Maricopa County Justice & Mental
Health Collaboration Project-
Understanding the Unique Needs of Justice-Involved Women
SEEDS Conference
October 1, 2014
Goals of Today’s Presentation
• Understand each organization’s roles, responsibilities and limitations in planning & service delivery.
• Partners will share information related to both health care and criminogenic risks & needs to coordinate services for the 20 pilot participants.
• Give examples of lessons learned.
Project
Partners
3
GOAL 1Elevate the knowledge, skills, and abilities of
probation officers, detention officers,
correctional health staff, court and judicial staff,
and comprehensive community-based
behavioral health services and case
management staff, in the effective supervision
and treatment of female offenders with serious
mental illness and/or
co-occurring disorders.
4
GOAL 2Develop and implement a program of
treatment and support services that
targets justice-involved women with
serious mental illness and/or co-
occurring disorders that is gender specific, trauma informed, and
criminogenic responsive.5
GOAL 3Enhance the quality, impact, and reach of
interagency collaboration among and
between those agencies engaged in the
arrest, confinement, adjudication,
supervision, treatment, and support of
women with psychiatric impairments in
general and women with SMI/co-occurring
disorders in particular.
6
Detention Officer
determines jail assignments &
CHS checks RBHA data to identify SMI
status
CHT writes up assessment RN reviews
assessment to determines if face-to face needed in
holding cell
Decision
Flowchart Key
Start/Terminate
Document
Process/Action
Police arrests then transports
individual to 4th Avenue jail for intake
While in waiting area, Correctional Health
Technician (CHT) conducts initial screening with inmate
After meeting with IA, released on bond
or DO transports inmate to holding
cell at Estrella
Pre-Trial Officer gathers information to share with
Initial Appearance (IA) Judge determines offence &
stability. RBHA MH Advocates present at IA.
If inmate identified as having a BH issue nurse conduct EPI &
put on sick call ‘damp’ list
Within 24 hours, inmate will see the IA
judge who will determine if inmate will have be eligible
for a bond
Inmate gets booked (paperwork, fingerprints, search & picture taken)
Inmate is moved to the holding cell
Inmate meets with pre-trial officer
Maricopa County Sheriff’s Office: Arrest & Jail Processing
If in crisis sent to Mental
Health Unit (MHU) at Lower
Buckeye jail (psych. Unit
until stabilized)
8
Decision
Flowchart Key
Start/Terminate
Document
Process/Action
Detention Officer (DO) transports from
4th Avenue jail (intake) inmate to
Superior Court
Preliminary Hearing with -Public Defender, Mitigation
Specialist & Judge
Maricopa County Adult Probation and MH Court Processes
Yes- Judge orders Probation Officer (PO) to write presentence report & 1st screener completes OST. Discharge Officer calls clinic to coordinate D/C plan
MCAP Discharge Planner gets involved (may see inmate) and PO complete presentence report .
Inmate goes and sees their Probation Officer, and they develop their case plan (must update
every 6 mths)
Plea Agreement
Early Disposition Court helps people get sentenced quicker
if they have offenses like possession of marijuana. Otherwise within 28 days
from the plea agreement or finding guilt and sentencing
occurs .
If sentenced to jail time refer to Housing Flow
Chart
Inmate is released and given reporting
instructions for probation
Client reports to probation and sees the 2nd screener who
conduct OST and screen for SA treatment . Pilot
participants are assigned a co-located SMI PO and given
probation handbook.*
SMI PO calls and sets up face to face meeting and
reporting instructions
Issue with following
case plan?
Yes- PO can utilize Mental Health Courts for status review applies sanctions and incentives (see grey box fro details)
No- client goes to trial (not eligible
for pilot)
Determine if need Rule 11 or MH Court
Initial appearance could take up to 2yrs.
Rule 11 restoration typically 60 days
Sentencing Hearing
Sentenced to Prison
(not eligible)
Remains on probation until terms are met or time frame
expires. Probation will participate in PCN F-ACT ISP development meetings and
reviews with their client.
Mental Health Court Overview - For the first half of mental health court, the client would go to a staffing that includes the judge, public defender (PD), F-ACT CM, Hope Lives and RBHA Court Liaisons. After the staffing, client meets with her PD (client’s ally ). The PD updates the PO then client goes in front of the judge. PO will review what the client needs to do, the case manager will say if they have anything to add, and the judge will also comment. Afterwards, incentives are given out (e.g. claps, praise, gift cards) then the judge will go through the sanctions. Sanctions may include “flash incarceration” in jail up to 120 days.
9
Is the inmate struggling or a safety risk?
Decision
Flowchart Key
Start/Terminate
Document
Process/Action
Transport Officer brings
inmate to Estrella Jail
Inmate released or serves
sentence then reenters
community in no new charges or
infractions
classification reviewed to
determine where inmate will be
housed
No, inmate will be showered in a group shower, given her
stripes to wear, and strip searched process
Maricopa Country Sheriff’s Office & Correctional Health Services : Housing
Med & Max in Towers
Min & Med in Dorms
Inmates are escorted 2x2 to their individual housing
assignment. Checked in- given bunk assignments, bedding &
rules
Unstable?
Yes-inmate sent to Mental Health Unit Lower Buckeye Jail for psychiatric or medication intervention or if petition required
Inmate accepted into the holding cell and logged into the
system
Yes-Correctional Health is called to see inmate in
holding cell for assessment and intervention-if ongoing
care need placed on the damp list for follow up
Correctional Health reviews damp list –creates
treatment plans, conducts follow up visits, psychiatric evaluations, and discharge
coordination.
Correctional Health has interns providing two groups (Hope & TAMAR) twice a week and also individual sessions. SA groups in administrative segregation and closed custody Inmates also can complete a health needs request
10
Grant Pilot Program Referral Process
Jail Data Link flags all SMI women booked for non-felony and notifies Magellan
MCAP screens
eligibility based on,
sentencing & current
charge
MCAP adds inmates to screened PENDINGtab for continued monitoring of courtprocess and screening continue after signingthe plea and notifies S. Clay/Court Liaison tocoordinate with Public Defender
MCAP adds inmate to the
screened NOT-ELIGIBLE
tab
PCN reviews packet and completes
screening for F-ACT
Eligibility
If determined NOT-ELIGIBLE for F-ACT Team notifies MCAP and
MCCH documents decision on spreadsheet
If determined ELIGIBLE for F-ACTnotifies MCAP & MCCH documents decision on spreadsheet. PCN meets with the inmate to explain program. If inmate agrees, coordinates transition to POCN , if needed.
Maricopa Correctional Health Services (MCCHS)=BrendaMaricopa County Adult Probation (MCAP)=Norma/RhodaPeople of Color Network (PCN)=Rachel
Revised 3/22/13
MCCHS obtains ROI (MH & SA) from inmate and faxes referral packet to Rachel at
POCN
Decision
Flowchart Key
Start/Terminate
Document
After determined eligible, MCAP notes status as Eligible on the tracking SS and notifies S. Clay/ Court Liaison to determine if good case for FACT, if ok for FACT Rhoda is notified to complete MOST (Modified Offender Screening Tool)
Process/Action
ADOP add name(s) to“pending” on EXCELspreadsheet
11
POCN, MCCHS & MCAP discuss newly enrolled program participants
Decision
Flowchart Key
Start/Terminate
Document
Process/Action
Within 30-90 days F-ACT completes: Demographics (EA10-13), Psych. Eval., Housing NA, ASAM, MCAW, HRA, CHI, At-risk Crisis Plan and TIC Counselor Assess.
F-ACT CM meets with the person to discuss goals and conducts Motivational Interview Conducted with Inmate – 1 hr (T
Consultation with the Clinical Team to obtain
recommendations30 minutes
Review Medical Record 1 hour by psychiatrist
Develop ISP/ within 7 days: Face to Face Interview with BHR; & F-ACT meets without the person to draft plan – 30 minutes. Ideally would include SMI PO, TIC Counselor and others requested by the person
Person reviews & signs the plan, then it is returned to the F-ACT team to also sign & Clinical Coordinator “finalizes” ISP in Claimtrack by entering the date signed by the inmate
Client will see the TIC Counselor within the first two weeks and complete
TIC Assessment
Referral packets created by Office Assistant with ROI.
Every 6-mths-updates ISP &ARC
Yearly-Form E, HRA & EA10-13 Will remain on F-ACT
until determined no longer needed
PCN F-ACT & Individual Service Planning (ISP) Processes
PCN TIC Liaison goes to jail with MD to complete grant screening , MD to determine
F-ACT eligibility and coordinate transition to PCN (if needed)
Transfer to PCN can take up to
2-weeks
Client released at 10am two people from PCN will
transport to clinic & meet with F-ACT representative to
schedule assessments
The person meets with the provider agencies, & they
complete s provider “assessment and service”
plans
12
Organizational Standards: Trauma-informed Care
1. Safe, calm and secure environment with supportive care;
2. System-wide understanding of trauma prevalence, impact, and trauma-informed care;
3. Cultural competence;
4. Consumer voice, choice, and self-advocacy;
5. Recovery, consumer-driven, and trauma-specific services; and
6. Healing, hopeful, honest, and trusting relationships.
National Council for Community Behavioral Healthcare’s Organizational Self-Assessment: Adoption of Trauma-informed Care
Practices.
13
Principals:Gender-responsive
1. Awareness that gender “makes a difference;”
2. A safe environment where all clients/offenders are treated with respect and dignity;
3. Organizational policies, practices, and programs that promote healthy relationships with children, family, and significant others, as well as community connections;
4. Comprehensive, integrated and culturally appropriate services and supervision that address substance abuse, trauma, and mental health needs;
5. Opportunities for clients/offenders to improve their socioeconomic conditions; and
6. Collaborative system that provides comprehensive services and supervision upon reentry into the community.
Gender-Responsive Strategies for Women: Supervision of Women Defendants and Offenders in the Community (U.S. Department of Justice/National Institute of Corrections, 2005) and Gender- Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders (U.S. Department of Justice/National Institute of Corrections, 2002).
14
10 Facts about Justice-Involved Women
1. Women pose a lower public safety risk then
men
2. Women’s pathways to the criminal justice
system is different than men’s
3. Women’s engagement in criminal behavior is
often related to their connects with others
4. Women entering jails and prisons often report
histories of victimization and trauma
5. Corrections policies and practices have largely
been developed through the lens of managing
men
6. Jail and prison classification systems can result
in the unreliable custody designations and over-
classifications
7. Gender‐informed risk assessment tools can
more accurately identify women’s risk and needs
10 Facts about Justice-Involved Women
8. Women are more likely to respond favorably
when corrections staff adhere to evidence-
based, gender responsive and trauma-
informed principles
9. Transition and reentry can be challenging for
women
10.The cost of overly involving women in
criminal justice is high
10 Facts about Justice-Involved Women
Nei, B. (2014). Ten facts about women in jails. American Jail Association. Retrieved from http://www.americanjail.org/10-facts-about-women-in-jails/
Principals:Risk-responsive
1. Services are provided in an ethical, legal, just, humane and decent manner;
2. Assesses criminogenic needs and matches level of service to the offender’s risk to re-offend;
3. Uses human services and general personality & cognitive social theory rather than relying on severity of penalty to effect behavior change;
4. Uses structured and validated instruments to assess risk, need, and responsivity;
5. Engages higher risk cases in programs and strategies to minimize dropout (i.e., pro-social modeling, cognitive restructuring, motivational interviewing);
6. Effective supervision of staff and monitoring and evaluation of service delivery and programs and community linkages
Principles taken from Andrews & Bonta’s The Psychology of Criminal Conduct (Newark, NJ: LexisNexis, 2006) and Andrews “Principles of effective correctional programs” in Compendium 2000 on Effective Correctional Programming (Correctional Services of Canada, 2001).
18
Risk-Need-Responsivity Model as a
Guide to Best Practices
RISK PRINCIPLE: Match the intensity of individual’s
intervention to their risk of reoffending
NEEDS PRINCIPLE: Target criminogenic needs, such as
antisocial behavior, substance abuse, antisocial attitudes,
and criminogenic peers
RESPONSIVITY PRINCIPLE: Tailor the intervention to the
learning style, motivation, culture, demographics, and
abilities of the offender. Address the issues that affect
responsivity (e.g., mental illnesses)
Council of State Governments Justice Center
What do we mean by
Criminogenic Risk?
≠ Crime type
≠ Failure to appear
≠ Sentence or disposition
≠ Custody or security classification
level
Risk =
How likely is a person to commit a crime or
violate the conditions of supervision?
Council of State Governments Justice Center
What Do We Measure to Determine
Risk?
Conditions of an individual’s
behavior that are associated with
the risk of committing a crime.
Static factors – Unchanging
conditions
Dynamic factors –
Conditions that change over
time and are amenable to
treatment interventions
Council of State Governments Justice Center
Targeting Interventions- The Big Four
Criminogenic Need Response
History of anti-social behavior Build non-criminal alternative behaviors to risky situations
Anti-social personality Build problem solving, self management, anger management, and coping skills
Anti-social cognition Reduce anti-social cognition, recognize risking thinking and feelings, adopt an alternative identity
Anti-social companions Reduce association with criminals, enhance contact with pro-social
Source: Ed Latessa, Ph.D
Target Interventions
(Eight Evidence-Based Principles)
The Next FourCriminogenic Need Response
Family and/or marital Reduce conflict, build positive relationships and communication, enhance monitoring/supervision
Substance abuse Reduce usage, reduce the supports for abuse behavior, enhance alternatives to abuse
School and/or work Enhance performance rewards and satisfaction
Leisure and/or recreation Enhance involvement and satisfaction in pro-social activities
Source: Ed Latessa, Ph.D
Evidence-based Services for Individuals
with Substance Use Disorders
Cognitive behavioral therapy
Motivational enhancement therapies
Contingency Management
Pharmacological therapies
Community reinforcement
Council of State Governments Justice Center
Factors Correlated with Positive
Outcomes
PERSONAL STRENGTHS – beliefs, talents, supports
RELATIONSHIP – perceived empathy, acceptance, and
warmth
EXPECTANCY – optimism and self-efficacy
MODELLING – theoretical orientation and
intervention techniques
Key“Take Away” Points
Dedicate more intensive resources for offenders who pose a
greater likelihood of recidivism
Remember that “more” is not necessarily “better” for every
offender
Consider responsivity factors when developing and
implementing case management strategies
Build incentives into case management plans and reward
positive behaviors
Evaluate what is and is not “working” for offenders in your
jurisdiction – prioritize for change those strategies
demonstrated to be most effective in reducing recidivism
And remember – one size does not fit all and gender
matters
unavoidable triggers-processes & procedures often re-traumatize
-environment can mimic dynamics of past abuse
jails are a challenge for trauma-informed approaches-stressful work environment for staff
-designed to house perpetrator, not victims
absence of primary coping mechanisms (e.g. drugs &
alcohol) for inmates with trauma & addiction histories
SCREEN AT BOOKING: EARLY IDENTIFICATION
CONTINUITY OF CARE
CARE IN THE JAIL SETTING
TRANSITION PLANNING: “REACHING IN” &
WARM TRANSFERS
CRITICAL WINDOWS: 24- 48 HOURS
SAFETY: HOUSING
TIC AND “RIGHT FIT” SERVICES
Age Profile of Females in Jail
Age profile of women in Maricopa County jails for the two years ended Dec., 2013:
23
2,850
10,480
7,464
6,563
262
0
2000
4000
6000
8000
10000
12000
Under 18 18 - 21 22 - 30 31 - 40 41 - 60 61 & above
Nu
mb
er
of
Fem
ale
s in
Jai
l
Age Groups in Years
38% of the women in Jail are between the ages of 22 and 30 years.
Proxy Distribution of Female Jail Population
0
1,000
2,000
3,000
4,000
5,000
6,000
0 1 2 3 4 5 6
7%
12%
23%24%
21%
10%
3%
Nu
mb
er
of
Fem
ale
s in
Jai
l in
2-y
ear
p
eri
od
en
din
g 1
2/3
1/1
3
Proxy Score
24% of the female jail population has a proxy score of “3.”
Description of Serious Mental Illness (SMI) population in Maricopa County jails
1 2 3 4 5 6 7 8 9 10 11 12
10
12
Media
n Num
ber o
f Day
s in
Custo
dy
Non-SMI SMI
23
71
163
390
37
95
200
431
0 50 100 150 200 250 300 350 400 450
25%
50%
75%
95%
Days to Recidivate
Perce
ntage
of Ja
il Pop
ulatio
n tha
t Rec
idiva
ted
Non-SMI
SMI
50% of SMI population that recidivated returned to jail within 71 days of release. 50% of non-SMI population that recidivated returned to jail within 95 days of release.
48%52%
Court of Origination for SMI -City vs. Non-City Courts
City Courts Non-City Courts
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Felony Misdemeanor Sentenced Holds
39%
8%
1%4%3%
44%
0.3% 1%
Charge Level Breakdown for SMI -City vs. Non-City Courts
Non-City Courts City Courts
5.6% of individuals in Maricopa County jails are SMI.
*Approximately 8% of individuals in jails reported being currently or recently homeless. Among the homeless
population in jails 10% are as SMI.
*Among frequent homeless jail users (4 or more stays in a 5-year period) 13% are SMI.
Description of Serious Mental Illness (SMI) in Maricopa County Jails
Noor Singh
Justice System Planning & Information May 27, 2014
Individuals with SMI stay longer in Jails
5.6% of individuals in Maricopa County jails are SMI.
Alternatively stated, at any given time, there are approximately 437 SMI individuals in Maricopa County jails, and 680 SMI individuals on probation.
Among the SMI in the jails, only 8% of them are low-risk to recidivate.
Of the SMI that do come back to jail, they come back sooner than non-SMI.
SMI population in the Maricopa County jails tends to be older and more likely to be female than the general jail population.
Approximately 8% of individuals in Maricopa County
jails reported being currently or recently homeless.
Among the homeless population in Maricopa County
jails, 10% are as SMI.
Among frequent homeless Maricopa County jail users
(4 or more stays in a 5-year period) 13% are SMI.
County leadership focus on the justice-involved SMI in Maricopa County.
Close working relationship between Maricopa County and Arnold v. Sarn project manager.
New data and research internally to inform decision-makers on the realities of this population.
Awareness and examination of court and prosecutorial best practices.
Specialty courts (Homelessness Court, Mental Health Court, Continuum of Care Court).
Peer navigator and other programs from Maricopa County Correctional Health Services to provide services upon community reentry from jail.
Strong County partnership with CASS and the Human Services Campus.
SMI, Homelessness, and Jail Usage in Maricopa CountyMelissa Kovacs, Justice System Planning and Information, Maricopa County
What is Maricopa County doing about this?What does SMI and homelessness look like in
the Maricopa County jails?
Grant Lessons Learned
This unique multi agency partnership developed as a direct result of the BJA grant
Transition Planning Aligned Services with a shared vision, voice and commitment from each agency involved for each participant
Collaboration involves all entities at the exact same table working towards the same outcome, with open honest communication and a willingness to see the perspective of each partner with a view from a different lens.
Focused Delivery of Trauma Informed Gender Responsive Care to 20 Women in alignment with each service agency’s internal policies, processes, staff development and administration.
Several Changes in Practice (as a direct result of the Grant Partnership) Shared Vision created endless capacity for change.
Fact Criteria Revision, service delivery and implementation of Trauma Counseling at the onset of services.
“The challenge of every team is to build a feeling of oneness, of dependence on one another because the question is usually not how well each person performs, but how well they work together." - Vince Lombardi (1913 - 1970)
Strategic Challenges
Transitional Care is essential to re entry into the community , housing, wrap around services and supports that have been developed in concert with the unique needs of each individual
Specific services developed that are related to female, felony offenders, substance abuse, housing and trauma
Determine specialized needs prior to release from jail and ensure they are met upon transition to the community
Services are strength based, multi agency and developed with an unconditional commitment to each participant with a goal of community integration, service delivery that is empathetic and empowering.
Communication and Collaboration that fosters immediate real time needs for specialized interventions, coordination of care is priority.
"My opinion, my conviction, gains immensely in strength and sureness
the minute a second mind has adopted it." - Novalis (1772 - 1801), German Author and Philosopher
Transformation of FACT
FACT Recipients served
FACT Recipients closed due to DOC incarceration
FACT Recipients closed due to jail incarceration
FACT Recipients transferred to connective/supportive due to long term incarceration
Changes that have occurred as direct result of BJA grant
125 105
8 1
1 0
10 4
2013 2014
Recommendations/Next Steps
1. Trauma Informed/ Gender Responsive Assessments need to be fully integrated into performance improvement practices and serve as the example
2. Trauma Informed Counseling needs to be fully integrated into practice for all integrated care teams.
3. Development of Transitional Care protocol that involves care collaboration and communication at each phased for the transition.
4. Trauma Informed Gender Responsive Care that promotes self resiliency, determination and independence.
Maricopa County Justice & Mental Health Collaboration ProjectProgram Logic Model, v. 6
Population & Environment Theory & Assumptions Interventions Outcomes
Client Target PopulationFemale offenders with serious mental illness & co-occurring substance use disorders
Population Characteristics•Non-violent offender•GAF no higher than 60•Continuous high service needs (3 of 7 indicators on F-ACT Admission)•Incarcerated a total of 6 months or more during the past 12 months•Not eligible if primary diagnosis is Axis II Personality Disorder
Systems Target Populations• Maricopa County Sherriff
Detention Officers & Program Staff
• Maricopa County Correctional Health Clinical Personnel
• Maricopa County Adult Probation & Surveillance Officers
• People of Color Network Forensic Assertive Community Treatment clinicians & staff at La Comunidad Clinic
• Arizona MH & CJ Coalition
Environmental Context• Phoenix is a large metropolitan area•Highly privatized & capitated funded behavioral health care system•In-jail mental health services
Concept of InterventionA gender specific, trauma informed, & criminogenic responsive criminal-justice & behavioral health systems that target offenders with co-occurring disorders to reduce criminal recidivism & promote community stability.
•Developing gender specific, trauma informed, & criminogenic responsive systems capacity requires multi-level, multi-agency organizational interventions
•Gender specific, trauma informed, & criminogenic responsive systems behavioral health services enhance treatment effectiveness, promotes community stability, & reduces criminal recidivism
•Gender specific, trauma informed, & criminogenic responsive systems offender management practices & supervision reduces in-custody incidents, incidents requiring isolation (resources) & enhances supervision effectiveness.
Risk Factors for Criminal Justice Recidivism• Criminogenic Risk Factors• Residential instability• Insufficient(availability, quantity
& array) behavioral health treatment
• Treatment adherence• Undetected & untreated Co-
occurring Substance Abuse D/O • Non-targeted treatment &
service delivery
Interagency Collaboration•Multi-agency Project Management Team•Meeting communications support to PMT•Strategic planning & leadership development targeting the AZ MH & CJ Coalition and advisory board members
Knowledge & Awareness Raising•Develop & disseminate information & practice tip sheets•Organize “expert exchanges”
Skill Development•Identify & distinguish mental health issues•Assess trauma & criminogenic risk•Develop a service & supervision plan that addresses gender specific, trauma & criminogenic risk
Model (Practice?) Development•Universal in custody trauma screening & criminogenic assessment •Forensic-Assertive Community Treatment (FACT) case management•Short term transitional housing•Evidence-based probation supervision•Multi-agency release of information(Cross agency procedures?) •Service delivery targeted to addressing MH issues & criminogenic risks
Systems Capacity Building•Learning circle communities with model purveyors•Systems embedded Master Trainers & Practice Champions
Short-term Systems:•Increase gender specific, trauma informed, & criminogenic responsive awareness & knowledge of criminal justice & behavioral health systems personnel•Attitude & environment changes (access to services in jail)Clients:• Secure housing and benefits upon release• Case plan completed and informed ISP by teamCoalition:• Increase membership• Strengthen the organizational structure• Develop a strategic plan
Intermediate Systems:•Established network of ‘master trainers’•Operational program manual with F-ACT
Clients (6 -months post):•Maintain housing•Feel safe•SA-use reduction
Coalition:•Identify policy issues and needs•Develop website
Long-term Systems:• Pre-service educational curriculum infusion• Expansion of pilot program to additional clinics
& regions• Pilot program manual with F-ACT • Expansion of F-ACT Clients:•Successfully complete probation terms•Reduce recidivism•Engaged in behavioral health servicesCoalition:• Advise on policy issues and become a resource
for the community44