7.2.1 Define a partnership and its relevance in community and law enforcement collaboration Definition of a partnership: An arrangement between two or more parties who have agreed to work cooperatively toward shared objectives in which there is: shared authority and respect, joint investment of resources, shared liability or risk taking, and ideally, mutual benefits Definition of collaboration: A system that integrates the resources and delivery of appropriate Mental Health care services through processes or techniques used by different entities in order to control or influence: the quality, accessibility, utilization, costs and prices, or outcomes of social services provided to a defined population. Components of a collaborative effort: Stakeholders interest in the collaboration Trusting relationship Shared vision and common goals Expertise Teamwork strategies Open communication Motivated partners Means to implement/sustain the collaboration An action plan Why is collaboration important? Consumers/family seeking help in both systems Full range of services improves quality of treatment Mental Health professional: feels less overwhelmed due to safety factors Law Enforcement feels more confident in managing this population Focus on consumer needs Ensures highest standards Maximizes the value of funds Breaks down barriers “ The criminal justice and mental health worlds are very different. We come from different traditions, we speak different languages, and to some degree have different values, expectations, and goals. Furthermore, few of us expected or desired to work in both the criminal justice and mental health worlds, and few of us have been trained or educated to understand the other world.” (Chart from TCLEOSE Curriculum p.77 on slides 6 and 7) These biases make it almost impossible to work together. But do they have more in common then they think? Both care about the people they serve, want to live more productive and happier lives, to protect the world, fear the newspaper headlines involving on of their “customers”. First step to successful collaboration: desire to work together on solutions. “…the fundamental and realistic commonalities shared by the mental health and criminal justice systems could potentially span the boundaries artificially erected between the two systems.” Result: For maximum success, people who become increasingly comfortable working with the other systems must emerge. Perhaps the most difficult challenge is a willingness to give up some degree of control to allow for real collaboration. These collaborations require time, commitment, and risk. Without such efforts we will continue to inappropriately incarcerate people who suffer from serious mental illness and need effective treatment, not punishment. Ideally people with mental disorders would come to the attention of the criminal justice system with the same frequency as the general population with the same demographic characteristics. People with mental illness who commit crimes with criminal intent and unrelated to symptomatic mental illness should be held accountable for their actions as would anyone else. While mental illness does not preclude criminal behavior, there is no reason to believe people with MI are more prone to commit criminal acts. People with MI should not be arrested simply because of their mental disorder. Nor should such people be detained in jails or prisons longer than others because of their illness. There is a direct link between inadequate mental health services and the growing number of mentally ill who are incarcerated…CJ/MH consensus project It has been long recognized that Law Enforcement collaborative agreements with Mental Health agencies is the key approach in dealing with the national Mental Health service crisis. Instructor Note: Discuss this statement and list on whiteboard or flip chart the statements reasoning. Utilize this as a class review exercise. 8.0 Understanding program evaluation in demonstrating measuring success It is critical to do at least a basic program evaluation. Measuring program effectiveness can assist in determining how successful your program responses are to your area. It will also evaluate any changes or adaptations/modifications that might be appropriate. Look at trends for the total agency. In order to obtain an effective measurement, effective documentation is necessary. Start by identifying performance measures based on your program goals. These measures should consider quantitative data on key aspects of program operation, as well as qualitative data on the officers and community member’s perceptions of the program. It will be helpful to gather documented baseline data prior to program implementation for later comparisons with new program information, as well as to compare the performance of CIT trained officers to non-CIT trained officers. Sharing statistics with other agencies for comparison evaluation may also be helpful. The quantitative data collected should focus on questions most critical to the programs success in achieving its goals. Such information would include: The number of injuries and deaths to officers and citizens Officer response time Number of incidents to which specially trained officers responded The number of repeat calls for service Officers disposition decisions (linking services) Time required and method used for custodial transfer Data should also be used to refine program operations as needed, as well as review individual case outcomes and determine if follow-up by MH professional is warranted. Methods for compiling qualitative data could be from officer surveys, both from specialized officers and others. In this manner chief administrative officers can better assess the programs usefulness to the entire department and be informed in order to address any concerns. Three other types of useful data could include: Quantity Data: The number of training events, officers trained and CIT officers on duty. Process Data: The number of: Identified CIT calls CIT calls handled by CIT officers Post intervention follow-up Response time Time delays in admission Outcome data: Service links Civil protective custody Use of force incidents Injuries Jail diversion Criminal bookings Collecting Data Ensure mechanisms are in place to capture data consistent with the process and outcome measures identified Agree upon common definitions of MI and the characteristics of the general population Capitalize on existing management information systems to facilitate data collection and analysis Solicit comments and opinions from staff, crime victims, family members, and program participants Establish procedures early in the process to share information that will facilitate the data collection of people served by both the criminal justice system and mental health systems Departments also should focus on sustaining internal support for the program, such as offering refresher training to help officers refine their skills and expand their knowledge base, incentives and other organizational support for serving in the program should also be considered. Instructor Note: Example Exercise Exercise I: The following are questions that could be adapted to data collection. Utilize these questions for a group exercise. Have students place these questions in appropriate categories per data collection information explained in above section. What is your desirable outcome? Jail diversion-decreased cost Decreased use of force and injuries-improved risk management Increased links-improved treatment and decreased crisis events Improved general public and consumer/officer relations Arrest and use of force has decreased Underserved consumers are identified by officers and provided with care Patient violence and use of restraints in the ER has decreased Officers are better trained and educated in verbal de-escalation techniques Officers’ injuries during crisis events have declined Officer recognition and appreciation by the community has increased Less victimless crime arrests Decrease in liability for health care issues in the jail Overall cost savings Reduced victimization of people with mental illness Reduced repeat victimization of people with mental illness Reduced total calls for service involving people with a mental illness Reduced calls for service at “hot spots” (do not include group homes etc.) Reduced amount of police time consumed by calls involving people with mental illness Reduced total calls for each type of situation involving people with a mental illness Reduced arrests of people with a mental illness (assuming alternatives to incarceration are available) Increased referrals of people with mental illness to community-based services Reduced injuries to police officers caused by people with mental illness Increased “customer” satisfaction-post incident satisfaction of complaints, victims, and offenders Increased “expert” satisfaction-high ratings of police effectiveness by mental health and legal professionals. Instructor Note: Exercise II Discuss this list with class and have students add to the list as appropriate. Measuring and evaluating Outcomes: Establish process measures to assess how well the program activities have been implemented Number of people served Units of service Timeliness of service Public safety Quality of life Cost Quality of Service
Improving Mental Health and Criminal Justice Outcomes
Community Solutions for Effective Criminal Justice and Behavioral Health Interventions Leon Evans President and Chief Executive Officer, The Center for Health Care Services Mental Health and Substance Abuse Authority, Bexar County, San Antonio, Texas, firstname.lastname@example.org
Raise your hand if you think there will be more Local, State, and Federal Dollars.
President’s Freedom Commission On Mental Health Interim Report: “… the mental health delivery system is fragmented and in disarray…leading to unnecessary and costly disability, unemployment, homelessness, school failure and incarceration.” 2003 President’s Freedom Commission On Mental Health – Final Report “ In addition to the tragedy of lost lives, mental illnesses come with a devastatingly high financial cost. In the US, the annual economic, indirect cost of mental illness is estimated to be $79 billion”.
"abject failure of our society to address critical needs for persons with severe mental illness" FAILED PUBLIC POLICY The Problem:
Community Wide Jail Diversion The Problem <ul><li>Criminalization of Mentally Ill </li></ul><ul><li>Inappropriate Cost to Society </li></ul><ul><ul><ul><ul><li>20% + in jail </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increase use of </li></ul></ul></ul></ul><ul><ul><ul><ul><li>emergency rooms </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Homelessness </li></ul></ul></ul></ul><ul><li>Public Safety Net </li></ul><ul><ul><ul><ul><li>Consumers at risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Law Enforcement at risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Public at risk </li></ul></ul></ul></ul>
The Cost <ul><li>Costly for taxpayers </li></ul><ul><li>Space is taken up which could be used </li></ul><ul><li>for violent offenders </li></ul><ul><li>It's just wrong </li></ul>In the U.S., the annual economic, indirect cost of mental illness is Estimated to be $79 billion. 2003 President’s New Freedom Commission on Mental Health
The Case of Million Dollar Murray MILLION-DOLLAR MURRAY by MALCOLM GLADWELL The New Yorker Magazine, Issue of 2006-02-13 and 20, Posted 2006-02-06 News Release Emergency Departments See Dramatic Increase in People with Mental Illness Seeking Care Emergency Physicians Cite State Health Care Budget Cuts at Root of Problem American Psychiatric Association Hillarie Turner, 703-907-8536 June 2, 2004 email@example.com Release No. 04-30 Sharon Reis 202-745-5103 Cost “ in one study, it had been concluded that one homeless person can cost the City and County about $200,000 in one year”. Philip F. Mangano, Executive Director of the United States Interagency Council on Homelessness (USICH), May 1, 2007. “ It cost us one million dollars not to do something about Murray,”
More Challenges <ul><li>The United States has roughly 2 million people incarcerated in federal, state and local prisons or jails USA Today July 14, 2011 </li></ul><ul><li>67% of former prisoners are re-arrested, and 52% are re-incarcerated at a cost of $60 billion a year Commission on Safety and Abuse in America’s Prisons </li></ul><ul><li>In Texas, the estimated lifetime cost of maintaining one person in the criminal justice system is more than $2 million Report to 81th Texas Legislature, Integration of Health and Behavioral Health Workgroup, August 2010 </li></ul><ul><li>16 to 20+% of incarcerated persons have a serious mental illness and 64 percent of jail inmates have a mental health problem Mental Health Association, nmha.org et al </li></ul><ul><li>75% of inmates and prisoners with mental illness also have an addiction disorders Skeem and Louden, 2006 </li></ul><ul><li>More than 50% of prisoners have substance abuse problems but only one in ten receive treatment jails USA Today July 14, 2011 </li></ul>
The Problem gets worse: Poor and or reduced funding Scant, limited and rationed services Reduction of State Hospital treatment beds
<ul><li>Poor communication </li></ul><ul><li>Poor system design </li></ul><ul><li>Silos </li></ul><ul><li>No strategic </li></ul><ul><li>improvement plan </li></ul><ul><li>Little use of prevailing best practices </li></ul><ul><li>Lack of leadership and overview </li></ul>Why ?
Poor System Design There’s no integrated Plan The Individual Vocational Services Employment Law Enforcement Treatment Housing Poor Communication Jails Emergency Rooms Medical Homeless Services
Severe Mental Illness: the illness is devastating because of the illness a person can’t manage their own lives at onset, most people don’t understand mental illness, families don’t understand it and the person is rejected by the family and friends because of it many times the person starts self medicating with alcohol or drugs there is a lack of education and services because of the pain and suffering personal ties are cut
Homeless persons <ul><li>People who are homeless frequently report health problems: </li></ul><ul><li>38% report alcohol use problems </li></ul><ul><li>26% report other drug use problems </li></ul><ul><li>66% report either substance use and/or mental health problems </li></ul><ul><li>39% report some form of mental health problems (20-25% meet </li></ul><ul><li>criteria for serious mental illness) </li></ul><ul><li>26% report acute health problems other than HIV/AIDS such as </li></ul><ul><li>tuberculosis, pneumonia, or sexually transmitted diseases </li></ul><ul><li>46% report chronic health conditions such as high blood pressure, </li></ul><ul><li>diabetes, or cancer </li></ul>Source: National Resource Center on Homelessness and Mental Illness, 2004 People with Serious Mental Illness die 25 years early : People with serious mental illnesses served in the public system are dying 25 years early, on average, from a full range of preventable health problems such as heart disease and diabetes. (NASMHPD, 2006)
Therapeutic Justice Model: The Integration of Treatment and Justice “The Therapeutic Justice model is defined as a systemic approach which insures a collaborative partnership between the Courts, the Criminal Justice System and the Health/Behavioral Health system while providing that the public safety net is able to provide for the most efficient and effective support for persons who are in crisis and or are experiencing psychiatric and substance abuse disorders.” Leon Evans, President and CEO, CHCS Bexar County Mental Health Authority
Starting Points Two Views Sequential Intercepts for Developing CJ-MH Partnerships Gains Center The Bexar County Jail Diversioin Model System County Wide Entry Points
Sequential Intercepts for Developing CJ-MH Partnerships * * The Center for Mental Health Services, National GAINS Center
Law Enforcement Detention/Jail CIT Judicial/Courts Magistrate County District Mental Health Public and Private Providers Crisis Care Center Jail Diversion Psychiatric and Medical Clearance Substance Abuse Services Specialty Offender Services Community Dynamic Crisis Jail Diversion Information Exchange Police, Sheriff Probation, Parole CIVIL AND CRIMINAL DIVERSION INITIATIVES Treatment Continuity of Care County City-wide Emergency Services <ul><li>Community Collaborative </li></ul><ul><li>Crisis Care Center </li></ul><ul><li>Crisis Transitional Unit </li></ul><ul><li>Crisis Hotline (Nurselink) </li></ul><ul><li>CIT/DMOT </li></ul><ul><li>Jail and Juvenile Detention </li></ul><ul><li>Statewide CARE Match </li></ul>System County City-wide Entry Points System Level The Bexar County Jail Diversioin Model System County Wide Entry Points
Collaboration: It’s an unnatural act between… … two or more unconsenting adults .
“ If you want a partner, you have to be a partner”.
First Steps Identify one single accountable person – full time Engage Continuous Quality Improvement Show the data Show me the Data!!!
How the Process Worked <ul><li>Designated Full Time (Coordinator) </li></ul><ul><li>Empowered Staff assigned to </li></ul><ul><li>attend meetings </li></ul><ul><li>Monthly Stakeholder meetings </li></ul><ul><li>Recorded Minutes with </li></ul><ul><li>Action/No Action updates </li></ul><ul><li>Set Community Priorities </li></ul><ul><li>Reported all successes/failures </li></ul><ul><li>Followed Data Based Outcomes </li></ul><ul><li>with Continuous Quality </li></ul><ul><li>Improvement (CQI) </li></ul><ul><li>Focused on creating a culture of </li></ul><ul><li>collaboration </li></ul>Community Partnership City Government County Government State Government University – Local Private Hospitals Law Enforcement Criminal/Civil Courts Advocacy – NAMI Consumers San Antonio State Hospitals Mental Health Partners The Jail Diversion Over-sight Committee The Jail Diversion Planning & Advisory Committee Community Medical Directors Roundtable Private Sponsorship
<ul><li>Jail Diversion Oversight Committee </li></ul><ul><li>(34+ Community Agencies/Stakeholders) </li></ul><ul><li>Community Medical Directors Roundtable </li></ul><ul><li>Children’s Medical Directors Roundtable </li></ul><ul><li>Bexar County Children’s Diversion School District Sub Committee </li></ul><ul><li>Bexar County Children’s Diversion Child Protective Services Sub </li></ul><ul><li>Committee </li></ul><ul><li>Bexar County Children’s Diversion Juvenile Justice Probation Sub </li></ul><ul><li>Committee </li></ul><ul><li>Community Co-Location Coalition (29 Community Agencies including law </li></ul><ul><li>enforcement entities meeting to address the homeless & public inebriate) </li></ul>Stakeholder Collaboration via:
Evolution - Milestones 2002 – Bexar County Jail Diversion Collaborative meets for 1 st time 2003 – First Crisis Intervention Team Training begins 2004 – Specialty Jail Diversion Facility opens 2005 – 24/7 One Stop Crisis Care Center Opened 2006 – Bexar County Jail Diversion receives APA’s Gold Award 2008 – Detox, Sobering, Drug Abuse Restoration Center Opened 2010 – Haven for Hope 1,600 Bed Homeless Facility Opened 2010 – International Crisis Intervention Team Conference hosts 1,600 Officers 2000 – CEO begins diversion efforts, full time coordinator is hired 2003 – Deputy Mobile Outreach Team begun
Across the Nation with Diversion Efforts http://gainscenter.samhsa.gov/html/jail_diversion/jd_map.asp
With more mental health utilization there is less incarceration.
The Bottom Line Outcomes: <ul><li>Treatment Works – Revocation Rates </li></ul><ul><li>Involuntary Outpatient Commitment Data </li></ul><ul><li>Impact on Wait Time for Law Enforcement </li></ul><ul><li>Documented and Immediate Cost Avoidance </li></ul><ul><li>Jail Census </li></ul>
Revocation Rates 2010 Federal Revocation Rate : 66% Two-thirds of returning prisoners are re-arrested for new crimes within 3 years or their release. Second Chance Act, 110TH CONGRESS REPORT to US HOUSE OF REPRESENTATIVES <ul><li>State Revocation Rate : </li></ul><ul><li>Texas Felony Revocation Rate = 11.8% </li></ul><ul><li>* For Offenders enrolled in TDCJ Casemanagement </li></ul><ul><li>Local Revocation Rate: </li></ul><ul><li>Bexar County Mentally Impaired </li></ul><ul><li>Caseload Department </li></ul><ul><li>Probation Department = 10.8% </li></ul>* Report to the Governor and LBB, December 2010
Involuntary Outpatient Commitment Program Pre IOPC Program Post 79% Reduction in Bed Day Use, Post Program First Year Evaluation
<ul><li>Then (prior to Sept 2005) </li></ul><ul><li>Wait times for Medical </li></ul><ul><li>Clearance/ Screening at </li></ul><ul><li>UHS ER - 9 hours, 18 min. </li></ul><ul><li>Wait times for Medical </li></ul><ul><li>Clearance/ Screening and Psychiatric Evaluation was between 12 and 14 hours. </li></ul><ul><li>Now </li></ul><ul><li>The wait time for Medical Clearance/ Screening at the Crisis Care Center is 45 minutes. </li></ul><ul><li>Wait time for Medical Clearance/Screening and Psychiatric Evaluation is 60-65 minutes. </li></ul>Impact on WAIT TIME for LAW ENFORCEMENT
Combined CCC and Restoration Documented and Immediate Cost Avoidance Documented and Immediate Cost Avoidance, Two Year Analysis April 16, 2008 – March 31, 2010 $6,668,693 $8,825,403 $15,494,096 $5,174,599 $7,002,055 $12,176,654 $1,494,094 $1,823,348 $3,317,442 Total Year 1 Total Year 2 TWO YEAR TOTALS $385,522 $221,000 $385,522 $221,000 K. 0 Reduction in Jail Time for Competency Restoration on Bond and on Return $137,898 $900,000 $137,898 $900,000 J. 0 Reduction in Wait Time in Jail for Outpatient Competence/Wait Time for Restoration compared to Inpatient $255,055 $1,020,000 $255,055 $1,020,000 I. 0 Reduction in Competency Restoration Wait Time in Jail for Hosp Admission $579,509 $502,133 $371,350 $322,300 H. $208,159 $179,833 G. Mentally Ill Diverted from Magistration Facility $1,096,500 $959,500 $774,000 $676,000 F. $322,500 $283,500 E. Mentally Ill Diverted from UHS ER Cost $1,795,200 $1,479,000 $1,267,200 $1,044,000 D. $528,000 $435,000 C. Injured Prisoner Diverted from UHS ER $2,419,009 $3,743,770 $1,983,574 $2,818,755* B. $435,435 $925,015 A. Public Inebriates Diverted from Detention Facility Direct Cost Avoidance Bexar County City of San Antonio Cost Category
As of May 2011, there were 883 empty beds in the jail
Leon Evans, President and Chief Executive Officer, The Center for Health Care Services San Antonio, Texas For additional information contact: Leon Evans, Ph. 210 731-1300 Email: [email_address] Thank you !