A Synergistic Approach to Improving Outcomes for Homeless Mentally Ill Remand Prisoners

Transcription

1 A Synergistic Approach to Improving Outcomes for Homeless Mentally Ill Remand Prisoners Dr. Damian Smith, Ms. Orla Reynolds and Mr Philip Hickey National Forensic Mental Health Service and Cloverhill Prison, Dublin Quality Network for Prison Mental Health Services Special Interest Day, RCPsych 14 th March 2017

2 Introduction

3 Transinstitutionalisation

4

5 Transinstitutionalisation

6 Homeless Mentally Ill Prisoners Homeless individuals with MMI and SUDs are overrepresented in prison populations. Recidivism (Greenberg 2008) Mortality (Geddes 2011)

7 Difficulty Accessing Healthcare - Why? I know him, its just the drugs... And hes a PD Acutely Unwell Hard to find INVISIBLE Intoxicated No address Not our catchment area Always out of it I told you... Its just the drugs

8 Ireland s Homeless Crisis

9 Sentenced vs. Remand

10 Cloverhill Prison Inreach and Court liaison Service (PICLS)

11 Homeless Mentally Ill Prisoners An Unmet Prevalence of Homelessness among those seen by PICLS? Need? How do the characteristics of homeless and non-homeless mentally ill prisoners differ? 3 year observational study with longitudinal data collection 1 st Jan 2012 to 31 st Dec 2014 Sources of Referral

12 Prevalence of Homelessness 35.0% (n=298) of all committals (n=1110, 902 individuals) seen by PICLS were homeless. This map displays the HSE regions of origin for non-homeless detainees seen (n=604) 298 The population of a fictional homeless region surpassed each of the HSE regions (n=298).

13 Comparison of Homeless vs. Non- Homeless Z-test statistic was used to test for differences in distribution of the variables between homeless and nonhomeless subgroups X 2 * was used for binary outcome variables.

14 An unmet need was identified 35% of all referrals to PICLS over a 3 year period were homeless. These individuals had significantly increased levels of psychosis and comparable rates of substance misuse. Most were charged with Non-Violent Offences

15 Homeless Mentally Ill Prisoners Homeless individuals with MMI and SUDs are overrepresented in prison populations. Recidivism (Greenberg 2008) Mortality (Geddes 2011)

16 Improving Outcomes for Homeless Mentally Ill Prisoners A housing first approach: recidivism hospitalisation (Srebnik 2013) This model targets homeless individuals with complex needs and provides them with supported accommodation FIRST, without the usual prerequisites of sobriety and stable mental health. (Tsemberis 2004)

17 A Synergistic Approach to Improving Outcomes for Homeless mentally Ill Remand Prisoners HSW

18 Aims and Objectives To identify and support homeless mentally ill prisoners by: Improving their access to accommodation and by arranging appropriate mental health care In addition we aimed to measure: i. Prevalence of homelessness ii. Homeless status of individuals seen by the HSW at time of reception iii. Housing outcomes iv. Mental health outcomes v. Proportion of individuals registered with their local housing authority before and after the introduction of the HSW

19 Method

20 Method Cloverhill Prison Setting: Closed, Medium Security, Male Capacity = % of Ireland s Remands Small number of sentenced prisoners

21 Method Study Design: Observational Study Longitudinal Data Collection PICLS screened all new committals to Cloverhill Prison From 1 st January 2014, PICLS referred homeless mentally ill prisoners to the HSW Participants: All those seen by HSW + PICLS who were released from 1 st January 2014 to 31 st December 2015

22 Method Demographics Clinical Variables: Number of committals Homeless Status on Reception and at time of release Housing and Mental Health Outcomes Statistical Analysis: The z-test statistic was used to test for differences between groups

23 The PICLS Team

24 Housing Support Worker (HSW) Identification Support, Advice and Advocacy Liaison with local authorities and housing support agencies to arrange for accommodation and support upon release Liaison with Community Mental Health Teams Court attendance Time-limited period of post-release support

25

26 Results

27 Results Prevalence of Homelessness Two Years Pre-HSW 749 committals seen 293 were homeless (n=236 individuals) 39% (95% CI ) Two Years with HSW 769 committals seen 248 were homeless (n=191 individuals) 32%, (95% CI ) No significant difference in the proportion of homeless individuals seen between the two time periods (p=0.15).

28 Results: Flow Diagram from Committal to Mental Health Outcome Total New Committals N= 5283 Total New Assessments by PICLS N= 769 (14.6%) Not Seen by PICLS N= 4514 (85.4%) Total Homeless N= 248 (32.2%) Total seen by HSW N= 123 (49.6%) CMH Admission N= 2 Hospital Admission MHA 2001 N= 16 Community based CMHT, Addictions, GP, Rehab N=66 Discharge to Prison GP N=3 Prison Transfer / Extradition N=34

29 Results HSW met with 123 separate committal episodes (n=90 individuals) 303 face-to-face meetings (mean 2.5, SD 2.1) All those seen: 1. Received a Homeless Service Information booklet, 2. Registered with the homeless Central Placement Service (CPS) 3. Offered assistance in applying for a medical card.

30 Results Registration with Housing Authority 25 individuals (28%) were newly registered with their local housing authority of registration from 38% (n=34) to 66% (n=59), by the end of 2015 (p<0.001)

31 Results Pareto Prisoners 1 Committal 71 Individuals 2 Committals 12 Individuals 3 or More Committals 7 Individuals ALL had history of Psychosis and PSA

32 Homeless Status at Time of Reception (n=123, 90 individuals) Categories defined by the DRHE (Dublin Regional Homeless Executive)

33 Results Rough Sleeping 30.1% (n=37) of new committals seen by the HSW were sleeping rough at the time of reception

34 Results - Accommodation at Time of Reception vs. Time of Release (n=73, 56 Individuals) ** ns ns Rough Sleeping Emergency Accom. - One- Night Only 1 Short Term Hostel Medium Term Supported Hostel Returned to live with family / Friend Secure Tenancy / own home / rental / Long TermSupported Hostel Housing at Time of Commi al Housing at Time of Release

35 Results Housing Outcomes The remaining 50 committal episodes resulted in the following outcomes: Transfer to CMH (n=2) Transfer to AMHS Hospital (n=16) Transfer to another prison (n=31) Extradition (n=1).

36 Mental Health Outcomes Following Input from PICLS and HSW (n=123) CMH Admission AMHS - Hospital Admission Community based OPD / GP / Addic on Psychiatry / Rehab Discharge to Prison GP Prison Transfer and referral to Receiving Prison Inreach MHS

37 Results - Mortality Tragically 2% (n=3) of those seen died following release within the two year period

38 Conclusions: Making the Invisible: Visible Homelessness is prevalent among Mentally Ill remand Prisoners. These individuals have high rates of psychosis and PSA. Housing outcomes were improved following input from the HSW including: Improvement in housing status Increased levels of registration with local housing authorities

39 A Day in the Life of the Invisible

40 Case 1: Entrenched Rough Sleeper You are Mr Smith, a 41yo, single man You were released from court this afternoon after the Judge gave you time served (4 weeks) for 2 public order offences. You have been homeless for years You prefer to sleep rough because the hostels are full of messers and junkies Your doctors tell you have Schizophrenia but you don t believe this to be the case; its just a bit of confusion You aim to celebrate your release with a few cans of beer... It never did you any harm before now... And sure it s a Friday!

41 Case 2: Long Term Homeless You are Mr Hickey, a 25yo man You were released from court earlier today on a suspended sentence. You have to meet with your probation officer. You have been homeless for the past two years. You were staying in a hostel before prison but you re unsure if you can go back to it You ve been barred from many hostels previously because you don t pay your rent and the staff think you re trouble You ve been told you have schizophrenia but you rarely go to appointments because they always give out to your drug use You were drug-free in prison and would like some support to stay drug-free in the community.

42 Case 3: First time Homeless You are Mr Reynolds, a 30yo man You were charged with breach of a barring order and unexpectedly released on bail this morning You only have 20 euro in your pocket You can t return to your parent s house or you ll be arrested Your doctor s told you that you re delusional and that you might be a risk to your dad if you go back on the drink You think that's a load of rubbish, but you think you should follow their advice and attend the Psych Apt just in case they breach your bail

43 DISCUSSION

44 Discussion Homeless mentally ill prisoners present a challenge to services due to their complex needs. This can result in a cycle of relapse and recidivism. Although an inappropriate setting to provide healthcare, could a remand prison be viewed as an opportunity to engage this (hard to find, difficult to engage, vulnerable group) with much needed mental health and housing supports? In an environment where they can be: i. found ii. are sober iii. are on medication iv. have access to advocates

45 An Opportunity to Engage? On Medication VISIBLE Found Sober

46 Discussion Urgent need for: 1. Prison Inreach social work and HSW input in other prisons? 2. Community based step down unit aimed at providing rehabilitation and community reintegration? B-HOP Network Interagency Think Tank Future Research: 1. Level of engagement? 2. Improvements in Functioning and Quality of Life? 3. Pareto Patients?

47 Acknowledgements Dr Conor O Neill Mr Martin Caddow Mr Fergal Duffy Mr Philip Hickey Ms Donna Madill Dr Fintan Byrne Dr Jamie Walsh Dr Mark Joynt Dr Tom Cronin Dr Zetti Azvee Prof Harry Kennedy Mr Larry Keevans Gov Ronan Maher Gov Chris McCormack

48 Thank you! Contact details: