YOU NEVER WANT A SERIOUS CRISIS TO GO TO WASTE
Our society is receiving loud signals during the COVID-19 pandemic of profound issues that deserve significant attention. One such signal is the magnitude of health disparities that exist amongst most vulnerable populations, such as the elderly, immunocompromised individuals, and patients with serious chronic medical conditions (such as diabetes, heart disease, or lung disease).
In this THCQ Consulting Health Care Quality Insights blog article, featured is a ground-breaking program that achieves transformative results focused on a specific vulnerable population – one often not on society’s radar screen – nonviolent misdemeanor and felony defendants with serious mental illnesses (SMI) or co-occurring SMI and substance use disorders. This population is, however, on the radar screen of local and state government officials because of the dramatic impact to state budgets. Last year for instance, local governments collectively spent over $80 billion dollars on correctional costs – much of it due to untreated mental illnesses and substance use disorders and the states spent an additional $70 billion dollars.
As we navigate through the treacherous waters of this pandemic, we thankfully can derive solace from the great good that is happening in key places. It was Winston Churchill that first said, “Never let a good crisis go to waste.” In looking forward to the post-COVID-19 new normal era, we should ask questions that will lead us to “not let this crisis be wasted.” One question I would challenge us to pose is: Where are the areas of greatest opportunity in our society today that can help catalyze transformative solutions facing vulnerable populations?
The Eleventh Judicial Circuit Criminal Mental Health Project (CMHP), Miami-Dade, Florida, is one such area of great opportunity. One that can very well function as the seed of widespread transformational change for the specific vulnerable population it serves [as it currently does], as well as a relevant model for programs helping other vulnerable populations. CMHP is a national best practice model, nearly two decades in its evolution, fostering hope and recovery for one of the most vulnerable populations in the U.S. The program already is a focal point to continue to be built on, to spread to other parts of the country, and a model to emulate for programs looking to effectively serve other vulnerable populations.
THE PROBLEM: Jails are the Largest Psychiatric Institutions in the Country
A big part of the motivation for my writing about the CMHP in this month’s blog issue was PBS’s recent airing (on April 14th) of the powerful, Rob Reiner-narrated documentary, “The Definition of Insanity” (https://www.pbs.org/show/definition-insanity/). I recommend it highly!
The documentary begins with the Honorable Judge Steven Leifman, Associate Administrative Judge, Criminal Division for the Eleventh Judicial Circuit Court of Florida, describing how he encountered a case in 2000 where he, by way of a highly educated, psychotically ill defendant before his court, became confronted with a vexing and disheartening dilemma.
Following that day in 2000, Judge Leifman emerged with a resolve to disrupt the status quo; unwilling to continue, unaffected, doing his job in a business-as-usual manner. As Chair of the Miami-Dade CMHP for the last 20 years and Special Advisor on Criminal Justice and Mental Health for the Supreme Court of Florida, Judge Leifman has not rested from: deepening his education and educating others; articulating a vision; enrolling others in that vision; instituting a reformed system; and sharing their best practice model across the country and world.
I had the pleasure in August 2009 to meet and collaborate over a period of time with Judge Leifman in my role at Janssen Neuroscience. Judge Leifman provided subject matter expertise on the design of a clinical trial for an injectable psychotropic medication for individuals with schizophrenia and recent history of criminal justice system involvement. The study resulted in a publication in the Journal of Clinical Psychiatry (Alphs et al., 2015). It was through this engagement that I first learned about the progressive, cross-system collaborative work being undertaken by the many stakeholders in the Miami-Dade County government to address the previously intractable problem that I outline below.
Criminalization of People with Mental Illnesses
- Incarceration has largely replaced hospitalization for thousands of individuals with SMI (e.g., schizophrenia, schizoaffective disorder, bipolar disorder, major depression, etc.) in the U.S.
- Last year, there were approximately 2 million arrests of people with serious mental illnesses
- On any given day in the U.S., there are approximately 400,000 people with serious mental illnesses behind bars and another 800,000 are under correctional supervision
- Those with SMI are 10 times more likely to wind up in jail than in a hospital
- There are approximately 1,800 state and federal prison facilities in the U.S., compared to over 3200 county, city, and local jails. This problem is predominantly with jails
- In prisons, inmates serve sentences of at least a year, whereas in jails most people are released relatively quickly. Importantly, jail recidivism rates for people with serious mental illness are high
- Costs to states and taxpayers are unsustainably high. It costs $31,000 a year to incarcerate a person with mental illness. In contrast, community mental health services cost $10,000 a year
Judge Leifman further shared with me, “40% of all people with serious mental illnesses will come into contact with the criminal justice system at some point in their lifetime. We have failed those with serious mental illnesses miserably in this country. We have applied a criminal justice model to an illness rather than a population health or a disease model necessary to manage these illnesses. We use acute systems of care – jail and hospitalization to ‘treat’ these illnesses rather than apply a continuity of care model like we would do with any other chronic illnesses like diabetes.”
A CROSS-SYSTEM COLLABORATIVE SOLUTION: The Miami-Dade CMHP
Judge Leifman stated in the PBS documentary, “We know how to fix this problem. It is a community problem requiring a community solution.”
The solution involving the de-criminalization of mental illness is exactly what the Miami-Dade CMHP does – and with a deeply human touch. At its core, the 12-month program is a cross-system collaborative with a focus on helping individuals with SMI that have been charged with nonviolent misdemeanor or felony offenses achieve recovery, successful reentry into the community, to live a normal, hope-filled life.
Success of CMHP is dependent on its people – the people that comprise the CMHP and those among the many community stakeholder collaborators. Table 1.0 lists the many cross-functional stakeholders, cross-system stakeholders, and innovative collaborator programs that make things happen with the CMHP.
Table 1.0. Functions and Programs Comprising the CMHP Cross-System Collaboration
The program does its work through the cross-system collaborative partnering of the stakeholders listed above to divert nonviolent misdemeanor or low-level felony defendants (in two separate arms of the program) with SMI with warm handoffs into community-based treatment and support services.
Specifically, the CMHP operates two major programs: (1) Pre-Booking Jail Diversion; and (2) Post-Booking Jail Diversion: Misdemeanor and Felony Programs. Pre-Booking Jail Diversion focuses on providing Crisis Intervention Team (CIT) training for law enforcement to prepare officers to recognize the signs and symptoms of mental illness and to respond more effectively and appropriately to people in crisis. Post-Booking Jail Diversion for misdemeanor and low-level, non-violent felony defendants involves diverting individuals with a SMI and other program admission criteria away from the criminal justice system and into comprehensive community-based treatment and support services. A significant program benefit to program clients is that legal charges may be dismissed or modified based on treatment engagement. The comprehensive spectrum of services and supports aim to aid clients in achieving successful recovery and community integration.
Importantly, the true glue to the CMHP’s success is rooted in its secret weapon – that everyone cares deeply about the clients. The result is that it impacts clients in not wanting to disappoint those that they know care about them, and it very often leads to the clients bringing another level of accountability to their own lives. The Peer Specialists also play a significant role by helping individuals in the program re-establish relationships who due to their illnesses no longer have support from family or friends. The PBS documentary powerfully demonstrates this in the case of CMHP client, Trevor Dolan; my second plug to watch the 60-minute PBS documentary.
Table 2.0 enumerates several of the CMHP notable successes.
Table 2.0. Miami-Dade Criminal Mental Health Project (CMHP) Successes
Cindy Schwartz, Director Criminal Mental Health Project, shares in the documentary that “hope is the cornerstone of recovery.” Cindy also conveyed to me, “People need to be involved and responsible for their own future. But unfortunately, transition from jail to community treatment and services is often based on a ‘one size fits all’ reality. Our work is centered on assessing individual risks/needs and assisting with the development of a reentry plan that is focused on successful recovery and community integration.”
CLOSING THE BEST PRACTICE GAPS AND SHARING THE WEALTH
The CMHP has a greater than 70% success rate in helping clients complete the 12-month program and achieve recovery, where many lead successful family lives, jobs, and are pursuing their hopes and dreams. Not every client succeeds, however. Approximately 20-30% of the CMHP clients do not complete the 12-months, even after several rounds in the program; their psychotic symptoms reoccur, and they fall back into a cycle of jail recidivism and community homelessness. They are too sick, their deficits too great. The good news is that Judge Leifman and others in Miami Dade have studied and now understand what is needed to close the gap.
This highest-need cohort of clients need a structured environment – and the solution is well on its way.
The Miami Center for Mental Health and Recovery, a seven-story, 181,000 sq. ft. multiservice facility, slated for completion in 2021, will serve as a one-stop shop for this most vulnerable population. The Center will offer a comprehensive continuum of mental health, substance use, and primary healthcare services targeting the highest-cost, highest-need individuals who often “fall between the cracks” in our current system. It is a great story of evolution in a best practice. Learn more about the Center at miamicentermentalhealth.org.
Another crucial progression in this best practice model is that the successes of Miami-Dade County are being shared with top leaders in every state and territory across the U.S. This best practice sharing is with the aim for states/territories to adopt a similar model which is well-suited to the specific needs of their respective states.
Over the last year and a half, Judge Leifman has traveled extensively under the sponsorship of National Center of State Courts to be a guest speaker with Chief Justices of state Supreme Courts and other state and county officials in regional and state-wide summits. Judge Leifman stated to me, “It is really happening. With the Chief Justices of every state Supreme Court learning about the intersection between mental illness and the criminal justice system they are taking an active role in addressing this horrible inequity. While there is still much to do, I am encouraged that we are finally on the road to a better and more appropriate system of care.
SEVEN VALUABLE INSIGHTS FROM CMHP FOR POPULATION HEALTH MODELS
- High-touch personal attention and service are essential
- Caring really matters
- Data-driven storytelling gets people to buy into the vision
- Being deliberate about the influence pathway necessary to gain cross-system stakeholder buy-in (e.g., Chief Justices of state Supreme Courts, governors, etc.)
- Learn from models, such as CMHP, that have done it before (even if it represents a different vulnerable population) and engage with stakeholders that run those models (like Judge Leifman and Cindy Schwartz)
- Executive leadership (e.g., state and county government officials, health system C-suite executives, etc.) support and funding will be commensurate with level of budget savings
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