This morning, inmate Gibbs had a visit.  The nurse passing medications in the housing unit noticed that he was not ready when his name was called.  Unusual.  Mr. Gibbs is typically aware of his visits and is up and ready at least five minutes before it’s time to go.  The nurse asked Mr. Gibbs if he was feeling ok.  Mr. Gibbs just shrugged and left the unit for his visit.  Later that day, the nurse noticed that Mr. Gibbs was not out in the day room playing cards with others, like he usually is.  The nurse walked by Mr. Gibbs’ cell and noticed he was just lying on his bunk looking at the ceiling.  The nurse asked again if everything was ok and Mr. Gibbs stated, “Just not my day.  Things aren’t working out for me.  That’s the problem with hope, you always get disappointed.”  “Anything I can do?” the nurse asked.  “No, man.  Thanks.  Just gotta do what I gotta do.”

Every individual who works in a correctional setting has unique experiences with inmates.  Based on your role, your personality, your style of interaction and how others perceive you, you are likely to see and hear things that others do not see and hear.  In the above example, the nurse has a unique perspective on what’s happening with Mr. Gibbs. 

Do not underestimate the value and importance of what you see and hear.

When you notice things are out of the ordinary, ask questions.  If the answers leave you feeling unsure, make a referral. 

In the above example, Mr. Gibbs’ needs appear to be mental health needs. There is no indication that he is physically ill, but the changes in his behavior and mood require further evaluation by a mental health professional.  A referral is needed.  The question is, what type of referral?  Below is a description of the typical referral types available in correctional settings:

Emergent –when concerns raised during any interaction with a patient clearly indicate that the patient cannot and must not return to a general housing setting, action must be immediate and appropriate.  In most cases, the immediate action involves placing the patient in a safe housing area and engaging a qualified mental health professional to conduct a more thorough evaluation of the patient’s needs.  In these instances, communication and coordination are required.  The staff member should communicate first to the patient that s/he is going to be moved to another location for safety until an evaluation can be completed.  Then, communication and coordination with custody staff is required to ensure the patient is placed in a proper location. Next, a referral needs to be generated to the qualified mental health professional who will complete an evaluation.  Lastly, clear documentation is required.  While a standard form is used in most settings, it is important to include a thorough narrative description of what prompted the emergent referral. 

Urgent – when concerns indicate that the patient needs further assessment soon but is not in immediate danger or does not have acute needs, an urgent referral is required.  In most settings, urgent referrals require follow up within 24-48 hours.  Again, communication with the patient and documentation including a thorough narrative description of the rationale for an urgent referral is necessary. 

Routine – these are the standard referrals generated when a patient requires follow up but does not need a rapid response.  Timelines for routine referrals range from 3 days to 14 days in most settings.  Again, communication with the patient and documentation are essential.

For the Mr. Gibbs scenario above, it seems to me that either an urgent or routine referral is needed.  I tend to err on the side of caution, so for me, I would likely submit an urgent referral.  But I can see where someone else may determine that a routine referral is appropriate.  This decision would be based on the nurse’s sense of what Mr. Gibbs needs.  If this is truly extraordinary and truly concerning given Mr. Gibbs history, then urgent is the way to go.  If, on the other hand, his presentation did not seem way outside of the range of Mr. Gibbs’ ordinary behavior, a routine referral may be just fine.

Regardless, you hopefully saw that in the above discussion of referrals, two elements are universally required – communication with the patient and thorough documentation.  Telling the patient that you intend to make a referral lets the patient know that you are concerned and prepares the patient for the upcoming evaluation.  When it comes to documentation, I cannot overemphasize the importance of clear communication and rationale when generating mental health referrals.  Often, patients will report one thing to one staff member or show signs of distress, only the downplay or change their presentations later.  If you see something that is concerning enough to warrant an evaluation by a clinician, then take the 1-2 minutes needed to document what you observed and what you believe needs evaluating. 

What I have shared here is my opinion, based on my training, research and experience.  I could be wrong.  If you think I’ve got it wrong, please let me know why in the Comments.

Do you have any recommendations regarding referrals?  Please feel free to share.