Medical Case Management in Jail Mental Health Units

Patients with mental illness have high levels of medical co-morbidities and dramatically shorter lifespan than those without mental illness. In correctional settings, accessing medical care may be more difficult for patients in any specialized housing areas, including those in mental health units. Within the New York City jail system, comprising 11 jails and approximately 90,000 admissions per year, a pilot program was recently instituted to incorporate medical case management into several mental health housing areas. A registered nurse is assigned to three dorms (approximately 120 patients) that house patients with the highest level of mental illness. The case management nurse reviews each patient's chart and has at least a monthly visit with each patient, in order to ensure that both the medical and mental health concerns of the patient are addressed. In addition, brief teaching regarding compliance with medical and psychiatric care is provided during these visits and weekly meetings are conducted with the mental health staff to review the nurse's assessments and recommendations of patient care. Finally, the case management nurse identifies patients who have missed medical appointments, have lapsed medication orders or have other concerns that might not come to the attention of the medical clinic staff without the presence of the patient in clinic. Patient needs that are not related to medical and/or mental health care (such as linen changes, temperature of the housing area, and access to sick call) are addressed by a staff analyst that works closely with the case management nurse. The first month of this pilot yielded small (5-10%) increase in sick call utilization and similar decreases in medical emergencies and injuries. The real benefit of the case management program appears to be in coordinating the medical and mental health care of patients. Prior to this pilot program, medical and mental health teams rarely communicated about a patient's care unless a problem developed. Patients with poorly controlled mental illness are less likely to be produced to medical and specialty care and conversely, when these patients have exacerbations of their medical problems, they are less likely to be available for mental health care. The initial data from this pilot support reporting by medical and mental health staff that case management in these mental health units has greatly improved coordination of care.