As a nonpartisan, nonprofit think tank with a long-standing history in Cuyahoga County, focused on health, social and economic issues throughout Ohio, The Center for Community Solutions welcomes this opportunity to submit information as it pertains to developing a Diversion Continuum for Cuyahoga County. Over the past several months, we have worked closely with Greater Cleveland Congregations, the Cuyahoga County Prosecutor’s Office, MetroHealth, the Ohio Department of Medicaid and many other stakeholders to produce a report on jail diversion as it relates to behavioral health in Cuyahoga County. Our report compares and details four diversion programs containing five crisis intervention diversion centers in four states. We gained insight into their successes, strengths and shortfalls to develop recommendations for a pilot diversion program in Cuyahoga County.

The full report can be found here:https://comsolutionst.wpengine.com/wp-content/uploads/2020/03/Issue-Brief%5FPreBooking-Report%5F03162020.pdf

Prior to this report, Community Solutions worked alongside the Mental Health and Addiction Advocacy Coalition (MHAC) for nearly a decade to produce four By the Numbers reports which provide data and context to increase knowledge of Ohio’s mental health and substance use disorder (SUD) services. The goal of the series is to support sound, data-driven policy decisions and improvements in the delivery of these services.

Over the past several decades, not only has the number of individuals incarcerated skyrocketed, but jails and prisons have become de facto mental health treatment facilities for people with behavioral health disorders. Cuyahoga County is not exempt from this trend as MetroHealth’s jail health care administrators estimate 50 percent of the jail population at any given time has Serious Mental Illness (SMI), a substance use disorder (SUD) or a Co-Occurring Disorder (COD), where an individual is struggling with both mental illness and SUD. We found through our research that moving Cuyahoga County toward the creation of a pre-arrest/pre-booking crisis intervention center focused on diversion will bring a much needed, coordinated resource to the county.

Facility

A central drop-off site available 24-hours a day, seven-days a week 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 and away from the criminal justice system, it is necessary to have a place to stabilize individuals to determine what a person needs, and to provide linkages in the community when they are engaged by law enforcement. 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.

While we did not recommend where exactly a potential diversion center should be located within the county, or how many physical centers should be, we do recommend that any center works with and contracts with all law enforcement agencies in the county so each agency is able to drop off individuals at the center to be assessed. No resident of the county should be more or less likely to have an opportunity to go to the center versus being arrested and booked into jail because of where they live. As highlighted in the report, many officers in Cuyahoga County, specifically officers in the Cleveland Department of Police, have already taken individuals in crisis to hospital emergency rooms and St. Vincent Crisis Center instead of making arrests. We want to assure that officers know this is still an option and that implementing a diversion center doesn’t mean the options are only diversion center or jail.

Additionally, while it is important that any centralized diversion facility or location is available for use by the entire community and not just by 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 would instead make an arrest) if they believe the person in custody will not be accepted for evaluation due to a center being over capacity. This is especially true for law enforcement who would pass by a jail or holding facility en 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.

Of the programs we evaluated, only one, located in Bexar County, Texas, had more than one diversion facility. The two facilities were opened three years apart to help serve the needs of the more than two million residents in the county. The facilities also have different staffing ratios and capacity as patients can only remain at the Crisis Care Center for up to 23 hours as opposed to the Restoration Center which coordinates with a homeless shelter for a much longer stay. Our report highlights the other distinctions between these two facilities in the same community.

Target population/potential users

The target population of the four programs assessed were consistent overall, consisting of individuals experiencing homelessness, severe mental illness, substance use disorder, co-occurring disorder and developmental disabilities who are suspected to have committed low-level, non-violent crimes or have been charged with such. What was less consistent and worth considering, however, is whether or not an individual could be in acute crisis and be eligible for admission into the diversion center since the diversion center needs to be completely voluntary. Other conflicting policies among the programs included whether or not offenders who currently have open warrants or detainers were eligible for diversion and how past criminal convictions are handled, especially those that are violent and/or felonies.

Since we at Community Solutions do not specialize in criminal justice policy, we did not make any determinations on what constitutes a low-level or non-violent crime, but we did however recommend that once the county has made these determinations, they 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 and jail populations through criminal justice reform policies that impact the classification of crimes.

Additionally, 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.

To maximize potential users, every jail in Cuyahoga County (including the county and city facilities) must use the same full and evidence-based mental health screening for inmates at jail booking to ensure every inmate who needs it can access 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 illnesses, they may begin to decompensate. 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, especially as the county considers changes to its Justice Center to include a Central Booking Facility.

Services

It’s critical that any facility used for diversion is also a venue to provide sobering and addiction-treatment services. Many justice-involved individuals have substance use problems and have co-occurring mental disorders that would be difficult to assess until the person is sober and stable.

There is very little variation amongst the services offered at the diversion facilities we assessed in our report, with a heavy emphasis placed at every facility on all services being direct and integrated. These services include:

Medication management
Crisis housing support
Detox/sobering unit
Permanent supportive housing
Individual treatment plans
Post-release case management
Treatment for minor injuries
General healthcare
Non-emergent psychiatric care
Group and peer support therapy
Crisis intervention
Risk assessmentWhile the length of stay did vary at each facility, it’s important to reiterate that individuals should be free to leave the diversion facility whenever they choose, otherwise there would be an issue of civil rights. In some diversion programs, the length of stay at the diversion facility depends on which program you qualify for, that said, length of stay varies from up to a 24-hour hold to three weeks.

Staffing

We recommend staffing levels be assessed after the number of beds available is determined. While staffing levels differed between communities in our report since they are largely attributed to funding and number of beds, the type of staff required is invariable. Diversion facilities across the country employ a team of multidisciplinary staff to ensure the facility can meet the needs of all individuals who enter and that the facility remains safe. Many facilities employ (plain clothed) crisis intervention team trained law enforcement to handle initial intake assessments and to accept hand-offs from patrol officers. Additionally, facilities employ physicians, benefit specialists, psychiatrists, licensed mental health professionals (counselors, social workers etc.) as well as peer support/recovery specialists, nurses and sometimes even paramedics.

Coordination with current resources

We recommend, as part of the diversion plan, that an information technology system is developed that can compare the county and city jail booking data as well as any data collected from the diversion facility, existing post-booking diversion programs such as drug and mental health courts as well as Cuyahoga County Alcohol, Drug and Mental Health (ADAMHS) board claim data. This would help to determine where overlap is in systems and ensure providers can identify and access their members who are incarcerated or in a diversion facility to facilitate transition planning and provision of treatment and services upon release. We also recommend the 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.

A 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 would enable patients to be connected to their historical providers of choice. The Institutions for Mental Diseases (IMD) exclusion is tied to the history of deinstitutionalization, and the history of deinstitutionalization, in part, explains the increase in jail and prison settings for individuals with behavioral health disorders. 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, and any contracts awarded to administer the site should stipulate assurances in connecting people to their historical provider. 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 on a model which is informed by evidence and focused on maintaining continuity.

Funding sources

The 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 23 reimbursement scheme in the SUD waiver, services offered in the pre-booking center would 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. 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.

In addition to Medicaid, we found diversion services are typically covered by private insurance in other states. In Harris County, Texas, funding for the diversion center is made possible through state legislation that included appropriations, several grants, funding from the Texas Health and Human Services Commission and in-kind matches. In Oakland County, Michigan, much of the support staff is funded through grants and treatment services are funded through Medicaid dollars. In Bexar County, Texas in addition to relying on grants, insurance reimbursement and the Veterans Administration, there is also a county initiative for county residents who don’t have access to private or federally-funded health care which pays for treatment for many residents. Through our research and analysis of other diversion programs, relying on insurance reimbursement alone is not enough to maintain the program.

Any data gathered on the program including recidivism after diversion, costs of the program, number of individuals assessed per day, decrease in jail population and any other non-identifying information regarding the diversion program should be made public so other communities in the state and in the country can assess best practices.

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