Hampton Roads Regional Jail in Portsmouth houses hundreds of mentally ill from the peninsula. The special units sometimes hold mentally ill in solitary. There are anywhere from 6 to 12 inmates on suicide watch at any given time at the jail.

They've served their jail time or they've been released from hospital custody. Then what happens to those diagnosed with a mental illness?

Without sufficient community support, many will cycle back into crisis care at a hospital or the criminal justice system, some sooner than others. A 2008 Old Dominion University study cited a recidivism rate of 77 percent within two years. Currently more than 6,300 Virginians diagnosed with a mental illness are held in a jail; of those, almost half have schizophrenia, bipolar disorder or PTSD, post-traumatic stress disorder. Most receive little or no mental health treatment and several hundred are kept in solitary confinement.

The odds are seemingly stacked against successful reentry into the community. Funding cuts have reduced supportive housing options and even though the 2012 report by the Office of the Inspector General put the relative annual costs at $214,000 for institutional care as compared to $44,000 in the community, the funding hasn't been there for community service boards and other support systems to reach all those who need help.

"All the treatment in the world and all the medications in the world aren't going to make a difference without stable housing and supportive services," said Mira Signer, director of the Virginia chapter of the National Alliance on Mental Illness.

James W. "Jim" Stewart III, the commissioner for the Department of Behavioral Health, the state agency charged with overseeing mental health services, agreed. "It's very difficult for anyone to make progress without housing. We haven't adequately built in Virginia the array of community supports to enable individuals to avoid crisis," he said.

Hospital or community care?

Stewart is, however, committed to boosting community supports rather than restoring state hospital capacity, which has fallen from 5,967 to 1,252 beds since 1976. "Putting people back in the hospital — that's not the answer. We have the techniques, the tools, the medications. We only need beds for short-term stabilization," he added. He also cited the prohibitive cost of hospitalization.

Not everyone agrees. Gabriel Koz, who retired in 2006 after a decade as medical director of Eastern State Hospital, believes beds are essential. "Crisis teams aren't going to do it. Beds are the answer," he said, referencing New York and Vermont as states that have reversed policy to expand hospital capacity. "It's like closing the emergency rooms and relying on outpatient care. It's too costly to lives and communities," he added.

Others — from David L. Simons, superintendent of the Hampton Roads Regional Jail, to Baltej Gill, senior medical director of the Hampton-Newport News Community Services Board — cite the frustration of families who can't access needed outpatient or hospital mental health care, and for whom jail becomes the default institution. "Jail is not the venue," said Simons, whose jail houses almost 400 inmates diagnosed with a mental illness, half of whom are prescribed psychotropic drugs.

Who pays?

At the HRRJ, which serves the jurisdictions of Hampton, Newport News, Portsmouth and Norfolk, Simons estimates the per-diem cost for an inmate with mental illness escalates from $65 to $500 or more for round-the-clock observation, meds and medical care. Currently, the localities bear the brunt of this cost. The state reimburses the jail at $8 a day for pre-trial inmates and $12 a day for those convicted. "There ought to be a higher per-diem for inmates that need this care and used to get it at state hospitals at state expense," said Simons. "By closing those beds — [Eastern State Hospital downsized by 85 beds in 2010] — and saving money, they should have diverted some to jails." As the director of a correctional facility that houses the most inmates waiting for an ESH bed, he believes a better option would be for the state to fund a mental health wing and supply the appropriate psychiatric treatment and drug therapy. "It would help treat them in a more therapeutic way and give them the treatment they need in a timely manner," he said. The wait to get in to ESH can span months as typically 15 percent of the hospital's discharge-ready patients stay past their release date, unable to find a community placement.

The hospital, whose 300 beds are assigned among geriatric, adult and forensic patients (those involved with the criminal justice system) serves about one-quarter of the state's population, focusing on regions covered by nine of the state's 40 community services boards. In its 2013 budget it received almost $48 million in state general funds and $20.5 million in Medicaid funds.

Chuck Hall, director of the Hampton-Newport News Community Services Board, objects to the hospital's current use of Medicaid funds. "The state shouldn't be running a Medicaid-reimbursed nursing home," he said, referencing ESH's geriatric unit. He would like to see those beds freed up for use instead by "individuals like those residing at the HRRJ."

If Virginia were to adopt the expansion of Medicaid as proposed by the Affordable Care Act, eligibility would increase from 80 percent to 138 percent of the federal poverty level and extend coverage for inpatient psychiatric care to many of the uninsured that the CSBs currently spend $5 million annually on at private hospitals, he said. That, in turn, would free up local funds to pay for beds at ESH for those in jail on account of their mental illness. "Now, there is not sufficient funding to cover both acute care in local private inpatient facilities and pay for this extended care at ESH that would be necessary for these very ill individuals," said Hall.

Community supports

Like Hall, John Pezzoli, assistant commissioner for the Department of Behavioral Health sees the expansion of Medicaid as vital to a better mental health system. "Many more people insured would make a huge difference.… It would be a huge step in the right direction," he said, noting that it would provide access to clinical and rehabilitation services for the neediest population, including those with serious and persistent mental illness. "The basic services that are the least widely available to a population that's all uninsured is seeing a psychiatrist or therapist and getting meds and prescriptions filled," he said.

This year's state budget funneled an additional $7 million to mental health care in the community, divided among drop-off centers, children's mental health crisis services, discharge assistance planning funds, suicide prevention and permanent supportive housing.

"We have to go back to the basics — housing, food, health care, appropriate social activities and jobs," said David Coe, director of Colonial Behavioral Health in Williamsburg. He'd also like to see an end to the stigma along with recognition that mental illness is a brain disease that merits the same treatment, research and funding as any other diagnosis, such as diabetes.

"In the past, priority has been on crisis response rather than intensive ongoing supports," affirmed Stewart, who commended the efficacy of the Crisis Intervention Team, CIT program, which has trained 70 percent of the state's law enforcement in the identification of mental illness and alternatives to arrest. Similarly Cross-System Mapping in 39 communities has identified gaps in services and fostered more effective communication between law enforcement and mental health systems, he said. And he commended PACT, an intensive round-the-clock support system now operating in 18 communities statewide that employs "wrap-around services" with a trained staff and peer supports caring for high-need individuals at a 1 to 8 ratio.

Preemptive help

One barrier to successful reintegration is the up to two-month delay those leaving jail encounter in restoring their SSDI benefits that are cut off during incarceration. At Hampton's Center for Child and Family Services, Ellen Williams, director of behavioral health services, oversees 22 programs that include Fresh Start for re-entry and free counseling and job readiness coaching. "We need to stop being punitive and ask not 'what's wrong with them' but 'what happened to them'" she urged. "I think we're getting more open with juveniles. I want it to take hold in the adult system." She believes it's important for localities to pitch in for mental health care as an investment in the health and safety of the community.

For veterans, the Hampton VA Medical Center has been operating a Veterans Justice Outreach Program since 2009. One of its goals is to assist the transition from jail to residential treatment at the VA with no downtime in the community for those who require that level of treatment, said Kimberly Cheney-James, its coordinator. The VA provides both acute care stabilization services as well as intermediate residential care, along with assistance in connecting veterans with counseling and community resources. The increased number of returning troops exhibiting symptoms of PTSD has the center reaching out proactively to veterans and their families for treatment before a crisis occurs. Outreach workers also scour local jails for veterans in order to connect them with services.

Jail diversion programs

In order for the multiple community resources to be effective, they need to be instituted in a coordinated manner, emphasized NAMI's Signer. Currently, she said, many localities are practicing these efforts, but in a piecemeal fashion.

She pointed to the Sequential Intercept Model as a comprehensive approach that plans for mental health and criminal justice crossover at every juncture: pre-booking, post-booking, jail and re-entry. "At each point, there's a step that can be taken to intercept and alter the outcome," she said. For example, dispatchers can be trained to recognize calls involving mental illness; officers can be trained in crisis intervention, CIT; a defense attorney would have the full health history; there would be a specialty docket or a mental health court; and the need for housing and support groups would be recognized.

Hampton/Newport News has one of the state's 10 drop-off centers and has been a leader in CIT training. A drop-off center is a secure place staffed by medical and mental health professionals and security used as an alternative to arrest and jail. The cities' CIT program, led by Dean Parker, has trained hundreds of officers, and Jay Sexton, coordinator of the new Colonial area CIT program has used it as a model to train 62 officers, as well as crisis workers, dispatchers and nurses. "We try to instill in them a lot of good communication skills and patience," Sexton said.

Nearby, Norfolk General District Court has the only specialty mental health docket in the region; it has met twice a month since September 2011 without extra funding. "It creates a more appropriate atmosphere for family members and more consistency. It allows us to assemble all the services that the court may want to appoint in the disposition of cases," said Judge Joseph Migliozzi, the sole presiding judge. "We're not a therapeutic court, but a docket that facilitates discharge planning for those with mental illness charged with misdemeanors. It requires a great deal of cooperation from city services and the jail." In its first year the court heard cases for 320 individuals and reduced the average wait for admission to a state hospital for evaluation from 160 days to 95.

No solution yet

Thousands of Virginians diagnosed with a serious mental illness continue to cycle in and out of the criminal justice system. With limited access to hospital beds, the appropriate level of community care remains elusive.

"What we don't have is a way for people who used to be served by state hospitals to be served in the community safely for them and for the community," said Associate Inspector General for Behavioral Health Doug Bevelacqua.

To that end, earlier intervention and expanding access to care before a crisis develops are gaining traction as priorities with the state.

"The earlier we intervene, the more successful we can be. There's a wide range of gaps," said Commissioner Stewart, who endorses more psychiatric services for children. "We need more ongoing outpatient support and adequate coordination in the community. It does require more resources."

Day One: "Jail is not the environment for treating the mentally ill'

Day Two: Hampton Roads Regional Jail and Eastern State Hospital: Same population, different treatment

Day Three: Meet some mentally ill inmates in Hampton Roads Regional Jail

Day Four: A Navy veteran with PTSD deals with jail after a vandalism change

Day Five: A better way to look after those diagnosed with a mental illness