Criminal Justice Symposium

Criminal Justice Symposium


– [Dr. Huang] Okay. Good morning, and welcome to SAMHSA, the Substance Abuse and
Mental Health Service Administration’s first ever
virtual behavioral health and criminal justice symposium. Wherever you may be across the nation, we are pleased you have joined
us for this important event. I’m Dr. Larke Huang, I direct
the Office of Behavior Health Equity and Justice, and
coordinate the behavioral health and justice portfolio of work at SAMHSA. The disproportionate number of individuals with mental and substance use disorders who enter the criminal justice system is a key concern and
priority of our agency, and of our Assistant Secretary,
Dr. Elinore McCance-Katz. Unfortunately, Dr. McCance-Katz
was called away to a meeting with the deputy secretary so she’s unable to kick off our symposium
today and sends her regrets. However I will share with
you some of her remarks. So, I want to begin with why are we convening this symposium. Every year, approximately
two million individuals with mental and substance use disorders cycle in and out of local jails. We know that a brief incarceration results in disruptions in treatment, disruptions to housing,
health care, employment, and it severely impacts the
families and the children of those incarcerated. We also know that certain
population groups, especially populations of color, have unequal access to
high quality treatment, and experience over-representation in our criminal and
juvenile justice system. Once in the criminal justice system, individuals with mental and
substance use disorders, stay in jails longer, and have an increased risk for self-harm. For individuals already
receiving medications and treatment in the community, their services may be
interrupted during incarceration, creating lapses in treatment, and difficulties in resuming treatment upon release and re-entry
to the community. And in the midst of the
opiod crisis we now face individuals with opiod use
disorders are at significant risk of death by overdose in the
first two weeks after re-entry. So it’s vital that we pay
attention to these issues. All of us on SAMHSA’s
criminal justice team have worked at some point with criminal or juvenile justice systems. We have seen individuals
and young people, youth, cycle through hospitals to
jails to detention centers, to crisis services and back again. This was and continues to
be and is unacceptable. The criminal justice system,
the juvenile justice system, is not an evidence-based practice for treating mental illness
and substance use disorders. Outcomes from SAMHSA’s Early Diversion and drug treatment court program, and the Justice and Mental Health Collaboration grant program at the Bureau of Justice Assistance in
the Department of Justice show that collaborations between
behavioral health providers and criminal justice
professionals are critical if we want to make sure people
get the treatment they need and not go to jail. Behavioral health providers
and law enforcement working together can divert
people with mental illness or substance use disorders into treatment before they even touch the
criminal justice system. Sheriffs and jail administrators can work with behavioral health providers to ensure that screening
for mental illness and substance use is
done every single time someone is booked into jail. And in collaboration with probation, behavioral health providers
can support individuals in staying in treatment
in their communities and leading productive lives. So, what do we hope to accomplish
in this all day symposium? First, we want to provide
education and information on the critical issue
of justice involvement of individuals with these disorders. Second, we will highlight
local behavioral health and criminal justice
collaborations and strategies for diverting individuals
with these disorders from the criminal and
juvenile justice system. We want to showcase how local communities are solving these problems. Finally, we want to share
our federal toolkits, resource guides, informational bulletins, and action oriented publications
from SAMHSA, our agency, from our Assistant Secretary
for Planning and Evaluation, from our Centers for
Medicare and Medicaid, from the Social Security Administration, National Institutes of Mental Health, and our Department of Justice. It is our hope that you learn
something in the presentations that you can bring back
to your discussions with other leaders, partners, or policy makers in your community. This would be success for us. Before we move on to
our program for the day, and it is really I think
a rich set of panels that we’ve planned throughout the day, I’d like to thank our federal partners from across the Department
of Health and Human Services, particularly CMS, ASPE, and IMH. And the Department of Justice, the Department of Veterans Affairs, and the Social Security Administration, who have given their time,
resources and expertise to support SAMHSA in
convening this symposium. You will hear from them on the
various, on the five panels over the course of the day. And I think it demonstrates
at the federal level the kind of collaboration and commitment that is needed to truly
tackle and solve these issues. We want also to thank our colleagues at Policy Research Associates, that run SAMHSA’s GAINS Center, and bring deep expertise to this topic. They’ve played a major role in putting this symposium together, we are very grateful to them. And also gratitude to my colleague Dr. Jennie Simpson at SAMHSA, who was instrumental in
setting up this symposium. And we want to thank all of
you who are tuned in virtually, we’ve had I think nearly
800 registrations, as you are the difference-makers committed to tackling these issues. So at this point, I
would like to introduce our opening speaker, Mr. Pete Earley, and before Pete comes up
I want to just give you a few words about Pete. Mr. Pete Earley is a New
York Times bestselling author and former reporter for
the Washington Post. He was also a reporter for
the Kansas Emporia Gazette, and the Tulsan Tribune in Oklahoma. He is the author of six novels
and 11 nonfiction books, including Crazy: A Father’s Search Through America’s Mental Health Madness, which was a finalist for the
2007 Pulitzer Prize award. Mr. Earley is a member
of the National Alliance on Mental Illness, serves on the board of the Corporation for Supportive Housing, and was appointed to the
Virginia Supreme Court taskforce that recommended changes to that state’s involuntary commitment laws, and is currently serving on a
committee investigating ways to improve Virginia jails. A strong, relentless advocate
for behavioral health, Mr. Earley has testified
numerous times before Congress, lectured internationally
and throughout the U.S., and toured a combined total
of more than a hundred jails, prisons, treatment programs,
and housing facilities. We are honored to have him
as our opening speaker today. Pete? – [Pete] Thank you very much. Thank you. I’m absolutely thrilled to
be with you this morning. I know that I’m preaching
to the converted. Many of you have much more experience and much more knowledge than I do. My purpose today is to bring a human face and to remind you why you do what you do. I am the parent of an adult son with a serious mental illness. What does that mean,
what does that feel like? It means that I know what
it is like to look at a son who I saw born and see a complete stranger standing in front of me. Someone who I recognize
when it comes to his body, but is a complete alien to
me when I hear him speak. I am the father of a son with
a serious mental illness, what does that mean, it means
I’m the subject of whispers. Gosh, someone with mental
illness, what causes that? Is it bad parenting, something wrong? Or as a social worker told
me before he found out that I had a son with a mental illness, the apple doesn’t fall far from the tree. All you have to do is look at the parent to see why this kid has so many problems. I am the parent of an adult
son with a mental illness. What does that mean? It means that I have seen the police come, I have called the police, I
have seen them taser my son, I’ve seen them handcuff my son, I’ve seen them laughing at my son as he’s laying on the floor
because of all the silly things that he is saying in his delusions. I am a parent of an adult
son with a serious illness. What does that mean, it means
having lawyers and a judge decide whether or not my
son needs to he hospitalized based on a five minute
conversation with him and then leaving him angry at me to deal with him after
they walk out of the room. What does it mean to be
the parent of an adult son with a mental illness? It means spending countless hours trying to convince your son that he needs to take medication, and in my son’s case, medication helps. And then having an insurance agent say, “Well I don’t know why
you take that medication, “it’s just a placebo.” What does it mean to
be the parent of a son with a serious mental illness? It means consulting parents whose sons and daughters have
died, taken their own lives, or are incarcerated in jails and prisons. What does it mean to be the
father of a an adult son with a serious illness? It means having your heart broken as you hold your sobbing adult
son in your arms like a baby, listening to him talk about
how he wants to be normal just like everyone else. When everyone else is telling
him that he is not normal, that he can’t afford an apartment, that he doesn’t deserve a job, even though he has a college education. Or seeing that no one wants
to date him or be his friend. I know those feelings, every one of them, because I’ve experienced
them with my son Kevin. I’ve been asked today to
speak specifically about Kevin and my interaction with
the criminal justice system so I’ll skip over his first two breaks. When he was first diagnosed
with bipolar disorder and given medication and why
he didn’t take that medication, and I’ll get right to his third breakdown. And that story begins with
his older brother Steve calling me from New York saying, “Dad, you’ve got to get up
here, Kevin’s gone crazy.” And me racing to Manhattan
where I found my son wandering around the city for five days. He’d barely slept, he’d
hardly eaten, he was convinced God had him on a special mission. And during our four hour ride from Manhattan to Fairfax, Virginia, Kevin would laugh one minute, and then begin sobbing the
next and I pleaded with him to take his medication and he screamed, “Pills are poison, leave me alone.” And we got to the
emergency room in Fairfax and the nurse rolled her eyes
while Kevin talked gibberish about God having him on
this special mission. And then we were taken in a
room far away from everyone else because of how he was acting. And we sat there and we
sat there and we sat there and we sat there and finally Kevin said, “There’s nothing wrong
with me, I’m gonna leave.” And I said, “Hold on son, hold on.” And I raced out and I
literally grabbed a doctor. And I will never forget how
that doctor came into the room. He came in with his hands up
as if he were surrendering. He said, “I’m sorry Mr. Earley, “I really can’t help you and your son.” I said, “You haven’t even examined him.” And he explained to me it didn’t matter, Virginia law was very
specific at that time. A person had to pose an
imminent immediate danger to themselves or others
before they could be required to undergo treatment, and Kevin
had already told the nurse that pills were poison,
and we’d been sitting there for four hours so obviously
there was no immediate threat. But the doctor turned to me and he said, “Mr. Earley, you seem
like a concerned dad. “You bring your son back after
he tries to harm or kill you “or harm someone else.” So I took my son home and
during the next 48 hours I watched him sink deeper and
deeper into a mental abyss. At one point he had tin
foil wrapped around his head to keep the CIA from reading his thoughts through our television. He slipped out of the house, he slipped out early one
morning, he slipped out. He broke into a stranger’s
house, luckily no one was there. He broke in to take a bubble
bath because he was convinced that he was dirty and
needed to be cleaned. It took five police officers
to get him out of that house and when they did they drove him over to a mental health center. And I went racing over there
and a very kind officer was standing outside, and
he said, “Whoa whoa whoa, “let me give you some
father-to-father advice. “Even though we picked up
your son in a stranger’s house “taking a bubble bath,
even though he’s told us “he has bipolar disorder, “even though he’s told us
he’s off his medication, “unless you go in and you
tell that psychiatrist “your son’s threatened to harm you, “he will not go into a hospital, “he will go to jail, and
you don’t want that.” And I looked at the officer and I said, “My son hasn’t threatened me.” And he shrugged and walked away. So I’m here today to tell
you, I do it with no pride, because it hurt my
relationship with my son, I went in and I lied. I said my son had threatened to kill me and that was good enough to
get him taken to a hospital where he voluntarily admitted himself. And I thought, wow finally,
he’s gonna get some help. And 48 hours later I received a call from the Fairfax County Police. My son was being charged
with two felonies, breaking and entering, and
destruction of property. How could this be happening? I couldn’t get my son help, and now Virginia wanted to punish him for a crime he’d committed
when he was psychotic. I decided as a former
Washington Post journalist to investigate this. But before I left to do that
I wanted to talk to my son. I said, “Kevin, I want
to investigate this.” He said, “Dad, if it helps
someone else, tell my story.” Well I did a little
digging, and I discovered what happened to Kevin
was not some aberration, it wasn’t some freak event. I discovered what many
of you already know, that as we sit here there’s
an estimated 365,000 people with schizophrenia and bipolar
disorder and depression sitting in jails and prisons. That 2.2 million are booked into our jails and prisons every year. That more than one million
people with mental illnesses are currently on probation. That 40% of persons with
serious mental illness will have an encounter
with law enforcement during their lifetime. That 49% of all police shootings involve someone with
a mental illness, 49%. That persons with serious
mental illness are four times more likely than the general public to be fatally shot by the police. That individuals with
serious mental illness stay in jails and prisons
four to eight times longer than other people charged
with identical crimes. That persons with serious mental illness have a higher likelihood of
getting additional charges filed against them when
they are incarcerated. That persons with serious mental illness have a recidivism rate that is 15% higher than the national average. 85% of persons with serious mental illness will return to jails and prisons. And finally, that in 44
states a jail or prison holds more mentally ill individuals than the largest remaining
state psychiatric hospitals. In every county in the United States with both a county jail and a
county psychiatric facility, more serious mentally ill individuals are incarcerated than hospitalized. These troubling statistics
gave me the idea. I would find a jail in a major city far away from Fairfax County, ’cause I didn’t want to
irritate a judge or prosecutor, and I’d go and I’d spend
time there, up to a year following people through
the criminal justice system to see what really happened to them. And then I’d come back and
I’d talk to the experts and the correctional officers,
the parents, the judges, and try to make sense of all of it. Well I began in LA, Twin Towers, largest public mental
facility at the time. That’s how it was being reported. And I lasted two days. They threw me out because of HIPAA, but the truth was they
didn’t want me to see what I was seeing. So I tried Cook County Jail next. They said no. I tried Rikers Island next
in New York, they said no. I tried Baltimore and they said no. I tried Washington, D.C., and they literally said, hell no. And I ended up going to Miami Dade because of Judge Steve Leifman, a name I’m sure many of you heard. He said, “I want you to see
what’s happening in my jail.” I want to take you there briefly. There are 19 cells in the
ninth floor in C wing, the suicide wing. The cell block is a U-shaped. The officers walk down the
center, the 19 cells around them all had plexiglass fronts. And as a reporter you go in
and you try to figure out every sight and sound and
smell and remember it. And when I walked in there I
smelled urine, I smelled feces, I smelled this human sweat. And as you walked in there you
saw people completely naked in cells that had nothing else in them. And because of the design of the jail, plexiglass cut off the air
conditioning blowing in the cells and it was bone chilling cold
but there were no blankets. And because the jail was old
the water system broke down at least once a week. And so there was no
water for people in cells and you literally saw people
drinking out of toilets because their medication
made them thirsty. And when you walked through that jail you heard the normal jail
sounds of people coughing and spitting and doors closing, but when you listened closer
you heard the asylum sounds. You heard people screaming
at unseen tormentors. And then I heard a thud thud thud, then quicker, thud thud thud. Then louder, thud thud thud. It was one of the inmates running forward, smashing his forehead into the plexiglass. “I ain’t crazy,” he screamed. “Then quit acting like you are,” an unconcerned officer called back. Now during the 10 months I spent there, I discovered they called this
floor the forgotten floor. And I thought they were
talking about the inmates. And they were, but they
were also talking about the employees. I got to know these officers,
and every one of them told me they had received absolutely no training to work with anyone who
had a mental illness. And even worse, every one of them told me that they were troublesome employees, they were sent to work on the ninth floor because their bosses hoped they would quit because they had the
worst job in the jail. My tour guide was Dr. Joseph Poitier, a fabulous doctor with an impossible job. A lot of people think you’ll get help if you get put in jail. We aren’t a hospital, we’re a jail. I went with Dr. Poitier
on his morning rounds. There were 92 inmates on
the ninth floor, 92 inmates. His rounds took us 19 minutes. That’s an average of 12.7 seconds that we spent talking to each inmate. But Pete, these are criminals,
they deserve to be in jail. Do they? Let’s talk about Alice Ann
Collier, chronic schizophrenia, the kind of person who
used to be locked up in a state hospital, but now we’ve moved her
back in the community, which is fantastic but
let’s look at her life. She lives in a cardboard
box two-by-four contraption behind a restaurant. And when I checker her record, she’d been arrested more than
10 times in the last year, but she’d never gotten any kind of help. And this time she was in jail because she was walking down the street and her eyes locked with an older woman who was waiting for a bus, and Alice Ann Collier screamed,
“Stop stealing my thoughts.” And she raced over and she
shoved the older woman. Not hard enough to knock her over, but she shoved her and went running away. And well-meaning witnesses
came out and said, “You should get her arrested,
you get that woman arrested, “and she’ll get help.” Well help is not what
Alice Ann Collier got. Florida takes crimes against persons over age 65 very seriously. In fact a prosecutor
can use his discretion to charge any of those crimes as a felony. And because Alice Ann Collier
had shoved two other people at bus stops, she was
charged under that state’s three strikes rule with
shoving people with felonies. That meant that she faced a
mandatory five years in prison. But when she went before the judge, the judge looked at her and went, hmm, this person can’t be
tried, she’s not competent. And in our system you have to be competent in order to be put on trial. So he said, “I’m gonna send
you away to the state hospital “in Chattahoochee to be made competent.” Competency restoration, not treated, and there’s a difference. Treatment means you get help. That’s not what Alice Ann Collier got. Every day she was taken into a room and she was shown three chairs. And on one chair was
written the word judge, another one prosecutor, and
the third, defense attorney. And when Alice Ann Collier
could tell her keepers who sat in which chair, she
was deemed competent enough to be put on trial, and she
was sent back to the jail. Of course she wasn’t competent
and when she appeared before the judge he said,
“Why are you back here? “Go back to Chattahoochee
and get made competent.” When I found Alice Ann Collier in the jail she had been traveling between
the jail and Chattahoochee 1,151 days, and she’d still not been brought to trial. Now I’m a reporter, I got
my little pen and paper and I went running over there, I said, “Look what I found prosecutors,
look what I found.” And they told me without any embarrassment they knew exactly what was
happening to Alice Ann Collier, in fact they planned to
keep her for five years, which was the maximum they could hold her without putting her on trial. Why, because she was dangerous. Medications didn’t seem to help her and there was no safe place in
the entire state of Florida. No long-term treatment
facilities, no hospital beds, so they were keeping her on that bus simply to keep her off the streets. So now she was typical. These people were not Hannibal
Lecter serial killers, they were people with
schizophrenia and bipolar disorder and severe depression. Let’s talk about April
Hernandez, same age as my son. When I saw her in the jail, correctional officers came up and said, “You should investigate that case. “April was framed for car theft.” And I went, “What? Who framed her?” Her own parents. Why did her parents
conspire with relatives to have her arrested for car theft? Because she was psychotic, she was living on the
streets of South Beach, where she had been gang raped
twice and beaten three times by teenagers who thought it was hilarious to pick on people who were
homeless on the streets, and there was nothing anyone could do because she was not considered a danger to herself or others. Now what’s interesting about April’s case is she had started using
drugs as a teenager, and everybody went, oh
that’s why she’s homeless, oh it’s because she’s using drugs, that’s why she acts so strangely. And it was only after she
was correctly diagnosed as having a co-occurring disorder, having a drug addiction
and a mental illness, that she finally began
getting some kind of help. And we know that 40% of persons who develop a serious mental illness as bipolar disorder and schizophrenia, have co-occurring problems. And 70% nationally of
people in jails and prisons have a co-occurring problem. And 90% of the ones I
encountered in the jail had a co-occurring problem. Finally, let’s talk about Freddie Gilbert. I don’t care where you live, you know someone like Freddie Gilbert. A Miami study found that in
a population of 1.5 million, at any given day there were 1700 people living in cars on the
streets, they were homeless. But that same study found
of those 1700 people most were able to move
through our criminal, or move through our social system into some kind of supportive housing, except, except 510 individuals. They are always homeless,
they are always on the street. And Freddie Gilbert was one of these 510. And every one of them had been arrested and every one of them
had a mental illness, mostly schizophrenia. And when I met him in
the jail he was so sick he could not speak. He stood naked in his cell
and he grunted like an animal, and they treated him like one, offering him sandwiches in
return for his obedience. And when I checked his record
I discovered that Gilbert had been in and out of that Miami jail more than a dozen times and he’d never gotten any kind of help. And that’s because he was
charged with misdemeanors and under Florida law
he could not be admitted into a treatment program
even if one were available. And the result, he was stuck
on that revolving door. After my book was published
the University of South Florida Mental Health Institute
followed 97 of these frequent utilizers of services
in Miami like Freddie Gilbert over a five year period. Nearly every one of
them had schizophrenia, every one was homeless. Those 97 individuals were
arrested 2,200 times, spend 27,000 days in jail, 13,000 days in crisis stabilization units, state hospitals, and emergency rooms. They cost 13 million and
there was absolutely no sign of any kind of help or
treatment or progress for them. But you wrote your book years ago, Pete, surely things have changed. Yes, some progress has been made, but let’s not forget Jamycheal Mitchell, less than two years ago,
Hampton Roads, Virginia. Jamycheal Mitchell, schizophrenia,
locked in the jail there. Waiting to go to a state hospital to be restored to competency
so he could put on trial. Jamycheal Mitchell, who couldn’t
get in the state hospital because there were no beds,
whose paperwork was not found until six days after
his dead body was found in his feces covered cell. Jamycheal Mitchell died
from a heart attack brought on by starvation. According to a lawsuit
the correctional officers denied him food because
he would not obey orders. He lost more than a
third of his body weight. What was his crime? He stole $5.05 worth of snacks from a convenience store. Back to my son, Kevin was put on probation after he broke into this house,
he did great for two years, he was fantastic during that probation. He took his medication,
medication seems to help him. He just did super and as
soon as that two years of probation ended, he
stopped taking his medication. I could see that he was slipping. So I called our mobile
crisis response team. I said, “Please come, my
son is off his medication “and I’m afraid that he’s
gonna get in trouble.” And they said, “Wait a
minute, is he dangerous?” And I said, “No, he’s not dangerous yet, “but let me tell you what happened.” And no you can’t judge him
on what happened last time, that’s not fair. You call us when he becomes dangerous. We just can’t come over, there are 1.5 million
people in Fairfax County, we had one mobile crisis
response team at the time. We get 500 calls a month. We just can’t come over when
somebody’s off their meds, you call us when he’s dangerous. Well the night I didn’t have to lie, the night that my son became violent I called that same dispatcher and I said, “Please please come, my son is violent.” And that dispatcher said
you me, “Is he dangerous, “or is he violent?” And I said, “He’s violent.” “Oh we don’t come then. “Call the police.” Well I called the police
and my son was shot twice with a taser and taken away. How are we reacting to this
crisis of the criminalization of persons with mental illness? Because our badly underfunded
mental health care system that is broken and flawed
can’t help our people who need their help. We are turning to the criminal
justice system to save us. And the first step is always crisis intervention team training. And I am thrilled that my
colleague from ISMICC, Ron Bruno, will be talking, taking into
a deep dive today about CIT and I’ve always supported CIT. It is the doorway to community
change, to social change, to cultural change. It’s the doorway to jail diversion. It becomes the entryway
that sets communities up for problem solving courts. It becomes the doorway to use of the Sequential Intercept
Model, and I am thrilled today that you are going to
have Dr. Mark Munetz, the co-creator of the
intercept model, here to talk. You’ve got some really fabulous people. And I’m glad that Ruby, and
I’m gonna mess your name up. (muffled speaking) Quak-uz, what? – [Woman] Qazilbash. – [Pete] Kutchel-buch. This is why I’m not on the radio folks, is here today to discuss federal programs. She is such a blessing, such an expert. She can talk about things such
as the Stepping Up campaign. But let’s use some common sense here. If I had a broken arm, I wouldn’t
call the police department and say come fix it. If I needed heart surgery, I
wouldn’t call up the sheriff and say, come on over
and give me a new heart. And if I had really
nasty nasty hemorrhoids, I wouldn’t call up a
judge and say hey judge, will you come over and take a look. So why are we expecting the police and the sheriff and judges to solve what is a community mental health problem. The best way to stop the incarceration of persons whose major
crime is they got sick, is by zero intercept. By not getting law
enforcement involved at all. And how do we accomplish that? We accomplish it by waking
up and understanding that you can’t talk about
mental health support reform unless you want to talk
about supportive housing. And again, I want to compliment SAMHSA, ’cause you’re gonna have Ryan Moser from the Corporation of
Supportive Housing here today to tell us how you get supportive
housing in your community. And you can’t get better when
you’re living under a bridge. Housing is essential to
mental health recovery. And you can’t talk about it unless you want to talk about
jobs, you can’t talk about it unless you want to talk
about transportation, you can’t talk about it
unless you want to talk about drug and alcohol programs. And you can’t talk about it unless you want to talk about PTSD. And you’ve got to remember
that’s not only veterans. Do you know that last
year was the first year in our country’s history where
more law enforcement officers took their own lives than were
killed in the line of duty because of PTSD. And you can’t talk about it
unless you want to talk about social connectivity that bonds you with your neighbors and friends. People with serious mental
illness are the most isolated in our society, and that’s why peers and peer run clubhouses are so important. And why are they important,
because they give people hope. Writer Hal Lindsey said, man can live about 40 days without food, about three days without water, about eight minutes without air, but only one second without hope. And how do I know that collaboration between law enforcement and
community services work? Let’s go back to Miami, after
Judge Leifman got me in there he took my book, he went
to a local TV station, he got them in, he started demanding that all the different
stakeholders come together. He got that community
to pass a bond issue. He has closed down the ninth floor. He is setting up the gold standard for jail diversion in Miami as we speak. The results so far, arrests have decreased from 118,000 to 56,000 annually. Recidivism has dropped by almost 50%. The jail population plunged from 7,300 to 4,000 inmates, enabling Miami to actually
close one of its jails, generating 12 million in annual savings. How do I know that cooperation
between law enforcement, communities, and providing
mental health services works? Because it’s what helped save my son. The last time Kevin got sick
was on Thanksgiving Day, he had gone off his meds. I could tell he was off of
them, he could tell I knew. He was scared I’d call the
police, he’d get tasered, so he ran out of our house, he jumped in his car and he took off. And I called and I called and I called and he wouldn’t answer his
phone, and he finally answered. I said, “Where are you going,” and he said, “I’m going to heaven.” Well that’s not real
reassuring to a father. Well he got as far as North Carolina, where he ran out of gas. And he called me, he
was crying, and he said, “Dad, dad, help me.” I said, “I’ll come.” He said, “No, don’t come dad, don’t come.” I said, “Okay, come home.” “I can’t, I’m out of gas.” “Okay, go to a, I’ll get
gas delivered to you, “or go to a station I’ll
give you a credit card.” “No dad, you don’t understand,
you don’t understand.” The voices in his head,
the voices in his head were telling him if he stepped
out of that car he would die. Now we know that’s all ridiculous, but how do you know
you’re listening to me, how do you know this is Friday, how do you know you’re tuned in to SAMHSA? Because you’re brain is telling
you, and I’m telling you if your brain told you that you would die if you walked out of the
building you’re in right now, you wouldn’t leave that building. So I did what no father should do, I arranged for Kevin to get gas and he drove completely
psychotic all the way home. He went off the road twice. He didn’t hit anyone, he wasn’t stopped. I said, “Look, I’m tired of
fighting, I want to be a parent. “I want to be your
partner, not your parent. “What can I do?” And he said, “There’s a safe place, “a safe house you can go to. “Take me there, I want to think. “I don’t want to take medications,
I just want to think.” I said, “Fine,” and I took
him over to a safe house and he checked in. And that was great, I went home, I took a big sigh of relief, finally would could get somewhere on this. Well he got up in the middle of the night, took off all his clothes,
’cause we all know if you get naked then you’re invisible, and he went walking outside. But listen to what happened
to my son this time around. This time, a crisis intervention
team trained officer pulled up next to him,
rolled down his window, said, “Hey buddy, what are you doing “walking naked down the street?” He said, “Maybe we should go
over to the emergency room “and get you checked out.” “It’s really not safe for you to do this.” And Kevin said, “Don’t handcuff me, “that’s when I got tasered. “I ran away, I’m not a criminal.” And that officer used his discretion, he did not handcuff him, and he put in the back of that squad car. And then he turned to my son and he said, “What kind of music do you like?” And Kevin said, “I like rap music.” And that officer turned on rap music. He treated him with respect. When they got to the hospital
my son actually got out, shook his hand, and said, “This
is better than a taxi ride.” He didn’t stop there though. That officer went inside
and when that doctor said to the officer, “Well
walking naked down the street “is not dangerous,” the
officer actually said to him, “Okay Dr. Smith I’m gonna
look up where you live “and I’m gonna drop him
off on your front lawn.” All of a sudden my son was admitted. And then he got a fabulous case manager. And that case manager said to him, “Why don’t you take your medication?” “I’ve gained 50 pounds, I
can’t drink, I can’t have sex.” She said, “You need to talk to a doctor “and try to get that formulary correct.” Do you know of my son’s
seven psychiatrists only two have ever
bothered to learn anything but his name and his diagnosis? And that’s because
they’re only gonna be paid for a 15 minute med check
and they’re gonna shove him out the door and have a
social worker take over. But treating the mind
requires treating the heart. And the doctor talked to him and they found a medication
that had few side effects and Kevin started taking his
medicine and it really helped. And then the case manager
came to him and said, “You need housing.” And I said, “Well that’s
ridiculous, he can live with me.” “No, he’s too old to do that. “He needs to be independent
and he needs to have pride. “He needs to be responsible. “He needs to pay 30% of his income “even if he makes no income,
he needs housing first.” So she moved him into an
apartment with two guys with schizophrenia, and I
was amazed at what that did for his self-esteem and confidence. And then she went to him and she said, “You know Kevin, you’re a lot more stable, “you’re doing a lot better
than a lot of folks, “you need a job.” “What can I do, I have a mental illness.” “Knock it off, control the illness, “don’t let it control you.” So my son got a job. College educated. He was the guy at Home
Depot who went around and picked up shopping carts. And he got depressed. All of his friends were moving on, all of them were getting married, all of them had friends and careers, and he was picking up shopping carts. And then one day he saw his therapist and his therapist said, “Oh
help me load some things. “Man Kevin, you’re doing great.” And Kevin thought he was mocking him. He said, “No, no, you
need to come to my group. “You need to see how
ill other people are.” And so he went. And he realized that he could help people because they were inspired by
seeing how well he was doing. And so he came back and
the case manager said, “I have a great program
you need to learn about, “it’s called peer-to-peer.” Being a peer, someone with mental illness who’s helping someone with mental illness. So my son underwent the
courses and today he works in Arlington County as a
peer-to-peer specialist, a person with mental
health, mental illness, who helps others with mental illness. One of his clients, over
300 pounds, schizophrenia, hadn’t been out of his
parents’ basement for months. Kevin started going over,
he started visiting him. Got him out, got him to go
to a fast food restaurant and to a movie. Now that’s not a big thing,
unless that is your son. Today, Kevin and his mother
are buying a home together. He’s paying taxes and
complaining about it. He’s working full time. He’s attending graduate school. And he’s just applied to Fairfax to become the peer specialist leader, the top dog over there in peers. So don’t tell me people can’t recover. I’ve seen it with my own eyes. And it was collaboration
between law enforcement, community services, they
gave me my son back. I am the parent of an adult son with a serious mental illness. What does that mean? It means seeing my son
given not a second chance, but a third and a fourth and a fifth, and sticking with him until
he embraced his recovery. I am the parent of an adult
son with a mental illness. What does that mean? It means interacting with CIT
trained officers who care, judges who care, prosecutors
and defense attorneys and community leaders who care. It means working with
people who are able to see beyond the madness of his eyes and recognize him as a person of worth whose parents and brothers and sisters love and care about him. I am the parent of an adult
son with a mental illness. What does it mean? It means that my son has
taught me about resilience and the human spirit, about
an individual’s ability to overcome tremendous obstacles, and I am tremendously proud of my son and the man he has become. And I want other persons to
get the same kind of services that Kevin got. The same kind of opportunities
that he’s received. That is what I want. And that’s what you can help me achieve. You are not widget makers. You have chosen a much more noble calling. Every day you make a
difference in every moment you have an opportunity
to help reform our system, to help save people such as Kevin. You need to make today the day
that you make a difference. I’m gonna close, I always
close my speeches with a story. It’s a religious story. I am not promoting religion, I
am not down-grading religion, I simply like the story. And I like the imagery that it shows. I was brought up in Oklahoma, my father was a small town minister. And right there you will know
that I got dragged to church every Wednesday night, twice on Sunday, and I got really good at sitting there, not listening to a word my dad said. Except for one story he told, and that’s because it’s about
a woman who’s having sex. It’s always women in the
Bible who are having sex, never the men, and you can find them if
you know where to look. The woman is caught in adultery. She’s brought to the
center of the community. Everybody gathers a stone,
they’re gonna stone her because this awful thing she has done. And we read that the teacher
lifts up a rock and says, “Let ye who’s never sinned
throw that first stone.” And we read that people
put down the rocks, they put down the stones,
because they realize none of us are pure,
all of us have sinned, all of us have fallen short. Sadly, today we live in a culture where people don’t put down those rocks, they don’t put down those stones. They want to stone
people who are different, they want to lock them up,
get them off the streets, just get rid of them. My friend Bryan Stevenson
talks about stone catchers, people who stand between those angry mobs and protect people until they’re
strong enough to join us. It is the stone catchers in
our society who give me hope. You are stone catchers. Thank you for doing that. Thank you. (audience applauding) – [Dr. Huang] Okay. Pete thank you very
much for those remarks. I’m really at a loss of
how to follow with that. I can pronounce Ruby’s last
name though, so (laughs). Okay. Your remarks were incredibly
compelling, inspirational, and it’s a challenging time that we are in both in terms of trying
to be stone catchers and in terms of trying to fix systems that we think are starting to improve, then we see gaps and we see breaks. Then we see infusions of funding and people who are committed to it, then we see that go away. So we’re really in many ways
on a roller coaster ride trying to get what you have painted as a compass north we should think about. I think your remarks
reinvigorate us with hope that things can get better. And your sharing of your personal journey I think will be our
compass north for today. And really not just for
today but even beyond that. We have partners in the
room, partners on the phone, and we hope we can take your story, the gems of what you shared with us today, your son’s and other people’s
stories that you shared, will compel us to make
sure we are relentless in our work here around trying
to improve the situations, the services, the communities, the opportunities for people
with serious mental illness, and those also with co-occurring
substance use disorders. So thank you very much for that. I know the people in the
room probably want to have open discussions with you. We can’t do that right now, but we’ll try to do that
perhaps during a break. So thank you very much Pete. Again, let’s give Pete
applause for sharing his story. (audience applauding) So I have the task now of
beginning to set the stage for our next panel. And Pete, you’ve given us
the human face of that stage. You’ve shared statistics with us as well. So I’m going to go briefly
through some of the slides I have which also have some of the statistics. Okay, whoops. And I’m not gonna really
go reading through those but just to really again say that people with mental health issues, with serious mental illness, with addictions and substance use, are really over represented
in our jails and prisons. And you can see that more
than half of state prisoners, about two thirds of
sentenced jail inmates, meet our Diagnostic and
Statistic Manual criteria for drug dependence or abuse. We also see that about one in seven state and federal prisoners,
and one in four jail inmates, meet the threshold for serious
psychological disorders. So those are some of the
behavioral health issues we see in jails and prisons. But beyond that, we also want to… Now Selby, okay here we go. We know that incarceration also impacts other aspects of one’s lives. That we know that there are
serious health conditions and chronic health conditions that occur for people who are incarcerated, such as chronic health
conditions such as diabetes, or higher prevalence of HIV and AIDS in correctional settings. We also know that housing, housing and housing opportunities, which we know housing is a
critical stabilizing force for people with addictions, people with serious mental illness. That that is a disrupted
part of people’s lives when they’re incarcerated. And that roughly 48,000 people
entering shelters each year are coming directly from prisons or jails. And of the 11 million people
detained or incarcerated in jails each year, as many as 15% report having been homeless. So we think about all of
these barriers to services, all these barriers to
recovery compiling for people with serious mental
illnesses or addictions. It’s not just the behavioral health issues that often go unattended,
but the other health issues. And then all of the things we think of as the social determinants of a healthy life in the community also are impacted. So. Somebody’s moving my slides here, so let me catch up with them. So what are we doing around this now? And Pete has really drawn
attention to the gaps we have in our treatment systems, and the needs for better partnerships across different service systems. The 21st Century Cures Act
passed in December of 2016 is a key policy driver for
some of the work we’re doing here at SAMHSA along with
our federal partners. The section of the bill Helping Families in Mental Health Crisis
Reform Act focused on particular issues regarding
mental health and substance use. The prevention issues, the
prevention and treatment of these disorders, the coverage, looking at financing and coverage for treatment for these conditions. There was a focus also
in this congressional del on reducing criminal
justice system involvement specifically for people with
serious mental illnesses. And it also established
the Interdepartmental Serious Mental Illness
Coordinating Committee. It also elevated the status
of SAMHSA’s administrator to an assistant secretary level position. Again, focusing, really saying that we’re going to prioritize on
these particular conditions. I want to say a little
bit about this ISMICC, or the Interdepartmental
Serious Mental Illness Coordinating Committee. Which is also a big framework or structure for how we’ve organized the
panels for today’s symposium. So this committee consists of both federal and non-federal membership. We have 14 non-federal members who were selected and appointed
by the assistant secretary, including Mr. Earley who was on the ISMICC and Mr. Ron Bruno who
you’ll hear from later, who is also with us in this room today. The non-federal membership
generated 49 recommendations in their required 2017 report to Congress. There are five focus areas
in those recommendations. So there was a focus on
data and quality measures, a focus on access and
engagement of services, focus on treatment and recovery and what should a
continuum of care look like for people with serious mental illnesses and co-occurring substance use. There was also a focus
on criminal justice. And that’s what we are focusing on today. And there was also an area of
focus in those recommendations on financing of services and financing the continuum of care. The… I want to get to the next slide. So five of the key ISMICC interdepartmental criminal
justice recommendations are what you see on the slide there. To support interventions,
that is treatment, prevention, recovery interventions that correspond to all stages of justice involvement. To develop an integrated
crisis response system that diverts people with SMI and young people with
serious emotional disorders away from jails, emergency departments and criminal and juvenile justice system. To prepare and train all first responders, which may be law enforcement
as well as fire fighters, EMTs, to train them to work with
people with SMI and SED. And we heard Pete’s compelling
story of law enforcement that had been trained in
crisis intervention training. Require universal screening
for mental illnesses and substance use disorders and other behavioral health needs of every person booked into jail. And Pete, I did have an
opportunity to get into Cook County Jail some years
ago and meet with a judge, Judge Heston, who was
actually at the juvenile level implementing screenings of all juveniles coming into detention. So there are some people who
are trying to move the system. But to require this
screening so that we know the levels of need of people
coming in and we can identify whether they can be diverted
away from incarceration. And then finally also to reduce barriers that impede access to
treatment and recovery services upon release from correctional facilities and re-entry back into, and transition back into community living. So those were five of
the key recommendations put forward by the ISMICC committee. And so our panels today really
mirror those recommendations. Today you’ll hear discussions
from subject matter experts around that as well as
innovative programs, and many of them are
collaborative programs that Pete alluded to
going on in communities that have really tried to
tackle this intersection of, the crossroads really between behavioral health and criminal justice. Okay. And so our criminal justice,
so each one of those five focus areas of the ISMICC had a designated implementation workgroup to support implementing
the recommendations. This is the composition of our
criminal justice workgroup, the other federal agencies
that were represented. And so the ISMICC is
not just a SAMHSA effort but it’s really an effort which requires a lot of collaboration with
our other federal partners. So these are the federal
partners you see on the slide that are part of our criminal
justice, juvenile justice implementation workgroup. And it is, the workgroup
is led by staff at SAMHSA, myself and Dr. Jennie Simpson. So I want to give you an
overview of today’s symposium but first want to talk
to you about what our criminal justice implementation
workgroup is trying to do around each of those recommendations. That we are trying to put
together what we are calling very practical, feasible,
implementation technical toolkits. That can have ready uptake
and access in the field, both on the behavioral health side, behavioral health providers and personnel, as well as criminal justice practitioners. Each recommendation will have a toolkit which we will make available, which are in process
of being made available to the field now. And that along with that we will look at facilitated training and technical
assistance for the field. We’re starting off today’s symposium with two of the foundational concepts for the work in looking
at the intersection of criminal justice and behavioral health. We have developed here at SAMHSA, again with federal and expert input, principles of community-based
behavioral health treatment for justice-involved individuals. And PRA has, along with Mark Munetz, has really developed and further advanced the concept of the
Sequential Intercept Model. So our next panel
presenters are gonna really start with those foundational concepts. Then the other four panels
remaining through the day are going to reflect again
those recommendations, and the first is gonna
be really looking at building collaborations. Second on crisis response
and early diversion. Third on screening in jails and prisons. And the fourth with a focus on re-entry. Each panel is comprised of
national subject matter experts, local innovators, and federal
partners sharing resources that are available to you in the field. So that’s the structure of our day. So I want to now bring up, let’s see, I want to now
bring up Dr. Jennie Simpson who’s going to talk to
us about the principles, document and guide. And Jennie is a senior staff person in our criminal justice
team here at SAMHSA. And then following her
will be Mr. Chan Noether, who is our project director
at SAMHSA GAINS Center. Both of them bring tremendous
expertise and experience in working at the intersection
of behavioral health and criminal justice. So Jennie? – [Jennie] Great, thank you Larke. So today I have the I
would say distinct honor of introducing for the first
time SAMHSA’s principles of community-based
behavioral health treatment for justice-involved individuals. The development of these principles, as many people may know, has been a truly collaborative process across federal stakeholders,
national experts, local practitioners, and it’s really been a labor
of love for us here at SAMHSA. And I think Pete’s talk this morning really puts a face on these principles, and that I hope you keep in mind as I go through this presentation, because that’s what I
can’t capture right now, so thank you for that. Advancing the slide, hold on one second. Okay, thank you. So why principles, why did
we start off on this process? So historically work at the intersection of criminal justice and behavioral health has focused on criminal
justice professionals. So training law enforcement,
working with corrections, providing that information awareness, behavioral health awareness, deescalation for criminal
justice professionals, and less have focused on
behavioral health providers. So we recognized this gap in information, tools and resources. Recognizing that when you go
into a psychiatry program, or a social work program,
you may not get any training as a clinician on working with
justice-involved individuals. And so we saw that there was there a gap that needed to be addressed. Thank you. So when we were developing the principles we started with what are the
key challenges for providers, and as we were developing these it was a rigorous consensus-based process. So we took into, we listened, had listening
sessions with providers, with local practitioners,
criminal justice professionals, with national experts. And we looked, we found
really three key challenges. First were partnerships. Whether it be with law
enforcement, pre-trial services, courts, community corrections. And I know as someone
who worked in the field, having those partnerships, I didn’t know where to turn to find them. And that was an incredibly important piece if we shared a client who maybe
was on probation or parole and someone I was providing services to. So that partnership, even how to do that was knowledge that wasn’t
readily available to me. Second was knowledge of
criminal justice system and concepts, so that kind of
who, what, when, where, why. Where might my client be? I’m not sure, you know, what
pre-trial services might mean, or community corrections. Who are the personnel that
this individual may be with? What do I do when someone enters jail? All these questions that for
providers who aren’t trained with any kind of knowledge
of criminal justice present a knowledge gap. And third, effective and
responsive treatment, recovery, and support services for
justice-involved individuals. And I’ll say this starts
with evidence-based treatment for justice-involved individuals, which includes, and part
of this effective treatment is addressing criminogenic
risk and needs factors. And I will come back to that later when I discuss one of the principles. And this is really a
necessary part of treatment and something that as the
behavioral health field is working at this intersection, recognizing that those
criminogenic factors must be addressed, and they’re an important
part of treatment. And also case management
and support services to justice-involved individuals. So as Pete detailed,
difficulties in finding housing, employment, opportunities for people who have criminal records. Those are challenges if you are not, you don’t have the information
to work with someone who has those challenges,
know where to go, that’s really a gap in your knowledge. So from providers we also heard that they’re as I described
there’s a complexity in working with
justice-involved individuals, where they may be in the system, the unique needs that they have in finding that housing or employment. Things that are specific to
the risk and needs factors, which I’ll return to. And for providers
there’s additional skills that they have to, that they’re
aware that they don’t have and that they need to
find that information. And then there’s also, and
what I would say stigma. So in a recent article
from Psychiatric Services, and this is just one survey that was done, among 627 psychiatric
rehabilitation program providers, the findings were that
providers reported lower regard for criminal justice clients than for clients without
criminal justice involvement. Providers were also less likely to report having a great deal of
respect for clients with, versus without criminal
justice involvement. That’s really a hurdle to overcome. So when we went to
developing the principles, there we go, we started with first the draft. And we took that draft through
a technical experts panel held on August 17, 2017. And this technical experts
panel, we had national experts, community-based behavioral
health providers, criminal justice professionals,
professional associations, federal representatives who came together to really give us feedback, work with us, problem solve what
these principles needed. After revisions to that initial document, we took the document to go
through peer review in the field by experts in psychiatry,
psychology, social work, criminal justice, criminology, medicine. We really tried to hit as
many people as we could to make sure that this was
as strong and consensus-based as we could make it. And finally, we put the
principles through public comment in May of 2018, allowing
anyone who wanted to to comment on these principles. So I’m happy to say
the principles document is going to be published
in 2019 by SAMHSA. And it includes along
with these principles, information and resources
for providers and agencies who want to implement these principles. So now I’d like to go through
introducing the principles. So the first principle is
that community providers are knowledgeable about the
criminal justice system. This includes the sequence
of events, terminology, and processes of the
criminal justice system, as well as the practices of
criminal justice professionals. Now as I spoke about on some
of these key challenges, understanding where your client may be in the criminal justice system can help you with that
continuous and coordinated care when an individual may
enter into jail or prison and when they come back
out into the community. So it’s essential for knowing as you track and those services that you can provide to the client where they are. You also can understand
whenever you’re working with another, with your
criminal justice colleague, what the terminology is they are using. That’s one we don’t necessarily
speak in the same language. And I think there’s cross-education
that can happen there because criminal justice professionals may not know our language. And that’s a really,
knowing that demonstrates the desire for collaboration as well. There’s also opportunities to recognize when you can divert clients
into treatment and services such as drug treatment courts. And when under probation or parole you can facilitate coordinated care, and adhere to supervision
and requirements as well. Now for the second principle, community providers collaborate
with criminal justice professionals to improve public health, public safety, and individual
behavioral health outcomes. Again, this one is really key. That collaboration is
essential when you think about ensuring continuity and care coordination when there are transitions
from jail, prison, emergency rooms also. We have law enforcement who
may be taking an individual to an emergency room. It’s really essential
that you have someone that you are connected with. That collaboration includes
information sharing when appropriate, clarifying
roles and responsibilities. What behavioral health providers do, what criminal justice professionals do. Ensuring that treatment and
supervision requirements are complementary. So that requires talking with your criminal justice colleague
on the other side, and making sure that
those efforts together serve the person that you
are both working with. And then working with the
client to identify and meet their treatment and supervision goals. So just at the very heart
is ensuring that care, the individual gets the best
care that they can receive. And so later today you
are going to hear about the Bureau of Justice Assistance’s Police-Mental Health
Collaboration Toolkit, which can establish, help establish these
important connections. The third principle is evidence-based and promising programs and practices in behavioral health treatment services are used to provide high
quality clinical care for justice-involved individuals. So now evidence-based programs
and practices should be used for all individuals, we’ll start with that as just the key baseline there. But there may be
adaptations or interventions that are specific to a
justice-involved population. And these adaptations can include the, include recognizing and
addressing the risk factors that may increase the likelihood
of someone re-offending. So there’s a focus, some
of these interventions focus on motivation, problem
solving, skill building, coping skills, anger management. Things that providers
will be familiar with but with additional skills can really tailor these to
justice-involved individuals. It also includes integrated treatment for substance use disorders, including medication-assisted treatment for opiod use disorders, which is the standard of care
for substance use disorders. Principle four, community
providers understand and address criminogenic risk and need factors as part of a comprehensive treatment plan for justice-involved individuals. I think this may be one of
the hardest for providers who are not familiar with
the criminal justice system, haven’t worked with criminal
justice professionals, and understanding criminogenic risk. It sounds like someone may be at risk of violence,
that’s not what this means. We know, and research is really
continuing to demonstrate, that behavioral health treatment alone does not reduce the likelihood that someone is going to re-offend. And conversely, interventions
that only address criminogenic risk and need factors, do not improve behavioral health outcomes. So they are complementary. Criminogenic factors
include rick and needs that research have demonstrated increase an individual’s
likelihood to re-offend. These include, and I
would suggest that people after I announce these
be sure to take a look at the research, look at tools. If you’re a provider
understand these more. Because just this little bitty piece is not gonna give you
a full understanding. But these include a history
of antisocial behavior, antisocial personality
pattern, antisocial cognition, antisocial associates,
family and marital problems, work-school problems,
lack of health and leisure and recreational pursuits,
and substance use. All these together they’re
risk and need factors. Providers may have experience
in addressing some of these so I think those
transferable skills are there for working with
justice-involved individuals. So when we move to principle five, integrated physical and
behavioral health care is part of a comprehensive treatment plan for justice-involved individuals. So research, we know through the research that formerly incarcerated individuals are at an increased risk
for serious and complex chronic health conditions and may require coordinated care with other health care professionals. So rates of infectious and
non-communicable chronic diseases are high in incarcerated populations and those under supervision. And incarceration can
exacerbate these conditions. So this can include HIV,
hepatitis C, tuberculosis, diabetes, liver disease, and hypertension. So testing for these diseases and working with health
care providers is essential in ensuring that
justice-involved individuals receive good quality care. Principle six is services and
workplaces are trauma-informed to support the health and safety of both justice-involved individuals
and community providers. Research also tells us that
justice-involved populations have high rates of exposure
to traumatic events. And while incarcerated, this
trauma may be compounded by trauma that’s specific to
the jail or prison setting including sexual and physical
violence, intimidation, confinement, isolation and coercion. And prior trauma even
before someone enters, again compounded by that experience. So for the safety of both
clients and the providers, creating and promoting a
trauma-informed workplace and approach to services to the setting promotes safety and trust and can minimize any kind
of situations that might put providers or justice-involved
individuals at risk. Principle seven. Is that slide, let’s see if I
can advance that slide. Can I get it? There we go, okay great, thank you. Case management for
justice-involved individuals incorporates treatment, social
services, and social supports that address prior and current involvement with the criminal justice
system, and reduce the likelihood of recidivism or the
likelihood of to re-offend. So individuals involved
with criminal justice, the criminal justice system,
re-entering from communities from jails and prisons
face unique obstacles in finding housing, employment, coordinating health and
behavioral health care. And case managers play a critical role in connecting an individual to services that address the social factors that can lead to reduced quality of life, poor health outcomes, and recidivism, including that lack of
housing, employment, social services supports, and untreated substance use disorders. And I think Pete you gave us a really good clear understanding of what
that can mean for someone, so case management is so critical there. And finally, the last principle
is that community providers recognize and address
issues that may contribute to disparities in both
behavioral health care and the criminal justice system. So different populations,
including those that are based on race, ethnicity, gender,
sexual orientation, gender identity, and economic status, have disparate access to high quality behavioral health treatment. We also know that there’s a
disproportionate representation in the criminal justice
system of minorities, sexual and gender minorities as well, and those with low socioeconomic status. So it’s important for
providers to understand that there are structural
biases in our system that can lead to an inequality and further perpetuate
disproportionate representation in the criminal justice system, as well as reducing access to
behavioral health services. So one very clear step in reducing disparities and addressing this principle
is to welcome opportunities to serve this population. And I think in closing,
that’s our last principle, I will say that these principles
will support and drive SAMHSA’s work going forward. And through the GAINS Center
you will see additional tools and resources that
will be coming out in 2019 to support these. We know that we present these principles and providers need the
information and resources to fill that gap that has existed. So we look very forward
to these coming out and putting these out to the field. Thank you. (audience applauding) – [Chan] Good morning. Everyone in the room, and
thank you for everyone on the phone for joining us today. I want to welcome you all on
behalf of the GAINS Center. We’ve had some SAMHSA welcomes and we’re pleased as
operators of the GAINS Center to have such a high rate of participation on the webinar today. My name is Chanson Noether, and I am the Director of
SAMHSA’s GAINS Center. For my portion of the
panel I’ll be providing an introduction and overview of the Sequential Intercept
Model, or the SIM, which as Larke mentioned is foundational. The SIM serves as an organizing framework for much of the work that we
do through the GAINS Center, much of the work that
SAMHSA does generally around criminal justice
and behavioral health, and about which the upcoming
panelists will discuss in more detail. Why is this not working. The focus of the
sequential intercept model is on men and women with
serious mental illness, substance use disorders,
co-occurring disorders, and who are also involved
with or in contact with the criminal justice system. The SIM can be used as a tool to develop cross-system strategies that
promote and support recovery, ensure safety and quality of
life for everyone involved, keep people out of jail and in treatment, while in jail provide
constitutionally adequate treatment, and upon release, link people
to comprehensive, appropriate, and integrated community
behavioral health services. The SIM can be used to address
challenges to collaboration. Limited resources can
often create a competitive and/or protective
environment among systems. Funding silos can make communication about cross-system efforts
much more challenging. Systems often represent
different cultures, with their own histories, languages, values, concerns, and operations. But these challenges can be overcome using the SIM as a tool. The SIM can be used to improve
integrated service delivery by promoting and enhancing collaboration. Collaboration among professionals who work in the justice and
behavioral health systems, people with lived
experiences in those systems and family members and
other advocates for people involved in criminal justice
and behavioral health. But it’s not just the criminal justice and behavioral health systems, it’s also all of the
other systems and supports that are so necessary to
supporting a person’s recovery. Support systems such as social services, benefits and entitlements,
health, housing, and in many cases veterans services are also critical players
to be at the table. The sequential intercept
model helps illustrate how people typically move through the criminal justice system
in somewhat predictable ways. While we know that the
criminal justice system is not necessarily linear, we can use the SIM to ensure
prompt access to treatment, that there are
opportunities for diversion, ensure timely movement through
the criminal justice system and engagement in community resources. Some of you may have seen the
SIM presented as a circle. Others may have seen the
SIM presented as a funnel. The model that we use at the GAINS Center and that is most familiar to
SAMHSA is the linear version of the sequential intercept model. As you can see the
sequential intercept model consists of six intercepts,
intercepts zero through five. So let’s take a closer look at each. So at intercept zero, we examine what the crisis
care continuum looks like. Intercept zero is focused on
what services are available and whether or not there
are mechanisms in place for people to understand
how to access these services without having to call 911. Some examples of the services and programs that are frequently part of intercept zero include emergency room diversion
and use of peer support or peer navigators in
emergency room settings. Crisis stabilization,
residential crisis facilities, crisis respite, peer
respite, mobile crisis, critical time intervention, and others. As we transition from intercepts
zero to intercept one, the arrows between these two
intercepts go back and forth. There’s a relationship
between these intercepts because we know that these
intercepts often interact. Sometimes contact with law
enforcement is unavoidable for a person in crisis so the interaction between these two intercepts is necessary. When we talk about
coordination and collaboration between these intercepts it’s imperative that the behavioral health community and behavioral health professionals try to help law enforcement
officers to answer one very important question, and that question is divert to what. If there is no answer to that question, or no viable option in
answer to that question, then the person is most
likely going to jail. When we look at integrating
intercept zero and intercept one there are several specialized
crisis response models that we can look at that
help promote this integration and collaboration between
crisis and law enforcement. One of those is centralized
drop off facilities. Especially facilities that are co-located with substance abuse services, and have police friendly policies such as no refusal of anyone
who comes through their doors. And very importantly, a
streamlined intake process. Minimizing the amount
of time that it takes for a law enforcement
officer to drop an individual who is in crisis off at
one of these facilities can substantially enhance the interest of law enforcement in utilizing these facilities
for people in crisis. Cross training is another
very important feature of specialized crisis response. Mental health and behavioral
health professionals understanding what the
law enforcement aspect of crisis response looks like. Often ride alongs with officers
are one strategy for that. And then developing community linkages such as case management,
care coordination, co-response, or warm handoff strategies. As we look more toward intercept one, looking at law enforcement
and emergency services, there are several models
that are often used in different communities
across the country. One is the crisis intervention team model, which we’ll hear more about
in one of the later panels. The co-responder model. Off-site support models,
where officers in the field receive support via
telephone or video conference from mental health professionals. Mobile crisis. And specialized EMS responses. Some common gaps at intercept zero and one include lack of crisis stabilization units and continuum of crisis care
services, including detox. Lack of sufficient mobile crisis response, and lack of mental health
or crisis intervention team training for 911 dispatchers. As we move into intercept two, which looks at post-arrest, pre-booking, we find that some essential
elements that need to be present at intercept two include the
screening and identification of mental health and
substance abuse issues. The presence of a court-based clinician who can identify people
who should be referred out of the criminal justice system. The use of recovery-based
engagement strategies that focus on choice and
prioritize the services most important to the person considering behavioral health needs. And a proportional response
that takes into account what services are necessary at that moment and what services are
necessary longer term. Looking more closely at the identification and referral aspect of intercept two, the personnel who are involved
in this process may vary depending on how the
court systems are set up. The process may include people such as law enforcement
officers, booking officers, jail medical staff, pre-trial
service agents and agencies, public defenders, prosecutors, and in the case of a history
of prior military service, a veterans justice outreach specialist. Identification and
referral at intercept two can utilize many different strategies including data matching, mental health and
substance abuse screening, and potential diversion
options for the individual being presented at arraignment. Some common gaps at intercept two include the lack of
diversion opportunities, lack of specialized supervision for people with mental and substance use disorders who are on pre-trial supervision, and lack of multiple
behavioral health screening and identification strategies. As we move into intercept three we look at the courts and the jails. Some key issues at intercept three include screening
identification and assessment, while in jail, access to medication, mental health and substance
use treatment services, and communication with
community-based providers who may have been providing
services to the individual prior to his or her incarceration. Court-based post-booking
diversion options, treatment courts such as
drug courts, DWI courts, mental health courts,
veterans treatment courts. There may be one or multiple specialty treatment court options
available in the community, and in particular when
multiple options are available a consideration of which
option is the best match for the individual and
collaboration among the courts in the screening, identification, and referral process, is critical. Some common gaps at intercept
three in the jails include lack of sufficient screening for veterans or a history of military service. Continuity of medication and use of off-formulary medication. And insufficient data about the population with serious mental illness
and substance use disorders in the jail census. When we look at courts we
find that there’s often an over reliance on treatment courts over other viable diversion options. Treatment courts are sometimes limited to post-conviction models. Treatment courts may be
focused on misdemeanors only, or limited to felony or misdemeanors only. And co-occurring disorders are
sometimes not well understood in our specialty courts. As we move to intercept four, this is where we’re looking
at the re-entry process, the prison or jail, from prison or jail. Some re-entry models
include refer out models where jail or prison institutional
staff provide inmates referrals to community-based
services upon release. In reach models where
community-based providers conduct intakes and arrange
service plans prior to release. And transitional re-entry
programs, which are a coordinated and shared responsibility
between institution staff and community-based providers
for all aspects of re-entry. Some common gaps and
issues at intercept four include lack of coordination
across multiple services and support systems. Insufficient medication or
prescriptions upon release, lack of enrollment in Medicaid or SSI. Insufficient connection to
community-based services. The timing of release
is often a big issue. Procedures surrounding release. Transportation issues upon release. Lack of stable and
appropriate housing options, and lack of treatment providers
who can meet the multiple and often very complex needs
of people with mental illness and substance use disorders
who are involved in the criminal justice system. As we move into intercept
five you can see that at intercept five there
are two sets of lines. One that goes into the community, and one that points back into
the criminal justice system. The second set of lines is
due primarily to violations of the terms and conditions
of parole or probation. And one of the promising practice models that can help address
this issue are the use of specialized caseloads by
probation and parole departments. Specialized caseloads models
rely on effective partnerships between supervision probation
and parole officers, and community-based treatment
providers, and other supports, and can reduce the risk
of a technology violation by improving linkage to services
and improving functioning among people who are under supervision. Some common gaps at intercept five include lack of alternatives to violating someone. Lack of specialized caseloads and caseloads with a high ratio
of probationers to officers. Again, access to appropriate housing. And issues with behavioral
health providers, including lack of agreements
on what information is and can be shared with probation, poor implementation of
risk-need-responsivity strategies, and lack of access to medication assisted treatment programs. Across the six intercepts
there are many gaps that are common. Information sharing and issues
having to do with HIPAA, whether real or imagined, can
create significant barriers to coordination of care and treatment between and among the systems. Cross-training of criminal justice and behavioral health professionals, what is the role of one
versus the role of the other, and lack of understanding among both the criminal justice and
behavioral health systems of the issues and the constraints and the things that they face every day working with this population
can contribute to myths and can contribute to
adversarial relationships. The lack of trauma-informed approaches and trauma-specific services. You heard Jennie speak a few moments ago about one of the eight principles, and spoke about trauma-informed
care and how often our criminal justice
settings and interactions, particularly for those
people who have histories of traumatic events,
can be re-traumatizing. Cross-system screening for
veterans and military service. Issues related to health care reform. Integration of peer
support and peer services. Housing options and
access are a big issue. Lack of a formal cross
systems planning structure. And that’s one of the things
that we utilize the SIM for in communities across the
country is as a planning tool working with cross-disciplinary and cross-agency teams of stakeholders to develop a formal planning structure and formal strategic plans
to address many of the issues that we’ve talked about as
part of this presentation. And finally, little use of data to inform decision making
and program planning. And that’s certainly an
issue that particularly over the last several years
has had a lot of attention paid to it and a lot of resources being dedicated to further developing data-based decision-making protocols and supporting communities
that want to but don’t know how to implement data-based
decision-making strategies. So in summary, the importance of the SIM is that it helps keep people out of the criminal justice system and in community-based
behavioral health services. It promotes seamless transition to the community upon re-entry. Supports the development
of a strategic approach to protect public safety
and improve public health. And can be used to leverage
the community brain trust and help criminal justice
and behavioral health professionals to speak
a more common language. I want to encourage you if
you’re interested in learning more about the sequential intercept model, and the work that SAMHSA does and that we do through
SAMHSA’s GAINS Center, to visit the GAINS Center’s web page at www.samhsa.gov/gains-center. You’ll find SAMHSA’s 800 number, which you should feel free
to reach out to SAMHSA via that number, or via 1-800-311-GAIN. That’s a direct link to the GAINS Center if you’re looking for more information about the sequential intercept model. Thank you. (audience applauding) – [Jennie] Thank you to
everyone on the, Chan. Thank you Larke, Pete. We are ahead of schedule right now, so we will allow questions
from the virtual audience, also questions in the room. We’ll have to restate them so
that the audience can hear, but we’re glad to take
questions right now. Okay and while we are switching over to questions and answers, we will have the webinar
archived and available, and the slides will be available as well. So for those of you who I know
have been asking about that, this all will be available. Okay. So we do have one of the
first questions that we have. Is there a way to approach our
court and emergency systems to begin doing, closing the
gap between mental disorder and providing services? I will ask Chan, would you
like to take this question? – [Chan] Sure, and I potentially
think there’s anybody in our audience from that
panel who might want to deal with that question
as well, so the question? – [Jennie] The question is,
is there a way to approach our court and emergency systems
to begin closing the gap between mental disorder
and providing services. – [Chan] I think if you take a look at the sequential intercept model
and some of the information that we have available on
the GAINS Center website, there are some suggestions about
how to begin the discussion of collaboration between and among different systems on these issues. Since I’m not sure, this is Amy, what perspective you’re coming from. Best way to approach our
court and emergency systems. It would be hard to give
you very specific advice not knowing your system and not knowing the perspective
that you’re coming from, but I would encourage you
to visit the GAINS Center, to contact us, we have
virtual consultations where we can help you talk
through what your issues are, who your stakeholders are, and
help you come up with a plan to address those issues in your community. Should I read? – [Woman] Yeah, yes. – [Chan] Oh, down here. So I think the next question is, you mentioned difficulty with providers implementing
risk-need-responsivity strategies. It is common knowledge with
criminal justice professionals, but do you know of any
resources or training for behavioral health
providers on the RNR model? Will you talk about that at
all as part of your panel? – [Woman] Yes, yeah. – [Chan] Yeah. Yeah, so one of the
things that we’ll be doing through the GAINS Center
is a learning collaborative on risk-need-responsivity. If you haven’t heard about that panel yet, be on the lookout for more
announcements about that, and again you can visit
the GAINS Center website. We’ll have some more resources
as we go throughout the day who will be talking about some of the places where
you can get training as a behavioral health
professional on RNR. And the GAINS Center has also conducted three webinars on the
topic that are archived and forthcoming, and will be available and announced when those are available. So keep on the lookout for those as well. Some other resources include
the National Association of Drug Court Professionals, I believe BJA has some resources
on risk-need-responsivity. Yes. The next question is are states currently using
the sequential intercept model that are good examples of
successful implementation. There are states that are using the sequential intercept
model as a way to understand how their state systems work together or don’t work together,
and how the state can help better support collaboration
and coordination between behavioral health
and criminal justice at the local level. The SIM model has broad applicability but was really designed to be a model that looks locally at systems. Part of what we use the SIM map
to do is to help communities understand their systems by
engaging in a mapping process of their systems where they
can create a local systems map that really reflects using the general sequential intercept
model, what the local, usually county-based system looks like. We’ve worked with many states in the past and I’ll look to my colleagues in the back to see if there’s any particularly
good state level example that you would like me to highlight, or you would want to
come up and highlight. (muffled speaking) Okay. So… (muffled speaking) Mm-hmm, and there’s a new, I’m not sure if it’s quite
a center of excellence is the name in Pennsylvania as well. I think that much of the
work’s being funded by BJA that’ll be doing some
implementation work in Pennsylvania at the state level as well using the SIM. Good. So with that we will go ahead
and take a few moments break and transition to the next panel. – [Melissa] Okay, good morning everyone. My name is Melissa Neal and I
am a senior research associate with Policy Research Associates and I’m the lead for communications with SAMHSA’s GAINS Center. And am very excited to
present this first panel talking about partnerships. To pique some interest in this panel we are gonna be covering some information about statewide efforts in using the SIM. So please stay tuned. I’m really excited that
we start with partnership when you look across the
nation and you look at the jurisdictions that are
doing good work in this area, in enhancing their behavioral health and justice system collaboration and creating diversion opportunities, the key that we see in
many of those places is effective collaboration. People are working well together. Whether you have funding or no funding, whether you are a rich
or poor resource area, collaboration can make all the difference and create really unique
and innovative opportunities to move people out of the justice system into treatment and services. And so with this panel we’ll
be covering statewide efforts as well as efforts done by one agency. We’ll have a supervisor talking
about how her one agency, a probation office, is
leveraging partnership to improve services to
people with mental illness. And so I’m just gonna
provide a brief introduction of all of our panelists. We have Dr. Mark Munetz. And as Pete mentioned earlier,
he is one of the co-creators of the Sequential Intercept model. He’s is a professor and
the Margaret Clark Morgan Endowed Chair of Psychiatry at Northeast Ohio Medical University. He oversees the Ohio Criminal Justice Coordinating Center of Excellence, which he will be talking about
more in his presentation. Dr. Margie Balfour is the Chief of Quality and Clinical Innovation at
Connections Health Solutions and she’s an assistant
professor of psychiatry at the University of Arizona. Jessica Ethington is a supervisor
with the Maricopa County Adult Probation Department since 2005. She also supports a
community living placement for justice-involved people
who are under probation and have a serious mental illness. And finally, Maria Fryer
is a policy advisor with the Bureau of Justice Assistance, and she oversees the justice
and behavioral health discretionary grant portfolio. And without further ado
we’re gonna turn things over to Dr. Mark Munetz. – [Dr. Mutetz] Well thank
you and good morning. I’m really excited to be
part of this symposium and hopefully what I’m gonna
talk about will build on what we’ve already heard this morning. I’ve been asked to talk about
the work we’ve been doing in Ohio, we’ve been doing this
work for nearly two decades, and I’ve been given a maximum
of 15 minutes to talk, so I’m gonna be talking fast and won’t cover this in the
depth that I would love to. But you’ll get my slides and I’d be happy to have
contact with you subsequently. So I’m gonna talk about the Ohio Criminal Justice Coordinating
Center of Excellence, what we call the CJ CCoE. And this goes back to May of 2001 at a time when Dr. Mike
Hogan was the director of the Ohio Department of Mental Health, and had the idea that the
state could be more effective in a decentralized system in
the age of community-based care if they worked with local universities, predominantly medical schools,
but also other institutions, where there was interest,
expertise, and energy around a particular
evidence-based practice. And they created a number of these coordinating centers of excellence. And at that time I was a medical director of the Summit County, which
is the greater Akron area, Alcohol and Drug Addiction and
Mental Health Services Board, the mental health
authority for the county. And we had started some, what at that time were
very innovative programs. We were the first county in
Ohio to have a CIT program, and had the first mental
health court in our state. And so I was enthusiastic, as were some of my colleagues,
in spreading the word about these jail diversion opportunities. And so we convinced Dr.
Hogan, I think with some help from Hank Steadman at the GAINS Center, to create a coordinating
center of excellence around jail diversion. So the center was funded by the state using SAMHSA block grant dollars
as a one year experiment, which has been renewed
for the past 17 years. One year at a time, we’ve
never gotten an increase in our funding, funding is quite modest. We’re operated by Northeast
Ohio Medical University, NEOMED, where I’m now the chair. And we have a very small
staff, one full time director, a full time dissemination
coordinator, part of my time, and a growing number of consultants, which have become increasingly important, as well as partners, as we’ll talk about, ’cause this is all about collaboration. Our mission is to promote
jail diversion alternatives for people with serious mental illness, most of whom have co-occurring
substance use disorders. To keep them out of the justice system and keep them in the treatment
system as much as possible. And I think really at the inception Dr. Hogan and Dr. Steadman had the idea that the work that the GAINS
Center was doing nationally could have even more impact
if there was a local version, a state-level version, what
Hank called a mini GAINS Center. So that’s what we’ve
been and I think we’ve realized his vision to some degree. If I could have the next slide. So, very gratifying to hear the emphasis on the sequential intercept
model because in fact when we started the work of our center, although there were some
promising practices, we were supposed to be, the centers were to promote
evidence-based practices, and we really didn’t
have any at that point that we could say had
strong evidence behind them. So Dr. Hogan encouraged
me, actually ordered me, to create a conceptual model. And working with Patty Griffin,
who was a senior consultant with the GAINS Center, who
had been consulting with us in Summit County, and with Hank Steadman, the sequential intercept model evolved. As you’re hearing it’s
continuing to evolve. And that’s been the framework of our work and has been widely disseminated, which has been very gratifying. Much of our attention in the
first decade of our center was to disseminate the crisis
intervention team program. CIT as created in Memphis, we see as the most effective way of partnering between law enforcement and the mental health system, people with mental illness
and their families. And in answer to one of the questions of how you get people together, starting a CIT program is
a tremendously helpful way of beginning collaboration. In Ohio early adopters
of CIT through our center developed a document describing
the core elements of CIT, which informed the Memphis CIT Center creating the core elements of CIT that are now endorsed
by CIT International, kind of the current expert
consensus around CIT programs. And we’re very proud of
having trained close to 12,000 sworn law enforcement
officers since we started in 87 of our 88 counties, and are continuing to evolve CIT programs. More recently, in the
last half a dozen years, we’ve with the benefit of
training from the GAINS Center we had a cadre of facilitators trained in operationalizing
the sequential intercept model into sequential intercept mapping as the GAINS Center has developed. And we’ve used that I
believe quite effectively now in helping to map serious
mental illness services and its intersection
with the justice system in 24 Ohio counties, and we’ve
adapted that more recently to address the opiod crisis, and have completed
sequential intercept mapping focusing on opioids in nine Ohio counties. If I could have the next slide. If there’s one word to
the key to our success, it’s collaboration, and
collaboration at multiple levels. So we’ve been able to benefit
from strong partnerships with national partners, in some cases those national
partners are also funders, which is terrific. And also with state partners and funders. I don’t have time to go
through each of these, and they each play a very important role, but I want to make particular
note of our partnership with our state NAMI organization, ’cause the work that we’ve
done would not have moved as quickly as it has without
the partnership with NAMI Ohio. A lot of that’s in-kind, some of it’s actually sharing funds. I also have to point out
that if you want to get collaboration to happen,
it’s really wonderful if you can find a judge, and even better if you can
find a supreme court justice. We’ve been just fortunate in Ohio to have Justice Evelyn Stratton, who when we started was
a supreme court justice, subsequently retired and
is now even more active in this work in partnering with us as she’s taken on leadership
of Stepping Up in Ohio, with support from a local foundation. Another key collaborator if
you’re fortunate enough to find a foundation that can be
interested in this issue. We have in Peg’s Foundation
in northeast Ohio. Next slide please. So the second key to our success, which conforms with the
collaboration idea is showing up when invited, and at times asking to be invited. And we have to be a little pushy at times, but we’ve been very active
at state level meetings that bring the stakeholders
together across the systems. Modeling for local
communities the collaboration that needs to happen at the state level. And then we also convene meetings with our various stakeholder
groups across systems. When I refer to friends in
the slide, it’s people who we don’t have funds to support but they’re very involved in our work. It’s state level agency representatives, advocacy groups, people from the mental
health system, et cetera. We communicate as much as we can. Our CIT coordinators are a
statewide group that’s informal but very meaningful, very important. We communicate by e-mail and increasingly through
video conferencing. Next slide please. So the real work that makes a difference is at the local level. What we’re doing is really
to support that work and we’ve conceptualized our approach as a top-down and bottom-up. And the bottom-up is much more important. The grassroots work is
really where things happen. The top-down is some of it’s cheerleading, a lot of it’s providing expertise, but the real work happens
at the local level. And so we’ve done that through
our dissemination of CIT. I think the way it’s happened
in Ohio with local champions at local counties spreading the word. And we’ve assisted in
developing a peer review process so that these programs continue to evolve and continue to gain in their quality in adherence to the core elements of CIT, and by convening people involved in coordinating these
programs on a regular basis so we can all learn from each other. We’ve been very involved in
the Stepping Up initiative at the county level. Our Center director has
been traveling the state with retired Justice Stratton, Thom Craig from Peg’s
Foundation, visiting counties, encouraging them to convene
the right group of stakeholders across the systems. Including county commissioners
or county executives so that the counties will
issue the resolution, step up to try to reduce
the number of people with mental illness in their jails, and then refer to our center to do sequential intercept mapping as we were trained to do
by the GAINS Center folks. So we then help the counties
assess their readiness to do this, ’cause they
need to be prepared, they need to be ready, and then
plan in a comprehensive way for a mapping workshop. And then after the mapping
workshop is complete we provide ongoing technical assistance to maintain the momentum that they have coming out of those workshops and to provide ongoing
expertise going forward. Can I have the next slide please. Another benefit of doing
sequential intercept mapping in a broad number of counties is you identify in a very concrete way, and it’s graphically displayed here, what common gaps are across a state. So in our state, and I think we knew this, I don’t think it’s a surprise, and I suspect this is true
in may states, but we found in the first 23 counties
where we did mapping that 20 of them prioritized as a gap that needed to be addressed, some aspect of the crisis
response continuum. 18 of the 23 counties
identified as a priority gap challenges in data collection
and information sharing. Housing, you can follow forward. If I could have the next slide. Identifying those gaps at the
state level then allows us to work with our state partners to begin to address those
gaps on a wider system level because some of these
cannot be solved locally. So we’ve been trying to
address with our state partners the crisis response continuum. In March we held a statewide conference to look at best practices
in our state and nationally. We brought Dr. Hogan back to Ohio to talk about the Crisis Now initiative. We brought Dr. Balfour in, who
you’re gonna hear from next, to talk about the model program that she’s been part of
developing in Tucson, Arizona. In terms of the data collection challenge, we have engaged an attorney to develop a manual intercept
point by intercept point on what the legality is and the possibility of
sharing information, and there’s more possibility
than most people think at each of the intercept points. We started with law
enforcement-mental health, then we’ll be working our
way through the intercepts. We’re working statewide on figuring out how to better use CIT encounter data, to use data to inform both CIT programs at the officer level, but
perhaps even more importantly at the level of the individual who’s encountering the police, particularly those encountering
the police repeatedly. And then consistent with
what we heard earlier, we’ve identified that the
mental health community really doesn’t have the tools yet to address criminogenic risks and needs, and we convened recently a
group of national experts to help think together, A, is this an unmet need for which there’s not yet a good answer. And then if the answer to
that was yes, which is was, then what can we do to develop
an approach that can be used in the mental health community
to address these needs. Next slide, please. So I know I’m going real fast
but I want to conclude with some lessons learned. A state level technical
assistance training and dissemination center,
a mini GAINS Center, I believe can make a
difference in a state. I think we have done that. We’ve been able to use
the block grant dollars available to the state to have
an ongoing base of support. And you need that ongoing base of support to then be able to leverage
to get additional funding. And we’ve been able to
braid additional funding from state and federal sources, and private foundation sources to expand the reach of our work. And I believe there are
advantages to states to work with the university
rather than to try to have centers at the state level. Although universities
have a lot of bureaucracy, my observation suggests
it’s a little bit less than in state government. You’ll also have the opportunity
to stimulate research. We have researchers who
are not part of our center but are with us and help us
then take the work we’re doing and begin to develop research studies to address some unanswered questions. We might be able to
address some policy issues that are harder for state
employees to address. And you can find areas of
synergy, where for example, another part of our
department is spreading coordinated specialty care programs for first episode psychosis. And we realize in those programs
we’re not finding people being referred by CIT officers,
by jails, or by courts, so we’re working to help all of those criminal justice intercept
points understand that there are there specialized programs, and unfortunately those
are sites and individuals who may encounter someone
having their very first episode of psychosis, and we want to
get them the best help we can. Next slide please. I’ve given you a lot of words, and I thought some
pictures would be helpful to really finish up. The map of Ohio, which Ohioans
are very familiar with, with our 88 counties, we’re
very proud in the upper left of how widely we’ve
spread CIT, and I think, and now CIT coordinators
getting up to speed in how to do that job. The photographs really just
emphasize the importance of bringing people together. To the left is a group
doing action planning after a sequential
intercept mapping exercise, and you can see people in uniform with people who are probably mental health professionals or advocates. And the picture to the right
is one of our statewide CIT coordinators meetings where we come and learn from one another. And my final slide, please. The work that we’re doing
is very much a team effort and we have our small team,
and I need to particularly shout out to Ruth Simera
the CCoE center director who’s doing a fabulous job
and Lieutenant Mike Woody, who’s been with us from the start. Founding president of CIT International. And then a special
thanks also to Mike Hogan and Hank Steadman for having this concept of a mini GAINS Center that
we’ve been able I think to carry out reasonably well. And I think my final slide
has my contact information as well as the website of the CJ CCoE, which we would encourage you to visit. It has a lot of information,
a lot of resources. And with that I thank you and I’m done. – [Dr. Balfour] Oh. Am I good to go? – [Melissa] All right,
now we’re gonna turn to Dr. Margie Balfour for her presentation. – [Dr. Balfour] Hi, good morning. Thank you so much for having me. I’m gonna be talking about examples of how we’ve actually
done some of the things to support the sequential intercept model down in Tucson, Arizona. Next slide please. And we have things across
all the intercepts, but what I’m gonna talk
about is the program that I’m involved in that is mostly living around intercepts zero and one. Next slide please. And to start off with,
I want to talk about our behavioral health system structure, because really Medicaid has
played an important role in the ability for us to be
successful in this state. A lot of our people
are funded via Medicaid so they’re a very important partner. Arizona is divided into three
regions, the north, the south, and then the central, which is Phoenix. We’re down in Tucson where
the little wildcat is. Our Medicaid department is named AHCCCS and it for each region contracts with a regional behavioral
health authority, which is then responsible
for all of the payments and oversight of the crisis system as well as a large part of
the behavioral health system. They put it out for bid every year. Ours is Cenpatico, which
is part of Centene, although they recently, the
local group changed their name to Arizona Complete Health. They take money from Medicaid, they braid it along with SAMHSA funds, state crisis funds, county funds, and the result of that is that we have a financing and governance structure that supports accountability and oversight of the crisis system. Next slide. And what that means is that there can be centralized planning around what should the crisis system do, what should its goals be, and then holding all the
different partners accountable. And we’re a red state out in Arizona, and they are very fiscally responsible, but we are a Medicaid expansion state because that did make financial sense. And what this, this is
a really good example of where the clinical
goals and the fiscal goals are actually pretty closely aligned, which also is something that allows kind of disparate groups to work together. ‘Cause me as a clinician,
my goal is I want my people not in the jail, not in
the ER or the hospital, and instead being in the
community engaged in care, and those are also things
that from a payer standpoint are fiscally responsible. And so like the little conductor there we have the regional
behavioral health authority overseeing all the pieces, ’cause they contract with
all their various providers, but to make sure that
they’re working together. Next slide please. And this is kind of an example
of how these strategic goals can filter down from the state. So at the state level there was a goal set through the governor’s
office around decreasing think that’s probably
why we’re the only state where every single county
has signed on to Stepping Up. And granted, we only have
15 counties, so it’s better, easier than 88, but it’s
been a statewide effort. And so then the Medicaid
department, AHCCCS, contracts with all of its
managed care organizations and the regional behavioral
health authorities, and in those contracts
there are deliverables around reducing criminal
justice involvement. So then the RBHAs, the regional behavioral
health authorities, which are financially at risk, they then are contracting with
their subcontracted providers and in those contracts there’s requirements around doing things to reduce justice involvement. So that results in some
targeted processes. So for example, in southern
Arizona we have a crisis line and some of those 911 calls
are transferred over to them. The crisis line has a dedicated
law enforcement number, so when they need to access
the crisis line for information and things like that, they
get a supervisor right away. We have crisis mobile teams and they are contractually
required to respond faster if law enforcement calls them
than versus a routine call. And there’s also co-responders as well. And then that also leads to, and the RBHA contracts with the providers, they contract for some specific programs that are designed, like
evidence-based programs that have been discussed previously around the justice population. And another thing that
they are required to do is what they call reach in. So if people are in jail
and it’s their plan member, they have to go in and find that person and work with them on
a plan, discharge plan, before their release date. And so all of this is designed to reduce justice involvement. Next slide. So in Tucson, our approach, in our programs, where
I’m mostly involved, is to really have close collaboration with our mental health
systems and law enforcement. We have shared goals. We want care in the least
restrictive setting. A no wrong door policy. And really treating, this
idea that law enforcement is a preferred customer of ours. Because if we want to
keep people out of jail, law enforcement has the patients, so they’re as much as a
customer as the patients are. And then really using data
to drive our system design. And so as a result we’ve
been working together to align our training,
operational processes, and performance incentives
to facilitate these goals. Next slide. And so this is a schematic
that’s actually from SAMHSA around all the different
components of a crisis system. And we have a lot of
these, and I’m gonna be mostly talking about the
stuff in the red area, the response, and then
later I’ll talk about some of the early
intervention, prevention. Next slide. So, sort of one of the main centerpieces of our crisis system in Tucson is the Crisis Response Center. And this facility was built in 2011 with county bond funds. And it was really driven
by the county’s desire to reduce the seriously mental
ill population in the jail. So it was designed to be
an alternative to jail, but also EDs and hospitals, but really driven by the justice system. We serve about 12,000 adults
and 2,400 kids per year. And the services, even though
the county owns the building, the services are financed through that regional behavioral
health authority system. And it’s sort of one of its main missions is to be the law enforcement
receiving center, with really a no wrong door approach. So we don’t ever turn
law enforcement away, you can’t be too drunk or
too acute or too agitated. We have a 24/7 for both adults and kids, there’s a 24/7 urgent care. Anybody can walk in, say I’m new to town, I need to be connected to services or I missed my appointment
or I’m just not feeling well and we can see them and get
them out in a couple hours as like just an urgent care walk-in. The heart of the operation
is really our 23 hour observation unit, which
I’ll talk about in a minute. And then we have a short
term inpatient sub-acute unit for the adults as well. We’re staffed 24/7 with providers, these are psychiatrists,
nurse practitioners, or PAs. Nurses, techs, we have a lot of peers, social services staff. And it really was also meant
as a place for the community to come together so there’s
space in the building where over the life of
the building there’s been different organizations that
have co-located staff there. Right now there’s a different organization that runs a peer run post crisis kind of follow up wrap around program, and they have an office
right there in the building so we can easily refer to them. And then the whole campus is really designed to facilitate all, for this to work. It’s adjacent to a
level two trauma center, so there’s a breezeway
connecting us to the ED so they can send people to us,
we can send people to them. It helps us sort of be able
to do that no wrong door where if someone has a medical issue we can transfer them over really quickly. The crisis call center is in the building, they’re kind of like air traffic control for the whole system. There is an inpatient psych hospital where most civil commitments go, and then the health court is right there, so that it all can work together. Next slide. And people talk about CIT a lot and it’s more than just the training. If you actually go and dig
up the original CIT papers, or the white paper, it talks about how having a mental
health receiving facility is critical to the success
of pre-arrest diversion and there has been later
research that backs that up. And these are the original requirements for the receiving facilities, and I highlighted number three and four because when we do
consulting around the country and we see all these places, and it’s really number three and four that are the hardest to do well. The not having clinical barriers to care, and not keep, you know,
getting the officers in and out really quickly. Next slide. We kind of have this
reputation in mental health where it’s easier to get into heaven than a psychiatric facility. So what this means is we don’t do that. Some places will be like
well, the person can’t be too drunk, they can’t come
in if they’re intoxicated. Or they can’t be too agitated,
they can’t be too violent. We want those people, we
think we can treat them better than the emergency rooms can. Definitely better than the jail can. And so we never turn officers
away even if they bring us someone that was quote
taken to the wrong place. Maybe they should have
gone to the detox place across town, or maybe they
do have a medical issue, it doesn’t make any sense
to tell that officer put the person back in
the back of your car and then take them home. Or take them somewhere else because then they’ll never come back. So we take everybody, and
we say to the officers, thank you sir, may I have another. And then we, we do what’s right for that patient, we don’t put all that decision
making on the officer. Next slide. And then another key feature is cops are busy and they
have crimes to fight, and if we’re training them in all of this recognizing behavioral health issues and bringing them to
treatment instead of to jail, then we need to make that easy for them because they’re as well
intentioned as they could be, they also have a lot of competing stresses where they’ve got all these
calls to get back on the street. So we want to get them in
and out as quick as possible. So our goal, it takes like
a half hour or so, or more, to book somebody into jail,
so our goal is to beat that and we set as a target 10
minutes turnaround time for cops to get in and out when they’re dropping people off to us. The law enforcement was involved in the design of the building, they really felt like
if they were gonna be bringing people to treatment
rather than to jail, they didn’t want to, they
wanted it to be secure and not like they’re dropping them off to some sketchy clinic somewhere. So they really wanted a secure entrance. And so this gated sally port was built. So the officers buzz a button, it rings a phone that
we all have like PTSD from the ringtone, so it
triggers our admissions team to come in and meet them. They have an intake area. We’ve got their own, an office for them and a restroom for them where
they have everything they need right back there so they
don’t have to be walking all over the facility
and then staff ask them to take their guns off ’cause
like they don’t like that. So it’s really designed
to just have them be able to go in and out. Next slide. And it’s working. This is a graph that shows
the law enforcement drop offs that we have every month. And then the orange dots are
the turnaround time in minutes, the median turnaround time. And so we hit our 10 minute
goal pretty much every month. And the bars are divided into
voluntary and involuntary, and I want to talk
about this for just a… Usually when law enforcement
is dropping people off they’re under some sort
of involuntary hold, so some sort of civil
commitment, involuntary hold. But in Tucson it’s the opposite. 60% of the people they’re
dropping off to us are actually voluntary and they see it’s a real testament to them because they are going out
and they’re interacting with people and engaging
with them and saying hey, would you like to come to a place where you can get treatment? So 60% they drop off because they’re giving
them a ride basically. And one of our docs
calls it the Uber police, but I think it’s a great thing. Next slide. And we do have a lot
of different services, and it’s taken 20 years to build this, but I want to spend just a
few minutes if I have time, to talk about what the law
enforcement teams are doing, these mental health support
teams at the bottom left. Next slide. So I talked about the crisis continuum, and CIT is great around
responding to a crisis, but what about preventing the
crisis in the first place. Next slide. So Tucson actually has
a very old CIT program and despite that we had the Gabby Giffords shooting in Tucson. And so the law enforcement
community looked and said well really is there,
let’s take a fresh look and is there a way that we can
prevent some of these things from happening by
getting people connected. Next slide. So they developed these
mental health support teams that have a group of officers
who are really focused on people who are already in
the civil commitment system and making sure they stay connected and that if they need to
be brought in for treatment that they are done so in
a safe and humane way. And then the really innovative
part is the detectives who are looking for people who might be falling through the cracks and getting them connected ahead of time. Next slide. So these are the mental health
team, the MHST team officers. They wear plain clothes,
and they have unmarked cars, which I think it looks like a cop car. But they’re unmarked
and so that really helps diffuse the situation and not get people so agitated when they see local law
enforcement rolling up ’cause they look like social workers. Next slide. And then the detectives,
what they’re doing is things that like, if you call the police and you were robbed, you
get a robbery detective. Or if there’s a murder,
there’s a homicide detective, but there’s not any
weird stuff detectives, like my neighbor’s not doing well, or like there’s some guy acting funny who walks up and down the street. So they investigate those and then they look to see if
there’s a mental health issue. Does that person need to be connected to the mental health system, or
are they already connected. Maybe their case manager isn’t
aware of some of the stuff that’s going on. And then if there’s some sort
of threat to public safety then they work with the court system, but in all of the years
they’ve been doing this, I don’t think they’ve ever
sent somebody to jail. They’re able to divert them from further going down
the justice system. Next slide. And this is the training
model, we’ll just skip that. I think I’m at my time, so if you just go all the way to the last
slide with my contact info. Oh wait wait wait, do that one. Go back, go back. And just some outcomes is
that as a result of this, so these nuisance calls, like these are the things
that land our people in jail. Civil disturbances, drinking
in public, vagrancy, things like that. And as this model’s been put in place those have been decreasing every year. And then really a culture change on how the organization responds, or how people respond to crisis. So if someone, there’s like a call that someone is suicidal and they need to be picked
up and brought into treatment because there’s whatever
involuntary document out there that says they need to be brought in, the person says go away, in most cities, that’s a suicidal barricaded person which necessitates a SWAT
team call, which like my, the sergeant over on the MHST says, if they’re not gonna come out
for my two plainclothes guys, they’re not coming out
for 30 guys in a tank. So it doesn’t make any sense to do that and so they’ve stopped
using the SWAT team, and really taken the time to have the MHST team work with them, sometimes they call us and
then we can help negotiate, and those have gone down, and that’s a big huge cost savings. So if you’d now go to the last
slide with my contact info. And that is me, and we
are a BJA learning site. So if people want to come visit, you can follow that link or e-mail me, and be happy to talk
about more of what we do. Thank you. – [Melissa] Thank you Dr. Balfour. And now we’re gonna turn
over to Jessica Ethington for her presentation. – [Jessica] Good morning everyone. As she said, my name is Jessica Ethington, I’m one of the SMI supervisors
with Maricopa County Adult Probation Department
in the Phoenix area. If we could go to my first slide please. So what I want to talk
about is the collaboration that we have with a variety
of the stakeholders, some of those in the mental health court. And I want to talk about some
cross-training that we’ve done with the regional
behavioral health authority. And also how we’ve been
working on bridging the information sharing gap between law enforcement
and clinical teams. But first let’s start with probation and our specialized mental health court. So in this court, it’s
a post-disposition court for a couple of different
types of court proceedings. We have review hearings, which
is where we try to intervene with somebody’s probation grant when maybe they’re going
down a different path than we would like them to. We also have our probation
violation hearings for the SMI probationers in that court so we can
have the full team present to create a proper plan
for these individuals. So the team that we have in this court, it’s a very strong collaborative
relationship between the attorneys, both defense
attorneys and prosecution. We have judicial officers
who are trained in the SMI population and
the mental health system. We have the clinical teams present, the probation officers,
community providers, and we also work with the jail staff, specifically some of the internal programs inside the jail for any kind of pre-treatment
that we may need to do. And we also have something called correctional health services
where they will assist in making sure that the SMI probationers are getting the care they need
while they’re incarcerated. So this court is a combination
of a problem solving and a therapeutic court. And what we try to do here is
take a more proactive approach to discharge planning
and crisis intervention that does not require hospitalization so that we can try to minimize
any kind of incarceration that these individuals
may be subjected to. When I say proactive
approach, what we typically do is focus on what are the
needs of these individuals, what is it that led
them to be incarcerated for whatever reason, and what is it that we can
do differently with them, with their buy-in, so that
we can try to minimize this type of situation in the future. So in order to do so we have
a collaborative approach that’s going to include the
use of the RNR principle, the risk-needs-responsivity. So what we do there is
probation will assess the risk that they pose to the community
through our risk assessment. Here in Maricopa County we have an OST, which is a pre-sentence risk assessment, and then we have the FROST,
which is the reassessment once they’re in the community
being supervised by a PO. Then we need to identify the needs, and this is something that
we do with a clinical team. So we can find out what
their clinical needs are, and what their normal everyday needs are. Once we have those two
pieces of information, we’re gonna figure out how to best respond in order to meet the
risk that they may pose to the community or to the
victim of their offense, and we want to make sure
that we’re also responding to the needs, so that we
can increase their stability and we can hopefully
enhance the likelihood of their success in the future. Next slide please. So here in Maricopa
County we have a total of 22 probation officers
who are specially trained to only work with SMI probationers. They are required to
complete a specific amount of training hours annually that
are specifically related to mental health issues such
as different medications, different community
programs, different agencies, and how to work best
with the clinical teams in order to incorporate
the harm reduction approach and the risk reduction approach so that we can have a very comprehensive supervision level for these individuals. One thing that we have done is the regional behavioral
health authority has allowed us to have access to their training system. So the probation officers can
get the exact same information that the case managers and the
clinical teams are getting. So we can share that perspective with them and have a better
understanding of what it is they’re doing for the people
we’re also working with, and then we can marry
our approach with theirs. Another thing that we
do is we have consistent and regular communication
with agency leadership regarding changes in any kind
of procedures or practices that we may need to implement. For example, we have a
community provider here called Community Bridges. They have three FACT teams,
and a couple of ACT teams. So every quarter, myself and
the other SMI supervisor, along with our division
director from our department, meet with their leadership
and the clinical coordinators for each of those teams. We review what has and hasn’t worked, what we may be able to improve on, and then we try to make some changes both from the clinical side
and from probation side so that we can try to
meet everybody’s needs and make sure that we’re addressing anything that the
probationers are experiencing so that we can help them
achieve that success that they need. Next slide, please. So one thing that Maricopa
County Adult Probation is doing with this cross-training is
we create monthly trainings that we conduct, or that we
share with the clinical teams. These trainings explain what probation is. Explain probation’s purpose and the goals. We talk about how we’re
trying to assist them in implementing positive behavior change so that they don’t come back to us. We focus on the fact
that the clinical teams are going to be there long term and probation is here short term so that we can do everything
we can to assist them in establishing a lifestyle that’s absent of the
criminal justice system. We’ve shared our risk
assessments, how we conduct them, why we conduct them, and
when we conduct them. And how we’re trying to
incorporate a risk reduction model into our supervision. When we’re doing a risk reduction model what we’re trying to do is assess the risk of each of the criminogenic needs, or the criminogenic factors, I’m sorry. When we identify what their
highest risk-needs are then we want to try and figure
out what is the behavior that is driving them to have
this consistent involvement in the criminal justice system. Once we identify that we’ll create a plan that’s going to marry well with
the harm reduction approach that the clinical teams are taking. We’ve also discussed
the mental health court and the individual
roles inside that court. We talk about what the
judge’s responsibilities are, the attorneys, probation
officer, the community providers, as well as the clinical team’s roles. There’s a clear delineation of roles but also an understanding that sometimes we have to blend those lines
in order to make things work. So another thing that we’ve
done is we’ve made sure that clinical teams understand
what our case plans are, which is basically a
probation version of an ISP. And we’ve also made sure
that the officers understand what an ISP is and how it’s
created and how often and why. We’ve also created a way
for the probation officers and the case managers to
share these with each other without violating HIPAA
so that we can make sure that these plans marry,
that they mirror each other so that we’re not
overwhelming the individual with a variety of goals and
a variety of responsibilities and we’re trying to reach
the same ultimate goal for their success and their stability. Next slide please. So one thing that we’re really focusing on with the clinical teams and the the RBHA is bridging that information sharing gap, which can be a daunting task. We have to make sure that we’re protecting their right to privacy,
we want to make sure that we’re not violating HIPAA, we want to make sure that we’re
not oversharing information that not everybody may be privy to. One thing that we do have from our court is an administrative order that allows for information sharing between
probation and community partners that does not necessarily require an ROI but it’s only for public safety issues. Such as if we have a
probationer who may be having contact with a victim and maybe it was a pretty severe offense that they’re on probation for. If we don’t have an ROI, maybe
they’ve switched clinics, or something like that,
if we don’t have that ROI we can tell them, the court
has said it’s okay for you to give us some basic
information so that we can try and protect the victim
and protect the community. This has allowed us to really
work with the clinical teams so that we can try to reduce
the number of warrants that we issue for the probation violation. That way we can kind of
tackle those issues ourselves rather than involving
the courts and the jails. So that we can try and
get them back on track without having to put them
into, take them into custody. We’ve also created some
secured inboxes in Outlook, in our e-mail system to
streamline the sharing of the protected health information. So we have court every Wednesday, and one thing that the
case managers have to do is prepare a progress report for court. That progress report is going to have some protected information such as medication and diagnoses and programs. So instead of them having to send that through multiple channels
in order to maintain the confidentiality of the information, we were able to create
these protected inboxes so that they can send it
straight to our Outlook, our e-mails and probation
officers can pull the information straight from there
instead of having to wait ’til the eleventh hour sometimes for them to work through their
own process through the RBHA and we can pull that information and have everything ready a
little bit earlier for court. We’re working on trying to do
that from probation’s reports to the clinical teams as well
instead of having to fax them we can try and share them electronically. The e-mails that we had
were only able to send encrypted e-mails within the county, so we’re trying to find
a way to reciprocate that with the clinical teams. We want to make sure that the case plans that the probation officers
are creating are very similar to the ISPs that the
clinical teams are creating. So in order to do that we found a way to redact the information
that we can’t share outside with other agencies that
are not law enforcement, and we share that information
as often as we possibly can with the clinical teams. This would include their terms
and conditions of probation, the pre-sentence reports and
the probation violation reports and the case plans, and we
can also share the results of their risk assessments. So we just have to take some
basic information off of there and we provide all of
that as often as possible to the clinical teams
so that we can make sure that they’re aware of what’s going on with this person’s probation grant and that way we’re not running into issues with victim safety or community safety that the clinical team may
not have been aware of before that could impact the
compliance with probation. So the result of our efforts with bridging this information gap has led
to probation being considered as part of the clinical team. In doing so, we’ve been able to establish an expectation that probation be part of the regular staffings at the clinics or in the hospitals
for discharge planning. That they are in attendance
or at least brought into the creation of any kind of discharge plan that’s outside of court. They’re consulted on housing
placements and applications that are submitted by the
clinical teams for treatment plan, or residential, or anything like that. And we’re able to put, and to incorporate the court’s expectations
for these individuals into the clinical expectations so that we can make sure to streamline the supervision from both
sides and to make it more of a comprehensive and
collaborative approach. Thus leading to lower recidivism rates and more success for these individuals. Thank you. – [Melissa] And now we welcome
Maria Fryer to the podium to share about federal
resources that are available. – [Maria] Hello, and thank
you for being here today. I apologize for the sound of my voice. It’s a little bit, it’s
the time of year I think, and I’ve been told by close colleagues it doesn’t sound that bad, so with a few slides I’m
just going to continue. Thank you very much to
SAMHSA, Jennie in particular, Larke, and David for having us. So to start at the beginning, these are just some of
the products and services that BJA bring to actually operationalize the policy discussion and
bring it to a local level. And one of the biggest programs,
and what I’m most proud of, to start at the beginning,
is with the JMHCP, the Justice and Mental
Health Collaboration Program. A little history about the
JMHCP and how it came to be. It was authorized through
the Mentally Ill Offender Treatment and Crime Reduction
Act, known as MIOTCRA, and it authorizes 50 million for criminal justice and mental health. It was reauthorized in 2008 and we had continued changes to the legislation in 2016. You may have heard of the
21st Century Cures Act, which amended and
reauthorized the JMHCP program first created by MIOTCRA. And typically each year the
funding that’s allocated is between 10 and 12
million for programming and training and technical assistance. In fiscal year ’18 that
dramatically increased from typically the 10 to
12 million to 30 million, which substantially increased our ability to support states, tribes
and local governments and how they respond to
people with mental illness and co-occurring mental illnesses and substance use disorders. And through JMHCP our focus
has increasingly shifted toward more system-wide improvements to create bigger impact on the problem identifying people early
on from first contact, of course with law enforcement,
collecting more data, understanding the gaps
and the drivers of people with mental illness in the system, and learning how to facilitate broader, more comprehensive approaches that include additional stakeholders in
government, health, and safety. Next slide please. So the purpose of the
Justice and Mental Health Collaboration Program of
course is to help states, local governments, and
tribal organizations improve responses to
people with mental illness who are involved in the
criminal justice system. Since its inception,
JMHCP has been promoting the development and implementation
of statewide change. In many ways it has been
the fire starter for change between multiple community stakeholders. Its broad application has
provided states, tribes and communities the mechanisms to open up those communication lines between
justice, juvenile justice, mental health, and substance
use treatment systems to meet local needs and grow the strengths that may already exist in
a coordinated response. JMHCP requires that grantees partner between justice and
mental health authorities to improve outcomes by increasing access to appropriate community-based
service delivery systems of care, and coordinating
public safety outcomes. Next slide, please. There are three categories of
the Justice and Mental Health Collaboration Program, two of which focus on presenting
people with mental illness or co-occurring mental
illness and substance use from moving deeper into the
criminal justice systems, and those are categories one and two. Category three is the broadest category in terms of what it can fund
for project development. It can enhance or expand a
front-end collaborative response, it can help expand a well
established needed services for people that are in the system to help improve those recidivism rates and improve upon connections to care when a person is preparing to re-enter. Having these three broad
categories requires our training and technical assistance providers to possess a wide variety of expertise. From law enforcement all
the way through to re-entry. Each grantee is assigned a training and technical assistance
provider to assist in the implementation and
sustainment of the project after the federal funds have ended. Next slide please. This is one of our proudest achievements, which was mentioned earlier by Tucson and described by the Tucson Center, and it’s the Law Enforcement-Mental
Health Learning Sites. The BJA supported Law
Enforcement-Mental Health Learning Site Initiative
delivers peer-to-peer learning through a cooperative agreement with the Council of State
Governments Justice Center. The current 10 agency sites above represent a diverse
cross-section model strategy, and examples of police-mental
health collaboration. These 10 learning sites as host agencies offer their experience and
expertise to promote strategies through a police-mental
health collaboration. Such as, crisis intervention teams, co-response teams, mobile crisis teams, case management approach,
and a tailored approach that can save the life of an officer, a person with mental
illness, or a family member. Together, these sites provide resources for states and local
law enforcement agencies to more effectively respond to people who have mental illness. Agencies that receive technical assistance through the learning sites
to enhance their strategy can reduce repeat encounters
with law enforcement and make encounters with officers safer. Each learning site will answer
questions from the field, they host visits, they work with the CSG Justice Center staff to develop materials for practitioners and community partners. So please contact the
Council of State Governments Justice Center if you would
like more information. You can also go to the
Police-Mental Health Collaboration Toolkit
where the information on these learning sites is also listed at www.bja.gov/pmhc. Next slide. The online and mobile
resources for law enforcement, one of our biggest achievements in 2016 was the Police-Mental Health
Collaboration Toolkit. Prior to the launch of this toolkit, in actually 2014 and going a ways back, we convened a group of law
enforcement practitioners, researchers from the field,
academics, and advocates and really wanted to hear
what is a need of the field. And overwhelmingly we heard loud and clear that they needed information. They needed information
on how to collaborate, what are the resources, what
are considered best practices. And they needed it in one place. This inspired the one stop shop of the Police-Mental Health
Collaboration Toolkit. So what is the toolkit
and how can it be used? The toolkit is an online
and mobile resource designed to give law
enforcement specific answers to design a strategy and
partner with behavioral health that meets their agency’s needs. It guides law enforcement
through the process of starting a new police-mental
health collaboration or enhancing an existing collaboration. It’s designed to be
operational, and interactive. Each module is arranged
by content like overviews and narratives, videos,
FAQs, and loads of resources. It’s self-contained, and
everything is contained within the toolkit. The toolkit addresses key topic areas, including PMHC program
planning, implementation, management, training, and
performance measurement. The material is drawn from the experiences of law enforcement practitioners,
including the 10 agencies that serve as the law
enforcement mental health learning sites we just mentioned earlier. It is currently in new development with modules such as
behavioral health perspective. We knew this was an important piece if we’re going to talk
about a collaboration of course we stared with law enforcement, but we know the other half of that is the behavioral health community. Of course people with lived experience, a very important piece. And the law enforcement executive needs and how do they implement,
how do they maintain, how do they collect data, and how do they continue to
tell the story of what works. These are all coming in the next year and I’m so happy to be here today and share with you those resources. We’re going to have more
resources this afternoon by someone who sounds a lot better, so thank you very much for having me. (audience applauding) – [Melissa] Thank you Maria. And that concludes our panel. We are now taking a break for lunch. And we will start back
promptly at 12:30 Eastern time for our second panel on Crisis
Response and Early Diversion. Thank you. (audience applauding) – [Brian] All right,
good afternoon everybody, this is Brian Case, I’m
with SAMHSA’s GAINS Center. This panel number two that we
have for the symposium today is gonna look at crisis response and early diversion programs. Which are really a laboratory. A lot of communities are
focusing on developing different models for approaching adults with serious mental illness in crisis and also youth with serious
emotional disturbances in both community and school settings. Our speakers today are gonna,
first we’ll have Ron Bruno, who’s a founding board member of CIT Utah, or I’m sorry CIT International. – [Ron] Actually both. – [Brian] All right. And the current Senior Vice
President of CIT International and founding Board Director and Executive Director of CIT Utah. Director of CTS services, and also a member of the Interdepartmental Serious Mental Illness
Coordinating Committee. Our second presenters
are from Diversion First in Fairfax County, Virginia. We’ll have Lieutenant Redic Morris of the Fairfax County Sheriff’s Office. He’s the co-CIT Coordinator and Supervisor at the Merrifield Crisis Response Center. Presenting with him will be Lisa Potter, who’s the Diversion First lead at the Office of Strategic
Management in Fairfax County. Our third presenter today will be, our third presentation
will be from Jacqui Greene, who’s an Assistant Professor
of Public Law and Government in the School of Government at the University of North
Carolina at Chapel Hill. She’s also a senior advisor
to the National Center for Youth, Opportunity, and Justice. And finally today to talk
about federal resources will be Ruby Qazilbash, who’s
the Associate Deputy Director for Justice Systems Policy with the Bureau of Justice Assistance at the United States
Department of Justice, excuse me, where she oversees
BJA’s criminal justice reform work including the
Justice Reinvestment Initiative. So let’s get started today
with our first presentation by Ron Bruno on crisis response systems. – [Ron] Well thank you
Brian, and good morning, or good afternoon depending on
where you are in the country. I’m gonna be talking about
crisis response, crisis response. And just so you know I do have
a law enforcement background, I am still a law enforcement officer. So I’m gonna share some perspectives as a law enforcement
officer, a CIT officer, as an administrator of
a statewide CIT program, and as an advocate for
crisis intervention teams internationally. But you know, when I talk to communities and try to talk to them
about crisis response, what kind of system, there’s always this
overarching, looming question that is hanging out there and
I would like to actually begin by addressing that
question with you today. Crisis response. Should the criminal justice system or the mental health care system have primary responsibility? Sounds like a simple question. Sounds like it should
have a simple answer. But it really doesn’t, it really doesn’t. Because of course
historically it has defaulted to the criminal justice system. And I can tell you one thing,
the criminal justice system really does find ways to
try to address things. Not always the correct way, not always the most effective way, but they always find a
way to correct things, or to work on things. And a lot of times it’s
throwing training at it. Well if there’s a problem, hey, we’ll just train our way out of it. But unfortunately crisis
systems are something that we just can’t train our way out of. We’ve got to look at who has
the major responsibility, whether it is law enforcement services or if it’s criminal justice services, or mental health care services. And that’s what I kind of
want to talk about today. Which direction we should head into. I’m gonna be kind of
pointing out some of the ISMICC recommendations and then
I’m going to walk us through a crisis response system that’s integrated and can be effective, and
talk about the different types of components and how they’re integrated. But as we look at the recommendations that were in the ISMICC report that were provided to Congress last year, especially the ones that were from the criminal justice workgroup, if we look at 4.1 support
interventions to correspond to all stages of justice involvement. Consider all points including the sequential intercept model. We’ve already heard about the
sequential intercept model and we heard about intercept zero. That actually was, for those
of you that were not clear, that actually was an intercept
that was added later on. The original model began with one, law enforcement involvement. But then they thought, hmm, but isn’t there something before that? And that’s where zero came along. And if you look and
read the recommendation in the ISMICC report,
it actually clarifies. It says, pay particular
attention to the zero intercept. Community services. Because that’s where we
really should be addressing crisis response is at
the community services. If we look at the next recommendation 4.2, it says develop an integrated
crisis response system to divert people with
serious mental illness and serious emotional disturbances
from the justice system. And it goes on in detail to say, community-based mental health
services must be in place to address the crisis needs of
the people with SMI and SED, again going back to intercept zero. We need to make sure
we have those accesses. And it goes on to define that a person with serious mental illness or a serious emotional disturbance who, a disturbance, who is in crisis, should be able to get
adequate mental health care in the community without
contact with law enforcement, without contact with law enforcement. I mean, if you think about it, and as a couple of my colleagues have said and have confirmed, one of my colleagues Dr.
Amy Watson says, you know, the problem is is that families and people that have a lived experience
will wait ’til it’s very dire before they will reach out to 911 to have somebody with a
gun toting on their side come out and deal with their
loved one or that person. And I asked my other colleague
Pete about that today, says how do you feel about that, and he agreed that you know, if there’s access within
calling law enforcement, yes, people would access that
quicker instead of waiting until the crisis is that much more severe. So we really kind of got to
look at how we can develop that. So let’s walk through a
crisis response system. As you can kind of see there’s
two kinds of fields here. If you divide this right down the center there’s two kinds of fields here. On one side it is the
criminal justice system, on the other side it is the
mental health care system. The criminal justice system has the ECC, which is dispatch, the
emergency communications center. On the other side, the
mental health care system, hopefully has a 24 hour a day,
seven day a week crisis line. And I say hopefully, because
many places in this country the crisis line does become 911. And in other parts of this country, we actually have a dedicated crisis line but at five o’clock everybody goes home, so somebody calls up, gets the crisis line thinking they’re gonna talk to a clinician and the words they hear are
911, what’s your emergency? And that’s the issue is again we’re bringing the criminal
justice system into it. We’re bringing it up front
and we want to put it as a supporting role in back. You’ll notice that
there’s that big fat arrow that is in between those two systems, the ECC and the crisis response, and the reason is is because
those two have got to be working together in collaboration. So for example, we train our dispatchers, or our call takers I should say, to ask a few series of questions to determine is there a real need for law enforcement to respond out. And if not, they can do a warm
handoff to the crisis line, and many times that crisis
can actually be resolved just over the phone with
the crisis counseling. When I go around the country and I teach law enforcement officers how
to deescalate situations, how to recognize behavioral health issues and deescalate a person
that might be in crisis, I always ask a series of questions. And one of the questions
I ask is, raise you hand if you would say that the
majority of calls for service regarding mental health issues require a law enforcement response. And guess what, nobody raises their hand. The majority of calls we’re
sending our police officers out on for crisis do not
require law enforcement, so why are we doing it? We’re making it a criminal justice system every time we sent a law
enforcement officer out to that. Let’s step down to the next level because we need to have some
resources past those two. And you’ll notice that over
on the criminal justice side from the ECC of course we
can always dispatch out and it’s a resource EMS
and law enforcement. Over on the other side, hopefully we have some
resources under there too. So for example, a warm line. A warm line is generally staffed by a certified peer specialist, somebody with lived experience
that can actually understand what somebody might be going through. Law enforcement gets a
lot of calls sometimes where a person because of
their mental health issues might believe something
and call law enforcement about that issue. And law enforcement will go
out and make the determination, well there’s really nothing I can do, the person’s not a danger
to themselves or others, this is obviously just a
mental health situation, I can’t do anything, and they leave. And then a few days later, a week later, person calls in again because of that, and all of a sudden law
enforcement goes out and it’s just this rotating door. However that warm line has actually shown that communities that have
integrated a warm line, that a call can come into the crisis line, they determine that it is not a need or it’s not a real crisis. This is a person that
needs an empathetic ear, somebody that can understand
what their going through and they can hand that off and generally build up a
relationship so the next time that person is having those
symptoms, feeling that way, or have those concerns, they
can contact the crisis line and say, I want to talk
to John at the warm line, and get handed down and completely
remove all of those calls that were going to law enforcement. But hopefully they also have an MCOT, mobile crisis outreach team. Let me just talk right now real quick, we’ve got some major law
enforcement agencies in our country that are doing co-responder models. And that’s really great for
those very very very few gigantic law enforcement agencies that could possibly even support it. But we know that the majority
of law enforcement agencies in this country cannot support mobile, or embedded dedicated co-response. Just cannot do it. In fact, if you look at the
ones that are our there, to be honest with you, I cannot name one that is a primary response that can handle the
load of their community. So they’ve got to have something else. And if the co-responding team is strictly always a cop coming with them, then that’s again always making sure that criminal justice is involved. However, if you look at
this model where we can have a dedicated mobile crisis outreach team that is separate from law enforcement, and allow them to go out
and actually deal with the situation when law
enforcement isn’t needed, and at those times when
law enforcement is needed, they can contact MCOT,
they can come out together, and guess what, we have
a co-responder model. So it kind of can serve both. And as far as that law
enforcement component, and I’ll talk about that in
just a little second here, we need to have not just every single law enforcement officer. We need to have an expert, a specialist, but a specialist from patrol. We don’t want to ask a
law enforcement agency, hey you’ve got to create
something special. What we want to ask them is,
identify some patrol officers that have that in their heart
that they want to deal with this population and
become and expert in that, and give them the training and the support and the continued
training so that they know the resources that are out there. Not only the resource of hey, this person needs help in that building, not just the resource that says hey, they need to speak to a
clinician in that building, but a resource they’re
so expert they can say, I know the resource,
you need to talk to John in this building, in fact, let me call him and set something up. And then we go to the next level, which is the ER from the ECC side. Or hopefully we have a
dedicated receiving center, triage center, whatever
you want to call it, or even in some areas are access centers, which is part of a hospital system, but it is in a separate way and it goes off the living room model. We’ve already heard from Tucson today how successful that model is. And it really does work. But you’ll notice that box in the middle. And that’s really the whole idea is that the person can remain at the scene. We’ve got to stop training our community, our communities in our country
to think that when my son, my loved one, my child, has a crisis, or when a person with lived
experience becomes symptomatic, we’ve got to stop training them to think I got to contact law enforcement
so they can come out here, put me in handcuffs, take me
to the hospital, to an ER, so they can talk to me for a few minutes because that’s the only way I can have my symptoms addressed. We need to get them started thinking, hey I need to contact the crisis line, and hopefully they can resolve it there, but if not they can send out a clinician that can provide that exact
same destabilizing care that they would get in the ER,
right into their living room. Because what happens is
then we start to train our communities to
understand you can deal with your symptoms many times
right in your house. You do not have to be
unplugged from society or from your community. And then the last focus that I
want to just quickly touch on is 4.3, prepare and train first responders on how to work with people
with serious mental illness and serious emotional disturbances. And it says, ideally crisis
amongst people with SMI and SED should be resolved without
involving law enforcement. You see that continuous theme. But when the crisis system fails, or the level of dangerousness warrants, law enforcement and other first responders should be prepared to responds
safely and effectively to people with SMI and SED. I’m with Crisis Intervention Team, and that program is realistically
not a training program. It is so misunderstood, people
think that it stands for CIT instead of Crisis Intervention Team, they think it’s Crisis
Intervention Training. That program realistically,
it stands for development. First off, development of
how do you build the system. How do you bring the partners together, what do they talk about, and how do you develop that
crisis response system. It’s development. How do you develop that expert officer. And that’s really what CIT’s about. I invite anybody that has an interest, you have my contact information, but you also have the website
is www.citinternational.org. You can go on there,
read our research papers, you can read our statements,
our position statements, and you can get the core elements of CIT. Thank you. (audience applauding) – [Brian] Thank you Ron. So our next presentation is gonna be on Fairfax County’s
Diversion First Initiative featuring Second Lieutenant Redic Morris and Diversion First Manager Lisa Potter. – [Lisa] Hi, good afternoon. So we wanted to start off our presentation just by providing you
a little bit of context about our community. Fairfax County is a large,
urban suburb of Washington, D.C. We’re about 15 miles west of the District. We have over 1.1 million residents and our county spans
about 400 square miles. We have the largest
community services board, which is the behavioral health entity, the largest jail, police department, and public safety system in the state. It’s a very diverse community, approximately 30% of our county residents were born outside the United States, and there are over a
hundred languages spoke in households throughout the county. It’s generally a very
prosperous community, but we do have very large pockets of economic, social,
and other disparities. Certainly among people with
behavioral health needs. We have had tremendous
community and political support for our diversion initiative,
but in a county of our size one of our challenges has
been taking this to scale. Next slide please. So just a quick note about our overarching Diversion First Initiative. And this is our system-wide effort to offer alternatives to incarceration for people with mental illness, co-occurring substance use disorders, and or developmental disabilities who come into contact with
the criminal justice system. And our goal is at every intercept point, and we do use the
sequential intercept model, to provide either some
type of intervention or an alternative to incarceration. We started this initiative in 2015, but really kicked in our efforts and started programming
in January 1st of 2016. Next slide please. So our initial efforts really
kicked off with gathering a group of stakeholders and
mobilizing the community. And we started with a group
of about 40 stakeholders and now we’re over 200 strong. We also have a very active
Diversion First leadership group, and that’s a group of policy
makers who come together when there are barriers and challenges that can’t be resolved
at the program level. Early on we tried to align ourselves with national efforts and best practices. We signed on to the Stepping Up Initiative as well as the White House
Data-Driven Justice Initiative. And we started planning for our Merrifield Crisis Response Center in August of 2015. We had a very aggressive timeline and our goal was to open January 1st, which was about six months later. And for those of you know
or work in local government that was lightning speed to
get things up and running. We had a lot of MOUs to get in place, processes and business practices
for exchange of custody. Staffing, physical space. But we were able to do that and opened that crisis response center. Which allows for exchange of custody among seven jurisdictions, it’s open 24/7, and Lieutenant Morris will
speak a little bit more about the activities that occur at the MCRC in just one moment. We also focused heavily on CIT and mental health first aid
training for first responders, for law enforcement
officers, police department, office of the sheriff. Also for fire and rescue, for the magistrates,
general district court. Juvenile court, we really
cast a very wide net for CIT and mental health first aid. So that was the bulk
of our efforts in 2016. Then in ’17 and ’18 we moved
into a focus on the jail, and instituted the Brief
Jail Mental Health Screening for everyone booked into the jail, focused on supervised release programs and pre-trial services,
and other court services. We also did design a co-responder model that we’ve just piloted. And to the earlier point about
that being the only response, we do also have a mobile
crisis unit that responds to other emergency calls not as part of the co-responder model. We have a veterans docket, we
just initiated a drug court, and we have a supervised
release compliance docket, we’re in the process of
submitting an application to the Virginia Supreme Court for a full mental health docket. We are also working on
on-site medical clearance for our crisis response center, continuing to work on data and evaluation, and our focus in the next
year and probably beyond will be more work in
intercepts four and five. Next slide please. So our Merrifield Crisis
Response Center, or MCRC, is located within our
behavioral health site in Merrifield, Virginia. And this site offers law
enforcement personnel an opportunity to transfer custody, and we have an array of
mental health services that are also provided to
include screening assessment, outpatient, case management, for both use in adults, psychiatric and med management services, peer supports, and integrated health care. So at this point I’d like to turn it over to Lieutenant Morris who’s
gonna talk more about the services and supports offered at MCRC. – [Lieutenant Morris] Good afternoon, if we can go to the next slide please. Thank you, Lisa. As you can see here,
Lisa just talked about the Merrifield Center, 254,000 square feet of building here, which
CSB was able to bring all their services that were once located throughout the county into
one particular facility. As she mentioned earlier
you have the diversion from potential arrest, as we
are able to take individuals who may have a low level
offense in the field for a call for service. Individuals may be experiencing
a mental health change. Officers who have gone through training, the mental health training from CIT, to mental health first aid, are able to make that
determination in the field and bring those individuals to the Merrifield Center
for an assessment. And that exchange of custody
is usually with my group here where we do that warm
hand-off of individuals from officers from the field to the officers from the police department as well the sheriff’s office
here at the Merrifield Center. At which point they can be assessed for their mental health change. But there’s not only
involuntary admissions, we have voluntary admissions as well, that come through here. We also have referrals to
the appropriate level of care and connections into the community. And we also have a very
robust peer support group. So we have peer recovery
support specialists that are here as well. Next slide, please. As I spoke earlier in
reference to training as we talked about the CIT piece, the Fairfax County law
enforcement officers, we have over 550 that
have been trained in CIT but we have a very
robust partner group here with other agencies in northern Virginia, and we’ve trained over 700 in the CIT 40 hour block of instruction. But also to help out in making sure that our law enforcement
community is trauma-informed, we have taken on the mental health first aid training as well. And that mental health first aid training for the sheriff’s office is a
100% investment for all staff. And we’re at 571 and we’re just about 85% done. And then we also have our fire
department partners as well. They have over 900 of their
staff that have been trained. And as we talked earlier in
reference to the diversion from arrest, over 5,000
people have been brought into the Merrifield Center
by our officers in the field. And this is part of that piece as we’ve seen our numbers greatly increase from the paperless emergency custody order to the paperless emergency custody order. And of those 5,000, 1,200 were diverted from potential arrest. And that’s a very big number
as it relates to almost over 80 some odd thousand
dollars to incarcerate someone in the local jail for one year who may have a mental health concern, so that’s a very big savings
to us here in Fairfax County. Next slide, please. One of the things that we’ve
learned as far as staffing, data, and as we celebrate our successes, from the staffing piece that
when we first started in 2015 we started here with four people two from the Fairfax
County Police Department and two from the Fairfax
County Sheriff’s Office, and it was a 12 and a half hour schedule. As we move forward with the support and the vision of our executive
leaders from our agencies as well as from the
local government itself, we went 24/7 over a year ago. So our staffing increased. Presently we’re sitting at
16 law enforcement officers, excluding supervision,
and we’re doing 24/7, which is greatly aided from the field. With the training that the
law enforcement community has received, with those
numbers that have increased from the ECO perspective,
it greatly helps. And one of the big things we have to do, we have to take into account, is this individual the right fit. As you know training is one thing, but an individual employing that training is something that’s very important to us as we are supporting the
Diversion First Initiative here. So finding the right people
and being able to select those individuals based
off of our recommendations has been huge and we’ve been very successful
for those 16 people that are our boots on the ground. As far as our data, as we
know data runs in everything. We have our own data in collection, any individual here who
reports back to the state, but also reports out to
our stakeholders group because they want to see what’s
the return on investment. And one of the big things we’re able to do is provide that information. And as we continue to
grow we look at other ways and other data that we can collect which will give our executive leadership here in Fairfax County the
information that they need. As we celebrate the successes, sometimes that’s a little hard because we’re in the middle
of it and making it happen, but we do have an annual report
that goes out every year. Right now they’re working
on the one from last year, from the data for last year. So that’ll be coming out soon. We celebrate our 24/7 operations here at the Merrifield Center,
which is very very big for us. And also we get out as much as we can, and quite often to be honest,
to present to the community. And that’s an ongoing endeavor for us and it’s also the piece that
helps us to market our brand that we have here at the Merrifield Center just so that we can get the
word throughout the county and throughout the region
that we have here as well. Next slide please. So the lessons learned,
staffing and resources. Well we have great success
here that we’ve experienced in Fairfax County with
the Diversion First piece and the Merrifield Center
and being able for officers to spend probably about
45 minutes to an hour so they can get back into the field. But with that and that training endeavor we’re seeing a spike in our
numbers as I mentioned earlier, as far as the ECO perspective. So officers are very well
informed, they’re trauma-informed, and they’re taking those new skills and they’re employing them in the field. And so a lot of individuals
are being diverted to the Merrifield Center. One of the things we look to
do is as we continue to grow and we look to increase
our business process is to make sure we have those clear goals and we also take the time to
review what we have in place. And we also look for champions, we look for champions everywhere. As I’m speaking to this group here we hope that we’ll get
some feedback from you all and champion the successes
that we have here and maybe even speak to a few
of you who’d like to launch a similar endeavor that
we did here in Fairfax. Some of the challenges, and I
think this is across the board as we get into information sharing. As we know, our mental
health professionals are covered under HIPAA
and we also we have those who are in the substance
abuse community with 42 CFR. And obviously when you bring a group of law enforcement folks
into a human services side it’s a little different, so there are some different cultures as to how we may conduct business, but we all are one for one common goal. So over the time we’ve been
able to meld that pretty good through our leadership on site
from the public safety side and also the leadership
that’s here from the CSB. One of the other things
is with this success, that’s the other thing
that comes back to get us as we co-locate here, with
that success we’re outgrowing what this brand new building
that came open back in 2016. But I’d rather have the success and a place to bring our individuals and then we can continue to grow from that point moving forward. Next slide please. Well that completes our presentation piece but as you can see here there is a link to the fairfaxcounty.gov as well the Diversion
First site for us here, so there’ll be additional
information as it relates to what we’re doing, where we’re going, and we invite any of
you to reach out to us if we can assist you in any way. – [Brian] Thank you Lisa
and Lieutenant Morris. Our next presentation
is from Jacqui Greene to discuss the School Responder Model. – [Jacqui] Thanks Brian. Holley you can go ahead and
advance to the next slide. So I am here today to talk with you about a younger population
than you’ve heard about so far in this panel. I’m here to talk with you
about our young people who are still school age. So that can run anywhere from our wee ones who are going to school all
the way up to our oldest ones who are in high school. And I’m gonna talk to you about
the School Responder Model. So this is an effort that
began with what we call the Models for Change, which was a huge juvenile justice reform initiative funded by the MacArthur
Foundation for many many years. And there was a Mental
Health Juvenile Justice Action Network as part of that work, which was a bunch of state
folks coming together to think through the problem that we have in the juvenile justice system, that youth with mental health needs are way over represented. So about 70% of young people who come into the juvenile justice system have some kind of mental health need. These folks came together
and started to think through what do we do about that, and one of the things they
thought should be done is that many of those young people who were not true risks to public safety ought to stay out of the
juvenile justice system. And that’s where the School
Responder Model was born. The first folks who worked
on it were in Connecticut and Summit County, Ohio, we
consider them our founders. And as you see on that
slide the work has expanded. There was a really great
public-private partnership between SAMHSA and the
MacArthur Foundation that helped us support
folks in two cohorts to kind of expand this
work where they are. And currently there are four
high schools in Michigan and four high schools in
Louisiana who have just launched school responder models as part of an NIJ Comprehensive School
Safety Initiative study, who we’ve worked with as well. Next slide. So why schools? Well first, we know from a lot of data that if kids are going to
access mental health services and the data tell us most often kids with mental health
needs don’t have access to those services, but if they do they are most likely to
access them at school. That doesn’t necessarily mean
school runs those services, they might be host to those
services of a community provider inside the school, but we
know if kids are gonna get mental health services,
the most likely place for them to get them is at school. We also know from lots of
national data that young people who are classified with disabilities for educational purposes
are disproportionately arrested in school. So they make up about 12% of
the overall student population but they represent a full quarter of kids who are arrested in the school setting. And generally if you want to find kids, look for them at school, they
spend a lot of time there. So schools are a great place the get a big bang for your buck if
you want to focus on this work. Next slide. So something that’s very different about the School Responder
Model than lots of other quote unquote initiatives
that you hear about, is that it has key components, and those key components are
operationalized differently from community to community depending on what existing
resources they have. So you saw on that first slide
all these different places across the United States
that have worked on building and implementing school responder models. That was done in all of those places with very little new resources. And while people in the first instance are sometimes frustrated by that and really want a big new grant, start a new program, the School Responder Model is different, and we think because it’s
different, more sustainable. So it is really these key components that folks operationalize
within their existing resources so that once you’ve
planned it and built it, it just becomes a new way of
doing business that will endure and there’s no particular
grant that’s gonna fall away and make the work end. So just quickly, the key
components you see on the slide, first is building a
cross-systems collaborative team. And I can’t emphasize
enough how important this is as we’ve worked with these schools in some radically
different kinds of places, they all seem to have in common
feeling like they function as little islands inside
their communities. And they are very often
trying to problem solve mental health issues for their students with just the people who
work inside that school. When they might be
sitting inside a community that has some pretty robust
mental health services for young people, that’s
not always the case, I know. But in some places it is the
case and so getting people from the school, the local
mental health service system and law enforcement to sit
around a table and think through how can we create new
pathways for our students. So just as Ron talked about
in the first presentation of this panel, so that the
response is not just remove them and find some other place for
them to get their needs met, how can we create a new pathway
because for kids we know that very often means entry into the juvenile justice system. And you see that the second key component is family and youth engagement. So family and youth also
have to be part of this cross-systems collaborative team. Really critical here
because having conversations with family members about kids who are having trouble in school, and sometimes having conversations
about mental health needs of their kids are both
very delicate things, and need to be done right,
and need to be planned with family voice at the table and involved from the beginning so that you create a process that families actually feel welcome in
and are likely to use. And then you get to the implementation of that behavioral health response, so this is really what
most people would think is the school responder model. And this is about creating a structure to have students screened for any kind of mental health need. If they flag on that
screening to then connect them in a very intentional and structured way to a clinical resource that
can do a full assessment. And based on that clinical
assessment get that young person into the community-based
services that will meet the needs that they have. And as I said, and I’m gonna
give you a couple of examples, people operationalize that differently depending on what they
have in their community. And then the last key component is creating formal structures. So we’ve working on lots of
places where they have had a fantastic school social worker, and maybe a really wonderful therapist who works at a community-based provider, and so they feel like,
well our students are fine because we call this great social worker who works in our school,
she calls her friend who works at the community-based provider, and our students get
connected to services. The problem with that of course
is that people change seats, right, and so the school social worker might not be there next year. The treatment provider might get promoted, or move to a different provider who doesn’t take the
insurance that your kids have. And we have found especially
in struggling schools the turnover is just tremendous
at the personnel level. So creating these pathways in formal ways so that there is formal training, there are formal policies and procedures, there are MOUs between the
school and the provider and law enforcement,
is really the best way to operationalize an SRM so
that it lasts and endures even when maybe your champion retires. Next slide, Holley. So what does this look
like, well in the places where we’ve worked it can
look really really different, as I said, depending on local resources. The most kind of pure
crisis intervention model that you’ll find in the
school responder model is in Connecticut. So Connecticut was one
of the original sites for the school responder
model, and they created what is called the School-Based
Diversion Initiative. And that involves a bunch
of training for people who are working at the school and that means not just
teachers but anybody, any adult, who is in that school setting. They also have the luxury in Connecticut of having a very robust mobile
crisis service for children. So in Connecticut if you
dial 211 you can access a mobile crisis service
for children that has a maximum 45 minute response time no matter where you are in the state. That is a luxury that we don’t
find most other states have. But they have it there and they use it for their school responder model. So folks from the school are
trained to start thinking, like, you know, this young
person is acting out, or this young person is having a crisis. Perhaps the people who could
best help in this situation are mobile crisis. And so they’ve changed
who they’re calling. They aren’t necessarily
calling the police now, they’re calling mobile crisis. Or maybe they’re calling them both. But they call crisis and crisis does the screening assessment, connection to mental health services. And they can stay with the kid’s family for a little bit of time to make sure that connection happens. In Summit County, Ohio they
have a very different structure for their school responder model. So they’re SRM is housed
at a family resource center that is at their juvenile court but please don’t understand
me to mean that that means they have an open court
case, because they don’t. So the school refers to the case manager who works at the family resource center, and the case manager reaches out, connects with the
student and their family, and does the screening and connection to community-based resources,
and that is all outside of any kind of formal
petition or court process. Next slide. We also did this work with
folks in Schenectady, New York. And they made an interesting
choice in Schenectady. They decided that they wanted
to actually work with students who were getting into big
trouble in their schools. Most places we’ve worked
start by working with students who are getting in trouble in school but usually it’s the low-level stuff that people want to work on first because that’s usually easier
to kind of sell to people. But in Schenectady they went
straight for their students who are at risk of long-term suspension. So they’ve done something serious enough that they could get suspended
for quite a long time. And they created a diversion process that runs in tandem with the suspension process and shortens the suspension
process for students. That includes a screening
done by a social worker, a whole team, an emergency response team, who then develops a case plan. And they actually have implemented a lot of school-based therapeutic
options for their students including a very robust use
of restorative practices and a real trauma-informed approach inside their school system. So that’s a different way that an SRM has been operationalized, and then finally four of the high schools
we’re working in right now in Oakland County, Michigan are working to, they just launched, and they are screening students and then they created,
their biggest provider there is called Easter Seals, and
there was a lot of confusion about what would happen with students once you made a referral for them. So Easter Seals created a point person for each of these schools
so that the schools have a person they can call
about their students, which has really helped
kind of clarify the pathways for students and helped better
connect them to services. Next slide. So a little bit about the results here. Some data from Schenectady,
and this is just the first 13 weeks of
the last two school years and this school year. So it’s a year to year comparison
of just part of the year. And I think there are a couple
of important things to note in the data you’re seeing on this slide. One is you’ll notice that
the totals are going down. So in the first 13
weeks they had (mumbles) the year before they implemented they had, I’m sorry, their first
year of implementation they had 70 students who were referred for superintendent hearings
for long-term suspensions. And you’ll see that the
second year of implementation it went down to 57, and this
year in their third year it went down to 52. And that reflects the
fact that they are having fewer serious incidents at their schools. And they do credit this diversion program for a lot of that change in numbers that they’re seeing there. You’ll also see how
the red and the yellow, the balance between those have shifted. So in the first year, all of this is, it’s something that students
and their families can choose. You can choose diversion,
you’re not mandated to diversion in this process, if
you don’t want to do it you go to your traditional
superintendent’s hearing and you just follow that
traditional pathway. And you’re probably out of
school for quite a long time. And the first year you see
they, a lot of people said yeah I’d rather take the
superintendent’s hearing. But as they implemented this structure and they had some success,
word kind of got out that actually this diversion
pathway can be really good, and really successful
for kids in Schenectady. And you see that far
more people are accepting the diversion pathway now as they’re further into implementation. Next slide. This just puts together
a couple of data points from some of the other places. So Connecticut, I told
you SBDI in Connecticut is really kind of the most
robust full responder model we have right now. And they have a lot of data there. And they have found that in the
first year of implementation of SBDI, court referrals from the school drop on average 45%. And what I didn’t put
on the slide, but know, is that their referrals to
mental health for those students went up I think it’s 98%, almost 100%. So they’re seeing a big
shift in those schools from using the court system
to respond to students to using the community-based
mental health system to respond to students. And just very quickly, in Nevada, that was a very interesting site for us because it was incredibly rural. So this was in Lyon County, Nevada, which is a very very rural
place where they don’t have a lot of services at all for their kids. And they had been only accessing services for their students in
need through probation before they started their
school responder model work. And in just the first
year after implementing their school responder model
they saw a 15% reduction in referrals to probation
in that community, which they really credit
for having this new pathway, which is really what we think
of it as, it’s a new pathway. It’s not a school justice pathway, it’s a pathway for students to get the kind of treatment services
and support that they need. Holley can you flip to the last slide? So here are just some resources for you. There are bunches of them on the web, especially if you go to that SRM website, which is the second
link down on that slide. Once you get in there, a lot
of resources are embedded and they are practical
resources that localities used and allowed us to put up on the website in developing their SRMs. So we hope that if it’s
something you’re interested in you can find some
resources and tools there to help you get started. Thanks. – [Brian] All right, thanks Jacqui. So for our final presentation
we have Ruby Qazilbash of the Bureau of Justice
Assistance, excuse me. They’ll advance your slides. – [Ruby] Okay. Good afternoon everyone, or good morning depending on where in the
country you’re joining us from. I’m happy to be able to share with you some information about federal resources that can support crisis
response and early diversion. Just a reminder about the funding resource that my colleague Maria
Fryer mentioned earlier. BJA is going to be
releasing all solicitations I would imagine within
the first quarter of 2019. So please be on the
look out for the Justice and Mental Health Collaboration Program. And some of the great work that you heard on the juvenile side,
those are also eligible and allowable uses of
Justice and Mental Health Collaboration Program funds
can support both adult and juvenile diversion related activities. If we could advance to the next slide. I’m gonna spend the bulk of my 10 minutes talking to you about some
new resources that BJA and its partners have put
out to support counties that are engaged in the
Stepping Up Initiative. I’m also gonna tell you about a training and technical
assistance resource center that can support law enforcement responses called Serving Safely. And then I’ll end with a new resource that we’ll bring online in
2019 that provides a framework for police and mental health collaboration that Maria also spent
some time talking about. The Stepping Up Initiative
is one of the most exciting initiatives that
I’ve been able to be a part of in my tenure with the Bureau
of Justice Assistance. And this was really a
collaboration between the Council of State
Governments Justice Center and the National Association of Counties. BJA is a funder of this as well as the American Psychiatric
Association Foundation, and it has really strong support
from our federal partners at SAMHSA, the National
Institute of Corrections, and also other organizations like NAMI and the National Sheriff’s Association. The point of Stepping Up is for
counties to pass resolutions and to build consensus to do the hard work of reducing the prevalence
and the number of people within the nation’s jails who
have serious mental illness. The slide said 450, I
checked this morning, we’re actually up to a
little bit over 460 counties have now passed resolutions. These counties are within 43 states and actually over 40% of
the country’s population now lives in a Stepping Up county. We can just advance the slide. We came to the, this wasn’t happenstance on how we came to realize that
this was a good way to go, how to invest dollars, how
to begin work with counties and how to guide their efforts. BJA had supported through
the Justice and Mental Health Collaboration Program
some really deep dives into the data, policies,
and practices of over, in between five and 10
jails around the country to take a look at who was in those jails. And first understood
that the prevalence rates are astronomical. So if 4% of the general population has a serious mental illness, in the average jail it’s about 17%, or over four times the rate
of the general population. Why, and what can we do about it? The other thing that we realize
is that they’re staying, people with serious mental
illnesses are staying for longer at every step of the way. So whether you’re in
the phase of a jail stay that’s pre-trial, or for
the sentenced population, we also realize that a lot of times we’re making people worse. So if they were engaged in
community mental health services on the way in, we didn’t always make sure that we reconnected or used
that kind of golden opportunity while folks were in the jail
to provide a new connection to meaningful services in the community. And then fourth, I think
what a lot of those counties, why they come to this is
that they’re sick of seeing the revolving door for individuals that desperately need to
be connected to services, but they keep getting arrested
and booked into the jail and so it happens again. What I love about Stepping Up is that it really focuses
counties on these four goals. So we want to reduce the
number and the prevalence of people that are booked into the jail. We want to shorten length of stay. We want to increase those connections when people are reintegrating communities. And we want to reduce recidivism rates. In order to do number one, it necessitates universal screening for serious mental
illness, and a follow up with an assessment if
that person is screening and looking like there is the
presence of mental illness. We can advance to the next slide. One of the major documents
that came out first about Stepping Up was these six questions that county leaders need to ask. Is their leadership committed,
and what does that look like? Do we conduct timely
screening and assessments? At the time this came
out we were hard-pressed to name a county in the
country that was actually doing universal screening of
everyone booked into the jail. Do we have baseline data, are we conducting a
comprehensive process analysis and inventory of our services? Sequential intercept
mapping is a great way that counties can do that number four. Five, have we prioritized
our policies, our practices, and are funding improvements
so that we can impact those four outcome measures. And then are we tracking our progress. Is what we’re doing yielding the results that we set out to achieve? On the next slide we haven’t
stopped in developing resources and so briefly I’m gonna tell you about three relatively new ones and ones that we continue to
develop around Stepping Up. One is the Project Coordinator’s
Handbook, this came out. Usually there is one poor
soul that gets tasked with the coordinator role and that’s
usually not their only job, and that’s the task master
and the boundary spanner, the data collection geek, the
subject expert, you name it. Someone usually ends up with that position and so we felt like having a handbook to arm that individual
with would be a good idea. Also this summer we launched an online county self-assessment, and
then we continue building upon a series of briefs that bring
people towards the goals and break down each
component of Stepping Up. On the next slide, just a
little bit of a deeper dive into that project coordinator’s handbook. So for that person that
is sitting in their county in those 463 counties that
are Stepping Up counties, this really takes them through
and helps them figure out who do I need at the table,
what agencies do I need represented to make this change happen. And how do I get them at the table. What data am I gonna need and what do data sharing
agreements look like. How do we compile all this
data and report it back in a meaningful way instead
of scattershotting folks that we convene and are
spending their precious time to work us on initiative. How do we feed them
information that’s actionable. So that’s what the project
coordinator handbook does. The Stepping Up Self-Assessment
Tool, this is an online tool that counties can do together,
you can save your progress. It basically asks you
questions that tracks with those six key questions
to get at Stepping Up goals. You can save progress along
the way, you can print it out, you can figure out where have
we not done anything yet, what have we partially implemented, what have we fully implemented. And what I like about this is I think it really focuses teams so they know what do we need to be working on next. What’s the next piece of
information that we need. What are we gonna tackle next. And it helps you organize
your thoughts and your efforts and figure out where as a
team you should be focusing. Again, this is available
online for any county that wants to create a
login and begin using it. And then on the next slide,
there’s a series of briefs. One of them has been released and its focus is on
screening and assessment. There’s another one that
will come out in early 2019 and we plan to continue releasing them. They’re kind of quick snapshots
that are great to hand out to Stepping Up team members to understand what are we trying to
accomplish and what are kind of key takeaways about how we get there. So really would encourage
folks to take a look at stepuptogether.org, that’s where all of these
resources can be found. Another resource that the
Bureau of Justice Assistance has supported, in 2017
Congress appropriated a new funding stream of
2.5 million and tasked BJA with standing up a national training and technical assistance center to improve law enforcement responses to people with mental illness as well as intellectual and
developmental disabilities. Serving Safely is the name of that center. It is operated by the
Vera Institute of Justice. And I am happy to say
that they are available a phone call away or an e-mail away to request training or
technical assistance. Every week Marie and I get a digest of the technical assistance
requests that have come in. We have team meetings to determine how they’re gonna be responded to and how we can most
effectively provide resources and whether that need be
a deep or a shallow dive. Maybe it’s just information or connection to a peer law enforcement agency
that’s doing the good work that they’re trying to do. So Serving Safely is another resource. And my last slide is to preview something that will be coming out in 2017. We have been deep in this work
for the last 12 to 15 years of really understanding
what are the key components of a successful police-mental
health collaboration. Ron Bruno talked earlier about
crisis intervention teams, CIT International, and the amazing work, and the thousands of
law enforcement agencies around the country that have started crisis intervention team efforts and baked them into standard
operating procedures for law enforcement
agencies around the country and what those collaborations
should look like. We’ve got 18,000 law enforcement
agencies in this country so we have more I would
argue still to date than not, more who do not have a
collaboration in place than do, and so we find that we
continue to build out resources to help describe what effective
collaboration looks like, whether a law enforcement agency and their partner mental health authority are choosing to implement the
crisis intervention team model or a co-responder model, or a case management model, or what works for their communities. The police-mental health
collaboration framework, just like Stepping Up,
really focuses counties on four key measures that you
should be looking to impact. The framework is gonna really
focus those collaborations on four key measures that you
should be looking to impact. And they are increased
connections to resources, fewer arrests, reduced repeat encounters with the same individuals
with serious mental illness, and reduced use of force
during those encounters. So please be on the
lookout for that in 2019, we’ll make sure it’s available everywhere. At bja.gov the Police-Mental
Health Collaboration Toolkit that’s online that
Maria mentioned earlier, and through Serving Safely. We don’t want there to
be any one wrong door. So thank you, that’s all I
have for you this afternoon. (audience applauding) – [Brian] And at this time
we’re gonna take a brief break in advance of our next panel
on Screening for Mental Illness and Substance Use Disorders. – [Lisa] Good afternoon,
my name’s Lisa Callahan. I work with SAMHSA GAINS Center and Policy Research Associates. The next panel is going to be on screening for mental illness and
substance use disorders in jails and detention centers. As we heard from a number
of the earlier speakers there often are times when
people with mental illness and other behavioral health
disorders are transported to the jails and to detention centers, and at that point in time we’ve also heard it’s really important for
there to be universal screening for behavioral health disorders when people are in jail or detention. We’re gonna hear from four speakers today. The first speaker is Paul
Leffingwell, he’s a clinician and Forensic Services Team
Lead with the Bert Nash Community Mental Health Center
in Douglas County, Kansas. He has a number of years of
experience working in both county and state corrections
and he’ll be our first speaker. The second speaker is Dr. Merrill Rotter. Dr. Rotter is a forensic
psychiatrist in New York, where he advises the Commissioner of the Office of Mental Health
for the state of New York, and is also on the faculty at the Einstein College of Medicine. He’s the director of the
Law and Psychiatry program and has worked for years in the crossroads between criminal justice
and behavioral health. The third speaker is Dr. Keith Cruise. Dr. Cruise is a clinical psychologist who specializes in youth and adolescents. He is on the faculty at Fordham University in both the Department of
Psychology and the law school. Dr. Cruise, his clinical practice includes providing direct care assessment
and treatment services with justice-involved youth, and he provides a considerable
amount of training and technical assistance to jurisdictions to improve their services and responses to justice-involved youth. Finally, John Berg,
who is the program lead for a number of SAMHSA’s drug court and re-entry grant programs will be the speaker to talk
about federal resources. John is the Senior Public
Health Advisor in the CSAT for SAMHSA and he has over
17 years of experience in state corrections and has
served in many capacities as a clinician in corrections. So I will turn this
over to Paul Leffingwell from Douglas County, Kansas. – [Paul] Good afternoon. In a kind of an update I got I
was asked to speak more about some of the kind of
front line applications in the screening and assessment process that we use here in Douglas County and be with an eye towards
providing some information about some maybe usable options for people working in
facilities elsewhere. And so just to briefly summarize. Our facility is in Lawrence, Kansas, which is in Douglas, Kansas in the eastern part of the state. And it’s a 186 bed facility. We serve five different
law enforcement agencies over four cities. And we have got a capacity of 186 beds and we are typically over
capacity by 30 to 50. Which means we’re what we
call farming people out to other facilities we have contracts with to take our overflow. So what we in the forensic
services team here do is we work for the most part a normal kind of eight to five schedule,
and what that means is we’re not able to always see face to face every inmate who’s booked
into the facilities. Well our screening process
starts with the booking officers who now have the Brief
Jail Mental Health Screen included in the booking process. And so those inmates who
responds positively to some of the questions with the
mental health screen there, we’ll be notified of that
and then we make plans kind of during regular
working hours to follow up with those inmates who get
booked into the facility. Now we have an advantage
in that I work for the community mental health center so I have access to our
electronic medical record. And so myself and the
other clinicians here can go through our record,
match it with all the bookings and see who is in fact
a mental health client, who has been a past client, who’s had crisis
screenings at the hospital. As well as co-responder contact. So we do have a pretty
comprehensive database to go through each day with everyone who
gets booked into the jail. So we have pretty good information. It’s people who might
come from out of county or for whatever reason
have never had contact with the mental health system that we have no information on. But in addition to that Brief
Jail Mental Health Screen those inmates who are identified, then us we do a more comprehensive
mental health evaluation. Like I said, we do a records review. We also perform the SBIRT,
the Brief Trauma Questionnaire and the LSIR screening version. If a person in jail is in
the facility long enough to where they might qualify
for re-entry services they’ll then get a full LSIR prior to them participating
in that process. For us what that means is
we have a pretty good list of people to see each day. For those folks who might
be either too intoxicated or for whatever reason don’t particularly want to talk with us, we’ll
let that be for the time being. We of course will do any sort
of crisis assessment as needed and if necessary we
can, we have a protocol for managing a mental health
crisis here in the jail and we’ll implement that
kind of on as-needed basis. We are trying to catch
people after their arrests prior to their first appearance. Sometimes from a practical standpoint that doesn’t always work and we’re catching them
after their first appearance, maybe they’re waiting on an
attorney to represent them at their next court appearance, or waiting to make bond
or something like that. But we’re trying to catch up
with that person to make sure that if in fact they are in
need of mental health services or substance abuse or trauma services, including maybe domestic
violence shelter care or something of that nature, we connect up with them, provide
them with that information, provide them with contact
information for us at the jail, and then what happens is as, if they’re agreeable to all this, as they transition out of the
facility we can act as actual kind of short term gap
case management services and actually go out into the
community with that person and help physically get them
connected with those services. Typically this will almost always involve intakes at the mental health center. We have several agencies that can provide some mental health services, but the community mental
health center’s the primary. We have a substance abuse
recovery, of course. But then we will kind of
psychically assist them with doing that. Sometimes that can be a difficult process especially with our homeless population. We try to make staying in touch
with us as easy as possible. We have gone to the homeless shelter, we have gone to the public
library for example, where we might need to locate people and to continue to help
facilitate that process. I mean I’ve worked with people over weeks getting them to and from court appearances to prevent their re-arrest
for missing court. But that’s kind of the ground
level process that we use. You can go ahead and advance the slide. Just kind of keep intervening
with people, assess, refer as needed. And hopefully get them connected, and then once we’ve done that
process we are in touch with the mental health center so
if they do have case managers we’re gonna be contacting
them to make sure their case managers know
about their court dates, assist with transportation as needed. Basically kind of take care of the ground case management work until they
get really more established with other care providers in the community to help provide those services. So our focus is really on assessing them when they come into the facility,
referring them as needed (clears throat), pardon me,
as needed when they get out. And then doing what we can to make sure they kind of meet their
obligations in terms of appearing in court or appointments with probation or something like that. To kind of keep them out. Typically once people
have engaged in services we are seeing a reduction in bookings for seriously mentally ill folks, so that’s been pretty good. Go ahead and advance the slide. So the Brief Jail Mental Health Screen we get pretty, I guess, pretty good cooperation
from people getting booked in answering those questions. For those who choose not
to answer the questions, like I said, we are going over our records to kind of determine if this
is a person who has had contact with the mental health system before. Like I said, we’re lucky
to have access to our electronic medical record system
at the mental health center which will have crisis
screeners at our local hospital, it’ll have their information in there. Contacts by our co-responder
in the community, who responds with police,
the police department. So we do have a pretty good database of information to go by. And occasionally people will
just say no to everything. Their symptoms are perhaps too intense, maybe some paranoia or
something and they won’t want to answer the questions. In any case, even if the
officers are not necessarily familiar with the person, if he’s presenting with something unusual or there’s some reason to suspect they may need mental health follow up, we take referrals from
the officers in booking, nursing staff who may
follow up with people, our nurses have their own
mental health screen they do. And then anything the officers
might observe in the pod as well as requests from
the judge, the prosecutor, the defense attorney, at
their first appearance, if they’ve got an attorney at that time. So we will take any request from anyone to follow up with
someone here in the jail. Anytime we find out
there’s someone who might be in need of our services we
try to get with that person as quickly as possible to do a screening and further assess them as needed. Go ahead and advance the slide. So what we’re looking at doing
is our most severe cases will be referred to a newly established behavioral health court. And we also have a program where the district attorney started a, it’s kind of the drug court, right now it’s for female offenders. And then we’re looking to
add substance abuse treatment here in the jail, we don’t
have that up and running yet but hopefully that will start
here in a couple of months. So we’ll be able to address
some of those needs from here. That’s the person where they get released to go to treatment, for example. The advantage to getting
it started here in jail is so we don’t end up with
people sitting here waiting on treatment
beds when they could be actively engaged in some treatment. And then we started adding
some of the screening data from the bookings to our
criminal justice data system we have here. We have mental health alerts
already on some of the inmates who are booked in as, it’s
one way we get alerted to their presence here in the facility, and the need for us to
follow up with them. Go ahead and advance the slide please. But basically we look at trying to catch up with
people who may have also been released
prior to us seeing them. We have a lot of people who
don’t spend very long here. I believe it’s 25% of all of our bookings are in the jail for three hours or less, so that means anybody who appears after the staff has gone home, and hasn’t been in need of
after hours crisis screenings, they’re gonna be out and gone by the time we all get into work the next day. So we then review the booking sheets for the presence of any indicators and we will try to contact that person out in the community if we have a means of getting ahold of them to just see if there was any follow
up that might be needed. We also will alert any
people who are active clients of the mental health center, we will alert their case managers that
they’ve been incarcerated, to let them know that they may need some additional follow up outside of the regularly scheduled appointments. And then from there, like I said, we’ll do any short term case management that’s necessary. Case workers will go
out into the community and meet with people there, for example to schedule more comprehensive substance abuse evaluations, just help people to get to appoints, kind of the basic case management work. All four of us clinicians here, I’m the clinically licensed supervisor, and then we have four
masters level licensed, or three other masters level
licensed social workers, and then typically some students who also assist with us in that process. I think that’s covered all the slides. – [Lisa] Okay, thank
you Paul for giving us an overview of the work that you’re doing in Douglas County, Kansas. Next we’re gonna hear
from Dr. Merrill Rotter, who will continue the
discussion about screening and assessment of adults
with mental illness and substance use
disorders in adult jails. – [Dr. Rotter] Okay,
good afternoon everybody. To the next slide please. So this is obviously
something that you’ve seen multiple times in the past,
including earlier today. Sequential intercept model. What I want to suggest here, and is when thinking
about the jail role here, is that conceptually
we want to see the jail as part of a continuum
of care, if you will when it becomes required or necessary, such that we’re thinking
beyond the day of care but rather that the person
came from somewhere, is going back to somewhere, and what are the opportunities once they’re in the jail system to do both meet the immediate needs but
think conceptually beyond and what else we can think
about for longer term needs and perhaps discharge planning. So what I’ll be talking about
over the next several minutes, right, is kind of a conceptual
approach of thinking about in an intentional and mindful
fashion what our role is, why we are screening and
assessing our clients who end up in jail, while they’re there. I’ll give some examples
of some of the tools but beyond the fact that we
only have 12 minutes here, and that there are, actually SAMHSA has a very
comprehensive monograph on screening and assessment of people with co-occurring disorders
in the justice system that came out in 2016
that’s worth looking at and has dozens of tools over
a course of hundreds of pages, the pros and cons. I’ll give a couple of examples,
but as we’ll see at the end when I circle back to conceptual ideas, what are some of the considerations that are worth thinking about
that will drive what tools may be appropriate for
your particular situation, and there are several variables that I think are worth
being intentional about. Next slide. Right, so the two basic, if you will, parts that we’re talking about here within the sequential intercept model really are two roles and
two goals here, right. So the intercept two there that is that first initial detention, meaning that they’re in jail right now and we can think about
our role in terms of the cross-sectional
needs someone might have, and meet the immediate
need and how we identify and screen for those. And then of course once they’re in jail and may be heading back to the community, or will be certainly,
what are the opportunities for more comprehensive re-entry planning. And my sort of if you
will conceptual argument to drive up the point home
is that we can think about what the opportunities for one or both are both depending on our current,
our system, our staffing, et cetera, as we’ll look
at in a couple of minutes, but again, being intentional
about what our role is vis a vis the client who is in jail, and what our goal is, is important if we’re gonna be getting to look at what we want to assess
for, identify, screen for, and then therefore then what
tools that we might use. But let’s pick those apart
for a couple of minutes. Next slide, please. Next slide? Thank you. So in terms of the cross-sectional
needs, if you will, here are just some examples
that one might think about, one of which you just
heard some detail about, the sequential, I’m sorry, the, I lost
my slide here, sorry. Pardon me, oh here we go. The Brief Jail Mental Health Screen, so you heard the details
from Paul just now about that essentially. It’s an eight item scale
on which you’re looking for six are current symptoms, two are some historical factors, two or more positive
suggest a lifetime diagnosis of a mental illness. The advantages of that, the pros of that are that it can be done by
very non-clinical staff, including corrections
officers, as you just heard. It does not however screen for anxiety, does not screen for personality disorder. As Paul mentioned, it’s
not diagnostic specific, just the presence of some
kind of mental illness. So that it’s got a positive
and we want to make sure we don’t miss people, but it
doesn’t necessarily tell us a lot about what to do
for that individual. The DAST and the MAST, which
were noted earlier as well. The DAST being the Drug
Assessment Screening Test and the MAST being the
Michigan Alcohol Screening Test really are two short tools
to pick up the presence of a history of drug use or alcohol use, or both. And again, the pros are it’s
a quick thing that can be done by almost anybody, and
will help identify somebody whose risk for destabilization
or behavioral issues may include substance use, but
doesn’t necessarily tell us a quantity or frequency. Doesn’t necessarily tell us which drugs. And even more relevantly
for the cross-sectional, it doesn’t in and of itself tell us is this person potentially intoxicated, do they potentially
need more detox services or something for medical reasons in the jail or jail setting, if you will. And then doesn’t tease
out for us whether the, if there are behavioral health symptoms, are they due to the substance use or not, we just know that it’s present. Again, these are identifying
tools as opposed to really deeper dive assessment tools. And then finally,
clearly just to note that many if not all jails now
are screening in some way, shape, or form for suicidality. And the CSSRS or the Columbia
Suicide Severity Rating Scale is one of many but it really
is becoming to my mind the state of the art largely outside of the
jail or prison setting, but it’s being increasingly
used in that setting as well to identify people who have
had a history of suicide and even a recent history of
suicide or suicidal ideation. At least within the past
six months, I would suggest that perhaps a deeper dive for
current ideation, et cetera, needs to be considered. Again, so I think the, I
would argue the three things you want to be really concerned about from a cross-sectional
perspective, is indeed, is there a mental illness,
maybe substance use, and suicidality of course, but the critical focus for
that, the role we have there is identifying those things
to help the client get as safely through the day as possible to maximize their cross-sectional
stability in their health. But again, these are just
identification tools. One would have to ask more
substantive questions, non-structured questions, to get at what the diagnosis might be, and indeed what medications
might be appropriate if that’s appropriate to manage what may be an acute presentation of mental illness and or substance use or substance withdrawal essentially. But again, the important
thing here from my perspective conceptually is to think about
these as what tools do I need to get through the day, to get the client as safe as possible and
as stable as possible through the day. Next slide, please. We can then, then re-entry
planning again is a separate role and a separate goal, is
something that can also be done within the jail or prison setting, but the jail setting of course
we’re talking about today. The APIC model is one
model for thinking about how do you plan for re-entry with reference to what we’re talking about this afternoon or this morning, we’re talking about
really the I and the C, the identification of, I’m sorry, the planning
for the treatment services, and then within that then the
plan then helps us identify the programs and coordinate
the transition plan, but really what do you need
to do to assess for that plan. And that’s potentially slightly different. Still behavioral health, but when we talk about
like a psychosocial, it will add certainly the
social aspect to that. So for example, next slide. The types of instruments
that might be relevant here beyond the Brief Jail
Mental Health Screening would be the Modified Mini Screen, or the Mini International
Neuropsychiatric Interview, the MINI, which is really
more of a diagnostic interview for things like depression,
schizophrenia, et cetera. Help identify what
exactly the disorder is, or disorders are, that
may need intervention. It’s been tested largely
in non-offender populations though it’s been applied
to offender populations. It doesn’t pick up the
possibilities of malingering, which is certainly an issue within an offender population as well. But it does identify mood, does look at anxiety and psychosis. And again, helps drive diagnosis, which is better for treatment planning. Substance use, again
the DAST and the MAST, but what I don’t have
here is something like the Addiction Severity Index or the ASI. That’s a structured tool that
then begins to drill down to what the actual substances
are, how frequent, how recent. Again, to get a sense of how
much of the re-entry planning should include substance
treatment essentially. Trauma’s a huge issue as we know of course in the offender population,
practically universal. The PCL-5, which is the Post
Traumatic Stress Disorder Checklist for DSM-5 is an item scale looking specifically at the presence of post traumatic stress
disorder symptoms. The challenge there of course is that while the presence of or history of trauma may be almost universal
in an offender population, how it presents isn’t
always within a PTSD, if you will, framework. People become depressed,
have personality disorders, substance use, et cetera. So it’s an important kind of
area to be thinking about. The PCL-5 is one of the most
frequently used examples, but doesn’t necessarily capture the array of possible trauma,
sequela, or consequences. Frankly it also doesn’t ask
about the trauma itself. It’s just about the symptoms. So one has to them really
screen earlier for a history of any traumatic exposure. The PCL-5 doesn’t do that. And then finally, and this
was mentioned by Paul as well, if we’re thinking about re-entry planning, it really pushes beyond
their immediate needs into what are the risks of recidivism, which often are related not only to the serious mental
illness a person may have, but in fact also other
significant criminogenic or social factors that will
lead to a greater history or risk of re-arrest. And so something like the
level of symptom inventory, or the case management version of that, is a way of picking up all the needs associated with recidivism, which is a concern for our clients. And then certainly risk of violence to the extent that violence is present can also be looked at
in a structured fashion. The HCR-20 is a training in and of itself but is worth noting that there
are structured approaches to the risk of recidivism
and structured approaches to the risk of violence with
the notion of risk management and risk planning around that for when the individual
returns to the community. Again, these are examples of instruments that allow us to think about
where the person’s going and not just getting
through the day in jail. Next slide. And finally, having laid
out a number of these tools and it’s just worth noting
that which tools you choose, not just from the menu that I shared in the last few minutes, but
in fact what you may choose if you choose to go to look
at the SAMHSA monograph on screening and assessment
tools for example, will have to take into account,
and should take into account in a again intentional
fashion, all the considerations relevant to your specific jail setting. And these are several. The volume, how many
people are coming through any given day, so how
much you can do, how much, how deep a dive you can do. How much you can think
beyond cross-sectional will partly depend on how
many people are coming through that you need to see, essentially. So you can triage your
efforts appropriately. I’m gonna skip the next one for a moment. What kind of staffing you
have within your jail system. How dependent you are on COs frankly to do parts of this screening, non-clinical staff, if you will. Do you have higher level clinical staff who can do deeper dives in
terms of clinician interviews. The clinician version of the MINI, the neuropsychiatric interview, is certainly much more specific
than the general version, the modified version of the MINI. Helps you get better
diagnoses, better history, and better treatment planning. But you may not have that available. So depending on indeed
the level of staffing will also drive which tool
will be most appropriate for your particular setting. What services you have will also partly dictate that essentially. Do you have access to detox. Should you be screening for
people who may be withdrawing, so you can actually get them
to the appropriate services. So that’s gonna be a piece of it. None of these tools necessarily help you with placement
within your facility. Partly because the tools aren’t
specific to your facility, whether you have
segregated units for people who are at risk for decompensating, or not being able to care for themselves, or are at risk in general population. Whether you have
segregated units for people who are higher risk for violence, where the DOC drives a
lot of those decisions, rather than clinical decisions. All of that will vary from place to place, and indeed then will also add to what you need to be thinking
about at your screening level when someone comes into the jail system. Certainly differentiating
people, SUD from SMI is an important challenge
in thinking about treatment planning for our patients. It typically isn’t something
that we think about necessarily in the jail itself. But certainly in re-entry planning, getting a sense of how
much of, if there are, often there are both obviously present, but what’s the greatest contributor and how to prioritize services
is an important issue. And then finally, back to
the original concept here that there are at least
two roles and goals for us in the jail screening
and assessment process. That is, the cross-sectional
getting through the day, if you will. The re-entry planning that,
seeing jail as a weigh station, if you will, and someone’s
going back to the community, and thinking about where
they’re going to go. Those are separable, and separable roles, and separable goals and
separable ways of approaching. However, depending on the
length of stay within your jail, they may not be separable temporally. If most of your clients come
in and go out in 24 to 48 hours then you can’t necessarily
punt on the re-entry planning even if you wanted to. So that it’s worth noting that sometimes you can’t really weigh
in on discharge planning and maybe what indeed the old
adage from hospitalization, that discharge planning starts
on the day of admission. Perhaps that also would
apply in your case, if in your jail people
move through that quickly. So that said, what I
tried to present here, in summary therefore, is just an approach to thinking intentionally about what we’re trying to accomplish. That there are pros and
cons to the various tools that are available to you, and that understanding those pros and cons in the specific context
of the considerations of your particular jail setting, is really the best approach
I believe to picking the right tools for your
population and for your staff. Thank you. – [Lisa] Thank you, Merrill. Next we’re going to be moving on to hear from Dr. Keith Cruise,
who will talk about screening and assessment in detention
with juvenile offenders. – [Dr. Cruise] Thank you so much, Lisa. And if you could go ahead and
move it to the next slide. Basically in the sort
of brief amount of time that I have here today is
you’re gonna be hearing at least from me some
kind of universal concepts as it applies to screening and assessment, that you’ve already heard
from other presenters. I’ll try to help capture
some of information that is a little bit more specific to a juvenile justice sub-population. And I’d like to take, to start with sort of
a top down view here, and a little bit of history at this point. In 2003, there was a blue ribbon panel of mental health professionals, juvenile justice professionals, policy makers, et cetera,
that convened and published what was referred to as the
Consensus Conference paper on juvenile justice
screening and assessment, and it outlined a series
of recommendations in 2003, which were pretty important for the field in terms of juvenile justice at that time. And some of them are listed here. Of course, one of the
first recommendations was to provide an evidence-based
emergent risk screening within the first 24 hours
of a youth’s arrival at a juvenile justice facility. And of course with emergent
risk screening being, primarily at that time
the focus on suicide risk. Active suicide ideation. And then the possibility of
thinking about picking up on potential harm to others as well. And the second recommendation
was then to provide an evidence-based mental
health screen and/or assessment for all youth as early as possible to determine their need
for mental health services. And so what we see is that
mental health screenings were recommended as serving two roles. One, to identify emergent risk-needs, and then broader mental
health needs as well. And than of course,
screening then should lead to the identification of a
smaller sub-set of individuals who are universally screened
at the point of intake and identifying youth who
may need a more comprehensive mental health assessment
that should of course then look much more like a traditional mental health assessment process, drawing on multiple
sources of information, measuring a range of relevant
mental health concerns that were either identified by the screen or from other collateral
sources of information. Another important recommendation was that this reassessment should
occur on a regular basis and that regular staff
training should occur on your overall screening
and assessment processes. Next slide, please. And of course what we
need by an evidence-based, in terms of these recommendations
is a screening tool that is of course standardized. Meaning it’s a brief
process, likely to be used, can be used by non-clinical staff. That it’s relevant, meaning
that it is essentially validated and has been tested that
there is a research supporting the use of the tool in a
juvenile justice sample. And the outputs of that
screen should be then to of course identify
youth with conditions that would be suggestive of
a mental health disorder, suicide risk, potential
risk of harm to one another. And so the outputs of a
screen are essentially to lead to some decisions
or structured rules that allow staff to essentially
screen in and screen out individuals who are suggestive
of mental health difficulties in a reliable and valid manner
based upon research findings. With the important caveat, and to remember that the screening is
not a diagnostic process, nor does it replace a
comprehensive assessment. Next slide. And so what we know is that of course good juvenile justice screening practices are those that are based
on a tool that’s relevant, it’s designed for use with the population, in this case a justice involved youth. It’s has research supporting
the tool’s reliability and validity for the various
scores or decision rules that have been created for the screen. And that it can be administered and scored based on a standardized approach to support uniformity
in the system response. Screens are typically conducted at intake. But what we know, a unique
thing in terms of juveniles is how fast and quickly mental
health symptoms can change, particularly in an adolescent population, and how different contexts or
environments can impact that. So we also typically think
about screening tools as something that is
not just done at intake and is filed away, but is something that juvenile justice staff can
bring out and re-utilized and re-screen youth based
on changes in circumstances, changes in settings, et cetera. And the most important thing
that I think is to get across, and Merrill has already referenced this, is that screening is more
than just selecting a tool. I always refer to screening as a process and the fact that it needs
to be supported by policies that can involve the
selection of the tool, and the tool can then drive
some aspects of the policies, but every screening policy and practice needs to have some
guidance that facilitates how the screening tool is
going to be administered, who’s going to administer
the screening tool. Who’s going to have
access to that information from the results of the screening tool, and policies and practices that facilitate both the communication with other staff and between the juvenile
justice professional and the youth or the family who is going through
the screening process. And clear policies that
involve the protection or confidentiality of those results. Essentially, who is going
to see this information and how it’s going to be used. Next slide. And in reference and sort of
acknowledgement of this idea of screening in juvenile justice
settings being a process, I will point you just
to a document that was offered up and developed
at the National Center for Mental Health and Juvenile Justice, which outlines mental health screening in juvenile justice settings as involving 10 different steps and four phases. Sort of reflecting this idea of a process, where the first is the first phase is really setting your framework. Figuring out what exactly
do we want to accomplish in this screening and assessment process. What are our needs,
what are our resources, what do we hope to learn from a screen. And you have to essentially work on setting your framework first before you jump into
selecting the screening tool. Oftentimes in my work with
juvenile justice agencies that’s the first thing that they ask. What tool is best to screen for what. And in my consultation back,
I redirect them to say, what do you want to learn from the tool, what are your resources,
and how will this fit in to your overall process. You have to set the framework essentially before you can get to good
decisions about identifying the tool that’s gonna most
appropriately meet your needs. Then the third broad phase is
essentially developing a plan to implement that screen. That’s developing the decision rules, hopefully that is guided by
evidence, research evidence. And then locally developed responses to those empirically identified
screening indicators. This often means locally
developing sort of a service matrix and guiding staff in terms
of what you’re going to do in response to each of
the flags from a screen. And this will also look at
a juvenile justice system developing information sharing policies. And then of course piloting
hopefully the screen and also making sure that
you’ve rigorously trained your staff in the screen as well. But then we’re not done there, the final phase is of
course data collection. Creating a database where
you’re tracking the results of your screen and evaluating essentially the number of youth that are screened in and screened out. How does that compare
to a prior literature, how does that compare to
the use of these tools and processes in other systems to make sure that you’re
actually capturing the youth that you intend to in
your screening process. Next slide. And I do a lot of work
in the area of trauma. As Merrill was just
referencing, trauma is of course a very important target
given that between 15 to 25% of youth in the juvenile justice system likely meet criteria for post
traumatic stress disorder. And this is one example where
you need to really think about the setting and the context
of what you’re going to try to accomplish through your
trauma screening process because not all trauma screening tools are built in the same way. While they may all universally
identify or flag youth that might be in need of a further comprehensive trauma assessment, or flag you who be needing
trauma specific services. Trauma screens are not all built the same, they could be an exposure only screen, focusing on just past
potentially traumatizing events. It could also focus just on those symptoms of post traumatic stress disorder, or what I refer to as essentially
current trauma reactions. Or you could get a screen
that would focus more broadly on trauma related symptoms,
things like dissociation, other types of depression
and anxiety difficulties. And if you just jump into
and say which tool works best without an understanding
that there could be different dimensions to a screen, you may be identifying a
screen that really doesn’t fit your purpose and context from within your juvenile justice agency. And of course then with any of these it’s that third step there is developing a very very specific implementation plan in terms of the training of your staff. The development of that
policy and procedure, and then developing your quality assurance and data monitoring component as well. Move to the next slide please. And some of my colleagues
who have also written on distinguishing of course the differences between screening and assessment and just following on the trauma example, this is just a visual depiction of some of the characteristics of a good trauma screening process
and how it’s differentiated from a trauma assessment. And so these are some guiding concepts that are perfectly appropriate for the adult context as
well, but we also see them as also being relevant for
screening for a particular area, in this case, trauma in juvenile justice. That a good trauma screen
should be universal, should be able to be
administered to all youth, particularly at system intake. Should be cost-effective, meaning that it’s a quick and efficient, and doesn’t take up a lot of staff time. It should descriptively end with being able to identify
youth who may be suggestive of having current trauma difficulties. And ultimately, an output
of that should be used to guide who you would want to refer for further secondary screening or some type of a further
trauma assessment. And of course that’s
very very different from, a more comprehensive trauma assessment, which is gonna be targeted
very specifically around potential traumatic events,
current trauma reactions. It’s gonna be comprehensive
in that it’s gonna draw on multiple pieces of information. Ultimately a good trauma assessment should be more diagnostically driven. And a good question with
that is does this youth currently meet diagnostic criteria for something like acute stress disorder, or post traumatic stress disorder. Is there the presence of any other co-occurring mental health disorders that sits alongside that trauma diagnosis. Of course it needs to be done by a trained mental health professional, and is often gonna involve a referral for this type of assessment
most likely generated from the non-clinically
trained juvenile justice staff at the earlier trauma screening process. And of course the outcome
of a trauma assessment is also very different. It should be used to formulate
a good case conceptualization and to inform treatment planning to help to monitor then
that treatment progress. And help to evaluate and help essentially juvenile justice staff
to detect and prevent decompensation or any
of the adverse reactions that may be co-occurring
alongside the trauma that have relevance to the
juvenile justice system. These might include things
like anger problems, difficulties in school,
difficulties in relationships, aggression and violence, et cetera. Next slide. And the most important thing
that I just want to pass along in this brief time is that of course just as the other
presenters have mentioned, we have a host of screening
tools for different areas, and they’re just represented, a few of them are
represented here with links. We have screening broadly for
mental health difficulties. The Massachusetts Youth
Screening Instrument is one of the most common
mental health screen that is utilized in
juvenile justice settings. We also have screens
obviously specific to trauma. We have what I would refer to
as sort of a combined screen that would look at both the
combination of mental health and substance abuse risk. We also have substance use
specific screens as well, with the CRAFFT being a
very common example of that. And consistent with what Merrill mentioned is we also have different
screening versions to assess for risks and needs. We have a screening
version of the Youth Level of Service Case Management Inventory, and also the Youth Assessment
and Screening Instrument has a pre-screen component
that then would alert and determine who we need to refer to for a more comprehensive
risk-need assessment. All of these have been utilized not only in terms of
juvenile detention centers or long-term juvenile
correctional facilities, but given that the most common, or the common placement of a youth is actually on community
supervision and probation, all of these screens
are utilized by juvenile probation officers in
community contexts as well. And I think you can
move to the next slide. – [Lisa] Okay, thank you Keith. I wanted to also just, a
couple of takeaways from both Dr. Cruise and Dr.
Rotter’s presentations is, especially before Jon Berg
speaks about the resources that are available on this topic, how important it is for planning and thoughtful consideration
of what your resources are both in your detention
facility or your jail, and in your community when
you start to think about introducing screening in
detention or jail facilities. That it is a really
thoughtful, planned activity, not something that is just
sort of someone’s decision that they want to implement
a particular screening tool. So I’d like to introduce Jon Berg now. He’s going to talk about
the federal resources that are available around
screening and assessment. – [Jon] Thank you Lisa. Good afternoon, I’d like to
thank you for participating in today’s symposium. I appreciate the
opportunity to share about a few of SAMHSA’s resources. It’s very important to screen
adults for mental illness and substance use within
the criminal justice system. A significant and growing number of people in the justice system have
co-occurring disorders, and approximately 17 to 34%
have serious mental illness. People with co-occurring disorders present numerous challenges
within the justice system. These individuals can
exhibit greater impairment in psychosocial skills and
are less likely to enter and successfully complete treatment. They’re also at a greater risk for criminal recidivism and relapse. The lack of screening
for CODs also prevents comprehensive treatment and case planning. It prevents matching
justice-involved people to appropriate levels of
treatment and supervision, and rapid placement into
specialized programs to address CODs. Next slide. The Screening and Assessment
of Co-Occurring Disorders in the Justice System is a
monograph available online through the SAMHSA store. It is intended as a guide
for all who are interested in developing and operating
effective programs for justice-involved individuals
who have mental illness, substance use and co-occurring disorders. It is the most comprehensive screening and assessment resource to use across the criminal justice system as it uses a wide range of
evidence-based practices for screening and assessment
of people in the juvenile or justice system who have co-occurring mental health and substance use disorders. The monograph reviews a
range of selected instruments for screening, assessment, and diagnosis for use in justice settings, and provides a critical analysis
of advantages, concerns, and practical implementation
issues such as cost, availability, and training needs. Although the title of the monograph includes co-occurring
disorders as an overall theme, the document is broken down into sections for tools to screen or
assess for mental illness, substance use disorder, trauma, treatment readiness, and suicide. Many of the instruments
described in the monograph are available online
and free to the public. The monograph has links throughout, which allow direct access to the resource. The monograph also
includes this chart, next. Okay, thank you. Includes this chart of
recommended screening instruments used to screen for mental disorders, substance use disorders,
co-occurring disorders, motivation and readiness, trauma history, and PTSD and suicide risk. Next slide. The monograph also includes this chart of recommended assessment instruments used to assess mental disorders,
substance use disorders, and treatment matching,
co-occurring disorders, trauma history, and
PTSD, and suicide risk. Next slide. And here’s a link that we provided. A new version for the monograph
is currently under review and will be made available
through the SAMHSA store when it is complete. Next slide. Just as in the case with adults in the criminal justice system, it’s also important to screen
children and adolescents within the juvenile justice system. Some children and adolescents
have mental illness and serious substance use problems. Almost 21% of children and
adolescents in the United States have a diagnosable mental
health or addictive disorder that affects their ability to function. Five to 9% of youth ages nine to 17 have a serious emotional disturbance that causes substantial
impairment in how they function at home, at school, or in the community. Many children and adolescents
with mental illness and substance use problems,
do not receive treatment. An estimated 60% of
children and adolescents with mental health problems do not receive mental health services. Furthermore, screening and early detention can help parents and caregivers identify emotional or
behavioral challenges and assist in obtaining
appropriate services and support before the problems intensify. Next slide please. Identifying Mental Health
and Substance Use Problems of Children and Adolescents
is a resource guide for staff, providers, and clinicians who deal with adolescents. The purpose of the guide
to address the approaches, methods, and strategies used to identify mental health and substance
use problems of high risk youth in settings that serve
either a broad spectrum of children and adolescents,
or a high risk population. The guide identifies youth as those between birth
and 22 years of age. The information in this
guide targets specific child-serving settings to help
determine the best approach. The seven settings addressed in this guide are child welfare, early
care and education, family, domestic violence,
and runaway shelters, juvenile justice, mental health and substance abuse treatment
for co-occurring disorders, primary care and schools
and out of school programs. Next slide please. The guide includes this list of resources on screening young children with the links to access the resources. Next slide. The guide also includes
a list of resources on assessing and treating young children with the links to access these resources. And the next slide provides
the link to the guide. Next slide. SAMHSA created a new Evidence-Based
Practice Resource Center to provide communities,
clinicians, policy makers and others in the field
with the information and tools they need to incorporate
evidence-based practices into their communities
or clinical settings. The resource center contains
scientifically-based resources including treatment
improvement protocols or TIPs. Toolkits, resource guides,
clinical practice guidelines and other science-based resources. Next slide. The treatment improvement
protocol or TIPs as we call them, series, provides science-based
best practice guidance to the behavioral health field. TIPs reflect careful
consideration of all relevant clinical and health service research, demonstrated experience, and
implementation requirements. TIP 63 reviews the use of the three Food and Drug
Administration-approved medications used to treat opioid use disorder, methadone, naltrexone, and buprenorphine. And the other strategies
and services needed to support recovery for
the people with OUD. It is important to link
health care providers, behavioral health treatment providers, and officials in law
enforcement and in corrections, to resources that will prevent
opioid overdose deaths. SAMHSA’s TIP 63 is one resource that can assist professionals,
providing assistance to those in the criminal justice system. Next slide please. This toolkit offers strategies
to health care providers, communities, and local governments for developing practices and policies to help prevent opioid-related
overdoses and deaths. This is an important resource for those that are working in the
criminal justice field with substance use disordered individuals that are at risk of overdose. Next slide, yeah. We list the resources that we mentioned. And thank you very much. (audience applauding) – [Lisa] We’ll take a five minute break and prepare for the next panel. – [Dan] Good afternoon, this is Dan Abreu from the SAMHSA national GAINS Center and I’ll be moderating
our last panel of the day promoting successful community re-entry. And it’s arguably one
of the most important areas of focus of the symposium today. There’s a study out of
the state of Washington following 30,000 inmates released, and within two years the death rate, mortality rate of that
cohort of individuals was 13 times that of the general population within the first two weeks of release. That study was later
replicated in Rikers Island and they found similar results. Re-entry, good re-entry
is actually a matter of life and death. And we know some things
about how to do it well. Maybe it’s the season of the year, but the analogy I like to use
is that good re-entry planning is a little bit like putting
up Christmas tree lights, there’s a lot of needs to consider. There’s health needs,
there’s substance use needs, there’s mental health needs. Then there’s housing and benefits. And if any one of those lights goes out, the whole discharge plan can break down. And we’re gonna focus today on three main areas, housing, benefits, and the specific needs of veterans. It’s important, again,
when looking at re-entry that you’ve got your programs in place immediately upon release. As soon as that step, the first footstep on the sidewalk. We know that recidivism is
highest within the first 90 days. And with the current opioid crisis, again, we want to make
sure that that transition from prison into those services for medication-assisted treatment are in place promptly upon release. So I’m going to introduce
our panelists now. So our first panelist will be Ryan Moser with the Corporation
for Supportive Housing, where he is the Vice President
for Strategy and Impact. And he’s responsible
for data and analytics, strategic alignment, and
impact investment portfolios. Next panelist. Kristin Lupfer will be talking about the SOAR Technical Assistance Center. She’s the Program Area
Director at Policy Research for the SOAR TA Center,
and she previously worked as the director of the
Georgia SOAR program. Marguerite Schervish
is a Technical Director for the Prevention and Treatment Team, and she’ll be talking about the important, the federal guidelines around Medicaid eligibility for incarcerated populations. There’s a lot of confusion
around this issue around the country, which is a barrier to getting those Medicaid services, and she’ll be addressing that
issue in her presentation. And lastly, Sean Clark, who’s
the National Coordinator for Veterans Justice Outreach in the United States Veterans Affairs. He will be speaking about the Veterans Justice Outreach program, and I’m pretty sure that
he’ll also be addressing the Health Care for
Re-entry Veterans Program which looks at the re-entry
piece of the veterans services, while the VJO is more, the
Veterans Justice Outreach is more of a front end piece. So I’m gonna turn it over to
our first panelist, Ryan Moser, to speak about housing. – [Ryan] Thank you so much Dan, and thank you to SAMHSA, and everybody for having me here today. I am Ryan and I’m extremely
happy to be talking to you about justice housing because
I work in a lot of different housing areas in looking
at behavioral health, health needs, aging needs,
youth needs across the board and thinking about how supportive housing in particular plays into those. But are nearer and dearer to
my heart than justice concerns. So next slide please. All right, so just to let you
know who’s talking to you, CSH is a national non-profit,
we’re an intermediary. We are a community development bank, so we finance supportive
housing with loans and grants. And we help design programs,
create public policy. We work in about 48 states
over the course of a year. Nationally we’re a federal
assistance contractor and we’re very deep in homelessness roots, but also in these other
feeder systems, like justice, that are so important to understanding housing and community service needs. Today I’m gonna try to just
set a baseline to think about what does housing and health look like around the justice population, in particular thinking
about behavioral health, and what does that need
feel like, how big is it. How does it differ and how variable is it across people and individuals and places. Right, and then I’m gonna
talk you through some models where we look at what does this look like in New York and Ohio. What are different models
for family reunification, how is Pay for Success
fitting into the mold. So that’s kind of the agenda
of where we’ll take it, and I’ll try to then help
you think about how to engage with communities and how this
can fit into your systems. Go ahead, next slide. All right, so there’s a ton
of conversation out there now. You have to kind of have missed the truck and fallen off of a different
one to not have heard about social determinants of health, right, everybody’s talking about
how important housing, jobs, employment, school are, in
order to get health outcomes in our struggling health economy. Right, but I’m here to tell
you that housing is also an equally important social
determinant of safety. Right, and when we think
about how people are involved in the criminal justice system,
the collateral consequences that accompany not having
housing, and extreme poverty, we look at this kind of cycle
of involvement that happens. We understand that housing
can be in every single point in the sequential intercept
a factor that creates greater complications and can
prevent people from recovery, can prevent people from
engagement effectively with employment or their families. Can prevent and disrupt
people’s housing status, right, can cause eviction and lease violations. And can in fact cause
further incarceration. Go ahead to the next slide please. All right, however, now
especially this is important if you’re thinking about this from either a behavioral health or
a criminal justice lens, right, but housing, if you have any conversation
with anybody coming out of jail it’s one of the top three,
right, maybe four issues that you hear about. So it’s either employment, or I got to get back
together with my family, or I need some transportation,
or it’s housing. Right, and those issues are
just always rising to the top as one of the cruxes. Housing is one of the
most challenging to fix because we have a culture
that has an exceptionally high rate of housing instability and high cost in the
housing markets, right, so we have a lot of housing
issues that are much broader than just the ones that we’re facing. Right, but we also need
to know that just because somebody has designated
that they need housing or says that they need housing doesn’t mean that that
housing need is all the same. Right, and the reality is
that when we look across different correctional facilities, different behavioral health facilities, there is very little consistency with the way we ask people about housing, how we use that data, and how we understand
what that need looks like. I think about housing need as a sort of a three-tiered bucket here, right, so that top piece is the low need, and that’s about half of
people that are coming back. And these are folks that
are probably gonna go back to family, to existing
housing settings, right. Maybe there’s been a disruption
but there’s not gonna be a major disruption,
they’ll be able to get back on their feet very quickly or
with limited supports, right. Those folks probably have
lighter behavioral health needs or other disabilities and issues
going on underneath, right. They have fewer complicating factors, they probably have a strong work history and are more likely to be able to re-enter with limited supports
in the community, right. The next set, and here it’s like 30 to 40% at a broad stroke. These are people with much higher needs at still what I would consider moderate. So there’s probably behavioral
health or mental health needs going on here, maybe
addiction issues, right. We might have a limited or
spotty education history, limited work history. Some disruption, could be
histories of lease violations or rent arrears, things
like that that are gonna be harder to fix when
somebody’s coming out, right. But the notion is that
maybe with some support over a period of time, or with some assistance
helping reunify with family, or with some assistance helping
somebody with rental costs in the beginning or with housing search, they may be able to get
back into the market without a huge disruption and
with short-term assistance and be able to pretty quickly
stand up on their own. Right, now that doesn’t necessarily mean that that’s a good
long-term stable situation, right, and so those longer issues related to housing stability
and access to treatment, all those things are gonna
continue to rear their heads. But it’s very different when
you think about the high need. And these are the folks
that CSH focuses on heavily. Right, so when I think about high need, I think about people that may have concurrent disorders going on. So severe mental health issues, a lot of disruptive addiction disorders, maybe physical barriers as well. Histories of trauma, long-term
involvement with systems, maybe long histories of homelessness or really sporadic housing, right. Probably little to no rental
history that’s effective. Maybe a whole list of arrears and different kind of credit
issues that will pop up if you ever do try to get into housing. And can create issues
related to employment and reunification with family, all sorts of other things too. Right, so that high need of the folks that I generally am talking about when I think of supportive housing. So it’s important to think about this need and this variation so that
when you’re looking at somebody coming out or when you’re
working with a community to prioritize limited resources, you can help them think
about okay you know what, let’s focus our supportive
housing resources on those with the highest need, let’s
build those partnerships. For moderate need maybe we can think about other housing supports and
resources we can bring to bear. Next slide please. So how big is the need, really, right, so we did a national needs assessment really for the first time two years ago looking at supportive housing
need across the country, and you can find this on CSH’s website. All the information is public
and available, csh.org/data. And you can sort by different systems. So this particular map that
I produced for the slide is showing you the jail population, or the jail custody numbers,
right, on a point in time at a daily census amount,
the prison census amount, and people in juvenile justice care, so young people in
juvenile justice, right. So that, when we look
at our need nationally, that’s about a quarter of
the supportive housing need that we think of, right. So I want to call that out
because when you think about the amount of time and energy that’s spent related to supportive housing
in the homelessness sector versus that in the
criminal justice sector, it’s nowhere near proportionate, right. The amount of people involved
with the criminal justice settings that have these deep
needs that are unaddressed, that really need long-term
community supports and services, is vastly outnumbering the effort and the resources that
are in place, right. So the overall need we see
around criminal justice is about 1.2 million on, or sorry, nationally around supportive housing across all the sectors that we look at, is about 1.2 million
on a given day, right. So that’s about the number
of housing need that’s unmet on any day in our culture, right. When you think about it,
there’s a quarter of that, so you got about a quarter million people that are falling into that
because of their involvement in the criminal justice system, or are showing up in the
criminal justice system because of those unmet needs. Okay, next slide please. All right, so (coughs) and
I’m sorry, I have a bit of a chest cold so I apologize
for coughing at you, but at least you get this
nice raspy voice of mine. Dan can tell you I normally have a little bit of a higher timbre. So you get a more pleasant
listening experience maybe, minus the cough. So FUSE, this is one of
our strategic initiatives. We call it a signature
initiative from CSH, we’ve been working on it. It’s what I first came to
work on at CSH 12 years ago, so it’s a long-standing program at CSH. And it basically was the
first program in the country that tried to use administrative data to look at the overlaps
between, at the time, criminal justice and jail in particular and homeless services and
looking at housing instability and find the people
that had those matches, right, and to help them get
into housing with services, and see what happened, right. And the postulate was, you
know what, if we do this, if we dedicate supportive housing and we go find these
folks and we recruit them, get them into housing, it’s gonna work. And I can tell you from the
early days of recruitment that was not a shared concept, right. So when we went out to many
of our tried and true partners to try to recruit providers
to work on this stuff, people laughed at us,
they closed the door, they said, you know what, this is great, but it’s an awful idea. These folks are never
gonna do well in housing. They don’t deserve housing,
they don’t belong in it, and they’re not gonna be stable. Right, we’re gonna be
wasting public resources. And this is a picture of
what one of those people looked like, right. So the purple that you see
here is time spent in jail, right, the blue that you see, and this is over a two year period, is time spent in shelter. And these gray periods, the
little bits that they show up are we don’t know, right. But I can guess and you
can probably guess too based on your experience
with these people, they might be in a detox facility or a residential treatment program, they might be showing up in a hospital. They might be doubled
up on somebody’s couch or living in an abandoned building, right. They might be showing up in
some other crisis service. They’re probably not showing up in a happy stable home life, right. So this is the person that
we went out and we said, you know what, we’d like to focus here. Instead of saying let’s avoid dysfunction and try to screen people out of housing, we flipped the script and said, let’s try to get people into
housing that need it the most, that have this greatest
sense of dysfunction, of disruption in their
lives, and see what happens when we create the stability of services, tied with the very affordable housing that they could actually afford to be in, which sometimes is almost free, right. So let’s flip to the next slide. Basically supportive housing
and FUSE aligns corrections and criminal justice need, it aligns services to
support behavioral health, community health,
community support services, and it aligns affordable housing. And it brings those together
in a case management model that is very tenant-centered,
very personalized, and it can include any of the services that you here see on this slide. Right, so it ranges everywhere
from family reunification or employment supports to thinking about how do you connect with treatment. Or engaging people about whether or not they would like to be in treatment or what other things
they’d like to focus on. Right, when Dan talked
about that death rate that happens right after jail, right, and it’s higher in the
two years following jail, it’s higher still in that
30 days following jail. A lot of that leads to
reintroduction of addiction and the severity of drugs
that are out there today, right, and the use that happens and the spikes in need
and tolerance issues. Right, a lot of it relates
to just frankly exposure. Failure to have access
to a stable place to be and the things that
follow from that, right. But it’s important when
you’re working with the justice population or
with people that are involved in the justice system, to say, hey we don’t just have to
know how to do housing. We don’t just have to know how to address behavioral health needs, we have to understand the
criminal justice system. We have to talk to people about what it is that’s gonna help them stay out of the criminal justice system,
meet compliance issues. We have to understand how to interface with their defense attorneys
if they might have one, or how to work with them to resolve a stipulation from the court. Right, we just have to
understand what the triggers that might be happening. And really good criminogenics
and risk-need-responsivity kind of goals, and I know
that you’ve heard about that from smarter people than me today. All right, so next one. Okay, so the amazing thing though, right, despite all of this concern and I don’t know if this’ll happen, and we placed the first
hundred people in this program, was that it worked. Right, despite those concerns, the people that took a
chance and they said, you know what, maybe these
folks aren’t so different. Maybe housing could make a difference for people that don’t have it. Maybe these community-based
services could actually turn the curve and break
the cycle of incarceration. Right, and so we saw that in
fact it reduced jail stays, it reduced shelter stays. And we’ve seen this over and over again in project after project. People get connected to
community-based care, they start using primary care services, they can engage in treatment. Some studies show reductions
in opioid use, right. So we see just a variety
of clinical effects. It doesn’t mean that
housing alone does that. Just sticking somebody in a housing unit doesn’t necessarily make the bridge. Just giving people money
doesn’t necessarily make it that they’re gonna be able to maintain an employment position, right. But when you appropriately
pair it with effective services that are savvy, that
understand someone’s need and that are driven and
directed by the tenant, you can see amazing things happen. ‘Kay, next slide please. Okay, so now I’m gonna flip through a couple of other projects,
right, so that was FUSE, and I’ll come back to FUSE at
the end again for a moment. But here’s one that’s
called Returning Home Ohio, and this is a project that we
manage that’s actually done with the Ohio Department of Correction and Rehabilitative Services. So ODRC, and this was
started, and one of the things that’s interesting about
it is that it became, it came into existence because
the commissioner decided you know what, we need
to invest in housing because I don’t want to
build another prison. Like, I am brushing right up
against the population numbers that I have and I can barely
contain our prison system, so I need to find out some alternatives of how I can get people out of my system, stop them from coming back, and get them out in the community, right. And so using that logic
he diverted funding from a halfway house program that they ran that was not effective and
didn’t get good results, which frankly a lot of times is the case with halfway housing. And they moved it towards
supportive housing and services in the community. And so CSH was brought in, we contracted with
community-based service providers to go find the housing,
help people access it, provide the community
supports in the community. Right, or the services in the community. And then we worked with the
Ohio Department of Corrections to look at risk assessments, think about how the criminal
justice risk assessments align with social need
and behavioral health need risk assessments in the community
and what it’s gonna take for somebody to be
stable after they leave. And the reality is that we
have had tremendous results with this program, it’s
really targeted heavily towards people with mental
illness and severe addictions, a lot of co-occurring disorders, right, and we see a really
good reduction in recidivism. We see strong increases
in services connection, particularly around addiction issues. All right, next slide please. Here’s another program in Ohio. This is called the Community
Transitions Program, and it’s run by a group called CareSource. CareSource is a behavioral
health managed care company, they’re a non-profit accountable
care organization in Ohio and they have the
behavioral health carve out. So they provide the services
on the behalf of the state for people that are poor, indigent, that need access to behavioral
health services primarily. Right, and so what they
do then is that they have this set up and we helped to generate this with the state government, but they have this set-aside
of resources that they use and they are focusing on housing as a way of addressing
their member’s needs. So they’re taking out of
the capitation that they get for their services, and they’re
pushing housing money out to try and reduce their need. Right, so this program is fascinating because it actually applies a couple of different
housing interventions. So it includes permanent housing,
supportive housing, right. And then it also has rapid re-housing, which is basically you can
think of it as bridge assistance in helping people adjust to a new access and adjust to a new apartment living, and they pulls away supports. Right, and then the last
piece is recovery housing. Which is actually not
very popular in the model, but Ohio has a very robust
recovery housing program and so that is an accessible
resource for people. Right, the way that people get into the different program distinctions is based partly on their needs assessment and how severe their needs
show up, and how they show up, and then partly on their
choice, so people get to say, you know what, I would prefer this model. And then the last piece is availability. So on the day that somebody
comes out they may or may not have access to the resource
that is their top choice, so they might have to choose
something else, right. The program has now housed over 600 people and has a 4% recidivism
rate after two years, or going on two years. Right, so we’re working with some folks around risk-needs-responsivity in Ohio, we’ve been training our staff to improve their criminogenic knowledge, and the folks that are
contracted under this program. And the folks that are doing
the risk-needs-responsivity have said, this is great, we’re so happy to be working with you
and building this in. Well love it and it’s a great response. And they’ve also said,
we also just want to be really careful not to
screw this program up because frankly you’re
getting better results than anything else that we’re seeing. And so we want to make sure
that as we’re adding in this layer of risk-needs-responsivity
in effectiveness and really doing it to fidelity, we do it in a way that
allows the flexibility that you have in your program
to address people’s needs and help them maintain their housing and their place in the community. Okay, so let’s go ahead to the next slide. Thank you, so this next slide is about family reunification really, and this is a pilot that
was done in New York City Housing Authority, and this
is for the folks that come out and about half of the
participants in this group are people that are young,
right, and they’re coming back and they can’t return to
their family because they have an exclusionary bar because they committed a criminal offense, they
were removed from housing, and arrested, right, and
now they can’t go back or their family will be evicted. So we worked with NYCHA and
a bunch of great providers to say what would it take
to bring these folks back. If we provided say six
months of additional supports and services for the family and for the person that’s returning. If the family has a chance to
say yes we do or no we don’t want these folks to come back, and they have the right to
be safe in their own space, can we work with you to
alleviate these restrictions and then maybe after a year
get them re-added to the lease and returned to the
normal living situation. So NYCHA said, yeah we’ll do
that, and they tried it out. And basically it opens the door for people that otherwise are unable
to access housing, right. And you just got to think
about that for a minute, right, ’cause a lot of people live
in public affordable housing that has restrictions like this, right. It would be akin to if you
in your family at your house got arrested, were taken away, and then your wife or your
father, or your mother, was unable to let you back
into the house that you live in because if you came back they
would all be evicted, right. And imagine the disruption
that causes just for a minute. And think about how impactful
an approach like this can be. And I bring it up to think
about how can you think about different innovative ways of
engaging with housing agencies to do this kind of work. Okay, next slide. All right, the last model
I’m gonna talk about, and then I’ll wrap up
with two slides from FUSE, is this Denver Pay for Success project. So we’re seeing a real
increase in impact investing and pay for success,
or social impact bonds. This is one of the projects
that we manage in Denver, right, and it’s placing about 250 people, primarily through scattered site, although through some set asides in larger affordable
housing buildings as well, into supportive housing with services designed to help them
maintain their stability. It’s targeted to people that
are chronically homeless and jail involved, right, because that was a real
pressing issue in Denver that they are having problems with, right. So you can see on the slide
what the measures look like in thinking about it,
but the idea here is that it’s pay for success, right. So as opposed to saying we’ll
pay you for what you’re doing, the program is required to show results, and actually demonstrate that people are in fact reducing their recidivism, people are staying out in the community, people are not returning to the shelter, they’re staying in the housing
that they’re supposed to be put in, or that they’re being
supported into accessing, right, and then those
payments that are agreed upon with the city in Denver are
issued based on that success, and that’s what repays. It also brings in private investment. So in this case some banks are investing and some foundations into a corpus that’s running the project,
right, those funds are used and then they’re replenished when we get the success repayments from the city. And then that returns the
money to private investors and if it’s successful beyond expectations they get a bit of a return as well, right. So it’s really tied to the
performance of the program. So this project is about to
offer its second success payment to investors, it’s closing
in on its second year. It’s exceeding its benchmarks right now, it was a little bit slow starting, but it’s running exceptionally well. And it’s really the second
program in the country that has has success
payments of this type. Right, so in all of the
conversations you hear about social impact investing in bonds, it’s important to know that housing, supporting housing in particular, is one of the first that’s
really able to show the success that’s needed to repay
private sector partners. Next page please. All right. So this was a bunch and sort
of drinking from a fire hose run of examples of different
ways you could think about engaging with communities and partners. But I also think about
FUSE as a process, right, and this is the one that we’ve laid out for that FUSE initiative that we work on. And really just kind of thinking about how do you engage communities. And we think about planning exercises. We think about pilots or testing or scaling small
interventions in the beginning in a jurisdiction to test them out, kick out the kinks in the
system, get it working. Right, and then we think about moving directly to scaling it,
start to think about how do you increase investment. And that’s where tools
like pay for success or federal or local legislation
come in to advance the work. All right, so this is
another thing you can access on our website, it’s all
up and public as well. Go ahead, next slide please. All right, and the last thing
is just that this is something that needs to happen at
a national scale, right. So going back to that need,
there’s a little bit over 30 FUSE projects that we’ve
helped launch and know about and that we sort of claim
as ones that we’ve been involved with across the country. Right now we have about 27 communities engaged in planning processes around this, through a learning collaborative that we’re doing nationally. Right, so for you in thinking
about your government role, the programs that you have, new resources that might be coming down the board from, down the pike from re-entry legislation, from opioid planning, we
really need to be thinking from a public sector perspective
around what can we do to foster these relationships. How can we make these connections happen. How can we support people to bridge data, bring partnerships together
to make this work, come alive. And I’m here to tell you it can be done. And next slide if we have one. And that’s it, so Dan
I’ll turn it back to you. – [Dan] Thanks Ryan and
first I want to reassure you that your voice timbre was just fine. And also want to say that we did
sequential intercept mapping, and you’re right, one of
the biggest priorities across communities that we
work in is always housing. But very often they’re stymied thinking it’s too big of an issue for the people in the room to address. And yet you’ve shown us a
lot of different strategies that break this issue
out into smaller pieces that communities can manage. So I hope it stimulates some partnerships and working with public
housing authorities and providers in the communities. One of the other keys
though to accessing housing, I used to oversee re-entry
from prison in New York state when we implemented a SOAR program, and when the housing providers found out that people were coming out
with Social Security benefits in place and they’d get the
check that first full month that they were in the housing program, that reduced a lot of
the barriers right away. So Kristin Lupfer from the
SOAR Center, SAMHSA SOAR Center is gonna talk about
implementing a SOAR program in criminal justice settings. Kristin? – [Kristin] All right, thanks
Dan and hello everyone. I’m very excited to speak
with you about how SOAR can be a re-entry tool for individuals involved in the criminal justice system. I’m gonna share with
you a little bit about the SOAR program, why it’s
important, and how it works. And I’ll share with you
how programs nationwide are implementing SOAR with
justice-involved persons. Next slide. So SOAR stands for SSI SSDI
Outreach Access in Recovery. But it’s not just about the applications, it’s about the role that benefits can play in really transforming lives. So SOAR is a SAMHSA-sponsored
program that’s really focused on increasing access to Social
Security disability benefits for individuals who are experiencing or at risk of homelessness, and have a serious mental
illness, medical condition, or co-occurring substance use disorder. And that at risk of
homelessness absolutely includes individuals who are
currently incarcerated, involved in the criminal justice system, and have no place to go upon release. SOAR is active in all 50 states and the District of Columbia, but each state is at a different
level of implementation. There is no specific
federal funding or grants for SOAR activity and
so the SOAR TA Center works with states and
communities to develop plans for implementing the program through technical assistance and training. Next slide. I wish that I could spend
a few hours, or even days, talking with you about SOAR, but they tell me I have 17 minutes, so I’m just gonna share a few
basics to whet your appetite. Social Security benefits
and programs are complex, and there’s a lot to learn,
so we’re gonna give you this taste and leave
you wanting some more. So the Social Security Administration has two disability benefits programs, Supplemental Security Income, or SSI, and Social Security
Disability Insurance, or SSDI. SSI is needs based and it’s for people who are blind, disabled, or elderly, and who have low income and resources. The federal benefit rate in
2019 is gonna be $771 a month. And SSI generally comes with Medicaid. SSDI is an insurance program,
and the benefit is based on payments that are made into
the Social Security Trust Fund through those FISA contributions
from your paycheck. And SSDI generally comes with Medicare after a two year waiting period. Next slide. It’s very important to understand how SSA defines disability. So the Social Security
definition is gonna be different than your doctor’s definition, your insurance company’s definition, and even the VA’s definition. SSA is looking for three
primary components. Do you have a medically
determinable physical or mental impairment that’s
lasted or is expected to last 12 months or more, or result in death. And do you have a significant
functional impairment that impedes your ability to work. So SSA wants to know if you are able to, despite these impairments, work and earn at a
substantial gainful level. And that’s measured at earnings of, in 2019 will be $1220 a month. This is not a short-term or
partial disability program. And having a diagnosis is not enough. Having a chronic condition is not enough. The illness or the
condition must be impacting the person’s ability to work. Next slide. So we talk a lot about
income and health insurance, and those benefits are
really essential bricks but only individual
bricks in the foundation for stable housing,
recovery, and wellness. So SOAR is seeking to end homelessness through increased access to these SSI and SSDI income supports,
and that really is essential. And for many persons in recovery accessing benefits is that first step. But like Ryan mentioned at the
beginning of his presentation the social determinants of
health are vitally important. And so SOAR extends beyond that and also encourages employment
as a means to increase individual income and promote recovery. And that sounds kind of funny
talking about employment when we’re talking about disability, but in fact they can work hand in hand. And so once a person has been approved for disability benefits,
that sense of accomplishment and relief, it can make us
feel like our work is done, but really it’s just the beginning. The income and health
insurance that are gained help ensure someone’s basic needs are met, but there is so much more to recovery. And so it’s a big piece
of what we encourage. And we know that helping
people stabilize in housing will help decrease incarcerations
and hospitalizations, reduce recidivism rates,
so it can make a div, excuse me, a big difference
in that stability. Next slide. So when we talk about
Social Security benefits for justice-involved persons it’s really important to
understand what happens when someone who is receiving
benefits is incarcerated, and how someone who is
incarcerated can access benefits as part of their re-entry planning. So because SSI is a needs-based program and SSDI is an insurance program, SSA handles the suspension and termination of each benefit program differently. So the table on the slide gives
you a little bit of detail about what happens to SSI benefits. So if you’re incarcerated
for less than a full calendar month there’s no
effect on your benefit. If you are incarcerated
for a full calendar month, one through 12, your benefit is suspended and you can be, your
benefits can be reinstated upon your release. But if you are incarcerated
full 12 calendar months, your benefits are terminated
and you have to reapply. And so it’s when individuals
are in this situation of needing to reapply for benefits because they’ve been terminated or because they’ve never received benefits or weren’t recently receiving benefits, that they need to do a
pre-release application. And the wonderful opportunity
that Social Security provides is that you can do a
pre-release application before someone is released from custody. The general rule is 30 days prior to their expected release date, but with pre-release agreements
that time can be extended up to 120 days prior to release. So by doing those
applications prior to release we can get someone set
up with their benefits, like Dan mentioned, have
that first check ready to go once they’re official
released in a community and get those rent payments
out and have money available to really help someone
have a smooth transition back into the community. Next slide. So for SSDI, another table,
it’s a little bit different. Because it’s insurance,
if you are incarcerated for less than 30 days there’s
no effect on your benefit, your check still comes. And not until you are both
convicted and confined of your criminal offense
are your benefits suspended. And there is no termination of benefits. So someone who was
receiving SSDI benefits, they can get their benefits
reinstated upon their release, no matter the length of
time of that incarceration. Next slide. So we know that it’s important to do pre-release applications for individuals who might be eligible for benefits, but how does SOAR work
and how can we actually make a difference in this regular SSI and SSDI application process. So we really focus on case managers actively assisting applicants to get it right the first time. We focus on documenting the disability, and forming support systems
and processes in communities to really make the
efforts more successful. And we do that through serving as the individual’s representative, collecting and submitting medical records, writing and submitting a
medical summary report, getting that co-signed by their physician. Doing a quality review of applications, working in collaboration
with Social Security. There’s a lot that kind
of goes into submitting complete and quality applications that really makes the difference. So we really say those
SOAR trained case workers are the heroes in the process. So it seems a little overwhelming, seems like there’s a lot that
goes into it, and there is. But we don’t want you to be overwhelmed because what we’ve done
is set up a really strong support system to support case
managers in their efforts. Next slide. So SOAR cannot and does
not function in a vacuum. We really rely heavily on
our community partners. So first and foremost the
Social Security Administration is really an essential collaborator. They’re the federal agency
that’s administering SSI and SSDI and because SSA is federal, their eligibility rules are
the same in every state. And SSA is the one who’s making
that non-medical decision on the claim. But it doesn’t stop there. So every state has a Disability
Determination Services or DDS that works in partnership with SSA to make that medical or
disability determination. And they’re often the unknown
player in the process, but with SOAR they’re
really absolutely key. Medical and treatment providers
are extremely important in terms of access to
assessments, evaluations, and the corresponding medical records needed to support the claim. And also we involve partners from criminal justice
organizations of course, and Veterans Affairs
and employment programs and housing providers to really ensure that the individuals
that are served by SOAR are receiving comprehensive
services and supports. So SOAR programs, we really
don’t want them operating in a silo, it’s not that you’re
going to this benefits shop, but really you’re going and
getting someone the benefits and stability that they need
to thrive in the community. Next slide. So we created this
organizational chart of sorts that you can tell is a
pretty flat structure, it includes the SOAR TA Center,
all 51 state team leads, hundreds of local leads, and
thousands of case managers. And we all have slightly
different roles and expectations when it comes to providing
training or answering questions, tracking outcomes, giving quality review, and assisting directly with applications. However we’re all kind of ambassadors for the SOAR initiative
and are really united in ending homelessness for individuals with disabling conditions. Next slide. So the SOAR TA Center provides support to states and communities both virtually and through on site support,
all supported by SAMHSA. We have liaisons who
are responsible for SOAR in multiple states, and who
build relationships locally to provide a real personalized service. We provide assistance
from strategic planning at the state level in
developing funding plans and key collaborations
with federal partners, to helping case managers with question 25 on the SSI application. If it has something to
do with Social Security disability applications, we
want to help make the process smoother, more timely,
and at a higher quality. So we offer SOARing Over Lunch calls for new and seasoned case workers to get their questions answered. We celebrate success
stories in our newsletter, we train local and state leaders
in our leadership academy and maintain a library packed
full of tools and resources for use by stakeholders at
all levels in the process. Next slide. So it’s through all of this
community collaboration and partnerships and the
hard work of SOAR-trained case managers that we’ve been
able to successfully assist over 39,213 people to get approved for benefits
on their initial application. And as you may be aware
the Social Security disability application’s pretty complex. So for unassisted applications from people experiencing homelessness, the average approval rate
on the initial application is only about 10 to 15%. And the national average
for all applicants isn’t much higher, only about 28%. Most people are, should be 29% this year. Most people are denied on
their initial application. However, if you go to the next slide, the national SOAR approval rate
is over double that, at 65%. And SOAR decisions are made in an average of 100 days in 2018. So there’s no more waiting one
and two years for an appeal. SOAR’s really about getting
it right the first time. Next slide. So 65%, that’s an incredible number. But what we know is
states that are utilizing all of the SOAR critical components can achieve an even higher approval rate. So our top 10 states which are doing that have an average 82%
approval rate right now on over 14,000 decisions. So they’re making a huge impact
and doing an incredible job. And not only is SOAR successful at getting applications approved and
transforming individual lives through that life-saving
income and health care, but they are also helping
communities and programs by bringing reimbursements and income into communities and providers. So we track Medicaid reimbursements and general assistance reimbursements, the back payments that
individuals receive, the other money that’s
brought into local economies, and it turns out to be millions
and millions of dollars and makes a huge difference. Which in turn states and
communities and local providers have utilized those outcomes to leverage for funding for positions. And so there are 347 full and part time SOAR positions nationally. Providers have shown that
their programs are effective. They’ve convinced funders to fund these dedicated SOAR positions. Next slide. So we’ve been working
hard the last few years to really expand our efforts
in criminal justice settings and have held technical
assistance opportunities for criminal justice providers. And so the two maps you see
here are the six facilities in 2017 and six facilities in 2018 that received our TA
Award where we went out and did onsite implementation meetings and prepared local leads and
helped get the facilities ready to implement SOAR in their institution or in their program or in their community, and have seen great success from this. Next slide. So just a few of our
criminal justice outcomes. So just pulling data from our SOAR online application tracking program, we’ve been able to see a cumulative total of 319 applications
assisted for people who were residing in correctional facilities when their applications were submitted. Their applications were decided
in an average of 79 days which is incredible, and have a 76% approval rate. So we know that we can
get applications approved on a pre-release basis for
folks who are in facilities. Next slide. So I have a few examples
that I want to talk through with the little bit of
time we’ve got left. So this is actually a program that Dan worked with many years ago, but we had a collaboration
with Sing Sing prison and a community services
agency in New York City where they were doing
in-reach with the prison. So staff from the community
agency would do applications for individuals who were
getting ready for release and so prior to their
release to the community. They had an incredible approval rate. 90% of the pre-release
applications were approved in less than two months. Many were approved prior to release and the rest were approved within one month of their release. So it made a big impact in getting people into housing directly from prison. Next slide. Our great SOAR and jail collaboration in Davidson County, Tennessee,
which is in Nashville, or Nashville is in Davidson
County, I should say. They’ve had a great
collaboration with their Mayor’s Office of Innovation
and the Sheriff’s Office and their Metro Social Services to implement an initiative with the jail. And their mission is really
to assist individuals who were experiencing homelessness
and didn’t have income, had a serious mental illness, to get them benefits
before they were released back to the community. And they’ve had great success with that, having a dedicated SOAR
case worker in their jail. Next slide. Next slide? I’m not sure if the slide advanced, I got connection problem notification. Confirm for me you still have my audio. – [Holley] Kristin, this is Holley, we’re on slide 243, SOAR Online Courses. – [Kristin] Okay, great, so if
you can actually go one back to the Oklahoma slide. Thank you, so we have a
incredible collaboration with the Oklahoma
Department of Corrections. They have a program that was funded by the Oklahoma Department of Mental Health and Substance Abuse Services where they have staff who
were trained to assist with accessing public benefits,
including SSI and SSDI, and they nurtured some
really great relationships with state and federal partners, they collaborated on a
number of re-entry grants. And this program has been going
on now for the past 11 years and their approval rates
have been greater than 80% and it’s made a really big
difference in their state. It’s been a great success. So next slide now, thank you. So the SOAR Online Course
is how you can get started. Some of you may have been
familiar with SOAR in the past. It’s been around now for over 10 years. And so we used to have a
two day in person training that was available, and
over the last four years SOAR training’s been provided online through the SOAR Online Course. And it’s really made a significant impact in standardizing the training,
expanding it to new areas, adding a practice application that’s really grounded the learning. So the course has seven
classes that include videos, articles, quizzes, and the practice case. Let’s see we now, since the end of October, we’ve
launched a child curriculum and are training case managers now to assist with child SSI claims. So SOAR has been focused
only on adult applications up to this point and we’re really excited about the expansion to include child SSI. Which would include youth involved in the juvenile
justice system as well. Next slide. So the course, like I said,
it’s online, it’s free, available to take anytime, anywhere. We estimate that it takes
about 20 hours to complete, including the practice case component. And successful completion
comes with 20 free CEUs from the National Association
of Social Workers. And that’s both courses individually. So if you complete both
courses, it’s 40 hours of CEUs. Yes, great, next slide. So we talked about it’s
comprehensive articles and content and this practice case component, which really make a huge difference in kind of confirming that
individuals have really learned and taken in the knowledge. Next slide. So I talked a few slides back about the criminal justice technical
assistance opportunity that we had the past two years. Well we are currently
accepting applications for the 2019 opportunity, so it’s a planning and technical
assistance opportunity that includes like I mentioned
an implementation meeting, leadership academy participation, and the online course and OAT. It just requires a three
to five page application, which you can access the RFA
on the SOAR Works website, and applications are due next
week so it’s not too late. Next slide. We have a number of SOAR and
criminal justice resources on the website, including a
really helpful infographic, and some sample tools and an issue brief you can access here. Next slide. So next steps, we encourage you to gather some more information about SOAR, consider incorporating
it into your services. And if you visit the SOAR website and go to SOAR in your state you can find your state team lead and
your SOAR TA Center liaison. So we’d love you to check out
the website and the course and reach out to us at
the SAMHSA SOAR TA Center for any questions you might have or if you’d like to make
a plan for using SOAR. And I think this last
slide has my contact, oh, no it doesn’t (laughs)
all right thanks so much. – [Dan] Thank you, Kristin. So staying with the benefits theme here we’re going to move to
Marguerite Schervish who’ll be talking about the
Center for Medicaid Services guidance to states around Medicaid and incarcerated individuals. Again, another really important component in re-entry planning, without Medicaid, some kind of insurance coming
out of jails or prisons, you’re denied access to medication and prompt services very often. So this is not as well
understood across the country as it needs to be, especially
with the Affordable Care Act expanding Medicaid to inmate populations. So Marguerite, lead us
through your presentation. – [Marguerite] Dan, I thank you very much for your introduction,
I have to call back in on a different phone, I apologize. I’ll do that promptly. – [Man] Maybe we should go on to Sean? – [Woman] If you want to. – [Man] Huh? – [Woman] If you want to, yeah. – [Man] Yeah? – [Dan] You want to cue Sean up? Sean are you ready to
move up your presentation? – [Sean] Sure Dan. – [Dan] Okay, we’ll start with you in the interest of time and we’ll have Marguerite talk at the end. So certainly talking about re-entry and jail diversion we want to emphasize the
importance of the need of veterans and so we’re gonna look to
you to guide us through that. Sean Clark. – [Sean] Well thanks very much Dan, and thanks to our hosts for the chance to be a
part of the discussion this afternoon, and to all
of you for your interest in services for justice-involved veterans. I want to take some time
and highlight VA resources that are available to
veterans who are engaged with different arms in the
criminal justice system. And in particular talking
about two outreach programs here at VA that are designed
to facilitate access to those services for those
veterans in those settings. So as Dan mentioned in the introductions, there are two justice programs here at VA and I will be talking about both of them. I just want to note at the beginning that our outreach programs of course aren’t an end in themselves, and the point of them both
and of everything that we do in these programs is
to go out in the world, find justice-involved veterans
who have access to the serv, who have barriers to
the access, excuse me, to the services that we offer, and help those veterans get
connected to the services that are appropriate
to them as individuals as quickly as possible. So that’s what animates
everything that we do in these two programs. And if we could go to
the next slide please. This graphic comes to us from
the Department of Justice’s Bureau of Justice Statistics, and they are the authoritative source on the overall population
of justice-involved veterans in the United States. So we can talk, and I
will in a few minutes, about the justice-involved veterans who we have contact with in our programs, but BJS is the gold standard as far as determining the number of veterans
who are incarcerated in prisons and jails across the country. This information comes from
their most recent report on veterans in prisons and
jails, it was published in 2015, and it includes data that was
gathered in 2011 and 2012. And the declining curve here
kind of tells the story. This is BJS’s estimate dating
back now close to 30 years of the number of veterans
in prison and jail, excuse me, not of the number,
but of veteran’s share of the overall US adult
resident population and of their share of the US
prison and jail populations. And as you see that has been declining since BJS has been looking at this number starting in the late 1970s. And now, as has been the
case since they looked in the late ’90s, veterans
are underrepresented in the prison and jail
populations compared to their prevalence in the
overall US adult population. The overall number of
veterans in prison and jail as of 2011-2012 according
to BJS is 181,500. So if we move to the next slides, we can get another perspective on that. This is the incarceration rate
of veterans and non-veterans over that same period. So a different angle to look
at this question through. The incarceration rate for
veterans has also been declining since the late 1990s as you can see here. So taken together, these
pieces of information really are good news. Veterans are not over-represented in the criminal justice system, I think that’s a misconception
that is still out there to a significant extent. In fact, they’re under-represented
relative to their size as a general population. And they’re incarcerated at lower rates than their non-veteran adult counterparts. All that said, 181,500 is a huge number. And when you think about it in
terms of 181,500 individuals each of whom faces a unique combination of challenges and barriers
to successful functioning when they return to their communities, the task appropriately seems
as huge as it really is. And if we could move to the next slide. Picking up on the point
that Ryan made earlier in the discussion, a significant
part of the reason for that is because of this nexus between incarceration and homelessness. And you see here a few points about that issue, starting with Martha Burt
and her colleagues finding that incarceration as an adult male, and of course that’s the vast majority of the VA service population, is the single highest risk
factor of becoming homeless. I think that it’s intuitive when you think about
long-term incarceration, so going to state and federal prison, spending a period of
years at great distance from family and other social supports, it makes sense that inmates
coming out of that situation would face an increased risk
of becoming homelessness because all of your social
ties and your resources have eroded during a long period of time. I think that’s easy to grasp. I think what’s often
harder for folks to realize is that it doesn’t take very long at all for incarceration to really threaten your housing stability
for a variety of reasons. Losing a job after not turning
up for a couple of days, losing your ability to
maintain your housing for nonpayment of rent after
a very short period of time. And so that’s always a point
that we try and keep in mind. It’s not just long-term incarceration that bears on folks’ risk
of becoming homeless, it’s the fact of incarceration itself. And so looking at it through that lens justice involvement of any
kind is a potential risk factor for incarceration certainly, and by extension for homelessness. So as Dan mentioned as well, another good point that’s not on the slide but worth making for
sure is that the risk, the link between re-entry
from incarceration and suicide risk is
becoming clearer and clearer all the time. These are two of VA’s
absolute top priorities. Suicide prevention for veterans is VA’s very top clinical priority, and homelessness has
been the focus of a major national initiative in
VA for several years now. So from a VA perspective, justice involvement is
an outreach priority because we’re trying to connect
with veterans who are facing increased risks of
catastrophically bad outcomes on a number of fronts. So if we can move to the next slide. Thank you, so taking a step
back and looking at our agency I want to talk for just
a moment about what VA, what VA is in the very broadest sense. The US Department of Veterans Affairs and many different organizations
go by the name VA, there are state department
of veterans affairs that also of course serve
veterans but usually have a very different array
of services and benefits that they have to offer, they work with veterans
in a very different way. There are county veterans service offices all over the country. There are also veterans
service organizations that are separate, but the US
Department of Veterans Affairs is made up of these three main components. First is the Veterans
Health Administration, which is an integrated
national health care system for veterans, it consists of 170 flagship facilities,
the VA medical centers, over 800 outpatient clinics that vary significantly
in size and capacity. Some of these are very small and offer a limited range of services. Some of them you’d have a very hard time distinguishing from a hospital. And also 370 Vet Centers,
which are storefront operations that are separate from the
main VA health care facilities. They offer a focus on
counseling provided to veterans who have experienced combat, more often than not by counselors who are themselves combat veterans. So it’s a part of the
VA health care system but a very distinct part. And in fact Vet Center counseling
records are not visible to clinicians in the broader
VA health care system. So that’s an important and
again a distinct component of the health care system. These services, as I mentioned, it’s a national integrated
health care system, this is a comprehensive
array of health care services that are available to
veterans through the VA. So primary care, mental
health, substance use disorder, and a list of services that goes on and on and is too long to cover in its totality. But the array of services
that are available to veterans through the VA health
care system is very broad. And VA’s definition of what
constitutes health care is itself broad. So VA’s homeless programs for example are located in its health care system. Indicating a holistic definition of what makes up health care. Second is the Veterans
Benefits Administration. And VBA administers benefits
that I’m sure many of you are very familiar with, and these are primarily
financial in nature, but not exclusively. The GI Bill and other education programs, those are administered by the Veterans Benefits Administration. Also, financial programs
like disability compensation. Pensions, life insurance,
the VA home loan program, vocational rehabilitation
and others as well, this is a partial list. But that’s a separate administration within the US Department
of Veterans Affairs. Last and not least is the
National Cemetery Administration which administers we see here
over 130 national cemeteries, provides funding for state,
for veterans cemeteries that are operated by the states, and also provides some of these
services that you see listed for veterans who are
buried in any cemetery across the country. So those are the three
main components of VA. And if we could go to the next slide. Within the health care system are the Veterans Justice Programs, and I won’t read our mission
and vision statements to you, but I’ll just say again
that we are a part of the homeless programs in
the VA health care system and I’ll pull out a few
key notes from this slide to give you a sense of what we’re about. Our mission leads with
the need to identify justice-involved veterans. That is something that has
not been done historically in many places in the
criminal justice system. Fortunately that’s
changing and it’s becoming much more common for local
law enforcement departments, for local jails, state
and federal prisons, to systematically try and identify the veterans who are passing
through their systems in order to identify them
and potentially determine their need for services and
hopefully partner with us to be able to connect veterans to those at the earliest possible point. The second key concept here is outreach. These are both outreach programs. We’re not working
strictly behind the walls of the VA medical centers in the communities that we’re serving, the staff in these programs are going into criminal justice
settings and so to speak taking VA to veterans where they are. And helping them access what they need. Access itself is the next key concept, this is the point of all of our work, connecting justice-involved
veterans to the VA services that they’ve earned as soon as possible. And partnerships are, hard to overstate the
importance of partnerships. We are entirely partnership dependent in veterans justice programs because the work that our
staff do when they go into local jails, state and
federal prisons, local courts, we’re working in settings where
VA has no right of access. We can’t demand to get into
a state prison, for example. That has to be worked out
by building a relationship and maintaining that
relationship over time. So that our staff can get
into these facilities, can make contact with
justice-involved veterans and start working on helping
them get what they need. Our vision here as you see, which I won’t read to you either, access to services for all
justice-involved veterans, avoiding homelessness and over time disentangling from the
criminal justice system. And if we could go next. A very familiar graphic, or a take on a very familiar
graphic I’m sure for everyone. I’ve included this to
make the point visually the the VA’s justice
programs really are intended as an off ramp into treatment
from every intercept point on the famous sequential intercept model. This graphic itself is a creation
of Department of Justice’s National Institute of Corrections and although there are
some additions to it here, some modifications, it’s
lineage is very clear, it’s obviously built on the
work of Drs. Munetz and Griffin. And this is a tremendously
useful tool to us in part just to help explain
what it is that we do and to show that we’re
intending these programs as a presence for VA at each
stage of a veteran’s progress through the criminal justice system. And if we could go next. So here side by side are a few details about these two programs
that I’ve been talking about, and the first thing that you’ll see is there are a lot of similarities. We’re providing, a good way to think about it is, one intervention that’s being
provided along a continuum that has significantly different features. It’s very different to work with a veteran who’s going through a local
treatment court program when compared with working with a veteran who’s coming out of a federal prison after serving a 20 year sentence. But broadly speaking,
Veterans Justice Outreach is the program that addresses veterans who are at the front end so to speak of the criminal justice process, and VJO specialists
again work with veterans in local courts, local jails, and they also provide outreach and information to local law
enforcement agencies as well. We want local law enforcement who are there at the
very front of the process to be as informed as possible
about the VA services that are available for
veterans in their communities and hopefully to avoid
negative consequences where those can be avoided
in crisis encounters. Health Care for Re-entry Veterans or HCRV is the state and federal
prison outreach program that you see detailed here
on the right hand side. Again, the basis function
of both of these programs is to conduct outreach
in justice settings, assess veterans needs, and help them connect to those
services as soon as possible. There are a couple of key
differences here, one is size. The VJO program is considerably larger than Health Care for Re-entry Veterans, and in fact we’re gonna be adding another 50 VJF specialists
to the program this year. But when you think about
it that makes sense. Given the size of these components of the criminal justice system. So there are over a thousand
state and federal prisons across the country, but
with more than 3300 counties across the US, VJO specialists are working primarily at the county level. Each one of those counties
has a local court system, most of them have local
jail systems as well. So VJO ends up being
the much larger program and one that’s continuing to grow. So if we can go to the next slide. So what do we know about the veterans that we’re serving in these programs, and what we can do for them,
is this outreach productive? What’s the result of all this? The first thing that we’ve learned, and an important thing that we’ve learned is what a high need population this is. The levels of mental
health and substance use disorder diagnoses among veterans who are served by these
programs is more than double the rate that we see in the
overall VHA patient population. And particularly striking, I
won’t rattle all these numbers off to you, but particularly
striking to me is the fact that in the VJO program more
than half of the veterans who we serve go on to
receive both a mental health and a substance use disorder diagnosis. So our average veteran is dually diagnosed in the VJO population, so
this is a group of veterans with a significant level of needs and they’re often a clinically
complex population to serve. The news on access is good. The veterans who we
serve in these programs are accessing responsive
VA treatment at high rates, again compared to the overall
VA patient population, and they’re staying engaged
with that treatment over time. At lower rates, but rates
that are still robust. So the short version of all of this is that this outreach is
serving the intended purpose, that we’re finding the veterans in criminal justice settings
who need these services, and we’re successfully
helping them connect to them and to stay connected to them over time. Next please. – [Dan] Sean, I’m afraid I’m
going to have to interrupt. We need to move on to our next panelist in the interest of time. Are there any last comments
that you’d like to make? – [Sean] Oh, sure, I
will close and just say that my final slide, if
we could pull that up is probably the most important one because this is contact
information for myself, my colleague Jessica
Blue-Howells in the HCRV program. And critically, local
staff in the two programs at sites across the country. So please feel free to share
that with any communities that may be interested in partnering. Thank you. – [Dan] Thank you Sean. And again, I apologize for
shortening your presentation. Marguerite are you back on the line? – [Marguerite] I’m back and
I thank you and I apologize. I’ll be as quick as I can. I’m Marguerite Schervish
and I work for Medicaid in the federal government, and
what I’m going to cover today is when can Medicaid pay
for health related services to persons after they are
released from incarceration. So first, I’ll go to the next slide. I will go through the definitions briefly. An inmate is a person living
in a public institution. That’s not a very helpful definition, but a person could be an adult or somebody under age 21, which we consider a child. Now the public institution
is an institution that is the responsibility
of a governmental unit or over which a governmental
unit exercises control, and it includes various types
of correctional institutions. Next slide. Medicaid cannot pay for care or services provided to inmates of
a public institution when they are in that institution. However, next slide please. There is an exception. And the exception to when
Medicaid can pay is if the person is admitted to a hospital,
a nursing facility, an intermediate care facility for individuals with
intellectual disabilities, or a psychiatric residential
treatment facility. Next slide. Let’s see, the only thing I
want to comment on this slide is that there are Medicaid requirements that are going to have to be met as with any service there
are Medicaid requirements and these are a few of the
ones that would have to be met for somebody to get coverage of services. Next slide. Okay, eligibility and enrollment. I’m not an eligibility expert,
but I got a couple of slides from our eligibility staff. Incarceration in and of
itself does not disqualify an individual from
Medicaid eligibility, and it’s our preference that
the Medicaid eligible person who’s incarcerated is
placed in a suspended eligibility status or a
suspended coverage status, because it’s easier to
re-activate their Medicaid when they are re-entering
into the community. Next slide. That’s is an important slide, ‘kay. This one tells you all the instances when the exclusion no longer applies over and above the admission
to a medical institution. Basically all four of these instances, what they have in common is that the person has been released. They’re on parole, they’re on probation, they’re on home confinement, they’re voluntarily residing
while other arrangements are being made for them to transfer to a community residence, or they’re living in a halfway house. Next slide. The halfway house situation
is where the person has freedom of movement and association according to the tenets that
are listed there on the slide, and states make this determination
on a case by case basis. Medicaid and the federal government don’t make these determinations. So a halfway house again is another time when we will pay for services, Medicaid-covered services that a person may be eligible
for in a particular state. Next slide. I only want to mention this institution for
mental diseases exclusion because if a person is admitted to a psychiatric facility, they may run into another
exclusion where we couldn’t, where Medicaid could not
pay for their services in what we call this
institution for mental diseases. Next slide. But there are two
exceptions when we will pay. It’s when somebody receives
psychiatric services and they are under 21, and the facility complies
with all the requirements that are listed here on
this slide, slide 258, or when the person is
65 or older in an IMD. Again, when one of the facilities listed meets our federal requirements. Those are two exceptions when we will pay for someone receiving care and services in what we call an IMD. Next slide. I’m gonna go right to the
caution on this slide. Even if an inmate is an inpatient admitted to a qualified
medical institution, if the facility is an IMD, i.e., they’re not in
one of those exceptions, we cannot pay for services
provided to that individual in that institution because it’s an IMD. Next slide. This just says that
Medicaid can help pay for administrative matching when help is needed to help people
in prison apply for Medicaid or to reactive their Medicaid eligibility. Next slide. Here’s two resources. Our State Health Official
Letter basically goes into much greater detail than I did just now. And then the State Survey
Agency Director letter should be read in
conjunction with the Medicaid State Health Official Letter. Next slide. And I think that’s it, and
that’s my contact information. Thank you all. – [Dan] Thank you Marguerite. Just one caution to states. Even where, what we’ve found is, even where there is legislation that allows for Medicaid suspension it’s important whether
you’re a local official or a state official to follow up on how well
that’s being implemented. We’ve found very often that there is Medicaid suspension allowed
but it’s poorly implemented, so Medicaid is still
terminated very often. So it’s important to follow
through on implementation of a lot of the things
that Marguerite addressed in her slides. That concludes the symposium today. I’d like to turn the final session to Dr. Larke Huang, who’s gonna do some
wrap up comments, Larke. – [Dr. Huang] Well I started
out today saying good morning. I think I should say
good evening (mumbles). This has been an incredible symposium. And it’s been kind of like a marathon seven hour webinar, so. I can’t thank people enough
for sticking with us today. I think we had about 500 plus people with us throughout the day. I want to say kudos to
our technology folks. I was very concerned that we
would have technology crashes, but other than a clicker that has some
synaptic difficulties we were fine. I want to very much thank our presenters who came on at the right time, speaking on the right subjects. That was also quite a challenge as we were across three
or four time zones. I think this has been an incredible information-packed event. I feel like I’ve sat through
a semester of classes in this one day. And thought I knew a lot, but I realize that I didn’t
know so much, and learned a lot both from the community examples, things going on in the
states as well as from our federal partners, and the
myriad of resources available. In thinking back to where we
started with Pete Earley’s tremendous story of his very
tortuous travels with his son through various behavioral
health and criminal justice and community support
or non-support systems, and listening to what we heard over the five panels,
six panels we had today, I think we have pieces of
exemplary programs and resources and work and practitioners
in different arenas that if there was some way we
could piece it all together we would actually have the beginnings of a true perhaps continuum of care. Our objectives in starting out were to really share information
about what’s going on at the intersection of
criminal, juvenile justice, and behavioral health. I think we learned a lot about that. But our second two objectives, one looking at innovative
and exemplary programs, and resources, were really
to not just pound into us that we have problems and
we have a broken system, but in fact we have programs that work. Real innovative programs
across the country that we need to learn more about, and figure out how we replicate them, modify them for different
communities and scale up. And then certainly the
federal resources available from our different agency partners, or within HHS and across departments. I don’t know if anybody knew about all of those resources available. So I want to say that in
terms of some of the questions that came in there was a theme of can I get more information. And there were quite a number of questions that came in as well. So for those of you who are
registered for this symposium you will get an e-mail from us that’s requesting feedback
on this day long symposium. What worked well for you,
what didn’t work well. What you found helpful, other topics you would
like us to do this on. Maybe not seven hours at
a time but other topics that you might want us to
focus on and share resources. So please look for that e-mail, and I believe the questions that came in that we couldn’t in this
format directly address, we will triage them out to our experts and to our PRA experts,
to our federal experts, to get responses to you as well. In terms of just a few closing themes other than the fact that
people really had stamina to go through this day, what struck me is that in
listening to the innovations and even listening to
the resources available, we’re not talking about needing a vast infusion of new resources. We heard a lot about people redeploying, re-scoping, re-using existing resources in their counties or in their states. We heard a lot about the
need for political will. That there maybe had been
some mandate from the state to reduce jail involvement,
particularly of people with SMI, and that gave leverage to people to do things in their counties. We talked to you about eight principles that SAMHSA has developed
with its partners. And probably the principle
I heard constantly running throughout was collaboration. Collaboration in different
configurations of parties. Listening to the collaborations
that Ryan Moser talked about through the supportive housing work. Listening to the collaborations
that Johnson County, Kansas talked about in terms of shared data. Listening to the collaborations
that are really intended by the CIT program from Ron Bruno. That was a constant theme, and how do we really
look at the whole realm of players and we all have our own system and we put ourselves at
the center of that system, and our collaborations. But then that means we have to layer on with other systems that
might be centered on housing, or centered on school-based programs. And really think, how do we really advance
these collaborations. I also heard a lot about
refocusing, reinventing our crisis response model,
and what does that mean from the perspective of law enforcement. What does that mean from the perspective of health, of behavioral health. We heard a lot about
clinical types of work and screening and assessment, but we also heard that that’s necessary but maybe not sufficient. That we also have to pay attention to such things as benefits and coverage and clearly social determinants of health. And the one that was running through a lot of the presentations was housing. So I don’t want to keep people any longer. I really want to thank
our federal partners, thank my SAMHSA colleagues, thank very much our
GAINS SAMHSA GAINS Center and our colleagues at PRA. PRA, you did a tremendous job and I know you’ve had two of your staff glued to the computers making
sure everything went smoothly. We want to hear from those of
you who participated on it, maybe you’ve hung up by now, but any of you who are still there, please send us your
feedback so you can know did this format work for you, and what could be future topics. Anybody in the room,
anything else that we need to think about or did I forget
any messages or reminders? Okay, so I want to say terrific. We pulled this off and
congratulations everyone, and thank you all very much
for the work that you do. Thank you. (audience applauding) Are we off? (muffled speaking and laughing) – [Woman] Pull it together really fast. – [Woman] Are we done, are we offline? – [Man] Yes.

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