BOS Agenda Date .January 25, 2005

County of Santa Clara
Santa Clara Valley Health & Hospital
System
Mental Health Services

HHS07 012505

Prepared by: Nancy Pena, Ph.D
Director, Mental Health
Department

Submitted by: Nancy Pena,Ph.D
Director, Mental Health
Department

DATE:

January 25, 2005

TO:

Board of Supervisors

FROM:

/SfA
Robert Sillen

Executive Director, Santa Clara Valley Health & Hospital System

SUBJECT: Report Back on Referral Regarding De-escalation Training and Crisis
Intervention for First Responders to Calls Involving Mentally 111 Consumers

RECOMMENDED ACTTON

Accept repprt back on,de-escalation training and crisis intervention for first responders to
calls involving mentally ill consumers.

Board of Supervisors: Donald F. Gage, Blanca Aivarado. Pete McHugh,Jinl'iBeall. LizKniss
County Executive: Peter Kutras Jr.

BOS Agenda Date January 25, 2005

FTSCAT. TMPTJCATIONS

There is no impact on the County General Fund due to acceptance of this informational report.
REASONS FOR RECOMMENDATION

At its November 2, 2004 meeting, the Board of Supervisors approved Supervisor Jim Beall's

request for a report on the current services available to incarcerated mentally ill consumers in
Santa Clara County. The referral further requested information on the cost of the services and
'the source offunding for these services. Specific information requested included:
1. Recent history and current status of collaboration between County Mental Health

Department and first responders when addressing incidents involving mentally ill consumers.
2. Provide estimates of the un-reimbursed general fund dollars spent on medical care for the

mentally ill in the criminal justice system; pre-sentencing through incarceration.
3. Provide list of services or rights to medical care that mentally ill clients lose once placed in
the criminal justice system.

4. Provide medical perspective of case management challenges for mentally ill clients within
criminal justice system.

5. Provide description of potential consequences of interruption of medical treatment to
incarcerated mentally ill clients.

6. Describe best practices that improve both practices and communications between mental
health professionals and first responders, and improve client outcomes.
BACKGROUND

The Custody Health Services(CHS)Division of the Santa Clara Valley Health and^Hospital
System(SCVHHS)provides medical and mental health services to incarcerated adults. The
Mental Health Department(MHD)provides the mental health services to juveniles in Juvenile
Hall and Ranch custody and medical services are provided through CHS. MHD also provides

Board of Supervisors: Donald;F. iSage, Blarica Alvarado. Pete McHugh,Jim Beali, Liz Kniss
County Executive; Peter Kutras Jr.

BOS Agenda Date :Januaty 25, 2005

the aftercare services to adults and juveniles through county-operated and contracted

community providers, with the exception of the PALS (Providing Assistance with Linkages to
Service) program that is administered through CHS.

Approximately 17% of the average 4,000 adult Jail population receives mental health services
while in custody. Due to the lifestyles of many adult inmates, Jail often becomes the first

provider of medical and mental health services. Initiation of treatment for long-standing but
previously unidentified health problems, such as AIDS, Hepatitis, and Schizophrenia, is
common among the inmate population. Additionally, due to the unique stressors associated
with incarceration, many inmates receive mental health services in Jail (i.e., medications,
support therapy, and counseling) that they would not seek or qualify to receive free of charge
in the community.

When inmates are to be released from Jail, CHS staff work aggressively to connect them to

community based services to insure continuity of services. Inmates who are diagnosed with
serious mental illnesses are referred to MHD for continued treatment through an established
referral protocol.

. .

Mental health services provided by CHS to referred inmates in the adult custody facilities
include:

a. Crisis Services— Crisis assessment and intervention, brief supportive counseling 24 hours

per day,7 days per week. Referrals may be made to Mental Health at the time of booking by
the arresting officer, medical staff(based on arrestees response to several screening
questions). Department of Correction(DOC)staff, family members, or at the request of the
arrestee. Referrals may also be generated automatically based on the particular charges (i.e.,
murder, crimes against a child, sex crimes, etc.).

b. Outpatient Case Management- Ongoing supportive counseling, medication management,
and crisis intervention for inmates who are not in the acute psychiatric treatment unit. Inmates

treated on the acute psychiatric unit are followed by Outpatient Case Management staff upon
release from the acute psychiatric unit(8A).

Board of Supemsors: Donald F. Gage, Blarica Aivarado, Pete McHdgh,Jirn'Beaii, Liz Kniss
Counti' Executive: Peter Kutras Jr.

BOS Agenda Date January 25, 2005

c. Acute Psychiatric Treatment- Hospitalization for inmates who are dangerous to self,
dangerous to others or are gravely disabled as a result of mental illness.
d. Medical Aftercare — CHS has recently implemented a Discharge Planning Program to

provide continuity of care for inmates released from jail who have a medical condition that
requires follow up care. The goal of this program is to provide medication prescriptions,
medical provider and appointment information to inmates who need to continue medical care
after release from custody. This program targets all inmates, mentally ill or not.
The following addresses specific items outlined in the referral from Supervisor Beall:
1. Recent History and Current Status of Collaboration Between County Mental Health

Department And First Responders When Addressing Incidents Involving Mentally 111
Consumers.

MHD has worked to provide for the mental health needs of community members that come in
contact with law enforcement and other first responders. The most enduring collaboration is
the Crisis Intervention Team Academy (CIT), a collaborative training effort that provides 40
hours of training to police personnel. The training, designed in collaboration with San Jose
Police Department(SJPD), National Alliance for Mentally 111(NAMI), and, public and private
mental health professionals, gives police officers a basic understanding of the symptoms and
behaviors associated with mental illness, and offers strategies for managing mental health
related concerns in the course of community police work. To date, fifteen academies have
been offered to approximately 322 SJPD law enforcement personnel, and an additional 33 law
enforcement personnel from other jurisdictions.

In addition, police have access to mental health information when they are dealing with a
community crisis where a possible mental health client is involved. The law allows for the
Emergency Psychiatric Services(EPS)staff to provide information that may assist in the
management of the situation. EPS evaluates approximately 35 individuals each day who are
brought to the emergency service for evaluation and treatment. Approximately 75-85% of
those individuals, approximately 28 per day, are brought in by police. In addition, MHD
administration provides consultation and coordination to SJPD upon request, and continues
ongoing dialog regarding the interface between SJPD and MHD.

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.

BOS Agenda Date iJanuarj' 25, 2005

In the FY02/03 budget reduction process, the Board of Supervisors approved the elimination
of the Mental Health Mobile Crisis Team ($376,998), a program consisting of 4.5 FTE
clinicians who responded to calls for mental health assistance with police situations involving
the mentally ill. The elimination of this program was proposed in large part because of the
dramatic reduction in calls for mental health assistance since the implementation of the GIT
training program.
A second program that was also eliminated in recent reductions was the Intensive Alternative
Program (lAP), a program for dually diagnosed individuals referred from the custody setting.
This program offered residential and treatment services and showed promise in providing
specialized services to the criminal justice population. It was eliminated during budget
reduction process, the rationale being that the program was not a mandated, core service of the
MHD.

A third successful program that continues is the. Pual.Diagnosis Treatment Court, which
offers case management and linkage services to individuals with concurrent mental health and
substance abuse problems through the Drug Treatment Court.
2. Provide Estimates Of The Un-Reimbursed General Fund Dollars Spent On Medical Care
For The Mentally 111 In The Criminal Justice System; Pre Sentencing Through Incarceration.

Information on FY03/04 medical and mental health service costs provide a picture of general
fund dollars spent each year to care for incarcerated individuals served in the Main Jail,
Elmwood/CCW. Total health costs to the Health and Hospital System in FY03/04 totaled
approximately $27.5 million.
Clients Served FY03/04

Average FY04 Admissions to 8A Inpatient Unit: 1,484 (includes 175 out of County)
Average Daily Inpatient Census: 27.5

Outpatient Main Jail Monthly Caseload: 476

Board ofSupetvisors: Donald F. Gage, BlancaAlvarado, Pete McHugh,Jim Beali, LizKniss
County Executive: Peter Kutras Jr.

BOS Agenda Date January 25, 2005

Outpatient Elmwood Complex Monthly Caseload 380
Main Jail Crisis Referrals 18,128

Elmwood Complex Crisis Referrals 6,577
Total Number of Inmates on Psychotropic Medication 7,585
Total Number of Inmates seen by MD/Nurse Practitioners 6,544
Total Expenses

FY03/04 Adult Custody Mental Health $ 8,224,039
FY03/04 Adult Custody Medical $19,327,384
FY03/04 Total Adult Custody Medical/MH $27,551,423

Revenues associated with the provision ofthese services are not credited to SCVHHS even

though the majority of the reimbursed cost is attributed to SCVHHS (Custody Mental Health
expenses are charged back to MHD). Department of Correction(DOC)staff indicates that
FY03/04 revenue from other Counties for Mental Health services in the jail totaled

$1,919,091 and this revenue is credited to the DOC budget. In addition to this amount, a small
portion of the daily rate revenue DOC collects for Federal/State prisoners relates to routine
medical services provided in the jail by CHS. Finally, upon implementation of new
information technology CHS will be able to identify specialized medical services provided to
Federal/State inmates so that DOC can bill for these services.

3. Provide List Of Services Or Rights To Medical Care That Mentally 111 Clients Lose Once
Placed In The Criminal Justice System.

Mentally 111 clients that are incarcerated in the Jails in Santa Clara County do not lose access
to any health care services during their detainment that they would have received or had
access to in the community. In fact, the majority of inmates incarcerated in the Jails in Santa
Clara County receive more medical and mental health services in Jail than they typically
receive when they are residing in the Community.

Title XV,CCR (California Code of Regulations), mandates the provision of medical and
mental health services to inmates incarcerated in California Jails and Prisons. The regulations

Board of Supervisors: Donald F. Gage. Bianca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.

BOS Agenda Date iJanuaty 26, 2005

specific to Medical and Mental Health Services are delineated in Article 11, Sections 1200 to
1230 and include regulatory statutes related to Medical Records, Treatment Plans,
Pharmaceutical Management, Communicable Disease Management, Suicide Prevention,
Admission Screenings, Access to Treatment, Mental Health Services, Detoxification
Treatment, Informed Consent and Dental Care.

A full array of medical and mental health services are provided to inmates incarcerated in the
Santa Clara County Jails. We have historically interpreted the Title XV regulatory
requirement of access to care as provision of health services to inmates that are comparable to
services that inmates could access in the community if they were not detained in the Jail.
Thus, health care services in the Jails include disease prevention, treatment of chronic and
episodic physical and mental illnesses, and rehabilitative and palliative treatment for life
threatening diseases. To the extent possible, services are provided on site at the Jail facilities
but services that are not provided on site at the Jail such as specialty medical treatment and
hospitalization are provided at Valley Medical Center(VMC). The Jail does maintain a
designated LPS Unit for inmates who require acute level of mental health services during their
incarceration.

4. Provide Medical Perspective Of Case Management Challenges For Mentally 111 Clients
Within Criminal Justice System.

Experience in Santa Clara County with programs designed specifically for mentally ill clients
upon release frorn custody has shown that the majority of clients who are admitted to
treatment programs upon release from custody, came into custody on felony charges
(approximately 80%)while misdemeanor charges accounted for a much lower number
(approximately 20%). Of those that came in on felony charges, about 60%(ofthe 80% of
felony charges) were related to drugs. Problems providing mental health services in the
custody setting present in several ways in the criminal justice system:

a. Initial Identification of persons with a mental illness may be missed or delayed for several
reasons:

* At the time of booking some mentally ill clients deny that they take medications or have
a mental illness. This may be due in part to the fact that the arresting officer is present

Board of Supervisors: Donald F. Gage, BlancaAlvarado, Pete t^lcHugh, Jim Beali, Liz Kniss
Counti' Executive: Peter Kutras Jr.

BOS Agenda Date ;Januaiy 25, 2005

during the booking process. Mentally 111 clients often believe that admitting to having a
mental illness will label them in the system or create additional problems related to the
charges and court case.

* Many clients stop taking their psychotropic medications for a variety of reasons, and
revert to street drugs. They come in under the influence and are seen initially as requiring
detoxification. The need for mental health treatment doesn t make itself apparent until
later.

* Although there may be a delay in initial identification of a mentally ill inmate, they
typically come to the attention of mental health once they are in jail because of their
behavior which will cause officers or other inmates to initiate a referral. MHD staff also

receives calls from attorneys or family members or the mentally ill client will self refer
because they are experiencing symptoms which cause them distress.
b. Release from Custody prior to Case Management Services being completed:

* Arranging Community Mental Health Services for a Seriously Mentally 111 client in and
of itself is not a problem. MHD has been receptive and facilitates these connections,
however, system issues complicate this process. For example, it can take as much as six
weeks to obtain an appointment with a MHD service team. When inmates are released
prematurely they do not have access to the mental health system and will not have access
unless they take the initiative themselves.

* Mentally ill clients may be identified and treated by CHS mental health staff, however,
inmates are bailed out and leave the jail prior to case management services being
completed.

c. The Court may release mentally ill inmates after a court date, and by law they must leave
the facility by midnight. Although an inmate may be undergoing treatment with custody
mental health, their case management services may not have been completed, and mental
health is not aware of their release until after they have left the jail.

Board of Supervisors: Donald F. Gage, Biarica Alvarado, Pete=McHugh,Jim Beail, Liz Kniss
County Executive: Peter Kutras Jr.

BOS Agenda Date iJanuaty 25, 2005

* CHS mental health staff triage the priority order for Case Management Services in Jail
by release dates noted in Criminal Justice Information Computer(CJIC). This is done to
ensure that mentally ill are not released prior to completing case management services.
* Inmates who are mentally ill with a low level of functioning, but with misdemeanor
offenses are often sentenced to programs. Once they are in the programs, they can t
function at the level required to participate, and they go AWOL from the program. These
individuals are often rearrested, and having gone AWOL,they have violated a condition of
their probation and this creates a cycle of recidivism.

* An incarcerated mentally ill client may be stable on medication while in jail, however
they may not be able to maintain stability once released risking re-incarceration.
d. Level of community based support may not meet the needs for this population due to the
extensive and complicated nature of their problems.
• Chronically mentally ill clients involved in the criminal justice system often have

compliance problems that require an intensive period of hands-on support and linkage to
services to promote effective engagement in follow up services. Such services are only
available to a limited number of clients in the community.

• Chronically mentally ill clients have firequently alienated their families and have no support

system on the outside. Left on their own to cope with the requirements of the court, i;egistering
with probation, payment of court fines/fees, reinstitution SSI, attending court dates, and
appointments with mental health, they fail to be able to organize and complete these
requirements. This leads to the issuing of Bench Warrants, and when police stops the client,
this leads to re-arrest and recidivism.

5. Provide Description Of Potential Consequences Of Interruption Of Medical Treatment To
Incarcerated Mentally 111 Clients.

As indicated above, many inmates receive mental health services for the first time upon their
incarceration. The interruption of services is not the most critical issue, as ongoing treatment
is provided for those who are incarcerated who enter jail while in treatment. Rather, the

Board of Supervisors; Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim,Bea'll, LizKniss
County' Executive: Peter Kutras Jr.

. BOS Agenda Date Januarj' 25, 2005

biggest barriers to treatment appear to be more related to coimecting discharging inmates to
effective aftercare services that will address a multitude of complex problems, which often

include substance abuse,joblessness, homelessness, medical problems, absence of medical
insurance, and resistance to treatment. Thus, it is most important that effective aftercare and
diversion services be established to reduce the number of mentally ill who are involved in the
criminal justice system.

6. Describe Best Practices That Improve Both Practices And Communications Between
Mental Health Professionals And First Responders, And Improve Client Outcomes.

It is not realistic to expect that mentally ill individuals who are released from custody will be
able without assistance to meet the requirements of the court system to address the fines and
fees incurred during their incarceration, to address the need to register with the probation
department and meet requirements of probation, and to comply with traditional requirements
in the community for their mental health treatment. These clients, many with complex

problems, require specialized and often expensive individualized services to break the cycle of
untreated mental illness and repeated incarcerations.

Programs that provide intensive case management, such a the lAP and the PALS Program, at
the time of release iBrom custody have a higher compliance rate and have demonstrated some
reduction in recidivism. In addition, programs funded through AB34 are proving successful in
Santa Clara County and across the state. These programs are producing positive outcomes,
including a decline in new arrests for new offenses.(It should be noted that there are often
times remands to jail for failure to follow probation requirements which can skew the
recidivism rates, and that these remands are often seen by attorneys and judges as a slip vs.
commission of a new crime).

Some ofthe key best practice elements to services most effective with the mentally ill
involved in the criminal justice system include:

§ Intensive case management and engagement Criminal justice involved mentally ill clients
require a period of hands-on support and linkage to services to promote effective
engagement in follow up services.

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
10

BOS Agenda Date January 25, 2005

§ Integrated substance abuse and mental health treatment Criminal justice involved mentally
ill clients frequently have concurrent substance abuse problems that often are the primary
issue leading to incarceration. Effective services provide an integrated treatment approach that
addresses both problems.

§ Self-Help and Recovery Strategies Criminal justice involved mentally ill clients are often
alienated from families and primary social support that offer a sense of hope and opportunity
for recovery. Self help programs, often run by recovered consumers have proven to be
successful at providing alternative social support and incentives for recovery. Programs such
as the PALS Program- designed to address the needs of this population are effective and
relatively low cost.

§ Housing and Vocational Support Criminal justice involved mentally ill clients often lack
adequate housing and vocational skills. Intensive support is needed to assist these individuals
to obtain stable, drug-free housing. Many lack vocational skills and require assistance in
acquiring vocational skills that will allow them to support themselves.
Because services that include the above elements and are geared towards the criminal justice

involved mentally ill are expensive(many of these individuals do not qualify for public health
benefits) and limited, these individuals are much more likely to return to behavior that is
comfortable and known to them upon release from custody. Unfortunately this behavior often
involves resuming old contacts and relationships that were responsible for creating the
situations for which they were incarcerated in the first place, thus creating a cycle of
recidivism.

To ensure the adequacy of treatment for mentally ill (or those with medical problems),
treatment must be viewed as a continuum of services involving the jail and treatment
resources and providers in the community. Failure to view the need for treatment on a
continuum results in a splintered overall program for provision of adequate treatment.
An important aspect of treatment for mentally ill clients, is that both a person s mental
disorder and his substance abuse problems must be addressed. As noted, most inmates have
both problems. To treat only one or the other does not effectively address the inmates total
treatment needs. However, detoxification must occur before an inmate s treatment needs can

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Bete McHugh,Jim.Beaii, Liz Kniss
County Executive: Peter Kutras Jr.
11

BOS Agenda Date January 25,-2005

be effectively identified and then addressed. For inmates who remain in custody for a longer
time, experience has shown that treating both disorders, at the same time in an integrated
manner, using cross trained staff in the same service setting is most effective for people who
have moderate to severe symptoms.

Expanding the PALS Program (increasing the PALS Staff and numbers served), and including
a coordinator for medical discharge planning would provide a wrap-around model. This
model would incorporate best practices to deal with continuity of care issues and improve
client outcomes.

Additional measures which would improve client outcomes would be to have a liaison person

responsible for communication between VMC,Community Law Enforcement Agencies,
Community Mental Health, DOC,and Custody Health Services. Custody Health Services has
attended meetings with these entities and made significant headway in dealing with problems

specific to Custody Health and each ofthese agencies. A designated liaison could provide
linkages and communication between these agencies, thus assisting with the resolution of
issues on a more global scale, which would be a significant benefit to each of the entities
involved.

CONSEOUENCES OF NKQATTVE ACTION

The Board will not receive the requested information.

Board of Supervisors: Donald'F. Gage, B!aniiCa.'Alvarado, Pele McHugh,Jim Beail, Liz Kniss
County Executive: Peter Kutras Jr.
■ .

12