The following is a proposed Continuum of Care. Underlined items are currently missing from the delivery system. The effectiveness of the proposed continuum, and efforts to divert and successfully treat and maintain mentally ill individuals in the community, will rely on all pieces of the continuum being operational.
I. Initial Contact with Law Enforcement
A. Dependent on the nature of the offense and the presenting mental status and behavior of the individual that comes to the attention of the law enforcement officer, the officer may:
1. Make a decision to charge.
2. Consider pre-arrest diversion.
a) Obtain screening, assessment, and referral by community service gatekeeper in large communities.
b) Directly transfer the individual for assessment by outpatient mental health providers, hospital or detox facility.
II. Intake into Department of Corrections facilities
B. Mental health status screening conducted by nursing staff shortly after intake (within 24 hours) on new remands to Department of Corrections.
C. If indicated, referral to Department of Corrections mental health staff for further assessment, diagnosis, and treatment recommendations. If indicated:
3. Recommendations to institutional staff regarding behavioral management.
4. Mental health treatment.
D. Identify potential candidates for misdemeanant diversion.
1. Coordination between court and legal system on case prosecution and sentencing.
2. Once stabilized, release mentally ill misdemeanant offender to community on court ordered intensive probation with coordinated mental health follow-up.
III. Department of Corrections Treatment Programs
E. Individual treatment plan to include:
5. Medication prescription and monitoring.
6. Individual and group counseling.
7. Specialized programs e.g., anger control, life skills, substance abuse treatment, sex offender treatment, values clarification, thinking errors, cognitive skills.
8. Housing placement determination based on acuity:
c) Psychiatric hospital care available when needed.
d) Acute care (24 hour intensive monitoring, treatment and protection), makes it possible to deliver frequent therapeutic interventions for people experiencing psychotic or similar symptoms. (Currently Cook Inlet Pre-Trial Facility Mike Module is available for men. A psychiatric assessment and treatment unit for women is critically needed. A women's psychiatric unit is scheduled to open in 1998 with initial funding provided by the Alaska Mental Health Trust Authority; continued funding by the Legislature is critical).
e) Sub-acute care--residual symptoms and impaired functioning prevents person from being mainstreamed with general population (currently provided in Cook Inlet Pre-Trial Facility-Mike Mod).
f) Sheltered living--separate from general population (e.g., Hiland Mountain Correctional Center special needs wing for men).
g) Crisis bed--short-term use of mental health segregation bed monitored by correctional officers and mental health staff.
h) Transitional housing in preparation for release, i.e. furlough.
9. Contact with community mental health centers regarding mentally ill inmates in custody:
a) Occurs regarding their clients at time of arrest.
b) Referral made to community mental health centers during incarceration. Intervention/involvement of outpatient providers periodically occurs during incarceration for continuity of care.
c) Formal transfer of patient care at release.
IV. Post Release Treatment and Services
F. Specialized probation officers for mentally ill male and female felons, and probation officer or some other form of monitoring for misdemeanants.
G. Options in housing ranging from 24 hour structured supervised housing, to group homes, to independent apartments with case management.
H. Programs that provide daily structure, support, rehabilitation, treatment, and supervision. These could include partial hospitalization, specialized work programs, clubhouses, therapeutic/recreational activities, life skills, and anger management, as needed by the patient.
I. Special substance abuse treatment for the mentally ill (emphasizing relapse prevention), including residential, outpatient, transitional, and long-term specialized housing.
J. Option of intensive case management with daily outreach contact.
K. Specialized sex offender treatment for mentally ill offenders (modified relapse prevention model).
L. Community mental health center programs ranging from emergency care to outpatient support to intensive 24-hour supervised care in the community, including a full range of housing options.
M. Access to hospital treatment beds.
N. Mentally ill inpatient stay at hospital long enough to be stabilized.
O. Long term or tertiary care in structured setting for severely chronically mentally ill.
P. Specialized substance abuse treatment for the mentally ill emphasizing relapse prevention to be offered in the community.
VI. Notes to the Continuum of Care: Potential Legal Issues
Q. There is a systematic relationship between Alaska Psychiatric Institute admissions criteria, bed capacity, length of stay, and patient stability. If people are not admitted when necessary or do not receive adequate lengths of stay, they may become involved with the criminal justice system. The involuntary commitment statute should be reexamined to determine if a change is needed to insure access to psychiatric care.
R. Persons who are hospitalized under Title 12 whose charges are dropped may need continued psychiatric care under Title 47. Present Alaska statutes and procedures should be re-examined to determine if this transition can be streamlined to effectively insure adequate psychiatric care for the individual.
S. The guardianship statute, A.S. 13.26.150 (e) (1), prohibits voluntary admissions to Alaska Psychiatric Institute for mentally ill persons who have a court-ordered public guardian. Admission is by formal commitment proceeding only. Mentally ill individuals who have a guardian must severely decompensate in their illness before they are able to obtain inpatient hospital care. Legal change is needed to make it possible for these individuals to have earlier access to appropriate psychiatric hospital care.
T. Criminalization of the mentally ill is an increasing problem. Alaska lacks a system of diversion from jail into community based mental health programs. Jail should not be used as intake into the mental health system. Diversion of mentally ill offenders arrested on misdemeanant charges is needed to reduce criminalization of the mentally ill. A system for diversion of mentally ill misdemeanant offenders needs to be developed. It is expected it will include close coordination between the court, defense and prosecuting attorneys, correctional and community mental health staff, and when funded, a misdemeanant case coordinator to monitor treatment compliance in hopes of reducing clinical and legal recidivism. Ultimately, a single point of entry mechanism to ensure assessment of the individual is needed in large communities.
U. In June, 1997, the U.S. Supreme Court upheld the constitutionality of civil commitments of dangerous sexual predators after they have served their prison sentences. If enacted in Alaska, such a law could have negative consequences for people with mental illnesses and for the public mental health system. Sexual predator legislation could potentially increase the number of individuals needing locked facilities. Increased resources would be required to manage this population without negatively impacting public mental health and correctional services.
V. Confidentiality issues need to be addressed to allow for exchange of information to identify mentally ill individuals who come in contact with the criminal justice system and will be in need of increased coordination between members of the legal community and mental health providers. Management information systems could be designed to address both the need to identify individuals entering each system and those common to both systems.