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Preliminary Findings of a Forensic Intensive Case
Management (FICM) Program
March 18, 2008
Kathleen Moore, PhD
Autumn Frei, MA
Karen Williams, MS, CAP
Rick Buhl
David Kershaw, PhD
SAMHSA Jail Diversion Grant
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Awarded April, 2006
Up to 3 years of funding
Serves post-booking adults, mentally ill & substance
impaired, diversion eligible, current misdemeanor
charge
Utilizes Forensic Intensive Case Management
(FICM) model
Completed Strategic Planning
Implementation Committee (i.e., Advisory
Committee) meets on a monthly basis
Implementation Committee
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Hillsborough County
Agency for Community Treatment Services
Florida Mental Health Institute
Mental Health Care, Inc.
Hillsborough County Sheriff’s Office
Public Defender’s Office
Florida Dept. of Children & Families
Gulf Coast Community Care
Family Emergency Treatment Center
Central Florida Behavioral Health Network
Why important?
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5% of divertees accounted for 20% of diversions
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Mentally ill misdemeanant offenders are disproportionately
represented in jail population because they spend more time in
jail than non-mentally ill offenders
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Highly recidivistic are high SA, high MH
Not voluntary and usually require inpatient hospitalization after transfer
from jail
Fail to bond out
Incompetent to plead
In 2006, an average of 13% of Hillsborough’s jail inmates were
treated with psychotropic medications
Pre-Existing Jail Diversion Services
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In existence since 2000
 2 full time MHC staff housed in jail
 Targets Mentally Ill Misdemeanant Defendants
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Case Finding
• Daily review of psych pods census
• Identification by jail staff or PD
• External notification (e.g., family, provider, etc)
Diversion
• Negotiate ROR release
• Arrange other dispositions (e.g., civil commitment)
• Jail release is usually to MHC’s Emergency Service for
commitment screening with admission or release/referral
Pre-existing MH Diversion Activities (cont.)
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Contact with Diversion Staff between 1st appearance
court (24 hrs after booking) and video court (1-2 weeks
after booking)
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Charges typically dropped and no continuing criminal
justice involvement after transfer out of jail
Where do we want to go?
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Develop mechanisms for early
identification/screening (sequential
intercept)
Develop diversion pathways other than to
emergency services
Develop post release comprehensive and
continuous services that would be
appropriate for special needs of the
recidivistic mentally ill offender
Developing Mechanisms for Early
Identification/Screening
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Goal: Implement sequential intercept model for identification and screening
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Newly Developed under SAMHSA grant
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GAINS Screening (1st intercept)
• Used internally at jail but does not trigger referral to existing diversion or FICM
 Developing Referral information sheet for offenders who bond out rapidly
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Datalink (2nd intercept)
• Only defendants with history of contact with MHC
 Goal to expand database of consumers (esp. active consumers of FACT,
Forensic) and include felony charges
 Automatic email system similar to emergency service notification
• Barriers related to confidentiality concerns limit expansion of datalink
 Universal consent
 Specific consent
 Business agreement
Developing Alternative Diversion
Pathways
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Goal: expand diversion to community based programs and circumvent secure
emergency screening program if possible
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Goal: use existing jail diversion staff (non-FICM) as a single point of
assessment/contact for diversion, initiating in-reach from community based
programs or referral to appropriate diversion program (e.g., FICM)
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Barriers
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legal decision makers have been reluctant to divert to non-secure programs.
Other MH/SA programs not eager to accept diversions or jump waitlists
Lack of in-reach screening/engagement from other community based programs
Lack of regular meetings among stakeholders and boundary spanner
Implemented Under SAMHSA Grant
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Monthly service delivery committee meeting including staff from FS 916 diversion
program
• Increasing comfort/trust among providers/stakeholders
• Sharing information/contact information, shared agenda/goals
• Development from bottom-up operational needs
FICM/Diversion staff collaboration as a model for other partnerships
Developing Post Release Services to address the
needs of difficult, recidivistic mentally ill
offenders (FICM)
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Goal: Involve and retain mentally ill offenders in
meaningful recovery-oriented activities by providing early
engagement and post release services that client directed,
stage appropriate, continuous, comprehensive and
integrated.
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CONTINUOUS INVOLVEMENT IS A PRE-REQUISTE
FOR ANY CHANGE INTERVENTION TO BE
SUCCESSFUL
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Balance care with expectation, empathic detachment,
consequences and contingent learning
Hillsborough Targeted
Capacity Jail Diversion
Program – Treatment
Component
Karen Williams, MS, CAP, RMHC
Kim Fridie, BS
Tanya Walwin, BA
Quarmul Chowdhury, MD
Rick Buhl, Asst. Case Manager
David Hawkins, Peer Support Specialist
Mental Health Care, Inc.
Continuous Community Based Treatment and
Care Management (FICM)
Target Group
2+ Misdemeanor Arrests within past year
Violent Felony is exclusion
Probable SPMI diagnosis, co-occurring substance abuse not required
Team Structure
MD, 4 hours/week clinic (one of two jail psychiatrists)
Team Manager (Certified Addiction Professional, Registered MHC)
Staff with vocational, mental health and substance abuse expertise
Peer Specialist planned at .1 but increased to .5
Up to 15 cases per Intensive Case Manager
Team Manager does individual therapy
Continuous Community Based Treatment and
Care Management (FICM) (cont.)
Scope of Service
• Time limited, One Year
• Office or community contacts
Direct Service
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Medication Management
Stage Appropriate, Recovery Oriented Treatment/Goals
Individual Co-occurring Therapy
Life Skills Training
Aggressive Supervision/Monitoring
Brokering access to appropriate levels of care
Wrap Around Services
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Transportation
Housing via contingency funds
Navigating SSI/SSDI
Representative Payee
Forensic Intensive Case
Management (FICM)
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In-Jail FICM Screening, Engagement, Enrollment
• Person Centered
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Person identified problems/goals
Introducing and promoting FICM
• Determine eligibility
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Screening instruments if needed
History often more valid than current status or report
Assessment of Motivation?
• Enrollment
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Problems inherent in the short time frames involved in criminal
justice dispositions and this grant.
• The most ill defendants do not get enrolled
TAPA Tracking Form
Post-release FICM Activities
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Continued Assessment/Engagement
Psychiatric Examination/Treatment
Individualized Treatment, Dual Diagnosis Capable, TIP 42
Support services not conditioned on medication compliance or etoh/drug
abstinence
Phase of Recovery Appropriate Treatment
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Phase 1: Stabilization
• Goal: Stabilization of acute psychiatric symptoms or active substance abuse
Phase 2: Engagement/Motivational Enhancement
• Goal :Engagement in Tx, movement from pre-contemplation to
contemplation/preparation/action stages
• Interventions: Assertive Outreach/Engagement, Education, Motivational
Interviewing, Contingency Management, Welcoming/Charity, Low Demand
Phase 3: Prolonged Stabilization
• Goal: Involvement in Active treatment
• Interventions: Education, 12 step supports; relapse prevention; Maintenance,
Relapse prevention
Phase 4: Recovery and Rehabilitation
• Goal: Continued sobriety and stability
SAMHSA Jail Diversion Flow Chart
Datalink identifies individuals with a history of contact
with MHC (8-10 per day)
• SPMI (on psych meds or overnight stay in hospital
• 2+ misdemeanors in past year
• no violent felonies
MHC staff screen from 8-10 am every
morning (1 hr paperwork, 1 hr screening)
Approximately 3 clients per week meet
eligibility criteria. If appropriate, MHC staff
will present case to Judge
If client is accepted into program and
Judge diverts client, will be discharged
to caseworker within 48 hours
Client discharged to MHC for
assessment. FMHI interview conducted
after initial assessment is complete
Hillsborough Targeted
Capacity Jail Diversion
Program :Evaluation
Component
Roger Peters, PhD
Kathleen A. Moore, PhD
Mark Engelhardt, MSW
Autumn Frei, MA
Department of Mental Health Law and Policy
Louis de la Parte Florida Mental Health Institute
Project Evaluation: Overview
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Evaluate the implementation of an evidence-based
practice, Forensic Intensive Case Management (FICM),
for adults ages 18 years and older with a history of mental
illness and/or substance abuse who have been arrested two
times within the past year.
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Over the three-year term of the grant, the project will have
the capacity to serve 30 persons during the first two years
with 20 new persons projected for the third year.
Therefore, the total number of persons projected to be
served and evaluated is 80.
Project Evaluation: Client Outcome
Methodology
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80 face-to face interviews with
participants over the course of the three years
 Baseline
(intake), 6-month, and 12-month followup data collection
 Participants
are paid $20.00 for each interview
Project Evaluation: Process
Evaluation Methodology
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Conduct process evaluation using the survey
instrument, the Assertive Community Treatment
Fidelity Scale.
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Staff will be observed at a team meeting, then asked
questions pertinent to completing the scale. In
addition, two clients will be selected for a brief
interview regarding the program.
Project Evaluation: Measures
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GPRA Client Outcome Measure. This measure includes information on (1)
demographics; (2) education, employment, and income; (3) drug and alcohol use; (4)
family and living conditions; (5) crime and criminal justice status; and (6) mental and
physical health problems and treatment.
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DC Trauma Collaboration Study Violence and Trauma Screening. This is
an 8-item scale inquiring about events that are upsetting or stressful.
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Posttraumatic Checklist – Civilian Version. (PCL-CV; Weathers, Litz, Huska,
& Keane, 1994). This is a 17-item scale that assesses the 17 PTSD symptoms.
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Perceived Coercion Scale (Gardner et al., 1993). This is a 5-item scale adapted
from the MacArthur Mandated Community Treatment Survey and re-worded to be
relevant to individuals in a jail diversion program. The items measure the participants’
perceptions of freedom and choice in the diversion process.
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Colorado Symptom Index (CSI; Shern, Wilson, Cohen, Patrick, Foster, Bartsch, &
Demmler, 1994). This is a 14-item scale that assesses psychological symptoms during
the past month.
Project Evaluation: Measures (cont.)
Additional measures include the following:
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Addiction Severity Index (ASI; McLellan, Kushner, Metzger,
Peters, Smith, Grissom, Pettinati, & Argeriou, 1992). The complete ASI
measures seven domains of problematic behaviors, however, only the
drug and alcohol subscale will be utilized for the present study.
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Brief Symptom Inventory (BSI; Derogatis, 1993). This is a 53item measure of current, psychological status. Studies have used it
extensively in homelessness, mental health, and substance abuse
research.
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The University of Rhode Island Change Assessment
Scale (URICA; DiClemente & Hughes, 1990). This is a 32-item measure of
readiness to change.
Project Evaluation: Update on Data
Collection Activities
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Event Tracking – Collected the following event
tracking forms:
• 112 initial screening forms
• 49 subsequent assessment forms
• 22 court decision forms
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Person Tracking Forms – Collected 19 person
tracking forms
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Interviews – Conducted 27 face-to-face structured
interviews (19 baselines; 8 six month follow-up)
Project Evaluation: Demographic
Information (Baseline, N=19)
Characteristic
Mean (SD) or %
Gender:
Male
58%
Age:
20-29 years
42%
30-39 years
11%
40-49 years
36%
50+ years
11%
African-American
32%
Caucasian
68%
Hispanic
11%
Race:
Ethnicity:
Project Evaluation: Demographic
Information (cont.)
Characteristic
Mean (SD) or %
Primary Diagnosis: Depressive disorder
Primary
Arrest Charge:
32%
Schizophrenia disorder
26%
Bipolar disorder
21%
Psychotic disorder
21%
Trespassing
53%
Battery (domestic violence)
26%
Petty theft
11%
Poss. of open container
11%
Poss. Of drug paraphernalia
5%
Code Violation – Property
5%
Unlawful act as a precursor to prostitution
5%
Preliminary Client Outcomes
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Stabilized on Medication
Actively Seeking Employment after Vocational Rehabilitation
Services
Implemented services to help consumers gain independence and
autonomy
 Payee Services
 SSI – Disability
 Medical Care
Resolved issues of homelessness
 Transitional Living Facility – group home with therapy sessions
 Own apartment
Successfully completed Drug & Alcohol Rehabilitation
No re-arrests