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.
3CSJ 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
6Goals of Presentation
- Overview and Context
- Target Population and Program Design
- Screening and Assessment
- Supervision and Treatment Planning
- Evidence Based Practices
7Skyrocketing Criminal Justice Populations
Bureau of Justice Statistics, 2005
8Scope 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
9GAINS, 2004
10GAINS, 2004
11Co-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
12Goals of Presentation
- Overview and Context
- Importance of Target Population and Program
Design
- Screening and Assessment
- Supervision and Treatment Planning
- Evidence Based Practices
13Diversion 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
14Target Population and Program Design Three
Questions
- Who is your target population?
- What will you do for them?
- How will you sustain your program?
15Defining the Target Population
Finding your target population not so simple
16Finding the Target Population
SCREENING FOR MHPTR ELIGIBILITY
17Defining the Target Population
18Impact of Target Population on Outcomes
Pennsylvania Comparisons of Simulation Models
19Some 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
20Goals of Presentation
- Overview and Context
- Target Population and Program Design
- Screening and Assessment
- Supervision and Treatment Planning
- Evidence Based Practices
21Mental health service delivery begins with
identification
- Three stage process
- Screening
- Assessment
- Supervision/Treatment Planning
22Screening, 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
24Screening for Mental Illnesses
25Why 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
26What else to screen for ?
- Suicide Risk
- Substance Use Disorders
- Motivation
- Criminogenic Risk
27Features of Useful Screening Instruments
- High sensitivity (but not high specificity)
- Brief
- Low cost
- Minimal staff training required
- Consumer friendly
27
28Historic 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
29NIJ 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
30Brief 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
31Validation 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
32Validation Results
- Males
- 80 correctly identified
- 64 sensitivity
- 84 specificity
- 8 False Negatives
- Females
- 72 correctly identified
- 61 sensitivity
- 75 specificity
- 14 false negatives
33BJMHS - 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
34Screening for Suicide Risk
35Suicide 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.
36Suicide 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
37Suicide 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
38Suicide 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
39Screening 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
40Screening 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
41Screening 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.
43Domains 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
44The Best Assessment Tool
44
45An Assessment Approach The APIC Model of
Transition Planning for Persons With SMI Leaving
Jails
46Outcomes of Inadequate Transition Planning
- Compromised public safety
- Increased psychiatric disability
- Relapse to substance abuse
- Hospitalization
- Suicide
- Homelessness
- Re-arrest
47Jails 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
48The 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
49ASSESS
- 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
50PLAN
- Planning must be multidisciplinary
- Address short-term and long-term needs
- Critical time intervention
- What has worked before?
- Seek family input
51PLAN (cont.)PLANNING DOMAINS
- Housing
- Medication
- Integrated treatment for co-occurring dx
- Medical Care
- Food and Clothing
- Transportation
- Child Care
- Civil Legal Services
52IDENTIFY
- 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
53IDENTIFY(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
54Coordinate
- 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
55Coordinate(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
56APIC 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
57Comprehensive 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.
58Goals of Presentation
- Overview and Context
- Target Population and Program Design
- Screening and Assessment
- Supervision and Treatment Planning
- Evidence Based Practices
59Principles 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)
60Principles 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)
61Collaboration Outcomes
62Goals of Presentation
- Overview and Context
- Target Population and Program Design
- Screening and Assessment
- Supervision and Treatment Planning
- Evidence Based Practices
63Why 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
64What 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
65Pyramid of Research Evidence
(COCE, 2005)
66What 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
67Evidence 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
68Challenges 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
69Past 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
70The Bottom Line (Osher and Steadman, 2008)
71Is 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.
72Moving Forward
73- 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
75Infonet 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.
76The 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)
77Contact Information Fred Osher fosher_at_csg.org
www.justicecenter.csg.org