Practical Advice on Jail Diversion:

Ten Years of Learnings on Jail Diversion from the CMHS National GAINS
Center

CMHS National GAINS Center

CMHS GAINS TAPA Center for Jail Diversion

Delmar, NY

Recommended citation: CMHS National GAINS Center. (2007). *Practical
advice on jail diversion: Ten years of learnings on jail diversion from
the CMHS National GAINS Center*. Delmar, NY: Author.

This publication is based on content produced by the CMHS National GAINS
Center and the CMHS GAINS Technical Assistance and Policy Analysis
(TAPA) Center for Jail Diversion, with support from the Substance Abuse
and Mental Health Services Administration (SAMHSA) Center for Mental
Health Services (CMHS). The material contained in this publication does
not necessarily represent the position of the SAMHSA Center for Mental
Health Services.

Susan Milstrey Wells was contracted to write this publication. The CMHS
National GAINS Center acknowledges the members of the review panel,
program and evaluation staff of the 32 grantees of the CMHS Targeted
Capacity Expansion for Jail Diversion Programs initiative, the
communities that provided feedback, and the individuals and programs
that shared expertise and materials for the project.

This publication is available from the CMHS National GAINS Center
website at http://www.gainscenter.samhsa.gov. You can contact the Center
at (800) 311-4246 or gains@prainc.com.

Contents

Message from the GAINS Center Director iv

User Guide 4

SECTION 1: Why Develop a Jail Diversion Program? 10

SECTION 2: What Is Jail Diversion Really? 15

SECTION 3: Making Jail Diversion Happen in Your Community 22

SECTION 4: Getting Started 29

SECTION 5: Putting the "Action" in Your Action Plan 51

SECTION 6: Planning for Sustainability 78

SECTION 7: Data 101 85

Moving Forward 98

APPENDIX A: Resources 99

APPENDIX B: Program Examples 125

APPENDIX C: Glossary 133

References 138

Message from the GAINS Center Director

Since 1995, the CMHS National GAINS Center, under Federal support from
the Substance Abuse and Mental Health Services Administration, has
provided direct technical assistance to upwards of 175 U.S. communities
and indirect support to hundreds of others around the issues of
developing appropriate and comprehensive services for justice-involved
persons with mental illness, the vast majority of whom have co-occurring
substance use disorders.

In the process of providing these supports we have learned much about
how to keep people with mental illness out of jail that are there
because there are not community-based treatment alternatives, i.e.
diversion. Our intent in this document is to collect as much of our
learning as we can.

In down to earth terms, we trust you will find guidance here to
implement the political will that exists in so many communities around
this country who just need some explicit direction to do the right
things. As you use this document, please also use our Web site to give
us feedback that could improve it as we make future revisions.

Henry J. Steadman, Ph.D.

User Guide

Responding to fragmentation in service delivery for people with serious
mental illness, the President's New Freedom Commission on Mental Health
has called for nothing short of *fundamental transformation* of the
mental health care delivery system in the United States. Perhaps nowhere
is service system fragmentation and its devastating impact on
individuals more evident than in the lack of coordination between the
criminal justice and mental health systems.

-   People with mental illness and substance use disorders are greatly
    overrepresented in the criminal justice system compared to their
    prevalence in the general population.

-   These individuals cycle in and out of the mental health, substance
    abuse, and criminal justice systems, often receiving little, if any,
    treatment.

-   People with mental illness are costly and time consuming for law
    enforcement officers and local jails. Courts become backlogged
    trying to deal with the influx of these complex cases.

-   People whose mental illness is untreated may act in ways that the
    general public considers to be frightening or threatening. However,
    when effective treatment and support services are available and
    used, people with mental disorders present no greater risk to the
    community than other people.

Over the last two decades, jail diversion programs have been developed
with the goal of reducing or eliminating the time people with mental and
substance use disorders spend in jail by redirecting them from the
criminal justice system to community-based treatment and supports.
Groups that plan jail diversion programs develop and build on
broad-based community consensus and collaboration to integrate services
and systems designed to improve the lives of people with mental
disorders and enhance public safety.

Jail diversion programs are designed to bridge the gap in fragmented
systems and break the cycle of recidivism for people with serious mental
illness and co-occurring substance use disorders. As such, they reflect
a holistic, systemic approach to mental health service delivery that
will allow most people with mental disorders to live, work, learn, and
participate fully and safely in their communities.

Who Should Read This Publication

The Federal Substance Abuse and Mental Health Services Administration
(SAMHSA) in the U.S. Department of Health and Human Services (HHS) has
sponsored development of this publication to serve as a guide for
interested community members who want to know how to design, plan,
implement, and evaluate a successful jail diversion program. Whether
you're a case manager in a community mental health center, a substance
abuse counselor, a jail mental health practitioner, a cop who walks a
beat, a prosecuting attorney, a local judge, a consumer, or a family
member, you'll want to read this publication if you are leading
development of a jail diversion program in your community or hope to do
so. You'll gain a better understanding of what jail diversion really is,
why it makes sense, and how to adopt or adapt a program for your
community. See the section below for a more detailed look at what you'll
find in these pages and how to make the best use of it.

It was beyond the scope of this publication to go into depth about the
structure and processes of the mental health and criminal justice
systems. For this, two comprehensive publications are available from
SAMHSA's CMHS National GAINS Center:

> *Overview of the Mental Health Service System for Criminal Justice
> Professionals* is available at
> www.gainscenter.samhsa.gov/pdfs/jail_diversion/MassaroII.pdf.
>
> *Working with People with Mental Illness Involved in the Criminal
> Justice System* is available at
> www.gainscenter.samhsa.gov/pdfs/jail_diversion/Massaro.pdf.

You can also order copies by contacting the CMHS National GAINS Center
at (800) 311-GAIN or the Technical Assistance and Policy Analysis (TAPA)
Center for Jail Diversion at (866) 518-TAPA.

How to Get the Most Out of This Guide

There is no one correct way to use this publication, there is no
specific order in which you have to read it. Where you start and what
you get out of it will depend on where you are in the process of
implementing a jail diversion program for people with mental and
substance use disorders. For example:

-   If you're just beginning to think about jail diversion but not ready
    to start, you can use this guide as a springboard for discussion.
    Share it with your colleagues or others you think will have a vested
    interest in jail diversion and talk about it informally or at
    initial meetings of your stakeholder group.

-   When you're ready to begin, you can use this publication as a
    checklist of the activities you need to consider. You won't
    necessarily do everything suggested in each section, and you'll most
    likely implement these steps in the order that makes the most sense
    for your community. For example, though many jurisdictions begin
    jail diversion programs with no dedicated funding, you may find that
    the decision makers in your community will require a source of funds
    before you begin accepting consumers.

-   Finally, it's not too late to use this guide even if you've already
    begun implementing a jail diversion program. Use it with your
    planning group to determine how much progress you've made and
    whether you need to revisit some of your decisions, such as
    determining what type of criminal charges you'll accept and what
    level of services your consumers need.

Here's what you'll find in the pages that follow:

-   **Section 1: Why Develop a Jail Diversion Program**? In this
    section, you'll learn about the scope of the problem, how it affects
    the key players---including people with mental and substance use
    disorders, the mental health and criminal justice systems, and the
    community---and why jail diversion makes sense from public health
    and public safety perspectives.

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-   Begin with this section, and read the next two as well, if you're at
    the very earliest stages of thinking about jail diversion in your
    community.

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-   **Section 2:** **What Is Jail Diversion Really?** In this section,
    you'll learn exactly what jail diversion is, the characteristics of
    the major types of jail diversion programs, and the five basic tasks
    and the six factors for success that are essential regardless of the
    particular model you choose.

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-   This section is a good primer for your planning group; you may want
    to extract it and take it to your first stakeholder meeting.

    -   **Section 3: Making Jail Diversion Happen in Your Community**.
        In this section, you'll learn why some individuals and groups
        initially may be opposed to adopting a jail diversion program in
        your community and how you can respond when they ask, "What's in
        it for me?"

-   You have to be able to address stakeholders' concerns if you hope to
    move forward.

    -   **Section 4: Getting Started**. In this section, you'll learn
        why collaboration among the criminal justice, mental health, and
        substance abuse systems is not as difficult as it first seems;
        how to develop consensus and create a strategic plan; and where
        to find the resources you need to begin.

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-   Start here if your community is committed to developing a jail
    diversion program and you are ready to begin. Pay special attention
    to the importance of identifying your consumers and mapping the
    service system.

    -   **Section 5: Putting the "Action" in Your Action Plan**. In this
        section, you'll learn how to implement your action plan by
        developing formal agreements and sharing information; providing
        a set of mental health, housing, and support services for your
        consumers; creating key positions and training the staff who
        fill them; and devising and implementing a marketing strategy.

        -   One the most important topics in this section is how to
            staff your program, including the development of boundary
            spanners and the vital roles your practitioners and case
            managers will play.

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-   **Section 6: Sustaining Your Program**. In this section, you'll
    learn why it's important to think about sustainability from day one,
    what types of services you need to sustain, and how to approach
    potential funders and use creative strategies to support vital
    services.

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-   Ideally, you thought about how to keep your program going even
    before you began. Review this section for further ideas on how to
    find funding and use technical assistance.

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-   **Section 7**: **Data 101**. In this section, you'll learn why it is
    in your best interests to collect data, what types of data you need
    to gather, and how to use data to answer some key questions about
    the success of your program.

    -   Whether you are just beginning or your program is well underway,
        this is a "must read" section; data will help inform your work
        and secure your program.

Each of these sections is divided into three parts:

-   **The Problem** sets the stage for each section.

-   **What You Need to Know** reviews relevant research and literature
    that lends support to the recommended strategies.

-   **What You Need to Do** gets to the heart of the matter. Here is
    where you'll learn the mechanics of designing your jail diversion
    program, implementing your action plan, and gathering the data you
    need to support your program's future.

Throughout the text, you'll find additional resources: They include:

-   **Shaded boxes** with program profiles, helpful tips, and consumer
    success stories. The success stories serve as good examples of the
    type you'll want to develop and showcase. If you're not quite
    certain what a jail diversion staff person really does, see three "A
    Day in the Life" profiles scattered throughout the text.

-   **Clear boxes** that highlight the types of implementation barriers
    you're likely to encounter and some possible solutions you can try.
    Look for this symbol  to point you to the information you need.

Finally, in addition to these substantive sections, this publication
contains several appendices with important ancillary materials:

-   **Resources**. Here you'll find a compilation of relevant Web sites,
    key literature, and tools, such as the Brief Jail Mental Health
    Screen, that you can adopt or adapt. You'll see references to this
    material throughout the text. Please note that inclusion of specific
    publications or Web sites does not imply the endorsement of SAMHSA,
    HHS, or any agency of the Federal government.

-   **Program Examples**. This section includes a number of brief
    examples of how pre- and post-booking jail diversion programs have
    been implemented in communities around the country. If you'd like
    further details, contact the individual listed at the end of each
    profile.

-   **Glossary**. Mental health and criminal justice professionals speak
    very different languages, which can hamper collaborative efforts.
    This section defines key terms unique to mental health, criminal
    justice, and substance abuse treatment that you'll encounter in
    planning your jail diversion program.

We invite your comments on the material presented. This publication is
designed to be a living document; future iterations will build on what
we learn from sharing this information with you.

SECTION 1: Why Develop a Jail Diversion Program?

On the face of it, diverting people with serious mental illness and
co-occurring substance use disorders from the criminal justice system
seems like "the right thing to do." This is especially true when the
behaviors that bring people to the attention of law enforcement are the
result of untreated mental illness. But in today's economic and
political climate, this rationale often is not enough. In this section,
you'll learn about the scope of the problem, how it affects the key
players---including people with mental illness and substance use
disorders, the mental health and criminal justice systems, and the
community---and why jail diversion makes sense from more than just a
humanitarian perspective.

The Problem

Significant numbers of people with serious mental illness and
co-occurring substance use disorders are threatened with arrest or
placed in jail, often for minor offenses, many of which are the result
of or associated with untreated mental illness. This phenomenon disrupts
jail operations, clogs court dockets, and impedes recovery from mental
illness and substance use disorders.

What You Need to Know

**The Scope of the Problem**

Each year, 14 million people are arrested and booked into jails. An
estimated 1,100,000 people---8 percent of annual jail bookings---have
current symptoms of serious mental illness, and of these, approximately
three-quarters have co-occurring substance use disorders. (Bureau of
Justice Statistics, 2006; The National GAINS Center, 2004; Steadman &
Naples, 2005; New Freedom Commission, 2004).

People with mental illness in jails are likely to be poor and uninsured
and more than half are members of minority groups. They cycle in and out
of the mental health, substance abuse, and criminal justice systems,
receiving inadequate or inappropriate treatment, if they receive
treatment at all. Many become homeless and end up on the streets, where
they engage in survival activities (e.g., panhandling, public urination,
theft of services) that get them into trouble. In other cases, people
whose mental illness is untreated may act in ways that the general
public considers to be frightening or threatening, resulting in a call
to law enforcement.

Often as a result of circumstances beyond their control, people with
mental illness are more likely to be arrested; to be detained because
they cannot post even very low bail; to be charged with more serious
crimes; to have stiffer penalties imposed; to spend two to five times
longer in jail; and to be involved in more fights, infractions, and
sanctions (Massaro, 2004). Further, people with serious mental illness
and co-occurring substance use disorders are at increased risk of
returning to jail on a probation violation, as compared to probationers
without a mental illness. Behaviors either directly or indirectly
related to their mental illness or substance use disorder (e.g.,
substance abuse, failure to keep appointments or a job) and the
increased scrutiny that people with mental illness may receive from
their probation officers or treatment providers might be to blame (Skeem
& Louden, 2006) for this elevated risk of technical violation.

Frequently, people who are caught in the "revolving door" of
corrections, mental health treatment, and homelessness are thought of as
"bad clients" or "treatment resistant," when in reality, they are the
casualty of "client resistant services" (H. J. Steadman, personal
conversation, March 6, 2006).

Indeed, numerous clinical, system, and individual barriers combine to
make it difficult even for the most functional and motivated people with
mental illness and co-occurring substance use disorders to get help.
These barriers include:

-   Lack of funding for mental health services

-   Lengthy waits for treatment and services

-   Lack of adequate housing

-   Fragmentation among mental health, substance abuse treatment,
    housing, social services, and health care providers

-   Lack of culturally competent service delivery and trauma-informed
    care

-   A gap between what is known to be effective for treatment of mental
    illness, based on the best scientific evidence, and services
    delivered at the community level

-   Previous negative experiences in both the mental health and
    substance abuse treatment systems

-   Stigma and discrimination

**How Individuals and Agencies Are Affected**

When people with serious mental illness and co-occurring substance use
disorders are inappropriately arrested or incarcerated, outcomes are
often ineffective and can result in tragedy.

-   Law enforcement officers spend an inordinate amount of time on calls
    involving people with mental illness. Frequently, police officers
    transport people to mental health centers or hospitals only to learn
    that staff are unable to admit the individual. Arrest is often the
    only option when officers lack knowledge of alternatives or cannot
    gain access to them. Further, if people with mental illness feel
    threatened, they may lash out at police. Encounters between law
    enforcement and people with mental illness sometimes end in
    violence, endangering the safety of people with mental illness,
    officers, and the community (Council of State Governments, 2002;
    Reuland, 2004; Munetz & Griffin, 2006).

-   People with mental illness are costly and time consuming inmates for
    local jails. They may require extra security if they are on suicide
    watch, resulting in overtime costs. Inmates with mental illness may
    have to be in special housing units with 24-hour medical staff, and
    they might be taking expensive medications. Often, they're
    disruptive, which impacts jail operations and staff morale.

-   Some people with mental illness do well with structure, but for
    others, jail is a high-stress environment that may exacerbate their
    symptoms. Pretrial facilities that are loud, uncomfortable, and
    often dangerous tend to aggravate symptoms of untreated mental
    illness. Inmates with mental illness become vulnerable to assault
    and are at risk of harming themselves or others. An increase in
    symptoms may delay legal proceedings, causing further decompensation
    (Bush, 2002; Council of State Governments, 2002).

-   Courts become backlogged, unable to process quickly the increasing
    number of cases involving people with mental illness.

-   Mental health providers lose touch with consumers who cycle in and
    out of the justice system, disrupting ongoing treatment and
    derailing progress toward recovery.

-   Members of the community lose confidence in the ability of the
    justice system to keep them safe and to serve their relatives and
    friends with mental illness fairly and appropriately.

**What Jail Diversion Has to Offer**

Over the past two decades, jail diversion programs have been offered as
a viable and humane solution to the criminalization and inappropriate
detention of people with mental illness. There are a number of reasons
why communities have embraced jail diversion, but chief among them is
this: for most people, ***jail diversion works***.

Research indicates that jail diversion results in positive outcomes for
people with mental illness, systems, and communities. In particular,
jail diversion:

-   Reduces time spent in jail for people with mental illness and
    co-occurring substance use disorders

-   Links these people to community-based services

-   Results in lower criminal justice costs

-   Does not increase public safety risk (TAPA Center, 2004; Steadman &
    Naples, 2005).

Because people with mental illness who are diverted spend less time in
jail and more time in community-based services, treatment costs increase
during the first 12 to 18 months of a jail diversion program. This is
particularly true for people who have not received treatment previously
or who have been disconnected from treatment for some time. As people
become stabilized in treatment and services, these costs decrease,
representing a cost savings to the community as a whole.

Indeed, as the Criminal Justice/Mental Health Consensus Project points
out, "...jail, prison, and hospital beds are among the most expensive
resources available to the criminal justice and public health
systems...when it comes to people with mental illness and the criminal
justice system, *policymakers simply can't afford not to do business
differently* (Council of State Governments, 2002, p. 13, emphasis
added).

Saving money may be one of the most compelling reasons for policymakers
and funding agencies to support jail diversion, but it is by no means
the only significant outcome. Mental health recovery is both a reason to
commit to jail diversion and one of its most important results. The good
news is *people with mental and substance use disorders can and do
recover*.

Recovery is more than the current catchphrase in mental health. It is
the fundamental concept on which a transformed mental health system is
based. In a transformed mental health system, people with mental illness
receive evidence-based treatment and services in the amount and type
they need, provided in ways that are accessible and acceptable to them,
and that are designed to promote self-direction, choice, empowerment,
peer support, and respect. While arrest and incarceration interrupt and
impede an individual's recovery, people who receive appropriate mental
health treatment in the community are more likely to have a better
long-term prognosis. They become productive members of their community,
which decreases their chances of returning to jail.

What You Can Do

Despite a pressing need to address the increasing numbers of people with
mental illness who are inappropriately involved with the criminal
justice system, and though empirical evidence shows positive outcomes
for jail diversion, these programs can be a difficult sell in many
communities and among key constituent groups. It's natural for those
with a stake in the process---individuals and groups referred to as
"stakeholders" in the balance of this document---to question what they
have to gain by participating. Further, they may be confused about what
jail diversion really is.

If you're leading the jail diversion effort in your community, you need
to be able to address these issues. The next two sections will help you
do that. Section 2 defines diversion and examines different models.
Following that, Section 3 highlights specific concerns stakeholders may
have and provides answers to the all important question, "What's in it
for me?"

SECTION 2: What Is Jail Diversion Really?

Jail diversion is not as simple a concept as it first appears and, as a
result, it can be misinterpreted or misconstrued as crisis services or
transition planning. There are two general categories of jail diversion
programs defined by the point in criminal justice processing where
diversion occurs---pre-booking or post-booking---and post-booking
programs are further divided into jail-based and court-based models. In
this section, you'll learn exactly what jail diversion is, the
characteristics of the major types of jail diversion programs, and the
five basic tasks and the six factors for success that are essential
regardless of the particular model you choose.

The Problem

Jail diversion may be a much touted but little understood response to
the problems of people with serious mental illness and co-occurring
substance use disorders in contact with the criminal justice system. In
particular, key stakeholders may focus too much on what type of program
to adopt or adapt and not enough on the key features that will ensure
their success.

What You Need to Know

**Defining Jail Diversion: What It Is and What It Isn't**

A jail diversion program is one that identifies people with serious
mental illness and co-occurring substance use disorders in contact with
the justice system and redirects them from jail by providing linkages to
community-based treatment and support services. **In essence, jail
diversion is the avoidance or radical reduction in jail time achieved by
linkage to community-based services** (see the jail diversion logic
model on the next page).

This definition implies two areas of intervention---first is the means
by which the individual is identified at some point in the arrest
process and diverted into treatment and services. Second is the system
of community-based mental health, substance abuse, housing, and other
social services to which the person is connected (Draine & Solomon,
1999).

It's important to differentiate jail diversion from mental health crisis
services and transition planning. As opposed to crisis services, jail
diversion focuses on access to treatment as an alternative to arrest or
incarceration. The emphasis of a jail diversion program is not on
getting consumers away from one system and into another, but on
"integrating the two systems to better serve the interests of clients in
common" (Draine & Solomon, 1999, p.
60).![](media/image1.jpeg){width="5.678472222222222in"
height="2.6527777777777777in"}

Likewise, jail diversion is not the same as transition or discharge
planning. Transition planning activities should be part of usual
criminal justice processing and occur only when the detainee would
ordinarily leave the jail. By contrast, jail diversion is a special,
targeted program designed to eliminate or reduce the amount of time an
individual with mental and substance use disorders spends in jail, to
the benefit of the inmate, the correctional staff, and the community.

Finally, jail diversion doesn't end when the inmate leaves the jail.
Diversion programs for people with mental illness will not work without
coordination of appropriate services (Steadman, Morris, & Dennis, 1995).
The types of services required for successful diversion programs are
discussed in Section 5 of this publication.

**Types of Jail Diversion**

Diversion programs can be divided into pre-booking and post-booking
models, and post-booking programs can be either jail-based or
court-based. Court-based programs can be further separated into
specialty (e.g., mental health and drug courts) and regular
dispositional courts. Each of these is described in brief below.

Pre-booking Diversion

Pre-booking diversion occurs at the point of contact with law
enforcement officers and relies heavily on effective interactions
between police and community mental health and substance abuse services.
Specially trained officers who encounter a person exhibiting symptoms of
a mental disorder are allowed to use their discretion to determine the
necessity of arrest (Lattimore et al., 2003). The most recognized
pre-booking program is the Crisis Intervention Team (CIT) as developed
in Memphis, TN.

The Memphis CIT is considered a *police-based specialized police
response*. A second type of pre-booking diversion is called a
*police-based specialized mental health response*, in which police
departments hire mental health consultants to provide on-site and
telephone consultation to officers. For example, in Birmingham, AL, a
Community Services Officer program---civilian police employees with
professional training in social work or related fields---helped police
officers in mental health emergencies by providing crisis intervention
and some follow-up assistance.

A third pre-booking strategy is referred to as a *mental health-based
specialized mental health response*, which often includes a mobile
crisis team that responds when requested by police. All three types of
programs reduce arrest rates for people with mental illness, and each
has its benefits and drawbacks. CIT is marked by a rapid response time
and the lowest arrest rate, while mental health professionals who
respond with police are particularly adept at resolving mental health
disturbance calls on the scene. The sometimes slow response time for a
mental health crisis team makes this option less likely to be used by
patrol officers (Steadman et al., 2000; Munetz & Griffin, 2006).

Successful pre-booking programs are characterized by specialized
training for police officers and a 24-hour crisis drop-off center with a
no-refusal policy that is available to receive people brought in by the
police. A central drop-off site provides police with a single point of
entry into the mental health system, though some larger or more rural
communities adapt this model to work with multiple facilities.
Regardless of the configuration, without some type of triage facility
that is prepared to accept police referrals, Reno police officer Patrick
O'Bryan noted, "CIT will be a service to nowhere."

It's important to point out that not all encounters with police that
result in a referral to treatment can be considered pre-booking
diversion. **Diversion is what happens when charges could have been
filed**. In many cases police intervene with people in a mental health
crisis (e.g., a suicide attempt) that does not involve commission of an
offense. In other cases, the specialized police response is believed to
have prevented the commission of an offense. These are important roles
for police in contact with people who have mental disorders, but they do
not constitute jail diversion (Reuland & Cheney, 2005).

Post-booking Diversion

Post-booking diversion is the most prevalent type of diversion program
in the United States. As of mid-2007, there were approximately 500 jail
diversion programs in the country, and 65 percent were post-booking
programs. Post-booking programs identify and divert people with mental
illness after they have been arrested and at or after booking. Nearly
all post-booking diversion programs include some type of monitoring of
compliance with treatment, though the level of supervision and the
active involvement of the court vary from jurisdiction to jurisdiction.

A post-booking program at either the arraignment court or the jail is
one that:

-   ***Screens*** people potentially eligible for diversion for the
    presence of mental illness;

-   ***Evaluates*** their eligibility for diversion;

-   ***Negotiates*** with prosecutors, defense attorneys,
    community-based mental health providers, and the courts to produce a
    disposition outside the jail in lieu of prosecution or as a
    condition of a reduction in charges; and

-   ***Links*** people to an individualized array of community-based
    services.

***Court-based programs*** can occur at any stage in the criminal
justice process prior to sentencing and may be decentralized---with
diversion staff working in multiple courts with multiple judges---or
centralized in a specialty court such as a mental health or co-occurring
disorders court. Specialty courts are marked by the use of one primary
judge, a courtroom team approach, separate court calendar, court
supervision, and interaction with the mental health treatment system
(Lattimore et al., 2003; Broner et al., 2004; Steadman, Davidson, &
Brown, 2001).

***Specialty courts*** such as mental health courts are based on the
concept of "therapeutic jurisprudence." To produce a beneficial outcome,
many of the courts use dismissal of charges after successful completion
of the mental health court program as an incentive to participate in
community treatment and avoid re-offenses. Though based on the drug
court model, mental health courts operate somewhat idiosyncratically;
currently there is no one definitive mental health court model
(Steadman, Davidson, & Brown, 2001).

Some mental health courts only accept people who have committed
low-level offenses, though increasingly, many mental health courts are
accepting felony cases. Courts that accept offenders with more serious
charges often require defendants to enter a plea and to be supervised by
criminal justice personnel, and they are more likely than mental health
courts that do not accept felonies to use jail as a sanction for
noncompliance with court-approved diversion plans (Griffin, Steadman, &
Petrila, 2002; Redlich et al., 2005).

***Non-specialty court*** models address a number of barriers to the
development of mental health courts. In particular (Clark, 2004):

-   In some communities, the size or configuration of the court system
    may not make such dockets feasible or practical, particularly
    because of the need to dedicate substantial judicial resources to
    actively supervising cases.

-   Many mental health advocates are cautious about these courts,
    believing that they create additional stigma for people with mental
    illness or abridge defendants' rights.

-   Some observers fear that mental health courts may have the
    unintended consequence of making a limited set of mental health
    services available on a priority basis to those who have been
    arrested rather than expanding community-based treatment to serve
    all people with mental illness and co-occurring substance use
    disorders. This argument has been made against jail diversion
    programs in general.

-   Even where mental health courts exist, not all defendants with
    mental illness are appropriate candidates for these courts.

While similar in purpose to many mental health court models,
non-specialty court approaches that rely on deferred prosecution or
conditional release strategies do not require dedicated court resources
and can apply to a broader group of offenders with mental illness,
including those with extensive criminal histories or violence associated
with their charges (Bush, 2002).

***Jail-based programs*** are operated by pretrial service personnel or
by specialized jail personnel, often for defendants who have more
serious charges or more severe mental health problems, or who have not
been identified earlier in the process. For example, in Hawaii, staff of
Oahu Intake Services screened new detainees in jail and referred those
with symptoms of mental illness to the diversion team. The team
negotiated with the judge, prosecutor, and public defender to arrange
for diversion into community-based mental health treatment (Lattimore et
al., 2003).

What You Can Do

While all diversion programs engage in some form of identification and
linkage, *there is no definitive model for organizing a jail diversion
program*. Jail diversion programs will be unique to the community and
the services they provide will be tailored to the consumer. In fact,
jail diversion programs in your community may differ even from those in
the neighboring city or town because your jurisdictions will vary in the
size and structure of the criminal justice system, the resources
available to the mental health and substance abuse treatment systems,
and the political and social climate in which you work. The model you
choose will be based on these factors and it may seem at times that
there is a dizzying array of options from which to choose.

As you begin planning, remember the old adage to "keep it simple."
Listed below are the five basic tasks involved in any jail diversion
program and the six key features that will make them successful. Think
of these as *what you are going to do* and *how to make it work*.

**Five Basic Tasks**

Regardless of the type of diversion program you select, you are going to
be required to do some or all of the following:

-   **Know who you are looking for**: Determine your eligibility
    criteria.

-   **Find them**: Screen and assess the people you believe are
    eligible.

-   **Engage them**: Develop trusting relationships with consumers and
    plan for services they want and will accept.

-   **Cut a deal**: Negotiate the terms and conditions of the jail
    diversion plan with the key players in your system, including law
    enforcement, defense attorneys, prosecutors, judges, mental health
    and substance abuse treatment providers, and consumers.

-   **Make it stick**: Link consumers to the treatment and supports they
    need to recover from mental and substance use disorders and remain
    stably housed in the community.

**Six Factors for Success**

Across all types of approaches, the following six key features have
emerged as essential for creating an effective jail diversion program
(Steadman, Morris, & Dennis, 1995). These elements are crucial in
linking the criminal justice and community treatment systems:

1.  **Interagency collaboration**: Services should be integrated at the
    community level, including involvement of social services, housing,
    mental health, health, local corrections (institutional and
    community), criminal justice, workforce development, Medicaid, and
    substance abuse agencies.

2.  **Active involvement**: Stakeholders must hold regular meetings for
    service coordination and information sharing and establish formal
    agreements, such as written Memoranda of Understanding (MOUs).

3.  **Boundary Spanner**: Programs require staff that bridge the mental
    health, criminal justice, and substance abuse systems and manage
    cross-system staff interactions.

4.  **Leadership**: You need a strong leader to network and coordinate
    activities.

5.  **Early identification:** People should be screened at the earliest
    point possible (ideally, in the first 24--48 hours of detention) for
    mental health treatment needs and to determine whether they meet the
    criteria for diversion.

6.  **A specialized case management program**: An effective case
    management program is one of the most important components of
    successful diversion. Case managers should have adequate knowledge
    and experience with mental health and criminal justice systems.

Further discussion of these key components can be found in sections 4--6
of this publication.

SECTION 3: Making Jail Diversion Happen in Your Community

Regardless of whether you approach jail diversion as a way to save costs
or save lives, you may encounter resistance among the very people and
systems such programs are designed to help. Some resistance is
understandable, but much of it stems from misinformation or
misinterpretation of what a jail diversion program involves. In this
section, you'll learn why some individuals and groups initially may be
opposed to adopting a jail diversion program in your community and how
you can respond when they ask, "What's in it for me?"

The Problem

Despite what seem like clear benefits, some individuals and groups
initially may resist adopting a jail diversion program for people with
serious mental illness and co-occurring substance use disorders. This
makes it more difficult to gather stakeholders, reach consensus, and
develop a strategic plan.

What You Need to Know

Each group that will be party to jail diversion efforts will likely have
some concerns you need to address. They include those noted below.

**Responsibility for Criminal Behavior**

Criminal justice professionals may think the person is not being held
accountable for his or her actions. In particular, police officers may
feel that a specialized jail diversion approach is inconsistent with
traditional policing, which focuses on putting people in jail. While law
enforcement professionals may think the person is getting out of
punishment, mental health providers may see the same process as helping
people get into treatment.

One way to reconcile this difference is to focus on *avoiding
incarceration rather than avoiding punishment* (Draine & Solomon, 1999,
p. 59, emphasis added). Treatment and accountability are not mutually
exclusive; many people enrolled in a jail diversion program will spend
more time in community treatment, often under the supervision of the
court, than they would have spent in jail.

Further, in no case is anyone who advocates for a jail diversion program
for people with serious mental illness suggesting that people who commit
serious crimes or crimes unrelated to their mental illness should be
exempted from appropriate punishment. Munetz & Griffin (2006) make this
clear:

People with mental illness who commit crimes with criminal intent that
are unrelated to symptomatic mental illness should be held accountable
for their actions, as anyone else would be. However, people with mental
illness should not be arrested or incarcerated simply because of their
mental disorder or lack of access to appropriate treatment---nor should
such people be detained in jails or prisons longer than others simply
because of their illness (p. 544).

**Fears about the Forensic Consumer**

Mental health providers may be reluctant to work with people diverted
from the justice system for several reasons. The first is their fear
that offenders with mental illness have a higher potential for violence,
which they don't (see section below). However, people with mental
illness may have previous problems, such as an arson charge, that make
it challenging to find an appropriate array of services for them. Also,
many people who are diverted have co-occurring substance use disorders
and mental health professionals may not be trained in treatment of
co-occurring disorders or have access to an integrated treatment
program.

In addition, mental health professionals may believe that people in
contact with the justice system are difficult to engage in services and
resistant to treatment. In fact, most people are amenable to treatment
given the right combination of services delivered in the right way
(Massaro, 2005). Engagement into services can be difficult, though much
has been learned about the importance of respectful, trauma-sensitive,
culturally competent, and peer-supported techniques that make services
attractive and appropriate for people with serious mental illness and
co-occurring substance use disorders.

Interventions specific to a criminal justice population are also being
developed. For example, many former inmates have acquired beliefs and
behaviors that, while adaptive in jail or prison, get in their way of
succeeding in a mental health program and in the community. The Bronx
Psychiatric Center has developed a half-day training workshop for
providers to help them understand how these behaviors are traditionally
misinterpreted in mental health treatment settings and a group therapy
program for former inmates that helps them make a successful transition
to the community. For more information about the SPECTRM (Sensitizing
Providers to the Effects of Correctional Incarceration on Treatment and
Risk Management) program, contact Merrill Rotter, M.D., at
mrotter@omh.state.ny.us.

Finally, regardless of any real or unfounded concerns they may have,
mental health providers face the very real problem of limited resources.
Jail diversion consumers, some of whom may not have been enrolled in
services previously, are an added burden on an already strained system.
When jail diversion staff help consumers access such mainstream benefits
as Supplemental Security Income (SSI) and Medicaid, it reduces the need
for agencies to provide uncompensated care. See Section 5 for more
information on this topic.

The Risk of Violence

Public perception of the risk of violence among people with serious
mental illness is skewed by media stereotypes in news coverage, movies,
and novels. When effective treatment and support services are available
and used, people with mental illness pose no greater threat to the
community than other people and may in fact be the victims rather than
the perpetrators of violence. Co-occurring substance abuse represents a
much greater risk for violence than does mental illness alone (Steadman
et al., 1998; Massaro, 2004; Dvoskin & Steadman, 1994).

Even when people with mental illness do have violent charges, most can
be successfully diverted with no additional risk to public safety. A
study of federally funded jail diversion programs found no empirical
evidence showing more negative outcomes for people with violent charges
who are diverted from jail to treatment in the community (Naples &
Steadman, 2003). This issue is important when determining a target
population for jail diversion, an issue that will be discussed further
in Section 4.

**Concerns About Coercion**

Though all jail diversion programs are voluntary, people with mental
illness in contact with the justice system, particularly those who have
had previous negative experiences in the mental health system, may feel
they will be forced to participate in treatment that is not in their
best interests. Some may believe they are better off spending a few days
in jail than 6 months or more in treatment.

Further, though it may make sense for a person to accept mental health
treatment as part of a plea agreement, jail diversion programs that
require offenders to enter a guilty plea in order to participate must be
certain the person makes this decision with the aid of competent defense
counsel. A person should never be asked to forfeit significant
constitutional rights to enter a jail diversion program, cautions public
defender Stephen C. Bush, J.D., Coordinator of Mental Health Systems for
the Shelby County (TN) Public Defender's Office.

While consumers may fear forced treatment, mental health advocates and
family members may worry that the inherently coercive nature of the
criminal justice system might endanger people or compromise the positive
strides the mental health system has made in reducing coercion in
treatment and services. It is up to professionals in both the criminal
justice and mental health systems to arrange for or provide services
that are appropriate, respectful, and useful to help people see the
potential for long-term benefit, including the likelihood of reduced
contact with the justice system.

**Political and Financial Liability**

Elected officials whose support is critical to the success of a jail
diversion program may fear a high-profile failure, though in reality the
community will be safer when people with mental illness are in services
and, often, under court supervision. They also worry about the costs of
implementing new programs, particularly when any savings are not likely
to be realized for several years.

What You Can Do

One of the most important tasks you will accomplish in planning your
jail diversion program will be gathering your key stakeholders (see
Section 4) and helping them achieve consensus. This will be easier when
each of the individuals and groups you approach are very clear about how
such a program would benefit them.

Here are some reasons you can give them.[^1] Each of these benefits
speaks to the problems that various stakeholders experience when
services and systems are unresponsive to the needs of people with
serious mental illness and co-occurring substance use disorders. In
addition, you may want to consult the Resources and Program Examples
sections of this document to have ready evidence in hand to show that,
in fact, for most people, ***jail diversion works***.

**The Criminal Justice System**

For the criminal justice system in general, partnerships to create jail
diversion programs can help alleviate:

-   Low staff morale and high turnover

-   The cost of providing expensive medication and treatment services
    within the jail

-   Expensive overtime pay

-   Limited space for more serious felons

-   Burgeoning court dockets

*For people enrolled in the Clark County (WA) Mental Health Court,
arrests were reduced from an average of 2 in the year prior to
enrollment to 0.48 in the year following enrollment (Herinckx et al,
2005)*.

For law enforcement, in particular, a diversion program that helps
address the needs of people with mental illness in crisis can reduce:

-   Injuries to police officers and to people with mental illness

-   The amount of time officers spend accompanying people with mental
    illness while they are evaluated for treatment admission

*A one-stop medical and psychiatric crisis center in Bexar County, TX,
has reduced significantly the waiting time for officers in the county's
pre-booking diversion program to about 15-20 minutes*.

**The Mental Health System**

For mental health providers, programs that divert people with mental
illness from inappropriate arrest and incarceration to community
treatment can help:

-   Minimize the impact of treatment interruption for those who are
    consumers of the system

-   Provide outreach to those who are disengaged from services

-   Present opportunities for greater stability and fewer crises

-   Offer an additional source of motivation to participate in treatment

*The community-based mental health services offered through the Clark
County (WA) Mental Health Court resulted in a 75 percent reduction in
inpatient treatment days for people enrolled in the program (Herinckx et
al, 2005)*.

**Individuals with Mental Illness**

For people with serious mental illness in contact with the justice
system, a diversion program can help them:

-   Avoid jail time

-   Reconnect to supports and services

-   Focus on recovery

-   Avoid recidivism

*The Nathaniel Project in New York, NY, for felony defendants on Rikers
Island, had an 80 percent participant retention rate over 2 years with
100 percent of participants engaged in treatment (The National GAINS
Center, 2002)*.

**Family Members**

Family members are supportive of diversion efforts that help their
relative:

-   Stay out of jail

-   Get access to the treatment, services, and housing they need

-   Reconnect to family and other social supports

-   Recover from mental illness and substance use disorders

*In Milwaukee, WI, when an individual with mental illness is diverted by
the city's Crisis Intervention Team, a member of NAMI-Greater Milwaukee
follows up with family members in order to gather their perspectives on
the situation.*

**Policymakers and Funders**

For elected and appointed officials, as well as key leaders in the
mental health and criminal justice systems, reasons to support jail
diversion include the need to (Council of State Governments, 2002):

-   Enhance public safety

-   Use criminal justice resources more efficiently

-   Reduce taxpayer expenditures

-   Increase public confidence in the justice system

-   Gain access to resources

*Through the support of County Criminal Court Judge Steven Leifman,
Miami-Dade County received voter approval for a \$23 million bond to
develop a facility for jail inmates with mental illness.*

You may not be able to quell initial fears even with the best
information about how successful jail diversion is in other communities.
Some people will only be convinced of the value of jail diversion when
you are able to connect people in contact with the justice system in
your own community to treatment, housing, and supports. The next two
sections will help you develop and implement a plan to do so.

SECTION 4: Getting Started

Planning for and designing a jail diversion program may seem like a
daunting task. You have to convene key stakeholders, map the service
system, and secure funding, responsibilities that are not part of your
everyday routine. During the start-up phase, it's particularly helpful
to keep your goals in mind---your hard work will help improve the lives
of people with serious mental illness and co-occurring substance use
disorders, enhance public safety, and use criminal justice and mental
health resources more effectively. In this section, you'll learn why
collaboration between the criminal justice, mental health, and substance
abuse systems is not as difficult as it first seems; how to develop
consensus and create a strategic plan; and where to find the resources
you need to begin.

The Problem

People with serious mental illness and co-occurring substance use
disorders come into contact with the criminal justice system for a
number of reasons, not the least of which is the fact that services
designed to help them are fragmented, uncoordinated, and underfunded.
The mental health, substance abuse, and criminal justice systems have
their own histories, languages, values, concerns, and protocols. This
leads to inefficient and ineffective services and results in failed
systems, wasted resources, and lost lives (Council of State Governments,
2002).

What You Need to Know

People with mental illness and substance use disorders in contact with
the criminal justice system need multiple services, including housing,
health care, mental health services, substance abuse treatment, income
supports and entitlements, life skills training, education, and
employment. These services typically are provided by multiple agencies
in different systems, leaving individuals to coordinate their own care.
They may receive duplicate services at multiple agencies or no services
at all. Both practically and clinically, coordinating the services they
need to recover from their illness and remain stably housed in the
community simply makes sense (SAMHSA, 2003; Council of State
Governments, 2002).

The solution to fragmentation is to integrate services and systems by
promoting collaboration. Community collaboration and integration help
increase retention in services and stability in the community for people
with mental illness and substance use disorders and decrease public
safety risk and criminal justice costs. What does it mean to integrate
services and systems?

***Integrated services*** are designed to maximize an individual's use
of existing resources through such techniques as case management. In
contrast, ***integrated*** ***systems*** are designed to change service
delivery for a defined population and involve fundamental changes in the
way agencies share information, resources, and consumers. As such,
systems integration goes beyond service integration. It does not require
the creation of a single system, but it does demand an interconnected
network of organizations that can complement each other by coordinating
their assessments, treatment services, administration, management
information systems, and staff training (Dennis, Cocozza, & Steadman,
1999; The National GAINS Center, 1999a).

Both services and systems integration are important for creation of an
effective jail diversion program. In fact, systems integration cannot
succeed without an emphasis on integrated services, as well. Successful
jail diversion programs have a boundary spanner who helps coordinate and
integrate the activities of the mental health, substance abuse, and
criminal justice systems *and* specialized case managers who help people
with mental illness and substance use disorders gain access to the full
range of services to which they are entitled. Creation of these
positions and the important roles they play will be expanded on in
Section 5 of this publication.

Despite distinct advantages to both systems and consumers, the barriers
to integrating service systems are both broad and deep. As one observer
notes, "While everybody is in favor of coordination, nobody wants to be
coordinated" (Feldman, 1976). Barriers to effective collaboration
include:

-   Funding "silos" make communication about cross-systems efforts more
    challenging.

-   Limited resources create a competitive and/or protective
    environment.

-   Regulations concerning confidentiality create both real and
    perceived hurdles.

-   The mental health, substance abuse, and criminal justice systems
    have their own, separate treatment philosophies, administrative
    policies, and funding streams.

-   Lack of political will and public support can stymie even the most
    dedicated efforts.

However, the mental health, substance abuse, and criminal justice
systems share common issues that can be leveraged for collaboration.
These include public safety, responsibility, and accountability.
Further, though the work of systems integration may be difficult and
take years to accomplish fully, it often begins with a simple step. As
the Criminal Justice/Mental Health Consensus Project points out:

The single, most significant common denominator shared among communities
that have successfully improved the criminal justice and mental health
systems' response to people with mental illness is that *each started
with some degree of cooperation between at least two key
stakeholders---one from the criminal justice system and the other from
the mental health system* (Council of State Governments, 2002, p. 14,
emphasis added).

Creating and sustaining these relationships will be critical as you
follow the steps outlined below for creating systems change.

What You Can Do

Each community will develop a tailored jail diversion program. However,
regardless of the specifics in any community, there are common steps on
the road to success.

To develop the infrastructure for jail diversion, you need to:

-   Designate a lead person

-   Gather your key stakeholders

-   Really do strategic planning (see box)

-   Secure funding

-   Communicate regularly

**Designate a Lead Person**

You need someone to lead the charge. Sometimes this person is referred
to as a "change agent." He or she needs to be a ***strong leader*** with
good communication skills and an understanding of the systems and the
informal networks involved. This may be a prosecutor, public defender,
judge, jail medical staff, or a political champion. For example, in
Miami, County Criminal Court Judge Steven Leifman of the 11^th^ Judicial
Circuit convened a group of interested parties to discuss jail
overcrowding. Judges can be particularly effective at motivating
distinct agencies and systems to see the shared responsibilities they
have for improving outcomes for people with mental illness in the
justice system. Indeed, support from critical community leaders is often
the key to crystallizing your drive and vision into concrete programs
(The National GAINS Center, 1999a).

**Gather Your Key Stakeholders**

***Stakeholders*** are "individuals and organizations in the community
who have a vested interest in mental health services or the criminal
justice system, or who would be affected, whether positively or
negatively, by the implementation of a diversion program" (National
Mental Health Association, 2003, p. 1). You'll need their active
involvement, because you can't do this alone. As the Criminal
Justice/Mental Health Consensus Project points out, "a community
partnership becomes a single voice that demands attention and appeals
convincingly for assistance needed to solve the problem" (Council of
State Governments, 2002, pp. 9-10). The specific stakeholders will be
unique to your community, but typically they will include:

-   Police

-   Jail administrators

-   Corrections officers

-   Jail mental health and health service providers

-   District attorneys and prosecutors

-   Public defenders

-   Local judges and magistrates

-   Probation officers

-   Community mental health and substance abuse treatment
    providers/administrators

-   Housing and social service providers

-   Elected officials (mayor, county commissioners, legislators, etc.)

-   The State Medicaid director or his/her designee

-   Consumers and consumer advocacy groups

-   Family members

You may also want to have the following important constituents
represented:

-   Workforce development agencies

-   Education and training providers

-   Victim advocates

-   Agencies that provide services for parents with children, including
    Women, Infants and Children (WIC), child protective services,
    childcare providers, etc.

Also, be certain to include representatives of other diversion programs
that may be operating in your community. Your goal should be to enhance
the services each program provides. For example, Shelby County, TN, has
three levels of intervention to divert people with mental illness from
the criminal justice system, beginning with the well-known Memphis
Crisis Intervention Team. Each of the three distinct programs, which are
designed to identify and divert people at different stages of the
justice system, is supported by the Mayor's Jail Diversion Committee.

Make Sure You Have the Right People

Even if you have representatives of all the agencies listed above, you
may not have the people you need to make things happen. Some questions
to consider when forming a coalition include (National Mental Health
Association, 2003, pp. 1--2):

-   What types of expertise will the coalition need and who would best
    offer each type of expertise \[e.g., knowledge about research and
    data, diversion programs, public education campaigns, potential
    funding sources, etc.\]?

-   Who can make or influence important decisions in the community?

-   Do these people have resources and time to commit to the coalition?

-   From whom does the community need buy-in to make this project
    successful

Of particular importance, each organization should be represented by the
chief executive or his or her designee, for two reasons: First, they
have the authority to commit the resources of their organization, and
second, their involvement signals to their subordinates and to other
stakeholders that their agency is committed to the initiative (Council
of State Governments, 2002).

At the same time, it's equally important to get low-level buy-in from
the earliest stages (Reuland, 2004). For example, in a pre-booking
program, it's the patrol officers on the street who will be implementing
jail diversion activities discussed and decided upon by the coalition.
In addition, if you're having trouble convincing the head of your law
enforcement agency about the wisdom of beginning a jail diversion
program, you may be able to find informal leaders on the front line of
service who can help break through organizational resistance.

Some of these individuals may already be meeting together as part of
existing groups, such as local homeless coalitions, so they will be easy
to identify and contact. In other cases, you may have to make "cold
calls," introducing yourself to local human services organizations or
law enforcement agencies. If this is the case, it may be helpful to take
someone with you who is known to and respected by the organization whose
support and expertise you need. For example, in Philadelphia, well-known
homeless services provider Sister Mary Scullion was well received by the
local police department when discussions began about developing a CIT
program.

Consumers and consumer advocates---particularly people with mental
illness and co-occurring substance use disorders who have experienced
justice involvement---should have an early and continuing role in the
coalition because they are invaluable in defining problems and
identifying solutions. However, the stigma attached to both mental
illness and substance use disorders and to justice involvement may make
it challenging to locate and involve consumers, especially if other
stakeholders are not attuned to recovery as a viable outcome for people
with mental illness, substance use disorders, and justice involvement.

In addition, though the consumer movement in mental health is fairly
well organized and increasingly respected, some criminal justice
stakeholders may be reluctant to elicit or heed advice from people they
have seen only in times of crisis. Finally, it is important to remember
that consumers don't speak with one voice. Some may be opposed to jail
diversion if they equate it with "coerced treatment." Educating all
constituents, including consumers, about the value of jail diversion is
one of the tasks for your stakeholder group.

Get Your Stakeholders to the Table

Once you identify who needs to be part of your coalition, you have to
bring them together. Benefits likely to appeal to key leaders in the
mental health and criminal justice system include the following (Council
of State Governments, 2002, p. 17):

-   Improving the lives of people with mental illness and reducing the
    frequency of their contact with the criminal justice system

-   Enhancing public safety

-   Using criminal justice resources more efficiently

-   Improving the safety of line staff and the environment in which they
    work

-   Reducing taxpayer expenditures

-   Increasing public confidence in the justice system

-   Gaining access to resources

-   Enlisting allies capable of attracting support from policymakers
    previously unmoved by the need to bolster the mental health system

Sometimes a high profile incident or damaging story in the media serves
to motivate a core group of prospective partners. For example, following
the deaths of two men with mental illness in recent contact with the
police, the Rochester Police Department formed the Emotionally Disturbed
Persons Response Team (EDPRT).

A new funding opportunity, particularly one that requires collaborative
efforts, often helps bring stakeholders together. Likewise, legislation
can prompt joint ventures through the establishment of task forces
(Council of State Governments, 2002).

Compelling data also may promote interest in a jail diversion program.
Though there may be barriers to collecting and reporting such data, you
don't need a university cost study to prove the case for jail diversion.
In Reno, NV, patrol officers Steve Johns and Patrick O'Bryan conducted
their own informal survey of how much it cost to care for several people
who were in and out of emergency rooms, substance abuse treatment, and
the local jail. In one case, which has now been well publicized as the
story of "Million-Dollar Murray," Johns and O'Bryan discovered that the
City of Reno spent \$1 million over 10 years to not provide adequate
treatment for one individual, who later died on the streets (Gladwell,
2006). See more about how to collect and present such data in Section 7.

Assess Your Current Level of Collaboration

Some of the stakeholders in your group may already be collaborating with
one another. For example, mental health providers and local law
enforcement officers may hold informal meetings to discuss areas of
mutual concern. But others will be new to the idea of a criminal
justice/mental health collaboration. To help stakeholder groups
determine their current level of collaboration, the Criminal
Justice/Mental Health Consensus Project has developed a collaboration
assessment tool available at http://consensusproject.org/assessment.
Your answers will help reveal:

-   The process by which agencies involved in the initiative define,
    identify, track, share, and evaluate information on the target
    population within and across agencies.

-   The process by which different systems work together to define
    common goals, identify mechanisms to achieve those goals, support
    their service providers, and evaluate and refine their initiative to
    ensure positive outcomes.

-   The process by which service providers from different systems
    coordinate---and potentially integrate---treatment and services for
    a shared population in order to achieve system goals.

-   The process by which agencies involved in the initiative identify
    and secure resources (e.g., staffing, funding) that sustain the
    initiative and advance its goals.

This information will help guide your planning activities, particularly
as you begin to map the system and identify gaps in services (see
discussion of these topics later in this section).

Plan and Run Effective Meetings

Every one of your planning group members is a busy person with competing
priorities, so it may be challenging to find a time and place where all
of your diverse constituents can meet. You might want to plan a
breakfast or lunch meeting, with food provided by the host agency.
Alternating meeting sites among various organizations---e.g., the police
department one time and the local mental health center the next---helps
group members become familiar with the various settings in which people
are seen. Choosing a site that would create the greatest sense of
importance, such as the courthouse or the district attorney's office,
might help increase buy-in from the stakeholders whose influence will be
critical. You also may want to plan a field trip or two; visits to the
local jail can be enlightening for human services personnel and law
enforcement officers can benefit from talking to consumers at a local
mental health center (see more in "Create a Shared Vision" below).

To keep your meetings focused, be certain to have a written agenda and
stick to the time frames you establish. If you're new at this, you can
find helpful tips and techniques for planning and running effective
meetings at www.effectivemeetings.com.

**Really Do Strategic Planning**

This is where the rubber meets the road. Strategic planning is important
for two reasons. First, it is the most direct way to ensure involvement
from all the individuals and groups who need to buy into your efforts to
plan a jail diversion program. Second, and equally important, good
strategic planning models the type of collaboration and cooperation you
need to successfully improve services for people with mental illness and
substance use disorders involved in the justice system and enhance
public safety.

Create a Shared Vision

Planning a jail diversion program begins with reaching agreement on
desired outcomes or goals. Eventually, everyone in your group needs to
be on the same page, but they won't start out there. The opening
dialogue may be uncomfortable and time-consuming, but everyone needs a
chance to be heard.

Resist the tendency to engage in "finger pointing" by emphasizing a
problem-solving (rather than a position-taking) approach, which focuses
on the interests or concerns that underlie the stakeholders' positions
on issues. Inevitably, at early meetings, there will be some tensions
often associated with particular cases that need to be resolved. To
shift the dynamics to more creative problem solving (Fisher, Ury, &
Patton, 1991; see also www.resolv.org):

-   Discuss and address interests. Interests are less rigid than
    positions.

-   Understand the role of interpersonal dynamics in negotiations and
    help people move on (separate the people from the problem).

-   Generate a wide range of options, minimizing judgments at first.

-   Agree on criteria by which to generate options for resolution.

A key part of reaching consensus about the need for a jail diversion
program and what its outcomes should be will be to educate each other
about the services you provide and the constraints you face. This is
where the field trips mentioned above can be useful. If you're in the
mental health or substance abuse treatment system, you need to learn
about the unique challenges faced by criminal justice agencies in
working with people who have mental illness and substance use disorders.
On the criminal justice side, you may lack knowledge about how people
with mental illness who have access to appropriate services can live in
and contribute to the life of the community. You might want to invite
key members of your group to spend a day following the footsteps of
someone with co-occurring disorders who is trying to navigate the
system. Public education and advocacy are vital tools to reach community
consensus (The National GAINS Center, 1999a; National Mental Health
Association, 2003).

When developing your goals, keep in mind that they should remain broad
enough to encourage general buy-in, but narrow enough to keep your
target in mind. For example, some broad goals for those considering a
pre-booking program may be (Reuland, 2004, pp. 25-27):

-   Improved services to people with mental illness

-   Improved efficiency and effectiveness of law enforcement response

-   Diversion from the criminal justice system

-   Reductions in officer and civilian injuries

-   Improved officer knowledge about mental illness

-   Effective partnerships with the mental health community

The goals then become your vision, which must be refined into a simple
concept that captures the complex issues at hand.

For example, in Miami, *diversion and linkages to comprehensive care
make jail the last resort*. The goal of jail diversion activities in
Montgomery County, VA, is to *narrow the door into the criminal justice
system and open the door to treatment*.

Finally, remember that your vision and the goals they embody must
embrace a set of values that are critical to successful community
integration of people with serious mental illness and co-occurring
substance use disorders in contact with the justice system. Any program
you develop must be ***consumer focused, gender sensitive, culturally
appropriate***, ***strengths based***, and include ***peer support***.
These are more than politically correct terms. They are the foundation
on which individuals with mental illness and substance use disorders are
able to recover their health and their place in the community, thereby
avoiding future contact with the criminal justice system. These values
are particularly important given the prevalence of trauma, including
physical and sexual abuse, among the individuals you will be serving.
More information about trauma-informed services can be found in Section
5 of this publication.

Define the Target Group

This is big! This step can't be overstated. You need to determine who
you are going to serve, how many of these people there are, and what
services they require. This is critical because if you choose your
criteria too narrowly, you may find you don't have enough people for
your jail diversion program.

Often, because it's safer politically, communities begin by serving
people with serious mental illness who have committed non-violent or
low-level offenses, typically misdemeanors. You may find your group
wants to further restrict participants by eliminating from
consideration, for example, people charged with operating a motor
vehicle while intoxicated or those who have a violent offense in their
past.

Sometimes this strategy is effective if it allows you to build on early
successes. Stakeholders in Lancaster County, NE, initially decided the
jail diversion program should only accept people charged with nonviolent
misdemeanors. Based on a positive track record, this program is now
working with people charged with higher level misdemeanors and lower
level felonies.

Nonetheless, you may want to come equipped at your initial coalition
meetings with research and tools that show what you have to gain by
serving people with more serious offenses. When stakeholders in Chester
County, PA, pilot tested a Jail Diversion Cost Simulation Model,
developed by Human Services Research Institute of Cambridge, MA, in
collaboration with the TAPA Center for Jail Diversion, they discovered
that diverting people with the lowest level offenses ***did not
result*** ***in a cost savings.*** However, other iterations of the
simulation model that did include at least the lowest level felony
offenders resulted in ***significant cost savings*** for Chester County
over a 2-year period. See the box on the next page for a more complete
description of the resource simulation model.

Further, research supported by the Massachusetts Mental Health Diversion
& Intervention Program and the National Institute of Mental Health,
which tracked nearly 14,000 mental health service recipients for 10
years, indicates that only choosing those individuals with mental
illness who commit misdemeanors would miss a significant number of
people who could potentially be helped by a jail diversion program. For
more information on this study, contact Principal Investigator William
H. Fisher, Ph.D., at bill.fisher@umassmed.edu.

One additional group you may want to work with is probation violators,
who represent a significant percentage of the population in local jails.
By working with local probation departments and officers to identify and
divert individuals with mental illness at risk of re-incarceration due
to a technical violation of probation, jail diversion programs and
mental health courts can have a meaningful impact on the number of
unnecessary incarcerations; this frees beds for those individuals who do
pose a risk to public safety. For example, the Women's Support Program
operating in New Britain and Bristol, CT, has forged a successful
relationship with the local probation department, which has resulted in
the program receiving a significant number of referrals from their
partners at probation.

Determine the Services Your Target Group Requires

Once you decide who you are going to serve and how many people are in
this group, you'll need to determine the types and amount of services
they require. The service packages you plan to offer should be based on
the functional level of the people you intend to serve. Most jail
diversion consumers, who have been unconnected to treatment and services
for some time, will require a greater intensity of services at the
outset. As a person's functional level improves, he or she needs a less
intense set of services.

In general, the cost simulation model profiled above indicates that a
basic level of necessary services, such as housing, Assertive Community
Treatment (ACT), and substance abuse treatment, must be provided before
jail diversion can be expected to improve consumer outcomes. Improved
outcomes can lead to lower costs. If you provide fewer or less intense
services at the outset, people who are more seriously impaired will take
longer to improve, and you run the risk that they will relapse, thereby
requiring more expensive emergency intervention and resulting in higher
recidivism rates.

In addition to determining the type and intensity of services your
consumers require, you need to plan for how long they will be in your
program. If you establish a 90-day program but find that your consumers
require twice that long to become stable in the community, you will have
a backlog that will make it difficult for you to accept new consumers.
Once you begin collecting data (see Section 7), you may have to revise
your projected timeline based on actual results. Developing a flow chart
of where consumers are at various points in the program may be helpful.

Finally, if you are working with women, you need to be aware that most
incarcerated women have, at the time of their arrest, one or more
children in their custody. In 1998, more than 1.3 million minor children
had mothers who were in the care, custody, or control of Federal, State,
or local corrections agencies (Greenfeld & Snell, 1999). Jail diversion
programs serving women with minor children will have to help consumers
plan for childcare and related services so they can keep appointments
and feel comfortable meeting program requirements. Those who have
children in foster care may need reunification assistance. Agencies that
provide these services should be included in your stakeholder group. The
CMHS National GAINS Center has an excellent set of resources on the
special needs of women in the justice system that is available at
www.gainscenter.samhsa.gov. Click on the "Publications" link on the
"Resources" tab. ![](media/image2.jpeg){width="6.461111111111111in"
height="1.5395833333333333in"}

Examine Available Models

To further educate your planning group about jail diversion, you'll want
to examine models that have been developed and tested in other
communities. Though the program you create will be unique to the needs,
resources, and political climate in your jurisdiction, there is no need
to reinvent the wheel. Many planning groups send key members to visit
programs in communities that are similar to their own. For example, the
Lancaster County, NE, Mental Health Jail Diversion Project used Federal
technical assistance funds to send two county commissioners to visit a
similar program in Portland, ME. Most police agencies that are
considering creating a pre-booking diversion program begin by examining
model approaches that have already been developed, particularly the
Memphis CIT program (Reuland, 2004).

As you review other program models, you'll need to consider how they
could be adapted to fit your local context and constraints. Items to
consider include, but are not limited to, the following:

-   How will you determine legal and clinical criteria?

-   How, where, and when will you assess potential consumers?

-   How long will they spend in your program?

-   How will you supervise consumers, and who will be responsible for
    doing so?

-   What consequences will you impose for noncompliance?

-   How will consumers transition from criminal justice-based programs
    to community services?

-   What will be the disposition of the case when consumers complete the
    program? What will happen if they don't?

The answers to many of these questions will depend on how your system is
structured, who the key players are, and at what points in the system
your consumers interface with various agencies and individuals. This is
where mapping the system can help. The section that follows describes
this process in more detail.

Map the System

If your community is like most, the structure of the mental health,
substance abuse, and criminal justice systems, and the points at which
they intersect, are sufficiently complex that no one person in your
planning group sees the system as a whole. When you examine the pathways
through which a person with mental illness and substance use disorders
in contact with the justice system has to travel to get treatment and
services, you begin to understand how people with multiple and complex
needs fall through the cracks of fragmented systems of care.

System mapping may be an unfamiliar term, but it's a simple idea. It's a
tool for identifying gaps and needs in the system and for doing
prioritized action planning. The goal of a system mapping exercise is
both simple and profound: *to* *transform fragmented services into a
system that makes sense to the people and the professionals who use it*.
This is a dynamic and interactive process, and you may choose to
contract with an outside facilitator to help negotiate the competing
priorities that will emerge. See the box in this section for a
description of one such service.

At its core, system mapping uses what is called the "sequential
intercept model" to determine the key points at which people with mental
illness and substance use disorders may be diverted and the critical
strategies that can be employed at each juncture. The five intercept
points are:

-   Law enforcement and emergency services

-   Initial detention and initial hearings

-   Jails, courts, forensic evaluations, and forensic commitments

-   Reentry from jails, State prisons, and forensic hospitalization

-   Community corrections and community support services

The sequential intercept model can help you decide where to begin your
intervention. For example, pre-booking diversion programs represent the
first point of intervention; mental health courts are an example of an
intervention at the third intercept point. Ideally, most people will be
intercepted at early points. Using this model, communities can develop
targeted strategies that evolve over time to divert people with mental
illness and substance use disorders from the justice system and link
them to community treatment (Munetz & Griffin, 2006).

**Sequential Intercept Model**

Identify Gaps

As you map your service system, you'll begin to identify where gaps in
services exist. Based on knowing who you want to serve and the services
they require, you'll need to determine whether these services exist in
sufficient quantity, and, if so, whether the agencies that provide them
are prepared to work with your consumers. You might want to use a tool
such as the Community Needs Assessment developed by the National
Consumer-Supporter Technical Assistance Center (NCSTAC), funded by the
Federal Substance Abuse and Mental Health Services Administration. The
NCSTAC tool guides the collection of both quantitative and qualitative
data designed to help communities determine the current strengths and
service gaps in the system, with an emphasis on recovery-oriented mental
health services. A companion document, Assessing Communities for Systems
Transformation, is also available. Visit the NCSTAC Web site at
www.ncstac.org and click on the "Resource Library" link.

When you identify where the gaps are, you have to decide how to fill
them. The solution for each community will be different. Depending on
how you structure and finance your jail diversion program, you may
choose to add a service that doesn't currently exist, or adapt
one---such as an Assertive Community Treatment (ACT) team---to serve the
needs of your consumers.

In many communities, the mental health and substance abuse systems are
underfunded and oversubscribed and affordable housing resources are
scarce. Finding appropriate treatment and housing for your consumers may
be difficult, which is why your program's boundary spanner and case
managers are critical for success. The boundary spanner can reach across
agencies to develop solutions that may require little new funding or
expansion of services. Individual case managers can help broker limited
resources for their consumers. Where such services don't exist or have
waiting lists, the case managers can provide them. In Lancaster County,
NE, lack of substance abuse treatment, in particular, necessitated
development of an intensive case management model. While waiting for
substance abuse treatment slots to open, the intensive case managers
provide jail diversion consumers with individual and group therapy and
offer opportunities for peer support. More information about how to
access mental health services on behalf of jail diversion consumers can
be found in Section 5 of this publication.

Determine Where to Invest Scarce Resources

It's no secret that few communities planning jail diversion programs
will have all the resources they need to accomplish everything they want
to do. This is where all the steps you've taken to this point are so
important. To estimate the cost of needed services and begin to locate
funding for your jail diversion program, you'll need to be equipped with
the information you've gathered, including:

-   Who you want to serve

-   How many potential consumers you have

-   The types and level of services they need

-   The features of existing models you plan to adopt or adapt

-   Where you want to begin to intervene

-   What types of services you have and which ones you lack

-   How you plan to fill any service gaps

In the section below titled "Secure Funding," we outline some
suggestions for seeking new funding or making innovative use of the
resources you already have.

Create an Action Plan

If you've followed all the strategic planning steps to this point,
you've learned much about how your system operates, what type of jail
diversion program you want to develop, and what you hope to accomplish.
Now it's time to make your plans concrete by creating an action plan
that is designed to ensure continued collaboration and progress toward
achieving goals. Your stakeholder group should collectively determine
action items, identify who is responsible for overseeing the progress or
completion of each item, and report on progress at subsequent meetings
(National Mental Health Association, 2003).

Your action plan should be designed to do the following, as highlighted
more fully in Section 5:

-   **Designate specific responsibilities** among participating agencies
    for each point in your diversion pathway. Memoranda of understanding
    (MOUs) or interagency agreements are good ways to do this.

-   **Share information** about the consumers you have in common and
    about their treatment and service needs. You'll have to do this
    within the bounds of confidentiality, but there are effective ways
    to do so.

-   **Plan for services** that will help your consumers achieve
    psychiatric and residential stability and avoid recidivism. Services
    packages will be unique to each consumer, but there are a common set
    of services---including housing, treatment, and supports---that most
    consumers will require.

-   **Identify key positions** for the diversion program and
    **cross-train your staff**. These positions include the
    all-important boundary spanner and specialized case managers. In
    keeping with the need to be culturally relevant to your program's
    consumers, you'll want to pay special attention to recruiting staff
    who reflect the cultural and racial diversity of the people you
    intend to serve.

-   **Devise a marketing strategy** to share the good news about your
    program's successes and to head off any potential negative
    publicity.

**Secure Funding**[^2]

In an era of scarce resources, finding the money for your jail diversion
program requires creativity, perseverance, and ongoing advocacy.
Taxpayers in your community may be more supportive of spending limited
public resources to build and fill more jails rather than creating
community-based treatment and supports for people with mental and
substance use disorders in contact with the justice system. Further,
categorical funding that targets dollars to specific populations,
providers, and programs makes it difficult to fund the integrated
services that mark a successful jail diversion program. Finally, the
emergence of managed behavioral health care in the public sector holds
out both promise and peril for people with multiple and complex needs.

There are, however, several key strategies highlighted below that have
proven successful in helping communities overcome these barriers.
Additional resources are outlined in Section 6.

Custom Blend Funding Sources

No single system can pay for the multitude of services needed by people
with mental illness and substance use disorders in contact with the
criminal justice system. Since you need to integrate several types of
services in order to provide comprehensive treatment, you should
identify a mix of funding sources that respond to the specific needs of
your consumers and reflect the way services are funded and delivered in
your community. By blending funds, you will be less susceptible to
reductions in any one funding stream and your funding package will
mirror the diversity of the services you provide.

Blending funds may require you to shift attitudes among many of your key
stakeholders from one of "my funds" and "your funds" and "my customers"
and "your customers" to one of "our funds" and "our customers."
Potential funders, in particular, may be nervous about co-mingling
historically separate funding streams. If legislation is required to
create the mix of funding you need, you'll want to be certain to involve
key lawmakers in your planning process.

Whatever you do, heed the caution of others who have created jail
diversion programs and don't retrofit your plan to a specific funding
source. Rather, decide on the services you need to provide and find a
way to pay for them. For example, the Tulsa County (OK) Jail Diversion
Program is funded by the county, the Oklahoma Indigent Health Care
System, and the Oklahoma Department of Corrections Community Sentencing
Program. Programs that secure funds from several sources and blend them
according to the specific needs of their localities have the best chance
of carrying pilot programs into the mainstream and ultimately achieving
their goals.

Reorganize Existing Funds

From Albuquerque to Miami to Augusta, ME, communities around the country
have begun their jail diversion efforts with no money specifically
targeted to their activities. Though you may eventually need new money
to expand or enhance your program, it's important to look at how
existing funds in the mental health, substance abuse, and criminal
justice systems can be reorganized to better serve the consumers you
have in common.

You can be creative with small amounts of money and with funds that are
already available. Consider sharing staff, space, equipment, or
expertise, for example. You might piece together full-time positions
with multiple agencies, eachto people with mental illness (Council of
State Governments, 2002; Reuland, 2004).

In a related vein, you may be able to "find" money by redirecting
savings from your jail diversion program or a related initiative. When
King County (Seattle), WA, initiated a managed care program, it
redirected funds previously spent on institutional and other high-cost
care into services for those diverted from the criminal justice system.
In addition, the managed care entity is required to treat jail diversion
consumers and report its performance in doing so (Bazelon Center, n.d.;
Council of State Governments, 2002). When you attach funding to
outcomes, you can ensure that your consumers will be served.

Use Best Practices

Evidence-based and promising practices are not only the most effective
way to ensure recovery for your jail diversion consumers; because many
of these services are reimbursable under your State's Medicaid program,
they can generate Federal matching funds. Best practices that are
eligible for Federal match include the following (Bazelon Center, n.d.):

-   Psychiatric rehabilitation (building social skills and skills for
    daily living)

-   Assertive Community Treatment (ACT)

-   Integrated treatment for co-occurring disorders

-   Supported employment

-   Disability management

-   Family psychoeducation

-   Peer services

**Communicate Regularly**

You've reached consensus on a vision, developed a plan, and located
funding for your jail diversion program. However, the work of creating a
jail diversion program doesn't end when your plan is complete and you
begin accepting consumers. You have to communicate regularly with
representatives from all key agencies through continued group meetings.
This may occur naturally if some of your stakeholders are involved in
the jail diversion program itself. For example, in Shelby County, TN, a
roundtable that includes key partners---pretrial services, jail medical
staff, provider agencies, and boundary spanners---meets to plan service
packages for people who are eligible for diversion.

Every time your stakeholder group meets, it should set goals for the
next meeting, such as assigning members to make telephone calls to
recruit support. These small steps help your group learn to work as a
team to build on initial successes and to monitor progress toward
long-term goals (National Mental Health Association, 2003). Indeed, all
the good work you've done to date now becomes the foundation for what
you need to do to implement your action plan successfully. Such
important steps as moving from informal to formal arrangements, ensuring
access to services, creating boundary spanner positions, and
cross-training your staff are discussed in Section 5.

SECTION 5: Putting the "Action" in Your Action Plan

Developing an action plan to guide jail diversion activities requires
reaching broad community consensus, examining available models, and
selecting a program to adapt based on common goals, available resources,
and political and popular support in your community. But planning for
change isn't enough; you must put your plan into action. In this
section, you'll learn how to implement your action plan by developing
formal agreements and sharing information; providing a set of mental
health, housing, and support services for consumers; creating key
positions and training the staff who fill them; and devising and
implementing a marketing strategy.

The Problem

There are a host of difficulties that can derail your best intentions to
implement a jail diversion program if you are not prepared to address
them. Popular and charismatic leaders may retire or move away, creating
a vacuum in leadership. Staff may be ill prepared to work across systems
and with consumers who have multiple and complex problems. A negative
news story about a jail diversion consumer can bring unwanted attention
to your program from lawmakers, funders, and a skeptical public.

What You Need to Know

The goal of a well developed jail diversion action plan is to integrate
the services of three distinct systems with often conflicting values and
modes of operation: mental health, substance abuse, and criminal
justice. This takes creativity, flexibility, and patience. True systems
integration is an ideal state and one you may not achieve fully, but you
can tell you're making progress by the degree to which you proceed along
a continuum that includes the following stages (Konrad, 1996; The
National GAINS Center, 1999a):

-   **Information sharing and communication**: At the beginning, key
    personnel from mental health, substance abuse treatment, law
    enforcement, and corrections may have an informal arrangement to
    share information about programs, services, and target populations.
    They may exchange brochures, share newsletters, and hold joint staff
    meetings.

-   **Cooperation and coordination**: Though still informal, mental
    health/criminal justice partners at this stage may establish
    reciprocal program referral and follow-up processes or mutual
    agreements to provide priority response to each other's target
    populations.

-   **Collaboration**: Collaborative efforts are usually formalized and
    may include written agreements, formalized operational procedures,
    joint funding, cross-training of staff, and shared management
    information systems.

-   **Integration**: A fully integrated system features joint planning,
    training, decision-making, information systems, purchasing,
    screening and referral, care planning, service delivery, monitoring,
    and feedback (Leutz, 1999).

Typically, arrangements between agencies become more formal as they
progress through these stages. The steps highlighted in this section
will point you in the direction of moving from cooperative ventures to
true partnerships.

What You Need to Do

Jail diversion efforts in your community might begin with something as
simple as an informal agreement between a law enforcement officer and a
mental health crisis counselor to coordinate their activities on behalf
of people with mental illness and substance use disorders who risk
arrest and incarceration. However, to reach beyond informal, handshake
agreements and create the more formal structures that will ensure
lasting system change for people with mental illness and substance use
disorders involved in the criminal justice system, you will need to:

-   Develop formal agreements

-   Share information

-   Plan for services

-   Identify key positions

-   Cross-train and support your staff

-   Devise a marketing strategy

**Develop Formal Agreements**

You can begin jail diversion activities with little more than verbal
agreements to coordinate services on behalf of people with mental
illness in the justice system. But at some point you'll want to
formalize your efforts so they outlive the personalities and
relationships on which they are founded.

Memoranda of understanding are formal agreements between public service
agencies that can facilitate service delivery through cooperative
efforts (Massaro, 2005). A memorandum of understanding (MOU) or
interagency agreement is a good way to formalize what the partners in
your collaboration have agreed to do. Elements of a successful MOU
include (Council of State Governments, 2002, p. 202):

-   A well-defined target population

-   An overarching purpose that underlies the agreement

-   Discussion of any relevant legislation or regulations

-   Elaboration of specific goals, both shared and germane to a
    particular partner

-   Definition of any new responsibilities

-   Time lines for the implementation of new initiatives and for review
    of the implementation process

Other key elements include the terms of agreement, procedures for
communication and information sharing, primary and secondary contacts
for each agency, and signatures. In Miami, the stakeholder group
developed a written cooperative agreement that spells out the process
for the city's pre-booking and post-booking diversion efforts. The
Hawaii jail diversion program drafted a program manual that outlines
rules and responsibilities for individuals and for participating
agencies. See the Resources section of this publication for a sample
MOU.

**Share Information**[^3]

To plan effective services for people with multiple and complex needs,
you'll need to be able to share information about the treatment and
services they require. Information-sharing restrictions may appear to be
a significant barrier to collaboration, but there are several steps you
can take to overcome this potential obstacle.

First, learn everything you can about local, State, and Federal laws
that govern exchange of information between mental health providers and
law enforcement. Your agency's legal department may be a good place to
start.

In general, though State statutes are not entirely consistent, they
typically require that the consumer provide written consent if
information is to be shared beyond the immediate clinical team providing
services. The Federal Health Insurance Portability and Accountability
Act (HIPAA) makes some exceptions for the exchange of information with
correctional facilities or law enforcement; however, local or State
regulations may be stricter than HIPAA requirements. Finally, Federal
statute governing information related to substance abuse treatment is
stricter than provisions covering mental illness treatment records. A
comprehensive set of resources on HIPAA, including a checklist to help
you get started, is available at www.hipaa.org.

Second, establish a subcommittee of your stakeholder group to review or
develop policies that facilitate information sharing, including the
development of a standardized release of information form that meets all
Federal, State, and local requirements. A written consent form should
indicate, at a minimum, the purposes for which the requested information
may be used, the period for which consent is valid, and the parties with
whom it may be shared. This can be an important way to build trust with
consumers and between providers. A sample release of information form is
included in the Resources section of this publication.

Third, consider the use of some form of advance planning that allows
consumers to decide in advance of a crisis whether and how much
information should be divulged and to whom. The concept of a psychiatric
advance directive is gaining recognition in the mental health system and
is particularly relevant for individuals who have previously been in
contact with the criminal justice system or whose behaviors put them at
significant risk. The Bazelon Center for Mental Health Law at
www.bazelon.org is a good source of information on psychiatric advance
directives.

Another resource is the section on developing crisis plans in Mary Ellen
Copeland's Wellness Recovery Action Plan (WRAP) curriculum. Created by
consumers for consumers, WRAP is a systematic approach for monitoring,
reducing, and eliminating uncomfortable or dangerous physical symptoms
and emotional feelings, some of which may increase risk for contact with
law enforcement. WRAP can also be an important adjunct to the delivery
of best practices designed to promote recovery (Copeland, 2000;
www.mentalhealthrecovery.com).

**Plan for Services**

There is probably nothing else you will do to implement a successful
jail diversion program that is more important, and more difficult, than
ensuring access to a full range of comprehensive and coordinated
treatment, housing, and services for people with mental illness and
substance use disorders in contact with the justice system. Indeed, as
Munetz and Griffin (2006) note, "An accessible, comprehensive, effective
mental health treatment system focused on the needs of individuals with
serious and persistent mental disorders is undoubtedly the most
effective means of preventing the criminalization of people with mental
illness" (p. 545). Unfortunately, few communities in the United States
have this level of services. Without adequate and appropriate services
to which people can be referred, jail diversion will be an exercise in
futility.

Regardless of whether your organization has the immediate ability to
increase or enhance the level of community-based mental health and
substance abuse treatment services available to jail diversion
consumers, you must become knowledgeable about the services that are
available; how services are organized, delivered, and financed; and what
services are deemed to be most effective. Only then can you successfully
advocate for the type and level of services your consumers need to
recover from their illness and avoid recidivism.

Understand the Mental Health System

As you examine the structure of the mental health system in your
community, focus not only on what currently exists, but, more important,
on what an ideal system would look like if all the pieces were in place.
This may be more difficult than it sounds, because as the Criminal
Justice/Mental Health Consensus Project points out, "'System,' indeed,
may be a misnomer for what is often a patchwork of programs, services,
and complex funding sources" (Council of State Governments, 2002, p.
17).

Though it is beyond the scope of this publication to explore in detail
the changing context of care for people with serious mental illness,
several key facts are worth noting:

-   The full range of services and supports that people with the most
    serious mental illness need to live successfully in the community
    doesn't exist in many localities today. In particular, lack of
    intensive outreach, limited treatment for co-occurring mental
    illness and substance use disorders, and inadequate and
    inappropriate housing result in people with serious mental illness
    receiving fragmented and uncoordinated treatment, housing, and
    support services, if they receive them at all.

-   Unlike the criminal justice system, which has a fairly
    straightforward structure, the mental health system draws revenue
    from a "dizzying variety of sources." These include Medicaid,
    Medicare, State general revenue funds, local matches, the Community
    Mental Health Services Block Grant, and fees paid by consumers
    (Council of State Governments, 2002, p. 16). Each of these funding
    sources has its own eligibility rules, required services, and
    reporting mechanisms.

-   There is a significant gap between research and practice, which
    means that the best, science-based treatments for serious mental
    illness aren't being delivered at the community level (Institute of
    Medicine, 2006).

-   There is a growing body of evidence that evidence-based practices
    (see box in this section) improve outcomes for both the consumer and
    the system. If they were implemented more broadly, it is likely that
    fewer people with mental illness would become involved in the
    criminal justice system (Council of State Governments, 2002).

**Use Best Practices**

Your challenge as key stakeholders planning a jail diversion program for
people with mental illness and substance use disorders is to ensure that
evidence-based practices become more broadly available and to
incorporate them into the service packages you plan for your consumers.
You also need to understand the potential limitations of using
evidence-based practices with a criminal justice population.

One of the most essential services you need to provide for people in
contact with the justice system is integrated treatment for serious
mental illness and co-occurring substance use disorders. Frequently,
people are excluded from mental health treatment because of their
substance use disorder and from substance abuse treatment because of
their mental illness, meaning they may receive treatment for only one,
or for neither, disorder.

There is a significant body of research which shows that treating mental
and substance use disorders simultaneously and in one setting reduces
alcohol and drug use, the severity of mental health symptoms, and
homelessness. For individuals with co-occurring disorders, integrated
treatment appears seamless, with a consistent approach, philosophy, and
set of recommendations (Drake et al., 2001, 1998). At least one model of
integrated treatment, the modified therapeutic community (MTC), has
demonstrated lower rates of reincarceration and a reduction in criminal
activity for MTC participants (Sacks et al., 2004).

The Federal Substance Abuse and Mental Health Services Administration
(SAMHSA), part of the U.S. Department of Health and Human Services, has
published a set of six Evidence-Based Practice Implementation Resource
Kits to encourage the use of evidence-based practices (EBPs) in mental
health (see box). The kits include a user's guide, information sheets
for all stakeholder groups, tips for implementing the practice with
fidelity to the model, and a workbook or manual for practitioners.
Complete versions of the publications can be downloaded from the SAMHSA
Web site at
www.mentalhealth.samhsa.gov/cmhs/communitysupport/publications/about.asp.
In addition, fact sheets on EBPs as they relate to individuals in
contact with the justice system are available on the CMHS National GAINS
Center Web site at www.gainscenter.samsha.gov. These fact sheets contain
important caveats for the use of EBPs with people who are involved in
the criminal justice system.

For example, a number of jail diversion programs have modified Assertive
Community Treatment (ACT) to serve the needs of individuals in contact
with the justice system, sometimes referring to this adaptation as a
forensic ACT or FACT team.

ACT teams feature a multidisciplinary group of mental health, substance
abuse, and social service specialists who provide, or arrange for, each
individual's clinical, housing, and rehabilitation needs.
Staff-to-consumer ratios are low (typically 10 to 1) and services are
available around the clock. ACT teams, when compared to other forms of
case management, have proven effective in reducing psychiatric
hospitalizations and improving housing stability for people with the
most serious disorders (Morrissey & Meyer, 2005).

Forensic ACT teams partner with criminal justice agencies with the goal
of preventing arrest and incarceration. Compared to regular ACT
programs, FACT teams typically: 1) require that all consumers admitted
to the team have criminal justice histories; 2) accept the majority of
their referrals from criminal justice agencies; and 3) place a greater
emphasis on developing supervised residential treatment for high-risk
consumers, particularly those with co-occurring substance use disorders
(Lamberti, Weisman, & Faden, 2004).

Though ACT is in many ways thought of as the "gold standard" for people
with severe disorders who are unlikely to engage in traditional
approaches, researchers caution that there is not yet enough evidence to
suggest that specialized FACT teams can achieve their stated goals of
preventing arrest and incarceration. Other forms of intensive case
management may be equally suited to the needs of jail diversion
consumers and less expensive to implement.

For example, the Lancaster County (NE) Mental Health Jail Diversion
Project uses an intensive case management team but refers consumers to
community agencies for such services as psychiatric and nursing care
that might be provided by members of a more resource-intensive ACT team.
Also, individuals who are accepted into the jail diversion program must
have some degree of stability; typically ACT teams work with a highly
disabled population. This approach allows the Lancaster County program
to incorporate the full support philosophy and team approach of an ACT
model with lower costs.

Incorporate Promising Practices

Best practices are necessary but not sufficient to ensure full community
integration for people with mental illness and substance use disorders
in contact with the justice system. Promising practices exist in a
number of areas, including supportive housing, consumer-operated mental
health services, and trauma-informed services. Brief descriptions of
these services follow, along with resources for more information.

***Supportive housing*** is generally defined as a broad range of
housing options linked to a variety of supportive services. Services,
which include case management, mental health and substance abuse
treatment, and employment assistance, typically are voluntary and are
designed to help individuals maintain residential stability. "Housing
First," a type of supportive housing, often is touted as a way to take
people with the most severe mental illness and substance use disorders
directly from the streets or from jails and prisons and place them into
permanent housing. New York City's Pathways to Housing program is one of
the most well-known examples of this approach (see
www.endhomelessness.org/best/pathways.htm).

The Corporation for Supportive Housing (www.csh.org) is an excellent
resource for information on how to develop, fund, and evaluate
supportive housing options. In your local community, be certain to
involve the homeless coalition or city homeless services coordinator and
the housing authority on your planning group. These individuals may have
information on affordable housing resources available to your consumers,
many of whom have experienced homelessness. For more information on
Federal affordable housing programs, see the list of resources on the
Technical Assistance Collaborative Web site at
www.tacinc.org/HH/Program_Policy/Programs_Policy.htm.

Unfortunately, housing availability and affordability remain significant
roadblocks in many communities for people of limited means. Many
individuals with serious mental illness who are unable to work rely on
Supplemental Security Income (SSI), but in 2004, the average rent of a
one-bedroom apartment was 109 percent of SSI (O'Hara & Cooper, 2005).

Further, Federal housing policy makes it difficult for ex-offenders,
particularly those with drug-related offenses, to secure public housing
assistance. Federally assisted housing programs, including public
housing authorities and Section 8 providers, are permitted, and in some
cases required, to deny housing to individuals with certain criminal
histories (Council of State Governments, 2002). For a discussion of
eligibility for Federal housing for people who have been incarcerated,
see the New Freedom Commission's Subcommittee on Criminal Justice report
at www.mentalhealthcommission.gov/papers/CJ_ADACompliant.pdf.

***Consumer-operated services*** are programs run by people who have
experienced serious mental illness, homelessness, and recovery from
substance use disorders, as well as those who have been involved in the
justice system. They include drop-in centers, recovery support programs,
case management programs, outreach programs, businesses, employment and
housing programs, and crisis services. Many of these services are more
"user friendly" for people who might have had previous negative
experiences with traditional providers.

Forensic peer specialists have demonstrated the ability to engage their
peers in services when other mental health service providers have been
unable to do so. They bring real-world experience with multiple service
systems and an ability to relate one-on-one to people struggling to
reclaim their lives. As such, they can be important members of ACT or
FACT teams (Massaro, 2005). The National Research and Training Center on
Psychiatric Disability at the University of Illinois at Chicago has a
set of resources on consumer-driven services and peer support outcomes
at www.cmhsrp.uic.edu/nrtc.

***Trauma-informed services*** are absolutely essential for development
of programs intended to serve people with mental illness and substance
use disorders in contact with the justice system. Men and women with
mental illness, as well as those with co-occurring substance use
disorders and those involved with the criminal justice system,
experience very high rates of physical and sexual abuse as children and
as adults. Untreated trauma may complicate recovery from mental illness
and substance use disorders and, in some cases, may precipitate the
disorder. In addition, individuals with histories of trauma are more
vulnerable to victimization and ongoing abuse (SAMHSA, 2003; Massaro,
2005).

The key principles of trauma-informed services are (Fallot, 2006):

-   *Safety*: Ensuring physical and emotional safety

-   *Trustworthiness*: Maximizing trustworthiness, making tasks clear,
    and maintaining appropriate boundaries

-   *Choice*: Prioritizing consumer choice and control

-   *Collaboration*: Maximizing collaboration and sharing of power with
    consumers

-   *Empowerment*: Prioritizing consumer empowerment and skill-building

There are a number of specific interventions designed to address trauma,
some of which have been used successfully with people in the justice
system. Information on these programs is available from the National
Trauma Consortium at www.nationaltraumaconsortium.org.

Begin Where You Are

Clearly, you need to focus on the quality of services to which you are
linking people. Best and promising practices, delivered in a culturally
appropriate manner, will help people with mental illness and substance
use disorders recover from their illness, remain stably housed, and
avoid recidivism. But don't let a lack of quality services stop you from
starting your program. As Munetz and Griffin (2006) note:

> Even the most under-funded mental health systems can work to improve
> services to individuals with the greatest need, including the group of
> people with serious and persistent mental disorders who have frequent
> interaction with the criminal justice system. Such efforts require
> close collaboration between the mental health and criminal justice
> systems (p. 547).

Everything you've done to this point---including reaching consensus,
developing an action plan, and moving closer to an integrated
system---has helped you strengthen and refine the relationships among
partners in the mental health, substance abuse, and criminal justice
systems. You can build on these relationships to find, adapt, or as
Stephen Bush suggests, "cobble together," the best service packages you
can arrange for your jail diversion consumers. Your success in helping
them remain out of the justice system depends on it.

**Identify Key Positions**

Because the jail diversion program you develop will be unique to your
community's resources and needs, the specific positions you create and
the people you choose to fill them will be distinctive, as well. Staff
positions required to maintain jail diversion programs generally include
mental health practitioners to screen and assess a person's eligibility,
case managers to broker services, and boundary spanners to coordinate
activities among systems. Your program might also include pretrial
services staff to provide oversight and monitoring and peer specialists
to support enrollees. Some of these roles may overlap; for example, a
mental health practitioner may act as a boundary spanner and a case
manager may offer personal assistance to consumers. Sample job
descriptions for some of these positions are included in the Resources
section of this publication, and several "day in the life" profiles of
jail diversion staff are included throughout the text.

Of all of these positions, the one that may be most unfamiliar to you,
and the one your jail diversion program can't do without, is that of a
boundary spanner. The material that follows outlines why you need a
boundary spanner, what the job entails, and how you can find the right
person to fill this all-important role. Some key functions that
diversion staff perform are detailed in the subsections that follow.

Create Boundary Spanners

Boundary spanners are known by different names. In your jail diversion
program, they may be called a:

-   Linkage specialist

-   Court diversion case manager

-   Case management specialist

-   Mental health liaison

-   Mental health coordinator

They also may be found at different levels in the organization---program
director, program coordinator, case manager, or court- or jail-based
mental health workers---and there may be more than one boundary spanner
in an agency or program. But regardless of their title, and wherever in
the organization they reside, their role is the same: they are the
"traffic cop" that manages interactions among the three, often
competing, systems of mental health, criminal justice, and substance
abuse. Each of the organizations that participate in your jail diversion
program has its own goals, policies, jargon, and organizational
structures, and managing the interactions between and among them is a
complex task (Council of State Governments, 2002).

Here are some of the key things you need to know when creating a
boundary spanner position and finding a person to fill the job:

-   There is no one best way to go about this. For example, in a jail,
    it doesn't matter whether boundary spanners work for the sheriff, a
    community mental health center, or as independent mental health
    contractors.

-   When you create a boundary spanner position, how you fund it and
    where in the organization you locate it is much less important than
    having a clear sense of what its functions are, selecting the right
    person for the job, and finding money from a variety of sources to
    fund it.

-   You need to find a person who knows both the formal and informal
    norms of the relevant organizations, as well as their internal
    operations and politics. They must have credibility within these
    systems.

-   In most organizations within the mental health and criminal justice
    systems, there are some very savvy people who have been around a
    number of years and know the ins and outs of both systems and their
    interface points. Often, you'll find them several levels down in the
    organization.

-   A boundary spanner's special knowledge and credibility comes from
    years of experience, usually combined with a good personality. A
    professional degree is less important and often not necessary.

-   Because of the sophisticated and difficult job they do, boundary
    spanners must receive a commensurate title and reasonable salary.

Some common functions of boundary spanners include:

-   Cultivate, develop, and maintain working relationships with criminal
    justice and service provider agencies and individuals

-   Identify people who meet program criteria

-   Make recommendations to the court regarding appropriateness for the
    program

-   Develop an initial service plan

-   Hold meetings to discuss service plans

-   Coordinate with the mental health system to link people with
    services

-   Maintain established program policies, procedures, ethics, and
    confidentiality

-   Monitor and follow-up on consumer service resolutions

-   Prepare and submit compliance reports

-   Serve on/chair/provide updates at oversight/advisory/steering group
    meetings

-   Maintain data for program evaluation activities

-   Provide appropriate training regarding individual role and program
    role

**Understand Key Roles of Jail Diversion Staff**

***Jail Diversion Staff Conduct a Thorough Assessment**.* An effective
service package for people with mental and substance use disorders in
contact with the justice system must be based on an accurate and
thorough assessment. Initially, jail diversion practitioners likely will
use a brief screening instrument that identifies individuals who may be
eligible for diversion. One example is the Brief Jail Mental Health
Screen developed by Policy Research Associates, Inc., which is included
in the Resources section of this publication.

A more complete assessment by program practitioners will form the basis
for selecting the treatment, housing, and support services each consumer
requires. Because of the complex nature of co-occurring mental illness
and substance use disorders, accurate diagnosis requires a longitudinal
assessment by a skilled practitioner, preferably one who has an
established, trusting relationship with the consumer. Currently, there
is no single tool that represents a "gold standard" for identifying and
providing a comprehensive assessment of an individual with serious
mental illness and a co-occurring substance use disorder. Rather,
specific tools may be used to assess different components of an
individual's functioning (SAMHSA, 2002).

Information about screening instruments for use with people who have
mental and substance use disorders and two specific instruments---one
for the substance abuse field to screen for mental health issues and one
for mental health settings to screen for substance abuse issues---are
included in appendices to SAMHSA's Treatment Improvement Protocol (TIP)
42: *Substance Abuse Treatment for Persons with Co-occurring Disorders*.
You can link to TIP 42 from
http://kap.samhsa.gov/products/manuals/tips/index.htm.

***Jail Diversion Staff Help Consumers Access Benefits**.* One of the
most important roles case managers can play is helping people with
mental illness access the income and entitlement benefits for which they
are eligible. Though many people with serious mental illness,
particularly those who are homeless, are eligible for such benefits as
Supplemental Security Income (SSI), Social Security Disability Insurance
(SSDI), and Food Stamps, they frequently are not enrolled. People with
severe disorders and those who are homeless face significant enrollment
barriers, including lack of appropriate documentation and complex
application procedures. Without assistance, the majority of people are
denied when they first apply, and lack of income may lead to such
"survival crimes" as shoplifting and bill evasion (SAMHSA, 2003; Council
of State Governments, 2002).

Clearly, people with mental illness and substance use disorders have
much to gain when they have access to stable income, but community
providers benefit when people receive entitlements, as well. For
example, SSI/SSDI eligibility for individual consumers, and Medicaid
eligibility that results from SSI eligibility in most States, help
agencies expand their capacity to serve people with the most complex
needs. State and local governments may recoup money spent on general
assistance to applicants, and health care providers may receive Medicaid
reimbursement for services they provide (SAMHSA, in press).

The process of applying for benefits can be lengthy and complex, but
many case managers have developed close working relationships with staff
in their local Social Security Administration (SSA) and Disability
Determination Services (DDS) offices. DDS is a State office that
contracts with SSA to make the medical determination of disability. Some
local SSA and DDS offices dedicate special staff and/or flag
applications for people who are homeless, many of whom have mental
illness and criminal justice involvement. Because it can take several
months for a person to be approved for benefits, jail diversion programs
may need to budget for funds to cover treatment and services during this
gap.

To help train case managers to assist people applying for benefits,
SAMHSA has developed a case manager training curriculum, an accompanying
train-the-trainer curriculum, and a reference manual as part of its
*Stepping Stones to Recovery* series designed to enhance access to SSI
and SSDI for people who are homeless. You can download a copy of the
reference manual at www.pathprogram.samhsa.gov/SOAR/tools/manual.asp.
For information about bringing a *Stepping Stones to Recovery* training
program to your area, contact Deborah Dennis at Policy Research
Associates, Inc., ddennis@prainc.com.

One important caveat is in order. People with a primary diagnosis of a
substance use disorder are excluded from receiving SSI benefits.
However, many of these individuals may have a co-occurring serious
mental illness, and case managers who develop relationships with
practitioners familiar with their consumers can help ensure that those
people whose substance use disorder is secondary to a mental illness can
still receive the benefits to which they are entitled.

Finally, though jail diversion programs aim to eliminate or reduce the
amount of time people spend in jail, it's worth noting that for
individuals who are incarcerated and who have been receiving SSI, SSA
policy specifies that its field offices should suspend, but not
terminate, eligibility status for SSI recipients incarcerated for less
than 12 consecutive months. In addition, individuals whose benefits are
terminated or who were not receiving them before being incarcerated can
file an application for SSI benefits 30 days prior to release. Having
benefits on release from jail or prison can mean the difference between
successful community integration and homelessness and recidivism
(SAMHSA, in press; Bazelon Center, 2001).

***Jail Diversion Staff Help Consumers Access Treatment and Services***.
Limited access to treatment and services is one of the most significant
barriers that jail diversion case managers encounter. Overburdened and
underfunded service systems and reluctance on the part of some
mainstream agencies to work with offenders require creativity,
flexibility, and good relationships among the partners in a jail
diversion program. By themselves, good relationships don't create
well-funded services, but without them, you can't overcome the
constraints you face. You may want to try several of the following
strategies that have been successful in some communities:

-   *Use the leverage your high-profile partners provide*.
    "Historically," notes a report from the Florida Mental Health
    Institute, "garnering support for increased funding for mental
    health services has been difficult. But as judges and other law
    enforcement officials increasingly engage in coalitions advocating
    for additional funds for mental health services, the coalitions may
    wield more political power" (Florida Mental Health Institute, 2001).

-   *Partner with community-based providers to ensure access to
    treatment for jail diversion consumers*. Use the relationships you
    have built with members of your stakeholder group to approach
    treatment agencies about reserving a few detox beds for jail
    diversion consumers or making your consumers a priority population
    for mainstream case management services. This will be a tough sell,
    since most of these programs have long waiting lists. Remember that
    you don't want simply to move your consumers to the head of the line
    at the expense of others who need critical services, so if lack of
    capacity is the issue, you may be able to work with community
    providers to enhance their services (see next bullet).

-   *If possible, work to expand capacity among local treatment
    providers*. Well-funded jail diversion programs may be able to
    provide funds or staff to enhance existing services, for example, by
    adding staff to an ACT team to serve jail diversion consumers. If
    your resources are limited, as is the case for many jail diversion
    programs during the start-up phase, consider ways to share existing
    staff and resources to maximize efficiency. See the discussion in
    the previous section about how to secure funding for more ideas on
    creative ways to stretch your program dollars.

-   *Consider the role that nontraditional providers, such as
    faith-based organizations, can play in providing needed treatment
    and services*. Many faith communities provide counseling, recovery
    support, and housing, and their services may be free or low-cost.
    This can fill an important gap while consumers are waiting for their
    benefits applications to be approved. Downtown associations may have
    city ambassadors that can extend your outreach efforts, and
    neighborhood associations may collect and distribute food and
    clothing that can provide basic necessities to help people gain a
    foothold in the community.

-   *Use peer specialists to promote engagement of consumers and free up
    case managers' time for making service linkages*. In some jail
    diversion programs, peers fill important roles by transporting
    consumers to appointments and teaching them daily living skills. See
    the profile "A Day in the Life of a Recovery Support Specialist" in
    this section to gain a greater understanding of how peer specialists
    can help.

-   *Offer to educate and train other organizations about the needs of
    jail diversion consumers*. You can train mental health and substance
    abuse treatment providers about the relative safety of working with
    forensic consumers, and you can educate housing providers about the
    role that affordable, supportive housing will play in your
    consumers' success. To the extent that you can help mainstream
    providers feel more comfortable about accepting your consumers, you
    will have an easier time transitioning them from your caseload.

-   *Support your consumers in housing to ease landlord's fears*. Some
    community providers have partnered with landlords on an informal
    basis to create transitional housing for consumers, even those with
    criminal records, as long as the consumer is receiving mental health
    services. Providing services in housing can be critical not only for
    supporting consumers, but also for encouraging potentially reluctant
    landlords to rent to people with special needs.

-   *Remember to begin with the services you have*. As noted earlier in
    this section, you may not have the ideal services to which to link
    consumers, but you likely have something available that will work
    until you can put more comprehensive services in place. Be creative
    and flexible while at the same time making certain your consumers
    are receiving the help that is appropriate for their needs.

-   *Finally, be proactive in linking your consumers to services*. Meet
    them at the point of their release from jail and schedule
    appointments for treatment within 24 hours, if possible. Arrange for
    transportation and childcare so they can attend counseling sessions
    and 12-step meetings. Be certain they leave jail with a sufficient
    supply of medications and a safe and stable place to live; a
    homeless shelter is never a preferred option, but you may have to
    consider it as a short-term alternative. Give shelter providers a
    way to reach you if a problem arises.

***Jail Diversion Staff Help Consumers Navigate the Criminal Justice
System***. Many of your consumers, including those who have been
arrested previously, may be unfamiliar with how the criminal justice
system operates. In fact, some of your consumers may have been arrested
because they failed to appear for a court date. Symptoms of mental
illness, cognitive impairments, and pressing needs to obtain food and
shelter may make it difficult for individuals to negotiate the criminal
justice system unaided. Both boundary spanners and case managers have a
role to play in helping jail diversion consumers meet the requirements
of the court. Here are some ways they can help[^4]:

-   Attend the initial court hearing with the consumer to advocate for
    him or her to participate in the jail diversion program.

-   Make certain the consumer understands the difference between the
    public defender (defense attorney) and the county/city attorney
    (prosecutor).

-   Talk about proper court etiquette (e.g., appropriate dress, speech
    toward the judge, etc.).

-   Call or visit consumers approximately 24 hours prior to the next
    court appointment to remind them of their responsibility to appear.

-   Arrange for or provide transportation to court appointments.

-   Appear at follow-up court appointments to provide requested updates
    to the judge, attorneys, etc., about the consumer's progress.

***Jail Diversion Staff Help Consumers Make the Transition to Mainstream
Services***. Jail diversion programs are not intended to provide
long-term services. Case managers need to transition consumers to
mainstream providers to ensure their stability in the community and to
enable the program to serve additional people in contact with the
justice system. Sometimes, consumers who have put their trust in a jail
diversion case manager may be reluctant to start over with a new
provider, and jail diversion case managers may be concerned that the
mainstream agency won't be able to meet their consumers' needs
effectively. For these reasons, helping consumers make the transition to
mainstream services should begin almost immediately on enrollment in the
jail diversion program. In particular, as a case manager or consumer
advocate, you should:

-   Let the consumer know early on that this is a short-term program.

-   Determine with the consumer what available long-term case management
    options will best meet his or her needs.

-   Have the consumer sign releases so you can share information with
    each agency to which you will be referring him or her.

-   Follow-up with referring agencies for updates on their waiting lists
    and submit any necessary forms they require.

-   When the consumer is accepted into long-term case management, but
    before you make the formal transition, accompany him or her to a
    meeting with the new case manager. Explain to consumers that the new
    case manager may spend less time with them but remind them that they
    have achieved a level of stability that makes this less intense
    involvement possible. Be certain the new case manager has all the
    information he or she will need to serve your consumer appropriately
    and effectively.

-   Allow a month or two to make the final transition, depending on each
    consumer's needs.

-   After the transition period is complete, write a letter to the
    consumer and all pertinent parties in the case to let them know that
    the consumer has successfully completed the jail diversion program
    and will now be served by a long-term case manager. Encourage the
    consumer to use the supports they have developed and congratulate
    him or her on coming this far!

**Cross-Train and Support Your Staff**

Staff in jail diversion programs don't work in isolation. They must be
knowledgeable not only about their own agencies but also about the
organizations and systems with which they interact. Cross-training of
staff is an excellent way to promote cooperation, build a common base of
knowledge, and create understanding and respect among professionals in a
jail diversion program. To achieve effective partnerships, the
professionals in each system must develop some basic understanding of
the other system, including (Massaro, 2005):

-   Its purpose

-   Responsibilities and functions of various system components

-   Roles and responsibilities of various professionals

-   Policy and procedures in areas in which the systems overlap

-   Some of the system's professional terminology to facilitate
    communication

In its 2002 report, the Criminal Justice/Mental Health Consensus Project
has an excellent set of policy recommendations for training
practitioners in the criminal justice and mental health systems (see
www.consensusproject.org). In particular, they recommend that you:

-   Establish new skills, recruit, in-service, and advanced skills
    training requirements for ***law enforcement personnel*** about
    responding to individuals with mental illness, and develop curricula
    accordingly.

-   Provide adequate training for ***court officials*** (including
    prosecutors and defense attorneys) about appropriate responses to
    criminal defendants who have a mental illness.

-   Train ***corrections staff*** to recognize symptoms of mental
    illness and to respond appropriately to people with mental illness.

-   Develop training for ***mental health professionals*** who work with
    the criminal justice system (Council of State Governments, 2002,
    Chapter VI, Policy Statements 28-31).

Formal job descriptions can help lend identity and purpose to specific
roles in a cross-system collaboration. This is particularly true for
consumer practitioners.

Further, there is no need to start from scratch or spend a great deal of
resources to train your staff. To minimize the expense involved in
training staff in a criminal justice/mental health collaborative effort,
you can (Council of State Governments, 2002):

-   Evaluate existing training materials and tailor them to the needs of
    your community.

-   Look to community mental health centers and other local partners,
    including board members of local advocacy groups such as the
    National Alliance on Mental Illness (NAMI) and mental health
    associations, to donate space for training, training materials, and
    staff time.

-   Recognize the value of informal training, sometimes called
    "experience exchange." For example, the police department can offer
    a ride-along program that exposes mental health service providers to
    the daily experiences of a police officer. Likewise, criminal
    justice personnel can visit community mental health centers or
    mental health crisis facilities.

-   Combine your efforts with a neighboring jurisdiction; this is
    especially helpful in small, rural communities that don't have the
    resources to develop and train one constituency in the criminal
    justice system. For instance, invite probation officials in the
    neighboring community to send their staff and some resources to your
    probation officers' training session.

Finally, because of the diversity of the consumers they serve, be
certain that your staff and those in the agencies with which you
collaborate are trained to provide culturally appropriate care (see the
box above).

Provide Practical and Emotional Support

Training staff is necessary but not sufficient to help them do their job
well. Because they work with people who have multiple and complex needs,
and because they are attempting to negotiate the often conflicting
demands of multiple service systems, staff in jail diversion programs
are susceptible to stress, depression, and burnout. This will affect
their physical and emotional health but also their success in working
with consumers. Case managers, boundary spanners, and other key staff
need appropriate outlets for discussing the difficulties of their jobs,
including regular supervision and formal staff meetings, as well as more
informal gatherings such as retreats or potluck dinners.

Providing breaks in the routine can also be helpful. For example, you
can support attendance at outside training events and conferences that
allow staff the chance to network with their colleagues from other
programs around the State or country. Adequate leave time also is vital.
Further, staff may benefit by having the opportunity to contribute to
program policies that affect the work they do with consumers.

Finally, as noted previously, staff who perform the difficult roles
inherent in successfully managing interactions among the mental health
system, corrections, and the courts must be adequately compensated for
their work and have prospects for promotion and regular pay increases as
resources allow. A set of articles on how organizations can address
employee stress is available at www.humannatureatwork.com.

**Devise a Marketing Strategy**

Marketing your jail diversion program might feel like shameless
promotion, but there are a number of critical reasons to do so. First
and foremost is the need to educate the general public about the
importance of mental health as a public health issue and the
effectiveness of treatment for most mental illnesses. You must help
combat the stigma and discrimination your consumers face if they are to
be welcome in treatment programs, in housing, and in their communities.

Second, you have to get the word out about the people your program
serves, what its goals are, and how potential consumers can be referred.
Initially, the St. Louis jail diversion program did not realize its
enrollment targets because most of the eligible population was already
being referred to a mental health court that had received widespread
publicity and community recognition.

Third, the old saying that there is "no such thing as bad publicity" is
NOT true for your jail diversion program. You must be prepared, in
advance, to respond to incidents that attract negative attention. Your
plan should include an agreement on how to respond to inquiries from the
legislature, other State or local governing bodies, the media, or
attorneys representing a plaintiff. Conversely, you'll want to be able
to trumpet the good news of your program (Council of State Governments,
2002).

There are a number of easy, low-cost ways to achieve these goals. They
include:

-   **Put a face on your program**. Develop case studies of successful
    consumers to complement the more quantitative data you're collecting
    (see Section 7 for more details on collecting and analyzing data).
    It is important to have such information ready as early as
    possible---often a negative news story will strike too quickly to
    prepare a case study after the fact (The National GAINS Center,
    1999a). Several case studies of the type you'll want to develop are
    featured throughout this publication.

-   **Use the media**. Develop and distribute newsletters, send press
    releases with stories and statistics to the local press, and write
    magazine articles. The Lancaster County (NE) Mental Health Jail
    Diversion Project was featured in the March/April 2006 issue of
    *American Jails* magazine.

-   **Get out in the community**. Make yourself available as a speaker
    for conferences, staff trainings, and legislative gatherings. Be
    involved in activities that affect your consumers, such as the local
    homeless coalition or NAMI chapter.

-   **Share ideas**. Plan a community forum or workshop on jail
    diversion and invite diverse groups from within your community and
    from surrounding communities, as well. They'll learn from you, and
    you may pick up some good ideas, as well.

-   **Advocate, advocate, advocate**. Remember that you are the voice
    for people with mental and substance use disorders in the criminal
    justice system. Take your data and case studies to visits with
    lawmakers, potential funders, and the general public. Carry
    information with you in case a spontaneous opportunity arises. Be
    mindful of any restrictions on advocacy activities that may be tied,
    for example, to grant funds that you receive.

The Web site www.entrepreneur.com has some good basic resources on how
to create a press release or a media kit and how to be a good
interviewee. If you have a few dollars to spend, *The Public Relations
Handbook for Nonprofits: A Comprehensive and Practical Guid*e by Art
Feinglass is available from Amazon (www.amazon.com) for \$50, though
used copies can be purchased for less. Check with your local journalism
school or Chamber of Commerce to see if they offer speakers or courses
on media relations. The more effectively you can communicate about your
program to lawmakers, funders, and the general public, the more likely
you are to maintain and sustain your efforts, even in an era of
diminished resources and competing demands. The next section looks at
other ways to ensure sustainability.

SECTION 6: Planning for Sustainability

Some jail diversion programs are funded by a Federal grant, such as
SAMHSA's Targeted Capacity Expansion (TCE) for Jail Diversion
Initiative. More often, jail diversion activities are begun on a
shoestring and funded by multiple resources that are pieced together to
support staff and services. In either case, programs must find ways to
sustain their activities beyond the first few years. In this section,
you'll learn why it's important to think about sustainability from day
one, what types of services you need to sustain, and how to approach
potential funders and use creative strategies to support vital services.

The Problem

Jail diversion programs are proliferating around the country, but rarely
are they budgeted for by either the mental health or criminal justice
system. They may be funded by a grant or other one-time resource that
can't be sustained over the long term. Programs that are serving
consumers and showing good outcomes may have to close their doors if
they don't have a plan to maintain services when initial funding ends.

What You Need to Know

Often, establishing a jail diversion program for people with serious
mental illness and co-occurring substance use disorders is easier than
sustaining it once initial funds run out. Competing demands for limited
resources strain political will and agency budgets. Yet sustainability
has become the byword in development of systems change initiatives. Most
government and private funders want to see a plan for sustainability
built into funding applications so they know that vital services won't
be discontinued when their support ends (SAMHSA, 2003). SAMHSA's TCE
jail diversion grantees must have an approved plan for sustainability
before they receive their implementation funds.

But ensuring the viability of your program beyond the first several
years is not just a matter of satisfying funders. In fact, more than the
fate of individual consumers is at stake. Jail diversion by its very
nature is both a reflection of the need for, and the success of,
services and systems integration efforts on behalf of people with mental
illness. As such, jail diversion programs represent transformation of
the mental health system at the local, State, and national levels, and
their success ensures replication. Helping people with mental illness
break the cycle of arrest and incarceration, and assisting the mental
health and criminal justice systems to work better together on behalf of
these consumers, is why you began your jail diversion program. Making
certain you can continue to carry out these objectives is as important
as starting them at all.

What You Need to Do

The single most important thing you can do to ensure the long-term
viability of your jail diversion program is to *plan for the future from
day one*. Indeed, even if you only have funding for a year or two, you
must develop your plans as if you intend to run your program
indefinitely (The National GAINS Center, 1999a).

**Begin at the Beginning**

Build sustainability into your initial program planning by following
some key steps:

-   **Find a local champion or change agent**. This person brings
    visibility and credibility to your project. For example, the
    enthusiasm for jail diversion demonstrated by County Criminal Court
    Judge Steven Leifman of the 11th Judicial Circuit helped the Miami
    program secure a combination of State and county funding sufficient
    to sustain initial diversion program staff and add two additional
    peer specialists.

-   **Engage potential funders from the beginning**. People will be more
    likely to support what they helped create. If you maintain frequent
    contact with potential funders throughout the planning and
    implementation stages of your jail diversion program, you will be in
    a far better position to ask for help than if your first contact is
    a request for money.

-   **Partner with consumers/program participants**. No one can describe
    the value of a jail diversion program like someone who has lived
    experience in the criminal justice and mental health systems. By
    sharing their story of how a diversion program improved their lives,
    consumers are able to put a human face on the program's statistics
    and funding requests. Additionally, consumers can provide the
    program with credibility and access to audiences that a criminal
    justice professional or mental health program administrator may not
    be able to reach on their own. Remember to include consumers in your
    planning group.

-   **Market shamelessly**. Jail diversion consumers are people that
    society frequently ignores. By securing press coverage of success
    stories, graduations, locally organized conferences, and statements
    of support from key stakeholders, you can advance a positive view of
    the diversion program and challenge commonly held stereotypes of
    people with mental illness and criminal justice involvement.
    Building a positive record in the press and community can help you
    obtain ongoing funding and educate those who might be opposed to
    your program about its value to the community.

-   **Collect and disseminate data**. Politicians and legislators need
    effective data to do their part in promoting your group's efforts.
    Funders need data to define how their money is being spent and to
    validate their funding choices. The value of program data is
    enhanced when they become part of regular updates to funders rather
    than confined to a single presentation when initial funding ends.
    The next section of this publication highlights the types of data
    you need to collect and how to do so in a cost-efficient way.

**Determine What You Need to Sustain**

Your need for continuing funding will depend on how you've structured
your program. For example, if staff help consumers enroll in entitlement
programs such as SSI and Medicaid, less of your program funding will be
used to provide direct services to consumers. You may only need service
funds to cover the gap between when a consumer applies for benefits and
when his or her application is approved. Or you may decide to limit your
services to people who are eligible for Medicaid, which reduces your
financial responsibility, though it also may restrict the number and
type of people you can serve.

With services supported through mainstream funding, most of the funds
required for sustainability are for program staff. Staff positions
required to maintain jail diversion programs generally include mental
health practitioners to screen and assess a person's eligibility, case
managers to broker services, pretrial services staff to provide
oversight and monitoring, and peer specialists to offer support and
assistance to program enrollees. Given the collaborative nature of these
projects, it is helpful to maintain a boundary spanner or program
director who is devoted, at least in part, to coordinating efforts among
systems.

**Find Continuing Funds**

As noted in Section 4, most jail diversion programs blend funds from a
variety of sources to support staff and services. Here are some places
you can look and ways to approach specific funders:

-   **Federal funding**. Federal funding for jail diversion programming
    remains scarce, but there are places to look. SAMHSA
    (www.samhsa.gov) may have funds available through its Targeted
    Capacity Expansion for Jail Diversion Initiative. Recently, the
    Bureau of Justice Assistance (www.ojp.usdoj.gov/BJA) has made funds
    available through its Justice and Mental Health Collaboration
    Program.

In addition, you may be able to provide services or housing for your
consumers with programs supported by other Federal agencies that benefit
people with serious mental illness and co-occurring substance use
disorders and people who are homeless. A good place to start looking is
Chapter 5 of SAMHSA's *Blueprint for Change*, which includes a list of
targeted and mainstream resources. You can download a copy of the
*Blueprint* at
www.mentalhealth.samhsa.gov/publications/allpubs/sma04-3870/default.asp.

In addition, you may want to check the Web sites of relevant Federal
agencies, including the Department of Health and Human Services
(www.hhs.gov), the Department of Housing and Urban Development
(www.hud.gov), the Department of Justice (www.usdoj.gov), the Department
of Veterans Affairs (www.va.gov), and the Substance Abuse and Mental
Health Services Administration (www.samhsa.gov). Also, because many of
your consumers will be eligible for mainstream benefits such as SSI and
Medicaid, check the Web sites of the Social Security Administration
(www.ssa.gov) and the Centers for Medicare and Medicaid Services
(www.cms.gov) for program rules and eligibility.

Consider becoming involved in your local Continuum of Care. The
Continuum of Care is both an application for funding and a plan for
services required of applicants for homeless housing assistance from the
Department of Housing and Urban Development. For information, contact
your city housing department and ask for the person who handles
Community Development Block Grant funds; he or she may be able to direct
you to the individual or group that oversees the planning process. The
publication *How to Be a "Player" in the Continuum of Care* is another
helpful resource. You can download a copy at
www.tacinc.org/Docs/HH/ContinuumofCareGuide.pdf.

-   **State funding**. Some jail diversion programs receive funds from
    the State agency responsible for mental health services. For
    example, the jail diversion project director in the Connecticut
    Department of Mental Health and Addiction Services succeeded in
    adding an appropriation to the Governor's budget to support both the
    Hartford and New Britain/Bristol Women's Support Programs. If you
    would like to contact your State mental health commissioner, you can
    search for his or her name at www.nasmhpd.org. You can find
    information on your State Department of Corrections at
    www.nicic.org/Links/31.htm.

State legislators are another source of potential support. You can
identify and cultivate relationships with those legislators who have
interests in issues of criminal justice or mental illness. This may
prove difficult, however, because budget requests likely will require
the support of more than a single legislator. You might consider
sponsoring a legislative breakfast at which you present your program to
a group of legislators early in their budget process. Be certain to have
program consumers tell their success stories.

-   **Local funding**. Funds from city or county governments may be your
    most dependable source of support. The key to success is initiating
    a relationship with the city or county early in the development of
    your program and maintaining that relationship through regular
    contact during the implementation period. Keeping local officials
    involved and up to date on the program's progress and outcomes helps
    to demonstrate its value and fosters a sense of ownership. Consider
    inviting local politicians to program graduations or offering tours
    of the program or affiliated service agencies. Providing politicians
    with a media event built around the diversion program can be useful
    in serving the needs of both parties.

-   **Private funding**. Consider tapping the private sector---including
    corporations, private donors, and foundations---for financial and
    in-kind support. Though most private funding is time-limited, it can
    be used to leverage or match other resources. The Foundation Center
    at http://foundationcenter.org includes a comprehensive set of
    resources for locating and approaching foundations. Also, don't
    overlook local businesses as potential supporters. Downtown
    associations, in particular, may support services that help people
    with mental illness who sometimes cause problems for local
    merchants. The International Downtown Association's publication
    *Addressing Homelessness: Successful Local Partnerships* contains
    some suggestions that may be useful. You can download a copy at
    www.ida-downtown.org. Click on the "Book Store" link.

**Use Technical Assistance**

To initiate and sustain your jail diversion program, you may have to
acquire a set of new skills and information, but you don't have to
reinvent the wheel. There is a substantial body of literature and
resources literally at your fingertips on several comprehensive Web
sites. In addition, there are a number of ways to use experts in the
field to fill in the missing pieces in your knowledge.

Become Familiar with Online Resources

Three key Web sites you'll want to know about and use are highlighted
below.

-   **The CMHS National GAINS Center**, www.gainscenter.samhsa.gov. The
    National GAINS Center for Systemic Change for Justice Involved
    Persons with Mental Illness and the Technical Assistance and Policy
    Analysis (TAPA) Center for Jail Diversion comprise the CMHS National
    GAINS Center. Operated by Policy Research Associates, Inc., under
    contract to SAMHSA, the GAINS Center provides consultation and
    technical assistance to help communities achieve integrated systems
    of mental health and substance abuse services for people in contact
    with the justice system. The TAPA Center serves as the national
    locus for all relevant jail diversion information and research.
    You'll find a wealth of information on this site about jail
    diversion, including program examples, outcome studies, and key
    literature, much of which is available as PDF files you can
    download.

-   **The Criminal Justice/Mental Health Consensus Project**,
    www.consensusproject.org. The Consensus Project is a national effort
    coordinated by the Council of State Governments Justice Center to
    help local, State, and Federal policymakers and criminal justice and
    mental health professionals improve the response to people with
    mental illness who become involved in, or are at risk of involvement
    in, the criminal justice system. The Consensus Project Web site
    provides access to the Project Report; information about relevant
    research, statistics, and Web-based resources; and a directory of
    program profiles from around the country, which allows visitors to
    communicate with program administrators online. The Consensus
    Project has partnered with selected Federal agencies to provide
    targeted technical assistance to a range of State and local
    jurisdictions and to the Bureau of Justice Assistance's Justice and
    Mental Health Collaboration Program.

-   **The Criminal Justice/Mental Health Information Network**,
    www.cjmh-infonet.org. The InfoNet is coordinated by the Criminal
    Justice/Mental Health Consensus Project and the CMHS National GAINS
    Center, with invaluable support from the National Alliance on Mental
    Illness (NAMI) and other organizations. Content on the site, which
    is still being developed, is organized and searchable using the
    components of the criminal justice and mental health systems with
    which individuals who have mental illness are most likely to come
    into contact: law enforcement, courts, corrections, and community
    supports.

Consider Ways to Use Outside Experts

If you haven't considered using technical assistance, you may not know
how it can help. Here are just a few examples of the ways in which
technical assistance providers can help you jumpstart a jail diversion
program, refine your strategies, or plan for sustainability:

-   **Strategic planning**. Jail diversion can be a touchy subject and a
    complex endeavor in many communities. Expert consultants can help
    you gather your key stakeholders, map the service system, and
    inventory resources. See the boxed feature on ACTION planning in
    Section 4 for more information on one such service.

-   **Best practices**. Perhaps you know that you want to provide
    trauma-informed services to your jail diversion consumers, but you
    don't know where to begin. Again, expert consultants can help you
    examine various models, choose the one that best serves your
    consumers, and implement it with fidelity to the model.

-   **Data collection and analysis**. Data collection and analysis
    needn't be costly or complex. You can get expert advice on what data
    you need to collect, where to find it, and how to interpret it for
    your various stakeholder groups.

Remember, too, that "outside experts" can be local. They may be outside
the group with whom you typically work but have special skills you can
use. Examples include college faculty, staff at local and regional
health foundations, and business leaders.

Be Creative

Above all, be imaginative in accessing help. Don't be constrained by the
need to have formal presentations by outside experts. Sometimes the best
technical assistance comes from your peers---people in communities
similar to yours who have implemented jail diversion programs. Consider
using technical assistance support to arrange a visit with a community
that has a program you would like to emulate. You'll learn what pitfalls
to avoid and what strategies to employ to make your program a success.

SECTION 7: Data 101

The motto for any successful jail diversion program has to be "data,
data, data." You will need it to build consensus for diverting people
with serious mental illness and co-occurring substance use disorders
from the criminal justice system, to make the case for initial or
ongoing financial support, and to sustain and expand your efforts beyond
the preliminary stage. Lawmakers, funders, and the general public will
hold you accountable for the outcomes you achieve. In this section,
you'll learn why it is in your best interests to collect data, what
types of data you need to gather, and how to use data to answer some key
questions about the success of your program.

The Problem

If saying that jail diversion is "the right thing to do" was a
compelling argument, you probably wouldn't need to collect any data at
all. However, in an era of diminishing public resources, the political
and financial backers whose support you need won't be convinced so
easily. Funders, in particular, will demand to know, "What did I buy?"
and "What good did it do?"

What You Need to Know

The data you collect and disseminate will serve a number of key
functions. It can help you:

-   Apply for grants

-   Educate policymakers and the community

-   Increase support for public funding

-   Justify continued funding

-   Defend system/policy changes

-   Improve your program

Initially, data can help confirm the need for a jail diversion program.
As noted in Section 4, you can use data to convince key stakeholders
that diverting people with mental illness and substance use disorders
from the criminal justice system makes sense from more than just a
humanitarian perspective. These data need not be complex or difficult to
gather. For example, early in the planning stages for jail diversion in
Miami-Dade County, stakeholders learned that (Steadman & Leifman, 2005):

-   Miami-Dade County has the highest percentage (9.1 percent) of people
    with mental illness of any urban community.

-   At any given time, there were 800-1,200 people with mental illness
    (20 percent of the inmate population) in the county jail.

-   Recidivism of defendants with mental illness was greater than 70
    percent.

-   Defendants with mental illness stay in jail eight times longer at
    seven times the cost.

-   Seven people with mental illness were killed during encounters with
    police.

Even the lack of such data---for example, if the local jail can't
determine how many people with mental illness are incarcerated---will
speak volumes about the need to proceed with initial fact finding.
People with mental illness and substance use disorders in the justice
system can't be served effectively if they aren't being identified.

More sophisticated analyses might be warranted to further galvanize your
efforts. For example, to justify a request for Federal funds, a study in
Miami-Dade County examined costs associated with offenders who
participated in a jail diversion program more than once within a
calendar year. Results showed that 31 people cost the corrections,
court, and mental health system more than \$540,000 in one year
(Steadman & Leifman, 2005).

This study was part of a formal research project that required
collaboration with multiple agencies to collect and analyze all required
data elements. If you will be collecting identifiable data on program
participants, you may be subject to Federal regulations governing the
protection of human subjects in research. More information about the
requirements for research that involves human subjects, in general, and
people who are incarcerated, in particular, is included in the final
part of this section.

Finally, one of the most important reasons you will collect and use data
is to ensure accountability. Positive outcomes provide justification for
continued services, which may help you sustain activities in difficult
fiscal environments and/or when start-up funding ends. Stakeholder
groups also use outcome measures to evaluate their progress in meeting
strategic goals and objectives (SAMHSA, 2003).

What You Need to Do

Remember that your first round of program funding is awarded on
promises, but the second round is given on results. You'll need to be
able to answer some essential questions about whether your program
results in positive outcomes in public safety and service participation.
Before you begin, however, you need to collect information about the
characteristics of the consumers in your program, including:

-   Gender

-   Race/ethnicity

-   Age

-   Principle psychiatric diagnosis

-   Presence of co-occurring substance use disorder

-   Other health problems

-   Homeless at intake/housing status

-   Most serious current charge

-   Prior convictions

-   Number of prior arrests

-   Jail days

Much of this information can be gathered from existing administrative
datasets or in a baseline interview by the staff person who screens
consumers for participation in the jail diversion program.

**Identify Data for Key Indicators**

Even before you begin your program, you need to decide how to measure
its success. The outcome measures should correlate to the specific goals
of the program as you identified them in your strategic plan. Though
each jail diversion program may collect a unique set of data, in general
your outcome measures should be designed to address the following four
indicators that respond to the key questions your stakeholders are
likely to ask:

-   **Public safety**: Are participants less likely to be arrested and
    if arrested, are they involved in less serious crimes?

-   **Retention**: Do participants remain engaged in your program?

-   **Treatment**: Are participants connected to the treatment and
    supports they need?

-   **Housing**: Are participants linked to stable housing?

You can use these data to address concerns of local partners in jail
diversion. For example, if the local judge is concerned about community
safety, you can show him or her your data on re-arrest rates, or if
housing is a major local issue, you can showcase data related to housing
of diverted consumers (North Carolina Jail Diversion Program, n.d.).

The data you need to collect for each indicator are outlined below.
Program examples in this section are from an evaluation of the Nathaniel
Project, a New York City diversion program for people with serious
mental illness who have been indicted on a felony offense and are facing
a lengthy prison sentence. For more information about the Nathaniel
Project, see the National GAINS Center program brief at
www.gainscenter.samhsa.gov/pdfs/jail_diversion/nathaniel_project.pdf.

Public Safety

**Outcome Measure***:*

-   The difference between the participants' number of arrests in the 12
    months prior to entry into the program and the 12 months from
    program entry [^5]

**Important Considerations**: There can be a difference not only in the
number of charges but also in the type of charges. Especially if your
program allows participants with more serious charges, the arrests
during program participation are more likely to be for technical
violations or for lower level, misdemeanor charges.

In addition, number of jail days can be used to complement the figure on
arrests. Remember, though it is easy to figure out the difference in
jail days and multiply that by the cost of a jail day, this figure will
likely lead to a false claim of savings. This is true for several
reasons:

-   The jail beds that are not being used by your consumers will be used
    by someone else;

-   The cost of keeping someone in jail has shifted from the criminal
    justice system to the mental health system; and

-   Existing jail per-diem costs reflect the cost of incarcerating an
    average inmate but don't take into account the fact that people with
    mental illness consume a disproportionately high amount of
    correctional resources (e.g., medications, lower staff-to-inmate
    ratios, staff overtime).

Data to Collect:

-   Number and type (felony, misdemeanor, technical violation) of
    arrests for people in the program in the 12 months prior to program
    entry

-   Number and type of arrests for people in the program in the 12
    months following program entry

-   Number of jail days in the 12 months prior to program entry and the
    12 months following program entry

-   Most serious current charge or instant offense at time of enrollment

**Program Example**: Participants in the Nathaniel Project demonstrated
a dramatic decrease in arrests. The number of arrests dropped from 101
(35 misdemeanors and 66 felonies) in the year prior to program
participation to 7 (5 misdemeanors and 2 felonies) in the year after
intake.

Retention

**Outcome Measures**:

-   The percent of participants who remained in the program for 12
    months

-   The point at which people who did not complete the program dropped
    out or were removed

Data to Collect:

-   Number of participants who have dropped out of or been removed from
    the program

-   Time frame when people dropped out or were removed from the program

**Program Example**: The Nathaniel Project had tremendous success
engaging consumers who had repeatedly dropped out of treatment. The
program retained 88 percent of its participants at 6 months and 80
percent at 2 years.

Treatment

**Outcome Measures**:

-   The percent of people enrolled in the program who currently are
    receiving treatment

-   What treatment services are available and in what proportion they
    are being used

Data to Collect:

-   Number of participants receiving treatment and supports

-   Type of services used

-   Percent of participants using each service

**Program Example**: At the Nathaniel Project, 100 percent of
participants were engaged in treatment.

Housing

**Outcome Measures**:

-   How many people enrolled in the program were homeless at intake

-   How many participants have housing after 12 months of program
    participation

-   The types and proportion of housing being used by program
    participants

**Data to Collect:**

-   Number of participants at program entry who do not have housing

-   Number of participants who have housing at 12 months into program
    operation

-   Types of housing used by program participants

**Program Example**: At intake, 92 percent of Nathaniel Project
participants were homeless. After one year, 79 percent of participants
had permanent housing.

**Measure Changes in Consumer Functioning**

The four key indicators noted above are, in effect, a proxy for
improvement in consumer functioning. If a person is arrested less often,
participates in the program, enrolls in services, and finds stable
housing, you might assume he or she will have fewer psychiatric and
substance use symptoms and a better quality of life. However, this may
not necessarily be true. Also, even if your consumers are receiving a
full complement of services, these may not be the types of services that
consumers want or feel they need. Though more difficult to measure, you
may want to assess the following indicators of consumer functioning and
satisfaction with services:

-   Mental health symptoms/improvement in functioning

-   Drug/alcohol use

-   Number of days homeless/in housing

-   Employment

-   Income

-   Health status

-   Family relationships

-   Social supports

-   Satisfaction with services

-   Quality of life

Some of the data you collect will be quantitative and some (e.g.,
satisfaction with services and quality of life) will be qualitative.
Qualitative data can be derived from anecdotes and/or from structured
surveys. A sample participant interview from the Lancaster County (NE)
Mental Health Jail Diversion Project that includes both quantitative and
qualitative questions is included in the Resources section of this
publication.

**Beware of Possible Pitfalls**

You need to look for and avoid possible pitfalls as you measure program
data so that you can be prepared to address stakeholder concerns. As you
gather and analyze your data, keep the following points in mind:

-   It is not possible to count prevented events. For example, contact
    with specially trained police officers may keep a person with a
    serious mental illness from committing an offense. Only people who
    receive psychiatric treatment as an immediate alternative to
    criminal incarceration should be counted as jail diversion consumers
    (Draine & Solomon, 1999).

-   Calls for service, for example to CIT officers, may spike as a
    program becomes better known. This could make it appear that law
    enforcement problems relating to people with mental illness and
    substance use disorders are increasing, when in reality, they are
    being handled more appropriately.

-   For many people with serious mental illness and co-occurring
    substance use disorders, recovery may be incremental and long-term,
    often marked by numerous flare-ups and relapses. Their progress,
    therefore, may be difficult to measure.

-   Some services that people diverted from the justice system need to
    become stable in the community, such as supportive housing, are ones
    that your program can't guarantee.

-   Initially a jail diversion program will *increase* costs to the
    community mental health system even as it *decreases* costs in the
    criminal justice system. This cost-shifting will begin to balance
    out after several years as people become stable in the community and
    require less intense mental and substance abuse services. Cost data
    may be more favorable and indicative of the value of your program
    several years out.

Still, having some cost data available can be particularly compelling to
funders. The Miami-Dade County jail diversion program saves \$2.3
million annually. Recently, the county commission allocated \$23 million
in public safety funds to build a forensic diversion facility for people
with mental and substance use disorders.

-   The outcome measures cited in this section are fairly easy to
    collect. More sophisticated program evaluations can be complex and
    expensive to conduct. You may be able to partner with local
    university research staff to cut costs and provide expertise. Some
    agencies have obtained grants that allow them to pay outside experts
    to collect and analyze their data.

**Collect Data**

Once you determine what information you need to collect, you have to be
certain you have mechanisms in place to capture the data. You can do
this by developing a basic management information system (MIS) to keep
track of where people are in the diversion process. This can be anything
as informal as 3 x 5 cards to standardized data entry screens on
networked personal computers.

An automated MIS can maintain data in an organized manner, provide quick
access to information, and reduce paperwork. When such systems are in
place, you may only need to add relevant fields to capture the specific
information you need. For example, law enforcement officials could add a
field to police record management systems that reflects successful
referrals to community-based services after a call is cleared (Council
of State Governments, 2002).

Further, you may be able to connect to an existing MIS that provides
valuable information about existing and potential jail diversion
consumers. See the example on the next page.

Finally, many of your consumers may be homeless on arrest or booking
into jail, and data about their characteristics and the services they
receive may be included in a Homeless Management Information System
(HMIS) required of all government and nonprofit agencies that receive
homeless assistance funds from the U.S. Department of Housing and Urban
Development. Homeless services providers who are part of your jail
diversion stakeholder coalition may be able to provide you with
information that is available to you from their records, providing that
you have established procedures to facilitate data sharing. See Section
5 for further discussion of sharing information about consumers.

**Get the Word Out**

Section 5 of this publication highlights the need to use the media to
get the word out about your program and its successes. This is where
your outcome data come in handy. You can use both quantitative and
qualitative data to make your case for building a new initiative,
replicating a pilot project, or engaging additional partners. Here are
some additional thoughts on how to do this:

-   **Issue periodic reports about the program**. You can do this in
    writing or as a presentation to a group of funders or lawmakers. For
    example, staff of the Lancaster County (NE) Mental Health Jail
    Diversion Project hold a biannual data meeting with the county board
    of commissioners. They use data which show that jail diversion is
    working to educate policymakers.

-   **Call on advocates for help**. Your local Mental Health America or
    affiliate of the National Alliance for Mental Illness (NAMI) may be
    only too glad to help you publicize program results. You can find
    your local chapter at www.nmha.org or www.nami.org, respectively.

-   **Develop press kits**. You can put fact sheets about your program
    and its consumers, your latest data, and individual case studies in
    a press kit for local and regional media. Include contact
    information for program spokespersons. See the "PR" section under
    "Sales and Marketing" on www.entrepreneur.com for tips on developing
    a press kit and how to be a good interviewee.

-   **Use the credibility of the criminal justice system**. Because law
    enforcement officials and corrections administrators are responsible
    for ensuring public safety, they have singular credibility in
    dispelling notions that people with mental illness and substance use
    disorders in the community compromise public safety (Council of
    State Governments, 2002). Be certain they have your latest data and
    case studies when they speak to their colleagues, legislators, or
    potential funders.

**Ensure the Protection of Human Subjects**[^6]

Research that is not considered ongoing administrative/clinical program
data collection being used for performance monitoring and evaluation and
that does involve collecting identifiable, private information from
individuals is regulated by the Protection of Human Subjects Title 45,
Code of Federal Regulations Part 46 (45 CFR 46), referred to as the
"Common Rule." With certain exceptions, these regulations apply to all
research involving human subjects that is supported by Federal funds.
(Institute of Medicine, 2000). State or local laws or regulations may
provide additional protections for human subjects.

Key Definitions

Some key definitions of the Federal statute include the following (45
CFR 46.102):

-   ***Research*** means a systematic investigation, including research
    development, testing, and evaluation, designed to develop or
    contribute to generalizable knowledge.

-   ***Human subject means a living individual about whom an
    investigator conducting research obtains 1) data through
    intervention or interaction with the individual or 2) identifiable
    private information.***

-   Private information ***includes information about behavior that
    occurs in a context in which an individual can reasonably expect
    that no observation or recording is taking place, and information
    which has been provided for specific purposes by an individual and
    which the individual can reasonably expect will not be made public
    (e.g., a medical record). Private information must be individually
    identifiable (i.e., the identity of the subject is or may readily be
    ascertained by the investigator or \[person\] associated with the
    information) in order for obtaining the information to constitute
    research involving human subjects. (Some examples might include
    name, date of birth, and Social Security number.)***

The Need for IRB Review and Informed Consent

Protection of human subjects hinges on review by Institutional Review
Boards and informed consent from participants in research (Institute of
Medicine, 2000). An IRB is a group of at least five individuals who are
knowledgeable and not directly involved in the research whose job it is
to review and approve, require modifications, or disapprove research
involving human subjects. The group must include at least one scientist,
one non-scientist, and in the case of research involving prisoners, a
prisoner or prisoner representative with appropriate background and
experience.

In addition to reviewing the research protocol, the IRB must determine
that study subjects have given free and informed consent to participate.
Elements that must be included in consent are:

-   Explanation that the activity is research

-   Explanation that participation is voluntary

-   Description of the overall experience that will be encountered

-   Any experimental components

-   Reasonably foreseeable risks

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-   Expected benefits

-   Alternatives to participation

-   Confidentiality protections

-   Explanation of compensation for injuries

-   Who to contact with questions about the research and research
    subjects' rights

-   Additional elements as applicable

It is important to note that the Common Rule contains additional
protections for prisoners. In particular, the IRB must find that:

-   Selection procedures are fair to all prisoners

-   Information presented is understandable

-   Participation will not affect a prisoner's parole or status

-   As-needed provisions are made for follow-up care

Though participants in jail diversion projects may not spend time in
jail or prison, it is reasonable to consider them a vulnerable
population for whom extra protections are needed. In particular, they
must be assured that information gathered as part of your
evaluation---for example, about their participation in substance abuse
treatment---will may be exempt from IRB review. For example, research
involving the collection or study of existing data, documents, records,
pathological specimens, or diagnostic specimens is exempt, if these
sources are publicly available or if the information is recorded by the
investigator in such a manner that subjects cannot be identified,
directly or through identifiers linked to the subjects (45 CFR
46.101(b)(4)).

In addition, the IRB may waive the requirement for informed consent
if: 1) the research involves no more than minimal risk to the subjects;
2) the waiver or alteration will not adversely affect the rights and
welfare of the subjects; 3) the research could not practicably be
carried out without the waiver or alteration; and 4) whenever
appropriate, the subjects will be provided with additional pertinent
information after participation (45 CFR 46.116(d)).

Use the Resources Available to You

There is sufficient complexity in regulations governing human subjects
protections that you will want to get help in determining whether and to
what extent you need to follow applicable Federal, State, and local
regulations. For example, there may be a fine line between data
gathering that could be considered research and that which might be
termed "internal quality assurance" (Institute of Medicine, 2000).

You will be well served to be in touch with your local university. They
will have researchers familiar with human subjects protections and an
IRB that may be able to help you determine whether your project
constitutes research as defined by Federal regulations. Further, you may
be able to enlist the help of graduate students to compile and analyze
your data.

There are also some excellent Web sites and other resources that can
help you make sense of the Common Rule. The Office for Human Research
Protections (OHRP) in the U.S. Department of Health and Human Services
has a Web site you'll want to bookmark at www.hhs.gov/ohrp. In
particular:

-   Each section of 45 CFR 46 is spelled out at
    www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm.

-   There is a comprehensive set of decision charts that will help you
    determine, for example, if an activity is research involving human
    subjects and whether your research is eligible for exemption, at
    www.hhs.gov/ohrp/humansubjects/guidance/decisioncharts.htm.

-   Information about how to register an IRB, should you need to develop
    your own, is available at www.hhs.gov/ohrp/assurances.

Another resource you might consult is the Institute of Medicine's 2002
report, *Protecting Data Privacy in Health Services Research*. Chapter 2
on human subjects protection is especially relevant and you can read it
online at http://darwin.nap.edu/html/data_privacy/ch2.html.

MOVING FORWARD

We hope that however you have used this publication---as a springboard
for discussion, a checklist of necessary activities, or a means of
evaluating your progress---you feel ready to move forward to the next
logical step in developing a jail diversion program for people with
serious mental illness and co-occurring substance use disorders.
Depending on where you are in the process, it may be time to gather your
key stakeholders, implement your action plan, or analyze your data and
present the case for ongoing support. There is no single formula for
success, no cookbook strategies that can be replicated in every
community. Your problems and your solutions will be unique to the
barriers you face and the resources you have at your disposal.

Still, as noted throughout the text, there is no need to reinvent the
wheel. We encourage you to borrow from communities that have implemented
successful programs and to share your best strategies with others.
Despite the fact that each program will be unique, you all have the same
underlying goals: improving the lives of people with mental and
substance use disorders, increasing public safety, and making more
efficient use of public resources. The individuals and the communities
you serve deserve nothing less.

APPENDIX A: Resources

The following Internet resources are cited throughout the text and are
grouped here in specific categories for your convenience. This is not
intended to be an exhaustive list of resources in any particular area
but is illustrative of the type of material available on the Web. Except
where noted, all publications are free. free. There is no implied
endorsement of specific Web sites or publications by SAMHSA, the
Department of Health and Human Services, or any agency of the Federal
government. Additional materials appended to this document are listed at
the end of the section.

**General Resources**

**The CMHS National GAINS Center**, www.gainscenter.samhsa.gov. The CMHS
National GAINS Center for Systemic Change for Justice-Involved People
with Mental Illness and the CMHS GAINS Technical Assistance and Policy
Analysis (TAPA) Center for Jail Diversion comprise the CMHS National
GAINS Center. Operated by Policy Research Associates, Inc., under
contract to SAMHSA, the GAINS Center provides consultation and technical
assistance to help communities achieve integrated systems of mental
health and substance abuse services for people in contact with the
justice system. The TAPA Center serves as the national locus for all
relevant jail diversion information and research. You'll find a wealth
of information on this site about jail diversion, including program
examples, outcome studies, and key literature, much of which is
available as PDF files you can download.

**The Criminal Justice/Mental Health Consensus Project**,
www.consensusproject.org. The Consensus Project is a national effort
coordinated by the Council of State Governments Justice Center to help
local, State, and Federal policymakers and criminal justice and mental
health professionals improve the response to people with mental
illnesses who become involved in, or are at risk of involvement in, the
criminal justice system. The Consensus Project Web site provides access
to the Project Report; information about relevant research, statistics,
and Web-based resources; and a directory of program profiles from around
the country, which allows visitors to communicate with program
administrators online. The Consensus Project has partnered with selected
Federal agencies to provide targeted technical assistance to a range of
State and local jurisdictions and to the Bureau of Justice Assistance's
Justice and Mental Health Collaboration Program.

**The Criminal Justice/Mental Health Information Network**,
www.cjmh-infonet.org. The InfoNet is coordinated by the Criminal
Justice/Mental Health Consensus Project and the CMHS National GAINS
Center, with invaluable support from the National Alliance on Mental
Illness (NAMI) and other organizations. Content on the site, which is
still being developed, is organized and searchable using the components
of the criminal justice and mental health systems with which

courts, corrections, and community supports.

**Publications**

*Blueprint for Change: Ending Chronic Homelessness for Persons with
Serious Mental Illnesses and/or Co-occurring Substance Use Disorders*

www.mentalhealth.samhsa.gov/publications/allpubs/sma04-3870/default.asp

*How to Be a "Player" in the Continuum of Care*

www.tacinc.org/Docs/HH/ContinuumofCareGuide.pdf

*Addressing Homelessness: Successful Local Partnerships*

www.ida-downtown.org (click on the "Book Store" link)

*The Public Relations Handbook for Nonprofits: A Comprehensive and
Practical Guid*e (\$50)

www.amazon.com

**Strategic Planning**

The Criminal Justice/Mental Health Consensus Project's collaboration
assessment tool

http://consensusproject.org/assessment

Tips and techniques for planning and running effective meetings

www.effectivemeetings.com

Tools and techniques for achieving consensus

www.resolv.org

Community Needs Assessment and Assessing Communities for Systems
Transformation

www.ncstac.org (click on the "Resource Library" link)

Comprehensive resources on the Health Insurance Portability and
Accountability Act (HIPAA)

www.hipaa.org

Resources on how to create a press release or a media kit and how to be
a good interviewee

www.entrepreneur.com

**Funding**

Information on allowable program activities and funding cycles for the
Byrne Memorial Grant www.ojp.usdoj.gov/BJA/grant/jag.html

A comprehensive set of resources for locating and approaching
foundations

http://foundationcenter.org

A fact sheet on blended funding for jail diversion in Seattle

www.gainscenter.samhsa.gov/pdfs/jail_diversion/Blending_Funds.pdf

An issue brief on HIPAA and criminal justice/mental health information
sharing

www.gainscenter.samhsa.gov/pdfs/integrating/Dispelling_Myths.pdf

**Services**

Information about psychiatric advance directives

www.bazelon.org

Wellness Recovery Action Plans (WRAP)

www.mentalhealthrecovery.com

Evidence-based practices in mental health services

www.mentalhealth.samhsa.gov/cmhs/communitysupport/publications/about.asp

Resources on consumer-driven services and peer support outcomes

www.cmhsrp.uic.edu/nrtc

Trauma interventions

www.nationaltraumaconsortium.org

The special needs of women in the justice system

www.gainscenter.samhsa.gov (click on the "Publications" link on the
"Resources" tab)

Screening instruments for mental and substance use disorders

http://kap.samhsa.gov/products/manuals/tips/index.htm (see the
appendices of TIP 42)

**Housing**

Information on how to develop, fund, and evaluate supportive housing

www.csh.org

Federal affordable housing programs

www.tacinc.org/HH/Program_Policy/Programs_Policy.htm

A discussion of eligibility for Federal housing for people who have been
incarcerated www.mentalhealthcommission.gov/papers/CJ_ADACompliant.pdf

**Training**

Articles on how to address employee stress

www.humannatureatwork.com

> The reference manual *Stepping Stones to Recovery: A Case Manager's
> Manual for Assisting Adults Who Are Homeless with Social Security
> Disability and Supplemental Security Income Applications*

www.prainc.com/SOAR/tools/manual.asp

A set of policy recommendations for training practitioners in the
criminal justice and mental health systems

www.consensusproject.org (see "The Report")

**Programs**

Project Link, Rochester, NY

http://psychservices.psychiatryonline.org/cgi/reprint/50/11/1477

Pathways to Housing, New York City

www.endhomelessness.org/best/pathways.htm

The Nathaniel Project, New York City
www.gainscenter.samhsa.gov/pdfs/jail_diversion/nathaniel_project.pdf

**Federal Agencies**

Centers for Medicare and Medicaid Services

www.cms.gov

Department of Health and Human Services

www.hhs.gov

Department of Housing and Urban Development

www.hud.gov

Department of Justice

www.usdoj.gov

Department of Veterans Affairs

www.va.gov

Social Security Administration

www.ssa.gov

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

**Individuals and Organizations**

State mental health commissioners

www.nasmhpd.org

**State Departments of Corrections**

www.nicic.org/Links/31.htm

**Mental Health Advocacy**

Mental Health America and local affiliates

www.nmha.org

The National Alliance on Mental Illness (NAMI) and local chapters

www.nami.org

**Human Subjects Protection**

45 CFR 46, The Common Rule

www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm

A comprehensive set of decision charts
www.hhs.gov/ohrp/humansubjects/guidance/decisioncharts.htm

Information about how to register an Institutional Review Board

www.hhs.gov/ohrp/assurances

*Protecting Data Privacy in Health Services Research*
http://darwin.nap.edu/html/data_privacy/ch2.html

**Resources Appended to the Text**

These are examples of forms and instruments which may be of use. Many of
these resources contain program specific and local information which
would need to be adapted for use by other programs.

-   A sample Memorandum of Understanding (MOU)

-   A sample participant interview from the Lancaster County Mental
    Health Jail Diversion Project

-   The New River Valley Crisis Intervention Team tracking form

-   The Oakland County Jail Diversion Program Notice

-   A sample release of information form from the Albany County Jail
    Diversion Program

-   The Brief Jail Mental Health Screen

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GENERAL INFORMATION:

This Brief Jail Mental Health Screen (BJMHS) was developed by Policy
Research Associates, Inc., with a grant from the National Institute of
Justice. The BJMHS is an efficient mental health screen that will aid in
the early identification of severe mental illnesses and other acute
psychiatric problems during the intake process.

This screen should be administered by Correctional Officers during the
jail's intake/booking process.

**Instructions for Section 1:**

> NAME: Enter detainees name --- first, middle initial, and last
>
> DETAINEE#: Enter detainee number.
>
> DATE: Enter today's month, day, and year.
>
> TIME: Enter the current time and circle AM or PM.

# INSTRUCTIONS FOR Section 2:

> ITEMS 1-6:

Place a check mark in the appropriate column (for "NO" or "YES"
response).

If the detainee REFUSES to answer the question or says that he/she DOES
NOT KNOW the answer to the question, do not check "NO" or "YES."
Instead, in the General Comments section, indicate REFUSED or DON'T KNOW
and include information explaining why the detainee did not answer the
question.

> ITEMS 7-8:
>
> ITEM 7: This refers to any *prescribed* medication for any emotional
> or mental health problems.
>
> ITEM 8: Include any stay of one night or longer. Do NOT include
> contact with an Emergency Room if it did not lead to an admission to
> the hospital

If the detainee REFUSES to answer the question or says that he/she DOES
NOT KNOW the answer to the question, do not check "NO" or "YES."
Instead, in the General Comments section, indicate REFUSED or DON'T KNOW
and include information explaining why the detainee did not answer the
question.

> General Comments Column:

As indicated above, if the detainee REFUSES to answer the question or
says that he/she DOES NOT KNOW the answer to the question, do not check
"NO" or "YES." Instead, in the General Comments section, indicate
REFUSED or DON'T KNOW and include information explaining why the
detainee did not answer the question.

> All "YES" responses require a note in the General Comments section to
> document:
>
> \(1\) Information about the detainee that the officer feels relevant
> and important
>
> \(2\) Information specifically requested in question
>
> If at any point during administration of the BJMHS the detainee
> experiences distress, he/she should follow the jails procedure for
> referral services.

**INSTRUCTIONS FOR SECTION 3:**

OFFICER'S COMMENTS: Check any one or more of the four problems listed if
applicable to this screening. If any other problem(s) occurred, please
check OTHER, and note what it was.

**REFERRAL INSTRUCTIONS:**

Any detainee answering YES to Item 7 or YES to Item 8 or YES to at least
two of Items 1-6 should be referred for further mental health
evaluation. If there is any other information or reason why the officer
feels it is necessary for the detainee to have a mental health
evaluation, the detainee should be referred. Please indicate whether or
not the detainee was referred.

APPENDIX B: Program Examples

**San Francisco's Behavioral Health Court: Helping the Underserved**

San Francisco Behavioral Health Court Judge Mary Morgan wears a black
robe and sits on the bench when she meets with court participants every
Thursday afternoon. But rather than meting out justice, she talks with
men and women about their progress in treatment. Many are doing well;
the court reports a low recidivism rate.

Former Behavioral Health Court Judge Herbert Donaldson, a retired jurist
who was the driving force behind developing the court, says he enjoyed
being able to make a difference in people's lives. "Many of these people
have no homes, they have no skills," Judge Donaldson says. "They have
mental illness and we don't have treatment facilities to treat them. And
sometimes terrible things happen to them" (Koopman, 2006).

On Thursday mornings, Judge Morgan meets with representatives from the
public defender's office and the district attorney's office, along with
staff from the county jail and various mental health programs to discuss
the cases that will come before them that day. Typically, clients are
accepted into the court from the county jail, where jail staff or the
person's attorney makes a referral. The person has to have a serious
mental illness and can't be accused of arson, sex crimes, domestic
violence, or assault resulting in great bodily injury. People with
developmental disabilities and mental retardation are also accepted into
the court (Johnson, 2004).

Members of the court team create a treatment plan that includes access
to intensive case management, counseling, medication, and housing.
Clients are monitored by the court and are encouraged, but not forced,
to comply with treatment. There are three characteristics that
distinguish San Francisco's Court from similar programs (Donaldson and
Johnson, n.d.):

-   Behavioral Health Court is a pre-plea court; clients are not
    required to enter a guilty plea to participate.

-   The court looks at the client's mental health diagnosis, and at the
    connection between the mental illness and the behavior that led to
    the client's arrest, rather than simply focusing on the criminal
    charges. Even individuals with more serious crimes may be
    considered.

There is no set legal outcome. The better the individual does in
treatment, the more favorable the disposition, which might include
having a felony charge reduced to a misdemeanor, a grant of probation
terminated, or a criminal charge dismissed. he court was chosen to
participate in a national evaluation of four mental health courts funded
by the John D. and Catherine T. MacArthur Foundation. "What started as a
pilot project is now viewed by many in the justice system as a necessary
component of the city's approach to some of its more vulnerable
citizens," Judge Donaldson concludes.^6^

**For more information, contact**:

Lisa Lightman, Director of Collaborative Justice Courts, San Francisco
Superior Court, (415) 553-9855, <llightman@sftc.org>

**Dallas County, TX: Using Real-time Internet Technology**

In 2003, roughly 20 percent of the inmates in the Dallas County jail
were seriously mentally ill. In fact, in one 6-week period that summer,
5 percent of the people booked into the jail were clients of the local
mental health authority, the Dallas Area NorthSTAR Authority (DANSA).

To respond to the needs of these individuals for treatment and services,
DANSA collaborated with a broad range of stakeholders---including the
sheriff's department, the jail mental health provider, the district
attorney's office, the public defender's office, judges, the felony and
misdemeanor courts, and the probation department, among others---to
develop the Dallas County Mental Health Diversion Program. The project
is funded by a grant through the Texas Correctional Office for Offenders
with Medical and Mental Impairments and Dallas County.

The original Mental Health Diversion Program targets offenders charged
with misdemeanor offenses. Successful completion of this 6-month program
results in the offender's criminal charge being dismissed. A companion
program, the ATLAS (Achieving True Liberty and Success) Mental Health
Diversion Program, targets offenders on probation for felony offenses
with pending motions to revoke their probation. Upon successful
completion of this 1-year program, the motion is withdrawn and the
individual is continued on probation. In both programs, participants
have severe mental illnesses and are enrolled in NorthSTAR for services.
Candidates for diversion are identified and initially screened through
the jail or are referred from the original court of jurisdiction for
some felony candidates. Participants are served by a team that includes
the judge, a psychologist, a public defender, a specially trained
probation officer, and a case manager who brokers or provides services
that include crisis housing, medication management, and psychiatric
rehabilitation.

One of the most unique aspects of the Dallas County program is the Jail
Diversion Instant Messaging (JDIM) system developed in collaboration
with HarrisLogic of St. Louis. Initiated by the Central Intake Unit at
the jail when a person is arrested, the JDIM searches the NorthSTAR
database and when it finds a match, notifies the DANSA jail diversion
coordinator that a NorthSTAR client has been booked into the county
jail. After the person is determined eligible for diversion based on
criminal charges, the supervisor can use the JDIM to inform the courts,
the district attorney, and the public defender's office that a diversion
case is in the pipeline. The JDIM also alerts the behavioral healthcare
organization when a client has agreed to participate and been released
by the judge.

The use of instant messaging allows for early identification of
offenders with mental illnesses and their expedited release from jail,
which may promote better mental health and criminal justice outcomes. It
also reduces time spent tracking people down, replying to e-mails, and
responding to voicemails. The JDIM is hosted in a secure environment
that supports HIPAA compliance and maximum privacy; data are encrypted
and made available to individuals on a "need to know" basis only. The
system is based on the widely understood Internet chat paradigm and
takes about 15 minutes to learn.

**For more information, contact**:

V.J. Lair, (214) 653-5300, VJLair@dallascounty.org

**New York's EXIT Program: A Unique "Sanction to Services" Approach**

The EXIT program is a post-booking diversion program for mentally ill,
nonviolent, repeat misdemeanants in the Manhattan Criminal Court
(arraignment court). EXIT is a unique public-private partnership between
the Mayor's Office of the Criminal Justice Coordinator and the Center
for Alternate Sentencing and Employment Services (CASES) that offers a
mandated 3-hour treatment assessment session followed by 6 months of
voluntary case management services in lieu of jail time to people who
agree to participate. The majority of EXIT clients (90 percent) have
substance use disorders, and more than half are homeless at the time of
intake.

Defense attorneys and other courtroom personnel refer potential clients,
and a clinical social worker provided by EXIT conducts in-court
screenings to determine eligibility. Following the recommendation of the
program, judges may sentence defendants to a 3-hour assessment session,
with the understanding that the program will continue to extend services
to defendants for up to 6 months. This "sanction to services" model is
designed to feature high engagement and low coercion; the program is not
obligated to report to the court beyond the participant's completion of
the initial mandated treatment assessment session.

The treatment assessment session inquires about the client's needs and
supports in the areas of mental health and substance abuse treatment,
housing, education, employment, entitlements, food, clothing, and
medical care. The aim of the session is to develop a preliminary service
plan based on the client's stated goals and to form a relationship with
the client that will encourage him/her to continue to pursue services
with the program.

Clients have access to a social worker, psychiatrist, and peer
specialist at the program who assist them in meeting goals related to
managing mental illness, maintaining sobriety, and achieving stability
in the community. EXIT provides supportive case management, escorts
clients to housing and service appointments, and helps them create a
network of community-based providers from whom they can receive
appropriate long-term care and support after leaving the program. Case
managers both broker and provide services, which helps sustain clients'
engagement. Client contact varies from once per month to several times
per week based on the person's needs.

Since the program's inception, more than 60 percent of clients released
to the program have taken part in some or all of these voluntary
services. During the program's second year of operation, more than a
third of all clients who accepted case management services remained
engaged in the program for at least 6 months, despite the lack of a
criminal justice mandate enforcing case management services and the
propensity for transient service engagement among the target population.
Some clients remained engaged with the program for as long as 1 year or
more. Finally, the program has demonstrated a correlation between a high
level of engagement in its case management component and reduced
recidivism, with the cohort of participants who were most engaged
constituting the largest proportion of defendants with no convictions
one year post-sentence.

**For more information, contact**:

Gerald Foley, Project Director, (212) 788-6833, GFoley@cityhall.nyc.gov.

**New River Valley, VA: The First Rural CIT Program**

The New River Valley covers 1,458 square miles in southwest Virginia
along the I-81 corridor. It encompasses four counties and one small
city, with a total population of 165,000. Across the New River Valley
there are 14 law enforcement agencies ranging in size from two officers
to more than 100. This appears to be an unlikely place to implement a
Crisis Intervention Team (CIT) model of pre-booking diversion, which has
been replicated in numerous metropolitan areas nationwide, but that's
exactly what the community has done. The New River Valley established
the nation's first rural, multi-jurisdictional CIT program. [^7]

The New River Valley CIT project began in April 2002 with a SAMHSA
Community Action Grant (CAG). The first 18 months were spent building
consensus among a broad range of stakeholders---including leaders from
law enforcement and government agencies; consumers, family members, and
advocates; public and private mental health care providers; local
magistrates; and community organizations. In March 2004, with the aid of
another CAG, the community sent 10 law enforcement officers and 10
civilians to Memphis, TN, to be trained by the creators of the CIT
program. These 20 people became the inaugural core faculty for the New
River Valley's CIT program.

CIT officers in the New River Valley receive 40 hours of specialized
training that includes 9 hours of role playing exercises based on
real-life scenarios. As part of their training, they also spend an
entire day visiting the region's mental health and substance abuse
inpatient and outpatient treatment facilities where they speak
one-on-one to mental health consumers and familiarize themselves with
the programs and staffing available in the community.

To date, the New River Valley CIT program has exceeded the community's
goal of having at least 20 percent of all uniformed patrol officers and
deputies trained in CIT; 62 officers representing 13 law enforcement
agencies were trained as of May 2005. In addition, nearly 100 percent of
dispatchers attended a 4-hour training designed to help them be part of
the team effort. Beginning in the fall of 2005, the CIT training was
opened to all Virginia law enforcement officers. New River Valley
officers attend the training for free, while those from other
jurisdictions pay a fee that is put toward continued administrative
support of the CIT program.

The New River Valley CIT program includes several important adaptations.
Because it takes in 14 separate law enforcement agencies, the program is
coordinated by a neutral organization, the local Mental Health
Association. However, each law enforcement agency establishes its own
CIT policies regarding, for example, whether CIT officers receive extra
pay for this assignment. Also, the chiefs and sheriffs meet quarterly to
discuss CIT issues. Finally, since there is no public mental health
hospital in the New River Valley, a private medical center serves as the
central triage facility, called "The Bridge." At the Bridge, emergency
assessment personnel use video technology to speed the process of civil
commitment, where this is deemed appropriate, by linking to the local
magistrates' offices rather than requiring the parties to appear in
person.

**For more information, contact**:

Dana Lebowitz, Jail Diversion Coordinator, Mental Health Association of
the New River Valley, (540) 953-4990, dlebowitz@mhanrv.org

**Shelby County's Jericho Project: Bringing Down Barriers to Recovery**

Among people familiar with jail diversion projects, Shelby County, TN,
is perhaps best known for its CIT program. But CIT is only the first
line of defense for the metropolitan Memphis area, which also has a
court liaison program run by its pretrial services agency. For those
people with serious mental disorders who can't be diverted at either of
these points, Shelby County developed the Jericho Project, a
non-specialty court post-booking program that relies on conditional
release strategies. All three jail diversion initiatives are supported
by Mayor A.C. Wharton's Jail Diversion Committee.

"Ours is a different take on a post-booking program," says Stephen C.
Bush, J.D., Coordinator of Mental Health Systems for the Shelby County
Public Defender's Office. Here's how the process works:

The Jericho Roundtable, which is composed of the project's key
partners---including pretrial services, the jail medical provider,
community agencies, and boundary spanners---meets twice weekly to
discuss potential clients and create transition plans tailored to the
needs of the individual. People can be referred to the Roundtable by any
of the partners or other community stakeholders. The Roundtable members
meet with the consumer and develop a community linkage plan based on the
APIC model of transition planning, which focuses on assessing the
client's needs, planning for treatment and services, identifying
community resources, and coordinating the transition from jail to the
community (Osher et al, 2002).

When the plan is ready and the client is clinically stable, defense
counsel enters into the negotiating process with the prosecutor and the
judge for a conditional order of release. The use of conditional release
taps the natural leverage of the criminal justice system to encourage
treatment engagement, Bush notes (Bush, 2002). If the individual does
well with the treatment plan, this can have a dramatic impact on his/her
case. Often charges are dismissed or reduced, and frequently the
individual receives probation.

That's how it works, but Bush is especially enthusiastic about why it
works. Because the Jericho Project doesn't depend on pre-approval by the
prosecutor, the staff doesn't have to screen out those who are most
difficult to serve. While in most cases prosecutors and defense counsel
are able to negotiate outcomes that result in a supervised release to
treatment, the Jericho Project approach respects the traditional
adversarial process and invites prosecutors to argue against planning
they believe is inadequate. Ultimately, of course, the final decision is
up to the court, which can always reject a plan it feels is not
appropriate, Bush says.

However, he reports, "Every one of our 18 judges has approved
conditional releases based on Jericho community linkage plans, and
courts routinely approve them 95 percent of the time, even for
individuals with a history of violence and prior arrest who wouldn't be
eligible for consideration in many mental health courts."

**For more information, contact**:

Stephen Bush, (901) 545-5835, stephen.bush@shelbycountytn.gov

APPENDIX C: Glossary

Assertive Community Treatment (ACT)

A service-delivery model that provides comprehensive, community-based
treatment to people with serious mental illness. ACT provides
individualized services directly to consumers through a team which
provides treatment and supports in their own home and other non-clinical
community settings. Team members are trained in the psychiatry, social
work, nursing, substance abuse, and vocational rehabilitation. These
services are available every hour of every day.

Boundary Spanner

A boundary spanner provides coordination across multiple organizations
or systems. In jail diversion programs, a boundary spanner may be
employed by the local mental health agency yet his or her office is
located in the county jail or courts. This person's role may be to
coordinate the approval of treatment and supervision plans by the mental
health agency and the courts, or to coordinate the systems at an
administrative level.

Case Management

A means of coordinating the services available in a community to ensure
continuity of mental health care across a non-integrated service system.
While some models of case management provide the services directly to an
individual with mental illness, most case management programs act as
brokers by developing service plans, linking people to services,
monitoring those services, and determining additional areas of need.

Community-Based Treatment

Treatment which takes place in community settings, as opposed to
treatment in an inpatient setting, a State hospital, or in correctional
settings. Community-based treatment may take place at the offices of
services providers or i*n vivo*, such as in an individual's home or
workplace.

Consumer

Any individual who does or could receive mental health and other related
services, such as substance abuse treatment or supported employment
services.

Co-Occurring Disorders (COD)

An individual with co-occurring disorders (COD) has both a mental
illness and a substance use disorder. From a treatment perspective, both
disorders are primary. Although the disorders may impact each other,
neither are merely symptoms of the other.

Consumer-Operated Services

Mental health treatment or support services that are provided by
consumers, such as clubhouses and peer support groups.

Crisis Intervention Team (CIT)

A law enforcement-based model of specialized response to people
experiencing a mental health crisis in the community. Crisis
Intervention Team (CIT) programs are comprised of a volunteer cadre of
officers who have completed a 40-hour training on recognizing the signs
and symptoms of mental illness, identifying a mental health crisis
situation, and de-escalation techniques. Crisis Intervention Team (CIT)
programs are a form of community partnership between local law
enforcement agencies, local mental health agencies, mental health
advocacy groups, mental health consumers, and families.

Cultural Competence

The set of attitudes, skills, behaviors, and policies that enable
effective interactions in cross-cultural situations.

Detainee

An unsentenced individual held in pre-trial custody.

Evidence-Based Practice (EBP)

An intervention which, through research, has been found to be
beneficial, effective, and replicable for people with serious mental
illness. The Center for Mental Health Services (CMHS) of the Federal
Substance Abuse and Mental Health Services Administration (SAMHSA) has
designated the following interventions as evidence-based practices:

-   Assertive Community Treatment (ACT)

-   Family Psychoeducation

-   Illness Management and Recovery (IMR)

-   Integrated Dual Disorders Treatment (IDDT)

-   Medication Management Approaches in Psychiatry (MedMAP)

-   Supported Employment

Forensic Assertive Community Treatment (FACT)

An adaptation of Assertive Community Treatment (ACT) which addresses an
individual's risk for arrest and incarceration in addition to the
model's public health goals.

Family Psychoeducation

The practice of working in partnership with families to help them
develop positive coping skills for handling problems posed by mental
illness in their family and skills for supporting the recovery process.
The Center for Mental Health Services (CMHS) has designated family
psychoeducation as an evidence-based practice (EBP).

Gender-Specific Services

Services that are of or for individuals of one gender to the exclusion
of the other.

Health Information Portability and Accountability Act (HIPAA)

The Federal Health Information Portability and Accountability Act
(HIPAA) provides protections for the privacy of an individual's health
care information. To comply with HIPAA, covered entities such as
hospitals, primary care providers, and mental health service providers
must obtain permission from an individual prior to sharing health care
information with other service providers. State and local laws may
demand stricter standards for the sharing of health care information
than are required for a service provider to comply with HIPAA.

Homeless Management Information System (HMIS)

A Homeless Management Information System (HMIS) is a software
application designed to record and store client-level information on the
characteristics and service needs of homeless persons. An HMIS is
typically a web-based software application that homeless assistance
providers use to coordinate care, manage their operations, and improve
services. All government and nonprofit agencies that receive homeless
assistance funds from the U.S. Department of Housing and Urban
Development are required to maintain an HMIS.

Housing First

A housing approach that relies on providing people who are homeless with
quick access to supportive housing for people who are homeless. Support
services are provided following the housing placement to meet housing
stability and individual needs. Housing is contingent only upon meeting
the terms of a lease rather than with treatment compliance.

Illness Management and Recovery (IMR)

Illness Management and Recovery (IMR) is a set of practices which
provides people with serious mental illness skills to manage their
illness in order to achieve personal recovery goals. Practices include
psychoeducation, relapse prevention skills, and the development of
coping strategies. Illness Management and Recovery is often referred to
as Wellness Management and Recovery (WMR) and Symptom Self-Management.

Inmate

A sentenced or unsentenced individual involuntarily confined in a jail,
prison, or other correctional facility.

Integrated Dual Disorders Treatment (IDDT)

Treatment of co-occurring disorders is integrated when mental health and
substance use treatment takes place in the same service setting with
cross-trained staff.

Institutional Review Board (IRB)

A group of at least five individuals who are knowledgeable and not
directly involved in the research whose job it is to review and approve,
require modifications, or disapprove research involving human subjects.
The group must include at least one scientist, one non-scientist, and in
the case of research involving prisoners, a prisoner or prisoner
representative with appropriate background and experience. Institutional
Review Boards (IRB) are registered through the U.S. Department of Health
and Human Services, Office of Human Research Protections.

Jail Diversion

The avoidance or radical reduction in jail time by using community-based
treatment as an alternative.

Medication Management Approaches in Psychiatry (MedMAP)

An EBP in the use of medications for the treatment of schizophrenia.
Medication Management Approaches in Psychiatry (MedMAP) is based on four
principles: a systematic approach in the selection of medication,
measurement of key outcomes, documentation of treatment and outcomes,
and use of approaches that promote adherence to treatment.

Memorandum of Understanding (MOU)

A document outlining the terms and details of an agreement between
parties, including each party's requirements and responsibilities.

Management Information System (MIS)

An information collection and analysis system, usually computerized,
that facilitates access to program and participant information. It is
usually designed and used for administrative purposes.

Post-Booking

A designation for jail diversion programs which divert people after
booking into the jail. Post-booking jail diversion programs may be
court-based or jail-based.

Pre-Booking

Jail diversion programs that divert people to services in the community
as an alternative to arrest.

Psychiatric Advance Directive (PAD)

A legal instrument which may be used to document an individual's
specific instructions or preferences regarding future mental health
treatment, as preparation for the possibility that the person may lose
capacity to give or withhold informed consent to treatment during acute
episodes of mental illness.

Recidivism

In terms of mental health and criminal justice, recidivism is examined
in different ways. Mental health recidivism is the use of emergency
services or hospitalization for mental illness following a period of
mental health services. Criminal recidivism is measured by reoffense,
rearrest, reconviction, or technical violation following a period of
incarceration.

Re-Entry

A term that covers issues relating to the transition of individuals from
correctional settings into the community.

Sequential Intercept Model

A strategic model which identifies points where communities can
implement interventions to prevent further criminal justice involvement
of people with mental illness. There are five intercept points: law
enforcement and emergency services, initial detention and initial court
hearings, jails and courts, re-entry, and community corrections and
community supports.

Supported Employment

A set of supportive services, including follow-along support, for people
with mental illness who want to pursue and maintain competitive
employment.

Supportive Housing

Affordable rental housing with support services. Support services, such
as case management or vocational training, may be offered on-site or at
locations in the community.

Therapeutic Jurisprudence

Approaches which are concerned with the impact of the law on an
individual's emotional and psychological well-being.

Transition Planning

Often called discharge planning, transition planning from jail to
community-based services entails assessment of an individual's service
needs, development of a comprehensive service plan, identification of
agencies responsible for treatment and supervision, and effective
linkages to those services and supports.

Trauma-Informed Services

Services that may be offered or modified to be responsive to the needs
of people with histories of trauma.

Trauma-Specific Services

Interventions that address the behavioral, psychological, and social
consequences of sexual, physical, and emotional abuse.

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[^1]: Except where noted, information in this section is derived from
    two key resources: Massaro, J. (2004). *Working with people with
    mental illness involved in the criminal justice system: What mental
    health service providers need to know* (2^nd^ ed.). Delmar, NY: The
    TAPA Center for Jail Diversion. Massaro, J. (2005). *Overview of the
    mental health service system for criminal justice professionals*.
    Delmar, NY: The TAPA Center for Jail Diversion. Both are available
    at www.gainscenter.samhsa.gov.

[^2]: Significant portions of this section are derived from two key
    sources: 1) The National GAINS Center. (1999a). *The courage to
    change: A guide for communities to create integrated services for
    people with co-occurring disorders in the justice system*. Delmar,
    NY: Author. 2) The National GAINS Center. (1999b). *Blending funds
    to pay for criminal justice diversion for people with co-occurring
    disorders*. Fact Sheet Series. Delmar, NY: Author. Both are
    available at www.gainscenter.samhsa.gov.

[^3]: Information in this section was derived from key sources: 1)
    Massaro, J. (2005). *Overview of the mental health service system
    for criminal justice professionals*. Delmar, NY: TAPA Center for
    Jail Diversion. www.gainscenter.samhsa.gov 2) Petrila, J. (2007).
    *Dispelling the myths about information sharing between the mental
    health and criminal justice systems.* Delmar, NY: CMHS National
    GAINS Center. www.gainscenter.samhsa.gov

[^4]: The information in this section and the one that follows was
    provided by Travis Parker, Director of the Lancaster County Mental
    Health Jail Diversion Project in Lincoln, NE.

[^5]: Though 12 months is the standard length of time to measure, other
    units of time---6 months, 9 months, 18 months, or 2 years---are
    equally appropriate depending on how long your program is funded and
    whether your primary funder has specific reporting requirements.

[^6]: Portions of this section are derived from Routh, A. (2005). Human
    subjects' protection. Presentation for TCE Site Evaluators Human
    Subjects Training.

[^7]: Portions of this write-up appeared in the May 2005 issue of
    *Mental Health Matters*, the newsletter of the Mental Health
    Association of the New River Valley, Inc., and on the association's
    Web site at www.mhanrv.org. Additional material is from a TAPA
    Center Net/Teleconference on "Making Jail Diversion Work in Rural
    Communities." An audio replay and PowerPoint slides are available on
    the GAINS Center Web site at www.gainscenter.samhsa.gov (click on
    the "Presentations" link under the "Resources" tab).