criminal justice mental health & substance abuse reinvestment grants alachua county’s...
TRANSCRIPT
1
CRIMINAL JUSTICE MENTAL HEALTH & SUBSTANCE ABUSE REINVESTMENT GRANTSALACHUA COUNTY’S PARTNERSHIP WITH MERIDIAN
A Presentation for Florida Partners in Crisis
November, 2013
Maggie Labarta, PhD, MERIDIAN BEHAVIORAL HEALTHCARE
2
ALACHUA COUNTY
• Population of 251,417.
• Capital of the Gator Nation, Gainesville is home to the University of Florida, with some 50,000 students
• 874 square miles, Alachua County is a mix of urban and rural communities
• Median household income of $41,373. According to the 2010 U.S. Census report, 24% of its residents live at or below the poverty level which is well above the State average of 15%.
3
MERIDIAN
• Comprehensive behavioral healthcare center
• Co-occurring enhanced services
• Services from outreach and prevention to in-patient, residential, and long-term supported housing
• Service area includes 12 North Central Florida Counties – 550,000 population
• Two crisis stabilization units (50 beds)
• Residential treatment – mental health, substance use, co-occurring
• Pre-post partum residential treatment
• Medically assisted treatment for substance use disorders
• 9 outpatient clinics
• 3 collocated sites within primary care
• School-based services
• Mental Health First Aid ©
• Part of the CIT Training Team
• Provide treatment services to almost 14,000 clients a year, contact another 11,000 through prevention and outreach
4
JAIL CHARACTERISTICS• Rated capacity of 976 with a 15% classification factor . Between Dec.
2012 and May 2013 the average daily population was at a low of 855 in March and a high of 983 in December
• The Department of Court Services interviews of all inmates prior to their first appearance.
• 23% of adults were arrested for an alcohol violation while only 8% stated they had an alcohol problem; paradoxically, 7% were arrested for an illegal drug incident yet 14% self-report a problem with drugs.
• About 1.6% self report as having a mental health problem; however, 30.2% of all Jail inmates receive psychotropic medications while incarcerated in Alachua County.
• Of the daily census, 57 individuals report being homeless .
5
FORENSIC SERVICES: MERIDIAN AND ALACHUA COUNTY PARTNERSHIP
Public Safety
Coordina-ting Council
MH/SA Provide
rs
Law Enforce-ment
County Govern-
ment (Elected &
Staff)
State’s Attorney
Courts (Judge
s & Staff)
Public Defende
r
1998
6
FORENSIC PROGRAMS
• Largely concentrated in Alachua County• 1998 – County Committee identified MI/SA as reasons for growing jail population and agreed
- That treatment was the correct thing to do- Partnership would be required
• 2000 – Mental Health Court established by Judge Jim Nilon• 2003 – Crisis Intervention Team grant written
– Felony Mental Health Court established Judge Martha Ann Lott– Community Based Competency Restoration program
established
7
• 2005 – community partners visited Denver• CIT classes started• In-jail to community competency restoration funded
by DCF
• County created Mental Illness Workgroup (“MIWg”) to identify needed services and develop Strategic Plan for effective jail diversion system.
8
SEQUENTIAL INTERCEPT MODEL1 + COMMUNITY VISION = STRATEGIC PLAN
Vision:A community that no longer
needs jails and courts to serve as a provider
of mental health and addictions treatment
Pre-Booking Intercepts
Crisis Intervention Teams
Fully funded community based
system of care
Post Booking Intercepts
Coordinated screening and classification Forensic Specialists
Court/Jail Intercepts
In-jail specialized treatment
Therapeutic Courts (Misdemeanor,
916, Felony) Community-
based Competency Restoration
Services Forensic
Specialist Team Forensic Diversion
Team
Re-Entry Intercepts Forensic Residential Treatment Forensic
Specialist TeamForensic Diversion
Team Peer Specialists
Post-Release Intercepts
Specialized Probation
Specialized, Supported Housing
Fully funded community based
system of care
Not available In placePartially in place
1 Facilitated by the USF-FMHI CJMHSA Technical Assistance Center
9
• 2006 – MIWg report leads to funding for enhancing existing competency restoration program and creating a “Forensic Specialist Team”
• 2007 – County Commission created CJMHSAG Planning Committee• Chaired by member of Court or a County Commissioner• County Advisory Board charged with responding to grants and other
funding opportunities• Awarded first 3-year $2million DCF CJMHSA Reinvestment ACT
Implementation grant created treatment team to which most ill individuals could be referred, worked hand in hand with staff funded by DCF (competency restoration) and Forensic Specialist Team
• 2010 – Awarded expansion $1 million DCF CJMHSA Reinvestment ACT Expansion grant
• Integrated the work of both teams to adapt to lowered funding• Expanded array of services through integration• Added trauma services and Moral Reconation Therapy
10
SPECIALIZED PROGRAMS: COUNTY, AND GRANT 1, GRANT 2 INTEGRATED THEM AND EXPANDED WHO WE SERVE
Forensic Specialist Team
• Outreach and Intervention
• Engagement
• Competency Restoration
• Referral
• Accessing benefits (SOAR)
• Monitoring
• Uses existing treatment resources
• Provides advocacy in Court
• Single point of accountability for court cases
Forensic Diversion Team
• Based on ACT model
• Self-contained team
• Engagement oriented
• Co-occurring enhanced
• Multidisciplinary
• Jail classification staff
• Counselor
• Peer specialist
• ARNP
• Treatment supports – housing vouchers
• Focus on high recidivists for both treatment and court systems
11
PROGRAM FOCUS• GOAL – Minimize jail time and increase participation in treatment
• At booking
• Post booking
• Re-entry
• METHOD
• Screen at booking
• First appearance evals
• Mental Health Court
• Competency restoration at jail and in community
• Diversion – VA, state hospital
• Treatment on re-entry
12
PROGRAM DESIGN• Phase I (Pre-engagement): Pre-treatment groups; motivational interviewing; program
orientation/education; linkage/referral to community resources/programs
• Phase II (Recovery Services): Starting treatment services; individual/group therapy; case management; medication management; drug testing; linkage/referral to community resources/programs
• Phase III (Stabilization): Advanced level of self-sufficiency; individual/group therapy; case management; medication management; drug testing; linkage/referral to community resources/programs; increased usage of peer support services
• Phase IV (Transition): Recommended for clients requiring minimal services to maintain stability; individual/group therapy; case management; medication management; drug testing ; linkage/referral to community resources/programs; increased usage of peer support services
• Phase V (Aftercare): After graduation from treatment; assigned a peer specialist; case management; medication management; drug testing; linkage/referral to community resources/programs; structured curriculum (Wellness Recovery Action Plan)
•
•
13
STAFFING
INITIAL
• 8 Staff
• Half funded by county, half CJMHSA Implementation Grant
• Team make-up:
• Team leader/program therapist (MA)
• 3 Forensic Specialists
• 2 Peer Specialists
• 1 Jail Classification Specialist (ACJ employee)
• 1 part-time Benefits Coordinator
(Court Services employee)
EXPANSION9.2 StaffCounselors 1.00Forensic Specialist 3.50Forensic Outreach Specialist 1.00Peer Specialists 0.50ARNP 0.20Assessment Specialist 1.00Benefit Coordinator/Data Analyst 1.00Admission Coordinator/Screener 1.00
14
EVIDENCE BASED PRACTICES
• Self-contained program
• ACT “light” based on essential elements (funding would not support full ACT)
• Continuous engagement efforts
• Motivational enhancement
• Rapid access to medication
• Therapy within the program – Trauma Informed Care
• Access to benefits for follow-up care - SOAR
• Screening for Re-entry – GAIN checklist
• Access, Plan, Identify & Coordinate (APIC) – coordination with community partners for successful re-entry
• Moral Reconation Therapy
• addresses needs of those with antisocial personality
• Effectiveness data compiled and aggregated data by Meridian and Court staff
15
MORAL RECONATION THERAPY
MRT is a 13 stage evidence-based cognitive behavioral, step by step treatment designed to enhance self-image, promote growth of a positive, productive identity, and facilitate the development of higher stages of moral reasoning.
• Step 1 & 2 (Trust and Honesty): Disloyalty, the lowest moral and behavioral stage in which a person can function.
• Step 3 (Acceptance): Opposition, starting to be somewhat honest.
• Step 4 (Raising Awareness): Uncertainty, may lie, cheat and steal but uncertain if they should do so.
• Step 5 & 6 (Healing Damaged Relationships and Helping Others): Injury, identifying that they have hurt others or themselves.
16
• Step 7 & 8 (Long-Term Goals and Identity and Short-Term Goals and Consistency): Non-Existence, do not have a firm sense of identity and do not feel connected to the world.
• Step 9 & 10 (Commitment to Change and Maintaining Positive Change): Danger, starting to commit to long-term goals.
• Step 11 (Keeping Moral Commitments): Emergency, sense of urgency in completing goals.
• Step 12 (Choosing Moral Goals): Normal, incorporating their identity into how they live their life.
• Step 13 to 16 (Evaluate Relationships Between Inner Self and Personality): Grace, few reach this step where the person sees others as an extension of self.
17
OUTCOMES: VOLUME OF SERVICES• Referrals: 1406 to date, average
50-55 per month
• Admissions: accepted to date 432, average 12 per month roughly 25%
• Average 15-20 pending referrals
• Active in program 157 (215-270/year),
average 150-160, plus another 50 in state hospital
• 100% receive Case Management
• 25% receive treatment
• 23% receive Competency Restoration
• 77% of participants are in Felony Forensic Court or Mental Health Court.
18
WHO IS NOT ACCEPTED?
19
• 25% of active program participants were participating in treatment (not just CM) services provided by the Forensic Treatment Program in Phases II to V
• Phase I participants are those in Pending status post screening and pre engagement in Treatment
• 44% (of program participants in treatment were in Trauma Groups.
• 59% (10 of 17) female participants in treatment services were in Women’s Trauma Groups
• Peer Specialists are providing follow up contact to participants who have been discharged
July 2013 Aug 2013 Sept 20130
5
10
15
20
25
30
Phase IPhase IIPhase IIIPhase IVPhase V
20
July 2013 Aug 2013 Sept 20130
1
2
3
4
5
6
Step 1&2Step 3Step 4Step 5&6 Step 7&8 Step 9&10Step 11 Step 12Step 13-16
Moral Reconation: 5% of treatment participants
21
OUTCOMES: EFFECTIVENESS• Days in the community: 91% for
those not at state hospital
• 12% in jail
• 64% in community
• 24% at state hospitals
• Recovery
• 12 % in a Vocational Program
• 12 % Employed
• 5 % in School
• Adherence with medication: 82%
The vast majority of unsuccessful discharges are for non-compliance
Successful Unsuccessful0
5
10
15
20
25
30
74%
26%
Type of Discharge
Type of Discharge
22
• Engagement works
• 66% of unsuccessful discharges occur in Phases 1 or 2
Phase I
Phase II
Phase III
Phase IV
Phase V or MRT
0
1
2
3
4
5
6
7
0
1
3 3
2
6
3
0 0 0
Successful Unsuccessful
23
Participation has long term effects
We see reductions in two year follow up for those who don’t succeed
Greatest impact is for those who stay with it
Graduates expanded benefit persists even after we refer them to traditional follow-up care FYE2008 FYE2009 FYE2010 FYE2011 FYE2012
Arrests by Admit date
0
0.5
1
1.5
2
2.5
3
3.5
Arrests
Pre-admit 12 month period Post admit months 1-12Post admit months 13-24
FYE2008 FYE2009 FYE2010 FYE2011 FYE2012Arrests by Admit date
0
0.5
1
1.5
2
2.5
3
3.5
Arrests
Pre-admit 12 month period Post admit months 1-12Post admit months 13-24
24FYE2008 FYE2009 FYE2010 FYE2011 FYE2012
Jail Days by Admit Date
0
20
40
60
80
100
120
Jail Days
Pre-admit 12 month period Post admit months 1-12 Post admit months 13-24
25
COST• Forensic Diversion Team (Funding & Data for May 2011-June 2012)
• MIWG - $370,000
• CJMHSAG
• State - $250,000
• County Match - $167,000
• In-kind match (various sources) - $78,000
• Total annual funding: $865,000
• Number served: 267
• Average annual cost per person: $3,230Post admission Jail Days 14,004 X $85/day = $ 1,190,340.00
Pre admission Jail Days 28,803 X $85/day = $ 2,448,255.00
PROGRAM IMPACT -14,799 $ (1,257,915.00)
NET COST AVERSION (IMPACT-COST) $392,915 per year
26
LESSONS LEARNED• The CJMHSA Reinvestment Act funding has made a dramatic impact
on the Planning, Implementation and Expansion of Jail Diversion services for persons with mental health and substance use disorders involved in the Alachua county Criminal justice system
• Get community "buy in" by using the Sequential Intercept Model.
• Utilize all community resources, bring them to the table.
• Programs should have an Outreach component to allow flexibility.
• Design the program to allow for flexibility with trends.... The program has to meet the needs of the clients, not the other way around.
• Contingency funding is absolutely necessary
27
THE REAL REASON IT’S GREAT• Ms. B is a 33 year old female with a long history of mental illness and substance
abuse.
• Formerly received services from FACT team ; dropped out two years ago.
• Arrested 4/7/13 for aggravated assault, with deadly weapon without intent to kill
• Not taking her medications, and experiencing severe psychotic symptoms
• She was immediately identified by the Forensic Liaison at the jail, who attempted to convince her to take her medications but she continued to refuse.
• She then was evaluated, found Incompetent to Proceed, and meeting criteria for State Hospital.
• Forensic Liaison succeeded in getting her to take her medications and provided competency restoration.
• By the time Ms. Brown’s case was transferred to Felony Forensic Court, she was stabilized on her medications and competent.
• The Forensic Program Director then advocated with the court that Ms. Brown did not need to go to the State Hospital and could be diverted to the community with supports in place.
• Ms. Brown was released from jail on 6/20/13 to Forensic Treatment with her charges completely resolved.
