Activity across the sequential intercept model and diversion program outcomes
Erin Comartin, Ph.D., LMSW
Liz Tillander, LMSW
Sheryl Kubiak, Ph.D.
From 2015 – 2020, ten jail diversion pilot programs were funded across Michigan by the Mental Health Diversion Council and the Michigan Department of Health and Human Services to improve response to individuals with serious mental illness (SMI) involved in the local criminal/legal system. The Center for Behavioral Health and Justice, under the leadership of principal investigators Sheryl Kubiak, Ph.D., and Erin Comartin, Ph.D., engaged the pilot counties in a system evaluation to identify and measure interventions across intercepts 1 – 5 of the Sequential Intercept Model. The system evaluation, which began in 2017, followed an implementation evaluation in 2015, as well as short- and long-term evaluation of the pilots in 2016 and 2017. The system evaluation consisted of two cohorts, Cohorts 2017 and 2019, both with two stages. The final aggregate report of Cohort 2019 Stage 2 was presented to the Mental Health Diversion Council on July 13, 2021. In addition, final county-level reports were presented to all ten pilot counties between June and July of 2021. This report summarizes the highlights of the aggregate presentation delivered to the Mental Health Diversion Council in July.
Outcomes by sequential intercept
Intercept 2: Initial detention/initial court hearings
- Prevalence of SMI – K6 SMI in 8 jail diversion pilot jails changed from 24% in 2015, to 20% in 2017, and 21% in 2019.
- In 2019, 36% screened positive for SMI by either the K6, through the jail's practice for mental health identification, or both.
- Of the 36% who screened positive for SMI:
- Identification - 38% were not identified by the jails' 'practice-as-usual' for identification of mental health concerns.
- Services - 38% were provided jail-based mental health services.
- Jail Diversion Program - 9% participated in a jail diversion program.
- Co-Occurring Disorder (COD) - 16% had both a history of mental health and substance misuse issues; a population at greatest risk for criminal-legal involvement.
- 'Divertable' Offenses - 64% of those booked into jails during the collection period were charged with a 'divertable' offense (i.e., misdemeanor, civil, ordinance or technical violation of the court).
Intercept 3: Jails/courts
- Length of Stay - For individuals with SMI, the median number of days spent in jail was 4 days*, compared to 1 day for Non-SMI individuals.
- Traditional Courts - 52% of individuals processed through a traditional court and found guilty were sentenced to jail or prison.
- Sentencing - 57% of those with SMI were sentenced to jail or prison compared to 49% of Non-SMI individuals, even after controlling for offense severity.
- Specialty Courts - 3% of individuals booked into the jails were processed through a specialty court.
Intercept 4: Reentry
- Discharge Planning Services (DPS) - those with SMI who received DPS during their jail stay were significantly more likely to engage in post-release treatment (53%) than those who did not receive DPS (39%); and were also more likely to receive it within 2 weeks of jail release (27% DPS vs. 13% Non-DPS).
- Warm Hand-off (WHO) - those with SMI who received a WHO (i.e., jail clinician sets a community-based follow-up mental health appointment) were even more likely to engage in treatment (61%) than those who did not receive a WHO (38%); and were also more likely to receive it within two weeks of jail release (35% WHO vs. 13% No WHO).
- Post-Release Mental Health Services Factors - factors significantly related to an individual with SMI engaging in post-release behavioral health services include:
- Receipt of a jail-based mental health service (18% received vs. 9% not received).
- Receipt of a diversion program service (28% received vs. 11% not received).
- Relationship with the community mental health (CMH) provider (21% relationship vs. 5% no relationship).
- Using these 2 or 3 of these factors simultaneously significantly increased both post-release mental health service engagement, and post-release mental health continuity of care.
- Co-Occurring Disorder - individuals with COD were significantly more likely to engage with behavioral health services post-release (64%) than those with SUD only (50%), and neither SUD or SMI (36%). They were equally as likely to engage as those with SMI (55%).
- Continuity of Care - median length of time to first post-release behavioral health treatment for those with SMI is 21 days*:
- Individuals with COD were significantly more likely to receive continuity of care (28%) than those with SUD only (18%) and neither SUD or SMI (13%), but were equally as likely as those with SMI (21%).
- Time to service was significantly less for those with CMH relationship compared to those without a relationship (18 days vs. 68 days).
- Time to service was significantly less for those with COD (18 days) as compared those with SUD only (43 days) and neither SMI or SUD (88 days); COD individuals were similar to those with SMI only (22 days).
Intercept 5: Community corrections
- Technical Violations - those with SMI are significantly more likely to be booked into jail on a technical violation (15%) compared to Non-SMI individuals (13%).
Intercept 1: Law enforcement
- Recidivism - individuals with SMI are significantly more likely to recidivate (45%) than Non-SMI individuals (37%).
- Co-occurring Disorder:
- Individuals with a COD are significantly more likely to recidivate (50%) than those with only SUD (40%) and neither SMI or SUD (34%). They are equally as likely to recidivate as those with only SMI (42%).
- Individuals with COD had significantly more bookings post release (.97) than individuals with SMI only (.69), individuals with SUD only (.75), and individuals with neither SUD or SMI (.61).
- Co-occurring Disorder:
- Time to Recidivism - the median number of days to recidivism is 96 days.
- Contacts with Law Enforcement - individuals with SMI had significantly more interactions with law enforcement in the year following a jail stay (1.8) than Non-SMI individuals (1.7).
- Rural County Law Enforcement Contacts - individuals with SMI in rural counties have more law enforcement encounters (2.1) than individuals with SMI in urban (1.9) and metropolitan (1.6) counties.
We looked at the impact of participation in the jail diversion pilot programs. It is noted that jail diversion programs varied across the ten pilot counties ranging from participation in therapeutic groups to advocacy for early release. When we compared individuals with SMI who participated in jail diversion pilot programs (Participants) to those with SMI who did not participate in JD programs (Non-participants) we found positive outcomes associated with post-release treatment and JD participation.
- Housing Insecurity – 52% of Participants were housing insecure compared to 42% of Non-Participants
- Post-Release Treatment – 50% of Participants engaged in post-release treatment compared to 36% of Non-Participants
- Continuity of Care – 25% of Participants received their 1st service in the community within two weeks compared to 10% of Non-Participants
- Recidivism – 54% of Participants recidivated compared to 44% of Non-Participants
The CBHJ recommends the following practices to improve jail diversion outcomes across the intercepts.
Validated Screening at Booking.
Nearly 40% of those who screened positive on the K6 were not identified by the jails' 'practice-as-usual' for identification of mental health concerns. Embedding short, validated mental health and substance use screening instruments into jail management information systems (JMIS) is needed to increase accurate identification of those with mental health needs in jail for connection to care when returning to the community.
Address Length of Stay with Boundary Spanners.
Individuals with SMI spent 27 days in jail compared to 16 days for Non-SMI individuals, even after controlling for offense severity. Jail-based clinicians and/or defense attorneys should advocate for early release, when possible. The use of a 'boundary spanner' who can work with the jail, court, and CMH staff for quick connections to treatment in lieu of time in jail is also beneficial.
Support Discharge Planning and Warm Hand-offs.
Those with SMI who received a discharge planning service were significantly more likely to engage in post-release treatment (53%) than those who did not (39%). Similarly, those with SMI who received a warm hand-off were even more likely to engage in treatment (61%) than those who did not (38%); and more likely to receive it within two weeks of jail release. Continued support of jail diversion pilot programs is needed to help individuals transition back to the community, with a particular focus on discharge planning and warm hand-off services. These services are particularly effective for individuals with SMI who cycle in and out of the jail.
Support CMH Jail-based Services.
The findings above show that CMH services impact linkage to treatment and elongate time to the next jail stay. Increased resources should be offered to CMHs to provide services to individuals in jail with SMI or who are 'mild to moderate'. In addition, supporting the federal House Bill (HR 995, 2021) Medicaid Reentry Act will fund such services within 30 days of jail release.
Increase Collaborations between Jails, CMHs, and Community Corrections.
Those with SMI are significantly more likely to be booked into jail on a technical violation (15%) compared to Non-SMI individuals (13%). Jail and CMH administrators should collaborate with probation and parole offices to decrease returns to jail for technical violations for individuals with SMI. When possible, focused attention on treatment engagement and basic needs could be provided in lieu of a jail stay.
Develop Statewide Standards for Crisis Response.
Individuals with SMI had significantly more interactions with law enforcement post-jail release (1.8) than Non-SMI individuals (1.7) significantly increasing the likelihood of recidivism (45% vs. 37%), particularly in rural counties. In line with the recommendations of the Michigan Joint Task Force on Jail and Pretrial Incarceration, we recommend the development of statewide training standards in behavioral health and crisis response for dispatch, law enforcement, and jail officers.
Develop Alternatives to Jail.
Two-out-of-three individuals in jail were charged with a 'divertable' offense. In line with the recommendations of the Michigan Joint Task Force on Jail and Pretrial Incarceration, we recommend the addition of statutory guidance to authorize local communities to create diversion programs and encourage diversion in certain cases, with consideration for public safety and resource availability, including development and expansion of local programs; diverting individuals charged with misdemeanors and other divertable offenses.
Importance of a County Champion.
In our work as evaluators throughout the jail diversion pilot program, the importance of a jail diversion champion within each pilot county grew increasingly evident. Counties with a champion – someone who is willing and able to raise awareness, engage appropriate stakeholders in the effort, build and sustain momentum, and embrace new opportunities – experienced improved sustainability, expanded programming, and new funding. The CBHJ will explore this facet of leadership in an upcoming webinar focused on developing leadership to envision and sustain long-term change.
*All averages shown are median number of days in order to reduce skew from outliers; however, all statistical tests are taken from means tests, as there are no statistical significance tests for medians.