[Slide 1]{.underline}

**Department of Corrections Mental Health Services**

Colleen Patrick-Riley, MSW, LCSW, Mental Health Clinician III

Director of Mental Health Release Programs

And

Deedee Raymond, MS, Mental Health Clinician II

Re-entry Coordinator for DOC Mental Health

August 2006

[Slide 2]{.underline}

**Implementing the APIC Model with DOC Offenders with Mental Illness and
Co-occurring Disorders**

New initiative funded by Alaska Legislature and the Alaska Mental Health
Trust Authority, AMHTA, in FY 2007

APIC is a best-practice program described in The President's New Freedom
Commission on Mental Health, Sub-Committee on Criminal Justice, 2004

APIC equals Assess, Plan, Identify, Coordinate

Goal: Access services, medication, housing, benefits, and jobs if able
to work

[Slide 3]{.underline}

**What Will We Cover**

Overview and Context of the Problem

Trust Beneficiaries in DOC

DOC Mental Health Services

DOC Mental Health Release Programs

Gaps in Services

[Slide 4]{.underline}

**What Is the Extent of the Problem: Reduction of Psychiatric Beds**

Nationally:

1955 to 1999

Psychiatric Beds: 159,000 to 70,000

In Alaska:

1979 to 1999

Psychiatric Beds: 220 to 79

2005

Psychiatric Beds: Reduced to 72

[Slide 5]{.underline}

**Results**

Up arrow: Neglect

Up arrow: Homelessness

Up arrow: Substance Abuse

Up arrow: Criminalization

[Slide 6]{.underline}

Cruel Irony of Deinstitutionalization

Promotion of the quote, Least Restrictive Alternative, unquote, for many
has unintentionally resulted in the Most Restrictive Alternative:
Incarceration

[Slide 7]{.underline}

**Reinstitutionalization**

Across the US, thrice as many individuals with a mental illness are
behind bars as are in psychiatric hospitals

Current estimates indicate that between 16 and 30 percent of prisoners
nationwide have a serious mental illness

[Slide 8]{.underline}

**Trust Beneficiaries in Alaska Department of Corrections**

DOC is largest provider of institutional mental health services in
Alaska

DOC mental health staff have seen more than 13,500 individuals with
mental illness or suicidal ideation since 1982

Not counting people who recycle, DOC mental health staff see an
additional 80 to 100 new people each month

See more than 2,000 unique individuals each year

[Slide 9]{.underline}

**Number Incarcerated**

[Year Number in Jail Number of Trust Beneficiaries]{.underline}

1990 2,700

1997 4,164 37 percent

2006 5,000, estimate 37 percent plus; 1,850

36,370 bookings statewide in FY 2006; 22,342 individuals

80 percent of bookings are for misdemeanor crimes

Typically, the number of offenders on felony probation slash parole
equals the number in DOC custody

[Slide 10]{.underline}

**Adult Inmate Who Have Mental Disorders**

Nationally in 1999:

> 16.2 percent or 283,800 inmates were estimated by the Bureau of
> Justice to have a mental illness

Alaska in 1997:

> 37 percent or 1,154 inmates incarcerated in Alaska prisons were
> beneficiaries of the AMHTA according to a one day 1997 study by Care
> Systems North; inmates in Arizona or other out-of-State facilities
> were not surveyed; CRC's were separately counted

29 percent of the DOC population experienced mental illness

12 percent were seriously mentally ill

8 percent were chronic alcoholics with a history of psychosis

0.04 percent had identified developmental disabilities

> 14 percent of the 625 offenders in Community Residential Centers were
> Trust beneficiaries

15 percent of a sample of probation and parole were Trust beneficiaries

[Slide 11]{.underline}

**Research Studies**

In FY 2007, a New Trust study covering FY 2003 to 2006 will tell us
numbers of Trust beneficiaries in DOC custody or on supervision in the
community

The Study will be a joint effort by the Trust, DOC, and DHSS working
together with research contractors Hornby Zeller Associates,
Incorporated

[Slide 12]{.underline}

**Need to Reduce the Number in Jail**

It's humane

It's cost effective

Beds at maximum capacity

Jail's not the best place to treat

DOC wants to work together with other agencies to help individuals
succeed in the community

[Slide 13]{.underline}

**DOC Response**\
In an effort to provide humane and appropriate treatment to individuals
in DOC custody and those who are released to the community:

A continuum of services in and out of corrections is essential

Several programs and initiatives have been implemented

[Slide 14]{.underline}

**What Happens in Alaska Department of Corrections\
**A map of Alaska identifies Anvil Mountain CC, Yukon Kuskokwim CC,
Fairbanks CC, Palmer CC, Mat-Su Pretrial, Highland Mountain Slash Meadow
Creek CC, Anchorage Jail, Cook Inlet Pretrial, Spring Creek CC, Wildwood
CC, Lemon Creek CC, and Ketchikan CC.

[Slide 15]{.underline}

**Mental Health Services in DOC**

The are 13 correctional facilities in Alaska operated by the Department
of Corrections (located in Anchorage, Palmer, Wasilla, Kenai, Seward,
Juneau, Fairbanks, Bethel, Nome, and Ketchikan).

DOC mental health staff members include psychiatrists, clinicians,
psychiatric nurses, and psychological counselors. State or contract
staff members provide services in all facilities.

[Slide 16]{.underline}

**Department of Corrections Institutional Mental Health Services**

At the top of the slide is a box marked Incarceration. An arrow points
rightward from it to a box marked Mental Health Screening, which has an
arrow pointing rightward to a box marked Mental Health Issues ID. A
downward arrow from that box branches to five boxes marked Medication
Management by Psychiatrist or ANP by Tele-psychiatry or in Person,
Mental Health Assessment Slash Evaluation, Acute Inmate Mental Health
Units, Sub-acute Mental Health Units, and Diversion and Release
Programs. Mental Health Assessment Slash Evaluation has an arrow
pointing rightward to Medication Management by Psychiatrist or ANP by
Tele-psychiatry or in Person. A downward arrow from Acute Inmate Mental
Health Units branches to two boxes marked ACC-W Mike Module for Men and
HMCC Women's Psychiatric Treatment. A downward arrow from Sub-acute
Mental Health Units branches to three boxes marked HMCC Women's Hope
Ring, PCC House 1 Men, and SPCC Echo Module Men. A downward arrow from
Diversion and Release Programs branches to four boxes marked Discharge
Planning, Coordination Resource Project, Jail Alternative Services, and
Institutional Discharge Project Plus. A downward arrow from Discharge
Planning branches to two boxes marked API Coordination Slash Emergency
Services and Case Planning Slash Community Referrals.

[Slide 17]{.underline}

**Mental Health Services in DOC**

General Mental Health Services

Medical and mental status screening exams within 24 hours by medical RN

Referral to and evaluation by MHC if indicated

Medication prescription and monitoring by DOC psychiatrist or ANP

Tele-psychiatry offered to all outlying facilities

Coordination with API

Crisis intervention services

> Discharge planning to the community for mentally ill individuals, if
> release date known and time allows

[Slide 18]{.underline}

**Mental Health Services in DOC**

General Mental Health Services

> 48-week offender mental health treatment offered to general population
> inmates: anger management, criminal thinking errors, values
> clarification slash moral reasoning, rational problem solving slash
> relapse prevention
>
> Medical emergency services: Title 47 alcohol and mental health holds,
> detox services for intoxicated individuals and intravenous drug users

[Slide 19]{.underline}

**Mental Health Services in DOC**

Inpatient Mental Health Units for acutely ill inmates provide assessment
and stabilization:

CIPT Mike Module for Men

HMCC Women's Psychiatric Treatment Unit

Sheltered Living: HMCC Women's Special Needs Wing, House 1 at PCC, and
Echo Mod at SCCC for Men

Community-based Services: halfway house services for general population
inmates, specialized probation, IDP Plus for mentally ill felons and
JAS, PCRP for voluntary misdemeanants

[Slide 20]{.underline}

**Mental Health Services in DOC**

Trust funding helped provide increased services for longer-term inmates
at Spring Creek Correctional Center in Seward:

Echo Module for up to 65 adult men who experience mental illness or
disability

> Youth Offender Program, YOP, for youth waived into the adult system,
> provides targeted services to males ages 15 to 22 with IEP
>
> The Spring Creek Initiative at Echo Module and YOP is an excellent
> model for providing integrated mental health, substance abuse, and
> educational services at one site

[Slide 21]{.underline}

**Substance Abuse Treatment in DOC**

RSAT 6- to 12-month intensive therapeutic community provides treatment
for women at Hiland Mountain Correctional Center in Eagle River; 32 beds

RSAT 6- to 12-month intensive therapeutic community provides treatment
for men at Wildwood Pretrial Facility in Kenai; 42 beds

An intensive year-long therapeutic community is offered to male felons
in Central Arizona Detention through Alaska DOC contract; 40 beds, may
increase to 60 in future

All three programs are cognitive therapeutic communities that provide
intensive residential substance abuse treatment meeting State-approved
treatment requirements

Reality is more than 85 percent of DOC inmates have substance use
disorders; 3-year federally funded Adam study at Anchorage Jail found 92
percent of inmates have abuse problem or addiction to alcohol and/or
drugs

72 to 90 percent of Mental Health Trust beneficiaries in DOC have a
co-occurring substance use disorder

[Slide 22]{.underline}

**Educational Services in DOC**

Individuals have the opportunity to take testing and Adult Basic
Education and earn a GED while incarcerated in any correctional
facility, to take a college correspondence course if they pay for it, or
to participate in vocational training at a sentenced facility

Education also offers life skills classes in health and safety,
communication skills, prerelease and preemployment, and cross-cultural
groups to inmates at all correctional facilities

While only a few inmates have a documented developmental disability or
traumatic brain injury known to DOC, it is believed many more are not
formally identified

[Slide 23]{.underline}

**Sex Offender Treatment in DOC**

Sex offender treatment was offered at Hiland Mountain Correctional
Center until FY 2004

Sex offender prerelease psychological evaluations are conducted to
determine risk and to make recommendations for management strategies for
community supervision

Outpatient sex offender treatment is offered in the community from
approved SOTP providers on DOC contract

All sex offenders must enter their names on a Sex Offender Registry and
are closely monitored in the community by probation slash parole
officers

[Slide 24]{.underline}

**Sex Offender Treatment in DOC**

A new pilot Sex Offender Containment Model was started in DOC in FY
2006. As mandated by the Alaska Legislature, all sex offenders will
participate in this model by FY 2008.

The containment model consists of a team approach to managing sex
offenders in the community; it includes community treatment, enhanced
supervision and close monitoring, and polygraph testing as parts of
treatment.

[Slide 25]{.underline}

**Sex Offender Treatment in DOC: Problem Areas**

There are a significant number of mentally ill who have convictions for
a sexual offense.

They are prohibited from entering residential substance abuse treatment
programs and federally funded housing options. Although they need added
supports and monitoring to succeed and be safe in the community, they
are often released homeless without access to appropriate supervised
housing.

Mentally ill benefit from sex offender-specific treatment.

Individuals with significant developmental disabilities and high-risk
behaviors should have access to groups at the Center for Psychosocial
Development. Funding has limited access; we hope to improve access in
the next year.

[Slide 26]{.underline}

**Department of Corrections Mental Health Referrals**

At the top of the slide, two boxes marked Misdemeanor and Felony have
arrows pointing sideways to a box marked Court. From Court, an arrow
points down to a box marked Incarceration, from which another arrow
points down to a box marked Within 24 Hours: Medical and Mental Health
Screening on All Inmates. That box has arrows pointing down to two boxes
marked Mental Health Issues ID and No Mental Health Issues, the latter
having a dotted line border. A box marked Inmate or Staff Request Mental
Health Assessment has a rightward arrow pointing to Mental Health Issues
ID, which has an arrow pointing down to a box marked Comprehensive
Mental Health Screening. A downward arrow branches from that box to two
boxes marked Institutional Mental Health Clinician: Anchorage, Hiland
Mt., Fairbanks, Wildwood, Spring Creek, Lemon Creek Palmer Correctional
Centers; and Contract Mental Health Provider: Anvil Mountain, Ketchikan,
Yukon-Kuskokwim Correctional Centers. Horizontally between those two
boxes, and connected to both by two-way arrows, is a box marked
Psychiatric Evaluation. The two sandwiching boxes have arrows pointing
down to the same three boxes, marked Misdemeanor, Felony, and
Institutional MHC Discharge Planning for Diagnosed Mentally Ill Inmates
Who Are Not Referred to IDP Plus or Participate in the Misdemeanor
Mental Health Courts, the last box having a dotted line border. The low
Misdemeanor box, being different from the one on top, has an arrow
pointing back up to a box on the Within 24 Hours level marked Jail
Alternative Services, JAS, and Coordinated Resource Projects. The low
Felony box, being different from the one on top, has an arrow pointing
down to a box marked Psychotic Disorder and Felony Probation or Parole,
which has an arrow pointing down to a box marked Institutional Discharge
Program Plus, which has an arrow pointing down to a box marked IDP Plus
Coordinator. Sideways arrows point from this last box to two boxes
marked Felony Probation and Community Treatment Provider.

[Slide 27]{.underline}

**Referral to Diversion and Release Programs**

There are four special release programs to which inmates can be referred

One for felons, three for misdemeanants

See handouts

[Slide 28]{.underline}

**DOC Current Diversion and Release Options for Mentally Ill Offenders**

This slide is divided into quadrants. The upper left is marked Felony:
Individual Discharge Project Plus, IDP Plus; Mandatory Probation Slash
Parole. A line connects it to a box in the lower left marked 1994 IDP
Plus: IDP Plus Coordinator Joint Project by DMHDD and DOC. A dotted
arrow points down from the box to a circle marked 2002 IDP Plus:
Programmatic Change from Joint with DMHDD to Solely DOC. The upper right
is marked Misdemeanor: Coordinated Resource Project, CRP, Mental Health
Court; Voluntary Participation. Line connect it to two boxes in the
lower right marked 1998 CRP: Anchorage; 1998: Jail Alternative Services,
JAS, Anchorage; and 2005 CRP:

Palmer, DOC Case Coordinator. The former box is connected by a dotted
sideways line to a box mark 2000 CRP: Anchorage OPA Case Coordinator,
which has a dotted arrow pointing down to a circle marked 2006: Changed
to ASAP Oversight.

[Slide 29]{.underline}

[\
]{.underline}**Felony Mental Health Release Program**

IDP Plus for Felons

Must be released on felony probation or parole

Must have a psychotic disorder

> Treatment plan and monitoring coordinated by DOC IDP Plus Coordinator
> working with community agencies and mental health probation officers

Current caseload: 60 to 70

Original caseloads were 35 to 50

Services provided statewide but tend to concentrate in Anchorage

[Slide 30]{.underline}

[\
]{.underline}**Misdemeanor Mental Health Release Options from DOC**

Anchorage District CRP Mental Health Court

> Mentally ill misdemeanants who voluntarily agree to be sentenced in
> Anchorage Mental Health Court
>
> DOC JAS Coordinator for eligible individuals with a psychotic
> disorder, and limited number with organic impairment, in DOC custody
>
> ASAP CRP Coordinator for individuals with any mental disability in or
> out of custody

Palmer District CRP Mental Health Court

> Mentally ill misdemeanants who voluntarily agree to be sentenced in
> Palmer Mental Health Court
>
> DOC PCRP Coordinator for individuals with any mental disability in or
> out of custody

All Case Coordinators link individuals to appropriate community based
services and monitor compliance with individualized case plan and court
release or probation conditions.

[Slide 31]{.underline}

**Remember**

Diversion from corrections works only if we have programs and resources
to which to divert people

Quick intakes, clinical supports, and stable sober housing in the
community are crucial

[Slide 32]{.underline}

**Gaps in Services**

Fragmented and Difficult to Access Services

> How does a person know what exists, where to go, and how to get into
> and pay for services
>
> Delays in intakes and doctor prescription appointments create barriers
> for effective transitions
>
> Medicaid driven funding for services do not cover all Trust
> beneficiary needs

Critical Needs: Existing Options Inadequate and Too Many Wrong Doors

Stable housing: the biggest gap

Dual diagnosis substance abuse treatment

> Transition services for young adults: many with co-occurring substance
> use disorders lack access to treatment

Treatment for inappropriate sexual behavior

Case management

Day treatment slash meaningful activities

Anger slash violence treatment for individual with disabilities

Services for older adults with dementia

> Assessment slash treatment for those with late onset or previously
> undiagnosed mental illnesses
>
> Funding for services slash developmental disability wait list;
> additional numbers have significant impairment but do not qualify for
> waiver criteria

Quick assessments and service intakes for any type disorder

[Slide 33]{.underline}

**Where Do We Go from Here**

Look at the existing continuum of services and prior recommendations

Identify any additional gaps and needs

Prioritize and address the biggest need

Consider and enlist slash leverage support of all available funding
sources

Create working Memoranda of Agreement and procedures to expedite smooth
process of referrals and benefit applications

Work as a team

Make recommendations for APIC implementation

[Slide 34]{.underline}

**Disability Justice, Background Historical Information, 1988 to 2006**

The following slides provide a review of changes in the Alaska system of
service delivery for mentally disabled individuals who come in contact
with the criminal justice system

[Slide 35]{.underline}

**Changes Since 1988**

1987 to 1990: Mentally Ill Offender Task Force: Nammy, DOC, CJS, APD,
API, AMHB, mental health agencies, and others work to create a vision of
the continuum of services needed to help mentally ill who come in
contact with the criminal justice system

> Task Force estimates two to three times as many mentally ill people in
> DOC than in API

[Slide 36]{.underline}

**Community Changes**

Community Mental Health Centers agree to accept referrals of people
coming out of corrections

1990 IDP Institutional Discharge Project

> DHSS funded CMHC's to have reduced caseloads and special services for
> individuals who meet special criteria: 6 months in jail or API, or
> three or more arrests/admits in the 12 months before entry

[Slide 37]{.underline}

**Changes Inside DOC: 1991**

Forensic Consultation Team moves from API to manage Mental Health
Services in DOC and oversee State and contract mental health staff in 13
correctional facilities

Mike Module, the men's mental unit opens at Cook Inlet Pretrial
Facility, AKA ACC-West, provides 24-hour assessment and treatment
services

[Slide 38]{.underline}

**1991 News Flash**

Alaska Department of Corrections has the fourth highest incarceration
rate in the United States

Transitional Living Center closes; funded by DHSS, it was the largest
mentally ill halfway house in Alaskan history; none ever has been built
to replace it

1992 to 1994: DMHDD slash DOC contract with Allvest to operate a halfway
house for mentally ill individuals leaving DOC

[Slide 39]{.underline}

**Release Initiatives in 1994: IDP Plus**

DMHDD and DOC develop and initiate a release program to provide
individualized treatment services for the seriously mentally ill
offender with a psychotic disorder releasing on felony probation

Since inception, program participants have not had any new violent
offenses while in the program

[Slide 40]{.underline}

**With Trust-funded Support, Services Added to DOC in 1998**

Women's Mental Health Unit; opens at Hiland Mountain Correctional
Center; provides 24-hour assessment and treatment services

JAS; begins as a pilot project in conjunction with the Anchorage
District Mental Health Court; provides specialized sentencing, links to
community resources, and monitoring for mentally ill misdemeanants in
Anchorage

[Slide 41]{.underline}

**Anchorage Pre-booking Diversion: On the Street Before Arrest for a
Crime**

Anchorage Police Department and Nammy Crisis Intervention Team; CIT:

Officers learn about mental disorders and associated behaviors

Learn about community alternatives to jail

> Respond to situations involving people with mental disorders,
> deescalate those situations

Operating since 2001

[Slide 42]{.underline}

**Anchorage Single Point of Entry: Providence Psychiatric ER**

Able to screen people in crisis

Can refer to detox, a Providence Psychiatric bed for up to 24 hours,
refer to Crisis Treatment Center, approve transfer to API, or make other
recommendations that make sense for the individual

Use Providence and Southcentral Counseling Center staff members to make
assessments and meet the needs of the individual

Operating since 2002

[Slide 43]{.underline}

**Anchorage Jail AKA Anchorage Correctional Complex-East**

Opened in 2002

Anchorage Jail or ACC-East serves as the booking facility for all of
Anchorage

Houses 416, census has been as high as 557, running more than 500 every
day this fiscal year

13,503 bookings in FY 2006

35 to 70 bookings per day in FY 2006, average 52 bookings per day

12 to 15-plus new referrals to DOC Mental Health each day

[Slide 44]{.underline}

**Nammy and Consumer Initiatives**

Nammy booklet, When a Person with a Mental Disability Is Arrested: How
to Help, written in 2003

Nammy and other consumer education slash self-help groups and
initiatives on the increase in 2003 to 2004

Trust Beneficiary Group Initiatives selected as Trust focus group for
funding in 2004

[Slide 45]{.underline}

**\
Former Misdemeanor Mental Health Release Option**

CCAP jail precharge diversion was available December 2003 to May 2006

> CCAP served mentally ill individuals arrested on Municipality of
> Anchorage misdemeanor charges who meet eligibility criteria and
> voluntarily agreed to participate in the Anchorage precharge diversion
> program operated by Anchorage Community Mental Health Services under a
> Federal Samsa grant through the Alaska DHSS Division of Behavioral
> Health

Funding for this program lapsed in FY 2006

Operated December 2003 to May 2006

[Slide 46]{.underline}

**CCRP Increased Collaboration Agencies Involved in 2003 MOA**

Memorandum of Agreement Among:

Alaska Court System

Anchorage Police Department

Division of Behavioral Health; DBH

Department of Corrections; DOC

Municipal Prosecutor's Office

National Alliance for the Mentally Ill

Southcentral Counseling Center

UAA Behavioral Health and Research Services; BHRS

With Additional Assistance from:

Alaska Mental Health Trust Authority

Consumer Advisory Group

[Slide 47]{.underline}

**Alaska Mental Health Trust Authority Focus Groups: Promoted
collaboration and funding focus beginning in 2004**

Trust convenes representatives from State agencies and four beneficiary
boards to identify major problem areas requiring attention

Four Focus Groups selected: Disability Justice, Housing, Bring the Kids
Home, and Trust Beneficiary Group Initiatives

Trust allocates funding to each focus group and promotes continued
planning and collaboration

[Slide 48]{.underline}

**Alaska Interagency Council on Homelessness:** **Promoted statewide
increased awareness in 2004**

President Bush asked that each State convene a statewide policy-level
council to address homelessness

State of Alaska Department Commissioners, the Trust, and Federal
agencies met to discuss the reality of homelessness in Alaska

Cross-education, Communication, and collaboration promoted

Recommendation for Housing Trust put forward

[Slide 49]{.underline}

**DOC and Social Security Administration Agreement: Starts in 2004**

DOC and SSA sign MOU in Nov 2004 to develop a Prerelease Application
Process; pilot program started and first application submitted in 2004

Pilot started with individuals being released to IDP Plus, with
documented diagnosis of severe psychosis and inability to work for at
least 1 year after release

Approval rate 100 percent for pilot prerelease program compared to 57
percent for comparative population

Win-win situation benefits consumer, SSA, DOC, and community providers

Plan to expand eligible populations for prerelease program processing

[Slide 50]{.underline}

**Palmer Mental Health Court: Started in 2005 with Trust funds**

Palmer Coordinated Resources Project PCRP; a second misdemeanor mental
health court starts in March 2005

DOC Mental Health Clinician serves as PCRP Case Coordinator working in
conjunction with the Palmer District Mental Health Court

PCRP provides specialized sentencing, links to community resources, and
monitoring for mentally ill misdemeanants in Palmer

[Slide 51]{.underline}

**With Trust-funded Support, Services Added to DOC in FY 2007**

National Best Practice APIC Model to be implemented in Alaska in 2007

State, Federal, and community agencies collaborate to improve reentry
and transitional planning and services for individuals with mental
illness and co-occurring disorders who will be released from Alaska DOC

Memoranda and procedures streamlined to assess, plan, identify, and
collaborate aiding Trust beneficiaries to transition to the community
successfully