Creating Integrated Service Systems for People with Co–Occurring Disorders Diverted from the Criminal Justice System

Finding a common ground for promoting systems integration

The need to divert people with co-occurring mental and substance use disorders from the criminal justice system to treatment is increasingly apparent. Many offenders—both youth and adult—whose misdemeanor offenses are related more to the symptoms of mental illness and substance use than to truly criminal behavior are poorly served in a criminal justice system that offers little in the way of structured treatment. Jailing these individuals only perpetuates the cycle of offense and incarceration. Diverting these individuals from the criminal justice system and providing intensive community-based treatment and support offers far more hope to improving the lives of individual offenders and the welfare of the larger community.

In King County (Seattle), Washington, the data supporting the need for effective diversion alternatives for persons in the justice system is compelling. For adults within the King County correctional system, active substance use is reported among 60 to 80 percent of those admitted to jail. Up to 15 percent of the locally incarcerated population suffer from a major mental illness, and a recent study of a random stratified King County Jail sample revealed that 23 percent of “high impact” (i.e., demonstrating repeated cycling through the criminal justice, mental health, and chemical dependency systems) jail inmates are diagnosed with co-occurring substance use and mental disorders.

The provision of an integrated approach to the multiple problems these populations present when they are diverted to community-based treatment and support is essential. Diversion itself helps little; diversion to appropriate services is key.

What is an integrated system?

Systems integration occurs when there is the sharing of clients, information, planning, and resources.

• Sharing clients: Multi-problem clients who traditionally receive services in only one system or receive uncoordinated care in multiple systems are shared by appropriate treatment systems and treated in a coordinated fashion (e.g., single treatment plans, multidisciplinary teams).

• Sharing information: Information about programs, services, treatment models, and clients move across the traditional lines of service delivery systems.

• Sharing planning: Multiple systems engage in joint processes to plan integrated services to multi-problem clients.

• Sharing resources: The resources available to multiple systems are blended and/or shared to ensure that services are configured in a way that meets the individualized needs of clients rather than the needs of the systems or providers offering care.
Finding support for integrated diversion
services

The current political environment is not conducive to funding expensive projects that promote jail diversion and systems integration. In fact, the opposite is usually the case. Increasingly, taxpayer sentiment has supported increased expenditures of limited public resources to build and fill more jails rather than to provide community-based treatment and supports. In King County, 67 percent of regular county tax revenues are spent to support criminal justice system costs. To further complicate the situation, the emergence of managed care in the public sector of behavioral health care presents a unique set of challenges to the mobilization of flexible diversion programs.

The strength of the coalitions built during the strategic planning phases of diversion efforts is critical. To make diversion occur, the fourth (and perhaps most threatening) principle of integration must be brought into play: sharing resources. Although in King County no single system could afford the upfront costs of effective jail diversion programming, all the systems that could potentially reap the long-term benefits of jail diversion collectively identified the resources required to mobilize initial projects. Each system was asked to bring to the table the resources it had available for the shared effort. “Resources” in this discussion were not limited to funds, but also included staff time, space, and the commitment to change policies and practices. A few examples illustrate the sharing of resources in the King County diversion efforts.

The Seattle Police Department: Without new staff or resources, the Seattle Police Department undertook a commitment to mobilize a Crisis Intervention Team (CIT) modeled on the Memphis, TN, program. A group of more than 100 volunteers from the existing ranks of the police force agreed to receive 40 hours of specialized training on interacting with persons with mental illness, drug/alcohol problems, and developmental disabilities. Training provided voluntarily by representatives of the treatment systems, consumers, and family members offered officers new skills to recognize different types of illnesses and to intervene to deescalate potentially dangerous situations without using force or making arrests. CIT officers are now regularly dispatched to calls involving persons with mental illness with a primary goal of jail diversion.

The County Hospital: Working with the active support of the local mental health and drug/alcohol systems, the county hospital provided the space and part of the staffing required to reconfigure an existing psychiatric emergency room into a Crisis Triage Unit capable of managing pre-booking diversion referrals made by police officers. This meant moving away from the traditional emergency room model of “treat and release” toward a strategy of “assess, intervene, and link to needed services.” Staffing of the psychiatric emergency unit was increased and diversified. “Back-door” staff were added from the mental health and drug/alcohol systems to ensure the effectiveness of referral linkages for persons leaving the Crisis Triage Unit.

The King County District Court: The District Court for King County committed time and resources to mobilize a mental health court. Representatives from the court, prosecuting attorney, public defender, probation, and mental health systems all agreed to provide dedicated staffing to the mental health court. Resources from the mental health system fund balance were provided to secure treatment capacity for Medicaid-ineligible referrals from the court. Mental health system liaison staffing was provided to ensure that linkages from the court to treatment were effective.

The Mental Health and Substance Abuse Systems: Participation of these systems required a reconceptualization of the managed care paradigm from the “enemy” to that of an active partner in systems integration. The managed care system, when held accountable to its stated goal of promoting increased client choice and individualized and tailored care, can support jail diversion efforts. Systems integration advocates argued that a portion of the systems savings (“fund balance”) generated by the managed care model could be reinvested in services targeting those for whom the managed care paradigm worked least well—including persons with co-occurring disorders involved in the justice system. This meant that fund balance dollars produced by the managed care process could be applied to supplementing the staffing needed to create the hospital’s Crisis Triage Unit and the Mental Health Court. Additionally, clear and precise policies were embedded in the managed care system contracts requiring providers of care in the community to accept referrals from the Crisis Triage Unit and the Mental Health Court. Finally, expectations related to these initiatives were embedded in outcomes and performance indicators that stressed integration and diversion from the criminal justice system.

Importance of disclosing “upfront” investments

As systems and stakeholders initiate the process of developing and promoting integrated jail diversion programming, there are a variety of “upfront” investments that will help to ensure positive outcomes. Most of these upfront investments require minimal fiscal allocations. As these upfront investments are identified, it is important to disclose them to stakeholders. These investments include:

• Effective placement and use of “boundary-spanner” staff at the systems and service levels. The systems integration literature describes the potential roles and uses of boundary-spanner staff at both the systems and service levels.1 Such staff are critical to the success of diversion initiatives. First, staff assigned to boundary-spanning roles at the system level can help identify and bring together the stakeholders required to build consensus around a vision and momentum behind implementing action steps. Second, boundary-spanning staff at the service level provide the essential “glue” that joins the different systems for each diverted individual. These staff are central to ensuring that referrals from the police, jails, and courts actually make it to the treatment systems that will offer the greatest benefit.

• Time commitment from key stakeholders. Mobilizing diversion projects requires that individuals from all levels of the multiple systems involved be available for and invested in the planning process. Funders must be willing to identify “one-time” resources available for systems integration pilot projects. Policymakers must commit to reviewing and altering policies that perpetuate gaps and barriers in the system. Service providers must help identify the “nuts and bolts” of what will and will not work in the field. The willingness of all these stakeholders to attend many meetings and remain connected to the process goes a long way to promoting success.

• Agreement to step outside of traditional service and business paradigms: In order to plan across multiple systems and blend local resources from different, often categorical, funding streams, all stakeholders must be willing to challenge the underlying assumptions about how business is transacted and develop new and creative approaches to funding, policies, and procedures.

• Willingness to take risks: Some pilot efforts to promote diversion will fail to produce the desired results for a variety of reasons. Failures must be reframed as opportunities to determine how to be more effective the next time. Although not the familiar turf of most bureaucrats, risk taking becomes easier when risks are shared across multiple systems, and finger-pointing is discouraged when things do not happen exactly as planned.

• Measurement and analysis of results: Resources must be set aside to evaluate the results of the efforts undertaken. Without this evaluation process, the long-term security of even the most effective diversion efforts will be jeopardized. Whether these evaluation resources are identified in existing evaluation staff units or funded independently as part of the initial pilot efforts, they are a critical component of any integration activity.

• Dissemination of findings and results: Systems integration and diversion efforts cannot shrink from public and media relations. Letting the stakeholders and community know what you are doing and the outcomes of these efforts will help to solidify consensus around vision, goals, objectives, and programming. Negative incidents involving offenders with co-occurring disorders that receive extensive media exposure should be considered opportunities to make the case for more effective integration of services, rather than examples of yet one more time that the system has demonstrated its ineffectiveness.

Conclusion

The King County experience demonstrates when there is political will, creative vision, and invested people, significant progress can be made in creating integrated systems of care to divert individuals with co-occurring mental and substance use disorders from the criminal justice system. Further, these experiences demonstrate that the infusion of large amounts of new money is not the key. Rather, it is a matter of joint planning, pooling resources, and more effectively managing existing resources toward new goals.

Additional Information

This fact sheet was developed by David Wertheimer, M.S.W., as Service and Systems Integration Administrator for the King County Department of Community and Human Services. The GAINS Center provided editorial support. Mr. Wertheimer currently operates an independent consulting firm, Kelly Point Partners.

Specific details on the King County experience can be obtained from:

David M. Wertheimer, M.S.W., M.Div.
Principal, Kelly Point Partners
600 First Avenue, Suite 305
Seattle, WA 98104
Voice: (206) 914-4475
Fax: (206) 903-9579
Email: david@kellypointpartners.com

Additional information on integrated services and diversion programs for people with co-occurring disorders in the justice system can be obtained from:

The National GAINS Center
Policy Research Associates, Inc.
345 Delaware Avenue
Delmar, NY 12054

Voice: (800) 311–GAIN
Fax: (518) 439–7612
Email: gains@prainc.com
Website: gainscenter.samhsa.gov

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