The Sequential Intercept Model

Leah Vail, MA Forensic Program Director Meridian Behavioral Healthcare, Inc.

Presenter Jim Santangelo, CAP Alachua County Court Services Clinical Programs Manager Co-Presenter

A Request

 Please turn off your cell phones, Blackberrys, Beepers, I-phones, Pagers and gameboys  Or place on silent mode

Training Agenda

 A. “Criminalization of the Mentally Ill”  B. Model Basics -It’s history -It’s use  B. Sequential Intercept Points  C. Alachua County Discussion

Impact of Consumers in the Criminal Justice System

 Current estimates suggest that as many as 700,000 adults entering jails each year have active symptoms of serious mental illness and three quarters of these individuals meet criteria for a co-occurring addictive disorder (GAINS, 2001)

General Involvement in the CJ System

 In 2005, over 7 million people were on probation, in jail or prison, or on parole at yearend – 3.2% of all U.S. adult residents or 1 in every 23 adults. (Bureau of Justice Statistics)  In 2001, the U.S. incarceration rate of 690 per 100,000 overtook Russia (670/100,000) to lead the world. Then by 2005, the rate had risen to 726/100,000.

Mental Health Involvement in the CJ system

 People with a Mental Illness are charged, convicted, and sentenced than more severely than others accused of similar crimes (Hochstedler, 1987; NY State Office of Forensic Task Force, 1991)  People with a Mental Illness spend 2 to 5 times longer in jail than those without MI (Criminal Justice/Consensus Project, 2003)

Alachua County Jail

 Alachua County Jail: between 10 and 25% of the detainees received psychotropic meds (2008-2009 CJMHSA Planning Group).

Alachua County Jail

 According to Jail statistics, 36% of all detainees at first appearance had either an open or previous SA or MH case. Approximately 5% had an open case, 23% had previously received MH and/or SA services as an adult, and 9% had treatment as a child.

The Alachua County Story

    1998 – County Committee begins to identify MH/SA as reasons for growing jail population – Consensus that treatment is important – Partnership solutions sought 2000 – Mental Health Court established 2003 – Crisis Intervention Team grant written – Felony Mental Health Court (Div V) established – Community Based Competency Restoration program established 2005 – CIT classes started – In-jail to community competency restoration – County created Mental Illness Workgroup (“MIWg”) to identify needed services and develop strategic plan for effective jail diversion system.

The Alachua County Story

    2006 – MIWg report leads to funding for enhancing existing competency restoration program and creating a “Forensic Specialist Team” 2007 – Meridian Forensic Specialist Team started -County Commission created CJMHSAG Planning Committee – Official County advisory Board charged with responding to grants and other funding opportunities – Resulted in award of 3-year $2million grant that is a county and state partnership.

2008 – CJMHSAG awarded funding creating the Forensic Diversion Team.

2010 – CJMHSAG awarded continued funding by merging the MIWg and CJMHSAG teams to create a comprehensive Forensic Team.

Partners since 1998

MH/SA Providers Public Defender Law Enforce ment Public Safety Coordina ting Council Courts (Judges & Staff) County Govern ment (Elected & Staff) State’s Attorney

Tools for Transformation: Alachua County’s Partners

             Court System, Judges, Administration Office of Public Defender, Office of State Attorney, Regional Council Alachua County Jail Law Enforcement Court Services Meridian V.A.

SAMH/DCF State Hospitals – FSH, NEFSH, NFETC Agency for Persons with Disabilities FACT team Gulf Coast Home Alachua/Gainesville Housing Authority

A systematic approach to the criminalization problem

  There is no single solution to the problem we are calling “criminalization of people with mental illness” Cecil’s Story

What is the Sequential Intercept Model?

 “Framework for thinking about how and where diversionary alternatives might best fit a community” – Marc Cherna, Director ALLEGHENY County Dept. of Human Services, Pitt, Penn

Basics of the Sequential Intercept Model

 A conceptual framework for communities to use when considering the interface between the Criminal Justice and Mental Health systems.  There are a series of points of inceptions at which an intervention can be made to prevent individuals from entering or falling deeper into the criminal justice system.

More Basics of the Sequential Intercept Model

 People with mental disorders should not “penetrate” the criminal justice system at a greater frequency than people in the same community without mental disorders.  Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point.

Final Basics of the Sequential Intercept Model

 The deeper that people enter into the system costs more time, money, and energy.

 And the harder it is to exit them from the system.

 Think of the model as a funnel  Handout

Why is this model important?

 State of Florida made it central to the CJMHSA grants  SAMSHA Best Practice

Five Stages of the Model

 1. Current Services (prevention) & Emergency/Police-Based Response  2. Initial Hearings and Initial Detention  3. Speciality Courts  4. Re-Entry to the Community from Jails and State Hospitals  5. Community Corrections and Community Support Services

1. Current Community Mental Health Services

 Outreach  Treatment & Medication  Case Management  Housing  Transportation  Meaningful Daily Activities  Crisis Services

Treatment & Medication

 Mental disorders are treatable.

 For most mental disorders, there is a range of treatments  Rehab Services/Case Management  Therapy  Pharmacological – 1 st generation medication – Newer medications

Consequences of a Lack of Treatment

 The consumer falling into a crisis  More Vulnerable  Involvement with LEO  CSU admission  Criminal Charges

Case Management

 In general, the more specialized, the more intensive services are better  Forensic Specialists (ave caseload of 35)  Intensive Case Management (caseload of 10)  FACT services (team approach, max 100 clients)  Traditional Case Management (caseload of 30)  VA - MHICM

Housing

 The importance of housing cannot be over stated  IDEALLY, the community has a range of housing options, including – Residential – SRT – AFP – ALF – Housing vouchers – Homeless Assistance Programs

Transportation

 Bus system/passes  Are there bureaucratic barriers interfering with staff transporting consumers?

 Medical transport  Medicaid transportation

Meaningful Daily Activities

 Employment or vocational program  Psychosocial Rehab  Education  Volunteering  Clubhouse  Peer activities  Drop-in Center  Partial hospitalization

Crisis Services

 Emergency screening services  CSU or receiving centers – How many beds does your community have?

 Public CSU vs. Private CSU – How easy is it to access these beds?

 Educating LEO re: the Baker Act  Involuntary Outpatient Commitment

If treatment is so effective, then why

          

are so few people receiving it?

Less than a third of adults with a diagnosable mental disorder and even smaller proportion of children receive any mental health services in a given year (Surgeon General report) Stigma Fear of being hospitalized Cost Organizational barriers - No access Not having the time Thinking that they could handle it alone Thinking that no one could help Denial –lack of insight into illness Side Effects Substance Abuse

1. Emergency/Police-Based Response .

 “Law enforcement agencies have played an increasingly important role in the management of persons experiencing psychiatric crisis” Lamb et al (2002)  7 to 10% of patrol officer encounters involve persons with mental disorders.

 Historically mental health and law enforcement have not worked closely together.

Emergency/Police-Based Response .

 The prototype of the specialized police officer approach is the Memphis Model Crisis Intervention Team (CIT), which is based on collaboration between law enforcement, the local community mental health system, and other key stakeholders.

 CIT has lower arrest rates, high utilization by patrol officers, rapid response time, and frequent referrals to treatment.

CIT in Florida

 CIT  Mobile Crisis Team (Tampa,FL)  Emergency/Police-Based Response a Rural and Multi-Jurisdictional Crisis Intervention Team  Enhanced mental health, crisis intervention, system awareness at the police academy

Emergency/Police-Based Response :Alachua

 CIT started March 2005 – Steering Committee contains representatives by GPD, ASO, UPD, DCF, Meridian, NFETC, Alachua County Crisis Center, VA – Three classes per year *Alachua County Crisis Center, CAREs Team, Crisis Hotline, Therapy *Mental Health Training for 911 operators *Mental Health and BA Training for LEO

2. Initial Hearings and Initial Detention –

 Even when optimal mental health service systems and effective pre-arrest diversion programs are in place, some individuals with serious mental disorders will be arrested.  On the basis of the nature of the crime, such individuals may be appropriate for diversion to treatment, as a condition of pre-trial release

Initial Hearings and Initial Detention –

 Post arrest diversion procedures may include having the court employ mental health workers to assess individuals after arrest  MH workers advise the court about the possible presents of mental illness and options for assessment and treatment.

 Courts may develop collaboration with the public mental health system, which would provide staff & services

Initial Hearings and Initial Detention : Alachua

 Several points of initial contact at Booking In and First Appearance: Jail classification Jail Mental Health Centralized Screening Team – Court Services First appearance staff – judges, attorneys

Initial Hearings and Initial Detention : Alachua

 Individual then are screened for services: MH Court Court Service Supervision, Day Reporting and Treatment Meridian Forensic Services Potential Div V cases Veterans Services Drug Court

At Sentencing

 Want the Judiciary to be informed at sentencing to make sure that the appropriate conditions are established

3. Specialty Courts –

 Incept 3 intervention that is receiving attention are the establishment of separate court programs specifically to address the needs of persons with mental illness.

 Special jurisdiction courts limit punishment and instead focus on problems solving strategies and linkage to community treatment to avoid further involvement in the criminal justice system.

Specialty Courts –

 The national GAINS center estimates that there are now 114 mental health courts for adults in the United States.

 Most are for misdemeanor defendants.

Court : National Best Practices

 Many Counties are starting to just develop misdemeanor courts  1 st such Court in the United States of America was in Broward county  2 nd such court in Florida was in Alachua County  1 st Felony Court in Florida was Alachua County

Court: Alachua (MH Court)

  The Alachua County Mental Health Court is a pre adjudication diversion program, and the charges will be dismissed if the individual successfully completes the mental health court plan. This is a VOLUNTARY court. Court Services, Meridian, State Attorney, Public Defender work as a team.

Alachua County and Columbia County  2011 data on 204 participants indicated that:  Average Jail Days was 39.05 before Mental Health Court  Average Jail Days was 2.4 after Mental Health Court

Court: Alachua (Div V Felony Forensic Court)

 Participants are individuals who have been found Not Guilty by Reason of Insanity, Incompetent to Proceed, and/or Probation with Mental Health conditions. This is a NON- VOLUNTARY court.

 Court Services, State Attorney, Public Defender, Regional Council, Probation and Meridian all work as a team.

4. Reentry/Reintegration

 Re-entry from Prison, Jail, and State Hospital  There is little continuity of care or communication between corrections and community mental health for mentally ill individuals who leave correctional settings.

 Public mental health systems may be unaware when their clients are incarcerated or released.

Reentry/Reintegration

 In addition, pressure is increasing on corrections and mental health systems to stop the cycle of recidivism frequently associated with people with severe mental illness who become involved in the criminal justice system.

 A ssess P lan I dentify C oordinate – APIC Model

Reentry to the Community from jail and state hospital

 The APIC model for transitional planning from local jails breaks new ground with it’s focus on assessing, planning, identifying and coordinating transitional care.

The APIC Model: Assessing

  Assess the clinical and social needs, and public safety risks of the consumer Cataloging the consumer’s psychosocial, medical, and behavioral needs and strengths  Gathering information from LE, courts, corrections, CMH, & families to create a fully informed transition plan  Incorporating a cultural formulation in the transition plan  Engaging the consumer in assessing their own needs  Ensuring the consumer has access to and means to pay for treatment and services

The APIC Model: Planning

 Plan for the treatment and services required to address the consumer’s needs  Addressing the critical period immediately following release (1 st hour,day, & week) as well as long term needs  Learning from the consumer what has worked or not worked during past transitions  Seeking family input  Addressing housing needs

The APIC Model: Planning-2

 Arranging an integrated treatment approach for the consumer with co-occurring disorders  Ensuring that the consumer is on an optimal medication regimen  Ensuring that they have sufficent medication to last until psychiatric appointment  Connect consumers with acute and chronic medical conditions with community medical providers

The APIC Model: Planning-3

  Initiating benefit applications/reinstatements for eligible inmates for Medicaid, SSI/SSDI, Veterans, food stamps, and TANF Ensuring the consumer has…  Adequate clothing  Transportation  Food

The APIC Model: Planning

 Almost all jail consumers with co-occurring mental illness and substance abuse disorders will leave correctional settings and return to the community. Inadequate transition planning puts people with co-occurring disorders who enter jail in a state of crisis back on the streets in the middle of the same crisis (Osher, Steadman, & Barr, 2002)

The APIC Model: Planning

 The outcomes of inadequate transition planning include the compromise of public safety, an increased incidence of psychiatric symptoms, relapse to substance abuse, hospitalization, suicide, homelessness, and re-arrest. (Osher, Steadman, & Barr, 2002)

The APIC Model: Planning

 Transition planning can only work if justice, mental health, and substance abuse systems have a capacity and a commitment to work together… The results will only be as good as the partnership in the community

The APIC Model:Identifying

 Identify required community and correctional programs responsible for post-release services  Naming in the transition plan specific community referrals   Forwarding a complete discharge summary to the community provider Ensuring every consumer’s belongings are returned upon release  Ensuring the consumer has a picture ID

The APIC Model:Identifying

 Ensuring that the treatment and supportive services match the consumer’s level of disability, motivation for change, and availability for community resources.

  Supporting conditions of release and community supervision that match the severity of the consumer’s criminal behavior Addressing the community treatment provider’s role vis-à-vis other social service agencies, probation, and the courts

The APIC Model:Coordinating

 Coordinate the transition plan to ensure implementation and avoid gaps in care  Supporting the staff in coordinating the timing and delivery of services and in helping the consumer span the jail community boundary after release  Case assignment must be made cooperatively by the consumer, jail, and community agency itself

The APIC Model:Coordinating

 Explicitly communicating to the consumer, family, releasing facility, and community treatment agency, the names and contact information of the person(s) who will responsible for care between the time of release and first follow-up appointment  Confirming the consumer knows details of the follow-up visit  Confirming that they have adequate medication  GAINs Re-Entry Checklist

Community Re-entry: Alachua

JAIL -Coordinated efforts are made to ensure an appropriate release plan, use A.P.I.C. model -GAINS Reentry Checklist, handout -SOAR application in jail PRISON -Limited discharge planning – usually a medication appointment with the local provider is made.

-VA has Prison release programs

5. Community Corrections

(and Community Support Services)

–

 Consumers under continuing supervision in the community by the CJ system (usually probation) are another large group to consider.

 Failure to attend treatment appointments often results in revocation of probation and a return to jail.

MI individuals have trouble with probation or conditional release

 Person may never understand instructions or follow through because of symptoms – Person may be experiencing symptoms of psychosis – Overwhelmed because of anxiety about the appointment – Experience paranoia & not trust enough to follow through – Unable to complete the terms of release – community service, fee’s – Zero tolerance probation standards – Inconsistent sleep patterns due to side effects of meds – Unable to plan how to get there

Community Corrections/Support: Alachua

 Interagency collaboration continues to be the key focus in Alachua County.  Once per month a continuity of care meeting in held consisting of key stakeholders of the forensic population. This meeting provides agencies with a floor for planning, networking, implementation, service coordination, collaborative problem solving, referrals, and information sharing.

Community Corrections/Support: Alachua

 Department of Probation – dedicated probation officer  Court Services -Day Reporting -County Probation -Work Release -Electronic Monitoring -Court Service Contact and Treatment Supervision

Alachua Team Ongoing Support

 Meetings, leadership, & Cooperation – Needed as boundary spanners  Information exchange – Timely information handoffs – HIPPA  Training. System training for LEO, PD, ASA, Jail, MH, Courts, & Court Services

Sequential Intercept Model + Community Vision  Not available  In place  Partially in place

Post Booking



Intercepts

Coordinated screening  Forensic Specialists, Court Services

Pre-Booking Intercepts

 Crisis Intervention Teams  Fully funded community based system of care

Court/Jail Intercepts

 In-jail specialized treatment  Therapeutic Courts (Misdemeanor, 916, Felony)  Community/Jail based Competency Restoration Services  Forensic Services  Court Services

Re-Entry Intercepts

 Forensic Residential Treatment  Forensic Specialist Team  Court Services  Peer Specialists

Vision:

A community that no longer needs jails and courts to serve as a provider of mental health and addictions treatment

Post-Release Intercepts

 Specialized Probation  Specialized, Supported Housing  Fully funded community based system of care

Working Together to Install Best Forensic Mental Health Practices

       Incentivize by funding, removing barriers, provide excellent resources to learn and grow Encourage improvement Require and regulate Assist local mental health systems to develop the capacity to identify and implement Best Practices Develop education and training materials Utilize and share fidelity scales or other measures to evaluate implementation Promote cross system sharing

Alachua Diversion Statistics

 At the end of March, a total of 184 clients were actively participating in the program. Approximately 16% (28 of 184) received outreach/case management in the jail. Approximately 6% (12 of 184) received competency restoration services in the jail. Approximately 78% (144 of 184) of participants received treatment and/or case management services in the community, with a total of 26% (38 out of 144 people in the community) receiving treatment services, treatment groups and individual sessions.

Re-Cap

 A. Model Basics  B. Sequential Intercept Points – 1. (Current Services) + Emergency/Police Based Response – 2. Pre/Post-arrests – 3. Specialty Courts – 4. Re-entry/Reintegration & the APIC model – 5. Community Corrections C. Alachua County Status & Recommendations

Status

  Handout Idea’s?

 Recommendations?

 Comments?

 Questions?

Thank You

 Please fill out the satisfaction questionnaire