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HomeMy WebLinkAboutAgenda - 04-22-2021 Virtual Work Session; Item 2 - Orange County Crisis-Diversion Facility - Findings and Recommendations by the Orange County Behavioral Health Task Force 1 ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: April 22, 2021 Action Agenda Item No. 2 SUBJECT: Orange County Crisis/Diversion Facility: Findings and Recommendations by the Orange County Behavioral Health Task Force DEPARTMENT: Criminal Justice Resource Department (CJRD) ATTACHMENT(S): INFORMATION CONTACT: Caitlin Fenhagen, 919-245-2303 PowerPoint Slides Tony Marimpietri, 919-619-7223 Barbara-Ann Bybel, 919-951-5819 PURPOSE: To receive information about the findings and recommendations of the Crisis/Diversion Facility Subcommittee of the Orange County Behavioral Health Task Force. In addition, the Behavioral Health Task Force is seeking feedback from the Board and initial support to move forward with detailed design and implementation planning. The first recommended action step is funding for contracting with a project design consultant to conduct detailed planning including design of Facility space, staffing, and licensing. Implementation planning would also include governance, policies and procedures, and cost estimates, budget sources, and funding needs. BACKGROUND: In April 2019, over thirty community stakeholders from the criminal justice system, healthcare, behavioral health system, and housing came together to participate in the Orange County Sequential Intercept Mapping (SIM) Workshop facilitated by the North Carolina Department of Health and Human Services. The SIM process is designed to inform and address community-based responses to the involvement of individuals with behavioral health issues and intercepts with the criminal justice system. An intercept map and Final Report were created (SIM Final Report) and one of the identified community gaps that emerged from this process was the critical need for a Crisis/Diversion facility that would support diverting individuals in behavioral health crisis from the criminal justice system and the Emergency Departments at UNC Hospitals. The Behavioral Health Task Force (BHTF), co-chaired by Barbara-Ann Bybel, Director of Inpatient Psychiatry Services at UNC Hospitals, and Caitlin Fenhagen, CJRD Director, formed in 2019 to address the behavioral health intercept gaps identified in Orange County. The mission of the BHTF is to improve outcomes for individuals with behavioral health disorders through partnerships across justice, law enforcement, mental health, homelessness and substance use service systems. Later in 2019, the Crisis/Diversion Facility Subcommittee was formed and tasked with bringing forth recommendations and a plan for a dedicated Facility. This Facility will offer 2 behavioral health crisis services and allow for law enforcement and hospital ED diversion. The Subcommittee, under Tony Marimpietri's leadership, has met diligently and frequently over the last two years to address this high priority need. This process has included a lengthy literature review of best-practices and elements for a crisis/diversion facility, studying existing state and national crisis/diversion facilities, seeking input from critical local stakeholders, looking at use case scenarios, examining available data and determining the appropriate scope and function for an Orange County Facility. This presentation will share the detailed findings and recommendations of the Subcommittee's work. An overview of these findings and recommendations has previously been shared with the Behavioral Health Task Force, the Justice Advisory Council and Orange County's law enforcement leaders. These presentations have been met with broad support and interest. It is the Behavioral Health Task Force's strong belief that the proposed Facility, and its evidence- based, holistic, trauma-informed policies and practices will lead to necessary enhancements in Orange County crisis system capabilities, will increase diversion and deflection from the criminal justice system and will improve healthy and safe outcomes for residents of Orange County. FINANCIAL IMPACT: There is no financial impact associated with receiving this information. SOCIAL JUSTICE IMPACT: The following Orange County Social Justice Goals are applicable to this item: • GOAL: FOSTER A COMMUNITY CULTURE THAT REJECTS OPPRESSION AND INEQUITY The fair treatment and meaningful involvement of all people regardless of race or color; religious or philosophical beliefs; sex, gender or sexual orientation; national origin or ethnic background; age; military service; disability; and familial, residential or economic status. • GOAL: ENSURE ECONOMIC SELF-SUFFICIENCY The creation and preservation of infrastructure, policies, programs and funding necessary for residents to provide shelter, food, clothing and medical care for themselves and their dependents. • GOAL: CREATE A SAFE COMMUNITY The reduction of risks from vehicle/traffic accidents, childhood and senior injuries, gang activity, substance use and domestic violence. ENVIRONMENTAL IMPACT: There are no Orange County Environmental Responsibility Goal impacts associated with this item at this time. RECOMMENDATION(S): The Manager recommends that the Board provide feedback on the Findings and Recommendations of the Behavioral Health Task Force and discuss initial funding for a detailed design and implementation plan. ORANGE COUNTY CRISIS/DIVERSION FACILITY Findings and Recommendations REPORT BY THE ORANGE COUNTY BEHAVIORAL HEALTH TASK FORCE DATE: APRIL 22, 2021 4 EXECUTIVE SUMMARY BHTF Report. This report presents Orange County Behavioral Health Task Force findings and recommendations for Orange County to establish a dedicated behavioral health (BH) crisis-diversion Facility to enhance its crisis response system and capabilities. Current Status. Orange County does not have a comprehensive BH crisis system. We have identified many gaps in current services and limited options to successfully divert an individual in crisis from either hospital-based emergency department (ED) or criminal justice (CJ) system. This need is characterized in terms of critical services that currently are lacking and estimated need for crisis care. Recommendation. The recommendation presented herein is for Orange County to enhance its crisis system by establishing a dedicated Crisis/Diversion Facility to provide for BH crisis services/criminal justice diversion. If implemented, this Facility and associated policies, procedures, and practices will lead to enhancements in Orange County crisis system capabilities by establishing services that currently do not exist or are limited in one or more important ways. Potential Benefits. The benefits of establishing the recommended crisis-diversion Facility accrue to: 1) the individuals in crisis, his/her family, and friends; 2) law enforcement and emergency medical professionals; 3) hospital-based ED and in-patient facility and staff; and 4) various criminal justice stakeholders including detention center operations and staff. Through communitywide collaboration and networking with all allied treatment and social services partners, Orange County will maintain a continuum of care thus facilitating effective transition from crisis care to community treatment. Next Steps. If the Board of County Commissioners accepts the BHTF recommendations, the next phase will address creation of a detailed implementation plan for construction/operation of an Orange County Crisis-Diversion Facility. Funding will be needed for this detailed planning and additional assessment work. 2 5 CONTENTS Acronyms Used in This Report Exhibit A. April 2019 Workshops Introduction Sequential Intercept Mapping Framework Background Orange County SIM Map Subcommittee's Charge Existing Resources Current Status Exhibit B. Best Practices Findings SIM Workshop (opportunities and gaps) Literature Review Local Stakeholders (needed services) U.S. Programs and Facilities Best Practices — opportunities for improvement Exhibit C. Orange County Data Sources and Notes Recommendation Dedicated Facility Scope and Function Potential Benefits Related Considerations Next Steps 3 6 ACRONYMS USED IN THIS REPORT 988. New national suicide/crisis hotline. ADATC. Alcohol and Drug Abuse Treatment Center. BH. Behavioral Health (includes serious mental illness and substance use disorders). BHTF Orange County Behavioral Health Task Force. BOCC. Orange County Board of County Commissioners. CHPD. Chapel Hill Police Department. Club Nova. Nonprofit community center for individuals with SMI. emPATH. Emergency Psychiatric Assessment, Treatment & Healing Unit. IDD. Intellectual Developmental Disorder. IVC. Involuntary Commitment. LE/LEO. Law Enforcement/Law Enforcement Officer. LME/MCO. Local Management Entity/Managed Care Organization (manages Medicaid funds for mental health). MAT. Medication Assisted Treatment (refers to medications for Opioid Use Disorder). NAMI. National Alliance on Mental Illness. OCSO. Orange County Sheriff Office. SIM. Sequential Intercept Mapping. SMI. Serious Mental Illness. SUD. Substance Use Disorder. 4 7 INTRODUCTION : REPORT PREPARATION AND REVIEW This report has been prepared by the Orange County BHTF Crisis/Diversion Facility Subcommittee. The report puts forth the Subcommittee's recommendation for an Orange County Facility and provides a summary of the research and assessment work used to reach its recommendations. These recommendations have been presented to and reviewed by several advisory and public interest groups operating in Orange County including: Orange County Behavioral Health Task Force (BHTF). January 20, 2021 . Orange County Justice Advisory Council (JAC). February 12, 2021 . Chiefs of Police and Orange County Sheriff. March 24, 2021 . Comments and edits provided during these discussions have been incorporated into this version of the BHTF's report for the Orange County Board of County Commissioners (BOCC). Pursuant to guidance from the BOCC, these recommendations will provide a basis for more detailed planning including design of Facility space, staffing, licensing, governance, policies and procedures, budget, and funding. 5 8 INTRODUCTION : BACKGROUND 2015. Orange County BOCC adopted a Resolution supporting Stepping Up Initiative to Reduce the Number of People with Mental Illness in Jails. 2018. Orange County Sheriff Charles Blackwood raised the idea of including in the planning for the new Orange County Detention Center a separate area that would serve as a diversion unit for law enforcement. The planning for such a facility was not completed in time for consideration by the Orange County BOCC. At the time, Jail Mental Health Work Group stakeholders toured NC facilities that are providing services that might be a model for an Orange County facility. 2019. On April 25-26, NC DHHS and Orange County held a series of workshops — Sequential Intercept Mapping and Taking Action for Change (collectively referred to as SIM Workshop) with 32 local representatives of organizations involved in criminal justice (CJ), UNC Health, community treatment, and emergency medical services to address issues involving BH and CJ. The workshop identified gaps in current services and assigned priorities for action: a crisis center was assigned high priority. 2019. In November 2019, responsibility for addressing this high priority action item was assigned to the BHTF Subsequently, the Crisis/Diversion Facility Subcommittee was formed and tasked with bringing forth recommendations. 2020. In December, the Governor's Task Force for Racial Equity in Criminal Justice reported its findings and recommendations: three of the Task Force's recommendations relate directly to situations involving individuals with BH issues and criminal justice diversion. 6 9 INTRODUCTION : SUBCOMMITTEE'S CHARGE The findings and recommendations presented herein are r V Subcommittee Members .,- based on the work of a subcommittee of the Orange County Tony Marimpietri Behavioral Health Task Force (BHTF). Chair NAMI-Orange County Mission: Address high priority item identified in SIM Caitlin Fenhagen OC Criminal Justice Resource Workshop: lack of a crisis center. Sponsor Department (CJRD) Goals: Formulate recommendations for Orange County crisis Barbara-Ann Bybel, UNC Health Care services that would facilitate diversion of individuals Sponsor experiencing BH (MH and SUD) crisis from either: Jamezetta Bedford OC Board of County hospital-based emergency department and/or Commissioners criminal justice system. Heather Griffin-Dolciney Freedom House Megan Johnson CHPD Crisis Unit Angela Strain UNC Health Care Pamela Weiden District Court Judge's Office Kim Woodward Orange County EMS Allison Zirkel Orange County CJRD 10 CURRENT STATUS : SIM WORKSHOP (OVERVIEW) The Orange County Criminal Justice Resource Department, District Court Judges' Office, and multiple other local stakeholders requested the Sequential Intercept Mapping and Taking Action for Change workshops held in April 2019 (SIM Workshop). The primary objectives of the SIM Workshop are: Develop a comprehensive picture of how people with BH disorders flow through Orange County criminal justice system. Exhibit A describes the Sequential Intercept Mapping Framework and provides details of the sequential intercept mapping for Orange County. Identify gaps, resources, and opportunities for intervention and deflection at each intercept. Determine priorities to improve system and service level responses for individuals in the target population. As noted in the workshop documentation, improving outcomes for justice-involved persons with behavioral health disorders requires partnerships across the justice, mental health, homelessness, and substance use service systems. The BHTF is charged with being the lead partnership, in conjunction with representatives of other partnerships, to oversee implementation of the action plan developed during the Taking Action for Change Workshop. Exhibit A summarizes the programs and resources that already exist in Orange County. These resources provide a solid foundation upon which crisis system enhancements can be made. 8 11 CURRENT STATUS: SIM WORKSHOP (FRAMEWORK) Interoepi 10 Irrlerccpt 1 Intercept 2 In teTimpt 3 InI-ercept 4 Intercep+t S Cx nmurALy Sw Yiccs LOW Ent -�l hdila1 Dec-ent w Jaila.00 3 C4wnrinuniW Ccwrectk�++r. I rrit:e I toe Briny s �rl�ls Lines Spec la tty D ,.I-_ 1 �pr ips 8n{ p� C3 2 Crisis Care Au rest kkidel1 Qi&Paslaip W1 L#�IL4w En(&rc*rriier�r # t � �+ rarrD* ,1�11 t3 ,1�11 �O�t}3ti��5 © 2019 Policy Research Associates. Inc. • The Sequential Intercept Mapping Framework (Griffin, et. al.) is organized as illustrated above. SIM Workshop output is organized according to these intercepts. Orange County is fortunate to have many existing cross-system programs, services, and partnerships that can implement action plans established during the Workshop. Workshop identified opportunities to build on existing Orange County programs and services without replacing or duplicating any existing services. Griffin, PA., Heilbrun, K., Mulvey, E.P, DeMatteo, D., & Schubert, C.A. (Eds.). (2015). The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York: Oxford University Press. DOI: 10.1093/med:psy ch/9780199826759.001.0001 9 12 CURRENT STATUS : SIM WORKSHOP (GAP ANALYSIS) Gaps identified by participants during the SIM Workshop are organized according to Intercepts as defined by the Sequential Intercept Mapping framework. Intercept 0: Community-Based Crisis Services. Existing crisis Intercept III: Jails/Courts (See Note). There is limited physical services have limited access due to exclusionary eligibility space in the Detention Center for additional programming, and criteria, limited hours of operation, long wait times/waitlists due no designated housing for persons with mental illness and/or to being at capacity, and/or offer limited discharge planning and substance use diagnoses. There is potential to increase referrals support. and clinical support for Outreach Court and Community Intercept I: Law Enforcement/Emergency Services. There are Resource Court and thereby allow for more individuals to receive limited options and support for law enforcement officers and assistance. other emergency service providers for diverting individuals from Other Considerations: There is a need to increase availability of CJ or the hospital-based ED. The key issue at this intercept is: Medication Assisted Treatment (MAT) for persons released from Divert to Where? CJ involvement; ensure a cross-systems endeavor (e.g., BH, Intercept II: Initial Detention/Initial Court Hearing. There are jail/prison, homeless services, courts, police, social services, insufficient clinical services in the Detention Center to treat consumers, family members, advocates); expand peer support someone experiencing a mental health crisis, screening tools not to promote recovery; and facilitate transition to appropriate fully consistent with best practices, and jail setting can services in the community. exacerbate mental health symptoms. Note: New Orange County Detention Center due to open soon will address many gaps identified during the April 2019 Workshop. 10 13 CURRENT STATUS: LOCAL STAKEHOLDERS (OVERVIEW) In addition to the gap assessment and action plan provided by the SIM Workshop, the subcommittee examined in detail the needs of stakeholders in Orange County. Subcommittee membership itself includes representatives of key stakeholder groups involved in Orange County crisis services: emergency medical services, existing clinical services including UNC Hospitals, law enforcement, courts, and jail. Working with stakeholder representatives, we examined crisis situations that arise in Orange County and used these to further identify the services and facility attributes that are absent and that if they existed would: Enhance crisis response to better serve individuals by providing quality care in the most appropriate setting Benefit stakeholders who engage individuals in crisis on a daily basis in Orange County by facilitating alternative responses that save these stakeholders time and dollars and result in better outcomes for all involved. This stakeholder input enriches our understanding of the gaps that exist in existing crisis services thus augmenting the findings of the SIM Workshops. 11 14 CURRENT STATUS: LOCAL STAKEHOLDER (GAP ANALYSIS) Several factors limiting effective, comprehensive crisis response in Orange County have been identified by the local stakeholder analysis. Existing services are limited by one or more of the following: Do not provide a no refusal intake for law enforcement or emergency services. Do not integrate well with CJ diversion programs. Do not meet all needs due to extensive exclusionary criteria. Do not provide an appropriate setting for BH crisis care (not the least restrictive setting). Do not have the capacity to provide readily-available clinical services for CJ proceedings. Do not serve incarcerated individuals due to billing restrictions. Do not always provide peer support or case management follow up. Do not always provide adequate discharge planning (fail to facilitate warm handoff to community treatment and/or social services). Do not have the capacity to facilitate holistic support (recognize all determinants of health). Do not offer immediate access to MAT. Only Freedom House and the UNC ED allow access by the public on a 24/7/365 basis, and services are often at or over capacity. Limited resources for people who are indigent and uninsured. 12 15 BEST PRACTICES : OPPORTUNITIES FOR IMPROVEMENT (LITERATURE) Literature Review Elements of Current Best Practices Currently there are no national standards for crisis Clear Objective. services such as those existing for medical services (e.g., Embrace the objective of diverting individuals in crisis away EMS). from traditional ED and jails Existing literature points to an emerging framework for Support this objective with dedicated facilities and programs. defining crisis services. Anyone, Anytime, Anywhere. There is an enormous body of literature that points to Community-wide Collaboration. evidence-based practices that can be adopted and Calming Environment. tailored to Orange County. Network with Community Treatment Providers. Two references are key to our work are: The Sequential Intercept Model. Holistic Wrap Around. National Guidelines for Crisis Care: A Best Practice Warm Handoffs and Case Management/Peer Specialist Support. Toolkit. Continuous Improvement. 13 16 BEST PRACTICES : OPPORTUNITIES FOR IMPROVEMENT (U .S . FACILITIES) 01 • In addition to the literature review, we researched existing Medical Jail Diversion Leans toward providing BH Limited to providing criminal programs and facilities. and SUD and Physical Health FOCUS justice stakeholders an alterative Services. to using jail. There are scores of existing programs and facilities across the U.S. Limited Scope Comprehensive • BH Crisis Assessment and BH&SUD Assessment& representatives of a Stabilization. ServlC@S Stabilization; calDetox: He Sobering Subcommittee members interviewed re p 23-hour operation. Center; Physical Health; dozen operating and planned facilities. Pharmacy;multi-day stays. This review includes two important N.C. facilities: Restricted Anyone Limiting conditions: Admit anyone regardless of intoxicated,violence potential, Who Is Served? situation, behavior,age. Wakebrook suicidal ideation, IVCs. General public walk-ins. (Wake County, Raleigh). C3 356 Comprehensive Care Center (Buncombe Traditional Calming Setting Traditional medical facility with Living room space. County Asheville). patient rooms and chairs. Ph SICaI DeSI n EmPATH emergency setting. Designed to mitigate trauma and deescalate crisis. Figure on right illustrates the wide variation in facilities IN across six dimensions. Internally Focused Community Networking • Focus on crisis intervention Networked with all community. Exhibit B contains more complete summary Of best and stabilization services Collaboration treatment and social services provided within the Facility. with peer specialists and case practices findings. management support. No Program Integration Wrap Around Services • Focus is on operation of the Warm handoff to facilitate Facility without much HOIIStIC transition from crisis care to emphasis on other programs. community treatment and social services. 14 17 RECOMMENDATION : FOCUSING ON THE NEED Hospital Courts and and ED Diversion Services Programs Emergency Detention Medical Center Services Services Public Facility- Safety Based (LEO) Services Community Social Treatment Services Services LJ7 Recap of Current Situation and Opportunities for Improvement. Multi-year series of actions in Orange County from 2015 to 2020. SIM Workshop gap assessment: focused on needs at the intersection of BH and Orange County criminal justice. Stakeholder Analysis: focused on local needs identified by those engaged in BH clinical services and criminal justice in Orange County. Best Practices: literature review. Best Practices: review of existing U.S. and N.C. programs and facilities. 15 18 RECOMMENDATION : ESTABLISH A DEDICATED CRISIS/DIVERSION FACILITY Hospital Courts and and ED Diversion Services Programs Emergency Detention Medical Center Services Services Public Facility- Safety Based (LEO) Services Community Social Treatment Services Services L_r LJ7 Dedicated Crisis/Diversion Facility L_r L_r We recommend Orange County enhance its crisis system by establishing a dedicated Crisis/Diversion Facility to deliver BH crisis services/criminal justice diversion. Recommended Facility will enhance Orange County's crisis care and complete a continuum of care resulting in benefits for patients, clinical/criminal justice stakeholders, and community at large. Facility will provide clinical and criminal justice-related services and will network with existing programs/services. Facility will provide services that currently do not exist for clinical care and serve as a default destination for law enforcement and EMS for diverting individuals in crisis. The Facility will build on and integrate with current capacity and strengths — it will not duplicate or replace existing services/programs. 16 19 RECOMMENDATION : SCOPE AND FUNCTION Some 50 services/facility attributes have been specified to define the scope and function of the recommended Facility. Implementing these recommendations will establish services that do not currently exist thus enhancing crisis services and benefiting all involved in crisis care. In summary, recommended Facility: Offers immediate clinical services for assessment, stabilization, and treatment for patients experiencing BH crisis (mental illness and substance use disorders) in a more appropriate/least restrictive setting (compared to hospital-based services or jail). Makes referrals to community treatment and social services with warm handoff supported by case manager and/or peer support specialist facilitating transition of individuals from crisis care to community-based treatment. Allows access for walk-in patients on a 24/7/365 basis. Provides law enforcement and emergency medical services with a default destination and operates without restrictive entry or exclusion criteria (e.g., accepts under the influence, IVC, agitated, suicidal). Provides criminal justice stakeholders with clinical assessment services and a facility to offer the most appropriate care for justice- involved individuals in the least restrictive setting possible. The next four pages provide a detailed list of specifications for the recommended Facility in four categories: Criminal Justice Clinical Services Community Treatment and Social Services Networking Physical Attributes of the Facility. 17 20 RECOMMENDATION : SCOPE AND FUNCTION (CRIMINAL JUSTICE) On-site LE personnel to maintain facility security. Locked, secure facility space available. On-site security personnel to maintain safe environment and provide readily available transportation for patients in custody, act as courier for IVC and other court paperwork to and from Facility. On-site presence (or video conference link) for criminal justice stakeholders (e.g., Magistrate, District Attorney, Public Defender, courts/judges, clinical social worker). On-site security to temporarily board patients who are in custody (e.g., transfers from jail). FIT (Formally Incarcerated Transitions) program liaison. Readily available transportation for IVC patients. Recommend hybrid model based on assessed need of patient to include private car, ambulance, or law enforcement. • Clinical assessment services for Magistrate & court processes. • Clinical services for individuals who are in custody (temporary transfers from detention facility) or awaiting other court processing/hearing. • No refusal admission for law enforcement and emergency medical services (24/7/365) including individuals who are agitated or under an IVC order. 18 21 RECOMMENDATION : SCOPE AND FUNCTION (CLINICAL SERVICES) • BH urgent care (24/7). 0 Serve individuals with special needs (e.g., IDD). • Serve short-term IVC patients. Peer support specialists. • Emergency SUD treatment services (24/7). 6 Multi-day temporary boarding pending transfer: that is, bridging • Non-hospitalization detoxification services. crisis management and community treatment. • Urgent Medical Care Services (to allow non-life-threatening • On-site pharmacy services to allow patient to be discharged with conditions to be treated at Facility) medication. • On-site pharmacy services to support stabilization and initial Third-party laboratory with available, expedited courier service. treatment. Serve patients in Facility. Serve patients in Facility. • Point of Care Testing (quick turnaround laboratory services). • Services for adolescent patients (16- and 17-year-old). Serve patients in Facility. 0 Walk-in Services for general public (24/7/365). • Capacity to manage individuals who are agitated, but do not Short-term ambulatory treatment services (e.g., non-medical require secured space and restraints. detox) to facilitate stabilization prior to discharge. • Referral and transportation to hospital and other treatment 0 Initiate MAT treatment in anticipation of transfer to community facilities (after dropping off by LE/EMS). treatment provider. 19 22 RECOMMENDATION : SCOPE AND FUNCTION (COMMUNITY SERVICES NETWORKING) Community Treatment Services Networking Provide information about all community treatment services (for all conditions) where Facility is well integrated with community providers. Referral to out-patient/in-patient BH treatment services. Referral to out-patient/in-patient SUD treatment services (e.g., Freedom House, MAT, ADATC). • UNC Hospital referral liaison (facilitate transfer of patients needing higher level of care without involvement of LE or EMS who may have brought patient to Facility). Patient transfer to other treatment facilities (e.g., UNC Hospitals, detox facilities). LME/MCO liaison. Warm handoff to community treatment services with support from peer specialist and/or case manager. fSocial Services Networking - OC Partnership to End Homelessness and Housing Access (via OC Housing Helpline). Liaison for NAMI programs. Health insurance enrollment liaison including legal representation. Provide information about and a warm handoff to the existing network of social services with peer specialist support. Transportation assistance. L 23 RECOMMENDATION : SCOPE AND FUNCTION (FACILITY ATTRIBUTES) • Dual entry (dedicated entry) for LE and EMS. Calming area or living room setting. Rooms/beds for agitated patients. Space for law enforcement and emergency medical personnel. Video conference facility to provide access to magistrate. • Video conference room for robust link between Facility and Magistrate, Courts, District Attorney. • On-site criminal justice space to support criminal justice stakeholders. • Short-term boarding space for patients awaiting transfer to third party community service. • Dedicated space/rooms for patients housed in Facility in lieu of jail. • Short-term boarding space for patients awaiting IVC or other hearing. • Adolescent (16- and 17-year-old) clinical space. ■ Call center coordination including 911 , EMS, LE/Crisis Units, Hospitals. • Space for resource library (references and information related to treatment services, social services, and related programs that are available to Orange County residents). 21 24 POTENTIAL BENEFITS The recommended Facility will fulfill the primary goal established by the BHTF in response to the SIM Workshop and based on the work of the Crisis-Diversion Facility Subcommittee: divert individuals experiencing a BH crisis from either jail or ED. Accomplishing these goals will result in an important set of benefits that will accrue to a broad cross-section of Orange County. These benefits fall into four categories. Consumers and Families. Law Enforcement and Emergency Medical Services. Criminal Justice System Stakeholders. Hospital-based ED and Inpatient Care. 22 25 POTENTIAL BENEFITS : CONSUMERS AND FAMILIES Stakeh14 �rojected C-D Facility Patient Demand • • Comm Homeless CJ MH Suicide SUD (Note 1) (Note 2) (Note 3) Total EMS 20 -- 48 68 Chapel Hill PD 8 3 5 8 24 Carrboro PD 3 1 2 2 8 Hillsborough PD 3 1 4 OC Sheriff 8 2 4 6 20 All Orange County LE 3 3 OC CJ/Detention Center 8 8 Magistrate/Courts 116 116 UNC Hospital ED 22 1 4 0 27 Total Cases Per Month 64 7 63 133 3 8 278 The table above shows projected long-term average monthly crisis episodes expected to be served by the recommended Facility based on current Orange County data (Exhibit C). Note 1 . Comm refers to commitments: All IVCs are recorded under Magistrate/Courts. Other commitments (e.g., voluntary, emergency medical) are recorded under the various law enforcement agencies. Note 2. Homeless relates to 911 calls associated with homeless individuals involving trespass or disturbances and are record for All Orange County LE. Note 3. Includes episodes involving justice-involved individuals or clinical assessments for court proceedings. 23 26 POTENTIAL BENEFITS : CONSUMERS AND FAMILIES (CON 'T. ) • Persons Served. There is a definite benefit that accrues to individual as indicated by the projected number of crisis episodes. The number of individuals projected to be served by the Crisis-Diversion Facility is estimated to be approaching 300 cases per month. A sensitivity analysis indicates that the number of individuals served could range from 255 to 305 per month. The detailed breakout of the midpoint by type of episodes that could be served by the recommended Facility is shown on the previous page. The range reflects various assumptions about the effectiveness of diversion policies, procedures, and practices in LE, EMS, UNC Hospital, Jail, and the needs of CJ proceedings. Walk-ins services could increase the number of individuals served above those noted above. Walk-in Services. Providing services on a walk-in 24/7/365 basis offers help before a crisis escalates to emergency services. • Access to Immediate Clinical Services. Individuals in BH crisis receive immediate access to assessment, stabilization, and treatment services for a broad range of MH and SUD conditions. Transitions. Facilitating transition of individuals from crisis care to community-based treatment with adequate discharge planning including referrals and bridging services provides the best chance of achieving success in terms of long-term outcomes for individuals in need. - Warm Handoffs. Individuals leaving Facility are supported by a warm handoff: support of case manager and/or peer support specialist. • Holistic Support. Support for the whole person facilitates connecting individuals in need with social services thus increasing chance of recovery and minimizing repeat crises. • Information and Guidance. Helps consumers cut though fog of obtaining BH services often experienced by individuals, families, and friends trying to get help. 24 27 POTENTIAL BENEFITS: LAW ENFORCEMENT AND EMERGENCY MEDICAL. Reduced Burden on LE and Emergency Medical Services. Facility will operate with a no wrong door approach; that is, it will be a default, no refusal intake option for law enforcement. LE and EMS stakeholders will be able to collaborate with clinicians to deliver services without restrictive entry or exclusion criteria thus transitioning individuals to crisis care in lieu of ED or Jail. This approach answers question of Divert to Where?. • Cost Savings. EMS and LE personnel responding to calls involving a BH crisis will spend less time in the field determining an appropriate response and less time at the Facility (less than 15-minutes) compared to either the ED or magistrate/jail. Such an approach will free up personnel and equipment to respond to other community needs. Supports Public Safety Reforms. Aligns with Governor's Task Force for Racial Equity in Criminal Justice (December 2020) by establishing a dedicated Facility that provides a resource for Orange County to support implementation of key recommendations of the Task Force. As noted above providing a No Wrong Door answers the question of Divert to Where? thus supporting the following Task Force recommendations: Task Force Recommendation: Reimagine public safety and reinvest in communities. Solution #1 : Respond more appropriately to situations concerning mental illness, autism, intellectual disabilities, substance abuse, homelessness, and other nonemergency situations. Task Force Recommendation: Promote diversion and other alternatives to arrest. Solution #16: Establish and expand access to diversion programs. Solution #17: Treat addiction as a public health crisis, including substance use addictions that disproportionately impact black and brown communities, such as crack cocaine. 25 28 POTENTIAL BENEFITS: CRIMINAL JUSTICE. Orange County Diversion and Harm Reduction Programs. The recommended Facility is aligned with Orange County's Commitment to diversions from criminal justice especially for individuals whose encounter with the criminal justice system is due to an underlying BH issue. The Facility will work with and enhance several programs: Adult Pre-Arrest Diversion (OC PAD) Pretrial Release Drug Treatment and Community Resource Courts Street Outreach, Harm Reduction and Deflection Program (SOHRAD). Detention Center/OCSO. Aligns with Stepping up Milestones. Provides criminal justice stakeholders an alternative for treating individuals with BH concerns in an appropriate setting instead of jail. Aligns with Orange County Detention Center Stepping Up milestones by treating individual outside of jail setting. Provides Least Restrictive Setting. Provides least restrictive setting for crisis care in a calming environment with case managers and peer specialists that can safely engage the individual in crisis. Individuals in custody are not transferred to other distant facilities nor require additional staff be brought in. Facility will supplement/coordinate with jail-based mental health and substance use programming. Aligns with New Detention Center. Supports new programming in Orange County's new Detention Center. Also provides alternative destination for individuals in custody who are in need of BH services thus eliminating burden on OCSO to remain at hospital. Courts/magistrate. — Supports mental health/treatment courts and provides criminal justice stakeholders ready access to assessment services thus avoiding extending custody because individuals can receive crisis care in Crisis/Diversion Facility or treatment in appropriate community treatment facility; provides immediate access to crisis services for justice-involved individuals who are not incarcerated, but present to court with BH crisis; and provides Magistrate with resources to explore options for individuals in a BH crisis in lieu of CJ or jail. 26 29 POTENTIAL BENEFITS: HOSPITAL-BASED CARE Reduces Use of Hospital Emergency Services. Studies have shown that absent a dedicated crisis facility, BH patients in crisis are treated in a hospital-based ED at greater rates than in communities with a dedicated crisis facility. The ED is required to board patients waiting for admittance to inpatient beds or other residential services. This overloads ED and is a poor setting for patients waiting for care. Boarding times in ED vary from a few hours to a few days and for some cases much longer. Having a dedicated crisis facility reduces burden on hospital-based ED, which is frequently at capacity. This allows ED to focus on patients who require hospital-based psychiatric emergency services and to maintain capacity for medical emergency escalations. Inpatient Bed Utilization. Nationally, data show that once a patient is admitted to hospital-based ED, there tends to be a higher rate of inpatient bed utilization as compared to having access to a dedicated crisis facility. A significant number of IVC patients can be treated in a dedicated crisis facility instead of requiring use of ED. If eventual transfer to inpatient or residential care is required, the Crisis-Diversion Facility will provide quality care in an appropriate setting at lower costs while awaiting transfer. Clinical Care Costs Savings. SAMHSA 2020, discusses a model developed by Crisis Now for comparison of clinical care costs in communities without a comprehensive crisis system (reliance on ED and inpatient beds) vs. communities with comprehensive crisis system (including a dedicated crisis facility). The Crisis Now analysis indicates that costs associated with hospital-based care can be reduced on the order of 50%. 27 30 RELATED CONSIDERATIONS. Some components of a comprehensive crisis system are ENHANCED CRISIS 24/7 COMMUNITY-BASED MOBILE CALL CENTERS CRISIS outside the scope of the subcommittee; however, they appear (911/988) Mobile crisis offers outreach and support where people in the best practices literature and are mentioned here These services provide real-time coordination across a in crisis are.Programs should include contractually system of care,leverage data for performance required response times and medical backup. because they are Integral components of a crisis System and improvement,and provide high-touch support to individuals/families in crisis. do not currently operate in Orange County. SAMHSA/Crisis Now cite Enhanced Call Center: Coordinate crisis hot lines key elements of comprehensive crisis including 911/988 to centralize crisis calls, provide for system. CRISIS STABILIZATION ESSENTIAL an on-line engagement and response, and guide crisis PROGRAMS PRINCIPLES & PRACTICES response assets. These programs offer short-term"sub-acute"care for These must include a recovery orientation,trauma- individuals who need support and observation,but not informed care,significant use of peer staff,a ED or medical inpatient stays,at lower costs and without commitment to Zero Suicide/Suicide Safer Care,strong Enhanced Crisis Response: Create a 24/7/365 the overhead of hospital-based acute care. commitments to safety for consumers and staff,and collaboration with law enforcement. / community-based mobile crisis response units that operates throughout Orange County and respond in lieu There are other elements of a crisis system that deserve of law enforcement, where appropriate. In addition, consideration in conjunction with creation of a Crisis/Diversion ensure law enforcement have trained mental health Facility (Re. SAMHSA 2020 and Crisis Now). Subcommittee teams or crisis units. addresses bottom two. While all elements of a comprehensive crisis system are important, action or inaction on other elements does not negate or reduce the need to move forward with recommended Facility. 28 31 NEXT STEPS The BOCC is being asked to endorse the recommendation presented in this report. This is an important, but preliminary step toward realization of the ideas contained in this recommendation. Additional work is needed to advance the project to an operating Facility in Orange County. The next steps are outlined below. Risk Mitigation. Compile additional data and conduct additional studies to reduce the uncertainty in current projections of the number and type of patients who will be served by the Facility, refine estimates of costs and benefits, and identify/evaluate funding options. Design. Conduct a preliminary design of Facility space to provide a proper basis for a financial assessment. This will include identifying and assessing potential locations for the Facility. Licensing and Staff Planning. Identify licensing options/requirements, associated staff plan and Facility attributes, insurance billing policies and practices, and identify/evaluate potential Facility operators. Governance. Determine and assess options regarding ownership and governance for the Facility. Policy/Procedures. Identification of needed policy and procedure enhancements for all stakeholders to ensure county-wide collaboration leading to realizing the Facility's full potential. Projected Savings. Develop/refine projection of savings that may accrue due to reduced clinical and criminal justice burden. Sources and Uses of Funds. Project capital/operating budgets for Facility. Identify/assess funding arrangements for the first five years of operation including local government, state government, LMEs/insurance, and private philanthropic organizations. Road Map. Develop an implementation plan or road map for establishing an operating Facility in Orange County in an expedited manner. 29 32 EXHIBITS Exhibit A. SIM Workshop Sequential Intercept Mapping Framework Orange County SIM Map Existing Orange County Resources Exhibit B. Best Practices Review Literature Review U.S. Programs and Facilities Key Findings Exhibit C. Orange County Data Sources and Notes 30 33 EXHIBIT A. SIM WORKSHOP: FRAMEWORK Inte roe pi 10 Intercept-1 1rwterce-pt 2 ° 1nIemept 3 inl-erecpt 4 Intercept S --U-lLV:Ser-Ce5; taw Entice*rFeri Mitial dhetentic� gi�cc-IrV „mu-iW C%wrectk;-n r- 1n4l.ieI IL1 WackNa Crisis LJrtiea �peclalt��.ourt Reen i -- F f St i CrfieiaCare Lt,CDI��w Arr-ext Inla:al ��u+M Jail nl:nuum Er5�br4 r r5� DLL-tenllon . ri Jail Probatl�rr © 2019 Policy Research Associates. Inc. • The Sequential Intercept Mapping Framework (Griffin, et. al.) is organized as illustrated above. Workshop output is organized according to these intercepts. Orange County map completed during the workshop is presented on next page. • The workshop participants noted that Orange County is fortunate to have a number of existing programs and services that provide a solid basis upon which to build. These are summarized in the following pages and are organized by Intercept. • The main body of this report summarizes the gaps identified by Workshop participates. Filling these gaps both creates new services that do not exist currently and leverages existing services to achieve better outcomes for individuals in crisis and for stakeholders engaged in providing public safety/emergency, clinical, and criminal justice services. Griffin, P.A., Heilbrun, K., Mulvey, E.P., DeMatteo, D., & Schubert, C.A. (Eds.). (2015). The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York: Oxford University Press. DOI: 10.1093/med-.psy ch/9780199826759.001.0001 31 34 EXHIBIT A. SIM WORKSHOP : ORANGE COUNTY MAP SupportsIntercept 0 low Intercept I �� 'I Intercept 2 Intercept 3 M Intercept 4 Intercept 5 Hospital,Crisis,Respite, Law Enforcement& Initial Detention&Initial jails& Court, Reentry Community Corrections Peer,&Community Emergency Services Court Hearings & Community Services Crisis Phone entralZ ispatc (Don'idispatchClToficers,but Violaons squadleadersdispatchthem)CIT-trainingd.po.tchers Initial Detention Parole Lines Courts[Specialty Courts Notion al Suicide Prison Few officers C IT trained Hotline Law Enforcement Orange County Detenton Center Drug Tx Court forthose facing sentences of Orange Correctional Institution(OCq Parole-no specialized caseloads 800-273-M5 Jail mental health screening 120 days in jail or more MAT will be offered at OCI for soon-to-1 ee Cardinal Hi h rcenta eofCfftainedoficersin (WMHS)bydotentionoiiceronall Family Treatment Court-tr triggered DSS InnovationsLME Mobile Crisis g g Arrest Y r99 Y roleasedinmaleswthOp(ad MCO Response Ihefollowingagencies; detainees at booking referral dependence. SA support torn TASC Dear&Hard of Team Orange County SherilPs Olice Screening for suicide at booking Truancy Court FIT Program provides MAT,caae Hearing Hotline SOHRAD; Chapel HillPD' OCSO collects behavioral data for DA-Initialed DeterredprosecnAon managementandpeersuppodfor Good support of veteransfollowrng NAMI Helpline Two teams- Hillsborough PD stakeholders Outreach Court for chronically homeless persons recently released with hearth prison-Veteran's Justice Outreach Opioid hotline Freedom House CanboroPD Corr murtily Resource Court-the flagship issues (VJOprogram) CompasSaDCRCC andtheother UNC fir) Nurse is available,but not24f7 MHcourtforothersinthestate-with Carol ina0uVeach ol>eraledby UNCUnverstyPD monthtydodcetof30.in he state BD-10t Local Re-enl Ceon.l ACT Crisis for ACT Daymark In addition,theChapel Hill PD has a Pretrial Release intakes on everyone people per year {-] FHospOl nl crisis unit(hat includes 5 mortal health booked and referralslaseessment as professionals needed pedomted by CJRD menta I Jai I Reentry O Crisis on eelOutreacit•HarmReductionand heath professionals ER Deflection Program(SOHRAD) [No interface between Cardinal Jail creates discharge plans for BH FreedomHcuse Pre-ArresOiversionProgramsinCJRD Innovationsdala&CJLFJIDS] r--� Faal(ty-Based Crisis MDP 1fi and 17 and OC PAD 18+ inmates.inc uding scrips VProbation I� University ( yo) ( ) Jail (Detox, bedavas ble2417-16 Z beds{but often full) Detention officers receive CfT-training and Clinical case assessment and discharge r_r and 76 beds) EIA7F16BuH hwa Patrol No Cl Arrai nment Mental Hoatlh Probation officer(1) &Wallk-in Crisis from 9 mental healm first aid. planning 8:3garn-4:OOpm M-F 0 UNC Hillsborough Hospitals All P.O's get Mental Health FirstAld MagisVateHearing GAINS shortscresneradminisleredand Naloxoneki[spmvidedrodelaineeswith Hospital training Two ACTT providers Goal for early lD and diversienof Risk l Needs Assessment for l6-t7ylos opioid dependence who were atADATC V -UNC Center of UNC Medical Center(76 beds- MHISUDA00offenders or pad of MAT pi lot IN Duke University Excellence in includes STEP program) Referral toTASCandrorRecovery Hospi al CDmmurAy RN on stall-but not 2417 Court for SA Tx. Psychiatry(serving Duke Medical Center in Durham(1; Two part-time UNC psychiatrists-2-4 Five(5)day supply for released jail WthroughOCSO nts),and bad inpatient;takes all Ws: hours perwk detainees_ [Freedom House may also n Family Psychiatrist in ER M-F-gad Ip Psychologist(Deron Coy)4-6 hours perwk provide short-term mods for some Relerralto Mental Health Provider Services Psychiatry residency program; Pre-Prosecution Diversion Peer Recovery Group for men in jail pwple released fromjail] Brief Therapy for some-provided by Freedom House offers the program Veterans'Administration Hospital in Pretrial Release program for Close Donna May Fri program may serve sore jail Recidivism Redudjon Service for h OCSO Durham held on secured bond. [Crimnogeric MAT available in the Jail for OUD detainees Velation those on local probation ce use N Risk and Needs Assessment EMS can only transport to ER orFBC performed.andsunmarysent101he CJRDmerntalhealhprofessionals[LCSW Nogea ders" b tiaumasupporlVJOkxre•enteringvelerano Services DA,PD and judge,who determines and PsyD)assess and provide lin ted tx and FH UNC ASAP and FH torpersansre- wheCrer[o release with or wAhaut Serves supervision.] Safe Keeping available for a limited number entering from prissoonwof jail deainees,buturham tali on s no Be psrate pod or housing for detainees wth mental illness Behavioral Health Recovery Supports HousinglShelter Cardinal Innovations LME-MCO catchment area NAMI of Orange County Oxford Houses available for those with$A issues UNC Hospitals d UNC Center of Excellence in Community Mental Health Oxford House,AIA;N!A IFC tranai Tonal housing(Comm House and Horne5ll Limited Rapid re-housing Freedom House 32 35 EXHIBIT A. SIM WORKSHOP : EXISTING RESOURCES Intercept 0. Existing Community Resources Orange County has a range of crisis services at the community level, including: One limited mobile crisis team operated by Freedom House Recovery Center. Facility-Based Crisis Services (with limiting eligibility criteria) at Freedom House Recovery Center. A suicide hotline / veteran's suicide hotline. NAMI NC Helpline. A deaf and hard-of-hearing lifeline. Opioid hotline. Cardinal Innovations 24/7 call center. Carolina Outreach Behavioral Health Urgent Care. Chapel Hill Police Crisis Unit staffed with mental health professionals. Compass Center 24/7 Domestic Violence Hotline. Crisis intervention services 24/7 for Assertive Community Treatment Team clients. EMS Community Paramedics. Street Outreach, Harm Reduction, and Deflection Program (SOHRAD). 33 36 EXHIBIT A. SIM WORKSHOP: EXISTING RESOURCES (CON 'T) Intercept I. Existing Law Enforcement Resources There are six local law enforcement agencies serving Orange County, the largest of which are the Orange Sheriff's Office and the Chapel Hill Police Department. Others include the Hillsborough Police Department, Carrboro Police Department, UNC Campus Police Department, and the UNC Hospital Police Department. All these law enforcement agencies participate in their local Crisis Intervention Training (CIT) programs. Orange County's law enforcement agencies have implemented several innovations at Intercept I, including: Chapel Hill Police Department's Crisis Unit staffed with mental health professionals. CIT training specific for the youth population. Josh's Hope Foundation — to register persons with mental illness with law enforcement. CIT training for EMS community paramedics. Provision of Mental Health First Aid and CIT training to Orange County Detention Center officers. Community Paramedics. 34 37 EXHIBIT A. SIM WORKSHOP: EXISTING RESOURCES (CON 'T) Intercept II. Existing Resources for Initial Detention/Initial Court Hearings Individuals may be deflected from the justice system through the Pre-Arrest Diversion Program (OC PAD) and SOHRAD. Brief Jail Mental Health Screen is used to identify those with potential mental health issues upon booking. Those who screen positive are referred to the Detention Center medical staff for further evaluation. Screening for suicide risk also occurs at booking. Screening for other medical conditions, such as substance use history, also occurs at booking. A nurse is in the jail to provide medical care, but not 24/7. The Pretrial Release Case Manager completes an intake with each person in the Detention Center on the first business day after they have been arrested. A Pretrial Risk and Needs Assessment is also completed for everyone with a first appearance hearing. Individuals with behavioral issues are identified in these intakes and information is shared with mental health professionals at the CJRD, who follow up accordingly. 35 38 EXHIBIT A. SIM WORKSHOP : EXISTING RESOURCES (CON 'T) Intercept III. Existing Jails/Courts Resources Individuals in the jail needing medical or behavioral health treatment are provided treatment through the services of a nurse who is on staff. Two psychiatric residents who provide 2-4 hours of psychiatric services per week, and/or the jail psychologist who provides 4-6 hours of services in the Orange County jail per week. One full-time clinician in the CJRD provides therapeutic services to the jail population and one part-time psychologist in the CJRD provides clinical care to youth who are detained or at high risk. Josh's Hope Peer Recovery Program (Foundations for Hope) provides a substance use peer recovery group for men in jail. Post-Arrest Diversion may occur through a number of court initiatives including DA-Initiated Deferred Prosecution and Community Resource Court. Adult Recovery Court. Family Treatment Court. Truancy Court. Outreach Court. 36 39 EXHIBIT B . BEST PRACTICES - LITERATURE REVIEW ■ Articles and videos about crisis practices and programs in the Key Elements from Best Practice Toolkit U.S. were identified and reviewed. ■ Regional Crisis Call Center. Regional 24/7 clinically staffed ■ The publication entitled National Guidelines for Behavioral hub/crisis call center that provides crisis intervention Health Crisis Care — Best Practice Toolkit published by capabilities. Substance Abuse Mental Health Services Administration . Mobile Crisis Team Response. Mobile crisis teams available to (SAMHSA 2020) is particularly relevant to the subcommittee's reach any person in the service area in his or her home, work. workplace, or any other community-based location in a timely This publication by SAMHSA incorporates many of the manner. learnings reported in the literature and provides a . Crisis Receiving and Stabilization Facilities. Crisis facilities comprehensive community guide to best practices in crisis providing observation and crisis stabilization services to all and diversion programs. referrals in a calming, non-hospital environment. ■ As stated in the Guide, it is intended to: ... help mental health authorities, agency administrators, service Note: The third bullet is the immediate focus of the providers, state and local leaders think through and develop the subcommittee, but the others are important as well. structure of crisis systems that meet community needs. 37 40 EXHIBIT B . BEST PRACTICES - U .S. PROGRAMS AND FACILITIES ■ The literature review is supplemented by direct Name of Facility or Program Area Served interviews conducted by subcommittee members with representatives of operational and planned facilities. Alamance County Diversion Program (RHA Health Alamance County, NC Services) - Proposed (Burlington) Selected programs in NC and elsewhere in U.S Buncombe County, NC provide: C3 356 Comprehensive Care Center p (Asheville) point of reference for the types of services that Roberto L. Jimenez, M.D. Restoration Center Bexar County, Tx (San can be included in a crisis/diversion facility. (Division of Center for Health Care Services) Antonio) Miami-Dade Criminal Mental Health Project more complete understanding about how such Dade County, FL (Miami) p g (Miami Center for Mental Health and Recovery) facilities are integrated with a community's Helen Ross McNabb Center, Diversion Program Knoxville, TN emergency and social services. Freedom House and Orange County NC; Forsyth Literature about these facilities was also reviewed. Freedom House-type Facility County NC Crisis Assistance Helping Out On The Street Eugene, OR (CAHOOTS) Connections Health Solutions - Crisis Response Phoenix and Tucson, AZ Centers UNC Wakebrook Wake County, NC 41 EXHIBIT B . BEST PRACTICES - U .S. PROGRAMS AND FACILITIES (CONTINUED) Medical Jail Diversion ■ Crisis/diversion facilities and programs have been or are Leans toward providing BH Limited to providing criminal and SUD and Physical Health FOCUS justice stakeholders an being developed in large and small communities and are Services. alterative to using jail. geographically dispersed across the U.S. 01 Limited Scope Comprehensive ■ Among the facilities and programs included in our study, BH Crisis Assessment and BH&SUD Assessment& Stabilization. SerVICeS Stabilization; Detox:Sobering there are widely differing models; however, they share a 23-hour operation. Center; Physical Health; Pharmacy;multi-day stays. common objective: divert individuals with MH and/or SUDS concerns from either a typical ED or jail. Restricted Anyone • Limiting conditions: Admit anyone regardless of intoxicated,violence Who Is Served? situation, behavior,age. ■ Figure to the right illustrates the variety in crisis/diversion potential,suicidal ideation,vcs. General public walk-ins. I facilities and programs across six dimensions. Traditional Calming Setting ■ Each facility/program reflects the unique needs and Traditional medical facility Living room space. with patient rooms and Ph sical Desi n EmPATH emergency setting. priorities of the local community. chairs. Designed to mitigate trauma and deescalate crisis. 01 Internally Focused Community Networking • Focus on crisis intervention Networked with all community. and stabilization services Collaboration treatment and social services provided within the Facility. with peer specialists and case management support. No Program Integration Wrap Around Services • Focus is on operation of the Warm handoff to facilitate Facility without much HOIIStIC transition from crisis care to emphasis on other programs. community treatment and social services. 39 42 EXHIBIT B. BEST PRACTICES - FINDINGS ■ Objective. Embrace the objective of diverting individuals in crisis away from traditional emergency departments and jails and support this objective with dedicated facilities and programs. ■ Anyone, Anytime, Anywhere. Facility needs to accept: ■ anyone experiencing BH crisis regardless of situation (e.g., intoxication, violence potential, IVC, suicidal ideation, age) ■ anytime on a 24/7/365 basis (including walk-in services for individual needing crisis care who may be acting on their own or referred by their treatment provider, but who arrive on their own or with aid of family or friends) ■ anywhere the crisis is occurring (e.g., in homes, in public, in custody, in schools and universities). ■ Community-wide Collaboration. Facilities alone are not sufficient. Facilities need to: ■ Integrate well with law enforcement and detention facility procedures to make it easy for the criminal justice stakeholders to access crisis services in lieu of emergency departments, arrest, and jail. This includes expedited intake (no refusal intake) and separate emergency services entrance. ■ Integrate well with community treatment facilities, hospitals, and all emergency services, including any new or expanding services, to better serve individuals and families involved in a BH (e.g., SMI, SUD) crisis. ■ Provide liaison to criminal justice processes (e.g., magistrate, district attorney, public defenders, courts, jail). 40 43 EXHIBIT B . BEST PRACTICES - FINDINGS (CONTINUED) Scope of Services. Provide comprehensive suite of services to address a broad range of BH (e.g., SMI, SUD) crises including assessment, stabilization, diagnosis, pharmacy, physical health urgent care, and resources to effectuate referrals to community treatment services and local hospital facilities and services. Calming Environment. Design facility to provide a calming environment (living room) with peer support counselors to reduce trauma and agitation of the person in crisis. May include emPath emergency room services. Network with Community Treatment Providers. Network with community treatment providers to provide information about and referrals to community-based treatment services and in-patient services as needed and facilitate a warm handoff to such services with case management and peer specialist support to ensure continuity of care. Holistic Wrap Around. Network with community social services. Provide warm handoff to both community treatment and social services: support for homelessness, employment, and access to support programs (e.g., NAMI, Club Nova) with appropriate support by case managers and peer support specialists. These warm handoffs ensure the individuals leave the facility with support to access and engage community services to address their BH and social service needs. Continuous Improvement. Develop performance objectives and metrics to ensure continuous improvement over time. The literature is continuing to evolve as are concepts of public safety. Any facility or program needs to learn by experience to improve public safety, criminal justice, and individual care outcomes. 41 44 EXHIBIT C : ORANGE COUNTY DATA SOURCES AND NOTES Municipal Police Departments Mental Health calls to 911 are taken from Orange County 911 records and reported separately for each Orange County law enforcement agency. Two types of episodes are included: those coded as MH-nonviolent and those coded as MH-violent. Examination of the potentially violent descriptions suggested that most of these episodes could be addressed at the recommended Crisis-Diversion Facility. Data were compiled for the last nine months of 2020. Disturbance/Trespass 911 calls associated with homelessness are recorded separately. Virtually all these calls involve Chapel Hill (87%) and Carrboro (8%). A small percentage of these may be transported to Crisis-Diversion Facility. These diversions may grow as programs to address homeless population evolve. Data were compiled for the last nine months of 2020. CHPD records were reviewed: data was compiled from Chapel Hill Police Records Management System (RMS) for 2015—2020. These records provide data on suicide and SUD episodes and for non-IVC commitments (voluntary and emergency medical). The CHPD data are used to make inferences for episodes in the other Orange County municipalities based on population. Currently, most of these calls result in transport to the UNC ED. Commitment episodes reported for LE agencies above do not include IVCs. All OC-initiated IVCs are reported under Magistrate. Emergency Medical Services EMS 911 calls were compiled from ESO data for three categories: MH-related (includes suicidal ideation), opioid-related, and alcohol- related for 2018 — 2020. Most episodes labeled as transported without sirens or lights can be diverted to Facility: less then 34% are too agitated to receive care at the Facility. These episodes do not include treated and released or AMA situations. 42 45 EXHIBIT C : ORANGE COUNTY DATA SOURCES AND NOTES (CONTINUED) UNC Hospital ED Data compiled from UNC ED represent two quarters just prior to the distortions caused by COVID. Potential diversions were identified from case records based on situations identified in the stakeholder analysis and reported as self- arrivals. Only the self-arrival episodes are included to avoid double counting LE and EMS episodes. Self-arrival cases represent potential walk-in patients. Courts IVCs Magistrate records were compiled to identify IVCs initiated in Orange County for 2018 — 2020. All IVC episodes are included in the Magistrate account and not under law enforcement. The majority of these IVC cases can be initially diverted to the Crisis-Diversion Facility. Requests for clinical assessment services by the courts are estimated based on best judgement by professionals involved in court proceeding involving individuals with BH issues. Detention Center Referrals from the jail population for treatment or observation in the Crisis-Diversion Facility are estimated based on best judgement by professionals experienced in providing BH services to this population. 43