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11/30/2016
1
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
Council of State Governments Justice Center | 2
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
Council of State Governments Justice Center | 3
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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Council of State Governments Justice Center | 4
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
Council of State Governments Justice Center | 5
Mental Illness is Overrepresented in Our Jails
5% Serious Mental Illness
General Population Jail Population
17% Serious Mental Illness 72% Co-Occurring
Substance UseDisorder
Council of State Governments Justice Center | 6
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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Council of State Governments Justice Center | 7
…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)
Council of State Governments Justice Center | 8
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
Council of State Governments Justice Center | 9
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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Council of State Governments Justice Center | 10
Rising Number of People in Prisons and Jails for Drug Offenses (1980 -2010)
Council of State Governments Justice Center | 11
“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
Council of State Governments Justice Center | 12
We traded these…
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Council of State Governments Justice Center | 13
And these...
Council of State Governments Justice Center | 14
For these…
Council of State Governments Justice Center | 15
And this…
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Council of State Governments Justice Center | 16
Instead of this…
Council of State Governments Justice Center | 17
Or this…
Council of State Governments Justice Center | 18
Or this...
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Council of State Governments Justice Center | 19
Or this.
Council of State Governments Justice Center | 20
There will be fewer people with mental illnesses in our jails
tomorrow than there are today.
Council of State Governments Justice Center | 21
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
Council of State Governments Justice Center | 23
300+ Counties “Step Up”
Approximately 115 million people reside in Stepping Up counties
Council of State Governments Justice Center | 24
26 North Carolina Counties “Step Up”
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Council of State Governments Justice Center | 25
Key Supporters
Elizabeth K. Dollard Trust
Council of State Governments Justice Center | 26
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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Council of State Governments Justice Center | 28
Media Coverage: National News & Features
Council of State Governments Justice Center | 29
“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”
Council of State Governments Justice Center | 30
Media Coverage: Local
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Council of State Governments Justice Center | 31
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
Council of State Governments Justice Center | 32
• 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
Council of State Governments Justice Center | 33
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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Council of State Governments Justice Center | 34
County Systems Analyses Leads to Policy Changes
Council of State Governments Justice Center | 35
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
Council of State Governments Justice Center | 36
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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Council of State Governments Justice Center | 37
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
Council of State Governments Justice Center | 38
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
Council of State Governments Justice Center | 39
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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Council of State Governments Justice Center | 40
Applying a Data-Driven Strategy
People with mental illness newly booked into jail
Average length of stay in jail in months
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
Council of State Governments Justice Center | 41
Improved Outcomes
People with mental illness newly booked into jail
People with mental illness in jail on first day of month100
150
Average length of stay in jail in months
50
0.3x
+
100
30 People connected to treatment and services(20% recidivism)
70
40%x Rate of recidivism
28 + 6 + 50 + 50 = 134
-
Council of State Governments Justice Center | 42
Isolated Programs, Diversion to Where?
Crisis Intervention
Team
Mental Health Court
Specialized Probation
Jail Reentry Program
?
?
?
?
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Council of State Governments Justice Center | 43
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
Council of State Governments Justice Center | 44
Improving Program Targeting Based on Risk-Need Assessments
HighSupervision/
ProgramIntensity
Moderate Supervision/
ProgramIntensity
Low Supervision/
ProgramIntensity
Programs Targeted Without Assessing for Risk-Need
Council of State Governments Justice Center | 45
Improving Program Targeting Based on Risk-Need Assessments
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
Moderate Supervision/
ProgramIntensity
Low Supervision/
ProgramIntensity
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Council of State Governments Justice Center | 46
Improving Program Targeting Based on Risk-Need Assessments
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
Moderate Supervision/
ProgramIntensity
HighSupervision/
ProgramIntensity
20-30% reduction
Council of State Governments Justice Center | 47
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.
Council of State Governments Justice Center | 48
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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Council of State Governments Justice Center | 49
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
Council of State Governments Justice Center | 50
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
Council of State Governments Justice Center | 51
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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Council of State Governments Justice Center | 52
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