Telepsychiatry for Jail Inmates in Carlton County, Minnesota

Jennifer Yopp
Justice Innovation Center
CNA

Overview
In small, rural, tribal and border (SRTB) counties, healthcare specialists are in short supply, and challenged to meet the needs of inmates who suffer from substance abuse and mental health problems. Until recently, for SRTB agencies—and even for many large and urban agencies—connecting inmates with mental health services meant transporting an inmate to a medical facility.

Transportation disrupts an inmate’s daily routine, requires dedicated staff, and often involves long commutes. This system also requires inmates to wait for an appointment, which can delay critical services for inmates in crisis.

Telepsychiatry services—psychiatric appointments conducted remotely using audiovisual equipment—can address the burden of transportation and create other improvements in mental health care provision for inmates, such as making services more accessible for inmates in need and keeping inmates from progressing to a crisis point, when an ER visit might be required.

Minnesota addressed the issue of improving inmates’ access to psychiatry services by deploying Vidyo, a secure, Health Insurance Portability and Accountability Act (HIPAA)-compliant video communication solution statewide.

Challenge
Carlton County is located in the northeast corner of Minnesota. With 48 beds and 17 staff, Carlton County jail is a small agency, housing between 38 and 62 inmates at any one time. Approximately 70 percent of its inmates have mental health or substance abuse issues; 20 to 30 percent suffer from such severe mental health issues that they cannot be diverted to other correctional programs or services. The closest hub for medical services is Duluth, about twenty miles away in neighboring St. Louis County.

The jail provides nursing services through Carlton County Public Health (with multiple nurses adding up to one full-time equivalent), but does not have psychiatric services on site. Transporting inmates for off-site psychiatric appointments used to require removing them from their cells in restraints, checking them out of the facility, and transferring them to a licensed officer for transport. Staff believe that inmates—especially those experiencing mental health issues—are more comfortable and relaxed during psychiatric services if they are able to stay at the jail, and that led the facility to implement Vidyo.

Implementation
The Carlton County jail was responsible for identifying and contracting with a provider for telepsychiatry services; in 2014 the jail entered into contract with the private, nonprofit organization Human Development Center, located in Carlton County. Staff also had to identify space in the facility that could be dedicated to telepsychiatry services, and the jail and nursing staff ensured that they integrated HIPAA compliance into their operating procedures for telepsychiatry services.

The Minnesota Department of Health facilitated the audiovisual equipment, its installation, and the Vidyo service for the Carlton County jail in 2013. The audiovisual equipment was provided through a grant from the Blue Cross Blue Shield, and the state pays for the Vidyo service. Through this partnered effort, nurses received 1 to 1.5 hours of training on the equipment. The training taught staff how to conduct sessions from start to finish, including tasks such as confirming an inmate for treatment, ensuring HIPAA releases are in place, and initiating a session. After the initial grant-funded training, the nurses train each other on system use and procedures. The Carlton County IT department helps with any technical problems.

Technology and operations solutions
When it is time for a session, an inmate is escorted from his cell to the medical room, which contains a wall-mounted 36-inch television, microphone and camera. At the Carlton County jail, telepsychiatry is not used for inmates in crisis; having a table between the inmate and the equipment suffices to deter physical access to the system. A correctional officer monitors the activity from another room nearby via video only, and can intervene if necessary.

A nurse remains with an inmate during a session, operates the Vidyo system, and ensures HIPAA compliance. The nurse can help an inmate interact with the provider on video and can also act as the eyes and ears for the doctor, picking up on non-verbal cues and other indications of the inmate's mental health (e.g., facial expressions, hygiene, behavior outside of the sessions). The presence of a nurse during sessions has had a positive effect on inmates’ participation; they see the nurse as helping them and creating a safe space for their treatment.

The jail has contracted for 1.5 hours of telepsychiatry every two weeks and can add additional hours if needed. The regular timing of the sessions allows inmates and staff to integrate the sessions into their schedules. A diagnostic appointment takes 1.5 hours; maintenance and medication management appointments are 30 minutes. By comparison, when an inmate had to be transported to psychiatric services, the travel, appointment, and dictation time would usually take 2.5 to 3 hours.

Outcomes and advice
Telepsychiatry has enabled the Carlton County jail to accomplish its mission of providing sufficient mental health services to its inmates. Inmates are more willing to participate in telepsychiatry sessions in the jail than when they have to be transported to other facilities. In-house service provision, even through remote services, supports continuity of care with diagnostic and follow-up sessions.

Efficiency and costs have improved. Since telepsychiatry was implemented, inmates have required fewer trips to the emergency room, representing a significant cost savings. In addition, mental health service provision costs have been reduced to the cost of a doctor and a dedicated corrections officer, eliminating transportation costs (which require one to two dedicated staff and a law enforcement officer). Holding sessions on a regular time schedule has further streamlined the process for both the inmates and staff, making service provision more efficient.

Although implementing technology can be daunting, videocommunication and remote service solutions are becoming more common, less intimidating, and increasingly accessible for small and large jails alike. The Carlton County jail administrator, Paul Coughlin, reports that they spent significant time on planning, but that it was time well-spent because it ensured that implementation and service provision would be smoother than if they had rushed to get the program off the ground. For Coughlin, finding the right partnership between the Carlton County Jail and the telepsychiatry service provider was pivotal for the program’s success.

For further information: Paul Coughlin, Jail Administrator, paul.coughlin@co.carlton.mn.us