The Development and Evolution of the Mental Illness and Drug Dependency Plan

1. The Development and Evolution of the Mental Illness and Drug Dependency Plan Andrea LaFazia-Geraghty MIDD Project Manager Christine Lindquist NAMI Greater Seattle, Director June 29, 2012

2. Objectives • Understanding of the development of the MIDD plan • Awareness of the jail and hospital diversion strategies • Understanding of the role of NAMI in the development of the MIDD plan and ongoing role in the MIDD and individuals living with mental illness

3. Background: Where We Started • Juvenile Justice Operational Master Plan to reduce use of juvenile detention. Began in 2000 • Adult Justice Operational Master Plan to reduce use of jails. Began in 2000

4. Background: Where We Started • Criminal Justice Initiatives to provide treatment alternatives to jail. Began in 2003 • Basic mental health and chemical dependency services chronically under-funded by state and federal government funding sources

5. Criminal Justice Initiatives: Vision • In King County, offenders with mental illness and/or chemical dependency needs receive a continuum of treatment services that is coordinated, efficient, and effective, and that reduces their rate of re-offense and jail time.

6. Criminal Justice Initiatives • $2 million provided by King County to fund programs • Focus on services in custody and linkage to community services upon release • Included design of assessment process in jail, cross system training, criminal justice liaisons, linkage to benefits, housing vouchers, methadone treatment, outpatient co-occurring treatment, and program evaluation

7. Criminal Justice Initiatives: Prior to the MIDD Gaps Remained • Pre-booking diversion programs • Accessible and appropriate housing • Accessible mental health and chemical dependency treatment systems • Prevention programs • Capacity to serve more people in existing programs

8. Opportunity to Fund System Change • The 2005 Washington State Legislature passed legislation allowing counties to impose a 0.1 percent sales tax to be used “solely for the purpose of providing new or expanded chemical dependency, mental health services and for the operation of new or expanded therapeutic court programs” • In King County, the sales tax was forecasted to raise$48-$50 million per year

9. First Steps • Mental Health and Substance Abuse Community Advisory Boards asked County Executive to implement sales tax to fund services • Executive directed staff to convene workgroup to identify priority needs and services • Workgroup with broad representation from county government stakeholders reached agreement on priority needs and services

10. Need in King County • Large number of people with mental illness and chemical dependency in jail and utilizing hospital emergency services • Individuals with a mental illness jail stay longer and cost more to serve • Over 8,000 homeless in King County

11. Need in King County • People without Medicaid coverage unable to get needed services • Little funding provided for prevention and early intervention • More capacity needed for youth and adult therapeutic courts

12. Service Improvement Recommendations • Provide crisis intervention team (CIT) training for first responders • Establish a crisis diversion facility • Expand therapeutic courts • Expand accessible and affordable housing options • Reduce caseload size in the mental health system

13. Service Improvement Recommendations • Increase access to services for people uninsured by Medicaid • Increase resources for high need youth and their families • Increase supported employment options for people with substance abuse and mental health

14. Next Steps • County Council briefed twice on problems and opportunities in caring for people with MH/CD needs in the justice system by panel of criminal justice and community treatment experts • Council passed motion calling for the development of a three phase action plan to address needs of people with CD/MH who are homeless and/or involved in CJ system

15. MIDD Action Plan Goal “to prevent and reduce chronic homelessness and unnecessary involvement in the criminal justice and emergency medical systems and promote recovery for persons with disabling mental illness and chemical dependency by implementing a full continuum of treatment, housing and case management services”.

16. Phase I • Described the service improvements needed to meet the goals of the action plan, including what steps could be taken within existing resources. • This work had already been substantially completed by the work group convened by the County Executive

17. Phase II • Goal was to address changes in criminal justice processing to more effectively deal with people with mental illness and chemical dependency. • Specifically asked to address prearrest diversion, prebooking diversion, alternative sentencing, assessment and discharge to connect directly to community services

18. Phase II • Sequential Intercept Model used to organize work • Separate workgroups for youth and adult populations • Adult workgroup divided into community services and criminal justice system committees • Both groups identified target populations, key intercept points, decision makers regarding diversion, information needed by decision makers, policy and legal changes needed, and services needed for successful diversion

19. Phase III Included: • Prevalence study of populations in jail, homeless, and in treatment systems • Service improvements needed to meet needs of these populations • Estimate of costs of providing services and benefits from providing these services • Proposal for financing full set of improvements

20. Prevalence Profile • Half of homeless in shelters have mental illness or chemical dependency • Half of youth in detention have a mental disorder • People of color are seriously overrepresented in adult and juvenile justice systems

21. Prevalence Profile • Mental illness is the leading cause of hospitalization for youth in Washington State • 13% of individuals receiving public mental health services in 2006 had a history of at least one jail booking

22. Phase Three Process Identified key stakeholders: • County jail staff • Jail health staff (provided by Public Health) • Judges • Prosecuting attorneys • Public defense • Law enforcement • County Council staff • Budget office • Community and human services department • Juvenile court • Advocates • Consumers • Service providers • Health Care for the Homeless

23. Phase Three Process Outreach to numerous key stakeholder groups: • NAMI • Association of police chiefs • County criminal justice committees • Mental health and substance abuse treatment providers • Youth service providers • Downtown business association • City governments

24. Use of Sequential Intercept Model • Provided framework for workgroup to determine what services needed to be provided for which people at what locations and at what times in order to help prevent incarceration, hospitalization, and homelessness • Expanded model to include people with substance abuse as primary problem, and to expand definition of core services to put more emphasis on youth and prevention

25. Adult Jail Diversion Sequential Intercept Model New/Enhanced Interventions Current Interventions Ultimate Intercept New and enhanced prevention and community treatment programs will prevent many adults from entering the criminal justice system • Intercept 1 • Jail high utilizer program • Intercept 1 • Crisis intervention training • Establish Crisis Diversion Center • Respite beds • Mobile crisis team • Intercept 2 • Incoming Referrals to CJ Liaisons from: • Family members • DOC community corrections officers • Jail Health psychiatric evaluation specialists • Inmate requests • Public defenders and public defense social workers • Probation officers 2. Assessments requested by Intake Services • Intercept 2 • Release prior to filing when community treatment available • Increase deferred prosecution cases • Increase referrals from Intake Services • Stay competency process to allow for community treatment • Intercept 3 • Initial Referrals from CJ Liaisons: • Reconnect with existing mental health case manager • Link to COD treatment • Link to DSHS • Refer to VA • Link to ADATSA for CD treatment 2. Refer to Mental Health Court • Link to Housing Voucher and Case Mgmt Program • Link to COD treatment • Intercept 3 • Increase CJ Liaison staff in the jail in order to: • Reconnect more inmates to community services • Refer more veterans and their dependents to VA for treatment and housing • Increase felony drop down referrals to MH Court • Increase program services for existing and new MH courts • Intercept 4 • Ongoing Referrals from CJ Liaisons: • Link to Reentry Case Management Program • Rental assistance • Intercept 4 • Increase Reentry Case Management Program staff in order to assist more offender-clients in connecting to treatment and housing • 2. Reduce MH caseloads • Intercept 5 • Forensic Programming at • Community Corrections: • Screen and assess CCAP participants for appropriate services • On-site CD treatment • On-site COD treatment • On-site educational classes • Intercept 5 • Urinalysis testing supervision at Community Corrections • Increased access to community services for non-Medicaid clients • Housing supportive services • Employment services

26. Selection of Strategies • Workgroups identified over 50 strategies and then prioritized strategies • Final selection by workgroup based on criteria that included meeting policy goals and legislative mandate, filling in gaps in continuum of services within Sequential Intercept Model, being a best or evidence-based practice, and serving those most at risk

27. Recommendations for Service Improvements in Action Plan Core Strategy Areas • Community Based Care • Programs for Youth • Jail and Hospital Diversion Programs

28. Strategies for Service Improvements Community Based Care • Make treatment more available to those without insurance • Improve quality of care • Increase access to supportive housing

29. Strategies for Service Improvements Programs for Youth • Provide prevention and early intervention • Expand assessments for youth in juvenile justice system • Expand team-based, intensive “wraparound” services for youth • Expand services for youth in crisis • Expand Family Treatment Court • Expand Juvenile Drug Court

30. Strategies for Service Improvements Jail and Hospital Diversion Programs • Divert people who do not need to be in jail before they are booked into jail • Expand mental health courts and other post-booking services to get people out of jail and into services more quickly • Expand re-entry programs for jails and hospitals

31. Housing • A range of accessible housing options for people with mental illness and/of chemical dependency was one of the top priorities of all the stakeholder workgroups • Only housing supportive services was included in the final plan due to the enabling legislation • Enabling legislation changed in 2008 to allow sales tax funds to be used for housing

32. Prevention Services Housing Jail/Hospital Diversion Community Services Core Strategy Areas

33. Prevention Services Housing Community Services Jail/Hospital Diversion JAIL/PRISON Core Strategy Areas

34. Policy Goals King County Ordinance 15949 • A reduction in the number of mentally ill and chemically dependent people using costly interventions like jail, emergency rooms, and hospitals. • A reduction in the number of people who recycle through the jail, returning repeatedly as a result of their mental illness or chemical dependency. • A reduction of the incidence and severity of chemical dependency and mental and emotional disorders in youth and adults. • Diversion of mentally ill and chemically dependent youth and adults from initial or further justice system involvement. • Explicit linkage with, and furthering the work of, other Council directed efforts including, the Adult and Juvenile Justice Operational Master plans, the Plan to End Homelessness, the Veterans and Human Services Levy Service Improvement Plan and the King County Mental Health Recovery Plan.

35. MIDD Implementation Plan The MIDD Implementation Plan strategies are grouped into six service areas. • Community-Based Care • Programs Targeted to Help Youth • Jail and Hospital Diversion • Domestic Violence and Sexual Assault Intervention and Prevention and Adult Drug Court • Housing Development • New Strategies

36. MIDD Strategies serving Youth • 1a-1: Increase access to community mental health treatment (20%) • 1a-2: Increase access to community substance abuse treatment (20%) • 1c: Emergency room substance abuse early intervention program (10%) • 1f: Parent partner and youth peer support assistance program (100%) • 2a: Workload reduction for mental health (20%) • 4a: Services for parents in substance abuse outpatient treatment (100%) • 4b: Prevention services to children of substance abusers (100%) • 4c: School based mental health and substance abuse services (100%) • 4d: School based suicide prevention (100%) -% refers to the percentage of youth served by the strategy

37. MIDD Strategies serving Youth • 5a: Expand assessments for youth in the juvenile justice system (100%) • 6a: High fidelity wraparound initiative (100%) • 7a: Reception center for youth in crisis (100%) • 7b: Expansion of children’s crisis outreach response service system (100%) • 8a: Expand family treatment court services and support to parents (100%) • 9a: Expand juvenile drug court treatment (100%) • 13a: Domestic violence and mental health services (25%) • 13b: Domestic violence prevention (100%) • 14a: Sexual assault and mental health services (25%) • 17b: Safe Housing and Treatment for Children in Prostitution Pilot Project (100%) -% refers to the percentage of youth served by the strategy

38. MIDD Strategies serving Adults 1a-1: Increase access to community mental health treatment (80%) 1a-2: Increase access to community substance abuse treatment (80%) 1b: Outreach and engagement to individuals leaving hospitals, jails, or crisis facilities (100%) 1c: Emergency room substance abuse early intervention program (90%) 2a: Workload reduction for mental health (80%) 3a: Supportive Housing Services(100%) 10a: Crisis Intervention Training (100%) (*there is a CIT youth specific training, but only adults are trained) 10b: Crisis Diversion Services (100%) 11a: Increase capacity for jail liaison program (100%) -% refers to the percentage of adults served by the strategy

39. MIDD Strategies serving Adults 11b: Increase services for mental health court (100%) 12a: Increase jail reentry program capacity (100%) 12b: Hospital reentry respite beds (100%) 12c: Increase capacity for Harborview’s Psychiatric Emergency Services to link individuals to community-based services upon discharge from Emergency Room (100%) 12d: Behavior Modification classes for CCAP (100%) 13a: Domestic violence and mental health services (75%) 14a: Sexual assault and mental health and chemical dependency services (100%) 15a : Expansion of Recovery Support Services for Drug Court (100%) 16a: New housing units and rental subsidies (100%) -% refers to the percentage of adults served by the strategy

40. Building a Full Continuum of Care • Housing, prevention programs, accessible and comprehensive community treatment programs, and jail and hospital diversion programs are all needed to meet the action plan goal “to prevent and reduce chronic homelessness and unnecessary involvement in the criminal justice and emergency medical systems and promote recovery for persons with disabling mental illness and chemical dependency”

41. Managing from a Mandate Establishing priorities of service need • Community stakeholder process • Described through Action Plan and 3 Phases of planning • Oversight Plan • Implementation Plan • Evaluation Plan • Noted in the 5 policy goals established by the King County Council which governs the MIDD Plan • 37 unique strategies

42. Managing from a Mandate Advisory Board Management • King County Ordinance 16077 established the MIDD Oversight Committee on April 28, 2008 • The MIDD Oversight Committee is an advisory body to the Executive and Council.

43. MIDD Oversight Committee • Its purpose is to ensure that the implementation and evaluation of the strategies and programs funded by the MIDD sales tax revenue are transparent, accountable, collaborative and effective. • The MIDD Oversight Committee is a unique partnership of representatives from the health and human services and criminal justice communities. • 30 members

44. MIDD OC members Christine Lindquist, National Alliance on Mental Illness (NAMI) Executive Director Representing: NAMI in King County • David Hocraffer, Director, King County Office of the Public Defender • Representing: Public Defense • Darcy Jaffe, Assistant Administrator, Patient Care Services • Representing: Harborview Medical Center • Norman Johnson, Executive Director, Therapeutic Health Services • Representing: Provider of culturally specific chemical dependency services in King County • Bruce Knutson, Director, Juvenile Court, King County Superior Court • Representing: King County Systems Integration Initiative • Jackie MacLean, Director, King County Department of Community and Human Services (DCHS) • Representing: King County DCHS • Donald Madsen, Director, Associated Counsel for the Accused • Representing: Public defense agency in King County • Linda Madsen, Healthcare Consultant for Community Health Council of Seattle and King County • Representing: Council of Community Clinics • Richard McDermott, Presiding Judge, King County Superior Court • Representing: Superior Court • Ann McGettigan, Executive Director, Seattle Counseling Center • Representing: Provider of culturally specific mental health services in King County • Barbara Miner, Director, King County Department of Judicial Administration • Representing: Judicial Administration • Sue Rahr, Sheriff (Past Co-chair) • King County Sheriff’s Office • Representing: Sheriff’s Office • Dan Satterberg, King County Prosecuting Attorney • Representing: Prosecuting Attorney’s Office • Mary Ellen Stone, Director, King County Sexual Assault Resource Center • Representing: Provider of sexual assault victim services in King County • Dwight Thompson, Mayor Pro Tem • City of Lake Forest Park • Representing: Suburban Cities Association • CheleneWhiteaker, Director, Advocacy and Policy, Washington State Hospital Association • Representing: Washington State Hospital Association/King County Hospitals Mike Heinisch, Executive Director, Kent Youth & Family Services (Co-chair) Representing: Provider of youth mental health and chemical dependency services in King County Barbara Linde, Presiding Judge, King County District Court, (Co-chair) Representing: District Court Claudia Balducci, Director, King County Department of Adult and Juvenile Detention Representing: Adult and Juvenile Detention Rhonda Berry, Assistant County Executive Representing: County Executive Bill Block, Project Director, Committee to End Homelessness in King County Representing: Committee to End Homelessness Linda Brown, Board Member, King County Alcohol and Substance Abuse Administrative Board Representing: King County Alcohol and Substance Abuse Administrative Board John Chelminiak, Councilmember, City of Bellevue Representing: City of Bellevue Catherine Cornwall, Senior Policy Analyst Representing: City of Seattle Merril Cousin, Executive Director, King County Coalition Against Domestic Violence Representing: Domestic violence prevention services Nancy Dow, Member, King County Mental Health Advisory Board Representing: Mental Health Advisory Board Bob Ferguson, Councilmember Metropolitan King County Council Representing: King County Council David Fleming, Director and Health Officer Public Health–Seattle & King County Representing: Public Health Zandrea Hardison, Program for Assertive Community Treatment Team Nurse, Downtown Emergency Service Center Representing: Labor, representing a bona fide labor organization Shirley Havenga, Chief Executive Officer (Past Co-chair) Community Psychiatric Clinic Representing: Provider of mental health and chemical dependency services in King County

45. Managing from a Mandate Contract and payment terms; performance based • Implementation Plan, was approved by the council throughOrdinance 16261 on October 6, 2008 • Details the 37 strategies and how (and to whom) the funding will be distributed • Schedule for strategy/program implementation, including the following: • staff level (FTE) and provider indentified • procurement process (that is, if a competitive process was necessary to release the funding) • milestones for implementation of the strategies • Quarterly reports to Council quarterly) • Payment terms are negotiated directly by the King County Executive (Department of Community & Human Services, Mental Health, Chemical Abuse and Dependency Services Division (MHCADSD)

46. Managing from a Mandate Contract and payment terms; performance based and Reporting Requirements & Monitoring • Evaluation Plan, the third and final plan, • approved by the council through Ordinance16262on October 6, 2008 • The Evaluation Plan describes the evaluation and reporting plan for the programs funded with the sales tax revenue, including the following elements: • process and outcome evaluation components • a proposed schedule for evaluations • performance measurements and performance measurement targets • data elements to be used for reporting and evaluations

47. Managing from a Mandate Evolution of politics and service needs requiring contract adjustments • 2009 Washington State Legislature passed Supplantation • Allows counties to supplant existing funding with the local sales funding (remember previously the law stated the sales tax could only be used for new or expanded programming) • King County was authorized to supplant up to 50% of the MIDD fund and use the funds for existing county funded substance abuse, mental health or therapeutic court services • Reduction clause 50%, 40%... And supplantation sunsets (this was in 2009). • In 2010, the law was revised again to remove therapeutic courts services from the supplantation % reduction schedule and restart the % sunset count down

48. Managing from a Mandate Managing the money • The MIDD Fund is currently budgeted at $53M, revenue is approximately $42. • We’re able to “over” budget due to fund balance due to some strategies being delayed which has carried over • Contracts with providers for specific strategies • Deliverable, timelines • Performance targets/evaluation requirements

49. Is what we’re doing working?

50. Is what we’re doing working? Overall, the sum of jail bookings went down for this sample from 4,008 to 3,094 and the sum of jail days went down from 91,205 to 69,795. This is a remarkable finding, as it is typical for jail bookings to decrease but jail days to increase during the first year of program evaluations of this type.