Justice Reinvestment

in North Carolina
Behavioral Health
Analysis
November 16 , 2010

Council of State Governments Justice

Center
Fred Osher , M . D ., Director of Health Systems and
Services Policy
Alexa Eggleston , Substance Abuse and Addictions
Project Director
Andy Barbee , Senior Research Associate
Megan Grasso , Policy Analyst
 Overview

What Works
•
•
•
Current Efforts In North Carolina
•
•

Findings and Opportunities

2
 Alcohol and Drug Use Disorders:
Household v. Jail v. State Prison
Percent of Population

Source: Am J. Psychiatry 167:4, April 2010

3
 Serious Mental Illnesses:
General Population vs. Jail vs. State Prison
Percentage of Population

Source: General Population (Kessler et al. 1996), Jail (Steadman et al, 2009), Prison (Ditton 1999)
4
 N a tio n a l E stim a te s : Behavioral Health
Disorders are Prevalent in Justice-Involved
Population
ith substance use and co - occurring mental health disorder

fairly consistent across prison , jail and community corrections but

ependency and mental illness higher among women

Individuals with serious mental illness and co - occurring su

Drug Addiction is a Brain Disease that
affects behavior

Brain changes in addiction help explain

continued drug use and relapse

6
Mental Illnesses are Brain Disorders as Well

NORMAL DEPRESSION Figure 1

J Douglas Bremner, MD, Yale University

7
Principles of Treatment for Justice Involved
Persons with Behavioral Health Disorders

• Screening and Assessment are the first steps



• Services must be comprehensive and matched to needs:

– careful monitoring of drug use/medication
adherence during treatment
– integrated treatment for co-occurring disorders
– target factors associated with criminal behavior;
cognitive behavioral therapies
– include strategies to prevent & treat serious,
chronic medical conditions (HIV/AIDS, Hep B & C
& TB)


• Continuity of care is essential



• Strategies to motivate engagement and retention in

treatment are key and a balance of rewards and 8
 Identify Who is High Risk & Needs
Treatment

High Intensive Intensive

Treatment Treatment
+ Minimal + Intensive
Supervision Supervision
Functional
Impairment
Less Intensive Less Intensive
Treatment Treatment
+ Minimal + Intensive
Supervision Supervision
Low

Low High
Risk of
Recidivism

10
 Supervise high-risk offenders closely
and mandate treatment.
Impact on Recidivism Rates

Intensive
Drug Treatment in Drug Treatment in
Supervision +
Jail Settings the Community
Treatment

0%
- 6%
- 8%

- 18%

Elizabeth Drake, Steve Aos, and Marna Miller (2009). Evidence-Based Public Policy Options to Reduce Crime and Criminal
Justice Costs: Implications in Washington State. Olympia: Washington State Institute for Public Policy. Victims and
Offenders, 4:170–196.
10
 What Works as Effective Interventions?

Specialized
ice - Based Responses
Integrated
Specialty Courts
Treatment
Integrated
and Supervision
Treatment: Probation
and Superv

Community Prison &

Arrest & Jail Court Supervisio
Corrections
n

Effective , Accessible , Community - Based Treatment

11
 W h a t W o rk s S u m m a ry

dentify who is high risk and also needs treatment .

rvise high - risk offenders closely and mandate treatm

3. Ensure treatment services are effective.

4. Fund what works , not what doesn ’ t .

12
 Overview

What Works
•
•
•
Current Efforts In North Carolina
•
•

Findings and Opportunities

13
 Behavioral Health Stakeholders

• Department of Health and Human Services officials

•
• Department of Corrections officials
•
• Judges
•
• Probation and parole officials and staff
•
• Jail superintendents and staff
•
• Community treatment providers and LME’s
•
• Consumers
14
 Promising but Limited Investments in
Diversion and Police-based Responses

Specialized
ice - Based Responses

Arrest & Jail Community Prison &

Court Corrections Supervision

18 Crisis Intervention Team (CIT) programs across the State


151 law enforcement agencies with 2,135 CIT-trained officers on staff

18 counties have jail diversion programs

15
 Drug Courts are Focus of Court-based
Interventions

Specialty Courts

Community Prison&
Arrest & Jail Court Corrections Supervision

ult DTCs in district and superior court with some emphasis on high risk and need
tal Health Courts
21 Sentencing Services programs operate in 57 counties

16
 Current Practices: Probation Behavioral
Health

Integrated Treatment and Supervision : Probation

Arrest Community Prison &

Court Correction Supervision
& Jail
s

gement Model (OMM) jointly developed by DOC and HHS to guide supervision practice
rry and Black Mountain provide some opportunity for integrating treatment and s
ed to link courts, community corrections and treatment

17
 Current Practices: Prison Behavioral Health

Integrated Supervision and Treatme

Arrest Community Prison &

Court Supervision
& Jail Correction
s

ace with increasing population

release supervision limiting treatment options
enter and Mary Frances Center provide long-term treatment to select group of low-
r post-release treatment

18
 Current Practice: Staff and Programs

Probation
1 , 400 Probation Officers ; $120 Million
110 , 000 Probationers

TASC CJPP DART - Cherry

$9 . 6 million $9 million $6 million

erved 15 , 000 Probationers Served Approx 1 , 300 Probatio

Served 6 , 700 Probationers

19
NC Still Spends More than $200 Million
Incarcerating Probationers with BH
Treatment Needs
FY09 Probation Revocations to Prison
MH SASSI Score Total
Score 1 2 3 4 5
1 2,153 3,327 4,343 2,407 1,401 13,631
2 65 117 161 157 169 669
3 126 273 445 402 323 1,568
4 0 2 1 0 6 10
5 5 17 29 35 30 115
Total 2,348 3,736 4,979 3,000 1,928 15,992

65% of revoked probationers indicate having a

substance use and/or mental health disorders (MH
or SASSI Scores at or above 3) and in need of
treatment.

Based on average length of stay in prison for

revoked probationers, NC spends approximately $204
million on each annual cohort of revoked
probationers needing treatment. 20
 Summary of North Carolina Efforts

Arrest & Jail  151 law enforcement agencies with 2,135 CIT-
trained officers
 18 counties have jail diversion programs
 Jails statewide screening for individuals with
mental illness
27 Adult DTCs in district and superior court
Court 3 Mental Health Courts

 21 Sentencing Services programs operate in 57

counties

Probation Supervision model developed by DOC and HHS

TASC intended to link courts, probation and treatment

services
CJPP funding for treatment + supervision

DART-Cherry and Black Mountain

Prison & Prison-based treatment limited

Few individuals on parole or post-release supervision
Supervision Private facilities, Evergreen Rehabilitation Center and

Mary Frances Center provide long-term treatment to select

group of low-risk individuals for completion of sentence
DART-Cherry and Black Mountain

21
 Overview

What Works
•
•
•
Current Efforts In North Carolina
•
•

Findings and Opportunities

22
 S u m m a ry : F in d in g s & R e co m m e n d a tio n s

Finding Recommendation
Treatment resources are Increase effectiveness of
spread across misdemeanor current treatment resources
1. and felony probation by shifting them to high
populations without regard risk felony probationers .
to
Somerisk .
components of treatment Increase funding for
programs funded by the state programs that work , and
have been shown to reduce reduce funding for those
2. recidivism , others have not . that do not .
Program data currently Monitor treatment program
collected does not allow the effectiveness through data
state to hold programs collection and hold programs
accountable for outcomes . accountable for performance .
3.

23
 Current Practice : Criminal Justice
Partnership Act Program

 CJPP is community-based treatment and supervision

program

 Created to reduce recidivism, probation revocations,
substance use disorders, and cost of incarceration.

 Counties have discretion to implement Day Reporting
Center, Satellite Substance Abuse Center or
Resource Center
– Lack of clear criteria for each based on risk and
likelihood of going to prison (i.e. in lieu of
revocation)
– Evidence base for each type of approach is
24
unclear
 Current Practice: DART-Cherry and Black
Mountain

• DART-Cherry: 300 bed residential treatment program for

male probationers/parolees
– 28 day program with CBT; 90 day therapeutic
community
– Of 2,000 served in 2008-09; 32% parolees, 68%
probationers


• Black Mountain: New 50 bed residential treatment

program for women


• Criteria:
– Probationers must be court ordered and assessed for
need by TASC
– Post-Release Supervision and Parole Commission can
25
also order participation
 1. Treatment resources are spread across
probation populations without regard to
risk
Receiving Services
Need Treatment
18 , 292 10 , 727 7 , 337 3 , 813 52 %
Felony Probationers High/Mod. Risk High/Med. Risk High/Med. Risk

7 , 565 4 , 206 1 , 781 42 %

Low/Min. Risk Low Risk Low Risk

39 , 231 18 , 384 11 , 416 4 , 922 43 %

sdemeanor Probationers
High/Mod. Risk High/Med. Risk High/Med. Risk

20 , 847 9 , 881 3 , 618 37 %

Low/Mod. Risk

26
 Recommendation: Increase effectiveness of
treatment by shifting resources to high risk
felony probationers
Receiving Services
Need Treatment
18 , 292 10 , 727 7 , 337 7 , 337 100 %
Felony Probationers High/Mod. Risk High/Med. Risk High/Med. Risk

7 , 565 4 , 206 0%
Low/Min. Risk Low Risk

39 , 231 18 , 384 11 , 416 6 , 797 60 %

sdemeanor Probationers
High/Mod. Risk High/Med. Risk High/Med. Risk

20 , 847 9 , 881 0%
Low/Mod. Risk

27
 2 . Some components of treatment programs
funded by the state have been shown to
reduce recidivism , others have not
Type of CJPP Services Provided to Probationers Terminated in FY
2009
Service Type All CJPP SSA DRC RC
# % of # % of # % of # % of RC
Outpatient SA 2,569 CJPP
22.5% 1,072 SSA
34.9% 744 DRC
14.3% 753 24.0%
Counseling 2,136 18.7% 786 25.6% 638 12.3% 712 22.7%
Intensive Outpatient 1,601 14.0% 647 21.1% 525 10.1% 429 13.7%
SA
CBI - Anger Mgt. 1,099 9.6% 150 4.9% 752 14.5% 197 6.3%
Drug Classes 881 7.7% 184 6.0% 522 10.0% 175 5.6%
TASC 295 2.6% 87 2.8% 112 2.2% 96 3.1%
Other 2,824 24.8% 143 4.7% 1,910 36.7% 771 24.6%
Total 11,405   3,069   5,203   3,133  

ment Only Comprises About Half of CJPP Services and Cognitive-Based Inte

28
 Recommendation : Increase funding for
programs that work , and reduce funding for
those that do not
Impact of Ohio Residential Correctional
Programs on Recidivism (Annual State Funding: $104m)

* Results for all participants

3. Program data currently collected does
not allow the state to hold programs
accountable for outcomes
State CJPP Expenditures Across Program Type

30
 R e co m m e n d a tio n : M o n ito r tre a tm e n t
p ro g ra m e ffe ctiv e n e ss th ro u g h d a ta
co lle ctio n a n d h o ld p ro g ra m s a cco u n ta b le
fo r p e rfo rm a n ce
• Better define data on service type and
utilization
•
• Collect data on recidivism
•
• Provide programs with data to allow for
quality improvement process
•
• Develop performance incentive approach

31
 S u m m a ry : F in d in g s & R e co m m e n d a tio n s

Finding Recommendation
Treatment resources are Increase effectiveness of
spread across misdemeanor current treatment resources
1. and felony probation by shifting them to high
populations without regard risk felony probationers .
to
Somerisk .
components of treatment Increase funding for
programs funded by the state programs that work , and
have been shown to reduce reduce funding for those
2. recidivism , others have not . that do not .
Program data currently Monitor treatment program
collected does not allow the effectiveness through data
state to hold programs collection and hold programs
accountable for outcomes . accountable for performance .
3.

32
  Thank
You
Fred Osher , M . D ., Director of
Health Systems and Services
Policy
For questions , please contact :
Alexa Eggleston , JD
Substance Abuse and Addiction Project
Director
aeggleston@csg . org

33