Pre-Booking Crisis Intervention

Diversion is the most direct path for better behavioral health care in Cuyahoga County

Creation of Pre-Booking, Crisis Intervention Center in Cuyahoga County likely to result in better care

By Hope Lane, Public Policy & External Affairs Associate     Loren Anthes, Public Policy Fellow, Medicaid Policy Center     Tara Britton, Director of Public Policy and Advocacy

Executive Summary

Jails have become de facto mental health treatment facilities for people with behavioral health disorders. In fact, the three biggest mental health facilities in America are jails. In light of recent trends in Ohio and across the country to try to find ways to prevent those with behavioral health disorders from entering the criminal justice system because of un- or under-treated conditions, The Center for Community Solutions explored what a pre-booking crisis intervention center would look like in Cuyahoga County. This research resulted in several recommendations including:

• A successful diversion program requires a physical facility with a 24-hour a day drop-off site and have sober and addiction treatment services available.
• Crisis center should have an open-door policy for anyone in or out of the criminal justice system.
• Every law enforcement agency in the county should have at least one Crisis Intervention Team (CIT) trained officer, and agencies should permanently add a social worker or case worker to crisis intervention response teams.
• Every jail in Cuyahoga County must use the same full and evidence-based mental health screening.
• Jails, providers and health plans should improve coordination and data sharing to ensure people who need treatment get it in the community once a crisis is stabilized. This can also allow agencies to pay additional attention to high users of multiple systems.
• In the short-term, there will be cost shifting between systems as the center is established and the community diverts people into more appropriate settings. This will mean significant justice system processing cost savings, but costs will increase for health and social support services as more people are stabilized and recidivism is reduced.
• Address social risk factors, like housing, food insecurity and access to adequate transit for people in crisis beyond the medical or clinical issues.

Moving Cuyahoga County toward the creation of a pre-booking crisis intervention center, will bring a much needed, coordinated resource to the county.

Moving Cuyahoga County toward the creation of a pre-booking crisis intervention center, will bring a much needed, coordinated resource to the county. While the county has many of the resources someone with a behavioral health disorder would need, they are not always fully coordinated. There are many factors laid out in this report to consider as Cuyahoga County embarks on this worthy endeavor.

Introduction

Jails have become de facto mental health treatment facilities for people with behavioral health disorders. Significant efforts are underway across the country, and increasingly in Ohio, to intervene sooner to prevent those with behavioral health disorders from winding up in the criminal justice system because of un- or under-treated conditions. Cuyahoga County has joined other jurisdictions across the country in exploring the possibility of establishing pre-booking crisis intervention centers for individuals suffering with addiction and/or severe and persistent mental illness (SPMI). These centers have been shown to result in positive effects for individuals and the community. Benefits can include reduced arrest rates, incarceration and inappropriate emergency department use. At the same time, they can assist individuals obtain needed treatment, and reduce racial inequities behind bars.

People who live with behavioral health disorders disproportionately engage with the criminal justice system.

People who live with behavioral health disorders disproportionately engage with the criminal justice system. Across the nation, in many jurisdictions, including Ohio,[1] jails and prisons are the largest providers of behavioral health treatment. A report from the Treatment Advocacy Center finds that nationwide, approximately 20 percent of jail inmates and 15 percent of state prison inmates have a severe mental illness.[2] When it comes to substance use disorders, 58 percent of state prison inmates and 63 percent of sentenced jail inmates reported drug use or dependence.[3] These figures compare to only about 5 percent of the general adult population who fall into this category.[4] Reports from the Cuyahoga County jail estimate that 50 percent of inmates deal with SPMI or co-occurring mental health and substance use disorders. A series of policy decisions and failures throughout the course of our country’s history have led to overrepresentation of people with behavioral health disorders in the criminal justice system.[5] Moving towards a system that prioritizes treatment in the most appropriate setting will be broadly beneficial. It is far past time to course correct. Establishing a pre-booking crisis intervention process in Cuyahoga County, with all of the necessary partners involved, will help move toward a more equitable, less onerous system for people with behavioral health disorders, and the community overall.

I. Current landscape of pre-booking crisis intervention centers to understand the possible universe of users

Crisis intervention team trainingThe Sequential Intercept Model (Figure 1) is a widely accepted approach developed by Mark Munetz that categorizes the different points of intervention an individual with serious mental illness (SMI) and/or substance use disorder (SUD) can be deflected away from the criminal justice system and into community-based solutions. Although there are intercepts from zero through five, pre-booking jail diversion programs focus on Intercept 0 (community services) and Intercept 1 (law enforcement), before an arrest occurs. The key to the success of the programs below is collaboration between law enforcement and behavioral health systems. This collaboration can take many forms but often includes officers receiving crisis intervention training and other instruction on how to properly deal with people with mental illness. This may also include partnering with behavioral health providers in the community to offer direct support when called.

Figure 1

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Source: Kraft, D. (2019, July 1). Maximizing the Cures Act by Utilizing the Sequential Intercept Model. Retrieved from https://www.prainc.com/curesact-sim/Crisis Intervention Team (CIT) training, developed by the Memphis Police Department, [6] is the most widely implemented, recognized and researched specialized law enforcement curriculum for interacting with individuals with mental illnesses. Not only is CIT training meant to improve police identification and communication with individuals with mental illnesses, it also aims to reduce the risk of serious injury or death, for all involved, during any interactions. Standard CIT training involves 40 hours of instruction which includes education on verbal de-escalation, mental health diagnosis, psychiatric medications, role playing and interacting with individuals with mental illnesses through first hand presentations. There are often shortened versions of the training offered to accommodate those who may also interact with mentally ill individuals directly or indirectly such as dispatchers, teachers and paramedics. Qualitative and pre-experimental research involving officers trained in CIT has found they express a better understanding of mental illnesses, increased empathy and patience towards people with mental illnesses and that they consider more options (e.g., redirection away from jail) when deciding the outcomes of crisis calls. [7]Officers receiving CIT training is especially crucial for Intercept 1 because law enforcement officers are often the first to interact with these individuals and are responsible for determining what, if anything, an individual has done wrong and where they should go next, whether it be the emergency room, jail or a jail diversion center. A responding officer’s familiarity with mental health and substance use disorders will ultimately determine who is appropriately safe for diversion and who is not.

A responding officer’s familiarity with mental health and substance use disorders will ultimately determine who is appropriately safe for diversion and who is not.

While quasi-experimental research examining disposition outcomes of CIT are sparse, one study in the State of Georgia provided a significant look at its impact. This study looked at 180 officers (91 with CIT training and 89 without) across six departments and found that among 1,063 encounters, CIT officers did not significantly differ from non-CIT officers in the use of force, nor did they differ in the percentage of calls that were resolved at the scene. However, referral to mental health or addiction services was significantly more likely and arrest was significantly less likely for those individuals in crisis who encountered a CIT-trained officer versus a non-CIT trained officer.[8]While Ohio also does not mandate statewide CIT training for officers, the Ohio Criminal Justice Coordinating Center of Excellence (CJCCoE), housed at Northeast Ohio Medical University in collaboration with the Ohio Department of Mental Health and Addiction Services and the Summit County Alcohol, Drug and Mental Health (ADAMHS) board has helped bring CIT to communities across the state. CJCCoE is committed to training not just sworn police officers but all people committed to public service including park rangers, parole officers, hospital security, correction officers, judges and court personnel, job and family service employees and more.According to CJCCoE, as of May 2019, 63 percent of law enforcement agencies in Cuyahoga County employed at least one CIT trained officer. As of July 2019, of Cuyahoga County’s 3,930 full-time law enforcement officers, 29 percent, or 1,160, were CIT trained.[9]

As of May 2019, 63 percent of law enforcement agencies in Cuyahoga County employed at least one CIT trained officer.

As part of the 2015 City of Cleveland Settlement Agreement with the United States Department of Justice, the Cleveland Division of Police (CDP) was to provide every CDP officer with at least 8 hours of CIT training by May 2016 (one year after the effective date of the settlement agreement). Additionally, all new recruits are to receive at least 16 hours of training in the academy and CDP is to provide all officers with annual in-service training thereafter. Specialized CIT officers at CDP are officers who volunteer to take the 40-hour CIT training course and are then called upon first to respond to incidents or calls involving individuals in crisis.[10] As of July 1, 2019, according to CJCCoE, CDP had 659 officers (44 percent) that were considered specialized CIT trained officers[11]and all officers had completed the required 8 hour CIT course.

Behavioral health partners

In addition to being CIT trained, another commonality between law enforcement departments in the communities below is their approach to policing. By emphasizing and committing to community policing versus traditional policing, law enforcement officers engage with their communities which helps to identify people with behavioral health problems early and to assist in providing access to treatment and services before police are ever called.Due to an uptick in community policing, police departments around the country have used crisis intervention response teams at mental health calls. These crisis intervention response teams typically consist of a partnership between law enforcement and mental health/substance abuse treatment professionals. The pairing of clinicians (social workers or case workers) and officers creates a more empathetic atmosphere in which to respond to mental health calls. The goal for these programs is to address problems without arrests.

The pairing of clinicians (social workers or case workers) and officers creates a more empathetic atmosphere in which to respond to mental health calls.

The Houston Police Department, which lies in Harris County, Texas and has a diversion facility, created a mental health division to house these teams within the department. The Houston Police Department touts the success of its mental health division by citing the case of one chronically mentally ill man with schizophrenia on whom the county spent $142,241 over the course of 18 arrests, 32 separate contacts with the police, 12 separate psychiatric clinic admissions, and jail and prison stays that, combined, lasted for about eight months. After two years in the diversion program, the individual stabilized and enrolled in college.[12]The Columbus (Ohio) Division of Police began a trial phase of its mobile crisis response unit in 2018 and officially made it a part of department protocol in 2019. Columbus’ mobile crisis response unit pairs five officers with five clinicians. The clinicians are paid by the Franklin County ADAMHS board. The teams arrive in an unmarked vehicle together and respond to mental health calls that come through police dispatch. The teams also follow up on referrals from friends, family and other jurisdictions, check on individuals and decide if they should be “pink-slipped” or left in the community. A pink slip is a form that allows doctors and police to have a person temporarily held against their will if they are deemed a danger to themselves and/or others. Since Franklin County does not have a diversion center or a crisis intervention center with a law enforcement drop off system, on any mental health run, there’s about a 50 percent chance the team transports the person to an emergency room for a mental health intake.[13]

The City of Cleveland received a federal grant in 2015 to run a similar program, called the CIT Co-Responder Pilot Project, through September 2018.

The City of Cleveland received a federal grant in 2015 to run a similar program, called the CIT Co-Responder Pilot Project, through September 2018. For this project, FrontLine Services partnered with CDP and managed a team that consisted of two mental health workers and two specialized CIT police officers from the 2^nd district. The team operated Tuesday through Friday on second shift only and due to safety concerns, they responded to calls in separate vehicles.[14]When the crisis care workers were on scene, a lower percentage of individuals were transported to an emergency department (44 percent) compared to when they were not on the scene (87 percent). Diverting transports from an emergency department saves law enforcement time and resources. Additionally, this diversion from emergency departments decreases the likelihood a situation will escalate since law enforcement does not have to take an individual into custody.[15]

This diversion from emergency departments decreases the likelihood a situation will escalate since law enforcement does not have to take an individual into custody.

The outcome of this program help to not only support the implementation of a crisis care center focused on diversion but also supports additional CIT training for law enforcement in Cuyahoga County and a reconvening and expansion of a similar program in Cleveland and Cuyahoga County generally.

Sampling of programs across the country to understand who’s engaged by these programs

Judge Ed Emmett Mental Health Diversion Center – Harris County, Texas.Target population: Individuals experiencing homelessness, severe mental illness, developmental disabilities and neurocognitive disordersThrough a collaboration with many stakeholders, including The Harris Center for Mental Health and IDD, and the Harris County Sheriff’s Office, the Judge Ed Emmett Mental Health Diversion Center was developed and opened in September 2018. This was made possible through two pieces of legislation passed through the Texas Legislature, Senate Bill 292, House Bill 13, grants from the Texas Health and Human Services Commission and various in-kind matches. Harris County, home to nearly five million residents, including the Houston metropolitan area, contains the nation’s third largest county jail with an average daily population of 9,000 inmates. Approximately one-third of its population is on one or more psychotropic medications to treat mental illness at any given time.[16] This pre-booking center creates a pathway for the county’s law enforcement agencies to drop off people with mental illness picked up for low-level misdemeanors somewhere other than the county jail or emergency room.

Harris County, home to nearly five million residents, including the Houston metropolitan area, contains the nation’s third largest county jail with an average daily population of 9,000 inmates.

It’s important to understand, however, that the Judge Ed Emmett Mental Health Diversion Center is part of a larger effort for jail diversion in Harris County that began in 1999 with the opening of the NeuroPsychatric Crisis Center (NPC). Law enforcement officers in Harris County who deem individuals need emergency psychiatric evaluation bring people to the NPC instead of the emergency room. It is estimated that more than 100,000 individuals have been brought to the NPC by law enforcement since the facility opened. Additionally, the Houston Recovery Center (Sobering Center) opened in May 2013 and allows individuals with alcohol and substance use issues, who are at risk of being arrested for public intoxication, to be brought to the Sobering Center to safely sober up.[17]Eligibility for the Diversion Center is focused on targeting people who would otherwise be charged with a crime, so it is limited to adult offenders who commit low level, non-violent crimes, where mental illness or homelessness appear to be a factor. Offenders are ineligible for the program if they are in acute crisis, have open warrants or detainers or do not/cannot volunteer to participate in the program willingly.

Offenders are ineligible for the program if they are in acute crisis, have open warrants or detainers or do not/cannot volunteer to participate in the program willingly.

Initially, the focus was on offenders who were arrested for trespassing. Criteria was then expanded in February 2019 to include those arrested for misdemeanor marijuana charges, and since May 2019 has included offenders who commit misdemeanor, non-violent crimes and are no threat to public safety. Examples of these charges include criminal mischief, theft under $750, obstruction of a passageway, failure to identify and indecent exposure.[18]The standardized intake flow begins when law enforcement drops someone off at the center. The average drop off time is 11 minutes, compared to the average time to book an offender in the Harris County Jail, which is 4 hours.[19] Upon entering the facility, which has 29 beds and 12 recliners, an initial screening and assessment is conducted to facilitate identification of potential diversion candidates. A medical assessment and evaluations by a psychiatrist, an internal medicine physician and a Master’s level clinician follow the initial triage. In total, the Diversion Center employs 50 people and is open 24-hours a day, seven-days a week.[20]

While the center does invoice patients for services and medications, they do not send bills to collections due to inability to pay.

Other services offered in-house include medication management, crisis housing support, detox/residential substance use disorder services, permanent supportive housing, individual treatment plans and post-release case management. While the center does invoice patients for services and medications, they do not send bills to collections due to inability to pay.During the first eight months, Harris County counted 1,308 diversions where 67 percent of participants saw no new jail bookings after their first diversion. The average length of stay at the Diversion Center during this time was 55 hours and the longest stay was 22 days. The county estimates the center saved $9.5 million during this period by diverting trespassing offenders from jail. Since the charges eligible for diversion have been expanded, experts expect that the county will divert double to triple the number of people, which will save the county millions more moving forward.[21]

Employees with the Diversion Center noted their biggest challenge is engaging and educating the community.

Employees with the Diversion Center noted their biggest challenge is engaging and educating the community so when people are taken to the facility, they don’t have misconceptions of its purpose. As of fall 2019, the facility has yet to reach full capacity at any given time. Since a person who is taken to the facility is never formally arrested and therefore is not in custody, there is nothing to stop individuals from walking out of the facility once the patrol officer who took them there leaves. This has also caused contention within the community on the facility’s location.

It costs as much as $232 per day for Harris County to house an inmate with mental health issues in the jail’s mental health unit.

It costs as much as $232 per day for Harris County to house an inmate with mental health issues in the jail’s mental health unit, as opposed to $57 per day to house an inmate in general population. Community programs can offer mental health services in Harris County for about $22 to $42 per day. [22]The Texas Legislature passed Senate Bill 1849 in 2017 which amongst many things, mandated law enforcement officers complete a 40-hour statewide education and training program on de-escalation and crisis intervention techniques to facilitate interaction with individuals with mental illness.[23]Merrifield Crisis Response Center: Diversion First – Fairfax County, VirginiaTarget population: Individuals experiencing severe mental illness, substance use disorder, co-occurring disorder, developmental disabilities According to data extracted from the Federal Data-Driven Justice Institute, the Fairfax County Sheriff’s Office estimated that mental health issues affect more than 40 percent of the inmates in the county’s adult detention center. As a result, the office began exploring ways to reduce the number of people with mental illnesses in jail. The Diversion First initiative developed through a joint partnership between the Community Service Board (CSB), the Fairfax County Sheriff’s Office, the Fairfax County Police Department, the Fairfax County Fire and Rescue Department and the Fairfax County Juvenile and Domestic Relations District Court in 2015.The program aims to offer alternatives to incarceration for people with mental illnesses or developmental disabilities who come into contact with the criminal justice system for low level offenses. The goal is to prevent repeat encounters with the criminal justice system, improve public safety, promote a healthier community and offer a more cost effective and efficient use of public funding. The Fairfax-Falls Church Community Services Board supported purchasing a new building as part of a land swap, and paid for it with a capital bond. This became home to the Merrifield Crisis Response Center (MCRC) which launched as part of the Diversion First Initiative. The county operates the 150,000 square foot building, which also includes a primary care clinic and four floors of behavioral health services.[24]

The goal is to prevent repeat encounters with the criminal justice system, improve public safety, promote a healthier community and offer a more cost effective and efficient use of public funding.

A team of law enforcement officers help staff the MCRC 24-hours a day, seven-days a week to accept people with mental illness who come into contact with the criminal justice system for low-level offenses. To help identify these people, and as part of Diversion First, Fairfax County police officers, deputy sheriffs and dispatchers all receive 40 hours of state certified CIT training. The MCRC also accepts walk-ins from individuals of all ages who are experiencing a mental health or substance abuse emergency and emergency custody orders from referrals by CSB staff from individuals in the county jail.[25]At the MCRC, individuals receive crisis intervention and risk assessment from a CSB clinician and connections and referrals to community resources. Additionally, the center houses a pharmacy so an individual’s psychiatric medication can be evaluated, or re-evaluated, and get appropriate medication to take with them back into the community. The center also houses recovery specialists and a peer resource center. Fees for services are charged on a sliding scale, but no one who is eligible for services is turned away due to inability to pay. CSB also accepts reimbursements from many health insurance plans as well as Medicaid and Medicare.[26] The MCRC has produced an annual report which indicated that 1,308 individuals were voluntarily transported and diverted from potential arrest since the facility opened in 2016 through the end of 2018.[27]

No one who is eligible for services is turned away due to inability to pay.

The Fairfax County Diversion First program also has a substantial post-arrest component including drug treatment court, veteran’s treatment docket, Co-Responder program and the Striving to Achieve Recovery (STAR) program.[28]The Center for Health Care Services Crisis Care Center and the Roberto L. Jimenez M.D. Restoration Center - Bexar County, Texas.Target population – Individuals experiencing homelessness, severe mental illness, substance use disorder, co-occurring disorder Bexar County, Texas has one of the most evaluated jail diversion programs in the country. The Center for Health Care Services (CHCS) Crisis Care Center is one of the country’s oldest crisis care facilities focused on diversion, as it opened in 2005 as a result of a collaboration between law enforcement, the court system, CHCS and the local community mental health authority as a way to address excessive spending by the county for jailing low-level offenders experiencing mental health crises.[29]The Restoration Center opened in 2008 in a former job corps building to address growing silos within substance abuse treatment, behavioral and mental health treatment and law enforcement by integrating the services in one place. By providing integrated care, the Restoration Center is able to provide psychiatric care, substance abuse services, general health care and transitional housing.[30]

The Crisis Care Center and the Restoration Center together serve approximately 2,200 people per month.

The Crisis Care Center and the Restoration Center together serve approximately 2,200 people per month. Bexar County, home to San Antonio, averages 3,500 people incarcerated at its Adult Detention Center on any given day. Of those, approximately 20 percent of inmates receive treatment for some type of mental illness, and most of that population did not have access to mental health treatment prior to incarceration.[31]The two centers work together as part of The Bexar County Jail Diversion Program to provide Bexar County law enforcement officials with quick access to treatment for individuals in crisis, who are struggling with substance abuse or homelessness.While both facilities are open 24-hours a day, seven-days a week and able to take walk-ins and referrals, the Crisis Care Center operates for law enforcement only from 8:00 p.m. until 8:00 a.m. To receive pre-booking service at the Crisis Care Center, an individual must have demonstrated symptoms of mental illness (such as a threat to self or others, confusion and disorientation), no threat of violence, a criminal history of misdemeanors and be at-risk for incarceration due to mental illness.

More than 95 percent of Bexar County and San Antonio law enforcement officers have participated in the training.

Since often the first time a mentally-ill person is identified is when that person comes in contact with law enforcement, the Bexar County planning and advisory committee offers CIT training through in-kind services, staff support from law enforcement, behavioral health and local hospitals. This saves around $800 per officer in training costs. So far, more than 95 percent of Bexar County and San Antonio law enforcement officers, more than 5,000, have participated in the training.[32] Prior to the Crisis Care Center and the Restoration Center, law enforcement agents averaged between 12 and 14 hours in emergency rooms waiting on psychiatric evaluations.[33] Drop-off time for officers at either facility currently averages about 15 minutes. It is estimated that since the opening of the Restoration Center in 2008, law enforcement agencies have saved more than 100,000 manpower hours that can now be spent on the streets.[34]The Crisis Care Center includes a 16-bed inpatient area, a medical procedures room to provide treatment for minor injuries and a 20-bed sobering area. Here, staff provides intervention services, crisis resolution, observation and coordination into alternative care. Patients can remain at the Crisis Care Center for up to 23 hours.The sobering unit, located at the Restoration Center, is funded by the City of San Antonio and costs approximately $1.9 million a year to operate. From 2008 through 2017, it is estimated to have saved the city $50 million. The sobering unit, also a voluntary program, allows people who are brought in by the San Antonio Police Department on public intoxication-related incidents to have a safe place to sleep on mattresses until they are sober enough to leave. This unit specifically averages about 5,000 people per year, with peak times of 11 a.m. through 6:00 p.m. and 11:00 p.m. through 6:00 a.m. Individuals stay an average of 4 to 6 hours after being processed and having their vitals taken. The Restoration Center contains 28 detox beds where patients can participate in a five-to-seven-day program where they are assigned a licensed chemical dependency counselor. This “detox room” is primarily for those who don’t have insurance and is funded by the Texas Department of State Health services (DSHS) which reimburses at $224 per patient per day with a FY 2017 budget of $1.9 million. While they also accept Medicaid reimbursement, the Texas Medicaid rate for inpatient detox is only $138 per patient per day. The Restoration Center also contains a 48-hour Extended Observation Unit which has 16 beds and costs approximately $5 million a year to operate.[35]

From 2008 through 2017, it is estimated to have saved the city $50 million.

Patients can be referred to the Restoration Center from the Crisis Care Center for extended observation. Located across the street from the Restoration Center, Haven for Hope opened a 962-bed homeless facility as part of the continuum of services for people in need of 24-hour psychiatric crisis assessment. The opening of this facility created a campus for the Restoration Center to provide long-term case management and follow up services since many of the individuals who come to the Restoration Center are homeless.[36]All services come in the form of direct care. The jail diversion program employs more than 150 multidisciplinary staff including physicians, benefits specialists, psychiatrists, licensed mental health professionals, including licensed clinical social workers and licensed professional counselors amongst other staff. The key goal of the diversion program is to provide housing and employment assistance as it is oriented toward community rehabilitation. It costs Bexar County $2,295 per jail booking but $350 per diversion.[37]

It costs Bexar County $2,295 per jail booking but $350 per diversion.

It costs approximately $9 million to operate the Crisis Care Center annually and $100 million to operate the Restoration Center. Funds are continuously secured through numerous ways. By screening people for mental illness and Medicaid eligibility, Bexar County is able to secure state funds which allows them to earn Medicaid Administrative Claims, which can cover anywhere between 25 to 30 percent of the cost of diverting an individual from jail. Medicaid, Medicare, the University Health System, the Veterans Administration and CareLink, which is a Bexar County initiative for county residents who do not have private health coverage and are ineligible for federally funded healthcare, all provide financial support for the care of patients. The diversion program also receives grants from the Substance Abuse and Mental Health Services Administration (SAMHSA) and private foundations.[38]

By screening people for mental illness and Medicaid eligibility, Bexar County is able to secure state funds which allows them to earn Medicaid Administrative Claims.

It is estimated that the jail diversion program saves taxpayers $10 million dollars annually by keeping individuals out of jails and emergency rooms and keeping patrol officers on the streets. Recidivism among non-violent offenders who are referred to treatment is below 10 percent countywide. As part of the jail diversion program, Bexar County also maintains a robust post-booking program that includes drug courts and mental health bonds.Common Ground Resource and Crisis Center – Oakland County, Michigan.Target population: Individuals experiencing homelessness, developmental disabilities, severe mental illness, substance use disorder, co-occurring disorderIn Oakland County, the jail diversion process began with a stakeholder group consisting of the current jail diversion coordinator, behavioral health providers and many local law enforcement agencies. Michigan also has a statewide task force on jail diversion which provided support to the Oakland County group. Since 2015, the Oakland Community Health Network (OCHN), with funding from the Michigan Health Diversion Council, has operated a law enforcement diversion program in Oakland County, Michigan. OCHN is the public behavioral health authority in Oakland County which operates Common Ground, the only comprehensive crisis center in Michigan. At Common Ground, police departments in Oakland County can drop off individuals experiencing a crisis so they are diverted to services rather than face charges, 24-hours a day, seven-days a week. There is a strict policy to never turn a person away who was brought in by law enforcement. Common Ground has an emergency door for law enforcement to expedite drop off, so even if it is full, the policy is to accept people brought in by law enforcement so Common Ground can be relied upon as a resource.[39]OCHN is required to work with law enforcement as part of its Medicaid contract with the state, and in turn it has contract requirements with providers to facilitate law enforcement/behavioral health collaboration including CIT training with the Oakland County Sheriff’s Office. The State of Michigan requires police departments to sign coordination agreements with OCHN and as of November 2019 only 14 of 43 police departments in Oakland County have signed. [40]

The State of Michigan requires police departments to sign coordination agreements with OCHN.

The Oakland County Jail Diversion Program has had a hard time engaging law enforcement agencies that are further away from Common Ground, stating that it is impractical for law enforcement to drive more than 45 minutes to drop a person at the crisis center. Alternatively, the Aurora Hills Police Department does not have a jail and as a result reports high use of the jail diversion process. Since the department does not have holding cells, and the county jail is further away from Aurora Hills than Common Ground is, more Aurora Hills officers have utilized the jail diversion process.[41] In 2017, OCHN released a report detailing the findings of the first year of jail diversion programming in Michigan. According to the report, Oakland County reported 568 calls involving an individual with a mental health issue from April 2015 through March 2016. Of these calls, 465 individuals were taken to Common Ground by law enforcement and 11 percent of these individuals were ultimately incarcerated at the county jail.[42]According to reports provided by Easter Seals, the estimated cost of housing an inmate at the Oakland County Jail is $104 per day, with the average stay being 30 days. It’s also estimated that at any given time more than 25 percent of inmates in the jail have some sort of mental health issue.[43]To be eligible for the pre-booking jail diversion program, individuals have to be diagnosed with a developmental disability, mental illness or have a substance use disorder to receive treatment. Additionally, individuals have to be charged with a non-violent misdemeanor. Services at Common Ground includes 9 adult crisis beds, and 2 child beds (up to 24-hour hold), a Sober Support Unit with 10 beds staffed by peer-recovery specialists, paramedics and nurses, a Sanctuary for at-risk youth offering a 3-week residential program and an inpatient residential (up to 2-week) recovery program for adults containing 16 beds.[44]

The estimated cost of housing an inmate at the Oakland County Jail is $104 per day.

Common Ground focuses on crisis resolution strategies that are tailored to each person’s specific needs, this includes psychiatric medication review, group therapy, art therapy, peer and social support programming and more. Admission to the crisis residential recovery program requires prior authorization through the Oakland Assessment Crisis Intervention Services.[45] Support staff at Common Ground are funded through grants and OCHN general funds. Crisis and treatment services are funded through Medicaid dollars as part of the OCHN provider network.[46]  The State of Michigan does not mandate CIT training for its law enforcement officers however the Oakland County Sheriff’s Office has offered it to Oakland County law enforcement since 2015 when their program started. [47]

II. Who would benefit from a pre-booking program in Cuyahoga County

Potential usersCollecting data to assess the universe of possible users in Cuyahoga County is difficult because while the Cuyahoga County jail system, which includes the downtown Corrections Center and the annexed facility in Bedford, has a contract with MetroHealth for jail health services, municipalities are responsible for jail health services elsewhere in the county. This includes three full-service city jails, 25 12 day jails and 18 holding facilities in the county.

This includes three full-service city jails, 25 12 day jails and 18 holding facilities in the county.

Consultants with Pulitzer/Bogard & Associates were able to secure jail data from the Cuyahoga County Corrections Center to conduct a similar determination of potential users in the county. They presented their research as a sliding scale of diversion permissiveness based on charge types and criminal history information. Since it is unclear what charges the county will choose to allow diversion for and what charges will make an individual ineligible for diversion, the universe of potential users is conservative. They presented many diversion opportunity scenarios based on data from the average jail population between May and November of 2019, and concluded that the diversion-suitable average daily population range is 114 to 222 for individuals who struggle with mental health and COD, and 66 to 118 individuals when accounting just for substance abuse. The diversion-suitable average daily population range is 95 to 101 for individuals who struggle with mental health and co-occurring disorder (COD) and 61 to 65 when accounting just for substance abuse. The consultants also noted that prior criminal history bookings may reduce diversion numbers even further.[48]

The consultants also noted that prior criminal history bookings may reduce diversion numbers even further.

While MetroHealth began to implement evidence-based full mental health screens upon booking in county facilities in October 2019, it is unclear if the same screening is consistently applied across the county in city facilities. Because of this, and the fact that MetroHealth does not track charge data as it pertains to the dispensing of psychotropic medications, it is unlikely that any data collected on jail or inmates with severe mental illness that was gathered and analyzed prior to November 2019 captures a complete picture. MetroHealth’s jail health care administrators estimate 50 percent of the jail population at any given time has SMI or COD as opposed to the roughly 30 percent represented in jail data. Without the use of consistent and evidence-based mental health screening tools at booking, many inmates have gone unidentified and thus may not have been appropriately housed on the county jail’s mental health floor or had access to the appropriate medications. Additionally, jail health care officials report inmates don’t have appropriate access to health care officials because there aren’t enough sheriff’s deputies available for transport.When considering the universe of possible users, it’s important to keep in mind that in many communities around the country the charges considered low-level enough to be diverted are nuisance and/or non-violent misdemeanors. What is less consistent, however, is how past criminal convictions are handled, especially those that are violent and/or felonies. While gathering data on past criminal convictions, psychotropic medication usage and diagnosis is difficult, we do know that the municipal jails, which are more difficult to gather data from, typically hold those charged with or sentenced on misdemeanors.

We do know that the municipal jails, which are more difficult to gather data from, typically hold those charged with or sentenced on misdemeanors.

While Cuyahoga County presently has a strong post-booking program in place which contains a Re-Entry Court, a Drug Court, a Recovery Court and a Mental Health and Developmental Disabilities (MHDD) Court amongst others, municipal and county court data does not overlap with jail or MetroHealth data. That means if a charge was ‘plead down’ or negotiated to a lesser charge, that would not be reflected in available jail or inmate data.Mental health response advisory committee As part of the 2015 settlement agreement between Cleveland and the DOJ, CDP formed a Mental Health Response Advisory Committee (MHRAC) to foster relationships and build support between police, the community and mental health providers. The committee’s 2018 annual report, released in January 2019, highlighted the work of CDP’s Crisis Intervention Team officers between 2014 and 2018. This provides further evidence to support the need for, and utilization of, a pre-booking crisis intervention center in Cuyahoga County. The committee was able to compile data using CIT Stat Sheets and ADAHMS board claims data to highlight the overlap in the criminal justice and mental and behavioral health system. Records were matched using client name, social security number (SSN), street address and date of birth. This compilation indicated a match rate of 60 percent.[49]

Over the five-year span, suicide threats and mental illness were the leading categories for the nature of adult CIT encounters.

Over the five-year span, suicide threats and mental illness were the leading categories for the nature of adult CIT encounters. Officers responded 85 percent of the time by using verbal de-escalation, and only 1 percent of all encounters ended in arrest. While 24 percent of the time individuals were taken to St. Vincent Charity Medical Center Emergency Department voluntarily, the hospital only has 15 crisis beds.See below for the breakdown of the disposition of encounters from the MHRAC 2018 Annual Report in Figure 2.‍

Figure 2

Disposition of EncountersSource: “Mental Health Response Advisory Committee 2018 Annual Report.” Alcohol, Drug Addiction and Mental Health Services Board, January 31, 2019.While the MHRAC tracks how many encounters individuals have with CIT officers per year using name, birth date and SSN, it does not compare CIT Stat Sheets to shelter, emergency room or jail data. Evidence and research in other parts of the country show that the population eligible for diversion is likely high utilizers of multiple systems (HUMS). These individuals likely cycle in and out of multiple systems because their needs are not met through less expensive means. By comparing CDP CIT Stat Sheet data against other systems, the county can examine the level of jail resources HUMS use and consider ways to address these individuals’ needs to reduce HUMS’ intensive use of public services.

These individuals likely cycle in and out of multiple systems because their needs are not met through less expensive means.

III. Current status of IMD waivers and Ohio Medicaid

Status of Institutions for Mental Diseases 1115 Medicaid waivers and the 16-bed limitSection 1905(a)(B) of the Social Security Act prohibits the use of federal Medicaid dollars to provide care to individuals with a mental health or substance use disorder (SUD) in inpatient and residential treatment facilities with more than 16 beds. These facilities, known as Institutions for Mental Diseases (IMDs) have traditionally been excluded from Medicaid coverage and the responsibility of reimbursing for these services has been left to states. However, with the rise in mortality due to opioid use disorder, which is a type of SUD, the Centers for Medicare and Medicaid (CMS) has altered this longstanding policy in substantial ways.[50]In May 2016, CMS published new regulations regarding Medicaid managed care that opened an opportunity for states to seek reimbursement for this type of inpatient service. The rule stated that IMD stays of fewer than 15 days could be covered as a part of a state’s managed care system.[51] While not included in Ohio’s managed care program, historically, behavioral health services were added as a managed care benefit beginning in January 2018 in a multiyear policy effort known as “Behavioral Health Redesign.” After enacting Redesign, Ohio leveraged the new regulatory flexibility for IMDs to finance inpatient substance use disorder treatment services. What became clear, however, was that Ohio’s arrangement did not meet all of the requirements set forth by CMS, and the Ohio Department of Medicaid needed to use a different tool to pay for these services.

The rule stated that IMD stays of fewer than 15 days could be covered as a part of a state’s managed care system.

In 2015, CMS issued guidance to states that invited them to apply for 1115 IMD SUD waivers that would enable state Medicaid programs to pay for short-term inpatient and residential treatment services. Waivers, which are time-limited projects requiring federal approval, had previously not been used in this way. This guidance, revised in 2017, describes, in detail, the expectations of the federal government in what these waivers would need to get approval, including clinical credentialing, a needs assessment, budget reporting and data.[52]In order to ensure Ohio could maintain the coverage of services previously paid for through the managed care rule, Ohio took advantage of the waiver policy and submitted an application in January 2019.[53] The waiver was approved by CMS in September 2019, with federal financing available October 1, 2019. With this approval, Ohio joined 25 other states with similar waivers.Ohio’s current waiver statusGiven the significant federal requirements regarding the use of these funds for waivers, Ohio’s Medicaid program has new standards to meet to stay in compliance. As such, it is unclear the degree to which the state would authorize payment to new facilities before it conducts the required needs assessment.Looking at the state’s approval package from CMS, Cuyahoga County was shown to have the highest number of SUD provider agencies at 29 and that utilization of available medication-assisted therapy (MAT) services was less than 25 percent. Moreover, as a condition of operating in Ohio, Medicaid managed care plans must ensure access to these services, and no plan had less than 92 percent of counties meeting the standard, with three plans at 100 percent. This data suggests that there is an abundance of capacity regarding access for individuals who would be eligible for MAT as a potential service.[54]

As a condition of operating in Ohio, Medicaid managed care plans must ensure access to these services, and no plan had less than 92 percent of counties meeting the standard, with three plans at 100 percent.

Whether or not a pre-booking center would have MAT services available on site would depend on a few factors. First, individuals seeking care would have to be covered by private insurance, eligible for the Medicaid program or have MAT services financed directly by the county. As this involves potential engagement with law enforcement, these individuals could not be incarcerated in order to receive Medicaid coverage as a matter of federal law. Given the fact, however, that pre-booking may in fact not result in incarceration, these individuals may be able to retain their eligibility, though the Ohio Department of Medicaid would be responsible for ensuring compliance with federal law. Additionally, any development of a center will also require licensure for such services to be offered and engagement with the Ohio Department of Mental Health and Addiction Services would be needed as well.

Any development of a center will also require licensure for such services to be offered and engagement with the Ohio Department of Mental Health and Addiction Services would be needed as well.

Another factor may be how the State of Ohio’s credentialing of the center would impact its ability to offer IMD-level services. If, for example, it is determined that an individual could benefit from access to an IMD-level of SUD inpatient treatment made available through the waiver, but the state determines the local capacity for treatment is already adequate, the center may not be credentialed to provide the service directly and will instead have to ensure access to the larger delivery system. In other words, as these services are explicitly time-limited and inpatient-focused, a system of referral may be preferred by the state in order to ensure a continuity of care to existing providers.Last, it should be noted that while the waiver covers inpatient services for SUD, no such coverage exists for mental health. While many individuals with mental health have co-occurring SUD diagnoses, mental health is not a Medicaid reimbursable service through the waiver.

While many individuals with mental health have co-occurring SUD diagnoses, mental health is not a Medicaid reimbursable service through the waiver.

Current community capacity for IMD servicesThere is currently no evidence to suggest that waivers are being used to finance IMD-like services in pre-booking or diversion centers, nationally.[55] With that said, many state Medicaid programs, including Ohio’s, do cover crisis stabilization as a service in their Medicaid programs.[56] Crisis stabilization is not intended for longer-term services and not only relies on Medicaid for funding, but, as a service in Ohio, received increases in funding through the past biennial budget that flow to ADAMHS boards. It is also important to understand that in both the context of the waiver, and in the context of providing services generally, the county will need to seek licensure and accreditation with the State of Ohio before delivering services. What’s more, as a requirement of Ohio’s waiver, the state will have to conduct a capacity assessment for SUD services along the continuum.

IV. A benefit analysis

It is clear from experiences in other communities, and the continuing needs of people who live with behavioral health disorders to receive treatment instead of incarceration, that diverting more of these individuals from jail to community-based mental health treatment can aid them to live in the community, rather than returning repeatedly to jail. Research reviewed from these communities, as well as from CDP CIT Stat Sheets, indicate that people with mental illnesses do not usually interact with police because of violent behavior but rather for low-level nuisance crimes or technical violations of community supervision, usually attributed to untreated or undertreated mental illness. Once they are in jail, they are more susceptible to intimidation and assault and thus may act out or break rules because the jail environment has exacerbated symptoms of their mental illnesses which may prolong their incarceration.[57] A pre-booking crisis care center will be a more humane site for this population who may be caught in a cycle of jail-emergency room-street without getting any sustainable treatment or resources to live with mental illness.

A pre-booking crisis care center will be a more humane site for this population who may be caught in a cycle of jail-emergency room-street without getting any sustainable treatment or resources to live with mental illness.

Research reviewed in regard to cost savings of jail diversion for people with mental illness however, produces mixed results. While there will be significant cost savings to local governments in Cuyahoga County, and for the county itself, associated with justice system processing, it may be obscured by increased behavioral health service costs connected with a crisis care center focused on diversion.Since research suggests patrol officers spend significant time away from patrol handling mentally ill individuals under their care, whether in the emergency room waiting for a psychiatric screen or in booking at a jail, a diversion facility can allow departments to get patrol officers back on the street sooner. This can result in departments paying less in overtime and having fewer officers on patrol on a shift.

A diversion facility can allow departments to get patrol officers back on the street sooner.

Consultants with Pulitzer/Bogard & Associates concluded that the average length of stay (ALOS) in the Cuyahoga County Correction Center was 27.2 days, individuals with a serious mental health or substance abuse diagnosis code however had an ALOS of 48.1 days.[58] This number conflicts slightly with data from the American Civil Liberties Union (ACLU) of Ohio who concluded the ALOS for inmates in the Cuyahoga County jail was 30 days.[59]The fact remains that having fewer people in the jail will save the county money.The county estimates that between the two jail facilities it operates, approximately $122 is spent per inmate per day. This number does not account for the amount of money spent on medication per day. Dr. Julia Bruner, Executive Physician with MetroHealth, estimates $32,000 was spent on psychotropic medication alone in 2019. The State of Ohio, through the Department of Mental Health and Addiction Services, operates a program that will reimburse local jails for costs associated with psychotropic medications. Cuyahoga County is not currently consistently taking advantage of this program. Fully utilizing this state program, while at the same time shifting many low-level, nonviolent individuals to a pre-booking center, will result in cost savings for the jail.

The State of Ohio, through the Department of Mental Health and Addiction Services, operates a program that will reimburse local jails for costs associated with psychotropic medications.

The cost of psychotropic medication and behavioral health treatment however will not disappear with a diversion facility, rather the cost would shift to Medicaid which would likely be responsible for the majority of diverted individuals in a diversion center. Ohio differs from several other states that have pre-booking centers in that it has expanded Medicaid. While an exact figure was not available, it was estimated by county staff that the majority of individuals who have a jail encounter fall into the income eligibility range for Medicaid. Provided the pre-booking center is positioned in a way that retains Medicaid eligibility for its users, Medicaid coverage will play a significant role financing services within the center.While the research reviewed above identifies referral services as an outcome, not all of them track individuals beyond the initial crisis-drop off point to evaluate whether these crisis services are effective at keeping an individual engaged in treatment or out of jail. Although the expectation is that a diversion program and facility will result in long-term cost savings in the physical and behavioral health systems and the criminal justice systems, long-term outcome and cost data on a potential program is hard to measure.

V. Conclusion and recommendations

ConclusionMoving Cuyahoga County toward the creation of a pre-booking crisis intervention center, will bring a much needed, coordinated resource to the county. While the county has many of the resources someone with a behavioral health disorder would need, they are not always fully coordinated. A pre-booking crisis intervention center could help facilitate this coordination through partnerships with stakeholders across the county. It is imperative that these partners are at the table throughout the planning process. Another key step to move toward the creation of a pre-booking center is engaging relevant partners in state government to ensure licensure, physical structure and funding are developed in the most beneficial way.Other jurisdictions across the country have implemented pre-booking crisis intervention centers which have resulted in cost savings and most importantly, improved care coordination for impacted populations. Each jurisdiction has its own unique set of circumstances around development, maintenance, operations, population, users and types of services in each respective pre-booking center. The center in Harris County, Texas saw $9.5 million in savings to the jail over an eight-month period by diverting offenders from jail while focusing on trespassing cases. The Crisis Care Center in Bexar County, Texas is estimated to have saved the City of San Antonio $50 million between 2008 and 2017. These figures are not directly transferable to Cuyahoga County, but are examples of results seen in other areas of the country. In order to produce comparable analyses, Cuyahoga County needs to fully identify relevant data elements related to users and potential users of the center and carefully track them over time.

The recommendations that follow outline key elements to consider as Cuyahoga County moves forward in a pre-booking crisis intervention planning process.

RecommendationsProgram characteristicsA successful diversion program requires at least one physical facilityA central drop-off site available 24-hours a day is a critical component of any diversion program. Since the purpose of a diversion program is to serve as a point of entry into the substance abuse and mental health services system, it is necessary to have a place to stabilize individuals to determine what a person needs and provide linkages in the community. Case management and treatment to any degree requires access to individuals. The center should be staffed by qualified mental health professionals who can provide services around-the-clock including clinical assessments, treatment and observation.

Any crisis care facility focused on diversion should have an open-door policy for individuals seeking assistance with behavioral health needs for themselves or their friends and family members.

Facility should belong to the communityAny crisis care facility focused on diversion should have an open-door policy for individuals seeking assistance with behavioral health needs for themselves or their friends and family members. By allowing anyone to access the facility, individuals not currently involved in the justice system can lower their risk of becoming involved by managing their mental health conditions. Having an open-door policy will help to establish trust within the community which will encourage widespread support for its development and continued services, and help to reiterate that the facility is voluntary and does not incarcerate anyone.Diversion facility needs to maintain “no-refusal” policy for individuals brought by law enforcement While it is important that any centralized diversion facility or location is available for use by the entire community and not just law enforcement, a no-refusal policy for law enforcement expedites the officers’ immediate return to their duties. Moreover, it recognizes the likelihood that officers would be deterred from using the facility (and instead make an arrest) if they believe the person in custody will not be accepted for evaluation due to being over capacity. This is especially true for law enforcement who would pass by a jail or holding facility in route to the diversion facility. This policy should be coupled with a priority for quick handoff, as law enforcement could be discouraged if it takes just as long to take an individual into custody and book them into jail as it does to get assessed at a diversion facility.Sobering and addiction treatment servicesIt’s important that any facility used for diversion is also a venue to provide sobering and addiction-treatment services. Many justice-involved individuals have a substance use problem and have a co-occurring mental disorder that would be difficult to assess until the person is sober and stable.Crisis Intervention Team trainingEvery law enforcement department in Cuyahoga County needs at least one CIT-trained officerTo ensure the uniform use of the Diversion Center, as opposed to jail, across Cuyahoga County, all of Cuyahoga County’s 76 law enforcement departments must have one full-time officer who has completed the 40-hour CIT course. Evidence in Cleveland and across the country shows that CIT-trained officers can handle individuals dealing with mental illness with more empathy, as the course emphasizes how to deescalate those in crisis while being vigilant about safety. It’s important to note here that Cuyahoga County has contracts with six cities and nine agencies to bring individuals to the Cuyahoga County Corrections Center. Of these, three agencies do not have a single CIT-trained officer on staff. It’s equally important that Cuyahoga County engages every department in the county to participate in a county-wide jail diversion effort.

Emergency dispatchers are often the first to interact with individuals experiencing a crisis.

Supplemental CIT training to emergency dispatchersEmergency dispatchers are often the first to interact with individuals experiencing a crisis, or their family members, so it is essential that supplemental CIT training (8 hours) is encouraged by those taking calls from within the county. The training should provide dispatchers with the groundwork so they can identify calls for service that may require a CIT response. Emergency dispatchers arguably play the most important role to initiate a crisis intervention response.Connections with community resources and within the criminal justice systemAdequate community-based resources at dischargeThe Cuyahoga County justice system should work collaboratively with the state and county to provide inmates discharged from its county and city jail facilities with information about and assistance signing up for programs and resources e.g. Medicaid and Supplemental Nutrition Assistance Program (SNAP). This will ensure that departing inmates with or without behavioral health needs have immediate access to treatment and supportive services to reduce recidivism and improve quality of life.Improved coordination among jails, providers and health plansCurrently, CDP exclusively compares CIT Stat Sheet data across ADAHMS board claim data to determine the overlap between the two systems. Other law enforcement agencies in Cuyahoga County should initiate the same process. Additionally, the county and city jail booking data should be regularly compared to ADAHMS board claims as close coordination between the two systems can ensure providers can identify and access members who are in jail, to facilitate transition planning and provision of treatment and services upon release.Attention to high utilizers of multiple systems (HUMS)CIT Stat Sheets, ADAHMS board claim data and booking data from the county and city jail systems should be regularly compared to shelter and emergency room data. This will facilitate discussions on how to target HUMS whose needs require more intensive case management, jail transition/discharge planning and wraparound services to provide a better quality of life for this population and reduce their intensive use of costly public services.

Law enforcement agencies within the county should work with the county ADAHMS board, the state and the federal government to secure grants to add clinical social workers or caseworkers to a department’s crisis intervention response team permanently.

Social work modelLaw enforcement agencies within the county should work with the county ADAHMS board, the state and the federal government to secure grants to add clinical social workers or caseworkers to a department’s crisis intervention response team permanently. This model, which has been used previously by CDP, has provided outcomes in Cleveland and across the country that indicate having a clinician on the scene changes the dynamic of an emergency and helps police to not only focus on the criminal component of an event. The partnership allows officers to perform criminal background checks while the ride-along clinician can search medical records and previous treatment of an individual.Prioritize closed loop referrals to community-based providersA centralized facility or location where individuals have access to myriad services to address needs has clear benefits for law enforcement and individuals in crisis. However, the current service landscape indicates that there are numerous providers offering similar services in various settings across Cuyahoga County. In order to develop an effective pre-booking center, any and all workflows should prioritize a continuity of care which enables patients to be connected to their historical provider of choice.

In order to develop an effective pre-booking center, any and all workflows should prioritize a continuity of care which enables patients to be connected to their historical provider of choice.

The IMD exclusion is tied to the history of de-institutionalization, and the history of de-institutionalization, in part, explains the increase in jail and prison settings for individuals with behavioral health settings.[60]The IMD exclusion not only served a policy role to decrease costs but was also intended to ensure individuals with behavioral health needs can receive services in the community.While there is an emergent challenge to satisfy the behavioral health needs of individuals in crisis, particularly as the result of the opioid use disorder epidemic, workflows prioritizing and incentivizing connections in the community should be of primary concern. Part of this relies on a pre-booking center being voluntary. More importantly, however, consumer choice and treatment continuity should be built into the delivery model of the center. As opposed to other states where similar facilities exist, Ohio has coverage through Medicaid, which has led to a well-articulated community behavioral provider network. The continuity of therapy at the direction of the consumer, then, should be prioritized over the economic and/or case management interests of any contractors operating in a pre-booking center.In order to ensure these community connections happen appropriately, no center should be pursued without first consulting with state authorities regarding capacity and licensure. Input should be sought from these authorities about a model which is informed by evidence and focused on maintaining continuity.

Every jail in Cuyahoga County must use the same full and evidence-based mental health screening for inmates at jail booking to assure every inmate who needs it can access mental health treatment.

Maximizing potential users of pre-booking centerEvidence based, full mental health screening in every full-service and 12-day jailEvery jail in Cuyahoga County must use the same full and evidence-based mental health screening for inmates at jail bookingto assure every inmate who needs it can have access to mental health treatment. This assessment often determines where inmates are housed and when inmates are housed inappropriately or don’t have access to the appropriate medication for their illness they may begin to decompensate because of lack of treatment. By guaranteeing consistent and equal access to mental health assessments early in the intake process throughout the county, inmates who need help can be identified, which increases opportunities for assessment, diversion and treatment. For this same reason, corrections officers should be encouraged to participate in a supplemental CIT-training course.Consider recodification and risk assessmentThe county should work with the state to regularly revisit the charges eligible for diversion as recodification of crimes occurs every General Assembly. The state, including the Ohio Supreme Court and the legislature, along with various coalitions, should routinely revisit ways to address the large prison population through criminal justice reform policies that impact the classification of crimes. Since we recommend the facility be staffed by mental health professionals and plain-clothed law enforcement, the safety of staff should always be considered. Risk of violent behavior should be assessed on the basis of knowledge of the person’s history of violence and on the viability of a person’s threats of violence.Improved data coordination for assessing cost savings and potential users  For any diversion program to be successful, there would need to be an information technology system in place for data to be compared across the judicial system, from all county and city jail facilities and their contracted medical providers on an ongoing basis to ensure that everyone who is eligible for diversion is identified. The MHDD docket does track diagnosis, medication and charge however it is largely inaccessible due to the Health Insurance Portability and Accountability Act (HIPPA).Additionally, to assess the full scope of cost savings, there are numerous data points that need to be identified and then tracked over time about potential users of the center. This would include information on a variety of factors including charge data compared with medication administered (to determine how much exactly is spent on candidates for diversion who are currently in jail), the average time an officer spends in the emergency room awaiting a psychiatric assessment and in jail booking versus the time it takes to drop off at a diversion center to determine manhours saved, cost of community care which can be determined with a request for proposals, percentage of new jail bookings after first diversion, and percentage of booking reduction compared to baseline. This is a preliminary list of key data points that should be identified and tracked, but to understand the full scope we recommend that a data committee be formed and maintained in the immediate future to assess early cost outcomes.Consideration of current policy and ongoing policy developmentConsider state and federal policy changesThrough administrative rule changes and legislation, eligibility for safety-net and social service programs is constantly changing. It is imperative that the county consider and monitor adjustments to qualifications for crucial programs and support services such as Medicaid and SNAP that would help diverted individuals maintain their health and treatment after leaving the diversion facility. Diversion away from the criminal justice system does not end with time spent at a diversion center as diversion success relies on a continuum of community-based services and social programs that are ever changing.

It is imperative that the county consider and monitor adjustments to qualifications for crucial programs and support services such as Medicaid and SNAP that would help diverted individuals maintain their health and treatment after leaving the diversion facility.

Maintain continuous eligibility where possible at all phasesThe possible services provided in the pre-booking setting have the potential for Medicaid reimbursement, including services that may be reimbursed through the SUD waiver. Using the American Society of Addiction Medicine (ASAM) criteria as a guide, which is the basis for the state’s reimbursement scheme in the SUD waiver, services offered in the pre-booking center would likely range from early intervention through more intensive treatment. This also means medically managed intensive inpatient services, the highest ASAM criteria for service, will likely need to be fulfilled through a psychiatric emergency department or alternative facility.For clients to access the breadth of services available, and concurrently to avoid any downstream county or client expense, coverage is critical. Cuyahoga County, with its role in eligibility determination, is uniquely positioned to develop both on-boarding and release workflows which could assist people to ensure they are covered by their insurance or Medicaid, and connected to other sources of support like SNAP and Temporary Assistance for Needy Families (TANF).This eligibility review and coverage guarantee is not limited to the pre-booking center, however, and is something that should be deployed in the jail setting as well. Fortunately, Ohio has a robust pre-release coverage program in place in state facilities which can serve as a model for best practices.[61] In both settings, the presence of severe mental illness or a significant medical issue could allow individuals to maintain Medicaid eligibility despite the pending implementation of work requirements. As such, any medical administration of benefits should contemplate an exchange of needed medical information for the purposes of eligibility maintenance. Further, the county should determine if it is possible to suspend, rather than terminate, Medicaid eligibility for individuals in the jail. MetroHealth, being a county-owned hospital, has the unique ability to process eligibility and to presumptively enroll individuals. This could be considered in the contractual arrangement between the county and MetroHealth.

There are clear needs for many in crisis that exist beyond the medical or clinical issues.

Understanding the pre-booking center in the context of overall health and human servicesAddress social risk factors systemically as a countyThere are clear needs for many in crisis that exist beyond the medical or clinical issues. Housing, food insecurity, economic mobility and access to adequate transit all impact a person’s ability to manage their behavioral health needs. Currently, Cuyahoga County can develop, through policy, strategies which address these issues, more systemically.According to County Health Rankings, Cuyahoga County ranks 79th out of Ohio’s 88 counties regarding social and economic factors (such as education and income inequality), 86th regarding physical environment (such as housing insecurity) but is 4th in regards to clinical care access.[62] If the needs of patients are to be addressed, the creation of a facility which prevents downstream collateral sanctions of individuals in crisis is a key strategy to reduce the disparate impact of the criminal justice system on those patients. That said, a systemic approach to address social risk factors, longer term, is paramount.[1] Johnson, Alan. Ohio’s prisons hold 10 times as many mentally ill as its psychiatric hospitals do. https://www.dispatch.com/article/20150419/NEWS/304199871[2] Treatment Advocacy Center Office of Research & Public Affairs. “Serious Mental Illness (SMI) Prevalence in Jails and Prisons.” Treatment Advocacy Center. Last modified September 2016. http://www.treatmentadvocacycenter.org/storage/documents/ backgrounders/smi-in-jails-and-prisons.pdf[3] Bronson Ph.D., Jennifer; Stroop, Jessica; Zimmer, Stephanie; and Berzofsky, Dr.,P.H.U.S., Marcus. Department of Justice Bureau of Justice Statistics. Drug Use, Dependence, and Abuse Among State Prisoners and Jail Inmates, 2007-2009. Report no. NCJ 250546. June 2017. https://www.bjs.gov/content/pub/pdf/dudaspji0709.pdf[4]Ibid.[5] By the Numbers 4, Developing a Common Understanding for the Future of Behavioral Health Care: Overview, History and Financing of Behavioral Health. https://www.communitysolutions.com/wp-content/uploads/2018/04/BTN4_Installment1_5.pdf[6] Crisis Intervention Team. (n.d.). Retrieved from https://memphistn.gov/government/police_department/crisis_intervention_team[7] Matejkowski, Jason; Severson, Margaret. “Review of the Literature on Jail Diversion Programs and Summary Recommendations for the Establishment of a Mental Health Court and Crisis Center within Douglas County, Kansas.” The University of Kansas, 2015. www.douglascountyks.org/sites/default/files/media/groups/cjcc/pdf/10012015-ku-school-of-social-welfare-review-of-literature-jail-diversion-programs.pdf[8] Compton, M.T., et al., The police-based crisis intervention team (CIT) model: II. Effects on level of force and resolution, referral, and arrest. Psychiatric Services, 2014.[9] Crisis Intervention Team (CIT) Reports: CJCCOE. (n.d.). Retrieved from https://www.neomed.edu/cjccoe/cit/reports/.[10] “Settlement Agreement, United States of America v. City of Cleveland, OH,” 2016. http://city.cleveland.oh.us/sites/default/files/forms_publications/SADoc2016.pdf[11] Crisis Intervention Team (CIT) Reports: CJCCOE. (n.d.). Retrieved from https://www.neomed.edu/cjccoe/cit/reports/[12] Gray, Katti. “The social worker in the cop car.” CBS News, 2015. https://www.cbsnews.com/news/the-social-worker-in-the-cop-car/[13] Namigadde, Adora. “When Mental Health Crises Arise, Columbus Police Brings Social Workers Along. WOSU Public Media, December 2019. https://radio.wosu.org/post/when-mental-health-crises-arise-columbus-police-brings-social-workers-along#stream/0[14] "Mental Health Response Advisory Committee: 2018 Annual Report." The City of Cleveland, January 2019. http://city.cleveland.oh.us/sites/default/files/dojsettlement/MentalHealthResponseAdvisoryCommittee.pdf[15]. Ibid[16] Ogg, Kim; Young, Wayne. “Mental Health Jail Diversion” The Harris Center for Mental Health and IDD, June 2019. https://txcouncil.com/wp-content/uploads/2019/06/TX-Council-Jail-Diversion-Center-06-16-10-FINAL.pdf[17] Crisis Intervention Team. (n.d.). Retrieved from https://www.harriscountycit.org/3583-2/[18] Ogg, Kim; Young, Wayne. “Mental Health Jail Diversion” The Harris Center for Mental Health and IDD, June 2019. https://txcouncil.com/wp-content/uploads/2019/06/TX-Council-Jail-Diversion-Center-06-16-10-FINAL.pdf[19] Ibid[20] Trovall, Elizabeth. “New Center in Midtown Offers Mental Health Treatment instead of Jail Time for Non-Violent Offenders.” Houston Public Media, October 2018. https://www.houstonpublicmedia.org/articles/news/2018/10/01/306350/new-center-in-midtown-offers-mental-health-treatment-instead-of-jail-time-for-non-violent-offenders/[21] Ogg, Kim; Young, Wayne. “Mental Health Jail Diversion” The Harris Center for Mental Health and IDD, June 2019. https://txcouncil.com/wp-content/uploads/2019/06/TX-Council-Jail-Diversion-Center-06-16-10-FINAL.pdf[22] Zedaker, Hannah. “Harris County leaders target better jail diversion programs.” Community Impact Newspaper, April 2019. https://communityimpact.com/spring-klein/city-county/2019/04/09/harris-county-leaders-target-better-jail-diversion-programs/[23] Senate Bill 1849. (n.d.). Retrieved from https://www.capitol.state.tx.us/Search/DocViewer.aspx?ID=85RSB018495B&QueryText="1849"&DocType=B[24] “The Diversion First Initiative to Reduce Incarceration of People with Mental Illnesses.” National Association of Counties, 2016. http://www.naco.org/sites/default/files/documents/SAMHSA%20Case%20Study%20-%20Fairfax%20County%20Virginia_FINAL.pdf[25] Site Settings. (n.d.). Retrieved from https://www.fairfaxcounty.gov/topics/diversion-first[26] Site Settings. (n.d.). Retrieved from https://www.fairfaxcounty.gov/community-services-board/services/emergency-what-happens[27] “Diversion First 2018 Annual Report.” Fairfax County, April 2019. https://www.fairfaxcounty.gov/topics/sites/topics/files/assets/documents/pdf/diversion-first-annual-report-2018.pdf[28] Ibid.[29] “Mental Health and Criminal Justice Case Study: Bexar County, Texas.” National Association of Counties, 2015. https://www.naco.org/sites/default/files/documents/Bexar%20County%20%20Mental%20Health%20and%20Jails%20Case%20Study.pdf[30] Klass, Kym. “Restoration Center: San Antonio’s answer to mental health.” Montgomery Advertiser, January 2017. https://www.montgomeryadvertiser.com/story/news/2017/01/27/restoration-center-san-antonios-answer-mental-health/96457170/[31] “Mental Health and Criminal Justice Case Study: Bexar County, Texas.” National Association of Counties, 2015. https://www.naco.org/sites/default/files/documents/Bexar%20County%20%20Mental%20Health%20and%20Jails%20Case%20Study.pdf[32] Ibid.[33] "Blueprint For Success: The Bexar County Model.” https://www.naco.org/sites/default/files/documents/Bexar-County-Model-report.pdf[34] Klass, Kym. “Restoration Center: San Antonio’s answer to mental health.” Montgomery Advertiser, January 2017. https://www.montgomeryadvertiser.com/story/news/2017/01/27/restoration-center-san-antonios-answer-mental-health/96457170/[35] Ibid[36] “Mental Health and Criminal Justice Case Study: Bexar County, Texas.” National Association of Counties, 2015. https://www.naco.org/sites/default/files/documents/Bexar%20County%20%20Mental%20Health%20and%20Jails%20Case%20Study.pdf[37] Ibid[38] Ibid[39]https://commongroundhelps.org/programs/[40] Pfefferle, Sue; et al., Approaches to Early Jail Diversion: Collaborations & Innovations. Abt Associates, July 2019. https://aspe.hhs.gov/basic-report/approaches-early-jail-diversion-collaborations-and-innovations[41] Ibid[42] “Report Shows the Success of Jail Diversion Programs in Oakland County.” Patch, July 2017. https://patch.com/michigan/northville/report-shows-success-jail-diversion-programs-oakland-county[43] Esshaki, Tiffany. “Jail diversion by the numbers.” C and G News, March 2015. https://www.oakgov.com/sheriff/Documents/CGNEWS_JAIL_DIVERSION_3.24.15.pdf[44]https://commongroundhelps.org/programs/[45] Ibid[46] Pfefferle, Sue; et al., Approaches to Early Jail Diversion: Collaborations & Innovations. Abt Associates, July 2019. https://aspe.hhs.gov/basic-report/approaches-early-jail-diversion-collaborations-and-innovations[47] Turk, John. “Oakland County deputies, officers to undergo mental health crisis intervention training.” Oakland County Sheriff, May 2015. https://www.oakgov.com/sheriff/Documents/DAILYTRIB_DEPS_MENTALHEALTH_TRAINING_5.1.15.pdf[48] Pulitzer/Bogard & Associates, DLR Group. “Mental Health & Substance Abuse Diversion Study.” January 2020.[49] "Mental Health Response Advisory Committee: 2018 Annual Report." The City of Cleveland, January 2019. http://city.cleveland.oh.us/sites/default/files/dojsettlement/MentalHealthResponseAdvisoryCommittee.pdf[50] Musumeci, MaryBeth; Priya Chidambaram; Kendal Orgera. “State Options for Medicaid Coverage of Inpatient Behavioral Health Services.” The Henry J. Kaiser Family Foundation, November 6, 2019. https://www.kff.org/medicaid/report/state-options-for-medicaid-coverage-of-inpatient-behavioral-health-services/[51] Kunkel, Christopher; Lewis, Catherine E.; Savage, Jie. “Medicaid's Winding Path Through Institutions of Mental Disease.” Milliman, 2018. https://www.milliman.com/uploadedFiles/insight/2018/Medicaids_winding_path_through_Institutions_of_Mental_Disease.pdf[52] Neale, Brian. SMD # 17-003 RE: Strategies to Address the Opioid Epidemic. https://www.medicaid.gov/federal-policy-guidance/downloads/smd17003.pdf[53] Tassie, James. Section 1115 Substance Use Disorder Demonstration Waiver Application, Section 1115 Substance Use Disorder Demonstration Waiver Application § (2019). https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/oh/oh-substance-use-disorder-treatment-pa.pdf[54] Ohio: 1115 SUD Demonstration Approval, The Center for Medicare and Medicaid Services https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/oh/oh-substance-use-disorder-treatment-ca.pdf[55] Widgery, Amber. “The Legislative Primer Series for Front End Justice: Mental Health.” National Conference of State Legislatures, August 2018. http://www.ncsl.org/portals/1/HTML_LargeReports/Mental_Health_Report_32598.pdf[56] “Medicaid Behavioral Health Services: Crisis Services.” Kaiser Family Foundation, 2019. https://www.kff.org/medicaid/state-indicator/medicaid-behavioral-health-services-crisis-services/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D[57] “Criminal Justice / Mental Health Consensus Project.” Council of State Governments, 2002. https://www.ncjrs.gov/pdffiles1/nij/grants/197103.pdf[58]Pulitzer/Bogard & Associates, DLR Group. “Mental Health & Substance Abuse Diversion Study.” January 2020[59] Clark, John; Logvin, Rachel. “Enhancing Pretrial Justice in Cuyahoga County.” Pretrial Justice Institute, September 2017. https://www.acluohio.org/wp-content/uploads/2017/10/Cuyahoga-County-Jail-Population-Analysis-Report-PJI-2017_final.pdf[60] “Deinstitutionalization - Special Reports | The New Asylums | FRONTLINE.” PBS. Public Broadcasting Service, May 10, 2005. https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html[61] “By the Numbers.” The Center for Community Solutions & The Mental Health and Addiction Advocacy Coalition, 2017. https://www.communitysolutions.com/resources/by-the-numbers/[62] “County Health Rankings & Roadmaps.” County Health Rankings & Roadmaps | County Health Rankings & Roadmaps. Accessed February 14, 2020. https://www.countyhealthrankings.org/app/ohio/2018/rankings/cuyahoga/county/outcomes/overall/snapshot