SIMPLE Scorecard
Improving outcomes for people with serious mental illness in the criminal justice system with Sequential Intercept Model Practices, Leadership and Expertise
The Center for Behavioral Health and Justice created the SIMPLE (Sequential Intercept Model Practices Leadership, and Expertise) Scorecard to assess county-level behavioral health and justice collaborations. The scorecard could be used as an evidence-based strategic planning tool to drive behavioral health and criminal legal system change at a county level.
May 2021 (updated June 2021)
Leonard Swanson, MSW; Victoria Nelson, MA; Erin B. Comartin, Ph.D., LMSW; Sheryl Kubiak, Ph.D., LMSW; Laine Putans, LMSW; Nanci Hambrick, MSW; Brad Ray, Ph. D.; Liz Tillander, LMSW; Aliya Washington, B.S.; Robert Butkiewicz, M.A., LPC; Matthew Costello, LMSW
- Assessing county-level behavioral health and justice systems with the SIMPLE scorecard Webinar
May 13, 10-11:30 amThis webinar describes the Sequential Intercept Model Practices, Leadership, and Expertise (SIMPLE) Scorecard's development, significant findings, and potential to direct county-level strategic planning to improve behavioral health and justice systems.
Presenters include:
- Brad Ray, Ph.D., Director - Center for Behavioral Health and Justice, Associate Professor - School of Social Work
- Erin Comartin, Ph.D., LMSW, Data Director - Center for Behavioral Health and Justice, Associate Professor - School of Social Work
- Leonard Swanson, LLMSW, Project Coordinator - Center for Behavioral Health and Justice
- Steven Mays, Diversion Administrator - Michigan Department of Health and Human Services, Liason to the Mental Health Diversion Council
Key Findings
- Counties who improved pre-booking SIMPLE scores (intercepts 0 & 1) showed decreased SMI jail bookings over two years.
- Counties with high post-booking SIMPLE scores (intercepts 2-5) connected more people with serious mental illness (SMI) to jail-based treatment.
- No single practice or policy was significantly linked with successful outcomes; multiple points were needed to affect the amount of SMI jail bookings and connections to jail treatment. Innovative practices and policies work best in tandem with others.
The SIMPLE Scorecard
Fifteen counties across Michigan were analyzed using the SIMPLE Scorecard. The Scorecard used a 36-point scale to measure best, promising, and evidence-based practices implemented by each county across each intercept of the sequential intercept model, their leadership and their expertise. The scale was divided into pre-booking measures (interventions and practices that would take place before an individual is booked into jail) and post-booking measures (interventions and practices that would take place after an individual has been booked into jail). Researchers also examined two control variables.
Pre-booking points
- Intercept 0: Community Services
Outside Grant
Did the county have a grant to help behavioral health services in criminal/legal settings?Access to outside funding can support programmatic expenses related to innovative change.
CBHJ partner counties that received jail diversion funding from the Michigan Mental Health Council received a point. In order for other counties to earn this point on their scorecard, researchers needed to hear about a prior grant award.
County Funding
Did the county, sheriff's office, or law enforcement agency pay for a public behavioral health position?
As public mental health providers struggle to find services outside of state- and federally-driven criteria, funding from other local sources designated toward the criminal/legal system can impact criminal/legal related outcomes.
In order for a county to earn this point on their scorecard, researchers needed to hear about the funding arrangement to award the point. For-profit mental health services in jails did not count.
Millage
Did the county pass a millage to support behavioral health programming?Some public mental health organizations are able to leverage additional funds from a county-level tax millage to support innovative criminal/legal programming, particularly as jail-based services are not eligible for Medicaid reimbursement.
In order for a county to earn this point on their scorecard, researchers needed to hear about a millage from a key collaborator
CMH SUD
Is the public mental health organization (such as Community Mental Health (CMH)) authorized to bill Medicaid for substance use disorder (SUD) services beyond its designated 10% carveout?Some public mental health organizations contract out its SUD provider, and are not able to provide SUD services 'in-house', complicating coordination of care; the presence of SUD presents high recidivism risk.
In order for a county to earn this point on their scorecard, researchers needed to hear about whether the CMH could bill SUD services.
Assertive Community Treatment (ACT)
Did the county have an Assertive Community Treatment (ACT) program?Some public mental health organizations contract out its SUD provider, and are not able to provide SUD services 'in-house', complicating coordination of care; the presence of SUD presents high recidivism risk.
In order for a county to earn this point on their scorecard, researchers needed to hear about whether the CMH could bill SUD services.
- Intercept 1: Law Enforcement
Police training
Are at least 20% of patrol officers trained in CIT or 50% trained in at least 8 hours of in-service behavioral health training (for Michigan, MMHC, MI-CIS, or MHFA)?While shorter training modules do not have much of an evidence base, the 40-hour CIT training curriculum has been shown to increase officer mental health knowledge and affect officer behavior.
Researchers did not have data on all police departments. A point was awarded if county hosted its own training program, not if they sent a handful of officers to another county's program.
Police coding of mental health calls
Do officers categorize mental health calls in police reports and report prevalence (is a mental health code used on over 1% of total calls)?Officers are not likely to divert subjects to appropriate resources without recognition of behavioral health symptoms, and coding of crises is a key indicator for officer recognition.
Researchers did not have data on all police departments. A point was awarded if the county had a reporting mechanism for mental health calls as a proportion of all calls.
Police referrals to treatment
Do law enforcement refer directly to Community Mental Health or a provider for mental health crises?Some law enforcement departments have established referral processes after or during crises to coordinate cases with treatment resources; otherwise, the treatment provider may not be aware of emergency incidents.
A point was awarded if the Community Mental Health Agency had to know about the referrals and talk about how it worked.
Dispatch sends trained law enforcement officer(s)
Does dispatch know which officers have received behavioral health training, and send them to appropriate crises?Dispatch has the ability to maximize efficiency by recognizing and sending behavioral health trained officers to crises, who may be less likely to escalate and result in additional charges.
Researchers did not connect with every county dispatch center. A point was awarded if a CIT or other law enforcement/behavioral health partner mentioned this kind of arrangement.
Co-responder model
Does the county have a co-responding unit of law enforcement and a mental health clinician to either respond to real-time crises or follow-up after mental health-related incidents?Co-response units, especially those with the capability of responding to real-time crises, are associated with greater linkage to treatment and fewer arrests.
In order for a county to receive a point, researchers needed to hear a key partner describe a ride-along program.
Alternative drop-off
Does the county have an alternative law enforcement drop-off center?Behavioral health training for law enforcement is more effective in tandem with an alternative drop-off location than emergency departments.
In order for a county to receive a point, the drop-off center needed to be a separate location from the jail that CMH would actively promote to law enforcement agencies.
Post-booking Points
- Intercept 2: Initial Detention/Initial Court Hearings
Evidence Based Screening
Did the jail use empirically validated screening instruments to identify and refer people during the booking process?As processes for identifying behavioral health concerns vary widely across jails, using evidence-based screening tools can optimize minimal resources toward a population with behavioral health risk.
In order for a county to receive a point, either the K6, BJMHS, or RODS needed to be used at booking as a referral tool. Other tools would count if they had been empirically verified.
Diversion
Did the county have a program designed to divert pretrial detainees who show signs of mental illness?Some counties have processes in place to advocate early release when the charges were directly related to a person's behavioral health condition.
In order for a county to earn a point, researchers needed to hear about a program that included advocacy for early release during pretrial status.
Jail-CMH Data Matching
Did the county have a mechanism to match CMH client lists with jail bookings on a regular basis?When systems are in place to match names across public mental health and jail booking databases, jail clinical resources have an opportunity to connect with clients and coordinate jail-based and post-release care.
In order for a county to receive a point, researchers needed to hear the CMH describe record matching as a regular process, either automated or performed by hand.
Jail Meetings
Did dispatch know which officers have received behavioral health training, and send them to appropriate crises?Ongoing communication between jail corrections and clinical staff can preempt crises, and additional charges, through a coordinated approach to cell placement, clinical services, and release planning.
In order for a county to receive a point, Meetings needed to be ongoing at a regular time, where a researcher could theoretically attend.
- Intercept 3: Jails/Courts
Not for profit jail provider
Did the county contract third-party not-for-profit providers for jail behavioral health programming?
Counties jails with for-profit behavioral health providers serve fewer people than counties with publicly-funded behavioral health providers.
In order for a county to earn this point on their scorecard, the jail's mental health clinicians needed to be employed by a non-profit agency.
Jail clinician
Did the jail have dedicated clinician(s) whose primary place of work is the jail?Though jail-based mental health services are not eligible for Medicaid reimbursement, some counties have clinicians positioned at the jail to attend to ongoing behavioral health needs .
In order for a county to earn this point on their scorecard, a clinician usually had to be 40 hrs/week at the jail. One exception spent 12 hrs/week since it was one of their primary responsibilities, as opposed to access center or emergency mental health callouts for crises.
Jail substance use disorder services
Did the jail offer substance abuse disorder therapeutic services (not just Narcotics Anonymous or Alcoholics Anonymous)?As substance abuse disorder is a criminogenic risk factor, jail-based therapeutic interventions targeting substance use disorder may have an impact on subsequent recidivism.
In order for a county to earn this point, any in-jail substance use disorder clinical service would count (if it was not Narcotics Anonymous, Alcoholics Anonymous, or a Vivitrol shot).
MOUD continuation
Were either Methadone or Buprenorphine available in jail for continuation?Though Medications for Opioid Use Disorder (MOUD) are the best practice for treating opioid use disorder, they are rarely available for continuation in jail, which can lead to relapse and subsequent criminal activity.
In order for a county to earn this point, researchers needed to hear the program mentioned by a key partner. A program for only pregnant women did not count.
MOUD induction
Were either Methadone or Buprenorphine available in jail for induction?Some jails have moved their MOUD programming beyond the point of continuation to an intervention of inducing medications for those showing signs of opioid risk, which may impact ongoing treatment engagement and avoid relapse.
In order for a county to earn this point, researchers needed to hear the program mentioned by a key partner. A program for only pregnant women did not count.
Low circuit court to prison
Were under 20% of circuit court dispositions sent to prison?A proxy for 'tough on crime' approaches to sentencing, circuit court judges weigh prison sentences against jail sentences, which are typically shorter, and may decrease entrenchment in the criminal legal system.
Counties with fewer than 20% prison dispositions gained a point. Michigan Department of Corrections Statistical Reports were used for the 2019 SIMPLE score.
Specialty court
Did the county have a specialty court other than a drug or sobriety court?Most counties have either a drug or sobriety court, but some have established mental health or veteran's courts that have shown positive impacts.
Researchers used the state Problem Solving Court database to score each county.
- Intercept 4: Reentry
Release time
Did the county have a daytime time-served release policy (anything that's not midnight), not just in special cases?County release time policies vary; releases at 12:01am on the last day of a sentence can be cumbersome to plan around, as most treatment agencies are only open during standard business hours.
Five in the morning (5:000 am) was the earliest acceptable release time for a county to earn a point. Researchers did not count exceptions for special cases.
Psych medications
Were people who receive psychotropic medications in jail routinely released with a prescription or supply, not just upon request, not just if someone takes back what they brought inDiscontinued psychotropic medication can lead to decompensation, which can inhibit care continuity after release; some jails ease the transition by supplying extra medication or a prescription.
In order to earn a point, partners in the jail could typically describe medication policies. Researchers did not count medications brought in by the individual, or by special request.
Discharge planning
Was discharge planning/care coordination a standard process in jail-based mental health services?Discharge planning is a distinct phase of jail clinical services that often involves high-intensity case management and linkage to treatment, though not all jail clinicians provide discharge planning in every clinical service.
By 'standard process', can we assume that everyone who got a mental health service also had a conversation about post-release?
Medicaid Reactivation
Was Medicaid reactivation part of a standard release processMedicaid accounts are suspended during incarceration, and require re-activation upon release; some jails aid continuity of care by installing a process to automatically reactivate Medicaid upon release.
One county made an arrangement with the DHHS office to automatically re-activate Medicaid upon release.
- Intercept 5: Community Corrections
Specialty probation
Did district and circuit courts have specialty probation officers for people with behavioral health needsSpecialty caseloads can attend to particular behavioral health needs, which may inform violation decisions that involve a return to jail.
In order to award a point, researchers needed to hear partners describe specialty probation officers as a distinct role.
CMH-Probation Collaboration
Did the public mental health system have frequent interactions, a formal interdisciplinary program, a regularly scheduled meeting, referral system or established processes with either probation or paroleAs parole and probation officers frequently encounter people with behavioral health issues, frequent communication with the mental health system may help clients avoid violations through the added support of case management.
If a county did not have a formal program or regularly scheduled meeting, researchers also awarded a point if we heard partners describe several informal interactions.
- Leadership
No data sharing issues
Have partners described HIPAA/42CFRPart2 as a barrier to care coordination in the jail and upon release?Misunderstanding of data protection laws can inhibit a continuity of care plan, potentially resulting in a lack of treatment connection post-release.
Did researchers hear HIPAA concerns come up in conversations with partners? If not, a county gained a point.
Champion
Did the county have a behavioral health and justice champion, defined as someone who can move a project along regardless of boundaries or institution?Interdisciplinary work benefits from strong, localized leadership to envision and enact change beyond traditional confines of a segmented system.
Did the key partners have power? As in, could they actively call people to meetings and get people to act? If so, the county was awarded a point.
No Resistance to change
Did leadership welcome change, work through data sharing barriers, or take on new behavioral health and justice mattersResistance to change among leadership of any institution in the system can thwart innovative action.
Was there a person that presented roadblocks to either the data collection or a new project? If not, a county gained a point.
Strategic planning
Did the county have regular strategic planning meetings to address behavioral health and justice issuesA formal, scheduled meeting between interdisciplinary partners shows a shared commitment and embedded structure to facilitate system changes.
Strategic planning group needed to have been operating for months prior to K6 collection. Meetings must occur either every month or quarter.
- Expertise
Measure own outcomes
Was the county able to measure outcomes on their own (e.g. prevalence, length of stay, recidivism, and connections to treatment) for people with serious mental illness?Strategic planning at a county level is best informed by local data, and having internal mechanisms to track outputs and outcomes can expedite the data-driven decision making process.
In order to earn a point, the county had to be able to report on any of the four key outcomes (prevalence, length of stay, recidivism, or connections to treatment) without third party help.
Networking
Did the mental health staff/supervisors regularly mention connections with counterparts in other countiesFrequent networking between systems can bolster sharing of best practices and innovative adaptations to common problems.
In order to earn a point, one of the key partners in a county had to already know other key partners in other counties.
Evaluation experience
Did the county work with an evaluation organization before the screenings took place?A working history and familiarity with research institutions, and evaluation methods, can improve knowledge of best and evidence-based practices to implement in the field.
In order to earn a point, researchers had to hear county partners describe working with an evaluator or with the Center for Behavioral Health and Justice.
Boundary spanner
Did the county have a boundary spanner, defined as someone who knows two or more systems intimately?A champion with 'boots-on-the-ground', a boundary spanner can use knowledge of mental health and criminal/legal systems to advocate for clients at key junctures in a criminal legal system.
To earn a point, researchers' mental health contact in the county had to operate across multiple intercepts of the Sequential Intercept Model.
- Control variables
Median Household Income
What was the standardized median household income? Richer communities provide more tax revenue to public county systems, and are more likely able to afford private mental health services without burdening the public mental health system.
Standardized median household income (median household income divided by the standard deviation of the median household income variable) was calculated from census data. Data can be found here.
Rural
Was the county rural?Rural counties generally have a smaller tax base and smaller public institutions, which makes it difficult to attempt innovative programming at scale. A county was considered rural if its population was under 100,000.
Results
Pre-booking SIMPLE Scores
Counties who improved their pre-booking SIMPLE scores from 2017-2019 (Intercepts 0 & 1) booked fewer people with serious mental illness (SMI) in 2019.1
| County | Pre-booking SIMPLE Change Score | SMI Jail Prevalence Change Score |
|---|---|---|
| A | +3 | -2% |
| B | +2 | -4% |
| C | +1 | -3% |
| D | +1 | 0% |
| E | +1 | +1% |
| F | +1 | +3% |
| G | 0 | +9% |
| H | 0 | +13% |
Eight counties were assessed for SIMPLE score and jail SMI prevalence at two time points: 2017 and 2019. Some counties improved their score by making system changes at intercepts 0 and 1, such as mental health training for law enforcement, coding mental health calls in police reports, and establishing law enforcement referrals to mental health services. Non-rural counties, as well as those with high median household income, were also found to have fewer SMI bookings.
Post-booking SIMPLE Scores
Counties with high post-booking SIMPLE scores (intercepts 2-5) connected more people with serious mental illness (SMI) to jail treatment.**
Each dot represents a county's SMI treatment connection score and SIMPLE score at the time of data collection. Post-booking SIMPLE score points included: data matching between jail and CMH, regular interdisciplinary meetings between corrections and mental health staff, discharge planning during jail-based mental health services, and more. Five Stepping Up counties were evaluated once; eight Jail Diversion pilot counties were evaluated twice, and were assigned two dots for SIMPLE scores and jailbased treatment connections in 2017 and 2019. Counties with several post-booking practices, such as evidence-based behavioral health screens, interdisciplinary meetings, and regular discharge planning, connected more people to jail based treatment.
Areas for Improvement
No single practice or policy was significantly linked with successful outcomes; multiple points were needed to affect the amount of SMI jail bookings and connections to jail treatment. Innovative practices and policies work best in tandem with others.
The SIMPLE Scorecard's comprehensive list of practices and policies, linked with key outcome measures, could inspire counties to improve their system. Some counties excelled in pre-booking intercepts, and others excelled in post-booking intercepts, but no county received a perfect score. No single practice or policy was significantly linked with successful outcomes; multiple points were needed to affect the amount of SMI jail bookings and connections to jail treatment. Innovative practices and policies work best in tandem with others.
Notes:
*Statistically significant at p<0.05. ^Back
**Significant at p<0.05, after controlling for median household income and county size (rural/non-rural). ^Back
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