Building an Effective County Behavioral Health Care Continuum

By: Chelsea Thomson

Interagency Collaboration Mental Health Substance Abuse February 17, 2022

Recognizing that too many people spend too much time in jails across America when their deeper need is for behavioral health treatment, counties are deploying innovative programs to help address this problem. To better support community members living with a behavioral health condition such as mental illness and/or substance use disorders, many counties are developing and implementing integrated behavioral health continuums of care.

Building an effective behavioral health care continuum targets the root causes of behavioral health emergencies by investing in comprehensive and accessible prevention, treatment, and real-time intervention. With almost one in four adults in the United States living with a behavioral health condition, county leaders understand the urgency to find approaches that balance community behavioral health needs and law enforcement response during an emergency.

The continuum of care helps people before, during, and after a behavioral health emergency by prioritizing a public health and person-centered approach. This reduces the overreliance on emergency rooms and the criminal legal system as de facto mental health providers.

The National Association of Counties is exploring the challenges and opportunities related to the behavioral health continuum of care in partnership with the Safety and Justice Challenge (SJC). This year we are producing a series of webinars and reports outlining the important work counties are undertaking in this space.

The first webinar in January focused on helping people before and after an emergency. Representatives from Orange County, NY, Johnson County, IA, and Hennepin County, MN discussed ways to assist people in the community through coordinated and wraparound services that often address social determinants of health. One panelist was Leah Kaiser, Director of Behavioral Health and Justice Strategy in Hennepin County—a community participating in SJC.

“Hennepin County includes Minneapolis. The impact of George Floyd in 2020 dramatically impacted our partnerships with law enforcement, with community providers, and with our communities,” Kaiser said. “We are really starting to reap the rewards that come from breaking down siloes to meet people’s needs.”

Kaiser discussed “intercept zero” of the sequential intercept model (SIM). The SIM details how people with behavioral health conditions come into contact with and move through the criminal legal system. Kaiser showed how practices such as care coordination, peer support and connections, and referrals to social services can help to address the underlying drivers of behavioral health conditions. It means deflecting people away from intercept one – when law enforcement or emergency services providers often respond to residents experiencing a behavioral health emergency.

“In our system redesign we’ve been centered on ‘what has been their experience when residents have a mental health emergency?’” Kaiser said. “Today, residents encounter a person, or multiple people, who do not have the right training and can do very little to help them resolve their crisis. The mismatch between training, response, and need is costly to both residents and the system at large. The result puts people on a path of repeated traumatic exposure, overuse of inappropriate interventions, and poor health outcomes.”

The system redesign in Hennepin County involved people from across the community, Kaiser said.

People facing a behavioral health emergency often have socioeconomic, health, and emotional needs across systems and are best served when those systems work together. That is why a recovery-oriented and cross-systems approach can stabilize a person in distress and equip them with the tools to effectively mitigate a future need before it turns into an emergency.

With differing needs, counties may prioritize pieces of the continuum but can best serve residents by supporting them throughout each step of their behavioral health condition. It is important to support community members during an emergency by providing them with someone to talk with, someone to respond, and somewhere to go—a framework created by SAMHSA—but services before and after are critical too. No one element of the continuum alone will resolve a problem.

The next webinar on February 22 will highlight counties that are using federal American Rescue Plan Act (ARPA) funds to support the behavioral health needs of their residents. Many counties are dedicating federal resources to programs and practices such as stabilization centers or providing mental health services in libraries and recreation centers. Counties are also deploying ARPA funds towards justice and public safety efforts.

As part of the SJC, NACo supports a dozen counties through the County Justice Peer Learning Network. Over the past two years, these counties have developed action plans and implemented practices to reduce the number of individuals living with a behavioral health condition in jails. They are bolstering their behavioral health continuums of care by increasing coordination across agencies and programs (Whatcom County, WA), launching a crisis triage center (Douglas County, KS), deploying a pilot mobile response unit pairing a paramedic and mental health worker (Dane County, WI), and expanding mental health diversion in the court system (Durham County, NC), among other accomplishments.

The future looks rich for a deeper discussion about behavioral health continuums of care. It should involve the right people in getting the right outcomes and keeping people out of jails who would be better served by treatment and support in the community.

Middlesex County, MA

Action Areas Diversion Mental Health

Last Updated

Background & Approach

The Middlesex County Restoration Center Commission was created by the Massachusetts Criminal Justice Reform Act of 2018 with the goal of researching and developing a model for diverting people with behavioral health conditions from arrest or unnecessary emergency department utilization. The Commission found that disproportionate numbers of people with mental health and substance use needs are (1) interacting with police, (2) incarcerated or detained, (3) utilizing emergency departments for behavioral health assessments even when inpatient hospitalization is not the outcome, and (4) “boarding” (waiting more than 72 hours) in emergency departments while awaiting psychiatric inpatient beds.

As a result of these findings, the Commission designed a model for a Restoration Center pilot in Middlesex County. The model seeks to address the identified gaps and needs in Middlesex County, drawing on best practices and evidence-based programming from around the country. A Restoration Center pilot in Middlesex County will seek to provide urgent and crisis care with core components including triage and assessment with medical clearance, crisis stabilization for both mental health and substance use, respite, and aftercare planning including case management and social determinants of health navigation. The Commission and its partner, Commonwealth Medicine, now seek to identify additional sources of funding and procure a vendor to launch a pilot Restoration Center.

Lead Agency

Middlesex Sheriff’s Office and Massachusetts Association for Mental Health

Contact Information

Catia Sharp
Commonwealth Medicine, a division of UMass Chan Medical School
Catia.sharp@umassmed.edu

Partners

Massachusetts State Senate Office of Senator Cindy Friedman; Massachusetts State General Court Office of State Representative Kenneth Gordon; Massachusetts Association for Behavioral Healthcare; Bedford MA Police Department; MA Office of the Trial Court; the National Alliance for Mental Illness (NAMI) Massachusetts; Massachusetts Executive Office for Health and Human Services; Massachusetts Department of Mental Health; Massachusetts Bureau of Substance Addiction Services

West Texas Centers, TX

Action Areas Diversion Mental Health

Last Updated

Background & Approach

West Texas Centers (WTC) is a community mental health center located in Big Spring, Texas. Since its inception in 1997, WTC has provided mental health services for individuals in 23 counties covering an area of 25,000 square miles.

West Texas Centers is committed to working with local governments to decrease the population of people with mental illness in our jails.

There has been much progress so far in this effort by the implementation of our Mental Health Deputy program and our Community Mental Health Grant: Jail Caseworker program. These two programs are unique in that our mental health staff have partnered up with local Sheriff’s departments and are integrated into each other’s systems. The staff in these programs are able to be the intercepts between Mental Health and Criminal Justice.

However there are still many challenges with not having a place to divert people with mental illness away from the jails.

West Texas Centers recognizes the lack of resources in our rural communities. This challenge has created our drive to work harder with local partners and continue our quarterly Jail Diversion Committees. Our Jail Diversion Committee includes; local Sheriff’s, Jail leadership, Parole/Probation, West Texas Centers mental health and IDD key staff, Hospital representatives, local County Judges, people with lived experience (Peers), State hospital representative and VA representative. Our strategies while working with the IMPACT Network sites are to implement new programs within the intercept model to divert people with mental illness from the jails. By learning from others in the network, we can create something that fits our smaller communities.

Specifically having more specialized court dockets with training for the judges on mental health and SUD issues. West Texas Centers also would like to work with local partners to design and implement a diversion center for law enforcement to utilize when they only have one choice; the jails.

Lead Agency

West Texas Centers

Contact Information

Patricia Watlington
patricia.watlington@wtcmhmr.org

Partners

Members of our Jail Diversion committees

Texas Health and Human Services, TX

Action Areas Diversion Mental Health Substance Abuse

Last Updated

Background & Approach

The Texas Health and Human Services Commission (HHSC) is collaborating with 13 local mental health authorities (LMHAs) to support community-based solutions for expanding or strengthening mental health crisis response and jail diversion. These 13 LMHAs serve North and West Texas and participate in All Texas Access as the North Texas State Hospital Regional Group and Big Spring State Hospital Regional Group, respectively. These regional groups of LMHAs work together to strengthen mental health care access and services in rural areas, providing access when and where it is needed, with the goal of reducing mental health crises that result in emergency room use, incarceration, transportation to mental health facilities, and other costs to local government. Texas is particularly interested in further strengthening partnerships between the behavioral health and the criminal justice systems in rural communities, since 70 percent of Texas is rural.

HHSC will support each LMHA in identifying at least one crisis response or jail diversion strategy that would work most effectively in their community. HHSC is particularly interested in law enforcement drop off or diversion centers, integration of behavioral health crisis staff in 911 dispatch centers, and the use of technology to support crisis services in Texas’ most remote areas. These strategies would complement services already offered by each LMHA, including 24/7 crisis hotlines and mobile crisis outreach teams. Participation in IMPACT also contributes towards HHSC’s implementation of Texas’s new strategic plan, Well and Safe: the Texas Strategic Plan for Diversion, Community Integration, and Forensic Services.

Lead Agency

Texas Health and Human Services Commission

Contact Information

Robert Dole, LCSW-S
Deputy Associate Commissioner

Dr. Jennie M. Simpson
State Forensic Director

Orange County, CA

Action Areas Diversion Mental Health

Last Updated

Background & Approach

With over 3 million people and 34 cities, Orange County California is the sixth most-populated county in the United States and is more populous than 21 U.S. states. Our jurisdiction’s interagency planning group, the Orange County Criminal Justice Coordinating Council (OCCJCC), has focused much of its work to date at Intercepts 3-5, including enhanced in-custody mental health and substance use treatment services, a coordinated reentry process, and a screening and referral system to connect probationers to the newly opened (March 2021) Behavioral Health Services Campus, BeWell OC.

We are hoping to initiate further reform at Intercepts 1-2 through a joint effort led by the District Attorney’s Office as the connection point to each of Orange County’s police departments. Our plan is to start a pilot program with the selected jurisdictions and police departments, building outcome and evaluation data that then can be used as justification to request further resources for countywide expansion.

Lead Agency

Orange County District Attorney’s Office

Contact Information

Jess Rodriguez
Supervisor, Mental Health Unit, Orange County District Attorney’s Office
jess.rodriguez@da.ocgov.com

Partners

Orange County Health Care Agency; Social Services Agency; Irvine Police Department; Orange County Sheriff’s Department; Seal Beach Police Department; University of California, Irvine