Sequential Intercept Model and Using the Sequential Intercept

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Sequential Intercept Model and Using the Sequential Intercept Mapping for NEOMED TEMPLATE Community Action

Sequential Intercept Model and Using the Sequential Intercept Mapping for NEOMED TEMPLATE Community Action Ohio Justice Alliance for Community Corrections 32 nd Annual Conference October 11, 2018 This project partially funded by a Justice Mental Health Collaboration Program expansion grant No. 2017 -MO-BX-0022 awarded by the Bureau of Justice Assistance through the Ohio Office of Criminal Justice Services.

Adult Correctional Population 1980 – 2014 (Bureau of Justice Statistics) 8 000 Total Probation

Adult Correctional Population 1980 – 2014 (Bureau of Justice Statistics) 8 000 Total Probation Prison Parole Jail 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12 14

Mental Illnesses: Overrepresented in Jails and Prisons Correctional Population General Population 5% Serious Mental

Mental Illnesses: Overrepresented in Jails and Prisons Correctional Population General Population 5% Serious Mental Illness 17% Serious Mental Illness 72% Co-Occurring Substance Use Disorder Slide courtesy of Fred Osher, M. D

Over-Representation of People with Mental Illness: The Ohio Story In Ohio prisons • Total

Over-Representation of People with Mental Illness: The Ohio Story In Ohio prisons • Total inmates = 49, 534 (July 2018) – Estimated 20% mental health caseload: 9% classified seriously mentally ill; percentage typically double for female population mental illness – 7 times rate of substance abuse as the general population – Ohio Department of Mental Health and Addiction Services completed 1769 community linkage packets for persons identified with a serious persistent mental illness in calendar year 2016. – On average 3/4 substance abuse and 1/2 trauma history • In Ohio psychiatric hospitals – 1, 081 individuals (9/9/18) • On average, 70 -75% are “forensic patients” Not Guilty by Reason of Insanity (NGRI) Incompetent to Stand Trial (IST) Competency or sanity evaluations

“Unsequential” Model Initial Hearings Arrest Jail Mental Health Substance Abuse Dan Abreu Prison

“Unsequential” Model Initial Hearings Arrest Jail Mental Health Substance Abuse Dan Abreu Prison

Criminal Justice Coordinating Center of Excellence (CJ CCo. E) • May 2001 – County

Criminal Justice Coordinating Center of Excellence (CJ CCo. E) • May 2001 – County of Summit Alcohol, Drug Addiction & Mental Health Board was designated by the Ohio Department of Mental Health – CJ CCo. E to help in the state-wide elaboration of Jail Diversion programs • Northeast Ohio Medical University (NEOMED) operates the Center • Promote utilization of Best Practices • Develop education and training materials • Promote cross system sharing • We have many partners

A Systematic Approach to the Criminalization Problem • There is no single solution to

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 Intercepts Best Clinical Practices: The Ultimate Intercept I. Law Enforcement/Emergency Services II. Post-Arrest:

Sequential Intercepts Best Clinical Practices: The Ultimate Intercept I. Law Enforcement/Emergency Services II. Post-Arrest: Initial Detention/Initial Hearings III. Post-Initial Hearings: Jail/Prison, Courts, Forensic Evaluations & Forensic Commitments IV. Re-Entry From Jails, State Prisons, & Forensic Hospitalization V. Community Corrections & Community Support Munetz & Griffin: Psychiatric Services 57: 544– 549, 2006

SEQUENTIAL INTERCEPT MODEL

SEQUENTIAL INTERCEPT MODEL

Cross Intercepts • The Gather, Assess, Integrate, Network and Stimulate (GAINS) Center has identified

Cross Intercepts • The Gather, Assess, Integrate, Network and Stimulate (GAINS) Center has identified several system-level approaches relevant across all the intercepts. – Encourage and support collaboration among the stakeholders – Many of the cross intercept approaches are part of what we called the “ultimate intercept” or Intercept 0 • Supported housing, education, employment, peer support, effective and accessible mental health system, evidence-based practice (EBP)s • Services which are culturally competent, gender specific and trauma informed • Services which address the specific needs of veterans • Court-ordered Outpatient Treatment (Ao. T)

Sequential Intercept Mapping Problem: In multiple systems; expensive, high service users Solution: Cross-system Coordination

Sequential Intercept Mapping Problem: In multiple systems; expensive, high service users Solution: Cross-system Coordination and Collaboration

Focus • Men and women with… § Serious mental illness, and often § Co-occurring

Focus • Men and women with… § Serious mental illness, and often § Co-occurring substance use disorders § Involved in the criminal justice system

Goals § § Promote & support recovery Provide safety, quality of life for all

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 Use Criminal Justice Consumers, Families and Advocates

Objective - Collaboration Substance Use Criminal Justice Consumers, Families and Advocates

Tasks §Map the local system §Identify gaps §Build an action plan §Build collaborations

Tasks §Map the local system §Identify gaps §Build an action plan §Build collaborations

Challenges to Collaboration § Funding “silos” § Limited resources § System “cultures” § Time

Challenges to Collaboration § Funding “silos” § Limited resources § System “cultures” § Time constraints

Enhancing Collaboration § Shared Vision and Direction § Data and Shared Definitions § Cross-training

Enhancing Collaboration § Shared Vision and Direction § Data and Shared Definitions § Cross-training § Funds – Creative Uses § Interagency agreements: § § Coordinate services Communication Information sharing Cross-systems partnerships 15

 • Approximately 75% of the group should be top and middle level administrators

• Approximately 75% of the group should be top and middle level administrators • About 25% should be front line staff and peers/consumers or family with lived experiences

COMMUNITY Dispatch 911 Local Law Enforcement Intercept 1 Law enforcement / Emergency services Arrest

COMMUNITY Dispatch 911 Local Law Enforcement Intercept 1 Law enforcement / Emergency services Arrest

Challenges – Intercept 1 • 7 -14% Law Enforcement encounters involve individuals with mental

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, deescalation • Meaningful exchange of information • Poor outcomes • Arrest • Use of force and unsafe responses • Further disruption of treatment • Injury, death 36

Specialized Crisis Response Sites: Basic Principles • • • Identifiable and centralized for law

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, Health Insurance Portability Accountability Act [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)

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 – Mental health 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

Crisis Intervention Team – Memphis Crisis Intervention Team Model • A police officer and

Crisis Intervention Team – Memphis Crisis Intervention Team Model • A police officer and mental health consumer safety program largely adopted in Ohio • A unique community partnership – Law enforcement, the mental health system, consumers and their families • A pre-arrest jail alternative program • A civil liability reduction program • Training and Core Program Elements Intercept I

Intercept 2 First Appearance Court Arrest Initial Detention Initial detention/Initial court hearings

Intercept 2 First Appearance Court Arrest Initial Detention Initial detention/Initial court hearings

Challenges - Intercept 2 • • • Multiple agencies have stake in outcome Less

Challenges - Intercept 2 • • • Multiple agencies have stake in outcome Less flexible – limited options and resources Meaningful booking process System moves fast – consumers swept up in rush Access to appointed counsel or public defense Competency Length of stay Bond/Release decision-making Defendants detained for the entire pretrial period are more likely to be sentenced to jail or prison – and for longer periods of time (Lowenkamp, Van. Nostrand, Holsinger/ Arnold Foundation) 44

Intercept 2: Initial Detention Considerations for Diversion and Pretrial Release Historical Criteria • Charges

Intercept 2: Initial Detention Considerations for Diversion and Pretrial Release Historical Criteria • Charges • Identification • Previous booking information (if available) • Screen for security and suicide issues • Criminal Arrest History 45

Intercept 2: Initial Detention Considerations for Diversion and Pretrial Release Best Practices (in addition

Intercept 2: Initial Detention Considerations for Diversion and Pretrial Release Best Practices (in addition to Historical Criteria) • Screen and assess for individual factors • Mental illness and substance use • Risk: public safety and re-arrest • Level of need – acute care, detox • Treatment history 46

Intercept 2: Initial Court Hearing Considerations for Diversion and Pretrial Release Historical Criteria •

Intercept 2: Initial Court Hearing Considerations for Diversion and Pretrial Release Historical Criteria • Charges – felony or misdemeanor • Nature of offense • Bail Schedule – led to high use of financial bonds • Criminal and Failure to Appear (FTA) history 48

Intercept 2: Initial Court Hearing Considerations for Diversion and Pretrial Release Best Practices (in

Intercept 2: Initial Court Hearing Considerations for Diversion and Pretrial Release Best Practices (in addition to Historical Criteria) • Utilize Validated Tools - determine public safety and Failure To Appear risk • Screen for mental illness and substance use • Obtain mental illness and substance use information from jail and community • Eligibility and referral to Specialized Courts, programs • Bail decisions related to risk; use of non financial Release on own Recognizance and least restrictive bail supervision and conditions 49

Promising and Best Practices • Role of Pretrial Services, bail investigators for felony and

Promising and Best Practices • Role of Pretrial Services, bail investigators for felony and misdemeanor charges • Use of management information systems to identify and re-link to services and inform pretrial functions • Immediate referrals to community services – warm hand-offs to reduce risk of overdose upon release • Screening • Liaisons, Service providers attending arraignment hearings • Court supervised release as condition of bail – in conjunction with orders for assessment or participation in treatment as appropriate • Follow-up into the community 50

Validated Screening Tools • Texas Christin University (TCU) Drug Screen V with opioid supplement

Validated Screening Tools • Texas Christin University (TCU) Drug Screen V with opioid supplement • Screens for mild to severe substance use disorder • GAIN SS (Global Appraisal of Individual Needs Short Screen) (Wood and Hancock Counties) • Can be used to screen for both mental health and substance use disorder • Veteran/Military Screening • Brief Jail Mental Health Screen (Sandusky, Shelby) • • • 3 minutes at booking by corrections officer 8 yes/no questions General, not specific mental illness • Ohio Risk Assessment System (ORAS) or other validated risk tool 51 Steadman et al. (2005)

Intercept 3 Jails/Courts Specialty Courts Other Court Programs Jail-Based: Mental Health & Substance Abuse

Intercept 3 Jails/Courts Specialty Courts Other Court Programs Jail-Based: Mental Health & Substance Abuse Services

Challenges - Intercept 3 § Longer Stays § Case Outcomes § Reason for Detention

Challenges - Intercept 3 § Longer Stays § Case Outcomes § Reason for Detention § Impact of Detention § Medication § Housing - classification 54

Intercept 3: Jails and Courts § Ohio Specialized Dockets: § § § Mental Health

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 and assessment at front door § Access to mental health/substance use services (medications, etc. ) § Communication with previous services as appropriate § Crisis Intervention Team training § Peer Supports

Using Criminal Charges to Lead to Treatment § Diversionary or Intervention in Lieu ---

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 4 Prison Reentry Jail Reentry

Intercept 4 Prison Reentry Jail Reentry

The Back Door: Linkages Between Institutions and the Community Intercept 4

The Back Door: Linkages Between Institutions and the Community Intercept 4

Challenges - Intercept 4 § Delay or break in continuity of services § Employment

Challenges - Intercept 4 § Delay or break in continuity of services § Employment § Supports § Transportation § Medication discontinuation § Housing § Organized discharge planning § Post release risk of death 62

Strategies and Promising Practices • GAINS Reentry Checklist - Based on Assess, Plan, Identify,

Strategies and Promising Practices • GAINS Reentry Checklist - Based on Assess, Plan, Identify, Coordinate (APIC) Model • Permanent supportive housing can reduce recidivism and homelessness in this population (Returning Home Ohio) • Ex-Offender Reentry Coalitions • Reentry Services – Employment, Peer Support, Resource Assistance • Public Benefits

Intercept 5 Probation Violation COMMUNITY Violation Parole Community corrections / Community support

Intercept 5 Probation Violation COMMUNITY Violation Parole Community corrections / Community support

People with Severe Mental Illness are Less Likely to Succeed on Probation • Probationers

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

Strategies to Improve Success for Probationers/Parolees with Severe Mental Illness • Reduce caseloads for specialty probation agencies to allow probation officers to: – Develop knowledge about mental health and community resources – Establish and maintain relationships with clinicians – Advocate for services – Actively supervise these individuals • Recognize multiple roles – Probation/parole officers take on both a legal/surveillance role and a therapeutic/problem-solving role. – The quality of the relationship between the officer and the probationer can strongly influence outcomes. Skeem & Louden (2006)

Sequential Intercept Model: The Revolving Door Approach Community Corrections & Community Support Jail Re-Entry

Sequential Intercept Model: The Revolving Door Approach Community Corrections & Community Support Jail Re-Entry Law Enforcement/ Emergency Services Best Clinical Practices: The Ultimate Intercept Booking/ Initial Appearance Jails, Courts Munetz & Griffin: Psychiatric Services 57: 544– 549, 2006

Missing Links • Lack of access to evidence based interventions (Osher & Steadman) •

Missing Links • Lack of access to evidence based interventions (Osher & Steadman) • Failure to incorporate risk factors for recidivism as points of clinical intervention (Skeem & Louden) • Modifying evidence based intervention protocols so that they incorporate services that target criminogenic issues (Morressey et al. Mueser et al. ) • Limited research on transition to adulthood age group. (Osgood, Foster & Courtney) Slide provided by Amy Wilson, Ph. D.

The Mapping Process 1. Map The System NEOMED TEMPLATE 2. Identify Gaps 3. Prioritize

The Mapping Process 1. Map The System NEOMED TEMPLATE 2. Identify Gaps 3. Prioritize 4. Action Plan

Effective Diversion: A different way of doing business for Criminal Justice, the Mental Health

Effective Diversion: A different way of doing business for Criminal Justice, the Mental Health System, consumers and their families

1. Map The System • Examine the process in a specific locality to identify

1. Map The System • Examine the process in a specific locality to identify ways to “intercept” persons with severe mental illness and co-occurring disorders to ensure: – Prompt access to treatment – Opportunities for diversion – Timely movement through criminal justice system – Linkage to community resources

1. Map The System 49

1. Map The System 49

2. Identify Gaps

2. Identify Gaps

3. Prioritize

3. Prioritize

Priority Action Items

Priority Action Items

4. Action Plan

4. Action Plan

4. Action Plan

4. Action Plan

Final Report • First cross-systems picture • Wide distribution among local partners • Planning

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

Technical Assistance – CJ CCo. E • • • Trainers and Consultants Website Lending

Technical Assistance – CJ CCo. E • • • Trainers and Consultants Website Lending Library Local, State and National Resources Guidance on Best Practices and Evidence-based Practices • Peer networking

Keys to Success § Task Force § Work Groups § Involvement of Individuals with

Keys to Success § Task Force § Work Groups § Involvement of Individuals with Lived Experience § Communication and Information Sharing § Boundary Spanner/Champion § Momentum § Evidence-based and Promising Practices

Wood County At Work § Feasibility Study - Crisis Stabilization Unit §Transportation coordination §Involuntary

Wood County At Work § Feasibility Study - Crisis Stabilization Unit §Transportation coordination §Involuntary Civil Commitment process §Data and Information Sharing - survey §Housing and Stability – merged with Reentry Coalition housing subcommittee §Trauma Informed Care - Sanctuary

Sandusky County At Work § Reentry Program – brochure; resource guide §Common observation form

Sandusky County At Work § Reentry Program – brochure; resource guide §Common observation form for law enforcement, agencies and others developed collaboratively by mental health and E. R. §Data and Information Sharing §Brief Jail Mental Health Screen §Regional CIT Training Center §EMS-sponsored CIT training

Ohio Criminal Justice Coordinating Center of Excellence NEOMED TEMPLATE Ruth H. Simera, M. Ed.

Ohio Criminal Justice Coordinating Center of Excellence NEOMED TEMPLATE Ruth H. Simera, M. Ed. , LSW Director 4209 State Route 44 Rootstown, OH 44272 PH: (330) 325 -6670 FAX: (330) 325 -5970 www. neomed. edu/cjccoe