1. Behavioral Health Treatment
Continuum of Care in
Behavioral Health Treatment
Data Driven Solutions

2. Brenda Epperly RN, MSN – Correctional Healthcare Consultant, Kitchell
Your Presenters
Brenda Epperly RN, MSN – Correctional Healthcare Consultant, Kitchell
Ken Harms - Vice President, Business Development, Kitchell
Ron Nelson – Commander, Ret.
Ventura County Sheriff’s Office Todd Road Jail
Gary Retel - Design Principal ,
DLR Group Justice + Civic
Ken

3. This presentation will explore the importance of making data driven design decisions. We will discuss the types of programs that are collecting data, how to use the data you currently do collect and how different programs are beginning to address the need for data in detention and corrections treatment, planning and design.
Ken

4. Mental Illness - How big is this problem?
450,000,000 people worldwide (1 in 4 ) suffer from a serious mental health disorder placing mental disorders among the leading causes of ill- health and disability worldwide
Nationally, there were around 6,741,400 people under some form of correctional control in 2015.
This includes approximately 870,500 people on parole, 3,789,800 on probation, 1,526,800 in prison, and 728,200 in county jails.
California’s criminal justice system alone includes around 200,000 people who are incarcerated and more than 400,000 who are under community supervision.
It is estimated that % of the incarcerated population has a serious mental illness. And this may be a low estimate
Health and medical costs now form a major part of most corrections budgets, totaling about a fifth of all corrections expenditures nationwide and 31 percent in California.
Data taken from the World Health Organization and the Bureau of Justice Statistics
Brenda

5. the lack of, or poor access to, community mental health services
Serious Mental Illness is especially prevalent in correctional populations. The disproportionately high rate of mental disorders in these facilities is related to several factors:
the lack of, or poor access to, community mental health services
the widespread misconception that all people with mental disorders are a danger to the public
the general intolerance of many societies toward difficult or disturbing behaviors (NIMBY)
Brenda
Many of these disorders may be present before admission to prison, and may be further exacerbated by the stress of imprisonment. However, mental disorders may also develop during imprisonment itself as a consequence of prevailing conditions

6. Have a severe mental illness 45% of local jail inmates
55% of males
73% of females
approximately
45% of local jail inmates
approximately
30% of state prison inmates
approximately
35% of federal prison inmates
Brenda

7. Jails must have a Behavioral Health Program- What does that look like?
Just as with any medical condition, behavioral health treatment is offered in different levels of care based on the individual patient.
Levels of care such as:
Acute Care or Hospitalization - The most intensive level of care. (short term)
Crisis Care- Suicidal ideation, increased symptoms, self harm or dangerousness (short-term)
Sub-Acute or step down - For those going into or out of crisis care or hospitalization (mid-term)
Supportive Care - For those who cannot live safely in a correctional environment (likely long- term)
Out-Patient or Case Management – Those who can live in the GP with ongoing treatment or assessments
Patients must be treated in the least restrictive environment.
Brenda

8. Out-Patient Supportive Sub-Acute Crisis Acute
Of your total county jail populations
Acute beds~ 0.5%
Crisis beds~ 0.4%
Sub-Acute beds~ 1%
Supportive beds~ 6%
Out-Patient housing~ 23%
Brenda
You should consider providing behavioral health housing (with treatment space)
for about 8 percent of your TOTAL population*
*This data is based on a stable BH population in CDCR and may be higher for jail populations

9. Healthcare Data
and
Best Practice Design

10. Best Practices Research
Behavioral health units and facilities should be designed to appear comfortable, attractive, and as residential in character as possible.
Nurse stations should provide the least possible barrier between staff and patients.
Location of gathering areas for patients near the nurse station is encouraged because patients often congregate by the nurse station to socialize.
Facilities for medication distribution should support the organization’s practices but allow for flexibility.
Locate service areas so they are accessible from both the unit and a service corridor.
Significant new developments in duress alarm systems greatly improve safety for staff who find themselves threatened by patients
Gary

11. Best Practices Research Reveals
Small Housing Units 6 – 12 for Classification & Treatment
Single Level units for Acute Care
Treatment Staff Co-located with Housing Units
Integrated Security and Treatment Team Unit Management – Cross-Training
Step-up/Step-Down Treatment Units – Acute, Sub-Acute, Chronic
Avoid long corridors and linear spaces
Reduce the sense of crowding and the “Apparent” density
Create dynamic therapeutic communities
Provide space for staff to rest and recharge – indoor lounge with outdoor patio
Views of Nature
Gary

12. Best Practices Research
Quality of Environment
Natural Light
Furnishings
Personal Space
Access to the Outdoors (even with murals)
Acoustics
Color & Texture
Scale and Character
Gary

13. Ventura County
Design and
Data Collection
Ron

14. Planning Process and Outcome
Ventura County
Three Facilities
1854 Rated Beds
Pre-Trial Detention Facility –Purpose built 12 Medical / Mental Health Beds
24 Beds Added
Overflow housed in general population
2007 – 18.9 % mental illness, 6% acute
Ron
Todd Road Jail
Built in 1995
796 Beds

15. Recommended Plan
Scheme 3: Direct Sight Lines to Cell Fronts (56,000 BGSF)
Ron and Gary

16. Highlights Treatment Focused- Smaller Units
Evidence Based Best Practice Design
Increased opportunity for “Out of Cell Time”
Six 10 Bed Sub-units allows increased flexibility in classification
Higher percentage of treatment spaces to inmate
Smaller Dayrooms- More Residential Scale
Ron and Gary
Ventura County Behavioral Health Housing Unit

17. Ventura County Behavioral Health Housing Unit
Ron
Ventura County Behavioral Health Housing Unit

18. Data Collection Pre/Post-Occupancy Study
Complete: Baseline & Post-Occupancy Results for Skagit County
In process: Gathering baseline information for Ventura County
Self report survey distributed to both staff and inmates
Staff – Online
Inmates – Hard Copy
Survey examines
Perceptions of building features such as acoustics, lighting, thermal comfort, and access to natural daylight.
Levels of stress, depression, and feelings of safety, security, victimization.
Functionality of common spaces
Skagit: Pre-Occupancy survey September 2017 and Post-Occupancy distributed September 2018
Ventura: Pre-Occupancy survey distributed December 2018
Ron

19. The Impact of Design on Environment
A Staff and Inmate Study
Gary

20. 6 year sentence 57-61 years old Officer Wellness Average career:
(+56,000 hours)
Average officer lifespan:
57-61
years old
(average 79 in USA)
Gary

21. Survature | Staff Data Collection
Gary

22. Survey | Inmate Data Collection
Gary

23. Outcomes and Limits Limits Pre-occupancy Study 2017 - Staff & Inmates
Pre-occupancy Study Staff & Inmates
Limits
Washington state participants only
Small sample size for staff
Staff and inmates from a smaller rural town
Majority Caucasian population (inmates & staff)
Low Cronbach’s alpha for inmate survey
Gary

24. Outcomes and Limits Staff Data Inmate Data
Pre-occupancy Study Staff & Inmates
Staff Data
Reporting higher levels of stress and lower levels of fear of being victimized
Reporting higher levels of depression also report higher levels of fear of being victimized
Older staff reported high levels of depression compared to younger staff
Inmate Data
Reporting the facility is noisy reported higher fear of being victimized
When access to natural light decreases, levels of depression increased
Inmates who reported higher levels of education reported higher levels of depression
Gary

25. As daylight deceases, staff feel less safe and secure
Inverse correlation, as access to daylight increase levels of stress decrease
As daylight deceases, staff feel less safe and secure
Gary

26. Significant at 95% confidence interval
Inmates:
Strong positive correlation access to natural daylight attributes to higher feelings of safety & security.
Significant at 95% confidence interval
Inverse correlation, as access to daylight increase levels of stress decrease
As levels of daylight increase, reported levels of depression decrease.
Gary

27. Ventura County Behavioral Health Housing Unit

28. Staff:
As acoustics get better, staff report lower levels of depression and lower levels of fear of being victimized.
Gary

29. Inmates:
Similar to the previous study, as inmates report lower noise levels they feel more safe and secure in their environment and less likely to be victimized
As inmates report higher noise levels, they feel more stressed in their environment
Gary

30. Ventura County Behavioral Health Housing Unit

31. Staff:
Inverse correlation, as access to daylight increase levels of stress decrease.
As reported feelings of stress decrease, staff report more satisfaction with their feelings of safety and security.
Higher levels of depression are correlated with higher levels of fear of being victimized.
Gary

32. Inmates:
As inmates report higher levels of feeling safe and secure they report lower levels of stress
Higher levels of depression are correlated with higher levels of fear of being victimized and low levels of feeling safe and secure
Higher levels of depression are correlated with low levels of access to daylight
Gary

34. Programs and Research

35. PCORI (Patient Centered Outcomes Research Institute)
Grant funded project in Ventura County, being conducted by researchers from New York University.  Commander Ron Nelson serves on the project steering committee.  The project goals are to gather as many stakeholders in the arena of Mental Illness and Criminal Justice to discuss the County’s programs and gaps in services in order to enlighten all in these areas.  Stakeholders include Police/Sheriff, District Attorney’s Office, Public Defender’s Office, Courts, Probation, Behavioral Health, County Human Services, NAMI, Behavioral Health clients, families, faith-based organizations and other community based service provider organizations. 
Raising the Barn- Inclusive decision making with all stakeholders at the table.
BetaGov- Data and evidence based decisions through in house research with different methods for testing innovations.
Changing Spaces- Measurable testing of controlled environments.
Ron

36. The Stepping Up Initiative
A national initiative to reduce the number of people with mental illnesses in jail. Sponsored by the National Association of Counties, the Council of State Governments Justice Center, the American Psychiatric Association Foundation and Bureau of Justice Assistance U.S. Department of Justice, it calls on counties across the country to reduce the prevalence of people with mental illnesses held in county jails. Questions leaders need to consider:
Is our leadership committed?
Do we conduct timely screening and assessments?
Do we have baseline data?
Have we conducted a comprehensive process analysis and inventory of services?
Have we prioritized policy, practice and funding improvements?
Do we track progress?
Gary and Brenda
Since Stepping Up launched in 2015, more than 475 counties across the country have passed a Stepping Up resolution, committing to create data-driven plans to reduce the number of people with mental illnesses in jails.

37. 35 California Counties are Involved in the Stepping Up Initiative - Are you?
Alameda
Calaveras
Contra Costa
Del Norte
El Dorado
Glenn
Humboldt
Imperial
Kern
Los Angeles
Madera
Marin
Mendocino
Merced
Napa
Nevada
Orange
Plumas
Riverside
Sacramento
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Solano
Sonoma
Sutter
Trinity
Yolo
Yuba
Gary and Brenda

38. The Restoration Center – San Antonio Texas
With the mission to provide hope and support recovery, the Restoration Center offers a full spectrum of nationally recognized innovative and medically supervised services that are customized to the individual in order to promote healing. From sobering to detoxification, on site observational assessment and, if needed, a medical and/or psychiatric diagnosis, the CHCS’ integrated treatment team is ready to help individuals chart a course to wellness and restore their lives.
The center, funded by multiple county agencies, provides a direct alternative to county jail. In one facility they provide:
Mental health assessments
Detoxification
Wound care
Counseling
Brenda
5150 (suicide) assessments
Community diversion
Overnight stays
Homeless services

39. Diversion Alternate Placement Community Resources Mental Health Courts
But the single best practice is . . .
Diversion
Alternate Placement
Community Resources
Mental Health Courts
Continued After-Care
Brenda

40. Further Study Resources
Gary

41. Q & A
Thank You
Ken