1. CRIMINAL JUSTICE MENTAL HEALTH & SUBSTANCE ABUSE REINVESTMENT GRANTS ALACHUA COUNTY’S PARTNERSHIP WITH MERIDIAN A Presentation for Florida Partners in Crisis November, 2013 Maggie Labarta, PhD, MERIDIAN BEHAVIORAL HEALTHCARE 1

2. ALACHUA COUNTY Population of 251,417. Capital of the Gator Nation, Gainesville is home to the University of Florida, with some 50,000 students 874 square miles, Alachua County is a mix of urban and rural communities Median household income of $41,373. According to the 2010 U.S. Census report, 24% of its residents live at or below the poverty level which is well above the State average of 15%. 2

3. MERIDIAN Comprehensive behavioral healthcare center Comprehensive behavioral healthcare center Co-occurring enhanced services Co-occurring enhanced services Services from outreach and prevention to in-patient, residential, and long-term supported housing Services from outreach and prevention to in-patient, residential, and long-term supported housing Service area includes 12 North Central Florida Counties – 550,000 population Service area includes 12 North Central Florida Counties – 550,000 population Two crisis stabilization units (50 beds) Two crisis stabilization units (50 beds) Residential treatment – mental health, substance use, co-occurring Residential treatment – mental health, substance use, co-occurring Pre-post partum residential treatment Pre-post partum residential treatment Medically assisted treatment for substance use disorders Medically assisted treatment for substance use disorders 9 outpatient clinics 9 outpatient clinics 3 collocated sites within primary care 3 collocated sites within primary care School-based services School-based services Mental Health First Aid © Mental Health First Aid © Part of the CIT Training Team Part of the CIT Training Team Provide treatment services to almost 14,000 clients a year, contact another 11,000 through prevention and outreach Provide treatment services to almost 14,000 clients a year, contact another 11,000 through prevention and outreach 3

4. JAIL CHARACTERISTICS Rated capacity of 976 with a 15% classification factor. Between Dec. 2012 and May 2013 the average daily population was at a low of 855 in March and a high of 983 in December The Department of Court Services interviews of all inmates prior to their first appearance. 23% of adults were arrested for an alcohol violation while only 8% stated they had an alcohol problem; paradoxically, 7% were arrested for an illegal drug incident yet 14% self- report a problem with drugs. About 1.6% self report as having a mental health problem; however, 30.2% of all Jail inmates receive psychotropic medications while incarcerated in Alachua County. Of the daily census, 57 individuals report being homeless. 4

5. FORENSIC SERVICES: MERIDIAN AND ALACHUA COUNTY PARTNERSHIP Public Safety Coordina-ting Council MH/SA Providers Law Enforce- ment County Govern- ment (Elected & Staff) State’s Attorney Courts (Judges & Staff) Public Defender 1998 5

6. FORENSIC PROGRAMS Largely concentrated in Alachua County Largely concentrated in Alachua County 1998 – County Committee identified MI/SA as reasons for growing jail 1998 – County Committee identified MI/SA as reasons for growing jail population and agreed population and agreed - That treatment was the correct thing to do - Partnership would be required 2000 – Mental Health Court established by Judge Jim Nilon 2000 – Mental Health Court established by Judge Jim Nilon 2003 – Crisis Intervention Team grant written 2003 – Crisis Intervention Team grant written – Felony Mental Health Court established Judge Martha Ann Lott – Community Based Competency Restoration program established 6

7. 2005 – community partners visited Denver 2005 – community partners visited Denver CIT classes started CIT classes started In-jail to community competency restoration funded by DCF In-jail to community competency restoration funded by DCF County created Mental Illness Workgroup (“MIWg”) to identify needed services and develop Strategic Plan for effective jail diversion system. County created Mental Illness Workgroup (“MIWg”) to identify needed services and develop Strategic Plan for effective jail diversion system. 7

8. SEQUENTIAL INTERCEPT MODEL 1 + COMMUNITY VISION = STRATEGIC PLAN Vision: A community that no longer needs jails and courts to serve as a provider of mental health and addictions treatment Pre-Booking Intercepts  Crisis Intervention Teams  Fully funded community based system of care Post Booking Intercepts  Coordinated screening and classification  Forensic Specialists Court/Jail Intercepts  In-jail specialized treatment  Therapeutic Courts (Misdemeanor, 916, Felony)  Community-based Competency Restoration Services  Forensic Specialist Team  Forensic Diversion Team Re-Entry Intercepts  Forensic Residential Treatment  Forensic Specialist Team  Forensic Diversion Team  Peer Specialists Post-Release Intercepts  Specialized Probation  Specialized, Supported Housing  Fully funded community based system of care  Not available  In place  Partially in place 8 1 Facilitated by the USF- FMHI CJMHSA Technical Assistance Center

9. 2006 – MIWg report leads to funding for enhancing existing competency restoration program and creating a “Forensic Specialist Team” 2006 – MIWg report leads to funding for enhancing existing competency restoration program and creating a “Forensic Specialist Team” 2007 – County Commission created CJMHSAG Planning Committee 2007 – County Commission created CJMHSAG Planning Committee Chaired by member of Court or a County Commissioner Chaired by member of Court or a County Commissioner County Advisory Board charged with responding to grants and other funding opportunities County Advisory Board charged with responding to grants and other funding opportunities Awarded first 3-year $2million grant created treatment team to which most ill individuals could be referred, worked hand in hand with staff funded by DCF (competency restoration) and Forensic Specialist Team Awarded first 3-year $2million DCF CJMHSA Reinvestment ACT Implementation grant created treatment team to which most ill individuals could be referred, worked hand in hand with staff funded by DCF (competency restoration) and Forensic Specialist Team 2010 – Awarded expansion $1 million grant 2010 – Awarded expansion $1 million DCF CJMHSA Reinvestment ACT Expansion grant Integrated the work of both teams to adapt to lowered funding Integrated the work of both teams to adapt to lowered funding Expanded array of services through integration Expanded array of services through integration Added trauma services and Moral Reconation Therapy Added trauma services and Moral Reconation Therapy 9

10. SPECIALIZED PROGRAMS: COUNTY, AND GRANT 1, GRANT 2 INTEGRATED THEM AND EXPANDED WHO WE SERVE Forensic Specialist Team Outreach and Intervention Outreach and Intervention Engagement Engagement Competency Restoration Competency Restoration Referral Referral Accessing benefits (SOAR) Accessing benefits (SOAR) Monitoring Monitoring Uses existing treatment resources Uses existing treatment resources Provides advocacy in Court Provides advocacy in Court Single point of accountability for court cases Single point of accountability for court cases Forensic Diversion Team Based on ACT model Based on ACT model Self-contained team Self-contained team Engagement oriented Engagement oriented Co-occurring enhanced Co-occurring enhanced Multidisciplinary Multidisciplinary Jail classification staff Jail classification staff Counselor Counselor Peer specialist Peer specialist ARNP ARNP Treatment supports – housing vouchers Treatment supports – housing vouchers Focus on high recidivists for both treatment and court systems Focus on high recidivists for both treatment and court systems 10

11. PROGRAM FOCUS GOAL – Minimize jail time and increase participation in treatment GOAL – Minimize jail time and increase participation in treatment At booking At booking Post booking Post booking Re-entry Re-entry METHOD METHOD Screen at booking Screen at booking First appearance evals First appearance evals Mental Health Court Mental Health Court Competency restoration at jail and in community Competency restoration at jail and in community Diversion – VA, state hospital Diversion – VA, state hospital Treatment on re-entry Treatment on re-entry 11

12. PROGRAM DESIGN Phase I (Pre-engagement): Pre-treatment groups; motivational interviewing; program orientation/education; linkage/referral to community resources/programs Phase II (Recovery Services): Starting treatment services; individual/group therapy; case management; medication management; drug testing; linkage/referral to community resources/programs Phase III (Stabilization): Advanced level of self-sufficiency; individual/group therapy; case management; medication management; drug testing; linkage/referral to community resources/programs; increased usage of peer support services Phase IV (Transition): Recommended for clients requiring minimal services to maintain stability; individual/group therapy; case management; medication management; drug testing ; linkage/referral to community resources/programs; increased usage of peer support services Phase V (Aftercare): After graduation from treatment; assigned a peer specialist; case management; medication management; drug testing; linkage/referral to community resources/programs; structured curriculum (Wellness Recovery Action Plan) 12

13. STAFFING INITIAL 8 Staff Half funded by county, half CJMHSA Implementation Grant Team make-up: Team leader/program therapist (MA) 3 Forensic Specialists 2 Peer Specialists 1 Jail Classification Specialist (ACJ employee) 1 part-time Benefits Coordinator (Court Services employee) EXPANSION 9.2 Staff Counselors1.00 Forensic Specialist3.50 Forensic Outreach Specialist1.00 Peer Specialists0.50 ARNP0.20 Assessment Specialist1.00 Benefit Coordinator/Data Analyst1.00 Admission Coordinator/Screener1.00 13

14. EVIDENCE BASED PRACTICES Self-contained program Self-contained program ACT “light” based on essential elements (funding would not support full ACT) ACT “light” based on essential elements (funding would not support full ACT) Continuous engagement efforts Continuous engagement efforts Motivational enhancement Motivational enhancement Rapid access to medication Rapid access to medication Therapy within the program – Trauma Informed Care Therapy within the program – Trauma Informed Care Access to benefits for follow-up care - SOAR Access to benefits for follow-up care - SOAR Screening for Re-entry – GAIN checklist Access, Plan, Identify & Coordinate (APIC) – coordination with community partners for successful re-entry Moral Reconation Therapy addresses needs of those with antisocial personality Effectiveness data compiled and aggregated data by Meridian and Court staff 14

15. MORAL RECONATION THERAPY MRT is a 13 stage evidence-based cognitive behavioral, step by step treatment designed to enhance self-image, promote growth of a positive, productive identity, and facilitate the development of higher stages of moral reasoning. Step 1 & 2 (Trust and Honesty): Disloyalty, the lowest moral and behavioral stage in which a person can function. Step 3 (Acceptance): Opposition, starting to be somewhat honest. Step 4 (Raising Awareness): Uncertainty, may lie, cheat and steal but uncertain if they should do so. Step 5 & 6 (Healing Damaged Relationships and Helping Others): Injury, identifying that they have hurt others or themselves. 15

16. Step 7 & 8 (Long-Term Goals and Identity and Short-Term Goals and Consistency): Non- Existence, do not have a firm sense of identity and do not feel connected to the world. Step 9 & 10 (Commitment to Change and Maintaining Positive Change): Danger, starting to commit to long-term goals. Step 11 (Keeping Moral Commitments): Emergency, sense of urgency in completing goals. Step 12 (Choosing Moral Goals): Normal, incorporating their identity into how they live their life. Step 13 to 16 (Evaluate Relationships Between Inner Self and Personality): Grace, few reach this step where the person sees others as an extension of self. 16

17. OUTCOMES: VOLUME OF SERVICES Referrals: 1406 to date, average 50- 55 per month Referrals: 1406 to date, average 50- 55 per month Admissions: accepted to date 432, average 12 per month roughly 25% Admissions: accepted to date 432, average 12 per month roughly 25% Average 15-20 pending referrals Average 15-20 pending referrals Active in program 157 (215- 270/year), Active in program 157 (215- 270/year), average 150-160, plus another 50 average 150-160, plus another 50 in state hospital in state hospital 100% receive Case Management 25% receive treatment 23% receive Competency Restoration 77% of participants are in Felony Forensic Court or Mental Health Court. 17

18. WHO IS NOT ACCEPTED? 18

19. 25% of active program participants were participating in treatment (not just CM) services provided by the Forensic Treatment Program in Phases II to V Phase I participants are those in Pending status post screening and pre engagement in Treatment 44% (of program participants in treatment were in Trauma Groups. 59% (10 of 17) female participants in treatment services were in Women’s Trauma Groups Peer Specialists are providing follow up contact to participants who have been discharged 19

20. Moral Reconation: 5% of treatment participants 20

21. OUTCOMES: EFFECTIVENESS Days in the community: 91% for those not at state hospital Days in the community: 91% for those not at state hospital 12% in jail 12% in jail 64% in community 64% in community 24% at state hospitals 24% at state hospitals Recovery 12 % in a Vocational Program 12 % Employed 5 % in School Adherence with medication: 82% Adherence with medication: 82% The vast majority of unsuccessful discharges are for non-compliance 21

22. Engagement works 66% of unsuccessful discharges occur in Phases 1 or 2 22

23. Participation has long term effects We see reductions in two year follow up for those who don’t succeed Greatest impact is for those who stay with it Graduates expanded benefit persists even after we refer them to traditional follow-up care 23

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25. COST Forensic Diversion Team (Funding & Data for May 2011-June 2012) Forensic Diversion Team (Funding & Data for May 2011-June 2012) MIWG - $370,000 MIWG - $370,000 CJMHSAG CJMHSAG State - $250,000 State - $250,000 County Match - $167,000 County Match - $167,000 In-kind match (various sources) - $78,000 In-kind match (various sources) - $78,000 Total annual funding: $865,000 Total annual funding: $865,000 Number served: 267 Number served: 267 Average annual cost per person: $3,230 Average annual cost per person: $3,230 Post admission Jail Days 14,004 X $85/day = Post admission Jail Days 14,004 X $85/day = $ 1,190,340.00 Pre admission Jail Days 28,803 X $85/day = Pre admission Jail Days 28,803 X $85/day = $ 2,448,255.00 PROGRAM IMPACT -14,799 $ (1,257,915.00) NET COST AVERSION (IMPACT-COST) $392,915 per year 25

26. LESSONS LEARNED The CJMHSA Reinvestment Act funding has made a dramatic impact on the Planning, Implementation and Expansion of Jail Diversion services for persons with mental health and substance use disorders involved in the Alachua county Criminal justice system Get community "buy in" by using the Sequential Intercept Model. Utilize all community resources, bring them to the table. Programs should have an Outreach component to allow flexibility. Design the program to allow for flexibility with trends.... The program has to meet the needs of the clients, not the other way around. Contingency funding is absolutely necessary 26

27. THE REAL REASON IT’S GREAT Ms. B is a 33 year old female with a long history of mental illness and substance abuse. Formerly received services from FACT team ; dropped out two years ago. Arrested 4/7/13 for aggravated assault, with deadly weapon without intent to kill Not taking her medications, and experiencing severe psychotic symptoms She was immediately identified by the Forensic Liaison at the jail, who attempted to convince her to take her medications but she continued to refuse. She then was evaluated, found Incompetent to Proceed, and meeting criteria for State Hospital. Forensic Liaison succeeded in getting her to take her medications and provided competency restoration. By the time Ms. Brown’s case was transferred to Felony Forensic Court, she was stabilized on her medications and competent. The Forensic Program Director then advocated with the court that Ms. Brown did not need to go to the State Hospital and could be diverted to the community with supports in place. Ms. Brown was released from jail on 6/20/13 to Forensic Treatment with her charges completely resolved. 27

28. QUESTIONS? Contact Leah Vail, Director, Forensic Services leah_vail@mbhci.org 28