Sequential Intercept Mapping Report

Sequential Intercept Model Mapping Report Tulsa, Oklahoma

SAMHSA’s GAINS Center

Policy Research Associates, Inc.

S EQUENTIAL I NTERCEPT M ODEL M APPING R EPORT FOR TULSA, OK Final Report September 2017 Daniel Abreu, MS, CRC LMHC Connie Milligan, LCSW SAMHSA’s GAINS Center Policy Research Associates

ACKNOWLEDGEMENTS This report was prepared by Dan Abreu and Connie Milligan of Policy Research Associates, Inc., for SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation. SAMHSA’s GAINS Center wishes to thank the Mental Health Association of Oklahoma, the George Kaiser Family Foundation, the Hille Foundation and the Women in Recovery Center for coordinating funding and hosting this event.

RECOMMENDED CITATION SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation. (2017). Sequential intercept model mapping report for Tulsa, OK. Delmar, NY: Policy Research Associates.

Contents Introduction .................................................................................................................................................. 6 Background ................................................................................................................................................... 7 Agenda .......................................................................................................................................................... 8 Sequential Intercept Model Map for Tulsa, OK .......................................................................................... 10 Resources and Gaps at Each Intercept ....................................................................................................... 11 Priorities for Change ................................................................................................................................... 19 Quick Fixes .................................................................................................................................................. 23 Parking Lot .................................................................................................................................................. 23 Recommendations ...................................................................................................................................... 25 Strategic Action Plans ................................................................................................................................. 29 Resources .................................................................................................................................................... 33 Appendices.................................................................................................................................................. 39

Introduction

S

ince 1995 SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation, operated by Policy Research Associates, has worked to expand community-based services and reduce justice involvement for adults with mental and substance use disorders in the criminal justice system.

The GAINS Center is support by the Substance Abuse and Mental Health Services Administration to focus on five areas: 

Criminal justice and behavioral health systems change

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Criminal justice and behavioral health services and supports

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Trauma-informed care

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Peer support and leadership development

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Courts and judicial leadership

On August 1-2, 2017, Dan Abreu and Connie Milligan of SAMHSA’s GAINS Center facilitated a Sequential Intercept Model Mapping Workshop in Tulsa, OK. The workshop was coordinated by the Mental Health Association of Oklahoma which was awarded this free technical assistance event through a competitive application process. Approximately 50 representatives from Tulsa County participated in the 1½-day event.

Melissa Baldwin, MHA Consultant for Consultant for Mental Health and Criminal Justice Reform welcomed participants and made opening comments on behalf of Tulsa County’s Stepping Up Committee, a collaborative group of agencies working to reduce the number of people with mental illness in jail. She thanked Women in Recovery, Tulsa County Sheriff’s Office, Aramark /QuickTrip and Tulsa Police Department for hosting and supporting the event. She also thanked FC&S, CSC, TCSO, TPD & City Communications, & NAMI, Juvenile Bureau for aiding in planning the event.

She acknowledged Commissioners Keith, Smaligo, & Peters for their leadership and commitment in the Stepping Up Initiative which has been key in maintaining momentum and meaningfully addressing barriers and improving strategies to reduce the number of persons with mental illness in jail.

She noted that this opportunity for Sequential Intercept Mapping will bring these efforts to the next level. It will also promote planning to be smart and strategic as the collective efforts to reform criminal justice and mental illness are prioritized. There are many significant efforts centering on this topic all working in harmony and coordination with each other. The intention is for the priorities identified in this workshop to be embedded in the 10-Year Tulsa Mental Health Plan that will be released January of 2018.

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Background

T

he Sequential Intercept Model, developed by Mark R. Munetz, M.D. and Patricia A. Griffin, Ph.D.,1 has been used as a focal point for states and communities to assess available resources, determine gaps in services, and plan for community change. These activities are best

accomplished by a team of stakeholders that cross over multiple systems, including mental health, substance abuse, law enforcement, pretrial services, courts, jails, community corrections, housing, health, social services, peers, family members, and many others.

A Sequential Intercept Mapping is a workshop to develop a map that illustrates how people with behavioral health needs come in contact with and flow through the criminal justice system. Through the workshop, facilitators and participants identify opportunities for linkage to services and for prevention of further penetration into the criminal justice system.

The Sequential Intercept Mapping workshop has three primary objectives: 1. Development of a comprehensive picture of how people with mental illness and co-occurring disorders flow through the criminal justice system along six distinct intercept points: (0) Mobile Crisis Outreach Teams/Co-Response, (1) Law Enforcement and Emergency Services, (2) Initial Detention and Initial Court Hearings, (3) Jails and Courts, (4) Reentry, and (5) Community Corrections/Community Support.

2. Identification of gaps, resources, and opportunities at each intercept for individuals in the target population.

3. Development of priorities for activities designed to improve system and service level responses for individuals in the target population

1

Munetz, M., & Griffin, P. (2006). A systemic approach to the de-criminalization of people with serious mental illness: The Sequential Intercept Model. Psychiatric Services, 57, 544-549.

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Agenda

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Sequential Intercept Model Map for Tulsa, OK

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Resources and Gaps at Each Intercept

T

he centerpiece of the workshop is the development of a Sequential Intercept Model map. As part of the mapping activity, the facilitators work with the workshop participants to identify resources and gaps at each intercept. This process is important since the criminal justice system and

behavioral health services are ever changing, and the resources and gaps provide contextual information for understanding the local map. Moreover, this catalog can be used by planners to establish greater opportunities for improving public safety and public health outcomes for people with mental and substance use disorders by addressing the gaps and building on existing resources.

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INTERCEPT 0 AND INTERCEPT 1 RESOURCES 

The National Suicide Crisis Line (COPES answers national line for local area codes)

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211 informational access

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MHA assistance center (not 24 hr., triage refer)

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The NAMI Tulsa call line operates Monday-Friday (triage and refer).

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Family and Children Services (FC&S) Crisis Care Center has a 16 bed Crisis Stabilization Unit with a length of stay of 3-5 days and a 12 chair Crisis Respite Unite with length of stay up to 24 hours.

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Tulsa Center for Behavioral Health (TCBH) has 56 beds, is state operated, offers 24 hour admission on triage, and requires emergency room clearance.

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Family and Children’s Grade Center immediate walk in services is open 5 days a week from 9:00 AM-5:00 PM.

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Civil Mental Health Court, Assisted Outpatient Treatment (AOT) and conditional release from jail to inpatient services.

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Access to some Crisis Intervention Team (CIT) trained members – 130 TPD CIT trained, 20% trained.

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

There is 38 hours of mental health training in the Tulsa Police Academy.

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Tulsa County Sheriff’s Office (TCSO) Civil Mental Health Unit

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Ride along Program

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The Police Impact Patrol Officers downtown. There are patrol working with homeless, etc.

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The Mental Health Association works with the Tulsa Police Department- rapid response outreach.

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Peers are involved in service delivery and promoting public awareness of services.

GAPS 

The crisis capacity is insufficient and services multiple individuals out of county.

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Transports to other jurisdictions (50.mo.) due to lack of state funding for crisis beds.

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There are high uncompensated costs among hospitals.

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There is a shortage of psychiatrists and inpatient psychiatrists.

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Individuals do not know where to go to receive services.

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There is a lack of service capacity.

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There is no place to send or there is a waiting list for individuals needing substance use opioid care.

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There is Monday through Friday services but a lack of evening and weekend service.

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Access to 911 data integration and crisis care data integration.

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The COPES center offered a 24 hour Community Response Team (CRT) however, CRT was al limited pilot and there is not a co-responder model in place.

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INTERCEPT 2 AND INTERCEPT 3 RESOURCES 

Citation to hold versus charging when taken to crisis care.



Ability to track date of care to month – 10% will go to 911.

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The Tulsa Police Department honors diversion to the hospital.

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Upon discharge from hospitals there is sufficient discharge medication to last until 1st appointment.

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The Broken Arrow Jail holds clients up to 30 days and has 30 beds.

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COPES responds to suicidal individuals through Child and Family Services

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Access to the hospital in Broken Arrow.

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The Tulsa County Jail has 1,943 beds in total; 1,500-1,600 are male, 280 female, 30 for juveniles aged 13-18 years old, and 70 for mental health which are all male.

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TCU Drug Screen and Brief Jail Mental Health Screen can be used.

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There is screening for felonies with RNR model for referral to diversion.

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There is a questionnaire to identify veterans and a PTSD evaluation.

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

The state determines at arraignment who qualifies for public defender.

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The arraignment and mental health judge are the same which results in diversion increase.

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Pre-trial does screenings to provide information if they want to release

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The veteran’s court for misdemeanors and felonies serves 103 individuals.

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The women in recovery court serves 125 individuals.

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There is CIT for detention staff.

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The courts are providing more printed information in jail and more updated in-reach information.

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There is CLE (continuing legal education) offered for attorney training on mental health diversion.

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Individuals are screened within 24 hours of booking.

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The civil hold is a known formal process.

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The Civil Court provides services 5 days a week and can keep tabs on police department referrals.

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The Turn Key is a contracted health care provider from 7am through 7pm with 3 mental health clinicians, and a mental health clinician on call during the weekend.

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There is access to inmate mental health providers.

GAPS 

Identifying repeat offenders in crisis

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Gap in referral from jail for medication and treatment.

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There is a high demand at the ER – can have 20 “sitters” on Mondays (post weekend) due to lack of resources.

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Lack of MH screening at jail

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Need data on Medical clearance – needed for CRT

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There is a need to divert non-emergency care individuals out of ERs.

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Lack of information on veterans in jail

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The Veterans Reentry Search Service (VRSS) is not utilized.

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

The private defense bar is not invested in making referrals for diversion



The pre-trial screening information does not get sent to the judge unless requested.

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There is a different judge on Sundays who sets bonds and is not familiar with the defendant’s background.

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Gathering information for interception and diversion

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The jail is used as a tool to stabilize mental health, homelessness, lack of medication, and other related issues.

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It is unclear how individuals go to docket and special services docket because there is no standard procedure.

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There is no misdemeanor court for drug charges.

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Lack of resources/services in housing, transportation, and employment.

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Issues of capacity at all levels of specialty courts – need is intensive.

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Lack of services for low risk individuals.

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INTERCEPT 4 AND INTERCEPT 5 RESOURCES 

There is a TCSO-community liaison for in reach services by community providers.



The Chaplain’s office coordinates faith based housing, work, and bible study. o

Case managers are available after hours.



The Women’s Justice Team offers court services/ pre-trial started ORAS-PSAT during interviews



FC&S does 2nd level screening o

Assessment is offender screening 

Tools used-ORAS-CST, TCU V, MHSF-lll



There are Kiosk Resource Centers.

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There is access to a family hotline. o



1-800-246-0881

There is a grant funded reentry one stop for prison releases aged 18-24, providing, legal aid, benefits, recovery, at 5 reentry locations.

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

There are specialized caseloads for sex offenders, women in recovery, mental health, female diversion, and community sentencing.



The Mental Health Court fees are waived.

GAPS 

County is not as connected to faith based services and needs to include faith services in planning.



There is a lack of AA/NA support.

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There is little family access to turnkey.

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Deficit in transportation and navigation resources.

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There is a lack of literacy in the County.

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There is lack of funding for general services.

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Fees for collateral sanctions, court fees (subsidize court/DA operation), and supervision fees.

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Priorities for Change

T

he priorities for change are determined through a voting process. Workshop participants are asked to identify a set of priorities followed by a vote where each participant has three votes.

The voting took place on August 2, 2017. The top three priorities are highlighted in italicized text.

Resources, program examples and comments to address the priorities are noted below specific priorities.

1. RNR at booking – guiding decisions at release and utilization of community resources (22 votes) For information regarding implementation of RNR with persons with mental illness, see Appendix 1. Persons with mental illness may have higher risk factors, e.g. homelessness, lack of family support, substance use etc. and may be considered higher risk to offend.

However, to the extent those risk factors can be addressed through the responsivity principle, risk factors can be addressed.

2. Expansion of information exchange and data integration across systems (20 votes) Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) has begun to develop dashboard indicators to track criminal justice/mental health programs and outcomes through its “One Pager” series. Modeling these efforts at the county level would help track program development and program outcomes. This priority is also addressed in the recommendations made in the Asemio Data Ecosystem project commissioned by the Tulsa County Sheriff’s Office. Additional resources to address this priority are listed below:



Vera Institute of Justice. Closing the Gap: Using Criminal Justice and Public Health Data to Improve Identification of Mental Illness.

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

Data-Driven Justice Initiative. Data-Driven Justice Playbook: How to Develop a System of Diversion.



Urban Institute. Justice Reinvestment at the Local Level Planning and Implementation Guide.

3. Increase housing options (16 votes) Housing First strategies are not generally used to target high need individuals for housing in Tulsa County. While there is a Continuum of Care Committee, there has not been focus on the justice involved population. Communities around the country have begun to develop more formal approaches to housing development, including use of the Housing First model.

The 100,000 Home Initiative identifies key steps for communities to take to expand housing options for persons with mental illness (see http://100khomes.org/resources/housing-firstself-assessment ). The following resources are suggested to guide strategy development: 

Moving Toward Evidence-based Housing Program for Person with Mental Illness in Contact with the Justice System http://gainscenter.samhsa.gov/pdfs/ebp/MovingTowardEvidenceBasedHousing.pdf



Stefancic, A., Hul, L., Gillespie, C., Jost, J., Tsemberis, S., and Jones, H. (2012).

Reconciling Alternative to Incarceration and Treatment Mandates with a Consumer Choice Housing First model: A Qualitative study of Individuals with Psychiatric Disabilities. Journal of Forensic Psychology Practice, 12, 382–408.



Tsemberis, S. (2010). Housing First: The Pathways Model to End Homelessness for People with Mental Illness and Addiction. Center City, MN: Hazelden Press.



Stefancic, A., Henwood, B. F., Melton, H., Shin, S. M., Lawrence-Gomez, R., and Tsemberis, S. (2013). Implementing Housing First in Rural Areas: Pathways Vermont, American Journal of Public Health, 103, 206–209.

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An Alliance for Health Reform Toolkit: http://www.allhealth.org/publications/Disparities_in_health_care/Health-andHousing-Toolkit_168.pdf

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Housing First Self-Assessment: http://100khomes.org/sites/default/files/Housing%20First%20Self%20Assessment% 20Tool%20FINAL%2010.31.13.pdf

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Shifting the Focus from Criminalization to Housing: http://homelessnesslaw.org/2016/07/shifting-the-focus-from-criminalization-tohousing/

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

Lehman, M.H., Brown, C.A., Frost, L.E., Hickey, J.S., and Buck, D.S. (2012). Integrated Primary and Behavioral Health Care in Patient-Centered Medical Homes for Jail Releases with Mental Illness. Criminal Justice and Behavior, published online.

Built for Zero (formerly Zero: 2016) is a rigorous national change effort working to help a core group of committed communities end veteran and chronic homelessness. Coordinated

by Community Solutions, the national effort supports participants in developing real time data on homelessness, optimizing local housing resources, tracking progress against monthly goals, and accelerating the spread of proven strategies. Tulsa City & County/Broken Arrow Continuum of Care (CoC) participates in this initiative. Including criminal justice agencies and data regarding housing needs of justice involved persons will insure their needs are addressed.

Contact: Wayne Kindrick is the CoC Coordinator for the Community Service Counsel of Greater Tulsa, Inc. wkindrick@csctulsa.org 4. Jail Mental Health and Substance Use screening for all booking (14 votes) See Recommendation #3 5. Increase Substance Use funding, including low risk offenders (11 votes) Findings in the Vera Report indicate that the most frequent charge for jail admissions was public intoxication, (p. 22) and felony admissions are driven by nonviolent crimes related to substance use and poverty (p. 22). Accessible substance use services and a continuum of substance use services are key elements of any successful diversion or jail reduction strategy.

Below are relevant resources and there are additional resources in the Resources Section of this report: 

 

The SAMHSA publication, Detoxification and Substance Abuse Treatment. Treatment Improvement Protocol (TIP) Series, No. 4 SAMHSA Tip 45 http://store.samhsa.gov/shin/content//SMA15-4131/SMA15-4131.pdf , provides communities with guidance on a continuum of inpatient and outpatient care for detoxification services and identifies best practices.

Jails and prisons are increasingly utilizing Medication Assisted Treatment at the point of reentry and program examples are identified in Appendix 2 The San Diego Serial Inebriate Program is a nationally recognized program to offer services to a chronic inebriate population. The program description can be found at, https://www.sandiego.gov/sites/default/files/legacy/sip/pdf/SDPD%20pages.pdf

6. Increase in Programs of Assertive Community Treatment, Assisted Outpatient Treatment, and Court Ordered Treatment (9 votes) 7. Facilitate continuum of residential care/stepdown through long term in patient stay/follow up (9 votes) 8. Create cross system staffing and case management (9 votes) 9. Expand CRT and cares team (6 votes)

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10. Develop a task force to look at high recidivism among homelessness and substance use individuals (5 votes) 11. Improve barriers in transportation 12. Embrace and utilize peer to peer model/peer navigator (3 votes) 13. Ensure safety for staff and other clients (3 votes) 14. Obtain information on services to consumers, families, and the community (2 votes) 15. Study hospital uncompensated care costs and increase hospital engagement (1 vote) 16. Develop specialized services for co-morbid and elderly (1 vote)

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Quick Fixes While most priorities identified during a Sequential Intercept Model mapping workshop require significant planning and resources to implement, quick fixes are priorities that can be implemented with only minimal investment of time and little, if any, financial investment. Yet quick fixes can have a significant impact on the trajectories of people with mental and substance disorders in the justice system.

1. Opioid Use Training and Crisis Intervention Team (CIT) training – Probation and Parole, and The Oklahoma Department of Mental Health (ODMH) will meet.

2. Weekly multi-agency staffing for frequent users of services.

Parking Lot 1. Probation and Parole is underfunded.

2. No Medicaid expansion and high drug use results in barriers to treatment and violence 3. Recent state funding decreases for 25% of the individuals who need it

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Planning Groups 1. Criminal Justice Probation and Parole a. Vera Subcommittee 2. Stepping Up 3. Outside/Inside Collaboration for Justice a. Jail Diversion- Tulsa Sheriff’s Office b. Core Team Monthly Meeting c. Five Workgroups i. Assessment ii. Data- Pilot iii. Medicaid iv. Education/training v. Discharge planning 4. Continuum of Care Committee a. A Way Home for Tulsa 5. Ten-Year Mental Health Plan a. Tulsa University manages this

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Recommendations PRA acknowledges and commends the collaboration and existing initiatives in Tulsa County. They provide a sound basis to address the priorities and recommendations herein. The “Report to Tulsa County Stakeholders on Jail Reduction Strategies” by the Vera Institute and “Data Echosystem” presentation by ASEMIO helped inform the recommendations below.

1. Coordinate various Criminal Justice and Behavioral Health Planning bodies that address the needs of justice involved persons with co-occurring mental health and substance use disorders.

There are a number of overlapping planning groups addressing criminal justice and behavioral health initiatives (see “Planning Groups” p. X) Discussion with participants determined follow-up from the SIM Workshop will fall under the auspices of the “Outside/Inside Collaborative for Justice” (OICJ). Coordinating the work with the OJIC with other planning groups may lead to more efficient planning of activities, less duplication of effort and insure the inclusion of the needs of justice involved persons with mental illness in broader criminal justice and behavioral health planning efforts.

This recommendation also relates to Recommendation 6 of the Vera Report.

Bexar County (Texas), Memphis (Tennessee), New Orleans Parish (Louisiana), and Pima County (Arizona) are examples of counties and municipalities that have developed Criminal Justice Mental Health Planning Committees.

2. Expand and enhance the Crisis Care Continuum and Police-Mental Health Co-response.

While Tulsa does have many components of the Crisis Care Continuum, (see Resources section) including Crisis Respite (23 hours) Crisis Stabilization (3-5 days), 24 hour mobile crisis services, a pilot Community Response Team (CRT) initiative involving EMS, TPD and Mobile Crisis and urgent care centers. Participants reported that the Crisis Stabilization Unit is frequently at capacity, urgent care may be underutilized for assessing mental health crises and hospital

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emergency rooms are overburdened. The current situation likely results in significant financial burdens to hospitals due to uncompensated care as many individuals are likely to be uninsured.

The states of Texas, Virginia, Wisconsin, Minnesota, California, and Colorado, among others, have sought to develop a crisis care continuum that is responsive to the needs of people experiencing behavioral health crises, decreases unnecessary utilization of emergency rooms, contains costs and provides more targeted program options for persons in behavioral health crisis (California Senate, 2013; Colorado Senate, 2013; Minnesota State Legislature, 2014; Texas Department of State Health Services, 2008; Strode, 2009; Wisconsin State Legislature, 2013).

Virginia conducted an uncompensated care study to examine costs of behavioral health use of Emergency Rooms and offered remedies to address uncompensated care costs “Hospital Uncompensated Care Costs in Virginia”, Policy Brief. September 2015. (https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_DHBP_HUCC_WEB.pdf ).

The Oklahoma Department of Mental Health (ODMH) has a good track record of data collection and funding programs for crisis services. In exploring the current cost saving in these programs, there may be justification for further investment in Crisis Services when the full cost of ER services are also factored into the cost. The CRT Team, while a pilot, reflects emergent crisis strategies in other communities. (Appendices X and X). These strategies reduce repeat crisis calls, reduce ED and inpatient costs and reduces demand on emergency resources and costs of responding to inappropriate calls.

Some communities have been able to expand crisis response to rural communities through telemedicine. Attached is the link to the GAINS Springfield MO webinar (https://www.prainc.com/wp-content/uploads/2017/09/GAINSWebinarVMCI-9517slides.pdf), two articles discussing EMS Appendix 3 and Remington, A.A. (2016). Skyping During a Crisis?

Telehealth is a 24/7 Crisis Connection Lincoln Program Appendix 4.

3. Develop more formal and coordinated screening and diversion strategies for Arraignment Diversion (Intercept 2) and pre plea diversion (Intercept 3) Priority 1 and 4 relate to screening to identify clinical and risk needs at early intervention points.

These priorities are overlapping and addressing them should be coordinated to insure lack of duplication of effort and enhance early identification of and diversion opportunities for persons with co-occurring disorders.

Participants reported that though there is a Municipal Court diversion program, pathways for prompt referral to the court were not clear. As a result, eligible defendants may not be able to take timely advantage the Municipal Court.

There is a lack of formal screening and diversion strategies at arraignment and at the jail.

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and that formal screening tools were not being utilized. Formalizing screening protocols at arraignment and at the jail is the first step in expanding and implementing diversion strategies.

Crucial to success of the early court diversion strategies is the prompt assignment of defense counsel, mental health screening by pre-trial services and court based clinician to link individuals promptly to mental health services.

Many screens, such as the Brief Jail Mental Health Screen, are in the public domain.

Additional brief mental health screens include the: 

Correctional Mental Health Screen



Mental Health Screening Form III

Brief alcohol and drug screens include the: 

Texas Christian University Drug Screen V

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Simple Screening Instrument for Substance Abuse



Alcohol, Smoking and Substance Involvement Screening Test

Guidelines for screening for Veteran status can be found in Appendix 5.

Essential elements of Intercept 2 diversion can be found in the SAMHSA Monograph, “Municipal Courts: An Effective Tool for Diverting People with Mental and Substance Use Disorders in the Criminal Justice System.” The monograph identifies four essential elements of arraignment diversion programs. Improving screening, clinical assessment, and behavioral health disorders who are released without referral or follow-up. Reference CASES Transitional Case Management and the Manhattan Arraignment Diversion Program found in Appendix 6 and Appendix 7.

While not a topic of discussion in the SIM workshop, PRA notes that Family and Children Services operates First Episode Psychosis Program, “Navigate”, which promotes early identification of mental illness and prompt treatment. Consulting with NAVIGATE staff while developing court and jail screening protocols may increase identification of persons experiencing 1st episode psychosis and insure prompt referral and treatment.

The above recommendation is consistent with the Vera report recommendations 1-5. In fact implementing the Vera recommendations relating to early release without considering the special service needs and circumstances of persons with co-occurring disorders could result in higher rates of failure under pre-release supervision and exposure to additional sanctions. This recommendation is also consistent with recommendations made in the Asemio Data Ecosystem project commissioned by the Tulsa County Sheriff’s Office.

Diversion strategies that do not result in a conviction are also important to consider. National Institute of Justice (NIJ) publication “Beyond the Sentence - Understanding Collateral Consequences” (https://www.nij.gov/journals/272/Pages/collateral-consequences.aspx ) demonstrates the debilitating effect successful recovery and rehabilitation due to collateral consequences of conviction and fines.

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4. Increase Trauma Informed Care training to justice involved personnel The ODMHSAS has promoted and supported Trauma Informed Care training to the mental health and provider community. Because of the prevalence of trauma in justice involved people, it’s also recommended that it be offered to the personnel involved in the court programs, police, jail, sheriffs and paramedics.

5. Enhance peer involvement across the intercepts.

The consensus in the SIM group was that peers have been a valuable addition to clinical settings, ERs and the Municipal Court. We recommend that have functional roles in the other courts and in the jail as their helpfulness has been shown to be effective in ameliorating the trauma of the justice process and aiding in service engagement. In addition, it’s recommended that peers be involved in planning groups so their perspectives and voice can be heard and understood (see peers in resource section) 6. Improve access to Transportation.

Transportation is frequently identified as a priority by communities across the country. Yet, nationally, few program models or planning strategies have been identified to address this critical component of service access.

Ohio Association of County Behavioral Health Authorities published “White Paper: Criminal Justice and Behavioral Health Care, Housing, Employment, Transportation and Treatment” (January 2015). The White Paper describes 3 transportation initiatives: 1. The NET – Plus initiative in Wood County, Ohio. NET Plus program coordinates transportation resources for Medicaid eligible populations and funds transportation for non-Medicaid eligible populations.

2. The Hardin County Volunteers in Police Service (VIPS) initiative operated by the Sheriff’s Department provides volunteer transportation to essential services for drug court clients.

3. The Franklin County Turn it Around Transportation & Re-development Services provides transportation for workers to various employers. The program is funded by self-contribution, payroll deduction and/or employers.

For a copy of the White Paper or for further information, contact: Ohio Association of County Behavioral Health Authorities Attn: Cheri L. Walter, CEO 33 North High Street, Suite 500 Columbus, Ohio 43215 614-224-1111 www.oacbha.org Email: cwalter@oacbha.org

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Strategic Action Plans PRIORITY AREA 1 RNR AT BOOKING – GUIDING DECISIONS AT RELEASE AND UTILIZATION OF COMMUNITY RESOURCES Objectives Identify individuals to share screenings/information

Consider PR release for who is determined probation eligible

Coordinate with OICJ #5

Action Step Build a list of group or persons who need information from screenings within the workgroup Share with workgroup #5 for workflow decisions Visit with district judges for permission to run docket this way DA will get list of names to arraignments judge for probation eligible individuals Warm handoff to workgroup #5 and information sharing/update

Who OICJ #1 workgroup

When

OICJ #1 and #5 workgroups

8/7/17 (next meeting)

Judge Moody and DA offices

Jill Young

8/7/17

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PRIORITY AREA 2 INFORMATION/DATA SHARING Objectives Create the common sharing “list serve� for information release

Action Step Determine organization structure

Who

When

Develop data storage Release of information/sharing Consult existing programs Jail Psychiatrist gains access to health and community D.B.

ROI distribution for review ID factors/parameters for individual inclusion (pilot threshold) Best practice review and application of other existing programs Seek/Review funding options Research 3rd sector TA Grant

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PRIORITY AREA 3 AVAILABILITY AND ACCESS TO HOUSING “A WAY HOME 4 TULSA” Objectives Coordinated entry to housing solutions and supported services

Barriers

Action Step One database on what housing is available

Who Community Service Council Kimberly Cummings

When 8/8/17 at 2pm

Universal housing application online

Mack Haltom, MHAOK, Jol. Am

January 2018

Bring hospitals in for housing prior to discharge (transitional)

Leah Price – TCBH Mike Brose (get release signed for process to start)

February 2018

Terry Cole, Jennifer Freeman

In process

Community Service CouncilJennifer Freeman NAMI Tulsa

In process

Mental Health Association

January 2018

Court must know housing is available Tulsa Housing Authority Private Landlords Inform Families Create Housing Solutions -New model; homes with occupants help pay for services to come in -Single family housing

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PRIORITY AREA 4 SUBSTANCE USE FUNDING – INCLUDING LOW RISK OFFENDERS Objectives Increase funding for Crisis Detox, Early Assessment (level of care), Hospital E.R.’s, and NARCAN

Action Step Funding from fine reductions/citations Detox: Hillcrest 12-n-12 Parkside SQ 780 and 781 – Funding how’s and funding accessed

Diversion Programs (Low-Risk) -Sobering Center -Pre-Booking Diversion -Court System Diversion -Leverage (Jail, Citations, Fine reduction, Self-funding)

Data Group Intro Early Prevention Education Operational Aware-Grant

Who State SQ (10-year plan) Private Insurance Private Funding Medicaid City (fines) County (fines) E.R. Hospitals City – Officer Time Walmart, Target, Restorative Justice Palmer 12-n-12 Tribal V.A. Commercial Self-pay Federal Grants

When 6 months

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Resources COMPETENCY EVALUATION AND RESTORATION 

SAMHSA’s GAINS Center. Quick Fixes for Effectively Dealing with Persons Found Incompetent to Stand Trial.



Finkle, M., Kurth, R., Cadle, C., and Mullan, J. (2009) Competency Courts: A Creative Solution for Restoring Competency to the Competency Process. Behavioral Science and the Law, 27, 767786.

CRISIS CARE, CRISIS RESPONSE, AND LAW ENFORCEMENT 

Substance Abuse and Mental Health Services Administration. Crisis Services: Effectiveness, CostEffectiveness, and Funding Strategies.



International Association of Chiefs of Police. Building Safer Communities: Improving Police Responses to Persons with Mental Illness.



Suicide Prevention Resource Center. The Role of Law Enforcement Officers in Preventing Suicide.



Saskatchewan Building Partnerships to Reduce Crime. The Hub and COR Model.



International Association of Chiefs of Police. Improving Police Response to Persons Affected by Mental Illness: Report from March 2016 IACP Symposium.



International Association of Chiefs of Police. One Mind Campaign.



Optum. In Salt Lake County, Optum Enhances Jail Diversion Initiatives with Effective Crisis Programs.



Bureau of Justice Assistance. Engaging Law Enforcement in Opioid Overdose Response: Frequently Asked Questions.

33



The Case Assessment Management Program is a joint effort of the Los Angeles Department of Mental Health and the Los Angeles Police Department to provide effective follow-up and management of selected referrals involving high users of emergency services, abusers of the 911 system, and individuals at high risk of death or injury to themselves.



National Association of Counties. Crisis Care Services for Counties: Preventing Individuals with Mental Illnesses from Entering Local Corrections Systems.



CIT International.

DATA ANALYSIS AND MATCHING 

Data-Driven Justice Initiative. Data-Driven Justice Playbook: How to Develop a System of Diversion.



Urban Institute. Justice Reinvestment at the Local Level Planning and Implementation Guide.



The Council of State Governments Justice Center. Ten-Step Guide to Transforming Probation Departments to Reduce Recidivism.



New Orleans Health Department. New Orleans Mental Health Dashboard.



Pennsylvania Commission on Crime and Delinquency. Criminal Justice Advisory Board Data Dashboards.



Corporation for Supportive Housing. Jail Data Link Frequent Users: A Data Matching Initiative in Illinois



Vera Institute of Justice. Closing the Gap: Using Criminal Justice and Public Health Data to Improve Identification of Mental Illness.

HOUSING 

Alliance for Health Reform. The Connection Between Health and Housing: The Evidence and Policy Landscape.



Economic Roundtable. Getting Home: Outcomes from Housing High Cost Homeless Hospital Patients.



100,000 Homes. Housing First Self-Assessment.



Urban Institute. Supportive Housing for Returning Prisoners: Outcomes and Impacts of the Returning Home-Ohio Pilot Project.



Corporation for Supportive Housing. NYC FUSE – Evaluation Findings.

34



Corporation for Supportive Housing. Housing is the Best Medicine: Supportive Housing and the Social Determinants of Health.

INFORMATION SHARING 

American Probation and Parole Association. Corrections and Reentry: Protected Health Information Privacy Framework for Information Sharing.

JAIL INMATE INFORMATION 

NAMI California. Arrested Guides and Inmate Medication Forms.

MEDICATION ASSISTED TREATMENT (MAT) 

American Society of Addiction Medicine. The National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use.



American Society of Addiction Medicine. Advancing Access to Addiction Medications.



Substance Abuse and Mental Health Services Administration. Federal Guidelines for Opioid Treatment Programs.



Substance Abuse and Mental Health Services Administration. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide.



Substance Abuse and Mental Health Services Administration. Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction (Treatment Improvement Protocol 40).



Substance Abuse and Mental Health Services Administration. Clinical Use of Extended Release Injectable Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide.

MENTAL HEALTH FIRST AID 

Mental Health First Aid.



Illinois General Assembly. Public Act 098-0195: Illinois Mental Health First Aid Training Act.



Pennsylvania Mental Health and Justice Center of Excellence. City of Philadelphia Mental Health First Aid Initiative.

PEERS 

SAMHSA’s GAINS Center. Involving Peers in Criminal Justice and Problem-Solving Collaboratives.



SAMHSA’s GAINS Center. Overcoming Legal Impediments to Hiring Forensic Peer Specialists.

35



NAMI California. Inmate Medication Information Forms



Keya House.



Lincoln Police Department Referral Program.

PRETRIAL DIVERSION 

CSG Justice Center. Improving Responses to People with Mental Illness at the Pretrial State: Essential Elements.



National Resource Center on Justice Involved Women. Building Gender Informed Practices at the Pretrial Stage.



Laura and John Arnold Foundation. The Hidden Costs of Pretrial Diversion.

PROCEDURAL JUSTICE 

Legal Aid Society. Manhattan Arraignment Diversion Program.



Center for Alternative Sentencing and Employment Services. Transitional Case Management for Reducing Recidivism of Individuals with Mental Disorders and Multiple Misdemeanors.



Hawaii Opportunity Probation with Enforcement (HOPE). Overview.

REENTRY 

SAMHSA’s GAINS Center. Guidelines for the Successful Transition of People with Behavioral Health Disorders from Jail and Prison.



Community Oriented Correctional Health Services. Technology and Continuity of Care: Connecting Justice and Health: Nine Case Studies.



The Council of State Governments. National Reentry Resource Center.



Bureau of Justice Assistance. Center for Program Evaluation and Performance Management.



Washington State Institute of Public Policy. What Works and What Does Not?



Washington State Institute of Public Policy. Predicting Criminal Recidivism: A Systematic Review of Offender Risk Assessments in Washington State.

SCREENING AND ASSESSMENT 

Center for Court Innovation. Digest of Evidence-Based Assessment Tools.

36



SAMHSA’s GAINS Center. Screening and Assessment of Co-occurring Disorders in the Justice System.



Steadman, H.J., Scott, J.E., Osher, F., Agnese, T.K., and Robbins, P.C. (2005). Validation of the Brief Jail Mental Health Screen. Psychiatric Services, 56, 816-822.



The Stepping Up Initiative. (2017). Reducing the Number of People with Mental Illnesses in Jail: Six Questions County Leaders Need to Ask.

SEQUENTIAL INTERCEPT MODEL 

Munetz, M.R., and Griffin, P.A. (2006). Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness. Psychiatric Services, 57, 544-549.



Griffin, P.A., Heilbrun, K., Mulvey, E.P., DeMatteo, D., and Schubert, C.A. (2015). The Sequential Intercept Model and Criminal Justice. New York: Oxford University Press.



SAMHSA’s GAINS Center. Developing a Comprehensive Plan for Behavioral Health and Criminal Justice Collaboration: The Sequential Intercept Model.

SSI/SSDI OUTREACH, ACCESS, AND RECOVERY (SOAR) Increasing efforts to enroll justice-involved persons with behavioral disorders in the Supplement Security Income and the Social Security Disability Insurance programs can be accomplished through utilization of SSI/SSDI Outreach, Access, and Recovery (SOAR) trained staff. Enrollment in SSI/SSDI not only provides automatic Medicaid or Medicare in many states, but also provides monthly income sufficient to access housing programs. 

Information regarding SOAR for justice-involved persons.



The online SOAR training portal.

TRANSITION-AGED YOUTH 

National Institute of Justice. Environmental Scan of Developmentally Appropriate Criminal Justice Responses to Justice-Involved Young Adults.



Harvard Kennedy School Malcolm Weiner Center for Social Policy. Public Safety and Emerging Adults in Connecticut: Providing Effective and Developmentally Appropriate Responses for Youth Under Age 21 Executive Summary and Recommendations.



Roca, Inc. Intervention Program for Young Adults.



University of Massachusetts Medical School. Transitions RTC for Youth and Young Adults.

37

TRAUMA-INFORMED CARE 

SAMHSA, SAMHSA’s National Center on Trauma-Informed Care, and SAMHSA’s GAINS Center.

Essential Components of Trauma Informed Judicial Practice.



SAMHSA’s GAINS Center. Trauma Specific Interventions for Justice-Involved Individuals.



SAMHSA. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.



National Resource Center on Justice-Involved Women. Jail Tip Sheets on Justice-Involved Women.

VETERANS 

SAMHSA’s GAINS Center. Responding to the Needs of Justice-Involved Combat Veterans with Service-Related Trauma and Mental Health Conditions.



Justice for Vets. Ten Key Components of Veterans Treatment Courts.

38

Appendices INDEX Appendix Appendix 1

Title Skeem, J. L., Steadman, H. J., & Manchak, S. M. (2015). Applicability of the Risk-NeedResponsivity Model to Persons With Mental Illness Involved in the Criminal Justice System. Psychiatric Services, 66(9), 916-922.

Appendix 2

Notable Public Sector VIVITROL Programs

Appendix 3

Stanaway, N. 2012. Community paramedic program cuts mental health patient call volume. The Business of EMS. Murawski, J. 2015. Wake County EMS has one solution to overcrowded emergency rooms. Wake County.

Appendix 4

Remington, A.A. (2016). Skyping During a Crisis? Telehealth is a 24/7 Crisis Connection Lincoln Program.

Appendix 5

The CMHS National GAINS Center. 2008. Responding to the Needs of Justice-Involved Combat Veterans with Service-Related Trauma and Mental Health Conditions.

Appendix 6

Jacob & Valeria Langeloth Foundation, CASES, Policy Research Associates. 2012.

Successfully Engaging Misdemeanor Defendants with Mental Illness in Jail Diversion: The CASES Transitional Case Management Program.

Appendix 7

Jacob & Valeria Langeloth Foundation, The Legal Aid Society, Policy Research Associates. 2013. Creating an Indigent Defense Diversion Team: The Manhattan Arraignment Diversion Project.

39

Notable Public Sector VIVITROL® Programs As of February 11, 2015 1. California – Effective January 2014, VIVITROL (naltrexone for extended-release injectable suspension) is available to all alcohol or opioid dependent patients who are Medi-Cal beneficiaries with a felony or misdemeanor charge or conviction who are under supervision by the county or state, or are within the AB 109 population (e.g., offenders with post-release community supervision, straight sentence, mandatory supervision, and parolees under jurisdiction of California Department of Corrections and Rehabilitation (CDCR) and the court). Substance Abuse Prevention and Control, a division of the County of Los Angeles’ Department of Public Health, continues to appropriate annual funds for VIVITROL and case management for the uninsured repeat detox population.

Ten additional counties are involved in funding programs through various county departments for the use of VIVITROL with treatment for uninsured and/or Medicaid patients with opioid or alcohol dependence.

2. Colorado – The Colorado Department of Corrections, in collaboration with the Department of Human Services, has allocated $500K in FY’15 to provide comprehensive treatment with VIVITROL for parolees.

3. Florida – There was $5M appropriated in the 2014-2015 General Appropriations Act: $3M appropriated for the use of VIVITROL in Florida Drug Courts; $1.5M to the Florida Department of Children and Families to provide VIVITROL and treatment for indigent patients; and $500K to the Florida Department of Corrections to provide VIVITROL and treatment in its community corrections program.

4. Maryland – Through the Washington County Health Department, Division of Behavioral Health Services, VIVITROL and psychosocial therapy is provided to offenders with opioid or alcohol dependence prior to leaving the county detention center, and continued in the community post-release. Program funded through a Second Chance Act Grant and County Funds. Program recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) with a 2013 Science and Service Award. a. Budget language includes $1M for VIVITROL pilot program in the treatment of opioid dependence in rural counties during FY’15.

5. Massachusetts – Ten of 13 Sheriffs are implementing comprehensive jail reentry programs with VIVITROL. Separately, the Massachusetts Department of Correction is implementing a statewide prison re-entry program with VIVITROL. $1M allocated through the Governor’s Opioid Task Force is expanding this prison re-entry program to two additional facilities, totaling nine prisons across the state.

6. Missouri – There is $3.9M of recurring non-Medicaid funding allocated annually to programs including the use of VIVITROL: $3.4M by the Missouri Department of Mental Health and $500K by the Missouri Department of Corrections. Funding is for statewide implementation of VIVITROL for the uninsured and for those under probation and parole supervision.

7. Ohio – General Assembly appropriated $5M to the Ohio Department of Mental Health and Addiction Services to fund a six-county drug court pilot program for opioid and alcohol dependent offenders. The program funds comprehensive treatment including the use of FDA-approved medications to treat opioid dependence. Additionally, four counties were awarded Smart Ohio Plan grants by the Ohio Department of Rehabilitation and Corrections to provide treatment with VIVITROL in community corrections.

8. Pennsylvania – The Pennsylvania Department of Corrections is implementing a VIVITROL re-entry program at eight State Correctional Institutes for opioid and alcohol dependence in 2015. Residential Substance Abuse Treatment for State Prisoners (RSAT) Program funds will pay for 175 offenders for a total of 12 months.

9. Wisconsin – The Wisconsin General Assembly passed AB 701 legislation, appropriating $2M in new funding to create opioid treatment programs in two to three rural counties to address the heroin epidemic. The new treatment programs will deploy the latest FDAapproved medications, including the use of VIVITROL. Governor Scott Walker signed AB 701 in a ceremony on April 7, 2014.

10. Illinois – The Illinois General Assembly appropriated $500K per year in the FY’14 and FY’15 budget to the Illinois Department of Alcohol and Substance Abuse (DASA). The funding is to be equally divided between two initiatives: 1) a collaboration between DASA, Treatment Alternatives for Safe Communities (TASC), the 17th Judicial Circuit Court, Winnebago County and Rosecrance Health Network to treat drug court patients, and 2) a collaboration between DASA, Gateway Foundation, and Family Guidance Center to treat patients who have suffered multiple relapses to opioid dependence.

Community paramedic program cuts mental health patient call volume

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THE BUSINESS OF EMS with Nathan Stanaway

Community paramedic program cuts mental health patient call volume By triaging patients with mental illness, especially repeat users, the Grady EMS Upstream Crisis Intervention Group provider has improved care, saved significant money and boosted morale May 23, 2016

The Grady EMS Upstream Crisis Intervention Group launched in January 2013 and is the brainchild of Michael Colman, vice president of EMS operations. While reviewing call volume data, Colman noticed that about 6 percent, or 6,410, of GEMS 911 calls were NAEMD triaged as category 25, which means psychiatric/suicide attempt.

Upon further analysis, Colman realized that an overwhelming portion of their frequent users — callers using EMS at least five times a month — suffered from a psychiatric illness. A financial analysis using a sample of 156 patients from this group determined that it cost Grady EMS over $100 more than they received in reimbursement for each of these transports.

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In addition, the emergency department spent over $400 more on each patient than they received in reimbursement. It quickly became obvious to Colman that caring for these patients in the current manner was unsustainable.

A community paramedic project focusing on the care and transport of patients with a psychiatric complaint was launched.

And room for improved patient care was quickly noticed.

Grady EMS Upstream Crisis Intervention Group focuses on care and transport of patients with a psychiatric complaint (Photo courtesy Grady EMS)

RELATED ARTICLES Behavioral emergency: 6 EMS success tips Psych patient transport: 5 tips to make it safe for providers and patients Community paramedic program focuses on preventive care RELATED FEATURE How to build firebased community health care programs The survival of firebased EMS may rest upon delivering services before 911 is called; it's

Patients experiencing mental health crisis were routinely subject to unplanned physical restraint, chemical restraint, police restraint and even arrest. Grady EMS wanted to find a way to better meet the needs of this special group of patients.

Pilot community paramedic program In late 2012, a pilot program was developed and began operation on Jan. 14, 2013. The Grady EMS crisis response team consists of a paramedic, a Grady Health System licensed counselor, a Behavioral Health Link clinical social worker and in some cases a third-year psychiatry resident.

During the pilot phase, the Grady EMS crisis group co-responded with ambulances, self-dispatched or responded at the request of Grady EMS caregivers on scene. The role of the team paramedic is to provide a medical evaluation and assessment. During the pilot phase, the GEMS crisis group did not respond as an independent unit and was only available during the day Monday through Friday.

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a tough proposition, but a doable one

Full program launches The pilot phase concluded at the end of April and the Crisis Intervention Group RELATED CONTENT SPONSORED BY began responding as the sole unit — without other co-responding ambulances or personnel — based on CAD data and proximity. The unit's hours changed to reflect the demand of EMD category 25 calls and were doubled from 40 to 80 hours per week.

All Grady EMS paramedics were provided in-service training on the Georgia Crisis Action Line system and were able to access that system from the field when the crisis unit was not available.

The paramedics would call the GCAL number and then hand the phone to the patient.

The average time to determine a disposition for a patient was 7 to 10 minutes.

This process allows for a mental health professional to evaluate the patient and determine the level of risk over the phone. The mental health professional stays on the phone with the patient and completes a safety plan after the paramedic obtains a patient refusal.

The crisis action line professional can also dispatch a mobile crisis team to the location within one to two hours or inform the paramedic of the necessity to transport the patient to an emergency psychiatric receiving facility.

Grady EMS has been allowing crews in some cases to transport patients to places other than an emergency department for many years now. As an extension of this program, the crisis response team transports some patients directly to in-patient psychiatric facilities.

For the patient, this process completely avoids unnecessary emergency department visits as it is essentially a direct admit into an in-patient mental health facility. Online Grady EMS medical direction is consulted prior to patient transport in the crisis team's SUV. In addition to on scene crisis team referring psychiatric patients to out-patient services, Grady EMS established an agreement to allow 911 call takers to directly transfer some callers who met NAEMD 25-alpha/omega criteria to the crisis action hotline. This transfer process is similar to the process used for the nurse advice and poison control lines. No ambulance responds unless GCAL calls Grady EMS back.

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Community paramedic program cuts mental health patient call volume

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Aside from the program's process changes, training throughout EMS fire and police organizations has resulted in much better care for Atlanta residents with mental illness.

Today, many patients who in the past would likely have been arrested are de-escalated and helped by the techniques learned from Behavioral Health Link and its staff.

When restraint or arrest are unavoidable, the joint training and relationships developed between the police and EMS providers helps remove stress from the process for all involved.

Cost savings of the community paramedic program In 2013, Grady EMS dispatch transferred 175 calls directly to Behavioral Health Line saving Grady EMS about $13,000. The Grady EMS Upstream Crisis Intervention Group responded to 20 percent of EMD category 25 calls totaling 1,250 responses.

The team obtained 275 refusals/no transports. Many of those patients were provided with safety plans and outpatient appointments, which prevented unnecessary emergency department visits totaling about 1,925 bed hours.

Paramedic Matt Thornton and DeAnn Bing, MDÂ (Photo courtesy Grady EMS)

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Colman reported the financial impact of these non-transports saved the emergency department and EMS system over $140,000. To put this in perspective, imagine a 24bed ER being empty for more than 3 days.

Combined with these non-transport referrals, the group generated other cost savings totaling just over $248,000 for FY2013.

In 2014 the psych unit responded to 1,778 calls, potentially saving EMS over $100,000.

In 2015, Grady EMS received 7,668 calls that were psychiatric in nature. Of those, the psych unit handled over 20 percent, again saving EMS over $100,000.

Increased job satisfaction for Grady EMS paramedics Many EMTs and paramedics are initially attracted to EMS as a way to earn a living while helping people. Almost inevitably, that newness wears away and becomes a grim realization that EMS in its most common form does not typically offer a long-term solution to the patient’s underlying problem. When that happens, the patient becomes a frequent flyer that no one wants to hear from.

Program director Tina Wright describes members of Grady EMS Upstream Crisis Intervention Group as problem solvers. She makes no illusion that the work is easy.

Wright reports that the providers working on this unit are normally busier than their colleagues on the transport units.

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Paramedic Tennyson and mental health social worker Candace respond to patients with psychiatric illness (Photo courtesy Grady EMS) Still the group members report higher-than-normal job satisfaction. In fact, some have even turned down promotion to field training officer in order to stay assigned to the crisis team.

Wright says that members of this team know they are having a huge long-term impact on the lives of virtually every patient they encounter. Critical thinking and solution driven decision-making are key abilities. All team members are empowered to do nearly whatever needs to be done to help meet the needs of their patients.

Wright reports that the 911 call volume generated by their mental health frequent users has decreased by well over 50 percent, which translates into thousands of calls.

For Grady EMS providers answering 911 calls, the success of the Upstream Crisis Intervention Group means they answer fewer calls generated by patients not necessarily experiencing a life-threatening emergency. It goes nearly without saying that the Upstream Crisis Intervention Group is well-loved by the paramedics and EMTs who prefer acute 911 calls from traumatic injury or medical illness.

Employee fulfillment is one of the most important keys to reducing turnover. Allowing paramedics to specialize and focus on their area of passion, like responding to patients with psychiatric illness, can have a huge impact on attrition rates. Allowing paramedics to grow and expand their area of interests while staying with the organization keeps experience and hard-earned knowledge from being lost.

Encouragement for other organizations Wright, Colman, and Eric Eason of Behavioral Health Link want other organizations to know about the Upstream Crisis Intervention group. They also wanted to encourage other EMS organizations to evaluate the users in their system and learn what needs are not being met.

Wright challenged any organization to grow its services and personnel. "We stepped back and asked: Is there a different way of doing what we are doing," Wright said.

Eason encourages other organizations to reach out to potential mental health service providers near them. "If you don’t find anyone with the vision it takes to do what you want, have them call us here at BHL, we’ll gladly consult with them and see if there’s anything we can do to support their efforts." Eason said.

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| News & Observer

WAKE COUNTY

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MARCH 14, 2015 4:00 PM

Wake County EMS has one solution to overcrowded emergency rooms HIGHLIGHTS

A Wake County pilot project allows specially trained paramedics to determine which patients need to go to an emergency room and which need a psychiatric facility or substance abuse clinic. During a 12-month period, it saved about $500,000 in hospital and related costs. The NC Department of Health and Human Services would like to replicate it in more counties across the state.

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Wake County paramedic Benjamin Currie steps out of an ambulance after helping a young man into the truck while on a substance abuse call Friday, Feb. 27, 2015, in Cary.

Currie was called to the scene to assist with a behavioral health problem. Currie calmed the man down and was able to assist him into the ambulance. The patient was diverted to the UNC Health Care Crisis and Assessment Service at WakeBrook rather than being transported to an emergency room. Jill Knight - jhknight@newsobserver.com

BY JOHN MURAWSKI

jmurawski@newsobserver.com

RALEIGH — Inside the ambulance dispatched to a Southeast Raleigh parking lot, Wake County paramedic Benjamin Currie calms a mentally troubled man who is coughing through an oxygen mask. The patient is well-known to Wake County Emergency Medical Services, sometimes calling 911 several times a day.

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“What’s going on? Anything different today?” Currie asks the man as he inhales his nebulizer treatment. “I think you know we’re repeating a pattern – going to the hospital and going home – and we want you to work on the long term.”

The patient, a low-income Raleigh resident, has come to rely on hospital emergency rooms to treat his recurring breathing difficulties. Each time he calls 911, paramedics have to assess whether they’re dealing with a health emergency or another case of panic and confusion.

In the past, he would have been taken to the hospital. But, under one of the first programs of its kind in the country, Wake County Emergency Medical Services is trying to keep people with behavioral health problems out of emergency rooms.

Instead, specially trained Wake County paramedics determine whether they should steer such patients to more appropriate care: a psychiatric facility or a substance abuse clinic. In some cases, the patients are persuaded to stay home and take their medicine.

“His problem is, he thinks he’s going to die every time he coughs,” Currie explained about the Southeast Raleigh patient. “If he has his way, it’ll be WakeMed for lunch, Rex Hospital for dinner and Duke Regional for breakfast.”

Wake County’s 6-year-old pilot project saved Medicaid about $500,000 in hospital and related costs during a recent 12-month period, according to data submitted March 1 to the state Legislature by the N.C. Department of Health and Human Services. The health agency’s report praises the Wake County EMS project and recommends expanding the approach in other parts of the state. Before a permanent statewide expansion could happen, there would need to be policy changes to Medicaid and Medicare. Until then, the state’s only option is to fund more training for pilot projects.

“It’s better care; it’s less expensive; it’s the right answer,” said Dave Richard, deputy secretary for behavioral health and developmental disabilities at the N.C. Department of Health and Human Services. “We’d like to see it replicated in places where it makes sense.”

The approach, launched here in 2009, is being replicated in several hundred communities around the country in an effort to prevent local hospitals from turning into high-cost way stations for the mentally ill.

Of the 260 paramedics in Wake EMS, 20 are advanced paramedics, specially trained to evaluate 911 callers for mental illness and substance abuse. An additional 30 paramedics in

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Wake County have gone through the 240-hour training program and would be deployed here if the program were expanded, said Wake County EMS director Brent Myers.

Wake County’s approach focuses on identifying the mentally ill, from their first 911 call. The patients are typically taken to a mental health facility by police cruiser or driven by a relative, or picked up by a van from a substance abuse facility.

Reducing wait times Psychiatric patients often end up in hospital ERs, or jails, for lack of available mental health treatment options. In 2001, North Carolina opted to shift mental health treatment for nonsevere patients from expensive state-run psychiatric hospitals to less intensive community facilities.

As a result, the number of state-operated psychiatric beds, reserved for the most serious patients, shrunk to 892 in 2014 from 1,314 a decade earlier. State policy calls for expanding bed capacity in the coming years to address the chronic shortage, but the extra beds have been set back by ongoing funding delays.

The bed shortage has become so severe that on Jan. 25 WakeMed’s Raleigh hospital for the first time closed its emergency room for 3 1/2 hours to nonserious cases after the ER overflowed with 65 psychiatric cases.

Once hospitalized, mentally-ill patients can wait for days for a psychiatric bed to become available. WakeMed Health & Hospitals, Rex Hospital and Duke Raleigh Hospital are all staffed with round-the-clock “sitters” to monitor psychiatric patients until they are transferred to a mental health facility. The sitters are not a reimbursed expense and cost WakeMed about $7 million in fiscal 2014, said hospital spokeswoman Deb Laughery.

According to the N.C. Hospital Association, about a third of mental health patients who enter the emergency department end up staying in the hospital for an extended time. Those who are going to a state psychiatric hospital wait 78 hours on average in area hospitals until they can be transferred, according to 2012 data hospitals reported to the association. Those going to a community mental health facility have a shorter wait – 27 hours on average. They go either to the private Holly Hill Hospital, the nonprofit Healing Place of Wake County, or the nonprofit UNC Health Care Crisis and Assessment Service at WakeBrook. In August, WakeBrook added a primary care clinic to provide basic medical care for mentally ill patients so that they don’t have to be taken to the hospital for minor health issues.

By comparison, when a patient is successfully diverted from a hospital ER, Wake County EMS typically assesses and treats that person in about an hour, Myers said.

Diverting from the ER and taking patients directly to a psychiatric facility may appear like the obvious thing to do, but the strategy bumps up against a complex health care system that operates by established safety protocol.

The biggest hurdle is built into the system: Ambulance services, including Wake EMS, are paid only for taking patients to hospital emergency rooms. They also are not paid for onsite evaluations of patients. The federal payment policy, set by Medicaid and Medicare, is also adopted by private insurers.

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The reimbursement policy creates a “perverse incentive” to deliver mental health patients to the most expensive option, regardless of a patient’s need, Myers said.

“People call 911 because they don’t know what else to do,” Myers said. “They don’t need a medical doctor. They end up in a hospital and stay there until they can go where they should have been taken in the first place.”

Alternatives must be safe Nationwide about 260 pilot projects are underway to divert psychiatric patients from hospital ERs, said Matt Zavadsky, chairman of the Mobile Integrated Healthcare/Community Paramedic Committee at the National Association of Emergency Medical Technicians.

Only one such diversion program, in Nevada, pays for ambulance transport to a non-ER treatment setting, Zavadsky said. That 3-year-old project, which is scheduled to end June 30, operates under a waiver of federal reimbursement policy as part of a $9.9 million federal Health Care Innovation Award grant.

Medicaid programs in just three states – Maine, Minnesota and Idaho – reimburse ambulance services for evaluations, home visits and other preventive treatments designed to avoid a hospital stay.

Zavadsky said in order for the federal payment policy to change, emergency health officials around the country will have to demonstrate the alternative approaches are safe and effective in a variety of settings. The pilot programs around the country are intended as a collective demonstration project, he said.

In this state, DHHS has made “mini-grants” of $5,000 each to seven local EMS agencies for paramedic training and equipment to develop programs similar to the one in Wake County. Wake EMS and Wake Technical Community College paid for the paramedics’ training. Myers would like to see agencies such as his paid by Medicaid, Medicare and private insurers for evaluating and treating patients even if they are not taken to hospitals.

In its report to the legislature, DHHS recommended that lawmakers explore funding options for such diversion programs through policy changes or waivers to state and federal reimbursement policies for alternative ambulance transport. The state would have to request such waivers from Medicare and Medicaid before it could adopt a permanent statewide program.

DHHS did not estimate the cost of extra training, equipment and payments.

In the Wake County pilot, EMS prevented 764 emergency room visits in the past two years, Myers said. That’s about 20 percent of the 3,831 patients evaluated for mental health and substance abuse between January 2013 and January 2015. Some of those who weren’t diverted refused any kind of help.

The range in savings to the Medicaid system is $124 to $415 per patient diverted from the hospital, depending on the seriousness of each patient’s health condition. The money represents reimbursements not paid to Wake EMS.

http://www.newsobserver.com/news/local/counties/wake-county/article14433806.html

1/19/2017

| News & Observer

Page 5 of 5

Currie’s Southeast Raleigh patient is among those who frequently need to be diverted. Between Jan. 1 and Feb. 23, he made 34 calls to 911. On Jan. 17 alone he called four times. In eight instances, paramedics were able to divert him from the emergency room.

Last week, Currie was able to persuade him to return home, escorting the man out of the ambulance and to a relative’s car awaiting in the parking lot. Currie then arranged to pick up the man’s inhaler from the pharmacy and take it to him.

Because the man told Currie he had no money, the paramedic paid for the prescription with $16 from the Wake County EMS petty cash account.

Murawski: 919-829-8932

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1/19/2017

SKYPING DURING A CRISIS? Telehealth is a 24/7 Crisis Connection

Arnold A. Remington Program Director, Targeted Adult Service Coordination Program

W

hen Nebraska law enforcement officials encounter people exhibiting signs of mental illness, a state statue allows them to place individuals into emergency protective custody. While emergency protective custody may be necessary if the person appears to be dangerous to themselves or to others, involuntary custody is not always the best option if the crisis stems from something like a routine medication issue.

Officers may request that counselors evaluate at-risk individuals to help them determine the most appropriate course of action. While in-person evaluations are ideal when counselors are readily available, officers often face crises in the middle of the night and in remote areas where mental health professionals are not easily accessible.

The Targeted Adult Service Coordination program began in 2005 to provide crisis response assistance to law enforcement and local hospitals dealing with people struggling with behavioral health problems.

The employees respond to law enforcement calls to provide consultation, assistance in recognizing a client’s needs and help with identifying resources to meet those needs.

The no-charge service program offers crisis services to 31 law enforcement agencies in 15 rural counties in the southeast section of the Cornhusker state.

Six months ago, the program offered select law enforcement officials a new crisis service tool: telehealth. The Skype-like technology makes counselors available 24/7, even in remote rural parts of the state. Officers can connect with on-call counselors for face-to-face consultations through secure telehealth via laptops, iPads or Toughbooks in their vehicles.

The technology, which is in use in select jails and police and sheriff departments, is proving to be a win-win for both law enforcement officers and clients. Officers no longer have to wait for counselors to arrive for consultations.

In rural communities, it is too common for officers to wait for up to two hours for counselors traveling from long distances.

Telehealth also supports the Targeted Adult Service Coordination program’s primary goal of preventing individuals from being placed under emergency protective custody. The program maintains an 82 percent success rate of keeping clients in a home environment with proper supports. The technology promotes faster response times that mean more expedient and more appropriate interventions for at-risk individuals, particularly those in rural counties.

their routines and adopt the technology.

Some officers still want in-person consultations, a method that is preferable when counselors are available and nearby.

But when reaching a counselor is not expedient and sometimes not even possible, telehealth can play an invaluable role.

Police officers’ feedback on telehealth has been mainly positive. Officers often begin using the new tool after hearing about positive experiences from colleagues. As more officers learn that they can contact counselors with a few keystrokes from their cruisers, telehealth will continue to grow.

The Targeted Adult Service Coordination program plans to expand the technology next year by making it available to additional police and sheriff departments.

Telehealth has furthered the Targeted Adult Service Coordination program’s goal of diverting people from emergency protective custody and helping them become successful, contributing members of the community. This creative approach to crisis response provides clients with better care and supports reintegration and individual autonomy.

So far, the biggest hurdle has been getting law enforcement officers to break out of

NATIONAL COUNCIL MAGAZINE • 2016, ISSUE 1 / 45

Responding to the Needs of Justice-Involved Combat Veterans with Service-Related Trauma and Mental Health Conditions A Consensus Report of the CMHS National GAINS Center’s Forum on Combat Veterans, Trauma, and the Justice System August 2008 … The 33-year-old veteran’s readjustment to civilian life is tormented by sudden blackouts, nightmares and severe depression caused by his time in Iraq. Since moving to Albany last June … [he] accidentally smashed the family minivan, attempted suicide, separated from and reunited with his wife and lost his civilian driving job.

In June … [he] erupted in a surprisingly loud verbal outbreak, drawing police and EMTs to his home.

War’s Pain Comes Home Albany Times Union – November 12, 2006 … His internal terror got so bad that, in 2005, he shot up his El Paso, Texas, apartment and held police at bay for three hours with a 9-mm handgun, believing Iraqis were trying to get in …

The El Paso shooting was only one of several incidents there, according to interviews. He had a number of driving accidents when, he later told his family, he swerved to avoid imagined roadside bombs; he once crashed over a curb after imagining that a stopped car contained Iraqi assassins. After a July 2007 motorcycle accident, his parents tried, unsuccessfully, to have him committed to a mental institution.

The Sad Saga of a Soldier from Long Island Long Island Newsday – July 5, 2008

On any given day, veterans account for nine of every hundred individuals in U.S. jails and prisons (Noonan & Mumola, 2007; Greenberg & Rosenheck, 2008). Although veterans are not overrepresented in the justice system as compared to their proportion in the United States general adult population, the unmet mental health service needs of justiceinvolved veterans are of growing concern as more veterans of Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) return home with combat stress exposure resulting in high rates of posttraumatic stress disorder (PTSD) and depression.

OEF/OIF veterans constitute a small proportion of all justice-involved veterans. The exact numbers are not known — the most recent data on incarcerated veterans is from 2004 for state and Federal prisoners (Noon & Mumola, 2007) and 2002 for local jail inmates (Greenberg & Rosenheck, 2008) before OEF/ OIF veterans began returning in large numbers.

Some states have passed legislation expressing a preference for treatment over incarceration (California and Minnesota) and communities such as Buffalo (NY) and King County (WA) have

implemented strategies for intercepting veterans with trauma and mental conditions as they encounter law enforcement or are processed through the courts. However, most communities do not know where to begin even if they recognize the problem.

This report is intended to bring these issues into clear focus and to provide local behavioral health and criminal justice systems with strategies for working with justice-involved combat veterans, especially those who served in OEF/OIF.

Combat Veterans, Trauma, and the Criminal Justice System Forum The CMHS National GAINS Center convened a forum in May 2008 in Bethesda, MD, with the purpose of developing a community-based approach to meeting the mental health needs of combat veterans who come in contact with the criminal justice system. Approximately 30 people participated in the forum, representing community providers, law enforcement, corrections, the courts, community-based veterans health initiatives, peer support organizations, Federal agencies, and veteran advocacy organizations. See Appendix.

www.gainscenter.samhsa.gov

We begin with the recommendations that emerged from this meeting and then provide the data that support them.

Did you ever serve in the U.S. Armed Forces?

Yes No In what branch(es) of the Armed Forces did you serve?

Army (including Army National Guard or Reserve) Navy (including Reserve) Marine Corps (including Reserve) Air Force (including Air National Guard and Reserve) Coast Guard (including Reserve) Other – Specify When did you first enter the Armed Forces?

Month Year During this time did you see combat in a combat line unit?

Yes No When were you last discharged?

Month Year Altogether, how much time did you serve in the Armed Forces? # of Years # of Months # of Days What type of discharge did you receive?

Honorable General (Honorable Conditions) General (Without Honorable Conditions) Other Than Honorable Bad Conduct Dishonorable Other – Specify Don’t Know

Recommendations for Screening and Service Engagement Strategies The following recommendations are intended to provide community-based mental health and criminal justice agencies with guidance for engaging justice-involved combat veterans in services, whether the services be community-based or through the U.S. Department of Veterans Affairs’s healthcare system — the Veterans Health Administration (VHA). hhRecommendation 1: Screen for military service and traumatic experiences.

The first step in connecting people to services is identification. In addition to screening for symptoms of mental illness and substance use, it is important to ask questions about military service and traumatic experiences. This information is important for identifying and linking people to appropriate services.

The Bureau of Justice Statistics of the U.S. Department of Justice, Office of Justice Programs, has developed a set of essential questions for determining prior military service (Bureau of Justice Statistics, 2006). These questions relate to branch of service, combat experience, and length of service. See Figure 1 for the questions as they were asked in the 2002 Survey of Inmates in Local Jails. One question not asked in the BJS survey, but worth asking, is: Did you ever serve in the National Guard or Reserves?

Yes No

Figure 1. Military Service Questions from the Bureau of Justice Statistics 2002 Survey of Inmates in Local Jails (Bureau of Justice Statistics, 2006)

A number of screens are available for mental illness and co-occurring substance use. Refer to the CMHS National GAINS Center’s website (www.gainscenter. samhsa.gov) for the 2008 update of its monograph on behavioral health screening and assessment instruments. The National Center for PTSD of the U.S. Department of Veterans Affairs provides the most comprehensive information on screening

instruments available for traumatic experiences, including combat exposure and PTSD. Many of the screens are available for download or by request from the Center’s website (http://www.ncptsd.va.gov).

Comparison charts of similar instruments are provided, rating the measures based on the number of items, time to administer, and more. Measures available from the Center include:

2

•• PTSD Checklist (PCL): A self-report measure that contains 17 items and is available in three formats: civilian (PCL-C), specific (PCL-S), and military (PCL-M). The PCL requires up to 10 minutes to administer and follows DSMIV criteria. The instrument may be scored in several ways.

hh Recommendation 3: Help connect veterans to VHA healthcare services for which they are eligible, either through a community-based benefits specialist or transition planner, the VA’s OEF/OIF Coordinators, or through a local Vet Center.

Navigating the regulations around eligibility for VHA services is difficult, especially for those in need of services. To provide greater flexibility for combat veterans in need of health care services, enrollment eligibility has been extended to five years past the date of discharge (U.S. Department of Veterans Affairs, 2008) by the National Defense Authorization Act (Public Law 110-181). Linking a person to VHA health care services is dependent upon service eligibility and enrollment. Community providers can help navigate these regulations through a benefits specialist or by connecting combat veterans to a VA OEF/OIF Coordinator or local Vet Center.

•• Deployment Risk and Resilience Inventory (DRRI): A set of 14 scales, the DRRI can be administered whole or in part. The scales assess risk and resilience factors at pre-deployment, deployment, and post-deployment.

•• Clinician Administered PTSD Scale (CAPS): A 30-item interview that can assess PTSD symptoms over the past week, past month, or over a lifetime (National Center for PTSD, 2007). hh Recommendation 2: Law enforcement, probation and parole, and corrections officers should receive training on identifying signs of combat-related trauma and the role of adaptive behaviors in justice system involvement.

Vet Centers, part of the U.S. Department of Veterans Affairs, provide no-cost readjustment counseling and outreach services for combat veterans and their families. Readjustment counseling services range from individual counseling to benefits assistance to substance use assessment. Counseling for military sexual trauma is also available. There are over 200 Vet Centers around the country. The national directory of Vet Centers is available through the national Vet Center website (http://www.vetcenter. va.gov/).

Knowing the signs of combat stress injury and adaptive behaviors will help inform law enforcement officers and other frontline criminal justice staff as they encounter veterans with combat-related trauma. Such information should be incorporated into Crisis Intervention Team (CIT) trainings. The Veterans Affairs Medical Center in Memphis (TN) has been involved in the development of the CIT model, training officers in veterans crisis issues, facilitating dialogue in non-crisis circumstances, and facilitating access to VA mental health services for veterans in crisis.

OEF/OIF Coordinators, or Points of Contact, are available through many facilities and at the network level (Veterans Integrated Service Network, or VISN). The coordinator’s role is to provide OEF/ OIF veterans in need of services with information regarding services and to connect them to facilities of their choice — even going so far as to arrange appointments.

The Veterans Health Administration has committed to outreach, training, and boundary spanning with local law enforcement and other criminal justice agencies through the position of a Veterans’ Justice Outreach Coordinator (Veterans Health Administration, 2008a). Each medical center is recommended to develop such a position. In addition to training, a coordinator’s duties include facilitating mental health assessments for eligible veterans and participating in the development of plans for community care in lieu of incarceration where possible.

In terms of access to VA services among justiceinvolved veterans, data are available on one criterion for determining eligibility: discharge status. Among jail inmates who are veterans, 80 percent received a discharge of honorable or general with honorable conditions (Bureau of Justice Statistics, 2006).

Inmates in state (78.5%) or Federal (81.2%) prisons have similar rates (Noonan & Mumola, 2007). Apart

3

from discharge status, access to VA health care services is dependent upon service needs that are a direct result of combat deployment and enrollment within in a fixed time period after discharge. So despite this 80 percent figure, a significant proportion of justice-involved veterans who are ineligible for VA health care services based on eligibility criteria or who do not wish to receive services through the VA will depend on community-based services.

Background Since the transition to an All Volunteer Force following withdrawal from Vietnam, the population serving in the U.S. Armed Forces has undergone dramatic demographic shifts. Compared with Vietnam theater veterans, a greater proportion of those who served in OEF/OIF are female, older, and constituted from the National Guard or Reserves.

Fifteen percent of the individuals who have served in OEF/OIF are females, almost half are at least 30 years of age, and approximately 30 percent served in the National Guard or Reserves.

hhRecommendation 4: Expand communitybased veteran-specific peer support services.

Peer support in mental health is expanding as a service, and many mental health–criminal justice initiatives use forensic peer specialists as part of their service array. What matters most with peer support is the mutual experience — of combat, of mental illness, or of substance abuse (Davidson & Rowe, 2008). National peer support programs such as Vets4Vets and the US Department of Veteran Affairs’s Vet to Vet programs have formed to meet the needs of OEF/OIF veterans. It is important that programs such as these continue to expand in communities around the country.

From the start of combat operations through November 2007, 1.6 million service members have been deployed to Iraq and Afghanistan, with nearly 500,000 from the National Guard and Reserves (Congressional Research Service, 2008). One-third have been deployed more than once. For OEF/ OIF, the National Guard and Reserves have served an expanded role. Nearly 40 percent more reserve personnel were mobilized in the six years following September 11, 2001 than had been mobilized in the decade beginning with the Gulf War (Commission on the National Guard and Reserves, 2008). The National Guard, unlike the active branches of the U.S. Armed Forces and the Reserves, serves both state and Federal roles, and is often mobilized in response to emergencies and natural disasters.

hhRecommendation 5: In addition to mental health needs, service providers should be ready to meet substance use, physical health, employment, and housing needs.

Combat stress is a normal experience for those serving in theater. Many stress reactions are adaptive and do not persist. The development of combat-related mental health conditions is often a result of combat stress exposure that is too intense or too long (Nash, n.d.), such as multiple firefights (Hoge et al., 2004) or multiple deployments (Mental Health Advisory Team Five, 2008).

Alcohol use among returning combat veterans is a growing issue, with between 12 and 15 percent of returning service members screening positive for alcohol misuse (Milliken et al, 2007). Based on a study of veterans in the Los Angeles County Jail in the late 1990s, nearly half were assessed with alcohol abuse or dependence and approximately 60 percent with other drug (McGuire et al, 2003).

Moreover, the same study found that of incarcerated veterans assessed by counselors, approximately one-quarter had co-occurring disorders. One-third reported serious medical problems. Employment and housing were concerns for all the incarcerated veterans in the study.

A recent series of reports and published research has raised concerns over the mental health of OEF/OIF veterans and service members currently in theater.

The Army’s Fifth Mental Health Advisory Team report (2008) found long deployments, multiple deployments, and little time between deployments contributed to mental health conditions among those currently deployed for OEF/OIF. The survey found mental health problems peaked during the middle months of deployment and reports of

Available information suggests that comprehensive services must be available to support justiceinvolved veterans in the community.

4

12% to 17%) and 92 percent for Army National Guard and Army Reserve members (from 13% to 25%) (Milliken, Auchterlonie, & Hoge, 2007).

Depression screens increased as well, with Army National Guard and Army Reserve members reporting higher rates than those who were active duty.

In addition to the increase in mental health conditions, the post-deployment transition is often complicated by barriers to care and the adaptive behaviors developed during combat to promote survival.

Behaviors that promote survival within the combat zone may cause difficulties during the transition back to civilian life. Hypervigilance, Figure 2. Most Reported Barriers to Care from Two Surveys of Individuals Who aggressive driving, carrying Served in OEF/OIF & Who Met Criteria for a Mental Health Condition weapons at all times, and command and control interactions, all of which may be beneficial in theater, problems increased with successive deployments. In can result in negative and potentially criminal terms of returning service members, a random digit behavior back home. Battlemind, a set of training dial survey of 1,965 individuals who had served in modules developed by the Walter Reed Army OEF/OIF found approximately 18.5 percent had a Institute of Research, has been designed to ease the current mental health condition and 19.5 percent transition for returning service members. Discussing had experienced a traumatic brain injury (TBI) aggressive driving, the Battlemind literature states, during deployment. The prevalence of current “In combat: Driving unpredictably, fast, using rapid PTSD was 14.0 percent, as was depression (Tanelian lane changes and keeping other vehicles at a distance & Jaycox, 2008). is designed to avoid improvised explosive devices Reports of mental health conditions have increased and vehicle-born improvised explosive devices,” as individuals have separated from service. By but “At home: Aggressive driving and straddling Department of Defense mandate, the Postthe middle line leads to speeding tickets, accidents Deployment Health Assessment is administered to and fatalities.” (Walter Reed Army Institute of all service members at the end of deployment. Three Research, 2005). to six months later, the Post-Deployment Health Many veterans of OEF/OIF in need of health care Reassessment is re-administered. From the time services receive services through their local VHA of the initial administration to the reassessment, facilities, whether the facilities be medical centers or positive screens for PTSD jumped 42 percent for outpatient clinics. Forty percent of separated active those who served in the Army’s active duty (from

5

duty service members who served in OEF/OIF use the health care services available from the VHA. For National Guard and Reserve members, the number is 38 percent (Veterans Health Administration, 2008b).

on Bureau of Justice Statistics data (Noonan & Mumola, 2007; Greenberg & Rosenheck, 2008), on any given day approximately 9.4 percent, or 223,000, of the inmates in the country’s prisons and jails are veterans. Comparable data for community corrections populations are not available.

A number of barriers, however, reduce the likelihood that individuals will seek out or receive services.

According to Tanelian and Jaycox (2008), of those veterans of OEF/OIF who screened positive for PTSD or depression, only half sought treatment in the past 12 months. To compound this treatment gap, the authors determined that of those who received treatment, half had received only minimally adequate services. In an earlier study of Army and Marine veterans of OEF/OIF with mental health conditions, Hoge and colleagues (2004) found only 30 percent had received professional help in the past 12 months despite approximately 80 percent acknowledging a problem. Even among OEF/OIF veterans who were receiving health care services from a U.S. Department of Veterans Affairs Medical Center (VAMC), only one-third of those who were referred to a VA mental health clinic following a post-deployment health screen actually attended an appointment (Seal et al., 2008). Based on surveys (Hoge, Auchterlonie, & Milliken, 2004; Tanelian & Jaycox, 2008) of perceived barriers to care among veterans of OEF/OIF who have mental health conditions, the most common reasons for not seeking treatment were related to beliefs about treatment and concerns about negative career outcomes.1 See Figure 2 for a review of the two surveys’ findings.

The best predictor of justice system involvement comes from the National Vietnam Veterans Readjustment Study (NVVRS). Based on interviews conducted between 1986 and 1988, the NVVRS found that among male combat veterans of Vietnam with current PTSD (approximately 15 percent of all male combat veterans of Vietnam), nearly half had been arrested one or more times (National Center for PTSD, n.d.). At the time of the study, this represented approximately 223,000 people.

Veterans coming into contact with the criminal justice system have a number of unmet service needs. A study by McGuire and colleagues (2003) of veterans in the Los Angeles County Jail assessed for service needs by outreach workers found 39 percent reported current psychiatric symptoms.

Based on counselor assessments, approximately one-quarter had co-occurring disorders. Housing and employment were also significant issues: onefifth had experienced long term homelessness, while only 15 percent had maintained some form of employment in the three years prior to their current jail stay. Similar levels of homelessness have been reported in studies by Greenberg and Rosenheck (2008) and Saxon and colleagues (2001).

Justice System Involvement Among Veterans

Conclusion

At midyear 2007, approximately 1.6 million inmates were confined in state and Federal prisons, with another 780,000 inmates in local jails (Sabol & Couture, 2008; Sabol & Minton, 2008). Based

This report provides a series of recommendations and background to inform community-based responses to justice-involved combat veterans with mental health conditions. Many combat veterans of OEF/OIF are returning with PTSD and depression.

Both for public health and public safety reasons, mental health and criminal justice agencies must take steps to identify such veterans and connect them to comprehensive and appropriate services when they come in contact with the criminal justice system.

1 In May 2008, Department of Defense Secretary Robert Gates, citing the Army’s Fifth Mental Health Advisory Team report (2008) findings on barriers to care, announced that the question regarding mental health services on the security clearance form (Standard Form 88) would be adapted (Miles, 2008). The adapted question will instruct respondents to answer in the negative to the question if the delivered services were for a combat-related mental health condition. Those whose mental health condition is not combat related will continue to be required to provide information on services received, including providers’ contact information and dates of service contact.

6

References Bureau of Justice Statistics. (2006). Survey of inmates in local jails, 2002. ICPSR04359-v2. Ann Arbor, MI: Inter-University Consortium for Political and Social Research.

Noonan, M. & Mumola, C. (2007). Veterans in state and federal prison, 2004. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Congressional Research Service. (2008). CRS report for Congress: National Guard personnel and deployments: Fact sheet. Washington, DC: Library of Congress, Congressional Research Service.

Saxon, A.J., Davis, T.M., Sloan, K.L., McKinight, K.M., McFall, M.E., & Kivlahan, D.R. (2001). Trauma, symptoms of posttraumatic stress disorder, and associated problems among incarcerated veterans.

Psychiatric Services, 52, 959-964.

Davidson, L. & Rowe, M. (2008). Peer support within criminal justice settings: The role of forensic peer specialists.

Delmar, NY: CMHS National GAINS Center.

Seal, K.H., Bertenthal, D., Maguen, S., Gima, K., Chu, A., & Marmar, C.R. (2008). Getting beyond “don’t ask; don’t tell”: An evaluation of U.S. Veterans Administration postdeployment mental health screening of veterans returning from Iraq and Afghanistan. American Journal of Public Health, 98, 714-720.

Greenberg, G. & Rosenheck, R. (2008). Jail incarceration, homelessness, and mental health: A national study.

Psychiatric Services, 59, 170-177.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351, 13-22.

Tanelian, T. & Jaycox, L.A., Eds. (2008). Invisible wounds of war: Psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Center for Military Health Policy Research.

Mcguire, J., Rosenheck, R.A., & Kasprow, W.J. (2003).

Health status, service use, and costs among veterans receiving outreach services in jail or community settings. Psychiatric Services, 42, 201-207.

U.S. Department of Veterans Affairs. VA healthcare eligibility and enrollment. Accessed July 8, 2008. Available from: http://www.va.gov/healtheligibility/

Mental Health Advisory Team Five. (2008). Operation Iraqi Freedom 06-08: Iraq and Operation Enduring Freedom 08: Afghanistan. Washington, DC: U.S. Army Medical Command, Office of the Surgeon General. Available from: http://www.armymedicine.army.mil/news/mhat/ mhat_v/mhat-v.cfm

Veterans Health Administration. (2008a). Uniform mental health services in VA medical centers and clinicals. VHA Handbook 1160.1. Washington, DC: US Department of Veterans Affairs, Veterans Health Administration.

Veterans Health Administration. (2008b). Analysis of VA health care utilization among US Global War on Terrorism (GWOT) veterans: Operation Enduring Freedom Operation Iraqi Freedom (OEF/OEF). Washington, DC: US Department of Veterans Affairs, Veterans Health Administion, Office of Public Health and Epidemiology.

Miles, D. (2008, May 1). Gates works to reduce mental health stigma. American Forces Press Service. Available from: http://www.defenselink.mil/news/newsarticle. aspx?id=49738 Milliken, C.S., Auchterlonie, J.L., & Hoge, C.W. (2007).

Longitudinal assessment of mental health problems among Active and Reserve Component soldiers returning from the Iraq war. Journal of the American Medical Association, 298, 2141-2148.

Yusko, D. (2006, November 12). War’s pain comes home: Veterans back from war zones sometimes carry an invisible wound — post-traumatic stress disorder.

Albany Times Union.

Nash, W.P. (n.d.). PTSD 101: Medical issues: Combat stress injuries. White River Junction, VT: National Center for PTSD. Available from: http://www.ncptsd.va.gov/ ptsd101/modules/nash_combat_stress.html

Walter Reed Army Institute of Research. (2005). Battlemind training I: Transitioning from combat to home. Rockville, MD: Author.

National Center for PTSD. (n.d.) Epidemiogical facts about PTSD. White River Junction, VT: Author. Available from: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_ shts/fs_epidemiological.html

Recommended citation: CMHS National GAINS Center.

(2008). Responding to the needs of justice-involved combat veterans with service-related trauma and mental health conditions: A consensus report of the CMHS National GAINS Center’s Forum on Combat Veterans, Trauma, and the Justice System. Delmar, NY: Author.

National Center for PTSD. (2007). PTSD Information Center. White River Junction, VT: Author. Available from: http://www.ncptsd.va.gov/ncmain/information/ National Commission on the National Guard and Reserves.

(2007). Second report to Congress. Arlington, VA: Author.

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Appendix Participants of the CMHS National GAINS Center Forum on Combat Veterans, Trauma, and the Criminal Justice System May 8, 2008, Bethesda, MD A. Kathryn Power, MEd, Director of the Center for Mental Health Services at the Substance Abuse and Mental Health Services Administration, provided the opening comments at the forum.

Richard Bebout, PhD Community Connections Washington, DC

David Morrissette, DSW Center for Mental Health Services Rockville, MD

Thomas Berger Vietnam Veterans of America Columbia, MO

Lt. Jeffry Murphy Chicago Police Department Chicago, IL

Mary Blake Center for Mental Health Services Rockville, MD

Fred Osher, MD Council of State Governments Justice Center Bethesda, MD

Judith Broder, MD Soldiers Project Los Angeles, CA

Matthew Randle Vets4Vets Tucson, AZ

Neal Brown Center for Mental Health Services Rockville, MD

Frances Randolph, DPH Center for Mental Health Services Rockville, MD

Sean Clark U.S. Department of Veterans Affairs Washington, DC

Maj. Cynthia Rasmussen US Army Reserve Ft. Snelling, MN

Karla Conway Community Alternatives St. Louis, MO

Cheryl Reese Educare Systems Washington, DC

Jim Dennis Corrections Center of Northwest Ohio Stryker, OH

Hon. Robert Russell, Jr. Drug Treatment Court Judge Buffalo, NY

Jim Driscoll Vets4Vets Tucson, AZ

Susan Salasin Center for Mental Health Services Rockville, MD

Alexa Eggleston National Council for Community Behavioral Health Rockville, MD

Lt. Col. Andrew Savicky New Jersey Department of Corrections Glassboro, NJ

Guy Gambill Minneapolis, MN

William Schlenger, PhD Abt Associates Bethesda, MD

Justin Harding National Association of State Mental Health Program Directors Alexandria, VA

Paula Schnurr, PhD National Center for PTSD White River Junction, VT

Thomas Kirchberg, PhD Veterans Affairs Medical Center – Memphis Memphis, TN

Elizabeth Sweet Center for Mental Health Services Rockville, MD

Larry Lehman, MD US Department of Veterans Affairs Washington, DC

Charlie Sullivan National CURE Washington, DC

James McGuire, PhD US Department of Veterans Affairs Los Angeles, CA

8

POLICY RESEARCH ASSOCIATES

Creating an Indigent Defense Diversion Team: The Manhattan Arraignment Diversion Project Jacob & Valeria Langeloth Foundation | The Legal Aid Society | Policy Research Associates

few of the diversion programs Relatively developed in response to the overrepresentation of people with mental illness in the United States criminal justice system have targeted initial arraignment or first appearance courts.

In 2010, the Legal Aid Society piloted the Misdemeanor Arraignment Project (MAP) in New York City Criminal Court through funding from the Langeloth Foundation.

The Project aims to better identify, assess, and represent individuals with mental illness facing criminal charges at the earliest possible stages after arrest.

MAP is an early intervention model that seeks to decrease the frequency of arrest and short jail sentences for individuals with mental illness. MAP enhances the ability of a community to serve people with mental illness and provides them with continuous community-based mental health treatment, appropriate housing, and supports.

The interdisciplinary team includes the attorney and paralegal assigned to the case and a MAP licensed clinical social worker.

The attorney is responsible for providing legal representation in arraignments. He/ she works together with the other team members to distinguish how and when screening and assessment information should be used in legal advocacy to assist in the successful resolution of the case. The licensed clinical social worker is responsible for identifying and assessing detained

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clients awaiting arraignment, treatment planning, and court advocacy. The social worker is also responsible for organizing collateral contacts with family, significant others, and community providers. He/she also offers referrals to community treatment and accompanies clients in emergency/crisis situations when necessary.

Individuals who qualify for the target population for MAP: are 18 years of age or more have a mental illness and/or a substance use disorder are at risk of xx being arraigned and released without supportive services xx a jail sentence xx being held in jail pending a court appearance consent to accept assessment, referral, and connection to treatment

Many MAP clients face challenges such as intellectual or developmental disabilities and homelessness or the risk of becoming homeless, in addition to behavioral health issues. MAP clients may be dealing with current crises (e.g., suicidal ideation) that require immediate attention in a psychiatric emergency room or may have a history of repeated use of inpatient treatment beds, crisis services, and/or correctional healthcare.

Current engagement in treatment does not preclude a potential client from use of MAP services.

Table 1. 149 MAP Jail-Divertible Case Assessments in Arraignments Status

Participants MAP served 250 clients between July 2010 and April 2012. These clients varied in age: 20 years old and below (10%), 21-29 years old (20%), 30-39 years old (24%), 40-49 years old (25%), 50-59 years old (16%), and 60 years old and above (5%). A majority of the clients were male (72%). About half of the clients were African American (49%), followed by Hispanic (28%), Caucasian (15%), and other varied ethnicities.

N

%

Diverted

88

59.1

Judge Denied – DOC

32

21.5

Client Refused

17

11.4

MAP Unable to Place

4

2.7

LAS Relieved

2

1.3

Parole Hold

2

1.3

Transfer (MMTC)

2

1

Open Warrants – DOC

1

0.7

Attorney Denied – DOC

1

0.7

149

100

Total

Mood disorders (38%) and schizophrenia and other psychotic disorders (34%) were the most frequently seen diagnoses in clients.

Overall, 57% of clients had co-occurring mental illness and substance abuse issues; 22% dealt only with mental illness; 7% dealt only with substance abuse issues; and 14% were missing diagnoses.

Table 2. Legal Outcomes of MAP-Diverted Pre-Arraignment Defendants

The crime that preceded enrollment in MAP was most frequently larceny (29.6%), followed by controlled substance offenses (12.4%), assault and related offenses (11.6%), other offenses relating to theft (10%), and burglary and related offences (9.2%).

Status

N

%

ROR: Released on own Recognizance

44

50.0

PGSI: Conditional Discharge

24

27.3

PGSI – CASES

7

8.0

PGSI: Time Served

6

6.8

PGSI: Adj. Contemplation of Dismissal

5

5.7

9.43 – Dismissed

2

2.3

Total

88

100

Eighty-eight individuals (59%) were diverted at arraignment. Table 2 shows the breakdown of legal outcomes for these 88 persons.

Outcomes

Of the 27 people assessed post-arraignment, 16 (59%) were diverted, for a total of 104 persons diverted. Of the 104 clients diverted between July 2010 and April 2012, 52% had no arrests within one year, 16% had one arrest, 13% had two arrests, 12% had three arrests, and 7% had four or more arrests.

Between July 2010 and April 2012, MAP completed 223 pre-arraignment assessments and 27 post-arraignment assessments. Of the 223 individuals assessed pre-arraignment, 149 were determined to be jail-divertible at arraignment. Table 1 shows the final determinations of all 149 cases.

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The above data was compared to the number of arrests for 61 non-MAP-diverted clients.

Twenty-three clients either refused MAP services, were unable to be placed, or their Legal Aid Society attorney was relieved, and 38 clients were either denied diversion by the judge, were on parole hold, were transferred, had an open warrant, or were remanded into custody for adjudicating or sentencing. Of these non-MAP diverted clients, 25% had no arrests within one year, 32% had one arrest, 11% had two arrests, 10% had three arrests, and 21% had four or more arrests. Figure 1 shows the difference in percentage of individuals arrested at 1 year between MAP-diverted clients and non-MAP-diverted clients.

perception of the success and usefulness of MAP are key to evaluating potential and ongoing success of the program.

Judicial feedback may indicate potential modifications to procedures in the courtroom.

In addition, judicial endorsement of MAP is an incentive for prosecutorial cooperation and overall success.

Attorney Engagement and Endorsement

Attorneys have not generally referred matters to social workers during arraignments but have waited until subsequent appearances to have social workers assist. Continuous education of attorneys, both new and experienced, through presentations by the social worker will help foster understanding of the overall arraignment part defense strategies that can utilize social workers.

Figure 1. Proportion Arrested 1 Year Post-MAP

Assertive Assessment and Engagement of Clients Throughout Each Arraignment Shift

80% 70%

The social worker in this role must have a skill set suited to working with many different personalities (clients, attorneys, judges) in a fast-paced environment, which can often be highly charged for the client. Social workers must screen files prior to the attorneys and take the initiative to suggest to the attorneys that a client could be diverted to treatment or back to treatment. The social worker in the MAP project has to be on the lookout for appropriate clients in all ways – reviewing files, discussing with the attorneys, and assessing clients visually and through initial interaction. Some clients don’t want to speak to anyone other than their attorney or speak to anyone without their attorney. The skill of the social worker in making clients feel at ease in a difficult and potentially traumatizing situation is essential.

60% 50% 40% 30% 20% 10% 0%

MAP Diverted

Non-MAP Diverted

Four Keys to Program Success Education and Engagement of the Judiciary

Judicial buy-in and appreciation of the goals of MAP are essential to its success. Focus groups prior to the initiation of MAP and subsequent follow-up with judges as to their

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Ability to Establish Data Collection Systems Prior to Program Initiation and Conduct Accurate Follow Up

This is a labor-intensive part of the project.

If it is possible to secure outside help to conduct extensive data analysis and program evaluation, either through partnership with a university or other outside source, this might be ideal.

References Ditton, P. M. (1999). Mental health and treatment of inmates and probationers. Bureau of Justice Statistics: Special Report. Retrieved October 10, 2012 from http://bjs.ojp.usdoj.gov/index. cfm?ty=pbdetail&iid=787.

Substance Abuse and Mental Health Services Administration. (1995). Double jeopardy: Persons with mental illnesses in the criminal justice system.

Report to Congress. Retrieved October 16, 2012 from http://gainscenter.samhsa.gov/pdfs/disorders/ Double_Jeopardy.pdf.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60(6), 761-765.

Teplin, L. A. (1984). Criminalizing mental disorder.

The comparative arrest rate of the mentally ill.

American Psychologist, 39(7), 794-803.

www.langeloth.org

www.prainc.com

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