Odrc Mental Health Services, Sumary of Reports, 2006
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SUMMARY OF REPORTS ON MENTAL HEALTH SERVICES WITHIN THE OHIO DEPARTMENT OF REHABILITATION AND CORRECTION July 25, 2006 Prepared by CIIC Staff 2 Table of Contents Page Introduction ..……….….………………………………………………..……………….. 3 Summary of Reports on Mental Health Services in Ohio Prisons ……………………….. . Report 1: Mental Health Care for Ohio State Prisoners: The View from the Director’s Office …………………………………………………………. Renaissance Organizational Structure………………………………………………… Table. Residential Treatment Units with Beds, Security Level and Institutions Served……………………………………………… Table. Population, Caseload, Percent in Segregation…………………… Mental Health Staffing………………………………………………….. Administration………………………………………………………….. Quality Assurance Community Reintegration Conclusion Report 2: Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S. 1194) …………………………………………………………………… Save Lives Increase Public Safety Reduce Spending…………………………………………………… Building on Ohio’s Successes 3 4 5 7 8 9 10 11 12 Report 3: Systems in Transition ……………………………………………………… 13 Reform Through Litigation The Problem of Funding Mental Health Services in Prison……….. 14 Report 4: Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio 15 Background, Expert Team, and the Report Report Acceptance……………………………………………………… 17 Negotiating the Consent Decree Consent Decree………………………………………………………….. 18 Monitoring Process Recommendations……………………………………………………….. 19 Continuity………………………………………………………………… 20 Organizational and Governmental Issues Clarity of Roles Transition Appendix A: Monthly Average Institutional Population (Jan - May 2006) ………………. 23 Appendix B: Institutional Population on Psychiatric Caseload (Jan – May 2006) ….……. 24 Appendix C: Institutional Population on Mental Health Caseload (Jan – May 2006)……...25 Appendix D: Mental Health Caseload in Segregation (Jan – May 2006)…………...……...26 3 Summary of Reports on Mental Health Services within the Ohio Department of Rehabilitation and Correction Introduction The concept of mental health services in a correctional system includes a matrix of individuals, policies, operations, procedures, programs, philosophies, and goals directed toward serving the mental health needs of incarcerated offenders while fulfilling the missions of the departments engaged in the work of corrections, mental health, and justice. This paper looks at mental health services within Ohio’s prison system. The paper provides summaries of four previously published reports on mental health services provided to inmates in Ohio’s correctional system. The four individual reports help create a chronological history of events, conditions, and responses contributing to the evolution and current status of mental health services in Ohio’s prison system. Summary of Reports on Mental Health Services in Ohio Prisons: History of Events and Evolution of Mental Health Services Four individually authored reports provided a base from which to consider the delivery of mental health services. These reports provide a portrayal of the evolution of mental health services within the correctional setting in Ohio. A summary of each report is provided in the following sections so as to help construct an understanding of the past and a snapshot of the current state of operations. Upon reading the four summaries, some duplication of important information will be noticed. Rather than dilute the substantive content of any of the reports, this paper includes the key points from each, even though minimal repetition is created as a byproduct of the comprehensive inclusion of information. The authorship of the four reports was provided by the former Director of the Ohio Department of Rehabilitation and Correction, the court appointed monitor in Dunn v Voinovich, a former Deputy Director of Mental Health Services in Ohio, and an organization known as Human Rights Watch, which conducts research and investigations, and publishes reports relevant to human rights issues, including issues inside prisons within the United States. The purpose of this paper is not to analyze or make recommendations; rather, it is the intent of this paper to provide an overview of these four reports in one document. The accuracy in the historical account found in these four reports is perceived to be trustworthy and therefore, worthy of inclusion in any consideration or future development of systems designed to serve individuals who are mentally ill and incarcerated. Further, statistical data collected by the Correctional Institution Inspection Committee has been inserted at appropriate places within the report narrative and as Appendices. 4 Report 1. Mental Health Care for Ohio State Prisoners: The View from the Director’s Office. Correctional Mental Health Report, January/February 2000. Wilkinson, Reginald A., Ed.D., Director. The report, Mental Health Care for Ohio State Prisoners: The View from the Director’s Office (2000), offers a historical description and chronology of events at a time when the services to the incarcerated mentally ill were undergoing some evolution. For clarity, many of the headings in the summary of Report 1 are taken from that report. As reported in Mental Health Care for Ohio State Prisoners, the long history in addressing mental illness in prisons and the goal of providing holistic health services became compromised by budget limitations during a time when security issues became a commanding priority. State appropriations for mental health services, while not ignored, were insufficient to keep pace with a growing number of incarcerants with serious mental illnesses. Renaissance. The Ohio Department of Rehabilitation and Correction (ODRC) experienced two events that gave rise to a renaissance in prison mental health care: a prison riot at the Southern Ohio Correctional Facility in 1993 in which nine inmates and one employee were killed, and the Dunn v Voinovich lawsuit in October 1993 that resulted in a five-year decree as a means of addressing the constitutionally inadequate care for prisoners with serious mental illness in Ohio. The goal of the decree was to achieve organizational change and decision-making autonomy in the area of mental health services in Ohio’s prison operations. Following Dunn v Voinovich, mental health care responsibilities for inmates, which had been the responsibility of the Ohio Department of Mental Health (ODMH), became the responsibility of the ODRC. Under ODRC authority, the state’s hospital for mentally ill prisoners, Oakwood Forensic Center (formerly for the criminally insane), was recommissioned as the Oakwood Correctional Facility (OCF). There was agency commitment to creating the best possible correctional mental health system as it was acknowledged that good mental health was also good security for the inmates and for the community. In addition, the federal court made the treatment of the seriously mentally ill a constitutional requirement. In Ohio, the court appointed a monitor, Fred Cohen, who identified in his fourth annual report (Dunn Consent Decree Monitoring Fourth Annual Report, 1999), at the conclusion of the five- year decree, that the Ohio system had indeed developed not only access to services, but also to refinement in the quality of care. Comprehensive Care. In identifying the critical nature of operating a comprehensive and sound correctional mental health service delivery system, ODRC Director Reginald Wilkinson offered the following points in Mental Health Care for Ohio State Prisoners (2000). 5 1. Judicial mandates require a quality system. 2. There is an ethical ‘right-thing-to-do’ mindset about providing such a system. 3. Seriously mentally ill inmates present a prodigious problem, representing nearly 12% of ODRC’s 47,000 inmates. 4. When mental health professionals work closely with security professionals it is possible to more accurately discern between behavior that is “mad” versus behavior that is “bad,” thus, enabling appropriate responses to the behavior. 5. With a mission of preventing mental deterioration and ameliorating mental health problems, prison administration and staff remain concerned with how the methods of operating a prison and managing inmates may help or hinder the realization of the mission. 6. There is a constitutional duty to protect ‘weak’ or vulnerable inmates from physical or mental assaults of stronger inmates. The duty to treat and duty to protect are considered dual obligations. 7. Screening and evaluations are essential to inmate-appropriate housing assignments, classification, job assignments, and individual treatment plans. Both physical and mental limitations are identified through screening and evaluations. 8. A holistic mental health service delivery program is important to the effectiveness of inmate treatments and to inmates’ inevitable transition back into the community. Transitioning occurs for 95% of all prisoners. Organizational Structure . The Ohio Department of Rehabilitation and Correction established an Office of Correctional Healthcare (OCHC) in 1995 in order to effectively achieve a holistic approach to correctional mental health care in Ohio. Under OCHC, prisoner mental health care, medical and substance abuse treatment, and care for the mentally retarded are provided. Within OCHC, the Bureau of Mental Health Services (BOMHS) is responsible for planning, implementing, monitoring, and evaluating the correctional mental health system and to provide oversight to day-to-day clinical care of all mentally ill inmates within the prisons. Funding for all mental health programs and for Oakwood Correctional Facility is provided through appropriated funds in the state’s operating budget. Appropriated funding is used for mental health care at Oakwood Correctional Facility and 11 “clusters” or catchment areas. Each of the state’s prisons falls into one of the clusters, and each of the 11 clusters has a Residential Treatment Unit (RTU) for appropriate mental health care and never for disciplinary purposes. As presented in Mental Health Care for Ohio State Prisoners (2000), RTUs offer care, treatment, and supervision on a graduated scale, with decreased supervision as the inmate’s mental disability improves or stabilizes. Within the RTU, an individualized treatment plan is developed for each inmate with the goal of returning the inmate to general population. In 2000, there were reportedly 730 inmates housed in RTUs, with an average population at Oakwood Correctional Facility of 95 inmates. Historically, the concept of a Residential Treatment Unit existed before the creation of the “clusters” per the Dunn case. It is the understanding of the Correctional Institution Inspection Committee that the Residential Treatment Unit that formerly existed at the 6 Mansfield Correctional Institution was closed post Dunn, reportedly as a cost cutting measure. However, the following clarification was provided by the ODRC: Historically, under the supervision of the ODMH there had been a Psychiatric Residential Unit (PRU) at CRC, which served the psychiatric residential treatment needs of all the institutions. Other step down type programs such as at CCI, were also under the supervision of the ODMH. The design of a Residential Treatment Unit serving a cluster of institutions was developed, but the number of inmates requiring that level of care was less than projected and the cluster plan evolved with more than one cluster feeding an RTU. By the end of Dunn, the system of comprehensive mental health care including outpatient services in all institutions was established and more inmates were maintained in the outpatient setting. The reduced number of inmates identified as requiring the more restrictive level of care of the RTU resulted in the closing of the RTU at Mansfield. Aside from information taken from Mental Health Care for Ohio State Prisoners (2000), communication from the Ohio Department of Rehabilitation and Correction’s Deputy Director of the Office of Health Care during 2004 indicated that inmates who need RTU services are transferred to an RTU of a similar security level when possible. Under this arrangement, minimum security or Level One inmates are included in the medium security or Level Two RTUs. If the RTU that normally accepts inmates from an institution is full, another RTU of the same security classification is used. As of October 8, 2004, it was the understanding of CIIC staff that RTU patients in the Ohio correctional system were served in institutions as shown in the following table. 7 Residential Treatment Units (RTU) – Distribution of Beds and Service Centers Ohio Department of Rehabilitation and Correction October 2004 INSTITUTION SECURITY LEVEL 2 AVAILABLE BEDS 80 Chillicothe Correctional Institution 2 150 Grafton Correctional Institution 2 73 Correctional Reception Center 3 106 Trumbull Correctional Institution Warren Correctional Institution Southern Ohio Correctional Facility Ohio Reformatory for Women 3 3 4 77 83 80 All security levels 74 Allen Correctional Institution INSTITUTIONS SERVED Madison CI (Level 1) London CI Dayton CI Montgomery CI Toledo CI Camp Belmont CI Hocking CF Noble CI Pickaway CI Southeastern CI Lake Erie CI Lorain CI North Coast CF Marion CI North Central CI Richland CI Madison CI Toledo CI Ross CI Correctional Medical Center (if medically stable) Pickaway CI Mansfield CI Lebanon CI (Also serves Level 5 inmates excluded from OSP due to mental illness) Franklin PRC Northeast PRC In addition, recent data made available to the Correctional Institution Inspection Committee from the Ohio Department of Rehabilitation and Correction’s Bureau of Mental Health reveals the following averages based on calendar year 2005 (January through December 2005). For the year, there was a monthly average of 43,565.5 total inmates in the Ohio system and 7,066 inmates or 16.2% of the average monthly population on the psychiatric caseload. Inmates receiving psychiatric treatment, and therefore on the psychiatric caseload, are those with classifications of C1, and C2 within the department. An additional monthly average of 942 inmates, classified as C3, did not receive psychiatric services and were not on the psychiatric caseload, but were still receiving diagnosis and therapies from the Mental Health Services. All categories together, for the 12- month period, there was a monthly average of 8,016 inmates, representing 18.4% of the total inmate population, receiving some form of services from Mental Health Services. The data for the period also reveals that of the total monthly average of 8,016 inmates receiving mental health services, a monthly average of 382.33 or 4.8% of those inmates were residing in segregation. The following table displays the full range of data reflecting the psychiatric caseload and segregation numbers for each adult institution as well as the statewide summarie s. 8 Ohio Department of Rehabilitation and Correction Statewide Mental Health Services Delivered – 2005 January February March April May June July August September October November December Annual TOTAL 43,578 43,567 43,518 43,845 43,928 44,174 44,218 44,339 44,682 44,903 41,679 40,355 Total Psychiatric Caseload (C1 + C2) 7,242 7,005 7,080 7,002 7,222 7,126 7,034 7,405 7,367 7,108 6,501 6,700 522,786 84,792 11,304 96,188 4,588 4.77 Monthly AVERAGE 43,566 7,066 942 8,016 382 4.77 Month Institutional Population C3 Total Caseload Inmates in Segregation 831 853 886 880 866 914 915 978 1,026 1,176 962 1,017 8,073 7,858 7,966 7,882 8,088 8,045 7,949 8,383 8,393 8,371 7,463 7,717 402 343 379 336 391 365 400 412 410 396 390 364 % of Caseload Inmates in Segregation 4.98 4.36 4.76 4.26 4.83 4.54 5.03 4.91 4.89 4.73 5.23 4.72 It is the understanding of the Correctional Institution Inspection Committee that mental health classifications are distinguished based on the presence of psychiatric care and the degree of significant mental illness. For example, an inmate classified as C1 is on the psychiatric caseload and has serious or severe mental illness or SMI. The criteria used to designate SMI includes a substantial disorder of thought or mood, which significantly impairs judgment, behavior, the capacity to recognize reality or cope with the ordinary demands of life within the prison environment, and has manifested by the presence of substantial pain or disability. An SMI designation requires a specific mental health diagnosis of schizophrenia, schizoaffective, etc. and/or functional assessment that required an RTU or inpatient hospitalization stay. According to follow-up communication from DRC staff, it does not require prognosis, appropriate treatment by the mental health staff, or psychiatric care. However, according to DRC policy 67-MNH11 on “Mental Health Classification,” C1 is defined as above, plus the policy states, “Serious mental illness requires a mental health diagnosis, prognosis and treatment, as appropriate, by mental health staff.” The policy effective April 21, 2005, fully defines and describes C1 as follows: C1: Psychiatric Caseload (SMI) – the inmate is on the psychiatric caseload and meets criteria for SMI designation: a substantial disorder of thought or mood which significantly impairs judgment, behavior, capacity to recognize reality or cope with the ordinary demands of life within the prison environment and which is manifested by substantial pain or disability. Serious mental illness requires a mental health diagnosis, prognosis and treatment, as appropriate, by mental health staff. 9 An inmate classified as C2 is on the psychiatric caseload, but does not meet the criteria for the most severe or deemed to have a serious/severe mental illness, thus is considered to be non-SMI. The C2 inmate receives mental health care and supportive services, which include the prescription and monitoring of medication, and can include the following based on identified treatment needs: individual and group counseling and therapy, crisis intervention, and behavior management. Last, an inmate classified as C3 receives no psychiatric treatment, but based on identified treatment needs can receive group or individual counseling, therapy, and skill building services. The C3 inmate has a mental health diagnosis and treatment plan and is treated by the mental health staff other than the psychiatrist. Further, as of this writing, the most recent data submitted to the Correctional Institution Inspection Committee from the individual adult institutions reveals the continuation of mental health services delivered to inmates for the five- month period January through May 2006. This data may be found in the tables in Appendices A through F of this Summary of Reports. As reported in Mental Health Care for Ohio State Prisoners (2000), one area that presents a challenge to service delivery is the sometimes-blurry distinction that must be made between behavior that is prompted by sickness or is willfully deviant in nature. An inmate’s mental condition is taken into account at disciplinary hearings as a way to determine their capacity to participate in the hearing and to construct a disposition consistent with the individual inmate’s security and treatment needs. Regarding cases where disciplinary action is warranted, Ohio State Penitentiary (OSP) functions as a “super-max” institution and is available as a disciplinary option. Per Ohio Department of Rehabilitation and Corrections policy, seriously mentally ill inmates are excluded from placement at the Ohio State Penitentiary, regardless of whether they have a security classification of level four or five. The report continues to address key issues associated with the delivery of services to mentally ill offenders. Among those topics of importance are mental health staffing, administration of services, quality assurance as it applies to the department’s need to meet the terms of the court ordered decree, and community reintegration of the exoffender who is returned to a community. Mental Health Staffing. Reportedly, diligent and continuous recruitment, competitive salaries, and time-consuming training are necessary for the Ohio Department of Rehabilitation and Correction to maintain professional mental health staff. In addition, specialized mental health training is provided for both mental health and non- mental health staff, such as corrections officers and clerical workers. Ongoing evaluations are conducted to assure that staff receive training that is appropriate to the specific work assignments. 10 Administration. The report relayed that administratively, the ODRC has instituted employee ‘quality’ teams to improve work processes, including those processes relevant to the delivery of quality mental health services. The staff teams were also responsible for compliance with the terms and conditions of the Dunn court order. The ODRC partnered with other organizations, such as the Ohio Department of Mental Health and community me ntal health agencies and boards, to augment delivery of services to offenders with mental disabilities. In order to aid maximum communication between the ODRC central office and personnel in the individual correctional institutions, regularly scheduled me etings for field administrative staff are held. The emphasis at these meetings was on the necessary correlation between good management and good clinical services. Quality Assurance. Reportedly, a temporary Quality Assurance (QA) Program was authorized in ODRC Policy 321-01 effective June 28, 1998, and a ODRC Quality Assurance Transition Team (QATT) had the duty of preparing the agency for selfmonitoring following the termination of the court-ordered decree so that quality improvements were continuous. In follow- up communication from DRC it was relayed that currently, the Department continues the self- monitoring/audits within the BOMHS through a process called mental health external reviews (MHERS) to ensure each mental health unit within the prison is in compliance with established policies and procedures. In the communication from DRC, it was further relayed that in addition, an integrated healthcare Quality Assurance/Quality Improvement program was authorized in the ODRC Policy 69-OCH-01, Quality Assurance in Correctional Healthcare effective 6-1804. The purpose of this policy is to implement the Quality Assurance Program and to facilitate the provision of high quality medical, mental health and recovery services care in a cost effective manner through a systematic approach of monitoring, evaluating and resolving health care issues. Community Reintegration. Intra-agency coordination was acknowledged as a necessary component for effective offender/parolee transitioning into the community. Within the Ohio Department of Rehabilitation and Correction (ODRC), the Division of Parole and Community Services (DP&CS) is responsible for the supervision of released offenders, including those with mental illness. The DP&CS operates the Offender Services Netwo rk (OSN), which continues to ensure offender access to appropriate community treatment services and mental health service providers. An inter-agency agreement was reached in 1997 between the Ohio Department of Rehabilitation and Correction and the Ohio Department of Mental Health such that 12 ODMH community linkage social workers assigned to the state prisons work with ODRC mental health staff to coordinate and link community mental health services to released prisoners. Conclusion. According to Mental Health Care for Ohio State Prisoners (2000), the numbers of individuals with mental illness or mental retardation who were entering the state prisons was increasing compared to those individuals who are entering mental hospitals. Therefore, the ODRC had to assume a role in the delivery of mental health services. At the heart of the issue, there continues to be a fundamental need for careful study directed at the process of prescribing the proper treatment in conjunction with the appropriate sanction for mentally ill offenders. 11 Report 2. Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S. 1194). Oral Testimony to The United States Senate Judiciary Committee; July 2003. Wilkinson, Reginald A., Ph.D. The Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S. 1194), was expected to help the Ohio Department of Rehabilitation and Correction implement programs and initiatives within the department into partnerships that would strengthen the delivery of services. The four components of the Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S. 1194) were believed to advance and benefit corrections and included: saving lives, increasing public safety, reducing state and local (county) government spending, and building on Ohio’s successes. In his testimony, the Director provided a brief history of Ohio’s operations in dealing with problems associated with the mentally ill inmate. Included in Dr. Wilkinson’s historical review were the 1993 riot at Southern Ohio Correctional Facility and the subsequent federal lawsuit, Dunn v Voinovich. The Dunn suit challenged the constitutionality of the Ohio Department of Rehabilitation and Correction’s mental health delivery system in Ohio. It was decided that rather than fight the suit, the money would be better spent in concentrating on a five-year consent decree. Thus, it was decided in 1995 to concentrate on improving Ohio’s mental health services for the mentally ill prisoner. Throughout the five-year consent decree period from 1995 through its settlement in 2000, all parties, including plaintiff’s counsel, the court monitor, the state attorney(s), correctional administrators, and health care professionals, agreed to manage points of contention privately. The Director relayed to the Judiciary Committee in 2003 that he was proud of the mental health delivery system in Ohio and that, in his opinion, it represented a national benchmark as it related to prison mental health care. Save Lives. According to the report, prisons and jails house more people with mental illnesses than do the country’s mental health institutions and therefore, correctional administrators are de facto mental health directors. The corrections community readily acknowledges that a correctional environment is not conducive to recovery for a person with mental health problems, especially those with a serious mental illness. Untreated mental illness may put an inmate at risk of committing suicide or being victimized by predatory inmates. There is, therefore, an obligation to one of the core missions in correctional institutions: to ensure safety and humane conditions for staff and inmates alike through the improvement of screening procedures and in training staff to make correct identifications of the signs for suicide. Increase Public Safety. Because most offenders, including those with mental illnesses, will be released to the community at some point, it is imperative to adequately prepare those individuals for release in a manner that they do not return to prison nor pose a threat to public safety. Recidivism among the released mentally ill offender is over 70%, as revealed in more than one study. There is a correlation between effective transition plans and inmate preparation and corresponding community safety. 12 Reportedly, S. 1194 promoted effective reentry planning for people with mental illness through efforts such as encouraging mental health providers to come into correctional facilities and connect with the offender prior to release and in ensuring that an adequate supply (more than merely a two weeks’ supply) of medications are provided to the inmate at release. In addition, under the bill, there must be planned follow-up services. Reduce Spending. Funds delegated to corrections have reportedly diminished nationally. Staff and operation budgets have experienced significant reductions. Capital budgets for building projects have also been reduced. According to the report on the Mentally Ill Offender Treatment and Crime Reduction Act of 2003 (S.B. 1194), correctional agencies must curb the rate of growth within the system to comply with state legislative and executive orders to cut costs. Per the report, the mentally ill remain in the prison system longer than other offenders and when they reenter the community, they do not have adequate community services to avail, so they frequently violate the law and are re-incarcerated. It is significantly more expensive to incarcerate the mentally ill offender than other offenders due to added costs for mental health services, medications, and additional staff. Pennsylvania, for example, estimates $80 per day for an average inmate, but $140 per day for a mentally ill inmate. A difficult burden rests with parole boards, which try to connect the parolee with community support. S. 1194 reportedly provides the tools to enable the Ohio Department of Rehabilitation and Correction to facilitate the design and implementation of risk assessment instruments, encouraging enrollment of exoffenders in federal benefit programs, and promoting aspects of programs that prove effective in reducing recidivism. Building on Ohio’s Successes. For departments of corrections to simply create and expand hospitals for the mentally ill within correctional institutions is not a viable or economically sound solution to addressing the needs of mentally ill offenders. There are both state and local barriers to overcome, but interagency collaboration between corrections and mental health agencies and community mental health service providers is the key to successful reentry. Reportedly, S. 1194 would help the Ohio Department of Rehabilitation and Correction translate fledgling initiatives into strong, sustainable partnerships that have a credible evidence base. Based on current information from the Ohio Department of Rehabilitation and Correction relevant to carrying out the programs and initiatives under S. 1194, the U.S. Department of Justice’s Office of Justice Programs’ Bureau of Justice Assistance announced in April 2006 that it was seeking applications to receive grants to fund programs under the Justice and Mental Health Collaboration Program. The Justice and Mental Health Collaboration Program operates at the federal level to further the Department of Justice’s mission by increasing public safety through innovative cross-system collaboration to reach and deliver programming to individuals with mental illness who also come into contact with the criminal or juvenile justice systems. Insomuch as the grant request for proposals (RFP) was released in April 2006 with an application deadline of June 2, 2006, the specific uses of the $5 million dollars that have been allocated for the grant are unknown at this writing. Reportedly, several county boards in Ohio intend to apply for the funding and if awarded, will use their awarded share of the five million total grant dollars to fund appropriate programs in Ohio. For example, the Franklin County Alcohol, Drug Addiction, and Mental Health Board reportedly was planning to apply for some of the grant money. 13 Report 3. Systems in Transition. Human Rights Watch: Ill Equipped: U. S. Prisons and Offenders with Mental Illness. <http://www.hrw.org/reports/2003/usa1003/6.htm> This researched piece establishes that there are two key forces for change in the corrections environment applicable to offenders with mental illness, and that these two forces often oppose each other. On the one hand, litigation has been used to induce reform of mental health services, and on the other hand, funding pressures and cutbacks have made implementation of reforms more difficult. A synopsis of these two dynamic forces, as reported in Systems in Transition, is presented in the following sections. Reform through Litigation. Litigation or the threat of it has reportedly become the prerequisite for systemic improvements in mental health services. Litigation has addressed the complete lack of mental health services and more recently, the need and development of improvements in existing systems. Ohio is among many states that have experienced class action suits and dealt with consent decrees and court orders instituting reforms and the court appointment of masters and monitors to oversee compliance. As reported in Systems in Transition, class action lawsuits have led to improvements in prison mental health care in many states, but progress to date is still far from enough. The following excerpt from Systems in Transition relays details of a lawsuit in Ohio that made a significant impact on the operational details associated with offenders with mental illness: In Ohio, for example, Dr. Reginald Wilkinson, the director of the Ohio Department of Rehabilitation and Correction, was confronted with a devastating expert assessment of Ohio’s mental health services developed after prisoners brought suit in 1993 claiming the services were so poor as to be unconstitutional. After receiving this assessment, Wilkinson engaged in a remarkable collaboration with correctional mental health experts, plaintiffs’ attorneys, and other stakeholders to develop the blueprint for a major overhaul of the state’s prison mental health services. The suit ended in a settlement without extensive adversarial proceedings, and the department has remained committed to providing quality mental health services. Within three years of the settlement, full-time equivalent staff providing psychiatric services increased from 61 to 284; the number of hospital beds had increased dramatically; and the percentage of prisoners on the psychiatric outpatient caseload had increased from 7.4 percent of the prison population to 12.2 percent. Systems in Transition makes a point of saying that successful litigation does not necessarily translate into actual improvement. There have been examples where directors of corrections accepted on-paper compliance with court decrees as a substitute for real, durable reforms. Simply, some correctional authorities have resisted putting reforms in place. This reluctance can stem from institutional inertia, bureaucratic obstacles, failure to understand the importance of adequate mental health services, or the lack of funding. The article provided examples from Texas, Iowa, and Rhode Island. 14 The Problem of Funding Mental Health Services in Prisons . The extra costs to provide adequate mental health services in prisons is an impediment to the delivery of those services. As reported in Systems in Transition and previously mentioned in this paper, Pennsylvania incurs costs of $80 per day to incarcerate the average prisoner, yet $140 per day to incarcerate inmates with mental illness. The additional expenses are incurred for medications, additional correctional and professional staff, and specific services that mentally ill inmates receive. Cost variables from state to state include decisions on quantity and quality of care provided and regional differences in salaries of mental health professionals. Budget cuts in Georgia, Florida, Michigan, Iowa, Massachusetts, and South Carolina have manifested in a variety of forms, including (a) reduced mental health professional staffing, (b) abandoning planned openings of new psychiatric units, (c) placing limitations/reductions on the use and type of psychotropic medications available to inmates, (d) reductions in intensive residential treatment programs by 25%–30%, (e) tightening criteria for outpatient eligibility, and (f) cuts in programs for the mentally ill. 15 Report 4. Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio. (JulyAugust 1997) Criminal Law Bulletin, Volume 33, Number 4, pp 299-327. Cohen, Fred and Aungst, Sharon. Report 4 provides details about the resolution of the class-action lawsuit, Dunn v Voinovich, in Ohio from the perspective of the court monitor of the decree and from the Deputy Director of Mental Health Services in Ohio at the time of the suit and resolution period. Fred Cohen, the monitor, and Sharon Aungst, the Deputy Director, worked collaboratively in a unique manner so as to redesign mental health services. Rather than follow a more typical adversarial relationship found in cases as this, the Ohio scenario modeled affirmative collaboration in the blending of law with organizational change. The remainder of this Summary of Reports is a presentation of the key material found in Report 4: Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio. The headings are the same as those in the report and the content reflects the writing of the monitor, Fred Cohen, and the Deputy Director, Sharon Aungst. The information represents, therefore, the thoughts and insights generated by these two individuals. Background, Expert Team, and the Report. The Dunn suit was based on allegations that the mental health delivery system was “deliberately indifferent” to a degree that there was violation of the Eighth Amendment to the U.S. Constitution. The case delved into the language of the law and included considerations of the showing of care. The suit held that care was delivered in a deficient manner that imposed needless suffering and deterioration judicially associated with cruel and unusual punishment. The suit began with the filing of a complaint on October 6, 1993 in which the plaintiffs did not seek monetary damages, but rather systemic, injunctive relief responsive to the allegations of systemic failure. Typically, during the deposition and discovery phase of a case, there are adversarial dynamics, which can produce numerous costs and consume large amounts of time. At this phase in the process, dispute resolution becomes operative. In the Dunn case, the discovery phase was held in a suspended state while a team of ‘experts,’ known as the Expert Team, on correctional mental health completed eight months of investigation. The Expert Team investigated the history of Ohio’s prisons, interviewed large numbers of employees and others with relevant information, and reviewed thousands of documents and records within Ohio’s correctional institutions. With an understanding of the traditional ‘military mindset’ and suspicion of outsiders that often exists among staff in prisons, the experts worked through the tension of the discovery phase. During the discovery phase, institutional staff experienced inevitable stress, yet staff dealt with media reports and inquiries, balanced fear associated with negative scrutiny, and still maintained hope that the situation would eventually improve. 16 The Expert Team’s findings were provided in a report that was to focus on factfinding, system adequacy, and recommendations for improvement as dictated by their findings. The Expert Team measured its findings in terms of “that which is minimally necessary to accomplish a particular objective or perform a given task.” Applying the “minimally adequate” standard, the Expert Team concluded that the defendants were deficient in three basic areas of legally mandated prison mental health care: appropriate personnel (including quantity and training), treatment/bed space (including hospital, crisis, and chronic care beds), and access to care (ability and means available to inmates to reach available staff and appropriate treatment). After deficiencies were found, solutions were proposed. In addition to deficiencies in the three legally mandated provisions named above, the following list displays eleven other basic findings, none of which were challenged by the plaintiffs or the defendants. 1. Inadequate intake screening. 2. Inadequate referral system. 3. Paucity of residential care and crisis beds and under use of beds at the Oakwood Correctional Facility, which was a facility designed specifically for the most severe cases of mental illness. 4. Shortage of clinical staff coupled with conservative decision-making such that there were obstacles created in gaining access to psychiatric care. 5. Psychiatric care that was limited to psychotropic drugs without adequate monitoring of medications and lithium blood levels. 6. Shortage of space for mental health providers and staff, which compromised safety, confidentiality, and appropriate care. 7. Lock-down tactics applied to some of the most severely mentally ill, affording them no care, no activities, no opportunities to walk, exercise, or breathe fresh air. 8. Absence of staff training, especially training of security staff in the signs and symptoms of mental illness, crippled access to mental health care due to the ignorance of staff assigned to deal with inmates most frequently on a day-to-day basis. 9. Deficient mental health records and an absence of treatment plans, progress reports and notes, and comprehensible diagnoses. 10. Noncompliance in following the guidelines on basic aspects of mental health care, which resulted in ongoing friction and role confusion between the Ohio Department of Mental Health (providers of psychiatric care) and the Ohio Department of Rehabilitation and Correction (providers of psychological services). 11. Absence of remedial action in response to earlier studies that pointed to similar problems and solutions. The Expert Team found that while Ohio’s prison population, including a large and growing number of seriously mentally ill inmates, had expanded, there had been a simultaneous decline in resources, which led to the situation where minimally adequate care for seriously mentally ill inmates was being provided. The report indicated that the errors were of omission rather than commission, that both mental health specialists and security staff felt frustrated by their inability to systematically recognize and provide care 17 where it was plainly indicated, and that there was no evidence of intentional infliction of harm toward inmates. The case resolved itself into a case of systematic inability to meet minimal conditions rather than commission of wrongful acts. The Dunn case shaped itself into a collaborative-implementation model. Report Acceptance. As anticipated, the report was given a favorable reception. The rehabilitation and corrections and mental health agencies pooled executive staff to develop a vision and Sharon Aungst of ODMH’s Office of Psychiatric Services to Corrections developed this vision into a conceptual and operational model for service delivery. The Expert Team advocated for the Ohio Department of Rehabilitation and Correction to become the provider of mental health care in a unified system. In October 1994, at an Open Space Conference, Ohio’s key stakeholders in the redesigning of the system met to design the “ideal” system. The “buy in” of all stakeholders was a significant component in the early success of the new system. Among the accepted system components was a “cluster” approach, which is a service delivery design whereby a group of two to five prisons in geographic proximity to one another provide for all mental health care (except hospital care) for their inmates. All prisons would provide outpatient care, but only one prison in each cluster would provide crisis stabilization and a Residential Treatment Unit. Action plans were developed following the conference in order to implement the system and negotiate settlement of the suit. Key to the success of the system was the timing with which the system was developed (prior to negotiations) and that the Ohio Department of Rehabilitation and Correction had created the system that it was to implement, rather than having a foreign system thrust upon the ODRC. Negotiating the Consent Decree. Reportedly, in the post conference period, Fred Cohen was asked by the defendants to take on the role of facilitator. Mr. Cohen served simultaneously as a mediator and drafter of an agreement. Because the drafter of the report was also the facilitator of the drafting of the consent decree, the proposed decree aligned with the experts’ report and with all parties in line, there was an early and amicable resolution. As reported in Prison Mental Health Care (1997), only a few points of the decree became difficult to resolve. For example, counsel for the plaintiffs insisted on a definition of “serious mental illness” that would include all DSM-IV, Axis I and II diagnosis as well as “alcoholic” and “drug addict,” however, to make the definition that inclusive could potentially mandate that mental health care be provided to a possible 80 percent of the total prison population. With agreement of the goal to dramatically improve the quality of mental health care in Ohio’s prisons, the negotiation and drafting of the consent decree was successful and void of many of the problems and manipulations that commonly accompanies such an effort. The major participants in forming the consent decree, (Governor, ODRC Director, Attorney General, Legislature, and Counsel for the plaintiffs), worked together under the assumption that decent mental health care plays a proportionate role in the level of safety and security of a prison. As the decree was undergoing fine-tuning, Fred Cohen provided monitoring and consultation so that the fine-tuning process was efficient and consensus would be reached 18 without unnecessary revisions. This phase lasted approximately 13 months extending from March 1995 through April 1996. The benefits of employing consultation during this phase included (a) the development of common understandings between the monitor and mental health and security staff concerning the expectations and the obstacles facing staff, (b) an increase in staff confidence due to the monitored visits being handled in a manner that presented “no surprises” to staff, (c) much collaboration between monitor and staff as they worked toward a common goal, and (d) a “buy- in” perspective on the process, which was supported by some key components including ODRC’s provisions for first-class staff, resources necessary to the process, ODRC enthusiasm, and support from the top- most level. Consent Decree. The Consent Decree established “substantial compliance” as the substantive goal for ending the judicial oversight and monitoring. The Ohio experience was notable in an absence of bitterness and contentiousness that has accompanied decrees in other states. Monitoring Process. There were two phases of the Dunn monitoring process: consultative phase and oversight monitoring phase. The consultative phase took on two parts, the first in the few months prior to the formalization of the decree, and the second during the six months after the formalization of the decree. During the six- month period post-decree, ODRC held itself to develop and draft 11 policies and procedures – a step that engaged the monitor in a collaborative manner. The monitor had authority to provide oversight of ODRC institutions by gathering empirical data, obtaining written reports, onsite inspections, and providing oral and written reports to the parties. Additional rights provided to the monitor included privileged communication and access to data from internal investigations and other sensitive information. At the heart of monitoring were monthly site visits, which began with an initial staff meeting and included the submission of various types of institutional-specific data and statistics pertinent to operations and services rendered to offenders. Following the executive meeting, the monitor proceeded to hold similar sessions with other staff within the institution. The decree described monitoring as a combination of gathering empirical data, obtaining written reports from ODRC, on-site inspections, and providing oral and written reports to the parties. The monitor was given access to privileged information. ODRC prepared quarterly reports for the monitor with special emphasis on staff and on bed or treatment space. Prior to a site visit, the monitor was provided with a package consisting of the names and status of inmates on the mental health caseload, the prison’s rated and current population, names and job descriptions of relevant staff, security status information, segregation data, and a summary of any prior findings, recommendations, or news clippings about Ohio prisons. This information was supplied to the monitor prior to the executive session at the onsite visit so that discussions at the executive session could be more productive in revealing problems and prompting analysis as a result of the monitor having time to review the data prior to the meeting. 19 Following the executive session, there were similar sessions with key mental health staff: psychiatrists, psychologists, psychology assistants, social workers, nurses, and activity therapists. During the site visit, inmate health charts were examined and a session was held with Residential Treatment Unit (RTU) inmates to explore complaints. In addition, corrections officers and segregation staff met with the monitor. A site visit always included an attempt to sit in on a disciplinary hearing involving inmates on the mental health caseload. A variety of issues associated with incarceration of the mentally ill were given consideration during the onsite visit. Some of the issues in this category included recordkeeping, policy and procedure compliance, discretionary flexibility in the system relevant to inmate behavior, medication policy and inmate discretionary latitude, medications in general, and staff training, among others. The site visit as part of the monitoring process included an exit interview, which was attended by representatives from Central Office, the warden(s), key staff, and some mental health personnel. The comments and notes generated by the site visit were taken seriously and staff welcomed the monitor as a partner in developing and improving their system. It was perceived that the monitor and agency shared the same goal: to improve the system for delivery of mental health services. Finally, following the site visit and sessions, reports were generated to document the observations, findings, recommendations, etc. Recommendations. The principles that were followed and the processes used in the implementation of the consent decree, in this case, offered some value to other jurisdictions contemplating a similar task requiring the enforcement of a judicial remedy within the correctional system. Fundamental principles that have been credited for the success in the Ohio case include communication, continuity, organizational and governmental support of “quality,” clarity of roles, and the transition process from implementation of the components of the decree and requisite independent monitoring to a system that operates in compliance and monitors its own performance. Communication was identified in the Ohio case (Dunn v Voinovich), as the key to building and maintaining the positive and productive relationships that were necessary to the success of the venture. Communication between the monitor and the state’s Deputy Director of Mental Health Services occurred frequently and honestly to avoid surprises. Concerns and disagreements were discussed openly with the goal of understanding, clarifying, and finding common ground. It was discovered that face-to- face meetings produced more constructive and less misunderstood communication than written “discussions.” The communication template, in this case, included the resolution of disagreements without any threat of litigation, regular feedback sessions, and a thorough sharing of paper documentation of the venture through reports and other written materials. 20 Continuity. In Prison Mental Health Care (1997), continuity was identified as a second important factor. Specifically, continuity was established by having Fred Cohen act as the author of the Expert Team Report, continue in a role as facilitator and author of the Consent Decree, then continue as a consultant, and finally serve as the monitor. The multiple roles filled by Mr. Cohen did much to assure that the process did not unravel or become misdirected during the various phases. Also, there was one consistent ODRC staff who assumed responsibility for psychiatric services, served as the “program expert’ in negotiations, oversaw the transfer of psychiatric services from the Ohio Department of Mental Health to the Ohio Department of Rehabilitation and Correction, and was responsible for building a new integrated mental health system within the Ohio Department of Rehabilitation and Corrections. The continuous service of these two key players, the monitor and the Deputy Director, in the situation helped to prevent misunderstandings or disagreements that might have occurred if either of the two players had changed in the middle of the process. Organizational and Governmental Issues. Reportedly, the perspective or philosophical framework held by the Ohio Department of Rehabilitation and Correction at the time of the case included a readiness to make changes, and a desire to embrace ownership of mental health services, thus controlling the future of those services within the ODRC rather than relying on another agency to provide those services. The leadership at ODRC was committed to improving service delivery and held a clear vision in that regard. A “quality-oriented” mode of business operations was encouraged from the executive branch such that all stakeholders in daily operations were encouraged to participate positively and constructively, rather than act as obstacles, in the cultivation and maintenance of operations that represented the highest quality. Staff training and support tools were given increased emphasis in cultivating a quality approach to doing business. Clarity of Roles. While the attorneys were concerned with legal issues surrounding the consent decree and in achieving and maintaining the best legal position for the state, the program managers were concerned with providing quality services and ensuring that legal positioning did not interfere with providing appropriate care. Roles remained clear and distinct in the Dunn case, however, there was cross-consultation concerning both program design and legal issues. The monitor also exercised distinction in the dual roles of monitor and consultant so as to be able to clearly distinguish the monitoring process separately from suggesting “best practices” to enhance services within individual institutions. Transition. A shift from development and implementation of the consent decree to day-to-day performance that met and maintained standards served as a transition point in the process of meeting the overall objective. In the Dunn case, the ODRC demonstrated its ability to monitor its own performance by hiring a compliance monitor and developing a quality assurance program. The role of the compliance monitor was to develop measures to track specific requirements of the decree and develop systems for the agency to self- monitor. The role of the quality assurance program was to monitor and evaluate the quality and appropriateness of mental health care, the resolution of specific problems, 21 and to ensure compliance to standards, which were integrated into the agency’s operating standards and audited annually. Acting on their authority in the post-transition period, the ODRC reportedly instituted a management information system to allow information to be available to staff when it was needed. Space, staff, and access were identified as the most critical elements in maintaining quality in the delivery of mental health services. It was identified that the previous ODRC system for delivery of mental health services essentially was ineffective even at reception because not all inmates were given assessments at reception. There was not, therefore, any initial screening for any mental concerns unless the individual was obviously symptomatic, in a crisis, or taking psychotropic medications. Under the changes of the decree, operations were impacted. Under the decree, inmates now receive screening at reception and mental health staff make weekly rounds to inmates assigned to segregation and in general population. The structured and frequent presence of mental health staff to the units enhances inmates’ access to care and strengthens the contribution that security staff may make in the identification step. Weekly contact with mental health staff helps to assure that inmates who may be exhibiting signs of serious mental illness are identified, referred, and given treatment in a timely manner. In addition, inmates are required to undergo a mental health screening whenever they make an institutional transfer so as to verify the inmates current mental health classification and level of care required. In order for the credible delivery of services to occur, major initiatives were put in place. The major initiatives for improving service delivery included improvement of the treatment planning process, building treatment teams that include security staff, improving recruitment and developing a credentials process applicable to the hiring process, improving clinical skills of staff, fully implementing the involuntary medication policy, and fully implementing the quality assurance program. The transition of prison mental health care from the Ohio Department of Mental Health (ODMH) to the Ohio Department of Rehabilitation and Corrections (ODRC) gave the ODMH the primary responsibility for linking inmates with mental illnesses to community providers of work upon inmates’ release. Twelve social workers were hired to work within the prisons to identify those inmates with mental illnesses receive continuity of care when they are released into the community. A primary objective of these measures is to reduce the risk of recidivism and re- institutionalization of the inmate. Relevant to the three criteria by which achievement may be measured: staffing, space, and access, reportedly, Ohio succeeded in all three categories. The data revealed that considerable achievements were made over a short period. Several hundred beds were added system-wide for inmates needing mental health services, mental health staff quadrupled within a few years, and mental health services were more prevalent at intake and delivered more frequently at other points during inmate incarceration. The accomplishments, as recognized by the monitor and the Deputy Director, were to be 22 shared among all participants in the process because it brought substantial recognition to Ohio. The Conclusions published in Report 4, Prison Mental Health Care: Dispute Resolution and Monitoring in Ohio (1997), include five concepts that the Monitor and the Mental Health Deputy Director believed to have made an important contribution to the quality of mental health services to inmates in Ohio. 1. 2. 3. 4. 5. There must be support for the change at the top. It must be communicated throughout the organization, and front-line players – those in the trenches – must buy into the change. The greater the contentiousness in the early stages and in the ultimate resolution of a lawsuit seeking systemic change, the greater the difficulty in implementing a change. Obviously, this principle implies a certain shared view of the problems and the need for resolution. This shared view need not exist at the initiation of litigation but must develop early in the process. Continuity in the agents of change, whether the agents come from the institution or from outside it, is a major factor in achieving change. The energy of a lawsuit can be converted to a positive force for change if a collaborative, mutually respectful posture is adopted early and consistently maintained. Identities of interest can be located in apparent antagonistic positions, yet these interests may then be converted into mutual effort. Certain challenges to prison conditions, for example, correspondence, visiting, and discipline, are consistently viewed as threatening by prison officials. Other challenges, like health care, are not viewed in such a threatening manner. With mutual effort, it is relatively easy to sell the notion that decent mental health care enhances security and the work environment generally. As identified in the fourth report, the trust began with the Director of the Ohio Department of Rehabilitation and Correction and was communicated and perpetuated throughout the levels of administration and staff to the correctional officers in segregation units. This trust was the dominant component in the success of complying with the court ordered mandate of the Dunn case. The ODRC executive staff and legal counsel made an initial decision to suspend discovery and look to a team of experts for an objective assessment of Ohio’s prison mental health system. The Department continued with an open mind in beginning discussions on the need and direction for change, followed by the acceptance of the team’s report. The Director repeatedly supported the inquiry and exploration process, giving it legitimacy at all levels of administration and staff and at all levels of operation. The early-established trust built upon itself and became a pivotal factor in accommodating change. The fourth report acknowledged that while changes in Ohio took place in response to the Dunn case, the problems that were faced in the Dunn case would not simply disappear. It may be that Dunn-like solutions to problems will reappear in other situations, yet there is always the possibility that those problems will not be addressed with as much success or cooperation as happened in the Dunn case. Ultimately, it would be preferable that future issues could be dealt with in a similar and effective manner as the response to the Dunn case. 23 APPENDIX A MONTHLY AVERAGE INSTITUTIONAL POPULATION Institution Chillicothe CI Belmont CI Richland CI Noble CI North Central CI Ross CI Mansfield CI Lebanon CI London CI Pickaway CI Madison CI Ohio Reformatory for Women Marion CI Lorain CI Lake Erie CI Southeastern CI Grafton CI Allen CI Trumbull CI Southern Ohio Correctional Facility Warren CI Correctional Reception Center Toledo CI North Coast Correctional Treatment Center Northeast Pre-Release Center Ohio State Penitentiary Hocking Correctional Facility Dayton CI Montgomery Education and PreRelease Center Corrections Medical Center Oakwood Correctional Facility TOTAL TOTAL (based on averaged monthly quantities statewide) Monthly Average Inmate Population per Institution Ohio Department of Rehabilitation and Correction January – May 2006 Monthly Average January February March Institutional 2006 2006 2006 Population (for the period) 2776 2712 2717 2788 2404 2160 2466 2470 2352 2308 2311 2385 2295 2307 2279 2291 2272 2271 2296 2249 2249 2209 2242 2247 2205* 2184 2211 2200 2163 2125 2153 2182 2150 2182 2138 2167 2003 1903 2247 1945 1985 1989 1970 1941 1951 1925 1911 1954 1777 1703 1708 1750 1706 1007 1828 1868 1457 1438 1462 1459 1447 1438 1429 1450 1399* 1401 1399* 1396 1321 1320 1315 1326 1314 1523 1248 1248 April 2006 May 2006 5-month Total 2826 2453 2381 2313 2269 2272 2224 2174 2136 1961 1958 1987 1873 1828 1470 1454 1399* 1326 1262 2838 2470 2373 2283 2274 2277 2205* 2179 2128 1958 2067 1980 1852 1997 1457 1463 1399* 1318 1291 13,881 12,019 11,758 11,473 11,359 11,247 11,024* 10,813 10,751 10,014 9925 9757 8886 8528 7286 7234 6994* 6,605 6572 1122 1043 832 800 1091 1065 1744 784 1123 1046 1830 796 1128 1052 1878 804 1122 1034 1870 808 1146 1020 1858 810 5610 5217 9180 4002 625* 573 554 472 417 628 564 555 468 420 632 564 549 482 409 619 593 578 466 420 620 562 545 477 416 625* 582 544 468 422 3124* 2865 2771 2361 2087 334 120 110* 45,722* 328 119 107 322 121 104 332 122 118 352 124 109 337 115 110* 1671 601 548* 45,727 (variance of 5 due to rounding) 44,469 45,807* 45,924 46,094* 46,340* 228,634* The * indicates an institutional entry or average total derived by using a calculated average due to incomplete institutional data available at the time of the report. 24 APPENDIX B Institution Oakwood Correctional Facility Ohio Reformatory for Women Franklin Pre-Release Center Northeast PreRelease Center Corrections Medical Center Southern Ohio Correctional Facility Hocking Correctional Facility Warren CI Allen CI Trumbull CI Southeastern CI Chillicothe CI Belmont CI Pickaway CI Mansfield CI Richland CI Correctional Reception Center North Central CI Madison CI Marion CI Lebanon CI Noble CI Grafton CI London CI Toledo CI Lake Erie CI Ross CI North Coast Correctional Treatment Center Lorain CI Ohio State Penitentiary Dayton CI Montgomery Education and PreRelease Center TOTAL PERCENT of MONTHLY AVERAGE INSTITUTIONAL POPULATION on PSYCHIATRIC CASELOAD January – May 2006 Percent of Monthly 5 Month Average Jan Feb Mar Apr May Total on Institutional 2006 2006 2006 2006 2006 Psychiatric Population on Caseload Psychiatric Caseload (C1 + C2) Monthly Average on Psychiatric Caseload Monthly Average Institutional Population 47.7 51 49 59 50 0 209 42 110* 44.0 692 697 711 749 747 4288 858 1951 42.1 208 216 211 203 204 1042 208 494 39.4 214 214 237 231 234 1130 226 573 30.8 35 39 39 38 33 184 37 120 27.9 314 320 311 308 314 1567 313 1122 22.7 21.7 21.3 20.5 18.1 18.1 16.5 16.0 15.6 14.6 107 227 284 268 257 364 406 325 339 336 107 224 278 264 269 512 397 314 342 322 107 227 281 269 265 528 399 315 348 336 108 229 280 264 258 560 383 337 344 357 104 223 286 278 260 550 395 314 343* 366 533 1130 1409 1343 1309 2514 1980 1605 1716* 1717 107 226 282 269 262 503 396 321 343* 343 472 1043 1321 1314 1447 2776 2404 2003 2205* 2352 14.2 13.5 13.4 12.8 12.6 12.2 12.1 11.8 11.6 11.4 10.6 238 298 280 210 260 292 166 273 86 163 231 267 297 275 219 275 286 169* 259 86 168 242 286 303 258 226 270 280 171 247 94 170 228 252 312 244 245 274 270 169* 247 94 169 241 257 322 272 240 281 272 169* 247 104 161 248 1300 1532 1329 1140 1360 1400 337* 1273 464 831 1190 260 306 266 228 272 280 169* 255 93 166 238 1832 2272 1985 1777 2163 2295 1399 2150 800 1457 2249 8.0 52 53 48 47 0 200 40 625* 7.8 48 136 167 158 158 667 133 1706 3.6 0 17 0 20 0 23 0 20 0 21 0 101 0 20 0 554 417 0 0 0 0 0 0 0 0 334 16.3 7041 7316* 7414 7441* 7403* 36,615* 7462* 45,722* The * indicates an institutional entry or average total derived by using a calculated average due to incomplete institutional data available at the time of the report. 25 APPENDIX C PERCENT of INSTITUTIONAL POPULATION on MENTAL HEALTH CASELOAD January – May 2006 Institution Oakwood Correctional Facility Northeast Pre-Release Center Franklin Pre-Release Center Ohio Reformatory for Women Corrections Medical Center Southern Ohio Correctional Facility Allen CI Warren CI Hocking Correctional Facility Trumbull CI Mansfield CI Belmont CI Southeastern CI Chillicothe CI Pickaway CI Richland CI Lebanon CI Madison CI North Coast Correctional Treatment Center Marion CI Noble CI London CI North Central CI Correctional Reception Center Ross CI Toledo CI Grafton CI Lake Erie CI Lorain CI Ohio State Penitentiary Dayton CI Montgomery Education and Pre-Release Center TOTAL Percent of Institutional Population on Mental Health Caseload (C1+C2+C3) 5-Month Total of Inmates on Mental Health Caseload Monthly Average of Inmates on Mental Health Caseload Monthly Average Inmate Population 53* 278 218 266 1354 1103 53* 271 221 110* 573 494 872 38 872 33 4190 184 838 37 1951 120 326 313 239 108 301 452 477 286 559 333 379 355 319 322 311 241 109 292 439 478 278 595 346 395 356 312 322 315 236 105 315 450 496 288 590 323 410 365 331 1639 1572 1196 536 1486 2258 2396 1418 2681 1671 1924 1774 1629 328 314 239 107 297 452 479 284 536 334 385 355 326 1122 1321 1043 472 1314 2205* 2404 1447 2776 2003 2352 2163 1985 109 269 354 315 335 91 278 353 317 333 92 300 341 332 341 100* 300 333 330 358 500 1403 1745 1629 1703 100* 281 349 326 341 625* 1777 2295 2150 2272 251 314 107 189 182 60 25 0 281 337 112 193* 186 169 29 0 299 328 121 197 189 226 31 0 267 341 122 193* 188 223 28 4 269 346 130 193* 183 276 30 4 1367 1666 592 965 928 954 143 8 273 333 118 193* 186 191 29 2 1832 2249 800 1399 1457 1706 554 417 0 0 0 4 4 3 11 2 334 18.8* 8199 8496* 8644 8697* 8855* 42,891* 8580* 45,722* Jan 2006 Feb 2006 Mar 2006 Apr 2006 May 2006 48.2* 47.3 44.7 52 264 221 50 264 226 60 279 221 51 269 217 43.0 30.8 803 35 812 39 831 39 29.2 23.8 22.9 22.7 22.6 20.5* 19.9 19.6 19.3 16.7 16.4 16.4 16.4 331 320 243 107 288 461 482 273 395 343 378 342 334 338 313 237 107 290 456 463 293 542 326 362 356 333 16.0* 15.8 15.2 15.2 15.0 108 256 364 335 336 14.9 14.8 14.8 13.8* 12.8 11.2 5.2 0 The * indicates an institutional entry or average total derived by using a calculated average due to incomplete institutional data available at the time of the report. 26 APPENDIX D MONTHLY AVERAGE of MENTAL HEALTH CASELOAD INMATES in SEGREGATION January - May 2006 Monthly Average of Mental Health Caseload in Segregation Jan 2006 Feb 2006 Mar 2006 Apr 2006 May 2006 5-Month Total in Segregation Monthly Average Total Mental Health Caseload Ohio Reformatory for Women Lebanon CI Ross CI Chillicothe CI Southern Ohio Correctional Facility Southeastern CI Warren CI North Central CI Mansfield CI Noble CI Lake Erie CI London CI Allen CI Marion CI Trumbull CI Pickaway CI Richland CI Belmont CI Toledo CI Correctional Reception Center North Coast Correctional Treatment Center Grafton CI Lorain CI Northeast Pre-Release Center Madison CI Hocking Correctional Facility Franklin Pre-Release Center Corrections Medical Center Dayton CI Montgomery Education and Pre-Release Center Oakwood Correctional Facility Ohio State Penitentiary 54 34 33 26 42 37 29 26 60 30 31 28 71 28 30 23 47 30 35 23 52 44 42 30 272 169 167 130 838 355 333 536 Percent of Monthly Average Mental Health Caseload in Segregation 6.4 9.6 10.0 4.9 26 24 23 21 16 15 14 13 12 12 12 11 11 10 9 6 18 23 21 17 19 23 11 0 11 13 11 12 15 16 8 6 22 23 20 11 21 11 18 20 19 9 14 15 9 14 9 4 32 24 27 6 17 14 18 11 13 9 12 9 7 6 8 5 28 28 22 71 21 16 14 18 4 18 9 15 8 9 10 13 29 22 23 0 0 10 10 18 11 13 13 6 16 7 11 4 129 120 113 105 78 74 71 67 58 62 59 57 55 52 46 32 328 284 239 341 452 349 186 326 314 281 297 334 385 479 118 273 7.9 8.5 9.6 6.2 3.5 4.3 7.5 4.0 3.8 4.3 4.0 3.3 2.9 2.1 7.6 2.2 4 4 4 4 4 2 2 0 0 4 12 1 3 0 2 5 0 0 6 0 7 6 0 2 3 0 0 7 9 2 4 0 3 0 0 0 3 0 3 5 7 1 0 0 0 0 0 9 0 14 3 3 0 1 20 21 22 18 21 11 11 0 1 100* 193* 191 271 326 107 221 37 2 4.0 2.1 2.1 1.5 1.2 1.9 1.0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 53* 29 0 0 0 TOTAL 406 385 412 395 458 391 2,041 8580* 4.7 Institution The * indicates an institutional monthly entry or monthly total derived by using the calculated monthly average for select months in certain institutions due to incomplete institutional data available at the time of the report.