# Presentation: 029909

## Department of CorrectionsMental Health Services

- Colleen Patrick-Riley, M.S.W., LCSW,
- Mental Health Clinician III
- Director of Mental Health Release Programs
- &
- Deedee Raymond, M.S., Mental Health Clinician II
- Re-entry Coordinator for DOC Mental Health
- 				              *August 2006*

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

- New initiative funded by Alaska Legislature and the Alaska Mental Health Trust Authority (AMHTA) in FY 2007
- APIC is a best-practice program described in *The President’s New Freedom Commission on Mental Health*, Sub-Committee on Criminal Justice (2004)
- APIC = Assess, Plan, Identify, Coordinate
- Goal: Access services, medication, housing, benefits, and jobs if able to work

## What Will We Cover?

- Overview and Context of the Problem
- Trust Beneficiaries in DOC
- DOC Mental Health Services
- DOC Mental Health Release Programs
- Gaps in Services

## What Is the Extent of the Problem?Reduction of Psychiatric Beds

- Nationally:
- 1955–1999
- In Alaska:
- 1979–1999
- 2005

- Psychiatric Beds:
- 159,000–70,000
- 220–79
- Reduced to 72

## Results

-  Neglect
-  Homelessness
-  Substance Abuse
-  Criminalization

## Cruel Irony of Deinstitutionalization

- Promotion of the* “Least Restrictive Alternative” *for many has unintentionally resulted in the* “Most Restrictive Alternative”* —    INCARCERATION

## Reinstitutionalization

- Across the U.S., thrice as many individuals with a mental illness are behind bars as are in psychiatric hospitals
- Current estimates indicate that between 16 and 30% of prisoners nationwide have a serious mental illness

## Trust Beneficiaries in AlaskaDepartment of Corrections 

- DOC is largest provider of institutional mental health services in Alaska
- DOC mental health staff have seen >**13,500** individuals with mental illness or suicidal ideation since 1982
- Not counting people who recycle, DOC mental health staff see an additional **80–100** *new* people each month
- See **>2,000** unique individuals each year

## Number Incarcerated

- _Year__	__	__# in Jail__	__# of Trust Beneficiaries_
- 1990		2,700
- 1997		4,164			37%
- 2006		5,000   *estimate*	37%+ (1,850)
- 36,370 bookings statewide in FY 2006               (22,342 individuals)
- 80% of bookings are for misdemeanor crimes
** Typically, the number of offenders on felony probation/parole equals the number in DOC custody*

- Nationally in 1999:
- 16.2% or 283,800 inmates were estimated by the *Bureau of Justice* to have a mental illness
- Alaska in 1997:
- 37% or 1,154 inmates incarcerated in Alaska prisons were beneficiaries of the AMHTA according to a one day 1997 study by *Care Systems North *(inmates in Arizona or other out-of-State facilities were not surveyed; CRCs were separately counted)
- 29% of the DOC population experienced mental illness
- 12% were seriously mentally ill
- 8% were chronic alcoholics with a history of psychosis
- 0.04% had identified developmental disabilities
- 14% of the 625 offenders in Community Residential Centers were Trust beneficiaries
- 15% of a sample of probation and parole were Trust beneficiaries

- Adult Inmates Who Have Mental Disorders

## Research Studies

- In FY 2007, a New Trust study covering FY 2003–2006 will tell us numbers of Trust beneficiaries in DOC custody or on supervision in the community
- The Study will be a joint effort by the Trust, DOC, and DHSS working together with research contractors *Hornby Zeller Associates, Inc*.

## Need to Reduce the # in Jail

- It’s humane
- It’s cost effective
- Beds at maximum capacity
- Jail’s not the best place to treat
- DOC wants to work together with other agencies to help individuals succeed in the community

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

- A continuum of services in and out of corrections is essential
- Several programs and initiatives have been implemented

## What Happens in Alaska  Department of Corrections?

**What Happens in Alaska  ****Department of Corrections?**

## Mental Health Services in DOC

- The are 13 correctional facilities in Alaska operated by the Department of Corrections (located in Anchorage, Palmer, Wasilla, Kenai, Seward, Juneau, Fairbanks, Bethel, Nome, and Ketchikan).
- DOC mental health staff members include psychiatrists, clinicians, psychiatric nurses, and psychological counselors. State or contract staff members provide services in all facilities.

## Department of Corrections Institutional Mental Health Services

***Incarceration***

**Mental Health Issues ID**

- Medication Management by Psychiatrist or ANP by Telepsychiatry or in Person

- Case Planning/Community Referrals

- Mental Health Screening

***Acute Inmate Mental Health Units***

- ACC-W Mike Module for ♂

- HMCC ♀ Psychiatric Treatment

- Mental Health Assessment/Evaluation

- Discharge Planning

***Subacute Mental Health Units***

- HMCC ♀ HOPE Wing

- PCC House 1 ♂

- SPCC Echo Module ♂

***Diversion & Release Programs***

- Jail Alternative Services

- Institutional Discharge Project +

- Coordinated Resource Project

- API Coordination/Emergency Services

## Mental Health Services in DOC

- General Mental Health Services
**Medical and mental status screening exams within 24 hours by medical R.N.**
**Referral to and evaluation by MHC if indicated**
**Medication prescription and monitoring by DOC psychiatrist or ANP**
**Telepsychiatry offered to all outlying facilities**
**Coordination with API**
**Crisis intervention services **
**Discharge planning to the community for mentally ill individuals (if release date known and time allows) **

## Mental Health Services in DOC

- General Mental Health Services
**48-week offender mental health treatment offered to general population inmates (anger management, criminal thinking errors, values clarification/moral reasoning, rational problem solving/relapse prevention) **
**Medical emergency services (Title 47 alcohol and mental health holds, detox services for intoxicated individuals and intravenous drug users)**

## Mental Health Services in DOC

- Inpatient Mental Health Units** for acutely ill inmates provide assessment and stabilization:**
**CIPT Mike Module for Men **
**HMCC Women’s Psychiatric Treatment Unit**
- Sheltered Living **(HMCC Women’s Special Needs Wing, House 1 at PCC, and Echo Mod at SCCC for Men)**
- Community-based Services **(halfway house services for general population inmates, specialized probation, IDP+ for mentally ill felons and JAS, PCRP for voluntary misdemeanants)**

## Mental Health Services in DOC

- Trust funding helped provide increased services for longer-term inmates at Spring Creek Correctional Center in Seward:
**Echo Module for up to 65 adult men who experience mental illness or disability**
**Youth Offender Program (YOP) for youth waived into the adult system, provides targeted services to males ages 15–22 (with IEP) **
**The Spring Creek Initiative at Echo Module and YOP is an excellent model for providing integrated mental health, substance abuse, and educational services at one site**

## Substance Abuse Treatment in DOC

- RSAT 6- to 12-month intensive therapeutic community provides treatment for women at Hiland Mountain Correctional Center in Eagle River (32 beds)
- RSAT 6- to 12-month intensive therapeutic community provides treatment for men at Wildwood Pretrial Facility in Kenai (42 beds)
- An intensive year-long therapeutic community is offered to male felons in Central Arizona Detention through Alaska DOC contract (40 beds – may increase to 60 in future)
- All three programs are cognitive therapeutic communities that provide intensive residential substance abuse treatment meeting State-approved treatment requirements
- Reality is >85% of DOC inmates have substance use disorders; 3-year federally funded *Adam* study at Anchorage Jail found 92% of inmates have abuse problem or addiction to alcohol and/or drugs
- 72–90% of Mental Health Trust beneficiaries in DOC have a co-occurring substance use disorder

## Educational Services in DOC

- Individuals have the opportunity to take testing and Adult Basic Education and earn a GED while incarcerated in any correctional facility, to take a college correspondence course if they pay for it, or to participate in vocational training at a sentenced facility
- Education also offers life skills classes in health and safety, communication skills, prerelease and preemployment, and cross-cultural groups to inmates at all correctional facilities
- While only a few inmates have a documented developmental disability or traumatic brain injury known to DOC, it is believed many more are not formally identified

## Sex Offender Treatment in DOC

- Sex offender treatment was offered at Hiland Mountain Correctional Center until FY 2004
- Sex offender prerelease psychological evaluations are conducted to determine risk and to make recommendations for management strategies for community supervision
- Outpatient sex offender treatment is offered in the community from approved SOTP providers on DOC contract
- All sex offenders must enter their names on a Sex Offender Registry and are closely monitored in the community by probation/parole officers

## Sex Offender Treatment in DOC

- A new pilot Sex Offender Containment Model was started in DOC in FY 2006. As mandated by the Alaska Legislature, all sex offenders will participate in this model by FY 2008.
- The containment model consists of a team approach to managing sex offenders in the community – it includes community treatment, enhanced supervision and close monitoring, and polygraph testing as parts of treatment.

## Sex Offender Treatment in DOC					Problem Areas

- There are a significant # of mentally ill who have convictions for a sexual offense.
- They are prohibited from entering residential substance abuse treatment programs and federally funded housing options. Although they need added supports and monitoring to succeed and be safe in the community, they are often released homeless without access to appropriate supervised housing.
- Mentally ill benefit from sex offender-specific treatment.
- Individuals with significant developmental disabilities and high-risk behaviors should have access to groups at the Center for Psychosocial Development. Funding has limited access – we hope to improve access in the next year.

## Department of Corrections Mental Health Referrals

***INSTITUTIONAL DISCHARGE PROGRAM PLUS***

- Felony Probation

- IDP+ Coordinator

- Community Treatment Provider

***INCARCERATION***

*No* Mental Health Issues

- Comprehensive Mental Health Screening

- Mental Health Issues ID

- Inmate or Staff Request Mental Health Assessment

***FELONY***

***MISDEMEANOR***

- Within 24 Hours: Medical and ***Mental Health Screening*** on *All* Inmates

- Jail Alternative Services (JAS) & Coordinated Resource Projects

- Court

*Institutional Mental Health Clinician:*
- Anchorage, Hiland Mt., Fairbanks, Wildwood, Spring Creek, Lemon Creek Palmer Correctional Centers

- Psychiatric Evaluation

- Psychotic Disorder & Felony Probation or Parole

- Felony

- Misdemeanor

*Contract Mental Health Provider: *
- Anvil Mountain, Ketchikan, Yukon-Kuskokwim Correctional Centers

- Institutional MHC Discharge Planning for Diagnosed Mentally Ill Inmates Who Are Not Referred to IDP+ or Participate in the Misdemeanor Mental Health Courts

## Referral to Diversion and Release Programs

- There are four special release programs to which inmates can be referred
- One for felons, three for misdemeanants
- See handouts

## Felony

***Individual Discharge Project Plus (IDP+)***
**Mandatory Probation/Parole**

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

**Misdemeanor**
***Coordinated Resource Project (CRP) Mental Health Court***
**Voluntary Participation**

***1998: CRP***
**Anchorage**** **
***1998:Jail Alternative***
***Services (JAS)***
**Anchorage**

***1994: IDP+***
- IDP+ Coordinator Joint Project by DMHDD & DOC

***2000: CRP *****Anchorage OPA Case Coordinator**

***2005: CRP***
**Palmer**
- DOC Case Coordinator

***2002: IDP+*** Programmatic Change from Joint with DMHDD to Solely DOC

**2006:**
**Changed to *****ASAP *****Oversight**

## Felony Mental Health Release Program

- _IDP+ for Felons_
- Must be released on felony probation or parole
- Must have a psychotic disorder
- Treatment plan and monitoring coordinated by DOC IDP+ Coordinator working with community agencies and mental health probation officers
- Current caseload: 60–70
- Original caseloads were 35–50
- Services provided statewide but tend to concentrate in Anchorage

## Misdemeanor Mental Health Release Options from DOC

- _Anchorage District CRP Mental Health Court_
- Mentally ill misdemeanants who voluntarily agree to be sentenced in Anchorage Mental Health Court
**DOC *****JAS *****Coordinator for eligible individuals with a psychotic disorder (and limited # with organic impairment) in DOC custody **
**ASAP *****CRP***** Coordinator for individuals with any mental disability in or out of custody**
- _Palmer District CRP Mental Health Court_
- Mentally ill misdemeanants who voluntarily agree to be sentenced in Palmer Mental Health Court
**DOC *****PCRP *****Coordinator for individuals with any mental disability in or out of custody**
- All Case Coordinators link individuals to appropriate community based services and monitor compliance with individualized case plan and court release or probation conditions.

## Remember

- Diversion from corrections works only if we have programs and resources to which to divert people!!!
- Quick intakes, clinical supports, and stable sober housing in the community are crucial

## Gaps in Services

*Fragmented and Difficult to Access Services*
- How does a person know what exists, where to go, and how to get into and pay for services?
- Delays in intakes and doctor prescription appointments create barriers for effective transitions
- Medicaid driven funding for services do not cover all Trust beneficiary needs
*Critical Needs – Existing Options Inadequate and Too Many Wrong Doors *
- Stable **HOUSING** – the biggest gap!
- Dual diagnosis substance abuse treatment
*Transition services for young adults* – many with co-occurring substance use disorders lack access to treatment
- Treatment for inappropriate sexual behavior
- Case management
- Day treatment/meaningful activities
- Anger/violence treatment for individual with disabilities
- Services for older adults with dementia
- Assessment/treatment for those with late onset or previously undiagnosed mental illnesses
- Funding for services/developmental disability wait list; additional numbers have significant impairment but do not qualify for waiver criteria
- Quick assessments and service intakes for any type disorder

## Where Do We Go from Here?

- Look at the existing continuum of services and prior recommendations
- Identify any additional gaps and needs
- Prioritize and address the biggest need
- Consider and enlist/leverage support of all available funding sources
- Create working Memoranda of Agreement and procedures to expedite smooth process of referrals and benefit applications
- Work as a team!
- Make recommendations for APIC implementation

## Disability Justice Background Historical Information1988–2006

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

## Changes Since 1988

***1987–1990: *****Mentally Ill Offender Task Force**  NAMI, DOC, CJS, APD, API, AMHB, mental health agencies, and others work to create a vision of the continuum of services needed to help mentally ill who come in contact with the criminal justice system
*Task Force estimates two to three times as many mentally ill people in DOC than in API*

## Community Changes

- Community Mental Health Centers agree to accept referrals of people coming out of corrections
- 1990 *IDP* **Institutional Discharge Project**
- DHSS funded CMHCs to have reduced caseloads and special services for individuals who meet special criteria *(6 months in jail or API, or three or more arrests/admits in the 12 months before entry)*

## Changes Inside DOC

***1991***
**Forensic Consultation Team** moves from API to manage Mental Health Services in DOC and oversee State and contract mental health staff in 13 correctional facilities
**Mike Module **– the men’s mental unit opens at Cook Inlet Pretrial Facility, *AKA    ACC-West  *– provides 24-hour assessment and treatment services

## 1991 News Flash

- Alaska Department of Corrections has the **fourth highest incarceration rate** in the United States
- Transitional Living Center closes – funded by DHSS, it was the largest mentally ill halfway house in Alaskan history; none ever has been built to replace it
*1992–1994* DMHDD/DOC contract with Allvest to operate a halfway house for mentally ill individuals leaving DOC

## Release Initiatives in 1994

***IDP+***
- DMHDD and DOC develop and initiate a release program to provide individualized treatment services for the seriously mentally ill offender with a psychotic disorder releasing on felony probation
- Since inception, program participants have not had any new violent offenses while in the program

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

**Women’s Mental Health Unit** – opens at Hiland Mountain Correctional Center – provides 24-hour assessment and treatment services
**JAS** – begins as a pilot project in conjunction with the Anchorage District **Mental Health Court** – provides specialized sentencing, links to community resources, and monitoring for mentally ill misdemeanants in Anchorage

## Anchorage Prebooking Diversion“On the street before arrest for a crime”

_*Anchorage Police Department*_* and *_*NAMI*_
*	**Crisis Intervention Team (CIT):*
- Officers learn about mental disorders and associated behaviors
- Learn about community alternatives to jail
- Respond to situations involving people with mental disorders, deescalate those situations
- 						*Operating since 2001*

## Anchorage Single Point of Entry Providence Psychiatric ER

- Able to screen people in crisis
- Can refer to detox, a Providence Psychiatric bed for up to 24 hours, refer to Crisis Treatment Center, approve transfer to API, or make other recommendations that make sense for the individual
- Use Providence and Southcentral Counseling Center staff members to make assessments and meet the needs of the individual
- 						*Operating since 2002*

## Anchorage Jail A.K.A. Anchorage Correctional Complex-East

- Opened in 2002
- Anchorage Jail or ACC-East serves as the booking facility for all of Anchorage
- Houses 416, census has been as high as 557, running >500 every day this fiscal year
**13,503** bookings in FY 2006
**35–70** bookings per day in FY 2006, average **52** bookings per day
**12–15**+ *new* referrals to DOC Mental Health each day

## NAMI and Consumer Initiatives

- NAMI booklet, “When a Person with a Mental Disability Is Arrested: How to Help,” written in 2003
- NAMI and other consumer education/self-help groups and initiatives on the increase in 2003–2004
- Trust Beneficiary Group Initiatives selected as Trust focus group for funding in 2004

## Former Misdemeanor Mental Health Release Option

- CCAP jail precharge diversion was available
- December 2003–May 2006
- CCAP served mentally ill individuals arrested on Municipality of Anchorage misdemeanor charges who meet eligibility criteria and voluntarily agreed to participate in the Anchorage precharge diversion program operated by Anchorage Community Mental Health Services under a Federal SAMHSA grant through the Alaska DHSS Division of Behavioral Health
- Funding for this program **lapsed** in FY 2006
*	**	**	**	**	**	**	*
*	**	**	**	**	**Operated December 2003–May 2006*

## CCRP Increased CollaborationAgencies Involved in 2003 MOA

***Memorandum of Agreement Among***:
- Alaska Court System
- Anchorage Police Department
- Division of Behavioral Health (DBH)
- Department of Corrections (DOC)
- Municipal Prosecutor’s Office
- National Alliance for the Mentally Ill
- Southcentral Counseling Center
- UAA Behavioral Health & Research Services (BHRS)
***With Additional Assistance from***:
- Alaska Mental Health Trust Authority
- Consumer Advisory Group

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

- Trust convenes representatives from State agencies and four beneficiary boards to identify major problem areas requiring attention
- Four Focus Groups selected: Disability Justice, Housing,** **Bring the Kids Home, and Trust Beneficiary Group Initiatives
- Trust allocates funding to each focus group and promotes continued planning and collaboration

## Alaska Interagency Council on Homelessness Promoted statewide increased awareness in 2004

- President Bush asked that each State convene a statewide policy-level council to address homelessness
- State of Alaska Department Commissioners,   the Trust, and Federal agencies met to discuss the reality of homelessness in Alaska
- Cross-education, communication, and collaboration promoted
- Recommendation for Housing Trust put forward

## DOC and Social Security Administration AgreementStarts in 2004

**DOC and SSA sign MOU in Nov 2004 to develop a Prerelease Application Process **– pilot program started and first application submitted in 2004
- Pilot started with individuals being released to IDP+, with documented diagnosis of severe psychosis and inability to work for at least 1 year after release
***Approval rate 100% for pilot prerelease program compared to 57% for comparative population  ***
- Win-win situation benefits consumer, SSA, DOC, and community providers
- Plan to expand eligible populations for prerelease program processing

## Palmer Mental Health Court  Started in 2005 with Trust funds

**Palmer Coordinated Resources Project ***PCRP* – a second misdemeanor mental health court starts in March 2005
- DOC Mental Health Clinician serves as PCRP Case Coordinator working in conjunction with the Palmer District **Mental Health Court**
- PCRP provides specialized sentencing, links to community resources, and monitoring for mentally ill misdemeanants in Palmer

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

**National Best Practice APIC Model to be implemented in Alaska in 2007**
- State, Federal, and community agencies collaborate to improve reentry and transitional planning and services for individuals with mental illness and co-occurring disorders who will be released from Alaska DOC
- Memoranda and procedures streamlined to *assess, plan, identify, and collaborate* aiding Trust beneficiaries to transition to the community successfully