Inmate Healthcare (HLC)

Steps Taken: 

The Sheriff's Office agrees with this recommendation and believes that group therapy will aid in the stability of the individual during incarceration and during re-entry into the community. 

On September 26, 2017, the Board approved an amendment to the agreement with Traditions Psychology Group, Inc., which increased the maximum contract amount and extended the agreement for a 24-month period to expand the number of psychiatry hours in the Intake Booking area from 16 hours day, 7 days a week to 24 hours day, 7 days week.  The addition of psychiatrists to the Intake Booking area 24 hours day, 7 days a week will provide essential psychiatric resources to provide timely responses to those screened and triaged by nursing staff and mental health clinicians to need psychiatry services immediately.  The psychiatrists will provide psychiatric treatment to inmate patients with urgent mental health needs, such as those with suicidal thoughts and plans as well as to continue treatment for those who were taking psychotropic medications prior to incarceration.
 
The Sheriff’s Office (SO) and Custody Health Services (CHS) agree with this recommendation.

CHS has implemented a two-tier triage screening at Intake Booking.  The initial screening is conducted by a registered nurse who takes individuals through a series of standardized intake admission and screening questions while obtaining baseline vital signs.  Those assessed with a severe medical condition are sent to the hospital.  Those assessed to have an increased risk for medical or behavioral needs are referred to a medical or mental health physician or a mental health clinician for further evaluation.  Following the evaluation, a treatment plan and discharge planning are initiated based on standardized protocols.

Both mental health and medical staff are available at Intake Booking twenty-four (24) hours a day, seven (7) days per week.  Staff includes registered nurses, mental health clinicians, and psychiatrists.  The psychiatrists provide timely responses to inmates with urgent mental health needs, such as those with suicidal thoughts and plans, and continue treatment for those who are taking psychotropic medications prior to incarceration.
 
The CHS staff provides the Classification Unit (CU) staff with recommendations regarding housing.  During the intake and reassessment interview, the CU staff asks inmates if they need Mental Health services.  Since December 2016, the Mental Health staff has been conducting weekly visits to the restrictive housing areas to check for decompensation among the population. 

The SO Programs Unit, CHS, and various contractors provide programs for inmates to participate in during their out-of-cell time.  CHS provides programs that are beneficial for inmates’ mental health and focus on rehabilitation efforts.

The Supportive Transitional Empowerment Program (STEP) provides linkage to services and resources, case management, transportation, temporary housing/shelter, food, medical/dental resources, education, job/skills training, and other re-entry services with a goal to ensure a warm hand-off to the STEP team in the community.  STEP consists of a team of six (6) substance use counselors (4 in-custody and 2 community-based), a clinical Lead, and a Program Director who have been contracted to provide in-custody and post-custody substance use treatment services. 

The in-custody STEP team provides inmates with substance use screening, treatment engagement, psycho-educational groups, and linkages to community services.  STEP also offers Living in Balance and Open to Change curriculums each week.

CHS adheres to the California Lanterman-Petris-Short (LPS) Act standards and assesses patient eligibility for conservatorship when appropriate.  All CHS policies and procedures, including PREA, are continually reviewed and revised by Quality Improvement Managers to ensure that they reflect and are in compliance with the most up-to-date mandates and best practices. 

CHS also developed a screening policy for suicide risk, implemented a suicide risk assessment tool, and conducts monthly meetings with the Custody staff to review critical incidents to determine if there are systematic issues that need to be addressed, and if necessary, makes recommendations to reduce or eliminate the likelihood of future adverse events.  Findings and/or recommendations may also be forwarded to the Suicide Prevention Committee for policy recommendations or implementation of recommendations when necessary.

As part of the Administrative Management Policy, inmates that are placed in Administrative Management housing are immediately referred for a mental health screening that shall be completed within 72 hours of placement. Additionally, inmates who are identified as having an excludable diagnosis shall receive a minimum of 14 hours of out of cell time and also receive individual and/or group therapy sessions with Mental Health staff.

On September 24, 2019, the Board approved the third amendment to an agreement with Traditions Psychology Group, Inc., relating to providing psychiatric physician services for County correctional facilities, increasing the maximum contract amount by $1,028,256. Additionally, on November 19, 2019, the Board approved the fourth amendment to the Traditions Psychology Group, Inc. agreement to increase the maximum contract amount by $17,173,902 and extend the term through September 29, 2022. On October 4, 2022, the Board approved the fifth amendment to the Tradition Psychology Group, Inc. agreement to increase the maximum contract amount by $5,699,538 and extend the term through September 29, 2023.

For the FY 2022/2023 Adopted Budget, the Board approved 4.0 FTE Medical Assistant positions for telepsychiatry services.  The proposed Telepsychiatry Program for ambulatory psychiatric services will provide greater access and treatment of patients by psychiatrics and patient treatment teams leading towards improved patient outcomes and potentially smoother transitions to continued care in the community.  Additionally, the Board approved 1.0 FTE Medical Social Worker II to work with an approved 1.0 FTE Attorney under County Counsel for a Jail Population Team that will work with justice system partners to expedite treatment placements from jail and reduce wait times in jail. The Board also approved the purchase of High Security Group Therapy Chairs that will enable targeted group psychotherapy treatment time in dedicated spaces while ensuring safety standards. Lastly, the Board approved 6.0 FTE Recreation Therapist II positions to establish a Recreational Therapy Services team for the provision of evidence-based therapeutic recreational activities for patients.

In late 2021, per the recommendation of the Chavez Consent Decree Mental Health Monitor and Don Spectator, CHS implemented an Acute Psychiatric Unit (APU) to replace the historical Lanterman-Petris-Short (LPS) unit (e.g., 5150 and 5250 holds) that included both admission and discharge criteria based on service needs and that allows patients to remain on the APU as long as that level of acute care was required and the patient could not manage at a lower level of care. In addition, pursuant to Penal Code 2603 (PC 2603), CHS began prescribed service provision timeframes within the APU.

Custody Health Services (CHS) has redesigned its Mental Health screening form at Booking/Intake by incorporating the evidence-based Columbia Suicide Risk Tool to stratify patients based on risk factors and acuity to include an updated patient triage policy, and aligned additional mental health suicide ideation and intent questions on the Booking Nursing Intake Screening Assessment tool. CHS also worked with the Chiefs of Police to update essential information on the agency report about the patient’s mental health status upon arrest. 

Per the Consent Decree, CHS is implementing Cognitive Support Plans (CSPs) for patients assessed as having a cognitive disability (e.g., TBI, FAS, ASD, ADHD) and multi-disciplinary accommodations those patients may need while in the Custody setting. 

The Medical Assistant, Medical Social Worker II, and a portion of the Recreation Therapist positions are in various stages of posting and hiring with expected placements by summer. There are three Recreation Therapist position filled with scheduled start dates in late March 2023.  The Recreational Therapists will be utilized to provide out of cell, evidence-based therapeutic recreational activities as well as offer face to face engagement with patients.

CHS has conducted market research on various High Security Therapy Chairs with a prospective vendor in mind and have installed three High Security Chairs to date. CHS and Sheriff’s Office Custody Bureau are currently considering logistical and operational needs for placement and integration of additional chairs.

In support of the Cognitive Support Plan (CSP) rollout, CHS conducted Cognitive Disability (CD) training for all CHS staff providing direct patient care. The training provided an overview of CDs in general as well as how it relates to the carceral setting and the Consent Decree Remedial Plan, how to identify individuals with CD, and the practices and procedures to provide care and support for individuals in Custody with CDs. A similar training was also provided to dedicated Sheriff’s Office Custody Bureau staff.

To enhance the group therapy program for seriously mentally ill (SMI) patients, CHS implemented a comprehensive approach that utilizes Recreational Therapists to facilitate out of cell therapeutic recreational
activities. 

For FY 2024, Custody Health Services secured a 1.0 FTE Medical Social Worker II and 2.0 FTE Rehabilitation Counselor positions to further augment the Medication Assisted Treatment (MAT) Program 
for opioid and substance use disorder treatment.

Regarding the Cognitive Support Plan (CSP) rollout, the CHS Quality Improvement team has initiated an ongoing audit on the CSP as it relates to identified patients. 

Budget Status: The Board approved the following:

• December 2015: 59 positions in Custody Health Services to provide multi-disciplinary healthcare staff and support staff ($16.6 million) for mentally ill inmates for behavioral health services during incarceration and re-integration into the community.
• FY 2017 Adopted Budget: 10 Sheriff’s Correctional Deputy positions and 1 Sheriff’s Correctional Sergeant position ($1.6 million) were added as Multi Support Deputies to support the teams noted above.
• FY 2017 Adopted Budget: 6 Rehabilitation Officer positions and 1 Senior Management Analyst ($1.1 million) for programming and discharge planning.
• FY 2018 Adopted Budget: Added new Psychiatrist position to provide on-site clinical oversight of behavioral health services, and Hospital Services Assistant position, 2 Clinical Nurse III positions, and one Staff Developer position to support jail reform efforts ($1.4 million).
• January 23, 2018: Added new Director, Custody Behavioral Services Positions, in Custody Health Services to provide oversight of all Custody Health behavioral health staff and services.
• May 1, 2018: An amendment to an agreement with NAMI Santa Clara County related to expanding Warmline/Help Desk services for Santa Clara County residents for a 12-month period through June 30, 2019 in the amount of $235,700.
• FY 2019 Adopted Budget: Added 4 Clinical Nurse III positions ($791,976), 2 Sr. Psychologist positions ($494,908), and 1 Administrative Assistant position and 1 Administrative Nurse II position ($351,137) to assist with providing comprehensive ambulatory medical, mental health and pharmacy services to inmates at the Main Jail and Elmwood facilities.
• FY 2019 Adopted Budget: Adjustment to the funding for the Custody Behavioral Health Teams by increase the Salaries and Benefits budget by $2.6 million. 
• FY 2019 Adopted Budget: Added 8 Sheriff Correctional Deputy positions to be assigned as part of the Behavioral Health Team in the Multi Support Unit and 1 Sheriff Correctional Sergeant position to be assigned to oversee facility-wide out-of-cell time and restrictive housing for Main Jail administration ($1,454,527).
• February 12, 2019:  Funded 2.6 Clinical Nurse III positions in the Main Jail (1.3 FTE) and Elmwood (1.3 FTE) Medical Services unit for the Custody Health Services Department to meet the increased demands for care, backfill for nursing staff attending trainings or taking time off, meet other needs ($595,788).
• FY 2020 Adopted Budget:
  - Added one Quality Improvement Coordinator position and 2 part-time (0.5 FTE) Health Care Program Analyst Associate positions to conduct quality assurance and improvement reviews, monitor processes, and conduct studies in various areas, including compliance with the ADA for the Custody Health Services Department ($319,075). 
  - Added 3 Assistant Nurse Manager positions to ensure coverage on every shift at the Main Jail facility on the acute psychiatric unit 8A ($662,704).
  - Added one Quality Improvement Coordinator position that will provide training on mental health focused topics ($155,605).
  - Funded 3.5 Medical Unit Clerk positions to support the Intake Booking area to ensure proper and timely processing and scheduling of dental, medical, and behavioral health appointments ($341,680). 
• August 27, 2019: Adopted a salary ordinance adding one Chief Psychologist position to lead the Psychology Team in the planning, implementation, and evaluation of treatment modalities ($258,641).
• FY 2021 Adopted Budget: Add 1.0 FTE Medical Unit Clerk position to support the Custody Health Services Department’s discharge process, review release prescription orders, and issue vouchers for transportation resources ($109,925).
• FY 2021 Adopted Budget: Funding for the Space Feasibility Study of the Main Jail North booking area, along with exam rooms adjacent to booking to allow for a more efficient booking process ($225,000).
• FY 2021 Adopted Budget: Delete 4.5 FTE Psychiatrist positions, which are difficult to fill and have been vacant for several years ($1,453,693).
• FY 2021 Adopted Budget: Delete 4.0 FTE Psychologist positions, which are difficult to fill and have been vacant for several years ($846,826). Custody Health Services will modify the treatment programs and coverage to provide enhanced care for inmates.
• FY 2021 Adopted Budget: Delete 1.0 FTE Rehabilitation Officer II position in the Inmate Screening Unit to screen inmates for in- and out-of-custody programs ($181,738).

• FY 2021 Adopted Budget: Delete 3.0 FTE Rehabilitation Officer positions ($545,214).

• FY 2021 Adopted Budget: Transfer 1.0 FTE Chief Psychologist position from the Santa Clara Valley medical Center to the Custody Health Services Department.

• FY 2021 Adopted Budget: Delete 2.0 FTE vacant Psychiatric Social Worker II positions funded by Public Safety Realignment (AB109).

• FY 2021 Adopted Budget: Delete 1.5 FTE Clinical Nurse positions (($386,265).

• FY 2021 Adopted Budget: Reduce ongoing funding of miscellaneous Services and Supplies by $205,894.

• FY 2021 Adopted Budget: Reduce ongoing Contract Services funding supporting psychiatric services by $1,209,844. This action will limit the contractor’s ability to provide critical services in Intake Booking and the Acute Inpatient Psychiatric Unit.

• February 9, 2021: The Board approved a salary ordinance deleting 1.0 FTE Director of Custody Behavioral Health Services and increasing the salary range for the Director of Custody Health and Custody Behavioral Health Services position by 7.7 percent.

• February 9, 2021: Delete 4.5 FTE Psychiatric Social Worker II position ($762,089) and 0.5 Staff Developer position ($116, 608) within Custody Health Services relating to the Voluntary Separation Incentive Program. 

• February 9, 2021: Delete 1.0 FTE Rehabilitation Officer II position related to the Voluntary Separation Incentive Program as part of the Fiscal Year 2020-2021 Mid-Year Budget Review ($206, 474).

• February 9, 2021: Delete 0.8 FTE Psychiatric Social Worker II position within Custody Health Services as part of the Fiscal Year 2020-2021 Mid-Year Budget Review ($135,482).

• March 23, 2021: Add 1.0 FTE Health Care Service Line Director position, 1.0 FTE Medical Social Worker position, Add 2.0 FTE Psychiatric Technician positions, 4.0 FTE Medical Assistant positions for Main Jail, 9.0 FTE Medical Assistant positions for Elmwood, 6.0 FTE Medical Unit Clerk positions, 1.0 FTE Management Analyst position, 4.0 FTE Janitor positions, 1.0 FTE Infection Control Nurse position, 1.0 FTE Health Care Program Analyst II position, 1.0 FTE Sr. Mental Health Program Specialist position, and 2.0 FTE Business Intelligence Analyst positions to meet the Consent Decree’s mandate to provide adequate integrated medical care to incarcerated patients as measured through access to care and population health quality indicators and evidenced-based clinical practices that mitigate risk and reduce patient harm, morbidity, and mortality.

• FY 2022 Adopted Budget: Add 1.0 FTE Chief of Quality Management position, 1.0 FTE Chief of Mental Health Position, 2.0 FE licensed Vocational Nurse positions, 2.0 FTE Administrative Assistant positions, 4.0 FTE Medical Unit Clerk positions, 2.0 FTE Management Analyst positions, and 1.0 FTE Community Worker positions as part of the phase two of Custody Health Services’ restructure to meet the requirements of the federal consent decrees ($1,945,598).

• March 8, 2022: Add 43.0 FTE Correctional Deputy positions related to the Chavez and Cole Consent Decree Remedial Plans to work directly with the Custody Health Services Behavioral Health Teams to provide acute or seriously mentally ill, intellectually disabled, and cognitive disability inmates with assisted daily living services, escorts, access to care, and constant and direct supervision of mental health structured programming and out-of-cell time ($750,224).

• FY 23 Adopted Budget: Add 4.0 FTE Medical Assistant positions for telepsychiatry services ($306,318); Add 1.0 FTE Medical Social Worker II position for Jail Population Team ($126,790); Acquire High Security Group Therapy Chairs ($32,000); Add 6.0 FTE Recreation Therapist II positions to establish a Recreational Therapy Services Team ($586, 588).

• For FY 2024, Custody Health Services secured 1.0 FTE Medical Social Worker II and 2.0 FTE Rehabilitation Counselors to augment the Medication Assisted Treatment (MAT) program for opioid and 
  substance use disorder treatment.

• September 19, 2023: The Board approved the sixth amendment to agreement with Traditions Psychology Group, Inc., relating to providing psychiatric physician services for the County of Santa Clara correctional facilities increasing the maximum contract amount by $4,500,000. 

Source Report(s): Sheriff’s Jail Reform Plan, Blue Ribbon Commission on Improving Custody Operations, Mental Health Gap Analysis – Gage, Zisser

Responsible Department(s): Sheriff’s Office, Custody Health Services

Master List Nos.: 44, 47, 52, 53, 101, 102, 123, 394, 396, 518, 616, 618, 620-621, 623

Review Date: FGOC reviewed on January 26, 2017.