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How the Stepping Up initiative is combatting the mental healthcare crisis in jails

Millions of times each year, people who have mental illnesses are booked into jails


The high number of people with serious mental illnesses in jails is a public health crisis.

AP Photo/Timothy D. Easley


By Allen Houston, Council of State Governments Justice Center

Editor’s note: When it comes to inmate healthcare, correctional facilities are facing a perfect storm. A growth in geriatric inmates poses significant challenges in regard to management of chronic diseases and environmental modifications; drug-addicted inmates are flooding correctional facilities; and in many jurisdictions, jails and prisons are now the largest providers of mental healthcare services. This special coverage series reviews key ways facilities can prepare to battle the storm.

Between 2013 and 2015, the Douglas County Jail population increased by 69 percent. No one was certain why.

“It was a mystery,” said Mike Brouwer, reentry director of the Douglas County, Kansas, Sheriff’s Office. “We had a community meeting to discuss what was happening and lots of people who attended couldn’t believe that we didn’t have the data to explain why the jail population grew so significantly.”

Home to the University of Kansas, Douglas County has a population of 120,000, with the majority residing in Lawrence, the county’s largest city.

A regional psychiatric hospital had cut its number of beds in half at the same time the jail population went up, said Brouwer; there was a sense among the public that the two events must be correlated.

“Without evidence, there was no way for us to verify whether that was true or not,” he said.

The sheriff’s office was surprised at the suggestion that people with mental illnesses might be the driving factor in the jail growth, said Brouwer. They considered themselves ahead of the curve in responding to this population. Douglas County hired its first mental health staff in 2002 and added a mental health reentry case manager in 2011.

To get to the root of the jail population uptick, Douglas County officials began compiling what little data they had. At the same this was occurring, two other things happened that proved to be catalysts for stronger data collection and improved responses to people with mental illnesses.

First, the county was awarded a 2015 Justice and Mental Health Collaboration Program (JMHCP) grant from the U.S. Department of Justice’s Bureau of Justice Assistance to implement mental health screening and assessment and hire two full-time clinicians.

The second was that Douglas County joined the Stepping Up initiative.

A Solution to the Problem

Any law enforcement official or behavioral health specialist will tell you that the high number of people with serious mental illnesses in jails is a public health crisis. In many counties, jails serve as the largest provider of mental healthcare.

National data also present a bleak picture. Millions of times each year, people who have mental illnesses are booked into jails. The percentage of people in jails who have mental illnesses is as much as six times higher than that of the general public, and their lengths of stay can be two or three times longer than people who don’t have mental illnesses. And, once they’re released, many of these individuals are caught in a revolving door between the criminal justice system, hospital emergency rooms and homelessness.

That’s why three years ago The Council of State Governments (CSG) Justice Center, the National Association of Counties and the American Psychiatric Association Foundation started the Stepping Up initiative with the goal of mobilizing counties to reduce the prevalence of people in jail who have mental illnesses.

Stepping Up counties first focus on building strong local collaborations between criminal justice and behavioral health leaders and obtaining public commitments from policymakers and agency leaders. Counties then turn to the Six Questions framework, a blueprint that lays out how counties can take stock of where they are and begin to implement change (blueprint available at end of this article). On May 1, 2018, the Stepping Up initiative launched a national push to increase the number of communities that effectively collect and track accurate data on the number of people with mental illnesses in their jails. As part of the data push, Stepping Up created a self-assessment tool that provides a baseline against which to measure progress over time and thereby positions counties to engage in data-driven decision making.

Since its launch, more than 450 counties in 43 states, including Douglas County, have pledged to take part in the initiative. Statewide Stepping Up projects have also launched in Ohio and Pennsylvania.

Even with increased awareness of this crisis, counties face tremendous hurdles to collecting the needed data, lacking validated screening tools, staff to track the data, and countywide processes to maintain the data and share it across agencies.

The Way Forward

Collecting accurate data isn’t easy, but leaders in Champaign County, Illinois – with a population of 209,000 that includes the cities of Champaign and Urbana as well as several rural communities – didn’t let that stop them.

“We were having capacity issues in jail and we began to examine if there was a way to reduce unnecessary bookings, like looking at the number of people with mental illnesses in our jail,” said Bruce Barnard, Champaign County’s JMHCP project director. Champaign County applied for a JMHCP grant, around the same time as Douglas County did, to help them better understand the prevalence of mental illness among people coming into their jail. County leaders also expressed their commitment by joining Stepping Up in 2015.

As they analyzed the numbers behind the jail capacity problem, the group discovered that they were lacking data to show how many people with serious mental illnesses (SMI) were coming into the jail on any given day.

“Everyone was using their own SMI definitions and it was hard to make sense of what the data meant,” Barnard said.

Since joining Stepping Up, both Douglas and Champaign counties have implemented mental health screenings in jail to get beyond guesswork and make more informed decisions about the strategies needed to have a measurable impact on the number of people with mental illnesses in their jails. Both counties were also named Stepping Up Innovator Counties for their recent efforts to accurately identify people with SMI and collect related data.

In Champaign County, people who are screened and flagged for mental illnesses or substance addictions are now referred to a community-based behavioral healthcare agent embedded in the jail. In the future, Champaign County leaders hope to implement a co-responder unit, which would pair a law enforcement official and behavioral health specialist on mental health-related calls for service.

“You collect data to understand what’s happening in your system,” Barnard said. “By expanding the data that we collect and sharing it with the right people, we can identify people with mental illnesses in the system, connect them to the services that they need and ensure they are attending follow-up sessions.”

Back in Douglas County, local officials have created a Criminal Justice Coordinating Council and hired a criminal justice coordinator and a data analyst. The county also announced the launch of an intensive project with the CSG Justice Center to reduce the prevalence of mental illness in the county jail. The results of that effort will be used to inform further local changes in 2019. This November, residents of Douglas County also approved funds for a behavioral health campus that will contain, among other things, crisis, sobering and detox beds, as well as 10 apartments for people who require longer-term behavioral health care.

By collecting and examining available data, the Douglas County sheriff’s office was also able to determine that the increase in their jail population was actually driven by an upsurge in the number of felonies in the jurisdiction, along with an increase in the number of substance addiction-related cases.

“Stepping Up helped us kick off a conversation that is continuing to this day about the importance of collecting data and collaborating across organizations to improve outcomes for people with mental illnesses, as well as reduce their risk of coming back into the system,” said Brouwer.

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About the author
Allen Houston is a public affairs manager at The Council of State Governments Justice Center.

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