Criminal Justice Behavioral Health Initiative

Leah KaiserHuman Service and Public Health Department

The Problem

• Disproportionate representation of persons with behavioral health needs in jails and correctional facilities

• Emergency Hospital beds are at capacity serving people with behavioral health needs

• Ineffective system response to behavioral health needs are driving public safety and health care costs

• Poor client health outcomes, poor public safety outcomes

The Underlying Reason

Ineffective Access Process– Gaps in access to medications, housing, treatment, jobs– Eligibility criteria promotes working the extremes and cycling, instead of promoting a range

of responses

System Fragmentation/Program Silos– Separate funding streams – Addressing behavioral health needs in controlled, inappropriate settings– Misuse of public safety and health care resources

Community Supports Insufficient for Complex Populations– State Operated Services- bottleneck (in and out) – Lack of discharge planning from Jail and Workhouse– Hospital discharges to shelters– Rule 20 - efficiencies and limited treatment options

The Partners

• Hennepin County Residents & Service Consumers, • Local Law Enforcement Agencies, • the Hennepin County Sheriff’s Office, • City and County Prosecutors, • the MN Fourth Judicial District, • the Hennepin County Public Defenders Office, • the Hennepin County Department of Community Corrections and

Rehabilitation, • the Human Services & Public Health Department, • the Hennepin County Medical Clinic, • National Council of Behavioral Health, • MN Department of Human Services & MN Department of Health, • Hennepin County Community providers.

The Response

• System Approach – Shared goals across sectors: individual responsibility, collective

accountability– Identify and activate partners

• Two Pronged Approach – System Level Change

» Policy Change/Process Change

– Service Level Change » Program and Service Development

• Use Best Practice Approaches– Tailor criminal justice system with behavioral health needs in mind– Tailor behavioral health services with criminal justice issues in mind

• Resources - ROI model– Think big, start small, move fast– Leverage system funds, grants, redeploy FTEs

The Response (continued)

• Dedicated Manager to Lead

• Stakeholder Priority Actions Taken– Integrated Access Team and TJC– Local restoration and services for incompetent clients– Gap Case Pilot

• Governance Structure: aligning public safety, health and human service partners

Integrated Access Team

• HSPHD, HCSO, and HCMC partnership• Multi-agency oversight• Imbedded social service team in jail• MOU with 2 navigator agencies• Functions:

1. Assist inmates apply for medical care

2. Complete file clearances to determine case involvement and facilitate care coordination

3. Complete mental health assessments

4. Develop individual service plans/transition plans, same day service linkages

in the community and support for 90 days post release

Local Competency Restoration

• Stakeholder agreement of problem and expected end result• Data Review shows R20 trending upward• Best Practice Models Reviewed• Options to consider:

– Triage & range of options based on Tx needs & public safety risk

1. Hospital

2. Community

3. Jail

Gap Case Pilot

52 R20 clients since JuneInitial Results:

– 38 clients offered pre-trial services, 6 open to short term intensive case management.

• Housing is the most requested service.  • Mental Health services are warranted in most cases but few clients believe this

is necessary. • Other services: coordination with probation, warrant coordination, AP

referrals, ES and SSI benefits, and service referrals.• Insurance: 15 MA, 16 uninsured, 21 PMAP 

– Custody Status: 25 Clients were IN Custody, 27 Clients were NOT in custody– 18 clients MI Committed– 1 DD commit– 18 clients Dismissed– 12 with No Disposition (waiting)– 2 MI Stays– 1 found Competent

 

Desired Goals & Outcomes:

• Increase health care coverage for high need clients• Reduced use of emergency room• Increased use of community based services• Early identification of BH needs • Decrease recidivism• Increase coordination and communication across county

systems

The Challenges

• Community Resource Issues– Housing, Forensic ACT, IRTS– Capacity – Appropriateness– Funding for in-custody services

• Data & Information sharing – health, welfare, public safety data privacy issues– Multiple source systems

Final Thoughts

• Success will not achieved independently, but will be achieved through the engagement of others with a diversity of perspective, knowledge and experience.

• The needs of our customers are complex and require innovative, systemic and integrated approaches to solve.

• Persistence and a strategic focus will ultimately result in the achievement of goals.

Input & Questions

Jennifer DeCubellis: 612-596-9416Jennifer.DeCubellis@hennepin.us

Leah Kaiser:612-596-1779Leah.Kaiser@hennepin.us

Olmsted County Forensic Mental Health Services

Timeline

• 1998– Social Worker in ADC .2

• 2000– Social Worker increased

to full time on site

• 2005– Jail diversion begins

• 2006– Second social worker

added on site

• 2007– 1st CIT local training held

• 2009– Re-Entry program begins

• 2010– Rule 20 process defined

internally

• 2014– WIT Grant

Sequential Intercept Model

• A conceptual framework developed by Mark R. Munetz, M.D. and Patricia A. Griffin, Ph.D..

• Used for decisions around criminalization of people with mental illness and provides interception points for intervention.

• Ideally people will be intercepted at earlier points with decreasing numbers at each subsequent point, preventing deeper penetration into the criminal justice system.

Olmsted County Adult Detention and Forensic Behavioral Health Programs

Crisis Intervention Team (CIT)

Post-Booking Jail Diversion

Forensic CommitmentsWIT Grant

Re-Entry Services

Community Supports

Pre- Booking Diversion/ CIT• Crisis intervention training provides police and probation

officers, social workers, detention deputies and other professionals who recognize and respond appropriately to people in psychiatric crisis.

• Local program is a self-sustaining collaboration between Olmsted Count Social Services, Sheriff’s Office, Rochester Police Department, and community providers.

• CIT training for police officers began locally in 2007, as of 2014 over 120 local officers and 24 dispatchers are now trained. A 2015 training is currently being planned.

Post Booking Jail Diversion & Forensic Commitments

• Rule 20– Collaboration with County Attorney, court services, and Competency Restoration

to streamline Rule 20 commitments and timelines.

• Forensic Commitments– Case management for SDP and MI&D commitments and competency cases from

admission to discharge.

• “Whatever It Takes” (WIT Grant)– The WIT grant was provided by DHS in June of 2014 to provide an array of wrap

around services including flexible funds, necessary to obtain and retain community tenure and stability for individuals discharged from Anoka Metro Regional Treatment Center (AMRTC) or Minnesota Security Hospital (MSH) St. Peter.

– Modeled after AMRTC liaison which reduced hospital days beyond medically necessary by 30%.

– Liaison case management for CREST region (Dodge, Fillmore, Goodhue, Houston, Mower, Olmsted, Rice, Steele, Wabasha, and Winona counties).

Jail Diversion • Decrease in jail diversions• Reduction in time spent

in jail prior to diversion

• Possible causes:– Beginning of CIT training in

2007 increasing CIT officers each year

– Increased collaboration with mental health, court services, and law enforcement

Mental Health Services in ADC

• Services– Full time mental health

professional– Psychiatry (4 hours per

week)– Full time forensic social

worker– Full time behavioral health

social worker– Part time discharge

planner– ADC program Sgt/deputies

• Population– May 2013 and July 2014

• 412 detainees assessed half met the criteria for Serious Mental Illness (SMI) or Serious/Persistent Mental Illness (SPMI)

– January through July 2014• 237 offenders with an

assessment, 47% met SMI/SPMI criteria.

• 63% of females met SMI/SPMI criteria compared to 42% of males

Re-Entry (ROC)

• Sentenced adults in Olmsted County Detention Center with at least 30 days before release

• Adults diagnosed with severe mental illness (SMI) or severe persistent mental illness (SPMI)

• Areas ROC can provide help with:– Case Management– Short and long term goal

planning– Referrals to community

providers/services/ supports

• 2012-2014– 14 people participated in ADC ROC– 8 people are still in community ROC – 1 has not yet been released– 5 people have been discharged

• 3 to prison • 1 moved with probation transferred out of

county• 1 now in Assertive Community Treatment

• 2009-2012– Two years after release:

• Re-Entry clients (14)– average of 1.6 visits to jail– averaging only 22.9 days (321 total days)

• Non-re-entry clients (10)– average of 2.1 visits to jail– averaged 99.6 days in jail (996 total days)

Goals

• Expand CIT into more community agencies• Increase Re-entry services• Improve Rule 20 tracking and commitment

process in CREST region• Reduce hospital days at St. Peter due to lack of

placements, resources, and system gaps

Ramsey County Mental Health Court:

Working with the Mentally Ill Defendant

Judge John H. GuthmannJudge William H. Leary Judge Theresa Warner

Brandi Stavlo, MSW, Program Coordinator

• RCMHC began in May 2005. It is a voluntary program.

• RCMHC has developed around two factors, desired outcomes and funding, and is based on a case-management model.

• Desired outcomes: Connect people with existing community mental-health and social-service resources that participants can access during and after court involvement. For that outcome, RCMHC formed a partnership with Ramsey County case-management services.

• Funding: RCMHC is currently funded by the Minnesota Department of Human Services, Adult Mental Health, and federal Bureau of Justice and Mental Health Expansion grants.

RCMHC Background

The goals of the RCMHC are to:

• Reduce recidivism.

• Improve public safety.

• Reduce the costs of arrest, prosecution, incarceration and treatment.

• Improve access to mental health and other treatment and social services within the community.

• Enhance collaboration between criminal-justice agencies and the mental health system to better serve those with mental illness.

• Improve the quality of life of mentally ill defendants.

Goals

• Will the defendant benefit from the program?

• Can the program provide or connect the defendant to appropriate community resources for recovery?

• Is the defendant capable of following through with the program and its conditions and treatment recommendations?

Important Considerations for Eligibility

RCMHC works closely with:

• Ramsey County Mental Health Center

• Ramsey County Pretrial Conditional Release Agency

(Project Remand)

• Ramsey County Adult Probation

• Ramsey County Correctional Facility

• Second Judicial District Research Department

Collaboration

1. Establishment of treatment plan

• The case manager provides the team with detailed psycho-social assessments of each defendant referred to RCMHC. This information is used in two ways.

• First, it allows the team to make an informed decision regarding the nature of a defendant’s illnesses—and the risks they pose to public safety.

• Second, the information is used to craft individualized treatment plans for each defendant, matching the defendant to appropriate service programs.

How it Works

2. Monitoring

• Treatment progress is primarily monitored by case manager and probation officer.

• Defendant is required to return to court at least every two weeks to appear before the judge, case manager, probation officer, county attorney and defense counsel to assess treatment progress.

• Frequency of appearances lessens as defendant completes treatment phases.

How it Works continued…

Among the mental-health supports and programs to which participants are connected are:

• County Case Management

• Adult Rehabilitative Mental Health Services (ARMHS)

• Personal Care Attendant

• Representative Payee

• Dialectic Behavioral Therapy (DBT)

• Mental Health Day Treatment

• Mental Health Pro-Social Centers

• Mental Health Support Group

• Mental Health Inpatient and/or Outpatient Treatment

Mental Health Supports

Recent Program Statistics [through December 2013]

Recent program highlights include the following:

• RCMHC has served 431 participants with serious mental illness.

• 99.3% have mental health community supports and programs in place at program completion compared to 30.4% at program acceptance.

• 82.6% have chemical health community supports and programs in place at program completion compared to 5.1% at program acceptance.

• 100% have sustained compliance with psychotropic medications at program completion compared to 41.2% at program acceptance.

RCMHC COMPARISON GROUP

Recidivism and Jail Impact

In both a one year and three year follow-up, RCMHC graduates have been less likely to be charged with a new offense and spend time in jail than those in a comparison group.

Comparison Group Graduates of RCMHC

One Year After RCMHC

New Charges 60% 17%

New Convictions 45% 9%

Jail Time 65% 9%

Three Years After RCMHC

New Charges 71% 30%

New Convictions 60% 26%

Jail Time 68% 25%

• 2009 Second Judicial District Pro Bono Award: Warren Maas, RCMHC pro bono defense attorney, was the 2009 Recipient of the Second Judicial District Pro Bono Award which recognized his outstanding commitment to pro bono work and extraordinary contributions to the criminal justice system.

• 2013 Minnesota Justice Foundation Award: Briggs and Morgan attorneys were recognized for their outstanding commitment to pro bono work with RCMHC. Suzula Bidon, a RCMHC legal intern, received the WMCL Student Award. The integrity and devotion they have brought to their RCMHC work has been a tremendous contribution to the district.

• 2014 Unsung Legal Hero Award: Brandi Stavlo received award from Minnesota Law and Politics for her local, statewide and national efforts on behalf of mental health courts.

• Federal Recognition: Brandi Stavlo, RCMHC Program Coordinator, was selected to be trained nationally by the Council of State Governments Justice Center to provide training to Minnesota courts that are interested in starting a mental health court or improving their existing program.

Awards and Recognition

Addressing the mentally ill who engage in criminal behavior and endanger public safety is low-hanging fruit. Make use of existing resources and divert people with mental illnesses from the criminal justice system into treatment and stable life-styles. Advocate for:

• Community mental health centers• Mental health crisis teams • Supportive housing and employment• Mental health training for law enforcement

officers• Mental health courts

Invest in Better Mental Health Services

These folks are people who have lost all their natural supports. They don’t have advocates any longer, they don’t have family members to take them in, and they’ve burnt all their bridges with treatment and everyone else. They’re the tough customers, and their lifestyles are really dissonant with the medical model of mental health and substance abuse treatment delivery. They tend to be more likely than not homeless, co-occurring disordered, without money. They don’t show up for appointments, and they often have complicating medical issues. On top of all that they often have a criminal history that makes them look in many ways worse than they are to the treatment system. So I think that the resource of a boundary-spanner and a linker, the case coordinator [manager] who can actually take the individual and hook them up with services appropriate to their condition is a tremendous resource. And what I’ve found is that the treatment system is far more likely to serve an individual who’s being monitored in the mental health court. And I think that what this tells me is to never give up.

Don’t give up on anybody because there may be a time in anyone’s life where they are ready, and readiness for change is so critical because you could meet a person four times during their life or even during the course of a couple of years, and if they’re not ready it’s not going to happen.

Stephanie Rhoades, Judge, Anchorage Mental Health Court

Final Thoughts….