Cost of Care: Counties, sheriffs struggle to treat inmates' mental health
Feb. 10--EDITOR'S NOTE -- This is part two of a three-part series on community mental health care and funding.
On a nearly daily basis, the Ottawa County Sheriff's Office responds to individuals having mental health crises. When someone with a mental illness ends up in jail, it can be a struggle to provide the proper care to treat the root cause of their run-in with police.
As Ottawa County Community Mental Health continues to struggle to maintain enough funding, its ability to serve inmates that need mental health care is an ongoing battle.
The scope of the issue
When asked by The Sentinel what the most pressing public safety issues in West Michigan were, Allegan and Ottawa county sheriffs named mental health care as a top priority.
Ottawa County Sheriff Steve Kempker said a lack of available mental health care is a two-pronged problem. Kempker said his deputies are interacting with many mentally ill people while on patrol, with little formal training about how to handle those situations.
Equally as concerning to Kempker and Allegan County Sheriff Frank Baker though, is what kind of care a mentally ill inmate receives if they end up in jail.
"When somebody doesn't have access to the care they need, they end up finding themselves in the criminal justice system," Baker said. "We know that the jail isn't the best place for them, but it is a place for them. You're trying to make the situation safe, but we know that people need mental health care."
The Ottawa County Jail has space to hold 462 inmates at a time, admitting 6,365 individuals for the year of 2016. According to the national nonprofit Treatment Advocacy Center, which aims to eliminate barriers to mental health care, approximately 16 percent of incarcerated Michiganders are severely mentally ill. Just for the Ottawa County Jail, that statistic would mean the jail admitted 1,018 severely mentally ill individuals over the course of 2016.
To attend to inmates suffering from mental illness, Ottawa County CMH has teamed up with the sheriff's office to evaluate, treat and recommend services to incarcerated individuals. Currently, Ottawa County CMH has one full-time crisis team member and one part-time team member evaluating all the inmates. For eight hours a month, an Ottawa County CMH nurse practitioner visits the jail and prescribes medication to inmates. According to Kempker, that's not enough manpower to handle the number of mentally ill people in the jail.
"You take a trainload of people and you're running it down the tracks. You know the bridge is out ahead, and the best thing to do is stop the train," Kempker said of the growing mental health crisis. "But what's happening right now is that the train is going off the bridge and falling down into the gully. We as law enforcement are at the bottom, picking up the pieces and trying to fix it.
"The bridge needs to be repaired."
An ongoing cycle
If a person is jailed for a minor crime, they might end up serving a sentence of a few days to a few weeks. Depending on the severity of their mental illness, that may not be enough time to be seen by an Ottawa County CMH professional.
While the jail and Ottawa County CMH have worked with other community partners to create alternatives like mental health treatment court and diversion programs to keep mentally ill people out of jails, there are still inmates that need care while in custody.
"Years ago, dealing with a mental health person, they were normally arrested, brought to the jail, and they became the jail's issue," Kempker said. "There are times when they'd be in jail, bond out and go right back into society. It starts a cycle, and they come back to jail.
Once an inmate is booked at the jail, they fill out some basic information that includes questions about their mental health. If an inmate scores at or above a certain threshold, the full-time Ottawa County CMH employee stationed at the jail performs a crisis assessment. This is the same process Ottawa County CMH does if someone ends up in a hospital for a severe mental health disorder or an attempted suicide.
"It's a historic problem that people end up in jail because of their mental illness," said Michele VanderSchel, Ottawa County CMH adult services program supervisor. "Really, their primary issue is mental illness, they're not criminally inclined."
Along with psychiatric evaluations, the two Ottawa County CMH employees stationed at the jail also handle court-ordered offender assessment referrals and substance abuse services.
Due to the lack of resources Ottawa County CMH can devote to the jail, psychiatric services have to be prioritized for the most severely mentally ill. If someone has a minor or moderate mental health issue, they may not be able to be evaluated before they leave the jail.
"We will identify that we want to do some follow-up (with someone), but we might go back four days later, and they're gone or we have 20 people to see," VanderSchel said. "Right now, it's who's in crisis today, who needs to see the nurse right now. It's hard sometimes to break that kind of cycle."
Kempker's concern is once a mentally ill person leaves the jail and re-enters the community without any treatment, the person can become a public safety concern or could harm one of his deputies during a future crisis.
"CMH is so backed up, they don't have the opportunity to see that (inmate)," Kempker said. "That person then gets out and has now left without contact or help. There's an issue there."
Not enough beds
If it is determined an inmate is in the midst of a mental health crisis that requires immediate inpatient or residential care, Ottawa County CMH works to find a bed at a hospital or other care provider. These crises could include suicidal thoughts, overt psychosis, or other severe mental illness that could cause danger to others.
But finding a bed for anyone having a mental health crisis is no easy task. Across the state and country, there is a lack of available beds for people that need psychiatric medical care.
In Ottawa County, the only public location with adult psychiatric care beds registered with the Michigan Department of Health and Human Services is Holland Hospital. In Allegan County, there are no such registered beds. Private residential crisis service centers like Pine Rest Christian Mental Health Services and Forest View Psychiatric Hospital in Grand Rapids try to fill the gap, but there aren't enough beds for the number of patients that need them.
Sometimes, VanderSchel's staff will have to make 30-40 calls for Ottawa County CMH to find a bed in Michigan for a patient. It's common for a patient to travel across the state to get to an available inpatient bed.
Because an inmate has to be in a locked inpatient facility, Ottawa County Jail inmates are only able to go to Holland Hospital, which has 16 psychiatric beds, Pine Rest or Forest View. The cost for an inmate to be housed in such a facility can be up to $1,000 per day. If there are no available beds for an inmate, a sheriff's deputy has to drive the individual elsewhere in the state to an available bed, taking the deputy away from their policing area and costing the county additional resources.
Statewide, there are 1,824 registered public hospital psychiatric beds as of March 2017. The Treatment Advocacy Center's recommendation is for states to provide 50 such beds per 100,000 residents. To meet that ratio for Michigan's 9.9 million residents, the state would need to have 4,964 beds available, a 172 percent increase from the current numbers. Ottawa County alone would need to have 140 beds, rather than its current 16.
Not enough beds CMH
Once a person is booked as an inmate, their private insurance, Medicare or Medicaid can no longer be billed, meaning any mental health care an inmate receives while in custody is paid for using the county's general fund.
While Ottawa County voters approved a mental health funding millage in 2016, that money did not go into the general fund. Money from the millage does pay for the nurse practitioner to visit the jail for the eight hours a month, and partially pays for the salary for the part-time crisis team member, but the millage did not address the lack of funding for inmate treatment.
"We used to be able to have the psychiatrist come out to the jail on a weekly basis and give prescriptions and then we had to stop that when the funding started to diminish," VanderSchel said. "The millage helps fill the gap, but it's not unlimited resources."
Most West Michigan lakeshore counties are facing significant cuts to their mental health budgets due to decreasing Medicaid funding. Seven counties are coordinated by the Lakeshore Regional Entity, which experienced a $23 million funding decrease after many Medicaid patients switched to the new "Healthy Michigan" Medicaid expansion. The Healthy Michigan plan does not put as much money into mental health funding as the previous Medicaid model.
Despite the regional issue, there are still some inmate care structures around the lakeshore that would be improvements to Ottawa County's current level of care, VanderSchel said. If she had the budget, she would model jail services after Kent County's program that includes therapy, medications and discharge planning for inmates. Right now, Ottawa County CMH simply doesn't have the money to fund that level of staffing or resources.
Kempker said Ottawa County officials are aware of the severity of Ottawa County CMH's funding needs, but much of Ottawa County CMH's budget comes from state and federal programming.
"The county made it clear that there's concern about funding," Kempker said. "I think it's important that the state really start looking at the whole mental health system. I really commend the community here that voted for the mental health millage. It helped, but it was a Band-Aid and it's starting to fall off."
One of VanderSchel's goals for 2018 is to apply for and receive more grants earmarked specifically for jail services, but most of the grants currently available are for people struggling with opiate addiction.
"We have a lot of ideal-world ideas, we just need ideal-world funding to get it done," VanderSchel said.
-- Follow this reporter on Twitter @SentinelAudra.