Programs Designed for Diversion and Aftercare from Jail for People with Mental Illness: Philadelphia

Arthur C. Evans, Jr. PhDCommissionerPhiladelphia Department of Behavioral Health and Intellectual Disability Services

BackgroundPhiladelphia Department of Behavioral Health and Intellectual disAbility Services

• Administrator for public mental health and addiction service system• Safety Net for 1.5 Million people (capitated for 600K Medicaid recipients)

• Substance use, mental health and intellectual disability services• Children, adult and family services• 200+ providers, full continuum of services• Medicaid managed by the city

Population Health Framework for Improving the Overall Health of Communities

Focus on:1. Attending to the whole population 2. Promoting health, wellness, and self determination3. Providing prevention and early interventions across

the health continuum of a persons life4. Addressing the social determinants of health 5. Empowering individuals and communities to keep

themselves healthy

Fiscal & Administrative

Policy & Procedure Alignment

A SYSTEMS APPROACHFour Building Blocks of a Recovery & Resilience-Oriented Systems

Community & CrossSystems

Collaboration

Optimize Treatment

Services

Recovery Support Services

High Numbers of Inmates with Serious Mental Illness and Other Behavioral Health Problems

K

2K

4K

6K

8K

10K

12K

2009 2010 2011 2012 2013 2014 2015 2016

Average Daily PDP Populations from Jan. 2009 to Jun. 2016 (Total, BH caseload, SMI)

Average daily total population Average daily BH caseload Average daily SMI

Sequential Intercept Model (Munetz & Griffin, 2006)

• People move through criminal justice system in reasonably predictable ways

• Examined process in Philadelphia 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

• Multiple problems and multiple systems– Need more effective strategies– Need more collaboration

Sequential Intercepts

1. Law Enforcement & Emergency Services

2. Post-Arrest: Initial Detention/Initial Hearings

3. Post-Initial Hearings: Jail/Prison, Evaluations, Courts

4. Re-Entry From Jails, Prisons, & Forensic Hospitals

5. Community Corrections & Community Support

Philadelphia Cross Systems Map

Intercept 1: Law enforcement

Intercept #1 Example: Training Police Officers and Police Academy Cadets

Crisis Intervention Team (CIT)

• Police-based specialized mental health response program

• Close working relationship between Police Department and DBHIDS, particularly Crisis Services

• Intensive training (40 hours) to volunteer patrol officers

1. Classroom and experiential training to recognize and de-escalate common behavioral health crises

2. Encouraged to refer people to treatment as alternative to incarceration when appropriate

• Outcomes from similar programs:

1. Improved collaboration between law enforcement and mental health

2. Decreased use of high-intensity police units

3. Lower rate of officer injuries

4. Increased referral of individuals with mental illness to treatment facilities

2433 Philadelphia Police Officers trained

CIT-Trained Patrol Officers by Division

Southwest

South

Northwest

Northeast

East

Central

459

2433

0

500

1000

1500

2000

2500

3000

Oct 232009

Feb 82010

Jun 182010

Nov 32010

Feb 112011

May 132011

Oct 282011

Mar 22012

June 292012

Dec 142012

April 262013

Oct 252013

Feb 282014

Jun 202014

Dec 122014

Nov 162015

April 42016

2009 - 2016

Southwest Division , 428, 17%

South Division , 256, 10%

Northwest Division , 378, 15%

Northeast Division , 340, 14%

East Division , 406, 16%

Central Division , 405, 16%

Others Trained*** , 181, 7%

All Other Special PPD Units**, 117, 5%

Current Distribution of All CIT-Trained Officers as of 5/16/2016 (N=2,621)*

*Takes June 2015 audit into account and includes

PPD of all ranks.

**Includes Airport, Detectives, Highway, Safety, and

Traffic, among others.

***Includes Amtrak, PPS, SEPTA, Temple, UPenn,

Drexel, Abington, PA Probation and Parole,

Sheriff's Department, & Middle Township.

Intercept 2: Initial Detention,Initial Court Hearings

Intercept #2 Example:

Forensic Screening and Assessment Coordinator• Address the gap between CIT and the jail• Embedded in Philadelphia Police Northwest Division which covers the 35th, 39th, and 14th Police

Districts • Conducts initial suicide and behavioral health screenings and makes referrals to new or current

behavioral health services• Passes continuity of care information to the Philadelphia Department of Prisons if the individual

is subject to incarceration• Our goals:

– Refine and improve suicide screening at important early stage– Divert individuals with behavioral health problems away from the criminal justice system at earliest point

possible after arrest while promoting public safety– Link and relink to community services – Reduce the average number of days incarcerated

15

Forensic Screening Outcome Data 2015-2016

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118

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Screening Outcomes Detainees Screened n = 303

Intercept #2 Example 2:

Veterans Court• US Dept. of Veterans Affairs works with VA eligible vets in Veterans Court • Through the Veteran Initiatives Unit (VIU), DBHIDS works with non-VA eligible

Veterans Court participants

– From 2011 – 2016, approximately 175 veterans referred to the VIU– May 2016 Graduation: 13 of 25 graduates served by the VIU– Drugs and Alcohol major reason for court involvement

• Screen all clients for trauma; assign them to treatment based on need– Dual Diagnosis, inpatient, intensive outpatient, drug and alcohol treatment, housing

needs, and job training

• Track treatment progress for courts

17

18

Veteran Initiatives Unit (VIU)Expanding VIU focus beyond Veterans Court to serve Veterans:

• With behavioral health challenges and criminal justice system involvement

• At each point along the Sequential Intercept Model (not just Intercept 2)

• Along a Continuum of Care1. Establish Veteran Status2. Conduct Clinical Assessment3. Propose Treatment4. Connect to Resources5. Follow Up Tracking

Intercept 3: Jails & Courts

Intercept #3 Example:

Addressing Forensic Waiting List- State Hospital

0

57

12

1719 20

22*

0

5

10

15

20

25

Jan-2016 Feb-2016 Mar-2016 Apr-2016 May-2016 Jun-2016 Jul-2016 Aug-2016

Discharged from NSH Since 1/27/2016

People who have been discharged from NSH since the ACLU settlement date of 1/27/2016. As of 8/10/2016,all 22 individuals have been discharged and placed into a DBHIDS facility.

*The court has ordered a furlough for one individual to Girard Recovery Center for 30 days. While individual is occupying a bed at the GRC, a bed is being held open at NSH for 30 days should a transfer back to NSH become necessary. She has not yet been discharged.

Intercept #3 Example:

Norristown State Hospital (cont’d)

GirardRecovery Center 10

Girard Recovery Center- Furlough,

1*Einstein Geriatric -

LTSR , 1

Gaudenzia New Beginnings , 1

COMHAR - Lehigh , 1

Westhaven - LTSR, 2

Unity Villa , 1

Seasons - LTSR , 1

Penrose Place -LTSR , 1

Parkside Manor , 1

Iris House - LTSR, 1

Independence House - LTSR , 1 Girard - RTFA , 1 Community Placement

Upon NSH Discharge

* Court has ordered a furlough for one individual to the GRC for 30 days

Intercept 4: Reentry

Intercept #4: Re-Entry

Re-entry barriers for inmates with behavioral health challenges:

• Institutionalization• Severed ties to family and community• Relearning life skills• Serious offenses• Establishing treatment and progressing

toward recovery

Intercept #4 Example:

Re-entry Mental Health Court• First Judicial District Mental Health Court

– Supervising Judge: Honorable Sheila Woods-Skipper

• Provides supervised community setting as alternative to incarceration for non-violent offenders with mental illness and co-occurring disorders

• Preparing offenders for re-entry by connecting them with:– Effective treatment options– Housing assistance– Benefit application assistance– Community support services

FJD MH Court Opening Day July 7, 2009

First Judicial District Mental Health CourtPROGRAM GOALS

• To divert offenders with mental illness from incarceration and into community treatment

• To maintain treatment, housing, benefits & community support services for offenders with mental illness

• To reduce recidivism /repeated criminal activity by offenders with mental illness

• To support effective communication between the criminaljustice and mental health systems

• To preserve public safety

Intercept #4: Example 2:

State Prison Reentry Coordination• Forensic Liaison coordinates reentry of inmates with severe

mental illness from the Pennsylvania Dept. of Corrections

• Forensic Peer Specialist facilitates a warm handoff

• Both positions collaborate with DOC to:

– Engage inmates prior to release

– Understand inmates’ individual needs upon release

– Connect inmates with community resources before release

• Treatment providers, case management services, housing assistance, rehabilitation services, medication management, etc.

State Prison Reentry Coordination

85

70

70

73

Q1

Q2

Q3

Q4

0 20 40 60 80 100

20

15

-20

16

DBH Coordinated DOC Discharges

Intercept 5: Community corrections

Intercept #5 Example: Mental Health First Aid for Public Safety Staff

• DBHIDS utilizing a population-based, city-wide approach in Philadelphia to provide MHFA training to :– As many community and public safety organizations as possible to be Mental

Health First Aid Instructors– As many citizens as possible to be Mental Health First Aiders

• 8-hour public education in identifying, understanding, and responding to signs of mental illness and substance abuse meant to:

1. Reduce stigma2. Increase mental health awareness3. Strengthen community and cross-system capacity4. Support recovery and resilience5. Increase early intervention, access to behavioral health services

Police Dept654

PHA Police Dept., 7

DA's Office, 23

Courts, 167

Adult Prob. & Parole, 278

Dept. of Prisons, 465

Fire, 297

FIR, 139

Defender's Association, 78

Mayor's Office (RISE), 30

Community Corrections, 265

Nat'l Constitution Ctr.,

149

Misc., 151 N = 2703# of Trainings = 135

Public Safety Mental Health First Aid: Aiders Trained

Public Safety Mental Health First Aid: Instructors Trained

N = 66# of Trainings = 135

Sheriff's Office, 1 Police Dept.,

6

PHA Police Dept., 6

District Attorney's Office, 1Courts, 4

Adult Prob. & Parole, 2

Phila. Dep. Prisons, 4

Fire Dep., 18FIR, 2

Defender's Association, 2

Forensic Peers, 1

Nat'l Constitution Ctr.,

13

Misc., 6

Future Directions…

• Lower presence of behavioral health population within criminal justice

system

• Lower criminal recidivism of this population

• Improve continuity of care across intercepts

• Increase integration of Forensic Certified Peer Specialists across intercepts

• Improve integration and understanding of data describing criminal

justice/behavioral health population

For more information: • DBHIDS Website: www.dbhids.org

• Philadelphia Mental Health First Aid website: http://healthymindsphilly.org/

• Arthur.c.evans@phila.gov

• @ArthurCEvans

• Sequential Intercept Model: – Munetz, M.R. & Griffin, P.A. (2006). Use of the Sequential Intercept Model as an approach to decriminalization of

people with serious mental illness. Psychiatric Services 57(4), 544-549.

– Griffin, P.A., Heilbrun, K., Mulvey, E.P., DeMatteo, D., & Schubert, C.A. (Eds.). 2015. The Sequential Intercept Model and criminal justice: Promoting community alternatives for individuals with serious mental illness. New York, NY: Oxford University Press.

– GAINS Sequential Intercept comprehensive planning brochure

• http://gainscenter.samhsa.gov/pdfs/integrating/GAINS_Sequential_Intercept.pdf

Arthur C. Evans, Ph.D.@ArthurCEvansArthur.C.Evans@phila.govDBHIDS.org ● Healthymindsphilly.org