Using the Sequential Intercept Model

To Target Early Intervention and Treatment

for Co-Occurring Disorders
in the Justice System

Patricia  A.  Griffin,  PhD  

April  13,  2011  
1  
•  Funded  by:  
–  Pennsylvania  Commission  on  Crime  and  Delinquency  
(PCCD)    
–  Department  of  Public  Welfare  Office  of  Mental  Health  and  
Substance  Abuse  Services  (OMHSAS)    
•  Oversight  by  the  Mental  Health  and  JusDce  Advisory  
CommiHee  of  PCCD  
Collaboration between
Drexel University
&
Western Psychiatric Institute and Clinic
University of Pittsburgh Medical School 2  
 Focus  

Men  and  women  with…  

 

•  Serious  mental  illness,  and  oMen  

•  Co-­‐occurring  substance  use  disorders  
•  Involved  in  the  criminal  jusDce  system  

3  
      The  Problem  
•  Many  of  the  same  people  in  mulDple  systems:    
–  Mental  health  
–  Substance  abuse  
–  Criminal  jusDce  
–  Other  social  services  
 

•  Expensive  -­‐  high  service  users,  people  who  cycle  and  

recycle  through  the  system  

SOLUTION:
Cross-Systems Collaboration and Coordination
4  
Bureau of Justice Statistics 5  
SequenDal  Intercept    
Model  
 

6  
 Unsequential Model

Community
Supervision

Initial Hearings
Arrest

Jail
VA
Prison
Community

Courts

Substance
Mental Abuse
Health 7  
7
7
Dan Abreu
 Sequential Intercept Model

8  
8
8
Dan Abreu
A systematic approach to the
criminalization problem
n  There is no single solution to the problem we are
calling criminalization of people with mental
illness or over-representation
n  The problem must be attacked from multiple
levels
n  The Sequential Filters Model
n  We conceptualized a series of filters. Each filter
provides a point to catch an individual with
mental illness. Over time, the filter rate should
increase earlier in the sequence.

9
 SequenBal  Intercepts  
Best  Clinical  PracDces:    The  UlDmate  Intercept  

I. Law Enforcement/Emergency Services

II. Post-Arrest:
Initial Detention/Initial Hearings

III. Post-Initial Hearings:

Jail/Prison, Courts, Forensic
Evaluations and Commitments

IV. Re-Entry From Jails,

State Prisons, &
Forensic Hospitalization

Munetz  &  Griffin   V. Community

Psychiatric  Services   Corrections &
Community
57:  544–549,  2006   Support

10  
 SequenDal  Intercept  Model    
Mark  Munetz,  MD  and  PaHy  Griffin,  PhD  (2006)    

•  Envisions  a  series  of  points  of  intercepDon  at  which  an  

intervenDon  can  be  made  to  prevent  individuals  from  
entering  or  penetraDng  deeper  into  the  criminal  
jusDce  system    
 
•  Using  the  model,  a  community  can  develop  targeted  
strategies  over  Dme  to  increase  diversion,  reentry,  
and  linkage  to  the  community    

11  
 SequenDal  Intercept  Model    
Mark  Munetz,  MD  and  PaHy  Griffin,  PhD  (2006)    

•  SequenBal:    People  move  through  criminal  jusDce  

system  in  predictable  ways  
 
•  Intercept:    Illustrates  key  points  to   intercept  to  
ensure:  
–  Prompt  access  to  treatment  
–  OpportuniDes  for  diversion  
–  Timely  movement  through  criminal  jusDce  system  
–  Linkage  to  community  resources  

12  
 Sequential Intercept Model
Intercept 1 Intercept 2 Intercept 3 Intercept 4 Intercept 5
Law Initial detention / Jails / Courts Reentry Community
enforcement Initial court corrections
hearings

Specialty Court
Violation

Parole
911

Reentry
Prison/
First Appearance Court
COMMUNITY

COMMUNITY
Initial Detention
Law Enforcement

Dispositional Court
Arrest

Violation

Re-entry

Probation
Jail
Jail

13  
Five  Key  Points  of  IntercepDon  

1.  Law  enforcement  

2.  IniDal  detenDon  /  IniDal  court  hearings  
3.  Jails  /  Courts  
4.  Re-­‐entry  
5.  Community  correcDons  

14  
The  UlDmate  Intercept    

15  
 Useful  Organizing  Tool  
•  IdenDfies  
–  ExisDng  local  services  and  systems  
–  Issues  considered  important  to  local  stakeholders    
•  Data    
•  Diagnosis    
–  Strengths  to  be  built  upon    
•  Helps  everyone  see   big  picture  &  how  they  fit    
–  Helps  diverse  groups  from  various  systems  understand  
where/how  everything  fits  
–  Intercepts  provide   manageable  venues  and  
opportuniDes  for  systems  intervenDons  
16  
SequenDal  Intercept  Model:    
A  Circular  View  

Law
Community Enforcement/
Corrections & Emergency
Community Services
Support

Access to
Appropriate
Community Services Booking/
Re-Entry Initial
Appearance

Jails,
Courts

Munetz & Griffin, 2006 17  

  
Summary  
 
•  Seamless  transiDon  to  community  
•  Moving  away  from  criminal  jusDce  system,  
into  services  
•  Strategic  approach  is  necessary  

18  
20
21
24
 SequenDal  Intercept  Model  as  
Basis  for  Cross-­‐Systems  Mapping  
Cross-Systems Mapping depicts local contact/flow
with the criminal justice system

A  tool  to    
•  Help  transform  fragmented  systems,  
•  IdenDfy  local  resources  and  gaps,  and  
•  Help  idenDfy  where  to  begin  intervenDons  
25  
Key:

Cross-Systems Mapping Completed  

Cross-Systems Mapping Scheduled
27  
28  
Indiana County

Draft 3-11
 Indiana  County  PrioriDes  
•  Systemic  reentry  from  jail  to  facilitate  successful  community  
reintegraBon  
–  Improved  coordinaBon  with  current  services  across  the  conBnuum  
of  care    
•  Data  across  intercepts    
•  Improved  diversion  at  Intercept  One  
–  Crisis  IntervenBon  Team  (CIT)    
–  Increase  training  for  Emergency  Room  doctors  re  community  
resources    
•  Access  to  Medical  Assistance  Benefits    
•  Expanded  Housing    

31  
 Franklin  County  
Top  10  PrioriDes  
•  Housing     •  Recruit  and  keep  psychiatrists/
•   Improved  InformaDon  Sharing     psychiatric  nurse  pracDDoners    
–  Data  at  front  door  of  jail   •  Cross-­‐system  educaDon    
•  Even  when  Missy  is  not  there   •  Increase  strategies  to  get  benefits  
back      
•  Earliest  idenDficaDon  and  diversion    
–  Increase  diversion  opportuniDes   •  Expand  Pretrial  Release  and  Jail  
Diversion  Programs    
at  police  contact  
•  Develop  more  strategies  to  increase  
–  Develop  expanded  alternaDves  to   non-­‐county  funding  sources  for  
arrest     human  services    
–  Drop  off  points,  non-­‐hospital,  and  
crisis  beds   •  Increase  transportaDon  opDons    
•  Explore  broad  range  of  engagement  
strategies    
–  Develop  effecDve  treatment  and  
supports  to  help  people  recognize  
their  mental  illness    
–  Peer  specialists  from  beginning  to  
end     32  
 BEHAVIORAL  HEALTH  AND    
JUSTICE  INVOVLED  POPULATIONS  
Pamela  S.  Hyde,  J.D.  
SAMHSA  Administrator  

NaBonal  Leadership  Forum  on  Behavioral  

Health/Criminal  JusBces  Services    
Washington,  MD  •  April  5,  2011    
BEHAVIORAL  HEALTH  àIMPACT  ON  AMERICA  
34  

è THE  ECONOMY:  Annually  -­‐  total  esDmated  societal  cost  of  substance  
abuse  in  the  U.S.  is  $510.8  billion  
•  Total  economic  costs  of  mental,  emoDonal,  and  behavioral  disorders  among  
youth  ~  $247  billion    

è HEALTH  CARE:    By  2020,  BH  condiDons  will  surpass  all  physical  
diseases  as  a  major  cause  of  disability  worldwide  
•  Half  of  all  lifeDme  cases  of  M/SUDs  begin  by  age  14  and  three-­‐fourths  by                
age  24  

è CRIMINAL  JUSTICE:    >80  percent  of  State  prisoners,  72  percent  of  
Federal  prisoners,  and  82  percent  of  jail  inmates  meet  criteria  for  
having  either  mental  health  or  substance  use  problems  
 SAMHSA S  FOCUS  
35  

è People  -­‐  NOT  money  

è People s  lives  -­‐  NOT  diseases  
è SomeDmes  focus  so  much  on  a  disease/
condiDon  we  forget  people  come  to  us  with  
mulDple  diseases/condiDons,  mulDple  social  
determinants,  mulDple  cultural  aotudes  
 
DRIVERS  OF  CHANGE    
36  

Health
Reform
 SAMHSA  à  LEADING  CHANGE  
37  

è  Mission:    To  reduce  the  impact  of  substance  abuse  and  
mental  illness  on  America s  communiDes  

è  Roles:      
•  Leadership  and  Voice  
•  Funding  -­‐  Service  Capacity  Development  
•  InformaDon/CommunicaDons  
•  RegulaDon  and  Standard  seong  
•  PracDce  Improvement  

è  Leading  Change  –  8  Strategic  IniBaBves  

 HHS  STRATEGIC  PLANS  à  SAMHSA  
STRATEGIC  INITIATIVES  
38  

è AIM:  Improving  the  NaDon s  Behavioral  Health  

1  PrevenDon  
2  Trauma  and  JusDce  
3  Military  Families  
4  Recovery  Support  
è AIM:  Transforming  Health  Care  in  America  
5  Health  Reform  
6  Health  InformaDon  Technology  
è AIM:  Achieving  Excellence  in  OperaDons  
7  Data,  Outcomes  &  Quality  
8  Public  Awareness  &  Support  
 TRAUMA  AND  JUSTICE  à  CHALLENGES  
39  

è Substance  abuse  or  dependence  rates  of  prisoners  >four  Dmes  

general  populaDon  
è Youth  in  juvenile  jusDce  have  high  rates  of  M/SUDs  
•  Prevalence  rates  as  high  as  66  percent;  95  percent  experiencing  
funcDonal  impairment  
è ~  Three-­‐quarters+  of  State,  Federal,  and  jail  inmates  meet  criteria  for  
either  MH  or  SU  problems,  contribuDng  to  higher  correcDons  costs  
•  >41  percent  State  prisoners,  28  percent  Federal  prisoners,  and  48  
percent  jail  inmates  meet  criteria  for  having  both  
 TRAUMA  AND  JUSTICE  à  CHALLENGES  
For  Veterans  &  Housing  
40  

è On  any  given  day,  veterans  account  for  nine  of  every  100  individuals  
in  U.S.  jails  and  prisons  

è Among  inmates  w/MH  problems,  13  percent  of  State  prisoners  and  
17  percent  jail  inmates  were  homeless  in  year  prior  to  incarceraDon  
è ~46  percent  of  people  who  are  homeless  have  a  mental  illness  

è Providing  housing  for  persons  with  MI  who  are  homeless  can  decrease  criminal  
jusDce  involvement  by  84  percent  for  prison  days  and  38  percent  for  jail  days  

è In  2009,  nearly  76,000  veterans  were  homeless  on  a  given  night,                  
~  136,000  veterans  spent  at  least  one  night  in  a  shelter      

 
 SAMHSA  STRATEGIC  INITIATIVE  
TRAUMA  AND  JUSTICE  –  GOALS  
41  

è Public  health  approach  to  trauma  

è Trauma  informed  care  and  screening;  trauma  specific  
service  
è ↓  impact  of  violence  and  trauma  on  children/youth  
è ↑  BH  services  for  jusDce  involved  populaDons  
•  PrevenDon    
•  Diversion  from  juvenile  jusDce  and  adult  criminal  jusDce  systems  
è ↓  impact  of  disasters  on  BH  of  individuals,  families,  and  
communiDes      
 TRAUMA  &  JUSTICE  
42  

è When  done  right,  jail  diversion  works  –  those  diverted:      

●  Use  less  alcohol  and  drugs  (last  30  days)    
•  Any  Alcohol  Use:    Baseline  at  59  percent  vs.  6  months  at  28  percent    
•  Alcohol  to  IntoxicaDon:    Baseline  at  38  percent  vs.  6  months  at  13  percent      
•  Illegal  Drug  Use:    Baseline  at  58  percent  vs.  6  months  at  17  percent      
●  Have  fewer  arrests  aMer  diversion  compared  to  12  months        
before  (2.3  vs.  1.1)  
●  Fewer  jail  days  (52  vs.  35)    
è CommuniDes  want  jail  diversion  programs:    three  of  four  
jail  diversion  programs  keep  operaDng  aMer  Federal  
funding  ends    
THE  ROLE  OF  PROBLEM-­‐SOLVING  COURTS    
43  

è Common  to  all  SAMHSA  iniDaDves    

•  PrevenDon,  early  intervenDon,  treatment,  and  recovery  
support  services  
•  Shared  vision  (e.g.  PPCs,  Community  Resilience  and  Recovery  
IniDaDve,  SBIRT,  Access  to  Recovery)  
è Expand  access  to  community-­‐based  BH  services  at  all  points  of  
contact  with  jusDce  system  
è People  served  by  drug  courts  and  mental  health  courts  tend  to  
have  mulDple  issues  which  create  mulDple  challenges  and  
opportuniDes  
 
  HEALTH  REFORM    
IMPACT  OF  AFFORDABLE  CARE  ACT    
44  

è More  people  will  have  insurance  coverage  

•  ↑Demand  for  qualified  and  well-­‐trained  BH  professionals    
è Medicaid  will  play  a  bigger  role  in  M/SUDs  
è Focus  on  primary  care  &  coordinaDon  with  specialty  care  
è Major  emphasis  on  home  &  community-­‐based  services;    less  
reliance  on  insDtuDonal  care  
è Theme:  prevenDng  diseases  &  promoDng  wellness  
è Focus  on  quality  rather  than  quanDty  of  care  
 In  2014:    32  MILLION  MORE  
AMERICANS  WILL  BE  COVERED  
45  

4-6
mil

6-­‐10  Million  with  M/SUDs  

 ACA  &  JUSTICE  INVOLVED  POPULATIONS  
46  

è Coverage  expansion  means  individuals  reentering  communiDes  from  

jails  and  prisons  (generally  have  not  had  health  coverage  in  past)  will  
now  have  more  opportunity  for  coverage  
è CJ  populaDon  w/  comparaDvely  high  rates  of  M/SUDs  =  opportunity  
to  coordinate  new  health  coverage  w/other  efforts  to  ↑  successful  
transiDons  
è Addressing  BH  needs  can  ↓  recidivism  and  ↓  expenditures  in  CJ  
system  while  ↑  public  health  and  safety  outcomes  
è SAMHSA  and  partners  in  OJP    will  develop  standards  and  improve  
coordinaDon  around  coverage  expansions  –    
è Enrollment  is  the  challenge  
 For  more  informaDon  

www.pacenterofexcellence.piH.edu