‘Too much money is go­ing into cor­rec­tional costs for peo­ple with un­treated men­tal ill­ness’

Modern Healthcare - - Q&A -

For nearly 20 years, Mi­ami-Dade Cir­cuit Judge Steven Leif­man has co­or­di­nated the work of state and lo­cal agen­cies in di­vert­ing men­tally ill peo­ple from the jail sys­tem and get­ting them into com­pre­hen­sive res­i­den­tial and out­pa­tient re­cov­ery ser­vices. He was a top con­tender for the new HHS as­sis­tant sec­re­tary po­si­tion in charge of men­tal health and sub­stance abuse pol­icy. In an in­ter­view with Mod­ern Health­care se­nior re­porter Harris Meyer, Leif­man de­scribed the struc­tural re­forms he be­lieves are needed in men­tal health­care and what the fed­eral govern­ment must do to achieve those im­prove­ments. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: Please de­scribe the re­forms you spear­headed in Mi­ami-Dade.

Steven Leif­man: I started the project in Mi­ami about 17 years ago pri­mar­ily be­cause of a de­fen­dant I had in my court­room who turned out to be a Har­vard-ed­u­cated psy­chi­a­trist. He had late-on­set schizophre­nia, be­came home­less, and was re­cy­cling through the crim­i­nal jus­tice sys­tem. At the time, if you got ar­rested in Mi­ami on a mis­de­meanor, there was lit­tle we could do ex­cept put you right back out on the street, which was ridicu­lous.

We looked at the en­tire sys­tem to see what kind of sys­tem­atic changes we could make in the com­mu­nity so we could re­duce the num­ber of peo­ple with se­ri­ous men­tal ill­ness com­ing into the crim­i­nal jus­tice sys­tem who didn’t need to be han­dled by that sys­tem. We looked at ways to de­ter­mine who should and shouldn’t be in jail, and di­vert those who didn’t need to be in the crim­i­nal jus­tice sys­tem into treat­ment.

We looked at why the po­lice were ar­rest­ing so many peo­ple with a se­ri­ous men­tal ill­ness. It turned out Mi­ami-Dade County has the largest per­cent­age of peo­ple with men­tal ill­nesses of any ur­ban area in the U.S., two to three times the na­tional av­er­age, while Florida of­fers very low-per­capita fund­ing for men­tal health­care. Like in most com­mu­ni­ties, the crim­i­nal jus­tice sys­tem had be­come a pri­mary gate­way for peo­ple with se­ri­ous men­tal ill­ness.

MH: What changes did you im­ple­ment?

Leif­man: We found what we con­sider to be the best train­ing for law en­force­ment, called cri­sis in­ter­ven­tion team polic­ing. It helps of­fi­cers iden­tify peo­ple who are in se­ri­ous men­tal health cri­sis and how to de-es­ca­late and avoid vi­o­lence, then where to take peo­ple as op­posed to ar­rest­ing them.

We worked with the county jail to de­velop a bet­ter as­sess­ment tool for iden­ti­fy­ing peo­ple com­ing in with men­tal ill­ness. Now, if a per­son with se­ri­ous men­tal ill­ness gets ar­rested, usu­ally within three days we di­vert them out of the jail into a locked cri­sis sta­bi­liza­tion unit.

Be­cause they’re on a crim­i­nal hold, the 72-hour civil com­mit­ment limit doesn’t ap­ply. We gen­er­ally set the case for hear­ing in about two weeks, al­low­ing the per­son to be­come sta­bi­lized. Dur­ing that

“We’ve come to un­der­stand the way to the solve the prob­lem is to use a pop­u­la­tion health model, as op­posed to a crim­i­nal jus­tice model, to help get peo­ple ser­vices.”

“Coun­ties are spend­ing over $80 bil­lion a year just on cor­rec­tional costs, and that’s mak­ing it hard for com­mu­ni­ties to in­vest in hos­pi­tals, schools and in­fra­struc­ture.”

pe­riod, some­one from our staff meets with the in­di­vid­ual and of­fers him or her the op­por­tu­nity to go into our pro­gram.

The pro­gram is about help­ing them get into and stay in re­cov­ery. We get them their ap­point­ments, trans­porta­tion, ben­e­fits, hous­ing, clothes, what­ever they need for re­cov­ery. About 70% to 80% of the peo­ple who are of­fered the pro­gram ac­cept it.

They are taken di­rectly from the sta­bi­liza­tion fa­cil­ity back to the court­room, where a peer spe­cial­ist is wait­ing for them. Four of our seven peer spe­cial­ists graduated from our pro­gram. That same day, we trans­port them by car to where they need to go for ser­vices. So it’s a warm hand­off into the sys­tem of care they need for their re­cov­ery.

MH: What kind of re­sults have you achieved?

Leif­man: It’s been phe­nom­e­nal. From 2010 through 2016, the city of Mi­ami Po­lice Depart­ment and the Mi­ami-Dade County Po­lice Depart­ment han­dled 71,628 men­tal health calls and made only 138 ar­rests. Our jail au­dit plum­meted from around 7,300 to about 4,000 to­day. It al­lowed us to close one of our lo­cal jails, sav­ing $12 mil­lion a year.

Re­cidi­vism for the mis­de­meanor pop­u­la­tion dropped from about 75% to 20%. It worked so well that with our state’s at­tor­ney, we were al­lowed to ex­pand the pro­gram to peo­ple with se­ri­ous men­tal ill­ness who are charged with non­vi­o­lent felonies. Seventy per­cent of peo­ple who go into the pro­gram suc­cess­fully com­plete it, with only a 6% re­cidi­vism rate. Over the last four to five years, that pro­gram alone has saved the county more than 68 years of jail bed days.

MH: What are you do­ing to re­duce the flow into hos­pi­tal emer­gency de­part­ments?

Leif­man: We are in the process of estab­lish­ing a first-of-its-kind foren­sic di­ver­sion fa­cil­ity, which we es­ti­mate will save the county hos­pi­tal and its ER at least about $8 mil­lion a year by keep­ing peo­ple with se­ri­ous men­tal ill­ness who are re­peat users in this other fa­cil­ity that will have both pri­mary-care and psy­chi­atric ser­vices un­der one roof.

MH: What does it take to get the health­care, the law en­force­ment, be­hav­ioral health and the po­lit­i­cal sys­tem to col­lab­o­rate on suc­cess­ful struc­tural changes?

Leif­man: It’s very doable, and it’s start­ing to hap­pen all around the coun­try. I’m part of an ini­tia­tive called Step­ping Up, which is a coali­tion in­volv­ing the Coun­cil of State Gov­ern­ments, the Na­tional As­so­ci­a­tion of Coun­ties, the Amer­i­can Psy­chi­atric As­so­ci­a­tion Foun­da­tion, the U.S. Depart­ment of Jus­tice, the Na­tional Al­liance for Men­tal Ill­ness, and the Sher­iffs’ As­so­ci­a­tion. It’s de­signed to de­velop col­lab­o­ra­tions and make struc­tural changes. Over 300 large coun­ties have passed res­o­lu­tions to set up th­ese types of pro­grams to help peo­ple with th­ese ill­nesses stay out of the crim­i­nal sys­tem.

The main fac­tor driv­ing this is coun­ties are spend­ing over $80 bil­lion a year just on cor­rec­tional costs, and that’s mak­ing it hard for com­mu­ni­ties to in­vest in hos­pi­tals, schools and in­fra­struc­ture. Too much money is go­ing into cor­rec­tional costs for peo­ple with un­treated men­tal ill­ness. The coun­ties have re­al­ized we can­not lock peo­ple up and ex­pect the prob­lem to go away.

We’ve come to un­der­stand the way to solve the prob­lem is to use a pop­u­la­tion health model, as op­posed to a crim­i­nal jus­tice model, to help get peo­ple ser­vices. When you do that, you’re go­ing to see bet­ter re­cov­ery. Peo­ple tend to for­get that th­ese are ill­nesses, just like heart dis­ease.

MH: What is the role of the fed­eral govern­ment in re­form­ing the men­tal health sys­tem?

Leif­man: The main role for the new HHS as­sis­tant sec­re­tary in charge of men­tal health and sub­stance abuse is to help all the dif­fer­ent agen­cies end the frag­men­ta­tion of the com­mu­nity men­tal health sys­tem. One of the big­gest prob­lems peo­ple have is try­ing to nav­i­gate this com­plex sys­tem of care that makes it re­ally hard for peo­ple to get the treat­ment they need. A lot of money gets wasted be­cause peo­ple aren’t get­ting the level of ser­vices that they need.

An­other is­sue is there is a huge gap be­tween the sci­ence and medicine of men­tal health and sub­stance abuse and what’s ac­tu­ally de­liv­ered in the com­mu­ni­ties. Half a dozen states do a good job dis­sem­i­nat­ing in­for­ma­tion and train­ing peo­ple on how to de­liver the most ef­fec­tive treat­ments to peo­ple, in­clud­ing work­ing with the courts and all the other stake­hold­ers. I would en­cour­age all states to set up cen­ters of ex­cel­lence so that the in­for­ma­tion can be more ef­fec­tively de­liv­ered into the com­mu­nity.

MH: Are health in­sur­ers ad­e­quately cov­er­ing treat­ment for men­tal health and sub­stance abuse disor­ders?

Leif­man: No, not at all. We have to keep the in­sur­ance in­dus­try’s feet to the fire, and make sure they are de­liv­er­ing the level of ser­vices that they’re sup­posed to be of­fer­ing, so peo­ple aren’t pushed into more ex­pen­sive acute sys­tems, such as the emer­gency room or the jail, where they get sicker.

MH: What do you think about the get-tougher-on-drugs rhetoric from At­tor­ney Gen­eral Jeff Ses­sions?

Leif­man: I am hope­ful that they will treat this pri­mar­ily as a med­i­cal is­sue, which it is. Jail should be the last re­sort for ser­vices, not the pri­mary place for peo­ple to go. We have to re­verse what we are do­ing to­day.

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