Download The APIC Model of Transition Planning for Persons With SMI

Responding to the Needs of Justice
Involved Persons with Mental Illnesses:
Screening and Assessment
Fred C. Osher, MD
Director of Health Systems & Services
Policy
July 24, 2008
Dear Abby……….
CSJ Justice Center:
National Projects
Council of State Governments Justice
Center: Florida Activities

NIC Learning Site

Chief Justice Initiative

Collaboration with FMHI
Goals of Presentation
• Overview and Context
• Target Population and Program
Design
• Screening and Assessment
• Supervision and Treatment Planning
• Evidence Based Practices
Skyrocketing Criminal Justice
Populations Bureau of Justice Statistics, 2005
Scope of the Problem

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Over 14 bookings into U.S. jails each year
Over 9 million adults
Over 1,000,000 will have serious mental
illnesses
¾ of these will have co-occurring substance
use disorders
The vast majority will be released to
community
GAINS, 2004
GAINS, 2004
Co-Occurring Substance Use Disorders Among
Jail Detainees with Serious Mental Disorders
Male Detainees
Female Detainees
28%
28%
72%
72%
■ % With Co-Occurring Substance Use Disorders
■ % Without Co-Occurring Substance Use Disorders
GAINS 2004
Goals of Presentation
• Overview and Context
• Importance of Target Population and
Program Design
• Screening and Assessment
• Supervision and Treatment Planning
• Evidence Based Practices
Diversion Programs
Logic Model
Steadman, Osher, Naples
Stage 1
Diversion
Identify Target
Group
Improved Mental
Health Outcomes
Stage 2
Comprehensive/Appropriate
Community Treatment
Improved Public
Safety Outcomes
Stage 3 - Outcomes
Target Population and Program
Design: Three Questions
1.
Who is your target population?
2.
What will you do for them?
3.
How will you sustain your program?
Finding your target population – not so simple
Defining the Target Population
Finding the Target Population
SCREENING FOR
MHPTR
ELIGIBILITY
Defining the Target Population
Impact of Target Population on Outcomes:
Pennsylvania Comparisons of Simulation Models
$150,000
$108,874
$100,000
$87,436
$50,000
$0
Simulation 1
Simulation 2
($50,000)
($79,700)
($100,000)
Savings to the County
Simulation 3
Some Common Front-end
Pitfalls

Vague criteria for target group

Missing key people in planning

Overly ambitious goals

EBP’s: what are they and where are they?

Workforce capacity and workforce quality
Goals of Presentation
• Overview and Context
• Target Population and Program
Design
• Screening and Assessment
• Supervision and Treatment Planning
• Evidence Based Practices
Mental health service delivery
begins with identification

Three stage process:
Screening
 Assessment
 Supervision/Treatment Planning

Screening, Assessment, and
Treatment Planning
Screening for
Need/Risk
Objective and Comprehensive
Screening and Assessment
(NIDA, 2006)
Definition: Screening

A formal process of testing to determine whether an inmate
does or does not warrant further attention at the current time in
regard to a particular disorder and, in this context, the possibility
of a mental disorder.

The screening process for mental illnesses disorders seeks to
answer a “yes” or “no” question. Might a mental illness exist?

Note that the screening process does not necessarily identify
what kind of problem the person might have, or how serious it
might be, but determines whether or not further assessment is
warranted.
23
Screening for Mental
Illnesses
Why screen for mental illness?

Jail populations have 3-4 times higher rates of
mental illness than the general population
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U.S. Supreme Court has held that jails and
prisons are obligated to provide mental health
care

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Public health opportunity
Critical to jail management
Essential for rapid engagement in specialized
treatment and supervision programs
What else to screen for ?
•Suicide Risk
•Substance Use Disorders
•Motivation
•Criminogenic Risk
Features of Useful Screening
Instruments
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High sensitivity (but not high specificity)
Brief
Low cost
Minimal staff training required
Consumer friendly
27
Historic lack of adequate
mental health screening
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83% of jails provide some screening
Steadman and Veysey (1997)
Only 37% of jail detainees with severe
mental disorder were identified during
routine screening
Teplin (1990)
Recent use of data matching programs
NIJ Research

Develop a brief jail mental health screening tool to be
used by correctional staff on all jail admissions
 Brief
 Easy to use
 Clear decision criteria
 Balance false negative and false positive rates

Validate the tool to confirm its utility and make
available to U.S. jails
Brief Jail Mental Health
Screen:Research Approach

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Use the screen in four jails for eight
months at two points in time
Administered structured clinical
interview (SCID)to a sub-sample of
inmates
Compare the screens with the clinical
interviews for validation
Validation study
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Screened over 20,000 inmates
Sampled 100 inmates at each jail
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Stratified by status (urgent, routine, nonreferral) and gender
Administered the Structured Clinical
Interview for DSM-IV (SCID)
Identified false positives and false
negatives rates and appropriate scoring
cut-offs
Validation Results
•Males
•80 % correctly identified
•64% sensitivity
•84% specificity
•8% False Negatives
•Females
•72% correctly identified
•61% sensitivity
•75% specificity
•14% false negatives
BJMHS - Conclusions

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A useful, cost-effective tool for
screening men and women booked into
U.S. jails
Reasonable referral rates (11 – 16%)
8 questions can be administered by
corrections staff in 2 – 3 minutes
NIJ – “based on successful validation results,
it is anticipated these tools will be
disseminated nationwide for use in all
correctional facilities”
Screening for Suicide Risk
Suicide and Corrections

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Suicide is a primary cause of death in many
county correctional facilities
It takes a team to prevent suicide
The correctional officer has the most critical
role in suicide prevention
Most suicides can be prevented when the
team knows what to look for and what to do
Liability is reduced significantly when the
team understands and follows the suicide
prevention plan.
Suicide Prevention (BJS, 2005)

Jail suicide rates – 47/100,000
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Rates in 50 largest jails (29/100,000)
Suicide rates are declining steadily nationally
No longer leading cause of death at 32.3% (now
illness at 47.6% is leading cause)
Nearly ½ of jail suicides occur in first week of
custody

The importance of screening
Suicide Intake Screening
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Suicide Prevention Screening Guidelines Form

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Takes less than 5 minutes to fill out
Devoted exclusively to identifying suicidal behavior
in arrestees
Encourages communication between
arresting/transporting and booking officers
Guidelines for acute referral
Standardized training available
Used in conjunction with BJMHS
Suicide Prevention – more
than a screening instrument
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Initial screen and periodic assessment
Suicide prevention training for correctional, medical,
and MH staff
Levels of communication between outside agencies,
among facility staff, and with the suicidal inmate
Suicide resistant, protrusion free housing for suicidal
inmates
Level of supervision for suicidal inmates
Timely emergency interventions following attempts
Critical incident stress debriefing to affected staff and
inmates, as well as a multidisciplinary mortality
review of suicides and serious attempts
Screening for Substance
Use Disorders
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TCU Drug Dependence Screen – II
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High overall accuracy
Tested in jail and prison settings
Brief, easy to score with low, medium, and
high cut-off points
Simple Screening Instrument
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High accuracy, tested in corrections
Brief, easy to score
Screening for Motivation
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Useful in matching to scarce treatment
resources
Caution: Motivation as state, not trait
Available measures

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SOCRATES – stages of change readiness
and treatment eagerness scale
URICA – University of Rhode Island
Change Assessment Scale
Screening for Criminogenic
Risk
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Long history in c-j settings
Useful in determining supervision
intensity
Potential application for assignment ot
cognitive behavioral programs
Brief Screens in Development – Austin 8
item scale
LSI-R, WISC –R, COMPASS
Definition: Assessment

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A basic assessment consists of gathering key information and
engaging in a process with the client that enables the
counselor/therapist to understand the client’s readiness for
change, problem areas, COD diagnosis, disabilities, and strengths.
An assessment typically involves a clinical examination of the
functioning and well-being of the client and includes a number of
tests and written and oral exercises. The COD diagnosis is
established by referral to a psychiatrist or clinical psychologist.
Assessment of the COD client is an ongoing process that should be
repeated over time to capture the changing nature of the client’s
status.
Domains of Assessment
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Acute Safety Needs
Quadrant Assignment
Level of Care
Diagnosis
Disability
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43
Strengths and Skills
Recovery Support
Cultural Context
Problem Domains
Phase of
Recovery/Stage of
Change
The “Best” Assessment Tool
44
An Assessment Approach:
The APIC Model of Transition
Planning for Persons With SMI
Leaving Jails
Outcomes of Inadequate
Transition Planning
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Compromised public safety
Increased psychiatric disability
Relapse to substance abuse
Hospitalization
Suicide
Homelessness
Re-arrest
Jails vs. Prisons
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Jails hold both detainees awaiting court
appearances, persons awaiting
sentencing, AND inmates serving short
term sentences
Short episodes of incarceration
Inmates less likely to have lost contact
with community supports
Unpredictable nature of jail release
The APIC Model

Assess
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Plan
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Identify

Coordinate
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Assess the inmate’s clinical and
social needs, and public safety
risks
Plan for the treatment and
services required to address the
inmates needs
Identify required community
and correctional programs
responsible for post-release
services
Coordinate the transition plan to
ensure implementation and
avoid gaps in care with
community-based services
ASSESS

Begins with identification of inmate with
mental illness
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Screening and Referral
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Need for valid and reliable screening measures
Applied to every newly admitted inmate during routine
intake process
Conducted by correctional staff
“red flags” result in need for discharge planning
Obtain old records
Engage the consumer in the transition
process
PLAN
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Planning must be multidisciplinary
Address short-term and long-term
needs
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Critical time intervention
What has worked before?
Seek family input
PLAN
(cont.)
PLANNING DOMAINS
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Housing
Medication
Integrated treatment for co-occurring dx
Medical Care
Food and Clothing
Transportation
Child Care
Civil Legal Services
IDENTIFY

Identify community providers that are
appropriate to the inmate based on:
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clinical diagnosis
demographic factors
financial arrangements
geographic location
legal circumstances
Clarify confidentiality and information sharing
processes and communication expectations
IDENTIFY
(cont.)
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Match conditions of release to severity of
criminal offense
Match intensity of community care to severity
of disability and motivational state
Ensure that every inmate’s belongings are
returned upon release
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Identification
Benefit cards
Medications
Coordinate
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Case management services
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To communicate the inmates needs to
planning agents
To coordinate the timing and delivery of
services
To span the boundary between institution
and community
In-reach activities to be supported
Coordinate
(cont.)
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Critical Transition Responsibilites
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Where, when and with whom are first visits
scheduled ?
Does the releasee has adequate supply of meds to
last through the first appointment ?
Who is contacted if any aspect of the plan falls
through or needs to be modified ?
Establish a tracking mechanism to follow-up
on failed appointments
APIC APPLICATIONS
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APIC Checklist for Every Inmate
Identified with a Mental Illness
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Brief, targeted, with multiple copies
Being used in numerous jails
Applied in jail diversion programs
Comprehensive Screening and
Assessment Approach
Peters, 2008
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All individuals entering the criminal justice system should
be screened for mental and substance use disorders
Screening should be completed at the earliest possible
point of involvement
Screening should occur at multiple points in the c-j system
Whenever possible, similar or standardized instruments
should be used at different points in MH and CJ systems
Information from previous screening and assessments
should be communicated throughout the different
systems.
Goals of Presentation
• Overview and Context
• Target Population and Program
Design
• Screening and Assessment
• Supervision and Treatment Planning
• Evidence Based Practices
Principles of Integrated Treatment
and Supervision
Supervision and treatment plans must be
individualized based on assessment
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Clinical need
Motivation for Treatment
Risk Assessments
Availability of Treatment
Timing of Intervention
(NIDA, 2006)
Principles of Integrated
Treatment and Supervision
Supervision and treatment must be
collaborative and complementary
o
Shared missions and visions
o
Multi-disciplinary teams
o
Clear lines of communication
o
Formal and Informal
Mechanisms for working together
(NIDA, 2006)
Collaboration Outcomes
Goals of Presentation
• Overview and Context
• Target Population and Program
Design
• Screening and Assessment
• Supervision and Treatment Planning
• Evidence Based Practices
Why Should You Care About
EBPs?

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They are the new buzz-words for
mental healthniks
There is increasing emphasis in
MH/SA/CJ on performance measures
and EBPs
They are critical to successful
alternatives to incarceration and to
slowing the revolving door
What is Evidence-Based
Practice ?
Evidence-Based Practice is
“the integration of the best
research evidence with
clinical expertise and
patient values.”
Institute of Medicine, 2000
Pyramid of
Research Evidence
(COCE, 2005)
8
7
6
5
4
3
Expert
Panel
Review
of Research
Evidence
Meta-Anal ytic
Studies
ns
Clinical Trial Replicatio
s
ion
lat
pu
Po
With Different
Literature Reviews
Analyzing Studies
Clinical Trial
Single Study/Controlledental Studies
rim
pe
Ex
siua
Q
le
Multip
Single Group Design
Large Scale, Multi- Site,
Quasi- Experimental
2
Single Group Pre/Post
1
Pilot Studies
Case Studies
What is Fidelity?
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Fidelity is the degree of implementation of an
evidence-based practice
Programs with high-fidelity are expected to
have greater effectiveness
Fidelity scales assess the critical ingredients of
an EBP
Evidence Base Practices for Justice
Involved Persons with Mental Illnesses
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Housing with Appropriate Supports
(Modified Therapeutic Communities)
Integrated Dual Disorder Treatment
Multidisciplinary Teams (ACT and FACT )
Supported Employment
Trauma-informed Systems of Care
Illness Self Management
Psychopharmacologic Medications
Challenges to EBP
Implementation
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Target population characteristics
Staff attitudes and skills
Facilities/resources (Physical environment,
staff and staffing patterns, funding
resources, housing, transportation)
Agency Policies/Administrative Practices
Local/State/Federal regulation
Interagency networks
Reimbursement
Past Year Treatment among Adults Aged 18
or Older with Co-Occurring SMI and a
Substance Use Disorder: 2003 (NSDUH)
Treatment Only
for Mental Health
Problems
Treatment for Both
Mental Health and
Substance Use
Problems
39.8%
7.5%
3.7%
No Treatment
49.0%
4.2 Million Adults with Co-Occurring SMI and
Substance Use Disorder
Substance Use
Treatment Only
The Bottom Line
EBP
Housing
Integrated Tx
ACT
Supported Emp.
Illness Mgmt.
Trauma Int./Inf
Medications
Data for J I
++
++++
+++
+
+
++
+++++
(Osher and Steadman, 2008)
Impact
+++++
++++
+++
+++
++
+++
+++++
Is there too much emphasis on
EBPs ?

There are not enough EBPs to cover the
range of clinical circumstances

Hence, Evidence-Based Thinking

The conscientious, explicit, and judicious use
of current best evidence in making decisions
about the care of individual patients.
Moving Forward
FMHI Jail Survey
• Current screening and assessment practices
• Database infrastructure and capacity
• Medication and clinical responses
• Information sharing practices
FMHI Jail Pilot Project

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Up to 3 County Jails
Implement Screening and Assessment
Processes
Identify Prevalence of Mental Illnesses
at point in time
Use data to evaluate community
interventions
Infonet Links



Through the TA Center website, grantees will be able
to access and search up-to-date profiles of the
collaborative programs in Florida and related media
coverage by county.
Grantees will be able to log in to create a detailed
program webpage to which they can refer others,
including funders.
Program profiles will be available in a national
searchable database, raising their national profile in
the field.
The Goal

“….must build lasting bridges between
mental health and criminal justice
systems, leading to coordinated and
continual health care for clients in both
systems”
(Lurigio, 1996)
Thank You
Contact Information:
Fred Osher
[email protected]
www.justicecenter.csg.org