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83% of jails provide some screening Steadman and Veysey 19

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Title: 83% of jails provide some screening Steadman and Veysey 19


1
  • Responding to the Needs of Justice Involved
    Persons with Mental Illnesses
  • Screening and Assessment

Fred C. Osher, MD Director of Health System
s Services Policy

July 24, 2008
2
Dear Abby.
3
CSJ Justice Center National Projects
4
(No Transcript)
5
  • Council of State Governments Justice Center
    Florida Activities
  • NIC Learning Site
  • Chief Justice Initiative
  • Collaboration with FMHI

6
Goals of Presentation
  • Overview and Context
  • Target Population and Program Design
  • Screening and Assessment
  • Supervision and Treatment Planning
  • Evidence Based Practices

7
Skyrocketing Criminal Justice Populations
Bureau of Justice Statistics, 2005
8
Scope of the Problem
  • Over 14 bookings into U.S. jails each year
  • Over 9 million adults
  • Over 1,000,000 will have serious mental
    illnesses
  • ¾ of these will have co-occurring substance use
    disorders
  • The vast majority will be released to community

9
GAINS, 2004
10
GAINS, 2004
11
Co-Occurring Substance Use Disorders Among Jail
Detainees with Serious Mental Disorders
  • With Co-Occurring Substance Use Disorders
  • Without Co-Occurring Substance Use Disorders

GAINS 2004
12
Goals of Presentation
  • Overview and Context
  • Importance of Target Population and Program
    Design
  • Screening and Assessment
  • Supervision and Treatment Planning
  • Evidence Based Practices

13
Diversion ProgramsLogic Model
Steadman, Osher, Naples
Stage 1 Stage 2
Identify Target Group
Comprehensive/Appropriate Community Treatment
Diversion
Improved Public Safety Outcomes
Improved Mental Health Outcomes
Stage 3 - Outcomes
14
Target Population and Program Design Three
Questions
  • Who is your target population?
  • What will you do for them?
  • How will you sustain your program?

15
Defining the Target Population
Finding your target population not so simple
16
Finding the Target Population
SCREENING FOR MHPTR ELIGIBILITY
17
Defining the Target Population
18
Impact of Target Population on Outcomes
Pennsylvania Comparisons of Simulation Models
19
Some Common Front-end Pitfalls
  • Vague criteria for target group
  • Missing key people in planning
  • Overly ambitious goals
  • EBPs what are they and where are they?
  • Workforce capacity and workforce quality

20
Goals of Presentation
  • Overview and Context
  • Target Population and Program Design
  • Screening and Assessment
  • Supervision and Treatment Planning
  • Evidence Based Practices

21
Mental health service delivery begins with
identification
  • Three stage process
  • Screening
  • Assessment
  • Supervision/Treatment Planning

22
Screening, Assessment, and Treatment Planning
Screening for Need/Risk
(NIDA, 2006)
23
Definition Screening
  • A formal process of testing to determine whether
    an inmate does or does not warrant further
    attention at the current time in regard to a
    particular disorder and, in this context, the
    possibility of a mental disorder.
  • The screening process for mental illnesses
    disorders seeks to answer a yes or no
    question. Might a mental illness exist?
  • Note that the screening process does not
    necessarily identify what kind of problem the
    person might have, or how serious it might be,
    but determines whether or not further assessment
    is warranted.

23
24
Screening for Mental Illnesses
25
Why screen for mental illness?
  • Jail populations have 3-4 times higher rates of
    mental illness than the general population
  • Public health opportunity
  • U.S. Supreme Court has held that jails and
    prisons are obligated to provide mental health
    care
  • Critical to jail management
  • Essential for rapid engagement in specialized
    treatment and supervision programs

26
What else to screen for ?
  • Suicide Risk
  • Substance Use Disorders
  • Motivation
  • Criminogenic Risk

27
Features of Useful Screening Instruments
  • High sensitivity (but not high specificity)
  • Brief
  • Low cost
  • Minimal staff training required
  • Consumer friendly

27
28
Historic lack of adequate mental health screening
  • 83 of jails provide some screening Steadman and
    Veysey (1997)
  • Only 37 of jail detainees with severe mental
    disorder were identified during routine screening

  • Teplin (1990)
  • Recent use of data matching programs

29
NIJ Research
  • Develop a brief jail mental health screening tool
    to be used by correctional staff on all jail
    admissions
  • Brief
  • Easy to use
  • Clear decision criteria
  • Balance false negative and false positive rates
  • Validate the tool to confirm its utility and make
    available to U.S. jails

30
Brief Jail Mental Health ScreenResearch Approach
  • Use the screen in four jails for eight months at
    two points in time
  • Administered structured clinical interview
    (SCID)to a sub-sample of inmates
  • Compare the screens with the clinical interviews
    for validation

31
Validation study
  • Screened over 20,000 inmates
  • Sampled 100 inmates at each jail
  • Stratified by status (urgent, routine,
    non-referral) and gender
  • Administered the Structured Clinical Interview
    for DSM-IV (SCID)
  • Identified false positives and false negatives
    rates and appropriate scoring cut-offs

32
Validation Results
  • Males
  • 80 correctly identified
  • 64 sensitivity
  • 84 specificity
  • 8 False Negatives
  • Females
  • 72 correctly identified
  • 61 sensitivity
  • 75 specificity
  • 14 false negatives

33
BJMHS - Conclusions
  • A useful, cost-effective tool for screening men
    and women booked into U.S. jails
  • Reasonable referral rates (11 16)
  • 8 questions can be administered by corrections
    staff in 2 3 minutes
  • NIJ based on successful validation results, it
    is anticipated these tools will be disseminated
    nationwide for use in all correctional
    facilities

34
Screening for Suicide Risk
35
Suicide and Corrections
  • Suicide is a primary cause of death in many
    county correctional facilities
  • It takes a team to prevent suicide
  • The correctional officer has the most critical
    role in suicide prevention
  • Most suicides can be prevented when the team
    knows what to look for and what to do
  • Liability is reduced significantly when the team
    understands and follows the suicide prevention
    plan.

36
Suicide Prevention (BJS, 2005)
  • Jail suicide rates 47/100,000
  • Rates in 50 largest jails (29/100,000)
  • Suicide rates are declining steadily nationally
  • No longer leading cause of death at 32.3 (now
    illness at 47.6 is leading cause)
  • Nearly ½ of jail suicides occur in first week of
    custody
  • The importance of screening

37
Suicide Intake Screening
  • Suicide Prevention Screening Guidelines Form
  • Takes less than 5 minutes to fill out
  • Devoted exclusively to identifying suicidal
    behavior in arrestees
  • Encourages communication between
    arresting/transporting and booking officers
  • Guidelines for acute referral
  • Standardized training available
  • Used in conjunction with BJMHS

38
Suicide Prevention more than a screening
instrument
  • Initial screen and periodic assessment
  • Suicide prevention training for correctional,
    medical, and MH staff
  • Levels of communication between outside agencies,
    among facility staff, and with the suicidal
    inmate
  • Suicide resistant, protrusion free housing for
    suicidal inmates
  • Level of supervision for suicidal inmates
  • Timely emergency interventions following
    attempts
  • Critical incident stress debriefing to affected
    staff and inmates, as well as a multidisciplinary
    mortality review of suicides and serious attempts

39
Screening for Substance Use Disorders
  • TCU Drug Dependence Screen II
  • High overall accuracy
  • Tested in jail and prison settings
  • Brief, easy to score with low, medium, and high
    cut-off points
  • Simple Screening Instrument
  • High accuracy, tested in corrections
  • Brief, easy to score

40
Screening for Motivation
  • Useful in matching to scarce treatment resources
  • Caution Motivation as state, not trait
  • Available measures
  • SOCRATES stages of change readiness and
    treatment eagerness scale
  • URICA University of Rhode Island Change
    Assessment Scale

41
Screening for Criminogenic Risk
  • Long history in c-j settings
  • Useful in determining supervision intensity
  • Potential application for assignment ot cognitive
    behavioral programs
  • Brief Screens in Development Austin 8 item
    scale
  • LSI-R, WISC R, COMPASS

42
Definition Assessment
  • A basic assessment consists of gathering key
    information and engaging in a process with the
    client that enables the counselor/therapist to
    understand the clients readiness for change,
    problem areas, COD diagnosis, disabilities, and
    strengths.
  • An assessment typically involves a clinical
    examination of the functioning and well-being of
    the client and includes a number of tests and
    written and oral exercises. The COD diagnosis is
    established by referral to a psychiatrist or
    clinical psychologist.
  • Assessment of the COD client is an ongoing
    process that should be repeated over time to
    capture the changing nature of the clients
    status.

43
Domains of Assessment
  • Acute Safety Needs
  • Quadrant Assignment
  • Level of Care
  • Diagnosis
  • Disability
  • Strengths and Skills
  • Recovery Support
  • Cultural Context
  • Problem Domains
  • Phase of Recovery/Stage of Change

43
44
The Best Assessment Tool
44
45
An Assessment Approach The APIC Model of
Transition Planning for Persons With SMI Leaving
Jails
46
Outcomes of Inadequate Transition Planning
  • Compromised public safety
  • Increased psychiatric disability
  • Relapse to substance abuse
  • Hospitalization
  • Suicide
  • Homelessness
  • Re-arrest

47
Jails vs. Prisons
  • Jails hold both detainees awaiting court
    appearances, persons awaiting sentencing, AND
    inmates serving short term sentences
  • Short episodes of incarceration
  • Inmates less likely to have lost contact with
    community supports
  • Unpredictable nature of jail release

48
The APIC Model
  • Assess the inmates clinical and social needs,
    and public safety risks
  • Plan for the treatment and services required to
    address the inmates needs
  • Identify required community and correctional
    programs responsible for post-release services
  • Coordinate the transition plan to ensure
    implementation and avoid gaps in care with
    community-based services
  • Assess
  • Plan
  • Identify
  • Coordinate

49
ASSESS
  • Begins with identification of inmate with mental
    illness
  • Screening and Referral
  • Need for valid and reliable screening measures
  • Applied to every newly admitted inmate during
    routine intake process
  • Conducted by correctional staff
  • red flags result in need for discharge
    planning
  • Obtain old records
  • Engage the consumer in the transition process

50
PLAN
  • Planning must be multidisciplinary
  • Address short-term and long-term needs
  • Critical time intervention
  • What has worked before?
  • Seek family input

51
PLAN (cont.)PLANNING DOMAINS
  • Housing
  • Medication
  • Integrated treatment for co-occurring dx
  • Medical Care
  • Food and Clothing
  • Transportation
  • Child Care
  • Civil Legal Services

52
IDENTIFY
  • Identify community providers that are appropriate
    to the inmate based on
  • clinical diagnosis
  • demographic factors
  • financial arrangements
  • geographic location
  • legal circumstances
  • Clarify confidentiality and information sharing
    processes and communication expectations

53
IDENTIFY(cont.)
  • Match conditions of release to severity of
    criminal offense
  • Match intensity of community care to severity of
    disability and motivational state
  • Ensure that every inmates belongings are
    returned upon release
  • Identification
  • Benefit cards
  • Medications

54
Coordinate
  • Case management services
  • To communicate the inmates needs to planning
    agents
  • To coordinate the timing and delivery of
    services
  • To span the boundary between institution and
    community
  • In-reach activities to be supported

55
Coordinate(cont.)
  • Critical Transition Responsibilites
  • Where, when and with whom are first visits
    scheduled ?
  • Does the releasee has adequate supply of meds to
    last through the first appointment ?
  • Who is contacted if any aspect of the plan falls
    through or needs to be modified ?
  • Establish a tracking mechanism to follow-up on
    failed appointments

56
APIC APPLICATIONS
  • APIC Checklist for Every Inmate Identified with a
    Mental Illness
  • Brief, targeted, with multiple copies
  • Being used in numerous jails
  • Applied in jail diversion programs

57
Comprehensive Screening and Assessment Approach
Peters, 2008
  • All individuals entering the criminal justice
    system should be screened for mental and
    substance use disorders
  • Screening should be completed at the earliest
    possible point of involvement
  • Screening should occur at multiple points in the
    c-j system
  • Whenever possible, similar or standardized
    instruments should be used at different points in
    MH and CJ systems
  • Information from previous screening and
    assessments should be communicated throughout the
    different systems.

58
Goals of Presentation
  • Overview and Context
  • Target Population and Program Design
  • Screening and Assessment
  • Supervision and Treatment Planning
  • Evidence Based Practices

59
Principles of Integrated Treatment and Supervision
  • Supervision and treatment plans must be
    individualized based on assessment
  • Clinical need
  • Motivation for Treatment
  • Risk Assessments
  • Availability of Treatment
  • Timing of Intervention

(NIDA, 2006)
60
Principles of Integrated Treatment and Supervision
  • Supervision and treatment must be collaborative
    and complementary
  • o Shared missions and visions
  • o Multi-disciplinary teams
  • o Clear lines of communication
  • o Formal and Informal Mechanisms for
    working together

(NIDA, 2006)
61
Collaboration Outcomes
62
Goals of Presentation
  • Overview and Context
  • Target Population and Program Design
  • Screening and Assessment
  • Supervision and Treatment Planning
  • Evidence Based Practices

63
Why Should You Care About EBPs?
  • They are the new buzz-words for mental
    healthniks
  • There is increasing emphasis in MH/SA/CJ on
    performance measures and EBPs
  • They are critical to successful alternatives to
    incarceration and to slowing the revolving door

64
What is Evidence-Based Practice ?
  • Evidence-Based Practice is
  • the integration of the best
  • research evidence with
  • clinical expertise and
  • patient values.
  • Institute of Medicine, 2000

65
Pyramid of Research Evidence

(COCE, 2005)

66
What is Fidelity?
  • Fidelity is the degree of implementation of an
    evidence-based practice
  • Programs with high-fidelity are expected to have
    greater effectiveness
  • Fidelity scales assess the critical ingredients
    of an EBP

67
Evidence Base Practices for Justice Involved
Persons with Mental Illnesses
  • Housing with Appropriate Supports (Modified
    Therapeutic Communities)
  • Integrated Dual Disorder Treatment
  • Multidisciplinary Teams (ACT and FACT )
  • Supported Employment
  • Trauma-informed Systems of Care
  • Illness Self Management
  • Psychopharmacologic Medications

68
Challenges to EBP Implementation
  • Target population characteristics
  • Staff attitudes and skills
  • Facilities/resources (Physical environment, staff
    and staffing patterns, funding resources,
    housing, transportation)
  • Agency Policies/Administrative Practices
  • Local/State/Federal regulation
  • Interagency networks
  • Reimbursement

69
Past Year Treatment among Adults Aged 18 or Older
with Co-Occurring SMI and a Substance Use
Disorder 2003 (NSDUH)
Treatment Only for Mental Health Problems
Treatment for Both Mental Health and Substance
Use Problems
39.8
7.5
3.7
Substance Use Treatment Only
No Treatment
49.0
4.2 Million Adults with Co-Occurring SMI and
Substance Use Disorder
70
The Bottom Line (Osher and Steadman, 2008)
71
Is there too much emphasis on EBPs ?
  • There are not enough EBPs to cover the range of
    clinical circumstances
  • Hence, Evidence-Based Thinking
  • The conscientious, explicit, and judicious use of
    current best evidence in making decisions about
    the care of individual patients.

72
Moving Forward
73
  • FMHI Jail Survey
  • Current screening and assessment practices
  • Database infrastructure and capacity
  • Medication and clinical responses
  • Information sharing practices

74
  • FMHI Jail Pilot Project
  • Up to 3 County Jails
  • Implement Screening and Assessment Processes
  • Identify Prevalence of Mental Illnesses at point
    in time
  • Use data to evaluate community interventions

75
Infonet Links
  • Through the TA Center website, grantees will be
    able to access and search up-to-date profiles of
    the collaborative programs in Florida and related
    media coverage by county.
  • Grantees will be able to log in to create a
    detailed program webpage to which they can refer
    others, including funders.
  • Program profiles will be available in a national
    searchable database, raising their national
    profile in the field.

76
The Goal
  • .must build lasting bridges between mental
    health and criminal justice systems, leading to
    coordinated and continual health care for clients
    in both systems


  • (Lurigio, 1996)

77
  • Thank You

Contact Information Fred Osher fosher_at_csg.org

www.justicecenter.csg.org
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