CONSTRUCTING A COMPREHENSIVE AND COMPETENT
CRIMINAL JUSTICE/MENTAL HEALTH/SUBSTANCE ABUSE
TREATMENT SYSTEM:
Strategies for Planning, Leadership,
Financing, and Service Development

Honorable R. Fred Lewis
Chief Justice
Supreme Court of Florida

Honorable Charles T. Wells
Justice
Supreme Court of Florida

Honorable Harry Lee Anstead
Justice
Supreme Court of Florida

Honorable Barbara J. Pariente
Justice
Supreme Court of Florida

Honorable Peggy A. Quince
Justice
Supreme Court of Florida

Honorable Raoul G. Cantero
Justice
Supreme Court of Florida

Honorable Kenneth B. Bell
Justice
Supreme Court of Florida

STEERING COMMITTEE ON FAMILIES & CHILDREN IN THE COURT
COMMITTEE CHAIR
Honorable Nikki Ann Clark
Circuit Court Judge
Second Judicial Circuit of Florida

MENTAL HEALTH SUBCOMMITTEE
SUBCOMMITTEE CHAIR
Honorable Steven Leifman
Special Advisor on Criminal Justice
and Mental Health
Supreme Court of Florida

WORKGROUP CO-CHAIRS
Standards and Evidence Based Practices Workgroup:
Rajiv Tandon, MD
Chief of Psychiatry
Florida Department of Children and Families

Robert Constantine, PhD, MPH
Research Associate Professor
Department of Mental Health Law & Policy
Louis de la Parte Florida Mental Health Institute
University of South Florida

Judicial Education and Rule Making Workgroup:
Honorable Martha Ann Lott
Circuit Court Judge
Eight Judicial Circuit of Florida

Honorable Melanie G. May
Appellate Judge
Fourth District Court of Appeal

Criminal Justice Advisory Workgroup:
Honorable Mark A. Speiser
Circuit Court Judge
Seventeenth Judicial Circuit of Florida

Honorable Harry L. Shorstein
State Attorney
Fourth Judicial Circuit of Florida

Policy, Legislative, and Finance Workgroup:
John Petrila, JD, LLM
Professor
Department of Mental Health Law & Policy
Louis de la Parte Florida Mental Health Institute
University of South Florida

Honorable Steven Leifman
Special Advisor on Criminal Justice
and Mental Health
Supreme Court of Florida

MENTAL HEALTH SUBCOMMITTEE AND WORKGROUP MEMBERS
Executive:
Secretary Andrew C. Agwunobi, MD
Agency for Health Care Administration

Secretary Robert A. Butterworth
Florida Department of Children and Families

Secretary James R. McDonough
Florida Department of Corrections

Secretary Walter A. McNeil
Florida Department of Juvenile Justice

Surgeon General Ana M. Viamonte Ros, MD
Florida Department of Health

Legislative:
Honorable Dave Aronberg
Senator, District 27
Florida Senate

Honorable Bill Galvano
Representative, District 68
Florida House of Representatives

Judiciary:
Honorable Nikki Ann Clark
Circuit Court Judge
Second Judicial Circuit of Florida

Honorable Jeffrey Colbath
Circuit Court Judge
Fifteenth Judicial Circuit of Florida

Honorable Gill S. Freeman
Circuit Court Judge
Eleventh Judicial Circuit of Florida

Honorable Hugh D. Hayes
Circuit Court Judge
Twentieth Judicial Circuit of Florida

Honorable Frederick J. Lauten
Circuit Court Judge
Ninth Judicial Circuit of Florida

Honorable Cindy S. Lederman
Circuit Court Judge
Eleventh Judicial Circuit of Florida

Honorable Louis H. Schiff
County Court Judge
Seventeenth Judicial Circuit of Florida

Additional Subcommittee and Workgroup Members:
Dean Aufderheide, Ph.D.
Mental Health Services Director
Florida Department of Corrections

Colonel Greg Brown
Department of Patrol Services
Hillsborough County Sheriff’s Office

Sally Cunningham
Chief of Mental Health Treatment Facilities
and Forensic Programs
Florida Department of Children and Families

Honorable Bob Dillinger
Public Defender
Sixth Judicial Circuit of Florida

Melissa Duncan
Attorney
Legal Aid Society of Palm Beach County, Inc.

Mark A. Engelhardt, MS, ACSW
Associate in Technical Assistance
Department of Mental Health Law & Policy
Louis de la Parte Florida Mental Health Institute
University of South Florida

Lauren G. Fasig, Ph.D., J.D.
Department of Psychology
University of Florida

Mark Fontaine
Executive Director
Florida Alcohol and Drug Abuse Association

Kathy Goltry, MSW
State of Florida,
Correctional Medical Authority

Steve Holmes
Director of Strategic Planning and Innovation
Florida Department of Children and Families

Susanne Homant, MBA, DPA
Executive Director
NAMI Florida

William H. Janes
Assistant Secretary for Substance Abuse
and Mental Health
Florida Department of Children and Families

Brian M. Keefe, MD
Assistant Professor of Psychiatry
and Behavioral Medicine
University of South Florida, College of Medicine

Merlin R. Langley, PhD
Associate Professor
School of Social Work
Florida A&M University

Anthony D. McCoy, Ph.D.
Statewide Forensic Treatment Coordinator
Florida Department of Children and Families

Aleisa McKinlay
Chief of Community Operations
Chief of Adult Community Mental Health
Florida Department of Children and Families
Martha Martin
Chief of Court Education
Office of the State Courts Administrator

Lonnie Mann
Medicaid/Health Care Program Analyst
Florida Department of Children and Families

Bethany Mohr, MD
Medical Director
Child Protection Team
University of Florida

Darryl Olson
Assistant Secretary for Probation
and Community Intervention
Florida Department of Juvenile Justice

Ellen Piekalkiewicz
Executive Director
Florida Substance Abuse
and Mental Health Corporation

Joseph Poitier, MD
Chief Psychiatrist
Jackson Memorial Hospital,
Corrections Health Services

Clint Rayner
Chief of Office of Consumer and Family Affairs
Florida Department of Children and Families

Sue Ross
Chief of Children’s Mental Health
Florida Department of Children and Families

Michele Saunders, LCSW
Executive Director
Florida Partners in Crisis

Bob Sharpe
President and CEO
Florida Council for Community Mental Health

Tracy L. Shelby, MS, EdS
Mental Health and
Substance Abuse Coordinator
Florida Department of Juvenile Justice

George Sheldon
Assistant Secretary for Operations
Florida Department of Children and Families

Kent R. Spuhler
Executive Director
Florida Legal Services, Inc

Mark Thomas
Chief of Staff
Agency for Health Care Administration

James T. Winarski, MSW, LICSW
Associate in Technical Assistance
Department of Mental Health Law & Policy
Louis de la Parte Florida Mental Health Institute
University of South Florida

Robin Wright
Trial Court Administrator
First Judicial Circuit of Florida

STAFF
Tim Coffey
Staff for Special Advisor on
Criminal Justice and Mental Health

ACKNOWLEDGEMENTS
•

We would like to thank Chief Justice R. Fred Lewis for recognizing the impact of mental
illnesses and co-occurring disorders on the justice system, and for his foresight and
leadership in bringing together all branches of government to address these issues of critical
importance to the State of Florida.

•

We would like to thank Governor Charlie Crist for recognizing the importance of identifying
and implementing more effective interventions and services for people with mental illnesses
and co-occurring disorders, and for making this issue an early and ongoing priority in his
administration.

•

We would like to thank Speaker of the House Marco Rubio, Senate President Ken Pruitt, and
all members of the Florida Legislature for providing support and funding for the work of the
Special Advisor on Criminal Justice and Mental Health and for their collaboration and
commitment to developing more effective and efficient systems of mental health and
substance abuse care in Florida.

•

We would like to thank DCF Secretary Robert A. Butterworth, AHCA Secretary Dr. Andrew
C. Agwunobi, DOC Secretary James R. McDonough, DJJ Secretary Walter A. McNeil, and
Surgeon General Dr. Ana M. Viamonte Ros for their leadership and participation in this
effort, and for bringing together key staff within each agency to address these difficult to
solve issues.

•

We would like to thank workgroup co-chairs Dr. Robert Constantine, Dr. Rajiv Tandon,
Judge Martha Ann Lott, Judge Melanie G. May, Judge Mark A. Speiser, Hon. Harry L.
Shorstein, and Professor John Petrila for lending their leadership, experience, and knowledge
to this effort.

•

We would like to thank Judge Nikki Ann Clark for her leadership as Chair of the Steering
Committee on Families and Children in the Court.

•

We would like to thank Lisa Goodner, State Courts Administrator, and the Office of the State
Courts Administrator for facilitating the work of the Subcommittee and providing
administrative support.

•

We would like to thank Ms. Ellen Piekalkiewicz and the Florida Substance Abuse and
Mental Health Corporation for assisting with information gathering and collaboration on this
effort.

•

We would like to thank the Louis de la Parte Florida Mental Health Institute and the
assistance of their staff for lending their depth of knowledge and expertise to this
collaboration and for their work to inform public policy.

6

•

We would like to thank the Florida Bar Association for providing initial funding to support
the work of the Special Advisor on Criminal Justice and Mental Health and for continued
support of this effort.

•

We would like to thank the JEHT Foundation and the Hilton Foundation for taking a national
leadership position on the issues of mental illnesses and co-occurring disorders in the justice
system and for generously funding statewide initiatives.

•

We would like to thank the Council of State Governments – Justice Center, particularly Mr.
Michael Thompson, and the National GAINS Center/TAPA Center for Jail Diversion,
particularly Dr. Henry J. Steadman, for lending their national leadership and expertise to this
project.

•

We would like to thank the Department of Children and Families for helping to provide
support for the Special Advisor on Criminal Justice and Mental Health throughout this effort.

•

We would like to thank Chief Judge Joseph P. Farina and the Eleventh Judicial Circuit of
Florida for their support and for accommodating the work of the Special Advisor on Criminal
Justice and Mental Health.

•

We would like to thank staff from the Office of Court Improvement, including Ms. Rose
Patterson, Ms. Linda McNeill, Ms. Dana Dowling, and Mr. Nathan Moon for their assistance
in support of the work of the Subcommittee.

•

We would like to thank Mr. Tim Coffey, staff for the Special Advisor on Criminal Justice
and Mental Health, for his assistance in support of the work of the Subcommittee and for
editing and compiling the information contained in this report.

•

Finally, we would like to thank all subcommittee and workgroup members and all individuals
who provided invaluable input to this report by participating in public hearings, submitting
recommendations, and reviewing drafts of recommendations.

7

TABLE OF CONTENTS

ACKNOWLEDGEMENTS .......................................................................................6
EXECUTIVE SUMMARY .......................................................................................9
TABLE OF KEY RECOMMENDATIONS............................................................14
Part 1: The Crisis of Community Mental Health Care in Florida and the United
States: 1800-2007.....................................................................................................16
Part 2: Organizing Framework for Criminal Justice/Mental Health/Substance
Abuse Initiatives: The Policy, Financing, and Administrative Content .................34
Part 3: A Guide for Local Planning and the Development of Comprehensive and
Competent Criminal Justice/Mental Health/Substance Abuse Systems..................57
Part 4: A Guide for Developing Comprehensive and Competent Criminal
Justice/Mental Health/Substance Abuse Systems....................................................73
Part 5: A Guide for Developing Comprehensive and Competent Juvenile Justice,
Foster Care, and Child Protective Services Mental Health Systems .......................84
Part 6: Judicial Education, Administration, and Community Collaborations ...... 101
REFERENCES...................................................................................................... 107
APPENDICES ...................................................................................................... 112

8

EXECUTIVE SUMMARY
200 years ago, people with severe and disabling mental illnesses in the United States were often
confined under cruel and inhumane conditions in jails. This was largely due to the fact that no
alternative system of competent mental health treatment existed. During the 1800’s, a movement
known as moral treatment emerged that sought to hospitalize and treat individuals with mental
illnesses rather than simply incarcerating them. The first state psychiatric hospitals were opened
in the United States during the 1800’s, and were intended to serve as more appropriate and
compassionate alternatives to the neglect and abuse associated with incarceration.
Unfortunately, overcrowding at these institutions, inadequate staff, and lack of effective
treatment programs eventually resulted in facilities being able to provide little more than
custodial care. Furthermore, physical and mental abuses became common and the widespread
use of physical restraints such as straight-jackets and chains deprived patients of their dignity and
freedom. The asylums intended to be humane refuges for the suffering had instead turned into
houses of horrors.
By the mid-1900’s, more than a half million people were housed in state psychiatric hospitals
across the United States. The system was stretched beyond its limits and states desperately
needed some alternative to addressing this costly and ever-expanding crisis. Around this same
time, the first effective medications for treating symptoms of psychosis were being developed,
lending further support to the emerging belief that people with serious mental illnesses could be
treated more effectively and humanely in the community. This period marked the beginning of
the community mental health movement.
In 1963, Congress passed the Community Mental Health Centers Act which was intended to
create a network of community-based mental health providers that would replace failing and
costly state hospitals, and integrate people with mental illnesses back into their home
communities with comprehensive treatment and services. In what would be his last public bill
signing, President Kennedy signed a $3 billion authorization to support this movement from
institutional to community-based treatment. Tragically, following President Kennedy’s
assassination and the escalation of the Vietnam War, not one penny of this authorization was
ever appropriated.
As more light was shed on the horrific treatment people received in state psychiatric hospitals,
along with the hope offered by the availability of new and effective medications, a flurry of
federal lawsuits were filed against states which ultimately resulted in the deinstitutionalization of
public mental health care. Unfortunately, there was no organized or adequate network of
community mental health centers to receive and absorb these newly displaced individuals.
The fact that a comprehensive network of community mental health services was never
established following deinstitutionalization has resulted in a fragmented continuum of care that
has failed to adequately integrate services, providers, or systems; leaving enormous gaps in
treatment and disparities in access to care. Furthermore, the community mental health system
that was developed was not designed to serve the needs of individuals who experience the most
chronic and severe manifestations of mental illness.

9

Executive Summary

Lack of strategic funding and programming, and adherence to treatment guidelines that do not
necessarily reflect current best practices have affected certain segments of the population in
particularly devastating ways. For many individuals unable to access care in the community, the
only options to receive treatment is by accessing care through the some of the most costly and
inefficient points of entry into the healthcare delivery system including emergency rooms, acute
crisis services, and ultimately the juvenile and criminal justice systems.
There are two ironies in this chronology that have resulted in the fundamental failure to achieve
the goals of the community mental health movement and allowed history to repeat itself in costly
and unnecessary ways. First, despite enormous scientific advances, treatment for severe and
persistent mental illnesses was never deinstitutionalized, but rather was transinstituionalized
from state psychiatric hospitals to jails and prisons. Second, because no comprehensive and
competent community mental health treatment system was ever developed, jails and prisons once
again function as de facto mental health institutions for people with severe and disabling mental
illnesses. In two centuries, we have come full circle, and today our jails are once again
psychiatric warehouses.
On any given day in Florida, there are approximately 16,000 prison inmates, 15,000 local jail
detainees, and 40,000 individuals under correctional supervision in the community who
experience serious mental illness (SMI). Annually, as many as 125,000 people with mental
illnesses requiring immediate treatment are arrested and booked into Florida jails. The vast
majority of these individuals are charged with minor misdemeanor and low level felony offenses
that are a direct result of their psychiatric illnesses. People with SMI who come in contact with
the criminal justice system are typically poor, uninsured, homeless, members of minority groups,
and experience co-occurring substance use disorders. Approximately 25 percent of the homeless
population in Florida has an SMI and over 50 percent of these individuals have spent time in a
jail or prison.
A 2006 report by the National Association of State Mental Health Program Directors
(NASMHPD) Research Institute reported that the State of Florida ranked 12th in the nation in
spending for forensic mental health services. Today, this estimate is likely to be considerably
higher as this ranking did not take into account the state’s investment earlier this year of more
than $16 million in emergency funding allocated by the Legislative Budget Commission and the
addition of $48 million in annual funding to add 300 desperately needed treatment beds to the
overflowing forensic system. Individuals ordered into forensic commitment are now the fastest
growing segment of the publicly funded mental health marketplace in Florida. Between 1999
and 2007, forensic commitments increased by 72 percent, including an unprecedented 16 percent
increase between 2005 and 2006.
To put this in a more acute perspective, the State of Florida currently spends roughly a quarter of
a billion dollars annually to treat roughly 1,700 individuals under forensic commitment; most of
whom are receiving services to restore competency so that they can stand trial on criminal
charges and, in many cases, be sentenced to serve time in state prison. Furthermore, the
treatment provided in Florida’s forensic hospitals is funded entirely by state general revenue
dollars, as Federal law prohibits Medicaid from providing payment for psychiatric services
rendered in such institutional settings. As a result, the state is investing enormous sums of

10

Executive Summary

taxpayer dollars into costly, back-end services that may render a person competent to stand trial,
but will do nothing to provide the kind of treatment needed to facilitate eventual community reentry and reintegration.
While expenditures in the area of forensic mental health services place Florida near the top of list
nationally, the level of expenditures on front-end community-based services intended to promote
recovery, resiliency, and adaptive life in the community place the state near dead last. According
to the NASMHPD Research Institute, the State of Florida ranks 48th nationally in overall per
capita public mental health spending. Difficult to navigate and inefficient points of entry have
resulted in barriers to accessing preventative, routine, and competent care. Last year alone, more
than half of all adults with SMI and about a third of all children with severe emotional
disturbances (SED) in need of treatment in the Florida’s public mental health system had no
access to care. Furthermore, despite recent research which has lead to the identification and
development of increasingly effective, evidence-based interventions for serious mental illnesses,
such treatments have yet to be adequately implemented by many service providers in the public
mental health system. Consequently, increasing numbers of people experiencing acute episodes
of mental illness are becoming involved in the justice systems.
Roughly 150,000 children and adolescents, under the age of 18, are referred to Florida’s
Department of Juvenile Justice (DJJ) every year. Many of these youth have been impacted by
poverty, violence, substance abuse, and academic disadvantage. Over 70 percent have at least
one mental health disorder, with females experiencing higher rates of disorders (81%) than males
(67%). Of youth diagnosed with a mental health disorder, 79 percent meet criteria for at least one
other co-morbid psychiatric diagnosis, the majority of whom (approximately 60 percent) are
diagnosed with a co-occurring substance use disorder.
The problems currently facing Florida’s mental health and, consequently, criminal justice
systems relate to the fact that the community mental health infrastructure was developed at a
time when most people with severe and disabling forms of mental illnesses resided in state
hospitals. As such, the community mental health system was designed around individuals with
more moderate treatment needs, and not around the needs of individuals who experience acute
and chronic mental illnesses. People who would have been hospitalized 40 years ago because of
the degree to which mental illness has impaired their ability to function are now forced to seek
services from an inappropriate, fragmented, and unwelcoming system of community-based care.
The justice system was never intended to serve as the safety net for the public mental health
system and is ill-equipped to do so. Florida’s jails and prisons have been forced to house an
increasing number of individuals who are unable to access critically needed and competent care
in the community. The consequences of the failure to design and implement an appropriate
system of community-based care for people who experience the most severe forms of mental
illnesses have been:
•

Substantial and disproportionate cost shifts from considerably less expensive, front end
services in the public mental health system to much more expensive, back-end services in
the juvenile justice, criminal justice, and forensic mental health systems

•

Compromised public safety

11

Executive Summary

•

Increased arrest, incarceration, and criminalization of people with mental illnesses

•

Increased police shootings of people with mental illnesses

•

Increased police injuries

•

Increased rates of chronic homelessness

To effectively and efficiently address the most pressing needs currently facing the mental health
system in Florida, it is recommended that the state invest in a redesigned and transformed system
of care oriented around ensuring adequate access to appropriate prevention and treatment
services in the community, minimizing unnecessary involvement of people with mental illnesses
in the criminal justice system, and developing collaborative cross-systems relationships that will
facilitate continuous, integrated service delivery across levels of care and treatment settings.
In this report, recommendations are made for the development of a comprehensive and
competent mental health system which will prevent individuals from entering the justice system
to begin with and will respond to individuals who do become involved in the justice system
quickly and effectively to link them to appropriate services and prevent recidivism. By
designing an appropriate and responsive system of care for individuals with serious mental
illnesses, severe emotional disturbances, and/or co-occurring substance use disorders, people
who otherwise would continue to recycle through the justice system will be served more
effectively and efficiently. Public safety will be improved and the rate of individuals accessing
more costly services in forensic mental health and criminal justice systems will be reduced.
Under this redesigned system of care, which will serve both adults with SMI and children with
SED there will be 1) programs incorporating best-practices to support adaptive functioning in the
community and prevent individuals with SMI/SED from inappropriately entering the justice and
forensic mental health systems, 2) mechanisms to quickly identify and appropriately respond to
individuals with SMI/SED who do become inappropriately involved in the justice system, 3)
programs to stabilize these individuals and link them to recovery-oriented, community-based
services that are responsive to their unique needs; and 4) financing strategies which redirect cost
savings from the forensic mental health system and establish new Medicaid funding programs.
Key elements of the proposed plan include:

12

•

Adoption of innovative financing strategies, designed around principles of managed care,
that create incentives to prevent individuals from inappropriately entering the justice
systems, and to quickly respond to individuals who do become involved in the justice
system.

•

Establishment of a multi-tiered level of care classification system targeting individuals at
highest risk of institutional involvement in the criminal justice, juvenile justice, and state
mental health systems to ensure adequate services in times of acute need when at risk of
penetration into institutional levels of care and maximizing limited state resources during
periods of relatively stable recovery.

•

Creation of a statewide system of limited enrollment, Integrated Specialty Care Networks
(ISCNs) under a newly authorized Medicaid state plan option targeting Home and

Executive Summary

Community Based Services (HCBS) and specifically tailored to serve individuals with
SMI/SED who are involved in or at risk of becoming involved in the justice system or
other institutional levels of care.
•

State certification of local providers and communities for participation in the proposed
ISCNs, who demonstrate:
o The ability to deliver effective, high-quality services across systems of care to
individuals at highest risk of becoming involved in the criminal justice system or
other institutional levels of care.
o Ongoing, collaborative relationships with state and local criminal justice and
community stakeholders that will facilitate early intervention and continuity of
care across systems.

•

Implementation of strategies targeting community readiness and individuals at highest
risk for institutional involvement.

•

Establishment of a partnership between DCF and AHCA to maximize funding streams
and opportunities to serve individuals covered under public entitlement benefits (i.e.,
Medicaid) as well as those not covered.

•

Programs to maximize access to federal entitlement benefits by expediting the application
process and increasing initial approval rates for individuals prescreened to be eligible for
benefits.

•

Strategic, phased in implementation over a six year period to ensure adequate
infrastructure development and sustainability.

•

Strategic reinvestment of general revenue appropriations currently allocated to the state
forensic system into community-based services targeting individuals at risk of criminal
justice system involvement.

•

Establishment of a Statewide Leadership Group to provide administrative oversight and
facilitate technical assistance with the development of state and local plans.

•

Implementing strategies and promising practices to maximize enrollment in federally
supported entitlement benefits such as Medicaid and Supplemental Security
Income/Social Security Disability Insurance (SSI/SSDI).

•

Expansion of the Criminal Justice/Mental Health/Substance Abuse Reinvestment Grant
Program to build local and statewide infrastructures.

•

Development of local and statewide collaborations.

13

TABLE OF KEY RECOMMENDATIONS
Creating a redesigned and transformed system of care will require the provision of communitybased services and supports which ensure that people with mental illnesses and/or co-occurring
substance use disorders are able to access care that is effective, efficient, safe, and appropriate to
individual needs and circumstances. In addition, services and supports must be available in the
community when and where they are needed. Services offered should be those that are most
likely to contribute to adaptive and productive life in the community, while minimizing
unnecessary or inappropriate involvement in the criminal justice system or other institutional
settings. While the needs of each community will be different, potentially producing significantly
different priorities and objectives, the efforts of each community must be guided by a common
vision and current knowledge regarding evidence-based and promising practices. Table 1 lists
key recommendations addressed in this report.
Table 1. Key recommendations
Recommendation area:
Phased-in implementation of a redesigned system of care targeting the provision of enhanced
services to individuals involved in or at risk of becoming involved in the criminal and juvenile
justice systems, with the provision of reasonable start up costs.
Creation of a statewide system of limited enrollment, Integrated Specialty Care Networks
(ISCNs) which maximize state funding, along with new Medicaid programs to serve individuals
with SMI/SED who are involved in or at risk of becoming involved in the justice system or other
institutional levels of care.
Development of financing strategies that creates incentives to prevent individuals from
inappropriately entering the justice systems, and to quickly respond to individuals who do
become involved in the justice system.
Certification of local providers and communities for participation in ISCNs, who demonstrate the
ability, commitment, and readiness to deliver effective, high-quality services, across systems of
care to individuals at highest risk of becoming involved in the criminal justice system or other
institutional levels of care.
Establishment of a classification system based on risk of institutional involvement in the criminal
justice, juvenile justice, and state mental health systems to target enhanced services based on
necessary level of care.
Establishment of a partnership between DCF and AHCA to maximize funding streams and
opportunities to serve individuals covered under public entitlement benefits (i.e., Medicaid) as
well as those not covered.
Implementation of strategies to maximize enrollment in federally supported entitlement benefits
such as Medicaid and SSI/SSDI.

14

Recommendation area:
Establishment of a Statewide Leadership Group to provide administrative oversight and facilitate
technical assistance with the development state and local plans.
Development of comprehensive and competent community-based mental health systems based on
evidence-based and promising practices.
Development of comprehensive and competent interventions targeting adults involved in or at
risk of becoming involved in the criminal justice system based on evidence-based and promising
practices.
Development of comprehensive and competent interventions targeting youth involved in or at risk
of becoming involved in the criminal or juvenile justice systems based on evidence-based and
promising practices.
Recommendations to promote and sustain a more effective, competent, and sustained mental
health/substance abuse treatment workforce.
Recommendations for oversight of psychotherapeutic medication prescribing practices in the
dependency system and child-protective services.
Recommendations for best practices in screening and assessment in the juvenile justice system.
Recommendations for educating judges and other professionals in the courts.
Recommendations for judicial leadership and the development of community collaborations.

15

Part 1: The Crisis of Community Mental Health Care in Florida and the
United States: 1800-2007 1
The current problems and weaknesses of the community mental health system can be traced to
historical events that have shaped public policy and attitudes toward people with mental illnesses
over the past 200 hundred years. From the time the United States was founded until the early
1800s, people with mental illnesses who could not be cared for by their families were often
confined under cruel and inhumane conditions in jails and almshouses. During the 19th century,
a movement known as moral treatment emerged which sought to hospitalize rather than
incarcerate people with mental illnesses. Unfortunately, this well-intentioned effort failed
miserably.
The first public mental health hospital in the United States was opened in Massachusetts in 1833
by the Boston Prison Discipline Society, a group of reformers seeking an alternative to
incarceration for people with mental illnesses (Goff & Guderman, 1999). The institution
contained 120 beds, which was considered by experts at the time to be the maximum number of
patients that could be effectively treated at the facility. By 1848, the average daily census had
grown to approximately 400 patients, and the state was forced to open additional public mental
health facilities. A similar pattern was seen across the country as more and more states began to
open public psychiatric hospitals.
During the early part of the 19th century, Floridians with serious mental illnesses requiring
hospitalization were sent to Georgia State Hospital in Milledgeville and South Carolina State
Hospital in Columbia, and the State of Florida was charged $250 per person annually for care.
In 1876, Florida State Hospital was opened in a former civil war arsenal in Chattahoochee, two
years after the state first enacted statutes governing people with mental illnesses. With little
effective treatment available, the institution functioned primarily to provide a custodial
environment where patients would not injure themselves, staff, or other residents, and to ensure
public safety. In 1947, two years after the end of World War II, Florida’s second state
institution, G. Pierce Wood Hospital was opened in Arcadia on the site of a former military
training grounds and air field. Because of tremendous population growth in the state following
the war, overcrowding quickly became a significant problem at both facilities. By the late 1950s
two additional hospitals were opened in Pembroke Pines and MacClenny.
Meanwhile, nearly 350 state psychiatric hospitals were in operation across the United States by
the mid-1900s. However, overcrowding, inadequate staff, and lack of effective programs
resulted in facilities providing little more than custodial care. Physical and mental abuses were
common and the widespread use of physical restraints such as straight-jackets and chains
deprived patients of their dignity and freedom.
With the introduction of the first antipsychotic medications in the 1950s, combined with the fact
that many large and aging state institutions were becoming increasingly inefficient to operate, the

1

Portions of this review adapted from DCF report: Mental Health and Substance Abuse Services Plan: 2003-2006.
Retrieved October 26, 2007 from: http://www.dcf.state.fl.us/mentalhealth/publications/stateplan2003.pdf

16

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

idea that people with serious mental illnesses could be treated more effectively and humanely in
the community began to take hold.
In 1963, Congress passed the Community Mental Health Centers Act which was intended to
create a network of community-based mental health providers that would replace failing and
costly state hospitals, and integrate people with mental illnesses back into their home
communities with comprehensive treatment and services. In what would be his last public bill
signing, President Kennedy signed a $3 billion authorization to support this movement from
institutional to community-based treatment. Tragically, following President Kennedy’s
assassination and the escalation of the Vietnam War, not one penny of this authorization was
ever appropriated.
As more light was shed on the horrific treatment people received in state psychiatric hospitals,
along with the hope offered by advances in psychotherapeutic medications, a flurry of federal
lawsuits were filed against states which ultimately resulted in the deinstitutionalization of public
mental health care by the Courts. Unfortunately, there was no organized or adequate network of
community mental health centers to receive and absorb these newly displaced individuals.
Much like the rest of the country, the early days of community-based mental health care in
Florida consisted primarily of individual clinics, funded by local governments, charitable
organizations and other voluntary sources. However, no organized system of publicly funded
community-based care existed. In 1968, the Florida Constitution was revised and health and
social services were assigned to the Department of Health and Rehabilitative Services (DHRS).
This newly-created agency was notable in that it represented one of the first attempts nationally
to integrate health and human services, and was intended to address the emerging realization that
many individuals accessing publicly funded programs and service often had complex health and
social needs that weren’t adequately served through categorically distinct programs.
In 1970, the Florida Legislature enacted the Community Mental Health Act to establish ways and
means for the distribution of federal funds through the state to community mental health centers.
Under this legislation, the State of Florida committed to funding mental health services for the
first time, requiring that local governments participate in the cost by providing a match of one
local dollar for every three state dollars.
To assure local participation in funding, the legislature created Mental Health Boards in each
service area identified by the Division of Mental Health within DHRS for planning and
allocating state and federal funds for services. The boards, funded by the state but independently
staffed, were to be comprised of local citizens appointed by local governments. The role of the
boards was to assess service needs, evaluate programs in the community, and contract with local
providers to allocate funds from public and private sources based on district plans. With the
exception of state hospitals, all mental health services were provided through board contracts
with private providers.
In 1971, the State Legislature passed the Florida Mental Health Act, which became better known
as the Baker Act, to provide due process in involuntary civil commitment proceedings and to
establish uniform criteria for people being admitted to state hospitals. Considered model

17

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

legislation at the time, the Baker Act built on case law that established the requirement of due
process for people being committed involuntarily and defined the concept of least restrictive
environment. The history of this legislation is addressed in the next section.
One of the most influential cases in defining the rights of people with mental illnesses and the
deinstitutionalization movement in the United States came out of Florida. In 1971, Kenneth
Donaldson, a patient at Florida State Hospital for almost 15 years, filed suit against the hospital's
administrator and other staff members, alleging that they had intentionally and maliciously
deprived him of his constitutional right to liberty. Over the years of confinement, Donaldson’s
frequent requests for release had been rejected despite there being repeated offers, both from a
halfway house in Minneapolis and a friend of Donaldson's in Syracuse, New York, to provide a
home and supervision for him. The evidence showed that during the course of his hospitalization,
Donaldson had refused all treatment, denied that he had an illness, and was neither dangerous to
himself nor others. Furthermore, even if he had a mental illness, the evidence indicated he had
not received treatment.
In 1975, the United States Supreme Court ruled in O’Connor v. Donaldson 2 that the state had no
right to confine an individual “without more.” The Courts decision read, in part, "A finding of
'mental illness' alone cannot justify a state's locking a person up against his will and keeping him
indefinitely in simple custodial confinement… In short, a state cannot constitutionally confine
without more a non-dangerous individual who is capable of surviving safely in freedom by
himself or with the help of willing and responsible family members or friends."
During the same year, the Florida Legislature mandated the first of many re-organizational
efforts within DHRS. Eleven geographically defined service districts were created to better plan,
contract, and integrate services at the local level. Each district had staff assigned to programs
under the purview of the Department, and the old division structure was eliminated and Alcohol,
Drug Abuse, and Mental Health (ADM) Program Offices were created. ADM program offices
were responsible for establishing and monitoring program standards and performance objectives,
evaluating programs, and developing funding allocation methods. Over time, the ADM program
offices took over many of the functions of the local Mental Health Boards, eventually replacing
them all together.
In 1984, the legislature made sweeping changes to the Florida Mental Health Act revising the
Baker Act and eliminating the mental health boards, which were replaced with planning councils
that had similar planning and evaluation duties but did not allocate funds. The district program
offices were vested with the responsibility for contracting directly with providers for services
consistent with district plans.
As federal funding became less generous and with the advent of block grants in the 1980s,
pressure mounted to develop alternative mechanisms for funding services to people with serious
mental illnesses. The 1980s marked the beginning of a shift in funding for community mental
health programs through Medicaid Community Mental Health Services Rehabilitation and
Targeted Case Management programs. The 1990s saw the continued expansion of Medicaid
2

O’Connor v. Donaldson 422 U.S. 563, 95 S. Ct. 2486 (1975, Florida)

18

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

funding for mental health services. The Agency for Health Care Administration (AHCA),
through its role as the state’s Medicaid authority, became a critical funding and planning partner
for community-based mental health services. Medicaid now accounts for over half of all state
expenditures for the public mental health system.
The late 1980s and 1990s brought significant changes in many of the legal and social
assumptions upon which the mental health service delivery system had evolved. Rapid
advancement in the fields of neurobiology and pharmacology saw unprecedented success in the
treatment of the most intractable forms of mental illness. At the same time, class action suits
increased the pressure on states to provide appropriate community-based services. As a result,
state mental health treatment facilities became smaller and demand on community resources
increased. People with mental illnesses and their families became increasingly articulate
advocates for the need for system reform and for their inclusion as full participants in the
planning and delivery of services. Overwhelming evidence that recovery from serious mental
illnesses was possible generated new energy and required a complete rethinking of the design of
the service delivery system.
In 1989, another significant lawsuit, Sanbourne v. Chiles, 3 was filed in Federal court on behalf of
Deidra Sanbourne, who had resided at South Florida State Hospital in Pembroke Pines for most
of her adult life. The class-action litigation lead to further deinstitutionalization of Florida’s state
hospitals and required ongoing monitoring of conditions at South Florida State Hospital,
particularly discharge planning for residents and services received in first 30 days after discharge
to the community. While Deidra Sanbourne was released from the confines of the state hospital
after 20 years of institutionalization, she later died at the age of 57 after being neglected in a
boarding home (Early, 2006).
The 1990s were also a period in which accountability became a driving principle in mental
health policy development. The passage of the Government Accountability Act and increasing
demands on state resources required that the DHRS and providers be accountable for measurable
outcomes. The legislature established target populations that were the priority groups to receive
services funded by the state. The collection of outcome data on the services provided became a
required element in contracts with providers. This focus on accountability was also fueled by
escalating health care costs. As demands on state resources increased, restructuring payment
mechanisms for mental health services became increasingly important.
In 1996 the Legislature reorganized DHRS, creating a separate Department of Health and
creating the Department of Children & Families (DCF). This reorganization also created separate
program offices at the state level for Alcohol, Drug Abuse and Mental Health, although the
separation did not extend to the district level. Due to the explosive population growth since the
1975 reorganization, the original eleven districts were expanded to fifteen.
In 2003, the legislature enacted changes that represented the next step in the evolution of
Florida’s human services delivery system. In response to concerns that the mission of the mental
health and substance abuse programs was not a high priority within the department, the
legislature created a Deputy Secretary for Substance Abuse and Mental Health within DCF, with
3

Case 89-6283-CIV-NESSBITT, (S.D. Fla. 1993)

19

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

accountability directly to the Secretary. In an effort to elevate the importance of services to
people with mental illness and substance abuse problems, the Legislature established the Florida
Substance Abuse and Mental Health Corporation, independent of the department, to review the
service delivery system, assess needs for services, staff and resources, and provide a forum for
direct advocacy with policymakers.
During the 2007 regular session, the Florida Legislature again took up legislation relating to the
public mental health system, authorizing DCF to modify its organizational structure to improve
the effectiveness and efficiency of the agency. Under this reorganization, which is currently in
progress, DCF is working to integrate substance abuse and mental health programs into the
Department’s overall structure and priorities and to realign the service districts to conform with
judicial circuits.
Also during the 2007 session, the Florida Legislature passed HB 1477, the Criminal Justice,
Mental Health, and Substance Abuse Reinvestment Grant Program. This legislation allocates $4
million in funding with a match from counties to be used for a statewide competitive grant
program, enabling communities to plan and/or expand joint problem-solving initiatives aimed at
responding more effectively to people with mental illnesses in the justice system. Similar to
Federal legislation passed under the Mentally Ill Offender Treatment and Crime Reduction Act
of 2004 (MIOTCRA), the grant program requires the establishment of collaborative partnerships
between the judiciary and other traditional and nontraditional stakeholders serving the needs of
people with mental illnesses.
History of the Baker Act: 4
In 1971 the Florida Legislature passed into law the Florida Mental Health Act, which went into
effect July 1st of the following year. This Act brought about a dramatic and comprehensive
revision of Florida’s 97-year old mental health laws. It substantially strengthened the due process
and civil rights of persons in mental heath facilities and those alleged to be in need of emergency
evaluation and treatment.
The Act, usually referred to as the “Baker Act,” was named after Maxine Baker, former state
Representative from Miami who sponsored the legislation, after serving as chairperson of the
House Committee on Mental Health. According to Representative Baker, the intent of the Act
was to encourage voluntary commitments as opposed to involuntary (when the person was
incompetent to consent), to separate the process of hospitalization from the process of legal
incompetency, to increase community care of persons with mental illnesses, and to facilitate
persons’ return to normal community life. Referring to the treatment of persons with mental
illness before the passage of her bill, Representative Baker stated “In the name of mental health,
we deprive them of their most precious possession – liberty.”
Before the Baker Act was enacted, a person could be placed in a state hospital if three people
signed affidavits and secured the approval of a county judge. The law stated that the committing
4

Parts of this review adapted from: History of the Baker Act – It’s Development and Intent. State of Florida
Department of Children and Families Mental Health Program Office Website. Retrieved from:
http://www.dcf.state.fl.us/mentalhealth/laws/histba.pdf

20

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

judge was required to have any destitute person with mental illness committed to the sheriff for
safekeeping until transferred to the hospital. Children as young as 12 years old could be placed
into state hospitals with adults. Payment could be required from friends, parents, or guardian for
the person’s care. Persons hospitalized in private or public hospitals were allowed only one
individual with whom he or she could openly and privately correspond. There was no specific
period of commitment before a person’s confinement would be reconsidered by a judge.
The Baker Act prohibited the indiscriminate admission of persons to state institutions or the
retention of persons without just cause. The Baker Act mandated court-appointed attorneys to
represent each person for whom involuntary placement was sought and provided for independent
reviews of all involuntary placements every six months. The new law established a patients’ bill
of rights, protecting persons’ rights to communicate with whomever they wished, to receive and
send unopened mail, to use their own possessions, and to vote, among many other rights. The
law also prohibited the placement of persons with mental illnesses in jails, unless they had
committed criminal acts.
Since the Baker Act became effective in 1972, a number of legislative amendments have been
enacted to further protect persons’ civil and due process rights. The most substantial reform
occurred in 1996 when greater protections were extended to persons seeking voluntary
admission, informed consent and guardian advocacy provisions were strengthened, notice
requirements were expanded, and suspension and withdrawal of receiving and treatment facility
designations was specified, among many other revisions.
The Baker Act was considered by many persons around the country as landmark legislation at
the time of its enactment. The movement to deinstitutionalize persons from large mental
hospitals back to their home communities became prominent since the 1970s and many newer
psychiatric medications have made it possible for persons to avoid or reduce the need for longterm hospitalization. Since the passage of the Act, there has been increasing public awareness
and understanding that the rights and liberties of people with mental illnesses are no different
than those bestowed to the rest of the general population.
In 1999, the Commission on Fairness of the Supreme Court of Florida conducted the first
comprehensive review of the judicial administration of the Baker Act since its enactment nearly
30 years earlier. The commission concluded that that this legislation effected certain populations,
particularly elders, in detrimental ways; and that the Baker Act was in need of overhaul,
including statutory reforms, improvements in court procedures, and increased funding
(Commission on Fairness, 1999).
The commission found that the number of Florida residents with mental illnesses and cognitive
disorders such Alzheimer’s disease (roughly one million individuals) was greater than the entire
populations of some individual states. They also found that an alarmingly large number of
Floridians were undergoing involuntary examination and civil commitment hearings every year.
They noted that, because of inadequate funding, hearings on petitions for involuntary placement
were not always held within the time frames required by law, resulting in lengthier detentions.
In addition, they recommended more funding for community-based mental health services to
avoid unnecessary institutionalization or criminalization of individuals with mental illnesses. It

21

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

was found that the Baker Act had sometimes been used maliciously for financial gain or personal
retribution, often against elders in nursing homes. Some people detained under the Baker Act
were found to have received inadequate legal help and some Baker Act hearings were so
informal that detainees did not understand their liberty was at stake, and in some instances, state
attorneys were not fully participating in the process. The Commission also concluded that
judicial and executive agencies that should have a role in preventing abuses of the Baker Act
were too poorly funded to be effective. Furthermore, they did not receive adequate training and
education to prepare them to participate effectively in Baker Act proceedings. Although the
Commission on Fairness published a list of recommendations addressing legislative, financial,
training, and procedural issues relating to the Baker Act, few corrective actions were
implemented.
In 2005, changes to the Baker Act were enacted that provide for involuntary outpatient
placement (IOP), or outpatient civil commitment. The intention of this legislation is to provide
for a less restrictive alternative to court-ordered hospital treatment for individuals with mental
illnesses who have demonstrated substantial difficulty with adhering to treatment and who, as a
result of treatment noncompliance, have experienced repeated, recent institutional involvement
in mental health or criminal justice systems. Considerable controversy relating to IOP has
emerged, in Florida and across the country, surrounding the appropriateness and value of courtordered outpatient care. In addition, this legislation was passed without providing consideration
for funding of services, or for the impact on the judiciary and the legal system. As a result, IOP
has yet to be fully implemented in many communities across Florida. In the handful of
jurisdictions where it has been implemented, it is reported to be yielding promising results.
During the fall of 2006, DCF convened a workgroup of key stakeholders from around the state to
address the increasing demands on the acute care system (particularly among individuals
involved in the criminal justice system), review and recommend alternative
treatment/intervention options, and make recommendations regarding the need for statutory
changes in the Baker Act. In their final report, the workgroup echoed many of the
recommendations made by the Commission on Fairness, as well as other recommendations
relating to judicial procedure which were recently referred to the Steering Committee on
Families and Children in the Court of the Supreme Court of Florida.
Children and Families:
In addition to criminal justice and judicial system related consequences, untreated mental
illnesses also contribute to non-justice system related consequences that are not only equally
tragic, but imminently avoidable. A recent study by a branch of the Department of Health and
Human Services, found that almost one-quarter of all stays in public hospitals in the United
States for patients ages 18 and older in 2004 (roughly 7.6 million of nearly 32 million total
hospital stays), involved mental illness and/or substance use disorders. Of all hospital stays
involving these disorders, 25 percent (1.9 million, or 6 percent of total hospital stays) involved a
principal psychiatric diagnosis, with the remaining 75 percent (5.7 million, or 18 percent of total
hospital stays) documenting a secondary psychiatric diagnosis on the discharge record (Owens,
Myers, Elixhauser, & Brach, 2007).

22

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

An estimated 30-40 percent of Florida children in out-of-home care have a serious emotional
disturbance (DCF, 2006). The National Resource Center on Homelessness and Mental Illness
estimates that 25.5 percent of people in Florida who are homeless have mental illnesses. About
2,000 individuals discharged from Florida’s civil commitment facilities every year have no
source of income and are reliant upon state resources for housing and services. Florida’s suicide
rate ranks 13th in the nation, and is the 9th leading cause of death in the state among the general
population and the 3rd leading cause of death among individuals aged 15 to 24. More teenagers
and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke,
pneumonia, influenza, and chronic lung disease combined (Florida Suicide Prevention
Coalition).
To the extent that changes are undertaken to reform the mental health system and to minimize
the unintended consequences of conventional policies and practices, it is imperative that issues
relating to pregnancy and infant care and development be given prominent attention. Among the
more compelling recent research on underlying causes of behavioral and emotional difficulties is
the contribution of prenatal, neonatal, and early childhood development on later expression of
mental illnesses and behavioral disorders. Research has demonstrated that poor maternal
nutrition, health, and prenatal care, along with exposure to illicit drugs and other toxic substances
in utero, have strong relationships with later development of behavioral and emotional
difficulties (Institute of Medicine, 2003).
Similarly, research now shows definitively that insecure and inconsistent patterns of attachment
to key caregivers during the first years of life are associated with development of psychiatric
difficulties, and can have profound effects on an individual’s ability to develop and maintain
meaningful relationships later in life. While risk factors associated with disorganized infantcaregiver attachment include parental trauma, maternal depression, maternal alcoholism, and
other substance-use problems and illnesses, they are also associated with infants who are placed
in environments that do not provide an adequate opportunity to develop stable, secure
relationships with one or more key caregivers (Lederman, Osofsky, & Katz, 2001). Such
impermanence in relationships may occur, for example, when infants enter into the foster care
system and move from one placement to another without having the opportunity to developed
meaningful attachments.
Another trend which has raised concerns involves the off-label prescribing of psychotherapeutic
medications to preschoolers and older children (Rawal, Lyons, MacIntyre, & Hunter, 2004; Zito,
Safer, dos Reis, Gardner, Boles, & Lynch, 2000). In the absence of formal standards and clinical
guidelines, the off-label use of these medications, usually in response to behavioral problems,
has been questioned for both its safety and efficacy. To complicate matters, judges in
dependency courts are now required to provide signatures authorizing the administration of
psychotherapeutic medications to children in foster care, which may present further legal and
ethical concerns that are worthy of review.
Traditionally, prevention and intervention strategies have focused on mental illnesses in adults
with the apparent presumption that the development of serious mental illness is something that,
by and large, cannot be predicted prior to the onset of symptoms in early adulthood. It is only
recently that the popular belief among policymakers and the public have entertained the notion

23

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

that events in early childhood development may foreshadow more significant impairments later
in life.
The emerging research on infant and childhood development suggest that attending to issues of
early human development, particularly on the part of service providers, policymakers, and the
courts by way of the dependency system, may not only respond more effectively to the needs of
children, but may also serve as a critical first line of defense against preventable and irreversible
consequences that may lead to future disability, institutionalization, and criminal justice system
involvement.
Trends in Service Organizations, Services Provided, and Funding:
To put in perspective current challenges facing the public mental health system, it is useful to
consider historical issues relating to the financing and delivery of mental health care services in
the United States and in Florida. The Substance Abuse and Mental Health Services
Administration (SAMHSA) of the United States Department of Health and Human Services
(DHHS) recently released Mental Health, United States, 2004 (Center for Mental Health
Services, 2006), the latest in a series of reports published biennially that address policies and
practices in mental health care service delivery in the United States. The latest compendium
includes detailed information on both aggregate and service-sector specific system capacity,
service delivery, and expenditures.
The types of mental health organizations
covered are state and county psychiatric
hospitals, private psychiatric hospitals,
non-Federal general hospitals with
separate psychiatric services, Department
of Veterans Affairs (VA) medical
centers, residential treatment centers
(RTCs) for children with severe
emotional disturbances (SED), and "all
other mental health organizations,"
which include multi-service mental
health
organizations,
freestanding
psychiatric outpatient clinics, and partial
care psychiatric organizations.
Services:

1970 1976 1980 1986 1990 1992 1994 1998 2000 2002
•

State and COUlly

~ Non-Federal general

•

RTCs

•

D
D

Private psychiatric

VA medical cooters
AI other mantal hea~h orgarizahons

Ffgure t. Percent Distribubon of 24-Hour Hosp~al artd ResKJential
Treatment Beds, by Type of Mental Hea~h Organizatkm: Un~ed States,
Selected Years, 1970---2002. Source: Foley et aI., 2006.

Between 1970 and 1998 the total number of mental health organizations in the United States
increased from 3,005 to 5,722. Between 1998 and 2002, the number of organizations decreased
from 5,722 to 4,301. Similarly, the total number of mental health organizations in Florida
between 1992 and 1998 increased from 177 to 223. Between 1998 and 2002, this number
decreased from 223 to 152. The majority of the increases in services were among organizations
providing less than 24-hour care and in non-federal general hospitals and RTC for children with
SED (Foley, Manderscheid, Atay, Maedke, Sussman, & Cribbs, 2006).

24

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

Although the total number of service organizations in the United States providing inpatient and
residential treatment care increased between 1970 and 2002, the number of treatment beds
declined dramatically. In 1970, 524,878 beds existed across all service sectors. As of 2002, this
number had dropped to 211,199, a decrease of 60 percent. State hospitals and VA medical
centers closed nearly 400,000 beds combined, resulting in decreased inpatient and residential bed
capacity of 86 and 81 percent respectively (see Figures 1 & 2).
A similar trend has occurred in Florida
where the number of community hospital
psychiatric beds decreased from 6,467 in
1994 to 4,021 in 2006, despite the
increase in the state’s population during
that time. This is a drop from 45.8 beds
per 100,000 total population in 1994 to
21.8 beds per total 100,000 population in
2006. There are currently a total of
3,823 beds for adults and 556 for
children that provide 24 hour care in a
community setting. Beds in Florida’s
civil state psychiatric hospitals have
decreased from 1,926 in 1997 to 921 in
2007, placing greater pressure on
community-based facilities (DCF, 2007).

225.0,---------------,
"".0

175.0
150.0
125.0
100.0
75.0

"'.0
25.0
0.0
1970 1976 1930 1986 1990 1m HIS4 1998 2COO 2002
~

Stataand county
_____ Noo-Fedoral gooaral

~

RTCs

Prtvata psychlatrtc
__ VA medical coot&rs

All othor mantal health Of9MI.llltiOns

Figure 2. Rate of 24-Hour Hospital and Treatment Beds, by Type of
Mental Health Organization: United States, Selected Years, 1970---2002.
Source: Foley et ai, 2006

In 1969, state hospitals served slightly more than 78 percent of all residents of psychiatric
facilities, whereas private psychiatric hospitals and non-Federal general hospitals accounted for
just over 6 percent of all residents. As of 2002, state hospitals accounted for roughly 29 percent
of all residents of psychiatric facilities, whereas the percentage of combined residents in private
psychiatric hospitals and non-Federal general hospitals had grown to over 25 percent (Foley et
al., 2006).
Along with the shift in patient care episodes from 24-hour hospital and residential treatment care
to less than 24-hour services, a shift also occurred across organization types within these two
services. For example, state hospitals accounted for 63 percent of hospital and residential
treatment episodes in 1955, compared with only 13 percent in 2002. Also in 2002, the majority
of hospital and residential treatment care episodes were in private psychiatric hospitals (22
percent) and non-Federal general hospitals (48 percent).
Expenditures:
Total expenditures by mental health organizations in the United States increased from $3.3
billion to $34 billion between 1969 and 2002. However, when adjusted for inflation, total
expenditures (in 1969 dollars) rose by only $700 million, or 21 percent (see Figure 3). By
contrast, the estimated United States population increased by roughly 87 million people, or 43
percent, during this same period of time. Only 2 percent of the $31 billion increase in

25

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

"",------------;---,

-------------~

expenditures between 1969 and 2002
represented an increase in purchasing
power. The remaining 98 percent was
due solely to inflation. Trends in per
capita expenditures followed similar
patterns between 1969 and 2002. When
expressed in constant dollars, total per
capita expenditures had an inconsistent
net decline of $2.97 between 1969 and
2002, from $16.53 to $13.56.

In Florida, total state mental health
appropriations increased from $219
__ Constant billions
---+- Current b~lions
million to $370 million between FY96F~ure 3. Atmual Expertd~ures in Current and Constant DoRars, All Mental
97 and FY06-07, an increase of $151
Health Organizations, United States: Selected Years, 1969--2002.
million. When adjustments are made for
Source: Foley el 31_. 2006.
inflation, total expenditures rose from
$219 million in FY96-97 to $248 million in FY06-07, an increase of $29 million (see Figure 4).
Trends in per capita state appropriations indicate an increase in funding between FY96-97 and
FY06-07 from $14.90 to $20.10; however when adjusted for inflation, per capita state
appropriations increased from $14.90 to $17.27 between FY96-97 and FY01-02 and then
decreased to $13.47 in FY06-07, a net loss of $1.43 per capita across the prior decade (see Figure
5). 5

, +;;;;;;;--;=~;;;__;==;__;;==c_;;;;;;;__==;CC
1969 1975 1979 1986 1990 1992 1994 1998 2000 2002

Medicaid is the largest source of public funding for mental health and substance abuse (MHSA)
treatment in the United States, accounting for roughly 44% of all MHSA spending (Kaiser
Commission on Medicaid and the Uninsured, 2007). Furthermore, Medicaid accounts for
roughly 18 percent of total United States healthcare spending, 60 percent of all acute care costs,
and more than one-third of all operating revenues for community health centers and public
hospitals.
Medicaid is jointly financed through federal and state matching funds; and accounts for roughly
8 percent of total federal outlays and an average of 18 percent of state general revenue spending.
Behind elementary and secondary education, Medicaid is the second largest item in most state
budgets. The federal share of spending is determined by the federal medical assistance
percentage (FMAP), which varies by state based on per capita state income relative to per capita
national income. In Florida, the FMAP for FY2007 is 58.8 percent federal dollars to 41.2
percent state general revenue dollars, resulting in $1.42 in federal funding for each dollar of state
Medicaid spending.
Of the roughly 55 million Americans covered by Medicaid, 11 percent receive MHSA services.
Expenditures associated with enrollees accessing MHSA services, however, tend to account for a
substantially larger proportion of Medicaid spending. Schizophrenia (and related disorders) and
affective disorders (depression and bipolar disorder) rank as the 4th and 5th most expensive
conditions billed to Medicaid for hospitalization services, totaling 316,000 hospital stays
5

Figures 4 & 5 are based on data provided by the Florida Council for Community Mental Health.

26

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

annually at a cost of more than $5 billion
annually (Russo and Andrews, 2006). In
many states, Medicaid is relied on to pay
for mental and behavioral health services
that are not covered under other sources
of health insurance.
While the Florida Department of
Children and Families (DCF) is
responsible for coordinating programs
and contracting for services with local
providers, the Agency for Health Care
Administration (AHCA) is responsible
for overseeing the administration of
Medicaid funds for the state. Although
Florida has seen consistent and
substantial growth in demand for mental
health services across all service
segments in recent years, growth in
funding for services has been relatively
nominal or flat (Legislative Committee
on Intergovernmental Relations, 2005).
In some areas, funding levels have even
declined.

fi\lll'"e ~. State of Fk>Oda: TomI AnruaI AppropO/Itioos {in miIionsl

"00 ~------------------,
",,0

$361

$275

-----..-- Current dollars

. .

.

S248

- Constant dollars

fil/Un! S. State of F _ : PerC21pilllAnnullI

Appropi~tions

$21.52

$20.00
$20.10

.

$18.00

$17.21

$16.00

$14.90
$14.00

Mental illness in state prison systems

.

.

$289

".

$13.47

To illustrate the impact of mental
------.-- Current dollars - Con slant dollas
illnesses and lack of access to
community-based care on individuals
entering the justice system, consider the following example from the state prison systems.
According to the Bureau of Justice Statistics (BJS, 2006), more than half of all inmates in state
prisons across the United States experience mental health difficulties, with one in six diagnosed
with a serious mental illness (BJS, 1999). Because of lack of community resources and
inadequate pre- and post-release service planning and coordination, many individuals with
mental illnesses who are released from prisons are unable to access basic supports needed for
successful community re-entry, such as housing and medications. As a result, substantial
numbers of individuals with mental illnesses, unable to successfully re-integrate into the
community are eventually re-arrested and returned to jails and prisons. Ironically, as many as
half of these individuals are re-arrested not for committing new offenses, but for violating
conditions of their probation or parole, such as failing to report to treatment or to maintain stable
housing or employment (Council of State Governments, 2002).
Over time, and in conjunction with a decrease in the availability of residential and communitybased services and supports, this has resulted in a substantial increase in the number of inmates
in Florida prisons who experience mental illnesses, along with significant burdens and costs to

27

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

the state prison system to respond to the needs of these individuals. According to the Florida
Department of Corrections, between 1995 and 2007 the percentage of inmates receiving ongoing
mental health services in state prisons increased from 10.6 percent to 18.1 percent, an overall
proportional increase of more than 70 percent. Among inmates with mental illnesses, the
percentage with severe and persistent mental illness (SPMI), requiring the most acute and costly
levels of care, increased from 17.3 percent to 39.1 percent between 1995 and 2006, an overall
proportional increase of 126 percent. Similarly, the number of inmates housed in inpatient
mental health settings within the Department of Corrections more than doubled between 2000
and 2006.
Providing appropriate levels of care to this rapidly expanding subpopulation has meant a
substantial increase in investment in costly acute care services and treatment infrastructure. The
Department of Corrections now provides ongoing mental health treatment to more than 18,000
inmates annually, with roughly 13,000 identified as requiring intensive levels of care. Currently,
mental health services are provided in all major correctional facilities, with 9 facilities providing
inpatient levels of mental health care. The Department of Corrections operates roughly 1,150
inpatient mental health treatment beds, which is more beds than currently exist across the state’s
entire inpatient civil commitment system. While many inmates with mental illnesses are housed
in the general population, this is not without added cost. In addition to requiring ongoing
medication and other treatment services in many cases, as these inmates are nearly twice as
likely to be placed in confinement settings as compared to inmates without mental illnesses.
It should be noted that the Florida Department of Corrections, in collaboration with various
community stakeholders, has undertaken commendable efforts to more effectively address
continuity of care and effective re-entry among inmates with mental illnesses released from the
state prison system. This has included creating an Interagency Agreement between the
Department of Corrections and the Department of Children and Families, coordinating with the
Social Security Administration to facilitate the application process for federal entitlement
benefits, establishing community partnerships with key stakeholders, creating administrative
processes and roles to oversee the coordination of re-entry and post-release services, and creation
of additional staff positions solely dedicated to coordinating aftercare services. While these reentry strategies markedly improve pre-release planning and continuity of care, they are of little
value in the absence of an effective and informed system of community-based care to receive
individuals exiting the justice system. As such, it is imperative that the efforts being undertaken
to enhance community re-entry from jails and prisons include the establishment of
comprehensive and competent services in the community targeted toward the needs of this high
risk population.
Unintended Consequences:
The fact that a comprehensive network of community mental health services was never
established following deinstitutionalization has resulted in a fragmented continuum of care that
has failed to adequately integrate services, providers, and systems; leaving enormous gaps in
treatment and disparities in access to care. Years of inadequate funding and adherence to dated
legislation and policies that don’t necessarily reflect the current demands and priorities of the
mental health system has effected certain segments of the population and the community in

28

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

particularly devastating ways. But for lack of adequate and appropriate sources of care in the
community many individuals experiencing episodes of profound and acute mental illness,
particularly those most economically and socially disadvantaged, are increasingly finding their
way into the criminal and juvenile justice systems.
According to DCF (2007), individuals subject to forensic commitments are now the fastest
growing segment of mental health consumers. Forensic commitments have increased by 72
percent since 1999, including an unprecedented 16 percent increase between 2005 and 2006, far
exceeding existing forensic treatment bed capacity. At the same time, prison sentences of a year
and a day have increased by 25 percent.
On November 30, 2006, a judge in west Florida fined the Secretary of DCF $80,000 and found
her in criminal contempt of court for failing to comply with an order to transfer inmates with
mental illnesses adjudicated incompetent to proceed to trial from the Pinellas County jail to state
forensic hospitals in a timely manner as required by law. This ruling followed months of
controversy and high-profile media attention surrounding DCF’s inability, due to lack of
resources, to abide by statutory requirements to place defendants found incompetent to proceed
to trial or not guilty by reason of insanity in forensic mental health treatment facilities within 15
days of adjudication. 6
At the time, roughly 300 inmates in jails across the state were awaiting transfer to the state’s
roughly 1,400 forensic treatment beds. More than 240 of these individuals had remained in local
jails beyond the 15 day limit, with an average waiting time of nearly three months. Judges in
Miami, Fort Lauderdale, and Jacksonville had issued similar court orders demanding that DCF
comply with state law, and threatened additional sanctions if the Department failed to promptly
move individuals in need of treatment out of local jails and into state facilities. The day after the
contempt ruling in Pinellas County, the Secretary of DCF submitted her letter of resignation to
the state’s outgoing Governor.
In subsequent months the state was forced to allocate an additional $16 million in emergency
funding and, later during the regular legislative session, $48 million in recurring annual funding
to create 300 desperately needed forensic treatment beds. In total, the State of Florida has
committed to spending roughly a quarter of a billion dollars annually to treat 1,700 individuals
under forensic commitment, many of whom are destined to be tried on criminal charges and
moved on to the state prison system.
To make matters worse, the urgency with which the state needed to add these additional beds has
meant that state hospital beds previously designated for the civil mental health system had to be
converted to serve the forensic population. This has resulted in a reduction in the already scarce
supply of civil state hospital beds intended as the proper safety net for individuals experiencing
severe and persistent mental illnesses who, as a result of their illnesses and not criminal
behavior, are judged to be an imminent risk of harm to themselves or others and in need of courtordered, long-term care in a hospital-based setting.

6

Chapter 916.107, Florida Statutes, Rights of Forensic Clients, “a jail may be used as an emergency facility for up
to 15 days following the date the department or agency receives a completed copy of the court commitment order”

29

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

The loss of such critical civil infrastructure increases the likelihood that individuals in need of
care, at times when they are least likely to be able to care for themselves, will eventually find
their way into the criminal justice system. Such indirect thinning of resources is a prime
example of the unintended consequences of a mental health system in which lack of adequate
front-end investment and planning has resulted in the further diminishment of the separation
between acute and chronic mental illnesses and entry into the criminal justice system.
Inadequate funding of community-based services has meant that more than half of all adults with
SMI and about a third of all children with SED in need of treatment in the Florida’s public
mental health system have no access to care (Department of Children and Families, 2007).
Because Florida is a state that does not require parity for mental health coverage with general
medical benefits, access to care becomes further restricted for many individuals, placing
increased demand on the public mental health system.
Although various legislatures in the state have taken up the issue of community mental health
over the past 40 years, the reality is that the system in place today, particularly as it relates to
areas such as the provision of involuntary treatment, is largely built on the philosophies,
assumptions, and best-practices of more than a generation ago. In an era of huge institutions that
warehoused people with mental illnesses, subjecting them to cruel and inhumane conditions, it
was necessary to have in place laws which protected individuals’ civil liberties and rights. While
protection of these same civil liberties and rights are no less relevant today, access to services for
individuals with SMI/SED in times of critical need are often met with roadblocks and
impediments that raise questions about the extent to which laws designed to protect the safety
and well-being of people with mental illnesses have resulted in consequences that effectively
block or obstruct access to care. There is a need to review the adequacy of current legislation
permitting court-ordered treatment on an inpatient or outpatient basis to ensure that not only does
the law provide protections to guard against civil rights abuses, but also that the law does not
function as a barrier to treatment for people who may need it the most.
It should also be noted that the consumer population accessing crisis services and the community
mental health system today, along with our scientific and social understanding of mental
illnesses, are in many ways quite different from the consumer population and conventional
wisdom of a generation or more ago. Whereas 40 years ago, individuals were much more likely
to reside in long-term hospital settings, today individuals are faced with the challenges of living
with illnesses that, if not properly treated, can be profoundly disabling and result in maladaptive
behaviors and functioning that make it all but impossible to reside independently in the
community. While the diagnoses and underlying disorders are the same, individuals with serious
mental illnesses and/or co-occurring substance use disorders today are much more likely to have
experienced life events such as criminal justice system involvement, incarceration, and chronic
homelessness. In addition, our current understanding of serious mental illnesses and the
prevalence of accompanying difficulties such as substance use disorders, trauma histories, and
incarceration histories means that interventions and treatment considerations must be informed
and responsive to a broader array of needs.
There is a need to ensure that the mental health system is organized and financed in such a way
as to provide appropriate levels of care when and where they are needed. The current system

30

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

provides inherent disincentives to the appropriate utilization of cost-effective, less intensive
community-based services; which in turn contributes to an increase in demand for significantly
more expensive acute care and hospitalization services. Because the community-based system to
which the individual returns upon discharge from crisis stabilization or hospitalization episodes
is the same one which was unwelcoming and overburdened to begin with, the entire process is
reset to begin anew contributing to a revolving door of discrete acute care episodes and
subsequent psychiatric decompensation, all too often interspersed with periods of criminal justice
system involvement and incarceration. Despite scientific advances that have lead to increasingly
effective treatment of serious mental illnesses, routine and efficient access to such evidencebased interventions in the public mental health system remains beyond the reach of many
seeking care.
The unintended, but nonetheless undeniable consequences of this system have been increased
homelessness, increased police injuries, increased police shootings of people with mental
illnesses, critical tax dollars wasted, and the reality that we have made mental illness a crime; or
at the very least a significant risk factor for criminal justice system involvement. Our jails and
prisons have become the unfortunate and undeserving “safety nets” for an impoverished system
of community mental health care, and some of the most vulnerable and disadvantaged
individuals in our society are allowed to unnecessarily suffer from horrific and imminently
treatable illnesses.
Consider the following: In 1955, some 560,000 people were confined in state psychiatric
hospitals across the United States. By the year 2000, only about 56,000 remained in such
facilities (Manderscheid & Hutchins, 2004). By some estimates, this figure may be as low as
40,000 today. Over this same period of time, the number of psychiatric hospital beds nationwide
has decreased by more than 90 percent, while the number of people with mental illnesses
incarcerated in our jails and prison has grown by more than 400 percent. Figure 6 illustrates this
dramatic shift in service delivery from inpatient to outpatient care between 1955 and 2002.
Today there are more than five times as many people with mental illnesses in jails and prisons in
the United States than in all state psychiatric hospitals combined (Ditton, 1999). Over the last
ten years, we have closed more than twice as many hospitals as we did in the previous twenty
and, if this weren’t bad enough, some of the hospitals that were closed were actually converted
into correctional facilities which now house a disproportionate number of inmates with mental
illnesses (Krauth & Dickerson, 1984).
The National GAINS Center estimates that more than 1.1 million people diagnosed with serious
mental illnesses are arrested and booked into jails annually (Steadman, 2007). Furthermore,
roughly three-quarters of these individuals also meet criteria for co-occurring substance use
disorders (Abram & Teplin, 1991; National GAINS Center, 2001). As of mid-year 1998, the
Department of Justice estimated that almost 300,000 people with mental illnesses were
incarcerated in jails and prisons across the United States, and more than 500,000 people with
mental illnesses were on probation in the community (Ditton, 1999). Today, these numbers are
likely to be significantly higher.

31

Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

In Florida alone, roughly 125,000 people
100%
with serious mental illnesses requiring
immediate treatment are arrested and
75%
booked into jails annually. Up to 23
percent of county jail inmates and 17
50%
percent, or more than 16,000, of
n%
Florida’s state prison inmates experience
serious mental illnesses. On any given
25%
day, the Miami-Dade County Jail houses
between 800 and 1200 defendants with
0%
SMI, making it the largest psychiatric
1955
2002
facility in the State of Florida. Inmates
designated as having a mental health • Less than 24-hour care episodes
problem in the Orange County Jail are • 24-hour hospital and residential treatment care episodes
more likely to be repeat offenders, stay
in jail 67 percent longer than other Figure 6. Patient Care Episodes in Mental Hea~h Organizations in
1955 (1.7 Million Patient Care Episodes) and 2002 (9.5 Million
inmates, and are more likely to return Patient Care Episodes). Source: Foley et aI., 2006.
within three years of being released
(Council of State Governments, 2007). Since 1999, 19 individuals experiencing acute episodes
of serious mental illness have died as the result of altercations with law enforcement officers in
Miami-Dade County alone.
From 2001 to 2005 total involuntary examinations under the Baker Act increased 35.2%, while
total population increased 9.4% during this time period. The number of involuntary examinations
for children 4 through 17 increased 32.5% during this time period, in contrast to 7.8% population
growth for this group (Christie & McCranie, 2006). In 2005, the number of examinations under
the Baker Act initiated by law enforcement officers exceeded the total number of arrests for
robbery, burglary, and motor vehicle theft combined. 7 Moreover, during this same year, judges
and law enforcement officers accounted for slightly more than half of all involuntary
examinations initiated. Also in 2005, there were at least 82,759 people with Baker Act
involuntary examinations initiated. Twenty percent of these individuals had more than one
involuntary exam initiated during the year (Christie & McCranie, 2006).
The sad irony is that we did not deinstitutionalize mental health care. We allowed for the transinstitutionalization of people with mental illnesses from state psychiatric facilities to our
correctional institutions, and in the process, made our jails and prisons the asylums of the new
millennium. In many cases, the conditions that exist in these correctional settings are far worse
than those that existed in state hospitals. In 200 years, we have come full circle, and today our
jails are once again psychiatric warehouses. To be fair, it’s not honest to call them psychiatric
institutions because we do not provide treatment very well in these settings.

7

Based on data published by the Louis de la Parte Florida Mental Health Institute retrieved November 2, 2007 from:
http://bakeract.fmhi.usf.edu/Document/BA_Annual_Report_2005.pdf and the Florida Department of Law
Enforcement 2005 Annual Crime in Florida Report. Retrieved November 2, 2007from:
http://www.fdle.state.fl.us/FSAC/UCR/2005/ CIFAcomp_annual05.pdf

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Part 1: The Crisis of Community Mental Health Care in Florida and the United States: 1800-2007

What is clear from this history is that the current short-comings of the community mental health
and criminal justice systems did not arise recently, nor did they arise as the result of any one
stakeholder’s actions or inactions. None of us created these problems alone and none of us will
be able to solve these problems alone. As a society, we all must be a part of the solution.
Borrowing from the Substance Abuse and Mental Health Services Administration’s (SAMHSA)
Federal Action Agenda, 8 the strategies for planning, leadership, financing, and service
development contained in this report are guided by the following five principles:

8

•

Focus on the desired outcomes of mental health care to attain each individual’s maximum
level of employment, self-care, interpersonal relationships, and community participation.

•

Focus on community-level models of care that effectively coordinate the multiple health
and human service providers and public and private payers involved in mental health
treatment and delivery of services.

•

Focus on those policies that maximize the utility of existing resources by increasing costeffectiveness and reducing unnecessary and burdensome regulatory barriers.

•

Consider how mental health research findings can be used most effectively to influence
the delivery of services.

•

Follow the principles of federalism, and ensure that (The New Freedom Commission on
Mental Health’s) recommendations promote innovation, flexibility, and accountability at
all levels of government and respect the constitutional role of the states and Indian tribes.

Accessed at: http://www.samhsa.gov/Federalactionagenda/NFC_TOC.aspx

33

Part 2: Organizing Framework for CJ/MH/SA Initiatives

Part 2: Organizing Framework for Criminal Justice/Mental Health/Substance
Abuse Initiatives: The Policy, Financing, and Administrative Content
Background:
In recent years, there has been an alarming increase in the number of adults with serious mental
illnesses (SMI) and children with severe emotional disturbances (SED) involved in the criminal
and juvenile justice systems because of behaviors related to untreated mental illnesses or, on
occasion, because it is the only means of accessing mental health services or basic life needs.
The justice system was never intended to serve as the safety net for the public mental health
system and is ill-equipped to do so; however, this is exactly the role that Florida’s jails, detention
centers, and prisons have been forced to assume as increasing numbers of individuals are unable
to access critically needed care in the community. Failing to adequately respond to the needs of
people with SMI/SED in the community has resulted in a myriad of avoidable, unnecessary, and
costly consequences for individuals, communities, and the State of Florida as a whole. These
include:
•

Substantial and disproportionate cost shifts from considerably less expensive, front end
services in the public mental health system to much more expensive, back-end services in
the juvenile justice, criminal justice, and forensic mental health systems

•

Compromised public safety

•

Increased arrest, incarceration, and criminalization of people with mental illnesses

•

Increased police shootings of people with mental illnesses

•

Increased police injuries

•

Increased rates of chronic homelessness

The fact that a comprehensive network of community mental health services was never
established following deinstitutionalization has resulted in a fragmented continuum of care that
has failed to adequately integrate services, providers, or systems; leaving enormous gaps in
treatment and disparities in access to care. Lack of strategic funding and programming, and
adherence to treatment guidelines that don’t necessarily reflect current best practices have
impacted certain segments of the population in particularly devastating ways. For many
individuals unable to access care in the community, the only options to receive treatment is by
accessing care through the most costly and inefficient points of entry into the healthcare delivery
system including emergency rooms, acute crisis services, and ultimately the juvenile and
criminal justice systems.
On any given day in Florida, there are approximately 16,000 prison inmates, 15,000 local jail
detainees, and 40,000 individuals under correctional supervision in the community who
experience SMI. Annually, as many as 125,000 people with mental illnesses requiring immediate
treatment are arrested and booked into Florida jails. The vast majority of these individuals are
charged with minor misdemeanor and low level felony offenses that are a direct result of their
psychiatric illnesses.

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

People with SMI who come in contact with the criminal justice system are typically poor,
uninsured, homeless, members of minority groups, and experience co-occurring substance use
disorders. Approximately 25 percent of the homeless population in Florida has a SMI and over
50 percent of these individuals have spent time in a jail or prison.
A 2006 report by the National Association of State Mental Health Program Directors
(NASMHPD) Research Institute reported that the State of Florida ranked 12th in the nation in
spending for forensic mental health services. Today, this estimate is likely to be considerably
higher as this ranking did not take into account the state’s investment earlier this year of more
than $16 million in emergency funding allocated by the Legislative Budget Commission and the
addition of $48 million in annual funding to add 300 desperately needed treatment beds to the
overflowing forensic system. Individuals ordered into forensic commitment are now the fastest
growing segment of the publicly funded mental health marketplace in Florida. Between 1999
and 2007, forensic commitments increased by 72 percent, including an unprecedented 16 percent
increase between 2005 and 2006.
The following figures, taken from testimony provided before the Legislative Budget Commission
prior to the approval of emergency funding for additional forensic beds, demonstrate just how
economically inefficient it is to invest in costly back-end services. The same $48 million
invested in the community would be enough to:
•

Fund mental health care for more than 260,000 children or 60,000 adults at current
spending rates

•

Fund substance abuse services for 238,000 children or 372,000 adults annually

•

Pay for psychotherapeutic medications for nearly 15,000 individuals for a year

•

Fund 37 new FACT teams, more than doubling the state’s capacity to provide 24-hour
community supports for individuals with SMI living in the community

•

Provide annual housing subsidies for nearly 15,000 individuals/families (at $300 per
month)

To put this in a more acute perspective, the State of Florida currently spends roughly a quarter of
a billion dollars annually to treat roughly 1,700 individuals under forensic commitment; most of
whom are receiving services to restore competency so that they can stand trial on criminal
charges and, in many cases, be sentenced to serve time in state prison. Furthermore, the
treatment provided in Florida’s forensic hospitals is funded entirely by state general revenue
dollars, as Federal law prohibits Medicaid from providing payment for psychiatric services
rendered in such institutional settings. As a result, the state is investing enormous sums of
taxpayer dollars into costly, back-end services that may render a person competent to stand trial,
but will do nothing to provide the kind of treatment needed to facilitate eventual community reentry and reintegration.
While expenditures in the area of forensic mental health services place Florida near the top of the
list nationally, the level of expenditures on front-end community-based services intended to
promote recovery, resiliency, and adaptive life in the community place the state near dead last.
According to the NASMHPD Research Institute, the State of Florida ranks 48th nationally in

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

overall per capita public mental health spending. Difficult to navigate and inefficient points of
entry have resulted in barriers to accessing preventative and routine care. Last year alone, more
than half of all adults with serious mental illnesses and about a third of all children with severe
emotional disturbances in need of treatment in the Florida’s public mental health system had no
access to care. Furthermore, despite recent research which has lead to the identification and
development of increasingly effective, evidence-based interventions for serious mental illnesses,
such treatments have yet to be adequately implemented by many service providers in the public
mental health system. Consequently, increasing numbers of people experiencing acute episodes
of mental illness are becoming involved in the justice systems.
Overview of Recommendations:
Although a shortage of funding for community-based mental health services and supports is not
solely responsible for the significant increase in the number of people with mental illnesses
becoming involved in the juvenile and criminal justice systems and the escalating numbers of
referrals to the state’s forensic mental health system, it is clearly a prevailing cause in Florida
and across the country. It would be short-sighted to suggest that concerted and sustained efforts
from local or regional stakeholders toward solving these problems could be achieved without
explicitly responding to financial resource needs.
Given the level of fragmentation, inefficiency, and wastefulness in the current system, it is
recommended that that the state focus on investment in a redesigned and transformed system of
care geared toward ensuring access to qualified and competent prevention and treatment services
in the community and prevention of the unnecessary and costly criminalization of people with
mental illnesses. Under the redesigned system of care, which will serve both adults with SMI
and children with SED, who meet additional eligibility criteria, there will be 1) programs to
prevent individuals from inappropriately entering the justice and forensic mental health systems,
2) mechanisms to quickly identify individuals with mental illnesses who do become
inappropriately involved in the justice system, and 3) programs to stabilize these individuals and
link them to recovery-oriented services in the community that are responsive to their unique
needs.
To achieve its purposes, this plan will require innovative financing strategies that will provide
more equitable, risk-adjusted compensation for providers who deliver high quality services to
individuals at highest risk for institutional involvement. Establishment of targeted, integrated
specialty care networks serving the highest utilizers of deep-end services, accompanied by
changes to Florida’s Medicaid state plan, will be required to provide incentives for qualified
providers to prevent individuals from inappropriately entering the justice systems, and to quickly
respond to individuals who do become involved in the justice systems through assertive in-reach
into the justice setting and diversion, as appropriate, to community-based stabilization and
recovery services. These new financing and service delivery strategies will be designed around
principles of managed care to control costs and guide implementation.
In an effort to identify individuals at highest risk for juvenile and criminal justice and other
institutional involvement, and to achieve service delivery that is effective, efficient, and least
wasteful, the state is encouraged to adopt a multi-tiered level of care classification system.

36

Part 2: Organizing Framework for CJ/MH/SA Initiatives

Under this system, service delivery will be targeted toward the ongoing needs of the individual
and their relative risk of requiring institutional levels of care.
Under the proposed classification system individuals with the highest levels of need, those with
SMI/SED and histories of institutional involvement coming out of criminal justice and state
hospital settings, will receive access to intensive levels of care, including services specifically
designed to facilitate community re-entry following periods of institutional involvement.
Individuals at the next level of need, those who are not currently institutionally involved,
however are at significant risk of becoming involved in the criminal justice system or other
institutional setting as a result of SMI/SED, will receive services at the same intensity as those
provided to individuals coming out of institutional settings, without the added benefit to address
community re-entry needs. At the lowest level of need will be individuals accessing routine care
in the community and not at substantial risk of involvement in the justice system or other
institutional levels of care. In this proposal, individuals at the two highest levels of need will be
targeted for services under the new Medicaid program. Those at the lowest level of need, who
also make up the largest number of individuals accessing care through the public mental health
system, will continue to access services under current Medicaid and DCF programs. Under this
proposal, processes will be created to facilitate movement across levels of care, thereby ensuring
adequate services in times of acute need when individuals are at risk of penetrating into
institutional levels of care. This process maximizes limited state resources during periods of
relatively stable recovery.
Florida’s mental health system requires a great deal of work related to both financing and the
improvement of the quality and effectiveness of care. For both financial and logistic reasons this
work cannot be done quickly. Improvements in treatment capacity and the application of
evidence-based practices must be approached from a systematic and practical perspective.
Therefore, it is recommended that the program be incrementally implemented in three phases
over a six year period. During initial implementation, the number of individuals covered under
the Integrated Specialty Care Network (ISCN) will be purposefully limited to a very small
number of individuals (roughly 900-1,000 participants) who are among the highest utilizers of
the most expensive state-funded institutional services, in three strategically targeted areas around
the state. This will serve to control costs, produce meaningful and significant reduction in
admissions to state forensic facilities early on, and allow time to develop a controlled and
strategic plan for expansion. Over time, the program will grow to cover about 25,000 individuals
annually.
To allow the necessary flexibility to maximize resources and serve individuals covered under
public entitlement benefits (i.e., Medicaid) as well as those not currently covered, it is
recommended that a funding and management partnership between DCF and AHCA be
established. In this way, both Medicaid and general revenue funding can be blended to achieve
optimal efficiency in the system. A Statewide Leadership Group, composed of representatives
from the key departments of state government and other community stakeholders from across the
state will also be in place to help drive these efforts, and to provide additional oversight and
fiscal review.
A primary short-term goal will be to eliminate, as soon as possible, the 300 beds DCF has

37

Part 2: Organizing Framework for CJ/MH/SA Initiatives

recently contracted for forensic competency restoration services, thereby freeing up the $48
million to be reinvested both in less expensive, front-end community programs that reduce
forensic hospital commitments and into the Reinvestment Grant Program to continue to build an
integrated statewide community system of care to serve individuals with chronic mental illnesses
and/or substance use disorders who are currently recycling through the justice and acute care
mental health systems. By reinvesting service dollars in this way, the state will achieve the
added benefit of being able to leverage additional federal resources through Medicaid and
Medicare. By contrast, current investment in back-end services in prisons, jails, forensic and
civil mental health facilities, and juvenile justice facilities is 100 percent dependent on state
general revenue dollars to operate services.
Successful implementation of this plan and transformation of the existing public mental health
system will require dedication and commitment from many stakeholders. To the extent that the
state works to make these changes and strategically reinvests resources from costly and
inefficient back-end services into the community, the resources to fund the full implementation
of this proposal will be realized largely within current state funding levels, thereby minimizing
the need to invest large amounts of additional revenues. It is critical, however, that savings
achieved from reductions in forensic services be reinvested into the community-based care and
not returned to general revenue.
While there is, and always will be, a need to invest in acute care services, there is an equally if
not more compelling need to invest in prevention and treatment at the front end so that the
demand for more inefficient services will be reduced. It makes no sense to continue investing in
costly back-end services in the justice systems and forensic mental health system, at the expense
of sacrificing resources that could be better used to support community-based prevention and
treatment services that are likely to promote recovery and reduce the likelihood of forensic
involvement.
The sections that follow describe in more detail the short- and long-term processes recommended
to move the mental health system in Florida toward improved delivery of services and supports
that will prevent inappropriate penetration of people with mental illness into the juvenile and
criminal justice systems, and promote recovery, resiliency, and adaptive life in the community.
Target Population and Level of Care Classification:
The target population served under the proposed program will include individuals with SMI/SED
involved in or at risk of becoming involved in the justice system or other institutional settings as
a direct result of severe behavioral or psychiatric disorders. Within each network, enrollees will
consist of individuals re-entering the community from jail, prisons, juvenile justice, and state
psychiatric hospital settings, as well as individuals in the community who are at significant risk
of becoming involved in juvenile or criminal justice or other institutional settings as a result of
mental illnesses.
Under the current system of health care delivery, the level and intensity of care available to
individuals who experience chronic mental illnesses and co-occurring substance use disorders is
inadequate to meet the complex clinical and social needs encountered by this population. In

38

Part 2: Organizing Framework for CJ/MH/SA Initiatives

order to more competently and efficiently address the needs of individuals who experience
psychiatric and behavioral disorders, particularly those with SMI/SED, it is recommended that
the State of Florida implement strategies that are more effectively tailored to the needs of
specific populations at increased risk of institutional involvement in the justice systems and/or
state mental health system. Unfortunately, the vastly disparate and intermittent needs of
individuals accessing care through the community mental health system means that it is virtually
impossible to design a single, universal benefit that will balance the need to provide effective
levels of care, while minimizing the delivery of unnecessary and often costly services.
For this reason, it is suggested that the State of Florida may benefit from the adoption of a
service delivery system that takes into account severity, chronicity, and disability in determining
appropriate levels of care. To some extent, the state has already initiated such strategies with the
implementation of specialized community-based services such as FACT Teams. Access to such
services remains limited, however, leaving many individuals who experience persistent
psychiatric disabilities with few options for receiving needed levels of care. The following is a
recommendation for a multi-tiered classification system for targeting appropriate levels of care
within the community mental health system:
Tier I:

Individuals without SMI/SED accessing routine, episodic, or crisis care, as well as
individuals with SMI/SED, currently stabilized and not at risk of CJ
involvement/institutional placement as a result of mental illness.

Tier II:

Individuals with SMI/SED at risk of CJ involvement/institutional placement as a
result of mental illness.

Tier III:

Individuals with SMI/SED with current CJ involvement/institutional placement as
a result of mental illness.

Effective implementation of such a system of classification is contingent upon:
•

Early and comprehensive assessment of acuity, chronicity, risk, addiction, specialized
needs, available supports, and consumer/family preference.

•

Development of an individually-tailored plan of care incorporating evidence-based
practices and specialized services targeting the unique experiences of people with
histories of criminal justice system involvement.

•

Timely access to problem-focused, goal-oriented treatment.

•

Ongoing review and assessment to ensure that the services provided are appropriate and
consistent with the identified level of care.

•

Ongoing utilization review which targets service delivery and resource allocation
among individuals with the most acute care needs, while minimizing unnecessary and
costly administrative oversight of services among individuals accessing more routine
levels of care.

For individuals accessing care at Tier I, which is the vast majority of mental health consumers,
the goal of service delivery should be to foster ongoing recovery and to ensure access to supports
and resources that will prevent further impairment or disability. Provided reasonable and
efficient access to services, most of these individuals will function adaptively in the community
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Part 2: Organizing Framework for CJ/MH/SA Initiatives

with modest supports, although they may encounter periods of acute crisis requiring more
intensive intervention. In addition, while some individuals at this level of care may experience
or have histories of involvement in the justice system, this should not be related to their current
mental or behavioral health needs. Most individuals accessing care at Tier I are anticipated to
experience relatively stable recovery and routine care, however, some may require a more acute
level of care from time to time.
Individuals accessing care at Tier II will be experiencing ongoing moderate to severe functional
impairment in the community as a result of mental illnesses. While these impairments will not
have resulted in current institutional involvement, they will place the individual at substantial
risk for becoming involved in the justice system or accessing care, either voluntarily or
involuntarily, in other institutional settings. The goal of services provided at this level will be to
achieve psychiatric stabilization and to prevent penetration into more acute levels of care. Such
services will require expanded interventions to engage individuals who otherwise may be
resistant or apprehensive about accepting treatment. Some individuals may require this level of
care on an ongoing basis, whereas others may transition through this level of care during periods
of acute illness exacerbation and recovery. In general, it is anticipated that most individuals
accessing this level of care will do so for a period of several months, but possibly as long as a
year or more.
Individuals coming out of institutional settings such as jails, prisons, juvenile justice facilities,
and state psychiatric hospitals who are at increased risk of recidivism in the absence of
immediate access to comprehensive community-based services, will receive services at the Tier
III level of care. Similar to individuals receiving services at the Tier II level of care, individuals
at Tier III will require access to expanded interventions that will promote adaptive community
living and progress in recovery. In addition, because of the unique needs of individuals reentering the community following periods of institutional confinement marked by severe
psychiatric or behavioral disturbances, individuals receiving services at the Tier III level of care
may require additional enhanced interventions to facilitate adaptive readjustment to life in the
community. Such services may entail enhanced in-reach to the individual prior to release or
discharge to the community, as well as additional assistance provided to ensure timely and
successful access to critical services and supports upon community re-entry. Most individuals
receiving services at the Tier III level of care will require such assistance only temporarily
during the first few months following community re-entry.
Because enrollment in ISCNs will be limited, it will be necessary to develop additional eligibility
criteria targeting the population to be served. It is recommended that enhanced eligibility criteria
be tailored to community needs, developed in coordination with local planning councils, and
incorporated into local plans. Examples of possible enhanced screening criteria may include:

40

•

Homelessness/unstable housing

•

Co-occurring disorders

•

Specified number of prior admissions to juvenile or criminal justice or other institutional
settings within specified period of time

•

History of repeated use of crisis/emergency services

Part 2: Organizing Framework for CJ/MH/SA Initiatives

•

History of medication/treatment noncompliance

•

History of dangerousness to self or others

•

Poor insight/cognitive impairment

•

Poor social/self-care skills

Individuals accessing care under the proposed ISCNs correspond with those classified to be
eligible for services at the Tier II & III levels of care. Individuals at the Tier I level of care will
continue to access care as administered under the standard benefits and programs administered
by Medicaid and DCF.
Implementation Strategy:
The redesign and transformation of Florida’s mental health system and Medicaid program will
not occur overnight. Both will be phased-in over time, and will require deliberate and systematic
implementation on a community by community basis. In order to control costs and to ensure
effective administration, initial implementation will be phased-in over a period of time, and
initial enrollment will be capped and limited to areas of the state that are likely to produce the
most benefit from enhanced community-based care. In addition, initial implementation will be
limited to areas of the state that have demonstrated community readiness to undertake such
system transformation. As such, it is recommended that the establishment of ISCNs be
implemented in three phases that will move systematically toward statewide administration.
In order to initially target individuals and communities that are the highest contributors to
institutional service utilization, Phase 1 implementation should target communities that: 1) send
the largest numbers of individuals to state forensic hospitals and 2) demonstrate the willingness,
commitment, and ability to implement the necessary changes (e.g., develop effective diversion
programs and adopt best practices to prevent individuals from entering the justice and forensic
mental health systems) to successfully undertake this effort. In addition, enrollment in the
network should be capped and limited to individuals with SMI/SED coming out of jails, prisons,
juvenile justice facilities, and state mental health facilities only (i.e., Tier III level of care).
Because these individuals tend to be the highest utilizers of acute care services and at highest risk
for recidivism and subsequent institutional involvement, providing more effective services at the
time of community re-entry is anticipated to produce the most immediate and measurable impact
on the system.
Over time, as savings are realized, resources currently allocated to the forensic mental health
system should be reinvested into more cost-effective community-based programs serving
individuals accessing routine care (i.e., Tier I), and enrollment in the ISCNs will be expanded to
serve individuals in the community who are not currently institutionally involved, however are at
significant risk of institutional placement in the justice system or state mental health system in
the absence of access to more comprehensive care services (i.e., Tier II level of care).
Producing early impact will depend not only on the identification of fertile ground for
improvement, but also on the local interest and political will of the judicial, criminal justice,
juvenile justice, governmental, provider, advocacy, and consumer stakeholders. For this reason

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

areas that have submitted qualified applications for funding to improve the CJ/MH system under
the HB 1477 grant program should be given priority consideration for Phase 1 implementation.
These areas will have already demonstrated some initiative and will have an infrastructure in
place that will facilitate local plans and legislative budget request (LBR) development.
Implementation in Phase 1 will take two years to complete. The experience garnered during this
period of time will facilitate subsequent efforts in additional areas. For this reason Phases 2 and
3 will include four areas each so that at the end of Phase 3 all AHCA area mental health systems
will have been affected. Early in the second year of Phase 1, four additional areas will be
selected for Phase 2 using processes similar to those described in the initial phase. Efforts will
begin in the final four AHCA areas during the second year of Phase 2.
It should be noted that although the current proposal recommends implementation areas
corresponding to AHCA service areas, consideration should be given to whether this is the most
efficient targeting for implementation or whether some other geographic breakdown (e.g., DCF
Districts) may be preferable.
Local plan and legislative budget request development:
When the areas are selected for Phase 1 implementation, two-year local plans and budgets will
be developed. The planning process must be community-based and directed by local planning
councils as defined in HB 1477 and involving the courts, law enforcement agencies, State
Attorney’s Office, Public Defender’s Office, correctional agencies, local government,
community mental health and substance abuse treatment providers, social services providers,
advocates, consumers, and family members. DCF district staff will play a vital role in identifying
the appropriate players and driving the process. The Criminal Justice Mental Health Technical
Assistance Center (TA Center) at FMHI will provide support for the plan and budget
development work.
The plans should include the following:

42

•

A description of locally established planning mechanisms and processes that will drive
and oversee change in the CJ/MH system.

•

Proposed changes in the deployment of existing resources to improve the effectiveness
and efficiency of the system.

•

Proposed expansions in service capacity and/or type that incorporate, among other things,
the use of evidence-based and promising practices.

•

Involvement of local government, the judiciary, and law enforcement agencies in support
of implementation of enhanced service delivery.

•

An articulation of local consensus concerning priorities and reasonable schedules for
implementation.

•

Plan for reducing admissions to state forensic facilities.

Part 2: Organizing Framework for CJ/MH/SA Initiatives

LBR’s should be developed based on the plans and reflect the costs of phasing in the new and
improved services and the annualization costs the following year. DCF and AHCA as well as the
TA Center will help the local areas identify appropriate state revenue sources (e.g. Medicaid,
general revenue etc.) for funding the different plan activities.
Plans and budgets for Phases 2 and 3 will be developed using the same processes described for
Phase 1. A Statewide Leadership Group, composed of representatives from the key departments
of state government as well as other community stakeholders from across the state, will be in
place to help drive these efforts. Phase 1 areas will be allowed two fiscal years to fully
implement their plans. The planning process for Phase 2 will begin during the second year of
Phase 1 implementation and for Phase 3 in the second year of Phase 2. A summary of the
schedule for plan and budget develop is presented in Table 2 below:
Table 2. Schedule of Plan and Implementation Dates
Phase:
1
2
3

Plan/LBR Development:
Fall 2007
Fall 2009
Fall 2011

Implementation:
FY 08-09 and 09-10
FY 10-11 and 11-12
FY 12-13 and 13-14

The redesign and enhancement process will take six years to complete.
Development of Statewide Leadership Group:
Because the criminal justice, mental health, and substance abuse initiatives being recommended
will operate across jurisdictions, it is recommended that the Legislature authorize an
independent, Statewide Leadership Group to direct and manage the implementation process over
the six-year phase in period. To ensure a high level of cross-systems involvement and
collaboration, it is recommended that the Statewide Leadership Group be co-chaired by the
Secretaries of DCF and AHCA, and be comprised of the executive leadership of key departments
of state government, quasi-state government, and community stakeholders including:
•

Secretary of Department of Children and Families (DCF)

•

Secretary of Agency for Health Care Administration (AHCA)

•

Secretary of Department of Corrections (DOC)

•

Secretary of Department of Juvenile Justice (DJJ)

•

Secretary of Department of Elder Affairs (DOEA)

•

Secretary of Department of Health (DOH)

•

Secretary of Department of Education (DOE)

•

Chief Justice of the Supreme Court of Florida/State Courts Administrator

•

Commissioner of Florida Department of Law Enforcement (FDLE)

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

•

Board Chair of the Florida Substance Abuse and Mental Health Corporation (SAMH
Corp)

•

Dean of the Louis de la Parte Florida Mental Health Institute (FMHI)

•

Executive Director of the Florida Association of Counties (FAC)

•

Executive Director of the Florida Sheriff’s Association (FSA)

•

Executive Director of the Florida Public Defender Association (FPDA)

•

Executive Director of the Florida Prosecuting Attorneys Association (FPAA)

•

Executive Director of the Florida Council for Community Mental Health (FCCMH)

•

Executive Director of the Florida Alcohol and Drug Abuse Association (FADAA)

•

Executive Director of the Florida Housing Finance Corporation (FHFC)

•

Executive leadership from statewide advocacy associations (e.g., FPIC, NAMI, MHA)

•

Consumers and family representatives

The specific functions of the Statewide Leadership Group include at a minimum the following:

44

•

Communicating and advocating for the needs of projects with statewide, regional, and
federal government authorities (e.g., recommended changes in process, rules, other
regulatory requirements, resource utilization).

•

Acting as the convener of criminal justice/mental health project leadership for the
purpose of identifying problems, developing collaborative solutions when possible,
sharing performance success and strategies that contributed to them.

•

Developing best practice guideline for criminal justice/mental health project operations
including system organization, communication channels, program operations that reflect
current best practices.

•

Developing standards based on the best practice guidelines.

•

Developing policies and procedures designed to assure projects meet standards in areas
where consistency across projects is important.

•

Promulgating rules based on the policies and procedures.

•

Developing a collaborative monitoring model that reviews programs against standards,
policies and procedures and best practice guidelines using teams composed of the best
qualified staff (and other state experts) that are external to the program being monitored.

•

Implement the collaborative monitoring model and address corrective actions.

•

Developing performance standards for programs and negotiating them with state level
constituencies.

•

Developing minimum common data reporting requirements that provide regular
information on program operations and performance and summarize reports for external
consumption.

Part 2: Organizing Framework for CJ/MH/SA Initiatives

•

Providing technical assistance to projects by using internal staff as well as individual
experts working in the projects and other university or field based experts.

•

Representing the projects with the different departments and branches of government that
have a stake in project performance.

•

Disseminating on an ongoing basis best practice information and change technology and
communicating it to the projects and interested constituencies.

•

Vetting best practices through the leadership group to identify practice change warranting
statewide implementation. Disseminating on an ongoing basis best practice information
and change technology and communicating it to the projects and interested
constituencies.

•

Providing accountability for the investments made in CJ/MH programs and services.

•

Providing ongoing program and system evaluation targeting quality assurance and
performance improvement.

Staff from DCF and AHCA will work together to provide support to the Statewide Leadership
Group and with local communities. In addition, the functions of the Leadership Group will
incorporate many of the responsibilities of the Criminal Justice Technical Assistance Center (TA
Center) housed at FMHI, as well as the Criminal Justice, Mental Health, and Substance Abuse
Policy Council created within the SAMH Corporation under HB 1477. To facilitate
implementation, it is recommended that for the phase-in periods the operational functions of the
Statewide Leadership Group be contractually assigned to FMHI and the SAMH Corporation so
that technical assistance, standard setting, network certification, monitoring functions, grant
administration, and logistic coordination are located under the respective, existing organizational
umbrellas. This is consistent with the unique statutory purposes of FMHI and the SAMH
Corporation as defined by the Legislature:
The purpose of the institute is to strengthen mental health services throughout the state by providing
technical assistance and support services to mental health agencies and mental health professionals.
Ch. 1004.44(1), F.S.
The Florida Substance Abuse and Mental Health Corporation shall direct efforts designed to improve
interagency coordination of substance abuse and mental health services in order to ensure that these
services promote recovery and resiliency-based systems of care. The corporation shall provide
oversight of the publicly funded substance abuse and mental health systems and make policy and
resource recommendations that will promote system transformation by providing mechanisms for
input from stakeholders, including primary consumers, family members, providers, and advocates,
concerning the management of the overall system, and that will improve the coordination, quality,
and efficiency of the system. Ch. 394.655(3)(a), F.S.

FMHI and the SAMH Corporation’s will coordinate with local state agency representatives,
provider networks, and local constituencies to facilitate the development and implementation of
local plans. In addition, these entities will develop proposed budgets to cover the costs
associated with the functions of the Statewide Leadership Group that exceed the SAMH
Corporation’s functions associated with HB 1477 and the TA Center functions already funded by

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

the 2007 Legislature. The proposed contracting scheme as well as the funding and management
of the systems described in the next section are summarized in Figure 7.
Financing and Contracting Strategies for Enhanced Community-Based Services:
The provision of services under the current proposal will require providers to implement highquality, evidence-based practices that are more targeted, frequent, and intensive than those
typically provided in the current system. Such evidence-based practices (e.g., assertive
community treatment, cognitive behavioral therapy, integrated dual diagnosis treatment,
supported employment) are often inherently more expensive than traditional service offerings;
and even when they are not, initial and ongoing training and monitoring to assure program
fidelity requires additional financing considerations. Because the mental health system lacks
sufficient capacity and resources within current funding levels to meet the demand for mental
health and substance abuse services in the community, it is unrealistic to suggest that the system
will be able to adequately meet the demand for additional services provided to those diverted
from the justice system without the development of sound and reasoned financial investment
strategies.
Because of a persistent lack of access to health care services across the board, many individuals
targeted under this proposal are likely to present with multiple, co-morbid physical and
psychiatric conditions. Furthermore, because symptoms and illnesses tend to co-vary across
multiple diagnoses, poor functioning in one area tends to undermine wellness and recovery in
another. As such, establishment of a comprehensive and responsive continuum of care serving
individuals with SMI/SED involved in or at risk of becoming involved in the justice system
requires careful consideration of the unique needs of the target population. These needs range
from prevention and routine care services addressing primary and behavioral health to more
complex needs including acute psychiatric crisis services, chronic physical illness (nonpsychiatric), and catastrophic illness or injury. It is critical that a comprehensive continuum of
care be established to support long-term wellness and recovery. To this end, it is recommended
that the state create Integrated Specialty Care Networks (ISCNs) which blend funding from
existing and newly-created programs to most efficiently serve both the physical and behavioral
health care needs of the target population.
The primary sources of funding for initial service expansion and improvement will come from
two appropriation categories, Medicaid and DCF general revenue SAMH funding. To offset
state liability for these costs, every effort will be made to maximize enrollment in federally
supported entitlement benefits such as Medicaid and SSI/SSDI. Use of promising practices for
accessing these benefits, such as Stepping Stones to Recovery and the SSI/SSDI Outcome
Access and Recovery (SOAR) model developed by the National GAINS Center with support
from the federal Substance Abuse and Mental Health Services Administration (SAMHSA), will
play a key role in achieving this goal. Such practices have been demonstrated to increase initial
approval rates for applications from 37 percent to 60-95 percent. For individuals coming out of
prisons and other long-term institutional settings, additional pre-release/discharge planning to
secure entitlement benefits and necessary supports will be initiated in accordance with practices

46

Governor’s
Office
1) Executive order creating
Leadership Group
2) Executive oversight

Legislature
1) Create Leadership Group
and process in statute
2) Funding appropriations

$ (DCF SAMH GR + MCD)

DCF

AHCA

Statewide
Leadership Group
FMHI TA Center
1) Establishment of:
- Best practices
- Standards setting
- Training protocols
- Data
collection/collaboration
protocols
2) TA for local planning
groups
3) TA support for certification
of local CJ competent SAMH
providers

1) Co-chaired by Secretaries of
DCF & AHCA
2) Comprised of Sec’y/Comm of:
- DC
- DJJ
- DOH
- DOEA - DOE - FDLE
3) Additional members:
- Chief Justice/OSCA
- Dean of FMHI
- Board Chair of SAMH Corp
- Exec Dir of statewide orgs
- Cons/family representatives
- Additional stakeholders
4) Develops strategic plan and
reports to Gov/Legislature
5) Full certification of local CJ
competent SAMH providers
6) Oversight of contracting
w/local managing entities

SAMH Corporation
1) Logistic support for
Leadership Group &
DCF/AHCA integrated staff
2) Administrative support for
certification of local CJ
competent SAMH
providers
3) Expanded Reinvestment
Grant management

DCF grant funds to
develop local
infrastructure.

Local CJ/MH/SA
Planning Groups
Managing Entities for
Local CJ/MH/SA Networks
Local Certified CJ/MH/SA
Competent Provider Networks
Figure 7. Proposed funding, management, and contracting plan

DCF & AHCA
blended/braided
funds for services.

Part 2: Organizing Framework for CJ/MH/SA Initiatives

outlined in Building Bridges: An Act to Reduce Recidivism by Improving Access to Benefits for
Individuals with Psychiatric Disabilities upon Release from Incarceration, published by the
Bazelon Center for Mental Health Law (2002). In addition, specific enhancements in screening,
assessment, and case-management services will be employed.
Medicaid:
A key component of the strategy to create a comprehensive continuum of care will be to expand
access to cost-effective community-based services. Since 1981, federal Medicaid has allowed
states to apply for optional Home and Community-Based Services (HCBS) waivers under section
1915(c) of the Social Security Act to cover a broad range of long-term community-based
services for individuals who would otherwise require institutional levels of care. Under this
program, the usual requirement to provide services that are comparable in amount, scope, and
duration to all individuals in particular eligibility categories is removed enabling targeted
populations to be served. Similarly, the HCBS waiver program does not have to be offered
statewide and enrollment can be limited. As such, the HCBS waivers allow states to target
specific populations of individuals, in specific geographic areas, to receive HCBS services.
While this program has been useful in establishing community-based services for many
individuals who would otherwise require institutional levels of care, its applicability to
individuals with mental illnesses has been relatively limited. In order to be approved for the
HBCS waiver, states are required to meet a federal budget neutrality test which demonstrates that
average costs for individuals accessing community-based services under the waiver do not
exceed the average costs of institutional care. While there is little doubt that community-based
mental health services are far more cost effective than institutional psychiatric care,
demonstrating this in accordance with the federal definition of budget neutrality is often difficult,
if not impossible. Because of the federal Institutions for Mental Diseases (IMD) rule which
prohibits Medicaid reimbursement for care provided in Institutions for Mental Diseases,
historically defined as inpatient facilities with more than 16 beds, there are no large federal
expenditures on institutional settings (e.g., state/local psychiatric hospitals) to transfer to the
community.
However, as of January 1, 2007, states have had the option to amend their Medicaid State Plan to
cover many HCBS without the need for a waiver. Under the HCBS State Plan Amendment
(SPA) option for HCBS, states do not have to demonstrate budget neutrality, however the ability
to limit enrollment geographically, to cap enrollment, and to target specific populations remains
in effect. Eligibility criteria are more flexible beyond the “otherwise need for institutional care”
standard and states have the ability to establish waiting lists.
To be eligible for services under the HCBS SPA option, income cannot exceed 150% of federal
poverty level (FPL), which is more restrictive than the waiver program, however states can
design plans to cover some children in families with income above 150% of the FPL. States are
encouraged to support self-directed care under the SPA option. Compared to the waiver
program, which allows states to request approval of services beyond those provided in the basic

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

waiver, the SPA option authorizes a more limited services package. There are eight different
services that can be covered as part of a HCBS SPA option:
•

Case management

•

Homemaker services

•

Home health aide services

•

Personal care services

•

Adult day health services

•

Habilitation services

•

Respite care

•

Day treatment and other partial hospitalization services, psychosocial rehabilitation
services, and clinic services for individuals with chronic mental illnesses

For the most part, these services are considered to be sufficient to provide for the communitybased needs of individuals with mental illnesses. Furthermore, it may be possible for states to
include a broader array of services under “psychosocial rehabilitation” than has been permitted
under more traditional state plan options.
To date, Iowa is the only state that has submitted and been approved to add HCBS to the services
covered under their state plan, although many states are considering similar amendments to their
Medicaid programs. The nature of the services covered under the HCBS SPA option, along with
the mechanisms in place to manage implementation and subsequent service delivery, make it a
favorable option for Florida in the effort to move toward improved delivery of services and
supports that will prevent inappropriate penetration into the justice system and institutional levels
of care.
Additional changes to the existing Medicaid contract and payment systems to create and
implement comprehensive services under the proposed ISCNs are as follows:
•

Individuals residing in the areas targeted for Phase 1 implementation, who are involved in
or at risk of becoming involved in the justice system, must be identified and the numbers
forecasted into the future. Estimating the “at risk” population will be difficult and there
will be a danger of drift of individuals into this category in the out years.

•

If enrolled in managed care, these individuals and their associated capitation, including
that associated with psychiatric inpatient care, will be removed from the HMO’s or prepaid behavioral health plans and, depending on what areas are chosen for Phase 1, from
plans operating in Medicaid reform areas.

•

Recovery oriented services procedure codes and payment rates will have to be established
for implementation of ISCNs in Phase 1 areas. These services will reflect evidence-based
criminal justice mental health practices, including enhancements in specialized casemanagement services and provisions for in-reach into the juvenile and criminal justice
setting and diversion services. Payment rates should be established based on those used
for similar services in other states and/or reasonable costs. Reasonable and equitable

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

payment rates will help assure service offerings are driven by consumer need rather than
financial expediency. Specific codes that need to be added or enhanced include:
o Intensive criminal justice case management: this would include the ability for the
service provider to perform linkage, assessment, monitoring, advocacy, planning
for counseling, arrangement of competency restoration if necessary, and liaison
with court personnel and attorneys.
o Criminal justice advanced therapy: this code could be retained as at present with
the addition of competency restoration as an eligible service under the provisions
of this code.
o Criminal justice specialized transportation: additional code for transportation of
individuals from jail/court to appointments or the residential facility.
Additional Medicaid Considerations and Recommendations:

9

•

During Phase 1 of the ISCN roll-out, the question of how to best finance services to
ensure successful implementation will arise. Under the state’s current Medicaid reform
initiative, this would entail establishing risk-adjusted capitation rates to reflect the
increased demand and intensity in service delivery at enhanced levels of care. Depending
on the availability of accurate and reliable historical data on which to base actuarial
estimates, there is a risk of setting the capitation rate too high or too low to achieve
optimal client and systems outcomes. As an alternative, it is recommended that the state
consider funding services under a fee-for-service structure for the first few years of
implementation, or longer if deemed appropriate, to establish capitation rates that are
more reliable. Should the state opt to base capitation rates on an initial period of fee-forservice reimbursement, it is not recommended that this period be less than two years as
this may be more reflective of factors associated with initial implementation as opposed
to more stable patterns of service delivery.

•

It is recommended that state develop policies and procedures to suspend, rather than
terminate, Medicaid benefits upon incarceration. Although no benefit coverage would be
provided during the period of incarceration, suspension would allow continued tracking,
facilitate continuity of care, and permit prompt reinstatement of benefits. 9

•

There is little doubt that an enhanced benefit and improved payment rates will increase
total Medicaid mental health expenditures for the targeted individuals in the Phase 1
areas, and therefore state general revenue commitments. The additional general revenue
cannot come from existing DCF mental health funding since these resources will be
needed to pay for services required by Medicaid enrolled individuals that are not paid for
by Medicaid (e.g., residential support) and for non-Medicaid enrolled individuals.
However, if the state needs to invest in improvements in community-based services to
reduce juvenile and criminal justice and forensic facility involvement of individuals with
serious mental illness, optimizing the use of Medicaid will reduce general revenue
requirements. For this reason, the state should also consider in its discussions with the

It should be noted that Medicaid coverage for many adults with mental illnesses is contingent on active receipt of
Social Security benefits. As such, it is equally important that efforts be undertaken to ensure that Social Security
benefits be suspended rather terminated upon incarceration.

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

federal Centers for Medicare and Medicaid Services (CMS), the strategy of increasing
income eligibility for targeted individuals to 100% or 150% of the federal poverty level.
•

It is recommended that Medicaid immediately implement a focused study to determine
the extent to which current behavioral health contractual requirements for Health
Maintenance Organizations and Prepaid Mental Health Plans for services to people in the
justice system are being implemented. These requirements include linkages to prebooking sites, access to psychiatric services within 24 hours of release from a jail, and
outreach to enrollees who are homeless or at risk of criminal justice system involvement.

Department of Children and Families:
The contracting and funding mechanisms used for DCF mental health funding would remain
intact during the first two years of implementation in each of the areas. The number and
distribution of services among the cost centers will reflect the local plans with flexibility
provided to shift resources so that consumer service plans can be appropriately funded. However,
the nature of the entities with which DCF contracts will change. Contracts will be developed
between DCF and integrated service provider networks in each of the areas. This mechanism will
facilitate coordinated management and service provision.
Integration of Medicaid and DCF Mental Health and Substance Abuse Programs: 10
To allow the necessary flexibility to maximize resources and serve individuals covered under
public entitlement benefits (i.e., Medicaid) as well as those not currently covered, it is
recommended that a funding and management partnership between DCF and AHCA be
established. In this way, both Medicaid and general revenue funding can be blended to achieve
optimal efficiency in the system.
Under this recommendation, Medicaid purchasing and policy-setting responsibilities for
Medicaid adult beneficiaries with SMI and children with SED, including populations involved
with or at risk of involvement in the criminal or juvenile justice systems, would be co-managed
by the DCF and AHCA. This would provide for the evolution of a well-integrated system of
care for those with serious mental illness and involved in multiple systems of care.
The rationale for this recommendation reflects that while DCF is statutorily responsible for
serving as the state’s public mental health authority, Medicaid has become the principal payer for
publicly-financed care. To ensure an effective blending of funding sources, provide cost
effective care, and prevent cost shifts, it is essential that the state use a single purchaser and
policy-setting authority for those with serious mental illness and high users of multiple systems
of care and to ensure an alignment of Medicaid reform and mental health transformation
strategies. This recommendation is consistent with Ch. 409.912 (4)(b)(2), F.S. relating to costeffective purchasing of health care services which mandated that:
By July 1, 2003, the agency and the Department of Children and Family Services shall
execute a written agreement that requires collaboration and joint development of all policy,
10

Please see Appendix A for additional details relating to this proposal.

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

budgets, procurement documents, contracts, and monitoring plans that have an impact on the
state and Medicaid community mental health and targeted case management programs.
It is recommended that this agreement be reviewed and amended as necessary.
Integrated Specialty Care Networks:
Each AHCA area will develop an Integrated Specialty Care Network (ISCN) having the capacity
to provide comprehensive services and supports needed by the target population, including
primary medical and acute care services. These services will be developed or revised so that
they reflect consumer needs and service plans and the evidence-based practices for criminal
justice/mental health consumers. Provider’s offerings will be organized and coordinated so that
service capacity is fully utilized and redundancy is minimized. Local communication and
information systems will assure consumer care is coordinated when more than one provider is
involved.
In order to participate in ISCN(s), providers must demonstrate that they are capable of providing
high quality services that employ evidence-based practices in a way in that is efficient, effective,
and accountable. Providers will be required to demonstrate established relationships with local
juvenile and criminal justice systems and stakeholders in the community to facilitate a seamless
continuum of care across systems. Providers will also be required to offer a comprehensive array
of services and supports including interventions that focus on co-occurring disorders, trauma,
and histories of justice system and institutional involvement, as well as assistance in accessing
housing, employment, entitlement benefits, transportation and other necessary services.
Provider contracts under ISCNs will also incorporate measurable outcomes and include
specifications for enhanced integration and responsiveness of services delivery, including: 11
•

For individuals re-entering the community from jails, prisons, or state hospitals:
o Provider to make contact with consumer well in advance of release/discharge to
the community and to be actively involved in discharge and transition planning
processes. Ideally, initial contact should be made as early as possible within 90
days of release/discharge.
o Provider to arrange face-to-face visit with consumer within 24-72 hours of
release/discharge to the community. At a minimum, this contact should entail
review of the individuals discharge plan with particular attention paid to current
living arrangements, community supports, and access to medications.
o Provider to complete face-to-face, comprehensive intake evaluation within 7 days
of release/discharge to the community.

•

11

For individuals living in the community who experience acute exacerbation of symptoms
requiring admission to inpatient crisis services:

Provider will obtain necessary consent and release of information forms where appropriate.

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

o Provider to make contact with staff (and consumer if possible) at crisis unit within
24 hours of notification of admission to discuss current medications, treatment
history, current symptoms, and discharge planning needs.
o Provider to maintain daily contact with staff at inpatient facility throughout the
duration of consumer’s inpatient stay.
o To the extent practical, provider perform face to face visit with consumer at
inpatient facility within 72 hours of notification of admission and at least
semiweekly thereafter throughout the duration of consumer’s inpatient stay. In
the event that consumer is admitted to a facility outside of the provider’s
immediate geographic area, contact will be made by telephone.
o As appropriate, provider to contact consumer’s primary family/social support to
engage in discharge planning.
o As appropriate, provider to participate in case staffing at the inpatient facility.
o Provider to be actively involved in discharge and transition planning processes.
o Provider to arrange face-to-face visit with consumer within 24-72 hours of
discharge to the community. At a minimum, this contact should entail review of
the individuals discharge plan with particular attention paid to current living
arrangements, community supports, and access to medications.
o Provider to complete face-to-face, evaluation within 7 days of release/discharge to
the community.
o Provider to complete audit of consumer’s compliance/engagement in treatment
and functioning in the community prior to hospitalization. Based on results of
audit, work with treatment/support-services providers, consumer, and family to
identify triggers and early warning signs related to acute-care episode, and revise
crisis treatment plan as necessary.
The Statewide Leadership Group with the participation of DCF and AHCA will review provider
networks and service offerings of individual providers to ensure the use of evidence-based
practices. These reviews will be done prior to the systems becoming live and annually
thereafter. The Statewide Leadership Group will certify local communities, the networks and
their individual providers indicating they are criminal justice/mental health competent. Providers
will not be eligible to bill for services under the revised Medicaid HCBS fee-for-service system
or for enhanced DCF funded services until they achieve this certification.
Each provider network will be managed by an existing or newly-created area administrative
services organization (ASO). The ASO’s primary functions will include the following:
•

Service management (utilization management-making sure that people get the right
service in the right amount at the right time) and coordination between MH/CJ systems;

•

Service improvement (quality improvement) and development of best and promising
practices.

•

Contracting and contract management.

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

•

Administrative services (data collection and outcome measurement).

The ASO will contract DCF mental health funds to network providers for the delivery of services
to non-Medicaid enrolled consumers and for services not paid for by Medicaid for Medicaid
enrolled clients. In addition network providers will report Medicaid billings to the ASO so that
there is a complete accounting of service delivery for each consumer in the target population.
The ASO will facilitate the coordination and integration of services and produce utilization,
performance, quality and other reports for the Leadership group.
The Leadership Group will establish standards and monitor the ASO’s and their provider
networks by virtue of its relationship with the SAMH Corporation. Standards will include
governance (including role of primary consumers of services), financial management, service
access and coordination, information reporting and performance standard requirements.
Conversion to Capitation Contracts and Organizational Considerations:
Assuming the state opts to fund services under a fee-for-service mechanism initially with later
conversion to capitation contracts: Funds will flow through fee-for-service mechanisms to each
area as described above for at least two full fiscal years of operation. During this time new and
improved DCF funded services will have been fully implemented and costs annualized.
Medicaid revenue will have increased as a result of the enhanced fee-for-service benefits and
cost-based payment rates. Although system improvements will require increased funding in the
early years it is assumed that the Legislature will want to stabilize its liability in the out years.
Therefore, beginning in year three in each area, combined DCF and Medicaid risk-based
capitation or case rate contracts will be implemented. Subsequent changes in funding in these
areas will only reflect changes in the number of individuals served and/or approved adjustments
for inflation. A schedule of the incremental change in contracting process is presented in Table 3,
which should be viewed in tandem with the implementation schedule described in Table 1
Table 3. Schedule of Conversion to Risk Base Contracts
Phase
1
2
3

Conversion to Risk-Based Contracts
July 1, 2010
July 1, 2012
July 1, 2014

The phase-in approach to service development and enhancement obviously makes areas ready
for capitation contracts at different points in time. When these points arrive in each area there
will have been an integrated provider network in place providing and managing care in the feefor-service environment for two full years. Assuming performance has been adequate, this would
logically lead to the development of capitation agreements with these organizations as they enter
their third year of operations. In the long term, this would create 11 separate publicly funded
(through AHCA and DCF) entities managing the care of adults involved in or at risk of
becoming involved in the justice system. Although it could be argued that is not the most
efficient organizational outcome, it is consistent with Florida’s long history emphasizing local

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control and management of health and human services. A summary of the short- and long-term
contracting process are described in Figure 8.

Contracting During Phase-In

DCF

AHCA

Provider
Network
1

Provider
Network
2

Provider
Network
3

Individual
Provider

Individual
Provider

Individual
Provider

Fee For
Service

Contracting After Completed Phase-In

DCF/AHCA
Joint Risk
Base Contract

TA
Center

11 Provider Networks

Figure 8. Contracting during and after phase-in process

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Part 2: Organizing Framework for CJ/MH/SA Initiatives

Phase out of the Leadership Group:
Leadership and management functions are added to the responsibilities of the SAMH
Corporation and the TA Center at FMHI to facilitate the phase in process of area programs and
services previously described. As DCF and the AHCA finalize capitation contracts with area
networks these functions will gradually diminish leaving the Criminal Justice/Mental Health
Technical Assistance Center and the SAMH Corporation Policy Council to operate as described
in HB 1477 by July 2014.
Reinvestment and Financial Incentives:
Some of the services and supports initially funded by DCF and Medicaid may, over the longterm, be supportable by other federal, state or local sources (e.g. HUD for housing) reducing the
need for state resources for routine program operations. In addition, as efficiency of service
provision improves over time, the ASO’s may begin to produce operating surpluses. These
surpluses should be maintained by the ASO’s to assure organizational and financial stability.
Funds in excess of the amounts required for these purposes should be reinvested in prevention
and/or early intervention programs that improve the lives of all Floridians.
Data Recommendations:
The strategies that we propose require collaboration between many local agencies, between
localities and the state, and between state agencies. Implementing and assessing the impact of
these collaborative strategies requires the availability of good data. Data are essential for at least
three reasons:
•

First, data must be shared between agencies to assure adequate care to individuals who
often cross agency lines.

•

Second, data must be collected to enable localities to target populations for interventions
funded by these initiatives.

•

Third, local and state data must be available to analyze the impact of these initiatives.

Given the central role of data, we recommend the following:
1. Data templates should be developed to guide localities in collecting uniform data relevant
to clinical care, planning, and program evaluation.
2. Model data-sharing agreements should be developed to enable localities to share data
across systems and to assure that mistaken notions about confidentiality laws do not
create barriers to appropriate data sharing.
3. Appropriate funding should be available to assure that local and state data can be
integrated and analyzed to determine the effectiveness of local interventions.
4. The current role of the Florida Mental Health Institute makes it the appropriate entity to
be charged with overall responsibility for carrying out these recommendations.

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Part 3: A Guide for Local Planning and the Development of Comprehensive
and Competent Criminal Justice/Mental Health/Substance Abuse Systems
Background:
By making comprehensive, individualized mental health and substance abuse services available,
appropriate, and readily accessible, the likelihood of individuals with SMI/SED becoming
involved with the justice system will be substantially reduced. Untreated mental illnesses
contribute to poor self-care, disorganized behaviors, and occasionally to violence and public
safety concerns. Untreated mental illnesses are also associated with a significant increase in the
risk of homelessness and high rates of substance abuse. All these factors lead to an increased
likelihood of engagement with law enforcement and the initiation of involvement with the justice
system. The current fragmented and under-resourced community mental health system in Florida
is unable to provide even reasonably adequate mental health services to many citizens. As such,
programs designed to divert individuals with SMI/SED from the justice system into communitybased care will be of little consequence if adequate and appropriate services are not available.
For this reason, during each of the phase-in period of the proposed initiative, plans for service
retooling and expansion must be developed. Although these plans must be the product of local
community needs, they must also be guided by a common vision of the types of services and
supports that are demonstrated to be effective and efficient. The process for creating service
plans must include providers, law enforcement, local government, the judiciary, consumers, and
family members. The Criminal Justice Mental Health and Substance Abuse Technical Assistance
Center at the Florida Mental Health Institute (FMHI) will provide the data analysis, consultation,
and hands-on assistance needed for the development of these plans.
While the needs of each community will be different, potentially producing significantly
different priorities and objectives, the efforts of each community must be guided by a common
vision and current knowledge regarding evidence-based and promising practices. The purpose of
this section is to suggest the outlines of this vision and to describe some of the principles and
practices that should be considered in the area planning and budgeting process.
Guiding Vision:
It has been four years since the publication of Achieving the Promise, the report from the
President’s New Freedom Commission on Mental Health recommending the transformation of
the nation’s public mental health system. It is the most important mental health policy document
of the last 25 years and has been the catalyst for systems improvement activities throughout the
country. The Commission assessed the current mental health system as “fragmented and in
disarray leading to unnecessary and costly disability, homelessness, school failures and
incarceration” and recommended fundamentally transforming service delivery based on a vision
of recovery (New Freedom Commission on Mental health, 2003). The Commission’s Report and
the documents of its subcommittees provide valuable guidance for translating the vision of
recovery into policies and practices.

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Part 3: A Guide for Local Planning and the Development of Comprehensive and Competent MH/SA Systems

Moving from more traditional and limiting views of mental illness to the recovery vision
described by the New Freedom Commission requires clear articulation of the vision and
supportive policies and practices (New Freedom Commission on Mental Health, 2003; TAPA
Center for Jail Diversion, 2003). The Council of State Governments’ Criminal Justice/Mental
Health Consensus Project Report (2002) provides useful guidance. It is designed to help local,
state, and federal policymakers and criminal justice and mental health professionals improve the
response to people with mental illnesses that come into contact with the criminal justice system.
The Consensus Project Report was written by Justice Center staff and representatives of leading
criminal justice and mental health organizations and emphasizes that a comprehensive and
efficient mental health system will result in fewer individuals inappropriately and avoidably
coming into contact with the justice system.
Statement on Co-Occurring Mental Health and Substance Use Disorders:
Development of a comprehensive and competent system of care serving individuals with
SMI/SED, particularly those involved in the criminal or juvenile justice systems, requires that
equally prominent attention be given to the integrated treatment of co-occurring substance use
disorders. Among individuals with SMI in the community, the prevalence of such co-occurring
disorders (COD) is between 25 and 50 percent (Regier, Farmer, Rae, Locke, Keith, Judd, &
Goodwin, 1990). Among individuals in the justice system, the prevalence of COD increases to
roughly 72 percent among adults with SMI (Abram & Teplin, 1991) and 60 percent among youth
with SED (Skowyra & Cocozza, 2007).
In traditional service systems, individuals with COD are often referred to parallel, but
disconnected, sources of care. This results in increased barriers to accessing both mental health
and substance abuse treatment services. In some cases, symptoms of mental illness may be
discounted or regarded as secondary to the effects of substance use disorders. In other cases,
individuals may be deemed too psychiatrically impaired to participate in traditional substance
abuse treatment or too disruptive to the treatment setting. The burden of navigating such
fragmented and discontinuous systems, which are frequently based on differing philosophies
regarding treatment and recovery, is often counterproductive and results in poorer rates of follow
through and lack of compliance with needed services. Consequently, many individuals with cooccurring disorders are labeled as treatment resistant when in reality it is the disconnectedness of
the systems of care that are resistant to unique needs of the client (Steadman, 2007). This
observation becomes even more significant in the context of people with histories of justice
system involvement, as these individuals often experience additional difficulties in accessing and
engaging services.
A comprehensive and competent system of care requires that treatment be provided across an
integrated, coordinated, and client-centered continuum of care. As such, it is imperative that
communities implement service planning and delivery strategies that are informed about and
responsive to the unique clinical and social needs of individuals who experience COD,
particularly for those involved in or at risk of becoming involved in the justice system.

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Part 3: A Guide for Local Planning and the Development of Comprehensive and Competent MH/SA Systems

Listed in Table 4 below are nine system characteristics identified in the Consensus Project
Report that should be incorporated into the development of local plans and LBR’s.
Table 4.
Characteristic:
Use of EvidencedBased Practices

Description:
Promote the use of evidencedbased practices and promising
approaches in mental health
treatment, services,
administration and funding.

Florida Examples:
• ACT Model of case
management

Integration of
Services

Initiate and maintain partnerships
between mental health and other
relevant systems to promote
access to the full range of
services and supports, to ensure
continuity of care, and to reduce
duplication of services.

•

Transformation Working
Group led by the SAMH
Corporation includes a broad
range of state agencies and
focuses on issues specific to
the mental health system

Co-Occurring
Disorders Treatment

Promote system and services
integration for co-occurring
mental health and substance use
disorders.

•

Comprehensive, Continuous,
Integrated System of Care
(CCISC) model activities in
District 11, 14, and the
Suncoast Region

Housing Initiatives

Develop and enhance housing
resources that are linked to
appropriate levels of mental
health supports and services.

•

Florida Supportive Housing
Resource Map to Services
(including strategic plan)

•

Florida’s Supportive Housing
Coalition

Consumer and
Family Member
Involvement

Involve consumers and families
in mental health planning and
service delivery.

•

Florida NAMI

•

Florida Peer Network

Cultural Competency

Ensure that racial, cultural, and
ethnic minorities receive mental
health services that are
appropriate for their needs.

Workforce Initiatives

Determine the adequacy of the
current mental health workforce
to meet the needs of system’s
consumers.

•

Florida Council for
Community Mental Health and
the Substance Abuse Mental
Health Corporation has
conducted meetings on this
critical issue

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Part 3: A Guide for Local Planning and the Development of Comprehensive and Competent MH/SA Systems

Characteristic:
System
Accountability

Description:
Establish and utilize performance
measures to promote
accountability among systems
administrators, funders, and
providers.

Florida Examples:
• DCF Dashboard
•

Recovery Oriented Systems
Indictors (ROSI)

Advocacy

Build awareness of the need for
high quality comprehensive
services and of the impact of
stigma and discriminatory
policies on access to them.

•

Florida Partners in Crisis

•

Florida NAMI

•

Florida’s chapter of Mental
Health America

Acute care – The pivotal system issue:
Florida’s law enforcement officers and courts are increasingly knowledgeable of and sensitive to
issues surrounding mental illnesses and are likewise increasingly inclined to divert people with
mental illnesses from the justice system to the mental health system. However, the capacity of
facility-based mental health resources to accept people in crisis for appropriate treatment in lieu
of incarceration is steadily diminishing. What’s more, the capacity of Florida’s mental health
system to provide less restrictive and less costly non facility-based crisis services to people who
do not strictly meet the legal criteria of danger to self or others because of mental illness is
grossly inadequate.
Increase in Baker Act Involuntary Examinations:
When a mental health professional or law enforcement officer believes a person may be an
imminent danger to self or others because of mental illness the person may be taken to a
receiving facility (designated community hospital or crisis stabilization unit) for an emergency
examination and subsequent treatment if authorized.

60

•

There were at least 82,759 people with Baker Act involuntary examinations initiated in
2005.

•

Twenty percent of these people had more than one involuntary exam initiated in 2005
(range 2 to 32).

•

Between 2001 and 2005, the increase in involuntary examinations substantially exceeded
population growth. Total involuntary examinations increased 35.2% while total
population increased 9.4%. The number of involuntary examinations for children 4
through 17 increased 32.5% during this time period in contrast to 7.8% population
growth for this group (Christy & McCranie, 2006).

Part 3: A Guide for Local Planning and the Development of Comprehensive and Competent MH/SA Systems

Reduced Capacity of Facility-Based Care:
The number of licensed hospital psychiatric beds in Florida has decreased from 6,467 in 1994 to
4,014 in 2006. This is a drop from 45.8 beds per 100,000 total population in 1994 to 21.8 beds
per total 100,000 population in 2006. Managed care, greater private insurance limitations on
mental health benefits, reductions in Medicare payments for psychiatry, and higher profitability
for other services, such as cardiac care, are driving the reduction in community hospital
psychiatric bed capacity. With one in four of Floridians without any form of insurance coverage,
these hospitals carry a substantial load of uncompensated care, including care for psychiatric
services. As the number of facilities and beds decline, there are increasingly fewer potential
resources for people in crisis as well as fewer portals available to law enforcement officers and
people seeking care.
Crisis stabilization units (CSU) and Short Term Residential Treatment (SRT) units are acute care
facilities operated by non-profit community mental health centers contracted to the Department
of Children and Families. Florida pioneered the crisis stabilization model in the 1970’s as a
public cost containment and least restrictive treatment model. They are licensed under Chapter
394, F.S. and operate for about $282 per bed per day. DCF funded crisis stabilization and shortterm residential treatment facility bed capacity increased from 1,102 in 1999 to 1,314 in 2006,
just 62 more beds than needed to keep pace with population growth alone. Crisis stabilization
units routinely run at or near capacity.
State Psychiatric Hospital bed capacity available for civil patients has decreased from 1,926 in
1997 to 921 in 2007, placing greater pressure on community-based facilities.
Florida Must Ensure that Maximum Value is Received for Facility-Based Acute Purchased
by the State:
Increased use of managed care by Medicaid and commercial insurers has steadily reduced stays
in these facilities to a point that many observers believe there is a minimal amount of time to
achieve therapeutic gains necessary to release individuals back to the community. Although
inpatient care is provided in licensed and accredited hospitals as well as in crisis stabilization
units that are licensed and operated by accredited mental health organizations, there is no
assurance that these entities use clinical pathways that maximize therapeutic gains in the time
that is available. Since these services represent the most expensive unit of care purchased by the
state, it is important to ensure that as much value is received as possible.
Inflation is Outpacing the Department’s Buying Power:
The Department of Children and Families primarily purchases acute care from crisis stabilization
units and short-term residential treatment facilities. The Department’s payments for this service
largely come from the Adult Baker Act funding category, which in fiscal year 2007-08 was $62
million, up from $49 million in 2000-01. Services at crisis units must be provided to anyone
who presents regardless of their ability to pay. Crisis units are required to attempt to collect fees
and third-party payments. Medicare does not pay for crisis stabilization unit services.

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Part 3: A Guide for Local Planning and the Development of Comprehensive and Competent MH/SA Systems

$49M in Adult Baker Act funds in 2000 inflated forward for medical increases of
approximately 4% is $63M in 2006. At the same time Florida’s population increased by
13% during this same period. Given the increase in CSU bed capacity over this period, it
is clear that funding for other community mental health services, such as case
management, are being redirected to shore up crisis stabilization capacity.
In 2004, the Medicaid fee-for-service program purchased 105,366 inpatient psychiatric days in
general hospitals at an average daily rate of $1,390 per day plus physician charges. The number
and dollar value of days purchased by Medicaid HMOs and Prepaid Mental Health plans was in
addition to this amount.
In many Florida communities, the acute care system is a patchwork of unrelated and often
competing hospitals and crisis stabilization units. From the consumer and family’s standpoint it
can be a bewildering and hostile environment. Florida’s Baker Act requires an officer who
observes a person who appears to meet the legal criteria for an emergency evaluation (danger to
self or others) to take the person to the nearest hospital or crisis unit authorized to accept people
involuntarily.
This means law enforcement may take someone to a facility without vacancies, resulting in
“wave offs” for officers, waits in emergency rooms and trauma for consumers. It may mean an
individual ends up in a facility that doesn’t have a contract with his payer or is not the facility
preferred by the consumer.
What’s more, a fragmented system does not ensure that an individual who does not strictly meet
Baker Act criteria and is determined to not require inpatient level of care has immediate access to
other available less intensive levels of crisis care appropriate to his needs. In such instances,
individuals may be released to the street or placed on a long wait list for outpatient intervention
when urgent but not emergency care is needed. A precipitous release back to the streets with no
immediate and concrete assistance in stabilizing the situation can result in frustration by officers
with a revolving door situation and inappropriate admissions to jails. It can result in an
exacerbation of an individual’s condition so that he soon does meet Baker Act criteria.
THE SOLUTIONS: BUILDING ON WHAT WE KNOW WORKS
Centralized Acute Care Referral Systems:
The centralized acute care system was originally developed in Hillsborough County Florida and
now operates in several other communities including Orange and Pinellas Counties. In
Hillsborough, leadership from the Department of Children and Families brought together a
public/private partnership composed of county behavioral health systems, mental health and
substance abuse providers, insurers, law enforcement, courts, state attorneys and public
defenders, public and private hospitals, and Medicaid. These stakeholders through a series of
scheduled meetings, data sharing and mutual agreements established an organized system of
acute care in which the crisis stabilization unit operated by Mental Health Care, a Tampa based
community mental health center, served as the central receiving facility where people are

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brought for emergency evaluation. Under a centralized arrangement there is increased capacity
for:
•

Law enforcement officers to know where to take someone for evaluation.

•

Efficient and prompt mental health evaluations without the wait time for officers
frequently associated with busy emergency rooms.

•

Linkages to a variety of programs and community resources that can lessen need for
costly facility-based care. These linkages would be difficult to replicate at every hospital
and receiving facility in the community but can be effectively coordinated centrally.

•

Assistance for consumers in accessing the hospital or crisis unit that accepts payment
from their insurance carrier and which has immediate vacancies.

•

Provision of explicit medical clearance standards that are agreed to by all participating
entities. This prevents the need for unnecessary transfers among facilities due to medical
conditions.

•

Facilitation of equitable and transparent distribution of consumers with third-party
coverage among local facilities as well as equitable distributions of consumers without
coverage when crisis stabilization units are at full capacity.

•

Provision of a focus for Pre and Post booking treatment services with jails, public
defenders, and State Attorneys

•

Creation of synergies between programs working in concert to achieve positive outcomes
for consumers.

Similarly, in Orange County, the Central Receiving Center (CRC) was established as the single
point of entry by law enforcement officers for those experiencing mental health and/or substance
abuse crises who require emergency evaluation. The CRC has achieved many of the same
outcomes as the Hillsborough model and has helped to improve the utilization of limited crisis
beds and increase service capacity. The CRC also has a formalized cross-systems governing
board for oversight and planning and an operational group among the providers that manages the
day to day functions.
In rural areas where there is a less complex delivery system a formal central receiving facility
may be impractical. However, there are alternatives that build on the strengths of the centralized
system concept. For example, in Pasco County the local CSU operates a Baker Act coordination
center that operates on a 24-hour/7 day per week basis. When a person is brought in under the
Baker Act law enforcement or hospital emergency rooms contact the center. The center keeps
track of facilities’ censuses, insurance payers, licensed/clinical capacities, and can direct the
officer to the appropriate facility, reducing unnecessary waiting and delays in care.

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Use of Defined Clinical Pathways to Optimize Value of Services Received in Facility-Based
Acute Care Settings Purchased by the State:
The Department and the Agency for Health Care Administration should work with Medicaid
plans and contracting facilities to establish clinical pathways that reflect efficient and effective
practice. The state should work in concert with these entities by establishing a practice
improvement initiative that will achieve this goal. Non-contracting facilities in Florida should be
invited to participate in the initiative. (For example see attached algorithm in Appendix B from
Glick and Tandon, The Acute Crisis Stabilization Unit for Adults, 2007).
Expanded acute care capacity:
There is not a credible needs formula that can determine the correct mix of acute/crisis care
mental health services needed in a given community. However, it is clear from the figures cited
above that a very large proportion of public acute care resources go into facility-based care and
that considerably more could be justified. However, because of the high cost of hospitals, crisis
stabilization units and short-term residential treatment facilities, the use of medical facility-based
crisis care should be considered a last resort. Likewise, from a clinical perspective, a wider
range of crisis services appropriate to individuals who do not immediately meet Baker Act
criteria could prevent exacerbation of crises that often involve law enforcement.
There are a number of less restrictive and less expensive programmatic alternatives to facilitybased acute care that have been used successfully in other states, countries and in some
communities in Florida. Wider access to these types of care is desirable for the following
reasons:
•

Research has shown that they can be more cost effective than facility-based care for
some people.

•

Access to less restrictive but appropriate crisis care results in less trauma to consumers
and therefore to more rapid stabilization.

•

Alternative models can more easily be employed in rural underserved areas or areas that
cannot support costly facility-based care.

•

Such models do not require the fixed capital outlay of facility-based services.

There is a very wide range of alternatives to facility-based care that could prove useful in a given
community. Within each of these alternatives there is wide variation in how programs with the
same label are staffed and operated. Table 5 identifies community-based treatment models
which have been shown to be effective and efficient and should be considered as communities
develop plans for improving their acute care systems.

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Table 5.
Intervention Model:
Mobile Crisis Teams

Description:
These are teams of medical and mental health professionals that can
effectively include peer counselors as team members. A team provides
rapid response, generally within several hours. A team may operate
24/7 or only during periods of peak demand. Teams can respond to
calls for assistance from law enforcement, emergency rooms, shelters or
individuals in crisis who need immediate assistance in their homes or at
other places in the community. Teams may provide a one-time response
with referral or more sustained services and supports over a period of
weeks. By providing an immediate assessment a more accurate picture
of a person’s situation may be obtained and in 30% to 50% of the time,
more intensive care can be averted.

Residential Crisis
Respite Services

Services are provided to people in crisis in a small, homelike setting
open 24/7 generally with 5 to 8 beds. Individuals who are not
considered to be a danger to themselves or others generally access these
services on a voluntary basis. The home provides housing, meals and
short-term acute treatment and support services intended to resolve an
immediate crisis and prevent hospitalizations or CSU admissions.
Residents leave the home during the day for treatment and socialization
and return in the evening. Stays are generally brief, 5 to 7 days, and
followed by more sustained ambulatory care. Staffing may consist of
one worker on day shift and two workers on the other two shifts.
Programs in Nassau and Clay counties, Florida, are currently testing the
model. Preliminary data from Nassau County indicates that this
program has significantly reduced CSU admissions and reduced the
necessity for law enforcement to transport people to Jacksonville. The
cost of the program is about two thirds that of a crisis stabilization unit
but could be reduced if the facility was not free standing.
Crisis services can also be provided to individuals in the homes of
families that are specially trained in crisis support services. District 8
Mental Health Program Office has been supporting this model of care
for a number of years and currently has 50 individuals in care, about 10
of whom are in forensic status. The individuals receive services through
mental health providers. The cost for the home setting is less than $50
per day.

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Intervention Model:
Family Emergency
Treatment Centers

Description:
These programs are urgent mental health care walk-in facilities that
serve people who are in crisis but do not appear to immediately meet
Baker Act criteria. They provide crisis intervention services that include
medication, counseling and access to supports as well as a bridge to
people awaiting treatment at local mental health facilities. For example,
In Pinellas County this program is operated by Personal Enrichment
Through Mental Health Services (PEMHS), which also operates the
local CSU. The program receives referrals from a forensic outreach
program serving some jail releases, a mobile crisis team and other
programs.

Living Room

A living room is a quiet and pleasant room that may be co located with
a CSU. It is a setting where people who present at a CSU for screening
and who are not actively violent or suicidal or experiencing acute
psychosis can get needed crisis intervention from professionals and
trained peer counselors as well as medications and medical
interventions. The living room service can deescalate crises and prevent
deeper penetration into the acute care system. Such a program is
currently operating in Pasco County and has been used in Arizona by
Value Options, which operates Medicaid Prepaid Mental Health plans in
Florida.

Psychiatric Advance
Directives

A psychiatric advance directive is a document that is developed by an
individual, with assistance from a mental health worker, if needed, that
permits the person to decide in advance how they would like to be
treated should a crisis occur. It may include preferences about
medications, restraint and seclusion, the locus of treatment, and who to
contact about care of their household. Research suggests that this
device can reduce involuntary admission into acute care and may be a
useful method for improving the course of treatment. It can also have
the effect of making the treatment process more friendly and responsive
for the consumer.

Telemedicine

Lack of timely access to physician/psychiatrist services is especially
problematic in providing acute/crisis care in underserved areas.
Telemedicine is currently billable under Medicaid in at least half the
states. Florida Medicaid should permit codes for medication
management and psychiatric evaluation by a physician to be provided
through telemedicine where justifiable due to staffing shortages.
Likewise, the Department should amend its cost center structure to
explicitly support telemedicine within the limits noted.

The variety of acute care options described above should be incorporated into the Home and
Community Based Services recommended for the target population should be compensated by
the DCF contracting and payment system.

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Evidence-Based Psychotherapeutic Medication Practices:
A range of psychotherapeutic medications (antipsychotics, antidepressants, mood stabilizers,
etc.) are currently available for the effective treatment of major psychiatric disorders. In
conjunction with psychotherapeutic and social support services, appropriate utilization of
psychotherapeutic medications can significantly enhance individual recovery from mental illness
and reduce the likelihood of justice system involvement or recidivism. Despite evidence-based
standards of medication use, however, there is wide variation in patterns of psychotherapeutic
medication use and frequent deviation from recommended best practice. The Medicaid Drug
Therapy Management Program (MDTMP) currently funded by AHCA is designed to address
these issues. The program periodically reviews and updates evidence based guidelines for the
psychotherapeutic treatment of major mental illnesses. Pharmacy utilization indicators are
derived from these guidelines and applied to pharmacy claims and service events in order to
identify patients whose prescriptions appear to be inconsistent with evidence based medicine and
their associated physicians. A hierarchy of interventions to address discrepancies between actual
practices and best practices are applied to physicians whose prescriptions frequently deviate from
evidence-based guidelines. These interventions include a variety of educational activities,
mailings suggesting that prescription be re-evaluated, peer-to-peer telephone consultation,
academic detailing and medical records reviews.
The MDTMP will increase the scope and intensity of its activities in AHCA areas as the phase in
of CJ/MH programs proceeds. Analysis of physician prescribing behavior will be organized by
provider network and interventions will be mounted in collaboration with the administrative
service organizations in these areas. Every effort will be made to assure that individuals in the
target population are receiving the right medication in the right dose and at the appropriate time.
Deviations from evidence-based practices will be carefully scrutinized to assure they are in the
best interests of the consumer. In addition, the program will monitor adherence with medication
regimens and potential interactions between mental health and general medical medications and
ensure treating physicians are appropriately advised.
In the development of local plans and budgets two issues related to psychotherapeutic
medications are critical. First, the criminal justice and mental health organizations servicing the
areas must ensure continuity of medications as individuals move from one component of the
community to another. Developing a common formulary, using common medication treatment
guidelines and communicating information across jurisdictions can accomplish this (For example
from jail to community providers). The Leadership Group will assure that the institutional
system is involved in this development so there is continuity in medications from forensic
hospitals and the correctional systems to the community.
Second, Medicaid enrollees have reasonable access to a range of psychotherapeutic medications.
However, the DCF appropriation category funding medications for individuals in the target
population that are not Medicaid enrolled is woefully inadequate at $6.7M. Additional funding
will be required to assure access to the appropriate medications for these individuals. Local
planning and budgeting must address both of these issues, ensuring that medications do not have
to be prescribed or switched based on availability rather than need.

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Evidence-Based Supported Housing Practices:
People with disabilities, particularly individuals with mental illnesses, have high risk factors for
homelessness. The FY 2002 Annual Report on Homeless Coalitions in Florida identified that
25.5 percent of individuals who are homeless had a mental health disorder.
Supportive housing has been documented as a critical intervention for persons with mental
illnesses who are homeless or at risk of becoming homeless. Studies have demonstrated that
people with disabilities who moved to permanent housing experience marked reductions in
shelter use, hospitalizations, length of stay per hospitalization, and time incarcerated (Florida
Supportive Housing Coalition, 2004).
Most permanent supportive housing programs provide some type of case management and
housing support, but also a broad array of services that can best match the needs of the
individual, including mental health and substance abuse services, vocational/employment
services, and life skills training/support (e.g., budgeting). All of the services can be delivered
on-site and are designed with the goal of ensuring successful community functioning. These
services can play a vital role in diverting people from emergency rooms, crisis care settings,
long-term psychiatric care, nursing facilities, and the justice system.
In June 2003, the Department of Children and Families published Florida’s Strategic Plan for
Supportive Housing for Persons with Mental Illnesses. The plan was developed by a partnership
of key stakeholders from throughout the state. It provides descriptions of strategies and
implementation tasks in relationship to six key goals. However, to date, it has only been
partially implemented. The plan provides a useful guide for implementing supportive housing,
specific to the needs of mental health consumers in Florida and should be revisited by policy
makers. If fully implemented, it can serve as the cornerstone for implementing effective
supportive housing policies and practices.
In an effort to further develop housing resources for the target population, the Statewide
Leadership Group recommended under this CJ/MH initiative should work with the Florida
Housing Finance Corporation communicate the housing needs of individuals with SMI/SED and
explore options for creating: 1) a Rental Assistance Program and 2) an Economic Development
Housing Initiative that produces affordable housing for persons who are disabled or on SSI.
Case Management: The Glue Binding the Elements of Consumer Service Plans:
Individuals with SMI/SED often lack the wherewithal to access needed services and supports
even when they are available in their communities. As a result they often languish in isolation
only to emerge when symptoms and behaviors bring them to the attention of law enforcement.
Case management is the key to reducing this isolation and assuring appropriate access to
services. Key case management activities include planning, linking, monitoring, and advocacy.
In more intensive models, direct services are provided. A variety of case management models
are currently implemented throughout Florida, including brokered approaches that refer
consumers to needed services, intensive case management that provides a range of direct
services, and Assertive Community Treatment (ACT) that provides a comprehensive array of

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services to the person in the community on a 24 hour basis. Case managers in each of these
models provide an important interface between the mental health and justice system.
Rapp and Goscha (2004), in an important synthesis of case management research, identified ten
principles or active ingredients of case management that are common to interventions that
produced statistically positive outcomes for people with serious psychiatric disabilities. These
ingredients are based on a comprehensive review of the research that focused on common
denominators of case management interventions that produced statistically significant positive
outcomes. This report examined 21 key studies and focused only on research that implemented a
random assignment or a quasi-experimental research design. Brokered model studies were
excluded because only two of the nine studies found any positive findings.
It is highly likely that all individuals with a SMI will require case management services. Local
area plans must address this need focusing on the active ingredients described below. For
individuals already involved in the justice system there are specialized case management services
that are described in the last section of the report.
Active ingredients of effective case management include: 12
1. Case managers should deliver as much of the “help” or services as possible rather than
making referrals to multiple formal services. Direct-services provided as part of an ongoing relationship produce the most positive outcomes.
2. Natural community resources are primary partners. Case managers need to establish
networks with landlords, employers, ministers, neighbors, teachers, and peers on behalf
of the people they serve.
3. Work is in the community rather than an office setting. In-vivo service delivery “removes
problems of generalization, minimizes drop-out, enhances engagement and allows for
more complete and accurate assessments.”
4. Both individual and team case management works. While both approaches are successful,
there is general consensus that treatment planning should be conducted by a team and that
this type of planning is one of the most critical components of effective case
management. The benefits of a team approach include reduced staff burnout, enhanced
continuity of care, and more creative service planning.
Person Centered Planning is critical to ensuring that evidenced based practices are
appropriately and effectively implemented (Adams & Grieder, 2005).
5. Case managers have primary responsibility for a person’s services. Fragmented
responsibility is not consistent with the integrated goals and objectives of case
management.
6. Case managers can be paraprofessionals. Supervisors should be experienced and fully
credentialed. “The evidence is that case managers can be selected from a wide pool of
people but need high quality supervision from seasoned professionals and easy access to
medical personnel and other experts”
12

Adapted from Rapp & Goscha (2004).

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7. Caseload size should be small enough to allow for a relatively high frequency of contact.
Caseload size needs to be tailored to the needs of consumers and the outcomes or benefits
sought by the intervention. Frequency and quality of contact rather than hours of contact
are critical.
8. Case management services should be available on an ongoing basis, based on the needs
of the individual. Most research strongly suggests that immediate gains can be made with
short-term services; many of these gains can be lost without long-term support.
However, intensity of services over time should vary based on need.
9. People need access to familiar persons 24 hours a day, 7 days a week. Twenty-four hour
case management is not required, but such access to crisis and emergency services is a
necessity. The effectiveness of crisis services is enhanced by access to staff who have
familiarity with the consumer, such as the case manager.
10. Case manager should foster choice. There is growing body of research suggesting that
choice is associated with improved outcomes.
Case management services have generally been available to individuals with a severe mental
illness that are enrolled in the Medicaid program although caseloads and payment rates have
been inadequate. Continued access to adequate case management services under capitated
arrangements should be reviewed. However, a major gap in access to case management services
exists for individuals in the target population that have not yet established disability through the
Social Security Administration. These are often younger individuals that have not had a
sufficient history of disability. Local plans and LBR’s must address this gap in order to assure
continuity of care for these individuals.
Consumer and Family Education:
If the comprehensive and competent mental health system is recovery oriented and one of its
goals is to empower those with an SMI and their families, educational and self-help programs are
critical to its success. The Leadership Group will work with the NAMI and in-state peer
networks to develop and underwrite the costs of implementing the most effective of these
programs so that consumers and family members are able to fully participate in the recovery
process.
Assuring Long-Term Assistance to CJ/MH/SA Consumers:
Access to shelter, income and medical and ongoing mental health care can reduce the need for
emergency/crisis care. It has been suggested that as many as 25% of people eligible for
Medicaid in Florida are not enrolled. Most people with serious mental illnesses become eligible
for care by establishing through medical records that they have a serious and long-term disability
that prevents them from engaging in substantial gainful employment. The bureaucratic and
paper intensive process of establishing medical disability requires considerable persistence and
cognitive capacity which represent formidable barriers for many people with a mental illness.
Maximizing access to income and medical benefits leverages federal funds. To the extent that
someone who is eligible is unable to negotiate this process a person either does without or relies
on meager state resources. Florida should invest in a cadre of trained benefits specialists to help

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people with mental illness in jails and in acute care initially obtain benefits or get their benefits
reinstated promptly on release from a jail. Gap funding should be made available to help support
people with serious mental illness while applications are pending. Since income benefits can be
retroactive, bridge funds advanced by the state can often be recovered.
Workforce Development:
The development of a comprehensive and competent system of mental health care, built on a
foundation of effective evidence-based practices, is contingent on the availability and
maintenance of a highly qualified and skilled workforce. A recent report released by the
Annapolis Coalition on the Behavioral Health Workforce (2007), identifies workforce issues
including difficulties in recruiting and retaining staff, absence of clear career ladders for
employees, marginal wages and benefits, limited access to relevant and effective training, the
erosion of supervision, a vacuum with respect to future leaders, and financing systems that place
enormous burdens on the workforce to meet high levels of demand with scarcely limited
resources as raising serious concerns nationwide as to the ability of the public mental health
system to deliver quality care.
In their report, An Action Plan for Behavioral Health Workforce Development (Annapolis
Coalition, 2007), the Coalition suggests:
The majority of the workforce is uninformed about and unengaged in health promotion and
prevention activities. Too many in the workforce also lack familiarity with resilience- and
recovery-oriented practices and are generally reluctant to engage children, youth, and adults, and
their families, in collaborative relationships that involve shared decision-making about treatment
options. It takes well over a decade for proven interventions to make their way into practice, since
prevention and treatment services are driven more by tradition than by science. The workforce
lacks the racial diversity of the populations it serves and is far too often insensitive to the needs of
individuals, as these are affected by ethnicity, culture, and language. In large sections of rural
America, there simply is no mental health or addictions workforce.
There is overwhelming evidence that the behavioral health workforce is not equipped in skills or
in numbers to respond adequately to the changing needs of the American population. While the
incidence of co-occurring mental and addictive disorders among individuals has increased
dramatically, most of the workforce lacks the array of skills needed to assess and treat persons
with these co-occurring conditions. Training and education programs largely have ignored the
need to alter their curricula to address this problem and, thus, the nation continues to prepare new
members of the workforce who simply are under-prepared from the moment they complete their
training. (p. 1)

As such, the following recommendations are intended to address issues that will promote and
sustain a more effective and competent mental health workforce:
•

Promote workforce training programs and core curricula standards in the State University
System of Florida, the community college system, private colleges and private
universities, public schools, and the vocational education system to ensure that
individuals pursuing careers in the mental health, substance abuse, behavioral health
systems (particularly in the public health system), criminal justice, juvenile justice, and

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legal professions possess the knowledge and skills that are necessary to work effectively
in various traditional and nontraditional behavioral health settings. Particular emphasis
should be placed on the use of evidence-based and promising practices.

72

•

Promote continuing education, such that treatment teams and providers develop and
maintain core competencies and skills in current evidence-based practices to effectively
serve individuals involved in the CJ system, or at risk of involvement in the CJ system,
especially those with histories of trauma/abuse, incarceration, and co-occurring mental
health and substance use disorders.

•

Identify effective leadership curricula and programs, and develop new training resources
to address gaps in prevention and treatment for individuals involved in or at risk of
involvement in the justice system.

•

Develop workforce resources to serve racial and ethnic communities and individuals in a
culturally competent fashion.

•

Promote racial, ethnic, and cultural diversity among the workforce, and ensure adequate
numbers of well-trained bilingual and bicultural staff.

•

Address staffing shortages in rural communities.

•

Expand the role of individuals in recovery, and their families when appropriate, to
participate in, ultimately direct, or accept responsibility for their own care; provide care
and supports to others; and educate the workforce.

•

Develop certification for peer specialists.

•

Promote the involvement of individuals in recovery in judicial education, law
enforcement training (e.g., CIT), and continuing legal education (e.g., training provided
by FL Bar Association) around mental illness and substance use disorders.

•

Ensure licensure and certification standards for mental health, substance abuse treatment,
criminal justice, and juvenile justice professionals address relevant criminal
justice/mental health/substance abuse issues.

•

Ensure non-licensed, frontline workers receive training adequate training in criminal
justice/mental health/substance abuse issues.

•

Increase the competency of the behavioral health workforce to build community capacity
and collaborate with communities in strengthening the behavioral health system of care.

•

Promote the increased availability and use of information technology to support the
workforce training and service delivery.

•

Ensure that fair, living wage jobs are available for both providers and consumers.

•

Provide living wages and benefits to employees, as many mental health and substance
abuse treatment professionals are not well compensated, resulting in high turnover,
difficulty in recruiting, and sometimes quality and safety problems.

Part 4: A Guide for Developing Comprehensive and Competent Criminal
Justice/Mental Health/Substance Abuse Systems
Background:
All best practices demonstrating positive outcomes for reductions in recidivism and effective
diversion from the juvenile and criminal justice systems among individuals involved with or at
risk becoming involved with the juvenile or criminal justice system incorporate initiatives that
involve multiple stakeholders working together. These stakeholder systems include mental
health and substance abuse providers, law enforcement, jails, courts, defense attorneys,
prosecutors, prisons, state funding agencies, local funding agencies, hospitals, provider networks,
HMO’s, social security, social services, families, consumers, housing services, vocational
services, educational services and others.
Whereas a comprehensive and effective community mental health system best promotes
prevention, ongoing recovery, and community integration, specialized mental health best
practices have also been developed to address diversion from the justice system, mental health
needs in jails and prisons, community re-entry, and the needs of individuals in the community at
high risk of criminal justice involvement.
Community mental health service providers, law enforcement, and jails share the legal
responsibility for effective implementation of these specialized services. Their respective and
relative roles should be clear with mechanisms in place to effectively coordinate their functions.
Also necessary are:
•

Joint training on pre- and post-diversion programming.

•

Effective screening and assessment for mental health needs of individuals at their first
contact with the juvenile or criminal justice systems.

•

Delineation of specific responsibilities for the provision of mental health diversion
services.

•

Improvements in the diagnostic and treatment services provided to individuals remaining
in the juvenile or criminal justice system.

•

Better coordination of services across agencies.

•

Strengthening of pre-release planning to address mental health needs.

•

Training and securing the effective involvement of families and consumers.

The Sequential Intercept Model:
Review of the literature has identified several known national best practices for use at various
intersect points with the juvenile and criminal justice systems. The Sequential Intercept Model
(Munetz & Griffin, 2006) is a suggested framework to consider when addressing what type of
programs to initiate and when to use them at the various intercept points.

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The sequential intercept model was initially developed to provide a conceptual framework for
communities in Ohio to consider the interface between the criminal justice system and mental
health systems as they grappled with the problem of the increasing criminalization of mental
illness. The model organizes the interface with the justice system at five key points in which
there are opportunities to divert individuals from further penetrating into the system or assisting
individuals already engaged in the criminal process with improved community linkages that will
sustain community living and recovery and reduce recidivism. The objective is to divert
completely and early, with the hope that most people could be intercepted early and engaged in
appropriate treatment and supports thereby decreasing the numbers at each subsequent point.
In this section we briefly discuss best mental health practices (both evidence-based and
promising practices) at each point of intersection between the criminal justice and mental health
systems that provides an opportunity for interception and effective diversion. The proximate
objective of applying these approaches is appropriate redirection of individuals with mental
illnesses from the juvenile or criminal justice system to the mental health system and provision
of individually optimized mental health services; the ultimate objective is to optimize individual
outcomes while promoting societal safety and the efficient and effective utilization of societal
resources.
There are several points at which services can be provided to individuals with SMI/SED to
prevent them from entering the justice system or appropriately redirecting them from the
different steps in the justice system to the mental health system. If adequate mental health
services are available and readily accessible in the community, individuals with SMI/SED are
much less likely to engage in behaviors or get into situations that initiate an engagement with law
enforcement. If prevention from criminal justice engagement is unsuccessful, there are several
opportunities for diversion at several stages of the law enforcement-judicial hearing process. If
individuals with a SMI are in jails or prisons because of the severity of their crime, provision of
constitutionally adequate institutional mental health services in these correctional settings
provides opportunities for reduced future criminal justice involvement. When individuals with
SMI/SED are in the process of being released from institutional settings back into the
community, provision of various reentry transition programs can substantially improve the
process of successful community reintegration and reduce recidivism back to the juvenile or
criminal justice system. Finally, once individuals with SMI/SED with a history of prior justice
system involvement are back in the community, provision of certain individually optimized
evidence-based services can reduce the probability of criminal justice recidivism. Please see
Appendix C for examples of CJ/MH/SA initiatives currently operating in Florida.
Prevention:
Prevention refers to the process of providing appropriate mental health services to individuals to
reduce the likelihood of initial engagement with the juvenile or criminal justice system.

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Diversion:
Diversion refers to the process of diverting individuals with severe mental illness and/or cooccurring substance use disorders away from the justice system and into the community mental
health system, where they are more appropriately served. Diversion thus entails:
1. Interception: Identification of mental health needs of individuals involved with the justice
system as early as possible.
2. Defining alternatives: Negotiating individualized community-based treatment alternatives
to incarceration.
3. Linkage to care: Implementing linkages to comprehensive systems of mental and
behavioral health care and community supervision consistent with the disposition of the
criminal justice contact.
While diversion involves the transfer of an individual from the criminal justice to the mental
health pathway which often involves either not filing or dismissing charges in exchange for
voluntary agreement to participate in some type of community-based mental health treatment
program, the two systems tend to focus on different aspects of the process. Whereas criminal
justice professionals emphasize aspects of criminal responsibility and jurisdiction, mental health
professionals stress aspects of treatment which is the alternative to incarceration. Both elements
are critical and a tight linkage between them is essential to successful diversion. Factors crucial
to effective linkage between the two systems include:
•

Interagency collaboration at the community level involving traditional and nontraditional stakeholders (with a defined memorandum of understanding regarding interagency collaboration and sharing of information).

•

Active ongoing engagement.

•

Boundary-spanners or staff who bridge the two systems.

•

Effective and defined leadership.

•

Use of coordinated judicial and behavioral health best practices.

•

Cross-trained case managers.

There are two principal categories of diversion defined by the point in criminal justice processing
at which diversion occurs. Pre-booking diversion refers to the identification of individuals with
mental illness and/or co-occurring substance use disorders by police before formal charges are
brought and their redirection to the mental health pathway. Post-booking diversion refers to the
process of identifying and redirecting individuals to the mental health pathway after they have
been arrested. Different mental health best practices are critical to the success of diversion efforts
at these stages.
Pre-booking diversion:
Pre-booking diversion occurs at the point of contact between individuals with SMI/SED and law
enforcement officers in the community and relies heavily on effective interactions between

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police and the individual, and between police and community mental health services. Several
best practices have been developed to facilitate successful pre-booking diversion. These include:
•

Crisis Intervention Team (CIT) Training. This is a well-established program that provides
specialized training to police officers about identification of and working with individuals
with probable mental illness. Although other models of police-based diversion have also
been developed, the CIT program is found to result in the lowest arrest rates, high
utilization by law enforcement officers, rapid response time, fewer injuries to officers and
citizens, and the most frequent diversion to treatment.

•

Centralized Mental Health Screening and Assessment Facility. This is a model that
emphasizes a defined point of crossover and potential hand-off from the law enforcement
to the mental health system and has been found to result in enhanced effectiveness and
efficiency of diversion from the criminal justice to the mental health system.

•

Other First Responder Training. Specific programs have been developed to provide
police dispatchers and other first responders with tools to evaluate the possibility of
mental illness and how to effectively communicate with and respond to individuals with
possible mental illnesses.

•

Specified operational procedures relating to on-scene assessment, on-scene response, and
incident documentation by police officers to incidents with possible mental illness have
been found to promote appropriate diversion.

•

The availability of an inventory of community mental health service resources that is
available to law enforcement officers and a specified diversion algorithm that facilitates
appropriate triage and linkage.

Post-booking diversion:
Post-booking diversion occurs after individuals have been arrested and the likelihood of mental
illness has been identified. Currently, post-booking diversion is the most prevalent form of
diversion of individuals with mental illnesses from the justice system to the mental health
pathway. There are several points at which post-booking diversion can occur and these include:
•

At or immediately after booking into jail, before the formal filing of charges.

•

Pre-trial release from detention, with the condition of participation in treatment.

•

Prior to disposition, for example, upon the prosecutor’s offer of deferred prosecution.

•

At disposition or sentencing and this may include either deferred sentencing or release on
probation with conditions which include participation in treatment.

•

When at risk of, or following, a violation of probation related to a prior conviction.

As with pre-booking diversion, successful post booking diversion from the criminal justice to the
mental health pathway is contingent upon effective interception, linkage to appropriate mental
health services, and ongoing close coordination between the two systems. Several evidencebased approaches have been developed to facilitate successful post-booking diversion. These
include:

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•

Use of Jail Mental Health Screening Tools: Several screening tools have been developed
to assist jails in the identification of individuals with SMI. These include the Brief Jail
Mental Health Screen (BJMHS; Osher, Scott, Steadman and Robbins, 2004) and the
Correctional Mental Health Screen (Ford and Trestmen, 2005). These tools have both
been endorsed by the National Institute of Justice and been found to be effective in the
identification of possible mental illness and the need for further mental health evaluation
and services. Appropriate jail personnel must be available and trained to administer
screening tools and interpret results.

•

Provision of Adequate Jail Mental Health Services: Once the need for mental health
services among persons in jail are identified a professional assessment must be done to
determine what in jail services should be provided if immediate transfer to a primary
mental health setting is not appropriate or possible. Coordination between local mental
health agencies and the jail are necessary to ensure appropriate care. Ease of information
sharing between the two systems is critical to facilitating continuity of care, as is
elimination of other barriers.

•

Problem-Solving Courts and Specialized Court Dockets: Several approaches have been
developed to help individuals with mental illnesses to negotiate pretrial issues,
adjudication, and the sentencing phases of the justice process and to enable their receipt
of necessary mental health and substance abuse treatment services. These include
educating prosecutors and defense attorneys about aspects of mental illness and
community mental health resources, educating defendants with regard to rights and due
process, development of mental health diversion alternatives to prosecution, provision of
support and tools to assist defendants with mental illnesses and/or co-occurring substance
use disorders with participating in their criminal proceeding (e.g., competency
restoration), assisting individuals in complying with terms of pre-trial or post-trial release
or probation, and provision of a range of dispositional alternatives and sentencing options
for appropriate diversion.
The Mental Health Court approach is the best developed such approach for individuals
with SMI/SED and it integrates a number of these elements into a single comprehensive
mechanism. There are several kinds of Mental Health Courts and key factors that
facilitate their effective and efficient application have been defined. Drug Courts have a
longer history than mental health courts and have also been found to be effective.
Although a combined mental health and drug court approach is uncommon, it has been
found to be the most effective approach to successful diversion in view of the common
co-occurrence of mental illness and substance use disorders. See Appendix D for
resources on different types of judicial problem-solving interventions.

Institutional Mental Health Services:
Several evidence-based and promising approaches have been developed to ensure the detection
of mental illness and provision of appropriate mental health services to individuals incarcerated
in prisons or jails. Some of these approaches include:

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•

Use of a consistent procedure to screen inmates for mental illness upon admission to state
prison or jail facilities and use of standardized referral mechanisms, as appropriate, for
follow-up mental health assessment and/or evaluation.

•

Use of a defined procedure to develop a comprehensive and individualized mental health
service plan based on the results of the assessment and to ensure the timely provision of
recommended mental health services.

•

Providing specialized training about mental illnesses and co-occurring substance use
disorders to correctional staff regarding signs and symptoms of mental illness to facilitate
earlier and more efficient identification of inmates with mental illnesses and behavioral
management techniques to minimize disruptive behaviors and facilitate crisis
intervention.

•

Ensuring the provision of appropriate mental health services consistent with community
and institutional standards and best practice.

•

Revising standards and procedures in state forensic mental health systems to ensure the
efficient and appropriate use of this expensive resource:
o Developing standardized forensic evaluation procedures.
o Developing community alternatives for competency restoration and placement of
individuals adjudicated incompetent to proceed to trial or not guilty by reason of
insanity (NGI).

Community Re-entry:
Several promising state and local approaches have been developed that facilitate the successful
re-integration of individuals with SMI/SED back into the community upon release from jails or
prisons. These include:

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Screening for active mental health benefits at the time of incarceration to ensure that
benefits are reinstated upon release.

•

Suspending rather than terminating entitlement benefits such as Social Security or
Medicaid.

•

Utilizing a systematic approach to pre-release planning that includes construction of and
linkage to a comprehensive individualized service plan, and establishment of transition
teams and community collaborations towards this end.

•

Providing assistance to inmates in complete applications necessary to access benefits and
services, and arrange expedited review and processing of these applications. In this
regard, the use of the web-based application process has proven to be efficient and
effective.

•

Providing inmates with access to consumer information and mental health education so
that they can better understand and manage their illnesses.

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Providing coverage for services and medication after release, while applications for
benefits are pending. Several “bridge” plans have been developed around the country and
can serve as models for this approach.

•

Providing specialized parole supervision.

•

Appointing a single agency to coordinate release planning.

•

Sharing information across agencies and ensuring inter-agency coordination and
collaboration through inter-agency agreements and collaborations.

•

Ensuring that inmates have access to necessary medical and social benefits immediately
upon release.

•

Ensuring availability of housing and linkage to the community mental health system prior
to release.

Several comprehensive programs to ensure continuous service delivery to individuals as they
transition from jails/prisons to the community have been developed that combine a number of the
above approaches. Since a break in one or more essential mental health or other services is a
frequent cause of relapse and recidivism back into the criminal justice system, these programs
are critical to effective and successful re-entry initiatives. Several such approaches include:
•

The APIC Model: Developed by the National GAINS Center, this is a best practice
approach to community re-entry from jails for individuals who experience co-occurring
mental health and substance use disorders.

•

Building Bridges: Developed by the Bazelon Center for Mental Health Law (2002), this
model legislation has been developed to ensure the provision of necessary services for
persons with SMI to enable their successful transition from incarceration in jails/prisons
back into the community.

•

Gap Funding: Gap funding is a concept in which a special pot of funding is available in
each circuit to use to pay for community-based services and supports until the person
becomes eligible for SSI/SSDI and Medicaid. The back pay the person would receive
once their application is approved would go back into the funding pot as a
reimbursement.

Other prison and jail re-entry initiatives have been adapted in some states for individuals with
mental health needs include prison transition accountability plans (TAP) and jail community
reintegration planning (CRP).
Specialized Community Mental Health Services for Individuals with Mental Illnesses with
Prior Criminal Justice Involvement:
Several evidence-based mental health practices have been customized for individuals with
histories of prior juvenile or criminal justice system involvement or a high risk of such
involvement. The objective of these adaptations is to meet the specific needs of this population
while promoting public safety and reducing the likelihood of recidivism back to the justice
system. A key component of services is the role of specialized case management.

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Forensic assertive case management (Forensic-ACT) has not been found to be superior to
forensic intensive case management (F-ICM), whereas forensic intensive case management has
been found to be more effective than traditional intensive case management with regard to
outcomes for this population. Although additional research is necessary, the National GAINS
Center recommends caution against the overuse of Forensic-ACT for this population because of
the greater expense and absence of evidence of greater effectiveness. Specialized Criminal
Justice Intervention and Transition Teams are one variant of F-ICM that has been found to be
effective in serving the needs of persons with severe and persistent mental illness who are at risk
for incarceration. These teams coordinate community-based mental health treatment alternatives
to incarceration, provide mental health linkage and transition planning for inmates released from
jail or prison, and monitor mental health compliance and participation to minimize re-arrest, reincarcerations, and improve public safety.
Specific co-occurring disorders treatment programs for individuals with prior forensic
involvement are another successful adaptation of evidence-based mental health treatment that
has been found to be effective in meeting the service needs of this group. Given the high
prevalence of co-occurring mental illness and substance abuse in this population, such programs
are of particular importance.
Sensitizing Providers to the Effects of Correctional Incarceration on Treatment and Risk
Management (SPECTRM; Rotter, McQuistion, Broner, & Steinbacher, 2005) is an approach that
educates providers about the impact of incarceration on people with mental illnesses and
subsequent treatment engagement, and is considered to be important in appropriateness of
service delivery and outcomes for this population.
Adaptations of the evidence-based supportive housing programs for individuals with mental
illnesses have also been developed for this group of individuals with a history of incarceration in
prison or jails. A range of community housing options for this population must be available. This
includes the development of residential treatment facilities with capacity designated specifically
for individuals involved with the criminal justice system. Such capacity is of significance in
providing the courts with community-based treatment alternatives to incarceration and providing
a transitional community placement for inmates returning to the community in need of this level
of supervised treatment and monitoring.
Because of the disproportionate number of individuals with SMI/SED with trauma histories, it is
of critical importance that services provided are trauma-sensitive. This requires developing and
implementing services that informed and aware of the impact of trauma and abuse on individuals
with mental illnesses, as well as best practices for providing comprehensive and competent care
for trauma victims.
Adaptations of the evidence-based Illness Management and Recovery (IMR) and supported
employment for individuals with mental illnesses with a history of prior forensic involvement are
in their early stages of development.

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Community-Specific Criminal Justice Competent Mental Health Systems:
A variety of evidence-based strategies are available to successfully and efficiently divert
individuals with SMI/SED, as appropriate, from the justice system to the mental health pathway,
while enhancing both public safety and individual recovery. Since it is highly unlikely that any
community will utilize each and every one of these approaches, the “best” strategies to be
utilized in different communities will vary as a function of the specific strengths and unique
needs of that community. Coordination and synchronization between the criminal justice and
mental health systems at the community level is crucial to the success of any approach.
Collaboration between these systems at the local/regional level is enhanced by the formalization
and institutionalization of the relationship through the use of memoranda of understanding and
specified procedures, development of protocols of information sharing across systems without
violating individual civil liberties, and explicit statement how the partners will make resources
available to address this shared problem. Workforce development and training in both systems
are pivotal in promoting effective collaboration.
Recommendations:
The State of Florida is encouraged to consider adopting the following recommendations, which
correspond to the five key points of intervention within the Sequential Intercept Model:
Intercept 1 – Pre-Booking:
1. All law enforcement agencies in Florida develop Crisis Intervention Team (CIT)
programs. That the CIT training program be conducted a minimum of semiannually and
that this training occurs in each county or set up regionally to serve multiple
communities, as appropriate.
2. Funds be allocated from the legislature through FDLE to support the CIT training
programs.
3. Each county have at a minimum one full time CIT coordinator who oversees the CIT
training and ensures CIT is being utilized within each law enforcement agency.
4. The Florida CIT Coalition provide technical assistance to communities developing CIT.
5. FDLE certify CIT curricula and establish continuing education credit for CIT
certification.
Intercept 2 – Post-arrest, booking, and initial court hearing:
1. All local jail booking units (adult and juvenile detention facilities) conduct a mental
health and substance abuse screening using evidence-based tools. Recommended tools
include the Brief Jail Mental Health Screen (Osher, Scott, Steadman and Robbins, 2004)
and the Correctional Mental Health Screen (Ford and Trestmen, 2005).
2. All jails should be required to provide the names of individuals admitted to the jail to
local community mental health providers or a local clearinghouse agency upon booking
so that mental health consumers may be identified early and efficiently.

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3. Each judicial circuit should develop a mental health post-booking diversion program that
focuses on all misdemeanor as well as low-level, third degree felony charges for
defendants with SMI or co-occurring SMI and substance use disorders.
4. Each Juvenile Assessment Center (JAC) should develop pre-trial release/diversion
programs for youths with SED.
5. Judicial circuits consider the implementation of Public Defender model programs similar
to those developed in Pinellas County and Orange County.
Intercept 3 – Courts:
1. All judicial circuits are encouraged to examine the feasibility of implementing mental
health problem-solving strategies within both adult and juvenile courts.
2. Each judicial circuit should have specially trained probation officers to manage and
monitor this population upon release from jail or prison.
3. Each judicial circuit should establish a community-based competency restoration
program to divert from the forensic state hospital those individuals found incompetent to
proceed to trial (ITP), not a danger to self or others, and not meeting other criteria for
hospitalization.
4. Each judicial circuit should have an in-jail competency restoration program to begin
restoration training while an individual awaits transfer to the state forensic hospital and
continued restoration training when they return and are awaiting court hearings.
5. Designate a staff position to coordinate the commitment process both to and from the
state forensic hospital to reduce length of stay in jail.
6. To reduce the de-compensation experienced by forensic mental health defendants when
the court system is not timely in resolving cases after competency has been restored and
to free up needed bed space and reduce waiting lists for individuals awaiting placement
for competency restoration, recommended statutory change to decrease the time frame to
return forensic patients to their respective jurisdictions once competency is restored and
to ensure prompt judicial hearings upon return.
7. Specialized criminal justice/mental health case managers and entitlement benefits
specialists should be located within jails to facilitate discharge planning, restoration of
terminated or suspended benefits, and initial applications for individuals who are eligible,
but not currently covered by benefits.
Intercept 4 – Re-entry from jail or prison:
1. Each judicial circuit should develop strategies that focus on inmates with SMI or cooccurring SMI and substance use disorders that will be transitioning back into the
community from the jail. Strategies need to include the use of boundary spanners with
both clinical and forensic knowledge and understanding to coordinate re-entry activities
among the court, jail and community where this does not already exist. This function
could be housed within the Public Defender’s office, jail, community service provider or
court.

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2. Recommend continued use of the Department of Corrections and Department of Children
and Families Interagency Agreement and established procedures for discharge planning
from prison to the community. In coordination and collaboration with the DCF District
Forensic Coordinators and the Department of Corrections mental health staff, the
community service providers should have a dedicated staff person be part of this
transition team for doing in-reach into the prison, coordinate appointments, assist with
linkages and follow up with needed clinical and support services, housing, transportation
and social security benefits.
3. Recommend use of the APIC model (GAINS Center), which focuses on assessing,
planning, identifying and coordinating transitional care from jails back to the community.
4. Recommend adaptation/adoption of Building Bridges model legislation (Bazelon Center
for Mental Health Law, 2002) to facilitate access to entitlement benefits for individuals
coming out of jails and prisons.
Intercept 5 – Community corrections and supports:
1. Consider split sentences. Currently under the Interagency agreement between DCF and
DOC a letter is sent to the court system encouraging the consideration for split sentences
for inmates with serious mental illnesses. This process needs to receive more attention
for potential use and outcomes which may reduce costs for state institutions.
2. Establish programs to provide gap funding for individuals awaiting approval of SSI/SSDI
benefits, pre-screened to meet eligibility criteria.
3. Include select state and county probation officers to participate in the local CIT program
for intensive training and integration within the local system of care.
4. Implement specialized case loads for state and county probation officers to work with
individuals with serious mental illnesses and/or co-occurring substance use disorders that
have been released from prison or jail.

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Part 5: A Guide for Developing Comprehensive and Competent Juvenile
Justice, Foster Care, and Child Protective Services Mental Health Systems
On any given day, there are roughly 130,000 juveniles residing in youth detention facilities
across the country (Sickmund, 2004). Studies have consistently shown that anywhere from 65 to
70 percent of these youth have a diagnosable mental health disorder (Teplin, Abram,
McClelland, Dulcan, & Mericle, 2002; Wasserman, McReynolds, Lucas, Fisher, & Santos, 2002;
Wasserman, Ko & McReynolds, 2004). Roughly 25 percent of these individuals experience
conditions resulting in severe functional impairment (Shufelt & Cocozza, 2006).
Although the recommendations in this report are, for the most part, intended to address the needs
of both adults with SMI involved in or at risk of involvement in the criminal justice system and
youth with SED involved in or at risk of involvement in the juvenile justice system, it is
necessary to devote specific attention to infants, children, and adolescents as these populations
have unique developmental needs that are too often overlooked or responded to with
inappropriate versions of interventions and treatment philosophies that are designed around adult
mental health needs.
Youth involvement in the courts extends beyond the juvenile justice/delinquency system. Many
infants, children, and adolescents involved in the dependency/foster care system or child
protective services experience significant behavioral and emotional disturbances which
contribute to and/or result from significant disruptions in family, social, and interpersonal
functioning. Because children are often unable to articulate these difficulties and/or advocate for
their own needs in these forums, it is imperative that a comprehensive and competent system of
care incorporate interventions and safeguards to ensure that the needs of this most vulnerable
population are recognized and addressed.
For years, little was known about the importance of attending to the emotional and behavioral
needs of children involved in various legal proceedings, and the role the court system and judges
may play in either contributing to or protecting children from more severe behavioral and
emotional impairment. In fact, many experts mistakenly assumed that children involved in legal
proceedings and the justice system were relatively unaffected by the process in long-term
emotional ways and that behavioral or emotional difficulties that did arise were more likely preexistent or coincident to legal matters. Recent research demonstrates that this is far from the
case. Such experiences can result in profound disruptions in social and developmental
functioning, particularly during infancy and early childhood development. Furthermore, these
early experiences have been demonstrated to contribute to more severe forms of mental illness
and functional impairment later in life. As such, early intervention is viewed as one of the most
effective and efficient means by which to identify and respond to individuals at risk of long-term
impairment and psychiatric disability.
The following recommendations addressing youth mental health needs in the juvenile justice and
foster care systems were developed by reviewing the literature on best practices and by
consulting stakeholders from across the state. Significant input was provided by the Florida Bar

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Association’s Mental Health Subcommittee of the Standing Committee on the Legal Needs of
Children.
Early Childhood Development and Attachment:
Among the more compelling recent research on underlying causes of behavioral and emotional
difficulties is the contribution of prenatal, neonatal, and early childhood development on later
expression of mental illnesses and behavioral disorders. Research has demonstrated that poor
maternal nutrition, health, and prenatal care, along with exposure to illicit drugs and other toxic
substances in utero, have strong relationships with later development of behavioral and
emotional difficulties (IOM, 2003).
Similarly, research now shows definitively that insecure and inconsistent patterns of attachment
to key caregivers during the first years of life are associated with development of psychiatric
difficulties, and can have profound effects on an individual’s ability to develop and maintain
meaningful relationships later in life. While risk factors associated with disorganized infantcaregiver attachment include parental trauma, maternal depression, maternal alcoholism, and
other substance-use problems and illnesses, they are also associated with infants who are placed
in environments that do not provide adequate opportunities to develop stable, secure
relationships with one or more key caregivers (Lederman, Osofsky, & Katz, 2001). Such
impermanence in relationships may occur, for example, when infants enter into the foster care
system and move from one placement to another without having the opportunity to develop
meaningful attachments. Often the result of such impoverished relationships early in life is
development of a condition known as reactive attachment disorder.
Promising practices are being developed to improve screening and assessment of infants and
young children’s mental health. In particular, the Miami-Dade County Juvenile Court in
partnership with community stakeholders has developed several very encouraging models of
prevention and early intervention including the Prevention and Evaluation of Early Neglect and
Trauma (PREVENT) Initiative, the Infant and Young Children’s Mental Health Pilot Project
(IMHPP), and the Miami Safe Start Initiative.
Psychotherapeutic Medication Prescribing Practices:
Another trend which has raised concerns involves the off-label prescribing of psychotherapeutic
medications to preschoolers and older children (Rawal, Lyons, MacIntyre, & Hunter, 2004; Zito,
Safer, dos Reis, Gardner, Boles, & Lynch, 2000). In the absence of formal standards and clinical
guidelines, the off-label use of these medications, usually in response to behavioral problems,
has been questioned for both its safety and efficacy. To complicate matters, judges in
dependency courts in Florida, and many other states, are now required to authorize the
administration of psychotherapeutic medications to children in foster care, which presents further
legal and ethical concerns that are worthy of review.
Chapter 39.407 of the Florida Statutes and Rule 8.355 of the Florida Rules of Juvenile
Procedure, 2007 Edition, define the requirements for obtaining court authorization to administer
psychotherapeutic medication to children in shelter care or foster care when parental consent has

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not or cannot been obtained. In addition, DCF has developed procedures for pre-consent review
of psychotherapeutic medication treatment plans for children under the age of 18 who are in the
custody of DCF in out of home care. These procedures involve the mandatory review of
medication treatment plans by a consulting child psychiatrist, under contract to DCF, prior to the
administering of psychotherapeutic medications. As an example, for children between the ages
of birth and five years in out of home placement the Psychotherapeutic Medication Treatment
Plan Review (DCF form CF-FSP 5279; see Appendix E) is completed by the child’s case
manager and prescribing physician. The completed form is then sent to the University of Florida,
School of Medicine via the MedConsult line for review by a consulting child psychiatrist. The
final recommendation of the consulting child psychiatrist is intended to be used by the person
who has legal authority to consent for extraordinary medical treatment or the judge who is
providing the court order for treatment with a psychotherapeutic medication. Similar procedures
are established and required for all children in the custody of DCF.
Because of concerns inherent in requiring judges to authorize medication administration for
children in the dependency system, it is recommended that state rules, statutes, and procedures
around the authorization and administration of psychotherapeutic medications to children in
foster care and child protective services be reviewed. As appropriate, it is recommended that
existing practices and procedures be expanded and/or revised to provide additional oversight and
review of medication administration for all children and adolescents in the dependency system.
Furthermore, it is recommended that specific training for juvenile judges around
psychotherapeutic medication prescribing practices in foster care, along with bench materials for
use by juvenile court judges, be developed. Alternatively, the state court system may explore
strategies adopted by other states around the country in which psychotherapeutic medication
being prescribed for children who are in the custody of the state must be reviewed and approved
by a consulting child psychiatrist working for the courts. California has developed one of the
more comprehensive such programs requiring the completion of a detailed application justifying
the use of any psychotherapeutic medications.
Delinquency System: Florida’s Sequential Redirection Strategy for Youth with Mental
Illness Involved with or at High Risk for Involvement with the Juvenile Justice System:
Roughly 150,000 children and adolescents, under the age of 18, are referred to Florida’s
Department of Juvenile Justice (DJJ) every year. Many of these youth have been impacted by
poverty, violence, substance abuse, and academic disadvantage. Over 70 percent have at least
one mental health disorder, with females experiencing higher rates of disorders (81 percent) than
males (67 percent). Of youth diagnosed with a mental health disorder, 79 percent meet criteria
for at least one other co-morbid psychiatric diagnosis, the majority of whom (approximately 60
percent) are diagnosed with a co-occurring substance use disorder (Skowyra & Cocozza, 2007).
At least 20 percent of these youth experience disorders that are so severe that their ability to
function is significantly impaired. Representative diagnoses include:

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Major depressive disorder.

•

Bipolar disorder.

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•

Attention deficit/hyperactivity disorder.

•

Anxiety disorder.

Frequently, disruptive or delinquent behaviors in youths are the result or symptoms of
undiagnosed and/or untreated mental health disorders. For some youth, contact with the juvenile
justice system is often the first and only chance to receive help. All too frequently, however, the
opportunity for effective early intervention is overlooked or neglected, and youth end up entering
into a system that is ill-equipped to adequately respond to their treatment needs. Even after
entering the juvenile justice system, roughly 50 percent of youth with SED remain undiagnosed.
Those who are identified are often not adequately treated, contributing to deeper penetration into
the juvenile justice system.
In July, 2007, the Florida Department of Juvenile Justice announced the formation of a 25member Blueprint Commission to evaluate the state’s juvenile justice system and to develop a
comprehensive set of recommendations to effectively and efficiently maximize public safety and
the rehabilitation of youth involved in, or at high risk of becoming involved in, Florida’s juvenile
justice system. We defer specific and comprehensive recommendations addressing the juvenile
justice/mental health interface to the Blueprint Commission (whose final report is scheduled to
be released in December, 2007); however, the following is a suggested framework for designing
mental health interventions in the juvenile justice system.
Recently, the National Center for Mental Health and Juvenile Justice (NCMHJJ) released a report
outlining a comprehensive model for addressing the needs of youth with mental illnesses
involved in the juvenile justice system (see Skowyra & Cocozza, 2007). The model outlines a
set of nine core principles which in turn relate to four cornerstones for system improvement.
Finally, six critical points of intervention (corresponding more or less to those outlined in the
Sequential Intercept Model) are identified. The components of the comprehensive model are as
follows:
Core principles:
1. Youth should not have to enter the juvenile justice system solely in order to access
mental health services or because of their mental illness.
2. Whenever possible and when matters of public safety allow, youth with mental health
needs should be diverted into evidence-based treatment in a community setting.
3. If diversion out of the juvenile justice system is not possible, youth should be placed in
the least restrictive setting possible, with access to evidence-based treatment.
4. Information collected as part of a pre-adjudicatory mental health screen should not be
used in any way that might jeopardize the legal interests of youth as defendants.
5. All mental health services provided to youth in contact with the juvenile justice system
should respond to issues of gender, ethnicity, race, age, sexual orientation, socioeconomic status, and faith.
6. Mental health services should meet the developmental realities of youth. Children and
adolescents are not simply little adults.

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7. Whenever possible, families and caregivers should be partners in the development of
treatment decisions and plans made for their children.
8. Multiple systems bear responsibility for these youth. While at different times a single
agency may have primary responsibility, these youth are the community’s responsibility
and all responses developed for these youth should be collaborative in nature, reflecting
the input and involvement of the mental health, juvenile justice, and other systems.
9. Services and strategies aimed at improving the identification and treatment of youth with
mental health needs in the juvenile justice system should be routinely evaluated to
determine their effectiveness in meeting desired goals and outcomes.
Four cornerstones:
1. Collaboration: The need for improved collaboration between the juvenile justice and
mental health systems.
2. Identification: The need for improved and systematic strategies for identifying mental
health needs among youth in contact with the juvenile justice system.
3. Diversion: The need for more opportunities for youth to be appropriately diverted into
effective community-based mental health treatment.
4. Treatment: The need for youth in contact with the juvenile justice system to have access
to effective treatment to meet their needs.
Critical intervention points:
There are several points at which services can be provided to youth with SED to prevent them
from unnecessarily entering the juvenile justice system or appropriately redirecting them from
the different steps in the juvenile justice system to the mental health system. These include:
1. Initial contact with law enforcement: This includes the initial contact a youth has with
the police at the time they are suspected of committing a crime. (Such intervention
should include ensuring that school police are trained in CIT.)
2. Intake (probation or juvenile court): This includes the point at which a youth is referred
by law enforcement to juvenile court.
3. Detention: This includes the point at which a youth is placed in a secure detention
setting.
4. Judicial processing: This includes the point at which a petition is filed in juvenile court,
an adjudication hearing is held, and the judge orders a disposition in the case.
5. Dispositional alternatives (juvenile correctional placement or probation): This includes a
discussion of two dispositional alternatives – placement in a juvenile correctional facility
or placement on probation supervision.
6. Re-entry: This includes the point at which a youth is released from a juvenile
correctional placement and returns home.

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7. Prevention:* If adequate mental health services are available and readily accessible in
the community, youth are much less likely to engage in behaviors or get into situations
that initiate an engagement with law enforcement.
8. Children and families in need of services (CINS/FINS) matters:* This point of intercept
is intended to make explicit the opportunity for intervention among children and families
of children who persistently run away from home, who persistently disobey reasonable
and lawful demands of their parents or legal guardians, who are habitually truant from
school, or engage in other behaviors that place the child at risk of future abuse, neglect,
or abandonment or at risk of entering the juvenile justice system as defined under Chapter
984, F.S.
* These points of intercept are not included in the original model contained in the NCMHJJ
report, however have been added for the purposes of this report.
Assessment in Juvenile Justice System:
The Center for the Promotion of Mental Health in Juvenile Justice (CPMHJJ) has developed six
recommendations for best practices in mental health screening and assessment in the juvenile
justice system and are recommended to guide assessment and evaluation in the juvenile justice
system (Wasserman, Jensen, Ko, Cocozza, Trupin, Angold, Cauffman, & Grisso, 2003). 13 The
recommendations have been adapted as follows:
Table 6. Mental health screening and assessment in the juvenile justice system
Recommendation:
1) Emergent Risk

Overview:
Provide an evidencebased, scientifically
sound mental health
screen within the first
24 hours of a youth’s
arrival at a facility.

Description:
An evidence-based, scientifically sound mental health screening
should be included in the general health screen. While
addressing legal protections for the youth, screening should
attend to current use of any medications, service/treatment
history, current substance use, and risk of suicidal, selfinjurious, and assault behavior.

2) Mental Health
Service Needs

Provide an evidencebased, scientifically
sound mental health
screening and/or
assessment for all
youth as early as
possible in order to
determine need for
mental health
services.

This comprehensive mental health assessment should occur
prior to disposition to inform judicial and probation planning.
Because mental health conditions may contribute to
misbehavior, treatment may help prevent re-contact with the
justice system. Because of the potential overlap between mental
health conditions and criminal activity, screening and
assessment must incorporate legal protections for youth. Among
these protections is the guarantee that no information elicited
through the screening process may be used in any way to
jeopardize the child's legal interests in any law enforcement
matter. Youths screening positive should receive comprehensive
mental health assessments.

13

These recommendations can also be found on the CPMHJJ website: http://www.promotementalhealth.org/
practices.htm

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Recommendation:
3) Mental Health
Assessment
Components

Overview:
A comprehensive
mental health
assessment must be
based upon careful
review of information
from multiple sources
and must measure a
range of mental
health concerns.

Description:
Most Axis I disorders and suicidality are important to measure,
as well as youth’s functioning and impairment in such contexts
as home and school. Assessment should consist of direct
observation and face-to-face interview with youth; mental status
examination; chart review; school records review; interview
with parents/other adults, if available; and family history.

4) Community Reentry

Provide an evidencebased and
scientifically-sound
screening or
assessment for all
youth preparing to
leave a postadjudicatory secure
facility and return to
their communities.

In order to facilitate linkage to community mental health
services, high risk youths should receive a comprehensive
assessment, and low risk youths should receive a screen to
identify any mental health concerns before release. Youths who
screen positive should receive a full mental health assessment.

5) Re-Assessment

Provide evidencebased, scientifically
sound
screening/assessment
on a regular basis for
all youth.

Certain components of mental health status are likely to change
over time in response to internal and external events. While the
exact timing and interval for mental health screening and
assessment may vary, at a minimum it should be a part of any
routine medical screening and/or assessment. Youth who screen
positive should receive a full mental health assessment.

6) Staff Training

Ensure that mental
health staff are
professionally
credentialed, or
directly supervised by
credentialed staff.
Provide training for
staff (appropriate to
their role) for
assessment in
evidence-based,
scientifically sound
mental health
screening/assessment/procedures.

Staff at a variety of levels need to be able to assist with
assessing youth’s risk to self and others, so that they will be able
to inform treatment and service planning/disposition for the
youth.

Key Recommendations for Screening and Assessment in the Juvenile Justice System:

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1. Every youth who comes into contact with the juvenile justice system should be
systematically screened for mental health needs, on an ongoing basis, to identify
acute crisis needs (e.g., suicide risk) and to identify youth who require further
mental health assessment or evaluation: Mental health screening is conducted to
determine short-term needs. Screening results alone should not be used to make longterm treatment planning decisions, but to make informed decisions about the need for
immediate service or follow-up evaluation.
2. Mental health screening and assessment should be performed routinely as youth
move from one point in the juvenile justice system to another: While screening is
considered most critical at a youth’s earliest point of contact with the juvenile justice
system, it should also be employed periodically to monitor mental health status at all
stages of justice system involvement. Since screening provides a view of a youth’s shortterm and immediate needs, it is recommended that it be performed repeatedly, as youth
transition within or out of the juvenile justice system (say from pre-trial detention to postadjudication detention or from a secure detention facility to the community), as well as
periodically during longer stays in detention to monitor any changes that may occur in a
youth’s mental status.
3. The mental health screening process should include two steps:
a. The administration of an emergency mental health screen – The first step in the
process involves an initial emergency screen to identify any immediate mental
health needs, the potential risk of suicide or harm to self or others, and to
determine whether the youth is currently taking any psychotherapeutic
medication.
b. The administration of a general mental health screen – The second step of the
screening process involves the administration of a general mental health screen to
identify mental health concerns that require further evaluation or assessment. This
screen should be brief in nature and easily administered by non-clinical staff
within a variety of juvenile justice settings.
4. Youth identified as “in crisis” must be provided immediate access to psychiatric and
other medical services: Access to immediate mental health services should be available
for all youth who, based on the results of the emergency screen or general mental health
screen and staff observations, indicate a need for emergency services. Crisis conditions
typically involve youth who are believed to be at risk of harm to self or others, youth who
are at immediate risk of substance use consequences (e.g., withdrawal), youth in acute
mental or emotional distress, and youth who are at risk of discontinued medication.
5. Mental health assessment should be administered to any youth whose mental health
screen indicates the need for further assessment: This assessment should be based on
direct observation and face-to-face interview with the youth, as well as review of information
from multiple sources (e.g., mental status examination, case records, family interviews,
school records), and must measure a range of mental health concerns. A mental health
assessment will yield more detailed, and sometimes diagnostic, information about a
youth’s mental health status and can be used to form the basis of treatment
recommendations.

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6. Instruments selected for identifying mental health needs among the juvenile justice
population should be standardized, scientifically sound, have strong psychometric
properties, and demonstrate reliability and validity for use with youth in the
juvenile justice system.
7. It is important to recognize that the developmental needs of younger children and
adolescents are different from those of older children and adolescents, and care
should be taken to select instruments that are developmentally appropriate for the
target group of youth who will be screened and assessed.
8. Mental health screening and assessment should be performed in conjunction with
risk assessments to inform referral recommendations that balance public safety
concerns with a youth’s need for mental health treatment: Assessing a youth’s risk
for future violence or re-offending is a critical function of the juvenile justice system and
is necessary in order for the system to satisfy its obligations to ensure public safety.
Mental health screening and assessment must be linked to the administration of risk
assessments, to fully inform decision-makers about the risks and needs that each youth
presents. The combined results of these screens and assessments should be used to guide
decisions that not only ensure the appropriate level of security or supervision, but that
also ensure that youth have access to the services and treatment that they need.
9. All mental health screens and assessments should be administered by appropriately
trained staff: Most instrument developers provide guidelines for the level of training
and/or education needed in order to appropriately administer the instrument. Often,
screening instruments are designed to be administered by non-clinical staff that are
trained on how to administer, score, and interpret the instrument. Assessments, on the
other hand, typically require more extensive and individualized data collection and most
often require the expertise of a mental health professional.
10. Policies controlling the use of screening information are necessary to ensure that
information collected as part of pre-adjudicatory mental health screen is not used
inappropriately or in a way that jeopardizes the legal interests of youth as
defendants.
11. Given the high rates of co-occurring mental health and substance use disorders
among youth involved in the juvenile justice system, all screening and assessment
instruments and procedures should target both mental health and substance use
needs, preferably in an integrated manner using instruments specifically developed
to identify the presence of mental health and co-occurring substance use disorders
among youth.
12. Existing screening and assessment instruments and procedures should be reviewed
and adapted, as necessary, to ensure that they are appropriate for use with various
cultural, racial, and gender subpopulations within the juvenile justice system.

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Mental Health and Substance Use Disorders as Factors in Detention Hearings:
An area of concern in the juvenile justice system that should be further explored is the role of
mental health and/or substance use disorders as factors considered by the court in determination
hearings regarding detention care placement. Under current state statutes, mental health and
substance use issues are not specifically addressed as part of the detention intake or
determination processes. While statute 985.24(1)(b) does identify, “substantial risk of inflicting
bodily harm on others as evidenced by recent behavior” as a finding in detention determination,
it does not make reference to the possibility that such risk of harm may be related to underlying
mental health and/or substance use disorders.
The Department of Juvenile Justice, in cooperation with representatives from the Conference of
Circuit Judges of Florida, the Prosecuting Attorneys Association, the Public Defenders
Association, the Florida Sheriffs Association, and the Florida Association of Chiefs of Police, is
currently developing a new risk assessment instrument for use in detention determinations as
defined under statute 985.245, F.S. Accordingly, this statute states:
The risk assessment instrument shall take into consideration, but need not be limited to, prior
history of failure to appear, prior offenses, offenses committed pending adjudication, any
unlawful possession of a firearm, theft of a motor vehicle or possession of a stolen motor vehicle,
and probation status at the time the child is taken into custody. The risk assessment instrument
shall also take into consideration appropriate aggravating and mitigating circumstances, and
shall be designed to target a narrower population of children than s. 985.255. The risk assessment
instrument shall also include any information concerning the child's history of abuse and neglect.
Ch. 985.245(2)(b), F.S. [Italics added]

Mental health and/or substance use disorders, particularly in the context of histories of abuse and
neglect, are arguably among the strongest aggravating and mitigating circumstances precipitating
juvenile justice system involvement. As such, incorporating mental health and substance abuse
issues into the risk assessment and taking these issues into consideration in recommending
various levels of secure, non-secure, or home detention, as well as eligibility for diversion
programs, merits further examination.
In some circumstances, such consideration may support placement in more restrictive and secure
hospital or detention facility settings because of a history of dangerousness and/or a current risk
of harm to self or others. In other circumstances, youth with histories of mental illnesses and/or
substance use disorders, particularly those experiencing acute exacerbation of symptoms
immediately prior to justice system involvement and who do not present as a danger to the safety
of the community or themselves, may be more appropriately diverted to non-secure placements
at home or in other community-based settings, with linkage to new or existing treatment
resources.
Because the short time period to detention determination often precludes the completion of
comprehensive assessment, it is recommended that consideration be given to statements from
parents or guardians regarding past or current mental health and/or substance abuse treatment. In
any scenario, placement of youth with mental illnesses and/or substance use disorders in the least

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restrictive setting with diversion to the community as appropriate, balanced against public safety
concerns, should be a primary goal of the detention determination process.

Use of Evidence Based Practices:
The following policy statement regarding the use of evidence-based practices was developed by
the American Academy of Child and Adolescent Psychiatry and is recommended to guide and
inform the adoption of evidence-based practices for youth interventions in Florida:
Evidence-Based Practice (EBP) comprises empirically-validated processes that facilitate the
conscientious, explicit and judicious integration of individual clinical expertise with the best available
external clinical evidence from systematic research in making decisions about the care of individual
patients. The ultimate goal of EBP is to base clinical decision making in the areas of causation,
diagnosis, prognosis, treatment and guidelines on empirical evidence. However, evidence is a
continuum and the best available evidence may not (and often does not) include the kind of empirical
validation that would support an unequivocal standard of care. For example, many interventions
currently used in the psychiatric treatment of children and adolescents need more rigorous controlled
studies. Furthermore, it is common for children to present with multiple diagnoses that affect their
psychological, social and academic functioning, and current available evidence rarely encompasses
all the factors relevant to a particular patient care decision in a single study. Thus, it is a central
principle of EBP that a treating clinician must use all available information in developing an
appropriate treatment plan for an individual child or adolescent.

Whereas a comprehensive and competent community mental health system best promotes
prevention and adaptive functioning in the community, specialized mental health best practices
have been developed to facilitate diversion and community reintegration among youth with SED
involved in or at risk of becoming involved in the juvenile justice system. Stronger partnerships
and coordination of activities and resources across the juvenile justice and mental health systems
has the potential to result in better screening, assessment, and treatment at key points of juvenile
justice involvement, enhanced opportunities for diversion away from the justices system, and
increased access to ongoing, effective mental health services in the community.
Additional and Supporting Recommendations:
In May 2007, a public hearing organized by the Mental Health Subcommittee of the Florida
Bar’s Standing Committee on the Legal Needs of Children and Florida’s Children First, was
held in Broward County to address the mental health needs of children in the legal system. 14
The following recommendations were developed with significant input from this event:

14

A full report from this event can be accessed at: http://floridaschildrenfirst.org/04_reports/CMHRecsFinal.pdf

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I. Children/Youth in the Dependency System
A. Screening/Referral for Assessment:
1. Requirement to implement and expand assessment of children under the age of five,
targeting prevention and early intervention.
2. Require screening for infant and early childhood neglect, trauma, and abuse with
particular attention to possible presence of attachment disorders and other possible
developmental delays. Recommend assessment and interventions be modeled after
successful existing programs such as those in Miami-Dade County Juvenile Court.
3. Children who enter the dependency system but are not into placed into the state’s
“care and custody” should routinely be provided comprehensive behavioral
assessments.
4. If those children are not provided complete assessments, they should be screened
for mental health and substance abuse needs and referred for services.
5. Provide regular, ongoing screening and re-assessment of youth in foster care. Do
not rely solely on initial assessment.
B. Health Insurance/Medicaid Enrollment:
1. Community-based care providers (CBCs) should apply for Medicaid for
undocumented immigrant children who have been awarded Special Immigrant
Juvenile status in the state’s care and custody.
2. The state requires that CBCs enroll all children who are not eligible for Medicaid or
receiving private insurance in the low-income health insurance program.
3. AHCA and DCF must work together to streamline the Medicaid approval so that
children entering state care are enrolled in Medicaid within a week of entering care.
4. All CBCs should ensure that all caregivers apply for Medicaid or other appropriate
low-income health insurance program for children in the dependency system not in
the state’s care and custody, unless the child is otherwise insured. The CBCs
should be further required to assist caregivers with completing the initial
application, and follow up to correct problems if Medicaid is denied.
5. The state should provide for seamless medical and behavioral health care coverage,
with consideration of a managed care concept including full risk assumption, that
allows foster children to maintain the same coverage and plan throughout their stay
in foster care as well as after they are either re-united or placed in a permanent
home, when eligible. Children must receive needed services regardless of changes
in locale - the availability of medically necessary services should not depend on
where a child lives.
6. The state should create a Medicaid presumptive eligibility status for children
entering the system providing full coverage immediately.
7. The state should establish specific transfer criteria to ensure continuity of medical
and behavioral health coverage for children leaving foster care.

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C. Comprehensive Behavioral Health Assessments (CBHAs):
1. Establish standardized protocol for Comprehensive Behavioral Assessments
(CBHAs) to ensure timely and consistent evaluations.
2. DCF should implement a quality assurance process to ensure the timely completion
of CBHAs for all children in dependency.
3. DCF should implement a quality improvement processes to improve quality of
CBHAs.
4. CBCs should educate case managers about how to use CBHAs in case planning.
5. DCF should implement a quality assurance process to ensure that CBHAs are
incorporated into case plans.
6. OSCA and DCF should educate dependency judges about the importance of the
required CBHAs and how they should be used in case planning.
7. DCF should require that CBCs conduct an annual training for all child welfare staff,
from program managers down on the utilization of CBHAs and other behavioral
health services.
D. Treatment:
1. Implementation of specialized interventions to target:
a. Development of healthy patterns of reciprocal bonding and attachment.
b. Abuse.
c. Neglect.
d. Provide gender-specific trauma services.
2. Provide children counseling to challenge the denial or reduction of mental health
and substance abuse services
3. Train case managers and CBC staff receive training on services covered by
Medicaid and how to advocate for children to receive those services.
4. DCF, CBCs and the Managed Care providers should work together to ensure
available, accessible services across the entire continuum of mental health and
substance abuse care.
5. CBCs should develop programs that enable children to remain in therapeutic foster
homes after the need for therapeutic services has ended.
6. CBCs should develop adequate capacity in their inventory of foster homes to avoid
placement in a therapeutic home when placement in a foster home with out patient
services would be more appropriate.
7. Encourage the Community Based Care Partnership to increase utilization of
Behavioral Health Overlay Services to maintain children in foster care placements.

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E. Residential Treatment Centers
1. Appoint a guardian or attorney ad litem to all children facing commitment to locked
residential facilities;
2. All facilities using residential treatment nomenclature should be reviewed to make
sure they are appropriately licensed;
3. DCF should conduct an annual evaluation of existing residential programs for
quality and begin to examine outcomes (success data); and
4. DCF should assess what types of programs are needed and plan accordingly.

F. Psychotherapeutic Medications:
1. Establish standards for reviewing and approving administration of
psychotherapeutic medication to children, for use by the courts.
a. Board-certified child psychiatrists, working for the courts, to review and sign
off on all psychotherapeutic medications prescribed for children in foster care
system and child protective services.
b. Explore options such as telepsychiatry or other electronic means of
consultation to serve areas where there are few child psychiatrists.
2. Judges, case managers and guardian ad litems should be trained on the evidence
required to ensure appropriate use of psychotherapeutic medications, and what side
effects to watch out for.
3. Train judges regarding state medication treatment plan review protocols.
4. Standards for reviewing and approving administration of psychotherapeutic
medications should be developed for the courts.
5. Judges and representatives of the child should review the records provided for each
judicial review for completeness and accuracy. If the records were not provided or
are incomplete, appropriate actions and follow up should be included in court order.
6. Prescribing doctors should provide information directly to parents in order to obtain
informed consent.
7. AHCA/DCF/CBC should be required to provide specific and comprehensive report
of the provision of psychotherapeutic drugs to children and youth by age, gender,
race, and location, each quarter.
8. Require AHCA/DCF/CBC to provide specific reports on children who have been on
medications for extended periods or are taking multiple drugs.
9. AHCA should conduct an annual evaluation of the utilization of approved
psychotherapeutic medication for children under the managed care services.
10. ACHA/DCF and its subcontractors should report physicians with unusual
prescribing practices to appropriate authorities.
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11. AHCA/DCF should ensure physicians report adverse incidents to the FDA and not
only to the pharmaceutical companies.
II. Youth in the Delinquency System
A. Screening:
1. DJJ should implement measures to ensure that mental health and substance abuse
information obtained in JAC assessments are conveyed to detention centers in
which youth are placed.
2. DJJ should develop a standard informed consent form and protocols that meets
recognized standards on testing of young incarcerated or detained human subjects.
3. DJJ should implement measures to ensure that information obtained through mental
health and substance abuse screening processes not be made available to law
enforcement for any purpose that may jeopardize the child's legal interests.
B. Health Insurance:
1. Provide families with the resources to obtain health insurance for youth within the
families’ financial means.
2. The state should create a Medicaid presumptive eligibility status for youth reentering the community.
3. Develop state policies and procedures to suspend, rather than terminate, Medicaid
benefits upon placement in juvenile detention.
C. Comprehensive Assessments:
1. Comprehensive assessments should be incorporated into a treatment plan for each
youth, if the parent and child have given informed consent, or with the child’s
attorney’s consent, or judicial order after a hearing where the child is represented by
counsel.
D. Pre-Dispositional Behavioral Assessments:
1. Behavior assessments conducted on children prior to disposition should be provided
to defense counsel for review and the opportunity to obtain revisions prior to
submission to the court.
2. Public defenders should increase their use of independent experts to examine youth
and make dispositional recommendations.
E. Treatment:
1. Implementation of specialized interventions to target:
a. Development of healthy patterns of reciprocal bonding and attachment.
b. Abuse.
c. Neglect.
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d. Provide gender-specific trauma services.
2. Increase behavioral health overlay services (BHOS) or other mental health care
services to cover all children in the JJ system and residential treatment programs.
3. DJJ should work with community providers to provide youth with access to the
mental health and substance abuse services they received in the community.
4. DJJ should initiate provision of mental health and substance abuse services to youth
in detention centers.
5. Begin working with families, utilizing funding for aftercare services, prior to
release from juvenile detention facilities.
6. Develop mechanisms to link educational records between schools in the
community.
F. Youth Incompetent to Proceed:
1. DCF, DJJ, and the Courts should collaborate to reorganize current juvenile
competency restoration program to:
a. Establish more appropriate treatment goals and long-term case plans for
children with developmental disabilities, such as mental retardation.
b. Emphasize the use of crisis stabilization and community-based diversion in
place of competency restoration where appropriate.
c. Create community-based competency restoration programs where appropriate.
d. Ensure adequate resources and infrastructure in the community to serve
juveniles with severe behavioral disturbances.
e. Review appropriate treatment and placement options for juveniles at
substantial risk of harm to self or others.
2. DJJ should investigate best practices in other states to create appropriate systems
for dealing with developmentally disabled youth in the criminal justice system.
3. Explore options for expansion of minimum risk commitment to include placement
in mental health and substance abuse treatment programs.
G. Psychotherapeutic Medications:
1. All youth who are being involuntarily treated with psychotherapeutic medications
should be appointed competent counsel to represent them.
H. Court Proceedings:
1. Guidelines and procedures should be developed for the handling of youth appearing
in court under DJJ supervision.
2. Encourage courts to ensure meaningful opportunity for youth to confer with an
attorney prior to pleading guilty or no contest in delinquency matters.

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3. Ensure that the quality of legal representation within juvenile proceedings reflects
the highest standards of practice.
4. Train public defenders on mental health and substance abuse issues for children and
implement procedures to enhance the quality of advocacy at the dispositional phase.
5. Bar associations should provide educational programs with CLEs for private
attorneys on mental health and substance abuse issues for children and implement
procedures to enhance the quality of advocacy at the dispositional phase.
I. Probation and Conditional Release (Aftercare):
1. The courts routinely require that the JPOs identify treatment providers and ensure
that services are in place.
2. DJJ and DCF should work with communities to enhance availability of mental
health and substance abuse services for youth released from DJJ custody.
3. Develop specialized re-entry strategies for youth coming out of the juvenile
detention settings.
III. Children/Youth With Developmental Disabilities
A. Provide children with developmental disabilities counsel to challenge the denial or
reduction of services.
B. APD should implement Ch. 393.065(5)’s priority for enrolling children in the child
welfare system in the Medicaid Waiver program for developmental services.
C. Implement or amend the “crisis tool” to expedite services for families when services
would prevent the need for removing the child from the parental home.
IV. Additional Recommendations
A. Establish specific transfer criteria to ensure continuity of medical and behavioral health
coverage for children leaving foster care, child protective services, and juvenile justice
settings.
B. Encourage voluntary screening and/or evaluation of children of adult clients receiving
services in the community mental health and substance abuse systems to promote early
intervention and identification of treatment needs.
C. Encourage screening and/or evaluation of children of incarcerated adults with mental
illnesses, along with the provision of prevention, early intervention, and primary care
services as necessary.
D. Provide screening and assessment for individuals with traumatic brain injuries or other
organic disorders.

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Part 6: Judicial Education, Administration, and Community Collaborations
Judicial Education:
In recent years, there has been an increasing awareness and appreciation among the courts and
members or the judiciary of the import of substance abuse, mental illnesses, and co-occurring
disorders on a variety of areas of law and the justice system. While these issues may be most
apparent in criminal forensic mental health and civil commitment arenas, they play a role in a
variety of other judicial contexts, including juvenile justice, domestic violence, drug courts,
family courts, and minor criminal matters. Substance abuse, mental health, and co-occurring
disorders underlie 70-80% of the cases handled in the criminal division, 70% of the cases
handled in the dependency division, 70-80% of the cases handled in the juvenile delinquency
division of the courts, and no doubt contribute heavily to issues arising in dissolution cases. Yet,
only a small percentage of the judiciary has received any education or training on these subjects.
At the very least, it is critical that judges are provided with basic knowledge regarding mental
illnesses, the mental health system, and available resources in the community so that they are
prepared to make informed decisions when mental health concerns or issues arise. Failure to do
so may mean that decisions are based on mistaken stereotypes or assumptions about mental
illnesses, which can have a variety of negative impacts on individuals, families, the community,
and the justice system (Reed, 2002).
In addition, it is desirable for members of the judiciary to be knowledgeable about issues relating
to mental illnesses because judges are uniquely positioned to play important roles in designing,
implementing, and administering a variety of problem solving approaches to address complex
social issues. For example, through court-based interventions such as drug courts and mental
health courts, judges play a significant role in determining how individual cases involving
defendants with mental illnesses should proceed and whether alternatives to prosecution or
incarceration should be considered.
Judicial pioneers recognized that to turn a blind eye to the underlying factors that lead to crime,
delinquency, and dependency; i.e., substance abuse, mental health, and co-occurring disorders, is
to court failure. Furthermore, simply ordering people to get treatment without insuring access
and follow through wastes valuable judicial resources and time, and produces a revolving door of
human suffering. But, ensuring a judiciary that is knowledgeable, prepared, and competent in
these substantive areas is a challenge. Although courses relating to substance abuse, mental
health, and co-occurring disorders have been increasingly offered at judicial conferences in
recent years, they tend to be attended by judges who already appreciate the prevalence of these
issues in their work. It seems that until this year, these courses have been preaching to the choir.
The Mental Health Subcommittee of the Steering Committee on Families and Children in the
Court worked with pertinent members of the court education community to incorporate
education around issues of substance abuse, mental illnesses, and co-occurring disorders into the
curriculums at Florida Judicial College/New Judges’ College, Circuit and County Court Judicial
Conferences, Florida College of Advanced Judicial Studies, and other subject-related seminars
and conferences. The National Judicial College, the National Council of Juvenile and Family

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Court Judges and the National Drug Court Institute also provide courses to educate the judiciary
on these important subjects. In short, we need to take all of the opportunities for judicial
education and saturate them with a variety of levels of knowledge and training on substance
abuse, mental health, and co-occurring disorders. Indeed, work has already begun to accomplish
this goal. Table 7 provides an overview of recent and upcoming judicial education
Table 7. Recent and upcoming judicial education opportunities
Date:
June 2007

Venue:
Circuit Court Judge’s
Conference

Description:
Three-hour plenary session addressing substance
abuse, mental health, and problem-solving
techniques. Judges experienced in drug courts,
mental health courts, and problem-solving techniques
discussed their awakening to the need for education
on these subjects and the vast improvement in case
outcomes when these issues are addressed
appropriately.

July 2007

County Court Judge’s
Conference

Three-hour plenary session addressing substance
abuse and problem-solving techniques with an
emphasis on DUI cases. In addition a plenary session
was dedicated to mental health issues.

2008

New Judge’s College

NEW COURSE: 90-minute segment on co-occurring
disorders will be presented by Judge Steve Leifman.
The course will acquaint new judges with the
pervasiveness of substance abuse, mental health, and
co-occurring disorders, how to recognize them, and
provide them with a decision tree to aid in fashioning
more effective and meaningful dispositions. New
judges will be given a list of resources that can be
used when they encounter these issues.

June 2008

Advance Judicial
Studies

This will be a three day intensive course covering a
wide variety of substantive and procedural issues
involved in handling cases involving substance
abuse, mental health, and co-occurring disorders. See
Appendix F for full schedule.

Summer
2008

Circuit Court Judge’s
Conference

Summer
2008

County Court Judge’s
Conference

Both the county and circuit conferences have once
again dedicated plenary time to address mental
health, substance abuse, and co-occurring disorders
in the summer of 2008. Both sessions will be
identical.

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Recommendations:
While it is critical that members of the judiciary become versed and competent in issues around
substance abuse, mental illnesses, and co-occurring disorders as they relate to the justice system,
being able to communicate effectively in judicial and administrative matters means that it is
equally important that other stakeholders within the court system receive adequate training as
well. As such, the following recommendations are intended to complement judicial education
and to support expanded educational and training opportunities for stakeholders throughout the
justice system:
•

Trial court administrators should receive a course on the use of case management in the
handling of cases involving substance abuse, mental health, and co-occurring disorders.

•

Develop justice system competent certification standards for judges, lawyers, and other
court personnel in mental health, substance abuse, and co-occurring disorders.

•

Develop additional specialized and continuing educational opportunities for judges,
lawyers, and other court personnel.

•

Law schools should develop and promote curricula specifically on problem-solving
approaches to issues relating to substance abuse, mental health, and co-occurring
disorders. Those trained in this area should volunteer to guest lecture at law schools.
The Florida Bar Association is encouraged to join in this effort by providing education
and training for its membership.

•

Create self-instruction manuals and links on the court system webpage to other sites for
information on these issues.

•

Compile a bench book on substance abuse, mental health, and co-occurring disorders
containing resources that can be updated and that can be made available to judges around
the state.

•

Acquire and distribute the publication Judge’s Guide to Mental Health Jargon to all
members of the judiciary.

In short, work is underway to educate and train Florida’s judiciary, but much more needs to be
done. Most importantly, this can not be an endeavor to “quick fix” the court system. It must be
a coordinated and long-term strategy to ingrain these subjects into judicial training.
Judicial Administration and Community Collaborations:
The Judiciary in Florida plays a unique and critical role in the juvenile/criminal justice, mental
health, and substance abuse systems of care. Because of the prevalence of people with SMI/SED
in our state who have difficulty accessing appropriate services and receiving the types of
supports they need for stabilization and recovery within community living environments, the
justice system often becomes by default the de facto mental health system.
Of all stakeholders, Judges have an influential role due to their positions of authority, respect,
impartiality, and responsibility for administering justice. Therefore they should take a leadership
role in their communities for convening, organizing and supporting existing inter- and cross-

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systems collaborations that focus on planning and developing diversion and intervention
programs; building system capacity for services and supports; and creating problem-solving
cross system partnerships for cases involving mental health and/or substance abuse
considerations. Cannon 4 of the Code of Judicial Conduct for the State of Florida specifically
encourages judges to …engage in activities that improve the administration of Justice. This
underlying effort certainly is contemplated by Cannon 4. As such, criminal justice, mental
health, and substance abuse collaborations need to be formally organized with missions, goals
and objectives. In addition, they need to be dynamic in their membership and have mechanisms
to document their achievements and communicate their efforts.
In order to accomplish this, it is recommended that each Judicial Circuit develop both a formal
mechanism to direct its leadership role through Administrative Orders as well as the
establishment of Memoranda of Understanding (MOU) among community stakeholders.
Suggested templates for developing such documents are included in Appendix G. In addition,
examples of existing MOUs for jail diversion programs and community collaborations around
the state are included in Appendix H.
At a minimum, it is recommended that each circuit through an Administrative Order consider:
•

Strategies which will promote and sustain significant involvement of the courts and
members of the judiciary in local criminal justice/mental health stakeholder
collaborations.

•

Ways in which the courts and members of the judiciary may serve in leadership roles in
addressing the effect of mental illnesses on the judicial system and supporting the
application of problem solving techniques in cases involving individuals with mental
illnesses.

•

Methods for the courts and members of the judiciary to stimulate, support, and sustain
joint problem-solving initiatives among stakeholders in the juvenile justice, criminal
justice and community mental health systems around issues relating to lack of community
resources, access to community-based services, system duplication, lack of coordinated
care, information sharing and programmatic and system outcomes.

•

Processes to ensure information-sharing among relevant stakeholders within the courts,
criminal justice system, juvenile justice system, and community mental health and
substance abuse systems regarding people with mental illnesses who are involved with or
at risk of becoming involved with the justice system, in order to improve early
identification and treatment of these individuals. A multi-agency informed consent form
should be created and considered for use.

•

Roles, responsibilities, resources and commitment among stakeholders to the group and
to the process for system improvement and system change.

With the input and guidance of judicial leadership, local cross-systems collaborations should
focus system improvement efforts around two key areas: developing and implementing known
best practices for juvenile and criminal justice system diversion, intervention and re-entry; and
the educational needs of the various providers within the system for increasing awareness and

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Part 6: Judicial Education, Administration, and Community Collaborations

competency. It is recommended that local cross-systems collaborations consider the following
structure:
•

High level oversight body.

•

Subcommittees addressing operational issues should include at a minimum:
o Justice system efficiencies and system mapping.
o Building community capacity.
o Funding, financing, and legislative committee.
o Complex Case Staffing committee.

•

Mechanisms for evaluating program processes and outcomes, system processes and
outcomes and expectations for reporting this information to the oversight body.

•

Media outreach and liaison.

Community and Stakeholder Education:
The other key area each cross system coalition, consortium or task force should focus on through
its judicial leadership is the educational needs of the various providers of the system. Each
provider within the justice, mental health and substance abuse systems comes from different
training backgrounds and sets of agenda and focus that effect outcomes. To be effective it is
critical to consider improved training and educational efforts to build awareness, competencies
and help create a common set of language and knowledge around this population.
In order to accomplish this it is recommended:
1. Each circuit work with FDLE as it continues to revise its law enforcement, corrections
and probation academy training related to understanding and responding to people with
mental illness, substance use disorders and those in crisis. Ensure the curriculum
provides useful information for all new law enforcement, corrections, juvenile justice and
probation officers.
2. All law enforcement agencies provide 8 hours of updated mental health and Baker
Act/Marchman Act training annually to all officers through their block training
schedules.
3. Eight to 16 hours of mental health and substance abuse training should be required
annually for all judges, prosecutors, defense attorneys, correctional officers and state and
county probation officers.
4. Require that those who conduct forensic evaluations attend the Forensic Evaluators
training put on by FMHI.
5. Require eight hours of updated annual training for psychologists and psychiatrists
conducting forensic evaluations.
6. Judicial circuits should promote the use of NAMI’s Family to Family training program
for parents and loved ones.

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Part 6: Judicial Education, Administration, and Community Collaborations

7. Each circuit should develop a training/information program directed at the judiciary and
law enforcement that identifies community resources and how to access services.
8. Develop a glossary that standardizes mental health and substance abuse related
terminology across all systems that address the needs of those with serious mental illness,
substance use disorders as well as those with co-occurring mental illness and substance
use disorders.

106

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Appendix A - A Proposal to Integrate Medicaid and DCF Mental Health and Substance
Abuse Programs for the SPMI and SED Populations
Summary of Proposal
Medicaid purchasing and policy-setting responsibilities for Medicaid adult beneficiaries with
severe and persistent mental illness and children with severe emotional disturbance, including
populations involved with or at risk of involvement in the criminal or juvenile justice systems,
would be reorganized in partnership between the Department of Children and Families and
AHCA. This would provide for the evolution of a well-integrated system of care for those with
serious mental illness and involved in multiple systems of care.
Rationale
The Department of Children and Families is statutorily responsible for serving as the state’s
public mental health authority, but Medicaid has become the principal payer for publiclyfinanced care. To ensure an effective blending of funding sources, provide cost effective care,
and prevent cost shifts, it is essential that the state use a single purchaser and policy-setting
authority for those with serious mental illness and high users of multiple systems of care and to
ensure an alignment of Medicaid reform and mental health transformation strategies.
Populations Affected
The target population to be served by the DCF administered plans would include adults with
severe and persistent mental illness; children with emotional disturbance; children and adults
with substance abuse problems; children transitioning to independent living; individuals with
criminal justice involvement; and other individuals and families that are at-risk because of
mental and substance use disorders
The populations that would be affected by the realignment of administrative responsibilities
would be the SPMI/SED populations enrolled in the Medicaid fee-for-service system and
Medicaid managed care plans. Qualifying criteria would include diagnoses, historical service
use, prescriptions, as well as certain risk criteria (e.g., inpatient/crisis service use, employment
status, criminal justice system involvement, homelessness/unstable housing, lack of family/social
supports, and assistance needs with activities of daily living). Initially, enrollment in the DCF
program may be limited, with full phase in to occur over a two- to three-year period.
Program Coverages
Mental Health Benefits
In consultation with AHCA, DCF would define the community mental health and targeted case
management benefits for the affected populations. Medicaid and DCF benefits would have a
recovery orientation and emphasize intensive case management; disease/health management;
community living and inclusion services and supports; supported employment, education and

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Appendix A – Proposal to Integrate Medicaid and DCF Programs (continued)

housing services; habilitation and rehabilitation services; social and leisure skill development;
personal care; protective oversight and supervision; and other services based on best practices.
Substance Abuse Benefits
DCF will work with AHCA to expand Medicaid substance abuse coverages in order to enhance
federal funding support for behavioral health services and assure the availability of
comprehensive mental health and substance abuse benefits for Medicaid beneficiaries.
Physical Health Care
For Medicaid beneficiaries served under the DCF/AHCA partnership, Medicaid physical health
care benefits would be provided through the Medicaid fee-for-service system. Eligibles enrolled
in Medicaid managed care plans would be reassigned to the FFS system at the time of their next
open enrollment. The DCF managing entities responsible for SPMI/SED Medicaid beneficiaries
will provide intensive case management, disease management, and health management services
to Medicaid eligibles enrolled in the DCF managing entities. They will also be responsible for
utilization management of physical health benefits and providing authorizations for care.
Eligibility Expansion
DCF and AHCA will explore the possibility of expanding Medicaid eligibility, though federal
waiver, to SPMI/SED eligibles that are not currently eligible for Medicaid but served by DCF.
This group would include populations with incomes immediately above Medicaid eligibility
limits and those that do not meet disability level criteria. This would enhance the state’s mental
health system and access to care using expanded federal funding.
Managed Care
On a phase in schedule, DCF will establish managing entities to oversee the local/regional
administration of services provided to both Medicaid and DCF populations. The managing
entities would be responsible for creating and maintaining organized systems of care; purchasing
care; coordinating, managing and integrating all contracted community mental health and
substance abuse services in the designated district(s); establishing, credentialing and monitoring
provider networks that include an appropriate mix of providers for the full range of mental health
and substance abuse services provided, including acute and emergency care, medical services,
residential treatment, recovery supports and preventive services; meeting medical loss ratio
requirements; ensuring continuity of care when payer source and needs change; ensuring
convenient, timely and accessible care; managing service utilization; designing and maintaining
information systems; administering data collection, analysis and reporting activities; accepting
responsibility for meeting performance and outcome measures; collaborating with related
systems of care (e.g., education, criminal justice, juvenile justice, housing, employment, health
care); complying with Medicaid state and federal fiscal and program requirements; developing
local strategic plans; establishing consumer and family advisory groups; offering self-directed
and consumer- and family-oriented care; and establishing quality assurance and improvement
programs.

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Appendix A – Proposal to Integrate Medicaid and DCF Programs (continued)

The DCF managing entities would lead system transformation at the local level, have established
relationships with their communities and agreements with related health and social service
agencies and programs, and provide a model design for the effective coordination, integration,
and management of publicly-financed mental health and substance abuse services that are
accessible, consumer-and family-oriented, and achieve desired performance and outcome
measures. The managing entities would:
•

Promote the recovery and resiliency of individuals served by the public mental health and
substance abuse systems.

•

Improve state and local accountability for access to and the quality, appropriateness and
cost effectiveness of mental health and substance abuse care.

•

Assure the continuity of care for all children, adolescents, and adults who receive
services from the publicly funded mental health and substance abuse service systems.

•

Provide early diagnosis and treatment to enhance recovery, prevent hospitalizations, and
avoid crises.

•

Identify and treat people with psychiatric disabilities and substance use disorders who are
at high risk of poor outcomes and involvement in other systems of care.

•

Improve the overall quality of mental health and substance abuse services through the use
of evidence-based and promising practice models.

•

Improve the coordination and integration of the mental health and substance abuse
systems and other systems, such as the physical health, housing, employment, education,
child welfare, emergency services, law enforcement, and criminal justice systems.

•

Improve public safety through the use of prevention, early diagnosis and treatment,
diversionary programs, and enhanced system coordination.

•

Improve the assessment of local needs for mental health and substance abuse services.
Program Administration

DCF
Pursuant to a memorandum of agreement and other contractual arrangements, the Department of
Children and Families would assume responsibility from the Agency for Health Care
Administration for administration and the delivery of Medicaid mental health and substance
abuse services for adults with severe and persistent mental illness and children with serious
emotional disturbance. In consultation with the Agency for Health Care Administration, DCF
would be responsible for establishing the Medicaid benefit package and designing service
delivery and financing methods. DCF would enter into multi-year contracts with managing
entities, ensuring fiscal accountability; promoting program achievement using model programs
and best practices; assuring timely follow up on any corrective actions required; complying with
applicable federal and state statutes and regulations; eliminating ethnic, gender, and age
disparities in access to care; improving the public understanding of the causes, effects and
treatment of mental illness and substance abuse; and promoting preventive programs and
services.
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Appendix A – Proposal to Integrate Medicaid and DCF Programs (continued)

AHCA
The Agency for Health Care Administration would continue to be the Single State Agency for
the affected Medicaid population, through its contractor serve as the fiscal agent for the DCFadministered Medicaid program, and be responsible for federal and state reporting and
maintenance of the Medicaid State Plan and required waivers.
Transition
Eligible beneficiaries enrolled in managed care plans would be reassigned to DCF managing
entities upon termination of the Prepaid Mental Health Plans pursuant to contract or
implementation of Medicaid reform in PMHP’s geographic coverage area or at the time of open
enrollment for those enrolled in HMOs or PSNs.
Budget Neutrality
DCF would assume responsibility for the operation of affected populations and benefits within
existing appropriations levels. DCF and AHCA would jointly develop any future budget
requests to reflect price or workload increases or program enhancements
Federal Authority
The federal authorities for the proposed realignment of certain Medicaid administrative roles and
responsibilities are Title XIX of the Social Security Act, Title 42 of the Code of Federal
Regulations, Part 431 and other relevant parts, and Section 6086 of the Deficit Reduction Act of
2005.

115

Appendix B - Adult Psychiatric Inpatient Unit Crisis Stabilization Pathway
Based on a 5-Day Length of Stay
DAY 1: ASSESSMENT AND CRISIS MANAGEMENT
ASSESSMENT

Assessment and Need Evaluation
Physician:
• History, Examination, Formulation
• Order laboratory tests, consults
Nursing:
• Safety and other Needs Assessment
Social Work:
• Contact Outpatient team/Collateral
• Informants, Legal status, Resources
BEGIN TO DEFINE FOCAL PROBLEM
Why Admission Here Now??

TREATMENT

Establish safety and Plan Focused Intervention
• Continue outpatient medications as appropriate
• Safety precautions/monitoring as indicated
• Plan family/network interventions as appropriate
• Orient patient to the unit
• Plan individual therapy as feasible and indicated

DISCHARGE
PLANNING

Assessment of after-care needs and resources
• Follow-up and living arrangements
• Financial stability and need for assistance
• Employment or educational issues
• Safety evaluation in likely post-discharge setting
• Other specific needs and issues

DAY 2: COMPLETE ASSESSMENT AND INITIATION OF "FOCUSED TREATMENT"
ASSESSMENT

•
•
•
•

Finalize presumptive Diagnosis, evaluate laboratory results
Define mental and physical health needs, Re-evaluate safety
Monitor safety, vital signs, sleep, nutrition, self-care,
Complete assessment of legal issues, living and financial needs.

CLEARLY DEFINE THE FOCAL PROBLEM
TREATMENT

Finalize and Begin definitive intervention
• Initiate new medication treatment and taper of prior medication as
appropriate
• Utilize "prn" medications for specific target symptoms as appropriate
• Individual and group therapeutic interventions as appropriate
• Family and other network interventions
• Implement individualized safety and behavioral/cognitive plan

DISCHARGE
PLANNING

Define after-care needs and Develop Plan to Address Them
• Address specific post-discharge needs-legal, living, care, fiscal,
• Coordinate with outpatient therapists or find new treators as needed
• Define approximate length of stay on inpatient unit

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Appendix B – Adult Psychiatric Inpatient Unit Crisis Stabilization Pathway (continued)

DAY 3: CONTINUE FOCUSED TREATMENT
ASSESSMENT

•
•
•

Assess physical health and psychopathology
Monitor safety, vital signs, self-care, sleep
Review progress towards defined target outcomes

TREATMENT

•
•
•
•
•

Continue to implement medication plan
Continue individual and group therapy as indicated
Evaluate effectiveness and response to interventions
Family and other network interventions as required
Medication and other patient education

DISCHARGE
PLANNING

Concretize Post-discharge Plan
• Begin to arrange outpatient appointments
• Identify likely discharge date
• Coordinate other post-discharge arrangements as necessary

DAY 4: SAFETY ASSESSMENT AND DISCHARGE READINESS
ASSESSMENT

•
•
•
•

Assess patient safety and physical/mental health
Assess adequacy of self-care and support needs
Evaluate response of target symptoms/needs
Assess extent to which focal problem has been addressed

TREATMENT

•
•
•
•
•

Complete implementation of medication plan
Prepare discharge prescriptions
Continue to assess response to various interventions
Evaluate learned coping strategies
Assess patient and family understanding

DISCHARGE
PLANNING

•

Identify tentative return to work/school and complete necessary
paperwork
Complete discharge paper-work
Confirm appropriate post-discharge living and care arrangements

•
•

DAY 5: DISCHARGE WITH SMOOTH HAND-OFF
ASSESSMENT

•
•
•

Carefully assess patient safety
Repeat physical and mental examination
Repeat structured assessments, including rating scales

TREATMENT

•
•
•
•

Review safety plan
Review post-discharge plan with patient and family
Continue various interventions as appropriate
Dispense post-discharge medications with education

DISCHARGE
PLANNING

•
•
•

Reconfirm and document post-discharge follow-up arrangements
Complete all aftercare arrangements
Review follow-up plan and confirm patient and family understanding

DISCHARGE PATIENT

117

Appendix C – Examples of CJ/MH/SA Initiatives in Florida
PROGRAM DESCRIPTION
Name of Program: Central Florida Crisis Intervention Team
Is this program:
X pre-booking ____ post booking (to include pretrial release, mental
health courts, competency restoration ____ re-entry
County or counties this program serves: Orange County
Target population program serves: Adults and children with mental illnesses or serious
emotional disturbances that are in crisis and come in contact with law enforcement officers
Brief description of how the program operates: The Central Florida CIT is a community
partnership between law enforcement agencies, the local mental health and substance abuse
treatment systems, mental health advocacy groups, and consumers of mental health services and
their families. CIT is more than just training. It establishes Teams of trained officers within
each law enforcement agency to respond effectively to people with mental illnesses, including
those with co-occurring substance use disorders that are in crisis.
The Central Florida CIT strives to achieve the following goals:
ƒ Better prepare police officers to handle crises involving people with mental illnesses,
including those with co-occurring substance use disorders.
ƒ Increase law enforcement officer safety, consumer safety and overall community safety
ƒ Collaboratively, make the mental health system more understandable, responsive and
accessible to law enforcement officers to the greatest extent possible with community
resources:
o Supply law enforcement officers with the resources to appropriately refer people
in need of care to the mental health/substance abuse treatment system.
o Improve access to mental health/substance abuse treatment in general and crisis
care in specific for people who are encountered by law enforcement.
ƒ Divert people with a mental illness who are in crisis from the criminal justice system
whenever possible which is consistent with the Baker Act or Marchman Act.
Officers/deputies attend a 40 hour intensive training course put on primarily by the community
mental health and substance abuse providers, families and consumers. Most of the instructors
volunteer their time for training. Several previously trained CIT officers also assist with the
training. The various law enforcement agencies involved have developed policies and
procedures that recognize the role of the CIT officer within their agency and the receiving
facility has developed user friendly policies for law enforcement. Once an officer becomes a
CIT officer for their agency, they are the primary responder to calls that involve a person with a
mental illness. The officer uses their knowledge and skills to de-escalate the situation in a
peaceful manner, avoiding use of force whenever possible. These skills the officer utilizes are
designed to increase officer and consumer safety. The CIT officer then is able to use their
knowledge and discretion and take a person in crisis to the mental health receiving facility vs.

118

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

jail when appropriate. CIT trained officers wear a CIT pin on their uniform so they are
recognizable in the community.
Bi-monthly, the CIT coordinators from each agency, the mental health and substance abuse
providers and families and consumers meet to discuss system issues and to ensure the CIT
program continues and thrives. The Central Florida CIT program holds an annual appreciation
breakfast to honor the men and women who are CIT as well as an annual in-service training.
Who are the community partners involved with this program? Orange County Sheriff’s
office and all 12 local police municipalities as well as Orange County Corrections, Lakeside
Behavioral Healthcare, Orange County Government, Human Services Associates, Center for
Drug Free Living, Pathways Drop in Center, Orlando Regional Healthcare, and Florida Hospital
How long has the program been in operation? Seven years
Contact person:
Michele Saunders, LCSW
Florida Partners in Crisis
4836 Lonsdale Circle
Orlando, FL 32817
407 574 7182
Michele.fpic@comcast.net

119

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

PROGRAM DESCRIPTION
Name of Program: Northwest Florida CIT Group
Is this program: X pre-booking ____ post booking (to include pretrial release, mental
health courts, competency restoration ____ re-entry
County or counties this program serves: Escambia and Santa Rosa Counties
Target population program serves: Persons with mental illness and/or substance use disorders.
Brief description of how the program operates: Multi-agency quarterly 40hr trainings from
patrol units and corrections staff in Pensacola Police Dept., Escambia Sheriffs Office, Santa Rosa
Sheriffs Office, UWF Police Dept, PJC Police Dept, Milton Police Dept. Headed by Mental
Health and Law Enforcement Coordinators and Agency Coordinators. Five additional training
slots at each class to include community first responders, EMS, probation officers, pre-trial
release officers and adult protective services staff. Monthly group meetings held for program
development and expansion.
Who are the community partners involved with this program?: Lakeview Center, DCF,
NAMI, Mental Health Association with above law enforcement agencies.
How long has the program been in operation?: CIT Group partnership established in 2006,
first training class October 2006.
Contact Person:
Peggie Iacuzio
Program Director
Lakeview Center Forensic
850 595 0041
Captain Fred Alford
Escambia County Sheriffs Office
850 436 9822

120

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

PROGRAM DESCRIPTION
Name of Program: Eleventh Judicial Criminal Mental Health Project, Miami, Florida
Is this program:

X

pre booking

X

post booking

County or counties this program serves: Miami-Dade County
Target population program serves: Individuals that are arrested for misdemeanors and have
been identified with Severe Mental Illness.
Brief description of how the program operates: The Eleventh Judicial Criminal Mental
Health Project (CMHP) was developed to redirect individuals with mental illnesses away from
the criminal justice system and into community-based mental health treatment and services. The
target populations are individuals with severe mental illnesses and possible co-occurring
substance use disorders that are at risk of or have been arrested for misdemeanor offenses. The
purpose of the Project has been to provide countywide Crisis Intervention Team (CIT) training
for all police agencies, and to provide better access and linkage to mental health treatment and
support services available in the community. The goal of the Project has been to assist
individuals served to become diverted from the criminal justice system, and engaged in
treatment, rehabilitation and support services that are essential to their long-term, successful
adaptation to community living.
The program operates both a pre-booking (Crisis Intervention Team Training, CIT) and postbooking jail diversion program, and brings together the resources and services of healthcare
providers, social-service agencies, law enforcement personnel, and the courts. Since the
implementation of this program, individuals in acute psychiatric distress are more likely to be
assisted by law enforcement in accessing crisis stabilization services in the community without
being arrested. Individuals in acute psychiatric distress arrested for misdemeanors, who are
booked into the jail are evaluated and, if appropriate, transferred to a crisis stabilization unit
within 24-48 hours. Upon stabilization, legal charges are typically dismissed, and individuals are
assisted at discharge with accessing treatment services, housing, and other entitlements in the
community.
Who are the community partners involved with this program?: The success of the program
can be attributed to the collaborative partnerships established among the judiciary, defense and
prosecuting attorneys, local law enforcement agencies, community service providers, and other
community representatives. The Florida Department of Children and Families has been
instrumental in providing financial support and promoting common goals. The Miami-Dade
Department of Corrections, Jackson Memorial Hospital, Public Health Trust- Corrections Health
Services and the Mental Health Hospital play an essential role in providing assessments and
treatment to the individuals served. Miami-Dade County has a comprehensive continuum of
public and private behavioral health and substance abuse treatment and services. Department of
Children and Families provides funding and support for indigent people through the Community
Mental Health Centers (CMHC) and other private providers. There are a wide array of best

121

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

practice and evidenced based treatment programs within the community that are utilized by the
CMHP.
How long has the program been in operation?: In mid-2000, the Eleventh Judicial Circuit of
Florida, with funding and technical assistance from the National GAINS Center, convened a
two-day summit meeting of traditional and non-traditional stakeholders to review how the
Miami-Dade community dealt with individuals entangled in the criminal justice system due to
untreated mental illnesses and co-occurring substance use disorders. The participants assessed
the available behavioral health services, tailored the technical experts’ suggestions with local
input, and created the Eleventh Judicial Circuit’s Criminal Mental Health Project (CMHP).
Contact Person:
Cindy A. Schwartz MS, MBA
Project Director
Eleventh Judicial Circuit Criminal Mental Health Project
Jail Diversion Program
1351 NW 12th Street, Room 226
Miami, Florida 33125
305 548-5319
305 416-0920 Fax
cischwartz@jud11.flcourts.org

122

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

PROGRAM DESCRIPTION
Name of Program: Public Defender’s Office Jail Diversion Program
Is this program: ____ pre-booking
health courts, competency restoration

X

post booking (to include pretrial release, mental
____ re-entry

County or counties this program serves: Sixth Judicial Circuit (Pinellas County)
Target population program serves: Adults with serious mental illnesses (Axis 1) who are
indigent
Brief description of how the program operates: The program used in the Sixth Circuit has
evolved over the four years. Other areas interested in this model need to adapt to their needs.
We asked for and received a change in the probable cause affidavit for first appearance hearings
that had a box the officer could check stating “Mental Health Issues”. This helped the court
recognize the issue as well as our interview staff. The interview staff then obtains information
regarding previous mental health treatment and obtains appropriate releases. These releases are
then given to the Medical Records Specialists, who obtains those records for the attorney.
Another source of identification is the court’s psychologist who attends all weekday
Misdemeanor First Appearance Hearings. The court psychologist knows many of the clients
from previous contacts and can immediately refer to our Mental Health Department. The court
psychologist can also immediately visit individuals exhibiting unusual behavior to determine if
the person is competent or should be Baker Acted. If the court psychologist opines the person is
incompetent, the State normally stipulates to that and the person is referred to our Misdemeanor
Incompetent to Proceed (ITP) Program and the full range of services that are available there.
The jail’s nursing staff is a constant referral source. The staff not only calls if the person has
mental health issues, they also help prepare the person for release to us, ensuring the person is
not released until we are there to provide transportation. The jail also will provide a prescription
for 30 days of medication.
This program provides screening evaluations and therapy by five Masters Level Therapists. If
the facility does not provide therapy, we can immediately go there to provide it. This is
incredibly important as evidenced by our recidivism rates. The recidivism rate was 15%. I
attribute this very low rate to the immediate providing of services. The impact of timing of
delivery of services is directly reflected in our drug court; there is a two to four month wait for
outpatient services and a 49% recidivism rate.
The program also provides for housing, medications and transportation. Transportation can
involve picking up at the jail and delivery to a housing provider as well as transportation to the
doctor or if necessary the probation officer.

123

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

The goal has been to have the Criminal Justice System delivery of mental health services self
contained within the system. There are numerous advantages to this, including rapid delivery of
appropriate services, increased accountability of services by judicial involvement and review,
and a recognition that our needs and clients are often different than those of the community
mental health providers.
In closing, it should be stressed the need for rapid delivery of services. In writing this I called
our primary community mental health provider and inquired as of the second week of September
what the first available appointment date would be, and was told it would be January. While this
is not beneficial in any circumstance, it clearly is not practical in the Criminal Justice System.
Who are the community partners involved with this program?: Includes several community
providers, judiciary, state attorney, Sheriff and other stakeholders when necessary
How long has the program been in operation?: Four years
Contact Person:
Bob Dillinger
14250 49th St. N
Clearwater, Fl 33762
727 464 6866 phone
727 464 6900 fax
Pd6@wearethehope.org

124

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

PROGRAM DESCRIPTION
Name of Program: Special Needs Diversion (SND) Court Program
Is this program: ____ pre-booking X post booking (to include pretrial release, mental
health courts, and competency restoration _ re-entry
County or counties this program serves: Orange County, Florida
Target population program serves: Misdemeanor and non-violent 2nd or 3rd degree felonies
offenders suffering from serious and persistent mental illness who may have co-occurring
substance abuse disorder, or are developmentally delayed, experiencing dementia or head injury.
Brief description of how the program operates: In Orange County, those charged with lesser
crimes who exhibit mental illness are now being diverted toward appropriate care and away from
formal prosecution. Cases are identified as part of the booking and medical/mental health
screening process and referred to the Special Needs Diversion (SND) Court Program. The court
will order the referred case to SND and the inmate will be released to case management with a
discharge/treatment plan. The case will be followed by a case manager, community corrections
and the court in compliance with the treatment plan which can last up to 12 months. Once the
treatment plan is successfully completed the inmate graduates from the Program and the charges
are dropped. If for some reason the treatment plan is not followed the case is revoked and the
offender is returned to jail.
Who are the community partners involved with this program?: Lakeside Behavioral
Healthcare, Inc. and community services for the homeless including entitlement services, public
defender, state attorney, correction, community corrections and judiciary.
How long has the program been in operation?: December 2006
Contact Person:
Lamerial Daniels
Assistant Manager, Mental Health
Corrections Health Services
P.O. Box 4970
Orlando, FL 32802-4970
407 254 7558
Lamerial.Daniels@ocfl.net

125

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

PROGRAM DESCRIPTION
Name of Program: Mental Health Screening of Inmates at Booking
Is this program: ____ pre-booking
health courts, competency restoration

X

post booking (to include pretrial release, mental
____ re-entry

County or counties this program serves: Orange County
Target population program serves: Adults who enter the booking facility at Orange County
jail who have been referred for a mental health screening
Brief description of how the program operates: Referred inmates are seen for an initial
mental health assessment shortly after being booked into the facility, at which point a decision
about mental health housing is made, as well as referrals to mental health sick call and
psychiatric sick call. Each inmate is also given a mental health acuity score indicating the degree
of mental illness.
The mental health unit utilizes an acuity level grading scale of mental health. All mental health
inmates are assessed during screening for treatment intervention and accurate housing
How long has the program been in operation?: Approximately 4 years
Standard Operational Procedure:
AUTHORITY: Florida Model Jail Standard – 7.02
REFERENCE:
• ACA Standard: 3-ALDF-4E-12
• FCAC Standard: 19.04
• NCCHC Standard: J-G-04
PURPOSE: The MH Grading system was designed to provide information on three variables
related to an inmate’s mental health status: acuity of illness, chronicity of illness, and
presence/absence of substance abuse factors. Each inmate will be rated on each of the above
factors, providing a three-digit code (e.g., 3-2-1)
SCALES:
Acuity of illness Scale
This provides for assessment of current level of functioning using a condensed rating system
patterned after the Global Assessment of Functioning (GAF).

126

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

5 = Includes individuals with no discernable mental
illness to those exhibiting some mild symptoms. Mild symptoms include depressed mood,
mild insomnia, and difficulties in social, occupational, or academic areas. Such individuals
are generally functioning relatively well and have meaningful interpersonal relationships.
This category includes anyone rated 61 or higher on the GAF Scale.
4 = Includes individuals displaying moderate symptoms (e.g., flat
affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social,
occupational, or academic functioning (e.g., few friends, conflicts with peers and coworkers). This category includes anyone rated from 51-60 on the GAF Scale.
3 = Includes individuals displaying serious symptoms (e.g., suicidal
ideation, severe obsession rituals, i.e., frequent shoplifting) or any serious impairment in
social, occupational, or school functioning (e.g., no friends, unable to keep a job). This
category includes anyone rated from 41-50 on the GAF Scale.
2 = Includes individuals who display any of the following:
• Impairment in reality testing (speech is at times illogical, obscure, or irrelevant)
• Major impairment in several areas, such as work or school, family relations, judgment,
thinking, mood, (e.g., depressed person avoids friends, neglects family, and is unable to
work; arguments/physical altercations with family members).
This category includes anyone rated from 31-40 on the GAF Scale.
1 = This category describes an individual whose behavior is considerably
influenced by delusions or hallucinations; is unable to function in almost all areas; is
suicidal; is unable to take care of self; whose communication is grossly impaired. This
category is used to describe the mostly acute ill individuals who would normally be rated 30
or below on the GAF Scale.
Chronicity of Illness Scale
This segment of the rating scale was designed to identify those individuals who carry a diagnosis
considered to include the severe and persistently mentally ill.
5 = Includes individuals who do not meet any of the categories described below,
and who do not present as in need of mental health services at this time.
4 = Includes any individual who has received outpatient mental
health services and counseling within the past two years, but has never been treated on an
inpatient basis or been prescribed psychotropic medication.
3 = Includes any individual who has ever experienced a major
psychiatric crisis that
• Resulted in a psychiatric hospitalization or
• Involved a suicide attempt, and
• The situation occurred over one year ago.

127

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

2 = Includes any individual who has experienced any of the
following over the past year, and who does not fall into the category of severely and
chronically mentally ill, as defined in #5.:
A. A psychiatric hospitalization
B. Been prescribed psychotropic medication
C. Engaged in any self-destructive behavior, or any suicide attempts
1 = This category is used to identify the seriously and chronically mentally ill, and
there is evidence that the inmate meets the criteria for one of the following diagnostic
groups:
A. Schizophrenic or Schizoaffective Disorder
B. Bipolar Disorder
C. Brain damage associated with aggression towards others
D. Major Depression
E. Any individual who has been force medicated within the past year
F. Any individual who has been Baker Acted within the past year
Level of Addiction Scale
This segment of the Rating System was designed to identify individuals with substance
abuse and chemical dependency issues.
5 = Available evidence does not support the existence of any substance abuse or
chemical abuse problem,
4 = There is insufficient evidence to determine whether or not substance abuse is
an issue, but the Mental Health Specialist does not feel it can be ruled out at
this time.
3 = Identifies those individuals whom the Mental Health Specialist determines
may have problems related to the use of alcohol and/or drugs, but there is
insufficient evidence to categorize the individual as meeting the DSM !V R
criteria for either substance abuse (see #2 below) or substance dependence
(see #1 below)
2 = Identifies individuals meeting the criteria for substance abuse. Substance
abuse is a maladaptive pattern of substance abuse leading to clinically
significant impairment or distress, as manifested by the presence of one (or
more) of the following over the past year:
A. Failure to fulfill major role obligations at work, school, or home
B. Recurrent use of substance which contributes to physical hazards (i.e., DUI arrests)
C. Recurrent substance-related legal problems (arrests for substance-related disorderly
conduct)

128

Appendix C – Examples of CJ/MH/SA Initiatives in Florida (continued)

D. Continued substance use despite having persistent social or interpersonal problems
caused or exacerbated by the effects of the substance (i.e., arguments with spouse about
consequences of intoxication, physical fights).
1 = Identifies individuals meeting the criteria for
Substance dependence. Substance dependence is a maladaptive pattern of substance use,
leading to clinically significant impairment or distress, as manifested by three (or more) of
the following over the past year:
A. Tolerance: as manifested by either a need for markedly increased amounts of the
substance to achieve intoxication or the desired effect OR markedly diminished effect
with continued use of the same amount of the substance.
B. Withdrawal: as manifested by either the characteristic withdrawal syndrome for the
particular substance OR the same substance is taken to avoid or relieve withdrawal
symptoms.
C. The substance is often taken in larger amounts or over a longer period than was intended.
D. There is a persistent desire or unsuccessful efforts to cut down or control substance use
E. A great deal of time is spent in activities necessary to obtain the substance, use of
substance, or recovery from its effects.
F. Important social, occupational, or recreational activities are given up or reduced because
of substance abuse.
G. The substance use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have been caused or exacerbated by
the substance.
Contact Person:
Lamerial Daniels
Assistant Manager, Mental Health
Corrections Health Services
P.O. Box 4970
Orlando, FL 32802-4970
407 254 7558
Lamerial.Daniels@ocfl.net

129

Appendix D – Criminal Justice/Mental Health/Substance Abuse Web Resources
LAW ENFORCEMENT
Without adequate training and access to community-based mental health resources, law
enforcement officers face tremendous obstacles in responding to people with mental illness. This
section identifies resources for local law enforcement agencies looking to address mental health
issues.
• A GAINS Center Guide for Implementing Police-Based Diversion Programs for
People with Mental Illness: Summarizes what law enforcement agencies are doing
across the country to improve their responses to people with mental illness and explores
how these agencies have overcome barriers to create and maintain effective programs by
collaborating with the mental health community.
www.gainscenter.samhsa.gov/pdfs/jail_diversion/PERF.pdf
•

Law Enforcement/Mental Health Partnership Program: Describes a Consensus
Project national initiative to provide resources for law enforcement leaders and their
community partners to develop and enhance law enforcement/mental health programs.
(Products are currently in development).
http://consensusproject.org/downloads/Lawenforcementonepager.pdf

•

Consensus Project Report Recommendations: Offers detailed recommendations,
endorsed by leaders representing law enforcement and mental health systems across the
country, to help policymakers and practitioners improve outcomes of law enforcement
encounters with people with mental illness.
http://consensusproject.org/topics/toc/ch-II

•

Navigating the Mental Health Maze: A Guide for Criminal Justice Personnel:
Provides a crash course for criminal justice professionals whose understanding of mental
illness and the mental health system may be limited.
http://consensusproject.org/mhcp/Navigating-MHC-Maze.pdf

•

Online Program Profiles of Specialized Law Enforcement-Based Responses: Allows
users to search law enforcement-based response programs in other communities across
the country, and post questions directly to representatives of these programs.
http://consensusproject.org/programs

COURTS
People with mental illness appear repeatedly before judges and cycle in and out of jail for lowlevel crimes which are often the result of untreated mental illness. This section identifies
resources for mental health courts or other court-based initiative targeting defendants with a
mental illness.
•

130

Essential Elements of a Mental Health Court: Outlines 10 elements essential to mental
health court design and implementation and provides background on why each element is
important and how courts can adhere to it. (Product currently in draft form).
http://consensusproject.org/mhcp/essential.elements

Appendix D – Criminal Justice/Mental Health/Substance Abuse Web Resources (continued)

•

A Guide to Mental Health Court Design and Implementation: Explains critical issues
such as determining whether to establish a mental health court, defining the target
population, ensuring confidentiality, sustaining the court, and other key considerations.
http://consensusproject.org/mhcp/Guide-MHC-Design.pdf

•

A Guide to Collecting Mental Health Court Outcome Data: Describes practical
strategies for collecting data and evaluating the effectiveness of mental health courts.
Written for mental health court practitioners and policymakers who want to measure the
impact of court-based programs.
http://consensusproject.org/mhcp/MHC-Outcome-Data.pdf

•

Navigating the Mental Health Maze: A Guide for Criminal Justice Personnel:
Provides a crash course for criminal justice professionals whose understanding of mental
illness and the mental health system may be limited.
http://consensusproject.org/mhcp/Navigating-MHC-Maze.pdf

•

A Judges' Primer on Mental Illness, Addictive Disorders, Co-occurring Disorders,
and Integrated Treatment: A one-page reference, written for judges, on mental illness,
addictive disorders, co-occurring disorders, and integrated treatment.
http://consensusproject.org/downloads/judges-primer.pdf

•

Online Program Profiles of Mental Health Courts and Other Court-Based
Programs: Allows users to search through court-based programs and post questions
directly to representatives of these programs. The database contains program profiles in
the following issue areas: Pre-trial, Adjudication and Sentencing, Training.
http://consensusproject.org/programs

•

An Evaluation of the Fiscal Impact of Allegheny County Mental Health Court:
Special courts that sentence people with mental illnesses who are convicted of
misdemeanors and low-level felonies to treatment instead of jail have the potential to
save taxpayers money, according to a RAND Corporation study conducted for the
Council of State Governments Justice Center.
www.rand.org/pubs/technical_reports/TR439

•

Problem Solving Justice Toolkit: Interactive, online toolkit for implementing problems
solving approaches in the justice system. Developed by the National Center for State
Courts.
http://www.ncsconline.org/d_research/Documents/ProbSolvJustTool-v16.pdf

•

Effective Judging for Busy Judges: Publication put out by Nation Judicial College and
Bureau of Justice Assistance which outlines critical elements of problem-solving
approaches and provides links to many resources.
http://www.judges.org/pdf/effectivejudging_book.pdf

131

Appendix D – Criminal Justice/Mental Health/Substance Abuse Web Resources (continued)

CORRECTIONS
The number of people with mental illness who are in prison or jail, or under probation or parole
supervision, has increased dramatically in recent years. This section identifies resources for
initiatives targeting people with mental illness upon their admission to jail or prison, while they
are incarcerated, and after they are released to the community to the supervision of probation
and/or parole.
•

Corrections/Mental Health Case Studies: Offers detailed and frank discussion of the
successes and setbacks that corrections and mental health leaders in Kansas and Orange
County, Florida faced as they worked together to improve the response to people with
mental illnesses transitioning from jail or prison to the community.
http://consensusproject.org/updates/features/nic-case-study

•

Collaboration Assessment Tool: Enables leaders in corrections or mental health
organizations to assess their current level of collaboration and chart a course for
improving collaboration in four categories: knowledge base, systems, services, and
resources.
http://consensusproject.org/assessment

•

Consensus Project Report Recommendations: Offers detailed recommendations,
endorsed by leaders representing jail, prison, community correction, and mental health
systems across the country, to help policymakers and practitioners improve correctionsbased responses to people with mental illness.
http://consensusproject.org/the_report/toc/ch-IV

•

Re-Entry Policy Council Report Recommendations: Offers detailed recommendations
for improving the likelihood of successful re-entry among adults with mental illness
released from prison and jail.
www.reentrypolicy.org/reentry/Ch_B_Prison_and_Jail.aspx

•

Navigating the Mental Health Maze: A Guide for Criminal Justice Personnel:
Provides a crash course for criminal justice professionals whose understanding of mental
illness and the mental health system may be limited.
http://consensusproject.org/mhcp/Navigating-MHC-Maze.pdf

•

SSI/SSA and Medicaid: Provides background, relevant research, and case studies on
promptly connecting people released from prison and jail, including those with mental
illness, with Medicaid and other federal benefits.
www.reentrypolicy.org/reentry/Access_to_Federal_Benefits.aspx

MENTAL HEALTH ADVOCACY
In communities across the country, mental health advocates have been a driving force for change
in improving responses to people with mental illness involved in the criminal justice system. But
while advocates in these communities may be familiar with how the lives of individuals with
mental illness in the criminal justice systems can be impacted, they may be less familiar with
how to engage potential partners in these systems. The resource in this section provides

132

Appendix D – Criminal Justice/Mental Health/Substance Abuse Web Resources (continued)

strategies for advocates to reach out to representatives from criminal justice / mental health
systems looking to address these issues.
•

The Advocacy Handbook: Recommends strategies to mental health advocates who want
to improve outcomes for people with mental illness involved in the criminal justice
system and are seeking to engage and focus policymakers and leaders in the criminal
justice system.
http://consensusproject.org/advocacy

ADDITIONAL RESOURCES:
Council of State Governments – Online Program Profiles of Corrections/Mental Health
Programs: Allows users to search through corrections/mental health programs in the following
areas and post questions directly to representatives of these programs. The database contains
program profiles in the following issue areas: http://consensusproject.org/programs/
Council of State Governments – Criminal Justice/Mental Health Consensus Project:
http://consensusproject.org
Council of State Governments – Criminal Justice/Mental Health Information Network:
www.cjmh-infonet.org
Council of State Governments – Re-Entry Policy Council:
www.reentrypolicy.org/reentry/default.aspx
Council of State Governments/GAINS Center – Judges Leadership Initiative:
http://consensusproject.org/JLI
Florida Department of Children and Families (DCF): www.myflorida.com/cf_web
Florida Partners in Crisis (PIC): http://floridapartnersincrisis.org
Florida Substance Abuse and Mental Health Corporation: http://samhcorp.org
Florida’s Children First (FCF): http://floridaschildrenfirst.org
Miami-Dade County Grand Jury Report – Mental Illness and the Criminal Justice System:
A Recipe for Disaster/A Prescription for Improvement:
www.miamisao.com/publications/grand_jury/2000s/index.html
Miami-Dade County Mayor’s Mental Health Task Force – Final Report:
www.miamidade.gov/mayor/library/03.29.07-Miami-Dade-County-MMHTF-Final-Report.pdf
National Alliance on Mental Illness: www.nami.org
National GAINS Center /TAPA Center for Jail Diversion: http://gainscenter.samhsa.gov

133

Appendix D – Criminal Justice/Mental Health/Substance Abuse Web Resources (continued)

Substance Abuse and Mental Health Services Administration (SAMHSA): www.samhsa.gov
-

Center for Mental Health Services (CMHS): http://mentalhealth.samhsa.gov/cmhs

-

Center for Substance Abuse Treatment (CSAT): http://csat.samhsa.gov

-

Center for Substance Abuse Prevention (CSAP): http://prevention.samhsa.gov

SAMHSA’s National Registry of Evidence-based Programs and Practices (NREPP):
http://nrepp.samhsa.gov/

134

Appendix E – Psychotherapeutic Medication Treatment Plan Review

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136

Appendix E – Psychotherapeutic Medication Treatment Plan Review (continued)

,"

Appendix F –2008 Advanced Judicial Studies Program
Substance Abuse and Mental Health in the Justice System
DRAFT SCHEDULE
MONDAY, JUNE 2, 2008
8:00 9:45

•

•

9:45 10:00
10:0011:00

11:0011:05
11:0512:00

12:001:00
1:00 2:15

2:15 2:30
2:30 3:15

Pre-Test & Small Group Breakout - Common
myths surrounding SA & MH – Judge Steve
Leifman, Judge Martha Lott, & Judge Mark
Speiser

Prevalence of Substance Abuse and Mental
Health, Course of Illness and how this leads to
court interface - Dr. Fred Osher – Center for
Behavioral Health, Justice, and Public Policy,
Judge Steve Leifman
Stretch Break

•

Screening and Assessment including cooccurring defined and explained as it appears in
the judicial system – Dr. Fred Osher

Lunch
•

Identifying with Substance Abuse and Mental
Health Issues (Virtual Experience and use of
Video) – Judge Leifman and Dr. Fred Osher
Break

•

•

Expert Evaluations and Competency
Restoration- Dr. Randy Otto

WEDNESDAY, JUNE 4, 2008

8:00 9:30

History and Future of Mental Health Issues and
Substance Abuse in the Criminal Justice System
- Judge Steve Leifman
Break

•

TUESDAY, JUNE 3, 2008

8:00 9:30

Screening, Assessment and In Court
Proceedings - Dr Fred Osher

9:30 9:45
9:45 11:00

11:0011:05
11:0512:00

12:001:00
1:00 2:15

2:15 –
2:30
2:30 3:30

3:15 –
3:20

Stretch Break

3:30 –
3:35

3:20 –
4:05

Understanding Terminology (Family Feud Game) –
Judges Leifman, Lott, & Speiser

3:35 –
4:35

Break
•

Best Practices in Substance Abuse and
Mental Health Treatment – Dr. Randy
Otto (FMHI)

Stretch Break
•

Best Practices In Substance Abuse and
Mental Health Treatment and
(Continued)

Lunch
•

Fashioning Appropriate Dispositions–,
Judges Lott & Speiser;

Break
•

Role Playing Scenarios By Division in
Break out groups – Judges Lott and
Speiser

Stretch Break
•

Questions – Dr. Randy Otto

9:30 9:45
9:45 11:00

11:0011:05
11:0512:00

12:001:00
1:00 2:15

2:15 –
2:30
2:30 –
3:30

•

Community Treatment

•

Baker Act – Judge Lott

•

Marchman Act Proceedings - Judge Lott

•

Juvenile Medication Orders– Judge Lott

Break
•

Felony Forensic Courts

•

Misdemeanor MH Courts

•

Drug Courts – Judges Speiser

Stretch Break
•

Lunch
•

Ethical, privacy, & confidentiality issues
– John Patrillo

Break
•

3:30 3:35
3:35 –
4:35

Statutory & case law update – John
Patrila

Consumer Panel Judge Leifman

Stretch Break
•

Post test – Judges Lott & Speiser

137

Appendix G – Sample templates for Administrative Order
and Memorandum of Understanding

MODEL ADMINISTRATIVE ORDER:
Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
The attached Model Administrative Order is intended to assist circuits in developing available
resources for and responses to people in the court system who experience mental health and/or
substance abuse disorders.
The concepts presented here are derived from the work of the Special Advisor on Criminal
Justice and Mental Health, and the Mental Health Subcommittee of the Steering Committee on
Families and Children in the Court.
The format of the model administrative order is intended to be a guideline from which each
circuit can develop its own administrative order to address this area of critical importance.

138

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

IN THE _______________ JUDICIAL CIRCUIT
______________ COUNTY, FLORIDA
WHEREAS, the ___________ Judicial Circuit recognizes the myriad difficult issues that arise
when persons with mental illness and/or substance use disorders become involved in the juvenile
or criminal justice systems;
WHEREAS, the Supreme Court of Florida, Steering Committee on Families and Children in the
Court was charged with addressing these issues and its subcommittee on Mental Health has made
the following recommendations for systemic improvements:
Each judicial circuit is encouraged to consider developing a Criminal Justice/Juvenile
Justice/Mental Health/Substance Abuse Advisory Committee to define strategies, criteria, and
community alternatives within statutory authority and existing resources for diverting individuals
involved in or at risk of becoming involved in the criminal justice system to the community
mental health system for appropriate levels of treatment and support services;
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
should develop local strategies which will promote and sustain significant involvement of the
courts and members of the judiciary in collaborative association with local criminal justice and
mental health system stakeholders;
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
should assume a leadership role to address the impact of mental illnesses on the judicial system
and collaborate with stakeholders to effectively address these impacts at every level of contact
with the justice system;
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
should stimulate, support, and sustain joint problem-solving initiatives among stakeholders in the
criminal justice and community mental health/substance abuse treatment systems to address
issues relating to untreated mental illnesses and/or substance use disorders, and access to
community-based services;
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
should work collaboratively with all stakeholders to consider pre-booking and post-booking
interventions (e.g., mental health courts, pre-trial diversion programs, jail re-entry programs,
specialized crisis response programs for law enforcement officers) involving evidence-based
approaches to alleviating problems associated with and contributing to untreated mental illnesses
and substance use disorders in the criminal justice and juvenile justice systems and in the
community;
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
should work to improve information-sharing among relevant stakeholders within the courts,
criminal justice system, juvenile justice system, and community mental health system regarding
people with mental illnesses who are involved with or at risk of becoming involved with the
justice system, in order to improve early identification and treatment of these individuals;

139

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

NOW, THEREFORE, pursuant to the authority vested in me as the Chief Judge of the
___________ Judicial Circuit, in order to effectuate the aforementioned improvements, and to
better serve the needs of the citizens of the state of Florida, it is hereby ORDERED as follows:
Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee
The Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee of
the ________ Judicial Circuit is hereby established. The Chief Judge or designee shall be the
Chair of the Criminal Justice Mental Health/Substance Abuse Advisory Committee of the
_________ Judicial Circuit. Membership should include representatives from the following:
Judiciary
Magistrates
Psychiatrists
Psychologists
Substance Abuse Service Providers
Guardian ad Litem
Private Attorneys
State Attorneys
Public Defenders
Legal Services/Legal Aid
Law Enforcement
Crisis Intervention Teams

Trial Court Administrator
Clerk of Court and Staff
Case Managers
Department of Children and Families
Department of Juvenile Justice
Department of Corrections
Consumers
School Board/Dept. of Education
Local Government Officials
Community Organizers
Local Colleges, University Professionals
Probation Officers

Criminal Justice/Juvenile Justice/Mental Health/Substance Abuse Advisory Committee shall
meet quarterly or upon call of the Chair.
This Administrative Order shall become effective upon signing.
DONE AND ORDERED in Chambers in ______ County, Florida, this ___ day of _________,
2007.

___________________________________
CHIEF JUDGE

140

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

SUGGESTED TEMPLATE FOR THE DEVELOPMENT OF A MEMORANDUM OF
UNDERSTANDING (MOU) FOR CROSS SYSTEM COLLABORATION
A Memorandum of Understanding (MOU) is a document describing relationships among
parties. It expresses a convergence of will between the parties, indicating an intended
common line of action.
For purposes of developing cross system collaboration among justice, mental health and
substance abuse systems as well as with other parties and organization that provide resources,
services and supports to individuals with mental illnesses, substance use disorders and/or cooccurring disorders this sample MOU template is designed to establish a framework and
articulate responsibilities for its stakeholders.

Title of MOU: The title should reflect the purpose of the group’s work
Intent: This section should articulate the desire to formalize relationships across systems to
address the needs of their target population. It should identify the stakeholder groups to be
involved at a minimum and indicate their desire to work together.
Example:
The intent of this MOU is to establish and maintain a partnership with the judicial system,
juvenile and criminal justice system, local mental health and substance abuse providers,
hospitals, families, consumers, provider networks, HMO’s, social services, educational
system, social security, housing, vocational services and other organizations that share and
will promote the common goals and objectives to address the needs of individuals with
serious mental illnesses and/or substance use disorders that come in contact with the juvenile
or criminal justice system
Another example:
The intent of this MOU is to formalize the establishment of the (name of group) and to
develop goals, objectives and guiding principles that address the needs of individuals with
serious mental illnesses and/or substance use disorders that come in contact with the juvenile
or criminal justice system; as well as establish membership and responsibilities of its
members.

141

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

Purpose: This section should state the purpose of this document in guiding the group’s work
Example:
This agreement is intended to guide the (name of group) in identifying the needs of
individuals with serious mental illnesses and/or substance use disorders that come in contact
with the juvenile or criminal justice system and developing shared strategies and best
practices that will address the needs and create system improvements, increase public safety,
use limited resources effectively and efficiently and promote advocacy for increased
resources
Goals: This section should outline the goals the group identifies that relate to the
overarching reason they have come together., i.e. what do they hope to accomplish, what
changes do they want to make, what are their primary outcomes, etc.
Example:
The goals of (name of group) are to:
1. Reduce recidivism of individuals with mental illnesses and/or co-occurring substance use
disorders from having contact with the juvenile or criminal justice system
2. Increase public safety
3. Increase access to services
4. Increase capacity of community-based services
5. Improve information sharing and data collection for continuity of care and outcome
reporting
6. Improve coordination of care among systems
Example:
Improve access to and quality of mental health and substance abuse services and supports
through a systematic approach to developing and supporting strategies to introduce, adapt
and apply evidence-based and best practices that reduce contact with the juvenile or
criminal justice system for individuals with serious mental illnesses and/or substance use
disorders
Guiding Principles: This section addresses the shared principles, values and ideals the
group will adhere to in its work together. This section can also outline the overall
responsibilities of its members. Guiding principles may be written as “Where As”
Examples
The members of (name of group) agree to adhere to the following guiding principles:
1. Be respectful of the ideas and opinions of all members
2. Be responsive to assigned responsibilities
3. Promote open communication
4. Work for the common good of the community and the people it serves
5. Adopt a shared vision and mission, goals and objectives

142

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

Example:
Whereas, the participating members agree to support this MOU
And whereas, this agreement is intended to promote system change and improvements to
reduce contact with the juvenile or criminal justice systems for individuals with serious
mental illnesses, emotional disorders and/or substance use disorders; and to promote
recovery and resiliency
And whereas, the participants of this agreement will work in collaboration to support and
strengthen this agreement
Objectives: This section outlines the strategies or processes of how the group will achieve
its goals. Also this section may also articulate the various roles and responsibilities of the
members.
Example:
The objectives of this (name of group) to achieve its goals are:
1. To complete a system mapping how a person moves through the system that will identify
strengths and weaknesses of the system, its resource needs, duplication, etc.
2. To identify and recommend evidence based and best practice approaches that will help
support a process of change within the community
3. To build on existing management and leadership skills at all levels to enable the
application of innovative and creative approaches for change and improvements
4. For members of this MOU to share resources to change and improve the system
Responsibilities of the Members: This section can be broad or specific for each member.
Example:
All members of the (name of group) will designate staff members to participate in meetings
and serve on committees
All members are expected to support the specific activities of this group (name of group)
All members must be willing to share necessary information for system change and
improvements
One member may be identified as providing meeting space
One member may offer staff to take minutes of group
Closing sentence before the signature lines: This is intended to imply that by signing this
MOU the person signing agrees with its intent, purpose, content and duties.
Example:
This agreement will be signed by the appropriate agency representatives. By signing, the
parties agree to support and uphold this agreement. The parties agree to renegotiate this
Agreement if revisions of any applicable laws or regulation make changes in this Agreement
necessary, or at least annually.

143

Appendix G – Sample templates for Administrative Order and Memorandum of Understanding

Signature Page: There should be a separate signature page that lists the Name and Title of
each participant and the date.
Example:
Signed by: ___________________________________
Name: John or Jane Doe
Title: Judge or Sheriff or CEO, etc
Date:________________________________________

144

Appendix H – Sample MOUs
District 7
Alcohol, Drug Abuse and Mental Health Program Office
Florida House Bill 2003
Section 18
Cooperative Agreement
Diversion of Misdemeanant Offenders From the Criminal Justice System to the
Civil Baker Act System
Intent:

The intent of this cooperative agreement is to establish and maintain a partnership
with the judicial system, the criminal justice system, and local community mental
health and substance abuse providers to divert individuals with mental health
disabilities and misdemeanor charges from the judicial system to the local Baker
Act delivery system.

Purpose:

This agreement is intended to promote the early identification and diversion of
misdemeanant offenders who are experiencing an emotional crisis pursuant to
section 394.463, F.S. and section 394.462 (1) (f), F.S.

Goal:

The goal of this agreement is to:
1) Encourage pre-booking diversionary strategies that reduces the likelihood of a
misdemeanant mentally ill offender being unnecessarily incarcerated in the
Orange County Jail.
2) Promote the diversion of individuals with misdemeanor offenses and mental
health disabilities from the jail to the local civil Baker Act delivery system.
3) Define and establish linkage and referral responsibilities to facilitate such
diversionary practices.
4) Enhance procedures for the assignment of Traditional and/or Intensive Case
Management services for this population.
5) Initiate a system to enable law enforcement to have access to mental health
professionals on difficult cases.
6) Establish a system which reviews individuals with mental health disabilities
and misdemeanor offenses who have been incarcerated in the Orange County
145

Appendix H – Sample MOUs (continued)

7) jail versus the Civil Baker Act delivery system. This process will be used for
the purposes of improving the process of diversion of misdemeanant
offenders.
Whereas, the participating members of the judicial system, the criminal justice, law enforcement
and mental health and substance abuse providers agree to support this Cooperative Agreement,
And whereas, this agreement is intended to promote pre-booking and post-booking intervention
strategies for the diversion of individuals with mental health disabilities and misdemeanor
charges from the judicial system to the civil Baker Act mental health delivery system,
And whereas, the participants of this agreement will work in collaboration to support and
strengthen this agreement.
Now therefore, together as a community, the below mentioned continuity of care practices will
occur to promote this cause:
1. Each organization will agree to identify a point of contact to actively assist in the resolution
of roadblocks that are incurred within the civil and forensic mental health delivery system of
Orange County.
2. The Department of Children & Families (DCF) will maintain a list of the assigned liaisons
that will be distributed to community stakeholders in this agreement. This working document
will be entitled the "Community Points of Contact: Systems Resolution Agreement" (See
attached document).
3. The law enforcement agencies serving Orange County will make reasonable efforts within
the scope of their departmental policies to divert individuals with non-criminal or minor
criminal behaviors to the nearest civil Baker Act receiving facility when it is apparent that an
individual is in need of involuntary Baker Act examination pursuant to section 394.463, F.S.,
and transported thereto, pursuant to section 394.462 (1) (f), F.S.
4. The DCF and local community mental health and substance abuse providers will work in
partnership with law enforcement to promote educational services and training that
encourages patrol officer's developing working knowledge of the local civil Baker Act
delivery system. These educational services will be designed to promote the diversion of
individuals with mental health disabilities to the less restrictive civil Baker Act system.
5. With the initiation of the Voluntary Medical Security Program, which provide an
identification bracelet and/or ID card identifying individuals with mental illness or special
needs, the Orange County Sheriffs Office and the Orange County Corrections Department in
cooperation with Lakeside Alternatives, Inc. will identify possible diversion options and/or
appropriate treatment resources.
6. Lakeside Alternatives, Inc. agrees to coordinate with the Department of Corrections to
facilitate post booking assessment that identify misdemeanant offenders who are

146

Appendix H – Sample MOUs (continued)

experiencing mental health related difficulties for the purposes of appropriate treatment
interventions in the community.
7. Orange County Department of Corrections, and Lakeside Alternatives, Inc., in conjunction
with the Public Defender's Office, and the State Attorney's Office, will assist the judicial
system in the early identification of individuals with apparent mental health disabilities and
to initiate jail diversion practices when appropriate.
8. Orange County Department of Corrections, and Lakeside Alternatives, Inc., agree to work
cooperatively to identify less restrictive community placement options that may be offered to
the defendant and for the Court's consideration, after review by the State Attorney’s Office.
These placement options are not limited to inpatient Baker Act evaluation, but should strive
for the less restrictive form of community placement.
9. Lakeside Alternatives, Inc., will maintain written protocols with Orange County Corrections
for the transfer of misdemeanant offenders from the jail when involuntary Baker Act
examination criteria is met and the Court allows for such a diversion pursuant to section
394.463, F.S.
10. In cases when the court has released individuals from the Department of Corrections, while
inpatient at Lakeside Alternatives, Inc., Lakeside Alternatives, Inc. will coordinate
community discharge and referral services that appropriately link the individual to
community mental health and/or substance abuse providers upon discharge. These services
will include referrals for any ongoing medication need and/or referral for case management
services, as appropriate. If the individual is returned to the jail and then released, Lakeside
Alternatives, Inc. agrees to provide the Department of Corrections with a discharge plan to
ensure continuity of treatment while incarcerated.
11. An individual can be referred for consideration of acceptance into Traditional or Intensive
Case Management services pursuant to DCF District 7 – Alcohol, Drug Abuse and Mental
Health Program Office policy by any party involved in the intervention and diversionary
practices referenced in this agreement.
12. Orange County Department of Corrections and Lakeside Alternatives, Inc. agree to work
cooperatively to develop mechanisms for community referral information. This information
will be made available to selected individuals who have been identified with mental illness
and are release into the community.
13. In the event an individual affected by this agreement has existing Traditional or Intensive
Case Management services, the assigned Case Manager will be responsible for assisting in
the facilitation of diversion practices pursuant to forensic case management policies and
procedures of the DCF District 7 – Alcohol, Drug Abuse and Mental Program Office.
Furthermore, this Agreement shall be reduced to writing and signed by appropriate agency
representatives. The parties agree to renegotiate this Agreement if revision of any applicable
laws or regulations make changes in their Agreement necessary, or at least annually.

147

Appendix H – Sample MOUs (continued)

In The County Court of The Eleventh Judicial Circuit In And
For Miami-Dade County
County Court Jail Division - Mental Health Agreement
November 27, 2000
Current law requires law enforcement officers serving Miami-Dade County, having custody of
individuals based on non-criminal or minor criminal behavior that meets the statutory guidelines
for involuntary examination, to transport such persons to the nearest Baker Act receiving facility
for examination, in accordance with the requirements of Florida Statutes 394.462(1)(f). In the
event an individual with mental illness is arrested for a misdemeanor, pursuant to Florida Law
99-396, the following procedures shall be implemented by the signatories hereto:
Mental Health Procedures
(1)

When an, individual is arrested for a misdemeanor (other than Domestic Violence*), a
Corrections Health Services qualified mental health professional (i.e. a physician, clinical
psychologist, psychiatric nurse or clinical social worker) will examine the individual in
need of mental health services. Based upon the examination, the professional may
execute a Professional Certificate to initiate an involuntary examination pursuant to
F.S.394.463(2)(a)(3). When possible, the Professional Certificate should be issued within
24 hours of the arrest.
*Domestic Violence Division will be responsible for creating an agreement consistent
with their needs.

(2)

Upon execution of a Professional Certificate, Corrections Mental Health will
immediately notify the Public Defender's Office (or other defense counsel), the State
Attorney's Office and the Mental Health Administrator's Office and provide them with a
copy of the Professional Certificate and the name and address of the receiving facility
that has agreed to provide an involuntary examination.

(3)

Upon receipt of the Professional Certificate from Corrections Mental Health, the Mental
Health Administrator's Office will calendar the case before the county court jail division
judge the next day of court for an Order of Transport to that receiving facility. The
Mental Health Administrator's Office will also provide telephonic notice to the State and
Defense of the calendared case. The signed Order to Transport will be delivered by the
Mental health Administrator's Office to the Corrections Transportation Unit. In the event
that the State or Defense has an objection to the transportation order, it is to be raised at
the scheduled court hearing.

(4)

Transportation to and from the receiving facilities and court hearings (in lieu of rebooking) will remain the responsibility of Miami-Dade County Corrections &
Rehabilitation Department, upon receipt of court order. The court will issue a bench
warrant hold upon release to a receiving facility. The bench warrant hold shall be
designated in the computer as BWTH (bench warrant treatment hold). Corrections Mental

148

Appendix H – Sample MOUs (continued)

Health shall also provide the receiving facility with a copy of the Professional Certificate,
any other evaluations and a copy of the arrest affidavit. Corrections Mental Health shall
work with the Public Defender's Office (when the Public Defender client agrees to
treatment) and the Mental Health Administrator's Office to identify an appropriate
receiving facility.
(5)

(6)

The Baker Act receiving facility will be responsible for performing an evaluation to
determine whether or not the individual meets criteria for involuntary placement pursuant
to Chapter 394, Part I of the Florida Statutes.
(5a)

If it is determined that the individual meets criteria for involuntary placement
pursuant to the Baker Act, the receiving facility shall provide the Baker Act
Assistant State Attorney with a copy of the arrest affidavit or charging document,
a copy of the individuals' psycho-social history and the names, addresses and
telephone numbers of any person expected to testify in support of the patient's
continued detention and the substance of their anticipated testimony.

(5b)

Once it is determined that the individual does not meet criteria for involuntary
placement pursuant to the Baker Act, but the individual wishes to receive
aftercare treatment, the receiving facility shall complete an aftercare report prior
to the discharge of the individual charged with a misdemeanor(s) and will make
all appropriate referrals. The report will include recommendations for aftercare
services, including but not limited to, documentation of medication distribution in
sufficient quantity pending follow-up appointment, a follow-up appointment for
continuing mental health care, and an appropriate residential placement, if
available. The report will be faxed by the facility 24 hours prior to the discharge
to the Mental Health Administrator's Office and to the Public Defender's Office
(or other defense counsel) and the State Attorney’s Office. The Mental Health
Administrator's Office will notify the Offices of the Public Defender and the State
Attorney of the impending discharge and shall place the matter back on calendar
before the county court jail division judge within 24 hours of the notice and shall
provide telephonic notice to the state and defense of the calendared case. The
report shall be presented to the court at the hearing. When the individual is ready
for discharge, the Mental Health Administrator's Office will make arrangements
with Corrections Transportation Unit to transport the individual back to court.
Unless otherwise required, Corrections shall return the individual directly to
Courtroom 6-7 (Jail Division), without first re-booking the individual.

(5c)

Once it is determined that the individual does not meet criteria for involuntary
placement pursuant to the Baker Act, and the individual does not wish to receive
aftercare treatment, the receiving facility shall denote and sign the aftercare report
that aftercare services were offered, explained and refused.

Upon returning the individual to the Jail Division, the County Court Judge shall consider
the disposition of the pending criminal charges and, when possible, appropriately resolve
them.

149

Appendix H – Sample MOUs (continued)

(7)

The Florida Department of Children and Families will provide information regarding
available resources for medication payment.

(8)

The Florida Department of Children and Families will provide a continuum of
appropriate mental health services, including case management services for the following
individuals:
•

Those individuals charged with a misdemeanor offense who upon transfer to a
Baker Act receiving facility are determined to meet Baker Act eligibility
requirements by a Baker Act receiving facility physician.

•

Those individuals charged with a misdemeanor offense who are diagnosed as
chronically and persistently mentally ill and who have an Axis I diagnosis of a
major mental illness pursuant to the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV).

•

Those individuals charged with a misdemeanor offense who are determined to
meet all necessary Medicaid eligibility requirements shall be provided intensive
case management services.

The provision of mental health services by the Department of Children & Families is
subject to the limitations as referenced in Attachment I of the Agreement. The provision
of mental health services by the Department is further limited to and contingent upon
availability of funding by the Legislature and allocation of necessary resources by the
State Alcohol, Drug Abuse, and Mental Health (ADM) program office.
(9)

The City of Miami Police Department and the City of Miami Beach Police Department
agree to implement a "Memphis style" Crisis Intervention Team (CIT) program within
their respective departments. The parties hereto will assist those police departments in the
planning, training and implementation of this program.

(10)

A multi-agency Task Force consisting of representatives of the agencies participating in
this Agreement will meet on a monthly basis to discuss and resolve issues pertinent to
individuals charged with misdemeanors who are in need of mental health services. This
Task Force will work with all of the Police Departments in Miami-Dade County
regarding the response of police to persons with mental illness who may be in crisis.

(11)

Upon signature of the Florida Department of Children and Families, this amended
Agreement shall supersede the previously agreed and signed November 22, 1999 County
Court Jail Division-Interim Mental Health Agreement.

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Appendix H – Sample MOUs (continued)

The undersigned this 27th day of November, 2000 agree to follow the above procedures.

________________________________
District Administrator
Florida Department of Children and Families,
District 11

______________________________
11th Judicial Circuit Court

________________________________
Department of Corrections

______________________________
Public Defender’s Office

________________________________
State Attorney’s Office

______________________________
City of Miami Police Department

________________________________
City of Miami Beach Police Department

______________________________
JMH – Public Health Trust

151

Appendix H – Sample MOUs (continued)

In The County Court of The Eleventh Judicial Circuit In And
For Miami-Dade County
ATTACHMENT I
COMMUNITY MENTAL HEALTH CENTER (CMHC)
PROVIDER AGREEMENT
If after professional screening and evaluation a misdemeanor defendant seems to be in need of
acute care, the individual shall be referred to a Crisis Stabilization Unit (CSU) or a Jackson
Memorial Hospital crisis unit. If the defendant appears to be mentally ill, but does not need
acute services, the individual shall be referred to Community Mental Health Centers that have
agreed to provide the following services:
1.
2.
3.
4.

Follow-up appointment with the psychiatrist within 7 days of jail release.
Sufficient medication to last through next follow-up appointment.
Housing, as available, since temporary & emergency housing is always needed.
Tracking and linkage to continued care by a case manager.

Or if the individual is an alleged felon, they will be referred to UM/JMH treatment services.
The CMHCs who will render the services outlined in this agreement are:
________________________________________________
Bayview Center for Mental Health
________________________________________________
Citrus Health Network
________________________________________________
Community Health of South Dade, Inc.
________________________________________________
Douglas Gardens Community Mental Health Center
________________________________________________
Lock Towns Community Mental Health Center
________________________________________________
Miami Behavioral Health Center
________________________________________________
New Horizons Community Mental Health Center

152

Appendix H – Sample MOUs (continued)

Hillsborough County Jail Diversion
Memorandum of Understanding (MOU)
October 16, 2006
I. Background:
For several years Hillsborough County Criminal Justice Office in collaboration with a host of
community partners has been developing an array of jail diversion interventions for persons with
mental illness and/or substance use disorders. In 2006, Hillsborough County was awarded a
federal Substance Abuse and Mental Health Services Administration (SAMHSA); Center for
Mental Health Service (CMHS) Targeted Capacity Expansion (TCE) grant for jail diversion
services. The timing of this grant is congruent with several jail diversion activities in
Hillsborough County and the Florida Department of Children and Families Substance Abuse and
Mental Health (SAMH) Program Office in the Suncoast Region. The grant will serve as a
catalyst for further jail diversion system and service delivery development.
II. Vision:
It is the vision of the Hillsborough County Jail Diversion partners that persons arrested for
misdemeanors who are in need of mental health and/or substance abuse services should be
offered treatment as an alternative to incarceration. The Jail Diversion partners recognize that
recovery-oriented services that are evidence-based will yield positive outcomes for persons and
enhance their opportunities to be productive citizens. It is also envisioned that a comprehensive,
continuous and integrated system of care be established in Hillsborough County for persons who
will benefit from a wide array of community-based jail diversion services.
III. Goals:
The following goals are agreed upon by the Hillsborough County Jail Diversion partners:
System Level:
•
•
•
•

To establish a Strategic Plan to implement the SAMHSA Jail Diversion Grant over the
next three years (2006-2009).
To agree on a set of Recovery-oriented principles that will drive the system.
To establish a longer range Jail Diversion Plan for Hillsborough County.
To establish a community-wide MOU that is mutually beneficial to Jail Diversion
partners and the community at large.

Program Level:
•

To develop and implement a Forensic Intensive Case Management Program (F-ICM)
based on evidenced-based mental health (Assertive Community Treatment – ACT
modified), substance abuse and co-occurring (SAMH) models and best practices.

153

Appendix H – Sample MOUs (continued)

•
•

To utilize all other community-based mental health, substance abuse, health and social
service programs in Hillsborough County that will support the Jail Diversion system and
individuals served by it.
To implement a Jail Diversion program that ensures voluntary treatment and public
safety.

Clinical/Practice Level:
•
•
•

To identify individuals entering or within the Hillsborough County Jail with mental
illness and/or substance use disorders that would benefit from community-based mental
health and/or substance abuse diversion services.
To provide evidence-based treatment services to persons served by the SAMHSA Jail
Diversion grant and other sources of mental health or substance abuse funded services in
the County.
To develop a comprehensive, continuous and integrated array of services for persons in
need of mental health and/or substance abuse services and may also need health or social
services.

Principles and Values: Consumer and Family Driven
The Hillsborough County Jail Diversion Partners agree to adopt SAMHSA’s National Consensus
Statement on Mental Health Recovery (available upon request) in guiding the Jail Diversion
Grant and strategic plan. The fundamental components of recovery include the following:
1. Responsibility
2. Self-direction
3. Individualized and person-centered
4. Empowerment
5. Holistic
6. Non-linear
7. Strengths-based
8. Peer Support
9. Respect
10. Hope
IV. Purpose:
This MOU between Hillsborough County Government and an inclusive group of community
partners will establish a comprehensive jail diversion system for persons in need of mental health
and/or substance abuse treatment and recovery. The MOU is a cooperative agreement that is
mutually beneficial to the parties named below and will outline the expectations, roles,
responsibilities and goals of all partners.

154

Appendix H – Sample MOUs (continued)

V. Community Partners:
Lead Agency – Hillsborough County Government, Criminal Justice Office – SAMHSA Jail
Diversion Grantee.
Partners:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Hillsborough County Sheriff’s Office (Jail).
Hillsborough County Health and Social Services.
Citizens, consumers and family members receiving and recovering from mental health
and substance use disorders in Hillsborough County.
Agency for Community Treatment Services, Inc. (ACTS).
Mental Health Care, Inc. (MHC).
University of South Florida; Florida Mental Health Institute (FMHI); Department of
Mental Health Law and Policy (MHLP).
Florida Department of Children and Families, Suncoast Region Substance Abuse and
Mental Health Program Office (DCF-SAMH).
Central Florida Behavioral Health Network, Inc. (CFBHN).
Drug Abuse Comprehensive Coordinating Office, Inc. (DACCO).
Gulf Coast Community Care.
Homeless Coalition of Hillsborough County, Inc.
National Alliance on Mentally Illness: NAMI Hillsborough.
Public Defender’s Office of Hillsborough County.
State Attorney’s Office for the Thirteenth Judicial Circuit.
13th Judicial Circuit Court.
Hillsborough County Public Safety Coordinating Council.
Other community partners are welcome to join as a part of building a comprehensive
system of care.

VI. Duration of the MOU:
This agreement will be in effect on the date signed by all partners and shall be in effect until the
MOU is cancelled by the partners in accordance with the terms set forth herein. The MOU will
be an integral part of the Strategic Plan and serve as a guide for achieving many of the goals of
the SAMHSA Jail Diversion grant and larger system development in Hillsborough County.
VII. General Provisions:
This MOU does not create additional jurisdiction or limit or modify existing jurisdiction vested
in the parties. It is understood by all parties that each should fulfill its responsibilities under this
MOU in accordance with the provisions of law and regulations that govern their activities.
Nothing in this MOU is intended to negate or otherwise render ineffective any such provisions or
operating procedures. If at any time a party is unable to perform its functions under this MOU
consistent with such party’s statutory and regulatory mandates, the affected party shall

155

Appendix H – Sample MOUs (continued)

immediately provide written notice to the others to establish a date for mutual resolution of the
conflict.
VIII. Responsibilities:
In consideration of the mutual aims and desires of the parties of this MOU and in recognition of
the public benefit derived from effective implementation of the programs involved, the primary
parties of the Jail Diversion grant agree that their responsibilities under this MOU shall be as
follows:
Hillsborough County Government: Criminal Justice Office – Jail Diversion Grant Management
and system coordination and long range strategic planning.
ACTS – Service provider contracts, substance abuse and co-occurring services coordination,
development of client confidentiality “business associate” or “covered entity” agreements.
MHC – Primary F-ICM program development and implementation, practice guidelines, best
practices, providing client demographics to USF-FMHI for evaluation purposes and obtaining
“release of information” for collaborating treatment providers.
FMHI – SAMHSA Jail Diversion strategic planning, data collection and evaluation. FMHI will
be responsible for getting approval from the USF Institutional Review Board (IRB) to conduct
the Jail Diversion evaluation. FMHI will also offer a series of best practices application to the
community through faculty consultation and training.
All other partners - Active participation in the strategic planning process and involvement on
agency appropriate committees, such as the Service Delivery Committee, Evaluation Committee
or Project Implementation Committee.
IX. Confidentiality and Procedures for Sharing of Information:
Treatment Partners (MHC, ACTS, HCSO, etc.) – Will agree to participate as a “business
associate” or “covered entity” of MHC or ACTS in sharing confidential information with other
providers for continuity of care. The treatment partners further agree that they will communicate
and/or disclose to one another, client information pertaining to mental health, alcohol and
substance abuse treatment only with the client’s written consent or as otherwise authorized by
applicable law (HIPAA, 42 CFR II).
Non-treatment partners – Responsible for sharing aggregate, non-identifying clinical information
for grant and evaluation purposes.
X. Effective Administration and Execution of this MOU:
A. This MOU shall be reviewed annually and remain in full force and effect until
specifically abrogated by one of the parties to this MOU with thirty (30) days written
notice to the other party.

156

Appendix H – Sample MOUs (continued)

B. Effective execution of the MOU can only be achieved through communication and
dialogue. It is recognized that each partner in this MOU works in a complex legal, social
and political environment. It is the intent of this MOU to foster a means of
communication and resolve questions, misunderstandings or complaints that are not
specifically addressed in the MOU.
C. After the execution of this MOU, Criminal Justice Office will provide copies to all
parties and submit the MOU to SAMHSA for approval and release of Jail Diversion
grant funding to proceed with F-ICM services.

157

Appendix H – Sample MOUs (continued)

MIAMI/DADE COUNTY (DCF DISTRICT 11A)
MEMORANDUM OF AGREEMENT AND CONSENSUS DOCUMENT
CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS
June 4, 2004
Overview
Individuals with co-occurring psychiatric and substance disorders in District 11 are recognized as
a population with poorer outcomes and higher costs in multiple clinical domains. They are
commonly “system misfits”, incompletely served in both mental health and substance abuse
treatment settings, with resulting overutilization of resources in the criminal justice system, the
primary health care system, the homeless shelter system, and the child welfare system. In
addition to having poor outcomes and high costs, individuals with co-occurring disorders are
sufficiently prevalent in all behavioral health settings that they can be considered an expectation,
rather than an exception.
In order to provide more welcoming, accessible, integrated, continuous, and comprehensive
services to these individuals (adults, children, families), the following entities in District 11 have
agreed to adopt the Comprehensive, Continuous, Integrated System of Care (CCISC) model for
designing systems change to improve outcomes within the context of existing resources: These
entities include funders (both direct funders such as DCF District 11 and Miami Dade County as
well as funding entities that are contracted to manage or oversee various funding streams within
the District system: Jackson Memorial Hospital Managed Medicaid organization, South Florida
Provider Coalition, Miami-Dade County Homeless Trust, etc.), Advocacy organizations (e.g.,
NAMI, SAMH Planning Council, consumer orgs); Mental Health, Substance Abuse, and
Children’s Mental Health Providers; Juvenile Justice; Mental Health Court Jail Diversion
(Dade); Public Health Trust – Jackson Memorial Hospital (Dade); Community Based Care
(CMH).
This model is based on the following eight clinical consensus best practice principles (Minkoff,
1998, 2000) which espouse an integrated clinical treatment philosophy that makes sense from the
perspective of both the mental health system and the substance disorder treatment system:
Dual diagnosis is an expectation, not an exception. This expectation has to be
included in every aspect of system planning, program design, clinical procedure, and
clinician competency, and incorporated in a welcoming manner into every clinical
contact.

2.

The core of treatment success is any setting is the availability of empathic, hopeful
treatment relationships that provide integrated treatment and coordination of care
during each episode of care, and, for the most complex patients, provide continuity of
care across multiple treatment episodes.

158

1.

Appendix H – Sample MOUs (continued)

3.

Assignment of responsibility for provision of such relationships can be determined
using the four quadrant national consensus model for system level planning, based on
high and low severity of the psychiatric and substance disorder.

4.

Within the context of any treatment relationship, case management and care, based on
the client’s impairment or disability, must be balanced with empathic detachment,
confrontation, contracting, and opportunity for contingent learning, based on the
client’s goals and strengths, and availability of appropriate contingencies. A
comprehensive system of care will have a range of programs that provide this balance
in different ways.

5.

When mental illnesses and substance disorders co-exist, each disorder should be
considered primary, and integrated dual primary treatment is required.

6.

Mental illness and substance dependence are both examples of chronic,
biopsychosocial disorders that can be understood using a disease and recovery model.
Each disorder has parallel phases of recovery (acute stabilization, engagement and
motivational enhancement, prolonged stabilization and relapse prevention,
rehabilitation and growth) and stages of change. Treatment must be matched not only
to diagnosis, but also to phase of recovery and stage of change. Appropriately
matched interventions may occur at almost any level of care.

7.

Consequently, there is no one correct dual diagnosis program or intervention. For
each individual, the proper treatment must be matched according to quadrant,
diagnosis, disability, strengths/supports, problems/contingencies, phase of recovery,
stage of change, and assessment of level of care. In a CCISC, all programs are dual
diagnosis programs that at least meet minimum criteria of dual diagnosis capability,
but each program has a different “job”, that is matched, using the above model, to a
specific cohort of patients.

8.

Similarly, outcomes must be also individualized, including reduction in harm,
movement through stages of change, changes in type, frequency, and amounts of
substance use or psychiatric symptoms, improvement in specific disease management
skills and treatment adherence.

Using these principles, we have agreed to implement a CCISC as a comprehensive quality
improvement project in District 11, incorporating quality improvement activities at the funder
level, advocacy level, and provider level, to achieve a system change process with the following
four core characteristics:
1.

The CCISC requires participation from all components of the behavioral health
system, with expectation of achieving, at minimum, Dual Diagnosis Capability
standards (and in some instances Dual Diagnosis Enhanced capacity), and planning
services to respond to the needs of an appropriately matched cohort of dual diagnosis
patients.

2.

The CCISC will be implemented initially within the context of existing treatment
resources, by maximizing the capacity to provide integrated treatment proactively
within each single funding stream, contract, and service code.

159

Appendix H – Sample MOUs (continued)

3.

The CCISC will incorporate utilization of the full range of evidence-based best
practices and clinical consensus best practices for individuals with psychiatric and
substance disorders, and promote integration of appropriately matched best practice
treatments for individuals with co-occurring disorders.

4.

The CCISC will incorporate an integrated treatment philosophy and common
language using the eight principles listed above, and develop specific strategies to
implement clinical programs, procedures, and practices in accordance with the
principles throughout the system of care.

Action Plan for the District:
1.

The DCF District Leadership, in partnership with representatives of managed care
funders, providers and stakeholders, will assist in sustaining the Project Leadership
Team, which is empowered to make key decisions regarding implementation
activities that will take place under the authority of DCF, and will affect performance
and participation of providers and stakeholders. The Project Leadership Team is the
collaborative process for overseeing a transformation of the District 11 behavioral
health service delivery system, with the first step being a focus on developing a
systemic CQI process regarding co-occurring disorders. Over time, other initiatives
may come under the auspice and design of this Team. Membership in the Project
Leadership Team will be open to all funders, providers and stakeholder agencies that
commit to contributing empowered consistent membership to the team, to be bound
by its decisions, and to commit to the initial activities defined in this memorandum of
agreement document.

2.

DCF will work collaboratively with all funders in the system to assure that
performance objectives and quality improvement plans developed by those funders
(in the funder’s own performance contract with the state or county) incorporate
indicators that are consistent with and supportive of the provider activities and system
development activities that are included in this Charter Document, and that these
indicators are translated by the funders into provider contracting and oversight
mechanisms in a manner that is developmentally consistent with the timing of the
objectives agreed to in this charter.

3.

The Project Leadership Team will be convened by DCF with a letter to CEOs of
involved entities. The Team will create a committee to define its mission and scope,
and disseminate that mission and scope, along with this memorandum of agreement
document, to all providers and stakeholders.

4.

The Project Leadership Team will be designed in such a way that there is clear
representation of the Children’s System on the Leadership Team, and with the intent
that the elements of this memorandum of agreement will be integrated so that dual
diagnosis capability will be built as an expectation of the Children’s System.

5.

The Project Leadership Team will design a plan for educating collaborative systems
to this initiative and bringing them into the Leadership Team process: Education,
Juvenile Justice, Adult Criminal Justice systems, Child Welfare, and helping them to

160

Appendix H – Sample MOUs (continued)

begin to initiate project expectations into their own contracts and program design
activities.
6.

The Project Leadership Team will create a subcommittee to develop a systemic policy
welcoming individuals and families with co-occurring disorders into the system of
care, and creating a definition of co-occurring disorders that recognizes that family
members of children are included in the definition (e.g. Substance abusing parents of
emotionally disturbed children; mentally ill parents with substance abusing children).

7.

This initiative will be organized as a comprehensive CQI project under the auspices
of the District, all funders, Planning Council representatives, and the Leadership
Team. They will formally charter the initiative within that framework.

8.

The Leadership Team will score the CO-FIT within the next six months to establish a
baseline measure for CQI improvement, and to define a methodology for project
outcome evaluation.

9.

The Leadership Team will identify an individual to be Project Director and develop
resources for project management, such as defining responsibility will be to develop
mechanisms for collecting data to monitor project performance by participants at all
levels.

10.

The Leadership Team will develop a process to identify simple methodology for
district level data capture for the prevalence of individuals and families with cod in
the service population, and align this with quality improvement efforts to improve
data collection for each of the funders. Efforts will be made to create a consistent
reporting mechanism for this information across the multiple funders, to the extent
possible.

11.

The leadership Team will develop and recommend mechanisms to establish
incentives for participation by agencies and providers, and align these incentives with
any quality improvement incentive mechanisms developed by the funders.

12.

The Leadership Team will assist in the development by each funder of clear
instructions or interpretive guidelines for providers on how to provide, document, and
bill for appropriate integrated treatment within the context of any funding stream or
contract. This will include the development of an integrated scope of practice for
singly defined clinical staff, which will define the range of appropriate activities.

13.

The Leadership Team will work to integrate dual diagnosis capability, cultural
competency, and Children’s system of care values into all other initiatives, so that all
key initiatives are properly aligned.

14.

Invite Drug Court to the table.

15.

Invite the Marchman and Baker Act offices to the table.

16.

The District will work in partnership with providers, trainers, stakeholders to effect
administrative, policy, and procedure changes to remove barriers to implementation,
and to facilitate utilization of existing resources to promote implementation.

161

Appendix H – Sample MOUs (continued)

Action Plan for Managed Care Funders and other intermediaries:
1.

To participate with DCF in aligning performance objectives, quality improvement
efforts, provider incentives, data collection, etc, with the elements of CCISC
implementation incorporated in this charter.

2.

To participate actively in the Leadership Team and in appropriate committees to work
in partnership with providers and stakeholders in designing the quality improvement
process for movement toward DDC implementation.

3.

To support the use of the CCISC toolkit by providers, and to participate in using the
CO-FIT as part of system level assessment of progress in CCISC implementation.

4.

To align policy development regarding welcoming, screening, billing for integrated
services with the overall objectives of DCF and with the development of CCISC
implementation

5.

To support the provision of technical assistance, training, and consultation as
appropriate to supporting the internal quality improvement objectives for their funded
providers within the context of this initiative.

Action Plan for Providers and Stakeholders:
In the first year of implementation, all participating agencies or programs will agree to the
following action steps:
Adopt this memorandum of agreement as an official policy statement of the agency or
program, with approval of the Board of Directors. Circulate the approved document
to all staff, and provide training to staff and board members regarding the principles
and the CCISC model.

2.

Assign appropriately empowered staff to participate in District 11 integrated system
planning and program development activities: in particular the Project Leadership
Team, and any relevant subcommittees.

3.

Formally adopt the goal of achieving dual diagnosis capability as part of the agency’s
or program’s short and long range strategic planning and quality improvement
processes.

4.

Participate in agency or program self-survey using the COMPASS to evaluate the
current status of dual diagnosis capability.

5.

Develop an agency or program specific action plan outlining measurable changes at
the agency level, the program level, the clinical practice level, and the clinician
competency level to move toward dual diagnosis capability. Monitor the progress of
the action plan at six-month intervals. Participate in system wide training and
technical assistance with regard to implementation of the action plan.

6.

Participate in system wide efforts to improve identification and reporting of
individuals with co-occurring disorders by incorporating agency specific
improvements in integrated screening and data capture in the action planning process.
Incorporate efforts to identify comorbidity in populations that are also identified by
cultural background.

162

1.

Appendix H – Sample MOUs (continued)

7.

Participate in system wide efforts to improve welcoming access for individuals with
co-occurring disorders (of all cultural backgrounds) by adopting agency or program
specific welcoming policies, materials, and expected staff competencies.

8.

Participate in system wide efforts to demonstrate increased efficiency of resource
utilization by developing agency specific policies, procedures, and training for staff to
define an appropriate integrated scope of practice for each category of staff and to
provide, document, and bill for appropriate integrated treatment within any service
contract or funding stream.

9.

Assign staff to participate in system wide efforts to develop dual diagnosis capability
standards, and dual diagnosis practice guidelines. One first step will involve defining
the content of an integrated assessment, for the purpose of measurable clinical
process outcome monitoring, as well as clinical training.

10.

Develop policies and procedures to support welcoming and eliminate any arbitrary
barriers to access based on comorbidity (e.g., no crisis evaluation until alcohol level is
below a certain amount; no admission of intoxicated individuals to CSU, no
admission to addiction treatment of individuals on psych meds) in both emergency
and routine situations.

11.

For all agencies participating in any children’s system of care initiative, incorporate
dual diagnosis capability into activities related to those initiatives: interagency care
coordination meetings, prevention activities, wraparound services.

12.

For prevention services, there will be an emphasis on identification of opportunities
to develop specific prevention approaches to substance abuse in individuals (children
and young adults) with emotional problems and serious emotional disturbance, and to
engage in early intervention with substance abusing young people to prevent the
emergence of mental illness.

13.

Participate in system wide efforts to identify required attitudes, values, knowledge,
and skills for all clinicians regarding co-occurring disorders, and adopt the goal of
dual diagnosis competency for all clinicians as part of the agency’s long range plan.

14.

Participate in clinician competency self survey using the CODECAT and use the
findings to develop an agency or program specific training plan.

15.

Identify appropriate clinical and administrative staff to participate as identified
“champions” and change agents for the initiative, and who may also become trainers
in a system wide train-the-trainer initiative, if developed. These individuals will be
designated to work with the Project Director, and to assume responsibility for
implementation of the agency or program training plan in relation to its action plan.

163

LIST OF ACRONYMS
ACT

Assertive Community Treatment

AHCA

Florida Agency for Health Care Administration

APD

Agency for Persons with Disabilities

ASO

Administrative Services Organization

CBC

Community-Based Care

CBHA

Comprehensive Behavioral Health Assessment

CIT

Crisis Intervention Team

CJ/MH

Criminal Justice/Mental Health

CRC

Central Receiving Center

CSU

Crisis Stabilization Unit

DCF

Florida Department of Children and Families (formerly DHRS)

DHRS

Florida Department of Health and Rehabilitative Services (currently DCF)

DJJ

Florida Department of Juvenile Justice

DOC

Florida Department of Corrections

DOH

Florida Department of Health

F.S.

Florida Statute(s)

FADAA

Florida Alcohol and Drug Abuse Association

FCCMH

Florida Council for Community Mental Health

FDLE

Florida Department of Law Enforcement

F-ICM

Forensic Intensive Case Management

FMHI

University of South Florida, Louis de la Parte Florida Mental Health Institute

164

FPIC

Florida Partners in Crisis

FPL

Federal Poverty Level

HCBS

Home and Community-Based Services (Medicaid)

IMR

Illness Management and Recovery

ISCN

Integrated Specialty Provider Network

ITP

Incompetent to Proceed to Trial

JAC

Juvenile Assessment Center

MHA

Mental Health America (formerly the National Mental Health Association)

MOU

Memorandum of Understanding

NAMI

National Alliance on Mental Illness

NGI

Not Guilty by Reason of Insanity

OSCA

Office of the State Courts Administrator

SAMH Corp

Florida Substance Abuse and Mental Health Corporation

SED

Severe Emotional Disturbance

SMI

Serious Mental Illness

SPMI

Severe and Persistent Mental Illness

SOAR

SSI/SSDI Outreach Access and Recovery

SPECTRM

Sensitizing Providers to the Effects of Correctional Incarceration on
Treatment and Risk Management

SSDI

Social Security Disability Insurance

SSI

Supplemental Security Income

165

500 South Duval Street
Tallahassee, FL 32399-1900