The Sequential Intercept Model

Leah Vail, MA
Forensic Program Director
Meridian Behavioral Healthcare, Inc.
Presenter

Jim Santangelo, CAP

Alachua County Court Services
Clinical Programs Manager
Co-Presenter
 A Request
 Please turn off your
cell phones,
Blackberrys, Beepers,
I-phones, Pagers and
gameboys
 Or place on silent
mode
 Training Agenda
 A. “Criminalization of the Mentally Ill”
 B. Model Basics
-It’s history
-It’s use
 B. Sequential Intercept Points
 C. Alachua County Discussion
 Impact of Consumers in the
Criminal Justice System
 Current estimates suggest
that as many as 700,000
adults entering jails each
year have active
symptoms of serious
mental illness and three
quarters of these
individuals meet criteria
for a co-occurring
addictive disorder
(GAINS, 2001)
 General Involvement in the CJ
System
 In 2005, over 7 million people were on probation,
in jail or prison, or on parole at yearend – 3.2% of
all U.S. adult residents or 1 in every 23 adults.
(Bureau of Justice Statistics)
 In 2001, the U.S. incarceration rate of 690 per
100,000 overtook Russia (670/100,000) to lead the
world. Then by 2005, the rate had risen to
726/100,000.
Mental Health Involvement in the
CJ system
 People with a Mental Illness are charged,
convicted, and sentenced than more
severely than others accused of similar
crimes (Hochstedler, 1987; NY State Office
of Forensic Task Force, 1991)
 People with a Mental Illness spend 2 to 5
times longer in jail than those without MI
(Criminal Justice/Consensus Project, 2003)
 Alachua County Jail

 Alachua County Jail: between 10 and 25%

of the detainees received psychotropic meds
(2008-2009 CJMHSA Planning Group).
 Alachua County Jail

 According to Jail statistics, 36% of all

detainees at first appearance had either an
open or previous SA or MH case.
Approximately 5% had an open case, 23%
had previously received MH and/or SA
services as an adult, and 9% had treatment
as a child.
 The Alachua County Story
 1998 – County Committee begins to identify MH/SA as reasons for
growing jail population
– Consensus that treatment is important
– Partnership solutions sought
 2000 – Mental Health Court established
 2003 – Crisis Intervention Team grant written
– Felony Mental Health Court (Div V) established
– Community Based Competency Restoration program
established
 2005 – CIT classes started
– In-jail to community competency restoration
– County created Mental Illness Workgroup (“MIWg”) to
identify needed services and develop strategic plan for effective
jail diversion system.
 The Alachua County Story
 2006 – MIWg report leads to funding for enhancing existing
competency restoration program and creating a “Forensic Specialist
Team”
 2007 – Meridian Forensic Specialist Team started
-County Commission created CJMHSAG Planning Committee
– Official County advisory Board charged with responding to grants
and other funding opportunities
– Resulted in award of 3-year $2million grant that is a county and
state partnership.
 2008 – CJMHSAG awarded funding creating the Forensic Diversion
Team.
 2010 – CJMHSAG awarded continued funding by merging the MIWg
and CJMHSAG teams to create a comprehensive Forensic Team.
Partners since 1998
MH/SA
Providers

Law
Public
Enforce-
Defender
ment
Public
Safety
Coordina-
ting
Council County
Courts Govern-
(Judges & ment
Staff) (Elected &
Staff)
State’s
Attorney
 Tools for Transformation:
Alachua County’s Partners
 Court System, Judges, Administration
 Office of Public Defender, Office of State Attorney, Regional Council
 Alachua County Jail
 Law Enforcement
 Court Services
 Meridian
 V.A.
 SAMH/DCF
 State Hospitals – FSH, NEFSH, NFETC
 Agency for Persons with Disabilities
 FACT team
 Gulf Coast Home
 Alachua/Gainesville Housing Authority
 A systematic approach to the
criminalization problem
 There is no single solution to the problem we
are calling “criminalization of people with
mental illness”
 Cecil’s Story
What is the Sequential Intercept
Model?
 “Framework for
thinking about how
and where
diversionary
alternatives might best
fit a community”
– Marc Cherna, Director
ALLEGHENY County
Dept. of Human
Services, Pitt, Penn
Basics of the Sequential Intercept
Model
 A conceptual framework for communities to
use when considering the interface between
the Criminal Justice and Mental Health
systems.
 There are a series of points of inceptions at
which an intervention can be made to
prevent individuals from entering or falling
deeper into the criminal justice system.
 More Basics of the Sequential
Intercept Model
 People with mental disorders should not
“penetrate” the criminal justice system at a
greater frequency than people in the same
community without mental disorders.
 Ideally, most people will be intercepted at
early points, with decreasing numbers at
each subsequent point.
 Final Basics of the Sequential
Intercept Model
 The deeper that people enter into the system
costs more time, money, and energy.
 And the harder it is to exit them from the
system.
 Think of the model as a funnel
 Handout
Why is this model important?
 State of Florida made
it central to the
CJMHSA grants

 SAMSHA Best
Practice
 Five Stages of the Model
 1. Current Services (prevention) &
Emergency/Police-Based Response
 2. Initial Hearings and Initial Detention
 3. Speciality Courts
 4. Re-Entry to the Community from Jails
and State Hospitals
 5. Community Corrections and Community
Support Services
 1. Current Community Mental
Health Services
 Outreach
 Treatment & Medication
 Case Management
 Housing
 Transportation
 Meaningful Daily Activities
 Crisis Services
 Treatment & Medication
 Mental disorders are treatable.
 For most mental disorders, there is a range
of treatments
 Rehab Services/Case Management
 Therapy
 Pharmacological
– 1st generation medication
– Newer medications
 Consequences of a Lack of
Treatment
 The consumer falling
into a crisis
 More Vulnerable
 Involvement with
LEO
 CSU admission
 Criminal Charges
 Case Management
 In general, the more specialized, the more
intensive services are better
 Forensic Specialists (ave caseload of 35)
 Intensive Case Management (caseload of 10)
 FACT services (team approach, max 100 clients)
 Traditional Case Management (caseload of 30)
 VA - MHICM
 Housing
 The importance of housing cannot be over stated
 IDEALLY, the community has a range of housing
options, including
– Residential
– SRT
– AFP
– ALF
– Housing vouchers
– Homeless Assistance Programs
 Transportation
 Bus system/passes
 Are there bureaucratic
barriers interfering
with staff transporting
consumers?
 Medical transport
 Medicaid
transportation
 Meaningful Daily Activities
 Employment or vocational program
 Psychosocial Rehab
 Education
 Volunteering
 Clubhouse
 Peer activities
 Drop-in Center
 Partial hospitalization
 Crisis Services
 Emergency screening services
 CSU or receiving centers
– How many beds does your community have?
 Public CSU vs. Private CSU
– How easy is it to access these beds?
 Educating LEO re: the Baker Act
 Involuntary Outpatient Commitment
If treatment is so effective, then why
are so few people receiving it?
 Less than a third of adults with a diagnosable mental
disorder and even smaller proportion of children
receive any mental health services in a given year
(Surgeon General report)
 Stigma
 Fear of being hospitalized
 Cost
 Organizational barriers - No access
 Not having the time
 Thinking that they could handle it alone
 Thinking that no one could help
 Denial –lack of insight into illness
 Side Effects
 Substance Abuse
 1. Emergency/Police-Based
Response.
 “Law enforcement agencies have played an
increasingly important role in the management of
persons experiencing psychiatric crisis” Lamb et
al (2002)
 7 to 10% of patrol officer encounters involve
persons with mental disorders.
 Historically mental health and law enforcement
have not worked closely together.
 Emergency/Police-Based
Response.
 The prototype of the specialized police
officer approach is the Memphis Model
Crisis Intervention Team (CIT), which is
based on collaboration between law
enforcement, the local community mental
health system, and other key stakeholders.
 CIT has lower arrest rates, high utilization
by patrol officers, rapid response time, and
frequent referrals to treatment.
 CIT in Florida
 CIT
 Mobile Crisis Team (Tampa,FL)
 Emergency/Police-Based Response a Rural
and Multi-Jurisdictional Crisis Intervention
Team
 Enhanced mental health, crisis intervention,
system awareness at the police academy
 Emergency/Police-Based
Response:Alachua
 CIT started March 2005
– Steering Committee contains representatives by GPD,
ASO, UPD, DCF, Meridian, NFETC, Alachua County
Crisis Center, VA
– Three classes per year

*Alachua County Crisis Center, CAREs Team, Crisis

Hotline, Therapy
*Mental Health Training for 911 operators
*Mental Health and BA Training for LEO
 2. Initial Hearings and Initial
Detention–
 Even when optimal mental health service systems
and effective pre-arrest diversion programs are in
place, some individuals with serious mental
disorders will be arrested.
 On the basis of the nature of the crime, such
individuals may be appropriate for diversion to
treatment, as a condition of pre-trial release
 Initial Hearings and Initial
Detention–
 Post arrest diversion procedures may include
having the court employ mental health workers to
assess individuals after arrest
 MH workers advise the court about the possible
presents of mental illness and options for
assessment and treatment.
 Courts may develop collaboration with the public
mental health system, which would provide staff
& services
 Initial Hearings and Initial
Detention : Alachua
 Several points of initial contact at Booking In and
First Appearance:
- Jail classification
- Jail Mental Health
- Centralized Screening Team – Court Services
- First appearance staff – judges, attorneys
 Initial Hearings and Initial
Detention : Alachua
 Individual then are screened for services:
- MH Court
- Court Service Supervision, Day Reporting and
Treatment
- Meridian Forensic Services
- Potential Div V cases
- Veterans Services
- Drug Court
At Sentencing
 Want the Judiciary to
be informed at
sentencing to make
sure that the
appropriate conditions
are established
 3. Specialty Courts–
 Incept 3 intervention that is receiving
attention are the establishment of separate
court programs specifically to address the
needs of persons with mental illness.
 Special jurisdiction courts limit punishment
and instead focus on problems solving
strategies and linkage to community
treatment to avoid further involvement in
the criminal justice system.
 Specialty Courts–

 The national GAINS center estimates that

there are now 114 mental health courts for
adults in the United States.
 Most are for misdemeanor defendants.
Court : National Best Practices
 Many Counties are starting to just develop
misdemeanor courts
 1st such Court in the United States of
America was in Broward county
 2nd such court in Florida was in Alachua
County
 1st Felony Court in Florida was Alachua
County
 Court: Alachua (MH Court)
 The Alachua County Mental Health Court is a pre-
adjudication diversion program, and the charges will be
dismissed if the individual successfully completes the
mental health court plan. This is a VOLUNTARY court.
Court Services, Meridian, State Attorney, Public Defender
work as a team.
 Alachua County and Columbia County
 2011 data on 204 participants indicated that:
 Average Jail Days was 39.05 before Mental Health Court
 Average Jail Days was 2.4 after Mental Health Court
 Court: Alachua (Div V Felony
Forensic Court)
 Participants are individuals who have been found Not
Guilty by Reason of Insanity, Incompetent to Proceed,
and/or Probation with Mental Health conditions. This is a
NON- VOLUNTARY court.
 Court Services, State Attorney, Public Defender, Regional
Council, Probation and Meridian all work as a team.
 4. Reentry/Reintegration
 Re-entry from Prison, Jail, and State Hospital
 There is little continuity of care or communication
between corrections and community mental health
for mentally ill individuals who leave correctional
settings.
 Public mental health systems may be unaware
when their clients are incarcerated or released.
 Reentry/Reintegration
 In addition, pressure is increasing on
corrections and mental health systems to
stop the cycle of recidivism frequently
associated with people with severe mental
illness who become involved in the criminal
justice system.
 Assess-Plan-Identify-Coordinate – APIC
Model
 Reentry to the Community
from jail and state hospital

 The APIC model for transitional planning

from local jails breaks new ground with it’s
focus on assessing, planning, identifying
and coordinating transitional care.
 The APIC Model: Assessing
 Assess the clinical and social needs, and public
safety risks of the consumer
 Cataloging the consumer’s psychosocial, medical, and
behavioral needs and strengths
 Gathering information from LE, courts, corrections, CMH,
& families to create a fully informed transition plan
 Incorporating a cultural formulation in the transition plan
 Engaging the consumer in assessing their own needs
 Ensuring the consumer has access to and means to pay for
treatment and services
 The APIC Model: Planning
 Plan for the treatment and services required to
address the consumer’s needs
 Addressing the critical period immediately
following release (1st hour,day, & week) as well as
long term needs
 Learning from the consumer what has worked or
not worked during past transitions
 Seeking family input
 Addressing housing needs
 The APIC Model: Planning-2
 Arranging an integrated treatment approach for the
consumer with co-occurring disorders
 Ensuring that the consumer is on an optimal
medication regimen
 Ensuring that they have sufficent medication to
last until psychiatric appointment
 Connect consumers with acute and chronic
medical conditions with community medical
providers
 The APIC Model: Planning-3
 Initiating benefit applications/reinstatements for
eligible inmates for Medicaid, SSI/SSDI,
Veterans, food stamps, and TANF
 Ensuring the consumer has…
 Adequate clothing
 Transportation
 Food
 The APIC Model: Planning
 Almost all jail consumers with co-occurring
mental illness and substance abuse disorders
will leave correctional settings and return to
the community. Inadequate transition
planning puts people with co-occurring
disorders who enter jail in a state of crisis
back on the streets in the middle of the same
crisis (Osher, Steadman, & Barr, 2002)
 The APIC Model: Planning
 The outcomes of inadequate transition
planning include the compromise of public
safety, an increased incidence of psychiatric
symptoms, relapse to substance abuse,
hospitalization, suicide, homelessness, and
re-arrest. (Osher, Steadman, & Barr, 2002)
The APIC Model: Planning
 Transition planning
can only work if
justice, mental health,
and substance abuse
systems have a
capacity and a
commitment to work
together… The results
will only be as good as
the partnership in the
community
 The APIC Model:Identifying
 Identify required community and correctional
programs responsible for post-release services
 Naming in the transition plan specific community
referrals
 Forwarding a complete discharge summary to the
community provider
 Ensuring every consumer’s belongings are
returned upon release
 Ensuring the consumer has a picture ID
 The APIC Model:Identifying
 Ensuring that the treatment and supportive
services match the consumer’s level of disability,
motivation for change, and availability for
community resources.
 Supporting conditions of release and community
supervision that match the severity of the
consumer’s criminal behavior
 Addressing the community treatment provider’s
role vis-à-vis other social service agencies,
probation, and the courts
 The APIC Model:Coordinating
 Coordinate the transition plan to ensure
implementation and avoid gaps in care
 Supporting the staff in coordinating the
timing and delivery of services and in
helping the consumer span the jail-
community boundary after release
 Case assignment must be made
cooperatively by the consumer, jail, and
community agency itself
 The APIC Model:Coordinating
 Explicitly communicating to the consumer,
family, releasing facility, and community
treatment agency, the names and contact
information of the person(s) who will responsible
for care between the time of release and first
follow-up appointment
 Confirming the consumer knows details of the
follow-up visit
 Confirming that they have adequate medication
 GAINs Re-Entry Checklist
 Community Re-entry: Alachua

JAIL
-Coordinated efforts are made to ensure an
appropriate release plan, use A.P.I.C. model
-GAINS Reentry Checklist, handout
-SOAR application in jail
PRISON
-Limited discharge planning – usually a medication
appointment with the local provider is made.
-VA has Prison release programs
 5. Community Corrections
(and Community Support Services) –
 Consumers under continuing supervision in
the community by the CJ system (usually
probation) are another large group to
consider.
 Failure to attend treatment appointments
often results in revocation of probation and
a return to jail.
MI individuals have trouble with
probation or conditional release
 Person may never understand instructions or
follow through because of symptoms
– Person may be experiencing symptoms of psychosis
– Overwhelmed because of anxiety about the
appointment
– Experience paranoia & not trust enough to follow
through
– Unable to complete the terms of release – community
service, fee’s
– Zero tolerance probation standards
– Inconsistent sleep patterns due to side effects of meds
– Unable to plan how to get there
Community Corrections/Support:
Alachua
 Interagency collaboration continues to
be the key focus in Alachua County.
 Once per month a continuity of care
meeting in held consisting of key
stakeholders of the forensic population.
This meeting provides agencies with a floor
for planning, networking, implementation,
service coordination, collaborative problem
solving, referrals, and information sharing.
Community Corrections/Support:
Alachua
 Department of Probation – dedicated probation officer
 Court Services
-Day Reporting
-County Probation
-Work Release
-Electronic Monitoring
-Court Service Contact and Treatment Supervision
Alachua Team Ongoing Support
 Meetings, leadership, &
Cooperation
– Needed as boundary
spanners
 Information exchange
– Timely information
handoffs
– HIPPA
 Training. System training
for LEO, PD, ASA, Jail,
MH, Courts, & Court
Services
 Sequential Intercept Model + Community Vision

Not available Court/Jail Intercepts

 In-jail specialized
 In place treatment
Therapeutic Courts
Partially in (Misdemeanor, 916,
Re-Entry Intercepts
 Forensic
place Post Booking
Intercepts
Felony) Residential
 Community/Jail- Treatment
 Coordinated based Competency
screening  Forensic Specialist
Restoration Services Team
 Forensic  Forensic Services
Specialists, Court Court Services
 Court Services  Peer Specialists
Services

Post-Release
Vision: Intercepts
Pre-Booking A community that  Specialized
Intercepts no longer needs Probation
 Crisis Intervention jails and courts to  Specialized,
Teams serve as a provider Supported Housing
Fully funded of mental health Fully funded
community based and addictions community based
system of care treatment system of care
Working Together to Install Best
Forensic Mental Health Practices
 Incentivize by funding, removing barriers, provide excellent resources
to learn and grow
 Encourage improvement
 Require and regulate
 Assist local mental health systems to develop the capacity to identify
and implement Best Practices
 Develop education and training materials
 Utilize and share fidelity scales or other measures to evaluate
implementation
 Promote cross system sharing
 Alachua Diversion Statistics
 At the end of March, a total of 184 clients were
actively participating in the program. Approximately
16% (28 of 184) received outreach/case management in
the jail. Approximately 6% (12 of 184) received
competency restoration services in the jail.
Approximately 78% (144 of 184) of participants
received treatment and/or case management services in
the community, with a total of 26% (38 out of 144
people in the community) receiving treatment services,
treatment groups and individual sessions.
 Re-Cap
 A. Model Basics
 B. Sequential Intercept Points
– 1. (Current Services) + Emergency/Police-
Based Response
– 2. Pre/Post-arrests
– 3. Specialty Courts
– 4. Re-entry/Reintegration & the APIC model
– 5. Community Corrections
C. Alachua County Status & Recommendations
Status
 Handout
 Idea’s?
 Recommendations?
 Comments?
 Questions?
Thank You
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questionnaire