nami north carolina decriminalization conference raleigh, nc november 27, 2007
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In-Custody Interventions and Diversion for People with Mental Illness A New Service Delivery System that Works. NAMI North Carolina Decriminalization Conference Raleigh, NC November 27, 2007 Connie Milligan and Ray Sabbatine Bluegrass Regional MH-MR Board. Review of the Problem. - PowerPoint PPT PresentationTRANSCRIPT
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
Ray Sabbatine 859-806-0935 [email protected]
ArticlesBehavioral Healthcare – August 2006 http://behavioral.net/issues/2006/08/027/
Corrections Today – February 2006 http://www.aca.org/fileupload/177prasannak/Milligan web.pdf