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Report
CRIMINAL JUSTICE MENTAL
HEALTH & SUBSTANCE ABUSE
REINVESTMENT GRANTS
ALACHUA COUNTY’S PARTNERSHIP WITH MERIDIAN
A Presentation for Florida Partners in Crisis
November, 2013
Maggie Labarta, PhD, MERIDIAN BEHAVIORAL HEALTHCARE
1
ALACHUA COUNTY
• Population of 251,417.
• Capital of the Gator Nation, Gainesville is home to the University of Florida,
with some 50,000 students
• 874 square miles, Alachua County is a mix of urban and rural communities
• Median household income of $41,373. According to the 2010 U.S. Census
report, 24% of its residents live at or below the poverty level which is well
above the State average of 15%.
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MERIDIAN
• Comprehensive behavioral healthcare center
• Co-occurring enhanced services
• Services from outreach and prevention to in-patient, residential, and long-term supported housing
• Service area includes 12 North Central Florida Counties – 550,000 population
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Two crisis stabilization units (50 beds)
Residential treatment – mental health, substance use, co-occurring
Pre-post partum residential treatment
Medically assisted treatment for substance use disorders
9 outpatient clinics
3 collocated sites within primary care
School-based services
Mental Health First Aid ©
Part of the CIT Training Team
• Provide treatment services to almost 14,000 clients a year, contact another 11,000 through prevention and
outreach
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JAIL CHARACTERISTICS
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Rated capacity of 976 with a 15% classification factor . Between Dec. 2012 and
May 2013 the average daily population was at a low of 855 in March and a high
of 983 in December
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The Department of Court Services interviews of all inmates prior to their first
appearance.
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23% of adults were arrested for an alcohol violation while only 8% stated they had an
alcohol problem; paradoxically, 7% were arrested for an illegal drug incident yet 14% selfreport a problem with drugs.
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About 1.6% self report as having a mental health problem; however, 30.2% of all Jail
inmates receive psychotropic medications while incarcerated in Alachua County.
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Of the daily census, 57 individuals report being homeless .
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FORENSIC SERVICES: MERIDIAN AND ALACHUA
COUNTY PARTNERSHIP
1998
MH/SA
Providers
Law
Enforcement
Public
Defender
Public Safety
Coordina-ting
Council
Courts
(Judges
& Staff)
County Government (Elected &
Staff)
State’s
Attorney
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FORENSIC PROGRAMS
• Largely concentrated in Alachua County
• 1998 – County Committee identified MI/SA as reasons for growing jail
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population and agreed
- That treatment was the correct thing to do
- Partnership would be required
2000 – Mental Health Court established by Judge Jim Nilon
2003 – Crisis Intervention Team grant written
– Felony Mental Health Court established Judge Martha Ann Lott
– Community Based Competency Restoration program established
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• 2005 – community partners visited Denver
• CIT classes started
• In-jail to community competency restoration funded by DCF
• County created Mental Illness Workgroup (“MIWg”) to
identify needed services and develop Strategic Plan for
effective jail diversion system.
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SEQUENTIAL INTERCEPT MODEL1 + COMMUNITY VISION =
STRATEGIC PLAN
Not available
 In place
Partially in place
1 Facilitated
by the USFFMHI CJMHSA Technical
Assistance Center
Post Booking
Intercepts
 Coordinated
screening and
classification
 Forensic
Specialists
Pre-Booking
Intercepts
 Crisis Intervention
Teams
Fully funded
community based
system of care
Court/Jail Intercepts
 In-jail specialized
treatment
Therapeutic Courts
(Misdemeanor, 916,
Felony)
 Community-based
Competency
Restoration Services
 Forensic Specialist
Team
 Forensic Diversion
Team
Vision:
A community that
no longer needs
jails and courts to
serve as a provider
of mental health
and addictions
treatment
Re-Entry Intercepts
 Forensic Residential
Treatment
 Forensic Specialist
Team
Forensic Diversion
Team
 Peer Specialists
Post-Release
Intercepts
 Specialized
Probation
 Specialized,
Supported Housing
Fully funded
community based
system of care
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• 2006 – MIWg report leads to funding for enhancing existing
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competency restoration
program and creating a “Forensic Specialist Team”
2007 – County Commission created CJMHSAG Planning Committee
• Chaired by member of Court or a County Commissioner
• County Advisory Board charged with responding to grants and other funding
opportunities
• Awarded first 3-year $2million DCF CJMHSA Reinvestment ACT Implementation grant
created treatment team to which most ill individuals could be referred, worked hand in
hand with staff funded by DCF (competency restoration) and Forensic Specialist Team
2010 – Awarded expansion $1 million DCF CJMHSA Reinvestment ACT Expansion grant
• Integrated the work of both teams to adapt to lowered funding
• Expanded array of services through integration
• Added trauma services and Moral Reconation Therapy
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SPECIALIZED PROGRAMS: COUNTY, AND GRANT
1, GRANT 2 INTEGRATED THEM AND EXPANDED
WHO WE SERVE
Forensic Specialist Team
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Outreach and Intervention
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Forensic Diversion Team
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Based on ACT model
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Engagement
Competency Restoration
Referral
Accessing benefits (SOAR)
Monitoring
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Uses existing treatment resources
Provides advocacy in Court
Single point of accountability for
court cases
Self-contained team
Engagement oriented
Co-occurring enhanced
Multidisciplinary
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Jail classification staff
Counselor
Peer specialist
ARNP
Treatment supports – housing vouchers
Focus on high recidivists for both
treatment and court systems
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PROGRAM FOCUS
• GOAL – Minimize jail time and increase participation in treatment
• At booking
• Post booking
• Re-entry
• METHOD
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Screen at booking
First appearance evals
Mental Health Court
Competency restoration at jail and in community
Diversion – VA, state hospital
Treatment on re-entry
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PROGRAM DESIGN
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Phase I (Pre-engagement): Pre-treatment groups; motivational interviewing; program orientation/education;
linkage/referral to community resources/programs
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Phase II (Recovery Services): Starting treatment services; individual/group therapy; case management; medication
management; drug testing; linkage/referral to community resources/programs
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Phase III (Stabilization): Advanced level of self-sufficiency; individual/group therapy; case management; medication
management; drug testing; linkage/referral to community resources/programs; increased usage of peer support
services
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Phase IV (Transition): Recommended for clients requiring minimal services to maintain stability; individual/group
therapy; case management; medication management; drug testing ; linkage/referral to community
resources/programs; increased usage of peer support services
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Phase V (Aftercare): After graduation from treatment; assigned a peer specialist; case management; medication
management; drug testing; linkage/referral to community resources/programs; structured curriculum (Wellness
Recovery Action Plan)
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STAFFING
INITIAL
• 8 Staff
• Half funded by county, half CJMHSA
Implementation Grant
• Team make-up:
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Team leader/program therapist (MA)
3 Forensic Specialists
2 Peer Specialists
EXPANSION
9.2 Staff
Counselors
Forensic Specialist
Forensic Outreach Specialist
Peer Specialists
ARNP
Assessment Specialist
Benefit Coordinator/Data Analyst
Admission Coordinator/Screener
1.00
3.50
1.00
0.50
0.20
1.00
1.00
1.00
1 Jail Classification Specialist (ACJ employee)
1 part-time Benefits Coordinator
(Court Services employee)
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EVIDENCE BASED PRACTICES
• Self-contained program
• ACT “light” based on essential elements
(funding would not support full ACT)
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Continuous engagement efforts
Motivational enhancement
Rapid access to medication
Therapy within the program – Trauma
Informed Care
• Access to benefits for follow-up care - SOAR
• Screening for Re-entry – GAIN checklist
• Access, Plan, Identify & Coordinate (APIC) –
coordination with community partners for
successful re-entry
• Moral Reconation Therapy
• addresses needs of those with antisocial
personality
• Effectiveness data compiled and
aggregated data by Meridian and Court
staff
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MORAL RECONATION THERAPY
MRT is a 13 stage evidence-based cognitive behavioral, step by step treatment designed to
enhance self-image, promote growth of a positive, productive identity, and facilitate the
development of higher stages of moral reasoning.
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Step 1 & 2 (Trust and Honesty): Disloyalty, the lowest moral and behavioral stage in which a person can
function.
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Step 3 (Acceptance): Opposition, starting to be somewhat honest.
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Step 4 (Raising Awareness): Uncertainty, may lie, cheat and steal but uncertain if they should do so.
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Step 5 & 6 (Healing Damaged Relationships and Helping Others): Injury, identifying that they have hurt
others or themselves.
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• Step 7 & 8 (Long-Term Goals and Identity and Short-Term Goals and Consistency): NonExistence, do not have a firm sense of identity and do not feel connected to the world.
• Step 9 & 10 (Commitment to Change and Maintaining Positive Change): Danger, starting
to commit to long-term goals.
• Step 11 (Keeping Moral Commitments): Emergency, sense of urgency in completing goals.
• Step 12 (Choosing Moral Goals): Normal, incorporating their identity into how they live their
life.
• Step 13 to 16 (Evaluate Relationships Between Inner Self and Personality): Grace, few
reach this step where the person sees others as an extension of self.
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OUTCOMES: VOLUME OF SERVICES
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Referrals: 1406 to date, average 5055 per month
• Admissions: accepted to date 432,
average 12 per month roughly 25%
• Average 15-20 pending referrals
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Active in program 157 (215270/year),
average 150-160, plus another 50
in state hospital
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100% receive Case Management
25% receive treatment
23% receive Competency Restoration
77% of participants are in Felony
Forensic Court or Mental Health Court.
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WHO IS NOT ACCEPTED?
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• 25% of active program participants were
participating in treatment (not just CM) services
provided by the Forensic Treatment Program in
Phases II to V
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25
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Phase I
• Phase I participants are those in Pending status post
screening and pre engagement in Treatment
• 44% (of program participants in treatment were in
Phase II
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Phase III
Phase IV
Phase V
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Trauma Groups.
• 59% (10 of 17) female participants in treatment
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services were in Women’s Trauma Groups
• Peer Specialists are providing follow up contact to
0
July 2013
Aug 2013
Sept 2013
participants who have been discharged
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6
5
Step 1&2
4
Step 3
Step 4
Step 5&6
3
Step 7&8
Step 9&10
Step 11
2
Step 12
Step 13-16
1
0
July 2013
Aug 2013
Sept 2013
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Moral Reconation: 5% of treatment participants
OUTCOMES: EFFECTIVENESS
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Days in the community: 91% for those
not at state hospital
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Recovery
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12% in jail
64% in community
24% at state hospitals
12 % in a Vocational Program
12 % Employed
5 % in School
Adherence with medication: 82%
Type of Discharge
30
25
20
15
Type of Discharge
74%
10
26%
5
0
Successful
Unsuccessful
The vast majority of unsuccessful discharges
are for non-compliance
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7
6
6
5
• Engagement works
• 66% of unsuccessful discharges occur in
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3
3
3
Successful
Unsuccessful
3
2
2
1
1
0
Phases 1 or 2
0
Phase I
0
0
0
Phase II Phase III Phase IV Phase V
or MRT
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Arrests
Arrests
3.5
3.5
Participation has long term
effects
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We see reductions in two year
follow up for those who don’t
succeed
2.5
2.5
Greatest impact is for those
who stay with it
1.5
1.5
22
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Graduates expanded benefit
persists even after we refer
them to traditional follow-up
care
0.5
0.5
00
FYE2008
FYE2008
FYE2009
FYE2009
FYE2010
FYE2010
FYE2011
FYE2011
FYE2012
FYE2012
ARRESTS
ARRESTSBY
BYADMIT
ADMITDATE
DATE
Pre-admit
Pre-admit12
12month
monthperiod
period
Post
Postadmit
admitmonths
months1-12
1-12
Post
Postadmit
admitmonths
months13-24
13-24
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Jail Days
120
100
80
60
40
20
0
FYE2008
FYE2009
FYE2010
FYE2011
JAIL DAYS BY ADMIT DATE
Pre-admit 12 month period
Post admit months 1-12
FYE2012
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Post admit months 13-24
COST
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Forensic Diversion Team (Funding & Data for May 2011-June 2012)
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MIWG - $370,000
CJMHSAG
• State - $250,000
• County Match - $167,000
• In-kind match (various sources) - $78,000
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Total annual funding: $865,000
Number served: 267
Average annual cost per person: $3,230
Post admission Jail Days
14,004
X $85/day = $ 1,190,340.00
Pre admission Jail Days
28,803
X $85/day = $ 2,448,255.00
PROGRAM IMPACT
-14,799
NET COST AVERSION (IMPACT-COST)
$ (1,257,915.00)
$392,915 per year
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LESSONS LEARNED
• The CJMHSA Reinvestment Act funding has made a dramatic impact on the
Planning, Implementation and Expansion of Jail Diversion services for persons
with mental health and substance use disorders involved in the Alachua county
Criminal justice system
• Get community "buy in" by using the Sequential Intercept Model.
• Utilize all community resources, bring them to the table.
• Programs should have an Outreach component to allow flexibility.
• Design the program to allow for flexibility with trends.... The program has to meet the
needs of the clients, not the other way around.
• Contingency funding is absolutely necessary
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THE REAL REASON IT’S GREAT
• Ms. B is a 33 year old female with a long history of mental illness and substance abuse.
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Formerly received services from FACT team ; dropped out two years ago.
Arrested 4/7/13 for aggravated assault, with deadly weapon without intent to kill
Not taking her medications, and experiencing severe psychotic symptoms
She was immediately identified by the Forensic Liaison at the jail, who attempted to convince her to take
her medications but she continued to refuse.
• She then was evaluated, found Incompetent to Proceed, and meeting criteria for State Hospital.
• Forensic Liaison succeeded in getting her to take her medications and provided competency restoration.
• By the time Ms. Brown’s case was transferred to Felony Forensic Court, she was stabilized on her
medications and competent.
• The Forensic Program Director then advocated with the court that Ms. Brown did not need to go to the
State Hospital and could be diverted to the community with supports in place.
• Ms. Brown was released from jail on 6/20/13 to Forensic Treatment with her charges completely
resolved.
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QUESTIONS?
Contact Leah Vail, Director, Forensic Services
[email protected]
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