Topic: Substance Abuse

Since 2015, Policy Research, Inc. (PRI) has partnered with MacArthur’s Safety and Justice Challenge (SJC) to reduce the number of individuals involved, or at risk of involvement with, the criminal legal system who have mental illness, substance use, and other complex needs. Studies highlight the importance of concentrating on this population as communities work to tackle the misuse and overuse of jails and create more equitable systems:

• About 5% of the general population has a Serious Mental Illness (SMI), compared with 5% of men and 31% of women incarcerated in local jails. An even greater percentage of both groups lives with broader mental health needs and are prescribed psychotropic medication.
• 63% of those incarcerated in jail have a substance use disorder.
• People with mental illness often remain in jail longer than individuals without.
• Despite overall jail population reductions in the last few years, many communities participating in the Safety and Justice Challenge have seen the proportion of individuals with mental illness increase.
• Despite stigmatizing myths, the majority of individuals with mental illness are not violent and the majority of violent acts are not committed by those with mental illness.

As part of the Safety and Justice Challenge, PRI created the IMPACT Network to provide technical assistance to participating communities on issues related to the over-incarceration of individuals with mental illness and substance use disorders. The IMPACT Network communities engage in a peer-to-peer learning model to accelerate best and promising practices in behavioral health reform and jail diversion, with a commitment to pursuing community-driven, race-conscious solutions to reduce harm to populations overrepresented in, or disparately impacted by, the criminal legal system.

The SJC IMPACT Network began in 2021 with a group of 11 jurisdictions.

Over the past two years, these communities have participated in topical technical assistance meetings focused on behavioral health data tracking and evaluation, equity within the intersection of the criminal legal system and behavioral health, developing early diversion strategies, building a robust jail continuum of care, and other critical topics.

The communities participating in the IMPACT Network focus on a variety of strategies to decrease inappropriate incarceration of people with behavioral health needs.

Allegheny County, PA

Allegheny County’s Justice Related Services (JRS) provides assessment, treatment placement, and service coordination to court-involved individuals with mental health or co-occurring diagnoses. They are also focusing on balancing risk and needs during decision making for people with behavioral health needs, developing alternative response to certain 911 calls, and building out a broader continuum of peer supports for court-involved people.

Orange County, CA

In April 2022, the Orange County District Attorney’s Office launched their Focused Intervention Route to Services and Treatment (FIRST Point) pre-filing diversion pilot program. The pilot program connects people who have committed low-level crimes with services to address mental health and substance use issues to ensure a criminal proceeding does not inhibit future work and education opportunities.

San Juan County, NM

San Juan County has worked closely with community stakeholders and cross-agency representatives through their Sequential Intercept Mapping (SIM) process, identifying gaps in services available to individuals with behavioral health needs. As part of their post-SIM work, the county plans to identify a system for data collection that will assist stakeholders in tracking the county needs and build planning capacity toward creation of a mental health drop-in center.

In early 2023, PRI expanded the IMPACT Network by adding six additional communities: Doña Ana County, NM; Solano County, CA; Sarpy County, NE; Douglas County, NE; Issaquah, WA; and Natrona County, WY, for a total of 17 jurisdictions. This new group of counties brings to the IMPACT Network communities from the West and Midwest, including several smaller and more rural jurisdictions.

We are excited to further diversify the IMPACT Network and continue this important work toward the goals of reimagining systems, reducing the footprint of local jails, and increasing equity.

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.

For years we have witnessed an increase in the number law enforcement interactions with individuals in the community with unaddressed behavioral health challenges. Conversely, there remain far too few alternatives to unnecessary arrest or transport to the emergency department.

Middlesex County, in Eastern Massachusetts, is New England’s most populous county. Our criminal justice and behavioral health leaders recognized the need improve capacity and access to behavioral healthcare in the community. In 2018, the Massachusetts legislature created the Middlesex County Restoration Center Commission to develop a pilot that would help solve the “divert-to-what?” question. In Middlesex County, the sheriff’s office offers evidence-based programing and treatment for incarcerated individuals, but individuals should not have to go to jail to receive the services they need.

We are grateful to have recently been invited to join the Safety and Justice Challenge’s new IMPACT behavioral health cohort, to share some of the lessons we have learned, and learn from our partner jurisdictions in this impressive network. The Commission has just entered its fourth year of work, and our path forward will be made easier through this tremendous peer exchange opportunity.

One of the biggest lessons we have learned, and hope to pass along to our partner jurisdictions, is the importance of improving collaboration and communication across siloed fields like public safety and behavioral health. All too often, addressing behavioral health needs of the community remains in traditional agency siloes. From the sheriff’s office to mental health service providers and police departments to peer and advocacy organizations, it is only this kind of collaboration that is able to stop people from falling through the cracks.

Middlesex County has 1.6 million people with 54 different police departments spread across urban, suburban, and rural areas. We are fortunate to have the progressive leadership of our police chiefs focused on diverting individuals away from the criminal justice system and into treatment. Similarly, we are fortunate to have a health and human services community poised to step up to increase outreach and engagement, to partner with public safety, and to provide appropriate assessment, treatment, stabilization, and support services to affected individuals.

In an effort to shift the responsibility back to the behavioral health community, we knew it was necessary to develop a model that knit together services in a way that made them easily accessible to both the public and local law enforcement. We wanted to move away from the traditional model of stabilization and release from the emergency department. The Restoration Center will offer both stabilization as well as a comprehensive assessment to inform referral to treatment so the needs of individuals can be appropriately met. Our goal is not only to stop the cycle of unnecessary incarceration but also to help individuals stay healthy enough that they do not have to return to the center.

After years of planning and implementation our goal is to launch a pilot Restoration Center in 2022. We believe we are well positioned to launch the model we have developed in large part due to our commitment to the cross-sector planning process which started with identifying gaps in the delivery of behavioral healthcare, a cost-benefit analysis, and interviews with individuals with lived experience. Through our state legislature, we were successful in securing initial funding as well as a trust fund that will allow the Commission to accept third-party funding.

Now that the Commission’s 2022 budget includes $1 million in funding for the pilot – endorsed by a recent editorial in the Boston Globe, we can begin our work of identifying a provider. We continue to pursue additional funding to ensure that we can implement a full range of services identified as critical to the success of individuals who might otherwise be arrested or hospitalized.

The center will provide behavioral health services to individuals in mental health or substance use crisis. These services will help support ongoing law enforcement efforts across the county to divert individuals with behavioral health conditions from arrest or unnecessary hospitalization.

Local law enforcement and corrections have shouldered this burden for far too long, with over 70 percent of people in our Middlesex Jail & House of Correction having an open mental health case and 80 percent have a history of substance use.  Each and every one of these individuals receives treatment while incarcerated, but these are services that people should be able to access in the community. Our hope is that the Restoration Center will help stop the cycle of unnecessary incarceration.

We attribute a lot of the success of the Middlesex County Restoration Center Commission to the commitment of our diverse stakeholder group. It is not common to have a sheriff co-chair a legislative commission with the president of a mental health advocacy group. It is also unusual to get representatives of the 80 largest behavioral health providers at the county, police chiefs, the chief administrative justice of the trial court, and key state legislators at that table. And sustaining the focus on a challenging goal for over three years is the rarest thing of all. But that is what it takes.

Unfortunately, political will is often the hardest thing to secure. But we owe it to the people falling through the cracks to get it right.