1. Decarcerating America
Ron Manderscheid, PhD
Exec Dir, NACBHDD & NARMH
Adj Prof, BSPH, JHU

2. The National Tragedy
“Each year, approximately 2 million people who suffer from complex illnesses – such as schizophrenia and bipolar disorder -- are admitted into correctional facilities. Once incarcerated, they tend to spend more time behind bars and face higher recidivism rates than other members of the prison population. They also face long odds for receiving adequate care for their mental illness – which often co-occur with substance use disorders and other medical conditions – once they are incarcerated.”
Renee Binder, MD

3. The National Uncertainty
Future of the Affordable Care Act (ACA)???
Future of Medicaid???
Future of Medicare???
Future of mental health, substance use, and ID/DD care???

4. We Lack Coordinated Action
Coordinated action is essential to reduce the national tragedy of inappropriate incarceration.
Broad agreement exists that such action is required, e.g., bipartisan 21st Century Cures Act.
We require a simple national plan.

5. Yet
No national plan has been developed to date.

6. What Needs to be Coordinated?
Federal Departments: HHS, DOJ, HUD, at minimum
State Departments: Behavioral Health, Health, Corrections, Housing Social Services
County and City Departments: Behavioral Health, Health, Corrections (Sheriff and Police), Housing, Social Services
Community: Neighborhood Support and Organization for Appropriate Action

7. How to Achieve Coordination?
Start with a small set of basic principles:
Provide community care
House when homeless
Divert whenever possible
Engage with job and friends.
Partition and assign responsibilty for coordination, e.g., Who will coordinate HHS and DOJ activities?
Draft a short manifesto for action.

8. My Question:
What actions will this Conference take to facilitate development of this coordinated national plan?

9. Our View of Jails has Changed Dramatically

10. View from 1904

11. View from 2016

12. Incarceration in the US: Very large, but a slight decline

13. Tonight – County and City Jails
About 730,000 persons in these jails:
182,500 (25%) persons with a mental illness
365,000 (50%) persons with a substance use disorder
Major co-morbidity between the two groups
The two groups (547,500) actually approximate the total number in state
mental hospitals in 1955 just before deinstitutionalization started (559,000) .

14. Tonight – Federal and State Prisons and Penitentiaries
Federal: About 215,000
State: About 1,270,800
At least 1in 2, or 50%, have MI or SUD, with a very high degree of comorbidity.
APA: “On any given day, between 2.3 and 3.9 percent of inmates in state prisons are estimated to have schizophrenia or other psychotic disorder; between 13.1 and 18.6 percent have major depression; and between 2.1 and 4.3 percent suffer from bipolar disorder.”

15. Tonight – Juvenile Justice Facilities
Juvenile Justice Facilities: About 70,800 (more than 500,000 in one year)
NCSL: “As many as 70 percent of youth in the system are affected with a mental disorder.”

16. Some Observations
The actual incarceration rate in the US is about 1 person in 100.
The actual rate of involvement in the criminal justice system, including probation and parole, is about 4 in 100.
US is generally thought to have the highest rates in the world!

18. What went wrong with mental health and substance use care?
Deinstitutionalization never really worked
Trans-institutionalization never really worked
Community system was never developed
We have defaulted to jails as health care institutions.

19. Why?
Some impediments:
Reagan Era changes and cuts, e.g. Mental Health Block Grant
Great Recession, e.g. behavioral health lost $4.5 billion
Philosophical differences in behavioral healthcare, e.g., conflicts between community and inpatient care approaches.

20. Two County Responses Today
NACo/CSG Stepping Up Initiative
Goal: Reduce the prevalence of mental illness and substance use in county jails.
Mechanism: County Board Resolution followed by county convening across systems, then development and implementation of a strategic plan.
NACBHDD Decarceration Initiative
Goal: Increase the capacity of county behavioral healthcare systems to intercept people before they fall into the jails and to provide continuous care.
Mechanism: Individual and group TA; webinars; some convening; a small pilot.

21. Sequential Intercept Model

22. NACBHDD Response: Intercept “0”
Improve the capacity and functioning of county behavioral health authorities to intercept person before they come in contact with the criminal justice system.

23. Key Principle Underlying Initiative
If we want to keep persons with MI and SUD out of jail, then we need to provide essential behavioral health and health services to these populations ( Intercept “0” ) .

24. Steps in the NACBHDD Initiative
Identify Key Issues through Focus Groups
Provide Individual and Group Consults, Webinars, etc.
Build a Library of County Best Practices
Do a small pilot: Determine what works and promote it.

25. Some Considerations Counties differ! SIZE: Rural; Intermediate; Urban
and
PROGRAMS: Operate or Contract for Behavioral Health Services
FUNDING SOURCES: Medicaid, State General Revenue, County Tax Assessments, etc.

26. Some Foci of This Work Crisis Response Systems
Peer-operated warm lines; Hot lines;
Awareness/Action & Crisis Intervention Trng (CIT);
Restoration Center; Sobering Center;
Supports, including short-term Housing;
Long-term community care
Care Coordination and Case Management
Key Partnerships
Long-term Housing, Work, Social Support
Information Technology

27. What’s Next: Time is Right: Bipartisan Support for Action
National Plan is needed. What will we do?
We need to seize the opportunity.

28. Discussion

29. Contact Information
Ron Manderscheid, PhD
Exec Dir
NACBHDD – The National Association of County Behavioral Health and Developmental Disability Directors
660 North Capitol Street, NW, Ste 400
Washington, DC 20001
(V) (M)
The Only Voice of County and Local Authorities in the Nation’s Capital!