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Council of State Governments Justice Center | 1

Stepping Up Initiative

North Carolina Council of Community ProgramsPinehurst, NCDecember 6, 2016

Richard Cho, Director, Behavioral Health Division, CSG Justice Center


Barry has been in and out of jail for

more than 7 years. His rap sheet

shows that he is booked into jail for

a variety of minor misdemeanor

offenses—hopping subway

turnstiles, failing to show up for

court hearings, and shoplifting food.

When not in jail, Barry stays in a

homeless shelter. And when not

staying in a shelter, he sleeps on

the streets or the NYC subway.

Whenever he has the chance, he

uses drugs and alcohol.

Barry

Photo credit: Alana Semuels


Millions of Adults Now Under Correctional Supervision

• Bureau of Justice Statistics 1980 - 2014

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 10 12 14

Total

Probation

Prison

Parole

Jail

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Jails are where the volume is

11,605,175

553,843 222,565 10,621

Jail Admissions Prison Admissions

Annually

Weekly

Number of National Admissions in a Week and a Year for Jails and Prisons, 2012


Mental Illness is Overrepresented in Our Jails

5% Serious Mental Illness

General Population Jail Population

17% Serious Mental Illness 72% Co-Occurring

Substance UseDisorder


While Jail Populations Have Declined…

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

00 01 02 03 04 05 06 07 08 09 10 11 12 13

Year

Annual Percent Change

Number of Inmates at

Midyear

Inmates Confined in Local Jails at Midyear and Percent Change in the Jail Population, 2000-2013

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…Jails Report Increases in the Number of People with Mental Illnesses

3,319 4,391

10,257

7,557

2005 2012

M Group Non-M Group

Average Daily Jail Population (ADP) and ADP with Mental Health Diagnoses

76%

63%

24%37%

13,576 Total 11,948

Total

NYC Jail Population (2005-2012)


A National Crisis Facing Law Enforcement and Jails

County is ready, but is it able to deal with mentally ill?

Mentally ill inmates at Franklin County Jail stay longer

Inmates with mental health issues inundate Pima County Jail

Nearly a third of county inmates require drugs for mental illness

Mentally ill Mainers are still warehoused, but now it’s in jail

Johnson County Sheriff: Mental health is number one problem

Mental health crisis at Travis County jails

Jail violence increasing due to mental illnesses


Factors Driving the Crisis

Longer stays in jail and prison

Limited access to health care

Low utilization of EBPs

Higher recidivism rates

More criminogenic risk factors

Disproportionately higher rates of arrest

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Rising Number of People in Prisons and Jails for Drug Offenses (1980 -2010)


“We Need Better Funding for

Mental Health Services”

“Kansas budget cuts force 200

layoffs at state mental health

centers”

Mental Health Report 2015:

“States Continue to Cut Mental

Health Funding”

Funding Cuts Challenge Provision of Effective

Community Treatment and Supports


We traded these…

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And these...


For these…


And this…

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Instead of this…


Or this…


Or this...

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Or this.


There will be fewer people with mental illnesses in our jails

tomorrow than there are today.


May 2015: Call to Action Issued to Counties

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Major Partners Rally Around a Common Goal

Federal Partners

Stepping Up Steering Committee

Lead Partners


300+ Counties “Step Up”

Approximately 115 million people reside in Stepping Up counties


26 North Carolina Counties “Step Up”

http://www.americanpsychiatricfoundation.org/

http://www.americanpsychiatricfoundation.org/

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Key Supporters

Elizabeth K. Dollard Trust


Webinars and Planning Guides

Webinar 1 (5/14/2015)

Webinars and corresponding planning guides were released following the Call to Action as part of a larger Resources Toolkit

Resources Toolkit available at Stepuptogether.org/toolkit

April 2016: National Summit

27

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Media Coverage: National News & Features


“When Police Deal with People Who Have Mental Health Issues”

“We Need Better Funding for Mental Health Services”

“A Crisis In Our Jails”

“Mental Illness is No Crime”

Media Coverage: Opinion

“Mental Illness Must Be Decriminalized”

“Homeless Crisis Should Not Derail Progress on Mental Illness”


Media Coverage: Local

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Early Successes: Forsyth County, NC

• Passed Stepping Up resolution in April 2015 and committed $50,000 to hire a part-time Stepping Up coordinator

• Currently applying for local funds to hire a full-time coordinator and peer support positions

• Initiated pilot project focused on women with mental health needs in their jail

• Developed screening system and a discharge plan in the jail that connects individuals to community based services

• Coordinated data sharing agreements between the jail and community service providers

• Will open a 24-hour crisis center in January 2017


• Passed a Stepping Up resolution in June 2015; attended and presented at the National Stepping Up Summit

• Implemented CIT training for law enforcement and corrections

• Hired part-time jail mental health worker to conduct screenings and assessments and reentry case planning

• Changed inmate release policy to better accommodate connections to services

• Secured short-term housing for individuals in crisis

Early Successes: Codington County, SD


Key Challenges Counties Face

Challenge 1 - Being data driven

Challenge 2 – Using Best Practices

Challenge 3 – Continuity of Care

Challenge 4 – Tracking Progress

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County Systems Analyses Leads to Policy Changes


A Common Framework for County-Level Action

1. Is your leadership committed?

2. Do you have timely screening and assessment?

3. Do you have baseline data?

4. Have you conducted a comprehensive process analysis and service inventory?

5. Have you prioritized policy, practice, and funding?

6. Do you track progress?

Six Key Questions


Defense Bar Probation ChiefDistrict

Attorney

County Commissioner/

Executive

CJ Coordinator

Sheriff/Jail Administrator

JudgeBehavioral

Health Director

Creating a County Collaborative Leadership and Management Structure

Families/Advocates

MayorsPolice

Departments

Providers

Services Providers

Community Leaders

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Adopt a uniform definition of mental illness (and SUD)

Select validated screening and assessment tools

Universal screening for everyone booked into jail

Validated assessment by clinical professional for all screened positive

Assess for pretrial risk or diversion

Improving Screening and Assessment


Strategies Must Focus on Four Outcomes

38

1.Reduce the number of people with mental illness booked into jail

2.Shorten the length of stay for people with mental illnesses in jails

3.Increase the percentage of people with mental illnesses in jail connected to the right services and supports

4.Lowerrates of recidivism


Current Practices Insufficient

People with mental illness newly booked into jail

People with mental illness in jail on first day of month100

200

Average length of stay in jail in months

100

0.5x

+

100

20 People connected to treatment and services (20% recidivism)

80

60%x Rate of recidivism

48 + 4 + 100 + 100 = 252

-

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Applying a Data-Driven Strategy



People connected to treatment and services

People returning to jail

• Police-Mental Health Collaboration programs

• Crisis diversion centers

• Routine screening and assessment for mental health and SUDs in jail

• Pre-trial diversion• Specialized MH court docket• Bail policy reform

• Expand community-based treatment & housing options

• Streamline access to services• Leverage Medicaid and other federal,

state, and local resources

• Apply Risk-Need-Responsivity principle• Use evidence-based practices• Ongoing program evaluation


Improved Outcomes


People with mental illness in jail on first day of month100

150


50

0.3x

+

100

30 People connected to treatment and services(20% recidivism)

70

40%x Rate of recidivism

28 + 6 + 50 + 50 = 134

-


Isolated Programs, Diversion to Where?

Crisis Intervention

Team

Mental Health Court

Specialized Probation

Jail Reentry Program

?

?

?

?

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Jail-based

Court-based

Pretrial

Court-based

Jail-based

Law Enforcement

Law Enforcement

Initial Contact with

Law Enforcement

Arrest

Initial Detention

First Court Appearance

Jail - Pretrial

Dispositional Court

Jail/Reentry

Probation

Prison/Reentry

Parole

Specialty Court

A System of Diversion

Intensive

Outpatient

Treatment

Peer

Support

Services

Case

Management

Psychopharma-

cology

Supportive

Housing

Outpatient

Treatment

Integrated

MH & SU

Services

Supported

Employment

Crisis

Services

Community-Based Continuum of Treatment, Services, and Housing


Improving Program Targeting Based on Risk-Need Assessments

HighSupervision/

ProgramIntensity

Moderate Supervision/

ProgramIntensity

Low Supervision/

ProgramIntensity

Programs Targeted Without Assessing for Risk-Need



45Typically 1/3 of the population Typically 1/3 of the population Typically 1/3 of the population

LOW RISK 10% re-arrested

MODERATE RISK35% re-arrested

HIGH RISK70% re-arrested

Risk of Re-offending

HighSupervision/

ProgramIntensity


ProgramIntensity

Low Supervision/

ProgramIntensity

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46

Risk of Re-offending

Typically 1/3 of the population Typically 1/3 of the population Typically 1/3 of the population

LOW RISK 10% re-arrested

MODERATE RISK35% re-arrested

HIGH RISK70% re-arrested

Low Supervision/

ProgramIntensity


ProgramIntensity

HighSupervision/

ProgramIntensity

20-30% reduction


Leveraging Health Financing (Medicaid)

CA

• Pilots under Medi-Cal’s 1115 demonstration waiver: Health Home Pilot, Whole Person Care Pilot, and the Drug Medi-Cal Organized Delivery System

PA• Recent passage of legislation to authorize the suspension of

Medicaid upon incarceration (Act 76)

TX

• Proposal submitted at the direction of state legislature to broaden scope of 1915(i) HCBS program to focus on people with serious mental illnesses with histories of incarcerations, as well as extended inpatient psychiatric stays and frequent ER visits.

RINY

• Health Home programs targeted to people who are involved in the criminal justice system.


Addressing Homelessness Through Housing Sector Partnerships

Conduct jail and HMIS data match to

identify shared population

Build partnerships with public

housing authorities and Continuums of

Care

Identify financing for

and providers of supportive

services

Create supportive

housing opportunities

targeted at jail-mental health

population

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Los Angeles County Office of Jail Diversion and Flexible Housing Subsidy Pool

FHSP

Los Angeles County Dept. of Health Services

503(c) nonprofit coordinating community-based partner

Property owners throughout LA County

LADHS Housing Rental Subsidy Program

1,000 Supportive Housing Rental Subsidies for Jail Diversion Population


State-Level Efforts to Support Counties

Texas:Statewide requirements &/or contracts for validated screening tools

Ohio and New York: Statewide training for Evidence Based Practices Curricula

Utah:Regional hubs for tele-screening and tele-psychiatry (26 states use tele-psychiatry in correctional facilities)

Utah, Connecticut, Oklahoma, & Ohio:Statewide CIT training academies


State Investments to Support County Level Efforts

Allocated $9 million between FY2014 and FY2016 to expand access to substance use treatment for people on supervision, with county-level grants awarded for treatment services and more.

West Virginia

$12 million over two years for behavioral health treatment for people on supervision.Alabama

$5 million added over two years in behavioral health treatment for people on supervision.Kansas

$10 million over two years to expand community-based recidivism reduction programs including mental health services, substance use treatment, and employment services

Wisconsin

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In 2008, Barry was referred to

permanent supportive housing through

the Frequent Users System Engagement

(FUSE) program.

Once he was stably housed, Barry went

through a drug treatment program. He

now lives in an apartment with multiple

roommates, and is part of a community

where he has access to case workers,

nurses, and peers.

He also enjoys spending time

volunteering at a church and writing

poetry.

Barry: A Success Story

Photo credit: Alana Semuels

Sources: Alana Semuels, “How to End Homelessness in New York City,” The Atlantic, January 4, 2016 StoryCorps, http://shnny.org/learn-more/real-stories

http://shnny.org/learn-more/real-stories

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