In-Custody Interventions and Diversion for People with

Mental Illness

A New Service Delivery System that Works

NAMI North CarolinaDecriminalization Conference

Raleigh, NCNovember 27, 2007

Connie Milligan and Ray SabbatineBluegrass Regional MH-MR Board

Review of the ProblemJails are the new psychiatric institutes

Closing of hosp beds in the 60’s - current Limited funding for community mental health resources 80’s War on drugs - Get tough on crime

8%-16% of 11m bookings have MI – Bureau of Justice Statistics - 2000

73% F and 63% M incarcerated have HX of MI – Bureau of Justice self report 2002

64% of people in local jails have some MH symptoms Bureau of Justice Statistics Special Report. September 2006

70% incarcerated have co-occurring disorders Inmate with MI jailed 2-3 times longer Suicide rate in jail is 9 times higher – now 4%

higher – Lindsay Hays web site: /www.ncianet.org

Community Response Trends CIT provides first point of diversion Judges see the revolving door person

with MH-SA problems Courts initiate “problem solving courts” Judges and probation officers take on

leveraging role for TX MH initiate new TX models with ACT Community Mental Health remains under

funded Jails still have legal responsibility to

respond with limited resources

KY Model of Partnership…Handshake between Jails and Mental Health

• People with mental illness filling KY jails – suicide rate high

• CJ report in ‘02• Mandated training for jail staff• Jails still wanted services • Developed Telephonic Triage • Success of pilot in ’03

prompted legislative lobbying• Legislation passed ‘04• Implementation began Fall ‘04

Jail Mental Health Crisis Network

Identify

IntakeAssessment

Booking Screening

InstitutionalAlert

Observation

Request

TelephonicTriage

ChargeShame

SubstanceAbuse

Suicide

MentalIllness

MentalRetardation

AcquiredBrainInjury

RiskAssessment

Critical

High

Moderate

Low

Follow-upReferral

CrisisCounseling

Diversion

202A504

Psychiatrist

Hospital

Triage Level Respond

Jail Mental Health Interfaces

Jail Intake AssessmentJail Intake Assessment

Institutional Alerts/ObservationInstitutional Alerts/Observation

Booking ScreeningBooking Screening

Secondary MH AssessmentSecondary MH Assessment

Protocol ManagementProtocol Management

MH ConsultationMH Consultation

ManagementManagement

MH ReleaseMH ReleasePlanningPlanning

AssessmentAssessment

Need:Need:•MedicalMedical•Mental healthMental health•SuicideSuicide•Risk related to the Risk related to the chargecharge

Police Screening Instrument

AssessmentAssessment•MedicalMedical•Mental healthMental health•SuicideSuicide•Substance abuseSubstance abuse•ABIABI•MRMR•Risk related to Risk related to chargecharge

Component: Booking Screening

Jail

Initiating the Telephonic Triage

The Mental Health

Assessment ToolData Dictionary

Training Instrument

The Type of

charge

Risk Related to the Charge

Misdemeanor, Felony or Capital

Offense

Yes or No?

Public Embarrassment

Life Altering Event

Critical, High, Moderate or Low

Suicide Risk Levels

Behavior Health TriageSuicide Risk Levels

Assessment of suicide risk

The clinicians best judgment of the likelihood that arrestee will make an attempt to take his/her life while incarcerated

Critical

Arrestee needs critical level of risk containment to reduce high risk behavior as evidenced by:

• Arrestee has immediate and clear intent to take his/her life as demonstrated by a current attempt with self harming/life threatening behavior

       

Behavior Health TriageSuicide Risk Levels

Arrestee needs high risk containment measures to reduce risk as evidenced by any one of the following:

•   History of attempt in jail

• Current suicidal ideations

•   History of attempt within last two years

• Attempt required medical attention

• High degree of shame related to charge·

•Any of these factors can be confounded by the presence of substance toxicity

HIGH

Behavior Health TriageSuicide Risk Levels

Arrestee needs moderate risk level containment to monitor suicidal risk as evidenced by:

• History of prior attempt more than two years

•Suicide survivor 

Moderate

Behavior Health TriageSuicide Risk Levels

•Arrestee needs low risk level containment to monitor suicidal risk as evidenced by:

–No history of suicide in the family –No current attempts–No current ideations for self harm–No history of attempts in the last ten years

LOW

Substance Use Potential for withdrawal

Yes or No

Describe

Refer to Medical

Drug Withdrawal Symptoms

ALCOHOL – 2-3 days, up to 2 wks after last use Severe withdrawal = DT, AV hallucinations, seizures,

vomiting & diarrhea, depression BENZODIAZEPINES - 12-24 hours after last use

Severe withdrawal = Depression, suicidal ideation, agoraphobia, seizure –

OPIATES - 8 hours after last use Moderate withdrawal = Sweating, running nose, eyes’

yarning & restlessness, stomach cramps, dilated pupils and joint pain

Severe – can be fatal AMPHETAMINES

Severe withdrawal = Psychosis, suicidal ideation, existential crisis

COCAINE Moderate withdrawal = Anxiety, agitation, depression,

extended sloop and fatigue, appetite increase Severe – Increased hostility – High risk for Suicide

Depression

Mania

Personality Disorders

Other Risk Factors Homicidal IdeationsHomicidal Ideations

History of History of victimization/ victimization/ trauma/ Post trauma/ Post Traumatic Stress Traumatic Stress Disorder (PTSD)Disorder (PTSD)History of substance History of substance abuseabuse

Hospitalization and Treatment

Name of TX Provider

HX of Hospitalizations Current Medications

Leveling Process

Charge Related Risk

Substance Abuse

Suicide Risk

Depression

Mania

Psychosis

Personality Disorder

Risk AssessmentLevels

Critical

High

Moderate

Low

Mental Health Symptoms

MR/ABI/ SA

CRITICAL RISK

        Arrestee needs critical level of risk containment to reduce high risk behavior as evidenced by:

Immediate and clear intent to take his/her life as demonstrated by a current attempt of life threatening harm toward self or others

CRITICAL Risk Protocols

Housing Restraint (Chair)

Supervision

Clothing

Property

Food

Constant Observation 2/4 Policy

Regular Jump Suit

None

Finger food

HIGH RISK

High – Arrestee needs high risk containment measures to reduce risk as evidenced by any of the following:

 Designation of HIGH suicide risk

behavioral health symptoms in any one or more of the categories that pose a risk of harm to self or others

High Risk Protocols

Housing Safe Cell / Single if Violent

Supervision

Clothing

Property

Food

Frequent and Staggered

Suicide Smock

None/Suicide Blanket

Finger food

MODERATE RISK

  Arrestee needs moderate risk level containment to monitor risk as evidenced by any of the following:

Designation of MODERATE suicide risk

 Behavioral health symptoms in any one of the categories that pose a minimal risk to self or others 

Moderate Risk Protocols

Housing As Classified

Supervision

Clothing

Property

Food

Individualized Checks

Regular Jump Suit

Full

Regular

LOW RISK

  Arrestee has low risk when

Designation of LOW suicide risk

No significant behavioral health symptoms

Low Risk Protocols

Housing As Classified

Supervision

Clothing

Property

Food

As Classified

Regular Jump Suit

As Classified

Regular food

Sharing Information HIPPA – not a problem

Data Exchange

Triage form emailed or faxed to the jail and the local CMHC

For email: “Adobe Reader” displays form

Form becomes part of the inmate’s fileCMHC response also added to the fileData from the form is reported by

categories of riskData substantiates jail’s needsData facilitates outcome evaluation

Follow Up CMHC Services

Local CMHC called for all acute casesDefinition of Consultation defined

EvaluationCrisis CounselingAssess need for hospitalization, medication,

diversionResponse times are tied to level of risk

Critical – 3 hoursHigh – 12 hoursModerate – Next business day or as needed

Response Process

• Local clinician reassesses situation• Go through the flags & triage

details• Interview arrestee• Clinician in role of advocate for

the inmates safety and humane treatment

• Increase diversion opportunities

Identificationof risk

Assessmentof risk

Levelingof risk

Managementof risk

Preventionof risk

Response Process

• Is risk level still appropriate?• Are management protocols

appropriate?• Issues to consider :

– Current mental health status– Substance intoxication/withdrawal– Risk related to suicide– History of TX, prior jail behavior

• Is there need for diversion to higher level of care?

Identificationof risk

Assessmentof risk

Levelingof risk

Managementof risk

Preventionof risk

Response Process

• Give recommendation:• Management issues to consider –

– Duration of incarceration– Immediacy of treatment needs– Cause of behavior problems– Ability of jail to appropriately

respond to needs

Identificationof risk

Assessmentof risk

Levelingof risk

Managementof risk

Preventionof risk

Response Process

•Diversion •Can charges be dropped?•Give DC info for care if

bonding out

Identificationof risk

Assessmentof risk

Levelingof risk

Managementof risk

Preventionof risk

KJCN Program Summary 90% jail participation 80% reduction in-custody suicide Screening instruments are working Triaging 5-15% of bookings Protocols provide consistency Cross training of jail and CMHC staff Follow-up provides immediate MH expertise Diversion is increased Collaboration/interface with pretrial release

services, courts, forensic hospitals and substance abuse diversion

New developments – video conferencing for MH services

Triage Program Data Triage Program Data SummarySummary

Total Triages since 9-1-04 = over 28,000Total Triages since 9-1-04 = over 28,000 Charges: Charges:

63% Misdemeanors63% Misdemeanors 36% Felonies36% Felonies .06% Capitol Offenses.06% Capitol Offenses

Charge a risk factor = 11-14%Charge a risk factor = 11-14% Hospitalization in last six months = 36% Hospitalization in last six months = 36%

Suicide critical or high risk in 35%Suicide critical or high risk in 35% Any suicide risk 65%Any suicide risk 65%

Triage Program Data Triage Program Data SummarySummary

Substance Abuse risk = 36% Substance Abuse risk = 36% Withdrawal risk present = 19% Withdrawal risk present = 19% Mental Health Risk = 75% with symptomsMental Health Risk = 75% with symptoms

Depression Depression 43% 43% ManiaMania 23%23% PsychosisPsychosis 8%8% Personality DOPersonality DO 40%40%

Summary of Mental Health Risk LevelSummary of Mental Health Risk Level• Critical = 2%Critical = 2%• High = 37%High = 37%• Moderate = 46%Moderate = 46%• Low = 15%Low = 15%

Triage Program Data Triage Program Data SummarySummary

Follow Up Referral Follow Up Referral 46% of all Triages have follow up referrals 46% of all Triages have follow up referrals 12% meet civil commitment criteria12% meet civil commitment criteria1% meet competency evaluation criteria1% meet competency evaluation criteria

Response Time CompliancyResponse Time CompliancyOverall response 98%Overall response 98%

Triage Program Data Summary

Follow Up Referral 45% of all Triages have follow up

referrals 13% meet civil commitment criteria1% meet competency evaluation

criteria

Response Time CompliancyOverall response 98%

For More InformationConnie Milligan 859-253-1686 x 570

cpmilligan@bluegrass.org

Ray Sabbatine 859-806-0935 sabbatine@adelphia.net

ArticlesBehavioral Healthcare – August 2006 http://behavioral.net/issues/2006/08/027/

Corrections Today – February 2006 http://www.aca.org/fileupload/177prasannak/Milligan web.pdf