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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 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 U.S. Supreme Court has held that jails and prisons are obligated to provide mental health care 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 High sensitivity (but not high specificity) Brief Low cost Minimal staff training required Consumer friendly 27 Historic lack of adequate mental health screening 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 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 Screened over 20,000 inmates Sampled 100 inmates at each jail 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 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 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 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 Suicide Prevention Screening Guidelines Form 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 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 TCU Drug Dependence Screen – II High overall accuracy Tested in jail and prison settings Brief, easy to score with low, medium, and high cut-off points Simple Screening Instrument High accuracy, tested in corrections Brief, easy to score Screening for Motivation Useful in matching to scarce treatment resources Caution: Motivation as state, not trait Available measures SOCRATES – stages of change readiness and treatment eagerness scale URICA – University of Rhode Island Change Assessment Scale Screening for Criminogenic Risk 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 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 Acute Safety Needs Quadrant Assignment Level of Care Diagnosis Disability 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 Compromised public safety Increased psychiatric disability Relapse to substance abuse Hospitalization Suicide Homelessness Re-arrest Jails vs. Prisons 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 Plan Identify Coordinate 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 Screening and Referral 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 Planning must be multidisciplinary Address short-term and long-term needs Critical time intervention What has worked before? Seek family input PLAN (cont.) PLANNING DOMAINS 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: clinical diagnosis demographic factors financial arrangements geographic location legal circumstances Clarify confidentiality and information sharing processes and communication expectations IDENTIFY (cont.) 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 Identification Benefit cards Medications Coordinate Case management services 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.) Critical Transition Responsibilites 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 APIC Checklist for Every Inmate Identified with a Mental Illness Brief, targeted, with multiple copies Being used in numerous jails Applied in jail diversion programs Comprehensive Screening and Assessment Approach Peters, 2008 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 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? 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? 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 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 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 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