Maricopa County Justice & Mental

Health Collaboration Project-

Understanding the Unique Needs of Justice-Involved Women

SEEDS Conference

October 1, 2014

Goals of Today’s Presentation

• Understand each organization’s roles, responsibilities and limitations in planning & service delivery.

• Partners will share information related to both health care and criminogenic risks & needs to coordinate services for the 20 pilot participants.

• Give examples of lessons learned.

Project

Partners

3

GOAL 1Elevate the knowledge, skills, and abilities of

probation officers, detention officers,

correctional health staff, court and judicial staff,

and comprehensive community-based

behavioral health services and case

management staff, in the effective supervision

and treatment of female offenders with serious

mental illness and/or

co-occurring disorders.

4

GOAL 2Develop and implement a program of

treatment and support services that

targets justice-involved women with

serious mental illness and/or co-

occurring disorders that is gender specific, trauma informed, and

criminogenic responsive.5

GOAL 3Enhance the quality, impact, and reach of

interagency collaboration among and

between those agencies engaged in the

arrest, confinement, adjudication,

supervision, treatment, and support of

women with psychiatric impairments in

general and women with SMI/co-occurring

disorders in particular.

6

Process Flow Chart Diagrams

&

Site Visits/Walk-throughs

Detention Officer

determines jail assignments &

CHS checks RBHA data to identify SMI

status

CHT writes up assessment RN reviews

assessment to determines if face-to face needed in

holding cell

Decision

Flowchart Key

Start/Terminate

Document

Process/Action

Police arrests then transports

individual to 4th Avenue jail for intake

While in waiting area, Correctional Health

Technician (CHT) conducts initial screening with inmate

After meeting with IA, released on bond

or DO transports inmate to holding

cell at Estrella

Pre-Trial Officer gathers information to share with

Initial Appearance (IA) Judge determines offence &

stability. RBHA MH Advocates present at IA.

If inmate identified as having a BH issue nurse conduct EPI &

put on sick call ‘damp’ list

Within 24 hours, inmate will see the IA

judge who will determine if inmate will have be eligible

for a bond

Inmate gets booked (paperwork, fingerprints, search & picture taken)

Inmate is moved to the holding cell

Inmate meets with pre-trial officer

Maricopa County Sheriff’s Office: Arrest & Jail Processing

If in crisis sent to Mental

Health Unit (MHU) at Lower

Buckeye jail (psych. Unit

until stabilized)

8

Decision

Flowchart Key

Start/Terminate

Document

Process/Action

Detention Officer (DO) transports from

4th Avenue jail (intake) inmate to

Superior Court

Preliminary Hearing with -Public Defender, Mitigation

Specialist & Judge

Maricopa County Adult Probation and MH Court Processes

Yes- Judge orders Probation Officer (PO) to write presentence report & 1st screener completes OST. Discharge Officer calls clinic to coordinate D/C plan

MCAP Discharge Planner gets involved (may see inmate) and PO complete presentence report .

Inmate goes and sees their Probation Officer, and they develop their case plan (must update

every 6 mths)

Plea Agreement

Early Disposition Court helps people get sentenced quicker

if they have offenses like possession of marijuana. Otherwise within 28 days

from the plea agreement or finding guilt and sentencing

occurs .

If sentenced to jail time refer to Housing Flow

Chart

Inmate is released and given reporting

instructions for probation

Client reports to probation and sees the 2nd screener who

conduct OST and screen for SA treatment . Pilot

participants are assigned a co-located SMI PO and given

probation handbook.*

SMI PO calls and sets up face to face meeting and

reporting instructions

Issue with following

case plan?

Yes- PO can utilize Mental Health Courts for status review applies sanctions and incentives (see grey box fro details)

No- client goes to trial (not eligible

for pilot)

Determine if need Rule 11 or MH Court

Initial appearance could take up to 2yrs.

Rule 11 restoration typically 60 days

Sentencing Hearing

Sentenced to Prison

(not eligible)

Remains on probation until terms are met or time frame

expires. Probation will participate in PCN F-ACT ISP development meetings and

reviews with their client.

Mental Health Court Overview - For the first half of mental health court, the client would go to a staffing that includes the judge, public defender (PD), F-ACT CM, Hope Lives and RBHA Court Liaisons. After the staffing, client meets with her PD (client’s ally ). The PD updates the PO then client goes in front of the judge. PO will review what the client needs to do, the case manager will say if they have anything to add, and the judge will also comment. Afterwards, incentives are given out (e.g. claps, praise, gift cards) then the judge will go through the sanctions. Sanctions may include “flash incarceration” in jail up to 120 days.

9

Is the inmate struggling or a safety risk?

Decision

Flowchart Key

Start/Terminate

Document

Process/Action

Transport Officer brings

inmate to Estrella Jail

Inmate released or serves

sentence then reenters

community in no new charges or

infractions

classification reviewed to

determine where inmate will be

housed

No, inmate will be showered in a group shower, given her

stripes to wear, and strip searched process

Maricopa Country Sheriff’s Office & Correctional Health Services : Housing

Med & Max in Towers

Min & Med in Dorms

Inmates are escorted 2x2 to their individual housing

assignment. Checked in- given bunk assignments, bedding &

rules

Unstable?

Yes-inmate sent to Mental Health Unit Lower Buckeye Jail for psychiatric or medication intervention or if petition required

Inmate accepted into the holding cell and logged into the

system

Yes-Correctional Health is called to see inmate in

holding cell for assessment and intervention-if ongoing

care need placed on the damp list for follow up

Correctional Health reviews damp list –creates

treatment plans, conducts follow up visits, psychiatric evaluations, and discharge

coordination.

Correctional Health has interns providing two groups (Hope & TAMAR) twice a week and also individual sessions. SA groups in administrative segregation and closed custody Inmates also can complete a health needs request

10

Grant Pilot Program Referral Process

Jail Data Link flags all SMI women booked for non-felony and notifies Magellan

MCAP screens

eligibility based on,

sentencing & current

charge

MCAP adds inmates to screened PENDINGtab for continued monitoring of courtprocess and screening continue after signingthe plea and notifies S. Clay/Court Liaison tocoordinate with Public Defender

MCAP adds inmate to the

screened NOT-ELIGIBLE

tab

PCN reviews packet and completes

screening for F-ACT

Eligibility

If determined NOT-ELIGIBLE for F-ACT Team notifies MCAP and

MCCH documents decision on spreadsheet

If determined ELIGIBLE for F-ACTnotifies MCAP & MCCH documents decision on spreadsheet. PCN meets with the inmate to explain program. If inmate agrees, coordinates transition to POCN , if needed.

Maricopa Correctional Health Services (MCCHS)=BrendaMaricopa County Adult Probation (MCAP)=Norma/RhodaPeople of Color Network (PCN)=Rachel

Revised 3/22/13

MCCHS obtains ROI (MH & SA) from inmate and faxes referral packet to Rachel at

POCN

Decision

Flowchart Key

Start/Terminate

Document

After determined eligible, MCAP notes status as Eligible on the tracking SS and notifies S. Clay/ Court Liaison to determine if good case for FACT, if ok for FACT Rhoda is notified to complete MOST (Modified Offender Screening Tool)

Process/Action

ADOP add name(s) to“pending” on EXCELspreadsheet

11

POCN, MCCHS & MCAP discuss newly enrolled program participants

Decision

Flowchart Key

Start/Terminate

Document

Process/Action

Within 30-90 days F-ACT completes: Demographics (EA10-13), Psych. Eval., Housing NA, ASAM, MCAW, HRA, CHI, At-risk Crisis Plan and TIC Counselor Assess.

F-ACT CM meets with the person to discuss goals and conducts Motivational Interview Conducted with Inmate – 1 hr (T

Consultation with the Clinical Team to obtain

recommendations30 minutes

Review Medical Record 1 hour by psychiatrist

Develop ISP/ within 7 days: Face to Face Interview with BHR; & F-ACT meets without the person to draft plan – 30 minutes. Ideally would include SMI PO, TIC Counselor and others requested by the person

Person reviews & signs the plan, then it is returned to the F-ACT team to also sign & Clinical Coordinator “finalizes” ISP in Claimtrack by entering the date signed by the inmate

Client will see the TIC Counselor within the first two weeks and complete

TIC Assessment

Referral packets created by Office Assistant with ROI.

Every 6-mths-updates ISP &ARC

Yearly-Form E, HRA & EA10-13 Will remain on F-ACT

until determined no longer needed

PCN F-ACT & Individual Service Planning (ISP) Processes

PCN TIC Liaison goes to jail with MD to complete grant screening , MD to determine

F-ACT eligibility and coordinate transition to PCN (if needed)

Transfer to PCN can take up to

2-weeks

Client released at 10am two people from PCN will

transport to clinic & meet with F-ACT representative to

schedule assessments

The person meets with the provider agencies, & they

complete s provider “assessment and service”

plans

12

Organizational Standards: Trauma-informed Care

1. Safe, calm and secure environment with supportive care;

2. System-wide understanding of trauma prevalence, impact, and trauma-informed care;

3. Cultural competence;

4. Consumer voice, choice, and self-advocacy;

5. Recovery, consumer-driven, and trauma-specific services; and

6. Healing, hopeful, honest, and trusting relationships.

National Council for Community Behavioral Healthcare’s Organizational Self-Assessment: Adoption of Trauma-informed Care

Practices.

13

Principals:Gender-responsive

1. Awareness that gender “makes a difference;”

2. A safe environment where all clients/offenders are treated with respect and dignity;

3. Organizational policies, practices, and programs that promote healthy relationships with children, family, and significant others, as well as community connections;

4. Comprehensive, integrated and culturally appropriate services and supervision that address substance abuse, trauma, and mental health needs;

5. Opportunities for clients/offenders to improve their socioeconomic conditions; and

6. Collaborative system that provides comprehensive services and supervision upon reentry into the community.

Gender-Responsive Strategies for Women: Supervision of Women Defendants and Offenders in the Community (U.S. Department of Justice/National Institute of Corrections, 2005) and Gender- Responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders (U.S. Department of Justice/National Institute of Corrections, 2002).

14

10 Facts about Justice-Involved Women

1. Women pose a lower public safety risk then

men

2. Women’s pathways to the criminal justice

system is different than men’s

3. Women’s engagement in criminal behavior is

often related to their connects with others

4. Women entering jails and prisons often report

histories of victimization and trauma

5. Corrections policies and practices have largely

been developed through the lens of managing

men

6. Jail and prison classification systems can result

in the unreliable custody designations and over-

classifications

7. Gender‐informed risk assessment tools can

more accurately identify women’s risk and needs

10 Facts about Justice-Involved Women

8. Women are more likely to respond favorably

when corrections staff adhere to evidence-

based, gender responsive and trauma-

informed principles

9. Transition and reentry can be challenging for

women

10.The cost of overly involving women in

criminal justice is high

10 Facts about Justice-Involved Women

Nei, B. (2014). Ten facts about women in jails. American Jail Association. Retrieved from http://www.americanjail.org/10-facts-about-women-in-jails/

Principals:Risk-responsive

1. Services are provided in an ethical, legal, just, humane and decent manner;

2. Assesses criminogenic needs and matches level of service to the offender’s risk to re-offend;

3. Uses human services and general personality & cognitive social theory rather than relying on severity of penalty to effect behavior change;

4. Uses structured and validated instruments to assess risk, need, and responsivity;

5. Engages higher risk cases in programs and strategies to minimize dropout (i.e., pro-social modeling, cognitive restructuring, motivational interviewing);

6. Effective supervision of staff and monitoring and evaluation of service delivery and programs and community linkages

Principles taken from Andrews & Bonta’s The Psychology of Criminal Conduct (Newark, NJ: LexisNexis, 2006) and Andrews “Principles of effective correctional programs” in Compendium 2000 on Effective Correctional Programming (Correctional Services of Canada, 2001).

18

Risk-Need-Responsivity Model as a

Guide to Best Practices

RISK PRINCIPLE: Match the intensity of individual’s

intervention to their risk of reoffending

NEEDS PRINCIPLE: Target criminogenic needs, such as

antisocial behavior, substance abuse, antisocial attitudes,

and criminogenic peers

RESPONSIVITY PRINCIPLE: Tailor the intervention to the

learning style, motivation, culture, demographics, and

abilities of the offender. Address the issues that affect

responsivity (e.g., mental illnesses)

Council of State Governments Justice Center

What do we mean by

Criminogenic Risk?

≠ Crime type

≠ Failure to appear

≠ Sentence or disposition

≠ Custody or security classification

level

Risk =

How likely is a person to commit a crime or

violate the conditions of supervision?

Council of State Governments Justice Center

What Do We Measure to Determine

Risk?

Conditions of an individual’s

behavior that are associated with

the risk of committing a crime.

Static factors – Unchanging

conditions

Dynamic factors –

Conditions that change over

time and are amenable to

treatment interventions

Council of State Governments Justice Center

Targeting Interventions- The Big Four

Criminogenic Need Response

History of anti-social behavior Build non-criminal alternative behaviors to risky situations

Anti-social personality Build problem solving, self management, anger management, and coping skills

Anti-social cognition Reduce anti-social cognition, recognize risking thinking and feelings, adopt an alternative identity

Anti-social companions Reduce association with criminals, enhance contact with pro-social

Source: Ed Latessa, Ph.D

Target Interventions

(Eight Evidence-Based Principles)

The Next FourCriminogenic Need Response

Family and/or marital Reduce conflict, build positive relationships and communication, enhance monitoring/supervision

Substance abuse Reduce usage, reduce the supports for abuse behavior, enhance alternatives to abuse

School and/or work Enhance performance rewards and satisfaction

Leisure and/or recreation Enhance involvement and satisfaction in pro-social activities

Source: Ed Latessa, Ph.D

Evidence-based Services for Individuals

with Substance Use Disorders

Cognitive behavioral therapy

Motivational enhancement therapies

Contingency Management

Pharmacological therapies

Community reinforcement

Council of State Governments Justice Center

Factors Correlated with Positive

Outcomes

PERSONAL STRENGTHS – beliefs, talents, supports

RELATIONSHIP – perceived empathy, acceptance, and

warmth

EXPECTANCY – optimism and self-efficacy

MODELLING – theoretical orientation and

intervention techniques

Key“Take Away” Points

Dedicate more intensive resources for offenders who pose a

greater likelihood of recidivism

Remember that “more” is not necessarily “better” for every

offender

Consider responsivity factors when developing and

implementing case management strategies

Build incentives into case management plans and reward

positive behaviors

Evaluate what is and is not “working” for offenders in your

jurisdiction – prioritize for change those strategies

demonstrated to be most effective in reducing recidivism

And remember – one size does not fit all and gender

matters

Correctional Health

Services

unavoidable triggers-processes & procedures often re-traumatize

-environment can mimic dynamics of past abuse

jails are a challenge for trauma-informed approaches-stressful work environment for staff

-designed to house perpetrator, not victims

absence of primary coping mechanisms (e.g. drugs &

alcohol) for inmates with trauma & addiction histories

Opportunities along the way

SCREEN AT BOOKING: EARLY IDENTIFICATION

CONTINUITY OF CARE

CARE IN THE JAIL SETTING

TRANSITION PLANNING: “REACHING IN” &

WARM TRANSFERS

CRITICAL WINDOWS: 24- 48 HOURS

SAFETY: HOUSING

TIC AND “RIGHT FIT” SERVICES

Age Profile of Females in Jail

Age profile of women in Maricopa County jails for the two years ended Dec., 2013:

23

2,850

10,480

7,464

6,563

262

0

2000

4000

6000

8000

10000

12000

Under 18 18 - 21 22 - 30 31 - 40 41 - 60 61 & above

Nu

mb

er

of

Fem

ale

s in

Jai

l

Age Groups in Years

38% of the women in Jail are between the ages of 22 and 30 years.

Proxy Distribution of Female Jail Population

0

1,000

2,000

3,000

4,000

5,000

6,000

0 1 2 3 4 5 6

7%

12%

23%24%

21%

10%

3%

Nu

mb

er

of

Fem

ale

s in

Jai

l in

2-y

ear

p

eri

od

en

din

g 1

2/3

1/1

3

Proxy Score

24% of the female jail population has a proxy score of “3.”

Description of Serious Mental Illness (SMI) population in Maricopa County jails

1 2 3 4 5 6 7 8 9 10 11 12

10

12

Media

n Num

ber o

f Day

s in

Custo

dy

Non-SMI SMI

23

71

163

390

37

95

200

431

0 50 100 150 200 250 300 350 400 450

25%

50%

75%

95%

Days to Recidivate

Perce

ntage

of Ja

il Pop

ulatio

n tha

t Rec

idiva

ted

Non-SMI

SMI

50% of SMI population that recidivated returned to jail within 71 days of release. 50% of non-SMI population that recidivated returned to jail within 95 days of release.

48%52%

Court of Origination for SMI -City vs. Non-City Courts

City Courts Non-City Courts

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Felony Misdemeanor Sentenced Holds

39%

8%

1%4%3%

44%

0.3% 1%

Charge Level Breakdown for SMI -City vs. Non-City Courts

Non-City Courts City Courts

5.6% of individuals in Maricopa County jails are SMI.

*Approximately 8% of individuals in jails reported being currently or recently homeless. Among the homeless

population in jails 10% are as SMI.

*Among frequent homeless jail users (4 or more stays in a 5-year period) 13% are SMI.

Description of Serious Mental Illness (SMI) in Maricopa County Jails

Noor Singh

Justice System Planning & Information May 27, 2014

Individuals with SMI stay longer in Jails

5.6% of individuals in Maricopa County jails are SMI.

Alternatively stated, at any given time, there are approximately 437 SMI individuals in Maricopa County jails, and 680 SMI individuals on probation.

Among the SMI in the jails, only 8% of them are low-risk to recidivate.

Of the SMI that do come back to jail, they come back sooner than non-SMI.

SMI population in the Maricopa County jails tends to be older and more likely to be female than the general jail population.

Approximately 8% of individuals in Maricopa County

jails reported being currently or recently homeless.

Among the homeless population in Maricopa County

jails, 10% are as SMI.

Among frequent homeless Maricopa County jail users

(4 or more stays in a 5-year period) 13% are SMI.

County leadership focus on the justice-involved SMI in Maricopa County.

Close working relationship between Maricopa County and Arnold v. Sarn project manager.

New data and research internally to inform decision-makers on the realities of this population.

Awareness and examination of court and prosecutorial best practices.

Specialty courts (Homelessness Court, Mental Health Court, Continuum of Care Court).

Peer navigator and other programs from Maricopa County Correctional Health Services to provide services upon community reentry from jail.

Strong County partnership with CASS and the Human Services Campus.

SMI, Homelessness, and Jail Usage in Maricopa CountyMelissa Kovacs, Justice System Planning and Information, Maricopa County

What is Maricopa County doing about this?What does SMI and homelessness look like in

the Maricopa County jails?

Turning Recovery & Resiliency Into Living Well℠

Grant Lessons Learned

This unique multi agency partnership developed as a direct result of the BJA grant

Transition Planning Aligned Services with a shared vision, voice and commitment from each agency involved for each participant

Collaboration involves all entities at the exact same table working towards the same outcome, with open honest communication and a willingness to see the perspective of each partner with a view from a different lens.

Focused Delivery of Trauma Informed Gender Responsive Care to 20 Women in alignment with each service agency’s internal policies, processes, staff development and administration.

Several Changes in Practice (as a direct result of the Grant Partnership) Shared Vision created endless capacity for change.

Fact Criteria Revision, service delivery and implementation of Trauma Counseling at the onset of services.

“The challenge of every team is to build a feeling of oneness, of dependence on one another because the question is usually not how well each person performs, but how well they work together." - Vince Lombardi (1913 - 1970)

Strategic Challenges

Transitional Care is essential to re entry into the community , housing, wrap around services and supports that have been developed in concert with the unique needs of each individual

Specific services developed that are related to female, felony offenders, substance abuse, housing and trauma

Determine specialized needs prior to release from jail and ensure they are met upon transition to the community

Services are strength based, multi agency and developed with an unconditional commitment to each participant with a goal of community integration, service delivery that is empathetic and empowering.

Communication and Collaboration that fosters immediate real time needs for specialized interventions, coordination of care is priority.

"My opinion, my conviction, gains immensely in strength and sureness

the minute a second mind has adopted it." - Novalis (1772 - 1801), German Author and Philosopher

Transformation of FACT

FACT Recipients served

FACT Recipients closed due to DOC incarceration

FACT Recipients closed due to jail incarceration

FACT Recipients transferred to connective/supportive due to long term incarceration

Changes that have occurred as direct result of BJA grant

125 105

8 1

1 0

10 4

2013 2014

Recommendations/Next Steps

1. Trauma Informed/ Gender Responsive Assessments need to be fully integrated into performance improvement practices and serve as the example

2. Trauma Informed Counseling needs to be fully integrated into practice for all integrated care teams.

3. Development of Transitional Care protocol that involves care collaboration and communication at each phased for the transition.

4. Trauma Informed Gender Responsive Care that promotes self resiliency, determination and independence.

Ready, Set, Integrate!Integrated Community Healthcare

Maricopa County Adult Probation

Stories from the Field

Maricopa County Justice & Mental Health Collaboration ProjectProgram Logic Model, v. 6

Population & Environment Theory & Assumptions Interventions Outcomes

Client Target PopulationFemale offenders with serious mental illness & co-occurring substance use disorders

Population Characteristics•Non-violent offender•GAF no higher than 60•Continuous high service needs (3 of 7 indicators on F-ACT Admission)•Incarcerated a total of 6 months or more during the past 12 months•Not eligible if primary diagnosis is Axis II Personality Disorder

Systems Target Populations• Maricopa County Sherriff

Detention Officers & Program Staff

• Maricopa County Correctional Health Clinical Personnel

• Maricopa County Adult Probation & Surveillance Officers

• People of Color Network Forensic Assertive Community Treatment clinicians & staff at La Comunidad Clinic

• Arizona MH & CJ Coalition

Environmental Context• Phoenix is a large metropolitan area•Highly privatized & capitated funded behavioral health care system•In-jail mental health services

Concept of InterventionA gender specific, trauma informed, & criminogenic responsive criminal-justice & behavioral health systems that target offenders with co-occurring disorders to reduce criminal recidivism & promote community stability.

•Developing gender specific, trauma informed, & criminogenic responsive systems capacity requires multi-level, multi-agency organizational interventions

•Gender specific, trauma informed, & criminogenic responsive systems behavioral health services enhance treatment effectiveness, promotes community stability, & reduces criminal recidivism

•Gender specific, trauma informed, & criminogenic responsive systems offender management practices & supervision reduces in-custody incidents, incidents requiring isolation (resources) & enhances supervision effectiveness.

Risk Factors for Criminal Justice Recidivism• Criminogenic Risk Factors• Residential instability• Insufficient(availability, quantity

& array) behavioral health treatment

• Treatment adherence• Undetected & untreated Co-

occurring Substance Abuse D/O • Non-targeted treatment &

service delivery

Interagency Collaboration•Multi-agency Project Management Team•Meeting communications support to PMT•Strategic planning & leadership development targeting the AZ MH & CJ Coalition and advisory board members

Knowledge & Awareness Raising•Develop & disseminate information & practice tip sheets•Organize “expert exchanges”

Skill Development•Identify & distinguish mental health issues•Assess trauma & criminogenic risk•Develop a service & supervision plan that addresses gender specific, trauma & criminogenic risk

Model (Practice?) Development•Universal in custody trauma screening & criminogenic assessment •Forensic-Assertive Community Treatment (FACT) case management•Short term transitional housing•Evidence-based probation supervision•Multi-agency release of information(Cross agency procedures?) •Service delivery targeted to addressing MH issues & criminogenic risks

Systems Capacity Building•Learning circle communities with model purveyors•Systems embedded Master Trainers & Practice Champions

Short-term Systems:•Increase gender specific, trauma informed, & criminogenic responsive awareness & knowledge of criminal justice & behavioral health systems personnel•Attitude & environment changes (access to services in jail)Clients:• Secure housing and benefits upon release• Case plan completed and informed ISP by teamCoalition:• Increase membership• Strengthen the organizational structure• Develop a strategic plan

Intermediate Systems:•Established network of ‘master trainers’•Operational program manual with F-ACT

Clients (6 -months post):•Maintain housing•Feel safe•SA-use reduction

Coalition:•Identify policy issues and needs•Develop website

Long-term Systems:• Pre-service educational curriculum infusion• Expansion of pilot program to additional clinics

& regions• Pilot program manual with F-ACT • Expansion of F-ACT Clients:•Successfully complete probation terms•Reduce recidivism•Engaged in behavioral health servicesCoalition:• Advise on policy issues and become a resource

for the community44