Editor’s note: This is the second part of a two-part series exploring the intersection of mental health and the criminal justice system. To see part one, go to www.fremonttribune.com.
Lieutenant Kurt Bottorff of the Fremont Police Department says that a growing number of the department’s calls deal with situations where he believes mental health plays a role—incidents ranging from drug use to violent situations.
“What we’re seeing out there is a lot of stress on the community, times are hard for certain people — the stress builds up and that’s where some mental health breakdowns can take place,” Bottorff said. “Their behavior ends up being a law violation and they’re sometimes jailed because of it instead of addressing the core problem.”
With the help of Lutheran Family Services, the Fremont Police Department has recently attempted to take aim at the problem, by becoming one of only two departments in the entire state of Nebraska to hire a crisis response co-responder—a licensed mental health practitioner who works directly in the police department two days per week, responding to 911 calls alongside officers when she believes mental health may be playing a role.
The pilot program, which started in July and is funded by a two-year grant from the Behavioral Health Support Foundation, aims to help keep those struggling with mental health issues out of the criminal justice system or involuntary hospital stays, and to connect them with resources in the community.
Law enforcement had already had access to Lutheran Family Services’ mobile crisis response teams that could provide similar action—but it required law enforcement to independently identify the need and make the call. And even then, the nearest services usually came from Omaha, which created a 40-minute lag time. Now, mental health practitioner Rachel Wesely can respond at her own discretion instantaneously, from within the department, and can follow up with callers after law enforcement leaves.
As concern mounts about a growing number of mentally ill individuals entering the criminal justice system and winding up in county jails, local stakeholders are taking a more focused approach to line those individuals up with more appropriate services.
But according to area officials, health providers and attorneys interviewed by the Tribune, challenges still persist. Some say a shortage in psychiatric providers, support services like transportation and challenges in affordability leave those struggling with mental illness without the resources they need to lead stable lives.
“There’s a need for access to treatment in jails and when individuals are incarcerated, it’s not getting filled,” Wesely said. “Sometimes when people are released back out into the community, they don’t have the supports in place, it kind of becomes a revolving door sometimes.”
Mental health care in Nebraska saw significant changes in 2004, with the passage of a mental health reform bill known as LB1083. The bill aimed to reduce the use of inpatient psychiatric services at the state’s three Regional Centers in Lincoln, Norfolk and Hastings, and invest more in outpatient and community-based services that could help those struggling with mental health in their own communities.
More than 200 beds were eliminated between the Hastings Regional Center, which now only holds juveniles, and the Norfolk Regional Centers, which now holds sex offenders. The state shifted more than $30 million in funding to community-based mental health services.
The reduction of inpatient beds was consistent with nationwide efforts to move away from institutionalizing the mentally ill and instead treat them in their communities. But those interviewed by the Tribune say that the infrastructure for community care was slow to materialize and still struggles to meet the need, especially for those who may be in need of more intensive care.
“There hasn’t been enough,” said Hylean McGreevy, a licensed mental health practitioner and alcohol and drug counselor at Methodist Fremont Health’s Behavioral Outpatient Services. “There’s a lot of people who aren’t even leaving their homes to get the services that they need because they’re just homebound because of their anxiety—they’re not functioning well and they fall through the cracks.”
Many are concerned that the criminal justice system—particularly at the jail level—is increasingly forced to warehouse those whose actions manifest in law violations.
According to numbers provided to the Tribune by the Nebraska Jail Standards Board, of 1,225 individuals discharged from the Regional Centers in a four-year period following mental health reform, nearly 500, or around 40 percent, ended up in the county jail system at least once. About six percent ended up in the prison system.
Linda Witmuss, deputy director of the DHHS Division of Behavioral Health, acknowledged that the system faces some challenges, particularly in workforce, rates and stigma. There also needs to be a “richer review of data” to better determine how the state’s finite resources should be allotted to best meet the need, Witmuss said.
But she argues that mental health reform has led to more services at the community level.
“There’s always room for more services—don’t get me wrong there,” she said. “All of our rehab options, services, including expansion of medication management that came about as a result of all of that reform. So there’s a lot more services that are out there as a result of reform.”
Most of the state is experiencing a shortage in mental health and psychiatric providers, according to the DHHS’ Office of Rural Health, including parts of Dodge, Washington and Saunders Counties.
The Fremont area benefits from a respectable number of behavioral health and substance abuse services, such as therapists and counselors. But there is a need for more medication prescribers and med management services—psychiatrists and advanced practice registered nurses. Over at Methodist Fremont Health, which offers those services, there’s growing demand, McGreevy said, and more providers could help improve access.
“The thing is that we’re a specialty clinic, and with specialists, there’s really rarely a same-day appointment,” McGreevy said. “The patient may have to wait and it could be up to a month to two months before they can be seen as a new patient.”
Medication and services can also be expensive. Many lack insurance to help cover costs, though some programs offer sliding fee scales, which can adjust payments based on income and family size. In recent years, copays and deductibles have become more expensive even for those who have insurance, providers say.
Additionally, treating mental illness is more complicated than treating physical ailments, and ensuring compliance to treatment plans poses challenges, providers say. Psychiatric treatment requires significant “trial-and-error” to find the right medications, doses and strategies. That means lots of time spent taking medications that may ultimately need to be adjusted or changed, and that may carry unpleasant side effects that deter compliance.
It’s a process that requires patience and follow-up. And ensuring that patients comply with their treatment plans, remain stable or avoid self-medicating with illicit drugs and alcohol is a challenge that’s only exacerbated by barriers like access and affordability.
“Let’s just use a hypothetical,” said Dodge County Attorney Oliver Glass. “I can’t afford my medication, my medication makes me feel strange anyway, but I do know that when I self-medicate with street drugs or alcohol, that’s going to make me feel better at least. And that’s when, at least in my experience here, that’s when a lot of crimes are committed.”
There’s also a need for more support services, like peer support services or family support workers—professionals who can follow up with patients to help them follow through on their treatment plans and keep them connected to resources after they leave the doctor’s office.
With a large number of resources concentrated in Omaha and a lack of resources in rural areas, transportation can also pose challenges.
“We have no public transportation here,” said Fremont attorney Pamela Hopkins, who is running for Dodge County Attorney. “Many of these people are unable to drive, for one reason or another, whether it’s because they use alcohol as a substitute for their treatment and they lost their licenses because of that, or they’re too poor to have a car. They’ve got to depend on the kindness of strangers.”
For individuals going through the criminal justice system, those barriers can create added consequences. Following through on treatment can help defendants prove to judges that they are are serious about addressing their problems.
“I personally have taken two clients down to a treatment center in downtown Omaha because they had absolutely no way of getting there,” said Fremont-based attorney Leta Fornoff.
Additionally, with the reduced usage of the Regional Centers, some see a need for more inpatient beds for individuals in crisis. Others argue that space could be cleared up with more “step-down” services, like housing or follow up services that need to be lined up before a person leaves the hospital.
“What gets the system backed up is the discharge process,” said Vicki Maca, the director of criminal justice and behavioral health initiatives with Behavioral Health Care Region 6. “Is there a provider that’s willing to take that person who’s ready to leave the hospital?”
Hospitals that provide inpatient stays, like Methodist Fremont Health, which has a 20-bed inpatient unit that serves Fremont and surrounding areas, as well as CHI Immanuel Hospital and Lasting Hope in Omaha, provide inpatient stays, often between three to five days, and often limited by however long an insurance company will authorize payments. Some argue it’s not long enough for those in the throes of a severe mental health crisis.
“They need some consistency, they need some time to be redirected, get used to their medication,” said Captain Rob Bellamy, who is in charge of Washington County Corrections.
The Regional Center has some space available to the regions for more intensive care. It houses individuals who have been ordered by a court to receive a competency evaluation or restoration, as well as individuals committed by a local mental health board. The latter process only occurs if an individual in crisis refuses to be voluntarily committed and is put under an emergency protective custody. But wait times to get into the often crowded Regional Center have gone up, officials say.
Witmuss said that the state is looking into the need to increase capacity, but cautioned that opening new beds alone wouldn’t solve the problem.
“We have a lot of complex cases,” she said. “When you can’t discharge folks, then you can’t admit folks, either.”
Mental health programs and services are funded through Medicaid as well as the state’s behavioral healthcare regional system. Providers contract with one of the six regions, which then funnels funding from DHHS’ Division of Behavioral Health, federal block grants and county-level matching funds.
But grants and pilot programs, like the Lutheran Family Services’ co-responder program, are only guaranteed for fixed periods of time. Agencies and organizations are always shifting their appropriations to keep up with where the demand is highest, which can lead to changes in program availability. The Spring Center in Omaha, for instance, used to provide short-term residential treatment like rehab for substance abuse, which providers like McGreevy say is lacking, but was ultimately closed after funding shifted to the creation of Lasting Hope, an acute inpatient facility in Omaha, to create more inpatient beds.
“That’s what happens,” McGreevy said. “Money gets redistributed. We needed Lasting Hope—that’s for sure. But we just didn’t have enough money to keep both of them going.”
Meanwhile, at the local level, stakeholders are giving new focus to the issue. Providers are exploring more innovative solutions to staff shortages, such as Telehealth, which would allow for remote counseling or med management.
Last year, Behavioral Health Care Region 6, which encompasses Douglas, Dodge, Cass, Washington and Sarpy Counties, hired Vicki Maca as a full-time employee, dedicated to trying to keep mentally ill individuals out of the criminal justice system.
That hiring decision was spurred on by a nationwide initiative between the National Association of County Officials, the American Psychiatric Association and the Council of State Governments known as the Stepping Up Initiative. The initiative is a data-driven effort to reduce the number of people with serious mental illness booked into jail, shorten their average length of stay, increase the connection to care for those individuals in jail and reduce rates of recidivism.
While other behavioral health care regions are engaging with the Stepping Up Initiative, Region 6 is the only one that’s hired a full-time employee devoted to the topic.
Maca has toured both the Saunders County jail, where Dodge County inmates are held, as well as the Washington County jail to begin discussing future steps and needs. Among the greatest needs there, Maca said, is re-entry planning services, which are available in the state prison system and in larger jails like Douglas County. Those services would help line inmates up with services prior to their release: vocational training, housing, proper identification, treatment, counseling or more. That could help reduce recidivism, Maca said.
But at this point, Stepping Up Initiative efforts have progressed further in the more populous Douglas and Sarpy Counties. Work there has centered on better defining and gathering data that can help track the issue and gathering local stakeholders to identify areas where the mentally ill are most susceptible to entering the justice system, and to outline priorities and needs.
Sarpy has said its biggest priorities are a “crisis stabilization center” and transportation. In Douglas, the highest priority was to increase use of mobile crisis response units and co-responders, like Wesely at the Fremont Police Department.
For Wesely, the co-responder at the Fremont Police Department, law enforcement’s enthusiasm and willingness to cooperate with the co-responder model has led to success, she said.
Bottorff sees the success, too.
“What I’m seeing now is a reduced calls for service for the same problem,” he added. “There are times when we get so bombarded with the same situation—they didn’t have the tools to fix their problem.”