Responding to the Needs of Justice Involved Persons with Mental Illnesses: Screening and Assessment...

Responding to the Needs of Justice Responding to the Needs of Justice Involved Persons with Mental Illnesses:Involved Persons with Mental Illnesses:

Screening and Assessment Screening and Assessment

July 24, 2008

Fred C. Osher, MD

Director of Health Systems & Services Policy

Dear Abby……….

CSJ Justice Center: National Projects

Council of State Governments Justice Center: Florida Activities

NIC Learning Site

Chief Justice Initiative

Collaboration with FMHI

Goals of Presentation

• Overview and Context

• Target Population and Program Design

• Screening and Assessment

• Supervision and Treatment Planning

• Evidence Based Practices

Skyrocketing Criminal Justice Populations Bureau of Justice Statistics, 2005

Scope 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

GAINS, 2004

Male Detainees

72%

28%

Female Detainees

72%

28%

Co-Occurring Substance Use Disorders Among Jail Detainees with Serious Mental Disorders

■ % With Co-Occurring Substance Use Disorders

■ % Without Co-Occurring Substance Use DisordersGAINS 2004



• Importance of Target Population and Program Design




Diversion ProgramsLogic Model

Stage 1 Stage 2

Stage 3 - Outcomes

Diversion Identify TargetGroup

Comprehensive/Appropriate

Community Treatment

Improved Mental Health Outcomes

Improved PublicSafety Outcomes

Steadman, Osher, Naples

Target Population and Program Design: Three Questions

1. Who is your target population?

2. What will you do for them?

3. How will you sustain your program?

Defining the Target PopulationFinding your target population – not so simple

SCREENING FOR MHPTR ELIGIBILITY

Finding the Target Population

Defining the Target Population

Impact of Target Population on Outcomes: Pennsylvania Comparisons of Simulation Models

$108,874

($79,700)

$87,436

($100,000)

($50,000)

$0

$50,000

$100,000

$150,000

Simulation 1 Simulation 2 Simulation 3

Savings to the County

Some Common Front-end Pitfalls

Vague criteria for target group

Missing key people in planning

Overly ambitious goals

EBP’s: what are they and where are they?

Workforce capacity and workforce quality

Mental health service delivery begins with identification

Three stage process: Screening Assessment Supervision/Treatment Planning

(NIDA, 2006)

Screening, Assessment, and Treatment Planning

Screening for Need/Risk

Objective and Comprehensive Screening and Assessment

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.

Screening for Mental Illnesses

Why 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

What else to screen for ?

•Suicide Risk

•Substance Use Disorders

•Motivation

•Criminogenic Risk

27

Features of Useful Screening Instruments

High sensitivity (but not high specificity)

Brief Low cost Minimal staff training required Consumer friendly

Historic 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

NIJ 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

Brief Jail Mental Health Screen:Research 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

Validation 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

Validation Results

•Males•80 % correctly identified•64% sensitivity•84% specificity•8% False Negatives

•Females•72% correctly identified•61% sensitivity•75% specificity•14% false negatives

BJMHS - 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”

Screening for Suicide Risk

Suicide 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.

Suicide 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

Suicide 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

Suicide 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

Screening 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

Screening 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

Screening 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

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 client’s 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 client’s status.

43

Domains 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

44

The “Best” Assessment Tool

An Assessment Approach: The APIC Model of Transition Planning for Persons With SMI Leaving Jails

Outcomes of Inadequate Transition Planning Compromised public safety Increased psychiatric disability Relapse to substance abuse Hospitalization Suicide Homelessness Re-arrest

Jails 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

The APIC Model Assess

Plan

Identify

Coordinate

Assess the inmate’s 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

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

PLAN Planning must be multidisciplinary

Address short-term and long-term needs Critical time intervention What has worked before?

Seek family input

PLAN (cont.)

PLANNING DOMAINS

Housing Medication Integrated treatment for co-occurring dx Medical Care Food and Clothing Transportation Child Care Civil Legal Services

IDENTIFY 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

IDENTIFY(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 inmate’s belongings are returned upon release Identification Benefit cards Medications

Coordinate 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

Coordinate(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

APIC 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

Comprehensive 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.

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)

Principles 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)

Principles of Integrated Treatment and Supervision

Collaboration Outcomes

Why 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

What 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

Pyramid of Research Evidence

(COCE, 2005)

What 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

Evidence 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

Challenges 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

Past Year Treatment among Adults Aged 18 or Older with Co-Occurring SMI and a Substance Use Disorder: 2003 (NSDUH)

Substance Use Treatment Only

4.2 Million Adults with Co-Occurring SMI and Substance Use Disorder

Treatment for Both Mental Health and Substance Use Problems

No Treatment

39.8%

49.0%

7.5%

3.7%

Treatment Only for Mental Health Problems

The Bottom Line (Osher and Steadman, 2008)

EBP Data for J I Impact

Housing ++ +++++

Integrated Tx ++++ ++++

ACT +++ +++

Supported Emp. + +++

Illness Mgmt. + ++

Trauma Int./Inf ++ +++

Medications +++++ +++++

Is 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.

Moving Forward

FMHI Jail Survey

• Current screening and assessment practices

• Database infrastructure and capacity

• Medication and clinical responses

• Information sharing practices

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

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.

Infonet Links

The 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)

Thank You

Contact Information:

Fred [email protected]

Responding to the Needs of Justice Involved Persons with Mental Illnesses: Screening and Assessment...

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