Using the Sequential Intercept Model for
Community
Action Planning
NEOMED
TEMPLATE
Ohio Justice Alliance for Community Corrections Conference
October 17, 2014
This project funded by Edward Byrne Memorial Justice Assistance Grant
No. 2013-JG-E01-6963 through the Ohio Office of Criminal Justice Services
PRESENTERS:
Mark R. Munetz, M.D.
Criminal Justice Coordinating
Center of Excellence
Northeast Ohio Medical University
Ruth H. Simera, M.Ed., LSW
Criminal Justice Coordinating
Center of Excellence
Northeast Ohio Medical University
ADULT CORRECTIONAL POPULATION
1980 – 2011 (BUREAU OF JUSTICE STATISTICS)
4500000
4000000
3500000
3000000
2500000
Jail
State
Prison
Parole
2000000
1500000
Probation
1000000
500000
0
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
PREVALENCE OF BEHAVIORAL HEALTH
DISORDERS
IN CORRECTIONS POPULATION
Total Corrections
Population
70% with Substance
Use Disorder (SUD)
50% Dependent
Substance Use
Disorders
31% Mental
Illness
•Prevalence fairly
consistent across
prison, jail and
community corrections
•Rates of dependency
and mental illness
higher among women
17% SMI
72% of
SMI with
SUD
Slide courtesy of Fred Osher, M.D.
OVER-REPRESENTATION OF PEOPLE WITH MENTAL
ILLNESS: THE OHIO STORY
• In Ohio prisons
• Total inmates = 50,117 (4/1/2013)
– 9554 inmates on the mental health caseload (~19%)
• Unclear how many have a serious and persistent mental illness
(SPMI)
– Ohio Department of Mental Health and Addiction Services
completes approximately 1800 linkage packets for persons
identified as SPMI per year
• In Ohio psychiatric hospitals
– 1022 individuals (2/28/2013)
• 60% are “forensic patients”
– Not Guilty by Reason of Insanity (NGRI)
– Incompetent to Stand Trial (IST)
– Competency or sanity evaluations
“Unsequential” Model
Dan Abreu
CRIMINAL JUSTICE COORDINATING
CENTER OF EXCELLENCE
(CJ/CCOE)
• In May 2001 the Summit County ADM Board
was designated by OhioMHAS to be a CCoE to
help in the state-wide elaboration of Jail
Diversion programs
• Northeast Ohio Medical University (NEOMED)
operates the Center
A SYSTEMATIC APPROACH TO THE
CRIMINALIZATION PROBLEM
•
There is no single solution to the problem we are
calling “criminalization of people with mental illness”
– People move through the criminal justice
system in predictable ways
– The problem must be attacked from multiple levels
– The Sequential Intercept Model
SEQUENTIAL INTERCEPTS
Best Clinical Practices: The Ultimate Intercept
I. Law Enforcement/Emergency Services
II. Post-Arrest:
Initial Detention/Initial Hearings
III. Post-Initial Hearings:
Jail/Prison, Courts, Forensic
Evaluations & Forensic Commitments
Munetz & Griffin:
Psychiatric Services
57: 544–549, 2006
IV. Re-Entry From Jails,
State Prisons, &
Forensic Hospitalization
V. Community
Corrections &
Community
Support
SEQUENTIAL INTERCEPT MODEL
CROSS INTERCEPTS
• The GAINS Center has identified several
system-level approaches relevant across all
the intercepts.
– Encourage and support collaboration among the
stakeholders
– Many of the cross intercept approaches are part of
what we called the “ultimate intercept”
• For example, supported housing, education and
employment, peer support and other EBPs
• Services which are culturally competent, gender specific
and trauma informed
• Services which address the specific needs of veterans
• Recent attention to criminogenic risks and needs
Sequential Intercept Mapping
Problem: In multiple systems;
expensive, high service users
Solution: Cross-system Coordination & Collaboration
Focus
• Men and women with…
–Serious mental illness, and often
 Co-occurring substance
use disorders
– Involved in the criminal
justice system
Goals




Promote & support recovery
Provide safety, quality of life for all
Keep out of jail, in treatment
Provide constitutionally adequate
treatment in jail
 Link to comprehensive, appropriate, and
integrated community-based services
Objective - Collaboration
Substance
Abuse
Criminal
Justice
Tasks
Map the local system
Identify gaps
Build an action plan
Build collaborations
Challenges to Collaboration
Funding “silos”
Limited resources
System “cultures”
Benefits of Effective Collaboration
Community Collaboration + Services
Integration =
 service retention
 stability in the community
 public safety
Additional Strategies
Shared vision & direction
 Evidence-based & promising
practices
 Funds: creative use
 Data
•Approximately 75% of the
group should be top and
middle level administrators
•About 25% should be front
line staff and
peers/consumers or family
with lived experiences
COMMUNITY
Dispatch
911
Local Law Enforcement
Intercept 1
Law enforcement / Emergency services
Arrest
Memphis Crisis Intervention
Team Model (CIT)
• 1988 introduced as vital component to the
community’s demand for safer police response
following worst outcomes of police shootings
• First responders, mental health system, and
consumer/family collaborations and partnerships
key to making changes in existing systems
• Some communities have no where to take people
other than jail. Need for law enforcement training
for helping individuals with mental illness
Intercept I
Intercept 1: Intercepting at First Contact Police & Emergency
Services (Deane, et al, 1999)
• Police-based specialized police response
– Front line police response
– Specialized training/support system
– Example: Memphis Crisis Intervention Team (CIT)
• Police-based specialized mental health response
– MH professionals employed by police dept.
– Example: Community Service Officers in Birmingham AL
• Mental Health-based specialized response
– Mobile crisis teams
– Examples: Montgomery County Emergency Services (PA);
Knoxville TN; Butler County, Ohio
Intercept I
Specialized Crisis Response Sites:
Basic Principles
•
•
•
•
•
•
•
Identifiable, central drop-off for law enforcement
“Police-friendly” policies and procedures
Streamlined intake
“No refusal” policy
Legal foundations
Innovative and extensive cross-training
Linkages to community services
– Even for those who do not meet criteria for inpatient
commitment
(Steadman, et al, 2001)
CIT
• A police officer safety program
• A mental health consumer safety
program
• A unique community partnership
– A different way of doing business for law
enforcement, the mental health system,
consumers and their families
• A pre-arrest jail diversion program
• A civil liability reduction program
Intercept I
Crisis Stabilization Units
Local Law Enforcement
Jail Releases
Other
COMMUNITY
Pre-booking Jail
Diversion
Intercept 1
Law enforcement / Emergency
services - Transition
Service Linkage:
ICM/ACT
EBP’s
Peer Bridging
Medical f/u
Trauma Specific Services
Jail linkage
Other Assistance:
Medication Access
Benefits
Housing
Information Sharing
28
Intercept 2
First Appearance Court
Arrest
Initial Detention
Initial detention/Initial court hearings
Characteristics of Intercept 2 Diversion
Legal Criteria:
• Misdemeanor
• Low history of
violence
• Multiple Arrests
Clinical Factors:
• Serious and Persistent
Mental Illness
• Difficult to engage
• High need
• Failed Treatment history
• Acute care
• Needs civil commitment
Compared to Mental Health Court, can serve more people
with fewer court staff, resources, sanctions and jail time.
Promising and Best Practices
 Role of Pretrial Services
 Brief Jail Mental Health Screen
 Use of management
information systems to identify
and re-link to services
 Immediate referrals to
community services
 Follow-up into the community
Intercept 3
Jails/Courts
Specialty Courts
Other Court
Programs
Jail-Based:
Mental Health &
Substance Abuse
Services
Intercept 3: Jails and courts
 Ohio Specialized Dockets:
 Mental Health Courts
Drug Courts
 OVI/DUI Courts
Domestic Violence Courts
 Child Support Enforcement Courts
 Re-entry Courts
Sex Offender Courts
 Veterans Courts
 In-jail services:
 Identification / screening
 Access to mental health / substance abuse services
(medications, etc.)
 Communication with previous services as appropriate
Using Criminal Charges to lead to
Treatment
 Diversionary or Treatment in Lieu --- Generally pre-adjudication contracts with
judges to participate in treatment; Conviction is not recorded
 Example:
 Prosecutor holds charges in abeyance based on agreement to enter treatment under supervision of
mental health court; Plea is entered but adjudication is withheld
 Post-Plea Based --- Adjudication occurs but disposition or sentence is deferred
 Example:
 Guilty plea is accepted; Sentence is deferred
 Probation Based
 Example:
 Conviction with treatment as a term of probation plus suspended
Griffin, Steadman, & Petrila 2002
jail sentence
Intercept 4
Prison
Reentry
Jail Reentry
The Back Door:
Linkages Between Institutions and the
Community
Intercept 4
Post Release Risk of Death
 30,237 Washington State Prison releases
 443 died during average follow up of 1.9
years
 Death rate 3.5 times higher than general
population
 Within first 2 weeks of release, death rate
12.7 times higher for inmates with SMI
 Drug overdose leading cause of death, then
heart disease, homicide and suicide
(New England Journal of Medicine, 2007)
Brad H. Case
• Class action filed by 5 inmates released from
Riker’s Island Jail in NYC
• Alleged that the City violated state mental
hygiene law and agency regulation in releasing
inmates with mental illness from jail without
discharge planning services
• In July of 2000, the NYS Supreme Court ordered
NYC to provide adequate discharge planning for
the class
• Finding was upheld on appeal to the Appellate
Division, First Department
• Settlement agreement signed April 2, 2003
Reentry Models
• Refer Out
– Institution staff refer to community agencies
• Community Linkage
• Reach In
– Providers come in for intake (CT, MA, PA, MI, AL)
• Transition Reentry
– Shared responsibility (NY, TX)
• Let the Other Guy Do It
– Parole assumes responsibility at or following
release
• $40 and Bus Ticket
Public benefits
•
•
•
•
•
•
•
SOAR (SSI/SSDI Outreach, Access, Recovery)
Expedite payment/application process
Reduce Barriers
Tenants Outreach
Youth Empowerment Program
Ohio Benefit Bank
ROMPIR
Coalition on Homelessness and Housing in Ohio
Strategies & Promising Practices
•GAINS Reentry Checklist - Based on APIC
Model: Assess, Plan, Identify, Coordinate
• Permanent supportive housing can reduce
recidivism and homelessness in this
population
(Returning Home Ohio)
• Ex-Offender Reentry Coalitions
• Reentry Services
– Employment, Peer Support, Resource
Assistance
Intercept 5
Probation
Violation
COMMUNITY
Violation
Parole
Community corrections / Community
support
People with severe mental illness
are less likely to succeed on
probation
• Probationers with mental illness were:
• Less likely to have had their probation revoked because of a
new arrest,
• Equally likely to have had their probation revoked because of a
new felony conviction, and
• More likely to have had their probation revoked because of a
new misdemeanor conviction.
• Probationers with mental illness are more likely to have their
probation revoked because of failure to pay fine or fees, and
“other” violations (e.g., failure to work).
• Why?
• Functional impairments that complicate their ability to follow
standard conditions of probation (e.g., paying fees).
• Different revocation thresholds set by judges or probation
officers.
Dauphinot (1996)
Strategies to Improve Success for Probationers/
Parolees with Severe Mental Illness
Reduce caseloads for specialty probation to allow
probation officers to:
– Develop knowledge about mental health & community
resources
– Establish and maintain relationships with clinicians
– Advocate for services
– Actively supervise these individuals
– Take on both a legal, surveillance role and a therapeutic,
problem-solving role.
– Develop quality relationships with the probationer that can
strongly influence outcomes.
– Use problem-solving strategies to resolve noncompliance
issues, including examining the specific inabilities or
barriers of each individual.
– Maximize limited resources in creative ways to address
specialized needs
Skeem & Louden (2006)
Sequential Intercept Model:
The Revolving Door Approach
Community
Corrections &
Community
Support
Jail
Re-Entry
Law
Enforcement/
Emergency
Services
Best Clinical
Practices: The
Ultimate Intercept
Jails, Courts
Booking/
Initial
Appearance
Munetz & Griffin:
Psychiatric Services
57: 544–549, 2006
Cross intercepts
The GAINS Center has identified several systemlevel approaches relevant across all the intercepts.
– Encourage and support collaboration among the
stakeholders
– Many of the cross intercept approaches are part of
what we called the “ultimate intercept”
• For example, supported housing, education and
employment, peer support and other EBPs
• Services which are culturally competent, gender specific
and trauma informed
• Services which address the specific needs of veterans
• - Using the Risk-Need-Responsivity Model as a
Guide to Best Practices
Missing links
• Lack of access to evidence based
interventions (Osher & Steadman)
• Failure to incorporate risk factors for
recidivism as points of clinical intervention
(Skeem & Louden)
• Modifying evidence based intervention
protocols so that they incorporate services
that target criminogenic issues (Morressey
et al. Mueser et al.)
• Limited research on transition to adulthood
age group. (Osgood,
Foster & Courtney)
Slide provided by Amy Wilson, Ph.D.
The Mapping Process
1. Map The System
NEOMED
2. Identify
Gaps
3. Prioritize
4. Action Plan
TEMPLATE
Effective Diversion:
A different way of doing business for
Criminal Justice, the Mental Health System,
consumers and their families
1. Map The System
• Examine the process in a specific locality to identify
ways to “intercept” persons with severe mental illness
and co-occurring disorders to ensure:
– Prompt access to treatment
– Opportunities for diversion
– Timely movement through criminal justice system
– Linkage to community resources
1. Map The System
51
2. Identify Gaps
3. Prioritize
Priority Action Items
4. Action Plan
4. Action Plan
Final Report
•
•
•
•
•
•
First cross-systems picture
Wide distribution among local partners
Planning reference
Support for future funding applications
Reference/resource materials included
Priorities addressed over time
– Especially with the CJAB and OBH
• Developmental tool
• Outcome measurement tool
TECHNICAL ASSISTANCE – CJ CCOE
•
•
•
•
•
Trainers and Consultants
Website
Lending Library
Local, State and National Resources
Guidance on Best Practices and Evidencebased Practices
• Peer networking
Keys to Success
Task Force
 Work Groups
Consumer Involvement
Communication & Information Sharing
Boundary Spanner(s)/Champion(s)
Momentum
Wood County At Work
 Feasibility Study - Crisis Stabilization Unit
Transportation coordination
Involuntary Civil Commitment process
Data and Information Sharing - survey
Housing and Stability – merged with
Reentry Coalition housing subcommittee
Trauma Informed Care - Sanctuary
Sandusky County At Work
 Reentry Program – brochure and wallet
resource guide
Common observation form for law
enforcement, agencies and others developed
collaboratively by mental health and E.R.
Data and Information Sharing – database
designed and under legal review
Brief Mental Health jail screen
Ohio Criminal Justice Coordinating
Center of Excellence
NEOMED TEMPLATE
Mark R. Munetz, M.D.
Chair, Department of Psychiatry
Ruth H. Simera, M.Ed., LSW
Program Administrator
4209 State Route 44
Rootstown, OH 44272
PH: (330) 325-6670
FAX: (330) 325-5970
www.neomed.edu/cjccoe