Gold Award: Prevention of Jail and Hospital Recidivism Among Persons With Severe Mental Illness

Project Link is a university-led consortium of five community service agencies in Monroe County, New York, dedicated to preventing repeated incarceration and hospitalization of persons with severe mental illness and promoting their reintegration into the community. The consortium spans the health care, social service, and criminal justice systems and features a mobile treatment team with a forensic psychiatrist, a dual diagnosis treatment residence, and multicultural staff.

The department of psychiatry of the University of Rochester formed Project Link in 1995 in response to growing concerns about the criminalization of the mentally ill population. The project, which incorporates principles of assertive community treatment and intensive case management, has already had a significant impact in decreasing the number of mentally ill individuals in jails and the number of persons admitted to psychiatric hospitals from jails. It has also reduced reliance on inpatient hospitalization in a high-risk consumer group.

This outstanding program is another example of the department of psychiatry's long history of innovation in serving persons with severe mental illness. In the 1960s the department formed a strong public-academic liaison with the state hospital, Rochester Psychiatric Center. The department was a leader in the development and evaluation of the Monroe-Livingston demonstration project, the first large deinstitutionalization program in the nation in which capitated funds followed patients into the community.

The demonstration project created a broad base of community services and forged early ties among providers committed to improving community-based care. However, despite the presence of these services, during recent years it became clear that many prospective patients were missed. They lived on the streets and were noncompliant with medication and often were dependent on alcohol and illegal drugs. They cycled between jails, hospital emergency rooms, and brief episodes of inpatient care, after which they were back on the streets without ever being adequately treated or stabilized. African Americans and Latinos were heavily overrepresented in this group of poorly served individuals.

In 1995 the Strong Ties Community Support Program of the University of Rochester's department of psychiatry formed Project Link by creating a partnership with five community organizations that served the inner-city population. The partner agencies are Action for a Better Community, the Ibero-American Action League, the Monroe County Clinic for Socio-Legal Services, Unity Health System, and the Urban League of Rochester. A director from each agency is a member of Project Link's collaborative management team, which meets regularly to oversee the project.

In recognition of its achievement in meeting the clinical, social, and residential needs of a vulnerable and difficult-to-treat segment of the chronically mentally ill population, Project Link was selected as one of two winners of the Gold Achievement Award for 1999. The award is presented annually by the American Psychiatric Association to recognize outstanding programs for mentally ill and developmentally disabled persons. It includes a $5,000 prize made possible by a grant from Pfizer, Inc., U.S. Pharmaceuticals.

Project Link was selected in the category of large academically or institutionally sponsored programs. The winner of the award for small community-based programs is described in a separate article on page 1473. The awards were presented on October 29 during the opening session of the Institute on Psychiatric Services in New Orleans.

Program development and organization

Project Link developed from a 1993 survey of the county jail conducted by the Monroe County Office of Mental Health. The survey identified a group of 126 individuals with severe mental illness who had experienced multiple jail and hospital stays during the previous three years. Most of these individuals were young men of African-American or Latino heritage who suffered from a combination of schizophrenia and drug addiction and who lacked stable housing. Costs for their mental health services and competency evaluations in 1993 alone totaled $628,000.

Based on these findings, the Office of Mental Health issued a request for proposals in 1995. The department of psychiatry of the University of Rochester responded in partnership with five community agencies to form Project Link. Project Link began as a team of bachelor's-level case advocates and a master's-level coordinator, with one case advocate employed at each of the community agencies. Currently the project employs five case advocates from these agencies.

The role of the case advocate is to prevent jail and hospital recidivism by linking consumers to psychiatric, medical, residential, and social services in the community. Each case advocate carries a caseload of 20 consumers, and the team is available seven days a week, 24 hours a day. Case advocates receive supervision and clinical support through the Project Link coordinator, a nurse with mental health and chemical dependency treatment experience. In addition, the coordinator directs community education efforts and represents the case advocates on Project Link's collaborative management team.

Admission criteria for Project Link include the presence of a severe and persistent mental illness and a history of involvement with the criminal justice system. Consumers are enrolled from a wide variety of sources, including state correctional facilities, the local jail, local police departments, the public defender's office, hospitals, and emergency rooms. Project Link places a special emphasis on engaging consumers who are members of minority populations. To effectively bridge barriers related to differences in culture, ethnicity, and language, Project Link features a diverse staff including African-American and Latino case advocates. In addition, all clinical and administrative staff of Project Link have received cultural competence training provided through the Urban League of Rochester. The case advocate team's workload has grown steadily since the project began. Case advocates logged 2,715 contact hours in 1996, 4,340 hours in 1997, and 5,712 hours in 1998.

Although Project Link was initially effective in engaging the target population, the case advocates encountered serious barriers to obtaining appropriate housing for some of the most impaired clients. Those with active drug abuse, multiple arrests, and felony convictions were usually denied admission to group homes or supervised apartments. Case advocates often had to house these consumers in single-room apartments or cheap hotels, which were typically located in drug-infested neighborhoods. In addition to housing problems, the case advocates reported serious difficulty gaining and maintaining access to outpatient health services because psychiatric and medical clinics did not provide the outreach necessary to engage this challenging group.

After a series of discussions that included consumers, case advocates, and staff of the partner agencies, Project Link applied for a Local Initiative Funding Partners grant from the Robert Wood Johnson Foundation in 1997. This effort was led by project director Steve Lamberti, M.D., and the goal was to obtain funds to address the clinical and residential service barriers that case advocates had encountered. The LIFP program was designed to match local dollars, and the administrative staff of Project Link raised a total of $278,000 from multiple sources to qualify for grant funding. Funding partners include the New York State Office of Mental Health, the Monroe County Office of Mental Health, Coordinated Care Services, Inc., Eli Lilly and Company, and Janssen Pharmaceuticals. Project Link was given a four-year grant totaling $557,000. The funds were used to develop a mobile treatment team and treatment residence for clients with severe mental illness and chemical addiction.

Mobile treatment team

The mobile treatment team is designed to ensure the delivery of comprehensive health services around-the-clock to 40 of the 100 total enrollees in Project Link who are in greatest need of assistance. The team is not limited to performing crisis intervention and referral but provides an extended period of intensive treatment and stabilization. Given the high level of impairment of clients of Project Link, the anticipated average length of stay in the mobile treatment team is two years.

The team was developed by adding a forensic psychiatrist (.6 full-time equivalent) and a full-time psychiatric nurse practitioner to the existing case advocacy team. The primary role of the forensic psychiatrist is to provide psychiatric evaluation and treatment services and to promote the integration of clinical services with all components of the criminal justice system. In addition, the forensic psychiatrist is responsible for educating and training case advocates and residence staff. The role of the nurse practitioner is to assist the team psychiatrist in delivering psychiatric services and to ensure the delivery of primary medical care. The nurse practitioner also collaborates with treatment residence staff by leading groups at the residence. Project Link's forensic psychiatrist and co-director is Robert L. Weisman, D.O., and the nurse practitioner is Nancy Price, M.S., R.N. Coordinator for the project is Rudo Munondo-Ashton, M.S., R.N.

All consumers served by the mobile team receive primary care through the Medicine in Psychiatry Service (MIPS), a program that specializes in providing medical services to adults with severe mental illness. Because Project Link and MIPS are both located at the Strong Ties Community Support Program, clients of the mobile treatment team are eventually linked to services at Strong Ties to promote continuity of care.

Treatment residence

The treatment residence for clients with chemical dependence was developed using an existing ten-bed residential facility that is managed by DePaul Residential Services. The facility is overseen by Deborah A. White, B.S. Grant funds were used to enrich the staffing in this facility, including the addition of a certified addictions counselor. The treatment residence is staffed 24 hours a day and offers a structured program that involves a four-level system of care. Consumers receive more privileges and have fewer restrictions as they advance through each level. For example, level I requires consumers to receive supervised transportation to and from all outside activities, and subsequent levels allow for and encourage the use of public transportation. The goal of the four-level system is to provide consumers with the opportunity to acquire and practice the skills necessary to live independently in the community.

Consumers in the treatment residence also participate in several groups and activities that address chemical dependency issues. They include psychoeducational groups about mental illness and addiction, self-help groups, recreational activities, and off-site Alcoholics Anonymous and Narcotics Anonymous meetings. The expected average length of stay in the residence is two years. After completing the program, consumers are provided housing options within DePaul Residential Services or in the community.

To promote the integration of clinical and residential services, all consumers in the treatment residence receive clinical services through the mobile treatment team. The mobile treatment team and the treatment residence staff meet three times a week. One meeting involves clinical rounds on all consumers enrolled at the residence. A second meeting is dedicated to staff education and development. This forum has been used by the forensic psychiatrist and a Strong Ties consultant knowledgeable about chemical dependency to provide safety training and substance abuse education to all residence staff members. The third weekly meeting involves discussion of administrative issues by the Project Link coordinator and residence manager. In addition to these meetings, clinical and residential staff members work together as needed to develop and implement individualized care plans for each resident in the program.

Integration with the criminal justice system

A key feature of Project Link is integration with the criminal justice system. Project Link staff members work with consumers in courtroom and jail settings, where they routinely talk with judges, public defenders, and jail staff. This dialogue promotes the disposition of consumers to Project Link as an alternative to incarceration and as a condition of release. Staff members also collaborate with probation and parole officers whenever consumers are involved in those programs. By enlisting the help of probation and parole officers in reinforcing treatment recommendations, Project Link is able to create therapeutic leverage with consumers who have a history of noncompliance. Such leverage is important in promoting consumers' participation in essential clinical and social services and in helping them initiate and maintain sobriety.

To further integrate criminal justice, health, and social services, liaison persons are designated within each local department of social services office to serve as points of contact for all consumers served by Project Link.

Project Link staff members have worked to educate professionals in the criminal justice system about severe mental illness and to promote awareness of Project Link services. During the past three years, staff members have presented seminars to several agencies, including the Monroe County Department of Parole, the Monroe County Department of Probation, the Rochester Police Department, the Monroe County Bar Association, the Monroe County Clinic for Socio-Legal Services, Alternatives to Incarceration of Monroe County, and the Monroe County sheriff's office.

To educate the general public about mental illness and Project Link, staff members have also presented lectures at several community agencies, including local churches, settlement houses, and emergency shelters.

Consumers' role

Consumers have played an important role in the development of Project Link. Consumer input about service gaps at the start of the project helped provide the impetus to pursue the Robert Wood Johnson grant. Consumer input is also obtained through satisfaction assessment surveys, and the information is used to improve performance. In addition, consumers recently participated in a Robert Wood Johnson site visit and provided feedback to foundation representatives about the effectiveness of the mobile treatment team and the treatment residence.

Program effectiveness

To examine the project's effectiveness, Project Link looked at the experiences of the 46 persons with severe and persistent mental illness who were admitted to Project Link's mobile treatment team between October 1, 1997, and December 1, 1998. The mean length of stay in the project for this group was 278 days. The largest referral sources were the jails and prisons (30 percent) and the local state hospital (28 percent).

Thirty-seven of these consumers were men, and their mean age at enrollment was 34 years. Thirty-three consumers were African American, seven were Caucasian, three were Hispanic, two were Native American, and one was Asian. At enrollment, 13 consumers were homeless. Thirty-seven failed to graduate from high school.

Twenty-one of the 46 consumers had a DSM-IV diagnosis of schizophrenia, 12 had a psychotic disorder not otherwise specified, six had schizoaffective disorder, four had bipolar disorder, and three had other diagnoses. Thirty-eight of the 46 consumers had histories of comorbid substance abuse or addiction. At enrollment, their mean score on the Global Assessment of Functioning Scale was 39.

Twenty-three consumers were on parole or probation at the time of enrollment, and charges were pending for an additional five consumers. Twenty had previous felony convictions. Compared with the year before enrollment in Project Link, the mean number of days spent in jail per month for the group of 46 consumers dropped from 9.1 to 2.1 per consumer, and the mean number of hospital days per month dropped from 8.3 to .3. Significant reductions were also noted in the total numbers of incarcerations and hospital admissions for the group.

A preliminary evaluation of the costs incurred by the group of 46 consumers revealed that average monthly jail costs for the entire group dropped from $30,908 to $7,235, or from $672 to $157 per consumer. Average monthly hospital and outpatient costs, including costs for services provided by Project Link, dropped from $197,899 to $42,247 for the group, or from $4,302 to $918 per consumer.

Consumer's ratings of satisfaction with the program yielded a mean of 4.6, with 5 indicating the highest level of satisfaction. In addition, 35 of the 46 consumers reported that Project Link helped them cut down on their use of illegal drugs and alcohol. No assaults, suicide attempts, or other reportable incidents have occurred in the group of 46 consumers since their enrollment in Project Link.

Program innovation and contributions

Several aspects of Project Link represent much-needed innovations and important contributions in serving persons with severe mental illness who have a history of involvement with the criminal justice system. The project has created critical links between health care, social service, and criminal justice systems. The coordinated efforts of several agencies are necessary to address the many problems of this consumer group. The project's emphasis on bridging cultural and language barriers and in providing cultural competence training to all team members has made it especially effective in engaging consumers and in gaining community support.

Although conventional assertive community treatment and intensive case management models have been used with similar populations, most studies show little effect of these approaches on time spent in jail. Project Link has made a significant contribution in reducing incarceration among consumers in Monroe County. As a result, Project Link has been used by the Monroe County Office of Mental Health as a model for other programs that serve populations at risk for arrest and incarceration. Project Link is regarded as a statewide model in New York. To promote the model, Project Link staff made a presentation in January 1999 to the commissioner's cabinet of the New York State Office of Mental Health. Project Link recently received national recognition when it was awarded second place in the clinical medicine category of the 1998 Lilly Schizophrenia Reintegration Award.

Funding and strategies to overcome barriers

The 1998-1999 operating budget for Project Link was $681,455, of which $430,000 was associated with case advocacy services and $251,455 with the mobile treatment team and the treatment residence. The New York State Office of Mental Health provided the bulk of the funding for these programs, a total of $471,953. Other sources of funding were the Monroe County Office of Mental Health ($30,000) and the Robert Wood Johnson Foundation ($74,805). Direct service revenue accounted for $43,661, and hospital support accounted for $61,063.

A major obstacle facing Project Link is to establish ongoing funding after termination of the Robert Wood Johnson grant in 2001. To address the issue, directors of the Monroe County and New York State offices of mental health and the New York State Division of Criminal Justice were invited to participate in a Robert Wood Johnson Foundation site visit in November 1998. Based on review of clinical and cost data presented at the visit, state and county officials agreed to consider Project Link for possible continuation funding after expiration of the grant from the Robert Wood Johnson Foundation.

The staff of Project Link are encouraged by its record of success in creating and maintaining critical collaborations among community systems and by the results seen daily among consumers who are living in their community and avoiding jails and hospitals. Project staff will continue to develop and evaluate the program as a model to serve a highly vulnerable group of persons with severe mental illness in urban communities across the nation.

For more information, contact J. Steven Lamberti, M.D., Director, Project Link, Strong Ties Community Support Program, 1650 Elmwood Avenue, Rochester, New York 14620; phone, 716-275-0300, ext. 2237; fax, 716-461-9504; e-mail, [email protected].