using validated mental health screening tools and others relying on other indicators of mental illness such as medication or suicidal tendencies.

The way that counties collect and store information gleaned from these tools also varies. Some counties have sophisticated electronic jail management systems in place to help collect and store — and sometimes share — information about the individuals in their jail, including their mental health status. Other counties do not have access to this type of tool and struggle with how to collect information in a way that can be easily accessed, analyzed or shared. Even when systems are in place, they do not always have the capacity to maintain confidential mental health records in compliance with HIPAA.

No mechanisms for information sharing. Many counties struggle with developing confidential and useful mechanisms for sharing information about the individuals they supervise in jails or serve in the community. Concerns over HIPAA regulations and privacy often stall attempts to share information between different agencies. Nonintegrated electronic systems and the lack of common definitions also do not help these efforts. If two data systems cannot talk to each other, some analyses must be conducted manually, with redacted names and identifying information — the time required to process this information by hand can be prohibitive.

While many counties are making progress on using data to identify individuals with mental illness in their justice systems, not all counties are at a place where they can perform these functions. Many are without some of the tools they need to create comprehensive, data-driven and systems-level plans to reduce mental illness in their jails, or to be competitive for state and federal grant opportunities to help further their work in this area.

Despite progress in individual jurisdictions, there still isn’t an answer to the question on everyone’s minds: Are all activities and efforts happening at the county, state and federal levels having the desired impact of reducing the number of people with mental illnesses in jails? Leadership on and investment in the use of data is absolutely critical to answering this important question.

Making progress is data collection

The Familiar Faces initiative in King County, Wash., is a systems coordination effort for individuals who are frequently in jail and who also have a mental illness and/or substance use disorder. As part of this initiative, three distinct King County departments, the City of Seattle and other housing and social service partners broke down their traditional data silos to share information and performed a data-matching exercise to create a more comprehensive picture of the individuals they were trying to serve with the initiative.

An initial data-matching effort demonstrated that 94 percent of individuals in the King County jail had a mental illness or substance use disorder. The initiative partners are currently working on a cross-sector data integration project that will allow the integration of various disparate data systems, including behavioral health, housing and some criminal justice information. The integrated data system will allow for the following functions: enabling individual client “lookup” for direct care coordination, identifying high risk groups for system-level care coordination and extracting datasets for analysis of population health, program evaluation and costs.

Louisville-Jefferson County Metro, Ky., developed a cadre of community partners to share information and pursue innovative solutions to identify, coordinate and deliver care to individuals who frequently use public services. This collaboration, known as the Dual Diagnosis Cross Functional Team (DDCFT), is composed of government agencies, behavioral health professionals and community organizations serving people with mental illnesses and substance use disorders.

Knowing the service delivery system they were using was fragmented, the DDCFT proposed the creation of a new Community Care Management Network (CCMN) to coordinate care for these individuals using the existing Homeless Management Information System (HMIS) as the technology platform for cross-agency intervention. Many of the involved service providers already had HMIS licenses, making it a logical choice, and agencies that were not part of the HMIS network agreed to purchase licenses.

As part of the project, participating agencies, including the HMIS network and the Metro Criminal Justice Commission, acting as the representative for the DDCFT, entered into a data-sharing agreement. Based this agreement, the names of the top 100 people with eight or more episodes of incarceration are cross-referenced with emergency room data to identify individuals with 10 or more admissions.

These individuals are then asked to sign a release of information that authorizes the disclosure of records to agencies involved in the delivery of community-based services. These agencies include providers of mental health, substance abuse, medical, homelessness and vocational services in addition to criminal justice partners. A “case manager quarterback” is then designated to oversee service delivery and development of a coordinated care plan for addressing the specific needs of the individual.

In Coconino County, Ariz., the Criminal Justice Coordinating Council (CJCC) reached an agreement with the Arizona Criminal Justice Information System (CJIS) to get the criminal history of every person arrested in their county, which the county uses, along with data from the jail, health department, education system and their budgeting department, to initiate research partnerships. The CJCC is working with Northern Arizona University to use the available data to look at the effectiveness of health and behavioral health interventions in the jail.

These data mean that the county will be able to address questions like, “How well does mental health court work?” with the ultimate goal of building a model for how to most effectively treat and fund the health and behavioral health needs of individuals in the jail.

In Athens-Clarke County, Ga., Advantage Behavioral Health Systems (“Advantage”), the 10-county regional community behavioral health provider, worked with the Clarke County Sheriff’s Office on a data-matching project for people with mental illnesses in the jail. Staff at Advantage reviewed jail intake data over a three-month period and used names and dates of birth to match individuals to their electronic health record. This allowed them to identify individuals with a mental health diagnosis who were being admitted to the jail.

HIPAA regulations prohibit the community provider from sharing this individual data with the jail, but the jail is free to share names and dates of birth with the provider, putting the onus on the provider to do this analysis.

Advantage found that around 700 individuals in the jail (38 percent of the records reviewed) were their clients, meaning they had some sort of mental health diagnosis. From there, they were able to review the criminal history records of a random sampling of these individuals to better understand when they were being arrested, their average length of stay per arrest and specific charges.

They are using this data to have conversations with law enforcement and probation to identify potential solutions to high arrest rates and high probation revocations for people with mental illnesses in the county and are planning to implement a case management system that can be accessed by the jail to share more of this information.

Washington, D.C., uses administrative records to identify frequent users of public crisis systems such as emergency departments, homeless shelters and jails. The D.C. Department of Corrections (DOC) and The Community Partnership for the Prevention of Homelessness (TCP), the agency that houses the city’s homeless management information system, have a data-sharing agreement that allows them to identify individuals who meet certain criteria for eligibility in the D.C. Frequent Users Service Enhancement (FUSE) program. Upon receiving a request for potential clients, DOC staff generates a list of individuals who meet the FUSE eligibility criteria and are currently incarcerated in the jail. During the program planning phase and initial six months of program implementation, five administrative searches of frequent users were conducted, which identified 196 eligible men.