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Agenda 02-01-22; 7-a - Orange County Crisis-Diversion Facility – Updated Progress Report by the Orange County Behavioral Health Task Force and Special Recognition of Tony Marimpietri
1 ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: February 1, 2022 Action Agenda Item No. 7-a SUBJECT: Orange County Crisis/Diversion Facility — Updated Progress Report by the Orange County Behavioral Health Task Force and Special Recognition of Tony Marimpietri DEPARTMENT: Criminal Justice Resource Department ATTACHMENT(S): INFORMATION CONTACT: PowerPoint Slides Caitlin Fenhagen, 919-245-2303 Tony Marimpietri, 919-619-7223 Travis Myren, 919-245-2308 PURPOSE: To receive updated information from the Crisis/Diversion Facility Subcommittee of the Orange County Behavioral Health Task Force, and express special recognition to Tony Marimpietri, the Chair of the Subcommittee, who has worked countless volunteer hours to expertly guide the planning process for the proposed behavioral health facility. 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 Deputy County Manager Travis Myren and Caitlin Fenhagen, Criminal Justice Resource Department Director, and with subject matter expertise from Barbara-Ann Bybel, Director of Inpatient Psychiatry Services at UNC Hospitals, 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 developing recommendations and a plan for a dedicated Facility. 2 This Facility will offer behavioral health crisis services and allow for law enforcement and hospital ED diversion. The Subcommittee, under Tony Marimpietri's leadership as Chair, has met diligently and frequently over the last two years, to address this high priority need. The 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. In April 2021, the BOCC received a presentation with 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. Since April, the Subcommittee has continued its work to plan for the next phase of implementation, with a specific focus on stakeholder use and operational needs and facility design specifications. This effort, which included subject matter and use expertise from a wide variety of crisis stakeholders, has resulted in updates to the scope of services and design. This Progress Report will address these updates and share the roadmap for implementation. Finally, special recognition from the BOCC is proposed for Tony Marimpietri, who voluntarily took on the role of Chair of the Subcommittee. Mr. Marimpietri's expertise as a retired Senior Project Manager at the Research Triangle Institute (RTI), and member of the National Alliance on Mental Illness (NAMI) Local Board, has been invaluable to Orange County. Tony has spent over two years and hundreds of hours of work leading the Subcommittee and guiding its work. This important effort to address Orange County's critical gap in behavioral health crisis services would not be possible without his efforts. FINANCIAL IMPACT: There is no financial impact associated with receiving this updated 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. 3 ENVIRONMENTAL IMPACT: There are no Orange County Environmental Responsibility Goal impacts associated with receiving this updated information. RECOMMENDATION(S): The Manager recommends that the Board receive the updated information, provide any comments or questions, and express special recognition to Tony Marimpietri for his efforts as Chair of the Crisis/Diversion Facility Subcommittee. ORANGE COUNTY CRISIS/DIVERSION FACILITY Progress Report ORANGE COUNTY BEHAVIORAL HEALTH TASK FORCE CRISIS-DIVERSION FACILITY SUBCOMMITTEE DATE:JANUARY 2022 5 i TOPICS Progress Overview. Recent Guidelines and Reports. Stakeholders Update. Design Update. Scope of Services Update. Other Ongoing Work. Implementation Road Map. Discussions and Questions 6 PROGRESS OVERVIEW:WHERE DO WE STAND REGARDING NEXT STEPS Risk Mitigation • Updating projection of number of patients expected to be served by Facility per month and per year. • Updating literature review. (validation) Validating use of Facility by key Orange County stakeholders. • Translated services recommended in April 2021 to physical Iayout.This document will be used with architect. Design 0 Funds budgeted for implementation planning. • Architect selection and contract will be by Orange County in consultation with BH health facility SMEs. • Confirmed that Facility can be licensed as: 1) Behavioral Health Urgent Care -Tier 4 (ages 4 and above) and 2) Facility Based Licensing Crisis (adults only),which will allow for all recommended services to be implemented. • Will be developing regulatory roadmap in conjunction with operator once one is selected. • Subcommittee will develop operational guidelines and quality metrics. Operations • Staffing and operations plan will be determined by the Operator as specified in regulatory and contractual documents. Governance Discussions underway among OC and potential operators regarding building design, location,and operations. Policy, • Address community-wide collaboration with multiple stakeholders in our Stakeholder Workgroup. Procedures • Included: EMS,LE, Magistrate, Detention Ctr.,Juvenile Justice,CHCCS/OPS,DSS,UNC ED/PES,UNC CAPS (stakeholders) • Develop a model for estimating savings likely to be accrued by various stakeholders in Orange County. Projected Savings 0 Will use a model from Crisis Now for health system savings and will be tailoring it for Orange County. • Identify possible sources of funding including Orange County,Alliance Health, Insurance Companies (want to serve all Sources & Uses of pavers),government grants,philanthropic organizations. Funds Prepare an information packet based on work done to date for use in engaging funding sources. Note:Items highlighted in Green indicate work has started and is on-going. 3 7 RECENT GUIDELINES AND REPORTS There continues to be a steady stream of publications and Roadmap To The Ideal Crisis System, March 2021 forums around BH crisis response. National Council for Behavioral Health Three recent notable items are listed in the text box on Builds on and consolidates guidance previously the right. published by others including SAMHSA 2020 Best Practices Toolkit,which is sited in the April 2021 report Each of these add to a series of publications which further presented to the BOCC. underpin a consensus around BH crisis response at the NAMI 988 Call forAction, November 2021 community level. A weeklong focus on mental health crisis response. Each is aligned with and supports the guidance referenced Underscored issues and best practices, citing recent in our April 2021 Report to the BOCC. guidelines, and envisioning a 988 future. Protecting Youth Mental Health, December 2021 U.S. Surgeon General's Advisory Presents a call for action by society regarding child mental health at all levels: policy, institutional, and individuals/families. 4 8 STAKEHOLDERS UPDATEMORKGROUP OUTPUT AND FOLLOW UP Purpose. Engage all stal<eholders who are lil<ely to have an Follow-up.Will be following up on the action items over operational relationship with the Facility and its staff. the next several months to ensure policies, procedures,and Who. Subcommittee facilitated 5 Stal<eholders Worl<group practices among various stal<eholders and the Facility are meetings and engaged over 15 representatives of Orange aligned.This worl< will parallel the design and operations County organizations: EMS, OCSO, CHPD, planning for the facility. Courts/Magistrate,juvenile justice, public schools, Contents of Stakeholder Action Plan: Department of Social Services, UNC ED/PES, individuals A. EMS involved in sobering services. B. Law Enforcement Focus. Discussion centered on how each group might use C. Courts/Magistrate/Detention Center the Facility and what input they have regarding Facility D.Juvenile Justice services that would best support their programs. E. Social Services and Schools Results.An action plan for follow up with each F. UNC ED/PES, UNC CAPS stal<eholder group regarding policies, procedures,and G. Sobering Services practices that would best facilitate community-wide H. Homeless/Street Outreach and Harm Reduction. collaboration around crisis response.This Worl<group also provided input to the Facility Design Worl<group. 5 9 i DESIGN UPDATEMORKGROUP OUTPUT AND FOLLOW UP Purpose.Translate the services recommended in our April Follow-up.The output from this workgroup will be used 2021 report into a description of the physical layout of the when working with the architect firm to be selected to Faculty and its special infrastructure needs and to clarify develop a preliminary design and cost estimates. regulatory requirements. Contents of Design Workgroup report: Who. Subcommittee facilitated about 4 workgroup A. Front Entrance/Waiting Areas. meetings and engaged approximately 10 SMEs who have B. Rear Entrance. expertise in crisis facility regulation and design. Draw on C. BHUC Clinical Areas. experience from other similar facilities. D. Adult FBC Areas. Focus. Discussion centered on key elements of the Facility E. Medical Areas. and the quality of user experience where users ranged from F. Facility Security. EMS/LE, courts/detention center,general public with special G. Outpatient Service Areas. attention to the needs of specific patient cohorts (e.g., H. General Purpose Areas. adults, children, special needs). I. Community Partner Offices/Workspace. Results. Created a description of the physical layout of the Facility, special infrastructure components, and regulatory J. Communications Infrastructure. requirements. 6 10 SCOPE OF SERVICES UPDATE:ADDITIONS TO APRIL 2021 REPORT Children Outpatient Services Discussion with stakeholders, LME, and insurers Recommend adding outpatient services as an adjunct to underscore the need for services focused on children. Facility's crisis services (see text box). Demand for theses services is loud and clear. These services should focus on Children (see notes Regulatory review confirmed that children 4 years of under Children). age and older can be served in a BHUC —Tier 4. Recommended scope of services has been revised to Definitions include BHUC services for minors ages 4 -17. Partial Hospitalization Program (PHP) is a structured Sobering Services mental health treatment program that runs for several hours each day, three to five days per week. Clients participate in Discussions with stakeholders focused on sobering scheduled treatment sessions during the day and return home center related issues underscore that such services are critical to the diversion mission of the Facility. at night.This program is a step down from 24-hour inpatient treatment. It can also be used to prevent the need for an Current demand for sobering services burdens UNC inpatient hospital stay. ED, EMS, LE, detention center, and homeless programs. Intensive Outpatient Program (IOP) is a treatment Recommended scope of services has been revised to program used to address addictions, depression, eating include routine and surge sobering services. disorders, or other dependencies that do not require detoxification or round-the-clock supervision.They enable patients to continue with their normal, day-to-day lives. 11 OTHER ONGOING WORK Continue with briefings for elected boards. Met with Carrboro Town Council in May 2021. Scheduling briefings for Chapel Hill and Hillsborough Town Councils and public-school boards. Update projection of number of patients expected to be served by the Facility per month/year. Update is occurring in January-February 2022. Will compile data for all of 2021 and add categories not included in previous projections. Savings Develop cost saving models for various sectors. Estimate cost saving by sector. Governance. Land ownership and use. Facility construction, maintenance, and operations. Transportation. Resolve identified transportation issues that could impede the efficient use of facility. Include perspectives of both stakeholders and general public. 8 12 IMPLEMENTATION ROAD MAP ik 0* 1. Preliminary Design and Costing >> 2. Identify Facility Partners >> >> >> OI 3. Identify Facility Operator(s) >> >> >> 4. Pre-construction Regulatory Roadmap > >> >> >> >> >> >> 5. Operations QA and Guidelines >> >> 6. Select Location and Approvals >> >> >> >> >> O 7. Demand Projections >> >> >> 8. Final Design >> >> >> >> O 9. Funding and Savings >> >> >> >> >> >> O 10. Issue Contract for Construction Milestone I. Key partners who will be responsible for construction/maintenance and for operations of Facility are identified. Milestone 2. Location for Facility is selected and associated approvals for site use are completed. Milestone 3. Final Facility design is complete— plans are ready for construction.To be completed in early 2023. Milestone 4.All costs/savings identified and funds for construction/maintenance/operations are secured.To be completed in 2023. Note. Items highlighted by red text are high priority for maintaining schedule that targets starting construction in 2023 9 DISCUSSION AND QUESTIONS ORANGE COUNTY CRISIS/DIVERSION FACILITY Findings and Recommendations REPORT BYTHE ORANGE COUNTY BEHAVIORAL HEALTH TASK FORCE DATE:APRIL 22,2021 15 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 16 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 17 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,Treatm e nt & 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 18 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 QAC). 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 19 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 q.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 20 INTRODUCTION: SUBCOMMITTEE'S CHARGE The findings and recommendations presented herein are based L Subcommittee . - 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 SIMWorkshop: Caitlin Fenhagen OC Criminal Justice Resource lack of a crisis center. Sponsor Department (CJRD) Goals: Formulate recommendations for Orange County crisis Barbara-Ann Bybel, services that would facilitate diversion of individuals UNC Health Care 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 21 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. ExhibitA 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. ExhibitA 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. s 22 CURRENT STATUS: SIM WORKSHOP (FRAMEWORK) Intercept 0 Intercept 1 Intercept 2 Intercept 3 tntece"A 4 Intercept 5 Community Ser ices Law Enforcenxnt Inst al[?etentxonf Jadslcourts y Ccrnmur:ty Correctwns MAW Court Hearings Crisis Lines SpeclaltY Court 911 Prison C> Z Reentry Parole First sidae, Crisis Care Local Law Arrest initial Court Jail Dispositional CM Continuum Enforcenwrit Detention Appearance Court Jail Probation Reentry 0 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,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 9 23 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 criteria, space in the Detention Center for additional programming,and no limited hours of operation,long wait times/waitlists due to being at designated housing for persons with mental illness and/or substance capacity,and/or offer limited discharge planning and support. use diagnoses.There is potential to increase referrals and clinical Intercept I: Law Enforcement/Emergency Services.There support for Outreach Court and Community Resource Court and are limited options and support for law enforcement officers and thereby allow for more individuals to receive assistance. other emergency service providers for diverting individuals from q Other Considerations:There is a need to increase availability of or the hospital-based ED.The key issue at this intercept is: Divert to Medication Assisted Treatment (MAT) for persons released from q Where? involvement;ensure a cross-systems endeavor (e.g., BH,jail/prison, Intercept II: Initial Detention/Initial Court Hearing.There homeless services,courts,police,social services,consumers,family are insufficient clinical services in the Detention Center to treat members,advocates);expand peer support to promote recovery; someone experiencing a mental health crisis,screening tools not and facilitate transition to appropriate services in the community. fully consistent with best practices,and jail setting can exacerbate Note• New Orange County Detention Center due to open soon mental health symptoms. will address many gaps identified during the April 2019 Workshop. 10 24 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. 25 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 q 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 q 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. 26 BEST PRACTICES: OPPORTUNITIES FOR IMPROVEMENT (LITERATURE) Literature Review Elements of Current Best Practices Currently there are no national standards for crisis services • Clear Objective. such as those existing for medical services (e.g., EMS). E Embrace the objective of diverting individuals in crisis away from Existing literature points to an emerging framework for traditional ED and jails defining crisis services. • Support this objective with dedicated facilities and programs. There is an enormous body of literature that points to • Anyone,Anytime,Anywhere. evidence-based practices that can be adopted and tailored to • Community-wide Collaboration. Orange County. • Calming Environment. Two references are key to our work are: • Network with Community Treatment Providers. The Sequential Intercept Model. • Holistic Wrap Around. National Guidelines for Crisis Care:A Best Practice Toolkit. E Warm Handoffs and Case Management/Peer Specialist Support. • Continuous Improvement. 13 27 BEST PRACTICES: OPPORTUNITIES FOR IMPROVEMENT (U.S. FACILITIES) In addition to the literature review,we researched existing Medical Jail Diversion Leans toward providing BH and Limited to providing criminal d facilities. SLID and Physical Health FOCUS justice stakeholders an alterative programs anServices. to using jail. There are scores of existing programs and facilities across the U.S. Limited Scope Comprehensive • BH Crisis Assessment and BH&SLID Assessment& Stabilization. $ervICES Stabilization;Detox:Sobering Subcommittee members interviewed representatives Of a 23-hour operation. Center;Physical Health;Pharmacy; dozen operating and planned facilities. multi-day stays. This review includes two important N.C.facilities: Restricted Anyone Limiting conditions:intoxicated, Admit anyone regardless of violence potential,suicidal Who IS Served? situation,behavior,age. Wakebrook ideation,IVCs. General public walk-ins. (Wake County,Raleigh). C3 356 Comprehensive Care Center (Buncombe County, Traditional rooCalm spaceng . ting P \ / Traditional medical facility with Living room space. 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 across six dimensions. Internally Focused Community Networking • Focus on crisis intervention and Networked with all community. Exhibit B contains more complete summary of best stabilization services provided Collaboration treatment and social services with within the Facility. peer specialists and case practices findings. management support. No Program Integration Wrap Around Services • Focus is on operation of theWarm handoff to facilitate Facility without much emphasis HOIIStIC transition from crisis care to on other programs. community treatment and social services. 14 28 RECOMMENDATION: FOCUSING ON THE NEED Hospital Courts and and ED Diversion Services Programs Emergency Detention Medical Center Services Services Public Facility- Safety Based (LEO) LJV Services Community Social Treatment Services Services L—PrI ? LJ7 LJ7 0 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 29 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) L_r LJV Services Community Social Treatment Services ServicesL—P, Dedicated LJ7 Crisis/Diversion L;7 Facility L_�7 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 30 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 31 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 32 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). a Multi-day temporary boarding pending transfer:that is,bridging crisis ■ Non-hospitalization detoxification services. management and community treatment. • Urgent Medical Care Services (to allow non-life-threatening r 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).Serve Services for adolescent patients (16- and 17-year-old). patients in Facility. 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 detox) require secured space and restraints. to facilitate stabilization prior to discharge. ■ Referral and transportation to hospital and other treatment Initiate MAT treatment in anticipation of transfer to community facilities (after dropping off by LE/EMS). treatment provider. 19 33 RECOMMENDATION: SCOPE AND FUNCTION (COMMUNITY SERVICES NETWORKING) n 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. Social 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 networl< of social services with peer specialist support. ■ Transportation assistance. 34 RECOMMENDATION: SCOPEAND 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 35 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 36 POTENTIAL BENEFITS: CONSUMERS AND FAMILIES Projected41 1 DemandStakeholder Comm Homeless CJ MH Suicide SUD (Note (Note 2) (Note 3) Total I) 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 q/Detention Center 8 8 Magi strate/Cou its 116 1 16 UNC Hospital ED 22 1 4 0 27 Total Cases Per Month 64 7 63 133 3 R 27R 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 37 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 q 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 38 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 39 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 q or jail. 26 40 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 41 RELATED CONSIDERATIONS. Some components of a comprehensive crisis system are outside ENHANCED CRISIS 24/7 COMMUNITY-BASED MOBILE the o scopef the subcommittee;however,the appear in the best CALL CENTERS CRISIS y PP (911/988) Mobile crisis offers outreach and support where people practices literature and are mentioned here because they are 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. integral components of a crisis system and do not current) improvement,and provide high-touch support to Ig P y y individuals/families in crisis. operate in Orange County. SAMHSA/crisis Now cite key Enhanced Call Center:Coordinate crisis hot lines elements of comprehensive crisisis sstem. including 911/988 to centralize crisis calls,provide for an stem. ESSENTIAL on-line engagement and response,and guide crisis CRISIS STABILIZATION PRINCIPLES&PRACTICES PROGRAMS 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 stays,inpatient at lower costs and without commitment to Zero Suicide/Suicide Safer Care,strong p y commitments to safety for consumers and staff,and Enhanced Crisis Response:Create a 24/7/365 the overhead of hospital-based acute care. 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 consideration of law enforcement,where appropriate.In addition,ensure in conjunction with creation of a Crisis/Diversion Facility (Re.SAMHSA law enforcement have trained mental health teams or 2020 and Crisis Now).Subcommittee addresses bottom two. crisis units. 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 42 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 43 EXHIBITS Exhibit A. SIMWorkshop 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 44 EXHIBIT A. SIM WORKSHOP: FRAMEWORK Intercept O Intercept 7 Intercept 2Intercept 3 Intmilm"A 4 Intercept 5 Comnwn.ty services Law Enforcement Initial Detention) Ja ts/Courc Reentry Conwvwnity Corrections Initial Court Hearings Crisis unas Spctialty Court 917 vnsdn� . .. a CrisCare LOW Court Arrest Initial First is pispositional tiaeo� C Jail ConBirwtrttBnforoalmiint Detention Appearance Court Jail Probation { Reentry V) 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 Comm u n iV Alternatives for Individuals with Serious Mental Illness.New York:Oxford University Press.DOI: 10.1093/med:psy ch/9780199826759.001.0001 31 45 EXHIBIT A. SIM WORKSHOP: ORANGE COUNTY MAP Intercept I 1 Intercept 1 Intercept 2 Intercept 3 Intercept 4 Intercept 5 Hospital,Crisis,Respite, Law Enforcement& Initial D, . Peer,&Community Emergency Services Court Hearings Services entraltz 1 isparch(tlon l dispatch ClToffhcers,but Cris],Phone squadteadersdhspalchthemlClT.h%ningdhspalchen Vholaflorls Lines Initial Detention CourtstSpeciahyCourts Parole National Sunda Prison Few officers CIT trained Hotline Law Enforcement Orange County Detention Center Drug Tx Court forthose facing sentences of Orange Correctional InsMution(OCIj Parole Flo 3peciatzed caseload$ 800-273-8255 Jail mental health screening 120 days in lad or more. MAT wii be offered at OCl for soon-to-be Cardinal High percentage trained officers in (BJMHS)by detention officer on as Famuy Treatment Court-triggered DSS Innovations LME- Mobile Crisis g Arrest tr"A'g Y released dependence enceth Ophohtl MCO Response the following agencies 10 detainees adeat b referral SA support from TASC dependence Team Orange County Sheriffs Office CSOcingror suhpdeallwokm0 Truancy Court DeaiBHardof g el OCSflmlledsbehavioraldatafor cy FIT Program menta case Goodsuppanofveteransfolloxrng Hearing Hotline SOHRAD, Chapel Hill PD' DA-Ineafed Deserted presecndon management and peer supportfor NAMIHelpline Two teams- Hillsborough PD stakeholders Outreach Court for chronically homeless persons recently released ob health prison-Veteran's Justice Outreach Goddhotlme Freedom House Carrboro PD Commu*Resource0ourt-theflagship issues (VJOprogram) Compassr5.?CRCC and Ne other UNC PD Nuri rs available.but not 24l/ MH court for others in the stale--vMy Carolina Outreach operated by UNC University PD monthly docket of 30-60.serving 8g-100 Lapi Re-entry Counal ACT Crisis for ACT Daymark 'in addition.the Chapel Hill PD has a Prelnal Release intakes on everyone peopleperyear. i nus one crisis unit that hndudes 5 mental health booked and reterralslaese�ssmert as j U professionals needed performed byCJRDmarts II Jell Reentry 7r Crisis an eel OhNeach.Harm Reducson and health professionals I�h I--i Deflectionprogram(SOHRAD) (No interface between Cardinal z � Freedom House Pro-Arrest Diversion Program in CJRD: Innovations data 8 CJ LEADS] Jail creales discharge plans for BH inmates,including snips p.l 1� UNC University Faality-BasedCmis MDP(16 and 17 yo)and OC PAD(18+) Jail Probation 1--h Hospital(Detox. avaibble 24(7-16 beds(but oxen full) Detention officers receive CIT-training and Clinical case assessmeri and discharge r and 76 beds) F1ATFr8BIrHr hwa Paorol N©C Arial nment I Mental Health Precision officer(1)z &Wall Crisis from f) mental health fir91 ab. planning 8:30am4:00pm M-F O UNC Hillsborough Hospitals All P.0'a gat Mental Health FlfslAid Hospital Magistrals Hearing GJJNS short screener admrrsleredand Naloxone kill providedbdelainees widh training Two ACTT providers Goal for early ID and diversion of Risk I Needs Assessment for l6-17 ylos cphod dependence who were at ADATC -UNC Center of UNC Medical Center(76 bads-- MH/SUDADD offenders or pad of MAT old Duke University Excellence in includes STEP program) p Referral to TASC andlor Recovery Hospital C.MrMm b, RN on stat-bud not 2417 Court for SA Tx Psychiatry(serving Duke Medical Center in Durham(16 Txo part-sive UNC Psychiatrists-2-4 detainees [Freedom rreleased jai 110 dhents),and bed inpatient,lakes all IVCs: hours per wk detainees.[Freedan House map also Lutheran Family Psychiatrist in ER M-F-8a-f 1p Psychologist(Deron Coy)4-6 hours per wk provide short-term meds for some Referral to Mental Health Provider services-both44P7 Psychiatry residency program, Pre-Prosecution Diversion Peer Recovery Group for men in lad peoplereleasedfromjahl[ Freedom House offers the Bnef Therapy dor some-provided by Recidivism Reduction Service for COORE program Veterans Administration Hospital in Pretrial Release program for those Donna May FR program may serve some jail through OCSO Durham held on secured boned.[Cnn nogac MAT available in the Jail for OUD detainees Violation those on local probation substance use be Risk and Needs Assessment. EMS can only transport to ER m`BC performed.and sunrrery sent b the CJ RD mental health professionals(LCSW Nogender specific caumasupport VJO for re-entering veterans Detox Services UNC and Fill DA,PD and judge,who determines and PsyO)assess and provide limited Ix whether to release with or without UNC ASAP and FH for persons re- eterens'Services supemshon.I Safe Keeping available for a limited nmba entering Pram pnsonwitlta of fail delaineesbut no separate pod or housing for detainees VA in Durham on wilh menial illness Behavioral HeaEth Recovery Supports HousingfSha@er Cardinal Innovations LME-MCO catchment area NAMI o1 Orange County Oxford Houses available for those with SA issues UNC Hospitals 8 UNC Center of Excellence in Coarmumy Mental Heath Oxford House:AIA:NIA IF C tianscronal housing(Comm House and Homeslari).Limited Rapid re-housing Freedom House 32 46 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 47 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 48 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 qRD,who follow up accordingly. 35 49 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 50 EXHIBIT B. BEST PRACTICES - LITERATURE REVIEW ■ Articles and videos about crisis practices and programs in the Key Elements from Best PracticeToolkit U.S.were identified and reviewed. ■ Regional Crisis Call Center. Regional 24/7 clinically staffed ■ The publication entitled National Guidelines for Behavioral Health hub/crisis call center that provides crisis intervention capabilities. Crisis Care— Best Practice Toolkit published by Substance Abuse 0 Mobile CrisisTeam Response.Mobile crisis teams available to Mental Health Services Administration (SAMHSA 2020) is reach any person in the service area in his or her home, particularly relevant to the subcommittee's work. workplace,or any other community-based location in a timely ■ This publication by SAMHSA incorporates many of the learnings manner. reported in the literature and provides a comprehensive ■ Crisis Receiving and Stabilization Facilities.Crisis facilities community guide to best practices in crisis and diversion providing observation and crisis stabilization services to all programs. referrals in a calming, non-hospital environment. ■ As stated in the Guide,it is intended to: ... help mental health authorities,agency administrators,service providers, Note:The third bullet is the immediate focus of the subcommittee,but state and local leaders think through and develop the structure of crisis the others are important as well. systems that meet community needs. 37 51 i 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 provide: Buncombe County, NC C3 356 Comprehensive Care Center ■ point of reference for the types of services that can (Asheville) be included in a crisis/diversion facility. Roberto L.Jimenez, M.D. Restoration Center Bexar County, Tx (San ■ more complete understanding about how such (Division of Center for Health Care Services) Antonio) facilities are integrated with a community's Miami-Dade Criminal Mental Health Project Dade County, FL(Miami) (Miami Center for Mental Health and Recovery) emergency and social services. Helen Ross McNabb Center, Diversion Program Knoxville, TN ■ Literature about these facilities was also reviewed. Freedom House and Orange County NC; Forsyth 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 38 52 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 and Limited to providing criminal SUD and Physical Health FOCUS justice stakeholders an alterative being developed in large and small communities and are Services. to using jail. geographically dispersed across the U.S. Limited Scope Comprehensive ■ Among the facilities and programs included in our study, BH Crisis Assessment and BH&SUD Assessment& Stabilization. $ervlCeS 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 potential, Who IS Served? situation,behavior,age. ■ Figure to the right illustrates the variety in crisis/diversion suicidal ideation,IVCs. General public walk-ins. facilities and programs across six dimensions. k. Traditional Calming Setting ■ Each facility/program reflects the unique needs and priorities Traditional medical facility with Living room space. patient rooms and chairs. PI7 SiCal Desi n EmPATH emergency setting. of the local community. Designed to mitigate trauma and deescalate crisis. Internally Focused Community Networking Focus on crisis intervention Networked with all community. and stabilization services Collaboration treatment and social services with provided within the Facility. peer specialists and case management support. No Program Integration Wrap Around Services • Focus is on operation of theWarm handoff to facilitate Facility without much emphasis I"IOIIStIC transition from crisis care to on other programs. community treatment and social services. 39 53 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 54 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 55 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 91 1 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 201 S — 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.AII OC-initiated IVCs are reported under Magistrate. Emergency Medical Services EMS 91 1 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 3-4% are too agitated to receive care at the Facility.These episodes do not include treated and released or AMA situations. 42 56 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