Memorandum of Understanding
between

The Mental Health Department,VMC Health and Hospital System
and

The Sheriffs Office, Santa Clara County

July?, 1997

Term ofthe Agreement and Relation to Other Agreements
This agreement for participation by the Sheriff’s Office in the Mobile Mental Health Team pilot

project will be in effect during July, 1997 through June, 1998; the term ofthis agreement may be
extended on mutual agreement ofthe parties. A thirty-day written notice from either party is
necessary to substantially change or terminate this agreement prior to June, 1998.
This pilot project was started February 6,1997 with the San Jose Police Department, and it will
continue to meet all obligations to support that Department. At this time, the Team will also begin
responding to other law enforcement agencies in the central San Jose area.
Pilot Program Objectives

The primary objective is to divert qualified persons with apparent mental disabilities from the
criminaljustice system by providing initial assessments, crisis intervention, and linkage to other
mental health services.

Operational Structure

The Mobile Mental Health Team will consist of qualified mental health professionals, employed by
the Mental Health Department. They will have LCSW or MFCC licence or waiver, and will be
authorized to write a 5150 psychiatric hold. The Team will be in service from 10:00 AM to 12:30
AM,daily, including weekends and holidays(In order to schedule a weekly staff meeting, the
times on Wednesdays will be 10:30 AM to 12:00 midnight). The base ofoperations will be the
Mental Health ACCESS program, located on the VMC campus at 2221 Enborg Lane. Staffuig
during the day shift(10:00 AM - 5:00 PM)will be one person; during the PM shift(5:00 PM 12:30 AM)two staff will be available, usually working together but able as needed and safe to
respond to two situations.

Memorandum of Understanding between Mental Health and the Sheriff
July, 7, 1997, page 2

The ACCESS unit will screen phone calls and provide the necessary clerical support. Access will

also facilitate new referrals to the various service providers in the public system of mental health
care.

All program staff will comply with the W&I Code Sec. 5328 regarding patient confidentiality.
Any incidents, procedural concerns or staff-related complaints will be reported promptly to the

appropriate supervisor. Mental Health staff will notify their supervisor ofconcerns about
deputies’ behavior, and the supervisor will discuss the incident with the Sheriffs Office liaison

with this project. Appropriate action will be up to the Sheriffs Office. Deputies with concerns

about Mental Health staff behavior will notify their supervisor, who will discuss the incident

with the Mobile Team supervisor. Appropriate action will be determined by the Mental Health
Department. In urgent incidents Team staffor deputies may contact the Sheriffsupervisor or
Mobile Team supervisor/director/on-call administrative staff as appropriate.

Target Group and Target Area

The intended target group for these services are those qualified adult persons with apparent
mental disabilities in the San Jose urban area who come to the attention ofSheriff deputies and
can benefit from the Mobile Mental Health Team intervention. This will generally be limited to

the Cambrian and Burbank Districts, the urban area ofthe East Side District, and to the Transit
Police in the urban San Jose area. Qualified persons may be arrested or cited for nuisance

misdemeanors, may have behavior as described in MS150, or may be involved in other public

disturbances.

Dispatch Procedures and Referrals

At the request ofthe deputy at the scene County Communications dispatchers will contact the
Team via cellular phone or pager. Ifthe Team is not involved in another police incident or 5150
evaluation, they will respond to the scene and evaluate the individual, with special consideration
to any possible diversion from the criminal justice system. The deputy will work cooperatively
with the Team until the situation is resolyed or until the deputy and the Team agree that the
deputy can leave and the Team can safely continue. It is understood that in managing the
situation at the scene and in final case disposition the deputy will be the ultimate authority. The

Sheriffs Office will give the Team a phone number for a direct line into Communications so that

the Team can discuss referrals and can call for assistance. The Sheriffs Office will give prompt

support to the Team when the Team feels their safety is at risk.
Transportation of clients

All clients who are on 5150 holds must be transported to an approved facility (usually EPS)by
ambulance or Sheriff deputy, or to a medical hospital by paramedics. Placement transportation

Memorandum of Understanding between Mental Health and the Sheriff
July, 7, 1997, page 3
Program Evaluation

Data requested by either the Sheriffs management team or Mental Health Administration will be
collected by the Team supervisor. Progress reports will generally be done bi-monthly.
The Sheriffs Office will send a representative to an planning group meeting monthly or as needed
to evaluate the effectiveness ofthe program and to plan for program changes, working
relationships, etc.

For the Mental Health Department

For the Sheriff

o

Cyt/jV^OSoleng

rn,MD

Interim Director

^UlO)
Charles tiPillingham
Sheriff, Santa Clara County

County of Santa Clara
Office of the Board of Supervisors
County Government Center, East Wing
70 West Bedding Street, l Oih Floor
San Jose, California 95 M o

(408) 299-5040

Pax:(408) 299-2038 TDD 993-8272
ww w.jim bea I l.o rg

James T, Beall, Jr.

Supervisor Fourth District

MEMORANDUM
November 1, 2004
TO:

Board of Supervisors

CC:

Peter Kutras

County Executive
FROM:

James T, Beall, Jr.

Supervisor, Distri^Four
RE:

Accept referraj^^garding de-escalation training and crisis intervention for
first responders to calls involving mentally ill consumers.

RECOMMENDED ACTION

Direct Administration to report back to the Board of Supervisors in early December

2004 related to providing training in mental health issues and de-escalation techniques,
and direct crisis

intervention for first responders to incidents involving mentally ill

consumers.

Staff report should include, the following:
♦

Recent history and current status of collaboration between County Mental Health

Department and first responders when addressing incidents involving mentally ill
consumers,

♦

..

.

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.

♦

Provide list of services or rights to medical care that mentally ill clients lose once
placed in the aiminal justice system.

Acid Fred Paper

♦ Provide medical perspective of case management challenges for mentally ill clients
within criminal justice system,

♦ Provide description of potential consequences of interruption of medical treatment
to incarcerated mentally ill clients.
4 Describe best practices that improve both practices and communications betw^een
mental health professionals and first responders, and improve client outcomes.
PTSCAL IMPACT

No fiscal impact to the general fund.
REASONS FOR RECOMMENDATION

From a humanitarian and treatment perspective the criminal justice system is

an

inappropriate environment to place individuals with serious mental illnesses. Many
homeless,or cirallenged with
people with mental illness; especially those who are poor,
health
treatment while
substance abuse problems, are unable to obtain mental
incarcerated. If they commit a crime,even for a nonviolent offense, sentencing laws
mandate imprisonment.

I believe that successful jail diversion is essential to ensuring the success of mental
health treatment programs. By referring and treating the non-violent mentally ill within
the community health and human service system,the County can provide better case
management,and provide appropriate treatment.An successful jail diversion program

promotes public health and improves public safety by expanding treatment alternatives

and thus improving outcomes for mentally ill clients.

state efforts to obtain a MediDepending upon the outcome of Proposition 63 and the
addressing the needs of

Cal waiver, there may be expanded opportunities for
incarcerated mentally ill clients in our community. Although the Board has prioritized
care for mentally ill clients within our community for many years,these additional

funds may assist in preserving services as we experience several years of budget deficits
For 2004-2005, the Large Urban County Caucus of the National Association of Counties
has selected the loss of federal entitlement benefits for the mentally ill in county jails as
of its top four legislative priorities (See attachment).
one

appropriately applied
I believe that jail diversion programs for the mentally ill when
that such programs are
are

ethically and fiscally prudent. Furthermore,1 believe

consistent with basic human rights,

BACKGROUND

issue for our
The fatal police shooting of the mentally ill have become a critical
and
resulted
in the death
commuiaity. The luost recent incident occurred in September
of a Bosnian refugee who had shown signs of a mental disorder. It was the fifth fatal
officer involved shooting by San Jose police this year alone.

Crisis Team ($376,998), The
In June 2002 the Board approved the elimination of MobileSocial
Workers and Rehab
Mobile Crisis Team had consisted of 4,5 FTEs Psychiatric

Counselors who provided de-escalation training and direct crisis intervention in
response to San Jose Police Department. Staff states that this budget elimination was
program as more police
justified, because fewer referrals had been forwarded to thisTeam
services. However,
officers became more directly trained in Crisis Intervention
where
collaboration
between the
staff has also indicated that there are important areas
mental health department and police department were improved as a result of the
Mobile Crisis Team.

absence of the
This referral seeks to better understand what resources exist in thethe
Mobile Crisis Team and within the current budget. Furthermore, referral seeks to

clarify what services incarcerated mentally ill clients receive and how those services are
paid for.

BOS Agenda Date January 25, 2005

County of Santa Clara
Santa Clara Valley Health & Hospital
System
<s>

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:

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

RFXOMMENDED ACTION

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

Board of Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jim Beall, Liz Kniss
Count'/ Executive: Peter Kutras Jr.
1

BOS Agenda Date January 25, 2005

FISCAT. TMPLICATIONS

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 of funding for these services. Specific infonnation 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 flind 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.
RACKGROUND

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. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County Executive: Peter Kutras Jr.
2

BOS Agenda Date January 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
the inmate population. Additionally, due to the unique stressors assoeiated
with incareeration, many inmates receive mental health services in Jail (i.e., medieations,

common among

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

3

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 elient 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
Count,'' ExecutVe: Peter Kutras Jr,
4

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 CIT
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 Dual 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 of Supervisors: Donald F. Gage, Blanca .Alvarado, Pete McHugh, Jim Beall, Liz Kniss
Count^i E:Kecutive. Peter Kutras Jr.
5

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 of these 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 ofSupemsors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jim Beall, Liz Kniss
Count/ Executive: Peter Kutras Jr.
6

BOS Agenda Date January 25, 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, Infonued 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 from 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%(of the 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, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
Count/ Executive: Peter Kutras Jr.
7

BOS Agenda Date Januaty 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 Serviees 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 aceess 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
eompleted.

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, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County' Executive: Peter Kutras Jr.
8

BOS Agenda Date ;January 26, 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 frequently alienated their families and have no support

system on the outside. Left on their own to cope with the requirements of the court, registering
with probation, payment of court fmes/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 ot Supervisors: Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
Couny Executive: Peter Kutras Jr.
9

, BOS Agenda Date :Januaty 25, 2005

biggest barriers to treatment appear to be more related to connecting 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
that effective aftercare and
insurance, and resistance to treatment. Thus, it is most important
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 from custody have a higher complianee 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 of the 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 Januar/ 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 adequaey 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
eontinuum 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 Supen/isors. Donald F. Gage, Blanca Alvarado, Pete McHugh,Jim Beall, Liz Kniss
County' Executhre: Peter Kutras Jr.
11

BOS Agenda Date iJanuaty 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 of these ageneies. A designated liaison could provide
linkages and eommunication 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.

CONSEQUENCES OF NEGATIVE ACTION

The Board will not receive the requested information.

Board ofSup8r^/isors: Donald F. Gage, Blanca Alvarado, Pete McHugh, Jim Beall, LizKniss
Count'/ Executive: Peter Kutras Jr.
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