# Presentation: 347923

## Making Jail Diversion Work in Rural Communities

**GAINS TAPA Center                       for Jail Diversion **
**Easy Access Net/Teleconference**
**March 27, 2006**

## C.I.T. in a Rural Community

- Brown County, Ohio’s Experience
**Colleen Chamberlain, LSW, M. Ed**
**CIT Project Director**

**Notes:**
Brown County is located in southwestern Ohio, on the Ohio river. It is approximately 40 east of Cincinnati. The Brown County Community Board of Alcohol, Drug addiction and Mental Health Services is the agency that receives state and federal funding to contract for needed services in the community. We also seek grants for other programs, such as This one.

## Brown County, Ohio

- Population = 42,890
- Total square miles = _492_
- Population per square mile = 86
- Per capita income = $17,100
- Medical facilities = 1 hospital with 35 beds
- Psychiatric facilities = none
- Detention facilities = 1 with 36 beds

**Notes:**
Here is a brief overview of the county

## Before CIT: Us and Them

- Lack of Understanding about Mental Illness
- Lack of Understanding about Mental Health Services
- Lack of Understanding about Law Enforcement’s Role and Responsibility

**Notes:**
When looking at the development of a CIT , there were some definite issues that had to be resolved...

ANECDOTE about john and Steve at the election board

## More Reasons Not to Get Along

- Lack of Historical Cooperation
- Resistance to Change
- Territorialism
- Scarce Resources and Little Funding

**Notes:**
There was no history of cooperation.. This is not really an exclusively rural issue

No reason to do anything any differently than we have always done... worked for 20 years, why change

This is your dance space, this is my dance space....

When there is nothing, everyone fights over the crumbs

## The Cast of Collaboration

- You must have the Key Stakeholders involved from the very beginning.
- Brown County Prosecutor
- Brown County Sheriff’s Office*
- Brown County Community Hospital
- Brown County Juvenile Court
- Brown County EMT’s
- Brown County Municipal Court Probation Department
- Brown County Counseling
- Brown County Common Pleas Court
- Brown County Board of Alcohol, Drug Addiction and Mental Health Services
- *represented law enforcement in the county as they are the largest agency

**Notes:**
This is a quick overview of the group that we identified as KEY stakeholders in the planning and implementation of this project. 

The chance of success would have diminished if we had left out any of these stakeholders

## The Background

**Police Perspective and Goals**
**Increase officers’ awareness of mental illness and mental health crisis**
**Increase safety for officers and individuals in crisis**
**Reduce return calls to residences on other days and other shifts by making an appropriate disposition initially**
**Increase the tools available to officers dealing with a mental health crisis**

**Notes:**
What were the selling point for the cops?

They face these situations all the time

A hands off approach is always preferable

Anything to reduce the number of frequent flyer calls

Free resources available to them with the ease of a call

Decrease the people going to jail 

Increase the care of those in jail when mental health services are necessary

## Making C.I.T. Viable

**Inventory of Services**
**Adapting an Urban Model **
**Supporting CIT**
**Implementation**

**Notes:**
Here are the necessary elements to make this work...

## Inventory of Services

**Community Resources as the Foundation**
**General Community Hospital**
**Telephone Helpline**
**Counseling Center**
**State Psychiatric Hospital**
**Psychiatric Beds in Neighboring Counties**

**Notes:**
Talk briefly about each of these. Emphasis on the fact that none were connected in any meaningful way.

## Adapting an Urban Model

**Making Modifications**
**Assessing what will work**
**Gaining consensus**
**Maintaining commitment**
**Ensuring sustainability**
**Maintaining fidelity to the intent and purpose of CIT**

**Poor Fit with Urban Best Practice Model**
**Community resources available**
**Training opportunities and obstacles**
**Geography**
**Law enforcement demographics within the county**

**Notes:**
The biggest start up challenge was to take the Memphis model which requires a 40 hour program that selected 25% of the officers to participate, and providing a 24 hour drop off triage site and modify it in such a way that is was do-able with our limited resources , covered all shifts, and met the needs of our officers and lour clients....

IE homelessness is not as big a problem in our Appalachian community ( family steps in most of the time), but there are many isolated locations in which the elderly live... these house often have limited conveniences .. The need for education about adult protective services  and resources for elderly caregivers who may be caring for an adult child with MR was necessary

here were several issues to consider... ,

Creating dispositional options other than jail for the CIT officers to access when none existed in the county

Lack of a quick turnaround 24 hour access point for officers to drop off clients 

2.Absolute impossibility of getting officers off for a 40 hour training... how much was enough time without compromising the integrity of the training. The need to train 100% of officers including CO’s, opening up the training to EMT’s and probation officers and hospital personnel

3.Logistically finding a way to do the training which would open the opportunity to departments that had less than 10 officers.. Some only have 2. And not create tremendous overtime pay issues for communities barely keeping their heads above water..... Days of the week. Starting times. 

3. Finding a way to give officers a chance to interact with mental health consumers in a non-crisis situation... without having group homes or social clubhouses to visit

4. Since it takes over an hour to travel from one side of the county to the other, it was important to facilitate the development of CIT mutual aid... although this existed with “real” emergency calls, often, mental health calls were seen as a nuisance rather than a crisis and hands off was the unofficial response policy...

5. Engaging the small department... face to face meetings.... Using the influence of your champions.... Making use of the first graduates in recruiting their buddies from other departments

Making modifications....

Fidelity is an important part of any best practice, but the ability to replicate the Memphis model or even the Ohio Akron model was impossible for us... we had to start with what we had.... Not what we wish we had..

Honing down the CORE ELEMENTS of CIT and focusing on them to create the training.. What is CIT really?
general education and improved understanding about mental illness- symptoms, behaviors
Providing perspectives from the “other side” for officers
Enhancing verbal de-escalation abilities. Increasing ability to communicate with those in mental health crisis
Increasing knowledge about dispositional options and improving the resource base for officers to use
Making sure mental health support is available to officers 24/7

3. The advisory group of key stakeholders became critical... evaluation of the curriculum, getting in as many “experts” to teach... these are local experts and the very same people that officers may encounter or hear of in their response to CIT calls, securing consumer support for CIT and using them in meeting with officers one to one along with the case management staff

4. Securing on-going involvement and commitment from the stakeholders so that sustainability really becomes a moot point as CIT becomes a part of the professional culture in the county

## Supporting CIT

**Train officers**
**Develop CIT curriculum for rural county and adapt urban model for local community**
**Jail Boundary Spanner**
**Work with requirements for jails and hire RN that has psychiatric experience****	****	**
**Develop screening tool for mental health and substance abuse issues**
**Develop operational policies**
**Linkage to community services**

**Notes:**
The placement of a full time RN with psychiatric experience has immensely improved the jail medical services and has introduced mental health screening for all inmates. When issues are identified that need attention, referral is made to the psychiatrist that is funded by this grant or the substance abuse counselor who is funded through a byrne grant. Linkage is made for inmates who are released from jail to appropriate community services. 

Whenever you make systemic changes,  there are secondary consequences of all actions– some good and some not so good

there are complaints from the local officials about the costs of psych meds being perscribed for inmates while in the jail. 

There was also thousands of dollars of medical cost savings as the full time nurse was able to deal with medical issues that in the past were sent out to the local hospital for treatment.

## Supporting CIT (Continued)

**Expanded Helpline Services**
**Provide direct cell phone access for officers to mental health responders **
**Provide 30 minute response time to secure triage site**
**Psych Triage Sites**
**Establish relationship with community hospital to provide a safe environment for assessment**
**Set up area at the jail for psych triage that is pre-booking**
**Security provided by transporting officer**
**Crisis Responders follow case through disposition**

**Notes:**
The help line services in our community were virtually telephone only. On the rare occasion, a counselor would do a face to face evaluation. The responsibilities of this position have changed and face to face evals are required for all officer involved calls. We have introduced the Suicide assessment scale and the Indicator of Violence prediction scale to the tools that the evaluators are using to provided objective data to support their clinical decisions. 

Triage sites at the local hospital with the creation of a mental health room and at the jail have given CIT officers the opportunity to get a quick evaluation of a person without having to drive to the next county, wait in the ED, and then return, often taking 3-6 hours

## Supporting CIT  (Continued)

**Psychiatrist for Consultation**
**Consultation services for jail inmates who can’t be diverted, but are presenting symptoms of mental illness**
**Crisis Stabilization**
**Contract with facilities that have crisis services**
**Issues continue with distance and transportation**

**Notes:**
Psychiatric time has been added for the jail. This provided consultation and supervision for the RN and medical physician, medication management for the inmates who are on or need to be on psychiatric meds. 

 Crisis stabilization contract for inpatient alternative.. But once again this is 2 couties awsay

## Implementation

**Develop contracts **
**Develop protocols**
**Develop policies **
**Develop CIT curriculum, recruit speakers, begin training**
**Set up outcome monitors**
**Prepare for Murphy’s Law**

**Notes:**
This si a quick checklist of the very basics for implementation, There were a million little things that have cropped up since the start. If you hope for the best and prepare for the worst, you are likely to succeed. 

## Contact Information

**Colleen Chamberlain, LSW, M. Ed**
**Associate Director**
**CIT Project Director**
**85 Banting Dr.**
**Georgetown, OH 45121**
**937-378-3504**

## 
Implementing Jail Diversion in 
Virginia’s New River Valley

Victoria Huber Cochran, JD
Amy Forsyth-Stephens, MSW
Mental Health Association of the New River Valley
Blacksburg, Virginia

- Implementing Jail Diversion in
- Virginia’s New River Valley
- Victoria Huber Cochran, JD
- Amy Forsyth-Stephens, MSW
- Mental Health Association of the New River Valley
- Blacksburg, Virginia

## Where in the world is the New River Valley?

## A beautiful place tolive and work...

**A beautiful place to****live and work...**

**...****a challenging place to implement jail diversion **

## 
1,458 square miles
Population 165,000
Four counties
One small city (pop. 15,000)
Ten towns 
Fourteen Law Enforcement Agencies
Two jails (one regional, one local)
Two public universities
One community college

- 1,458 square miles
- Population 165,000
- Four counties
- One small city (pop. 15,000)
- Ten towns
- Fourteen Law Enforcement Agencies
- Two jails (one regional, one local)
- Two public universities
- One community college

## Montgomery County Jail

Booked approximately 4,400 individuals in 2005
~60% non-violent crimes
~75% released w/in 72 hrs.
~150 potentially eligible for post-booking jail diversion

New River Valley Regional Jail

Average Daily Census: ~500 inmates
About half within catchment's service area 
16% anticipated to have MI/co-occurring SA disorders

- Booked approximately 4,400 individuals in 2005
- ~60% non-violent crimes
- ~75% released w/in 72 hrs.
- ~150 potentially eligible for post-booking jail diversion
**New River Valley Regional Jail**
- Average Daily Census: ~500 inmates
- About half within catchment's service area
- 16% anticipated to have MI/co-occurring SA disorders

## Mental Health Services in the New River Valley
Public mental health needs met by one community service board agency
No public mental health in-patient beds available in the NRV
Nearest state hospital facility is two hours away
One private, proprietary medical facility with an in-patient behavioral health unit—Carilion New River Valley Medical Center

- Public mental health needs met by _one_ community service board agency
- No public mental health in-patient beds available in the NRV
- Nearest state hospital facility is two hours away
- One private, proprietary medical facility with an in-patient behavioral health unit—Carilion New River Valley Medical Center

## Our Mantra:

“It’s All About Change!”

***“******It’s All About Change!”***

**Notes:**
We always all we accomplished was to bring people together to develop relationships and educate one another, then we would have accomplished so much!
CIT is a MINDSET, not just about the training!!!  If it was that easy, why all the fuss?
Importance of consumer piece- cathartic meeting at the jail, everyone opening up and recognizing the need for improvement.  Largely due to consumer disclosures.

So, we asked ourselves the age old questions, “How do we eat this elephant?”

## The Mechanisms for Making Change...
Identifying the needs
Targeting the programmatic solutions
Identifying and organizing the stakeholders
Identifying the leaders/power brokers
Acknowledging barriers
Allowing ownership in developing solutions
Providing consistent organizational support throughout the process

- Identifying the needs
- Targeting the programmatic solutions
- Identifying and organizing the stakeholders
- Identifying the leaders/power brokers
- Acknowledging barriers
- Allowing ownership in developing solutions
- Providing consistent organizational support throughout the process

## The Criminal Justice Continuum and
Mental Health Intervention Intersections:		
	Pre-booking
	Post-booking
	Trial
	Post-Trial
	Post-Incarceration (prisoner re-entry)

- Mental Health Intervention Intersections:
- 	Pre-booking
- 	Post-booking
- 	Trial
- 	Post-Trial
- 	Post-Incarceration (prisoner re-entry)

## 	Two SAMHSA Community Action Grants for Consensus Building, Planning and Implementation of CIT	(April 1, 2002 - September 30, 2005) 

	One SAMHSA Targeted Capacity Expansion
   Grant to Enhance CIT and Create a New Post-Booking Diversion Program (The Bridge)
		(October 1, 2005 – September 30, 2008)

**	****One SAMHSA Targeted Capacity Expansion**
**   ****Grant to Enhance CIT and Create a New Post-Booking Diversion Program (The Bridge)**
**	****	****(October 1, 2005 – September 30, 2008)**

## Pre Booking Diversion:

The Crisis Intervention TeamMaking Change in Our Community

Post Booking Diversion:

The Bridge Program
Putting the Puzzle Together

- The Crisis Intervention TeamMaking Change in Our Community
- Post Booking Diversion:
- The Bridge Program
- Putting the Puzzle Together

## Overall Goal of a Pre-Booking Diversion Program such as CIT:

*To prevent the inappropriate jailing of persons with mental illness and instead, provide treatment in the community.*
- The diversion occurs at the point of contact with highly trained, specialized law enforcement officers _*before*_ formal charges are made.

## Organized 65 Stakeholders into 3 “Strands”
Mental Health
Law Enforcement
Consumer/Community

Leaders from 14 law enforcement agencies
Representatives from 5 separate governmental entities
Consumers, family members and advocates
Public and private mental health care providers
Magistrates
Community organizations

- Mental Health
- Law Enforcement
- Consumer/Community
- Leaders from 14 law enforcement agencies
- Representatives from 5 separate governmental entities
- Consumers, family members and advocates
- Public and private mental health care providers
- Magistrates
- Community organizations

## Basics of Rural CIT Implementation

Centralized CIT Program coordination with a neutral agency
Assemble local volunteer CIT Faculty
Conduct at least two trainings per year
Reduce/eliminate training fees as resources allow
Establish goal for all agencies to train 20%
Allow each agency to establish own CIT policies
Establish ongoing quarterly meetings of chiefs and sheriffs
Train dispatchers 
Establish centrally located CIT triage facility

- Centralized CIT Program coordination with a neutral agency
- Assemble local volunteer CIT Faculty
- Conduct at least two trainings per year
- Reduce/eliminate training fees as resources allow
- Establish goal for all agencies to train 20%
- Allow each agency to establish own CIT policies
- Establish ongoing quarterly meetings of chiefs and sheriffs
- Train dispatchers
- Establish centrally located CIT triage facility

## Overall Goal of a Post-Booking Diversion Program such as The Bridge:

*To prevent the inappropriate pre-trial incarceration of persons with mental illness charged with crimes and instead, provide treatment in the community*
- The diversion occurs at the initial court appearance *within 24 to 72 hours of arrest*.

## How will the Bridge Program work?

**How will the Bridge Program work?**

## Slide 32

## Slide 34

## THE OBSTACLES WE ALL FACE

Under-funded public mental health systems
Stigma
Lack of effective means of communication among disparate stakeholder groups
Keeping people at the table
Developing EBPs and establishing mechanisms to deliver comprehensive services

- Under-funded public mental health systems
- Stigma
- Lack of effective means of communication among disparate stakeholder groups
- Keeping people at the table
- Developing EBPs and establishing mechanisms to deliver comprehensive services

**Notes:**
Read slide.

Let me read from the letter of support that Major Sam Cochran, CIT Memphis expert, wrote for our grant proposal:

“Your project offers particular interest.  First, the community effort is not about establishing just a crisis program and moving on.  It is about dedication and commitment to introduce a change—one that allows not only a collaboration of systems, but also, a collaboration of communities working together.  Secondly, your project in the NRV is unique because you serve a diverse, rural, multi-jurisdictional area.  To date, CIT has primarily been replicated in large municipalities.   Replicating in a rural setting that involves collaboration between multiple city and county law enforcement jurisdictions is a new challenge, but one very worthy of attention.”

Let me now reintroduce Victoria Huber, our Project Facilitator.  I’m not sure we could have gotten even this far without the passion, dedication, and caffeine consumption of Victoria.  She was the obvious choice as Facilitator, and you’ll now learn why I feel that way!

## 		MORE OBSTACLES WE ALL FACE

Identifying resources for support services e.g., housing, transportation
Overcoming consumer resistance
Addressing criminal justice systems needs
Obtaining judicial buy-in
Obtaining prosecutorial buy-in

- Identifying resources for support services e.g., housing, transportation
- Overcoming consumer resistance
- Addressing criminal justice systems needs
- Obtaining judicial buy-in
- Obtaining prosecutorial buy-in

## ... and on top of THAT because we’re RURAL!

Coordinating 14 Law Enforcement Agencies and 2 Jails 
Coordinating multiple public and private service providers
Closest public psychiatric hospital is two hours away (Marion)
Enlisting support from a local private hospital to develop a modified triage facility
Distance/transportation issues
Appalachian cultural mindset/values

- Coordinating 14 Law Enforcement Agencies and 2 Jails
- Coordinating multiple public and private service providers
- Closest public psychiatric hospital is two hours away (Marion)
- Enlisting support from a local private hospital to develop a modified triage facility
- Distance/transportation issues
- Appalachian cultural mindset/values

## AND THAT’S NOT ALL!

Complicated, multi-faceted interpersonal relationships 
Historical suspicion of change 
Resentment of inequitable resource distribution
Multiple court levels, jurisdictions, judges and prosecutors in relatively autonomous court sub-systems

- Complicated, multi-faceted interpersonal relationships
- Historical suspicion of change
- Resentment of inequitable resource distribution
- Multiple court levels, jurisdictions, judges and prosecutors in relatively autonomous court sub-systems

## Recognizing the needs
	Identifying the solutions
		Creating the context for change
			Turning obstacles into opportunities

- Recognizing the needs
- 	Identifying the solutions
- 		Creating the context for change
- 			Turning obstacles into opportunities

## Thank you for joining us!

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