HD5 - Evaluation of Inmate Mental Health Care

  • Published: 1994
  • Author: Joint Legislative Audit and Review Commission
  • Enabling Authority: Appropriation Act - Item 15 (Regular Session, 1992)

Executive Summary:
The U. S. Supreme Court determined in the 1970s that inmates have a Constitutional right to mental health treatment but the Court has not provided direction on what constitutes adequate treatment. Therefore, the level and quality of mental health care must be determined by treatment professionals within the corrections system.

JLARC staff estimate that the Virginia Department of Corrections(DOC)expended almost $4.9 million in FY 1993 to fund mental health treatment. The department employs 76.5 classified employees, 15 contract employees, and two temporary employees to provide mental health treatment in the institutions. One staff member within the central office is dedicated to mental health treatment and serves in an advisory capacity to the institutional staff.

DOC provides three levels of mental health treatment. Acute care for male inmates who are severely mentally ill and present a danger to self or others is provided at Marion Correctional Treatment Center. Acute care for female inmates is provided by the Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) at Central State Hospital. Sheltered care units at five facilities provide treatment and housing for inmates who are so mentally ill that they cannot function in the general population. Outpatient treatment is provided at 15 facilities for inmates who need periodic mental health treatment but are able to function within the general inmate population.

There are two major findings of this report. First, the department has not fully developed a system of comprehensive mental health care. Several problems with mental health service delivery appear to result from the lack of such a system. Second, the department has not developed adequate cost-control mechanisms, in part because it lacks data on the costs of the mental health services it is providing. The department, which is planning to add new mental health staffing and beds during FY1994, could also utilize its existing resources in a more cost-effective manner. While the new resources the department is adding should help it improve its mental health services, it is also important that DOC implement cost-control mechanisms and operate more efficiently, in order to use its existing and new staff to their full potential.

DOC Lacks System for Mental Health Treatment

The department has made a significant commitment to the provision of acute mental health treatment for male inmates and provides quality mental health treatment at Marion. However, problems exist in the provision of sheltered care and outpatient treatment. The department has not provided a sufficient oversight role in guiding the development of the mental health programs at the facilities and identifying and correcting problems.

DOC Needs to Improve Treatment Provision in Sheltered Care Units. The department needs to address identified deficiencies in treatment planning, treatment implementation, and record-keeping in sheltered care units (see figure, top of page iii). Individualized treatment plans, defined therapeutic interventions, and well-documented records are seen by mental health treatment professionals as necessary to help ensure quality treatment.

Individual written treatment plans document mental health staff recommendations for planned treatment interventions, and are used to monitor an inmate's progress during treatment. Written treatment plans are not prepared in three of the five sheltered care units. In the two units in which plans are prepared, the plans are too general to be used effectively in planning or monitoring treatment.

Treatment is usually provided in group settings, since this is the most cost-effective approach to dealing with the mental health problems of most inmates. However, two of the five units do not provide group therapy, relying instead on individual one-on-one therapy. None of the units providing group therapy have developed goals and objectives for the groups. Only one unit, Staunton's sheltered care unit, has developed outlines to describe issues which will be addressed in the groups.

Department operating procedures direct that an inmate's mental health files are to be included within the inmate's medical files. However, there are no department procedures which standardize the information which is to be included in mental health files. Including one unit which does not maintain mental health files, the quality of the mental health information is inadequate in four of the five sheltered care units.

Recommendation. DOC should formalize its expectations regarding the need for and content of written, individual treatment plans. These treatment plans should include at a minimum: the active problems of the inmate, specific objectives and plans for treatment, and the expected behavioral results of the treatment.

Recommendation. DOC should direct mental health staff at Powhatan and Mecklenburg to develop groups to be used in the treatment of mentally ill inmates in the sheltered care unit.

Recommendation. DOC should direct mental health staff at each sheltered care unit to develop written program descriptions for all groups provided. In addition, DOC should direct mental health staff at each sheltered care unit to develop written contracts to be distributed to all inmates housed in the sheltered care units.

Recommendation. DOC should require that organized mental health files be maintained for each inmate by standardizing the contents of the files and the format to be utilized. Further, DOC should standardize the procedures for taking progress notes by providing directions on what the notes should include and the frequency that notations are to be made.

Recommendation. DOC should develop policies to ensure that copies of treatment plans, mental health histories, progress notes, and screening forms accompany inmates when they are transferred out of sheltered care units.

DOC Should Conduct Quality Assurance Reviews. Currently, DOC does not conduct quality assurance reviews of mental health treatment programs. Through effective quality assurance reviews, many of the problems addressed in this report could have been identified and addressed by the department.

Recommendation. DOC should ensure that a quality assurance or continual quality improvement program for mental health treatment is established. The program that is instituted should focus on the quality, appropriateness, and scope of the treatment provided.

DOC Needs to Provide Acute Care for Female Inmates. Access to acute care for female inmates is limited since women requiring acute care must be committed to central State Hospital. Mental health staff indicated that some women needing this care are not receiving it. In response to this problem, DOC mental health staff have proposed a plan to house and treat acutely mentally ill women at Marion Correctional Treatment Center, the licensed psychiatric hospital operated by DOC to provide male inmates acute care.

Recommendation. DOC should proceed with the mental health staffs plan to provide acute mental health treatment to women at the Marion Correctional Treatment Center.

DOC Should Address Security Issues in the Sheltered Care Units. Correctional officers working in mental health units must be able to relate to inmates in these units as mental health patients while maintaining a secure facility. Several of the units reported problems with the correctional officers assigned to the sheltered care units. Mental health staff in these units had no input into the correctional officers assigned to the units and indicated that many of the officers were not helpful in establishing the secure therapeutic environment necessary to provide treatment in a correctional setting.

Inmates in the sheltered care unit at Powhatan Correctional Center were locked in their cells for 20 hours per day and three correctional officers had to be present when mental health staff were conducting treatment in the cells. These procedures resulted in inmates receiving limited access to mental health treatment.

Recommendation. DOC should develop written policy to ensure that mental health staff have input into correctional officer assignments to the mental health unit for all shifts. In addition, the department should ensure that all correctional officers working in mental health units have attended the Mental Health Basic Skills program.

Recommendation. DOC should ensure that the warden, or the assistant warden for programs, at Powhatan Correctional Center meet with mental health staff in the sheltered care unit to discuss appropriate policies regarding the amount of time inmates in the sheltered care unit spend in their cells and the number of security officers required to escort the inmates when out of their cells.

DOC Should Use Mental Health Expertise Available at DMHMRSAS To Improve Quality of Care. When DOC assumed responsibility for mental health treatment of inmates in 1984, a plan was prepared to direct the transfer of responsibility from DMHMRSAS to DOC. The plan outlines a continuing role for DMHMRSAS staff in the mental health treatment of inmates. Expertise available at DMHMRSAS should further help DOC improve the quality of its mental health treatment through the Interdepartmental Mental Health Advisory Committee. Important functions the committee was to have conducted, as outlined in the original plan, have not been completed or accomplished. These functions include establishing standards for mental health services, developing mechanisms for quality assurance reviews, and assisting in mental health program services design and development. In addition, DOC needs to pursue DMHMRSAS licensure of its five sheltered care units. Licensure would provide DOC an additional mechanism to improve the quality of treatment.

Recommendation. DOC should work with DMHMRSAS to begin the licensure process for the mental health units operated by DOC. DOC should establish a timeline and planning process whereby all DOC mental health units are licensed within five years or by 1998.

Recommendation. The Department of Corrections should reconvene the interdepartmental Mental Health Advisory Committee.

DOC Lacks Adequate Mechanisms to Ensure Cost-Effectiveness

The department is not currently utilizing its resources in the most cost-effective manner. Given the pending increase in mental health staff and beds, it is especially important that the department take action to ensure that existing resources are used to their full potential and additional resources are used effectively. There are four cost control or cost-effectiveness issues that DOC needs to address, including the utilization of beds, the use of psychologists to perform routine administrative duties, the lack of a distinct mental health budget, and the need to monitor costs at Greensville.

DOC Does Not Utilize Costly Mental Health Beds Efficiently. Inefficient use of costly sheltered and acute care beds is due in large part to the current practice of requiring mental health staff at the major institutions to arrange all transfers out of sheltered and acute care beds. This limits the amount of time mental health staff spend on treatment provision and causes delays in the transfer of inmates, clinically ready for discharge, out of sheltered and acute care units. Therefore, inmates no longer requiring these services are remaining in costly treatment beds longer than necessary.

Recommendation. DOC should address the problems with delays in the transfer process by centralizing the responsibilities within the central classification board. Written policy should instruct mental health staff to notify the designated contact person at CCB when a bed will be opening or when a bed is needed.

Psychologists Providing Outpatient Treatment Are Not Used Cost-Effectively. Many psychologists providing outpatient services spend large amounts of time on administrative duties such as filing and scheduling appointments. Consequently, there is limited time being spent providing mental health treatment. These administrative duties could be more efficiently performed by existing, lower-paid clerical staff.

Recommendation. DOC should examine the administrative duties being conducted by mental health staff to determine if all these duties are necessary. If so, the department should take steps to provide access to clerical staff from within the institutions, which would provide mental health staff more time to provide treatment.

DOC Should Examine Cost-Effectiveness of Mental Health Treatment. There is no separate distinct budget for mental health treatment within the Department of Corrections. Mental health staff are therefore limited in their understanding of the cost of mental health services and the reasons for the increase or decrease in those costs.

DOC should isolate the costs of the various types of healthcare by establishing individual "cost centers" dedicated to each type of inmate health care. Subsequently, DOC would be able to identify and control mental health treatment costs, take system-wide cost containment actions, and conduct and use cost comparisons to monitor cost effectiveness of the various units. Further, the Department should conduct analyses comparing the cost of renovating existing DMHMRSAS facilities to the cost of new construction as standard aspects of planning for capital expansion.

Recommendation. DOC should establish cost centers which differentiate mental health treatment expenditures from dental and medical expenditures.

Recommendation. The mental health program director should review mental health cost data at least quarterly. The cost data should be used in evaluating alternative means of providing mental health treatment and in making and justifying budgetary decisions.

Recommendation. DOC should ensure that the analysis of mental health cost data is used to the fullest extent possible in identifying efficient and inefficient mental health units.

Recommendation. DOC should ensure that cost-effectiveness is the basis for deciding whether to employ mental health staff as classified, salaried employees or on a contract basis.

Recommendation. DOC should conduct a cost analysis which compares the costs of renovating the existing DMHMRSAS structures to the cost of new construction. The information from this cost analysis should be included with all capital outlay requests presented to the Senate Finance and House Appropriations Committees.

DOC Should Increase Its Monitoring of the Sheltered Care Unit at Greensville. The Department of Corrections contracts with Correctional Medical Services, a private corporation, to provide mental health treatment at Greensville. As discussed previously, this review identified problems with the quality of treatment provided at Greensville. Further, comparison of the cost of the Greensville sheltered care unit to the acute care facility at Marion indicated that Greensville's care is more costly than might be expected. Therefore, DOC should thoroughly review both the costs and quality of the treatment provided under the contract with Correctional Medical Systems.

Recommendation. DOC should thoroughly review the cost effectiveness of the current contract with Correctional Medical Systems for mental health services.