NEOMED TEMPLATE

Alternatives to Incarceration for Addicted and Mentally Ill Populations

County Commissioners Association of Ohio

June 10, 2015

PRESENTERS:

Ruth H. Simera, M.Ed., LSW Program Administrator

Criminal Justice Coordinating Center of Excellence

Northeast Ohio Medical University

Scott A. Sylak, MPA, LICDC-CS Executive Director

Mental Health & Recovery Services Board of Lucas County

ADULT CORRECTIONAL POPULATION

1980 – 2011 (BUREAU OF JUSTICE STATISTICS)

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010

Jail

StatePrisonParole

Probation

OVER-REPRESENTATION OF PEOPLE WITH MENTAL

ILLNESS: THE OHIO STORY

• In Ohio prisons • Total inmates = 50,079 (3/23/2015)

– 21% living with mental illness; 42% female population MI

– 7 times rate of substance abuse as the general population

• Ohio Department of Mental Health and Addiction Services

completed 1594 community linkage packets for persons

identified as SPMI in calendar year 2014.

– 77% substance abuse history; 49% reported trauma

history

• In Ohio psychiatric hospitals – 975 individuals (5/6/15)

• Typically around 60% are “forensic patients” Not Guilty by Reason of Insanity (NGRI)

Incompetent to Stand Trial (IST)

Competency or sanity evaluations

“Unsequential” Model

Dan Abreu

A SYSTEMATIC APPROACH TO THE

CRIMINALIZATION PROBLEM

• There is no single solution to the problem we are

calling “criminalization of people with mental illness”

– People move through the criminal justice

system in predictable ways

– The problem must be attacked from multiple levels

– The Sequential Intercept Model

SEQUENTIAL INTERCEPT MODEL

Sequential Intercept Mapping

Problem: In multiple systems; expensive,

high service users

Focus

• Men and women with…

–Serious mental illness, and often

Co-occurring substance use disorders

– Involved in the criminal justice system

Solution: Cross-system Coordination & Collaboration

Goals

Promote & support recovery

Provide safety, quality of life for all

Keep out of jail, in treatment

Provide constitutionally adequate

treatment in jail

Link to comprehensive, appropriate, and

integrated community-based services

Objective - Collaboration

Substance

Abuse

Criminal Justice

Consumers, Families & Advocates

Challenges to Collaboration

Funding “silos”

Limited resources

System “cultures”

Benefits of Effective Collaboration

Community Collaboration + Services

Integration =

service retention

stability in the community

public safety

Effective Diversion

A different way of doing business for Criminal Justice, the Mental Health System,

consumers and their families

Additional Strategies

Shared vision & direction

Data

Evidence-based & promising

practices

Funds: creative use

NEOMED TEMPLATE

The Mapping Process

1. Map The System

2. Identify Gaps

3. Prioritize

4. Action Plan

Intercept 1

Law enforcement / Emergency services C

OM

MU

NIT

Y

Dispatch

911

Lo

cal L

aw

En

forc

em

en

t

Arrest

CHALLENGES – INTERCEPT 1

• 7-14% Law Enforcement encounters involve

individuals with mental illness

• No where to take people other than jail

• Lack of training – mental illness information, de-

escalation

• Poor outcomes

• Arrest

• Use of force and unsafe responses

• Further disruption of treatment

• Injury, death

SPECIALIZED CRISIS RESPONSE SITES:

BASIC PRINCIPLES

• Identifiable and centralized for law enforcement

• “Police-friendly” policies and procedures

• Streamlined intake

• “No refusal” policy

• Legal foundations (Ohio Revised Code, HIPAA)

• Innovative and extensive cross-training

• Linkages to community services – Even for those who do not meet criteria for inpatient

commitment

(Steadman, et al, 2001)

INTERCEPT 1: INTERCEPTING AT FIRST CONTACT

POLICE & EMERGENCY SERVICES (DEANE, ET AL, 1999)

• Police-based specialized police response – Front line police response

– Specialized training/support system

– Example: Memphis Crisis Intervention Team (CIT)

• Police-based specialized mental health response – MH professionals employed by police dept.

– Example: Community Service Officers in Birmingham AL

• Mental Health-based specialized response – Mobile crisis teams

– Ohio County Examples: Clermont, Portage, Lucas,

Butler (hybrid)

Intercept I

19

CO

MM

UN

ITY

Intercept 1 Law enforcement / Emergency services - Transition

Lo

ca

l La

w E

nfo

rcem

ent

Ja

il R

ele

ase

s

Oth

er

Cri

sis

Sta

bil

iza

tio

n U

nit

s

Service Linkage: ICM/ACT EBP’s Peer Bridging Medical f/u Trauma Specific Services Jail linkage Other Assistance: Medication Access Benefits Housing Information Sharing

Pre

-bo

ok

ing

Ja

il

Div

ers

ion

Intercept 2

Initial detention/Initial court hearings

Arrest

Initia

l D

ete

ntion

First A

pp

ea

rance C

ourt

CHALLENGES - INTERCEPT 2

• Multiple agencies have stake in outcome

• Less flexible – limited options

• System moves fast – consumers swept up in the

rush

• Appointed counsel or public defense

• Lack of resources

• Competency

• Bail decisions

• Length of Stay - Defendants detained for the

entire pretrial period are more likely to be

sentenced to jail or prison – and for longer

periods of time (Lowenkamp, VanNostrand, Holsinger/ Arnold Foundation)

VALIDATED SCREENING TOOLS

• Brief Jail Mental Health Screen (Sandusky, Shelby)

• 3 minutes at booking by corrections officer

• 8 yes/no questions

• General, not specific mental illness

• TCU Drug Screen V • screens for mild to severe substance use

disorder

• GAIN SS (Global Appraisal

of Individual Needs Short

Screen) (Wood County)

• can be used to screen for both MH and AoD

• Veteran/Military Screening Steadman et al. (2005)

PROMISING AND BEST PRACTICES

Role of Pretrial Services, bail investigators

Use of management information systems to identify and re-link to services

Immediate referrals to community services Screening Liaisons, Service providers attending arraignment hearings

Court supervised release as condition of bail

Follow-up into the community

Specialty Courts

Other Court

Programs

Jail-Based:

Mental Health &

Substance Abuse

Services

Intercept 3

Jails/Courts

CHALLENGES - INTERCEPT 3

Longer Stays

Case Outcomes

Reason for Detention

Impact of Detention

Medication

Housing - classification

USING CRIMINAL CHARGES TO LEAD TO

TREATMENT

Diversionary or Intervention in Lieu --- Generally pre-adjudication

contracts with judges to participate in treatment; Conviction is not

recorded Example:

Prosecutor holds charges in abeyance based on agreement to enter treatment under

supervision of mental health court; Plea is entered but adjudication is withheld

Post-Plea Based --- Adjudication occurs but disposition or sentence is

deferred Example:

Guilty plea is accepted; Sentence is deferred

Probation Based Example:

Conviction with treatment as a term of probation plus suspended jail sentence

Griffin, Steadman, & Petrila 2002

INTERCEPT 3: JAILS AND COURTS Ohio Specialized Dockets:

Mental Health Courts Drug Courts

OVI/DUI Courts Domestic Violence Courts

Child Support Enforcement Courts

Re-entry Courts Sex Offender Courts

Veterans Courts

In-jail services:

Identification / screening

Access to mental health / substance abuse services

(medications, etc.)

Communication with previous services as appropriate

Peer Supports

Priso

n

Jail Reentry

Intercept 4

Reentry

CHALLENGES - INTERCEPT 4

Delay or break in continuity of services

Employment

Supports

Transportation

Medication discontinuation

Housing

Organized discharge planning

Post Release Risk of Death

THE BACK DOOR: LINKAGES BETWEEN INSTITUTIONS AND THE

COMMUNITY

• Refer Out

– Institution staff refer to community agencies

• Community Linkage

• In-Reach

– Providers come in for intake (Butler County)

• Transition Reentry (Centers)

– Shared responsibility (NY, TX)

• Let the Other Guy Do It

– Parole assumes responsibility at or following release

• $40 and Bus Ticket

STRATEGIES & PROMISING

PRACTICES

• GAINS Reentry Checklist - Based on APIC Model:

Assess, Plan, Identify, Coordinate

• Permanent supportive housing can reduce

recidivism and homelessness in this population

(Returning Home Ohio)

• Ex-Offender Reentry Coalitions & Services

– Employment, Peer Support, Resource Assistance

• Maximizing use of public benefits: SOAR, Ohio

Benefit Bank, ROMPIR, Medicaid Expansion,

expediting applications, Fidelity Bonding

Paro

le

CO

MM

UN

ITY

Pro

bati

on

Violation

Violation

Intercept 5 Community corrections / Community

support

People with severe mental illness are

less likely to succeed on probation

• Probationers with mental illness were:

• Less likely to have had their probation revoked because of a new arrest,

• Equally likely to have had their probation revoked because of a new felony conviction, and

• More likely to have had their probation revoked because of a new misdemeanor conviction.

• Probationers with mental illness are more likely to have their probation revoked because of failure to pay fine or fees, and “other” violations (e.g., failure to work).

• Why?

• Functional impairments that complicate their ability to follow standard conditions of probation (e.g., paying fees).

• Different revocation thresholds set by judges or probation officers.

Dauphinot (1996)

STRATEGIES TO IMPROVE SUCCESS FOR

PROBATIONERS/ PAROLEES WITH SEVERE

MENTAL ILLNESS

Reduce caseloads for specialty probation:

– Knowledge about mental health & community resources

– Relationships with clinicians

– Advocate for services

– Actively supervise these individuals

– Dual role - legal, surveillance and therapeutic, problem-solving

– Quality relationships with probationers that can strongly influence

outcomes.

– Problem-solving strategies to resolve noncompliance issues and

address individual inabilities or barriers

– Maximize limited resources in creative ways to address specialized

needs

Skeem & Louden (2006)

Sequential Intercept Model: The Revolving Door Approach

Community

Corrections &

Community

Support

Law

Enforcement/

Emergency

Services

Jail

Re-Entry

Booking/

Initial

Appearance

Jails, Courts

Best Clinical

Practices: The

Ultimate Intercept

Munetz & Griffin:

Psychiatric Services

57: 544–549, 2006

CROSS INTERCEPTS

• The GAINS Center has identified system-level

approaches relevant across all the intercepts.

– Collaboration among the stakeholders

– The “ultimate intercept” = community based

services

• For example, supported housing, education and

employment, peer support and other EBPs

• Culturally competent, gender specific and trauma informed

services

• Services which address the specific needs of veterans

• Attention to criminogenic risks and needs

Keys to Success

Task Force

Work Groups

Consumer Involvement

Communication & Information Sharing

Boundary Spanner(s)/Champion(s)

Momentum

Lawrence

Scioto Gallia

Adams

Pike Meigs

Jackson

Brown

Clermont

Hamilton Highland

Vinton

Ross Athens

Clinton

Warren

Butler Washington Hocking

Fayette Morgan Pickaway

Greene Monroe Preble

Montgomery

Perry Fairfield Noble

Clark

Madison

Franklin

Muskingum Belmont Miami Guernsey

Champaign Licking Darke

Harrison Delaware

Coshocton Shelby

Union

Logan

Knox

Jefferson

Tuscarawas

Holmes Auglaize Marion Morrow

Mercer Carroll

Hardin

Allen Columbiana

Stark Van Wert

Wayne Wyandot

Richland

Crawford Ashland

Mahoning Putnam Hancock

Paulding

Seneca Medina

Huron Portage

Summit

Defiance Henry Erie Sandusky

Trumbull Lorain

Wood

Ottawa

Cuyahoga

Williams

Geauga

Fulton Lucas

Lake

Ashtabula

Ohio Sequential Intercept Mapping – Adult Systems

Key

Pre OCJS project

Ohio mapping initiative

In progress

Requests/waiting list

TECHNICAL ASSISTANCE – CJ CCOE

• Trainers and Consultants

• Website

• Lending Library

• Local, State and National Resources

• Guidance on Best Practices and Evidence-

based Practices

• Peer networking

Ruth H. Simera, M.Ed., LSW Program Administrator

330-325-6670

www.neomed.edu/academics/criminal-justice-coordinating-center-of-excellence

41

1. Map The System

2. Identify Gaps

Priority Action Items Lucas County, Ohio - March 2014

3. Prioritize

4. Action Plan

Final Report • First cross-systems picture

• Wide distribution among local partners

• Planning reference

• Support for future funding applications

• Reference/resource materials included

• Priorities addressed over time – Especially with the CJAB and OBH

• Developmental tool

• Outcome measurement tool

Keeping the Momentum Going!

• Behavioral Health / Criminal Justice Alternatives Committee

– Be inclusive but stay focused

– Monthly meeting schedule (2nd Wednesday @ 10 AM)

– Workgroups broken down by priority

– Monitor performance

– Adjust “on the fly”

– Celebrate the big (and small) accomplishments

The Ultimate Intercept – Best Clinical Practices

• Crisis Intervention Team Training – Intersect 1

– Goals include improving de-escalation skills of law enforcement when dealing with people in psychiatric distress, reduce physical altercations, increase diversion, increase knowledge of community resources

– 508 law enforcement officers & 64 justice professionals trained

– http://www.citinternational.org/

The Ultimate Intercept – Best Clinical Practices

• Program of Assertive Community Treatment (includes ACT & FACT)

– Intercept 1-5

– Team Approach

– Community based & personalized

– Flexible & Time Unlimited

– NGRI/ICST-CJ (recidivism < 5% over last 5 years)

– http://store.samhsa.gov/product/Assertive-Community-Treatment-ACT-Evidence-Based-Practices-EBP-KIT/SMA08-4345

The Ultimate Intercept – Best Clinical Practices

• Treatment Accountability for Safer Communities – Intercept 1-5

– Independent entity (Boundary Spanner)

– Assessment, Referral, Linkage, Case Management, Reporting

– Improves treatment, employment and recidivism outcomes http://www.lucastasc.org/research.html

– http://nationaltasc.org/

The Ultimate Intercept – Best Clinical Practices

• Specialty Dockets

– Team intensive treatment

– regular court attendance and drug testing

– Judicial oversight

– System of rewards and immediate sanctions

– Family, Reentry, Veterans (2 drug courts planning stage)

– http://www.nadcp.org/

The Ultimate Intercept – Best Clinical Practices

• Medication Assisted Treatment – Intercept 1 – 5

– Methadone (tab or liquid)

– Buprenorphene (Subutex – tab)

– Buprenorphene & Naloxone (Suboxone –tab & film)

– Naltrexone (Vivitrol – injectable)

– Always in conjunction with counseling

– Associated with improved treatment outcomes

– http://www.samhsa.gov/medication-assisted-treatment

Lucas County One Year Later