Peter Ash, MD Oct. 30, 2018

Transcription

1 Peter Ash, MD Oct. 30, 2018

2 Diverted Evaluator thinks IST Send report months Court finds IST Transfer To hospital months Admitted State Hosp. Expensive, LOS ~ days

3 Initial idea: many defendants didn t need the intensity of hospitalization Long wait to get into inpatient forensic unit Jail unit opened November 2011 Resistance from public defenders

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7 Vertical integration Started diverting out of system Clarified need for other services Flexible funding Funded another forensic psychiatry fellow and started forensic psychology post-doc program

8 Evaluator thinks IST Extended eval What intervention needed? Median time from court order to services < 1 month. Court finds IST Admitted Hosp. Admit to Pod Services in GP Outpt restoration Diverted out

9 Move away from One size fits all to Treatment matching (intensity matched to defendant s need) Array of services Extended evaluation Inpatient Jail pod Services in general population Outpatient restoration Diversion (dropped charges w/ outpt MH Tx)

10 Very important Differing laws, organizational structures, ways of doing things call for different approaches Patients who refuse meds Wait lists Other diversion processes: pre-arrest diversion, mental health courts Handling of misdemeanor defendants

11 Day program in the jail Staffing Part-time psychiatrist Psychologist/ program administrator 2 FT staff (social worker, group leader) Trainees- Forensic fellows and psychology post-docs Security 2 deputies from jail Nursing, physical med services provided by jail After hours coverage provided by jail Milieu approach Multiple groups/day Helps with med compliance Med non-compliant defendants Sell hearings Extended evaluations ~ inpatient evaluations

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13 Monday Tuesday Wednesday Thursday Friday 8:00 ************************Room Inspection*************** **Room Inspec.** 8:15 ************************Recreation Time*************** **Rec Time***** 8:30 Goals Goup Goal Group Goals Group Goals Group 9:00 Cog. Remediation Cog. Remediation Cog. Remediation Cog Remediation 8:30am- 10:30 Individual Community Legal Ed. Group Meeting/Goals/ Medication 9:30 Rewards Clinic Legal Ed.Group Current Events (Psychiatry Fellows) 9:45 Conflict Resolution Legal Ed. Group Legal Ed. Group Current Events Group 10:15 Current Events Current Events Rec Time Group 10:45 (Mock Trials, 3 rd Tues) Expressive Arts 11:00 Expressive Arts Health Awareness Music Time 11:00 Spiritual Study Group 1:00 Reading Group 1:30 2:15 3:15 Rec Time - opposite Monday Movie / Music -every other Monday Expressive Arts Rec Time Medication Compliance Group Substance Abuse Group Goals Group Coping Skills Group Legal Ed Rev. Expressive Arts Group Library Time Legal Ed Group- Open disc & DVD Coping Skills Group Life Skills Recreation Time Cognitive Cognitive Remediation Remediation- Advanced Transitions Group 1:1's Twenty Screenings/1:1 s 3:45 Screenings\Testing Testing/ 1:1 s Questions 1:1 s GROUPS MEDS 1:1 Art or Recreation

14 It s a Jail! Can t give involuntary medication Much greater emphasis on diversion out Severe behavior disorders not admitted Milieu different More friendships among inmates Fewer assault incidents

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16 Referred for CST eval N= 1090 Men N=928 Women N= 162 Opined IST N = 436 (47%) CST N=492 (53%) Opined IST N= 98 (60%) CST N= 64 (40%) Outpatient restoration N= 17 General population N= 117 Mobile legal ed in general population N= 50 In-jail restoration unit N= 252 General population N= 98 On bond Not suitable for rest unit - Refuse meds - Overly aggressive Not CST because of limited understanding, but fairly close to CST No special pgm for women at this time

17 Outcomes Referred for CST eval N= 1090 Men N=928 Women N= 162 Opined IST N = 436 (47%) CST N=492 (53%) Opined IST N= 98 (60%) CST N= 64 (40%) Outpatient restoration N= 17 General population N= 117 Mobile legal ed in general population N= 50 In-jail restoration unit N= 252 General population N= 98 On bond Not suitable for rest unit - Refuse meds - Overly aggressive Not CST because of limited understanding, but fairly close to CST No special pgm for women at this time 100 Outcomes Outpt Gen pop Legal Educ Restoration unit Women

18 Outcomes break out Not, not, nots Restored Not restorable Inpt Diverted 5 0 Males Pod admissions Males GP Female GP Outpt

19 Outcomes by med compliance 70% 60% 50% 40% 30% 20% 10% 0% Psychosis takes Psychosis refuses Cog+Psychosis takes Cog+Psychosis refuses Cog only Other takes Other refuses Restored Diverted Inpt

20 Diverted: 76.5% of misdemeanors and 25% of felonies. Non-diverted: Type of impairment (psychotic only, cognitive only, psychotic + cognitive) was correlated with restoration. Psychosis decreased likelihood of restoration. Taking medication nearly doubled the chances of being restored for psychotic defendants. While IQ was correlated with type of impairment, there was no correlation between IQ score and restoration for any subgroup. Type of crime was not correlated with restoration, but misdemeanors were 3 times more likely to be diverted out of the correctional system.

21 Decreased hospitalization (10,000 pt. days) Faster processing Shorter jail stays Shorter waits for services Shorter time to adjudication About 1/3 diverted out of jail

22 Jail restoration State hospital Cost $200/d > $900/d LOS 3 mos. 3-6 mos. Aggressive incidents 2 in 6 years Multiple per week Diversion out Third of inmates Uncommon Medication noncompliance Milieu pressure/ Sell hearings Milieu/ Involuntary meds

23 More rapid institution of restoration services Less cost More diversion out of correctional system and into mental health system

24 No involuntary medication Highly behaviorally disordered patients need hospitalization The issue of whether morally it s appropriate to keep an IST defendant in a jail Resistance by defense attorneys

25 Increase individualized assessment for targeted interventions Pushing for more pre-arrest diversion of misdemeanor offenders Special interventions for teaching plea bargaining Consortium of jail-based units with a core of measured variables

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27 44 states have laws that allow it Review in 2016 found programs in only 16 states Limited data: reported as ~ 70% restored but did not break out cases that were dismissed. Gowensmith et al, 2016

28 Jail-Based Restoration Units

29 Pre-booking diversion of misdemeanors Post-booking diversion Restoration units in no-state psychiatric facilities Special non-jail county based units

30 Other initiatives

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