Shannon Litz / Nevada AppealDavid Ramsey, nurse practitioner, is seen in his Carson City Jail office.
Sheriff Ken Furlong said getting help for mental health patients was something that had been pushed aside for a long time in Carson City. Saying it was an issue that “needs to be resolved,” the sheriff and other community leaders have partnered with the state in a new program.The Forensic Assessment Services Triage Team, or FASTT, is a partnership between the state and local governments to bridge a gap in mental health services from when someone is arrested on a low-level offense to after they are released but fail to engage the state's mental health services.“With these low-level cases, they're in and out so quick, that's why we call it FASTT,” said Dr. Joseph McEllistrem, the Carson City Jail's director of forensic health services.“Many of these people are known. They're known to law enforcement, they're known to the mental health service system, but it was the breakdown between the two systems, or not a formal relationship between them, that really is the crux of it,” Richard Whitley said. Whitley is the administrator of the Division of Mental Health and Developmental Services and the administrator of the Department of Health and Human Services' Health Division.Whitley has been one of the key players in so quickly organizing the FASTT program, Sheriff Ken Furlong, Partnership Carson City's Kathy Bartoz and other participants said.“The people that would qualify for the FASTT team intervention are going to be most readily identified by the arresting agent, the booking officer or the forensic health services team at the jail, because they're now not seen by a judge for at least three days,” McEllistrem said. McEllistrem said once someone who is in need of intervention is identified they fill out a referral form.“We do that just to get some buy-in from them. Tell us what's going on, help us quickly identify your needs. While they're filling that out, Lisa Treinen is contacted.”Triage Assessment Coordinator Treinen, along with psychiatric caseworker Kathleen Buscay, come to the jail and meet with the referral and do a clinical interview. Their findings allow David Ramsey, the jail's nurse practitioner, to write prescriptions and to make sure clients make their first, and continuing, appointments with Carson Mental Health Center. “In less than 24 hours, someone from Carson Mental Health and the FASTT team coordinator are on sight interviewing (the inmate,)” McEllistrem said. “Before they leave that interview, they have identified their needs, they have set an appointment with Carson Mental Health and developed a treatment plan.”So far, 41 people have been interviewed, five people have voluntarily enrolled in the program.“There are very few names I don't recognize” from previous contacts, Treinen said. “These are people whom we know.”McEllistrem has been seeing the same for many years. He is a clinical psychologist and known by most in the jail simply as Dr. Joe.“We have been dealing with how to integrate community collaboration between mental health providers, law enforcement and family,” McEllistrem said. “We kind of knew if we would integrate these groups, we could really reduce the number of crisis calls. “It was always reaching a crisis point before we were intervening.”MIND THE GAPThe problem everyone saw was the gap. When the jail released a low-level offender, usually arrested on a misdemeanor, an appointment had been made for the Carson Mental Health Center but the person rarely made it there. While the person was an inmate, he would be getting the proper medications but as soon as the jail bars closed behind him, he was left to his own devices. The gap in services had to be bridged.An October meeting between state and local leaders was called to discuss the issue. “They mobilized so quickly,” Whitley said. “I think it's because they were seeing the problem anecdotally and individually. They knew the problem. We put a number to it and said, we're a partner in this and in some ways, it was probably the state mental health system acknowledging the problem, quantifying it for ourselves and going to an existing forum in the community and saying, we're in. We need to be a part of addressing this problem and it did move very quickly, I think.”Bartoz praised Whitley's bottom-up approach. “He's allowing the community to take charge of our issues.”Before, Ramsey couldn't write prescriptions for longer than an inmate's stay. With the FASTT program, he can write prescriptions to last a few more days, just long enough for the client, as Whitley calls them, to get to his appointment with Carson Mental Health.Getting to the appointments, for many clients, can be more complicated than just continuing to take their medication. It's about their life skills, some of which many members of the community take for granted.“This isn't just about people being mentally ill,” Bartoz said. “It's about them not having the skills they need to function in society. It may be they can't navigate bus systems or have a difficult time with their social interactions skills and turn people off, don't get hired. It's people who are having a hard time functioning.”Those bridge medications, between the care they receive in the jail and the first appointment with Carson Mental Health, are a key part of the equation.“David Ramsey will write bridge medications,” McEllistrem said. “Once we verify the appointment with Carson Mental Health, if they're on meds, we want to keep them on their medications when they leave us, which in the past we weren't able to do because there was no guarantee of follow-up, which was too dangerous. Now we're able to supply these bridge prescriptions.”Whitley sees bridging the gap in services to be part of his duty.“I think it's negligent if we don't take an action to connect our systems because this is where the failure is occurring,” Whitley said. “These are our clients, so the fact that they were clients for out-patient mental health and now are coming into the criminal justice system, the question really is for us, on the mental health side, how is it that our services are failing and the client is having intervention from law enforcement. Unless we ask that question we can't get at what we could do differently.”Furlong, an enthusiastic partner the whole way through, said he, too, thought case management and proper hand-off are the key. Often, once a person was released from jail, they were really released not into the world or even back into Carson City but into “a dark hole.”“That dark hole was really the problem. They went right back to the street,” he said. “Case management is a critical issue when it comes to mental health. We weren't doing well at handing it off after they left the jail.”SILOS OF CAREPart of the new way of doing business is to break down the silos of care that existed, to build links and bridges and other sundry forms of transportation between service providers.“We're breaking down silos,” McEllistrem said.The FASTT team is made up of people, of faces. When someone comes in contact with the law and is being held at the jail, the FASTT team member, either Treinen or Buscay or both, will meet with them before they are released. When the client comes back to Carson Mental Health, they will be seeing the same, familiar face and reconnecting with someone they've already met.“Once you make that first contact, you take the mystery away,” McEllistrem said. Taking that mystery away, allowing a continuance of care, is one of the facets of the program.“Before, it was Band-Aid care.” McEllistrem said. “Deal with the crisis, put a Band-Aid on it and you move on to the next case that's burning on your desk. We just didn't have that ability to follow up and insure somebody's able to access the care they needed and said they wanted. In the end, it sort of already existed. We're just pulling them together and having a team follow them through the system so they don't fall through the cracks, so they don't miss an appointment, so they don't stop taking their medication. The barrier to successful treatment is really going to be addressed by the FASTT team.”When it comes to the actual costs of the program and the expanded care, on Whitley's end, it's almost nothing.“We're just moving personnel” and duties, he said. “We're formalizing the hand-off.”Bartoz was more enthusiastic. “He's taken existing resources and by moving them around and getting people to collaborate, get them all moved to the front-end of this problem, by doing the in-jail assessment, we have probably increased the success rate of these individuals three-fold without any additional money. It was just a matter of moving people around, getting them out of the silos, getting them out of their cubicles and saying, I'm putting you over here.”A similar program is ongoing in Reno, with the hope to expand statewide. UP AND RUNNINGWhitley came to Bartoz to help bring the local players together to bridge the gap in services he saw through the data his office had analyzed.“What we did with Carson City was we looked at the jail data and our mental health data for Carson City to see how many people in the jail had been clients of mental health and really let data drive where we needed to put services,” Whitley said. “What was unique, I think, was the sheriff being such a willing partner and being willing to share the data.“We had a meeting first with the sheriff (because) we're concerned that we're seeing a lot of people who are getting out of jail, not getting plugged in to mental health systems ...”With the draft report on the overlap between mental health patients and frequent visitors to the jail in hand, Whitley called Bartoz.“We're kind of a like a wedding planner,” Bartoz said of Partnership Carson City. “We bring all the resources together. He called us on (Oct. 17) to see what we could get done and, coincidentally, we had a steering committee meeting (two days later).”Whitley came to the meeting and presented his ideas and then the snowballing group contacted McEllistrem.The concept is not novel to McEllistrem, who had seen an earlier implementation of the Crisis Intervention Training program come and go as funding came and went. “We've been here before,” McEllistrem said. “We've done this before. We could never maintain it or sustain it. We're reworking a program from the past but now we have the support of the state.”The Crisis Intervention Training program, too, is being brought back into full swing come March, when the first training is planned. Much like the FASTT program, the CIT program aims to bring those who need help into contact with the Carson City's mental health resources, although its aim is broader.“CIT is not just mentally ill. Your crisis could be schizophrenic but this person's crisis is they just need shoes,” said Sgt. Daniel Gonzales with the Carson City Sheriff's Office.The problem has been here for a long time, Ramsey said. At 63, he's been in and around the medical field for 20 years. He went back to college at 43, graduated, and then bounced around before finally finding himself at the Carson City Jail.“This is kind of great,” Ramsey said. “Ever since we lost our mental institutions, those people were basically turned out onto the street and a big percentage of them ended up in jail. County jails have been the new mental institution. That's how it's been, so this is kind of a step in a new direction, which I appreciate.”Whitley was impressed by Furlong's own willingness to emerge from his silo. Furlong was the first sheriff to attend the meetings between the state and the local governments on the issue.“He's been directly involved,” Whitley said. “I thought it would be more challenging.”“This has come together quicker than any dealing I've had with the state in 30 years,” Bartoz said.