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The Sequential Intercept Model

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Presentation on theme: "The Sequential Intercept Model"— Presentation transcript:

1 The Sequential Intercept Model
Leah Vail, MA Forensic Program Director Meridian Behavioral Healthcare, Inc. Presenter Jim Santangelo, CAP Alachua County Court Services Clinical Programs Manager Co-Presenter

2 A Request Please turn off your cell phones, Blackberrys, Beepers, I-phones, Pagers and gameboys Or place on silent mode

3 Training Agenda A. “Criminalization of the Mentally Ill”
B. Model Basics -It’s history -It’s use B. Sequential Intercept Points C. Alachua County Discussion

4 Impact of Consumers in the Criminal Justice System
Current estimates suggest that as many as 700,000 adults entering jails each year have active symptoms of serious mental illness and three quarters of these individuals meet criteria for a co-occurring addictive disorder (GAINS, 2001)

5 General Involvement in the CJ System
In 2005, over 7 million people were on probation, in jail or prison, or on parole at yearend – 3.2% of all U.S. adult residents or 1 in every 23 adults. (Bureau of Justice Statistics) In 2001, the U.S. incarceration rate of 690 per 100,000 overtook Russia (670/100,000) to lead the world. Then by 2005, the rate had risen to 726/100,000.

6 Mental Health Involvement in the CJ system
People with a Mental Illness are charged, convicted, and sentenced than more severely than others accused of similar crimes (Hochstedler, 1987; NY State Office of Forensic Task Force, 1991) People with a Mental Illness spend 2 to 5 times longer in jail than those without MI (Criminal Justice/Consensus Project, 2003)

7 Alachua County Jail Alachua County Jail: between 10 and 25% of the detainees received psychotropic meds ( CJMHSA Planning Group).

8 Alachua County Jail According to Jail statistics, 36% of all detainees at first appearance had either an open or previous SA or MH case. Approximately 5% had an open case, 23% had previously received MH and/or SA services as an adult, and 9% had treatment as a child.

9 The Alachua County Story
1998 – County Committee begins to identify MH/SA as reasons for growing jail population Consensus that treatment is important Partnership solutions sought 2000 – Mental Health Court established 2003 – Crisis Intervention Team grant written – Felony Mental Health Court (Div V) established – Community Based Competency Restoration program established 2005 – CIT classes started – In-jail to community competency restoration – County created Mental Illness Workgroup (“MIWg”) to identify needed services and develop strategic plan for effective jail diversion system.

10 The Alachua County Story
2006 – MIWg report leads to funding for enhancing existing competency restoration program and creating a “Forensic Specialist Team” 2007 – Meridian Forensic Specialist Team started -County Commission created CJMHSAG Planning Committee Official County advisory Board charged with responding to grants and other funding opportunities Resulted in award of 3-year $2million grant that is a county and state partnership. 2008 – CJMHSAG awarded funding creating the Forensic Diversion Team. 2010 – CJMHSAG awarded continued funding by merging the MIWg and CJMHSAG teams to create a comprehensive Forensic Team.

11 Public Safety Coordina-ting Council Courts (Judges & Staff)
Partners since 1998 Public Safety Coordina-ting Council MH/SA Providers Law Enforce-ment County Govern- ment (Elected & Staff) State’s Attorney Courts (Judges & Staff) Public Defender

12 Tools for Transformation: Alachua County’s Partners
Court System, Judges, Administration Office of Public Defender, Office of State Attorney, Regional Council Alachua County Jail Law Enforcement Court Services Meridian V.A. SAMH/DCF State Hospitals – FSH, NEFSH, NFETC Agency for Persons with Disabilities FACT team Gulf Coast Home Alachua/Gainesville Housing Authority

13 A systematic approach to the criminalization problem
There is no single solution to the problem we are calling “criminalization of people with mental illness” Cecil’s Story

14 What is the Sequential Intercept Model?
“Framework for thinking about how and where diversionary alternatives might best fit a community” Marc Cherna, Director ALLEGHENY County Dept. of Human Services, Pitt, Penn

15 Basics of the Sequential Intercept Model
A conceptual framework for communities to use when considering the interface between the Criminal Justice and Mental Health systems. There are a series of points of inceptions at which an intervention can be made to prevent individuals from entering or falling deeper into the criminal justice system.

16 More Basics of the Sequential Intercept Model
People with mental disorders should not “penetrate” the criminal justice system at a greater frequency than people in the same community without mental disorders. Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point.

17 Final Basics of the Sequential Intercept Model
The deeper that people enter into the system costs more time, money, and energy. And the harder it is to exit them from the system. Think of the model as a funnel Handout

18 Why is this model important?
State of Florida made it central to the CJMHSA grants SAMSHA Best Practice

19 Five Stages of the Model
1. Current Services (prevention) & Emergency/Police-Based Response 2. Initial Hearings and Initial Detention 3. Speciality Courts 4. Re-Entry to the Community from Jails and State Hospitals 5. Community Corrections and Community Support Services

20 1. Current Community Mental Health Services
Outreach Treatment & Medication Case Management Housing Transportation Meaningful Daily Activities Crisis Services

21 Treatment & Medication
Mental disorders are treatable. For most mental disorders, there is a range of treatments Rehab Services/Case Management Therapy Pharmacological 1st generation medication Newer medications

22 Consequences of a Lack of Treatment
The consumer falling into a crisis More Vulnerable Involvement with LEO CSU admission Criminal Charges

23 Case Management In general, the more specialized, the more intensive services are better Forensic Specialists (ave caseload of 35) Intensive Case Management (caseload of 10) FACT services (team approach, max 100 clients) Traditional Case Management (caseload of 30) VA - MHICM

24 Housing The importance of housing cannot be over stated
IDEALLY, the community has a range of housing options, including Residential SRT AFP ALF Housing vouchers Homeless Assistance Programs

25 Transportation Bus system/passes
Are there bureaucratic barriers interfering with staff transporting consumers? Medical transport Medicaid transportation

26 Meaningful Daily Activities
Employment or vocational program Psychosocial Rehab Education Volunteering Clubhouse Peer activities Drop-in Center Partial hospitalization

27 Crisis Services Emergency screening services CSU or receiving centers
How many beds does your community have? Public CSU vs. Private CSU How easy is it to access these beds? Educating LEO re: the Baker Act Involuntary Outpatient Commitment

28 If treatment is so effective, then why are so few people receiving it?
Less than a third of adults with a diagnosable mental disorder and even smaller proportion of children receive any mental health services in a given year (Surgeon General report) Stigma Fear of being hospitalized Cost Organizational barriers - No access Not having the time Thinking that they could handle it alone Thinking that no one could help Denial –lack of insight into illness Side Effects Substance Abuse

29 1. Emergency/Police-Based Response.
“Law enforcement agencies have played an increasingly important role in the management of persons experiencing psychiatric crisis” Lamb et al (2002) 7 to 10% of patrol officer encounters involve persons with mental disorders. Historically mental health and law enforcement have not worked closely together.

30 Emergency/Police-Based Response.
The prototype of the specialized police officer approach is the Memphis Model Crisis Intervention Team (CIT), which is based on collaboration between law enforcement, the local community mental health system, and other key stakeholders. CIT has lower arrest rates, high utilization by patrol officers, rapid response time, and frequent referrals to treatment.

31 CIT in Florida CIT Mobile Crisis Team (Tampa,FL)
Emergency/Police-Based Response a Rural and Multi-Jurisdictional Crisis Intervention Team Enhanced mental health, crisis intervention, system awareness at the police academy

32 Emergency/Police-Based Response:Alachua
CIT started March 2005 Steering Committee contains representatives by GPD, ASO, UPD, DCF, Meridian, NFETC, Alachua County Crisis Center, VA Three classes per year *Alachua County Crisis Center, CAREs Team, Crisis Hotline, Therapy *Mental Health Training for 911 operators *Mental Health and BA Training for LEO

33 2. Initial Hearings and Initial Detention–
Even when optimal mental health service systems and effective pre-arrest diversion programs are in place, some individuals with serious mental disorders will be arrested. On the basis of the nature of the crime, such individuals may be appropriate for diversion to treatment, as a condition of pre-trial release

34 Initial Hearings and Initial Detention–
Post arrest diversion procedures may include having the court employ mental health workers to assess individuals after arrest MH workers advise the court about the possible presents of mental illness and options for assessment and treatment. Courts may develop collaboration with the public mental health system, which would provide staff & services

35 Initial Hearings and Initial Detention : Alachua
Several points of initial contact at Booking In and First Appearance: Jail classification Jail Mental Health Centralized Screening Team – Court Services First appearance staff – judges, attorneys

36 Initial Hearings and Initial Detention : Alachua
Individual then are screened for services: MH Court Court Service Supervision, Day Reporting and Treatment Meridian Forensic Services Potential Div V cases Veterans Services Drug Court

37 At Sentencing Want the Judiciary to be informed at sentencing to make sure that the appropriate conditions are established

38 3. Specialty Courts– Incept 3 intervention that is receiving attention are the establishment of separate court programs specifically to address the needs of persons with mental illness. Special jurisdiction courts limit punishment and instead focus on problems solving strategies and linkage to community treatment to avoid further involvement in the criminal justice system.

39 Specialty Courts– The national GAINS center estimates that there are now 114 mental health courts for adults in the United States. Most are for misdemeanor defendants.

40 Court : National Best Practices
Many Counties are starting to just develop misdemeanor courts 1st such Court in the United States of America was in Broward county 2nd such court in Florida was in Alachua County 1st Felony Court in Florida was Alachua County

41 Court: Alachua (MH Court)
The Alachua County Mental Health Court is a pre-adjudication diversion program, and the charges will be dismissed if the individual successfully completes the mental health court plan. This is a VOLUNTARY court. Court Services, Meridian, State Attorney, Public Defender work as a team. Alachua County and Columbia County 2011 data on 204 participants indicated that: Average Jail Days was before Mental Health Court Average Jail Days was 2.4 after Mental Health Court

42 Court: Alachua (Div V Felony Forensic Court)
Participants are individuals who have been found Not Guilty by Reason of Insanity, Incompetent to Proceed, and/or Probation with Mental Health conditions. This is a NON- VOLUNTARY court. Court Services, State Attorney, Public Defender, Regional Council, Probation and Meridian all work as a team.

43 4. Reentry/Reintegration
Re-entry from Prison, Jail, and State Hospital There is little continuity of care or communication between corrections and community mental health for mentally ill individuals who leave correctional settings. Public mental health systems may be unaware when their clients are incarcerated or released.

44 Reentry/Reintegration
In addition, pressure is increasing on corrections and mental health systems to stop the cycle of recidivism frequently associated with people with severe mental illness who become involved in the criminal justice system. Assess-Plan-Identify-Coordinate – APIC Model

45 Reentry to the Community from jail and state hospital
The APIC model for transitional planning from local jails breaks new ground with it’s focus on assessing, planning, identifying and coordinating transitional care.

46 The APIC Model: Assessing
Assess the clinical and social needs, and public safety risks of the consumer Cataloging the consumer’s psychosocial, medical, and behavioral needs and strengths Gathering information from LE, courts, corrections, CMH, & families to create a fully informed transition plan Incorporating a cultural formulation in the transition plan Engaging the consumer in assessing their own needs Ensuring the consumer has access to and means to pay for treatment and services

47 The APIC Model: Planning
Plan for the treatment and services required to address the consumer’s needs Addressing the critical period immediately following release (1st hour,day, & week) as well as long term needs Learning from the consumer what has worked or not worked during past transitions Seeking family input Addressing housing needs

48 The APIC Model: Planning-2
Arranging an integrated treatment approach for the consumer with co-occurring disorders Ensuring that the consumer is on an optimal medication regimen Ensuring that they have sufficent medication to last until psychiatric appointment Connect consumers with acute and chronic medical conditions with community medical providers

49 The APIC Model: Planning-3
Initiating benefit applications/reinstatements for eligible inmates for Medicaid, SSI/SSDI, Veterans, food stamps, and TANF Ensuring the consumer has… Adequate clothing Transportation Food

50 The APIC Model: Planning
Almost all jail consumers with co-occurring mental illness and substance abuse disorders will leave correctional settings and return to the community. Inadequate transition planning puts people with co-occurring disorders who enter jail in a state of crisis back on the streets in the middle of the same crisis (Osher, Steadman, & Barr, 2002)

51 The APIC Model: Planning
The outcomes of inadequate transition planning include the compromise of public safety, an increased incidence of psychiatric symptoms, relapse to substance abuse, hospitalization, suicide, homelessness, and re-arrest. (Osher, Steadman, & Barr, 2002)

52 The APIC Model: Planning
Transition planning can only work if justice, mental health, and substance abuse systems have a capacity and a commitment to work together… The results will only be as good as the partnership in the community

53 The APIC Model:Identifying
Identify required community and correctional programs responsible for post-release services Naming in the transition plan specific community referrals Forwarding a complete discharge summary to the community provider Ensuring every consumer’s belongings are returned upon release Ensuring the consumer has a picture ID

54 The APIC Model:Identifying
Ensuring that the treatment and supportive services match the consumer’s level of disability, motivation for change, and availability for community resources. Supporting conditions of release and community supervision that match the severity of the consumer’s criminal behavior Addressing the community treatment provider’s role vis-à-vis other social service agencies, probation, and the courts

55 The APIC Model:Coordinating
Coordinate the transition plan to ensure implementation and avoid gaps in care Supporting the staff in coordinating the timing and delivery of services and in helping the consumer span the jail-community boundary after release Case assignment must be made cooperatively by the consumer, jail, and community agency itself

56 The APIC Model:Coordinating
Explicitly communicating to the consumer, family, releasing facility, and community treatment agency, the names and contact information of the person(s) who will responsible for care between the time of release and first follow-up appointment Confirming the consumer knows details of the follow-up visit Confirming that they have adequate medication GAINs Re-Entry Checklist

57 Community Re-entry: Alachua
JAIL -Coordinated efforts are made to ensure an appropriate release plan, use A.P.I.C. model -GAINS Reentry Checklist, handout -SOAR application in jail PRISON -Limited discharge planning – usually a medication appointment with the local provider is made. -VA has Prison release programs

58 5. Community Corrections (and Community Support Services) –
Consumers under continuing supervision in the community by the CJ system (usually probation) are another large group to consider. Failure to attend treatment appointments often results in revocation of probation and a return to jail.

59 MI individuals have trouble with probation or conditional release
Person may never understand instructions or follow through because of symptoms Person may be experiencing symptoms of psychosis Overwhelmed because of anxiety about the appointment Experience paranoia & not trust enough to follow through Unable to complete the terms of release – community service, fee’s Zero tolerance probation standards Inconsistent sleep patterns due to side effects of meds Unable to plan how to get there

60 Community Corrections/Support: Alachua
Interagency collaboration continues to be the key focus in Alachua County. Once per month a continuity of care meeting in held consisting of key stakeholders of the forensic population. This meeting provides agencies with a floor for planning, networking, implementation, service coordination, collaborative problem solving, referrals, and information sharing.

61 Community Corrections/Support: Alachua
Department of Probation – dedicated probation officer Court Services -Day Reporting -County Probation -Work Release -Electronic Monitoring -Court Service Contact and Treatment Supervision

62 Alachua Team Ongoing Support
Meetings, leadership, & Cooperation Needed as boundary spanners Information exchange Timely information handoffs HIPPA Training. System training for LEO, PD, ASA, Jail, MH, Courts, & Court Services

63 Sequential Intercept Model + Community Vision
A community that no longer needs jails and courts to serve as a provider of mental health and addictions treatment Pre-Booking Intercepts  Crisis Intervention Teams Fully funded community based system of care Post Booking Intercepts  Coordinated screening  Forensic Specialists, Court Services Court/Jail Intercepts  In-jail specialized treatment Therapeutic Courts (Misdemeanor, 916, Felony)  Community/Jail-based Competency Restoration Services  Forensic Services  Court Services Re-Entry Intercepts  Forensic Residential Treatment  Forensic Specialist Team Court Services  Peer Specialists Post-Release Intercepts  Specialized Probation  Specialized, Supported Housing Not available In place Partially in place

64 Working Together to Install Best Forensic Mental Health Practices
Incentivize by funding, removing barriers, provide excellent resources to learn and grow Encourage improvement Require and regulate Assist local mental health systems to develop the capacity to identify and implement Best Practices Develop education and training materials Utilize and share fidelity scales or other measures to evaluate implementation Promote cross system sharing

65 Alachua Diversion Statistics
At the end of March, a total of 184 clients were actively participating in the program. Approximately 16% (28 of 184) received outreach/case management in the jail. Approximately 6% (12 of 184) received competency restoration services in the jail. Approximately 78% (144 of 184) of participants received treatment and/or case management services in the community, with a total of 26% (38 out of 144 people in the community) receiving treatment services, treatment groups and individual sessions.

66 Re-Cap A. Model Basics B. Sequential Intercept Points
1. (Current Services) + Emergency/Police-Based Response 2. Pre/Post-arrests 3. Specialty Courts 4. Re-entry/Reintegration & the APIC model 5. Community Corrections C. Alachua County Status & Recommendations

67 Status Handout Idea’s? Recommendations? Comments? Questions?

68 Thank You Please fill out the satisfaction questionnaire

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