Nahama Broner

The Cost-Effectiveness of Criminal Justice Diversion Programs for People with Serious Mental Illness Co-Occurring with Substance Abuse Four Case Studies

Many cities, counties, and states have criminal justice diversion or jail diversion programs, in which those committing low-level offenses and who have mental illness or substance abuse are diverted from the criminal justice system into treatment. However, there is little existing evidence on the cost and cost-effectiveness of such programs. This article presents the first such estimates for four sites. Estimates of the impact of diversion on both costs and effectiveness varied across the sites. This variation likely reflects heterogeneity in the structure and implementation of the programs across the sites. Directions for future research are suggested.

A Comparison of Prebooking and Postbooking Diversion Programs for Mentally Ill Substance-Using Individuals With Justice Involvement

Eight programs are described representing a variety of approaches to diversion in terms of point of criminal justice intervention (prebooking or postbooking), degree of criminal justice coercion, type of linkages provided to community-based treatment, and approaches to treatment retention. The authors also describe the characteristics of almost 1000 study participants who were diverted into these programs over an 18-month period and examine the extent to which systematic differences are observed between prebooking and postbooking subjects, as well as among sites in each of the diversion types. Results suggest that prebooking and postbooking diversion subjects were similar on most mental health indicators, but differed substantially on measures of social functioning and substance use and criminality, with postbooking subjects scoring worse on social functioning and reporting more serious substance use and criminal histories. Variability among sites was also observed, indicating differences in local preferences for the types of individuals deemed appropriate for diversion.

Knowledge transfer, policymaking and community empowerment: a consensus model approach for providing public mental health and substance abuse services.

An important problem in creating new programs and polices is how to encourage the transfer of knowledge in non-hierarchical ways so that new, relevant and specific knowledge is co-created by all interested parties. In this paper, we suggest that a consensus model of policymaking is one response and identify four key structural elements thought necessary for creating such a consensus infrastructure. These are a) a leadership and facilitating capacity for initiating and promoting such an endeavor, b) a network or consortium of key researchers, practitioners, consumers, and policymakers to empower community ownership of the endeavor, c) a process for consensus building and strategic problem-solving for such a consortium, and d) the continued creation of a multi-directional dialogue through information dissemination. We examine these elements in action by describing a particular problem solving and consensus building model for developing and implementing a program, resolving group differences, and evaluating the groups process and products.

Adapting a substance abuse court diversion model for felony offenders with co-occurring disorders: initial implementation.

Treatment Alternatives for Dually Diagnosed (TADD) was developed to address the need for criminal justice diversion of seriously mentally ill substance-using felons and persistent misdemeanants. The population served by the TADD program and key elements of the program are described, including identification, screening and assessment, specialized court processing and judicial oversight, case management monitoring, joint case conferencing between community and monitoring staff, enforcement, and key stakeholder collaboration. One hundred and thirteen clients diverted by the TADD program were followed for six months. A description is provided of these clients, the community services accessed, as well as the monitoring of clients drug use. During six months of program involvement 87% remained connected to the diversion team, 80% remained in community treatment and the majority took advantage of the rich service environment created through TADDs case management linkage services. The majority of these clients tested drug-free during this six-month period.

The effect of homelessness, housing type, functioning, and community reintegration supports on mental health court completion and recidivism

Although mental health court has been found to increase quality of life and functioning, it is unknown whether community stability indicators predict program completion and delay re-arrest for homeless versus non-homeless mental health court participants. Self-reported quality of life and social support, chart diagnosis, and administrative housing, services and criminal justice data were collected for 589 Bronx Mental Health Court participants for 12 months following diversion. Individuals who were homeless (n = 89) versus housed (n = 500) during the 12 months prior to diversion were compared to determine predictors of court graduation and re-arrest. Homeless status did not predict graduation or re-arrest, and quality of life, social support, functioning and housing type were not predictive of re-arrest. Housing instability negatively affected outcomes for both homeless and non-homeless individuals. An increase in functioning and a slight improvement in social support were predictive of successful graduation for homeless individuals, whereas a large increase in social support and lower functioning had a negative impact. In contrast, positive life satisfaction was predictive of successful graduation in non-homeless participants. Those who did not complete mental health court, whether homeless or not, were more likely to be re-arrested, particularly for felony and drug-related offenses than those who graduated. Mental health court was generally beneficial to mental health court participants. However, for those previously homeless, functioning and social support may play a unique and interconnected role in court graduations, whereas general life satisfaction may be a better indicator for program completion for non-homeless individuals.

Implementing Assertive Community Treatment in Diverse Settings for People Who Are Homeless With Co-Occurring Mental and Addictive Disorders: A Series of Case Studies

The Assertive Community Treatment model (ACT) was developed more than 30 years ago to treat individuals with serious and persistent mental illness. This qualitative study highlights practical challenges encountered when establishing ACT teams in diverse settings serving people who are homeless with co-occurring mental and addictive disorders (COD). Program administrators and evaluators from nine programs located in seven states completed a survey on implementation challenges, fidelity, modifications to the ACT model, and program successes. Challenges encountered related largely to staffing and funding limitations as well as to difficulties with implementing the ACT model without modifications. Several modifications to the model were believed beneficial to recruiting and retaining consumers. These included emphasizing housing, adding staff positions not prescribed by ACT, implementing mini-teams within the program, delivering in-office services in a group format, and placing time-limited services by transitioning consumers to less intensive settings. Successes included reduction in hospitalizations, psychiatric symptoms, and substance abuse. Stabilization of consumers was attributed largely to housing assistance and maintenance; medication adherence; and delivery of intensive, multidisciplinary services including substance abuse treatment. Implications of this study suggest the need to adapt the ACT model for people who are homeless with COD by tailoring program staffing and service delivery. Furthermore, there is a need for a measure capable of assessing ACT fidelity in the context of both housing models and integrated treatment for the homeless population.

Mentally Ill Elderly Jail Detainees: Psychiatric, Psychosocial and Legal Factors

Abstract Relatively little research has focused specifically on elderly offenders with severe mental illness. This study assessed psychosocial and legal issues in 83 male detainees, age 62 and above, who were hospitalized on a psychiatric forensic unit. This group included 38 Non-Hispanic whites, 31 blacks, 12 Hispanics, and 2 from other groups. Forty percent were diagnosed with a psychotic disorder. A series of chi-square tests found that patients charged with nonviolent crimes were more likely to report experiencing delusions. The victims of these alleged violent acts were primarily family members. There was no significant association between ethnic background and severity of legal charge or having a competency evaluation ordered. Suicidal ideation and thought disorders were more prevalent in nonwhite mentally ill elderly jail detainees.

The impact on taxpayer costs of a jail diversion program for people with serious mental illness

Mental illness is prevalent among those incarcerated. Jail diversion is one means by which people with mental illness are treated in the community - often with some criminal justice system oversight - instead of being incarcerated. Jail diversion may lead to immediate reductions in taxpayer costs because the person is no longer significantly engaged with the criminal justice system. It may also lead to longer term reductions in costs because effective treatment may ameliorate symptoms, reduce the number of future offenses, and thus subsequent arrests and incarceration. This study estimates the impact on taxpayer costs of a model jail diversion program for people with serious mental illness. Administrative data on criminal justice and treatment events were combined with primary and secondary data on the costs of each event. Propensity score methods and a quasi-experimental design were used to compare treatment and criminal justice costs for a group of people who were diverted to a group of people who were not diverted. Diversion was associated with approximately

Assertive Community Treatment Fidelity in Programs Serving Persons Who Are Homeless With Co-Occurring Mental and Addictive Disorders

2800 lower taxpayer costs per person 2 years after the point of diversion (p<.05). Reductions in criminal justice costs drove this result. Jail diversion for people with mental illness may thus be justified fiscally.

Mentally Ill Populations in Jails and Prisons: A Misuse of Resources

Fidelity rating of evidence-based practices ensures the implementation of interventions as intended and enhances the likelihood of replication of positive outcomes previously demonstrated. However, modifications have been necessary when a practice is adopted in settings or for populations other than those for which they were developed. This study reports fidelity findings for six programs implementing the Assertive Community Treatment model in different settings for adults who are homeless and who present with mental and addictive disorders, together with a methodology that can assist programs to achieve fidelity. Initial and final fidelity ratings using the Dartmouth Assertive Community Treatment Scale were collected from six programs. Findings indicate that while fidelity in programs can vary over time, core elements can be maintained, resulting in at least moderate fidelity in each program and modest overall increases across all programs combined with concomitant decreases in the variance of fidelity scales. The findings support previous research that fidelity change is minimal after initial fidelity is achieved during the first year of implementation, and they extend previous results to programs serving persons who are homeless and have co-occurring mental and addictive disorders. This study suggests that fidelity to evidence-based practice can be maintained for adaptation to new populations and settings. Understanding areas that are likely to be challenging to fidelity achievement and managing the variability of performance on the components of each fidelity aspect can assist the program manager and personnel to achieve and maintain adequate model fidelity.