Alabama Mental Health Suit, Expert Report, 2002
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ALABAMA DEPARTMENT OF CORRECTIONS IMPROVEMENTS IN MENTAL HEALTH SERVICES FOR INMATES December 12, 2003 When the Alabama Department of Corrections (ADOC) was under litigation from 1992 to 2000 regarding the provision of mental health services, there was concern that the mental health delivery system was less than adequate in addressing the needs of the inmates. Since 2000, the ADOC has demonstrated a total commitment to developing a quality mental health system. The progress the ADOC has achieved in three years is remarkable. Wardens, security supervisors, correctional officers, and inmates alike have acknowledged that the improved mental health system has reduced disruptions in the institutions previously experienced due to mental health crises. The need for suicide watches has dramatically decreased and administrative segregation units are calmer placements. The increased collaboration between security and treatment staffs has been a welcomed development. While the Bradley v. Haley lawsuit and the agreement that resolved the litigation applied only to male inmates, the Laube v. Haley case, initiated in 2002, addresses mental health services for female inmates. Consideration has been given to resolving the female inmate mental health issues using the standards and criteria of the Bradley Settlement Agreement. During the first six months of 2000, the ADOC and Southern Poverty Law Center brought in experts to review the services provided inmates with serious mental illness. Expert reports were written and depositions were conducted in preparation for a trial. In August of 2000, the ADOC and Southern Poverty agreed to resolve the issues through a settlement agreement. On August 8, 2000, two mental health experts hired by Southern Poverty Law Center and the psychiatric expert hired by the ADOC finalized the Bradley v. Haley Agreement of Experts. This document defined critical aspects of mental health care; established standards for mental heath services; established the various levels of mental health services required; established mental health staffing ratios; proposed options for the development of mental health units at various institutions; determined the mental health policies and procedures for development and implementation; and established requirements for correctional officer training in mental health issues. The Agreement of Experts established a blueprint for the development of the ADOC mental health delivery system. On September 28, 2000, the Bradley Settlement Agreement was signed. The Agreement of Experts became central to the agreement by establishing the standards and requirements of an acceptable mental health system. The agreement established deadlines for completion of specific tasks and established a consultant/oversight function. Jane Haddad, Psy.D., a former expert in the case for Southern Poverty Law Center, was identified to provide Page 2 technical assistance to the ADOC in achieving the required changes, review the mental health services at each institution, and review quarterly data related to the provision of mental health services. Based on these activities, Dr. Haddad was to submit a report to the Court in June of 2003 indicating the level of compliance the ADOC had achieved with the settlement agreement. Since the Bradley Settlement Agreement has been initiated, two amendments have been added. The first extended the agreement and deadlines for completion of specific tasks by three months to accommodate a delay in the change in contractors for the ADOC medical and mental health services. The second amendment in August of 2003 extended the Bradley Settlement Agreement until December 31, 2004. The ADOC requested this extension due to delays in the construction and implementation of a new mental health facility. At this time, the ADOC is expected to achieve compliance with the Bradley Settlement Agreement before December 31, 2004. Improvements During the Consultant Phase: During the first year of the Bradley Settlement Agreement, the mental health contractor, Mental Health Management (MHM), focused on recruitment to substantially increase the mental health staff. Prior to the agreement, less than 30 mental health professionals provided services for inmates with serious mental illness within a system of 20,000. The settlement agreement required an increase to 103 mental health staff. Specifics regarding the increased staffing will be discussed in the section: Staff Resources for Mental Health Services. The initial focus for the ADOC in addressing the settlement agreement was determining where mental health units would be located and what renovations would be required to accommodate the changes. Numerous tours and discussions ensued between the consultant, the ADOC Central Office staff, and the Wardens of various institutions. To ensure that all stakeholders had a common understanding of the issues, the wardens, deputy wardens, security supervisors, and current mental health staff at institutions where mental health units were to be located participated in a two-day workshop covering the principles and expectations of the Bradley Settlement Agreement. These sessions were critical in achieving consensus about the goals of the effort and in addressing the many questions about the “cultural shift” that needed to occur. At the same time as decisions were being made about the location of the mental health units, the consultant and the ADOC Director of Treatment collaborated in the development of mental health polices and procedures that were consistent with Bradley standards and the standards of the National Commission on Correctional Health Care (NCCHC). Accreditation by NCCHC was not a requirement of the settlement agreement, but compliance with NCCHC standards was mandated. After the completion of 35 mental health policies and procedures and the forms required to implement the procedures, drafts of the documents were submitted to all wardens and mental health staff for comment. When the policies and procedures were finalized, the ADOC made the Page 3 forward thinking decision to establish the policies and procedures as ADOC administrative regulations. All institutions are required to comply with the system-wide guidelines and are not permitted to adopt institution-specific procedures that are inconsistent with the administrative regulations. Also, if the ADOC mental health contractor should change, the requirements of the administrative regulations remain. The ADOC now has its own mental health delivery system, policies and procedures, and forms. Any contractor for mental health services will be required to implement the established system. The new administrative regulations addressed prior practices that had been repeatedly challenged. Inmates are no longer permitted to remain nude or sleep on a black mat for extended periods of time as part of suicide precautions. “Safe” crisis cells, suicide resistant tunics and blankets, beds raised from the floor, and transfer to a mental health unit if an inmate has not stabilized within 72 hours are now standard practice. Inmate transfers for mental health reasons receive priority and are based on clinical decisions of the mental health staff, rather than determinations by security and/or administrative staff. When an inmate with a serious mental illness receives a disciplinary report, consult with the mental health staff is required prior to the disciplinary hearing. Also, during the first year of the agreement, required training programs were developed. Each correctional officer participates in six hours of training related to mental health issues. In particular, issues related to the treatment and management of inmates with serious mental illness are part of the ADOC Basic Training. A two-day Specialized Mental Health Training was developed for the more intensive training of mental health, medical, and security staffs assigned to mental health units, segregation units, and infirmaries where crisis cells are located. Finally, the mental health component was developed for the annual Advanced Training required for all ADOC staff. This four to six hour training has been revised and enhanced each year to ensure that the training provides pragmatic, job-specific information that the staff can appreciate and use. According to reports by the inmates and correctional officers, the mental health training has had a positive impact. Officers now have the skills to identify and refer emerging mental health problems to the mental health staff. In 2001, the consultant provided the two-day Specialized Mental Health Training for all ADOC wardens, deputy wardens, and security supervisors. Similar to the training provided to the wardens and other administrative staff of the institutions housing mental health units, the training of management and supervisory staff at all institutions provided an opportunity for consensus building and for addressing the many questions related to the expansion of mental health services. The final project embarked upon during the first year of the Bradley Settlement Agreement was the “coding” of each inmate according to potential mental health needs. Inmates with serious mental illness, as defined in the Agreement of Experts, are coded SMI; inmates with a history of expressive violence, as defined by NCCHC, toward Page 4 themselves or other are coded HARM; inmates with a history of mental health treatment but no longer requiring services are coded HIST; and inmates with no identified mental health problems are coded NONE. Initiating mental health coding at the ADOC reception center was a relatively easy task. However, coding more than 20,000 inmates already in the system was a major challenge. Coding of these inmates was completed through interview and record review. As of September 30, 2003, 98% of all inmates have been coded. The majority of inmates not coded were still in the reception process. The coding has facilitated the identification of inmates with mental health issues during intra-system transfers and/or when assigned to segregation. Physical Resources for Mental Health Services: Prior to the Bradley Settlement Agreement, the ADOC had 18 single cells at Kilby Correctional Facility, which served as the intensive mental health treatment unit for male inmates. The mental health unit had a very small nursing station and no treatment area other than the day room. The ADOC also had one mental health dormitory of 20 beds at Kilby Correctional Facility, 24 single cells at Donaldson Correctional Facility, and dormitories with a total of 200 beds at Bullock Correctional Facility for inmates requiring long-term treatment for serious mental illness. None of the institutions had adequate treatment areas nor mental health office space. The Kilby mental health unit did not have adequate beds to address acute episodes of mental illness, particularly since admission to the state hospital, Taylor Hardin, was significantly delayed except for inmates at “end of sentence.” Inmates no longer requiring treatment for acute conditions, but requiring single cell placement were often maintained on the Kilby mental health unit because there were no long-term mental health single cells other than the 24 cells at Donaldson. The ADOC demonstrated a significant commitment to expanding mental health unit capacity. All of the cells on the mental health unit at Kilby were renovated to create “safe” cells. A nursing station, treatment room, and additional office space were developed. The 20-bed dormitory for long-term care at Kilby was closed, since the potential to develop adequate treatment space was limited. The most significant improvement in physical resources has been the opening of three mental health units at Donaldson in November of 2001. These units provide 48 single cells and 40 cells in which one or two inmates may be housed. While the majority of the Donaldson cells are designated for long-term mental health care, 12 cells have been designated as “infirmary” cells for the treatment of acute episodes of mental illness. The ADOC has made numerous renovations to the Donldson units to ensure their appropriateness for mental health treatment. A nursing station and treatment rooms were provided on two of the units. The units were air conditioned to address the risk to inmates prescribed psychotropic medications during times and seasons of extreme heat. Three mental health offices were constructed in the health care unit for mental health staff and a room near the three mental health units was renovated for a medication room. Finally, a Page 5 new Programs Building was constructed to provide treatment rooms and adequate office space for mental health staff. Donaldson is currently in the process of fencing a courtyard area to ensure that inmates assigned to the mental health units have adequate access to outdoor recreation. While the Bradley Agreement required renovations at Bullock Correctional Facility to increase treatment and office space for the large mental health dormitories, ADOC chose to build a new mental health facility at Bullock. Currently, the Bullock mental health unit is under construction with occupancy expected during the first quarter of 2004. The unit was designed to provide 200 dormitory beds, “state of the art” treatment areas, sufficient offices for mental health staff, and a 30-cell mental health unit for the intensive treatment of inmates experiencing acute episodes of mental illness. When the Bullock intensive stabilization unit is operational, the mental health unit at Kilby will no longer be required to operate in such a capacity. While the renovation and construction of mental health units received priority, other ADOC male institutions also required physical modifications to ensure adequate treatment and office space for outpatient services. All crisis cells in the system were required to comply with standards established by ADOC for “safe” cells. Providing additional treatment and office space within the very over-crowded ADOC system was a major challenge. As of September 30, 2003, adequate space has been established at all but two institutions. The mental health offices have computer lines that are linked with the ADOC tracking system to facilitate mental health staff access to information. While all mental health programs have at least one computer, the ADOC has committed to significantly increasing the number of computers during 2004. Staff Resources for Mental Health Services: As previously noted, less than 30 mental health staff provided services to male inmates with serious mental illness prior to the Bradley Agreement. Less than three psychiatrists had been available for the psychiatric follow-up on all 20,000 ADOC inmates. The Bradley Agreement required staffing of 103 mental health staff to include 11 psychiatrists of which 3 could be nurse practitioners and 24-hour nursing coverage for the mental health units that provided intensive mental health treatment. The Bradley staffing levels do not include the ADOC psychology staff. The ADOC psychology staff, who are state employees, conduct reception evaluation, conduct ADOC workshops, and provide follow-up for inmates who do not have a serious mental illness. The mental health administrative regulations define the specific responsibilities of the ADOC psychology staff and the contractor’s mental health staff. While interface between the two staffs initially experienced some difficulties, collaborative and supportive relationships have developed during the last three years. Recruiting for 70 new mental health staff positions was challenging, particularly for psychiatric and mental health nurse positions. As expected, there was also a great deal of Page 6 turnover in new staff as some learned that correctional mental health care was not for them. Fortunately, mental health staffing has now stabilized. As of September 30, 2003, 98% of the psychiatric hours were provided; 106% of the licensed psychologist hours were provided; 100% of the mental health professional hours were provided; 2 of the 3 supervising mental health nurse positions were filled; 99% of the mental health nursing hours were provided; 73% of the activities technician hours were provided; and 120% on the mental health clerk hours were provided. The new contract for mental health services that became effective November 3, 2003, increased mental health staffing levels at a few institutions based on increasing needs. All mental health staff are required to attend Specialized Mental Health Training. Typically, mental health staff complete this requirement within two months of being hired. Mental health nurses are required to complete an additional five days of jobspecific training and activities technicians are required to complete an additional eight days of job-specific training that includes practice in conducting psychoeducational groups. While there was a significant delay in developing the modules for the jobspecific training, excellent training modules were developed by September of 2003. All presently employed mental health nurses and activities technicians have participated in the required training. Outcomes of the Improved ADOC Mental Health System for Male Inmates: While increases in the mental health physical plant and staff resources were essential to improve ADOC mental health services, outcomes are the best indication of improvements. The current mental health delivery system reflects the following: 1 Inmates received by ADOC are screened for mental health issues immediately upon arrival. 2 Inmates receive an initial psychiatric evaluation within five days of admission to the ADOC if there is a history of mental health treatment or the inmate was prescribed a psychotropic medication. Inmates receive an immediate psychiatric evaluation if the screening nurse judges that such is clinically indicated based on the inmate’s history and/or presentation. 3 Inmates are coded to reflect their potential need for mental health treatment and mental health codes are considered in placement and disciplinary decisions. 4 Inmates requiring crisis intervention are placed in “safe” cells and receive daily mental health follow-up. If a crisis has not resolved within 72 hours, the inmate is considered for transfer to a mental health unit. 5 Inmates placed in segregation units receive cell-to-cell rounds weekly to ensure access to mental health services in addition to the twice a week segregation rounds conducted by the ADOC psychology staff. 6 The availability of psychotropic medication has improved. Nursing staff monitor medication compliance and ensure the provision of laboratory testing required by the use of some psychotropic medications. 7 Inmates with serious mental illness who are maintained with outpatient services are seen by mental health professionals monthly and by a psychiatrist or nurse Page 7 8 9 10 11 practitioner no less than every 90 days. Intensive psychiatric stabilization treatment includes daily psychiatric follow-up and 24-hour nursing coverage. Inmates who require long-term treatment and support for chronic mental illness receive services in adequately staffed Residential Treatment Units. The opening of Residential Treatment Units at Donaldson for inmates requiring single cell placement has been praiseworthy. The improvements in the functioning of the inmates and the opportunities afforded them, while on the unit, have been dramatic. Training of correctional officers has increased their sensitivity to mental health issues and appreciation for the role of treatment staff in institutional operations. Mental health staff have developed an effective quality improvement program that identifies and addresses system-wide and institutional-specific areas for improvement. It would be misleading to assert that the “outcomes” listed above are consistently achieved. Changes in mental health staff can compromise services and some institutions have developed more consistent services than others, however, overall compliance has been acceptable. Challenges Remaining for ADOC Mental Health Services for Male Inmates: While full implementation of the Bullock Correctional Facility program was the major reason for the extension of the Bradley Agreement, the additional time will allow for the following developments: 1 Individualized treatment plans can be consistently developed and reviewed by a multidisciplinary team. Previously, limited psychiatric coverage at some institutions providing outpatient services resulted in the psychiatrist signing the treatment plan without participating in the planning process. 2 Refinement of the inmate mental health codes by a multidisciplinary treatment team to ensure the accuracy of the codes. 3 Increased security coverage on mental health units permiting full implementation of treatment and programming services. The impact of the number of correctional officer vacancies at the various ADOC institutions was markedly increased by the number of correctional officers called to active duty with the armed forces. 4 Completion of remaining renovations for outpatient mental health office space and crisis cells. 5 Provision for an adequate number of computers for mental health staff. 6 Ensuring that the most appropriate psychotropic medication has been prescribed. The previous lack of a pharmacy report on psychotropic medications precluded an accurate assessment of prescribing practices. Previous reviews of psychotropic medications suggested a reliance on older anti-psychotic medications, particularly decanoate medications. 7 Ensuring that documentation of mental health services consistently reflects continuity of care. While the mental health documentation has improved during Page 8 the last two years, there is always room for improvements in documentation. Challenges Remaining for ADOC Mental Health Services for Female Inmates: As previously noted, the Bradley Settlement Agreement applies only to male inmates, however, since implementation of the agreement, the ADOC has attempted to include Tutwiler, the female institution, into the Bradley mandates. The mental health/treatment administrative regulations apply to all ADOC inmates. Female inmates receive mental health codes and staff attempt to provide services consistent with the administrative regulations. Improved services for female inmates appeared compromised by inadequate mental health staffing; the lack of adequate mental health office space; and the lack of physical plant resources for intensive and long-term mental health services. Recently, mental health staffing for Tutwiler was significantly increased and adequate mental health staff offices were provided. The provision of mental health services for female inmates should improve once the new mental health staff develops an efficient service delivery system and the ADOC determines how appropriate housing for intensive and long-term mental health treatment will be met. Conclusion: It has been a privilege to provide consulting and oversight for the Bradley Settlement Agreement since October of 2000. The improvements in mental health services have been impressive. Even in an environment of scarce resources and limited funding, positive changes have been observed in the functioning of individual inmates as well as the treatment opportunities offered throughout the ADOC system. These positive changes are attributed to the support of the previous Commissioner, Michael Haley, and the current Commissioner, Donal Campbell. Commissioner Campbell has been steadfast in ensuring that all ADOC and contracted staffs understand that the provision of appropriate mental health care is a priority. Finally, the “hands-on” support by Greg Lovelace, Deputy Commissioner of Operations, and Dr. Ronald Cavanaugh, Director of Treatment, have been essential in effecting the necessary changes. The appreciation of the wardens and security supervisors for the positive impact of improved mental health services on institutional management should facilitate the maintenance of the mental health delivery system long after compliance with the Bradley Settlement Agreement is achieved. Jane Haddad, PsyD ADOC Mental Health Contract Monitor