On Dec. 20, Brian Snyder spent the night sleeping on the floor at the Boyle County Detention Center, the same as he had for the past two weeks.

The fact the jail has more inmates than it has beds is well known — it’s been that way for more than a decade. But Snyder wasn’t just sleeping on the floor, he was recovering from having his gallbladder removed.

“It’s not the best environment to recover from a surgery,” Snyder said during a video call with his wife, Jeni McCabe, five days before Christmas.

McCabe said Snyder got sick pretty bad on Nov. 23, the day after Thanksgiving. He began filling out medical slips, trying to get help — “he got some Tums; that’s all they would give him,” McCabe said.

But others eventually began to notice how sickly Snyder looked and he was taken to Ephraim McDowell Regional Medical Center on Dec. 1, McCabe said.

Snyder’s medical records from the hospital confirm he was checked in on Dec. 1 and a CT scan showed he had hepatitis and cholelithiasis. A surgeon removed his gallbladder on Dec. 2 without any complications, and Snyder was discharged back to the jail on Dec. 6.

“When he gets back from the hospital, he was and still is on the floor. He’s recovering on the floor,” McCabe said on Dec. 18.

According to the Kentucky’s VINE offender database, Snyder has since been transferred and is serving time in the Roederer Correctional Complex in Oldham County.

Snyder’s experience doesn’t seem to be an outlier when it comes to medical care at the jail. A comprehensive jail study completed for Boyle and Mercer fiscal courts found that the current facility is “inadequate” to provide constitutionally required levels of medical and mental health care for the inmates.

“… Many inmates cannot receive adequate levels of care due to lack of medical and mental health classification housing areas and cells,” according to the study. “The single medical exam room is also the records room, nurses’ office and medication area. The booking (area) lacks space for adequate levels of privacy for conducting intake health screenings and nearby cells are often used to house suicidal and mentally ill patients. There is no shelter-care/infirmary housing unit and inmates recovering from serious health conditions are crowded into small cell areas. Some sleep on the floor in makeshift beds called “BOATS.”

Boyle County Jailer Brian Wofford said he’s well aware of the problems with the current jail facility: “I want people to come in and see how bad it is, because that’s the only way I can get it fixed.”

The jail currently contracts with Southern Health Partners to provide a 24/7 nursing staff and twice weekly visits from a nurse practitioner, Wofford said. The nurses see inmates when they first request medical attention. They decide if the inmate needs further attention when the nurse practitioner next visits the jail, or if they need to be taken to the hospital, he explained.

From January through September of 2018, SHP handled 2,867 calls from inmates for medical staff, according to numbers provided by Wofford. That amounts to an average of about 319 calls per month — more than 10 calls a day. That’s also more medical calls than the jail’s average daily population, meaning an average inmate sees a nurse more than once every month.

And those numbers don’t count some routine medical treatments, such as administering insulin for diabetic inmates.

“We have a very unhealthy population in our jail,” Wofford said. “A lot of that is just due to lifestyle choices and some of it is just like anybody else. We have cancer patients, we have people needing dialysis.”

Essentially all of the medical visits that happen at the jail happen in the facility’s single exam room.

“We have a little room and it looks just like a doctor’s office,” Wofford said. “It has a bed, a sink and then it has a little bathroom off of it. We have a refrigerator where we keep insulin … because we have a lot of inmates who are diabetic.”

Wofford said the jail has a two-person cell intended to provide beds for inmates with medical conditions, but the moment the jail has three or more such cases, “one is on the floor.” There have been as many as eight inmates at one time that needed a medical bed, back in 2017 when the jail’s population topped out at more than 400 multiple times, he said.

“Unfortunately, the jail has nada” when it comes to health care facilities, consultant Dr. Kenneth Ray said in November, when the jail study he helped compile was released. Jail staff are “doing the best they can, but you can’t create an infirmary where one does not exist,” Ray said.

From Snyder’s perspective as an inmate, he said he never saw anything he would consider a medical facility while he was in the Boyle jail. He said he got some Tylenol for pain handed to him through a cell door, but no real medical attention.

“I had basically resigned myself to dying in here,” he said.

Snyder said once he got to the hospital, a doctor told him his disease had progressed to the point that it was beginning to threaten his life. It can feel as though “if something is to happen to you” while in jail, “you’re not going to make it out,” he said.

“I’d just like to say there are a few staff members here who go above and beyond, but I feel like they’re so overwhelmed and outnumbered (that they can’t overcome) the facility itself,” Snyder said.

Wofford said he and his jail staff want to provide constitutional health care for the inmates, but the existing jail makes it essentially impossible.

“We don’t have the space to allocate a medical wing for those inmates that need it,” he said. “… This is something that we have to provide because the Constitution says we have to. Just because someone has been incarcerated does not mean they lose their constitutional rights. They’re still U.S. citizens. … Yes, they are here to be punished, but they’re not here to be mistreated.”

And inmates in a county jail, unlike in state or federal prisons, are largely being held pretrial — they are still considered innocent until proven guilty, Wofford added.

Mental health

Just as concerning to Wofford is the need for mental health care in the jail.

The jail study, compiled over most of 2018 by consultants with Brandstetter Carroll, found that the jail has “no formal mental health program.”

“Mental health care is limited to medication without individualized psychotherapeutic treatment plans, individual or group treatment,” the study reads. “… The facility lacks sufficient capacity and is poorly designed to deliver the most basic mental health care. There are no special housing units for inmates experiencing acute psychiatric episodes, no spaces for mental health treatment, no offices for mental health staff if mental health staff were employed and on-site. For inmates with severe and active mental health illness, care is limited to medication and segregation or isolation.”

The jail’s only mental health resource is the Kentucky Jail Triage hotline, Wofford said.

When an inmate is apparently experiencing mental health issues — if they seem to be off their medications or suicidal, for example — jail staff call the triage line, which is run by Bluegrass.org.

“Within a couple hours, somebody will call back and they will interview (the inmate) over the phone and do an assessment,” Wofford explained.

The jail has one cell designed as a suicide watch cell. When there’s more than one inmate in need of such a cell, the jail uses its detox cells, of which it has four, Wofford said. “Especially on the mental health side, it seems to take up a lot of our detox space.”

According to Dr. Ray, the number of triage calls the Boyle jail has to make is growing at an alarming pace.

Over the past four years, the annual triage calls has risen from 327 to 402, Ray said. When compared with the jail’s average daily population (ADP), the number of triage calls has risen from 102 calls per 100 ADP to 131 calls per 100 ADP.

“That’s a lot of inmates need mental health crisis health. It also tells you the jail doesn’t have the resources to deal with these issues,” Ray said in November. “… You’ve got a jail that’s not designed to deal with that stuff.”

On the mental health front, however, Wofford said he does see a way to make things better fairly soon.

“My goal is getting mental health (care) in here. I don’t know if I’m going to be able to do it until the next budget cycle,” which starts July 1, he said.

Wofford hopes to persuade Boyle and Mercer counties to provide an estimated $30,000 to $40,000 in funding for two part-time positions at the jail. One person would be a “qualified mental health professional” who would take the place of the triage hotline when on-duty by conducting evaluations of inmates in-person and potentially referring them to psychologists or psychiatrists outside the jail. The other would a “case manager” who would help inmates prepare for success after they’re released.

“They would help them re-enter our community when they’re released. Help them find housing, make sure they’re getting fed, getting their Medicaid or health care set up … so they can continue their treatment,” Wofford said. “Instead of … doing all this work inside and then there’s no continuance of care, they drop off and then a few days or weeks later, they’re going to be back. I think that’s where it would save us money. … To me that just seems like it’s common sense.”

Wofford said space at the jail is extremely tight, but he thinks he’s figured out how to give the two new positions a fairly private space to work out of. “We’ve got a room that used to be a closet that I think I could turn into a sort of office.”

Wofford said he would also like to see the county start a substance abuse program for county inmates similar to the very successful one already in place at the jail for state inmates.

“It’s great that we’re helping these folks, but they are going back somewhere else in the state” when they’re released, Wofford said of the state inmates in the substance abuse program. “We need to focus on those that are going to come out and be our neighbors first. Because they’re the ones that are going to affect our crime, our taxes, you know — the wellbeing of our community.“

Underreporting health problems

Another health problem identified in the jail study is underreporting of medical and mental health issues during intake of new inmates.

“Approximately 11 percent of inmates report having any health care need and approximately 13 percent report having a specific chronic or communicable disease at booking, yet 47 percent of the inmate population is being treated with medication for health problems,” the study states. “Only 3.6 percent report having mental illness, while approximately 5 percent report having received mental health services in the community. Approximately 4 percent report being prescribed medication for mental illness. However, approximately 19 percent of the inmates are being treated for mental/behavioral health problems with psychotropic medications, and the number of inmates who need mental/behavioral health treatment is likely much higher than reported.”

Wofford said as many as two-thirds of the jail’s inmates on any given day are suffering from a medical or mental health issues.

Dr. Ray said in November the underreporting may be partly due to “a badge asking the questions.” He said the accuracy of health screenings during booking goes up when health professionals can ask inmates questions in a private place. The jail has no private place for the questioning and no health professional to conduct the interview, Ray said.

Wofford said having a deputy jailer ask inmates about their medical problems is less than ideal. The inmates won’t tell the deputy that they used heroin last week or just recently smoked some marijuana, for example, “because they’re afraid it will be used against them,” he said.

“We’re not going to charge that, but we need to know that because if there’s a medical emergency, we need to be able to respond to that and be prepared for it,” he said.

Wofford said he believes the jail staff does “a great job with the space we have,” but “we could do it better if we had the proper facility.”

Adding a health professional to handle the health screenings would require the Boyle and Mercer fiscal courts that run the jail to request bids from companies that could provide the service, and then find funding for the cost, Wofford said.

Even then, Wofford said he worries a lot of inmates may still not report mental health problems because of how stigmatized mental illness is in the country. But a health professional asking the questions would be beneficial — especially if it’s “somebody here local. I think that’s going to play a big part in the continuance of care once they’re released,” he said.

The underreporting is a real problem when you consider the backgrounds of the people who typically end up in jail, Ray said in November.

“You’re dealing with a population whose life history includes trauma and violence and neglect at a much higher prevalence than we know,” he said. “… You’re dealing with a population that has stuff to the 10th power.”

Ray said what the Boyle County Detention Center and local criminal justice system need is “smart justice” that doesn’t “hug-a-thug,” but does acknowledge the large and growing presence of mentally ill and unhealthy people in the jail population.

“At some point, you’ve got to make a decision … what are you doing? In my career, I have not seen any dissipation in crime associated with drugs or mental illness. It’s not dissipating, it’s growing,” he said. “… It’s just more evidence that your jail is not designed well now to deal with your population.”

Solutions

Wofford said even if criminal justice reforms significantly reduced the jail’s current population, he doesn’t think the existing building could ever provide adequate health care facilities because of how it’s laid out. It would take at least renovation and expansion, or even a new facility to fix the problems.

The jail study’s biggest and most expensive recommendation is construction of a new jail building with around 450 beds — more than double the existing jail’s 220-bed capacity — at a ballpark cost of around $34 million. The existing jail could be renovated and expanded, but after accounting for costs such as moving inmates elsewhere during construction, the cost for that option is estimated at $36 million.

The study also offers a recommendation for a three-phase treatment center. The initial “detox” phase facility would cost an estimated $2.4 million; a secondary facility for a 30-day drug treatment program would be another $2.4 million; and a third facility that would provide training and life skills would cost $2.3 million.

The new 450-bed jail would probably be about 98,000 square feet; the treatment facility would need a total of about 30,000 square feet.

The study makes several other recommendations specific to medical and mental health care for inmates, including:

• “move medically ill inmates off floor and on permanent bunks;”

• “provide adequate spaces for proper medical examinations and care;”

• “implement an array of programs and services to adequately address inmate mental/behavioral health risks and needs;”

• “hire three to four licensed mental health professionals to assess and treat inmate mental illness on-site;”

• “add additional qualified health staff to eliminate use of deputy jailers for completing intake health screens;”

• “conduct intake health and safety interviews in a reasonably private area to increase inmate reporting of health and safety needs at booking;”

• expand community-based behavioral health services to increase access to care before and after incarceration;” and

• “assign a sub-committee of the (Criminal Justice Coordinating Council) to implement improvements in jail-based health and rehabilitation services and monitor compliance with those improvements.”

Asked which of the study’s recommendations he would like to implement first, Wofford said, “All of it.”

“It would be hard to single one thing out,” he said, but added: “Being able to provide mental health care inside the jail — I think that would save us money in the long run, because I think it would lower the recidivism rate … when they come back into our community, I think they would be better set up to succeed. I think they’ll have a better opportunity to be successful and we won’t have them coming back as often.”