2015

MichiganStateUniversitySherylKubiak,Ph.D.,PrincipalInvestigatorLizTillander,LMSWAngieGaaboCelesteRabautEditaMilanovicOaklandUniversityErinComartin,Ph.D.

StatewideJailDiversionPilotProgramImplementationProcessReportApril–September2015TheGovernor’sMentalHealthDiversionCouncilledbyLt.GovernorBrianCalley,hassupportedeffortstodivertindividualswithmentalillnessfromthecriminaljusticesystem.Aspartoftheseefforts,theJailDiversionPilotProgramlaunchedeightpilotprogramsacrossthestatefundedthroughtheMichiganDepartmentofHealthandHumanServices(MDHHS).ThemajorityofthepilotprogramswereimplementedbyApril2015andallarecurrentlyoperating.Thepurposeofthisreportistoprovideinformationaboutthecollectiveprocessofimplementingdiversionprogramsindiversecommunitiesandtodocumentthestructureandprocessofeachofthediversionprogramsduringthefirstsixmonthsofoperation.ThisreportisprovidedaspartoftheevaluationofthediversionpilotprogramsfundedbyMDHHSin2015–2016.Theevaluationisledbyprincipalinvestigator,SherylKubiak,Ph.D.,ofMichiganStateUniversity.

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StatewideJailDiversionPilotProgramImplementationProcessReport

April–September2015

TableofContents Section PageNumber

ListofTables iii

ListofFigures iv

I. ExecutiveSummary 1

II. Background 5

MentalHealthDiversionCouncilRequestsforProposals 5

SelectedCountiesforDiversionPilotPrograms 6

EvaluationProcess 7

III. CrisisInterventionTeam(Intercept1) 8

CrisisInterventionTeam(CIT)asanInterventionModel 8

CoreElementsofCIT 8

SitesImplementingCIT 8

SimilaritiesandDifferencesintheImplementationoftheFiveCITPilots 9

IsCITTrainingEffective? 11

DifferencesinCITTrainingOutcomesByCounty 13

LessonsLearned:WhatNeedstobeConsideredWhenProposing,ImplementingandEvaluatingCIT?

14

IV. ImplementationofJailServicesInterventions(Intercept3) 16

Jail-BasedServicesasanInterventionModel 16

SitesImplementingJailServices:WhatAreTheyProviding? 16

NumberofPeopleServedinJail-BasedProgramsAcrossSites 19

AssessingtheNeedForMentalHealthServices:ObjectiveandExpressedNeed

20

CommonalitiesandDifferencesAcrosstheSevenJailServicesPilots 21

LessonsLearned:WhatNeedstobeConsideredWhenProposing,ImplementingorEvaluatingJail-BasedDiversionServices?

22

ii

V. InterviewswithCommunityStakeholders 25

ProgramHighlights 25

UnexpectedAspectsoftheProject 27

ProblemsWithorBarrierstoImplementation 29

WhatAdviceWouldStakeholdersOffertoOtherSites? 31

VI. LessonsLearnedRegardingImplementationAcrossSites 32

ImplementationFactors:ExperiencesoftheCurrentProjects 32

VII RecommendationsfortheMentalHealthDiversionCouncil 34

RecommendationsforChangesintheProcesstoSupportBestPractices 34

RecommendationsforSystem-LevelChangestoSupportDiversion 36

VIII Evaluation:NextSteps 37

IX. Appendices I-A1

I. IndividualSiteSummaries I-A1

A. BarryCountySiteSummary I-A1

B. BerrienCountySiteSummary I-B1

C. KalamazooCountySiteSummary I-C1

D. KentCountySiteSummary I-D1

E. MarquetteCountySiteSummary I-E1

F. MonroeCountySiteSummary I-F1

G. OaklandCountySiteSummary I-G1

H. WayneCountySiteSummary I-H1

II. ProgramDataCollectionMethodology II-1

iii

ListofTables Page

Table1 AlignmentofMichiganDiversionCouncilPrioritiesWithSequentialInterceptModel 6

Table2 JailDiversionPilotProgramsApprovedByDiversionCouncil,December2014 7

Table3 ComparisonofCrisisInterventionTeamPilots 9

Table4 ComparisonAcrossCITSites 10

Table5 ComparisonofJailServicesProgramsAcrossSevenSites 17

Table6 ChangesinOrganizationalStructureofMentalHealthServicesWithinJails 19

Table7 EstimatingtheMentalHealthServiceNeedsIntheJails,OverallandbySite 21

Table8 IllustrationofUpcomingDataCollectionandReportWritingforEvaluationTeam 38

iv

ListofFigures

Page

Figure1 SequentialInterceptModel 5

Figure2 ChangeScoresinKnowledgeofPsychiatricServicesBetweenPre-andPost-TestOverallandbyOfficerCharacteristic

12

Figure3 ChangesinDe-escalationScoresBetweenPre-andPost-TestOverallandbyOfficerCharacteristic

13

Figure4 ComparisonofChangeScoresAcrossCounties 14

Figure5 VariationsinHowMentalHealthServicesWereProvidedPriortoDiversionGrantFunding

18

Figure6 IndividualsReceivingDiversionServicesbyCounty 19

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StatewideJailDiversionPilotProgramImplementationProcessReport

April–September2015

I . EXECUTIVE SUMMARY BackgroundIn2014,theMentalHealthDiversionCouncil(MHDC),throughtheMichiganDepartmentofHealthandHumanServices(MDHHS),soughtproposalsforjaildiversioninitiativesstatewide.Theintentwastoaddresstheneedsofmentallyillanddevelopmentallydisabledindividuals,thusdecreasingtheirinvolvementwiththecriminaljusticesystem.ApplicantsweretoproposeinterventionsatoneormorepointsalongtheSequentialInterceptModelframework.TheoverarchinggoaloftheDiversionCouncilistodetermineifthese‘pilot’interventionstrategiesaresuccessful,andifso,couldtheybereplicatedinothercounties.Recognizingthatcommunitieswouldalreadyhavestrengthsandweaknessesintheirjaildiversionactivities,theDiversionCouncilencouragedcommunitiestoutilizetheirresourcestobolstergapsindiversionactivitiesalreadyunderwaywithintheircommunity. Thisreportisthefirstinaseriesofreportsthatassesstheprocessesandoutcomesofthesepilotprojects.Asthefirst,thisimplementationreportprovidespreliminarydataandasummaryofthecommonalitiesanddifferencesacrossthesites.Itwillserveasacompaniontotheforthcomingoutcomereports(i.e.shorttermoutcomesreportinfall2016;longtermoutcomes2017).Eachreportbuildsupontheothers.Thegoaloftheimplementationreportistofacilitateanunderstandingoftheuniquecharacteristicsofeachprogram,whileunderstandingthecommonchallengesandsuccesseswithimplementationofdiversionprogramsacrossthestate.Understandingtheuniquecharacteristicsofeachprogramallowsustomorefullyappreciatetheforthcomingoutcomes,aswellasthedifferencesbetweenprograms.Similarly,understandingcommonsuccessandchallengesacrossprogramsassiststheDiversionCouncilintheireffortstocreateinterventionopportunitiesstatewideandtofacilitatestate-levelpolicychange.FundedPilotsEightjaildiversionpilotproposalswereapprovedandfundedbytheDiversionCouncilinJanuary2015.TheprimarymodelschosenacrosssitewereCrisisInterventionTraining(CIT)andJail-basedDiversionServices.Thesesitesandtheimplementingagenciesinclude:

! BarryCounty -BarryCountyCommunityMentalHealthAgency(BCCMHA)! BerrienCounty -BerrienMentalHealthAuthority(BMHA)! KalamazooCounty -KalamazooCommunityMentalHealthandSubstanceAbuse

Services(KCMHSAS)! KentCounty -Network180,thecommunitymentalhealthauthority! MarquetteCounty -PathwaysCommunityMentalHealth! MonroeCounty -MonroeCommunityMentalHealthAuthority(MCMHA)! OaklandCounty -OaklandCountyCommunityMentalHealthAuthority(OCCMHA)! WayneCounty -DetroitCentralCityCommunityMentalHealth(DCC)

FindingsRegardingImplementationofCrisisInterventionTeamTraining

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FiveoftheeightsitespilotedCrisisInterventionTeam(CIT)training.ThegoalsofCITaretoincreasesafetyinpoliceencountersanddivertappropriatepersonswithmentalillnessfromthecriminaljusticesystemtomentalhealthtreatment.Althoughtrainingprovedbeneficial,asevidencedbyenhancedknowledgeofresourcesinthecommunityandde-escalationskillsacrosssites,CITimplementationvariedandthesevariationsarelikelytoinfluenceoutcomes.Findingsregardingthesefactorsinclude:

! CITTrainingFactors:Variationacrosssitesinfactorsrelatedtotrainingincludethenumberofhoursofficersweretrained(8–40hours);theunit(s)oflawenforcementofficerstrained(city,township,county);whetherofficerswereengagedincommunitypatrolorworkedwithinjails;theproportionofofficerstrainedwithinthecommunity;andwhethercommunitytrainingincludesdispatchofficers.

! Community-LevelFactors:Variationinresourcesavailableinthecommunityincludedthepresenceorabsenceofa24-hourdropoffthatcouldbeutilizedbylawenforcement;andthepresenceorabsenceofacommunityadvisorycounciltodevelop,implementandproblemsolvetheintervention

! MeasurementFactors:VariationinhowCITinfluencesdiversionwilldifferbythedefinitionofdiversionused(i.e.doesacriminaloffenseneedtooccurforadiversiontoexist?);accesstolaw-enforcementleveldata;andthepresenceorabsenceof‘coded’data(dispatchorofficerdata)thatindicatesexistenceofmentalhealthissueduringacall.

FindingsRegardingImplementationofJailDiversionServicesSevenoftheeightsitesengagedinjail-basedservices–allconsideredpost-bookingdiversionprograms.AnabsolutestrengthofthediversionpilotsistheenhancedcollaborationbetweenCMHandlocallawenforcement/jailsacrosscounties.Thisisparticularlytrueofjailservices,whenCMHwasinvolvedinprovidingwithinjailservicesinthreecountiesforthefirsttime.Anobjectivemeasureoftheprevalenceofseriousmentalhealthissuesamongthosebookedintothejailwasconductedbytheevaluationteamandcomparedtothenumberofindividualsidentifiedashavingmentalhealthproblemsthroughroutineprocesseswithinthejail.Theagreement/disagreementbetweenthesenumbersprovidesabaselineforthejails,aswellasapotentialimpetustoexaminejailpractices.Thespecificjaildiversionmodelchosenbyeachcountyaswellashowtheirprogramsareimplementedhasresultedinwidevariabilityacrossthesites.Factorsthatwillinfluenceoutcomesareasfollows:

! Jail-basedServiceFactors:Becausesitestailoredtheirinterventionplantotheuniquecircumstancesoftheircommunity,differencesacrosssitesthatmayaffectoutcomesinclude:theinterventiontype(advocacy,treatment,and/orsupportservices);identificationandscreeningofmentalhealthissueswithinthejail;coordinationofcare(i.e.,Isjail-basedcarecoordinatedwithacontractedproviderorisitprovidedbythegrantee?);andtheamountoftimementalhealthprogrampersonnelhadtobuildtrustwithjailstaffandadministrators.

! Community-levelFactors:Outcomeswilllikelybeaffectedbythesupportivecommunityenvironmentandavailabilityofresources.Therefore,countieswithaccesstoafullcontinuumofcare,includingpsychiatricbedsandsimilarmedicationformularies,willlikelyhavebetteroutcomes.Similarly,resourcestoengageinjail‘in-reach’aswellascontinualcommunityoutreachwilllikelybeassociatedwithbettermentalhealthoutcomes.

! MeasurementFactors.Inassessinglateroutcomes,therearespecificissuesthatsurfacedregardingmeasurementduringtheimplementationperiod.SimilartoCIT,acommon

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understandingofthedefinitionofdiversionwouldbehelpful(note:theevaluationteamhascoined‘current’and‘future’diversionactivities).Inaddition,asprogrammodelswerealteredduringimplementation,programsneedtobedefinedmorespecifically(i.e.,Whenandhowdoesanindividualsuccessfulcompletetheprogram?Durationofservices?Aftercare?)todeterminewhichservicemodelisassociatedwithpositiveoutcomes.

PerspectivesoftheCurrentProjects:LessonsLearnedDuringImplementationThemultipleapproachesbeingimplementedacrossthestateofferauniqueopportunitytoassessthesuccessandbarriersofeachapproachandtothinkaboutlessonslearned.

! Importanceofadvisorycouncil.Ensurethatcriminaljusticeandmentalhealthtreatmentdecisionmakersareatthetablefromtheverybeginningandmeetonaregularbasis.

! Timetobuildrapportandtrustbetweenpartners.Providetimeduringtheinitialstagesofgrantimplementationforsitestobuildrelationshipsandestablishastakeholderteam.

! Benefitsofmulti-yearinitiatives.Launchdiversioninitiativesasmulti-year,notone-yeargrants.Allowformodificationandprovidesomeflexibilityandguidanceforchangestothemodelmid-stream.

! Desireforenhancedlearningandcommunicationacrosssites.Provideregularcross-sitelearningopportunitiesandongoingtechnicalassistance.

! Expandservicestonon-CMHenrolledindividualswithmentalhealthconcerns.Considerongoingstrategiesthatallowforservicestobeexpandedtoindividualswithmentalhealthconcernswhoarenotenrolledincommunitymentalhealthservices.

RecommendationstoDiversionCouncilTheinformationgatheredthroughsitevisits,interviews,monthlycalls,andongoingdatacollectioneffortsofferseveralinsightsintoprogramdesignandimplementationwhichmaybeusefultotheDiversionCouncilasitmovesforwardwithimplementingdiversionprogramsthroughouttheStateandaddressingsystem-levelchanges.→ RecommendationsforChangesinProcesstoSupportBestPractices

1. Define/operationalizethedefinitionofdiversion.

2. Requirequantitativeevidenceofneed/problemwithinthecommunity:What/whereistheneedfordiversionwithininthecounty?

3. UtilizeimplementationfindingstoenhancecurrentpilotsandformulatenewRFP.

4. Encouragetheuseofabriefvalidatedmentalhealthscreeninginalljailsatintake.

5. Suggestimprovementintheutilizationofjailmanagementinformationsystems.

6. Insistuponidentificationofco-occurringdisorders(COD)andintegratedmentalhealthandsubstanceusedisordertreatment.

7. Increaseemphasisonfamily,particularlychildren,andcommunitysupports.

8. Encouragecontinuityofcarebetweenjailandcommunitytreatmentandservices.

9. Emphasize‘criminogenic’factorsaswellasmentalhealthfactors.→ RecommendationsforSystem-LevelChangesThatWouldSupportDiversion

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1. Considerfundingcommunitymentalhealthstafftoprovidein-reachserviceswithincarceratedconsumersandout-reachservicesuponcommunityreentry.

2. PreventthetimelagforreinstatementofMedicaidcoveragepost-jailrelease.

3. Addressthestatewideneedforacutecarehospitalbedsforpsychiatricemergencies.

4. Incorporatede-escalationskilltrainingwithinpoliceacademy.

5. Enhancethespectrumofpsychotropicmedicationsavailableonjailformularies.NextStepsforEvaluationConsideringthevariabilityofprogramsandprogramimplementationacrosssites,outcomesofdiversionprogramswillneedtoconsiderthecontextualandimplementationvariationacrosssites.Thisreportprovidesinformationonprogrammodels;theevaluationteamwillthencollectevidencetoestablishprogramoutcomes.Thenextstepsfortheevaluationareasfollows:

1. Short-TermOutcomesReport.Six-monthjailrecidivismoutcomesforindividualsreceivingdiversionservicesin2015pluscomparisonofjailmentalhealthprevalenceratesbetween2015and2016.TobedeliveredtotheDiversionCouncilinfall2016.

2. Long-TermOutcomesReport.One-yearjailrecidivismandpost-incarcerationtreatmentengagementforindividualsreceivingdiversionservicesin2015-2016.TobedeliveredtotheDiversionCouncilinfall2017.

3. ComparingData-WarehouseandOtherAdministrativeData.Comparisonofdatagatheredontwopilotsites,OaklandandKent,only.Ifdatabecomesavailablefromthestate-leveldatawarehouse,additionaloutcomeswillbeassessed(i.e.morbidity,childwelfare,state-levelincarceration)andcomparedtodatagatheredthroughcounty-leveladministrativedata.Ifdataisavailable,itwillbedeliveredtotheDiversionCouncilinJanuary2018.

3)3)

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I I . BACKGROUND MentalHealthDiversionCouncilRequestforProposalsIn2014,theMentalHealthDiversionCouncil(MHDC),throughMichiganDepartmentofCommunityHealth,nowMichiganDepartmentofHealthandHumanServices(MDHHS),soughtproposalsforjaildiversioninitiativesstatewide.Theintentwastosecureproposalsthatwouldaddresstheincreasingneedsofmentallyillanddevelopmentallydisabledindividualswiththegoalofpreventingtheirinvolvementwiththecriminaljusticesystem.Applicantsweretopropose‘pilot’interventionsatoneormorepointsalongaframeworkknownastheSequentialInterceptModel.Eligibleapplicantsincludedagenciesworkingextensivelywiththementallyilland/ordevelopmentallydisabledpopulationsincludingbutnotbelimitedtoCommunityMentalHealth(CMH)agencies,CMHproviders,lawenforcement,courts,jailsandjailproviders.PointswhereactionscanbetakenalongtheSequentialInterceptModelshowninFigure1belowincludepre-arrest,pre-booking,post-booking,pre-sentencing,post-sentencing,andpre-andpost-releasefromincarceration.Figure1.SequentialInterceptModel

AdaptedfromMunetz&Griffin,2006

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Recognizingthatcommunitieswouldalreadyhavestrengthsandweaknesses,MHDCencouragedcommunitiestoutilize

theirresourcestobolstergapsindiversionactivitiesalreadyunderway.

ThepurposeofthegrantopportunitywastopilotandeventuallyreplicatemodelsaroundtheStatethatwoulddivertmentallyillanddevelopmentallydisabledpersonsfromjailthroughinnovative,sustainable,andreplicablejailorcommunity-basedactivities.Recognizingthatcommunitieswouldalreadyhavestrengthsandweaknessesintheirjaildiversionactivities,theDiversionCouncilencouragedcommunitiestoutilizetheirresourcestobolstergapsindiversionactivitiesalreadyunderwaywithintheircommunity.Priorityconsiderationwasgiventoapplicantsthatfocusedontheimmediategoalsofthestate’sMentalHealthDiversionCouncil.TheseprioritiesandhowtheylinktotheSequentialInterceptModelareshowinTable1below.Table 1. Al ignment of Michigan Diversion Counci l Pr ior it ies With Sequential Intercept Model

DiversionCouncilPrioritiesAlignmentwith

SequentialInterceptModel

InitiateorbolstereffortstoexpandtheuseofAlternativeOutpatientTreatmentthrough“Kevin’sLaw”. 1

InitiateexpandedserviceswithlawenforcementtoincludeCrisisInterventionTeams(CIT)trainingamonglocalpolice,firstresponders,anddispatchpersonnelthroughuseofthe40-hourCITtrainingmodelincludingbackfillfundingforpoliceofficersduringtraining.

1

Exploreneedforacentralizedcrisisassessmentand/ortreatmentfacilityforlawenforcementtoutilizeinlieuofjails.

1

Focusoncomprehensiveandenhancedmentalhealthtreatmentforthoseinjailandtransitioningoutofjailincludingaccesstopsychotropicmedicationsduringincarcerationanduponrelease;bolsteredhousingeffortspriortoandafterrelease;minimalwaittimestoseedoctors/psychiatristsinandoutofjail;increasedsupportsystemspriortoandafterrelease;anduseofeducationalandvocationalopportunitiespre-andpost-release.

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SelectedCountiesforDiversionPilotProgramsEightjaildiversionpilotproposalswereapprovedandfundedbytheDiversionCouncilinJanuary2015.Theselectedcountiesandtheimplementingagenciesarelistedbelow.NotethatallimplementingagenciesareCMHagencies.

! BarryCounty -BarryCountyCommunityMentalHealthAgency(BCCMHA)! BerrienCounty -BerrienMentalHealthAuthority(BMHA)! KalamazooCounty -KalamazooCommunityMentalHealthandSubstanceAbuse

Services(KCMHSAS)! KentCounty -Network180! MarquetteCounty -PathwaysCommunityMentalHealth! MonroeCounty -MonroeCommunityMentalHealthAuthority(MCMHA)! OaklandCounty -OaklandCountyCommunityMentalHealthAuthority(OCCMHA)! WayneCounty -DetroitCentralCityCommunityMentalHealth(DCC).

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Table2showstheapprovedsites,theproposedDiversionCouncilprioritiesselectedbythesites,andhowthoseselectedsitesalignwiththeSequentialInterceptModel.

Table 2. Ja i l Diversion Pi lot Programs Approved By Diversion Counci l , December 2014 MentalHealthDiversionCouncil

PrioritiesKevin'sLaw

CIT CentralizedAssessment

JailServices

Re-Entry

CommunitySupport

SequentialInterceptModel 1 1 2 3 4 5

County Grantee PrioritiesAddressed

Barry BCCMHA x x x

Berrien BMHA x x x

Kalamazoo KCMHSAS x x x

Kent Network180 x

Marquette Pathways x x

Monroe MCMHA x

Oakland OCCMHA x

Wayne DCC x*

x

*WayneCountyinitiallyproposedapre-arrestdiversionprogramminginvolvingDetroitPolice,butwaslatermodified.NOTE:Allofthejail-basedserviceprogramsengageinsometypeofdischargeplanningorfollow-up,howeverre-entrywasnottheprimarypriority.

AsshowninTable2,themajorityofproposalsconcentratedonIntercepts1and3.FiveoftheeightsitesfocusedonCITinterventions(Intercept1)andsevenoftheeightsitesfocusedonjailservices(Intercept3).OnlytwositesincludedafocusonKevin’sLaw(althoughneitherimplementedit)andnoneofthesitesfocusedonexploringtheneedforcentralizedassessmentwithinthecommunity.WhilethereisaconcentrationonIntercepts1and3,manyofthecountiesareactuallyengagedindiversionactivitiesthatspanacrossthesequentialinterceptmodel.However,forpurposesofthisreport,theevaluationteamisfocusingsolelyonactivitiesoutlinedineachproposal.(AmoredetaileddiscussionofthespecificobjectivesproposedbyeachoftheeightsitesisincludedinAppendixI.)EvaluationProcessThisevaluationreliesonmultipledatasourcestoassesstheimplementationandoutcomesoftheeightpilots.Theseincludeinitialsitevisitswitheachsite,useoftheK6jailscreening,developingindividualsiteprocessmapstovisualizehowproposedservicesarebeingimplemented,monthlydatacollectionreports,monthlytelephonecallswitheachsite,implementationinterviewswitheachsite,andasecondroundofsitevisits.AmoredetaileddescriptionoftheseprocessesinincludedinAppendixII.Theresultofthesemanydatasourcesisthattheevaluationisahighlyinteractiveprocess.Itallowseachsitetohaveregularandongoingaccesstoevaluationteammemberswhocananswerquestions,clarifythepurposeforwhichdataisbeingcollectedandhelpmodifydatacollectionprocessesasneededinresponsetotheneedsoftheindividualsites.Italsoallowsfortheevaluationteamtogainadeeperunderstandingofeachsite’sprogram.

Throughtheuseofmultiplemethodsandmanydatasources,theevaluationisahighlyinteractiveprocess.

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TheprimarygoalsofCITaretoincreasesafetyinpoliceencountersanddivertappropriatepersonswithmentalillnessfromthecriminaljusticesystemto

mentalhealthtreatment.

I I I . CRISIS INTERVENTION TEAM TRAINING (INTERCEPT 1) CrisisInterventionTeam(CIT)TrainingasanInterventionModelCIT,astrategyundertheSequentialInterceptModel1,wasdevelopedin1998.Followingtheshootingofamentallyillmanthatyear,MemphisPoliceChiefSamCochranputtogetheracommunitytaskforcecomprisedoftreatmentprofessionals,lawenforcementpersonnelandmentalhealthadvocatestodevelopwhatisnowknownastheMemphisCITModel.TheprimarygoalsofCITaretoincreasesafetyinpoliceencountersanddivertappropriatepersonswithmentalillnessesfromthecriminaljusticesystemtomentalhealthtreatment.‘Appropriate’infersapersonwhodoesnotposeathreattopublicsafetyorsomeonewhohasnotcommittedanassaultiveoffense.CoreElementsofCITCIThasthreecoreelements:

! A40-hourpolicetrainingmodel.! Collaborationwithcommunitypartnersincludingmentalhealthproviders.1! Acentral,psychiatricemergencydrop-offwithanorefusalpolicythatgivespolicepriorityso

officerscanbebackoutonthestreetwithin15–30minutes.2Ataminimum,CITtrainingincludesinformationonsignsandsymptomsofmentalillnesses,mentalhealthtreatment,co-occurringdisorders,legalissuesandde-escalationtechniques.Thetrainingispresentedbyexpertsinthesevariousareasandincludesexperientiallearningtechniquesofroleplaysusingscenarios.Inadditiontothetrainingoflawenforcementofficers,dispatcherscanalsobetrainedtoincreasetheirunderstandingofthesignsandsymptomsofmentalillnessandenhancetheirskillsindispatchingappropriateservicesorpersonnel.Althoughmosttrainingisbeingconductedwithcommunitybasedlawenforcementofficers,manyjailsandprisonsarealsotrainingtheircorrectionsstaff.WhiletherehasnotbeenenoughresearchtodeclareCITanEvidence-BasedPractice,ithasbeencalledaPromisingPractice3andaBestPracticemodelforlawenforcement4.SitesImplementingCITCITprogramsarebeingimplementedinfiveoftheeightsites.Foursites–Barry,Berrien,MarquetteandOakland–didnothaveanexistingCITprogramandsotheirproposalsfocusedonimplementinganewprogram.Onesite–Kalamazoo–hadanexistingCITprogramalreadyinoperationwithinthecommunity5.EffortsinKalamazoofocusedonimplementingCIT-Youthprogramming,anadditionaltrainingmoduleforofficerswhopreviouslycompletedtheadulttrainingcomponent.1Dupont,Cochran&Pillsbury,2007.2Steadmanetal2001.3InternationalAssociationofChiefsofPolice,2010.4Thompson&Borum,2006.5KalamazoobeganCITtrainingofofficersintheyearpriortothisevaluationwithsimilarpilotfundingfromthestate.Evaluationofthosespecificprogramactivitiesarenotpartofthisevaluationreport.

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Underthisgrant,CITwasintroducedinfourMichigancounties:Barry,Berrien,

MarquetteandOakland.Afifthcounty–Kalamazoo–addeda

trainingforofficersinteractingwithyouth.

ThereisconsiderablevariationacrossthepilotsasshowninTable3below.Thetargetaudienceforthetrainingvariesacrosssites,incorporatingpatrolofficers,jailstaff,and/ordispatchers.Thelengthoftrainingdeliveredalsovariesacrosssites.WhiletheRequestforProposalscalledforthedeliveryofa40-hourtrainingmodelinreferencetostandardadult-focusedCITtraining,onlytwosites–BerrienandOakland–deliveredthismodel.Berrienofficersattendedafive-daytrainingconductedbytheChicagoPoliceDepartmentinChicago,IL.Oaklandofficersattendedafive-daytrainingfacilitatedbySergeantRafaelDiazfromtheKalamazooDepartmentofPublicSafetyinPontiac,MI.BarryandMarquetteutilizedabbreviatedtrainingmodelsof24-and16-hoursrespectively.Kalamazooprovidedan8-hourtrainingfocusedonyouth-specificinformationandresourcesasanaddendumtoofficerswhohadpreviouslycompletedthe40-houradulttraining.

Table 3. Comparison of Cris is Intervention Team Pi lots

NewProgram

PopulationTrained:YouthorAdult

TrainingTarget No.ofOfficersTrained

(Proposed)

No.ofOfficersTrained(Actual)

LengthofTrainingDelivered(Hours)

Patrol

Dispatch

Jail

Barry x Adult x 3 9** 24Berrien x Adult X x x 6 14 40/24Kalamazoo* Youth X 89 90 8Marquette x Adult X x 40 17 16Oakland x Adult X x 80 111 40/8

*Note:inapreviousdiversiongrantaward,Kalamazootrainedcity,countyandtownshipofficersinadultCIT.**InBarry,3ofthe9individualstrainedwerementalhealthstaff.

Thenumberofpersonstrainedvariesaswell.SomecountiesexceededtheirinitialtraininggoalsbecauseofadditionaldollarsprovidedthroughasecondyearoffundingofferedbytheState.Twosites–BerrienandOakland–implementedasecondroundofCITtraininglaterinthefirstyearofthegrantperiod.Berriendevelopedanabbreviated24-hourtrainingmodelinordertoaccommodatealargernumberofpatrolofficersfromthesheriff’soffice.InOaklandCounty,anabbreviated8-hourtrainingmodelcustomizedfordispatcherswasdelivered.AlthoughitisnotCIT(thusnotincludedinTable3above),itshouldbenotedthatMonroehashadgreatsuccessintrainingjail-basedsheriffofficersinMentalHealthFirstAide.This8-hourtrainingalsofocusesonincreasingknowledgeandskillsanddecreasingstigma,throughinformationandscenario-basedlearning.SimilaritiesandDifferencesinImplementationoftheFiveCITPilotsAllfiveCITprogramssharesomecommoncharacteristics.

! Allprograms(exceptKalamazoo)arenew.KalamazoopreviouslyimplementedadultCITwithinthecommunityunderthefirstdiversiongrant.

! Allarefocusedondivertingtheadultpopulation;Kalamazooisalsofocusedondivertingyouthpopulation.

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TheCITprogramsvariedinthelengthofspecialtytraining

provided,theorganizationalunitoflawenforcementthatwastrained,thepercentofofficerstrained,thepresenceorabsenceofa24-hourdropofffacility,andthepresence

orabsenceofacommunityadvisorycouncil.

! Mostcountiesarefocusedprimarilyontrainingpatrolofficers,includingsheriffdeputiesand/orlocalpoliceofficers.Barry(exclusively)andBerrienCountytrainedjailofficerstocomplementtheirimplementationofjailserviceswithinthecountyjail.

Theyalsovaryinseveraldistinctways.

! Thetypesofspecialtytrainingprovided.Somecountiesusedthesametrainingforlawenforcementanddispatchwhileoneprovidedalessintensivetrainingfordispatch.Oneofferedadditionaltrainingoninteractionswithyouth.

! Theorganizationalunitoflawenforcementtrained.Whileallprogramstrainedpatrolofficers,insomecountiessheriff’sdeputiesweretrained,whileinothers,localpoliceoruniversitylawenforcementofficersweretrained.Jailstaffwasalsotrained.Somecountiestrainedstafffrommultiplelawenforcementunitswithinthesamegeographicregion.

! ThepenetrationrateofCITwithinthecommunity,i.e.theratioofofficerstrainedinanyspecificgeographiclocationincomparisontothetotallawenforcementstaff.

! Thepresence/absenceofa24-hourdrop-offmentalhealthorcrisisfacilityforlawenforcementtoaccess.Intheabsenceofsuchafacility,somecommunitiesprovideon-callstafftoconductassessments.Inothers,officersutilizelocalhospitalemergencyrooms.Generally,officersdislikeusingemergencyroomsduetothewaittime,whichtiesuptheofficersandpreventsthemfrombeingoutonpatrol.

Table4belowprovidesaglimpseoftheimplementationdifferencesinCITacrosssites.

Table 4. Comparison Across CIT S ites

County OrganizationalUnitofLawEnforcementTrained

Availabilityof24-hourdropoff

PresenceofanAdvisoryCouncil

Barry CountySheriff(mostlyjailstaff) No NoBerrien CountySheriff(patrolandjail

staff)No,utilizehospitalER Inprocess(formationof

committeearoundgrant)Kalamazoo Multiple(multiplecitiesplus

county,onetownship,anduniversitylawenforcement)

No,butCMHstaffareoncalltodoassessments24/7;amentalhealthcrisisunitisalsoavailableforyouth24/7

Yes,liaisoninplacebetweenallorganizationalunitsofpolicewithinthecountyandcommunitymentalhealth

Marquette Multiple(multiplecitiespluscountyanduniversitylawenforcement)

No Yes,liaisonleadsadvisorygroupcomprisedofrepresentativesfromlawenforcementagencieswithincounty.

Oakland CountySheriffpluslocallawenforcement

Yes,CommonGround No

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Todate,significantchangeshavebeennotedinskillsandknowledgebetweenpreandpost

trainingtests.

ThegoalofCITtrainingistocreatechangeinknowledge,attitudesandskillsoflaw

enforcementofficersinhowtheyrespondtoindividualswithmentalillnessandin

theirknowledgeofcommunitytreatmentsfor

thispopulation.

IsCITTrainingEffective?ThegoalofCITtrainingistocreatechangeinknowledge,attitudesandskillsoflawenforcementofficersinhowtheyrespondtoindividualswithmentalillnessandintheirknowledgeofcommunitytreatmentsforthispopulation.Inordertomeasuretheeffectivenessofthetraining,theevaluationteamusedtwoempiricallyderivedinstrumentsutilizedbyBroussard,Comptonandcolleagues(2011)intheirevaluationofCITinonestate.Thetwoinstruments–theOpinionsofPsychiatricTreatment(OPT)MeasureandtheDe-escalationScale-weregiventoparticipantsimmediatelypriortotakingthetraining(pre-test)andthenaftercompletionofthetraining(post-test).Atotalof118officerstookboththepreandtheposttest6.Themajorityweremale(n=88,75%)withanaverageof14yearsontheforce(rangefrom0to37years).Half(50%)oftheparticipatingofficershadaBachelor’sdegree.ThesearedescribedinmoredetailinAppendixII.Outcomesofeachinstrumentaredescribedbelow.

! OpinionsofPsychiatricTreatment(OPT)MeasureThis20-itemvalidatedmeasurewasdevelopedtoassesstheofficers’attitudesandknowledgeaboutpsychiatrictreatmentswithinthecommunity.TheOPTassessesattitudesaboutpsycho-pharmacotherapy,psychotherapy,andpsychosocialinterventionssuchasdaytreatmentprograms,residentialfacilities,andcasemanagement.Responsesaregivenasix-pointLikertscalerangingfrom1(stronglydisagree)to6(stronglyagree).Thepossiblerangeofscoresis20–120.Sampleitemsinclude“Moretaxmoneyshouldgotosupportresidentialfacilitiesforpeoplewithseriousmentalillnesses”and“Daytreatmentprogramsmayhelppeoplewithseriousmentalillnessesrecover”.

! De-EscalationScaleThis8-iteminstrumentwasdesignedtomeasure:de-escalationskills.Officers’opinionsontheeffectivenessofspecificactionsinthesituationwereratedonafour-pointLikertscalerangingfrom0(verynegative)to3(verypositive).Totalsubscalescoresrangefrom0to24.Thescaleiscompletedinresponsetovignettesdepictingscenariosthatcouldrealisticallybeencounteredbypatrolofficers.Sampleitemsinclude“KeepingsomespacebetweenyouandDavidwhileyoutalktohim”and“ArrestingDavidfordisorderlyconduct”.

→ OutcomesofCITPre/PostTestsSignificantincreasesinscoresfrompre-topost-testforbothmeasureswoulddemonstratethatthetrainingdidhaveanimpactonknowledgeandskilldevelopment.Todate,significantchangeshavebeennotedinskillsandknowledgebetweenpreandposttrainingtests.Detailsoftheresultsofthetwoinstrumentsaredescribedonthefollowingpage.

6Thereweresomedifferencesbetweenindividualswhotookboththepreandposttestwhencomparedtothosewhoonlytookthepretest:Thosewithonlyapre-testhadsignificantlylowerde-escalationscoresthanthosewhotookbothtests(average24versus26t(15.8)=-2.4,p<.05);.

12

CITwassuccessfulinchangingknowledgeof

treatmentinthecommunity.

CITwassuccessfulincreasingde-escalationskillsamongpatrol

officers,jailstaffanddispatchers.

Knowledge/OpinionsofPsychiatricTreatmentMeasureAtpre-test,theaveragescorewas72.8andatpost-testitwas79.0,showingastatisticallysignificantincreaseintheaveragescore7.Sinceahigherscoreindicatesgreaterandmoreaccurateknowledgeaboutpsychiatrictreatmentsforthementallyillwithinthecommunity,CITwassuccessfulinchangingofficers’knowledgeofmentalhealthtreatmentinthecommunity.Examiningthedegreeofchangebasedonvariouscharacteristicsofofficerswecanseesomevariationintheamountofchange.Figure2belowshowstheextentofchangeinknowledgebygender,typeoftraining,educationlevelandyearsontheforcethatresultedduetotheCITtraining;thehigherthenumber,thegreaterthechangeinknowledge.Itshouldbenotedthattherewasasignificantdifferenceinchangescoresbygender,withmalesdemonstratingagreaterincreaseintheirknowledgeacquisition.8TherewerenosignificantdifferencesinchangescoresontheOPTscalebyeducationlevel,ornumberofyearsinlawenforcement.Figure2.ChangeScoresinKnowledgeofPsychiatricServicesBetweenPre-andPost-Test OverallandbyOfficerCharacteristic

De-EscalationScaleAtpre-test,theaveragescorewas26.1andatpost-test,theaveragescorewas27.4,astatisticallysignificantincrease.9Thus,CITwassuccessfulinincreasingde-escalationskillsamongpatrolofficers,jailstaffanddispatchers.Figure3onthenextpageshowstheextentofthechangeinde-escalationskillsbygender,typeoftraining,educationlevelandyearsontheforce:thehigherthenumber,thegreaterthechange.TherewerenosignificantdifferencesinchangescoresontheDe-EscalationScalebygender,typeofofficer,educationlevel,ornumberofyearsinlawenforcement.

7Statisticallysignificantdifferencessuggestthatthechangewasnotaresultof‘chance’andthereforethechangeistheresultoftheintervention–inthiscase,thetraining.Averagechangescoreof6.2(t(117)=11.5,p<.001)8Malesincreasedtheirknowledgeonthescalebyanaverageof6.9points,comparedto4.3pointsforfemales(t(116)=2.097,p<.05).9Again,thisstatisticallysignificantresultindicatesthechangewasnota‘chance’occurrence.Averagechangescoreof1.3betweenpreandpost(t(116)=-6.135,p<.001).

6.26.9

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012345678

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1.4 1.41.2

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-0.5

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Variationinchangescorescouldberelatedtovariationintraining

acrosssitesandshouldbemonitoredovertime.

Figure3.ChangesinDe-EscalationScoresBetweenPre-andPost-TestOverallandbyOfficer Characteristic

DifferencesinCITTrainingOutcomesbyCountyWhiletheevaluationdidnotsetouttocomparecountiestoeachother,anaturalexperimentisoccurringamongthepilotsitesbecauseofthedifferencesinthetrainingsbeingofferedacrossthecounties.Tounderstandwhetherthereisanyvariabilityintrainingoutcomesacrossthesites,differencesinpre/posttestscoresofpatrolofficers(n=87)onthetwoscaleswereexamined.Patrolofficerswerechosenacrosssitestoincreasethesimilaritiesforthiscomparison.Themajorityoftheseofficersweremale(n=77,86%).Approximatelyone-thirdoftheseofficershadbeeninlawenforcementforlessthan13years(n=31,36%),one-thirdbetween13and18years(n=29,33.7%),andtheremainingthirdhadbeeninlawenforcementfor19yearsorlonger(n=26,30%).Figure4onthenextpageillustratesthevariationinchangescores(improvementbetweenpreandpost)betweenfourofthefivecountiesinvolvedinCITtraining.Therearedifferencesinimprovementintrainingbetweensites,forexampleCountyAhadachangescoreof3.2ontheOpinionsofPsychiatricTreatmentscalecomparedto7.9forCountyC.However,thesedifferencesonbothscalesarenotstatisticallysignificant.Thelackofstatisticaldifferencesinthesescorescouldbeareflectionofsmallnumbersinsomeofthecounties.However,thesedifferencesshouldbemonitoredovertimeasmoretrainingiscompletedbecausefactorssuchastraininglengthcouldcreatedifferencesintheseshorttermoutcomes.

14

Enhancingtheknowledgeandskillsoflaw

enforcementofficersinrelationtopersonswithmentalhealthproblemsisanimportantendeavor.Butwillnewknowledge

andskillsleadtodiversionsfromjail?And,willofficersutilizetreatmentoptionswithinthecommunity?

Figure4.ComparisonofChangeScoresAcrossCounties

LessonsLearned:WhatNeedstobeConsideredWhenProposing,ImplementingandEvaluatingCIT?Enhancingtheknowledgeandskillsoflawenforcementofficersinrelationtopersonswithmentalhealthproblemsisanimportantendeavor.Inmanycommunities,officershavediscussedtheabsenceofsuchinformationintheacademyorinsubsequenttraining.Pre/post-testsdemonstratethatofficersaregainingnewknowledgeaboutcommunityresourcesandtreatmentaswellasskillsinde-escalation.Butwillthisnewknowledgeandskillsleadtodiversionsfromjail?And,willofficersutilizetreatmentoptionswithinthecommunity?ThewidevariationswithintheCITprogramsbeingimplementedacrosstheStateunderthisJailDiversionpilot,assuggestedbythedatabeingcollected,alongwithareviewoftheliterature,suggestsmultiplefactorsthatshouldbeconsideredwhenimplementingandassessingtheoutcomesofCITinterventions.Thesetraining,community,andmeasurementlevelfactorsareimportantastheynotonlyimpactacommunity’scapacitytofullyimplementCITbutalsotoevaluateitsoutcomesinrelationtothegoalofdiversion.Thesefactorsinclude:CITTrainingFactors

1. Hoursoftraining.AlthoughtheRFPfromtheStaterequested40-hourCITtraining,somecountieshavefoundthatthecostandofficertime

0

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PsychTX Deescalaron

CountyA

CountyB

CountyC

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associatedwitha40-hourtrainingwastoogreatandhavedevelopedmoreconcisetrainingmodules.Thevariationintraininghoursmayaffectthedesiredoutcomes.

2. Unitoflawenforcementtrainedandrelationshipbetweenlawenforcementunitswithinthecounty.Rolesofvariouslawenforcementagencieswithinaparticularcountydiffer,asdoestheworkingrelationshipbetweentheagencies.DecisionsaboutwhichofficerstoincludeinCITtrainingshouldconsidertheroleofthelawenforcementagencyandthedesiredoutcomeoftheintervention.

3. Patrolorjailofficers.Thetargetofthetrainingshouldbeconsidered(i.e.,whetheritisfocusedoncommunitypatrolofficers,jailofficers,orboth),asoutcomesmaydifferbasedontheroleoftheofficer.

4. Theproportionofofficerstrained.Countiestrainingfewerofficersmaytakelongertorealizechangethanthosetrainingahigherproportionofthelawenforcementofficers.Althoughtheimpactonthelawenforcementorganizationmaybesubstantial,short-termoutcomesaredifficulttorealizeincommunitieswithfewertrainedofficers.

5. Includedispatchintrainingandplanning.TheinclusionofdispatchinbothplanningandCITtrainingwillaidinimplementingCITwithinthecommunity.DispatchstaffwhocanidentifyamentalhealthproblemcanproactivelyrequestthataCIT-trainedofficerrespondtothecall.Dispatchcodesmayalsoneedtobemodifiedtoaccuratelyreflectmentalhealth-relatedcallsordiversionsasCITisimplementedwithinthecommunity.

Community-LevelFactors

1. 24-hourdropoff.Theavailabilityofanemergencydrop-offsiteforcommunitylawenforcement(orequivalentresource)thatmakesiteasyforofficerstodivertanindividualwithmentalhealthneedsfromjailishelpful.Thelackofpsychiatricbedsinthecommunitymayalsoimpedealternativestoincarceration.

2. Relationshipbetweendispatchandlawenforcement.Therelationshipandstructuralinterfacebetweendispatchandtheunitoflawenforcementbeingtrainedneedstobeconsidered.Inparticular,whetherthereisacorrespondingtrainingofdispatchers,andifdataonthenumberandoutcomesofmentalhealth-relatedcallscanbecollected.

3. Activeadvisorycouncil.Thepresenceofanongoingadvisorycouncilcomprisedofcriminaljusticeandmentalhealthprofessionalsandadvocatescanenhanceimplementationaswellasongoingsuccessandsustainment.

4. Developspecificoutcomeobjectives.ManystudieshavedemonstratedfeweffectsofCITonarrest.PriortoCIT,manyofficersincommunitysettingsseemtobeusingjailasthelastresortforthoseidentifiedashavingamentalhealthproblem(afterfirstusingcommunityalternativesandhospitals),sodefiningdecreasedarrestsasanoutcomemaynotbethebestmeasureforsomecommunities.However,thereareotherpossibleoutcomesandreasonstoemployCITmodeloftrainingwithinthecommunity.CITexposesofficerstonewinformationaboutavailabilityofothercommunityresources/treatments,aswellasneededde-escalationskills.Identificationofintendedobjectivesshouldbeclearpriortoexecution.

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MeasurementFactors1. Aconcretedefinitionofdiversion.Severalquestionsarisewhenconsideringmeasurementof

outcomes:Isanyinteractionwithlawenforcementsynonymouswitharrestorthepotentialforarrest?Isdiversiondefinedsolelyasanabsenceofarrest/jailduringanencounterwithlawenforcement?Isclearevidenceofa‘crime’requiredfordiversion?

2. Mentalhealthcodeinpolice/dispatchdata.Codingoflawenforcement/dispatchrecordsthatindicatethata‘mentalhealth’problemwasidentified.Awarenessofmentalhealthandanincreaseinthenumberoflawenforcementcallscodedas‘mentalhealth’couldimplygreaterdiversion.

3. Accesstopolicedata/information.Assessingvariousdiversionactivitiesbylawenforcementrequiresaccesstospecificinformationfrompolicerecords(oralternatively,trainingof‘liaisons’tocapturesuchdata).Inaddition,multipleorganizationalunitsoflawenforcementinvolved(i.e.,city,township,county,university)complicatesdatacollectionandpermissionsforaccess.

IV. IMPLEMENTATION OF JAIL SERVICES INTERVENTIONS ( INTERCEPT 3) Jail-BasedServicesasanInterventionModelJailservicesconceptualizedintheseproposalsareaimedatdiversion.PertheinitialRFPpriorityconsideration,jailservices“focusonmorecomprehensiveandenhancedmentalhealthtreatmentforthoseinjailandtransitioningoutofjail.Effortsfundedundertheproposalmayincludeaccesstopsychotropicmedications,bolsteredhousingefforts,minimalwaittimesfordoctors/psychiatrists,increasedsupportsystemsandenhancededucationalandvocationalopportunities.”Itishypothesizedthatestablishingorenhancingjail-basedmentalhealthservicesforpersonswithmentalhealthdisorderswillhelpstabilizeindividualsincrisis,enhanceengagementincommunity-basedtreatmentandimprovecommunityfunctioning,thereby,reducingfuturerecidivism.SitesImplementingJailServices:WhatAreTheyProviding?Sevenoftheeightsitesareimplementingsometypeofjailservices.Programsvaryalongfourdimensions:whetherengaginginactivitiesthatwillresultinacurrentvsfuturediversion;whetherimplementinganewprogramorcontinuingorenhancinganexistingprogram;thetypeofservicemodelbeingimplemented(i.e.,advocacy,supportiveservicessuchasreferralsandcrisissupport,ortreatment);andtheorganizationalstructureofjailmentalhealthservicespriortothegrantaward.AswithCIT,thespecificjailservicesmodelchosenbyeachcounty,aswellashowtheprogramwasimplemented,resultedinwidevariabilityacrossthesites.Table5onthefollowingpagesummarizesthejailprogramsbeingofferedinthesevensites.AdetaileddescriptionofthejailservicesprogramimplementedwithineachcountyisprovidedinAppendixI.ThisgrantrepresentsthefirsttimecommunitymentalhealthproviderswerepermittedtodeliverserviceswithinthejailinBarry,Berrien,andWaynecounties.TheenhancedcollaborationbetweenCMHandjail

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Acurrentdiversioniswhentheindividual’scurrentjailtimeisreducedduetosomeactivitybyjailormentalhealthstaff.Futurediversionsareactivitiessuchastreatmentwithinthejailor

linkagestocommunityresourcesthatwillpromotereductionsinsubsequent(future)jailtimeandrecidivism.BothdefinitionsofdiversionarebeingusedacrossthevarioussiteswithinMichigan.

administratorsresultedinprovidingspacewithinthejailand/orexpeditedaccesstothejailfordiversionteammembers.

Table 5. Comparison of Ja i l Services Programs Across Seven Sites

CurrentvsFutureDiversion

NewProgram

Model

Current Future

Advocacy Treatment SupportiveServices

AdvocatesforEarlyRelease

FullTreatmentProvidedInJail

DischargePlanning&Referral

DischargeFollow-Up

Barry X X X XBerrien X X X Kalamazoo X X X X XKent X X X X X XMarquette X X Monroe X X* X XWayne X X X X X X X

*Monroehadanexistingjailprogram,buthasexpandedittobeavailabletoformerlyineligiblepersons.*BarryandBerrienCountiesengageinsomeadvocacyefforts,butitisnotaprimaryfunctionoftheprogram.

→ Currentvs.FutureDiversionDiversionactivitiescanbeviewedaseithercurrentorfuture.Acurrentdiversioniswhenanindividual’scurrentjailtimeisreducedduetosomeactivitybyjailormentalhealthstaff.Futurediversionsareactivitiessuchastreatmentwithinthejailorlinkagetocommunityresourcesthatwillpromotereductionsinsubsequent(future)jailtimeandrecidivism.BothdefinitionsofdiversionarebeingusedacrossthevarioussiteswithinMichigan.Threeofthesevensites–Kalamazoo,Kent,andWayne–areengagedincurrentdiversionactivities.Currentdiversionactivitiesgenerallyencompasssomekindofadvocacyandinterventionwhentheindividualisbookedintothejail.Thismayentailspeakingwiththeprosecutororjudgeorworkingwiththeindividual’scommunitycasemanager.Alloftheseadvocacyactivitiesaredependentuponstrongscreeningandcasefindingprocesseswithinthejail.Allofthesitesarefocusedonprovidingservicesthatwillresultindecreasingrecidivismand,thus,futurediversions.Sitesareusinggrantfundingtoeitherbeginoraugmentserviceswithinthejail.Programsvarybysitebutincludeenhancementstoserviceswithinthejail,dischargeplanning,and/orcasefinding.Barryimplementedmentalhealthandsubstanceabusetreatmentgroupswithinthejail.BerrienandMonroeaddedaCMHliaisonwithinthejailwhoisworkingtoidentifyandassistindividualsidentifiedashavingamentalhealthproblem.MarquetteexpandeditsMoralReconationTherapy(MRT)programtothoseservingjailsentences.Wayneaddednewserviceswithinthejailtoassistwithcasefindingandidentification.

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ThisgrantrepresentsthefirsttimecommunitymentalhealthproviderswerepermittedtodeliverserviceswithinthejailinBarry,BerrienandWaynecounties.Theenhanced

collaborationbetweenCMHandjailadministratorsresultedinprovidingspacewithinthejailand/orexpeditedaccesstothejailfordiversionteam

members.

→ Continuation,EnhancementorNewServiceTwosites–KalamazooandKent–focusedonexistingjailmentalhealthprograms,eithercontinuingorenhancingtheservicesalreadyinplace.Theremainingfivesites–Barry,Berrien,Marquette,Monroe,andWayne–focusedonnewjailmentalhealthprogramsornewservicecomponents.→ TypeofServiceModelUsedEachofthegranteesproposeddifferingservicemodelscontainingvariouselementstobeprovidedthroughthegrant.Thevariousmodelsofinterventionincluded:

! Advocacy,whichfocusesoncurrentdiversionorreleasefromjailforpersonswithmentalhealthdisorders.Jail-basedadvocatesfocusoncase-findingwithinthejail.

! Treatment,whichfocusesonprovidingafullcontinuumofmentalhealthtreatmentwithinthejailbymentalhealthprofessionals.

! SupportiveService,whichfocusesonprovidingcrisiscounseling,referralsandcommunitylinkage.

! Combined,whichprovidesoneormoreoftheabove.→ OrganizationalStructureInsomecountyjails,priortodiversionfunding,mentalhealthserviceswerefundedand/orcontracteddirectlybythejail/sheriffandnotbyaCMHorganization.Inothercounties,aCMHproviderwasprovidingmentalhealthserviceswithinthejail.Instillothercounties,partnershipsexistedbetweenexistingjail-fundedorcontractedservicesandCMHstaff/providers.Figure5belowilluminatestheorganizationalvariationinmentalhealthserviceswithinthejailpriortothediversiongrants.Figure5.VariationsinHowMentalHealthServicesWereProvidedPriortoDiversionGrantFunding

CMH-Supported

• MHprovidercomesintojaileitherasaworksiteortoprovideserviceswithin.• FundedprimarilythroughMHsystem.

Jail=Supported

• Sheriff/CountyemploysorcontractsforMHserviceswithnon-CMHpersonnel.• May/maynotbestrongrelaronshipwithCMH.

CollaborarveModel

• JailmaysupportoraugmentfundingforMHservices• CMHprovider/contracterworkswithjailpersonneltoprovidedirectservicesorlinkage.

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Thewidevariationinthenumberofindividualsreceivingservicesistheresultofhoweachcountydefinesdiversion(currentvsfuture)andhowtheyreport

theirstatistics.

Eachoftheseorganizationalstructuresprovidedchallengesandopportunitiesforgrantees.Countiesthatuseddiversionfundingtoaltertheirpre-existingorganizationalstructurehadmoredemandingimplementationissuestoovercomepriortoservicedelivery.Thegrantfundinganddeterminationtoimproveoutcomeswithinthecountyhaveledtomorecollaborativeprocessesinallsites,asshowninTable6below.

Table 6. Changes in Organizat ional Structure of Mental Health Services Within Jai ls County Pre-AwardStructure Post-AwardStructureBarry JailSupported CollaborativeBerrien JailSupported CollaborativeKalamazoo Collaborative CollaborativeKent Collaborative CollaborativeMarquette Jail-Supported IncreasinglyCollaborativeMonroe Collaborative CollaborativeWayne Collaborative/CMHSupport* Collaborative

*Note:WaynehashadgeneralfundingfromCMHpriortothisaward,butthisawardenhancedcollaborationbetweenoneproviderandthejail.

NumbersofPeopleServedinJail-BasedProgramsAcrossSitesFigure6belowdepictsthenumberofindividualsbycountyreceivingservicespaidforthroughthisspecificdiversionfunding.Thewidevarietyinthenumbersbeingservedisinnowayindicativeofthequalityorintensityoftheservicesbeingprovided,butisinsteadtheresultofhoweachcountydefinesdiversion(currentvsfuture)andhowdataisreported.Figure6.IndividualsReceivingDiversionServicesbyCounty

AcomparisonbetweenBarryandKalamazooillustratesthevariationinhowdiversionisdefinedandwhoiscounted.Barry,forexample,isestablishingnewmentalhealthservicesinthejail,providingmentalhealthandsubstanceabusegroupinterventions.EachCMHconsumerwhoattendsoneofthesegroupsessionsorwhoisseenbythementalhealthprofessionaliscountedassomeonewhoreceivesservicesasaresultofthegrant.Thecountydefinesthisasanactivitytowardafuturediversion.Incontrast,Kalamazoohasalongestablishedjail-basedinterventionprogram.Grantfundsallowedthemtoaddasecondmentalhealthprofessionaltotheirprogram.Thesetwo

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585

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162

50

0

100

200

300

400

500

600

700

Barry Berrien Kalamazoo Kent Marqueue Monroe Wayne

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professionalshaveprovidedservicestoover1,200individuals.ButsinceKalamazoo’sactivitieswiththeseindividualsspanabroadarraythatincludescourtadvocacy,medicationassistanceandresource/referral,theyarecountingonlyindividualswhoaretruecurrentdiversions–inotherwords,thosewhosejailstaysareshortenedduetotheeffortsofthejailmentalhealthstaff.Recognizingthesewidevariationsinthenumbersandtofurtherunderstandthedifferencesacrosssites,theevaluationteamhasaskedKalamazootoincludeinformationonfuturediversionservices.Thiswouldincludedischargereferralservicesprovidednon-CMHconsumerswhoareinneedofsupportortreatmentwithinthecommunitybecauseintheprocessofprovidingdischargereferralswiththeseindividuals,theyareengaginginactivitiesassociatedwithfuturediversions.AssessingtheNeedforMentalHealthServices:ObjectiveandExpressedNeedSomecountiesstruggledtoclearlyarticulatetheneedformentalhealthservicesintheirproposalsbecausemeasurementofmentalhealthproblemswasnotalwaysroutinelycollectedwithinthejail.Moreover,becausejailsusevariousmethodsforassessingmentalhealthproblems,thenumbersacrosscountiesweredifficulttodefine,interpretorcompare.→ ObjectiveNeedvsExpressedNeedforMentalHealthServicesBecauseofthesevariationsinmethodsusedtoscreenformentalhealthproblemsacrosscountyjails,theevaluationteamwasinterestedinusinganobjectivemeasurethatwouldensureconsistentmeasurementacrosssites.Alljailsagreedtousethesamevalidatedshortscreeningmeasure,calledtheK6,foraspecifiedperiodoftimetoscreenallpersonsbookedintotheirjails.Therefore,objectiveneedisdefinedasthenumberofindividualsidentifiedashavingaseriousmentalhealthproblemthroughtheuseofaempiricallyvalidatedscreeninginstrument.Eachjailalsohasitsownprocessforidentifyingandscreeningforpotentialmentalhealthproblemsandacorrespondingprocessofreferraltoamentalhealthprofessional.Thisnumberisreferredtoastheexpressedneed-orthenumberofindividualsthatjailpersonnelhaveidentifiedasneedingprofessionalscreeningandpotentialservicesinthecourseof‘businessasusual’.Articulatingthedifferencesbetweenobjectiveneedandexpressedneedwouldshowifthejailisidentifyingthosewithmentalillnesswithinthejail(expressedneed)inaproportionsimilartotheobjectiveneeddeterminedwiththeK6screeninginstrument.Table7onthefollowingpageillustratesthedifferencesineachcountybetweenobjectiveandexpressedneed.Notethatthefinalcolumnshowsthepercentdifferencebetweentheobjectiveneed(K6)andexpressedneed(numberactuallyscreenedformentalhealthwithinthejail).ApositivepercentindicatesthatthesitesareidentifyingagreaternumberofpersonswithmentalillnessthanwouldbeanticipatedusingtheK6.ItisnotedthatK6collectionwasnotconductedinOaklandCountyduetothecounty’ssolefocusonCITunderthisgrant.

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Table 7. Est imating the Mental Health Service Needs In the Jai ls , Overal l and by Site

TotalJailBookings:SixMonthPeriod

ObjectiveNeedNumberandPercentof

EstimatedNeedforMentalHealthServicesBasedonK6

ExpressedNeedNumberandPercentofPersonsReferredforJailMentalHealthServices

PercentDifference

# % # % COUNTY 42,202 11,047 27.9% 10,244 24.3% -3.6%Barry 1,044 175 16.8% 200 19.2% +2.4%Berrien 3,701 1,406*** 38.0% 342 9.2% -28.8%Kalamazoo 6,473 1,443 22.3% 1,277 19.7% -2.6%Kent 12,396 2,628 21.2% 4,240 34.2% +13.0%Marquette 857 320 37.3% 77 9.0% -28.3%Monroe 3,179 1,014 31.9% 900** 28.3% -3.6%Wayne 14,552 4,060 27.9%* 3,208 22.0% -5.9%

*Note:DuetoreliabilityissuesassociatedwiththescreeninginWayneCounty,wehaveusedthestateaverageasthepredictorofneed.**Note:Monroeiscurrentlyrefiningtheirdatareportingandthisnumberistobeverified.***Note:K6screeninginBerrienwasconductedlaterinthejailprocessatclassification,whileallothersitescollectedearlierinthejailprocessatbooking.Thislatercollectioncouldpotentiallyyieldahigherrateofneedformentalhealthservices.

→ WhyAre‘ObjectiveAndExpressedNeed’ImportanttoUnderstand?Thedatashowthatinsomecountiesthereiscongruence,ornearcongruence,betweenthemeasuresofobjectiveandexpressedneedformentalhealthservicesinthejail.Inotherwords,thepercentofindividualsidentifiedashavingaseverementalillnessviatheobjectiveassessmentscreeningtool,theK6,isclosetothepercentageofindividualsneedingmentalhealthservicesasidentifiedviathejail’sownscreeningmethods.Inothercountiesthereareagreaternumberofindividualswithmentalhealthconcernsfoundinthejailthanwouldbeanticipatedfromtheobjectiveassessment(K6).Instillothers,theexpressedneed–thenumberidentifiedviathejail’sownscreeningtool-isfarlowerthantheestimatedobjectiveneed.EachofthesescenariosisexplainedingreaterdetailinindividualcountyreportsfoundinAppendixI.Whilevariationinsomecountiesmaybeattributabletowhenandhowmentalhealthneedismeasuredoridentifiedwithinthejail,thesenumbersassistinfacilitatingplanningprocessesformentalhealthidentificationandserviceswithinthejailand,assuch,understandingwhythereisincongruenceisimportant.Ifidentificationistheissue,amendingtheinitialscreeningprocessatbookingwillremedytheincongruencebyimprovingdetection.Similarly,alackofresourceswithinthejailtoconductscreeningandassessmentsmaybesolvedthroughincreasedcollaborationwithCMH.InFebruary2016,asecondroundofdatacollectionatallofthejailswilldetermineiftheproportionsofobjectiveneedremainconsistentoverthecourseoftheyear.Thesefindingswillbepresentedintheshort-termoutcomesreporttobeprovidedtotheDiversionCouncilinfall2016.NotethatintheindividualcountyreportsinAppendixIinformationonobjectiveandexpressedneedisprovidedandmaybehelpfultocountyadministratorsinrevealingcontinuedunmetneed.CommonalitiesandDifferencesAcrosstheSevenJailServicesPilots

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Allprogramsarepost-bookingdiversion

programs,provideserviceswithinthecountyjail,and

areaccessibletoallinmatesregardlessof

whethertheyareaCMHconsumer.Mostoffersomelevelofdischarge

planning.

AnabsolutestrengthofthediversionpilotsistheenhancedcollaborationbetweenCMHandlocallawenforcement/jails

acrosscounties.

Asdescribedearlier,thejailservicesprogramsacrossthesevensitesvariedintermsofthescopeandservicesprovided.

! Justthreeprograms-Kalamazoo,Kent,andWayne-activelyadvocatefortheearlyrelease,ordiversion,ofindividualsfromjailtotreatment(i.e.,currentdiversions).

! Twocounties-KalamazooandKent-hadjail-basedprogramservicesthatwerealreadyinexistencewhileotherprogramsarenew.Thesenewprogramsarebeingusedtostrengthenorimplementscreening,referral,assessment,and/orcasefinding.

! Someprogramsprovidementalhealthtreatmentwithinthejail,whileothersofferin-jailcrisis-relatedservicessuchasreferral,support,andlinkageswithcommunityproviders.

! Someprograms–Barry,Kalamazoo,andKent–areconsideredtobethementalhealthunitforthejail,providingallmentalhealthandsubstanceabusetreatmentforinmates.Allotherprogramsoperateintandemwithanexistingmentalhealthunit.

However,whetherneworexisting,allprogramssharethefollowingcharacteristics:

! Allprogramsareconsideredtobepost-bookingdiversionprograms.Therearenopre-bookingdiversionactivitiesinplaceatanyofthepilotsitesatthistime.

! Allprogramsprovideserviceswithinthecountyjail.

! Allprogramsareaccessibletoallinmatesexperiencingmentalhealthconcerns,regardlessofwhethertheyareconsideredtobeaCommunityMentalHealthconsumer.

! Mostprogramsoffersomelevelofdischargeplanningpriortojailrelease.TheonlyexceptiontothisisinMarquette,wheretheseservicesareprovidedbythejailmentalhealthunit.

LessonsLearned:WhatNeedstobeConsideredWhenProposing,ImplementingorEvaluatingJail-BasedDiversionServices?AnabsolutestrengthofthediversionpilotsistheenhancedcollaborationbetweenCMHandlocallawenforcement/jailsacrosscounties.Thisisparticularlytrueofjailservices,whenCMHwasinvolvedinprovidingwithinjailservicesinthreecountiesforthefirsttime.Ininvestigatingtheefficacyoftheseeffortstowardthegoalofdiversion(currentorfuture),theevaluationteamwillbeassessingthelong-termrecidivismandtreatmentengagementofindividualswhoreceiveddirectservicesfromstaffsupportedwithpilotfundingAswithCIT,thereiswidevariationacrosscountiesinthescopeofjailservicesbeingimplemented,aswellaswide

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Establishingamentalhealthpresencewithinthejailwaschallengingforcountiesinwhicharelationshipdidnot

existbeforethegrant.

variationinhowdataiscollected.Thesevariationsservetohighlightsomefactorsthatneedtobeconsideredwhenimplementingjail-baseddiversionservices.Again,aswithCIT,theseareimportantastheynotonlyimpactacommunity’scapacitytoimplementjail-basedservices,butalsotoevaluateoutcomes.Jail-basedServiceFactors

1. Jailinterventiontype.Jailservicesacrossthecountiesencompassvarioustypesofservicesandinterventionstrategies(advocacy,treatment,orsupportiveservices).Outcomeswilllikelyvarybytypeofinterventionstrategy.Forexample,someprovideadvocacyandlittletreatment,whileothersprovideconsiderabletreatmentandlittleadvocacy.Stillothersprovidesupportiveservicesandreferrals,butlittleinthewayofadvocacyandtreatment.Distinguishingbetweenthesevariousstrategiesmayleadtogreateraccuracyindeterminingwhatworksindiversion.

2. Identificationandscreeningofmentalhealthwithinthejail.Variationandaccuracyinmechanismswithinthejailtodetectmentalhealthproblemscanresultinwidevariationinneedestimates.Moreover,dependenceonsubjectivemeasuresmayresultin‘missedopportunity’forintervention.Automatedscreeningsystemsmayprovidejailpersonnelwithpertinentinformation,buttheabilitytoattainandsharethatinformationwithinthejailisgenerallylimited.Processesfordetectionandscreeningcanbereviewedand/orrefined.Afirststepcouldbeexaminationofthe‘objectiveandexpressedneeds’datainthisreporttoassessdiscrepanciesbetweenwhatwasfoundwiththevalidscreeningmeasureandwhowasidentifiedwithinthejail.

3. Coordinationofcarewithinthejail.Countysheriffsresponsibleforjailadministrationhaveenactedvariousstrategiesformeetingthementalhealthneedsofdetainees.SometimesthisincludestheCMHandsometimesitdoesnot.WhenCMHisnotinvolved,itresultsineitherhiringprofessionalsasemployeesofthejailorcontractingwithaprivatehealth/mentalhealthservicesentityforservices.WhenCMHprovidersareworkingwithothermentalhealthprofessionalswithinthejailthereisanotherlevelofcollaborationnecessarybetweenmentalhealthprofessionals.Regardlessofwhatmechanismsareused,clearlinesofoperationneedtobedevelopedsothatjailstaffandadministratorsknowwhereandhowtoreferindividuals.

4. Timetobuildrapportandtrustpriortodiversionadvocacy.Establishingamentalhealthpresencewithinthejailwaschallengingforcountiesinwhicharelationshipdidnotexistbeforethegrant.Timetoestablishtheserelationshipsandbuildrapportmaybenecessarybeforeadvocacyservicescanbedelivered.Therefore,whetherCMHjailserviceswerenewlyacquiredversusenhancedunderthisgrantwillbeasalientfactorinmeasuringoutcomes.Theremaybeacontinuuminthejail/CMHrelationshipthatbeginswithallowingCMHproviderstoenterthejailtoprovideservicesinordertobuildtrust.OnlyaftertrusthasbeenestablisheddoesitbecomepossibleforCMHprofessionalstosuccessfullyadvocatefordiversion.

Community-LevelFactors

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1. Advisorycouncil.Acommunity-leveladvisorycouncilisanimportantfactortoaidinimplementationorproblem-solveongoingissues.Comprisedofcriminaljusticeandmentalhealthprofessionalandadvocates,theadvisorycouncilactsasamechanismforcommunicationbetweendirectpractitioners(jailandCMH)anddecision-makersinbothsectors.Theabsenceofthiscouncilresultsindelaysinimplementationandlimitedoptionsforproblem-solvingconcerns

2. Availabilityofacomprehensivecontinuumofservices.Mostcountyadministratorsdiscussedissuesbetweenwhatmightbeconsideredbestpracticesandwhatwasavailableinthecommunity.Forexample,therewasnearlyaunanimousexclaimovertheshortageofpsychiatricbedsacrossthestateandissueswiththediscrepanciesbetweenjailandCMHformulariesforpsychotropicmedications.Therearetwoconcerns:1)thelackofavailablebedsmayimpactjailprogramsasthelackoftreatmentoptionsresultsinjailasalastresort,and2)medicationinstabilityasaresultofchangingdrugs,willresultinbehavioralissues/subsequentchargeswithinthejail.

3. In-reach/outreachservices.Althoughresearchdiscussestheimportanceofrelationshipbuildinginordertoformtherapeuticalliance,therearefewCMHresourcesavailableforstafftoengageineitherin-reachoroutreachserviceswithCJ-involvedconsumers.Sometimes,evenifresourcesareavailable,thereareobstacleswithjailaccess.Furthermore,outreachactivitiesinthecommunityallowCMHstafftopursueconsumersintheirhomeenvironment,toencouragecontinuedserviceinvolvementaswellastosupporttheindividuals’needs.Somecountieshavefiguredoutwaystoengageinin-reach,outreachorboth–hypotheticallydecreasingpsychiatricinstability.

MeasurementFactors

1. Definitionofdiversion.Thenumberofdiversionsandhowitcanbequantifiedwilldependonhowdiversionisdefined.Therecanbemultipledefinitions,butacommonunderstandingofhowdiversionisdefinedandmeasuredwillbenecessarytoassessoutcomes.Forpurposesofthisreport,andfutureoutcomestudies,theevaluationteamhascoinedtheterms‘current’and‘future’diversionstodifferentiateactivities/servicesthatresultinacurrentreductionofjailtimeversusfuturediversionwhichisdefinedasservicesthatarelikelytoreducefuturerecidivism.

2. Programdefinition.Thevariationofjailserviceprogramsprovidesarichtapestryofpossibilitiesforreplication.However,replication–andmeasurementofoutcomes–willberestrictedifcountiesarenotabletoarticulateaspecificmodelofintervention.Forexample,isoneserviceorcontactconsideredaprogram?Willthiscontactleadtoenhanceddiversionoutcomes?Howdositesprovidingawiderangeofservices(i.e.,referraltointensivecasemanagement)differentiatetheintensityofservicesdelivered(i.e.,high,medium,andlowlevelservices)?Whendoesanindividualsuccessfullycompletetheprogramoristhisdefinedbythenumberofdays,services,typeofservices,orsomeotheraction(i.e.,dischargefromjail)?Duetovariationinimplementationfromwhatwasinitiallyproposed,theevaluationteamisworkingwithindividualcountiestoproduceadefinitionoftheprogramandtooperationalizetheintensityofprogramservices.

3. Trackingrecidivismandmentalhealthoutcomes.Specifiedoutcomesfordiversionprogramsarereductionsinrecidivismandengagementinmentalhealthtreatment.Trackingjailrecidivismatsix-monthandone-yearintervalscanbeachievedthroughdataextractionfromjail

25

managementinformationsystems.Trackingcontinuedengagementinmentalhealthserviceutilizationpost-releasefromjailwillbeconductedthroughuseof‘encounter’datafromthestatewideCMHdata.However,forindividualswhoarenotenrolledinCMHservices,trackingutilizationwillbeextremelydifficult.Accesstophysicalormentalhealthdatafromprivatepractitionerswillbeprohibitive,unlessMedicaideligibleindividualscanbetrackedwithinthestatesdatawarehouse.Inaddition,trackingpsychiatricfunctioningandmedicationadherenceincommunitysettingswillnotbepossibleinthisevaluationdesign,butshouldbeconsideredinsubsequentstudies.

V. INTERVIEWS WITH COMMUNITY STAKEHOLDERS InAugust2015,interviewsfocusedonimplementationissueswereconductedbytelephonewithcriminaljusticeand/orcommunitymentalhealthstakeholdersatsevenoftheeightJailDiversionprojectsitesincludingBarry,Berrien,Kalamazoo,Marquette,Oakland,andWayneCounties.Thepurposeoftheseinterviewswastolearnmoreabouttheprocesseachsitehadundertakentoimplementtheirproject.ImplementationinterviewswerenotconductedwithKentCountybecausetheirdiversionprogramwasanexistingprogram.Eachinterviewlastedonaverage60minutesandfocusedontheprimaryobjectiveofeachsite(i.e.,eitherjailservicesorCIT).Questionswereaskedaboutthefollowing:

! Highlightsoftheprojecttodate.

! Aspectsoftheprojectwhichwereunanticipatedorsurprising.

! Problemsorbarrierstoimplementation.

! Thelevelandkindsofcollaborationthathavebeenachievedtodate.

! Additionalsupportsthatwouldbenefitimplementationofthepilot.

! Anyadvicesiteswouldoffertootherswhoareconsideringimplementingadiversionproject.

ProgramHighlightsStakeholderswereaskedtodescribethreeorfourhighlightsoftheprojecttodate.Fourthemesemerged:collaboration,serviceenhancement,positiveimpactofservices,andsenseofaccomplishment.→ CollaborationAllstakeholderscommentedontheincreasedsenseofcollaborationthathasoccurredbetweenthecommunitymentalhealthandcriminaljusticesystems.Commentssuchas“Itfeelslikewearenowbothtryingtoachievethesamegoals”and“Thecollaborationisfarbetterthanweeverdreameditcouldbe”weresharedthroughouttheinterviews.Asonecommunitymentalhealthstakeholdersaid,“therelationshipsarekey”tosuccess.Theamountofcollaborationbetweenstaffmembers/administratorswithinthecriminaljusticesystemwashighlightedbybothcriminaljusticesystemandcommunitymentalhealthstakeholders.Morethan

Allstakeholderscommentedontheincreasedsenseofcollaborationthathasoccurredbetweenthe

communitymentalhealthandcriminaljusticesystems.

26

onestakeholderdescribedconversationstheywitnessedbetweencriminaljusticestaffabouthow“weneedtodothingsdifferentlynow.”Onecriminaljusticestakeholderdescribedbeingapproachbyajailinmatewhotoldhimthat“thismentalhealthprogramyou’vegotgoingon,it’sthebestthingthat’sbeendoneinthejailinalongtime.”→ ServiceEnhancementInsubmittingtheirproposalstotheStateforconsideration,sitesweregiventheopportunitytoselectoneormorepointsalongtheSequentialInterceptModeltoexpandservicestoindividualssufferingfrommentalillness.Regardlessofwhichpointorpointstheyselected,theopportunitytoexpandservicestotheseindividualswassomethingthatbothcommunitymentalhealthandcriminaljusticestakeholdersdescribedasamajorhighlightoftheproject.Asnotedearlier,whiletherewassomeactivityacrossallintercepts,themajorityofproposalsconcentratedonIntercept1,offeringCITtraining,orIntercept3,solidifyingin-jailmentalhealthservicesorexpandingthenumberofinmateswhoreceivedmentalhealthservicesinthejail.SomealsofocusedonIntercept5,expandingcommunity-basedservicessuchashousingcoordinationormentalhealthgroups,bothofwhichofferanincreasedopportunityforinmateswithmentalhealthissuestosucceedoncetheyarereleased.Twoprojectsareusingpeersupportspecialiststoengageconsumersuponrelease,helpthemsecurehousingandensurethattheystaylinkedwithcommunitymentalhealthservices.AlthoughCITwasviewedasaserviceenhancement,gettingCIToffthegroundprovedcomplicatedforallofthesiteswhoimplementedit.Asonestakeholdersaid,“Itwilltakeyearsofwork.”Butallbelieveitismakingadifference.Asonecriminaljusticestakeholdercommented,“Itgivesyouanopenmindonhowtodealwiththementallyill.”OnecommunitymentalhealthstakeholderexpressedsurprisethatmorejailsdonottraintheirstaffinCIT.Trainedjailstaffaregoodatspottingconsumersinthejailwhoneedmentalhealthservices.“Theyareoureyesandearswhenwe[communitymentalhealth]can’tbethere.”→ PositiveImpactofServicesOnceserviceswereinplace,stakeholdersfromthesitesimplementingjailservicesbegantoseetheimpact.Onecommunitymentalhealthstakeholdernowhasanofficeinthejailandakeytothemaindoorsostaffcancomeandgoasneeded.Anotherstakeholdertalkedaboutgoingfromservingnoconsumersinthejailatthestartoftheprojecttonowhavingservedover50.Asonestakeholdercommented,“Seeingsomeoneenterrecovery,whenwecannegotiatethemoutofjailandintorecovery”isoneofthethingsofwhichheismostproud.ThreesiteswhoprovidedeitherCITorMentalHealthFirstAidtrainingcommentedonthepositiveoutcomestheyhavewitnessedorheardfromofficerswhoparticipated.Asonecommunitymentalhealthstakeholdersaid“Ithumanizedpeoplewithmentalillnessforthem.”Onestakeholderdescribedseeingadifferenceinhowthecorrectionsofficersareapproachingtheinmates.Inmatesatonesitecommentedtocommunitymentalhealthstaffonthenewwaythatcorrectionsofficersarehandlingpeoplewhoaredecompensating.Onecommunitymentalhealthstakeholdernotedthatasfarassheknew,notraininghadpreviouslybeenprovidedtolawenforcementonhowtointeractwithpeoplewho

“CITgivesyouanopenmindonhowtodealwith

thementallyill.”

27

arementallyillandincrisis.However,sincethetraining,severalofherstaffmembershavenoticedhowthepolicearede-escalatingsituationswithheragency’sconsumers.Inatleastthreeofthesites,stakeholdersdescribedwaysinwhichcommunitymentalhealthstakeholdershavebeenextremelyresponsiveoftheneedsofthecriminaljusticestaff.Onecommunitymentalhealthstakeholderhasgivenallofthepolicechiefsinthecountyhispersonalcellphonenumber.AnothercommunitymentalhealthstakeholderdescribedgettinganemailonaFridaynightfromthejailregardingaconsumerwhowasabouttobereleased.Thejailwasconcernedabouttheindividualbeingreleasedintothecommunitywithoutaserviceplaninplace.Thecommunitymentalhealthstaffcontactedhisteammembersand,thatevening,coordinatedservicessothattheindividualwouldbeengagedincareuponrelease.Asthestakeholdersaid,“Wedidn’tgetthecallonthefrontendbutatleastwegotitonthebackendandwereabletohelp.”Atanothersite,acriminaljusticestakeholderdescribedcontactingtheircommunitymentalhealthcontactbecauseofanin-jaildeath.“Shewastherewithin30minutes.There’snocontractforhertodothis,butIcalledandshesaid‘I’llberightover.’”→ SenseofPrideinImplementingtheProjectAllstakeholdersspokewithagreatsenseofprideaboutsuccessfullyimplementingtheirpilotprograms.Foronecommunitymentalhealthstakeholder,therewasprideinbeingabletomovethedialoguewithlocalcriminaljusticestakeholdersthroughaconversationaboutpastfailuresoftheagencyandtowardwhatisnowpossiblewiththerenewedcollaboration.Forseveral,therewasasenseofprideinaccomplishingcomplexhiringorcontractingprocesses.Forafew,itwasthefactthattheproposedserviceswerenewtotheircommunityandtheyhadnoideawhattoexpect.Asonecommunitymentalhealthstakeholdersaid,theyhadto“tacklethehurdleofbeingabletogointothejailandprovideservices,bewelcomedintothejail,andbeabletocoordinatewiththejail.”Butthroughoutalloftheinterviews,evenforthosewhohadnotbeenabletoimplementeverythingthattheyhadplanned,therewasadeepsenseofaccomplishment.UnexpectedAspectsoftheProjectStakeholderswereaskedaboutsomeofthemostunexpectedaspectsoftheproject.Collaborationemergedasone,asdidtime,someofthelimitationstheyencountered,butalsoasenseofpersonalfulfillment.→ CollaborationInadditiontobeingahighlight,collaborationwasalsofrequentlymentionedwhenstakeholderswereaskedaboutthemoreunexpectedaspectsoftheproject.Sixsitesnotedtheirsurpriseatthelevelofcooperationandcollaborationthattheyareexperiencing.Phrasessuchas“howeveryoneissupportiveofthisproject,”“therelationshipswenowhave,”and“therelationshipthejailnowhaswithcommunitymentalhealth”weretheirimmediateresponsestothisquestion.Onestakeholdernotedthat“weweren’treallyexpectingtobesurprisedbyanything”andyettheytooweresurprisedathowmuchcooperationtheyarereceivingfromthejail.Whenasked

Allstakeholdersspokewithagreatsenseofprideaboutsuccessfullyimplementing

theirpilotprograms.

Thelevelofcooperationandcollaborationthesites

experiencedwasunexpected.

28

whytheythoughtthiswasthecase,theyconcludedthatitwas“becauseweareactuallysolvingtheproblem.”Onecriminaljusticestakeholder,afterdescribingthepositiverelationshiptheyhavewiththeircommunitymentalhealthagency,expresseddismaythatthevastmajorityofjailadministratorshetalkswithdonothavethis.→ TimeTheamountoftimeittakestoimplementtheprojectandmanageagrantofthisscopeandsizewassomethingthatwasalsounexpected.Thisincludesthetimeittakesto:buildandmaintaintherelationships;hireandretaintherightstaff;gettheK-6screeningdatacollectionimplemented;figureoutallthebudgetingandcontractualcomponentsofgrantimplementation;anddothedatacollection.ForthosesitesimplementingCIT,thetimeittooktocoordinatethetrainingsandidentifypresenterswasbeyondwhattheyhadexpected.(ThisisdescribedinmoredetailintheProblemssection.)Foreachsite,theleveloftimespentonimplementationofthepilotprogramdependedonseveralfactorsincludingtherelationshipsthatwerealreadyinplacebetweentheleadagency(communitymentalhealth)andthecriminaljusticesystem;theabilityofstafftofocusonthisprojectinthecontextoftheirotherworkresponsibilities;logisticssuchaslocatingaspaceinthejailtowork;andgettingclarityonexactlyhowtheprojectwouldwork,suchashowreferralswouldcomefromthejailtothecommunitymentalhealthagencyorhowserviceswouldbeimplementedwithinthejail.→ LimitationsAsnotedearlier,stakeholdersexpresseddisappointmentinnotbeingabletoimplementeverythingtheyhadplannedforthepilotoratthepaceatwhichtheyhadintended.Forallsites,thiswasdueinparttotime.Thefactthatthiswasaone-yeargrantincreasedthepressuretobeupandrunningquickly.Forexample,therewasnoroominthistimeframetocompensatefortheveryrealchallengesoflocatingandhiringstaff.Onesitedescribedreceivingaconsiderablenumberofapplicationsfromrecentcollegegraduateswhodidnothavetheexperienceshebelievedessentialtoworkinajail.“Ihadalotofapprehensionhiringsomeonetoogreengiventhepopulationweareworkingwith.”Whenshedidfinallyfindtherightperson,theyendeduptakingadifferentjob,sothesearchstartedalloveragain.Anotherstakeholderechoedthis.“Youcan’tgivethejailjustanymentalhealthworker.It’sverycomplexwork.”AnunexpectedlimitationencounteredbyoneofthesitesthatimplementedCITwasunioncontracts.ParticipatinginCITtrainingisnotpartoftheunioncontractsforofficersandthereforerequiredovertime.Anotherunexpectedlimitation,encounteredbyonepilotprogramthatencompassedahousingcomponent,isthatlandlordsareoftenafraidtotakerenterswithcriminalbackgrounds,particularlyanyoneconvictedofusingmethamphetamines.Bothoftheselimitationsimpactedthecapacityoftheleadagencytoimplementtheprogramasfullyastheyhadintended.→ PersonalFulfillmentTwocommunitymentalhealthstakeholdersofferedthatthis

Theamountoftimeittakestoimplementtheprojectandmanageagrantofthisscopeandsizewasunexpected.

“IfeellikeIammakingadifference.Ihaven’tfeltthatinalongtime.”

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projecthasgiventheirworknewmeaningandimportance.Despitethechallengesandfrustrations,theywereamazedathowmuchenergyandlifeithasbroughttotheircareers.Onestakeholdercommentedthat“Thisisworkworthdoing.”Theotherstakeholderechoedthissentiment,notingthatthisprojecthasgivenherasenseofpurpose.“IfeellikeIammakingadifference.Ihaven’tfeltthatinalongtime.”OthersperceivedanoticeabledifferenceinthelawenforcementofficerswhohadbeentrainedinCIT.“Ithassparkedashiftinthem.TheyarenowwonderfuladvocatesforCIT.”ProblemsWithorBarrierstoImplementationWhenaskedtodescribeanyproblemsorbarriersthestakeholdershadencounteredinimplementingtheproject,fivethemesemerged:timeandlogisticswithCIT;systemsissueswithCITimplementation;resistance;datamanagement;andbarrierstoaccessingneededcommunityservices.→ TimeandLogisticsofCITEvenwithsitesthathadexperienceinbringingprojectstoscalequickly,thosethatimplementedCITwereunpreparedfortheamountoftimetheprogramrequirestogetofftheground.Onestakeholdersharedthatheandhisstaffworked16hours/dayforeverydaytheCITtrainingwasoffered,plustheSundaybeforeandtheSaturdayafter.Thisdidnotcountthemonthsittooktoidentifyandrecruitthe30speakersneededtopresent26differentmodules,northetimeittooktocleanandpaintthefacilitywherethetrainingwastobeheld.Findingspeakerswhoarecomfortablepresentingtopoliceofficersalsoprovedtobechallenging.Asonestakeholdernoted,“Lawenforcementofficersarethehardesttoteach.Ifyouarenotanexpert,theywillcallyououtonit.Theymustrespectyouinordertolistentoyou.”ThetimerequiredtoattendCITwasalsoaproblem.Onesitedidnotgetthenumberofattendeestheyhadhopedasit“tooktoomuchtime”forthemtoattend,eventhoughtherewasconsiderableexcitementaboutit.AcommunitymentalhealthstakeholderdiscussedthechallengeofeducatingothercommunitystakeholdersaboutthevalueofCIT,asitisdifficulttotranslateCITtrainingintoaspecificnumberofdiversions.→ SystemsIssueswithCITImplementationAllofthestakeholderswhoimplementedCITtalkedaboutthechallengesofimplementingatrainingofthescopeandsizeofCITwithinthecomplexprocessesandpoliciesoftheirvariouslocallawenforcementagencies.ThemostfrequentlycitedchallengewasthecosttoindividualpoliceorsheriffdepartmentstosendofficerstoCITtraining.Manysheriffdepartmentsaroundthestatehavecontractswithcommunitiestoprovideaminimumnumberofpolicinghoursperweek.PullingofficersoffthestreettoattendaCITtrainingrequiresthatthesepositionsbefilledwithotherofficerstoensurethattheappropriatelevelofpolicingismaintainedatalltimes.Notalldepartmentshavesufficientovertimefundingintheirbudgetstopayforthis.Asasolutiontotheseissues,manycommunitiesoptedforshortertrainingperiods(i.e.,twodays)ratherthanthe40-hourtrainingthatisconsideredthe‘standard’treatmentmodel.

AllstakeholderswhoimplementedCITtalkedaboutthechallengesof

implementingatrainingofthescopeandsizeofCIT

withinthecomplexprocessesandpoliciesoftheirvariouslocallawenforcementagencies.

30

Thequestionofcommunityplacementforthosedivertedfromjailwasanissuefor

severalsites.

→ ResistanceThechallengeofback-fillingpolicepositionsfortrainingwasnottheonlybarriertoimplementationofCIT.Severalsitesdiscussedresistancefromofficers,primarilyastheydidnotunderstandwhatthetrainingwasabout.Justonecommunitymentalhealthstakeholderdescribedresistancetoimplementingdiversionservicesinthejail.But,asthisstakeholderreported,itdidnotseemtobeoppositiontotheprogramitself.Instead,itwasbecause“somanythingsstartupandthenend.Buttheyareseeingtheresultsnow.Itcanbeslow,sothatcanbeconfusing,buttheyareseeingthatweareavailableandtryingtobuildtrust.”→ DataManagementAllofthesitestalkedaboutdatamanagementasachallenge,althoughthetypeofchallengevariedgreatlybetweenthesites.Oneofthesmallersitesusesamanualprocesstocomparealljailbookingsheetswiththecommunitymentalhealthagency’sdatabase.Thisisquitetime-consumingand,combinedwithalloftheotherresponsibilitiestiedtothegrant,leaveslittletimetoask“WhatamIlearningfromthis?”Anothersiteregretsthattheydidnotputfundstowardspurchasingdatacollectionservices(“Itwouldhaveconsiderablyslowedmyagingprocess!”).Athirdsitedescribedtheproblemofmultiplepolicejurisdictionswithinthecounty,eachwiththeirowndatatrackingsystem,makingitdifficulttoaccuratelycapturewhatishappeningwithCITcounty-wide.OneofthecorrectionsofficersinterviewedsuggestedthatoneofthechallengesaroundrecordingCITdataisthepossibilityofliability.HewonderedifofficersinhiscommunitywhouseCITwerefearfulthatacrisismaydevelopwiththesameindividualadayortwolater,possiblyleadingtoviolenceordeath.IftheyhadarrestedtheindividualandnotusedCIT,theymighthavepreventedtheviolencefromoccurring.Soifsomethingviolentoccurs,“Nowtheyareliable,andtheyhavetolivewiththat.”→ BarrierstoNeededCommunityServicesThequestionofcommunityplacementforthosedivertedfromjailwasanissueforseveralsites.Asnotedearlier,onesitedescribedthedifficultyoffindinglandlordswhoarewillingtorenttoindividualswithcriminalrecords,whichsignificantlyimpactstheabilityofthecommunitymentalhealthagencytocontinuetoprovideservices.Asthisstakeholderreflected,“Iftheystayinthecommunitywecanworkwiththembutiftheyleave,they’relost.”Onesitecontinuestostrugglewithgettingtheirlocalmentalhealthcrisiscentertoacceptsomeonethepolicehaveencounteredanddeemedinneedofcrisisservices.Inoneexample,acriminaljusticestakeholderspokeaboutanindividualanofficerwastryingtodiverttoadrop-offcenterwho,duetodelaysandconfusionatthecenter,became“riledupandtheofficerendeduphavingtouseforce”.AnothersitestruggleswithcoordinatingthetimingofreleaseofindividualsfromthejailtoanAdultFosterCarefacility.If

Allsitestalkedaboutdatamanagementas

achallenge.

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theAFCownerarrivesaftertheyarereleased,theindividualmaysimplywalkaway.ThechallengeofMedicaidinsurancewasmentionedbybothcommunitymentalhealthandcriminaljusticestakeholders.IndividualswhohaveMedicaidinsurancelosecoverageuponentryintothejail.Whiletheyaregiventwoweeksofmedicationupondischarge,itcantakeupwardsof45daysforMedicaidinsurancetobereinstated.Thisgapincoverageresultsinlackofmedication.Onesitedescribedthelackofhospitalbedsfortreatment.Ifthelocalhospitalisfullorwillnotaccepttheindividual,communitymentalhealthstaffmustspendconsiderabletimelookingaroundthestateforabed.Thecommunitymentalhealthstakeholdernotedthat,“Itoftentakestwomonthstogetabedforsomeone.”Iftheindividualendsuphospitalizedoutsidethecounty,itisunknownwhethertheindividualwillreturnbacktothecountyandwhethertheywillendupbeinglosttothementalhealthsystemofcare.WhatAdviceWouldStakeholdersOffertoOtherSites?Allofthestakeholderswereaskedwhatadvicetheywouldoffertosomeonewhowasconsideringimplementingadiversionprogramelsewhere.Theirrecommendationscenteredonbuildingrelationshipsandtransparency,knowledgeoftheprogram,strategiesforcollaboratingwithlawenforcement,andkeepingfocusedonthegoal.→ BuildingRelationshipsandTransparencyNotsurprisingly,allsitesstressedtheimportanceofbuildingstrongrelationshipsbetweenthecommunitymentalhealthagencyandlawenforcement.Bothcommunitymentalhealthandcriminaljusticestakeholdersstressedtheimportanceofsomekindofasteeringcommitteeorteamthatmeetsregularlytodiscussissues,shareinformationandsolveproblems.Further,thiscommitteeneedstobecomprisedofpeoplewhohavedecision-makingauthoritysothatprocessesorsystemscanbechangedormodifiedasneededandinatimelymannertoenhancethedeliveryofservices.Butasonestakeholderadvised,“Advanceslowly.Ittakesalongtimetodeveloptheserelationships.”Transparencyisessentialtotheserelationships.Asonestakeholdersaid,“It’simportantthatyouletpeopleknowwhysometimesyoucan’tdowhattheywantyoudoto.Youneedtoletpeopleknowwhereyouarecomingfrom.Ifthatisabsent,theywillfillintheblanksontheirown,andyouhavenocontroloverwhattheydowiththoseblanksofinformation.”→ KnowledgeoftheProgramAllstakeholdersdiscussedtheimportanceofallpartnersbeingeducatedontheprogramstheyareproposingtoimplement,particularlyCIT,andonthesequentialinterceptmodelofintervention.NositethatimplementedCITexpressedanyregretabouttheirdecision,butseveralsaidthattheywishedtheyhadknownmoreaboutwhatwasrequiredbeforetheyhadbegun.→ StrategiesforApproachingLawEnforcementThethirdrecommendationcamefromthecommunitymentalhealthstakeholders,whowouldencouragenewprojectstorememberthatlawenforcementofficialsareconcrete,action-oriented

Allsitesstressedtheimportanceofbuildingstrongrelationships

betweenthecommunitymentalhealthagencyand

lawenforcement.

32

individuals,soasacommunitymentalhealthagency,itisimportanttohave“aconcreteplaninplacebeforeyouapproachthem”.ItisimportanttorealizethatCITtrainingisthefirststepintheimplementationofCIT;ongoingcollaborationisrequiredtofullyimplementandmaintaintheprogram.Continuousdialoguebetweenthecommunitymentalhealthandlawenforcementpartnersisneededtoencourageofficers’useofde-escalationanddiversiontechniquesandtomonitorresults.Asonecriminaljusticestakeholdernotedaboutdiversion,“Itisimportanttoknowthatofficerswilltrythisonlyonce.Iftheyhavetospendthreehoursonsomeoneanditdoesn’twork,it’sjusteasiertotakethemtotheEmergencyRoom.Thatonlytakes30minutes.”→ KeepingFocusedontheGoalFinally,everyonewouldencouragenewprojectstokeepinmindthat“thisisapositivething”andtonotgetdiscouraged.Asonestakeholdernoted,“Wearetryingtocatchupwithtwentyyearsofdealingwithmentalhealthissues.”OnecriminaljusticestakeholderdescribedlearningintheCITtrainingthatitcantakeseveraltriesbeforeapersonwithamentalillnessisontherightmedication.Asaresultofthisknowledge,shewouldencouragenewprojectstoremember“tonotgiveupontheperson.”

VI. LESSONS LEARNED REGARDING IMPLEMENTATION ACROSS SITES EachoftheprogramsundertheStateJailDiversionpilotisunique,asarethecountiesinwhichtheprojectissituated.Thisreportmakesnoclaimsthatprogramscanorshouldbecomparedtooneanother.However,thediversityofprogramsandvariationincountydemographiccharacteristicsisanassetintermsofdeterminingwhatworks.Themultipleapproachesbeingimplementedacrossthestateofferauniqueopportunitytoassessthesuccessandbarriersofeachapproachandtothinkaboutlessonslearned.Collectively,theinformationgatheredtodatethroughsitevisits,interviews,monthlycallsandongoingdatacollectionprovideseveralinsightsintoprogramdesignandimplementationwhichmaybeusefultotheDiversionCouncilasitmovesforwardwithimplementationofdiversionprograms.Therecommendationsbelowaredividedintothreeclusters:1)thoselearnedfromtheexperiencesofthecurrentprograms,2)system-levelchangesthatwouldsupportdiversionand3)thosefocusedonevaluationoutcomeactivities.ImplementationFactors:ExperiencesoftheCurrentProjects1. HaveanAdvisoryCouncil:Decision-makersneedtobeatthetablefromtheverybeginning

andmeetonaregularbasis.WhetherCITorjailserviceswereimplemented,thisisanobservationthatwasmadebyallofthestakeholders,eitherdirectlyorindirectly.Thechallengetoachievingthisinthemorepopulatedcountieswheretherearemultipleagencies,systemsanddecision-makersappearsfarmorecomplicatedthaninthesmaller,lesspopulatedcounties

ItisimportanttorealizethatCITtrainingisthefirststepintheimplementation

ofCIT;ongoingcollaborationisrequiredto

fullyimplementandmaintaintheprogram.

33

wheretherearefewerlayerstonavigate.Whilechallengingtoestablish,itwasclearthatprojectsthathadateamofcriminaljusticeandcommunitymentalhealthstakeholdersatthetableonaregularbasiswereabletomutuallyidentifyproblemsanddevelopstrategiestoaddressthemquickly,allowingthemtokeepalaserfocusontheconsumerstheyareserving.

2. BuildRapport/Trust:Providetimeduringtheinitialstagesofgrantimplementationforsitesto

buildrelationshipsandestablishastakeholderteam.Thecapacityofcommunitiestoimplementdiversionprojectshingestoagreatextentontherelationshipsbetweencommunitymentalhealthandcriminaljusticesystems.Establishingamentalhealthpresencewithinthejailwaschallengingforcountiesinwhichtherelationshipdidnotexistbeforethegrant.Timetoestablishtheserelationshipsandbuildrapportmaybenecessarybeforeservicescanbedelivered,andcommunitiesthatdonotalreadyhaveawell-establishedstakeholderteamshouldbeallowedaperiodoftimeintheinitialstageofgrantfundingtoestablishone.Thebenefitsappeartofaroutweighthecostoftime.

Theremaybeacontinuuminthejail-communityrelationshipbuildingstrategythatbeginswithallowingCMHproviderstoenterthejailtoprovideservicesinordertobuildtrust.OnlyaftertrusthasbeenestablisheddoesitbecomepossibleforCMHprofessionalstosuccessfullyadvocatefordiversion.

3. PlanMulti-YearEfforts:Launchdiversioninitiativesasmulti-year,notone-yeargrants.Allbut

onesitedescribedsignificantchallengesinimplementingaprojectofthisscopewithintheone-yeartimeframe.Recruiting,interviewingandhiringstaffwhohavetheknowledgeandexpertisetoimplementthiskindofaprogramandwhoarewillingtoworkforaprojectthatwilllastonlyoneyear;gettingcontractswithpolicedepartmentsorsheriffofficesreviewed,authorizedandsignedinatimelymanner;modifyingsystemsofassessment,reviewand/ornotificationwithinthejail;andsimplelogisticssuchasfindingofficespaceorinstallinginternetcapabilitiesinthejailarechallengesthatcantakeweeksormonths,notdays,toresolve.Becauseofthesechallenges,severalsiteswerenotabletolaunchservicesasquicklyasanticipated.Amulti-yearpilotperiodwouldallowsitestimetoadequatelydeveloptheprogramandcollaborationwithprogrampartners,establishprocessesandprotocol,hireandretainstaff,developprogramsustainabilityand,mostimportantly,successfullydivertthementallyillfromthecriminaljusticesystem.

4. AccommodateModifications:Providesomeflexibilityandguidanceforchangesinthemodel

mid-stream.Onesiterealizedthatthemodelofjailservicesproposedwas,uponimplementation,notthebestfitfortheirpopulation.Theopportunitytomodifytheirapproachwouldhaveallowedthemtoincreasethenumberofindividualstheyserve.Moretimeandtheabilitytomakeprogrammaticandbudgetaryadjustmentsduringthepilotperiodwouldpermitsitestheabilitytoadjusttheirprogramtobettersuittheneedsoftheircommunity.Guidancefromthestateontheprocessanddegreeofthemodificationwouldbehelpful.

5. IncreaseCross-SiteEngagementandLearningOpportunities:Provideregularcross-site

learningopportunitiesandongoingtechnicalassistance.Itwasclearthatstakeholdershaveextremelyhighexpectationsforthemselvestoimplementthebestprogramspossible.Severalexpressedthewishthattheycouldinteractwithothersitesonaregularly,bothtoknowmoreaboutwhatisgoingonaroundtheStateandalsotolearnhowothersitesarehandlingsimilarchallenges.Buildinganongoingdialogamongsites,whetherthroughmonthlymeetings,a

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listservdiscussiongrouporothermethodswouldallowsitestheopportunitytosharetheirrichknowledgeaswellaslearnfromeachother’sexperiences.Inaddition,technicalassistancefromtheStateonissuessuchasprogramimplementationofCIT,datacollectionandbuildingstakeholdercollaborationmayhelpreduceimplementationdelays.

6. ExpandServicestoIncludeNon-CMHconsumers:Considerstrategiesthatallowforthe

programtobeexpandedtonon-communitymentalhealthconsumers.WhileenhancedcollaborationwiththelocalCMHagencyisabigstepinaddressingtheneedsoftheseriouslymentallyillhousedwithinthejails,thecurrentsystemoftencannotaccommodatetheneedsofthosewhoareineligibleforCMHservices.

Fromtheperspectiveofthejail,thereisnodistinctionbetweenthosewhoareorarenoteligibleforservices.However,forcommunitymentalhealthagencies,thisisnotalwaysthecase.Onepilotwantstoprovideservicestoallseriouslymentallyillinmatesinthejail,butisabletobillonlyforthosewhoarealreadyconsumersoftheagency.ThoughsomeofthepilotsprovideservicesregardlessofCMHstatus,thelevelofserviceavailablefornon-CMHindividualsisoftenlowerthantheirCMH-eligiblecounterparts,bothinthejailandupondischargeintothecommunity.

Similarly,ifthereisaspecificmentalhealthproviderengagedincollaborationwiththecourtsorjail,individualswhoarenotalreadyenrolledwiththisagency,butwhoneedservicesarenoteligible.Althoughthismaybeafunctionofthe‘pilot’statusofmanyoftheprograms,astheprogramsexpandpastthepilotphase,diversionshouldbeanoptionforeveryonemeetingcriteriawithinthecountyandnotdependonproviderenrollment.

VII . RECOMMENDATIONS FOR THE MENTAL HEALTH DIVERSION COUNCIL Basedupontheinformationcollectedfromtheprojectsitesandtheanalysisofthedata,theevaluationteamprovidestheseobservationsandrecommendationstotheGovernor’sDiversionCouncil.→ RecommendationsforChangesintheProcesstoSupportBestPractices

1. Define/operationalizethedefinitionofdiversion.TheuseoftheSequentialInterceptModelallowsforasystemwideperspectiveindiversionprogramplanningandcreatesawidespectrumofactivitiesaimedatfosteringdiversion.However,italsocreatesawiderangeacrossprogramsinperceptionsofwhatareconsidereddiversion-relatedactivities.

2. Requirequantitativeevidenceofneed/problemwithinthecommunity.What/whereisthe

needfordiversionwithinthecounty?Evaluationofchangereliesonevidenceofapresentingproblemasabaselineofmeasurement.Insomesitestherewasdifficultyarticulatingevidenceofaproblembeyondanecdotalinformation.Thismaybeanartifactofthelackofsystematicidentificationofmentalhealthproblemswithinthecriminal/legalsystemorspecificdatacollectionsystems.However,communitiesshouldhavesomeobjectivemeasureoftheactualproblemprovidedwithintheirproposaltofacilitatemeasurementofchange.

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3. UtilizeimplementationfindingstoenhancecurrentpilotsandformulatenewRFPs.Thisreportprovidesinformationusefultotheindividualsites,aswellastheDiversionCouncil,astheycontinuetoimprovediversionefforts.Forexample,examinationofthediscrepancybetween‘objectiveandexpressedneed’shouldleadtoanassessmentofinternalprocessesassociatedwithidentificationofmentalhealthproblemswithinthejail.Furthermore,examinationofthevariationinimplementationacrosssitesmightrefinetheDiversionCouncil’sintentionintermsofdiversionandcreateamorespecificcallforintervention(i.e.,advocacyversusserviceswithinthejail).

4. Encouragetheuseofabriefvalidatedmentalhealthscreeninginalljailsatintake.Although

alljailsprovidesomelevelofobservationalandquestion-basedscreeningformentalhealthproblemsbyjailstaff,theprocessvaries.Generallyofficersreferindividualsforprofessionalscreeningwhentheydetectissuesuponobservation.Somejailsusespecificquestionsregardingpreviousmentalhealthservices.Ifearlydetectionisagoal,thenabrief,empirically-validatedmentalhealthscreeningmeasureshouldbeutilizedduringthebookingprocess.

5. Suggestimprovementintheutilizationofjailmanagementinformationsystems.Mostjails

useamanagementinformationsystemtooperateday-to-dayactivities.Thesesystemsoftenincorporatementalhealthscreeningquestions,butinformationgleanedfromthescreeningisnotdisseminatedtojailadministratorsormentalhealthstaff.Althoughthescreeningquestionscouldbeimprovedupon(seeabove),theinformationisimportantinassessingsystemwideneeds,aswellascommunicationwithneededstaff.

6. Insistuponidentificationofco-occurringdisorders(COD)andintegratedmentalhealthand

substanceusedisordertreatment.PilotsitesareunevenintheirapproachtowardidentificationandtreatmentofCOD.Theresearchonindividualswithseriousmentalillnessisconsistentinfindingthatthosewithco-occurringsubstanceusedisordersaremorelikelytogotojailandreturntojailmultipletimes.Moreemphasisonthedetectionofsubstanceusedisorders–aswellastheuseofintegratedtreatmentapproachesthattreatbothdisorderssimultaneously–isneeded.

7. Increasedemphasisonfamily,particularlychildren,andcommunitysupports.Researchdemonstratesthatstrengtheningfamilysupportandcommunity‘prosocial’networksareeffectiveinterventionsforindividualswithmentalhealthdisorders.Similarly,theidentificationofminorchildreninvolvedwiththetargetindividualmayprovetopreventfuturementalhealthdisordersassociatedwithneglectandearlytrauma.

8. Encouragecontinuityofcarebetweenjailandcommunitytreatmentandservices.Whilemanyoftheprogramsengagedinjail-basedservicespromotedischargeplanningandfollow-up,theseeffortscouldbestrengthened,particularlyforthosewhoarenotenrolledinCMHservices.Jailcanbeapowerfulmotivationforbehavioralchange,butthestrugglesofreentrycandiminishanindividual’sresolveforchange.Researchdemonstratesthat‘patientnavigators’havebeensuccessfulinassistingthosewithchronicphysicalhealthcareneedstransitionfromacutetoongoingcareandmanagementoftheirchronichealthconditions.Similarattention(beyondaphonecall)forthosetransitioningfromjailwouldbehelpfulinmanagingtheirchronicpsychiatricconditions.

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9. Emphasize‘criminogenic’factorsaswellasmentalhealthfactors.Theprimaryemphasisforallofthepilotprogramshasbeenappropriatelymentalhealthservices.However,researchindicatesthatmentalhealthsymptomsareresponsibleforaverysmallproportionofthe‘criminalbehavior’associatedwitharrest.Hence,recentresearchhascalledforinterventionsthattargetcriminogenicriskfactorsaswellasmentalhealthsymptommanagement10including‘criminalthinking’suchasrationalizingandblamingothers,lackofmotivation,impulsivity,traumaandpoverty.

→ RecommendationsforSystemLevelChangesThatWouldSupportDiversion

1. Considerfundingcommunitymentalhealthstafftoprovidein-reachserviceswithincarceratedconsumersandout-reachservicesuponcommunityreentry.Someofthepilotsareprovidingin-reachservicesintothejail.Inthismodel,aCMHstaffpersonorcaseworkerengageswithanincarceratedconsumertoprovidecrisisinterventionandadvocacyservicesduringincarceration,aswellassupportforcommunityre-entry.ThisisnotconsideredabillableserviceperCMHregulationsand,assuch,isabarriertoaneffectivecontinuumofcare.Whilesomecommunitiesfindin-reachanessentialpracticeirrespectiveoffunding,othersfeelthatthelackofreimbursementlimitstheavailabilityofhumanresourcesneededtoprovidethisimportantservice.Similarly,out-reachpost-jailreleaseactivelyseekstheindividualwithinthecommunitytoensureaccesstoandengagementinongoingservices.Thisisparticularlyimportantformedicationadherenceandassistanceinmanagementofsideeffectsofmedication.

2. PreventthetimelagforreinstatementofMedicaidcoveragepost-jailrelease.Suspensionof

MedicaidduringconfinementhaslongbeenapracticewithintheState.However,the45daystore-instatementcreatesaninsurmountablebarriertomedicationcontinuity,increasingtheprobabilityofde-stabilization.Medicaidshouldbeeffectiveuponjailreleasetoensurecontinuityofmedicationpastthetwo-weeksupplyprovidedbymostjailsuponrelease.Thiswouldensurethatindividualshavecontinuousaccesstoneededmedications,whichwouldincreasetheircapacitytosucceedinthecommunityandpotentiallyreducerecidivism.

3. Addressthestatewideneedforacutecarehospitalbedsforpsychiatricemergencies.Several

pilotsdiscussedthedwindlingnumberofpsychiatrichospitalbedsavailable.Whenapsychiatricbedisnotavailablelocally,individualsendupbeingplacedinhospitalsoutsidethecounty,greatlyincreasingthedifficultyincoordinatingmentalhealthandcommunityservicesuponrelease.Moreover,theabsenceofavailablehospitalbedsmayincreasetheprobabilityofofficersusingjailsasthemostprudentmentalhealthfacilityavailable.

4. Incorporatede-escalationskilltrainingwithinthepolicyacademy.Officersdiscussedthe

absenceoftrainingonmentalhealthissuesandde-escalationtechniquesinstandardlawenforcementtraining.Ataminimum,itwouldseemthattheincorporationofde-escalationtechniquesintostandardtrainingwouldpreventinjuriesofofficersandcitizensandperhapspreventexacerbationofasituationandcorrespondingcriminalcharges.

10Wolffet.al.(2013).Practiceinformsthenextgenerationofbehavioralandcriminaljusticeinterventions.InternationalJournalofLaw&Psychiatry,36;1-10.Epperson,et.al.,(2014).Envisioningthenextgenerationofbehavioralhealthandcriminaljusticeinterventions.InternationalJournalofLaw&Psychiatry,37;427-438.

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5. Enhancethespectrumofpsychotropicmedicationsavailableonjailformularies.Medicationisanongoingconcernatmanysites,includingthedestabilizationthatoccursforanindividualwhenmedicationschangeuponentrytothejail.Themorerestrictedavailabilityofdrugsonthejailformularymeansthatthemedicationregimentprescribedinthecommunityisabruptlyhaltedandswitchedtoacomparabledruginthejail.Thisswitchinmedicationscanresultinbehaviorchangesandpoorermanagementofsymptoms.Mentalhealthandjailpersonnelareconcernedthatthesedisruptionsputboththeindividualandjailstaffatriskandmayresultinelongatedjailstays.

VIII. EVALUATION:NEXTSTEPSAsexplainedpreviously,thisreportonprogramimplementationservicesasnecessarybackgroundinformationforfutureoutcomereports.Understandingthevariationacrossprogramsassistsinunderstandingvariationinoutcomes.Thenextstepsfortheevaluationteam,alsoshowninTable8onthefollowingpage,are:→ Short-termOutcomesReport

Theshort-termoutcomesreportwilluseindividual-leveldatatoassessjailrecidivismsixmonthsbeyondtheintervention.Thereportwillfollowindividualswhoreceivedservicesfromeachprogramduringtheimplementationperiod(April–September,2015).Individual-leveldatawillbecollectedfromeachoftheparticipatingjailstoassessjailactivity(i.e.,jailbookings,jailreleases,andrelatedoffensetypes)beforeandafterthediversionintervention.Jailmentalhealthscreeningdatacomparingmentalhealthneedsfrom2015to2016usingtheK6instrumentatsevencountyjailswillalsobepresented.Theshort-termoutcomesreportwillbedeliveredtotheDiversionCouncilduringthefourthquarterof2016.

→ Long-TermOutcomesReportThelong-termoutcomesreportwillfollow-upreportofrecidivismandtreatmentoutcomesforthoseadmittedintoadiversionservicefromApril1,2015–March31,2016.Inaddition,thisreportwillcoverindividualswhoreceivedservicesduringtheimplementationperiod(April–September2016)inthetwoadditionaljaildiversionpilotsiteslaunchedin2016inOaklandandLivingstonCounties.Thelong-termoutcomesreportwillbedeliveredtotheDiversionCouncilduringthefourthquarterof2017.

→ ComparingData-WarehouseandOtherAdministrativeDataThisreportwillassessdatagatheredonthetwopilotsites,OaklandandKent.Datawillbecollectedfromthestate-leveldatawarehouseandcomparedagainstdatagatheredthroughindividualadministrativedatapulls(i.e.,jail,treatment,andMichiganStatePolicedata)tocompareoutcomes.ThecomparisonreportwillbedeliveredtotheDiversionCouncilduringthefirstquarterof2018.ItisnotedthattheoutcomeofthisreportisdependentupontheavailabilityandaccessibilityofdatathroughOptumandtheState.

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Table8.IllustrationofUpcomingDataCollectionandReportWritingforEvaluationTeam

PROJECTSTASKS Year011/1/15-12/31/15

Year021/1/16-12/31/16

Year031/1/17-12/31/17

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

DataCollectionCohorts(beginindividualleveldataQ2)InitialSites:Cohortsofindividualsservedbydiversionprograms,byquarter,areidentifiedfordatacollectiontodetermineoutcomesforrecidivismandtreatmentengagement.(Original8sitesfundedin2015)

C1 C2 C3 C4

AdditionalSites:IndividualCohorts(n=2sitesprojectedtobeaddedin2016) C5 C6

InitialSites:Datacollectionfromjailsrelatedtoshort-termoutcomes(6monthjailrecidivism) C1 C2 X

InitialSites:Long-termoutcomes(1year);recidivismandtreatmentengagement C1 C2 C3 C4 X

AdditionalSites:short-termoutcomes(6monthjailrecidivism)anddatacollection(X)

C5 C6 X

DataCollectiononAll:datawarehouse,stateadministrativedata(jailsincluded)

X X

ReportWritingImplementation/ProcessReport X X Short-TermOutcomes:Countyjailrecidivismat6monthsandmentalhealthscreeningpre/postcompare(K6).

X X

Long-TermOutcomes:Recidivismandtreatmentcontinuity(anytx;timetotx;typeoftx;anyjailrecidivism;typeofrecidivism;timetorecidivism)

X X

ExpandingoutcomesusingStatedatawarehouse* X*ThisdeliverableissubjecttoavailabilityandaccessibilityofdatafromOptumandStateofMichigan

I-A1

AppendixI-A:BarryCountySiteSummaryIntroductionTheproposalputforthbyBarryCountyCommunityMentalHealthAgency(BCCMHA)introducedacomprehensiveplanacrossthecriminaljusticecontinuumthatinvolvedtraininglawenforcementandcourts;providingscreening,assessment,andmentalhealthserviceswithintheBarryCountyJail(BCJ);implementingaprocesstoidentifycommunitymentalhealth(CMH)-eligibleindividualsforenrollmentintojail-basedservices;andadvocatingonbehalfofconsumersfordiversionfromjailtocommunity-basedtreatment.Additionally,theproposalincludedone-timetraininginsupportofKevin’sLaw,oneofthefivekeyprioritiessetforthbyMDHHS.TheambitiousplanputforthbyBCCMHAisledbyasingleindividualwho,foralargepartoftheimplementationperiod,operatedallaspectsofthejailservicesandCITprogramssingle-handedly.Althoughtheplanwascomprehensiveinnature,actualimplementationrevealedsomebarriers.ThisreportdetailstheimplementationprocessduringYear1.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheevaluationteam’stwositevisits(March2015andMarch2016).

DescriptionofProgramImplementationinBarryCountyImplementationofCrisisInterventionTeam(CIT)TraininginBarryCounty:Intercept1TheimplementationofCITwithinBarryCountyfocusedondisruptiveandassaultivebehaviorexperiencedwithinthejail.Giventhelimitedresourceswithinthecommunity,thejailroutinelyhousesindividualsdiagnosedasseverelymentallyill(SMI)ordevelopmentallydisabled(DD)whoareexperiencingamentalhealthcrisisandexhibitingunstableanddisruptivebehavior.Itisreportedthattheseindividualsconstitutemostofthebehavioralproblemswithinthejail.CITtrainingwasrequestedtoimprovejailmanagementbyimprovingofficerskillsinpreventiveandde-escalationtechniquestomorereadilydiffusecrisissituations.Theprogramdelivereda24-hourCITtrainingcurriculumtoatotalofnineindividuals:sixjailofficers(threepershift)andthreeCMHstaff(onecasemanager,oneclinician,andonecertifiedpeersupportspecialist).ThetrainingwasheldinBarryCountyonJuly13–16,2015andconductedbyatrainerfromCrisisResponseConnection,LLC.Thetrainingsession,calledAssistingIndividualsinCrisisandGroupCrisisIntervention,wastailoredtobea3-day“powersession”thatcombinedtwoofferedbytheInternationalCriticalIncidentStressFoundation(ICISF)-theCriticalIncidentStressManagement:GroupCrisisInterventionandtheAssistingIndividualsinCrisisandPeerSupportCrisisInterventioncurriculum.BothICISFtrainingsarenormally2-day,16-hourcourses).Itwasanticipatedthattheinitialgroupoftrainees,i.e.jail-basedsheriff’sofficers,wouldeventuallyserveastrainerswithinBarryCountyinordertotrainlargernumbersofofficersinthejailandthecommunity.

I-A2

Todate,therehavebeennosubsequentCITtrainingsconductedinBarryCounty.AsdiscussedduringtheMarch2016sitevisit,limitedresourcesandminimalstaffingpracticeswithintheBarryCountySheriffDepartment(BCSD)maketheimplementationandsustainmentofaCITprogramproblematic.Specifically,thetraining,evenanabbreviated24-hourtrainingasinitiallyprovidedinthecounty,severelystrainedstaffresourcesastheBCSDsimplydoesnothavetheresourcestocoverorbackfillofficerpositionsduringthetraining.Goingforward,thestakeholdersplantoofferMentalHealthFirstAid(MHFA)trainingbeginninginthesecondyearofthegrantperiodtoallcommunityfirstrespondersincludingjailandpatrolofficersofBCSDandtheHastingsPoliceDepartment.Currently,thetrainingsarescheduledforJune,September,andNovember.Theshortereight-hourMHFAcurriculumisthoughttobeabettertrainingfitforthecommunitythanCITsinceitplaceslessdemandonstaffresources.Overtime,thestakeholdershopetobuildaprogramthatcanacquireandsustainCITwithinthecommunity.ImplementationofJailServicesinBarryCounty:Intercept3 BCCMHA,inpartnershipwiththeBCSDproposedtoincreasethenumberofmentalhealthservicesprovidedwithintheBarryCountyJail.Specifically,throughitsJailDiversion(JD)program,BCCMHAexpandedthenumberofmentalhealthservicesprovidedtoallinmates(CMHandnon-CMH)inthejailtoincludeindividualandgrouptherapy,advocacy,medicationreviews,dischargeplanning,enrollmentofnon-CMHinmatesintoBCCMHAservices,andfacilitationofMedicaidenrollmentviaapartnershipwiththeMichiganDepartmentofHumanServices(DHS).Priortothisgrant,mentalhealthservicesprovidedinthejailwerelimitedtothreedaysperweekandincludedmen’sandwomen’ssubstanceabusegroups,acourt-orderedcognitivebehavioraltherapygroup,andresponsetokitesorstaffreferralsformentalhealthservicesforonehourperday.Duetolimitedresourceswithinthecounty,BCCMHAemploysanexpandedclinicaleligibilityinordertoallowindividualswithlow-levelorsituationalmentalhealthissuestoaccessservices.Thisexpandedeligibilityfacilitatesfullaccesstomentalhealthservicesforallinmates(CMHandnon-CMH)withtheexceptionofmaximumsecurityinmateswhoareineligibleforgrouptherapy.Theprogramisaccessiblebyinmateswhoarereferredtothejaildiversionprogrambyjailstafforwhoinitiatea“kite”forthisserviceontheirown.Theprocessmap,includedasFigureA5onthelastpage,illustratestheprogramoperation,aswellasprocessnumbersduringtheimplementationperiod.TheJailDiversionteamalsoactivelyadvocatesforinmateswhoarealreadydemonstratinganefforttoadvocateforthemselves.Advocacyactivitiesincludedraftinglettersofsupport,consultationwithjudgesandprosecutors,andcollaborationwithcommunitycasemanagersandjailstaff.Theseactivitiesresultineitherareductionofjaildaysasindividualsaredivertedfromjailtocommunity-basedtreatmentorplacement,ordiversionfromprisoninfavorofjailtimeorparticipationintheSwiftandSureSanctionsProbationProgram.Theseactivitiesresultincurrentdiversion,whileotherservicesprovidedbytheJailDiversionteam,includingtreatmentgroups,individualtherapy,andcrisiscareareconsideredtobefuturediversion,withthegoaltoreducejailrecidivismthroughsupportiveservicesandcommunitylinkageswhileinthejail.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailduringprogramimplementation,theEvaluationTeamworkedintandemwithstakeholderstoidentifyandmeasurekeyprocessindicatorswithintheimplementationofjailservicesinBarryCounty.Basedonthe

I-A3

resultsoftheinitialconsultationwiththestakeholdersduringthefirstsitevisit,thefollowingprocessindicatorsweretobecollectedfromBarryCountybeginninginApril2015. Name,title,affiliationofCITtrainees Pre/Post-CITTrainingsurvey #JailBookings #K6/SuicideScreenings #JailConsults/ReferralstoBCCMHAJD #BCCMHAconsumersbookedtojail #MHAssessmentsConductedbyBCCMHAJD #CasesOpened/ReactivatedbyBCCMHAJD #Consumers(Current,Open/Reactivated)ReceivingMHServicesinJail Name,Booking#,M/F,DOBofCurrent,Open/ReactivatedCasesAsBCCMHAimplementedandgrewtheirjaildiversionprogram,theevaluationofthepilotprogramwasadaptedaswell.Specificchangeswereimplementedinthecollectionofprocessdatatoappropriatelyreflectchangestotheprogramasimplemented.ThesechangesincludedadjustingthewayinwhichthenumberofBCCMHAconsumersbookedtothejailisdeterminedandwhichindividualsservedbytheJailDiversionteamwillbetrackedforshort-andlong-termoutcomes.Additionally,somechangesweremadetoalignprocessindicatorscollectedinBarryCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincludejailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.Thefinallistofprocessindicatorswasrevisedtoincludethefollowing.Theseareindicatedontheprocessmap(FigureA5).

Name,title,affiliationofCITtrainees Pre/Post-CITTrainingsurvey

#JailBookings #K6/SuicideScreenings #JailConsults/ReferralstoBCCMHAJD Adjusted #BCCMHAconsumersbookedtojail #BCCMHAconsumersbookedtojail* #MHAssessmentsConductedbyBCCMHAJD #CasesOpened/ReactivatedbyBCCMHAJD Adjusted #Consumers(Current,Open/Reactivated)ReceivingMHServicesinJail

#IndividualsReceivingServices(Current,Open/Reactivated)ReceivingServices fromBCCMHAJD

*BCCMHAconsumersbookedtojailisestimatedbymanuallytabulatingK6surveysinwhichindividuals responded“yes”to“Haveyoureceivedmentalhealthservicesinthepastmonth?”.Thelong-termoutcomeevaluationtobeconductedbyEvaluationTeamandreportedin2017willfollowthoseBCMHAconsumersservedbythejaildiversionteamtoassesstreatmentengagementinthecommunityandrecidivism.CITPre/PostTrainingIndicatorsEightofthenineindividualswhoattendedthetrainingcompletedbothpre-andpost-testassessments.Thepre-andpost-testswereimplementedimmediatelypriorto(pre-)andfollowing(post-)thetrainingandwerebasedontwoinstruments:theOpinionsofPsychiatricTreatment(OPT)MeasureandtheDe-escalationScale.The20-itemvalidatedOPTMeasureassessesofficers’attitudesandknowledgeabout

I-A4

psychiatrictreatmentswithinthecommunityandattitudesaboutpsycho-pharmacotherapy,psychotherapy,andpsychosocialinterventions.Responsesaregivenasix-pointLikertscalerangingfrom1(stronglydisagree)to6(stronglyagree).Thepossiblerangeofscoresis20–120.The8-itemDe-EscalationScalemeasuresofficers’de-escalationskills.Officers’opinionsontheeffectivenessofspecificactionsinvarioussituationswereratedonafour-pointLikertscalerangingfrom0(verynegative)to3(verypositive).Totalsubscalescoresrangefrom0to24.AsshowninFigureA1below,therewasanaveragechangescorefrompre-topost-testof3.4pointsontheOPTscale.Thischangewasnotstatisticallysignificant(althoughasmallsample),suggestingthatthetraininghadlittleeffectontheknowledgeofdifferenttreatmentsforindividualswithmentalillness.The‘non-significant’findingsherebetweenpre-andpost-testcouldbealsoattributabletothreeofeightindividualsinthetrainingbeingmentalhealthprofessionalsandpresumablyalreadyawareofmentalhealthtreatment.FigureA1.DifferencesinOPTScalePre-toPost-CITTraininginBarryCounty

Similarly,asshowninFigureA2below,therewasa1.4pointnon-significantincreaseinskill/knowledgeregardingthede-escalationofanindividualwithmentalillness.Assuggestedearlier,thenon-significantfindingscouldbeattributabletothesmallsamplesizeortheparticipationofmentalhealthprofessionalsaspartofthetraining.FigureA2.DifferencesinDe-escalationScalePre-toPost-CITTraininginBarryCounty

75.879.1

60

70

80

90

100

OPTScale

Pre Post

25.727.1

20.0

22.0

24.0

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De-Escalaron

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ProgramReferral/EnrollmentAsshowninFigureA3below,theproportionofindividualsbookedintoBCJandreferredformentalhealthservicestothejaildiversionteamwas19%(200of1,044).Itisestimatedthatduringthesametimeperiod,approximately11%(116of1,044)ofindividualsbookedintothejailwereCMHconsumers.Ofthe200individualsreferredtothejaildiversionteamforservices,25%(49of200)wereopenedorreactivatedforCMHservices.FigureA3:BarryCountyProcessIndicatorsApril2015–September2015

*CMHConsumersBookedinJailisdeterminedbythenumberofpositiveK6screensconductedbyjailstaff.**Atotalof218individualswhoreceivedservicesfromthejaildiversionprogramincludingallcurrent,opened,orreactivatedCMHconsumers;theseindividualswillbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.NeedforMentalHealthServicesFigureA4onthefollowingpageshowstheexpressedneedformentalhealthservicesintheBarryCountyjail.Usingtheobjectivemeasureofestimatedneedformentalhealthscreening/servicesderivedfromthepreviousstudythatusedtheK6assessmenttoscreenallindividualsbookedintothejail,approximately16.8%ofindividualsbookedintothisjailwouldbeexpectedtorequirementalhealthservices(i.e.,objectiveneed).Usingthisestimateandcomparingtothenumberofreferralstomentalhealthdiversioninthejail,anadditional2.4%ofthejailpopulationwasidentifiedaspotentiallyrequiringservices(i.e.additionalneedcaptured).

1044

116200 200 218

49

0

200

400

600

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JailBookings CMHBookings*

ProfMHScreens

ReferralstoJDRecdSvcsfromJD**

CMHOpen/Re-open

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FigureA4.EstimatedNeedforIndividualsNeedingMentalHealthServicesintheBarryCountyJail

ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbystakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitandaddressboththejailservicesandCITprograms.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.Overall,theprogramisontracktosuccessfullymeetmostobjectivesrelatedtobothjailservicesandofficertraining. 1.Improvejailofficerpreventiveandde-escalationskillsthroughCITtraining.

Progress:Goalpartiallymet.Atotalofnineindividuals–sixjailofficersandthreecommunitymentalhealthprofessionals–attendedtheCITtrainingconductedinthecountyinJuly2015.TheofficerswhoattendedwerestrategicallyselectedtorepresentthetwoworkshiftsoperatedwithinthejailtoensureCIT-trainedofficerswereavailablewithinthejail24/7.Detailsofthepre-/post-testsadministeredatthetrainingareprovidedearlierinthisreport(seeImplementationofCITinBarryCounty:Intercept1).Goingforward,stakeholdersplantoprovidejailandpatrolofficerswithMentalHealthFirstAidacrossthreetrainingsin2016(seeNextSteps).

2.ReducethenumberofsentineleventsexperiencedwithinthejailthroughCITtraining. Progress:Goalpartiallymet.Inordertotrackreductionsinthenumberofsentinelevents

experiencedatthejailitwouldbenecessarytoestablishabaselineforsentinelevents–theaveragenumberofeventsoccurringbeforeCITtraining–andthenassessthenumberofsentineleventsoccurringafterCITtraining.Unfortunately,thislevelofdataisnotcurrentlyavailablefromthejail.However,duringthesecondsitevisitinMarch2016,onesergeantreportedanecdotalevidenceofimprovementswithinthejailincludingadecreaseinsentinelevents,theabilityofCIT-trainedofficerstoresolvecrisessoonerthanbefore,andadecreaseintheuseoflockdownstocontroldisruptiveorassaultivebehavior.

3.StrengthensystemtoidentifyBCCMHAconsumersbookedintojaileachday.

Progress:Goalpartiallymet.AsillustratedintheprocessmapforBarryCounty(FigureA5),thejaildiversionprogramreceivedreferralsviatwosources:fromthejailstaff,includingthoseself-identifiedthroughtheinitialscreeningprocesswithSMI,onpsychotropicmedications,atriskforsuicide,orwhoareknownBCCMHAconsumers;andfromthose

EsnmatedMHNeed(ObjecnveNeed),

16.8%

AddinonalMHNeedsCaptured,2.4%

NoMHNeeds,80.8%

I-A7

observedbythejailofficerstohavementalhealthconcerns.TheJailDiversionteamcanalsobeaccesseddirectlybyinmatesthroughthekiteprocess.ThesetwomechanismshaveprovidedtheJailDiversionteamwithasteadystreamofindividualspotentiallyinneedofmentalhealthservices.Thoughinitiallyattempted,theprocessofgainingreferralsthroughreviewofthedailybookingreportfromthejailwasnotimplementedbecauseoflimitedstaffresources.Theprocesshasreliedsolelyuponreferralsfromthejailofficersandkitestofeedtheprogram.

4.Developsystemtoidentify,assess,andopen/reactivateindividualswithinthejailassessedashavinganSMIwhoarenotcurrentBCCMHAconsumers.

Progress:Goalmet.AsillustratedontheprocessmapforBarryCounty(FigureA5),theJailDiversionteamreceivesreferralsandkitesfromindividualswhomaynotbecurrentCMHconsumers,butwhomayscreenpositiveforSMIorsuicideriskorkite.TheJailDiversionteamactivelyassessesthoseindividualswhoarenotcurrentCMHconsumers.Duringthesix-monthimplementationperiod(04/15–09/15),thejaildiversionteamopenedorreactivated49individualsintoCMHservices.

5.Attempttoidentifyindividualssuitableforpre-bookingandpre-chargediversionby

reducingthetimetoassessment/referral. Progress:Goalnotmet.Progressinidentifyingindividualssuitedforpre-bookingdiversion

continuestobedifficult.Currently,theJailDiversionteamisunabletoidentifyindividualssuitedfordiversionuntiltheyarebookedtothejail.Itisreportedthatthereiscurrentlynoplantoimplementapre-bookingorpre-chargediversionprogramwithinthecounty.However,theJailDiversionteamisactivelyengagedinpost-bookingdiversionforindividualswithSMI,substanceusedisorder,orthosewithco-occurringmentalhealthandsubstanceusedisorders.Duringtheimplementationperiod,itwasreportedthat13individualsweredivertedpost-bookingfromjailtocommunity-basedtreatmentorfromprisonintointensiveprobationorjail.

6.InitiatestakeholdertrainingsregardingKevin’sLaw.

Progress:Goalabandoned.DuetoissuesrelatedtothespecificlegislationsupportingKevin’sLawcurrentlybeingaddressedatthestatelevel,theKevin’sLawtrainingproposedbyBCCMHAwasnotimplemented.

NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforBarryCountyslatedforthesecondyearofthejaildiversionpilotprogram.Thefirststep,whichwasdiscussedearlierinthisreport,islistedbelowinsummaryformonly.

1. IncreasecommunityawarenessofmentalillnessthroughMentalHealthFirstAidtrainingforthecommunity’sfirstresponders.

2. Increasepost-bookingdiversionthroughtheimplementationofevidence-basedMRT

withinthejail.Duringthesecondyearofthepilotprogram,theJailDiversionteamplanstoimplementaMoralReconationTherapy(MRT)groupwithinthejail.Thoughthetransitioniscurrentlybeingnegotiated,theteamplanstoreplacethecurrent“ChangeforWellness”grouptothemorenarrowlyfocused,evidence-supportedMRTgroup.ThenewMRTgroup

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willtargetfelonsand/ormisdemeanantswithpreviousprobationfailureswhoaremandatedtotheprogrambythejudge.Completionofthein-jailMRTgroupwillresultinreleasefromjailasorderedbythejudge.StakeholdersanticipatethatthechangetoMRTwillincreasetheopportunityforpost-bookingdiversionsandprovideparticipantswithmorepositivelong-termrecidivismoutcomes.

3. StrengthendischargeservicesandsupportthroughtheimplementationofaPeer

Group/ResourceMeetingwithinthejail.TheJailDiversionteamwillimplementapeergroupresourcemeetingwithinthejailforinmateswhoarewithin30daysofrelease.Thegroup,tobefacilitatedbycertifiedpeersupportspecialists,willprovidesupport,referrals,andguidancethroughthedischargeperiod.Itisanticipatedthatthislevelofdischargeplanningwillresultinfuturediversionofthosewhoattendthegroup.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing:

1. IdentifyBCCMHAconsumersbookedtojail.Theabilitytoimplementamoreautomated

processtoproactivelyidentifyBCCMHAconsumersbookedintothejailwouldconceivablyresultinswifterandmoreconsistentaccesstomentalhealthserviceswithinthejail.Thisprocesswouldproactivelyidentifyconsumerswithinthejailinamoreobjectivemannerthanthecurrentreferral/consultandkiteprocesssolelyutilizedtoidentifythoseinmateswithpossiblementalhealthconcerns.

2. Implementacommunityadvisorycouncil.Presentlythereisnoactivemental

health/criminaljusticeadvisorycounciloperatedwithinBarryCounty.Anadvisorycouncilcomprisedofcriminal/legalprofessionals,mentalhealthprofessionals,mentalhealthadvocates,andlawenforcementthatcanengageinproblem-solvingandmonitoringofdiversionprogramsacrossallpointsofinterceptwillfacilitateproblemsolvingaswellasfutureplanningefforts.

I-A9

FigureA5.BarryCountyProcessMap

Arrest

JailIntakeInitialscreenconductedby

Officer

SMI/Meds/SuicideRiskorknownconsumer

NoSMI/Meds/SuicideRisk

ObservationbyJailStafforKitebyJailStafforInmate

DataCollectionPoint:

2.NumberofReferralstoJailDiversion:

200

3.NumberofMHAssessmentsConducted

byJailDiversion:54

4.NumberofCMHConsumersBookedtoJail*:

116

5.NumberofCasesOpened/ReactivatedbyJailDiversion:

49

IndividualsReceivingServices:218

OutcomeDataCollection:#/typesvcsprovidedinjailby

individual

OutcomeDataCollection:Jailbooking/releasedatesMHsvc/typepost-release

MentalHealthAssessmentLevelofSeverity/RoughDiagnosisConductedbyCMHJailDiversion

JailTreatmentServicesGroupTherapy(exceptMaxSecurity)

IndividualTherapyAdvocacy

MedicationReviewDischargePlanning(MHappt,30-daysupplyofmeds)

DischargeFollow-UpJDcontactwithcommunityprovidertodetermineifappointmentwas

kept

MaximumSecurityHighRiskofViolence

JailConsulttoJailDiversion

Non-CMH

CMH

GeneralPopulationNodetox,risk,meds

LowMH

ObservationDetox,pregnancy

HighMH

ContinuedAssessmenttoMovetoGP

YesSMINoSMI

OpportunityforPre-BookingJailDiversion

OpportunityforPost-BookingJailDiversion

CMHCaseOpenedforNon-CMH

DataCollectionPoint:

Providealistoftrainees(Name/Title/Agency)to

evaluationteam

Pre/PostOfficerSurvey

DataCollectionPoint:

1.NumberofJailBookings:1,044

CMHHistoryGAFScore

DeterminedbyDailyLivingAssess.

CITTrainingICISF

July13-16,20153JailOfficers(1pershift)

ExcelSpreadsheetID&Demo

DataforallCurrent,Opened,orReactivated

CMHConsumers–

Name,BookingID,CMHID,DOB,Gender,Race,

PrimaryDiagnosis

*ManuallytabulatedfromK6surveys;Individualsresponding“yes”to“Haveyoureceivedmentalhealthservicesinthepastmonth?”

AppendixI-B:BerrienCountySiteSummaryIntroductionTheproposalputforthbyBerrienMentalHealthAuthorityfocusedontheprovisionofCrisisInterventionTeam(CIT)trainingforBerrienCountySheriff’sOffice(BCSO)dispatchersandofficers,aswellastheintroductionofapost-bookingjaildiversionprogramlocatedwithintheBerrienCountyJail(BCJ).Specifically,Riverwood,theleadcommunitymentalhealth(CMH)providerinvolvedwiththegrant,intendedtotargetservicestothoseinmatesidentifiedashavingseriousmentalillness(SMI)whoarenotcurrentlyaffiliatedwiththeCMH.Additionally,theproposalemphasizedthedevelopmentofanoverarchingCoordinatingCouncil–aconsultativebodywithmembersfromlawenforcement,dispatch,theProsecutor’sOffice,thecourts,andmentalhealthproviders–tostreamlineandclosegapsinBerrienCounty’sjaildiversioninitiativesincludingjaildiversion,drugcourt,andmentalhealthcourt.ThisreportdetailstheimplementationprocessduringYear1.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearly2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheevaluationteam’stwositevisits(early2015andJanuary2016).

DescriptionofProgramImplementationinBerrienCountyImplementationofCITinBerrienCounty:Intercept1TheimplementationofCITwithinBerrienCountyfocusedoncallsdispatchedbytheBerrienCounty911&PublicSafetyCommunicationCenterincludingcallsinitiallyidentifiedanddispatchedasmentalhealthcalls(e.g.probateordersandpsychcalls)andaswellasthosedeterminedbytherespondingofficer(localpoliceorsheriffoffice)tobementalhealthrelated,suchasdisturbancecalls.Theinitialfocuswasontrainingsixsheriffdeputies.Itwasintendedthatthisinitialgroupoftraineeswould,inturn,serveastrainerswithinBerrienCountyinordertotrainofficersofBCSOandlocalpolicedepartmentsthroughoutthecounty.SixBerrienCountysheriffdeputiesattendeda40-hourtraininginChicago,ILconductedbytheChicagoPoliceDepartmentonApril20–24,2015.Traineesincludedthreepatrolofficers,twoBerrienCountyJailofficers,andonedispatchofficerfromBerrienCounty911&PublicSafetyCommunicationCenter.Asecondroundoftraining,anabbreviated24-hourmodel,wasaddedlaterduringYearOne.ThetrainingwasconductedinBerrienCountyonNovember2–4,2015andwasfacilitatedbyRiverwood’sJailDiversionSupervisorandBCSOofficerstrainedduringtheinitialtraininginChicago.TheabbreviatedtrainingmodelcontainedlesstimedevotedtotheBerrienCountymentalhealthsystemandcounty-specificresourcesandfocusedmoreonde-escalationtechniques.NineBCSOofficersattendedthesecondtraining,includingeightpatrolofficersandonedispatchofficer.ImplementationofJailServicesinBerrienCounty:Intercept3Riverwood,inpartnershipwiththeBCSO,proposedtoenhancethelevelofservicescurrentlyprovidedtothosewithintheBCJwhoareidentifiedashavingseriousmentalillness(SMI).Specifically,Riverwood

I-B2

intendedtotargetservicestothoseinmatesidentifiedashavingSMIwhoarenotcurrentlyaffiliatedwiththeCMH.InmatesarereferredtoaJailDiversion(JD)teamlocatedwithinthecountyjailbythejail’smentalhealthclinician.ServicesprovidedbytheJDteamincludeopening/reactivatingCMHservices,advocacyformedicationforconsumers,individualconsultsanddischargeplanning.Theprocessmap,includedasFigureB5onthelastpage,illustratestheprogramoperationaswellasprocessnumbersduringtheimplementationperiod.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailduringprogramimplementation,theEvaluationTeamworkedintandemwithstakeholderstoidentifyandmeasurekeyprocessindicatorswithintheirimplementationofCITandJailServicesinBerrienCounty.Basedontheresultsoftheinitialconsultationwithstakeholdersduringthefirstsitevisit,thefollowingprocessindicatorsweretobecollectedfromBerrienCountybeginninginApril2015. CIT: Name,title,agencyaffiliationofCITtrainees Pre/Post-CITTrainingsurvey #TotalCallstoDispatch #CallsCodedasMHatDispatch #CITReportFormsReceivedbyJailDiversionTeamatRiverwood11 #CallsClearedasMHatDispatch12 FinalDispositionofMHCodedCalls(jail,hosp,AC,shelter,home,notx)

CopiesofCITReportFormsreceivedbyRiverwoodJD JailServices: #JailBookings #InitialScreenings #RiverwoodConsumersBookedIntoJailperBookingList #IndividualsIdentifiedasMHatInitialJailScreening(JailOfficer) #MHReferralstoJailClinician #AssessmentsbyJailClinician #ReferralstoRiverwoodJailDiversionTeam #CasesOpened/ReactivatedbyRiverwoodJailDiversionTeam

#Consumers(Current,Open/Reactivated)ReceivingIn-Reach/OtherServicebyRiverwoodCaseManagerinJail

Name,Booking#,M/F,DOBofCurrent,Open/ReactivatedCasesAsRiverwoodimplementedandgrewtheirCITandjaildiversionprograms,theevaluationofthepilotprogramwasadaptedaswell.Specificchangeswereimplementedinthecollectionofprocessdatatoappropriatelyreflectchangestotheprogramasimplemented.Thesechangesincludedadjustmentstoreflectprocessindicatorsthatcouldorcouldnotbequantified(i.e.,eliminationofassessments

11TheEvaluationTeamisrequestingtheadditionoffivequestionstotheCITReportformprovidedbyChicagoPDandintendedtoserveasaCITReferralforminBerrienCounty.ThesequestionswillbeaskedacrossallpilotsitesimplementingCITduringthepilotperiod.Thesequestions,tobeansweredbylawenforcement,are:1.Wasthesubjectarrested?2.Couldyouhavearrestedthesubject?3.Areyouseekingcharges?4.Wasthesubjecttakenintoprotectivecustody?5.Otherservicesprovided.SincethecurrentCITReportalreadyaddresses“otherservicesprovided”(i.e.,disposition)intheMemberActionssection,addingquestions1–4wouldsuffice.12ThecollectionofDispatchclearancecodesisdependentonthedevelopmentandimplementationofnewclearancecodesatBerrienCounty911&PublicSafetyCommunicationCenter.

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conductedbyjailclinician)andafocusontheindividualsenrolledintheJailDiversionprogramforpurposesofshort-andlong-termoutcomes(i.e.,additionofnumberenrolledinJailDiversionprogram).Additionally,somechangesweremadetoalignprocessindicatorscollectedinBerrienCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincludedjailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.Therevisedprocessindicatorsareprovidedbelow. CIT: Name,title,agencyaffiliationofCITtrainees Pre/Post-CITTrainingsurvey #TotalCallstoDispatch #CallsCodedasMHatDispatch #CITReportFormsReceivedbyJailDiversionTeamatRiverwood #CallsClearedasMHatDispatch FinalDispositionofMHCodedCalls(jail,hosp,AC,shelter,home,notx)

CopiesofCITReportFormsreceivedbyRiverwoodJD JailServices: #JailBookings #InitialScreenings #RiverwoodConsumersBookedIntoJailperBookingList Eliminated #IndividualsIdentifiedasMHatInitialJailScreening(JailOfficer) Adjusted #MHFollow-upSessionsConductedbyJailClinician #AssessmentsbyJailClinician #ReferralstoRiverwoodJailDiversionTeam #CasesOpened/ReactivatedbyRiverwoodJailDiversionTeam Eliminated #Consumers(Current,Open/Reactivated)ReceivingIn-Reach/OtherServiceby

RiverwoodCaseManagerinJail Added #IndividualsEnrolledinJDProgram Name,Booking#,M/F,DOBofCurrent,Open/ReactivatedCasesCITPre/PostTrainingIndicatorsAtotalof14ofthe15officers/dispatcherswhoattendedthetwotrainingscompletedbothpre-andpost-testassessments.Thepre-andpost-testswereimplementedimmediatelypriorto(pre-)andfollowing(post-)thetrainingandarebasedontwoinstruments:theOpinionsofPsychiatricTreatment(OPT)MeasureandtheDe-escalationScale.The20-itemvalidatedOPTMeasureassessesofficers’attitudesandknowledgeaboutpsychiatrictreatmentswithinthecommunityandattitudesaboutpsycho-pharmacotherapy,psychotherapy,andpsychosocialinterventions.Responsesaregivenasix-pointLikertscalerangingfrom1(stronglydisagree)to6(stronglyagree).Thepossiblerangeofscoresis20–120.The8-itemDe-EscalationScalemeasuresofficers’de-escalationskills.Officers’opinionsontheeffectivenessofspecificactionsinthesituationwereratedonafour-pointLikertscalerangingfrom0(verynegative)to3(verypositive).Totalsubscalescoresrangefrom0to24.AsshowninFigureB1onthenextpage,therewasanaveragechangescorefrompre-topost-testof6.8pointsontheOPTscale.Althoughasmallsamplesize,thischangefrompre-topost-testwasstatistically

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significant13,indicatingthatthetraininglikelyhadapositiveeffectontheofficers’knowledgeofdifferenttreatmentsforindividualswithmentalillness.FigureB1.DifferencesinOPTScalePre-toPost-CITTraininginBerrienCounty

Similarly,FigureB2belowshowsthattherewasanaverage2.6pointincreaseinskill/knowledgeregardingthede-escalationofanindividualwithmentalillness.Althoughasmallsample,thischangewasalsostatisticallysignificant14,indicatingthatthetraininglikelyhadapositiveeffectonofficers’skillandknowledgeregardingde-escalation.FigureB2.DifferencesinDe-escalationScalePre-toPost-CITTraininginBerrienCounty

ProgramReferral/EnrollmentAsshowninFigureB3below,theproportionofindividualsbookedintothejailandidentifiedformentalhealthscreeningconductedbythejail’smentalhealthclinicianwasis9%(342of3,701).Approximately

13Note:Pairedt-testswereusedtotestindividuallevelchangescoresontheOPTscale(t(13)=4.444,p<.05).Thestatisticalsignificanceofthisfindingsuggeststhattheseresultsarehighlyunlikelytooccurduetochance.4Note:Pairedt-testswereusedtotestindividualchangescoresontheDe-escalationscale(t(12)=3.237,p<.05).Thestatisticalsignificanceofthisfindingsuggeststhattheseresultsarehighlyunlikelytooccurduetochance.

88.995.6

70

80

90

100

OPTScale

Pre Post

26.0

28.5

20.0

22.0

24.0

26.0

28.0

30.0

De-Escalaron

Pre Post

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9%ofthosebookedintothejailwerecurrentCMHconsumers(341of3,701).OfthosescreenedbytheJailClinician,56werereferredtotheJDprogram.Ofthese,35individualswereenrolledintheJDprogramand25wereopenedorreactivatedforCMHservices.FigureB3.BerrienCountyProcessIndicatorsApril2015–September2015

*Atotalof51individualswhoreceivedservicesfromthejaildiversionprogram,including35whowereenrolledintotheprogram,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

NeedforMentalHealthServicesFigureB4onthefollowingpageshowstheexpressedneedformentalhealthservicesintheBerrienCountyjail.Usingtheobjectivemeasureofestimatedneedformentalhealthscreening/servicesderivedfromthepreviousstudyofK6screeningsofindividualsatclassificationinBCJ,itispredictedthat38%ofindividualsmightrequirementalhealthscreening/services.Becauseonly9%wereidentifiedformentalhealthscreening(‘expressedneed’),itispossiblethatthereweremanyunidentifiedindividualswithmentalhealthproblems(29%)resultinginapotential‘uncaptured’need.FigureB4.EstimatedMentalHealthServiceNeedsintheBerrienCountyJail

However,itshouldbenotedthattheobjectiveneedestimateof38%ofthoseenteringthejailhavingsymptomsassociatedwithseriousmentalillness(SMI)asdeterminedbytheK6maybeinflated.TheK6

3,701

341 34256 51 35 25

0

500

1,000

1,500

2,000

2,500

3,000

3,500

IdennfiedMHNeeds(ExpressedNeed),

9.2%

PotennallyUnidennfiedMHNeeds,28.8%NoMHNeeds,

62.0%

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screeningprocessoccurredduringclassificationatBerrienCountyJail,whileallothersitesconductedthescreeningatbooking.Classificationoccurslaterinthejailadmissionprocess,sothescreenscouldhavebeenconductedupto48-hoursafterbooking.Screeningsconductedlaterinthejailadmissionprocesscouldpotentiallyyieldhighernumbersofindividualsscreeningpositivelyformentalhealthconcerns.ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbythestakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitconductedatRiverwoodinearly2015.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.TheplanputforthinBerrienCountywasambitious.Bothinterventions,CITandthepost-bookingjaildiversionprogram,werenewinitiativesforthecommunity,requiringRiverwoodtofirstestablishrelationshipswithBCSO,BCJ,andtheBerrienCounty911&PublicSafetyCommunicationCenterbeforetheactualworkofimplementationcouldbegin.Theprocessofestablishingrapportamongthepartneragencieswentexceedinglywellandpavedthewayforasuccessfulimplementationofbothinitiatives.Overall,theprogramisontracktosuccessfullymeetmostobjectivesrelatedtobothjailservicesandCIT. 1. Developasystemandprotocolstoidentifyandcodedistresscallstodispatchthatpossibly

involveexperiencingamentalhealthcrisiswithinthecommunity. Progress:Goalmet.UponcompletionoftheinitialCITtraininginApril2015,theBerrienCounty911&PublicDispatchSafetyCommunicationCenterimplementedtwonewcodeswithinthecallsystemtocaptureandreportmentalhealth-relatedcalls.Thecodeprovidesdispatcherstheoptiontocode/openacallas“mentalhealth”toindicatetorespondingofficersthatthecalllikelyinvolvesamentalhealthcrisis.Similarly,respondingofficersareprovidedacodetoclear/closeacallas“mentalhealth”if/whenitisverifiedthatthecallrespondedtoinvolvedamentalhealthcrisis.

2. Gainmorespecificinformationfromdispatchcallstoenhancesystem-levelplanning.

Progress:Goalpartiallymet.Theimplementationofamentalhealthcodetoopenandclosedispatchandpolicecallshasresultedintheabilitytogenerateinformationthatmightassistthecounty’splanningefforts.Theinformationavailableonthecallsprovidesdate,time,type(psych,suicide,suspicious,welfarechecketc.),location,disposition,andabriefnarrativeofthecall.ThesecallreportshavebeenprovidedtotheEvaluationTeamforanalysis(seeNextSteps).

3. Improvescreeningatdispatchtoeffectivelyandefficientlydetermineifdisturbancecallsare

relatedtoamentalhealthissueorcrisis. Progress:Goalnotmet.ThedispatchersupervisorfromtheBerrienCounty911&PublicSafety

CommunicationCenterattendedtheinitialCITtrainingconductedinChicagoinApril2015.However,itwasdeterminedthatchangestothewaycallsarescreenedatthedispatchcenterwouldnotbepossibleduetothetightlypromptedsystemthedispatchersfollow.Goingforward,in-servicetrainingwillbeprovidedtodispatchers.ThefocusofthetrainingwillbetheuseoftheCITreferralformdevelopedbytheJailDiversionteamtotrackpre-arrestdiversionsresultinginthereferralofindividualstomentalhealthservices.

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4. IncreaseincollaborationbetweentheSheriff’sOffice,theJailandRiverwoodviaCITReferralForm.Progress:Goalmet.StakeholdersproposedthedevelopmentofaCoordinatingCouncilcomprisedofmembersoflawenforcement,dispatch,thecourts,theProsecutor’sOffice,andtreatmentproviderstostreamlineandaddressgapsinthecounty’sdiversioninitiativesincludingthejaildiversionprogram,drugcourt,andmentalhealthcourt.Thiscouncilwastobeinadditiontoahigher-levelAdvocacyCouncilalreadyinplaceinthecommunityandwouldconceivablyserveasaforumforCITcollaborationandsustainment.ItisreportedthattheCoordinatingCouncilisinplaceandactivelyattendedbytwoRiverwoodadministrators.

Inaddition,theJailDiversionSupervisoridentifiedtwoadditionalforumstopromoteand/ordiscussCIT.First,aCITTrainermeetingwasimplementedimmediatelyfollowingthefirsttrainingsession.Participantsincludethefirstcohortoftrainedofficers.Additionaltrainedofficersareinvitedtoattendifinterested.Thegroupmeetsmonthlytotroubleshoot,enhancethetraining,anddiscussandresolveanyfieldissues.Second,theJailDiversionSupervisorregularlyattendsthePoliceChiefsmeeting,amonthlymeetinghostedandattendedbypolicechiefsfromareapolicedepartments.AttendanceatthismeetingisintendedtopromoteCITamongthelocalpolicechiefs.ItisreportedthatpromotionofCITatthesemeetings,whileyieldingsomeadditionalparticipationfromthelocalpolicedepartments,hasbeenmetwithsomeresistanceamongthechiefs.Thestakeholdersplantoaddressthisresistanceduringthesecondyearoftheprogram(seeNextSteps).

5. StrengthensystemandprotocolstoidentifycurrentRiverwoodconsumerswhoarebookedat

thejaileachday. Progress:Goalmet.Riverwoodactivelymonitorsthejail’sdailybookingreportMonday–Friday

inaprocessthatisseparatefromthejaildiversioninitiativeasshownontheprocessmap(FigureB5).Stakeholdersreportthatthisprocessincludestheidentificationofconsumers,notificationofcasemanagers,andreleaseofmedicalrecordstothejail’smentalhealthclinician.

6. Developasystemtoidentify,assess,andopen/reactivateindividualswithinthejailassessed

ashavingaseriousmentalillness(SMI)whoarenotcurrentRiverwoodconsumers. Progress:Goalmet.Asillustratedontheprocessmap(FigureB5),thejailmentalhealthclinician

refersindividualsassessedashavinganSMIandwhomayqualifyfortheJailDiversionprogramtotheJailDiversionteam.TheseindividualsmayormaynotbecurrentCMHconsumers.Ofthe43individualsreferredtoJailDiversionduringtheimplementationperiod(April-September),25wereopenedorreactivatedtoCMHservicesbytheJailDiversionteam.

7. Attempttoidentifyindividualssuitableforpre-booking/pre-chargediversionbyreducingtime

toassessment/referral.Progress:Goalpartiallymet.TheJailDiversionteamimplementedaCITreferralformforuseamongpatrolofficersanddispatcherstotrackindividualsdivertedtotreatmentwithinthecommunity.TheJailDiversionteamactivelyfollowsuponthesediversionstohelpensurethatthedivertedindividualsengagewithtreatmentinatimelymanner.

NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforBerrienCountyslatedforthesecondyearofthejaildiversionpilotprogram.

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1. Exploreopportunityfora24-hourdrop-off.Communitystakeholderswillconsiderexploring

theopportunitytoimplementa24-hourdrop-offforindividualsexperiencingmentalhealthcrisisinthecommunity.Theimplementationofsucharesourcewouldprovidepatrolofficerswithanadditionaltreatmentoptionotherthanthehospitalemergencyroom(ER)orthejail.Thedrop-offwouldalsoprovidetheopportunitytoincreasepre-arrestandpre-bookingdiversionactivities,bothofwhichcouldpotentiallyreducethenumberofindividualswithmentalhealthconcernsbookedintothejail.

2. InvolvelawenforcementtoimproveparticipationinCIT.StakeholdersplantoencourageCIT-

trainedofficerstoattendthePoliceChiefsmeetingwiththeJailDiversionSupervisor.DuringYearOne,theJailDiversionSupervisorattendedmostofthemeetingsalone.Itwasacknowledgedbylawenforcementstakeholdersatthesecondsitevisitthatlawenforcementofficialsaremorelikelytolistentootherlawenforcementofficialsand/oraremorelikelytobeinterestedinCITif“sold”on“what’sinitforthem”includingreductionofpaperwork,lesswaittimeatthehospitalER,andprovidingtoolsandresourcestomoreeffectivelydealwithindividualsincrisis.ItisanticipatedthatactiveparticipationinthesemeetingsbyCIT-trainedofficerswillimprovelocallawenforcement’sparticipationinCIT.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing.

1. ContinuetoassesseffectsofCITtraining.Duringtheimplementationperiod,BerrienCountyofferedtwodifferentCITtrainingmodelswhichvariedintermsoftraininglength(40v.24hours),location(Chicagovs.BerrienCounty),andtrainersfacilitatingthetraining.TheEvaluationTeamwillfocussomeefforttoassessdifferenceinscoresbasedonwhichtrainingwasattendedtodetermineiflengthoftrainingtimeeffectsoutcomes.

2. Definethediversionprogrammodelandeligibilitycriteria.AkeyitemtobeaddressedbytheJDteamisthejaildiversionprogrammodel,inspecificdefiningthetargetpopulationoftheprogram(e.g.CMHornon-CMH,mentalhealthdiagnosis,substanceusedisorderdiagnosis,offensetype,specificexclusions)andthestandardservicesprovidedbytheJDprogram(e.g.individual/grouptherapy,crisiscare,communityreferrals,dischargeplanning,dischargefollow-up,etc.).Basedonsitevisitdiscussions,anotherpointtoconsiderwouldbeifservicesareprovidedindividualswhoareineligible/notenrolledintheJDprogramand,ifso,thetypeandscopeofthoseservices.Itisanticipatedthatclearlydefiningeligibilityandservicesprovidedthroughtheprogramwillimprovethenumberofqualifiedreferralsfromthejail’smentalhealthclinician,aswellasfromotherreferralsources.

3. Assessadvocacyeffortsbythejaildiversionteamresultingincurrentdiversion.Duringthe

secondsitevisititwasrevealedthattheJDteamhasprovidedadvocacyservicestosomeindividualsthatresultedinacurrentdiversion(i.e.,experiencedfewerjaildaysduetoanactionoradvocacytakenbyJDteammember).TheEvaluationTeamwillcontinuetomonitorthesecurrentdiversionsasidentifiedbytheJDteam.

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FigureB5:BerrienCountyProcessMap

Arrest

InitialScreeningMedical/MHHistory/SuicideRisk

ConductedbyJailOfficer

CMH

Non-SMI

JailIntake

HospitalDeterminationofMHSeverity

ClearedforJail

Hospitalized

YesMH/SuicideRisk

NoMH/SuicideRisk

InmateReleaseSigned

ReferredtoJailClinicianforAssessment

ReviewofDailyBookingListConductedbyCMH

Non-CMH

CMHRecordsReleasedto

JailMedical/Clinician

EmailNotificationstoCMHCaseMgrs.

SMI

FollowupbyJailDiversionReactivation/

NewConsumers

JailIn-ReachbyCaseMgr.CurrentACT

ConsumersOnly

JailReleaseNomeds/prescription

ContinuedOngoingObservationbyJailStaff

CITReportFormtoJailDiversion

AdvocacyforMedicationsandConsultsProvidedbyCMH

DataCollectionPoint:

2.NumberofInitialScreens

ConductedbyJailMH:342

3.NumberofCMHConsumersBookedintoJail(perDaily

BookingList):341

4.NumberofMentalHealthFollowUpSessionsConducted

byJailClinician:505

5.NumberofInmatesReferredtoJailDiversion(usingCITForm):

56

6.NumberofCasesOpened/Reactivatedby

JailDiversionstaff: 25

7.NumberofindividualsEnrolledinJDprogram:

35

OutcomeDataCollection:#/typesvcsprovidedinjailby

individual

OutcomeDataCollection:Jailbooking/releasedatesMHsvc/typepost-release

ExcelSpreadsheet–ID&DemographicDataofIndividualEnrolledinJD–

NameBookingNo.CMHIDDOB

GenderRace

DataCollectionPoint:

1.NumberofJailBookings:3,701

I-B10

I-C1

AppendixI-C:KalamazooCountySiteSummaryIntroductionTheproposalputforthbyKalamazooCountyMentalHealthandSubstanceAbuseServices(KCMHSAS)forcalendaryear2015implementation,encompassedtheenhancementofexistingjailmentalhealthservicesprovidedbytheKCMHSASjailteamattheKalamazooCountyJail(KCJ)andthetrainingandimplementationofCIT-YouththroughoutKalamazooCounty. ThisreportdetailstheimplementationprocessduringYear1.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheevaluationteam’ssecondsitevisitconductedinJanuary2016.

DescriptionofProgramImplementationinKalamazooCountyImplementationofCITinKalamazooCounty:Intercept1AspartofthestatediversiongrantawardedtoKCMHSAS,theKalamazooDepartmentofPublicSafetyimplementedayouth-specificCrisisInterventionTraining(CIT-Y)forpoliceofficers.Thisparticulartrainingisonlyavailabletoofficerswhohavecompletedthe40-houradultCITtraining(thistrainingwasfundedthroughthe2014diversionfunding).Three8-hourtrainingsessionswereconductedbySgt.RaphaelDiazoftheKalamazooPoliceDepartmentandSusanDavis,ProgramManageroftheMobileCrisisResponseUnit.ThetrainingswereconductedonSeptember17,25,and29,2015.Atotalof89officersattendedthetraining.ImplementationofJailServicesinKalamazooCounty:Intercept3KCMHSAS,inpartnershipwiththeKCJ,proposedtoenhancementalhealthservicesprovidedinthejailthroughexpandingKCMHSASclinicalstafffromonetotwofull-timejailclinicians.Theclinicianshandleallpost-bookingjaildiversionsaswellasscreening/assessment,coordinationofcare,dischargeplanningandongoingconsultationandadvocacybetweencriminaljusticeofficialsandmentalhealthandsubstanceabusetreatmentproviders.Referredtoasthe‘housing’grant,thisprogramalsofocusesontheuseofacertifiedpeersupportspecialist(CPSS)toassistinhousingplacement.JaildetaineesarereferredtoKCMHSASjailteambyjailstafforbykiteinitiatedbytheindividual.Theprocessmap,includedasFigureC5onthelastpage,illustratestheprogramoperationaswellasprocesscountsachievedduringtheimplementationperiod.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailpre-andpost-programimplementation,theEvaluationTeamworkedintandemwithkeystakeholderstoidentifyandmeasurekeyprocessindicatorsassociatedwiththejailmentalhealthservicesandtheimplementationofCIT-YwithinKalamazooCounty.Basedontheresultsoftheinitialconsultationwiththestakeholders,thefollowingindicatorswerecollectedfromKalamazooCountystartinginApril2015.

I-C2

#JailBookings#KCMSASconsumersbookedtojail(frombookingreports)#ReferredtoKCMHSASJailClinicians#ScreenedbyKCMHSASJailClinicians #ReferralstoCommunity-basedTreatmentbyJailClinicians(Re-entryforms)%OccupancyofHousingUnitsName,ID,M/F,Race,DOBofInmatesDivertedbyJailClinicians

AsKCMHSASgrewtheirjaildiversionprogram,theevaluationofthepilotprogramwasadaptedaswell.Specificchangeswereimplementedinthecollectionofprocessdatatomoreappropriatelyreflecttheprogram.Thesechangesincludedthecollectionofidentifyingdataforthosewhoarereferredtocommunity-basedtreatment(viaaRe-entryForm)totrackshort-andlong-termoutcomesofthosedivertedfromjailaswellasthosewhowerereferredtotreatmentpost-release(seebelow).Additionally,somechangesweremadetoalignprocessindicatorscollectedinKalamazooCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincluded:jailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.Thefinallistofprocessindicatorsisincludedbelowandisreflectedintheprocessmap(FigureC5).

#JailBookings #KCMSASconsumersbookedtojail(frombookingreports) #ReferredtoKCMHSASJailClinicians Adjusted #ScreenedbyKCMHSASJailClinicians(MHAssessments)

#ReferralstoCommunity-basedTreatmentbyJailClinicians(Re-entryforms) %OccupancyofHousingUnits Adjusted Name,ID,M/F,Race,DOBofInmatesDivertedbyJailCliniciansorReferredto

Community-basedTreatment(fromRe-entryForm)Thelong-termoutcomeevaluationtobeconductedbytheEvaluationTeamandreportedin2017willfollowthoseindividualsservedbytheKCMHSASjailteam,includingthosedivertedandthosesimplyreferredtotreatment,toassesstreatmentengagementinthecommunityandrecidivism.CIT-YPre/PostTrainingIndicatorsPriortothetraining,apre-testwasadministeredtoallattendingofficers,followedbyapost-testattheendofthetraining.Thesurveyincluded27questionsthatinquiredabouttheofficers’knowledgeofnormalyouthdevelopment,youthmentalhealth,de-escalationtechniques,andcommunityresourcesandpoliciesrelatedtoyouthmentalhealth.EachquestionhadaLikertscaleresponsethatrangedfrom1(stronglydisagree)to5(stronglyagree).All27questionswerethensummedtogethertocreateatotalscoreforknowledgeintheseareas15.Thetotalscorecouldrangefrom27to135.Todetermineifthetraininghadapositiveimpactontheattendingofficers,thereshouldbeasignificantincreaseinscorefrompretoposttestonaverage.Atpre-test,thescoresrangedfrom84to117,withanaveragescoreof99.Atpost-test,theaveragescorewas105,witharangefrom84to126.Usingpairedt-teststoassessindividuallevelchange

15Somescaleitemsarereversedscoredsothatallquestionshaveasimilarmeasurementmetric.

I-C3

betweenpreandpost-tests,asignificantincreaseinscores,averaging5.9pointswasfound(t(82)=7.44,p<.001).Examiningchangescores–orthedifferencesbetweenpreandposttestscores–byvariousdemographiccharacteristicsasshowninFigureC1belowprovidesanindicationofwhomayhavelearnedmorefromthetraining.Analysisrevealedthatthosewhohadnotraisedanadolescentlearnedmore,onaverage,thanthosewhohad.Similarly,thosewithlowereducationalattainmentandlesstimeontheforcelearnedmorethanthosewithaBachelorsorgraduatedegreeandthosewhohadbeenonthepoliceforcelongerperiodsoftime.FigureC1.ChangeScorebyGender,RaisinganAdolescent,EducationLevel,&YearsinLaw Enforcement

CITDiversionsandClosures(AdultandJuvenile)ThediversionsassociatedwiththeadultCITtrainingarenottechnicallypartofthisevaluationastheywerefundedundera2014grant.However,thetrackingandsystemlevelchangesarerelatedandforthatreason,dataprovidedbyprojectpersonnelisbeingreported.TableC1showsthattherewere33individualsdivertedfromjailbylawenforcementinKalamazooin2015:27adultsand6juveniles.Asistrueforthejailprogram,Kalamazoodifferentiatescurrentdiversionsfromactivitiesthatmightsupportfuturediversion.Ifanindividualisinvolvedincriminalactivitythatcouldresultinarrestbutlawenforcementrecognizeamentalhealthissueanddiverttoatherapeuticsolution,itisconsideredacurrentdiversion.

012345678

5.9 5.9 5.95.4

6.97.5

5.5

3.1

7.2

4.63.5

TableC1.CITCurrentDiversionsin20152015 Adult Juvenile

January 0 February 3 March 3 April 2 May 2June 1 July 6 August 2 September 1 October 3 1November 2 2December 4 1 TOTALS 27 6

I-C4

InadditiontousingCITskillsforcurrentdiversion,Kalamazoolawenforcementfromseveraljurisdictions(i.e.,city,township,sheriff)utilizeCITskillstodefusesituationsorreferindividualstocommunityresources.Whenthisoccurs,theofficerscompleteafive-questionquerythatallowsforthetrackingofcallswhereCITskillsareused.Trackingofthese‘CITclosures’,asthesecallsaretermed,isfacilitatedthroughalawenforcementliaisonfromKCMHSAS.ThesenumbersprovideevidenceofCITskillsbeingutilizedevenwhennocurrentdiversioncanbecounted.FigureC2belowprovidesfurtherevidenceofCITskillutilizationacrossseverallawenforcementjurisdictionsinKalamazooCounty.Thecoordinationamongfivedifferentlawenforcementagencies(includingoneuniversitypolicedepartment)demonstratesthebreadthofadoptionofCITinKalamazooCounty.FigureC2.CrisisClosuresinKalamazooCountybyLawEnforcementAgencyin2015

Note:KDPS-KalamazooDepartmentofPublicSafety,KTPD-KalamazooTownshipPoliceDepartment,KCSD-KalamazooCountySheriffDepartment,PDPS-PortageDepartmentofPublicSafety,WMUPD-WesternMichiganUniversityPoliceDepartment.Note2:NumbersforPDPSrepresentalowestimateasmonthlytotalswerenotavailableforsomeoftheirdata.

ProgramReferral/EnrollmentAsshowninFigureC3onthefollowingpage,theproportionofindividualswhowerereferredbyjailstaffforscreeningand/orservicesbythecommunitymentalhealth(CMH)jailtreatmentteamwas20%ofthosebooked(1,277of6,473).

2124

1823

30

19

42

23 24

46

62 61

2 1 1 1

2419

13 13

21 19

4 3 2

1412 1115

38 40

84

0

10

20

30

40

50

60

70

KDPS KTPD KCSD PDPS WMUPD

I-C5

FigureC3.KalamazooCountyProcessIndicatorsApril2015–September2015

*Atotalof109individualswhoreceivedservicesfromthementalhealthunit,including20whoweredivertedfromjailand89whoreceivedacommunityreferral,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

CMHconsumersenteringthejailrepresentabout6%ofthosebooked(387of6,473).TheKCMHSASjailteamprovidedreentrydischargeplanningto89individualsand‘currentdiversion’(definedasdecreasingjaildaysduringthecurrentincarceration)to20individuals.NeedforMentalHealthServicesFigureC4belowshowstheneedformentalhealthservicesintheKalamazoojail.UsingtheobjectiveneedestimatederivedbythepreviousstudyusingtheK6withallindividualsbookedintothejail,itisestimatedthatapproximately22%ofindividualsenteringthejailmightrequirementalhealthservices.Becausethosereferredtomentalhealthscreeningwascloseto20%(expressedneed),itispossiblethatapproximately3%ofindividualswereunidentified,resultinginapotential‘uncaptured’need.FigureC4.EstimatedNeedforMentalHealthServicesintheKalamazooCountyJail

ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbythestakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitconductedinKalamazooCountyinMarch2015.Assuch,theresultingshort-termobjectivesaddressboththeCITandjailservicesprograms.Progressassociatedwitheachstatedobjectiveisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.

6,473

1,277

387 89 200

1,000

2,000

3,000

4,000

5,000

6,000

JailBookings ReferralstoMH CMHBookings ReentryReferrals* Diversions*

IdennfiedMHNeeds(ExpressedNeed),

19.7%

PotennallyUnidennfiedMHNeeds,2.6%

NoMHNeeds,77.7%

I-C6

1. Strengthenthesystemtoscreen,assess,andcoordinatecareforthosewithactiveseriousmentalillness(SMI)symptomsduringjailincarceration(CMHandnon-CMH).

Progress:Goalpartiallymet.Asshownontheprocessmap(FigureC5),individualswhoarebookedtothejailandflaggedformentalhealthorsubstanceabuseduringtheinitialscreeningprocessarereferredtotheKCMHSASjailteam.Uponreferral,theKCMHSASjailteamdeterminesiftheindividualissymptomaticand,ifso,determinestheirCMHstatus.ThosewhoarenotcurrentCMHconsumersarescreenedbytheKCMHSASclinician.Asdiscussedearlierinthisreport(seeImplementationofJailServicesinKalamazooCounty:Intercept3),itisestimatedthatlessthan3%ofindividualsidentifiedaspossiblyneedingmentalhealthservicesarenotbeingreferredtotheKCMHSASjailteamforservices.

2. Strengthenthesystemtoinfluencejudicialdecisionsandreducejailtimeforthosebooked

atKCJwhoareidentifiedashavingSMI(CMHandnon-CMH). Progress:Goalmet.TheKCMHSASjailteamactivelyadvocatesfordiversionfromjailto

treatmentonbehalfofindividualsidentifiedashavingSMI.Asshownintheprocessmap(FigureC5),thejailteamdiverted20individualsfromjailtotreatmentduringtheimplementationperiod.

3. IncreaseskillsandresourcesavailabletolawenforcementandCMHproviderstobenefit

youthwithpotentialmentalhealthproblemsandtoavoidarrest/incarcerationandoutofhomeplacementsthroughCIT-Y.

Progress:Goalmet.ThreeCIT-YtrainingsessionswereconductedinKalamazooCountyinSeptember2015.Atotalof89officersattendedthetraining.Resultsofthepre-/post-testsadministeredatthetrainingsareearlierinthisreport(seeImplementationofCIT-YinKalamazooCounty:Intercept1).

4. Improverelationshipsbetweencommunitymembersandlawenforcementrelatedto

troubledyouththroughCIT-Y. Progress:Goalpartiallymet.Oneprimaryresourcetobenefityouthincrisiswithinthe

KalamazoocommunityistheMobileCrisisResponseUnit(MCRU),a24-hour/7daysperweekservicefocusedonmentalhealthorsubstanceabusecrisesamong10-17yearolds.MCRUisa‘firstresponder’andalsoprovidelinkageandadvocacyservices.MCRUdoesnotdefinewhatacrisisis;theyallowthefamiliestodefineit.During2014,theMCRUreceived902crisiscalls,withwelloverhalf(62%)ofthecallsinitiatedbyparents.Thesecondhighestsourcewashospitals(17%).Duringthesametimeperiod,only8calls(.08%)wereinitiatedbypolice.However,sometimesMCRUstaffmemberscallpoliceorencouragefamilymemberstocallpoliceforassistanceinvolatilesituations.Itisreportedthatsometimesparentsarereluctanttocallpoliceforfeartheirchildwillbetakentojail.Conversely,policeofficersinteractingwithyouthincrisiscancallMCRUforassistance.ItwasreportedthatsomeofficersareunawareoftheexistenceofMCRUortheresourcesthatitoffersindiffusingcrisissituations.ItisanticipatedthatCIT-YtrainingwillincreasethenumberofreferralstoMCRU.TheEvaluationTeamwillcollectMCRUreportstomonitorthisrelationship(seeNextSteps).

I-C7

NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforKalamazooCountyslatedforthesecondyearofthejaildiversionpilotprogram.

1. MonitorrelationshipbetweencommunitymembersandlawenforcementrelatedtotroubledyouththroughCIT-Y.OneobjectiveforYearOnewasthecommitmenttoexpandtherelationshipbetweenthecommunityandlawenforcement.Asnotedearlier,CIT-Ytrainingwasprovidedto89officersinSeptember2015.OnemeasureofthesuccessoftheCIT-YtrainingwastheanticipatedincreaseinpolicereferralstotheMCRU.ThroughtheendofNovember2015,withjusttwomonthsofMCRUdata,nopolicereferralstoMCRUwerereported.TheEvaluationTeamwillcontinuetocollectmonthlyMCRUreportstomonitorthisrelationship.

2. TrackandassessCITclosureanddiversiondata.Crisiscalldata,asillustratedaboveinC2,wasprovidedbytheCITCoordinator(hiredunderthisgrant)totheEvaluationTeamduringthesecondsitevisit.CITcrisisclosuresanddiversioncallcountswillcontinuetobereportedbytheCITCoordinatortotheEvaluationTeamonamonthlybasisbeginninginJanuary2016.

3. TracktreatmentandrecidivismoutcomesforindividualsdivertedintheCITprogram.Stakeholdersareinterestedinrecidivismoutcomesforadultsdivertedtotreatmentbylawenforcement.Fortheseindividuals,trackingmayincludejaildata(i.e.,booking,releaseandoffensetype),similartotrackingforindividualsdivertedinthejaildiversionprogram.However,trackingpotentiallycouldbeexpandedtoincludepolicecontact/actionandarrestsascapturedintheiLEADSsystem--therecordsmanagementsystemusedbythreeofthefivepoliceagencieswithinthecountyincludingKDPS,KTPD,andKCSD--and/orthroughMSPdata.ItisunknownifaccesstoiLEADSforpurposesofthisevaluationwouldbegranted.Duringthesecondyearofthegrant,thestakeholdersandEvaluationTeamwillcollaborativelyidentifyshort-andlong-termobjectivesassociatedwiththecounty’sCITprogram.

4. TracktreatmentandrecidivismoutcomesforindividualsdivertedtothehospitalintheCIT

program.StakeholdersalsoexpressedaninterestintrackingthoseindividualsdivertedtoBorgessHospitalER(N=100)bylocalpoliceagenciesduringthepreviousgrantperiod(2014).Trackingoftheseindividualscouldincludestate-levelmentalhealthtreatment,jailbookings/releasesandoffensesthroughKCJ,and,possibly,ifaccessisgranted,policecontactthroughtheiLEADSsystem.Duringthesecondyearofthegrant,thestakeholdersandEvaluationTeamwillcollaborativelyidentifyshort-andlong-termobjectivesassociatedwiththecounty’sCITprogram.

AppendixI-D:KentCountySiteSummary

I-C8

FigureC5.KalamazooCountyProcessMap

Arrest

IntakeScreeningStandardPhysicalandMentalHealthQuestions

ConductedbyBookingOfficer

TransporttoJailObservedMHIssue/SuicideRiskProvidedon“GreenSheet”

CompletedbyArrestingOfficer

If“Yes”toMH/SA,Meds,Suicide

If“No”toMH/SA,Meds,Suicide

Risk

ReferraltoCMHJailStaff

DischargePlan/JailRelease

ObservationbyJailStaff/KitesfromInmates

JailClassificationforHousingPlacement

AssessmentofPhysical,MH,Suicide,Risk

OutcomeDataCollection:#/typesvcsprovidedinjailby

individual

OutcomeDataCollection:Jailbooking/releasedatesMHsvc/typepost-release

CMHJailStaffActionsCoordinationofCare/Medications

VideoArraignment/JudicialAdvocacyMH,SA,CJConsultation

CrisisIntervention/PsychiatricConsults(asneeded)

DischargeFollow-Up

GeneralPopulation

SpecialtyMedical

ReportLogObservedMH,SuicideIssues/KitesCompletedbyJailStaffandInmates

ReviewofReportLogCompletedbyCMHJailStaff

DailyBookingsReviewedbySecantSystem

EMRmessagetoprimaryclinician

CMHSymptomatic

Non-CMHSymptomatic

CMHNon-Symptomatic

ConsiderationofSymptoms

NotificationofJailReleasetoCMHCase

Manager

HousingPlacement12Units

Probation/ParoleCJStatus

DataCollectionPoint:

1.NumberofJailBookings:6,473

2.NumberofCMHConsumersBooked

toJail:387

DataCollectionPoint:

5.NumberofNewReferralstoCommunity-basedTreatment(from

Re-entryForms):89

6.NumberofIndividualsDivertedbyCMHStaff:

20

7.PercentOccupancyRateforHousing

Program:91%

ExcelSpreadsheet–ID&DemographicDataof

ConsumersCodedas“Diversion”:

Name,CMHID,JailID,BookingID,SSN,Gender,Race,DOB

PluscopyofCommunity

TreatmentRe-EntryFormsfor

IndividualsReceivingSvcs

DataCollectionPoint:

3.NumberofInmatesReferredtoCMHJail

Clinicians:1,277

4.NumberofInmatesScreened/Assessedby

CMHStaff:1,115

ReviewofMHHistoryorMHScreening

ConductedbyCMHJailStaff

AppendixI-D:KentCountySiteSummary

I-C9

I-D1

AppendixI-D:KentCountySiteSummaryIntroductionTheproposalputforthbyNetwork180,acommunitymentalhealthagency(CMH),focusedonthesustainmentofjailmentalhealthservicesprovidedwithintheKentCountyJail(KCJ)since1994.Sustainmentoftheprogramincludedmaintainingatotalof6.0FTE(3.0funded/contractedbyNetwork180throughthisgrantplus3.0fundedbyKCSD)toprovidementalhealthservices–includingmentalhealthassessment,individual/grouptherapy,anddischargeplanning–forallinmates(CMHandnon-CMH)identifiedashavingamentalhealthissue.Thisreportdetailsthefirstyearofgrantactivity.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearly2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheevaluationteam’ssecondsitevisitinJanuary2016.

DescriptionofPrograminKentCountySustainmentofJailMentalHealthUnitinKentCounty:Intercept3Network180,inpartnershipwiththeitscontractedjailmentalhealthprovider,FamilyOutreachCenter,andtheKCJ,proposedtosustainmentalhealthservicesprovidedintheKCJsince1994.Theprogramincludesmaintainingatotalof6.0FTE(3.0funded/contractedbyNetwork180throughthisgrantplus3.0fundedbytheKCJ)toprovidementalhealthservices–includingmentalhealthassessment,individual/grouptherapy,anddischargeplanningandfollow-up–forallinmatesidentifiedashavingamentalhealthissue.Individualsarereferredtothementalhealthunitbythejailcorrectionsstaff.Theprocessmap,includedasFigureD3onthelastpage,illustratestheprogramoperationaswellasprocesscountsfortheimplementationperiod.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailatthebeginningofthegrantperiodandoneyearlater,theEvaluationTeamworkedintandemwithkeystakeholderstoidentifyandmeasurekeyprocessindicatorsassociatedwiththejailmentalhealthservicesinKentCounty.Basedontheresultsoftheinitialconsultationwiththestakeholders,thefollowingindicatorswerecollectedfromKentCountybeginninginApril2015. #JailBookings

#IntakeScreenings #Referrals/NotificationstoJailMentalHealth #AssessmentsbyJailMentalHealth

I-D2

#Network180JailTreatmentPlansDeveloped #Non-Network180JailTreatmentPlansDeveloped

Name,bookingID,bookingdate,CMHID,last-4SSN,sex,race,DOB,countyof residence,CMHstatusofallindividualsprovidedwithaTreatmentPlan

Onechangewasimplementedinthecollectionofprocessdatatomoreaccuratelyreflecttheprocessthejailmentalhealthprogramfollowsinprovidingtreatmentplansasclarifiedduringthesecondsitevisit.Asnotedduringthesitevisit,whilemostindividualsreflectedintheTreatmentandComparisonGroupsdoreceiveatreatmentplan,somedonotiftheirlengthofstayisanticipatedtobelessthan20days.Thisisreflectedintheprocessmap(FigureD3).Also,somechangesweremadetoalignprocessindicatorscollectedinKentCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincludejailbookings,mentalhealthscreenings,mentalhealthassessmentsandindividualsreceivingservices.Thefinallistofprocessindicatorsincludesthefollowing:

#JailBookings #IntakeScreenings

#Referrals/NotificationstoJailMentalHealth #AssessmentsbyJailMentalHealth Adjusted #Network180ReceivingServices Adjusted #Non-Network180ReceivingServices Adjusted Name,bookingID,bookingdate,CMHID,last-4SSN,sex,race,DOB,countyof residence,CMHstatusofallindividualsreceivingservicesfromjailmental healthThelong-termoutcomeevaluationtobeconductedbytheEvaluationTeamandreportedin2017willfollowindividualsassembledintheTreatmentandComparisonGroupswhoreceivedservicesfromtheJailMentalHealthUnittoassesstreatmentengagementinthecommunityandrecidivism.ProgramReferral/EnrollmentFigureD1onthenextpageshowsthatduringthesix-monthimplementationperiod,therewereover12,000individualsbookedintotheKentCountyJail.Theproportionofindividualsreferredformentalhealthscreening/servicesduringthistimewas34%ofthosebooked(4,240of12,396).Allofthosereferredforscreeningwereassessedbyajailmentalhealthclinician(4,240of4,240).Ofthoseassessed,14%receivedtreatmentplansfromthejailmentalhealthunit.Ofthe585individualswhoreceivedmentalhealthtreatmentserviceswithinthejail,52%wereknowntobeCMHconsumersand48%werenot.ThosewhoareCMHconsumersreceiveafter-careservicesinthecommunitytoensurethatindividualsreceivemedicationandattendtheirnextcommunityappointment.Thosewhoarenotcurrentconsumers,butmeeteligibilitycriteria,areenrolledinCMHcommunitybasedservices.Intheevaluationoflongtermoutcomes,bothgroupswillbefollowed.

I-D3

FigureD1.KentCountyProcessIndicatorsApril2015–September2015

*Atotalof585individualswhoreceivedservicesfromthejaildiversionprogram,including306CMHand279Non-CMH,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

NeedforMentalHealthServicesFigureD2belowshowstheneedformentalhealthservicesintheKentCountyjail.Usingthe‘objectiveneed’estimatederivedfromthepreviousstudyusingtheK6screeningonthosebookedintothejail,itisestimatedthatapproximately21%ofindividualsmightrequirementalhealthservices.Basedonthisobjectiveestimate,FigureD2illustratesahigher‘expressedneed’baseduponthe34%ofindividualsreferredforscreening.Inotherwords,anadditional13%ofthejailpopulationwasreferredtojailmentalhealththanwhatmighthavebeenexpectedbythe‘objectivemeasure’.ThisadditionalneedcapturedintheKCJwasnotuncoveredinanyothercounty. FigureD2.EstimatedNeedforMentalHealthServicesinKentCountyJail

12,396

306

4,240 4,240

306 2790

2,000

4,000

6,000

8,000

10,000

12,000

JailBookings CMHBookings ReferralstoMH

ProfMHScreens

CMHReceivingSvcs*

Non-CMHReceivingSvcs*

EsnmatedMHNeed(ObjecnveNeed).

21.2%

AddinonalMHNeedsCaptured.

13.0%

NoMHNeeds.65.8%

I-D4

ProposedEvaluationPlanBecausetheprogramproposedbyKentCountywasaprograminexistencewithinthejailforover20yearsandnotanewprogramastheotherjaildiversionpilotprogramsare,short-termobjectiveswerenotestablishedinKentCounty.However,theEvaluationTeamandNetwork180developedanevaluationplantoassesstheeffectivenessofthementalhealthinterventionprovidedwithinthejailincludingaprocessandoutcomeevaluation.Theprocessevaluationfocusesontheprocessindicatorsassociatedwiththecurrentinterventiondeliveredwithinthejailanddetailstheprocessesandprotocolsassociatedwiththeinterventionasdefinedbythestakeholders.Theoutcomeevaluationisintendedtomeasuretheefficacy,oroutcomes,ofthementalhealthservicesdeliveredwithinthejail.Forpurposesoftheoutcomeevaluation,treatmentandcomparisongroupshavebeenidentifiedwithintheexistingjailmentalhealthtreatmentprocess.IndividualswithintheKCJdeterminedtohaveaseriousmentalillness(SMI)suchasmajordepressivedisorder,bipolardisorder,schizophrenia,butwhoare“non-Network180”(i.e.arenotenrolled/eligiblefor/inNetwork180services)willbeidentifiedaspartoftheComparisonGroup.ThoseindividualswithintheKCJdeterminedtohaveanSMIandcurrentlyenrolledinCMHservicesare“Network180”andwillbeidentifiedastheTreatmentGroup.Bothgroupshaveequalaccesstothementalhealthservicesprovidedwithinthejail.NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforKentCountyslatedforthesecondyearofthejaildiversionpilotprogram.

1. IdentifyCMHopens/reactivationsafterjailbooking.Duringthesecondsitevisit,itwas

notedthatthejailmentalhealthteamactivelyenrollsindividualswhoqualifyforCMHservicesintoNetwork180duringincarcerationattheKCJ.Thisenrollmentisfacilitatedbythejailmentalhealthteam.ThischangeinCMHstatuswillimpactthecompositionoftheTreatmentandCompareGroupsasinitiallyassembled.BecauseCMHenrollmentmaybefacilitatedinotherways(e.g.probation)and/orbeyondthefirstmonthofincarceration,CMHstatusmaychangebeyondthispointaswell.Goingforward,jailmentalhealthwillidentifythosewhoareknowntoenrollinCMHduringthemonthinwhichtheyarebookedtojail.TheEvaluationTeamwillthenworkwithNetwork180toflagadditionalopens/reactivationsoccurringafterthebookingmonth.

2. Trackadvocacyeffortsresultingincurrentdiversion.Followingthesecondsitevisit,itwas

revealedthatthejailmentalhealthteamalsoregularlyprovidesadvocacyserviceswhichmayresultinearlyreleaseforinmates.Thisadvocacyisusuallyprovidedintheformofaletterofrequesttothejudge/magistratetoissueapersonalrecognizance(PR)bondfortheinmatetobereleasedfromjailtocommunity-basedtreatment.Inordertoqualifyforadvocacy,theinmatemusthaveamisdemeanorornon-violentfelonychargeandbeSMIordevelopmentaldisabled.BeginninginJanuary2016,thejailmentalhealthteamwillidentifythoseindividualswhoreceivedthebenefitofadvocacyeffortandweresuccessfullydiverted(i.e.,currentdiversion)fromjailtocommunity-basedtreatment.Inaddition,thosewhoweredivertedpriortoJanuary2016willberetroactivelyidentifiedbythejailmentalhealthteamandconsideredtobecurrentdiversionsbytheEvaluationTeam.

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3. Exploreopportunityfor24-hourdrop-off.Communitystakeholderswillconsiderexploringtheopportunitytoimplementa24-hourdrop-offforindividualsexperiencingmentalhealthcrisisinthecommunity.Theimplementationofsucharesourcewouldprovidepatrolofficerswithanadditionaltreatmentoptionotherthanthehospitalemergencyroomorthejail.Thedrop-offwouldalsoprovidetheopportunitytoincreasepre-arrestandpre-bookingdiversionactivities,bothwhichcouldpotentiallyreducethenumberofindividualswithmentalhealthconcernsbookedtothejail.

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FigureD3.KentCountyProcessMap

Arrest

IntakeScreeningMH/SAHistory,Meds,Suicide

ConductedbyNursing

JailIntakeCursoryScreenforBehaviorsObservedbyArrestingOfficerConductedbyJailDeputy

If“Yes”toMH/SA,Meds,Suicide

If“No”toMH/SA,Meds,Suicide

Risk

Notification/ReferraltoJailMentalHealth

HazardsRatingAssignedS1=min1xperwkS2=min2xperwkS3=bothshiftsdaily

HousingPlacementMHorGP

ContactCMHCaseMgr.

Notificationofbooking;verifymeds;updatesoncourtdates,jailrelease

DischargePlan/JailReleaseAvailableforallLOSincludes

dischargeRX,transporttoprovider,referral/apptforcommunityprov

ObservationbyJailStaff

DevelopmentofTreatmentPlan

DataCollectionPoint:

1.NumberofJailBookings:12,396

2.NumberofIntake

Screenings:12,396

OutcomeDataCollection:#/typesvcsprovidedinjailby

individual(CollectedbyEvalTeam)

OutcomeDataCollection:Jailbooking/releasedatesMHsvc/typepost-release(CollectedbyEvalTeam)

MentalHealthAssessmentConductedbyMSW

CMH(TreatmentGroup)

Non-CMH/Private(CompareGroup)

OtherLessthanSMI

JailMHTreatmentServicesIndividualTherapyGroupTherapy

Medications/PsychEvaluation

DischargeFollow-UpJailMHcontactwithcommunity

providertodetermineifappointmentwaskept

JailIn-reachConductedonCase-by-CaseBasis

byCMHCaseMgr

1stMHTreatmentinCommunityRequiredwithin7daysofrelease

HospitalizationAsneeded

DataCollectionPoint:

3.NumberReferredtoJailMentalHealth:

4,240

4.NumberAssessedbyJailMentalHealth/MHAssess:

4,240_

DataCollectionPoint:

IndividualReceivingServices

5.NumberofCMHConsumers

306

6.NumberofNon-CMHConsumers

279

ExcelSpreadsheet–ID&DemographicDataof

IndividualswithTreatmentPlans–

IndividualsReceivingSvcs:Name,BookingID,BookingDate,CMHID,SSN,Gender,Race,DOB,CountyofResidence,CMHorNon-

CMH

Treatmentv.ComparisonGroups

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AppendixI-E:MarquetteCountySiteSummaryIntroductionTheproposalputforthbyPathwaysCommunityMentalHealth(CMH)introducedaplantoexpandaccesstoMoralReconationTherapy(MRT)providedinthejailandcommunityaswellastoimplementaCrisisInterventionTeam(CIT)trainingprogramacrossMarquetteCounty.ThisreportdetailstheimplementationprocessofthoseservicesandprogramsduringYear1.Itincludes:

! Adescriptionoftheprogramsbeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearlyMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheEvaluationTeam’stwositevisits(March2015andMarch2016).

DescriptionofProgramImplementationinMarquetteCountyImplementationofCrisisInterventionTeam(CIT)TraininginMarquetteCounty:Intercept1InpartnershipwiththeMarquetteCountySheriff’sOffice(MCSO)andtheMarquetteCityPoliceDepartment(MCPD),PathwaysproposedtotrainandimplementCITtrainingamongatotalofupto40officersincludingpatrolofficersanddispatchersfromMarquetteCountyCentralDispatchacrossMarquetteCountyincludingtheMCSOandlocalpolicedepartmentswithinMarquetteCounty.One16-hourtrainingwasconductedbyCIT-certifiedofficersfromMCSOatNorthernMichiganUniversityonJuly16–17,2015.ThetrainingcurriculumincludedintroductionstomentalhealthandCIT,de-escalationtechniques,legalissues,currenttopics(e.g.exciteddelirium,suicidebycopetc.)andscenariotrainingusinglocalactorstodepictindividualsincrisis.Atotalof17officersfromacrossMarquetteCountyvolunteeredtoattendthetrainingincludingthreeMarquetteCountySheriff’sdeputies;,twoAlgerCountySheriff’sdeputies,twoNorthernMichiganUniversity(NMU)publicsafetyofficersandtenofficersfromlocalpolicedepartmentsincludingMarquetteCity(sevenpatrol,onedispatch),Houghton(onepatrol),andChocolayTownship(onepatrol).StakeholdersinMarquetteCountycontinuetopromoteandexpandCITthroughoutthegreaterMarquettearea.ThePathwaysJailLiaisoncurrentlyleadsanadvisorygroupcomprisedofrepresentativesfromNMU,MCSO,andMCPD.Thegroupmeetsmonthlytoengageinproblem-solvingandmonitoringrelatedtotheCITprogramaswelltoidentifypotentialtrainingtargets.ThiseffortresultedinaCITintroductorytrainingconductedinnearbyDeltaCounty,thesecondlargestcountywithinthePathwaysCMHcatchmentarea,inJanuary2016.Thisisdescribedinmoredetaillaterinthisreport,inthesectiononNextSteps.ImplementationofJailServicesinMarquetteCounty:Intercept3InpartnershipwiththeMarquetteCountyJail(MCJ)andtheMarquetteCountyProsecutor’sOffice,PathwaysalsoproposedtodevelopamoreinclusivereferralanddeliverysystemforMRTgroupswithinthejailandcommunity.MRTgroupsinitiatedunderapreviousdiversiongrantwereaccessibletocurrentorre-activatedCMHconsumersonly.Underthisgrant,accesstoMRTgroupswasexpandedto

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includenon-CMHindividuals.Additionally,thenumberandtargetaudienceofMRTgroupsgrewtoincludeagroupwithinthejail,atPathways,atthecourthouse,andatthedetentioncenter.ThegroupsarefacilitatedbyPathways’JailLiaison(community),ajailmentalhealthprofessional(jail),andaprobationorparoleagent(courtanddetentioncenter).Theprocessmap,includedasFigureE6onthelastpage,illustratestheprogramoperation,aswellasprocesscountsduringthesix-monthimplementationperiod.TheplanputforthbyPathways,particularlyasitrelatedtoCIT,waslargelydependentonastrongcollaborationwiththevariouslawenforcementagenciesoperatingwithinMarquetteCounty.Althoughcooperationandsupportamongsomeofthelawenforcementagencieswasstrongerthananticipated,theimplementationprocessrevealedresistanceamongothers.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailduringtheimplementationperiod,theEvaluationTeamworkedintandemwithstakeholderstoidentifyandmeasurekeyprocessindicatorswithintheirimplementationofJailServicesandCITinMarquetteCounty.Basedontheresultsoftheinitialconsultationwiththestakeholdersduringthefirstsitevisit,thefollowingprocessindicatorsforCITandJailServicesweretobecollectedfromMarquetteCountybeginninginApril2015. CIT: Name,title,agencyaffiliationoftrainees Pre/Post-CITTrainingsurvey Collectionof5Questions(TBDinCITcallprocess) #TotalCallstoDispatch #CallsClearedasMHatDispatch

FinalDispositionofMHCodedCalls(jail,hosp/ER,CrisisSvcs/JailDiversion,home/family/noaction)

JailServices: #JailBookings #K6Screenings #In-JailAssessmentsbyPathways(Tami) #CasesOpened/ReactivatedbyPathwaysbyCrisisServices(Tami) #ReferralsforMRTtoJailMentalHealth #EnrolledinIn-JailMRTgroup(s)(Non-CMHonly) #EnrolledinCommunity-basedMRT(Non-CMHonly) #StartingMRT(Non-CMHonly) #CompletingMRT(Non-CMHonly) Name,ID,M/F,DOBofthoseenrolledinMRT(jailorcommunity)AsPathwaysimplementedandgrewtheirjaildiversionprogram,theevaluationofthepilotprogramwasadaptedaswell.Specificchangeswereimplementedinthecollectionofprocessdatatoappropriatelyreflectchangestotheprogramasimplemented.TheprimarychangetodatacollectioninvolvedtheexpansionofprocessindicatorstoincludeCMHconsumersinadditiontonon-CMHindividuals.Initially,datacollectionfocusedonlyonnon-CMHindividualsasthiswastheprimaryfocusoftheproposalputforthbyPathways.Additionally,somechangesweremadetoalignprocessindicatorscollectedinMarquetteCountywithcross-siteindicatorscollectedattheotherjaildiversion

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pilotsites.Theidentifiedcross-sitevariablesincluded:jailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.Thefinallistofprocessindicatorswasrevisedtoincludethefollowing.Theseareindicatedontheprocessmap(FigureE6). CIT: Name,title,agencyaffiliationoftrainees Pre/Post-CITTrainingsurvey Collectionof5Questions(TBDinCITcallprocess) #TotalCallstoDispatch #CallsClearedasMHatDispatch

FinalDispositionofMHCodedCalls(jail,hosp/ER,CrisisSvcs/JailDiversion,home/family/noaction)

JailServices: #JailBookings Removed #K6Screenings Added #ScreensConducedbyJailMH(ProfessionalScreens) Adjusted #AssessedbyJailLiaison(MHAssessments) #CasesOpened/ReactivatedbyPathwaysbyCrisisServices(Tami) #ReferralsforMRTtoJailMentalHealth Expanded #EnrolledinIn-JailMRT(CMH+Non-CMH) #StartingIn-JailMRT #CompletingIn-JailMRT Added #IndividualsReceivingServices Expanded #EnrolledinCommunityMRT(CMH+Non-CMH) #StartingCommunityMRT #CompletingCommunityMRT Name,ID,M/F,DOBofthoseenrolledinMRT(jailorcommunity)Thelong-termoutcomeevaluationtobeconductedbyEvaluationTeamandreportedin2017willfollowthoseindividuals(bothCMHandnon-CMH)enrolledinMRTinthejailandcommunitytoassesstreatmentengagementinthecommunityandrecidivism.CITPre/PostTrainingIndicatorsAtotalof13officerswhoattendedthetrainingcompletedbothpre-andpost-testassessments.Allweremale,withanaverageof13yearsontheforce(rangefrom3to22years).Overtwo-thirdshadabachelor’sdegree(69%).Thepre-andpost-testswereimplementedimmediatelypriorto(pre-)andfollowing(post-)thetrainingandarebasedontwoinstruments:theOpinionsofPsychiatricTreatment(OPT)MeasureandtheDe-escalationScale.The20-itemvalidatedOPTMeasureassessesofficers’attitudesandknowledgeaboutpsychiatrictreatmentswithinthecommunityandattitudesaboutpsycho-pharmacotherapy,psychotherapy,andpsychosocialinterventions.Responsesaregivenasix-pointLikertscalerangingfrom1(stronglydisagree)to6(stronglyagree).Thepossiblerangeofscoresis20–120.The8-itemDe-EscalationScalemeasuresofficers’de-escalationskills.Officers’opinionsontheeffectivenessofspecificactionsinvarioussituationswereratedonafour-pointLikertscalerangingfrom0(verynegative)to3(verypositive).Totalsubscalescoresrangefrom0to24.

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AsshowninFigureE1below,therewasanaveragechangescorefrompretopost-testof7.9pointsontheOPTscale.Althoughthesamplesizeissmall,therewasastatisticallysignificantdifferencebetweenthepre-andpost-test16.Basedonthissignificantdifference,itislikelythatthetraininghadapositiveeffectontheofficer’sknowledgeoftreatmentandservicesforthosewithmentalillness.FigureE1.DifferencesinOPTScalePre-toPost-CITTraininginMarquetteCounty

FigureE2belowshowsthat,onthede-escalationscale,therewasanaverageofa0.9pointincreaseinknowledge/skillsregardingthede-escalationofanindividualwithmentalillness.Thischangewasnotstatisticallysignificant(althoughasmallsample),suggestingthatthetraininghadlittleeffectonknowledge/skillsoftheofficersattending.FigureE2.DifferencesinDe-escalationScalePre-toPost-CITTraininginMarquetteCounty

ProgramReferral/EnrollmentAsshowninFigureE3onthefollowingpage,theproportionofindividualsreferredformentalhealthscreeningconductedbythejailmentalhealthclinicianwas9%ofthosebookedintothejail(77of857).Ofthosewhowerescreened,12%(9of77)werefullyassessedbythePathwaysjailliaison.Additionally,30individualswerereferredtoPathwaysforMRTbyavarietyofreferralsourcesincludingthejailclinician.Ofthosereferred,17wereultimatelyenrolledineitherajail-orcommunity-basedMRTgroup.

16t(12)=3.843,p<.01

70.578.4

60.0

70.0

80.0

90.0

100.0

OPTScale

Pre Post

26 26.9

20.021.022.023.024.025.026.027.0

De-EscalaronScale

AxisTitle

Pre Post

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FigureE3.MarquetteCountyProcessIndicatorsApril2015–September2015

*Atotalof17individualsenrolledinMRT,including9inthejailand8inthecommunity,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

NeedforMentalHealthServicesFigureE4belowshowstheexpressedneedformentalhealthservicesintheMarquetteCountyjail.UsingtheobjectiveneedestimatederivedfromapreviousstudythatusedtheK6toscreenallindividualsbookedintothejail,itwasestimatedthat37%mayrequirementalhealthscreening/services.Basedupontheexpressedneedof9%(the77whowerescreened),thereispotentiallya28%uncapturedneedformentalhealthscreening/serviceswithinthejail(28%of857=243).FigureE4.EstimatedNeedforMentalHealthServicesintheMarquetteCountyJail

However,itshouldbenotedthattheobjectiveneedestimateof29%ofthoseenteringthejailhavingsymptomsassociatedwithseriousmentalillness(SMI)asdeterminedbytheK6mayrequirefurtherconfirmation.DuetothesmallnumberofindividualsbookedintotheMarquetteCountyJail,screeningwiththeK6wasrequestedforafullyear.AsFigureE5onthenextpageindicates,atbestlessthanhalfofindividualswerescreenedwhentheyenteredthejail.BetweenAprilandSeptember2015therangeofindividualsscreenedwas0%to48%.Jailadministratorsreportthattherewasnopatternofwhowasscreenedandwhowasnot,butthefluctuationofproportionofthosescreenedpositiveforanSMI

857

77 30 9 9 80

200

400

600

800

JailBookings ProfMHScreens

ReferralstoJD MHAssessmentEnrolledMRT-Jail*

EnrolledMRT-Community*

IdennfiedMHNeeds(ExpressedNeed),

9.0%

PotennallyUnidennfiedMHNeeds,28.3%

NoMHNeeds,62.7%

I-E6

rangedfrom21%to35%ofthosebooked.The29%figureistheaverageproportionacrossthat6monthperiod.FigureE5:ComparisonBetweenProportionofThoseBookedWhoReceivedK6andProportionwith SMI

ProgressonYearOneShort-TermObjectivesThefollowingshort-termobjectivesweredevelopedbythestakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitconductedinMarch2015.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.Overall,theprogramisontracktosuccessfullymeetmostobjectivesrelatedtoMRTandCIT.

1. Developasystemandprotocolstoidentifyandcodedistresscallsthatpossiblyinvolveindividualsexperiencingamentalhealthcrisiswithinthecommunity.Progress:Goalpartiallymet.StakeholderssuccessfullyimplementedamentalhealthdispatchcodeattheMarquetteCityPoliceDepartment(MCPD)inOctober2015.Thiscodeprovidesthestakeholderswithamechanismtoquantifythenumberofcallsrelatedtoamentalhealthissuecleared/closedbyMCPDDispatch.Todate,thementalhealthcodehasnotbeenimplementedatCentralDispatchoperatedbytheMarquetteCountySheriff’sOffice,whichhandlesthemajorityofthe911/Emergencycallsacrossthecounty.StakeholdersanticipatethementalhealthcodecanbeimplementedatCentralDispatchduringthesecondyearoftheprogram.

2. Gainmoredirectedinformationfromdisturbancecallsatdispatchtodetermineifmentalhealthisafactor.Progress:Goalpartiallymet.Asoftheendoftheimplementationperiod,callscleared/closedasmentalhealth-relatedbyMCPDDispatchhavenotbeenprovidedtotheEvaluationTeam.Itisanticipatedthatdatacollectionwillbeginduringthesecondyearoftheprogram.

0%

10%

20%

30%

40%

50%

60%

Total April May June July August September

ProporronofJailbookingsthatweregivenaK6Assessment

ProporronofK6AssessmentsGiventhatwere+9

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3. Improveofficers’skillsinde-escalationtechniquesandimproveattitudesinrelationtopersonswithSMIandcommunitytreatmentthroughCITtraining.Progress:Goalpartiallymet.Atotalof17officersfromacrossMarquetteCountyreceivedCITtrainingconductedinMarquetteinJuly2015.Detailsofthepre-/post-testsadministeredatthetrainingareprovidedearlierinthisreport(seeImplementationofCITinMarquetteCounty:Intercept1).

4. ExpandreferralanddeliverysystemforMRTtoincludeindividualswhodonotqualifyfor

CMHservices(non-CMH).Progress:Goalpartiallymet.Duringtheimplementationperiod,MRTprogrammingwasexpandedtoincludegroupsinthejailandcommunity.Laterintheyear,groupswereaddedatthecourtanddetentioncenter.ProgrameligibilityisopentobothCMHandnon-CMHindividuals.

5. ImplementK6mentalhealthscreeningdatacollectionatjail.

Progress:Goalnotmet.Asindicatedearlier,mentalhealthscreenings(K6)weretobeconductedonallpersonsbookedandclassifiedintoeachcountyjailuntilasamplesizeofatleast200completedscreeningswasachievedateachsite.DuetotherelativelylownumberofjailbookingsintoMCJ(average147bookingspermonth),collectionwasextendedthroughoutYearOneinordertoachieveanappropriatesamplepre-andpost-intervention.DespitecontinuedeffortsbythePathwaysJailLiaisontoencourageconsistentscreeningpracticeswithinthejail,theoverallcollectionproducedscreeningsforjust24%ofallbookings(207screenings/857bookings).

NextStepsThesecondsitevisitinFebruary2016revealedanumberofpositivechangesandinitiativesforMarquetteCountyslatedforthesecondyearofthejaildiversionpilotprogram.

1. ImplementCITtrainingatNorthernMichiganUniversitypoliceacademycurriculumand

blocktraining.TheworkoftheCITAdvisoryCommitteehasresultedintheadditionofCITtrainingintoNorthernMichiganUniversity’spoliceacademycurriculumbeginningin2016.TheacademyservesasaregionalpoliceacademyforofficersinthecentralandwesternsectionsoftheUpperPeninsula.Stakeholdersplantoimplementa12-hourCITtrainingintotheacademy’sstandardpoliceacademytraining.Additionally,a4-hourCITtrainingwillbeimplementedintotheacademy’sblocktraining.Thisisa3-daytrainingheldquarterlyandbasedonMichiganCommissiononLawEnforcementStandards(MCOLES)trainingrequirements.Trainingcurriculumsforboththeacademyandblocktrainingsarecurrentlybeingworkedoutbythecommittee.

2. ExpandCITtrainingtojailofficersatMCJ.Inadditiontotheabovetraining,stakeholders

aretentativelyplanningtoprovidea4-hourCITintroductorytrainingtoofficersatMCJ.Asdiscussedduringthesecondsitevisit,jailofficersfaceseveralobstaclesinattemptingtoaddressthementalhealthneedsofinmates.Amajorconcernnotedbyonejailadministratorislimitedcellspace,pluscellsthatarenotconfiguredforappropriateobservationofindividualsexperiencingamentalhealthcrisis.Itwasalsonotedthatjailofficerscurrentlylacktheskillsnecessarytoproperlyde-escalateandbettermanagementalhealthcrises.Crisisissuesarereferredtothejailmentalhealthprofessionalcontractedby

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thejail,buttheclinician’shoursarelimitedtojusteighthoursperweekstrategicallyspreadoverthreedaystoprovideasmuchcoverageaspossible.Similartotheapproachstakeholderstookin2014–2015whenCITwasfirstintroducedinMarquette,thestakeholdersanticipatethatthe4-hourtrainingwillprovidethejailofficerswithanintroductiontomentalhealthsignsandsymptoms,andthatthisintroductorytrainingwillthenleadtothefull16-hourtrainingmodelthatwasusedinthecommunityin2015.

3. ExpansionofCITandMRTtoDeltaCounty.Asnotedearlier,DeltaCountyisthesecond

largestcounty,afterMarquette,inthePathwaysCMHcatchmentarea.StakeholdersareactivelyexpandingboththeCITandMRTinitiativeintothiscounty.InJanuary2016,a4-hourintroductoryCITtrainingwasheld,withatotalof38officersattendedthetraining.Itisanticipatedthat,similartoMarquetteCountyandMCJ,thisintroductionmayeventuallyleadtothefull16-hourtrainingmodelwithinDeltaCounty.

StakeholdersarealsoactivelyexpandingMRTtoDeltaCounty.Twogroupsaretentatively

plannedatthistime,includingoneatthecourthouseandoneatPathways.AswasthepracticeintheexpansionofMRTwithinMarquetteCountyin2015,bothstaffmemberswouldattendMRTtrainingprovidedunderthisgrant.

4. ExpansionoftheCITAdvisoryCommitteetoincluderepresentativesfromMCJ.Itwas

notedthattheCITAdvisoryCommitteecurrentlydoesnotincludearepresentativefromMCJ.Stakeholdershopetobeabletoengagejailadministratorsduring2016,bothintermsofparticipationonthecommitteeaswellasaroundtheimplementationofCITtrainingforjailofficers.Itisanticipatedthatimprovedcollaborationwiththejailwillstrengthendiversionactivitiesacrossthecontinuum.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing.

1. ImplementasecondroundofK6mentalhealthscreeningdatacollectionatMCJ.Dueto

theproblemsexperiencedwiththeK6mentalhealthscreeningdatacollectionattheMCJfromFebruary2015–January2016,theEvaluationTeamproposestoconductanewtwo-monthdatacollectionatthejailin2016.Itisanticipatedthatconsistentscreeningofallindividualsbookedtothejailovertwomonthswouldyieldanestimated294screenings,asampleatparwithMichigan’sotherjaildiversionpilotsites.

2. ExpanddatacollectiontoincludecallanddiversiondatafromMCPDDispatchandCentral

Dispatch.WiththeimplementationofthementalhealthcallcodeatMCPDDispatchandinprocessatCentralDispatch,datacollectioneffortsforbothsiteswillbeimplementedin2016.Dispatchandcalldata,asnotedinthepreviousdiscussionofprocessindicators,willbecollectedretroactivelytoOctober2015forMCPDDispatchandfromimplementationforwardforCentralDispatch.

3. ExpanddatacollectiontoaccuratelyreflectservicesprovidedbyPathways’JailLiaison.

Duringthesecondsitevisit,itwasrevealedthatthenumberandscopeofservicesroutinelyprovidedbyPathways’JailLiaisonwerenotreflectedincurrentprocessindicators.InordertoprovideamoreaccuratereflectionoftheservicesprovidedbytheJailLiaison,manyof

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whichcouldpotentiallyleadtocurrentorfuturediversionfromjail,theEvaluationTeamencouragestheexpansionofdatacollectiontoencompasstheseservices.Afollow-upmeetinghasbeenscheduledwithstakeholderstodevelopandimplementthisexpansion.

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FigureE6.MarquetteCountyProcessMap

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Arrest

Non-SMI

JailIntake

YesMH/SuicideRisk

NoMH/SuicideRisk

ReferredtoCMHforAssessment

ConductedbyJailLiaison

SMI

CMHConsumer

Current/Reactivated

ContinuedOngoingObservationbyJailStaff

DataCollectionPoint:

1.NumberofJailBookings:857

2.NumberofScreensConductedbyJailMH:

77

OutcomeDataCollection(collectedbyMSU):

Jailbooking/releasedatesMHsvc/typepost-release

Non-CMH

JailMHTreatmentServicesProvidedbyContractedMHProfessional(Non-CMH)

BriefsupportReferral/coordinationofserviceswithCMH

JailMRTGroups

DischargePlan/JailReleaseProvidedbyContractedMHProfessional

AllLOS,CMH/Non-CMH,timeframevariescase-by-case.IncludescoordinationwithCMH,5-7daysupplyofmedications.

Post-ReleaseServicesProvidedbyCMH

1sttreatmentservicewithin7daysofrelease.CrisisTeaminterventionforcoordination,

outreach(asneeded).

MRTReferralsfromProsecutor,Probation,Jail

MentalHealth,CMH

MRTGroupCMHConsumersFacilitatedbyCMH

MRTGroupNon-CMH

FacilitatedbyProbation

DataCollectionPoint:

3.NumberAssessedbyJailLiaison:

9

4.NumberofCasesOpened/Reactivated

byCMH:7

DataCollectionPoint:

5.NumberofReferralsforMRTtoJailMH:

30

6.NumberEnrolledIn-JailMRT:

9

7.NumberStartingIn-JailMRT:

9

8.NumberCompletingIn-JailMRT:

09.Total#receivingservices:

17

DataCollectionPoint:

10.NumberEnrolledinCommunityMRT:

8

11.NumberStartingCommunityMRT:

8

12.NumberCompletingCommunityMRT:

0

ExcelSpreadsheetID&DemographicDataofCMH&Non-CMHEnrolledinMRT

(In-Jail,CMH,Probation)–

IndividualsRecSvcs:Name

BookingIDCMHIDSSNDOB

GenderRace

MRTType(Jail,Probation,CMH)

ExcelSpreadsheetID&DemographicDataofCMH&Non-CMHEnrolledinMRT

(In-Jail,CMH,Probation)–

IndividualsRecSvcs:Name,BookingID,CMHID,SSN,DOB,Gender,Race,

MRTType(Jail,Probation,CMH)

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AppendixI-F:MonroeCountySiteSummaryIntroductionTheproposalputforthbyMonroeCommunityMentalHealthAgency(MCMHA)focusedontheenhancementofjailmentalhealthservicesattheMonroeCountyJail(MCJ).InpartnershipwiththeMCJandtheMonroeCountySheriff’sOffice(MCSO),MCMHAproposedtoenhancementalhealthservicesprovidedinMCJbyincreasingtheJailDiversion(JD)staffandenhancingtreatmentservices.Inaddition,MCMHAproposedtoprovideMentalHealthFirstAidtrainingtoallMCJcorrectionsstaff.ThisreportdetailstheimplementationprocessofthoseservicesandprogramsduringYear1.Itincludes:

! Adescriptionoftheprogramsbeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearlyMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheEvaluationTeam’stwositevisits(March2015andJanuary2016).

DescriptionofProgramImplementationinMonroeCountyImplementationofJailServices:Intercept3MCMHA,inpartnershipwithMCJandMCSO,proposedtoenhancementalhealthservicesprovidedinthecountyjailthroughanexpansionoftheMCMHA’sJailDiversion(JD)staffwithinthejail.Thiswastoincludeadditionalstaffing(1.5FTE)comprisedofafull-timejail-basedjaildiversionspecialistandapart-timecertifiedpeersupportspecialist(CPSS).Thestaffadditionsweretoallowtheexpansionofjailmentalhealthservicesincludingmentalhealthscreening,assessment,individual/grouptherapy,anddischargeplanningandfollow-upforallinmatesidentifiedashavingamild/moderatetoseriousmentalillness(SMI),irrespectiveoftheirinvolvementwithoreligibilityforcommunitymentalhealth(CMH)services.Inmatesarereferredtothejaildiversionteambythejail’snursingunit.Theprocessmap,includedasFigureF3onthelastpage,illustratestheprogramoperationaswellasprocesscountsachievedduringtheimplementationperiod.MCMHAalsoprovidedan8-hourMentalHealthFirstAidTrainingtoallMCJcorrectionsofficersandsergeants. IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailduringprogramimplementation,theEvaluationTeamworkedintandemwithstakeholderstoidentifyandmeasurekeyprocessindicatorswithintheirimplementationofjailservicesinMonroeCounty.Basedontheresultsoftheinitialconsultationwithstakeholdersduringthefirstsitevisit,thefollowingprocessindicatorsweretobecollectedfromMonroeCountybeginninginApril2015.

Name/Title/DateofOfficersParticipatinginMHFATraining #JailBookings #ReferralstoMCMHA

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#AssessmentsbyMCMHA #MCMHAConsumersReceivingIndividualorGroupTherapyfromJDinJail #Non-MCMHAIndividualsReceivingIndividualorGroupTherapyfromJDinJail #Activations/Re-activationsforCMHservices CaseID,CMHstatus,M/F,DOBofInmatesTreatedbyJDAsMCMHAimplementedtheirjaildiversionprogram,theevaluationofthepilotprogramwasadaptedaswell.Specificchangesweremadeinthecollectionofprocessdatatoappropriatelyreflectchangestotheprogramasimplemented.ThesechangesincludedadjustingprocessindicatorstomatchprocesseswhichcanbequantifiedbyMCMHA.Additionally,somechangesweremadetoalignprocessindicatorscollectedinMonroeCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincludejailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.Thefinallistofprocessindicatorswasrevisedtoincludethefollowing.

Name/Title/DateofOfficersParticipatinginMHFATraining #JailBookings Eliminated #ReferralstoMCMHA Added #ScreeningsconductedbyMCMHA Adjusted #AssessmentsconductedbyMCMHAJDclinician Eliminated #MCMHAConsumersReceivingIndividualorGroupTherapyfromJDinJail Eliminated #Non-MCMHAIndividualsReceivingIndividualorGroupTherapyfromJDinJail Added #IndividualsreceivinganymentalhealthservicefromJDprogram Eliminated #Activations/Re-activationsforCMHservices Added #IndividualsenrolledinJDprogram Adjusted CaseID,CMHstatus,M/F,DOBofindividualsenrolledinJDprogramInitially,itwasdeterminedthatthelong-termoutcomeevaluationtobeconductedbyEvaluationTeamandreportedin2017wouldfollowindividualsenrolledintothejaildiversionprogramtoassesstreatmentengagementinthecommunityandrecidivism.However,duringthesecondsitevisit,thisgroupwasexpandedtoalsoincludeindividualsreceivinganymentalhealthservicefromthejaildiversionteamduringfirstquarterof2016.ThisisdiscussedinmoredetailbelowinthesectiononNextSteps.ProgramReferral/EnrollmentAsshowninFigureF1onthenextpage,therewere3,179bookingsintotheMCJduringthesix-monthimplementationperiod.Theproportionofindividualsscreenedbythejaildiversionteamisestimatedtobenearly28%ofthosebooked(900of3,179).Ofthosescreened,25%wereassessed(225of900)formentalillness.Atotalof162individualsreceivedservicesfromthejaildiversionteamandofthose,57individualswithmildtoseverementalillnesswereenrolledintothejaildiversionprogram.

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FigureF1.MonroeCountyProcessIndicatorsApril2015–September2015

*Atthetimeofthisreport,MCMHAadministratorsestimatethat900mentalhealthscreeningswereconductedbytheJDteamduringsix-monthimplementationperiod.**Atotalof162individualswhoreceivedservicesfromjailmentalhealth,including57enrolledintheJDprogram,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

NeedforMentalHealthServicesFigureF2belowshowstheneedformentalhealthservicesintheMonroeCountyjail.Usingthe‘objectiveneed’estimatederivedfromthepreviousstudyusingtheK6screeningofallindividualsbookedintothejail,itisestimatedthatapproximately32%ofindividualsenteringthejailmightrequirementalhealthservices.BecausethosereferredtoJDwas28%(expressedneed),itispossiblethatapproximately4%ofindividualswereunidentified,resultinginapotential‘uncaptured’need.FigureF2.EstimatedNeedforMentalHealthServicesintheMonroeCountyJail

3,179

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225 162 570

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JailBookings ProfMHScreens* MHAssessments RecdSvcsfromJD**

EnrolledinJD

IdennfiedMHNeeds(ExpressedNeed),

28.3%

PotennallyUnidennfiedMHNeeds,3.6%

NoMHNeeds,68.1%

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ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbythestakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitconductedatMonroeCountyJailinMarch2015andaddressboththejailservicesandCITprograms.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.

1. Providecounselingtofirst-timeinmatesexperiencingmentalhealthissuesinordertohelpprevententréeintothementalhealthsystem.

Progress:Goalpartiallymet.Thecertifiedpeersupportperson(CPSS)hasbeenanassettojailstaffandhasprovidedcrisiscounselingtothoseinneed–irrespectiveoftheirmentalhealthdiagnosisorclassification–andhasassistedstaffnavigatedifficultsituations.Becausethisisoneperson–whohasseveralresponsibilitieswithinthejailaswellastotheprogram,ithasnotbeenpossibletospeaktoevery‘firsttime’inmate.

2. StrengthenthesystemandprotocolstoidentifycurrentMCMHAconsumerswhoare

bookedatthejaileachday. Progress:Goalmet.Asshownintheprocessmap(FigureF3),MCJnursingstaffandthe

certifiedpeersupportspecialist(CPSS)ontheJDteamactivelyreviewthejail’selectronicbookingsheetsonadailybasis.Onaverage,thereare16bookingsperdayandindividualsbookedintothejailaremanuallymatchedbytheCPSSinMCMHA’sdatasystem.ThisprocessallowsquickidentificationofMCMHAconsumersbookedintothejail.

3. Strengthenthesystemtoidentify,assess,open/reactivate,andprovideanindividualized

planofserviceforindividualswithinthejailassessedashavinganSMIwhoarenotcurrentMCMHAconsumers.

Progress:Goalmet.Asshownintheprocessmap(FigureF3),individualsbookedintothejailwhoareidentifiedtobeatriskforsuicideortohaveamentalhealthconcernarereferredbythejailstafftoMCMHAJDforamentalhealthscreening.Thescreeningsareconductedbytheteam’sCPSS.Anestimated900screeningswereconductedduringthesix-monthimplementationperiod.ThosewhoscreenpositivelyforamentalhealthconcernarethenreferredtotheMCMHAJDclinicianforafullassessment;atotalof225assessmentswereconductedduringtheperiod.IndividualswhoarenotcurrentCMHconsumers,butwhoqualify,areenrolledintoCMHservicesatthistime.

4. StrengthensystemtonotifyMCMHAcasemanagersofcurrentconsumerswhoare

currentlyincarceratedinthejail. Progress:Goalmet.Duringtheprocessofreviewingtheelectronicbookingsheetconducted

bytheCPSS,theCPSSisalsotonotifyMCMHAcasemanagersofcurrentconsumerswhohavebeenbookedintothejail.

5. Increasejailmentalhealthtreatmentservicestoincludeindividualandgrouptherapyand

dischargeplanningforallmild/moderateandSMIinmates(CMHandnon-CMH).Progress:Goalmet.Thisisthefocalpointofthisdiversiongrant.DuringYearOne,theJDteamimplementedindividualandgrouptherapyforindividualsexperiencinglongerstaysinthejail.Asshownintheprocessmap(FigureF3),theJDteamprovidedservicestoatotalof

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162individualsduringthesix-monthimplementationperiod;57individualsassessedashavingmildtoseverementalillnesswereenrolledintotheJDprogram.Asoutlinedlaterinthisreport(seeNextSteps),theJDteamwillcontinuetofocusontheexpansionofservicesprovidedinthejailduringthesecondyearoftheprogram.

TheprogramproposedbyMCMHAwaswellconsideredandbuiltuponastrongrelationshiptheagencyhadalreadyestablishedwithMCJ.ThehighdegreeoftrustandcollaborationbetweenthetwopartnersallowedforaquickimplementationoftheJDprogram,buttheprogramwasnotwithoutchallengesduringthefirstyearofthegrantperiod.Theprogram’skeystaffposition,theJailDiversionSpecialist,wasfilledduringthefirstquarteroftheyearbutvacatedduringthethirdandfourthquartersoftheyearwhenthisstaffmemberacceptedanewposition.Despitethisturnover,theMCMHAteamwasabletosustaintheJDprogramandcontinuetoprovideserviceswithinthejail.Overall,theprogramwashighlysuccessfulinmeetingtheobjectivessetforthforthejailservicesprogram.NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforMonroeCountyslatedforthesecondyearofthejaildiversionpilotprogram.

1. Continuetoexpandjailmentalhealthtreatmentservicestoincludedischargeservices.

TheJDteamwillcontinuetofocusontheexpansionofservicesprovidedinthejailduringthesecondyearoftheprogram.EffortsinYearTwowillincludetheadditionofasecondCPSSaswellasaJDsupervisortosustaincurrentservicesaswellastoenhancedischargeservicesprovidedtoindividualsreceivingmentalhealthservices.

2. ImplementanewJailManagementSystemreporttogatherdailyandaggregatedataon

mentalhealthconcerns.InordertoproducestatisticsasneededforfundingandquantificationoftheissueofmentalillnesswithintheMCJ,stakeholderswillimplementtheproductionofadailyreporttoidentifyindividualsbookedintothejailwhomaypotentiallyhaveseriousmentalhealthconcernsbasedonhowquestionspertainingmentalhealthandsuicideareansweredduringtheinitialbookinginterview.Thesereportswillbeusedtogenerateanewdataindicatorfortheevaluation–aswellasalertjailmentalhealthstaffaboutthepotentialneedsofdetainees.Thenewreport,tobetitledtheMentalHealthDailyLog,willbeusedtoproactivelyidentifyinmateswithmentalhealthconcerns.Thisreportwillsupplementcurrentprocessesalreadyutilizedwithinthejailincludingreferralsfromthejailstaffandkitesfrominmates.ThisprocesswillalsoaugmentthepracticeofreviewingthedailybookinglistconductedbytheCPSSinwhichthedailybookingreportismanuallycross-referencedintheCMHsystemtoidentifycurrentconsumers.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing.

1. Definethediversionprogrammodelandeligibilitycriteria.Akeyitemtobeaddressedby

theJDteamduringthesecondyearoftheprogramisthejaildiversionprogrammodel.Specifically,theteamshoulddefinethestandardservicesprovidedtothoseindividualsenrolledintotheJDprogram(e.g.individual/grouptherapy,crisiscare,communityreferrals,dischargeplanning,dischargefollow-up,etc.).

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2. Expandthelong-termoutcomeevaluationtoincludeindividualsenrolledinthejaildiversionprogramplusthosereceivinganymentalhealthservicefromthejaildiversionteam.Duetothehighnumberofindividualsreceivingservicesfromthejaildiversionteam(N=162duringsix-monthimplementationperiod),theEvaluationTeamwillexpandthelong-termevaluationtoincludetrackingmentalhealthandrecidivismoutcomesforthosewhoareenrolledintheJDprogram(N=57duringsix-monthimplementationperiod)plusthosereceivinganyserviceduringthefirstquarterof2016(estimatedtobeapproximately80individuals).ItisanticipatedthattheadditiontotheevaluationofthosereceivinganymentalhealthservicewillmoreaccuratelyassesstheimpactoftheJDprogramversustreatmentasusual.

3. Assessadvocacyeffortsbythejaildiversionteamresultingincurrentdiversion.Duringthe

secondsitevisit,itwasrevealedthattheCPSSprovidesadvocacyservicetoindividualswhichcanresultinacurrentdiversion(i.e.,experiencedfewerjaildaysduetoanactionoradvocacytakenbyateammember).Duringthesecondyearoftheprogram,theJDteamwillidentifythoseindividualswhoaredivertedfromjailtotreatmentgoingforward,aswellasretroactivelyidentifyingthosewhoreceivedacurrentdiversionduringyearone.

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FigureF3.MonroeCountyProcessMap Arrest

InitialScreeningElectronicBookingSheetMedical,Psych,PREA

CompletedbyBookingOfficer

If“Yes”toMH/SA,Meds,Suicide,Phys

If“No”toMH/SA,Meds,Suicide,Phys

ReferraltoNursingviaEMR

DischargePlanning30pre-release

SOAR60dayspre-releasebyCPSS(asneeded)

ObservationbyJailStaff

OutcomeDataCollection:#/typesvcsprovidedinjail

byindividual

OutcomeDataCollection:Jailbooking/releasedatesMHsvc/typepost-release

MentalHealthAssessmentFullBio-Psycho-Social

ConductedbyMCMHAJDS

JailMHTreatmentServicesIndividualTherapy(CPSSforMild-Mod;CMfor<90days)

GroupTherapyMedicationReviewbyNursing/MD

1stMHTreatmentinCommunityAppointmentbookedbyMCMHAJDSRequiredwithin7daysofrelease

EmailtoMCMHACaseManager

Asneeded

ElectronicBookingSheetsReviewedDailyby

NursingandMCMHAJD

JailBooking

ReferraltoMCMHA/KitefromInmate

24/7AssessmentbyMCMHAforSuicideRisk

MentalHealthIssueMildtoModorSMI

NoMentalHealthIssue

MentalHealthScreeningEnteredtoEMR

ConductedbyMCMHAJD

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Non-CMHSMI

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CMHCaseOpened/ReactivatedCompletedbyMCMHAJDS

IndividualizedPlanofServiceBasedonAppropriateLevelofCare

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LOS<90daysCaseremainsw/MCMHACM

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MCMHAConsumerWhoBondOutPriortoReferral

areFlaggedforCM

Non-CMHMildtoModerate

DataCollectionPoint:

1.NumberofJailBookings/JailMHScreenings:

3,179

DataCollectionPoint:

2.NumberofScreeningsConductedby

JailMHSpecialist:900

3.NumberofMHAssessmentsConductedby

JailMHClinician”225

DataCollectionPoint:

4.NumberofIndividualsReceivingAnyMHService:

162

ExcelSpreadsheet:ID&DemographicDataofIndividualsEnrolled

inJDProgram:(ProvideinExcelspreadsheet)SSN,BookingID,JailID,CMHID,Name,DOB,Gender,Race,BookingDate,CMHStatus

DataCollectionPoint:

5.NumberEnrolledinJDProgram:

57

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AppendixI-G:OaklandCountyIntroductionThediversionprogramproposedbyOaklandCountyCommunityMentalHealthAssociation(OCCMHA)encompassedonekeyobjectiveprioritizedbyMDCH,thetrainingandimplementationofCrisisInterventionTeam(CIT)training.OCCMHA,inpartnershipwiththeOaklandCountySheriff’sOffice(OCSO),proposedtotrainandimplementaCITamongatotalofupto80OSCOofficers.These80officersrepresentasignificantproportionofthetotalworkforceandprovideprimaryservicestomanyofthemunicipalitieswithinOaklandCounty.ThisreportdetailstheimplementationprocessoftheCITprogramsduringYear1.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearlyMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheEvaluationTeam’stwositevisits(March2015andFebruary2016).

DescriptionofProgramImplementationinOaklandCountyImplementationofCITinOaklandCounty:Intercept1TheimplementationofCITinOaklandCountyfocusedonprovidinga40-hourtrainingforupto80deputiesandsergeantsaswellasofficersoflocalpolicedepartmentsacrossthecounty.Two40-hourtrainingsessionswereconductedduringtheweeksofMay4andMay18,2015.Allofficersvolunteeredforthetraining.Ofthe79participants,60weredeputiesorsergeantsfromtheOaklandCountySheriff’sOfficeand19wereofficersfromlocalpolicedepartmentsincludingAuburnHills(one),BloomfieldTownship(one),FarmingtonHills(two),Novi(four),RochesterHills(one),Southfield(two),WestBloomfield(seven),andWhiteLakeTownship(one).Changesasaresultofthetrainingweremeasuredusingstandardizedinstruments.Significantpre/postchangeswerefoundinofficer’sknowledgeofmentalhealthresourcesandde-escalationskills.Moredetailsofthesefindingsareincludedbelow.Asecondroundoftrainingwasaddedlaterintheyearconsistingofanabbreviated8-hourtrainingforupto32dispatchofficersfromthecounty’scentralizeddispatchcenter.Four8-hourtrainingsessionswereconductedfromSeptember23–October14,2015,attracting32dispatchofficers.TheabbreviatedtrainingwastailoredtomeetthespecificneedsofdispatchofficersandincludedthehistoryofCITtraining,anintroductiontomentalhealthissues,areviewofthementalhealthsystemandcommunityresources,suicideawarenessandpreventionanda4-hoursectionofadvancedverbalde-escalationtechniques.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontothecollectionandanalysisoftheK6mentalhealthscreeningconductedatthejailpre-andpost-programimplementation,theEvaluationTeamworkedintandemwithkeystakeholderstoidentifyandmeasurekeyprocessindicatorsassociatedwiththeimplementationofCITwithinOaklandCounty.

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Basedontheresultsofaninitialconsultationwithstakeholders,thefollowingindicatorswerecollectedfromOaklandCountybeginninginApril2015.

Name,title,agencyofalltrainees Pre/Post-CITTrainingsurvey #TotalCallstoDispatch #CallsCodedasJailDiversion/CIT(L3545)inCLEMIS

NarrativeforCallsCodedL3545(todeterminefinaldisposition)Name,DOB,M/F,race,andlast-4(ifavailable)ofL3545CallsCommonGroundResourceandCrisisCenterLogBook

NochangesweremadetotheprocessindicatorsorthedatacollectionprocesssetforthinOaklandCountyinApril2015.CITPre/PostTrainingIndicatorsThegoaloftheCITtrainingistocreatechangeinknowledgeandattitudesoflawenforcementregardingrespondingtoindividualswithmentalillnessandcommunitytreatmentsforthispopulation.Forofficerswhoparticipateinthetraining,significantchangesfrompre-toposttestforboththeOPTandtheDe-escalationScalestoshowthattheCITtraininghadapositiveimpactontheofficersisdesired.Duetothedifferencesintraining(40hoursvs.8hours)androles(patrolversusdispatch),trainingoutcomeswereevaluatedbygroupusingthesamemeasures.Forbothgroups(patrolanddispatch),pre-andpost-testswereimplementedimmediatelypriorto(pre-)andfollowing(post-)thetrainingandwerebasedontwoinstruments:theOpinionsofPsychiatricTreatment(OPT)MeasureandtheDe-escalationScale.The20-itemvalidatedOPTMeasureassessesofficers’attitudesandknowledgeaboutpsychiatrictreatmentswithinthecommunityandattitudesaboutpsycho-pharmacotherapy,psychotherapy,andpsychosocialinterventions.Responsesaregivenasix-pointLikertscalerangingfrom1(stronglydisagree)to6(stronglyagree).Thepossiblerangeofscoresis20–120.The8-itemDe-EscalationScalemeasuresofficers’de-escalationskills.Officers’opinionsontheeffectivenessofspecificactionsinthesituationwereratedonafour-pointLikertscalerangingfrom0(verynegative)to3(verypositive).Totalsubscalescoresrangefrom0to24.Pre/PostCITScoresforPatrolOfficersAtotalof67ofthe79officerswhoattendedthe40-hourCITtrainingcompletedbothapre-andpost-testassessment.AsshowninFigureG1onthenextpage,therewasanaveragechangescorefrompre-topost-testof6.6pointsontheOPTScale.Thischangewasastatisticallysignificantdifference17indicatingthatthetrainingimprovedtheofficers’knowledgeoftreatmentsinthecommunity.Therewerenosignificantdifferencesinchangescoresbygender,educationlevel,ornumberofyearsinlawenforcement.Therewasanaverageincreaseof1.3pointsfrompre-topost-testontheDe-escalationScale.Thisseeminglysmallaverageincreasewasstatisticallysignificant18indicatingthatthetrainingimprovedtheofficers’knowledgeofwhatbehaviorsarebesttohelpde-escalatesomeonewithamentalillness.Therewerenosignificantdifferencesinchangescoresbygender,educationlevel,ornumberofyearsinlawenforcement.

17Pairedt-testswereusedtoassesstheindividualdifferencesontheOPTscale(t(66)=8.722,p<.001).Thestatisticalsignificanceimpliesthatitisimprobabletobelievetheresultsweredueto‘chance’.18Pairedt-testswereusedtotestindividuallevelchangescoresonthede-escalationscale(t(66)=4.199,p<.001).

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FigureG1.Pre/PostCITScoresforPatrolOfficers

Pre/PostScoresforDispatchOfficersAtotalof16ofthe32dispatchofficerswhoattendedthe8-hourCITtrainingcompletedbothapre-andpost-testassessment.AsshowninFigureG2below,therewasanaveragechangescorefrompre-topost-testof4.7pointsontheOPTScale.Thischangewasstatisticallysignificantindicatingthatthetrainingimprovedtheofficers’knowledgeoftreatmentsinthecommunity.19Therewerenosignificantdifferencesinchangescoresbygender,educationlevel,ornumberofyearsinlawenforcement.Therewasanaverageincreaseof1.4pointsontheDe-escalationScale.Thischangewasstatisticallysignificantindicatingthatthetrainingimprovedthedispatchofficers’knowledgeofwhatbehaviorsarebesttohelpde-escalatesomeonewithamentalillness20.Therewerenosignificantdifferencesinchangescoresbygender,educationlevel,ornumberofyearsinlawenforcement.FigureG2.Pre/PostCITScoresforDispatchPersonnel

19Note:Pairedt-testswereusedtotestindividuallevelchangescoresontheOPTscale(t(15)=4.858,p<.001).Thestatisticalsignificanceofthisfindingandtheonebelowsuggestthattheseresultsarehighlyunlikelytooccurduetochance.20Note:Pairedwereusedtotestindividuallevelchangescoresonthede-escalationscale(t(15)=2.626,p<.05.

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OtherProcessandOutcomeIndicatorsRelatedtoCITImplementationCallReportDataInanattempttoassessthechangeinofficerbehavioraftercompletionofthetraining,theEvaluationTeamexaminedcallreportsprovidedbytheOCSO.Thesearetheofficers’documentationofthecallstheyweresentviadispatch.Thesecallshavebeendividedintothreecategories:1)MentalHealth,2)Suicideand3)CIT/JailDiversion.Eachcategoryisbasedontheverifiedcodeenteredbytheofficerinthedispatchsystemattheopening/closingofthecall.Itisnotedthatthecodeaffixedbythedispatcherwhenthecallisopenedmayvaryfromthatusedbytheofficertoclosethecall.Becauseofthis,allcallsopenedorclosedasMentalHealth,Suicide,orCIT/JailDiversionwereprovidedtotheEvaluationTeam.ItisnotedthattheMentalHealthcodeisdesignatedformentalhealthcrises,whichincludessuicideideation.TheSuicidecodeisdesignatedforactionstakentowardsuicideorattemptedsuicideandcompletedsuicide.ThisSuicidecodeisdifferentiatedfromtheMentalHealthcodebytheactionorself-harmtakentowardssuicide.TheCIT/JailDiversioncodewascreatedbyOSCOtorepresentwhenaCIT-trainedofficerhasactuallydivertedanindividualwithamentalhealthprobleminvolvedincriminalbehaviorfromjailtotreatment.CommonGroundDrop-OffLogsAnadditionalattempttoassessthechangeinofficerbehavioraftercompletionofthetrainingwasthecollectionofdrop-offlogsfromCommonGround,a24-hourmentalhealthcrisiscenteroperatedinOaklandCounty.Thedrop-offlogs,orPoliceContactLogs,wereprovidedbyOCCMHAonamonthlybasisascollectedfromCommonGround.ThelogsprovidethenameofeachindividualdroppedoffbyamemberoflawenforcementatCommonGroundaswellasthedateandtheofficer’snameandpoliceagencyaffiliation.CallreportsfromJanuary2015–October2015wereanalyzedbytheEvaluationTeam.CommonGroundlogswerealsoanalyzedforthesameperiodaswellastheyearpriortotheimplementationofCIT(January2014–December2014).MentalHealthandSuicidecallsrepresentnoparticularpatternforthe2015calendaryearasshowninFigureG3onthefollowingpage.Incontrast,thereisanobviousincreaseindrop-offsatCommonGroundimmediatelyfollowingtheCITtraininginMay.Onepossibleexplanationfortheincreaseindrop-offstoCommonGroundisthattheCITtraininghelpedinformofficersoftheavailableresourcesincludingCommonGroundand,asaresult,officersbegantoutilizeCommonGroundmorethanbeforethetraining.

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FigureG3.AssessingMentalHealth,Suicide&CIT/JailDiversionCalls&CommonGroundDrop-offs

TofurtherassessifCITtrainingwasthecatalystfortheincreaseindrop-offstoCommonGround,drop-offsin2014wereanalyzedtocomparethenumberofdrop-offstoCommonGroundfrom2014to2015.AsshowninFigureG4below,theaveragenumberofdrop-offsin2014was21.9individualspermonth;theaveragein2015grewto32.8permonth.Thehighestnumberofdrop-offstoCommonGroundpriortotheCITtraininginMay2015was29;aftertheCITtraining,drop-offsincreasedtoover50permonthandhaveremainedatthishigherlevel.FigureG4.ComparingDrop-OffstoCommonGroundin2014and2015

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ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbythestakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitconductedinOaklandCountyinMarch2015.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.

1. UtilizeanewCIT/JailDiversioncodeinCLEARreportinCLEMISforcallsinvolvingamentalhealthissue.Progress:Goalmet.PriortothecompletionofthefirstCITtrainingsessionsinMay,theSheriff’sOperationCenterimplementedanewcodewithintheCLEMISdispatchsystemforrespondingofficerstocloseorverifyacallasCIT/Diversion.Thesystemwasalreadyequippedforrespondingofficerstoclose/verifyacallasmentalhealth-orsuicide-related.UseofthenewCIT/DiversioncodewasincludedintheCITtrainingprovidedtotheofficersinMay.UseofthenewCIT/Diversioncodewouldindicatetheofficer’suseofdiversion(i.e.,placementatahospital,crisiscenter)inlieuofjailasappropriatewhenanindividualcommittinganoffenseisdeterminedbyaCIT-trainedofficertobeexperiencingamentalhealthcrisis.Thisnewcodewasoneofthethreecallcodes–includingMentalHealth,Suicide,andCIT/JailDiversion–currentlycollectedfromOCSOandanalyzedbytheEvaluationTeam.

2. Developaprocesstointegratetheuseoffivediversionquestionsregardingthedecisionto‘arrest’or‘charge’individualsthatCITofficersinteractwith(asdevelopedbyOfficerRaphaelDiaz,KalamazooDepartmentofPublicSafety).Progress:Goalmet.ThefivediversionquestionsdefinedbySgt.DiazaretriggeredwhenofficersselecttheCIT/JailDiversiondispatchcode(seeabove).ThisdataisincludedinthecallreportsprovidedbyOCSOtotheEvaluationTeam.

3. Increasede-escalationskillsandfamiliaritywithcommunity-basedtreatmentasaresultofCITtraining.Progress:Goalmet.Atotalof79patrolofficersand32dispatchofficersattendedtheCITtrainingsconductedinthecountyduringMayandSeptember–Octoberrespectively.Detailsofthepre-/post-testsadministeredatthetrainingareprovidedinthisreport(seeImplementationofCIT:Intercept1)butpre/postscoresindicatethatofficersimprovedtheirknowledgeofcommunity-basedtreatmentandde-escalationtechniques.Goingforward,stakeholdersplantoprovideCITtrainingtotheremainingdispatchers,aswellasOCJofficers,in2016(seeNextSteps).

NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforOaklandCountyslatedforthesecondyearofthejaildiversionpilotprogram.

1. ProvideCITtrainingtoadditionalpatrolofficersthroughoutOaklandCounty.Underthisgrant,stakeholdersplantoprovideCITtrainingtoanadditional40officersin2016.Atthetimeofthesecondsitevisit,onetrainingsessionutilizingthe40-hourtrainingmodelwasplannedforJune.Anestimated40officersfromthroughoutOaklandCountyincludingOCSOandlocalpolicedepartmentsareexpectedtoattendthetraining.Goingforward,trainingswillbeconductedbySgt.ToddHillfromtheOCSOTrainingUnitoranequallyqualified

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designee;trainingswerepreviouslyconductedbySgt.DiazfromKalamazooPublicSafetyDepartment.AdditionalCITtrainingforOCSOdispatchersandcorrectionsstaffandCIT-Youthtrainingareplannedfor2016,butthesetrainingswillbecoveredinaseparatejaildiversiongrantfundedbytheMichiganDepartmentofHealthandHumanServicesfor2016–2017.

2. AddaCITCoordinatorpositionwithintheOCSO.StakeholdersinOaklandCountyhave

addressedCITimplementationissuesonacase-by-casebasis;however,duringthefirstyearofoperation,therewasnomechanisminplacetoformallyaddressissuesonaregular,ongoingbasis.CIT-relatedissues(e.g.difficultiesexperiencedbyofficerswhendroppingindividualstothecounty’s24-hourcrisiscenter)areaddressedastheyoccurbythekeypersonnelfromtheOCSOTrainingUnitandOCCMHAassignedtothedevelopmentandimplementationofthisgrant.Thislevelofcollaboration,whilesofareffectiveinremovingobstaclesintheimplementationofCIT,wastaxingonthekeypersonnelassignedtothegrantbecausethesedutiesfalloutsideoftherealmoftheirnormal,day-to-dayresponsibilities.Duringthesecondyearofthegrant,stakeholdersplantodevelopandimplementaCITcoordinatorposition.TheprimarypurposeofthispositionwillbetomanageCITdataissues,aswellastoserveasaliaisonbetweentheofficersandOCCMHA.Atthetimeofthesecondsitevisititwasanticipatedthat,duetolackoflong-termfundingforthisposition,therolewouldbeassumedbythekeystakeholderfromtheOCSOTrainingUnit.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing.

1. Implementacommunityadvisorycouncil.Thepresenceofanongoingadvisorycouncilcomprisedofcriminal/legalprofessionals,mentalhealthprofessionals,mentalhealthadvocates,andlawenforcementthatcanengageinproblem-solvingandmonitoringofCITdataishighlyrecommendedtoproperlysustaintheCITprogram.ThepowerofcollaborationbetweenagencieswasclearlydemonstratedduringthetourofCommonGroundwhenrepresentativesfromOCSO,OCCMHA,andCommonGroundstaffcandidlydiscussedandproblem-solvedanumberofquestionsandconcernsregardingOCSOdrop-offs.Additionally,elevatingCITtothecountylevelwillimproveawarenessoftheprogramamongthecounty’scriminal,legal,lawenforcement,andmentalhealthstakeholdersandproperlyplacetheprogramamongthevarietyofotherdiversionprogramscurrentlyoperatingwithinthecountyincludingmentalhealthandsobrietycourts.

2. EnhancedatacodingtoincludeCITskillutilization.InreviewingthecalldataprovidedbyOCSO,itisrecognizedthat,whilethenumberofcallsinwhichatruejaildiversionoccursarelow,thereareahighnumberofcallsinwhichCITskillsareutilizedbyofficers.InordertoaccountfortheutilizationofCITskills,inadditiontoCIT/JailDiversions,theEvaluationTeamwillcontinuetoreviewthenarrativeofallMentalHealthandSuicidecallreports.Thosecallsinwhichuseofde-escalationskillsaredescribedwithinthenarrativeandinwhichtheresolutioniseither1)drop-offatCommonGround,2)drop-offorresolvedathome,or3)drop-offatthehospital/ER,willbecodedandquantifiedassuch.

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AppendixI-H:WayneCountySiteSummaryIntroductionTheproposalputforthbyDetroitCentralCity(DCC)CommunityMentalHealthAgencyinWayneCounty--theIntensiveJailDiversionPilot(IJDP)--focusedontwotargetedintercepts:apre-arrestdiversionprogramdevelopedinpartnershipwiththeDetroitPoliceDepartment(DPD)andapost-bookingjailservicesprogramatWayneCountyJailbasedontheForensicAssertiveCommunityTreatment(FACT)Model.DuetodifficultiesingainingtheengagementoftheDPD,theinitialplanwasadjustedduringthefirstquarterofthegrant.Theresultwasa‘phase’strategyinwhichthepost-bookingjailservicesprogramwouldbeconsideredPhase1andaddressedfirst.Thepre-arrestdiversionprogramwithDPDwouldbeconsideredPhase2andphasedinlaterintheyearoncePhase1wasimplemented.ThisreportdetailstheimplementationprocessduringYear1.Itincludes:

! Adescriptionoftheprogrambeingimplemented.! Short-term(Year1)objectives,processindicators,andtheprocessmapagreeduponduring

theEvaluationTeam’sfirstsitevisitconductedinearlyMarch2015.! Informationyieldedfromtheprocessindicatorsgeneratedduringthesix-month

implementationperiodofApril–September2015.! EvaluationTeamobservationsandstakeholderfeedbackregardingprogramimplementation

generatedduringstakeholderinterviews,monthlydatacollectioncalls,andtheEvaluationTeam’stwositevisits(March2015andFebruary2016).

DescriptionofProgramImplementationinWayneCountyImplementationofJailServicesinWayneCounty:Intercept3DCC’snewjaildiversionprogram,developedinpartnershipwiththeWayneCountyJail(WCJ),wasdesignedtosupplementtwoexistingdiversionprogramscurrentlyoperatedbyDCC’sCommunityReentryDivision:DiversionIandtheMentalHealthCourt(MHC).Specifically,thenewdiversionopportunitytargetedcurrentand/orpreviousDCCconsumerswithseriousmentalillnessjailedforalowfelonyormisdemeanoroffense.Theprogramfocusesontheimplementationofajaildiversionteamlocatedwithinthecountyjail.InmatesarereferredtoIJDPinthreeways:bysocialworkersinthejail’smentalhealthunit;throughDirectorHeard,DirectorofJailPopulations,aspartofthejail’sadministrativejailreleaseeffort;andfromotherexistingdiversionprogramswithinthecommunityincludingMHCandVeteran’sCourt.ServicesprovidedbytheIJDPteam,originallyintendedtofollowtheForensicAssertiveCommunityTreatment(FACT)Model,includejailin-reach,individualandgrouptherapy,dischargeplanningandfollow-up,andhousingplacement.Theprocessmap,includedasFigureH3onthelastpage,illustratestheprogramoperationaswellasprocessnumbersduringtheimplementationperiod.ItwasanticipatedthatconsumersenrollingintoIJDPwouldlikelyhavedifferentneedsbasedontheirstability,functionality,andlengthofsentence.Theinitialplanwastoprovideallclinically-eligibleindividualsenrolledintotheprogramwiththeservicesprescribedundertheFACTModelbeginningduringincarcerationandcontinuinguponrelease.ServiceswouldincludedirectcontactwithIJDPteammembers(i.e.,thecasemanager,peersupportspecialist,nurse,orpsychiatrist)threetimesweekly,in-reachbytheassignedIJDPcasemanagerduringincarcerationatWCJ,andhousingassistanceandplacement.Others,outsideoftheDCCnetwork,wouldreceivelessintensiveservicessuchas

I-H2

transportation,dependingonindividualneed.Duetoahigherclinician-to-staffratiothanprescribedbyFACT,theIJDPteamhasadjustedtheabovelistedservicestomeettheneedsoftheconsumerandnotnecessarilyinfidelitywiththemodel.Duringthefirstsixmonths,theIJDPteamidentifiedanumberofissuesthathamperedimplementationofthemodel.Teammembersidentifiedalagtimeofupto30daysfromthetimeanindividualisidentifiedfortheIJDPprogramuntiltheyareabletobeenrolledintotheprogramand,ultimately,releasedfromjail.Thislagcanresultinlengthenedjailtimeforsomeonewithaqualifyingmentalhealthproblemandpotentialexacerbationofsymptoms.ItisanticipatedthatDirectorHeard’snewrolefocusedonjailpopulationwillenhancecommunicationwithinthejailsystem,ultimatelyincreasingthenumberofjaildiversionsandfurtherdecreasingjaildays.Additionally,teammembersidentifiedthatdelayedaccesstoapsychiatristalsohamperedimplementation.Itwasreportedduringthesecondsitevisitthatindividualswerewaiting30-45daysforanappointmentwithapsychiatristformedicationreview/renewal.Thiswasparticularlyproblematicgiventhatconsumersareprovidedwithjustatwo-weeksupplyofmedicationuponreleasefromjail.Duringthesecondyearoftheprogram,anadditionalpsychiatristhasbeenhiredtoprovideservicestoDCC’sjailservicesandreentrydivisionthreedaysperweek.Itisanticipatedthattheadditionofthepsychiatristwillimprovetimetotreatmentwithinthecommunity.IdentificationandMeasurementofProcessIndicatorsKeyProcessIndicatorsInadditiontoattemptingtocollectandanalyzetheK6mentalhealthscreeningsconductedatthejailpre-andpost-programimplementation,theEvaluationTeamworkedintandemwithstakeholderstoidentifyandmeasurekeyprocessindicatorswithintheimplementationofjailservicesinWayneCounty.Basedontheresultsoftheinitialconsultationwiththestakeholdersduringthefirstsitevisit,thefollowingprocessindicatorsweretobecollectedfromWayneCountybeginninginApril2015: #DCCConsumersBooked(perDailyBookingReports) #DCCConsumersReferredtoChiefHeardforConsiderationofAJR #ReferralstoIJDPfromWCJMHUJailClinician #ReferralsfromDickersonFacilitystaff #Referrals/ApprovalstoIJDPfromAJR #EnrolledinIJDP #IJDPEnrolleesReceivingEarlyRelease #In-reachSessionsConductedbyIJDPStaff #IndividualsReceivingIn-reachbyIJDPStaff #PhoneCallsorMeetingsRegardingPhase2ImplementationAsDCCrefocuseditsdiversionactivitiesonthepost-bookingcomponentofitsjaildiversionprogram,theevaluationofthepilotprogramwasadaptedaswell.Specificchangeswereimplementedinthecollectionofprocessdatatoappropriatelyreflectchangestotheprogramasimplemented.ThesechangesincludetheexaminationofreferralsourcesforindividualsreferredtoandultimatelyintheIJDP,aswellastheeliminationofindicatorsthatwerenotfeasiblyquantifiableincludingthenumberofDCCconsumersbookedtothejailandadvocatedfor/referredtoDirectorHeardforearlyrelease.Additionally,somechangesweremadetoalignprocessindicatorscollectedinWayneCountywithcross-siteindicatorscollectedattheotherjaildiversionpilotsites.Theidentifiedcross-sitevariablesincludejailbookings,mentalhealthscreenings,mentalhealthassessments,andindividualsreceivingservices.

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Thefinallistofprocessindicatorswasrevisedtoincludethefollowing.Theseareindicatedontheprocessmap(FigureH3). Removed #DCCConsumersBooked(perDailyBookingReports) Removed #DCCConsumersReferredtoChiefHeardforConsiderationofAJR Added #JailBookingsintoWCJ Added #MentalHealthStatusExamsconductedbyJailMHSocialWorker Added #ReferredtoMHUPsychologistbyRDCforMHAssessment

#ReferralstoIJDPfromWCJMHUJailClinician #ReferralsfromDickersonFacilitystaff #Referrals/ApprovalstoIJDPfromAJR #EnrolledinIJDP Added #EligiblebutNotEnrolledinIJDP

#IJDPEnrolleesReceivingEarlyRelease Removed #In-reachSessionsConductedbyIJDPStaff Removed #IndividualsReceivingIn-reachbyIJDPStaff Added #ServicesProvidedinJail Removed #PhoneCallsorMeetingsRegardingThelong-termoutcomeevaluationtobeconductedbytheEvaluationTeamandreportedin2017willfollowindividualsenrolledinIJDPtoassesstreatmentengagementinthecommunityandrecidivism.ProgramReferral/EnrollmentFigureH1belowshowsthatapproximately22%(3,208of14,552)ofthosebookedtoWayneCountyJailwerereferredformentalhealthserviceswhenscreenedformentalhealthproblemsbythejail’ssocialworker.FigureH1.WayneCountyProcessIndicators:April2015–September2015

*Atotalof64individuals,including50whoenrolledintheJDprogramand14whowereeligiblefortheprogram,butdidnotenroll,willbetrackedforshort-andlong-termoutcomesincludingjailrecidivismandmentalhealthtreatmentutilization.

Ofthese,38%(n=1,178)werereferredforcomprehensivementalhealthassessmentsbythejail’s

14,552

3,208

1,178255 50 14

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

JailBookings ReferralstoMH

MHAssessments

ReferralstoJDEnrolledinJD* EligibleNotEnrolledinJD*

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psychologist.Thenewjaildiversionprogram,IJDP,received255referralsandenrolled50individualsintotheprogramduringthefirstsixmonthsofimplementation.ThisenrollmentnumberindicatesthatDCCisontracktomeetenrollmentof100individualstoIJDPinitsfirstyear.NeedforMentalHealthServicesFigureH2belowshowstheexpressedneedformentalhealthservicesintheWayneCountyjail.AlthoughapreciseestimateofobjectiveneedisnotavailableforWayneCountyduetoissueswiththeimplementationoftheK6study,astateaverageof28%isusedasaproxytoassessestimatedneed.Sincethenumberofmentalhealthscreenings(3,208)is22%ofthebookedpopulation,itispossiblethatapproximately6%ofindividualswereunidentified,resultinginapotential‘uncaptured’need.FigureH2.EstimatedNeedforMentalHealthServicesintheWayneCountyJail

ProgressonYear1Short-TermObjectivesThefollowingshort-termobjectivesweredevelopedbystakeholdersduringtheproposalprocessaswellasjointlybetweentheEvaluationTeamandstakeholdersduringthefirstsitevisitandaddressboththepre-arrestandpost-bookingprograms.Progressassociatedwitheachstatedgoalisbasedoninformationandfeedbackgeneratedduringmonthlydatacollectioncallsandthesecondsitevisit.Overall,theprogramsuccessfullymetgoalsrelatedtoimplementationofthepost-bookingprogramwithinthejail.

1. Developandimplementasystemandprotocoltoidentifycurrent/previousDCCconsumerswhoarebookedatthejaileachday.Progress:Goalpartiallymet.Theprocessofgainingreferralsthroughreviewofthedailybookingreportfromthejailwasnotimplementedbecauseofthehighnumberofbookings(563perweek).BecausetheIJDPteamfoundthereviewofthedailybookingreporttobetooresourceintensivetoimplement,theprocesswasamendedtorelyuponreferralsfromothersourcestofeedtheprogram.

2. Developasystemtoidentify,assess,andopen/reactivateindividualswithinthejailwhomeetIJDPeligibilityandarenotcurrentDCCconsumers.

IdennfiedMHNeeds(ExpressedNeed),

22.0%

PotennallyUnidennfiedMHNeeds,5.9%

NoMHNeeds,72.1%

I-H5

Progress:Goalmet.Asillustratedintheprocessmapdevelopedduringthefirstsitevisit(FigureH3),thesystemdesignedandimplementedforIJDPencompassedreferralsfromtheWayneCountyJail’sMentalHealthUnitandDirectorHeard,DirectorofJailPopulation,whooverseesthejail’sAdministrativeJailReleaseinitiative.BothofthesereferralssourcesincludecurrentCMHandnon-CMHindividualswhomeetlegalandclinicalprogrameligibility.

3. DevelopaprocesstoadvocateonbehalfofeligibleDCCconsumersforparticipationthejail’searlyreleaseprogram.Progress:Goalpartiallymet.TheabilityofIJDPteammemberstoadvocateonbehalfofknownDCCconsumersforearlyreleasewashamperedwhenreviewofthedailybookingreportwasnotabletobeimplemented.Instead,asnotedabove,theprogramprimarilyreliesuponreferralstotheprogramratherthanproactivelyidentifyingconsumerswithinthesystem.However,thejailsocialworkstaffisidentifyingDCCconsumersduringthejail’smentalhealthscreeningprocess.IJDPteammembersreportahighlycollaborativeandaccessiblerelationshipbetweenIJDPandDirectorHeard,creatingafoundationforsuchadvocacyduringthisgrantperiod.

4. ImplementcomponentsofFACTModelasnecessarytoproviderecommendedtreatment“dosage”toIJDPenrollees.Progress:Goalmodifiedandinprocess.StrictfidelitytotheFACTModelhasreportedlybeenproblematicduetothehighcliniciantoconsumerratioof1:10requiredofthemodelandabsenceofkeycomponents(i.e.swiftaccesstopsychiatrist).Operatingatanestimatedratioof1:20,theIJDPteamhaslooselyfollowedtheFACTModelandisactivelyaddingcomponentsofFACT(i.e.,psychiatrist,individualtherapy).Theteamexpressedsome‘goalconflict’withstrictadherencetoFACTwiththeirenrollmentgoals(i.e.,100enrolleestoIJDPduringYear1)andisconsideringtransitioningtoamodifiedmodelmorealignedwiththeexistingstaff-to-consumerlevel.

5. Initiateatleasttwomeetingspermonthwithcommunityleadersand/orDPDofficialsrelatedtoPhase2objectives.Progress:Goalpartiallymet.EffortstoinitiatePhase2,thedevelopmentofthepre-arrestprogramwithDPD,wereunsuccessfulthroughoutthefirstyearofthegrantperiod.Asaresult,thisgoalwasnotmet.Itwasreportedatthesecondsitevisitthatthattheplanwillbeamendedandthepre-arrestprogramwillbeimplementedduringthesecondyearofthegrantperiod.Thereisamentalhealth/criminaljusticeadvisorycouncilinplaceinWayneCountyandthepre-arrestprojectwithDPDremainsontheagendaattheadvisorycouncillevel,althoughrepresentativesfromDPDhavebeenelusive.

NextStepsThesecondsitevisitrevealedanumberofpositivechangesandinitiativesforWayneCountyslatedforYear2oftheirprogramandareincludedhereasnextsteps.Asthefirstfourstepslistedbelowwerediscussedearlierinthisreport,theyarelistedinsummaryformonly.

1. Enhancecommunicationwithwithinthejailtoincreasethenumberofjaildiversionsand

furtherdecreasejaildaysbyreducingthelagtimebetweenidentificationofaneligibleconsumerandtheirenrollmentinIJDP.

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2. Improvetimetocommunity-basedtreatmentbyensuringthatconsumershaveaccesstoa

psychiatristformedicationreview/renewalbeforetheirtwo-weeksupplyofmedicationsends.

3. Continueengagementpost-jailreleasetoretainindividualsintreatment.4. Addressstaffingissuesinordertomaintaintheforwardmomentumoftheprogram.5. ServiceexpansiontoincludeindividualsdischargedfromthejailtoDetroitReceiving.A

memorandumofunderstandingwasrecentlysignedbetweenDCC,thejail,andDetroitReceivingHospitaltofacilitateservicesandhousingforindividualswhoaredischargedfromthejaildirectlytoDetroitReceiving.PreviouslytheseindividualswerenotfollowedintothecommunityandengagedintreatmentservicesbyDCC.Itisanticipatedthatthisagreementwillresultinimprovedcommunity-basedtreatmentengagementfortheseindividuals.

EvaluationTeamRecommendationsInadditiontotheaboveinitiatives,theEvaluationTeamrecommendsthefollowing:

1. Continuetoprovidefollow-upinformationforindividualswhoareeligiblebutnotenrolledinIJDP.TeammemberscurrentlyprovideidentifyingdataforindividualswhoarereferredtoandeligibleforIJDP,butwhochoosetonotenrollintotheprogram.Whileitwasnotedduringthesecondsitevisitthatthispracticeistime-consuming,weencourageteammemberstocontinueeffortstoprovidethisinformationtobolstertheevaluationofthejaildiversionprogram.

2. EstablishclearprogramguidelinesfordischargeandcontinuityofcarefromIJDP.Although

theFACTmodelindividualizesdischargebasedonattainmentofgoals,thereisnocurrentdemarcationbetweentheIJDP/FACTprogramservicesandcontinuityofcareaspracticedinthe‘treatmentasusual’communitymentalhealth.Stakeholdersareencouragedtoestablishanddocumentclearguidelinesfordischarge(i.e.,objectivestomeetforcompletionordischargefromprogram)andcontinuityofcare(i.e.,howtheconsumerwillbetransferredoutofIJDPcaseloadtocommunitycasemanager)fromIJDP.

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FigureH3.WayneCountyProcessMap

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Arrest

IntakeScreening10Medical/10MentalHealthConductedbyMedicalAsst.

JailBooking

If“Yes”toMH/SA,Meds,Suicide

If“No”toMH/SA,Meds,Suicide

Risk

ReferraltoRDCforMentalStatusExam(MSE)ConductedbyJailMHUMSW

FlaggedbyJailStaff

AssignedtoJailMentalHealth

DataCollectionPoint:

1.NumberJailBookings:14,552

DataCollectionPoint:

4.TotalNumberReferralstoIJDPfrom

allsources:255

OutcomeDataCollection:#/typesvcsprovidedinjailJailbooking/releasedatesMHsvc/typepost-releasePresence/absenceofprison

GenPopw/Treatment

GenPopNoTreatment

ReviewbyWCPOLegalEligibilityforDiversion

ReviewbyCDUClinicalandPreliminaryLegalEligibility

forDiversion

NoSMI

YesSMI

ReviewbyDirofJailPopulationEligibilityforEarlyReleasevia

IJDPorAJR

Diversion1

MHCIJDP

CMHIJDPEligibilityCriteria:

CMHConsumer(CurrentorReactivated)MisdemeanororLowFelonyIneligibleforMHC/Diversion1

ServicesProvided:

FACTModel(startingduringincarceration)Directcontactw/IJDPteammbrs3xweek

In-reachduringincarcerationHousingplacement

IneligibleforDiversion

ReferralfromJailMHUforIJDP Inpatient

NEWPROCESS:CMHIJDPReviewofDailyBookingReport

ReferCurrent/PreviousCMHConsumersforConsiderationofEarly

Release/IJDP

CommunityProvider

NEWPROCESS:DCCIJDPIn-Reach

AJR

ExcelSpreadsheet–ID&DemographicDataof

IJDPEnrolleesandNon-Enrollees:

Name,BookingID,CMHID,M/F,Race,DOB,ReferralSource

DataCollectionPoint:

5.NumberofConsumersEnrolledinIJDP:

50

6.NumberofConsumersEligiblebutnotEnrolledinIJDP(June–Sept.only):

14

7.NumberServicesProvidedinJail:221

DataCollectionPoint:

2.MentalHealthStatusExam(MHSE)conductedbyRDCMH

SocialWorker:3,208

3.ReferralstoJailMHU

PsychologistbyRDCMHSocialWorker:1,178

(ProvidedbyJail)

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AppendixII:ProcessDataCollectionMethodologyThisevaluationreliesonmultiplesourcesofdatatoassesstheimplementationandprocessesoftheeightpilotprograms. ProcessMethodsProcessmethodsemployedduringthisevaluationperiodincludedK6jailscreenings,sitevisits,processmapping,anddatacollection.ForthosesitesimplementingCIT,pre-andpost-testswereconductedacrossallofficersparticipatinginthetraining.Eachofthesemethodsisdescribedingreaterdetailbelow.K6JailScreeningsTheeightpilotprogramsrepresentdiversecommunities:differentgeographically,inpopulationsizeanddensity,andinthesizeandscopeoftheproblem.Theuniquenessofthepilotprogramslimitsthestate’sabilitytoassessthecumulativeimpactoftheprojectsstatewide.OnewaytocollectconsistentdataacrosssitesistomeasurethediversionofindividualswithSMIfromthelocaljails.Inanefforttomeasuretheimpactofthejaildiversionprogramsonalleightjails,theEvaluationTeamcollecteddatareflectingthenumberofindividualswithaSMIbookedintoeachjailbeforetheinterventionisimplemented(February2015)andoneyearlater(February2016).

Thedatacollectedfromeachjailconsistsofasinglesheetscreeningincluding:characteristics(e.g.,DOB,sex,ethnicity),sixquestionsrelatedtocurrentmentalhealthissues(lasttwoweeks),priorjailand/ortreatment.ThescreeningwasconductedbytheBookingOfficer(s)witheveryindividualbookedintothejail(withtheexceptionofINS/immigration/ICEdetainees)duringthetwocollectionperiods.Thegoalwastocollectatleast200completedscreeningsfromeachsiteduringbothcollectionperiods.If200screeningswereachievedduringthe1-weekperiod,collectionwasceased.If200screeningsarenotachievedduringtheinitial1-weekperiod,collectioncontinueduntilleast200completedsurveyswereachieved.Attwositeswherebookingnumberswerelow(BarryandMarquette),thecollectionperiodwasextendedfromFebruary2015–December2015toprovideasamplesizesuitableforanalysis.ThecollecteddatawasforwardedbythejailstotheEvaluationTeambyeitheremailorhardcopythroughthemailattheconclusionofbothcollectionperiods.InthetwocaseswherecollectionwasextendedthroughDecember,completedhardcopiesofthescreeningswereforwardedtoEvaluationTeamonamonthlybasis.ScreeningswerethenlabeledandnumberedbyamemberoftheEvaluationTeam.ScreeningdatawasthencodedandenteredintoadatabasebyamemberoftheEvaluationTeam.SiteVisitsInitialsitevisitswereconductedatalleightsitesinMarch2015.Allsitevisitswereconductedinpersonandlastedapproximatelyfourhours.Thepurposeofthesitevisitwastofamiliarizemembersoftheevaluationteamwithkeystakeholders,tounderstandprogrameligibilityandscope,todocumenttheflowofprogramactivitiesfrominitialintercepttodiversion,andtodevelopdatacollectionprocessesandmechanisms.Inaddition,short-termobjectivesfortheprogramwereidentified.Stakeholdersrepresentingmentalhealthandcriminaljustice(i.e.,jail,sheriff’sdepartment,localpolicedepartment)werepresentduringeachsitevisit.

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Secondsitevisitswereconductedwithalleightsitesduringthefirstquarterof2016.Ofthese,sixwereconductedface-to-face(Berrien,Kalamazoo,Kent,Monroe,Oakland,andWayne)andtwowereconductedbyphone(BarryandMarquette).Allsitevisitslastedapproximatelytwohours.Thepurposeofthesecondsitevisitwastoreviewshort-termobjectivesidentifiedduringthesitevisit;reviewanychangestotheprogramduringyearone;andtohighlightanychallengesandsuccesses.Inaddition,objectivesforthesecondyearofoperationwereidentified.ProcessMappingProcessmappingwasconductedinconjunctionwitheachsitevisit.AprocessmapwascreatedtoillustratejailservicesandCITinthosecaseswhereCITwasimplementedwithinthecommunity.Theprocessmapillustratestheinterceptofindividualspre-(i.e.,CIT)orpost-booking(i.e.,jailservices)andfollowstheindividualthroughthevariousprocessesandservicesassociatedwiththepilotprogramwithinthecontextofexistingjail-andcommunity-basedprocesses.Theprocessmapwasusedtoassesstheflowofthepilotprogramatboththeindividualandsystemsleveltoanswerthefollowingquestions:Whenandwhereareindividualsintercepted?Howareindividualsdivertedfromthecriminaljusticesystemtotreatment?Whatservicesareprovidedviathepilotprogram?Whatdataindicatorsareavailableformeasurementthroughouttheprocess?Inaddition,theprocessmapsillustratesimilaritiesanddifferencesacrosstheeightpilotprograms.ProcessmapsforalleightsitesarepresentedinAppendixIII.ProcessDataCollectionBasedontheprocessmap(s)established,auniquedatacollectionplanwasdevelopedandimplementedforeachsite.Datacollectionformswerecreatedforeachsitetoguidekeystakeholdersinthecollectionofspecificprocessindicatorsonamonthlybasis.Theprocessindicatorsincludedbothexistingprocesses(i.e.,jailbookingsandcallstodispatch)andthedevelopmentofnewprocessesrelatedtothepilotprogram(i.e.,referralstotheprogramandnumberofindividualsreceivingservices).Datawasprovidedbythekeystakeholdertotheevaluationteameachmonthinadvanceofthemonthlyconferencecall(seebelow).CITPre-andPost-TestsImmediatelypriortothestartoftheCITtraining,apre-testwasadministeredtoallattendingofficers.Apost-testwasadministeredimmediatelyfollowingthetraining.Twoinstruments,validatedinotherresearchonCITtraining,wereusedinthepre/post-tests.Thefirstinstrumentwasusedtoassessofficers’knowledgeregardingpsychiatrictreatmentsforindividualswithmentalillness(OPTScale);thesecondinstrumentwasusedtoassessofficers’understandingofhowtode-escalateaggressivebehaviorfromanindividualsufferingfrommentalillness(De-escalationScale,seebelow).Apre/post-testdesignwasutilizedtoassesschangesinknowledgeandunderstandingasaresultofthetraining.OpinionsaboutPsychiatricTreatments(OPT)Scale.Thefirstinstrumentincludedquestionsabouttheofficers’knowledgeregardingpsychiatrictreatmentsforindividualswithmentalillness.Thequestionsaboutmedication,psychotherapy,dayandresidentialtreatmentprograms,andcasemanagementservicesaskedfortherespondent’sagreementwiththestatementusinga5-pointscale(i.e.,stronglyagreetostronglydisagree).Thescalewassummedtoprovideanoverallscoreforeachofficer.De-escalationScale.Thesecondinstrumentincludedquestionsabouttheofficers’understandingofhowbesttode-escalatethebehaviorofanindividualsufferingfrommentalillness.Avignettewasprovidedconcerninganindividualwhopresentedsignsofmentalillness.Officerswerethenaskedifspecificverbalandbehavioralresponseswouldbepositiveornegative(4-pointscale)inthesituation.Ascale

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wascreatedwithapossiblescoreof32;higherscoresindicatetheofficerhadmorehelpfulresponsestowardsthepersonwithmentalillness.ImplementationMonitoringMethodsImplementationmonitoringmethodsemployedduringthisevaluationperiodincludedmonthlyconferencecallsandimplementationinterviews.Eachofthesemethodsisdescribedingreaterdetailbelow.MonthlyConferenceCallsMonthlydatacollectioncallswereconductedwitheachsitebeginninginApril2015.Thepurposeofthecallwastwo-fold:1)tocollectprocessindicatorsbasedontheprocessmap(seeabove),and2)tomonitortheimplementationofthepilotprogram.Theconferencecallswereheldbetweenmembersoftheevaluationteamandkeystakeholdersfromeachsiteasidentifiedbyeachpilotprogram.The30-minuteconferencecallsincludedareviewofthepreviousmonth’sdataprovidedbythesite,modificationandfinalizationofprocessmap(s),discussionofimplementationaccomplishmentsandchallenges,andanupdateonthecurrentstateoftheevaluationprovidedbytheevaluationteam.ImplementationInterviewsImplementationinterviewswereconductedwithkeycriminaljusticeand/orcommunitymentalhealthstakeholdersinAugust2015.TheinterviewswereconductedbyphonewithsevenoftheeightsitesincludingBarry,Berrien,Kalamazoo,Marquette,Oakland,andWayneCounties.Thepurposeoftheimplementationinterviewwastolearnmoreabouttheprocessundertakenateachsitetoimplementpilotprogram.AnimplementationinterviewwasnotconductedwithKentCountywherethepilotprogramwasactuallythesustainmentofanexistingjailservicesprogram.Eachinterviewtookapproximately60minutesandfocusedontheprimaryobjectiveofeachsite–eitherjailservicesorCIT.Questionswereaskedaboutthefollowing:

! Highlightsoftheprojecttodate.

! Aspectsoftheprojectwhichwereunanticipatedorsurprising.

! Problemsorbarrierstoimplementation.

! Thelevelandkindsofcollaborationthathavebeenachievedtodate.

! Additionalsupportsthatwouldbenefitimplementationofthepilot.

! Anyadvicesiteswouldoffertootherswhoareconsideringimplementingadiversionproject.