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On January 1, 2017, the KHI News Service became part of KCUR public radio’s new initiative, the Kansas News Service. The Kansas News Service will continue to cover health policy news and broaden its scope to include education and politics. All stories produced by the former KHI News Service are archived here. Stories and photos may be republished at no cost with proper attribution and a link back to KHI.org.

Structure sound, funding failing in Fargo jail’s mental health diversion program

By Andy Marso | October 26, 2016

Structure sound, funding failing in Fargo jail’s mental health diversion program
Photo by Andy Marso/KHI News Service Lynette Tastad, left, a licensed independent clinical social worker and mental health coordinator at the Cass County Jail in North Dakota, and Lt. Amanda Henrickson, the jail’s assistant administrator.

Editor’s note: Reporters from the Topeka Capital-Journal and KHI News Service collaborated for a six-month exploration of how the state’s legal system deals with people with mental illness. This is one of the stories in a four-day series.

THE MODEL

Who: Cass County, N.D., Jail.

What: Mental health screening for every incoming inmate.

When: Since 2008, as part of a federal grant establishing a diversion program to keep people with mental illness out of jail and in treatment.

Quote: “When you start reading the police reports, you see people that you’re like, ‘Uh, I’m not sure you’re supposed to be here.’” — Lynette Tastad, mental health coordinator for the Cass County, N.D., Jail.

Earlier this year police in Fargo, North Dakota, responded to a call about a suicidal man lying on train tracks.

When police tried to pull the man off the tracks, he fought them and ended up at the Cass County Jail, awaiting trial on charges of assaulting an officer.

Jail staff referred the man to Lynette Tastad, a licensed independent clinical social worker who is the jail’s mental health coordinator. It didn’t take long for Tastad to form a recommendation: The man needed treatment for his mental illness, not jail time.

“It’s not uncommon to get cases like that,” Tastad said in a recent interview at the jail. “It’s not always that cut and dried. But when you start reading the police reports, you see people that you’re like, ‘Uh, I’m not sure you’re supposed to be here.’”

Tastad started working at the jail in 2008, as part of a federal grant establishing a diversion program to keep people with mental illness out of jail and in treatment.

North Dakota officials would like to scale up the program statewide. That effort could be a model for Kansas, which shares the challenge of having large swaths of sparsely populated areas that are short on psychiatric providers.

With its oil revenues plummeting, North Dakota also provides a test case for cash-strapped Kansas when it comes to keeping such initiatives going during tight budget times.

The Cass County diversion program starts by training corrections officers to screen every inmate who comes through the door for mental illness, using an eight-question form. They’re taught to look for certain answers but also to use their judgment about whether inmates need mental health treatment.

Those who are flagged at the initial screening get referred to Tastad for a more comprehensive look. If she also determines they need help, she has three options:

  • Try to get their charges reduced or dismissed and get them into community services through the diversion program.
  • Bring behavioral health services to them in the jail.
  • Request, in the most extreme cases, they be admitted to the North Dakota State Hospital in Jamestown, the only state-run inpatient psychiatric facility.

Rosalie Etherington, superintendent of the state hospital, said the Cass County model is effective in reducing the criminalization of mental illness.

“We’re now trying to replicate that in other areas,” Etherington said.

[ Related story: Mental health issues drive some Kansans to repeated jail stays ]

Cass County, with Fargo as its county seat, has almost twice as many residents as any other county in the state. That means it has more mental health needs than the others, but the county also has access to more community-based services like psychiatrists.

Etherington said other parts of North Dakota with fewer resources are trying to fill those gaps through telemedicine, with programs already up and running in places like Grand Forks.

But as the state’s oil boom goes bust, Tastad and jail staff said they’re having trouble accessing services for inmates with mental illnesses even in their county.

Oil boom builds demand

Before the oil boom started in 2006, the incarceration of people with mental illness was not as much a problem in North Dakota as in other states.

In a study published by the nonprofit Treatment Advocacy Center and the National Sheriffs’ Association using data from 2004 and 2005, only North Dakota had approximately the same number of people with serious mental illness in its state hospitals as in its jails and prisons. The study’s authors estimated that every other state had a higher number incarcerated.

Oil well drillers struck black gold in western North Dakota a year later. North Dakota’s population grew quickly, as young men in particular flocked there seeking work while much of the United States remained mired in the Great Recession.

The state’s infrastructure struggled to keep up with population growth, as demand outstripped capacity in jails, hospitals and substance abuse and mental health treatment facilities.

Tastad said that when she started working at the Cass County Jail, the problem of crime due to untreated mental illness was on the rise.

Photo by Andy Marso/KHI News Service The diversion program in Cass County, North Dakota, starts by training corrections officers to screen every inmate who comes through the jail door for mental illness, using an eight-question form. They’re taught to look for certain answers but also to use their judgment about whether inmates need mental health treatment.

View larger photo

In addition to training jail employees to screen inmates at intake, Tastad encouraged them to seek crisis intervention training so they could recognize inmates having psychotic episodes and de-escalate those situations until she could get involved.

After some initial resistance from jail employees, Tastad said most of them are on board.

“They’ve gotten really good at identifying (mental illness), and most of the time they’re actually grateful to have someone to pass it on to,” Tastad said.

Capt. Andrew Frobig, the top corrections official at the jail, said the percentage of inmates referred out of the system through the diversion program typically been relatively small because they have to fit tight requirements.

But the initial mental health screenings give employees a better idea about who in their population needs extra attention.

Frobig said that in 2014 the jail had about 7,400 total bookings, and 4,302 of those booked were flagged for a mental health assessment with Tastad’s clinic. That’s a bit high compared to other years, he said, but not outside the norm.

“It is realistically about 50 percent of our people (that’s) a safe number to assume we flag,” Frobig said.

He noted that inmates who come to intake so intoxicated or high on drugs that they’re unable to answer the screening questions are automatically flagged.

Most of those Tastad and her team of nurses assessed that year did not need services or could be kept in the jail, which can dispense medications, do safety checks and bring in psychiatric care.

Tastad’s department referred 214 to outside psychiatric services on a non-emergency basis and 18 on an emergency basis.

“Those are the ones we feel really need to get into the state hospital,” Frobig said of the 18.

Only 17 inmates were accepted into the diversion program that year. They got their charges set aside because they agreed to participate in an individualized mental health treatment plan monitored by Tastad and a case manager from the local human services center.

“You always have to be a drill sergeant to keep them out of trouble,” Tastad said.

Frobig said the facility has “grown a great deal” in the last 10 years when it comes to identifying inmates with mental health problems.

Tastad agreed but said a new problem has emerged in the last few years.

“We identify them, definitely,” Tastad said. “It’s just that once we’ve identified them, the services are lacking.”

Budget cuts take toll

Oil prices have plummeted since 2014, denting the North Dakota economy and forcing cuts to state mental health services and general aid to counties.

Tastad said the need for the diversion program is only increasing as the oil jobs dry up and people migrate from the wells toward cities like Fargo. But at the same time, her diversion program is under more financial pressure than ever.

She said she lost a psychiatric nurse practitioner to budget cuts and no longer has access to a local psychiatrist due to a change in his insurance coverage.

“It’s very difficult to find anybody who wants to work with this population, even if the funding’s there,” Tastad said. “What resources we did have, have been getting cut.”

The jail now gets sporadic visits from a psychiatrist who works for a local safety net clinic.

Tastad said she’s been to Bismarck to testify about mental health issues to state legislators.

“It’s very difficult to find anybody who wants to work with this population, even if the funding’s there. What resources we did have, have been getting cut.”

- Lynette Tastad, mental health coordinator at the Cass County Jail in North Dakota

Those same legislators in 2013 commissioned an extensive study of the state’s behavioral health needs that was published in full last year.

“Everybody knows the issues are there,” Tastad said. “It’s just that there’s no funding.”

Tastad and Lt. Amanda Henrickson, the jail’s assistant administrator, both said that even finding services for people having acute psychotic episodes has become more difficult.

The state still evaluates people for placement in the state hospital within 24 hours of her requests, as required by law, Tastad said. But she’s seeing more denials than in the past.

Henrickson said she’s facing more resistance from hospital staff when she takes inmates to local emergency departments.

“It’s just a huge ordeal,” Henrickson said.

“In their defense, it’s usually full,” Tastad added.

Henrickson nodded.

“We all seem to run into that wall,” Henrickson said. “It’s a different wall, but we all seem to have one.”

Costs and benefits

Tastad and Henrickson both said they don’t expect the state funding to come roaring back any time soon.

“Obviously if oil production doesn’t increase next year, we’re probably in the same boat,” Henrickson said.

But one thing Tastad said could provide immediate help are policies that keep people insured even if they have a brush with the law.

Like most states, North Dakota terminates residents’ Medicaid eligibility when they’re incarcerated. Getting back on the rolls after release takes time, leaving a gap in coverage during a critical transition period.

Some states have begun suspending Medicaid coverage for people while they are incarcerated, rather than terminating it.

While that isn’t universally popular politically, Tastad said it’s important for getting people the treatment they need to keep from ending up back in jail.

“Obviously (mental health) providers can’t work for free,” Tastad said.

Failing to provide mental health services to people while incarcerated can end up costing more in the long run.

In Kansas, Sedgwick County paid $300,000 to settle a lawsuit following the beating death of an inmate with mental illness.

The Shawnee County Jail revamped its mental health screening procedures after the family of a man who committed suicide in his cell was awarded $252,000 in a lawsuit.

Brian Cole, director of Shawnee County Corrections, said the “nationally recognized” procedures include an initial mental health screening for all inmates and then a “full-blown suicide prevention screening” for those flagged as possibly suicidal.

“We had to learn the hard way, and in corrections you can’t be reactive,” Cole said.

In Cass County, Tastad said treating mental illness rather than criminalizing it is not only better for inmates, it’s better for everyone.

It costs the county $85 per day to house and care for each inmate. She said it makes more sense to spend that money on mental health services for people like the man police saved from the train tracks.

“If you look at the daily rate of what we would have spent to keep that person in jail for six months, we could have paid for two treatment providers,” Tastad said. “If you divert them from jail, that’s money saved.”