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Supporting Justice-Involved Individuals with SMI: ...
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Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director for SMI Advisor. I am pleased that you're joining us for today's SMI Advisor webinar, Supporting Justice-Involved Individuals with SMI, from Arrest to Recovery. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one CE credit for psychologists, one CE credit for social workers, and one Nursing Continuing Professional Development contact hour. Credit for participating in today's webinar will be available until November 27, 2023. Next slide. Captioning for today's presentation is available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Next slide. Also, slides from the presentation today are available to you. You can download them in the webinar chat. Select the link to view. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide. And now, I am thrilled to introduce you to the faculty for today's webinar, Dr. Deb Pinals. Dr. Pinals serves as the Director of the Program in Psychiatry, Law, and Ethics, and is a Clinical Professor of Psychiatry at the University of Michigan Medical School. She's also a Clinical Adjunct Professor at the University of Michigan Law School. She's the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. From 2008 to 2016, she was the Assistant Commissioner of Forensic Services, and between 2012 and 2014, she was the Interim State Medical Director for the Massachusetts Department of Mental Health. Dr. Pinals is board-certified in Psychiatry and Forensic Psychiatry, and is board-certified in Addiction Medicine. During her career, she has been a Clinical Psychiatrist in Community Mental Health, Inpatient Settings, Forensic and Correctional Facilities, Emergency Rooms, and Court Clinics. Dr. Pinals, thank you for leading today's webinar. Next slide. Thank you, Amy, for that great introduction, and it is a pleasure to be here on SMI Advisor and to be presenting to everybody here today. I just want to say that I have no conflicts of interest related to the subject matter of this presentation, although I do sit on the Board of Representatives for the National Commission on Correctional Health Care on behalf of the American Psychiatric Association. There's no particular conflicts of interest, and the opinions that I express are my own. So let me just walk us through what I'm hoping to accomplish today for you that are listening in. By the end of this webinar, I would like you to be able to describe various settings where individuals with SMI who are in the criminal system are likely to be and some information about how care is delivered in those settings, discuss some of the risks of criminal recidivism and poor retention and treatment for individuals with SMI, some of whom have co-occurring substance use disorders, and then also describe some frameworks and models of support that help enhance ongoing continuity of care across settings. We know that the population of individuals that revolve around having a serious mental illness, they may be houseless, they may be in and out of criminal settings, and medical settings can be some of the most challenging in terms of helping them ensure that there's continuity of care and seamless transitions in care. And I'm hoping to highlight some of that today and then be able to discuss your questions at the end of the presentation. So we're going to start with the first learning objective, which is to describe the various settings where individuals with SMI who are in the criminal system are likely to be and some information about how care is delivered in those settings. So first of all, I have shown this on other SMI advisor webinars. This is a very well-known graphic. If you've never seen it before, no worries. You're seeing it here today. Some of you may be familiar with it. But this graphic depicts what's called the sequential intercept model, which was conceptualized by my colleague Mark Munitz and Patty Griffin and written about in psychiatric services in about 2006, I believe, is when it was first published. And then it turned into something that has been used widely as a way of conceptualizing the pathway that individuals take when they go from arrest, through court processes, through jails, to reentry and back out into community settings. And so I just want to spend a little time looking at that. When the model first was developed, it started with intercept one. In 2017, intercept zero, looking at the crisis care continuum, was added to the model with the idea that people with serious mental illness are overrepresented in criminal settings, and that if we could find a way to identify them as they move through decisions that are made within the criminal process, and then route them out into treatment settings, we could potentially intercept the trajectory of going deeper and deeper into the criminal justice settings and world, and get them better served in treatment settings. And that's why it's called the sequential intercept model. It takes the premise that decisions, legal decisions are happening in sequence. Somebody's on the streets, they may get involved in a altercation, they may take something and steal something, there may be some kind of incident where law enforcement is called, and then there may be an arrest, and then they move through these various settings. And all too often, their SMI is unknown to the people that are dealing with them, or if it's known, there's not a system in place to help ensure that they have continuity of care across these settings. So for example, when somebody is first arrested, they may be taken most likely by local law enforcement to a local lockup, run by a municipality where people would be held for up to 72 hours if it's a Monday holiday waiting for court to open the next day. But they may be in these settings, these local detention settings, some local communities use their local jail as the place of detention. But there's a lot of churn and turnover for that. And when you go to a local lockup in your community, it is very much like you see on TV, you know, cells and not a lot of medical care, if any medical care at all. And so what somebody with SMI does for medications and whatnot can be very complicated. So somebody who's on a stabilizing medication on an antipsychotic medication may not have access to those medications, then they may show then if they remain in custody, and they're not able to be bail or bonded out, they would be held until they have a court hearing this initial court hearing, which is often called an arraignment hearing. They may be held in a local lockup during the day in the courthouse, brought up to the courthouse, and then arraigned, which means you know, formally charged with their crime, or the alleged crime, and then sent back into the place of detention, where then they're awaiting trial, they usually would get assigned if they're indigent, an attorney at that first court appearance, if there's usually a screening that determines whether they're indigent and qualify for a public defender. And this is when things start rolling in terms of the criminal process. But they would then go back to the place of detention. Again, at any point along the way, there may be reasons why they would be released from custody, back into the community. Sometimes we do see that people, instead of being arrested, are sent, say to a local emergency department, and then psychiatrically hospitalized. That's what we might consider a diversion program. That doesn't necessarily mean that the criminal complaint is not filed. And then that individual may later have to deal with the criminal complaint, or risk a no show or a non appearance and then come back into, you know, maybe brought into some kind of custodial arrangement. Once they go through court hearings, they admit there would be an opportunity for them to enter a plea. They can enter a plea of not guilty or guilty or not guilty by reason of insanity, they may enter a plea of no contest where the court decides what will happen. And they may end up in jail. Or if they are found guilty of a more serious charge, they may be sent to a prison setting. The jails are run at the county level. And the prisons are run at the state level. And usually jail stays are up to a year. However, people can have multiple charges, they can be pre trial for more than a year. So the sentence is usually up to a year. But they can be pre trial. And then they can be have multiple charges where their sentence runs consecutively. And so they could end up in jail for more than a year. Prison, however, is usually for people that are sentenced to more than a year. And in both prisons and jails, most people who are going in are coming out. Of course, in prison, you do have people serving a life sentence, but that's the minority of people in a prison. It is not an insignificant minority, but most people are going to be coming out of prisons and or jails. And that's where we talk about reentry. And I'll be talking a little bit more about that as I go. Now, somebody could bypass jail and be straight sentence to probation and monitored by a correctional supervisor, a probation officer that usually is an officer of the court. And again, it depends a little bit on how each jurisdiction runs it from prison, or even from jail, somebody could be on parole, which is often a separate entity. From the probation system, the parole is usually a parole board that monitors whether somebody's ready for release or not at a parole eligibility date. And then if somebody is on what we call community supervision, they are living in a community setting where if they do not follow the terms of their probation or parole, they are at risk of being violated. If that violation happens, one of the sanctions could be that they are returned either to prison or jail, depending on where they came from. So there's very much of a fluidity between the individual who's in jail or in prison, then going out on community supervision, and then potentially returning. Now, why does this matter? Well, number one, it matters. It matters for many reasons. We have many people in American society that are on some kind of correctional supervision, many more that are in the community on correctional supervision than are in a correctional setting on any given day, actually. And what matters for people with SMI, and that's what this talk is about, is really trying to understand, well, what happens with their illness? And across these settings, they may have different access to care. They may look different. They may act differently because of the environmental interaction. And so it's very challenging sometimes for there to be continuity of care, which can challenge recovery. So I wrote a paper years ago where I labeled this population the crossover population, because what we see, too, is that oftentimes care is delivered across multiple settings. So it could be in the correctional setting. Somebody might be routed out of the correctional setting, for example, if they're not competent to stand trial. We have some SMI advisor webinars on these kind of issues and pathways. But then they may be routed to a forensic hospital or a state hospital. They may go out into community settings, into the community mental health system. They may get their care in emergency departments. And again, as settings are different and record availability may be limited, you may see that people appear differently or that their illnesses are diagnosed differently. And it can be very confusing for that person who may or may not be able to weave their history together in a way that helps the clinicians to ensure that continuity of care. Oftentimes, the people that move through these crossover settings are high utilizers of services and often, and all too often, have poor outcomes, both criminally and psychiatrically. Now, there are many forces today that are really pushing, and I believe rightly so, toward people with SMI being served in community-based settings. We all know about this phenomenon called deinstitutionalization that happened long ago. But we are now in an era where there are many, many reasons why the community setting is so critical for people. There are laws and legal decisions that promote people being served in community settings. There are financial aspects to people being served in community settings where it's more cost-effective than in large institutions. There are staffing issues in large institutions. And there are policies and principles on a principled basis. People with SMI, just like people without SMI, should have a right to live in a community setting and live their best and most meaningful life with relationships and jobs and however they want to live it, of course, recognizing too that we have to keep the public safe and laws need to be followed. But that's true for anyone, not more so for people with SMI. And that's one of the challenges in terms of why we see people with SMI overrepresented in the criminal legal system is partly because of some of the stigma and belief, sometimes paternalistic, sometimes stigmatizing, a variety of reasons where there are differences in treatment. And we see this at an intersectional level also with diversity, with people, Black and Brown individuals with SMI living in poverty who are going to be most at risk of being criminally involved for a lot of reasons that we, through a diversity and equity lens, are trying to undo from a systemic level. Now, one of the legal decisions that is really important for you all to be aware of is a case called Olmstead v. L.C. This is a 1999 case, and it really relied upon the Americans with Disabilities Act. It went to the U.S. Supreme Court, and the argument was there were people in Georgia with disabilities, with SMI and also intellectual disability, who were institutionalized in a psychiatric hospital, state psychiatric hospital, and there was a lawsuit against the state that basically said these individuals were clinically determined to be ready to live in their community. They wanted to be living in a community setting, but there was no community setting that was appropriate, and thus they were held longer than necessary in that state institution. And basically, the plaintiffs, these people who were living in these institutions, prevailed, and the Supreme Court ruled that in accordance with the Americans with Disabilities Act, individuals with mental disabilities have the right to live in the community rather than in institutions if the community placement is appropriate, and although the state must take into account the resources available and the needs of others, in other words, others can't be harmed, the absence of resources is not a justifiable excuse for keeping people in an institutional setting. This case has now been interpreted to be relevant across a variety of contexts in the criminal legal space, even in terms of arrests and jail and forensic hospitals and all sorts of ways that it's been recognized that the Americans with Disabilities Act really means business in terms of people requiring community-based settings. So we are under constitutional and, you know, under the U.S. Supreme Court mandates to promote community-based services. There is another law that you should know about called the Civil Rights of Institutionalized Persons Act of 1980. You can see this goes way back before the ADA, actually, and this protects the rights of institutionalized persons who are in mental health and DD facilities, jails, prisons, nursing homes, and juvenile justice facilities, and it is administered by the Department of Justice's Civil Rights Special Litigation Section where somebody can file a complaint saying that somebody's rights are not being adhered to in these types of facilities, and there can be an investigation and findings and consent decrees and all sorts of things that require better services within these institutional settings. Now, are prisons immune from thinking about the priority of the community? The answer is no. There was a U.S. Supreme Court case in 2011 called Brown versus Plata in which prison overcrowding in California was determined to violate Eighth Amendment rights related to inadequate health care and mental health care. In other words, because of the overcrowding, it was determined that the inmates within the California prison system were not getting adequate health care or mental health care, and the Supreme Court ruled on this and said discharge planning is a key element and also that the court ordered the release of 40,000 inmates at the time. Now, many of those inmates were released to local jails. Some were released into communities. But nonetheless, there was a major push. And this also, even though this was a California case, this was a Supreme Court decision, which really kind of tells the world and tells the United States that, you know, we really need to think about community-based services for people with complex criminal histories, including those with mental illness. So now you've heard about some of the settings people would be in during their pathway in through the justice system, and you've heard about some of the legal issues that are really creating the landscape and the mandate for community-based settings to be prioritized when that is the appropriate and reasonable direction to go in. Now I'm going to spend a little bit of time talking about and having you learn about and being able to discuss the risks of criminal recidivism and poor retention and treatment for individuals with SMI, some of whom have co-occurring substance use disorder, because it's nice to have policies and practices, but it's hard on an individual basis when we're working with people who have multiple challenges. So the first thing I want to talk about is that there is literature in the criminal justice kind of arena that really looks at what are the factors that put somebody at risk for criminal arrest, violence, or return to a prison or jail. And studies from years ago, decades ago now, really pointed to what we call the criminogenic risk factors, eight key criminogenic risk factors that are most likely correlated with recidivism, criminal recidivism, return to criminal settings. The first four, sometimes called the big four, have to do with antisocial features. For example, a history of antisocial behavior, rule violations, a history of an antisocial personality pattern of somebody who lacks remorse and violates social norms as part of their personality style, somebody with antisocial cognitions, again, lack of victim empathy, sort of recognizing, not recognizing the problems with antisocial behaviors, and then antisocial attitudes, justification for violating social norms. And these four are most correlated with return to criminal recidivism. And then the other four that were identified in these statistical analyses were people with family or marital discord, people with poor school and or work performance, people with few leisure or recreation activities, and people with substance use disorders. Now, some of this is a little bit tautological, and there's been a lot of looking at, you know, well, because of our policies, that where we have been criminalizing substance use disorders, for example, of course, substance use disorders is going to be related to risk of criminal recidivism because of just the way our systems work. And a lot of this has to be teased out. There's also, again, a lot of embedded potential structural inequities in some of these frameworks, but it's important to think about, you know, how these factors alone have been associated with criminal recidivism. Now, one of the risk factors you'll notice on this SMI advisor webinar is that serious mental illness is not one of the risk factors that's directly associated with return to criminal recidivism. However, if a person with SMI has any of these other eight, then just like people without serious mental illness, they would be at greater risk of criminal recidivism. So this framework leads to this idea of the risk-need-responsivity framework. I showed you before the eight risk factors, and the idea behind those is if we could target resources where approaches will have the biggest impact for people with medium and high risk of recidivism, then perhaps we could lower the risk of criminal recidivism, which means we have to identify the target criminogenic needs, and then finally recognize that approaches that the criminal system uses, like probation, parole, may need to vary based on the individual's responsivity. For example, their responsivity may include their motivation to cooperate, their cognitive capacity to be able to cooperate with the rules set forth, cultural factors, mental health factors like SMI, and even trauma issues. So I was just doing a training the other day, and we used as an example for probation officers, if you have someone who's got serious mental illness, depression, serious anxiety, disorganization, if their probation officer wants them to show up for an appointment, but they're not able to because of their anxiety to get on the bus, or they're not able to organize themselves to know what time the bus is going to be at the bus stop, they may have a no-show to their probation officer, and then they look like they're at higher risk because they've not shown, but it's really the responsivity factor that needs to be addressed, and so approaches to helping people comply with the terms of their probation and parole are going to need to recognize that individual responsivity is a major factor, even though it's not directly correlated with criminal risk. Now, this is all really important because we know that people coming out of jails and prisons with serious mental illness are really at risk for rearrest. These are old studies, but the data is consistent. Individuals with serious mental illness convicted of felonies show poor follow-up with treatment services and up to 40 percent rearrest within three years. We know that the risk of death due to drug overdose, suicide, homicide, or cardiovascular events is much higher for people with substance use disorders and people coming out of prisons. It's going to be 12, almost 13 times higher within two weeks of release, and so these are really important statistics to realize why continuity of care and helping people move from arrest to recovery is going to be so important as we think about continuity, helping people get in the treatment they need, helping them get the service that they need across these various settings. Other concerning statistics involve treatment retention. Now, I'm sure that the people listening to this webinar can think of many examples of people with whom they have worked where treatment retention was a challenge. We talk a lot about treatment access, making sure people have an appointment to go to as soon as possible. That's all great. However, if the treatment that is accessible is not desirable, then the likelihood of retention in care or is not easy or has barriers, then the likelihood of retention in care is lower, and this, again, is a population. Remember, many of them have early trauma histories. They may have attachment issues. They've been in and out of systems. The continuity has been poor, high turnover of staff, so there may be many, many factors that make it hard for people we serve to stay in care, so we have to think about that. Here's some studies, just some interesting data. Geographic accessibility and resource availability was associated with continuity of care in VA patients with SMI, meaning if it's too far away or if you get to the clinic and they don't have the clinical services you need, you're not likely to get as much continuity of care. Factors that improved retention in one study looked at male gender and home-based CBT services along with helping the patient work from a shared decision-making process for people with first episode psychosis, so really engaging the patient with first episode psychosis in helping them see that they were empowered to make their own decisions and then teaching them some home-based cognitive behavioral skills was very helpful in improving retention in care. Another recent study showed intensive case manage, integrated treatment, and long-acting injectables facilitated achievement and rehabilitation goals compared to standard of care and oral medication, so providing some more intensive supports was helpful for people with long-acting injectables. Then the last study that I pulled just out of interest, and you have some of the citations, is that collaborative care helped improve engagement in depression care in primary care among underserved racial and ethnic populations. Really thinking about collaborative care and engagement strategies are going to be really important to improve treatment retention. Now, how do we think about high-risk individuals and what do we even mean by high-risk individuals? High risk is a very complicated phrase. High risk can mean high financial risk, meaning for an insurance company or managed care organization that's providing their care through a managed Medicaid, for example, or other benefits, this is an individual who gets their care in inpatient settings and expensive settings, so it can be a high financial risk. But what we know is that high financial risk may also parallel high recidivism risk for these crossover populations because they tend to not have the seamless continuity of care at lower levels. They tend to have dropouts of care, and then by the time they're found in care because they just got out of a jail or a prison, they may need more intensive services, and so they actually become a higher financial risk for those insurers. There is some risk that they get deselected from services or again are dropped off rosters because if they're in jail for more than 30 days or if they're in prison for more than 30 days, they may no longer be on somebody's case management roster because nobody knows when they're going to get out of prison, and then they have to kind of re-up to get services that they need. So it's a really tough issue that many policymakers are trying to solve, and I think there's some promising things that I'll talk about on the horizon, but people should be aware of it. What's really important is that when you're working with these populations is that we have empathy for their journey. I do a lot of tours of a lot of places to help my trainees see the journey that the patients that they're serving take. We want to make sure that in any of the settings we're appropriately screening people so we know what they need and that we may want to think about more and more specialized models of services integrated with probation and parole as well as attention to these criminogenic needs that they may have to help reduce the risk of the cycle in and out of the criminal system. So that covers the first part of the journey that I wanted to take you on in describing some of the challenges, and now I want to spend some time again describing frameworks and models of support that can help enhance ongoing continuity of care across settings. So we're going to go back to the sequential intercept model, and again when we think about it, it is not a clinical model. It is showing decisions that are made along the justice system, but I would say when you think about your patients who have been in these areas of intercept, are you aware of where they are? Do you have notice? Does anyone know to call you? Are releases signed? Is there information sharing? How do we maximize the ability to help people move through these settings where decisions are made not based on clinical grounds but based on other grounds, and yet this person still has their clinical needs that need to be supported? So diversion options is one strategy. Many states, many communities have quote jail diversion programs. We know that through 988 and crisis lines and building out mobile crisis services, we are working hard to route people away from law enforcement when law enforcement is not necessary and to get people bridged services and stabilization services in their even home environments, which is one way of intercepting the potential for arrest. Even once people are arrested, there are diversion programs that work at the initial detention, at the first court appearance. There are specialty courts like mental health courts, veterans treatment courts, and drug courts that help serve individuals as alternatives to incarceration, and a variety of specialized models that work with probation and parole so that people with SMI can receive more continuity of care despite being in a criminal justice framework. So diversion programs or alternative to incarceration programs are going to be really important in communities to serve some of the needs of individuals. So I want to spend a little bit of time just talking about, because I'm talking about continuity of care, and we often talk also about the continuum of care. Now those are two different words, so I just want to spend just a minute kind of helping us think through this. They relate to each other, but they're not identical. So continuity of care is the unbroken and consistent existence or operation of something over a period of time. So continuity of care for me is that if I have a treatment need, I will get that care whether I'm in a jail or not in a jail. If I have diabetes and I need insulin, I will get the insulin regardless of the walls that are around me. I will have continuity of care. If I have schizophrenia and I need an antipsychotic medication, or if I have bipolar disorder and I need a mood stabilizer, I will get that continuity of care across systems in an unbroken and consistent manner. Now my symptoms might look different here and there, and I might need some tweaking to my medications, but essentially it would be an unbroken chain of care over a period of time. The continuum of care that we talk about is a continuous sequence in which adjacent elements are not perceptibly different from each other, although the extremes might be quite distinct. So we talk about the role of the vital role of the continuum of psychiatric care, and what that means is the importance of continuity. So the way I look at it is the continuum of care is the service delivery system that provides the continuity of care from a person-centered, patient-centered perspective, the care that they need. So the continuum is the system, and we need to build out a continuum from crisis services to crisis stabilization units to inpatient care to outpatient care to partial hospitalization or however the continuum looks in your community from the crisis to beyond, and also to prevent crisis from happening in the first place. That's the continuum, and I as a person would be able to get the care that I need regardless of whether I have a relapsing, waxing, and waning condition, just like we see with alcohol use disorder, with diabetes, with cancer care, even with orthopedic care, you know, my knee may flare up from time to time, I might need a little bit more physical therapy here and there, and we see this across health care conditions, that we might need continuity at varying levels as long as the continuum exists, we should be able to access that. So there's a couple of papers that are publicly available that Beyond Beds describes for somebody with schizophrenia, for example, what is the vital role of a full continuum of psychiatric care, and why is that important to think about rather than just thinking about inpatient beds as the sole place for care to be delivered. And then another paper that we wrote, Ready to Respond, this was during the sort of waning days of COVID, well not really, it was in 2021, I guess that wasn't quite waning yet, of looking at beyond crisis and COVID and really having an ability for the system to respond to crisis and then move people into other levels of care. So some fixes that we see on the horizon that are quite hopeful are parity with more individuals with SMI able to access insurance, more federal parity enforcement so that there's equal insurance coverage for psychiatric conditions compared to medical surgical conditions, and then more payment for prevention services and crisis services to minimize the risk that somebody will have a much worsened course of their condition. For justice-involved individuals with serious mental illness, there are more systems that are doing screening at the court and in other places, in jails to screen for needs for more assessment and treatment. There's innovative coverage around transportation needs, so perhaps police don't become major transporters anymore, but there can be non-emergency medical transport that can provide a safe harbor and movement for individuals who might need to go from a hospital to a voluntary crisis residential program and the like. Hopefully we'll see minimized disruption of entitlements like Medicaid, really working at continuity of Medicaid coverage, integrating care with criminal justice partners. We're seeing a lot more work where probation and parole are working with leaders in mental health and substance use services and providers to integrate the work being done, and then risk management where you have care coordination across settings. So these are ways to help improve some of those outcomes. Additional ways include training behavioral health and justice professionals on co-occurring conditions, the risk of trauma, looking at criminogenic risks and recidivism factors, looking at behavioral and physical health care integration, and then specialized justice and mental health collaborative services like mental health courts, like crisis intervention team training, and re-entry supports. There's also some exciting work being done at the federal level for the incarcerated population. Traditional Medicaid does not cover services for people within public institutions, and so benefits are often terminated, but more and more states have suspended benefits so you don't have to reapply, because terminated Medicaid benefits can take months to re-enroll and restore. There's also some new opportunities for funding of actual services within the prison and jail system. California and Washington are examples of states that have received approval for some demonstration of doing up to 90 days of some services within the jail and prison to help with continuity of care across that re-entry divide. There's also frameworks that have been identified, like the APIC framework, which is assess, plan, identify, and coordinate, that helps with re-entry where you screen for needs, and then you plan for that individual who's being released, identify critical periods and practices to enhance continuity, and then coordinate how care will be delivered across the system upon release. There's also certified community behavioral health clinics that are growing, which is really cool. A new model of care, similar to the federally qualified health centers, that's going to help enhance prevention with early engagement, crisis prevention and outreach, as well as crisis response with mobile teams that partner with law enforcement and schools, suicide prevention and crisis stabilization for both people with mental health and substance use needs, and then post-crisis care. These certified community behavioral health clinics are funded in a different way than traditional fee-for-service models, so that will allow for more infrastructure and support for things that previously did not have sufficient funding, so it's very exciting to watch those grow. We have models like forensic assertive community treatment that are designed to support individuals with serious mental illness in their community settings when they have criminal justice involvement as well, and it utilizes the assertive community treatment model with a multidisciplinary sort of wraparound team and has a criminal justice component to help sort of translate what's happening between the criminal justice space and the clinical space. SAMHSA's key components of forensic assertive community treatment include addressing these criminogenic risks, looking at well-defined criteria for eligibility, including not denying people services, in fact wanting people who've had multiple incarcerations to be for these services because this is a specialized type of services, providing care around the clock, and delivering care through an integrated multidisciplinary cross-system kind of partnership training with some flexible funding models. Another model is intensive case management. I showed you a slide before about helping with retention and care through this intensive case management, which helps with a small team and small caseloads that offers routine supports 24-7, 365, and community-based outreach. A 2017 review of the literature showed that compared to standard care, intensive case management recipients were more likely to remain in services and have improved functioning, get a job, not remain homeless, and have fewer hospital days, so some very encouraging findings around intensive case management. Barriers to continuity of care include that there's different views of their needs and symptoms and diagnoses across sites, which is why information sharing is important. Medications may be stopped, restarted, or changed, which can be hard for that individual. We really want to enhance the ability for people to communicate what their care has looked like. Psychiatric advance directives is sort of one strategy to do that, but people in supports may become disconnected and high risk of non-retention in care, so it is up to all of us to try and do what we can to remove those barriers. Providing housing supports can be really important for people that face houselessness. Housing and support from a mental health team has resulted in decreased inpatient days, higher housing stability, and cost savings for people with schizophrenia or bipolar disorders, and supported housings may be a way to help maximize community tenure for individuals with mental illness, and that means following permanence and affordability, so not just temporary housing but permanent housing, services that are housing oriented with multidisciplinary team involvement, allowing for voluntary services but using assertive approaches, integrating into communities, emphasis on choice, and low entry barriers. Then of course we want to think about treatments for people with co-occurring mental health, substance use, and physical illness. One model that we have worked on is Mission Criminal Justice. It's just one model. It provides a case manager and a peer that provide wraparound supports with several evidence-based practices built together to provide wraparound supports during transitions of care from criminal justice settings to community based settings, and then of course your systems consensus is really important when you're working with a criminal justice population is ensuring that your systems partners are working together and understand what each other's roles and strengths are and leveraging each other's strengths to help maximize this person's ability to have that continuity of care across that continuum, and then looking at community policies and practices, looking at funding, clinical services, and psychosocial services that really can help support with peers, with access to medications, with access to other supports, housing supports, and the like to ensure that the policies and practices in the community enhance continuity. There's also the need for operational supports, making sure that there are professionals that are working from different systems collaborating together, navigational supports, convening stakeholders from multiple systems to map pathways, educational supports. For example, providing education, we developed a series for the National Center of State Courts called Facts and Briefs so that we could provide for the courts basic education around some of these challenges and the systems so that people aren't just making assumptions about their system partners, and then legal policies and practices, again, memoranda of agreement that can create a foundation for different systems to work together to help address privacy and information sharing and how we get authorization across systems. And you have on your slide deck some references that you can look at, and with that I will pause and take questions. Right, I want to say before I'm going to say something else, stay back on your reference slide for a second. One of the person, one of our audience members wrote in and said, could you tell them the article that you talked about at the very beginning when you talked about coining crossover population, is that paper on this page? It is not, it is a citation that we can, how do we, how would we get that to people, Amy? We can, let's see, we can, hmm, I will think about that as we go forward. It is a paper I wrote that you could actually google, it's available for free in the Journal of the American Academy of Psychiatry and Law, so if you go to japple.org and google pinals, it's called something, charting the course. Charting the course, okay, great, okay. Let's go to the next slide. Of course, it's an immense amount of information you've given us today, and we so appreciate it. Before we shift into Q&A, let's go to the next slide. I want to take a moment to let the audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access our resources, education, upcoming events, complete mental health rating scales, and even submit questions directly to our SMI Advisor experts. You can download the app now at smiadvisor.org forward slash app. So let's go to the next slide, and let's take a couple questions. I have quite a few people who've written in, and one of the early questions I thought was really relevant because we talked about Olmstead at the very beginning of your talk today. So this individual wrote in and said, there's so many dual diagnosis clients. However, I have noticed when you try to transition them to the community, many of the sober or recovery houses refuse to take them because of their mental health diagnosis. As a result, many find themselves homeless or back in the system. Would the denial of housing of these patients, these ones that she's trying to place in sober recovery houses, be considered a form of discrimination? Should we refer them to the ACLU? What would you recommend? She's trying to get her community, it sounds like, to be receptive, and if they're not receptive, how does she push? Yeah, I mean, I think there could be, I mean, first I would look at parity angles. I would potentially refer it up to state behavioral health leaders to see if there's anything that can be done, and it could be something where a disability rights group or an ACLU type group might be interested in that. I think there are more and more, I mean, I think states are often now saying you can't, you know, the policies and programs are saying you can't discriminate based on somebody also having a mental illness, but it doesn't mean that some providers in practice are still doing that. Right, of course, of course, and so you're kind of recommending contacting their mental health commissioner for their state, or at least that office, and seeing who in that office might be able to help? That might be a good strategy. Okay, how can we take, what specific steps can we take to facilitate building a consensus between and amongst the different elements of the legal and the mental health care systems in our community? In our system in Oregon, it seems that these systems are quite separate and siloed. This is a really, like, so critical question, is being able to get those two, those groups, not two, it's usually many groups, to be talking to each other. How does one begin to take concrete steps to get that to happen? You know, I think politics are local. I would start with your local leadership, your community mental health, and ask what they're doing. Many states, many communities, like the community, for example, Washtenaw County in Ann Arbor, has got a millage passed to ensure that there was collaboration between the mental health and the criminal system and substance use, and they're developing new strategies, so I would start in a way locally and see what's going on. There may be things going on already that you're not aware of. And it always feels like whenever we were building consensus, you got to just keep tapping around until you find a person who's open to communication and team building, and once you find them, then you start to build around those people who are willing to communicate and make a team with you, so that might already be happening, but I agree, and don't give up. Like, if the first person isn't open to it, go to the next, go to the next, like keep kind of tapping around. And I just want to say, Amy, really quickly in the chat, I didn't know how to do it in the Q&A, I put the reference for people. Okay, thank you so much. So this person writes in and says, I'm an intensive case manager for physical health slash social work. My participants are in the emergency housing shelters. More have had experience in prison and jail time. The slow availability of housing is causing a new trend with participants are feeling re-institutionalized. They feel they're regressing. Can you comment on this dynamic and how can clinicians empower these unhoused people? Not an easy question. Yeah, I mean, it's so hard because there is so, right now with workforce challenges as they are, the ability to provide sufficient supports is really, really challenging. So I would just say, encourage people to, you know, use as much patience as possible. Help people understand kind of the, to the best of your ability from a trauma-informed lens, just being respectful of some of the frustrations. And then also, you know, there's nothing wrong with internal advocacy within your system. If somebody is really stuck, you know, again, I'm a believer in bumping it up and not just being quiet about it. If you're really concerned that somebody is regressing, it is concerning that, that we're seeing regression, you know, it's not just that people aren't getting better. People sliding backwards from these systems is really a problem, which is why I think a webinar like this is so important to raise awareness. So this next question, I have a little response to, but I want to hear what you have to say. So this individual says, do you know why the government doesn't set aside money to fund assisted living facility placements for persons incarcerated with SMI to ensure a smooth transition and reduce risks talked about? Well, I would say it varies across jurisdictions in terms of what is funded by the state. I think if, you know, again, a carceral, the social security act specifically rules out Medicaid funding and they've used some demonstration language to now get this 90 day re-entry support, but there's Medicaid does not allow institutional care to be funded for institutions, people in these prisons. So that's part of the problem with the federal system. The state government does pay for different kinds of placements and, and some will provide, some prison systems have more medically oriented assisted living kind of placements that they will fund. So it depends on the state. Yeah. I think my reaction is we know that sometimes individuals with SMI are placed in assisted living and don't need their, need to be there for their physical health. And there's not a lot of behavioral health rehabilitation there or behavioral health knowledge. And so it's my experience is it's not the, it's not an ideal situation to put them in assisted living unless they need it for physical health. I mean, that's another really important point that all too often we say, we see that people are placed in settings, not based on their level of care need, but based on a housing need, and then they're not getting the care that they really need. Right. And I'm sure this person's intention is to have a roof over them is better than no roof. And I get, I totally agree with that. I just, I don't think that that's where the money should go in terms of just cause there's not, there's not a lot of mental health knowledge there, and there's not a lot of behavioral health rehab there to help someone really then get their full life back. And so that just kind of concerns me. I love that what this person said, there's, it's not really a question, but they said, I'm from Bermuda. We're a small island with one psychiatric hospital. We created a meeting called mental health clients in corrections. This meeting is held monthly with court services, prisons, and the psych hospital. We have transition of care to the psychiatric hospital and to try to seek housing for those in need. This is someone who's built something, right. He's built a team to ensure there's collaboration. And I mean, hats off to this person for, for really like building something like that. And although Bermuda is a, a, you know, a small island, you could imagine your community being kind of like that and building something like that. Yeah, that's exactly when I talk about these memorandums of agreement and these kinds of arrangements, this is a great opportunity to enhance continuity of care. I love it. Thank you everybody for participating today. I always love chatting with our audience and of course, chatting with stellar faculty like yourself, Dr. Pinals. Let's go to the next slide. Give me one minute. Here we go. Thank you. If there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, post a question or a comment in the SMI advisor discussion board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. If you have questions about this webinar or any topic related to the care of those with serious mental illness, you can get an answer from SMI advisor within one business day. This service is available to all mental health clinicians, peer support specialists, administrators, or anyone else in the mental health field who works with individuals with, who have SMI. It's completely free and confidential service. This is our consult service. Please visit us at smiadvisor.org forward slash submit consult. Next slide. SMI advisor offers more evidence-based guidance on assisting justice involved individuals, such as the mental health and the criminal justice system, a guide for clinicians. In fact, Dr. Pinals helped and led the development of this resource. This guide helps mental health clinicians to understand criminal justice system involvement of the people they serve and how they may be able to assist. Access the resource by clicking on the link in the chat or by downloading our slides today. Next slide. To claim credit for participating in today's webinar, you will need to meet the requisite attendance threshold for your profession. After the webinar ends, please click next to complete the program evaluation. This may take up to an hour and can vary basically based on local, regional, and national web traffic of the use of the Zoom platform. So be patient, but please claim your credit. Next slide. Please join us next week on October 6th as Dr. Nicole Martinez-Martin presents equity and access in digital mental health, the role of privacy, safety, and ethics. This is going to be a really good one. Again, this webinar is free. It's October 6th at 1230 Eastern time. That's a Friday. Thank you for joining us today. Thank you to Dr. Pinals, and until next time, our audience, take care.
Video Summary
Dr. Amy Cohen introduces the SMI Advisor webinar on supporting justice-involved individuals with serious mental illness (SMI). The webinar aims to provide clinicians with the answers they need to care for their patients with SMI who have been involved in the criminal justice system. Dr. Deb Pinals, a clinical professor of psychiatry, leads the webinar and discusses various settings where individuals with SMI are likely to be in the criminal justice system and how care is delivered in those settings. She also addresses the risks of criminal recidivism and poor retention in treatment for individuals with SMI and outlines frameworks and models of support to enhance continuity of care across settings. Dr. Pinals emphasizes the importance of collaboration between the mental health and criminal justice systems and offers strategies for building consensus and facilitating communication between these systems. She also highlights the need for more resources and funding to support individuals with SMI during their transition from the criminal justice system to the community.
Keywords
SMI Advisor webinar
serious mental illness
clinicians
criminal justice system
care delivery
criminal recidivism
continuity of care
collaboration
strategies
transition
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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