Preliminary Findings of a Forensic Intensive Case Management (FICM) Program

March 18, 2008

Kathleen Moore, PhDAutumn Frei, MA

Karen Williams, MS, CAPRick Buhl

David Kershaw, PhD

SAMHSA Jail Diversion Grant

Awarded April, 2006Awarded April, 2006 Up to 3 years of fundingUp to 3 years of funding Serves post-booking adults, mentally ill & substance Serves post-booking adults, mentally ill & substance

impaired, diversion eligible, current misdemeanor impaired, diversion eligible, current misdemeanor chargecharge

Utilizes Forensic Intensive Case Management Utilizes Forensic Intensive Case Management (FICM) model(FICM) model

Completed Strategic PlanningCompleted Strategic Planning Implementation Committee (i.e., Advisory Implementation Committee (i.e., Advisory

Committee) meets on a monthly basisCommittee) meets on a monthly basis

Implementation Committee Hillsborough County Agency for Community Treatment Services Florida Mental Health Institute Mental Health Care, Inc. Hillsborough County Sheriff’s Office Public Defender’s Office Florida Dept. of Children & Families Gulf Coast Community Care Family Emergency Treatment Center Central Florida Behavioral Health Network

Why important? 5% of divertees accounted for 20% of diversions5% of divertees accounted for 20% of diversions

Highly recidivistic are high SA, high MHHighly recidivistic are high SA, high MH Not voluntary and usually require inpatient hospitalization after transfer Not voluntary and usually require inpatient hospitalization after transfer

from jailfrom jail Mentally ill misdemeanant offenders are disproportionately Mentally ill misdemeanant offenders are disproportionately

represented in jail population because they spend more time in represented in jail population because they spend more time in jail than non-mentally ill offendersjail than non-mentally ill offenders

Fail to bond outFail to bond out Incompetent to pleadIncompetent to plead

In 2006, an average of 13% of Hillsborough’s jail inmates were In 2006, an average of 13% of Hillsborough’s jail inmates were treated with psychotropic medicationstreated with psychotropic medications

Pre-Existing Jail Diversion Services In existence since 2000

2 full time MHC staff housed in jail Targets Mentally Ill Misdemeanant Defendants

Case Finding

• Daily review of psych pods census

• Identification by jail staff or PD

• External notification (e.g., family, provider, etc) Diversion

• Negotiate ROR release

• Arrange other dispositions (e.g., civil commitment)

• Jail release is usually to MHC’s Emergency Service for commitment screening with admission or release/referral

Pre-existing MH Diversion Activities (cont.)

Contact with Diversion Staff between 1st appearance court (24 hrs after booking) and video court (1-2 weeks after booking)

Charges typically dropped and no continuing criminal justice involvement after transfer out of jail

Where do we want to go?

Develop mechanisms for early identification/screening (sequential intercept)

Develop diversion pathways other than to emergency services

Develop post release comprehensive and continuous services that would be appropriate for special needs of the recidivistic mentally ill offender

Developing Mechanisms for Early Identification/Screening

Goal: Implement sequential intercept model for identification and screening

Newly Developed under SAMHSA grant

GAINS Screening (1st intercept)• Used internally at jail but does not trigger referral to existing diversion or FICM

Developing Referral information sheet for offenders who bond out rapidly Datalink (2nd intercept)

• Only defendants with history of contact with MHC Goal to expand database of consumers (esp. active consumers of FACT,

Forensic) and include felony charges Automatic email system similar to emergency service notification

• Barriers related to confidentiality concerns limit expansion of datalink Universal consent Specific consent Business agreement

Developing Alternative Diversion Pathways

Goal: expand diversion to community based programs and circumvent secure emergency screening program if possible

Goal: use existing jail diversion staff (non-FICM) as a single point of assessment/contact for diversion, initiating in-reach from community based programs or referral to appropriate diversion program (e.g., FICM)

Barriers legal decision makers have been reluctant to divert to non-secure programs. Other MH/SA programs not eager to accept diversions or jump waitlists Lack of in-reach screening/engagement from other community based programs Lack of regular meetings among stakeholders and boundary spanner

Implemented Under SAMHSA Grant Monthly service delivery committee meeting including staff from FS 916 diversion program

• Increasing comfort/trust among providers/stakeholders• Sharing information/contact information, shared agenda/goals• Development from bottom-up operational needs

FICM/Diversion staff collaboration as a model for other partnerships

Developing Post Release Services to address the needs of difficult, recidivistic mentally ill

offenders (FICM)

Goal: Involve and retain mentally ill offenders in Goal: Involve and retain mentally ill offenders in meaningful recovery-oriented activities by providing early meaningful recovery-oriented activities by providing early engagement and post release services that client directed, engagement and post release services that client directed, stage appropriate, continuous, comprehensive and stage appropriate, continuous, comprehensive and integrated. integrated.

CONTINUOUS INVOLVEMENT IS A PRE-REQUISTE CONTINUOUS INVOLVEMENT IS A PRE-REQUISTE FOR ANY CHANGE INTERVENTION TO BE FOR ANY CHANGE INTERVENTION TO BE SUCCESSFULSUCCESSFUL

Balance care with expectation, empathic detachment, Balance care with expectation, empathic detachment, consequences and contingent learningconsequences and contingent learning

Hillsborough Targeted Capacity Jail Diversion Program – Treatment

Component

Karen Williams, MS, CAP, RMHCKim Fridie, BS

Tanya Walwin, BAQuarmul Chowdhury, MD

Rick Buhl, Asst. Case ManagerDavid Hawkins, Peer Support Specialist

Mental Health Care, Inc.

Continuous Community Based Treatment and Care Management (FICM)

Target Group2+ Misdemeanor Arrests within past yearViolent Felony is exclusionProbable SPMI diagnosis, co-occurring substance abuse not required

Team StructureMD, 4 hours/week clinic (one of two jail psychiatrists)Team Manager (Certified Addiction Professional, Registered MHC)Staff with vocational, mental health and substance abuse expertisePeer Specialist planned at .1 but increased to .5 Up to 15 cases per Intensive Case ManagerTeam Manager does individual therapy

Continuous Community Based Treatment and Care Management (FICM) (cont.)

Scope of Service• Time limited, One Year• Office or community contacts

Direct Service Medication Management Stage Appropriate, Recovery Oriented Treatment/Goals Individual Co-occurring Therapy Life Skills Training Aggressive Supervision/Monitoring Brokering access to appropriate levels of care

Wrap Around Services Transportation Housing via contingency funds Navigating SSI/SSDI Representative Payee

Forensic Intensive Case Management (FICM)

In-Jail FICM Screening, Engagement, EnrollmentIn-Jail FICM Screening, Engagement, Enrollment• Person CenteredPerson Centered

Person identified problems/goalsPerson identified problems/goals Introducing and promoting FICMIntroducing and promoting FICM

• Determine eligibilityDetermine eligibility Screening instruments if neededScreening instruments if needed History often more valid than current status or reportHistory often more valid than current status or report Assessment of Motivation?Assessment of Motivation?

• EnrollmentEnrollment Problems inherent in the short time frames involved in criminal Problems inherent in the short time frames involved in criminal

justice dispositions and this grant.justice dispositions and this grant.

• The most ill defendants do not get enrolled The most ill defendants do not get enrolled TAPA Tracking FormTAPA Tracking Form

Post-release FICM Activities Continued Assessment/Engagement Psychiatric Examination/Treatment Individualized Treatment, Dual Diagnosis Capable, TIP 42 Support services not conditioned on medication compliance or etoh/drug

abstinence Phase of Recovery Appropriate Treatment

Phase 1: Stabilization• Goal: Stabilization of acute psychiatric symptoms or active substance abuse

Phase 2: Engagement/Motivational Enhancement• Goal :Engagement in Tx, movement from pre-contemplation to

contemplation/preparation/action stages• Interventions: Assertive Outreach/Engagement, Education, Motivational Interviewing,

Contingency Management, Welcoming/Charity, Low Demand Phase 3: Prolonged Stabilization

• Goal: Involvement in Active treatment• Interventions: Education, 12 step supports; relapse prevention; Maintenance, Relapse

prevention Phase 4: Recovery and Rehabilitation

• Goal: Continued sobriety and stability

SAMHSA Jail Diversion Flow Chart

MHC staff screen from 8-10 am everymorning (1 hr paperwork, 1 hr screening)

MHC staff screen from 8-10 am everymorning (1 hr paperwork, 1 hr screening)

Approximately 3 clients per week meet eligibility criteria. If appropriate, MHC staff

will present case to Judge

Approximately 3 clients per week meet eligibility criteria. If appropriate, MHC staff

will present case to Judge

If client is accepted into program and Judge diverts client, will be discharged

to caseworker within 48 hours

If client is accepted into program and Judge diverts client, will be discharged

to caseworker within 48 hours

Client discharged to MHC for assessment. FMHI interview conducted

after initial assessment is complete

Client discharged to MHC for assessment. FMHI interview conducted

after initial assessment is complete

Datalink identifies individuals with a history of contact with MHC (8-10 per day)• SPMI (on psych meds or overnight stay in hospital• 2+ misdemeanors in past year• no violent felonies

Hillsborough Targeted Capacity Jail Diversion Program :Evaluation

Component

Roger Peters, PhDKathleen A. Moore, PhDMark Engelhardt, MSW

Autumn Frei, MA

Department of Mental Health Law and Policy Louis de la Parte Florida Mental Health Institute

Project Evaluation: Overview

Evaluate the implementation of an evidence-based practice, Forensic Intensive Case Management (FICM), for adults ages 18 years and older with a history of mental illness and/or substance abuse who have been arrested two times within the past year.

Over the three-year term of the grant, the project will have the capacity to serve 30 persons during the first two years with 20 new persons projected for the third year. Therefore, the total number of persons projected to be served and evaluated is 80.

Project Evaluation: Client Outcome Methodology

Conduct 80 face-to face interviews with Conduct 80 face-to face interviews with participants over the course of the three yearsparticipants over the course of the three years

Baseline (intake), 6-month, and 12-month follow-Baseline (intake), 6-month, and 12-month follow-up data collectionup data collection

Participants are paid $20.00 for each interviewParticipants are paid $20.00 for each interview

Project Evaluation: Process Evaluation Methodology

Conduct process evaluation using the survey instrument, the Assertive Community Treatment Fidelity Scale.

Staff will be observed at a team meeting, then asked questions pertinent to completing the scale. In addition, two clients will be selected for a brief interview regarding the program.

Project Evaluation: Measures GPRA Client Outcome Measure. This measure includes information on (1)

demographics; (2) education, employment, and income; (3) drug and alcohol use; (4) family and living conditions; (5) crime and criminal justice status; and (6) mental and physical health problems and treatment.

DC Trauma Collaboration Study Violence and Trauma Screening. This is an 8-item scale inquiring about events that are upsetting or stressful.

Posttraumatic Checklist – Civilian Version. (PCL-CV; Weathers, Litz, Huska, & Keane, 1994). This is a 17-item scale that assesses the 17 PTSD symptoms.

Perceived Coercion Scale (Gardner et al., 1993). This is a 5-item scale adapted from the MacArthur Mandated Community Treatment Survey and re-worded to be relevant to individuals in a jail diversion program. The items measure the participants’ perceptions of freedom and choice in the diversion process.

Colorado Symptom Index (CSI; Shern, Wilson, Cohen, Patrick, Foster, Bartsch, & Demmler, 1994). This is a 14-item scale that assesses psychological symptoms during the past month.

Project Evaluation: Measures (cont.)

Additional measures include the following:

Addiction Severity Index (ASI; McLellan, Kushner, Metzger, Peters, Smith, Grissom, Pettinati, & Argeriou, 1992). The complete ASI measures seven domains of problematic behaviors, however, only the drug and alcohol subscale will be utilized for the present study.

Brief Symptom Inventory (BSI; Derogatis, 1993). This is a 53-item measure of current, psychological status. Studies have used it extensively in homelessness, mental health, and substance abuse research.

The University of Rhode Island Change Assessment Scale (URICA; DiClemente & Hughes, 1990). This is a 32-item measure of readiness to change.

Project Evaluation: Update on Data Collection Activities

Event Tracking – Collected the following event tracking forms:

• 112 initial screening forms• 49 subsequent assessment forms• 22 court decision forms

Person Tracking Forms – Collected 19 person tracking forms

Interviews – Conducted 27 face-to-face structured interviews (19 baselines; 8 six month follow-up)

Project Evaluation: Demographic Information (Baseline, N=19)

Characteristic Mean (SD) or %

Gender: Male 58%

Age: 20-29 years 42%

30-39 years 11%

40-49 years 36%

50+ years 11%

Race: African-American 32%

Caucasian

68%

Ethnicity: Hispanic 11%

Project Evaluation: Demographic Information (cont.)

Characteristic Mean (SD) or %

Primary Diagnosis: Depressive disorder 32%

Schizophrenia disorder 26%

Bipolar disorder 21%

Psychotic disorder 21%

Primary

Arrest Charge: Trespassing 53%

Battery (domestic violence) 26%

Petty theft 11%

Poss. of open container 11%

Poss. Of drug paraphernalia 5%

Code Violation – Property 5%

Unlawful act as a precursor to prostitution

5%

Preliminary Client OutcomesPreliminary Client Outcomes Stabilized on MedicationStabilized on Medication Actively Seeking Employment after Vocational Rehabilitation ServicesActively Seeking Employment after Vocational Rehabilitation Services Implemented services to help consumers gain independence and Implemented services to help consumers gain independence and

autonomyautonomy Payee ServicesPayee Services SSI – DisabilitySSI – Disability Medical CareMedical Care

Resolved issues of homelessnessResolved issues of homelessness Transitional Living Facility – group home with therapy sessionsTransitional Living Facility – group home with therapy sessions Own apartmentOwn apartment

Successfully completed Drug & Alcohol RehabilitationSuccessfully completed Drug & Alcohol Rehabilitation No re-arrests No re-arrests