Process Measures at the Interface Between the Justice and Behavioral Health Systems

The identification of where in the criminal justice process behavioral health services can be integrated is one step toward creating a seamless system of care that addresses both public health and safety issues. The principles that follow are premised on the notion that both systems have a mutual responsibility to work together to maximize the opportunity for individuals to obtain care for their behavioral health needs:

1. Collaboration. The many different agencies that make up the criminal justice and behavioral health systems in each jurisdiction must work collaboratively to ensure that there is treatment available for people involved in the justice system who have substance use disorders, mental disorders, or co-occurring substance use and mental disorders.
2. Access and Retention. Jointly facilitating access to and retention in behavioral health services by criminal justice and behavioral health partners is essential for achieving better behavioral health outcomes for people involved with the justice system.
3. Options for Care. Individuals in the justice system who have behavioral health needs should have access to the appropriate level of care.
4. Process Measurement. Process measures provide the means to assess whether partners (justice, behavior health, or both) have met their goals of providing access to, retaining, and completing the appropriate level of care for people who have behavioral health disorders.
5. Quality and Joint Accountability. Process measures can promote quality and joint accountability in the delivery of substance use and mental disorders services.

Set 1: Identification and Referral (Systems Level)

• *Screening Rate: Percentage of people (arrestees, defendants, inmates, probationers/parolees) who screened positive for behavioral health issues using a validated screening tool1
• *Clinical Assessment Rate: Percentage of people (arrestees, defendants, inmates, probationers/parolees) clinically assessed using a validated assessment procedure as needing behavioral health services
• Referral Rate: Percentage of people (arrestees, defendants, inmates, probationers/parolees) screened or assessed for behavioral health disorders who are referred to a treatment program or linked to services
• *Initiation: Percentage of people who had been referred to behavioral health services who start services within 14 days of the screening or clinical assessmentⁱ

Set 2: Engagement and Completion (Individual Level)

• *Engagement: The individual participates in at least two treatment sessions within a 30-day period of initiationⁱⁱ
• Retention: Length of stay in treatment for different levels of care including outpatient treatment, intensive outpatient treatment, therapeutic community, and counseling servicesⁱⁱⁱ
• *Successful Completion Rate: Percentage of individuals (arrestees, defendants, inmates, probationers/parolees) who successfully complete treatment
• Medication-Assisted Treatment (MAT) Rate: Percentage of individuals (arrestees, defendants, inmates, probationers/parolees) screened or assessed for behavioral health disorders who require medication and who are provided medication in a justice setting
• Compliance with Treatment Plan: Percentage of individuals who are in compliance with their treatment plans developed by the behavioral health specialist and the individual

Set 3: Recovery Management (Individual Level)

• *Continuum of Care: Percentage of individuals who transitioned from one program to another (step up or step down) within 30 days
• Continuity of Care: Percentage of individuals who transitioned from one phase of programming to another within 30 days
• Transitioning of Care: Percentage of individuals who moved from one type of programming (i.e. substance use or mental disorder) to another, such as vocational or educational services

Set 4: Access Measures and Systemic Responsivity (Systems Level)

• *Uniform Screening Protocols: A core set of screening processes
  and criteria accepted by justice and treatment agencies to identify individuals with substance use and mental disorders
• Insurance Enrollment: Percentage of individuals involved in the justice system who are enrolled in health insurance
• Enrolled in Insurance at Time of Release: Percentage of individuals released from prison or jail who are enrolled in health insurance
• Responsivity Rate: Percentage of individuals involved in the justice system who can access appropriate services for their specific needs
• Availability of Programming: Capacity of the system to provide appropriate levels of care for individuals (in prisons, probation/parole, jail, or community settings) who have specific needs
• Access Rate: Percentage of individuals who can access a given program
• Participation Rate: Percentage of individuals who partake in programs during their period of incarceration or supervision

Endnotes

Of the above process measures, those marked with an asterisk (*) are prioritized.
ⁱ Garnick, D. W., Horgan, C. M., Lee, M. T., Panas, L., Ritter, G. A., Davis, S., Leeper, T., Moore, R., Reynolds, M. (2007). “Are Washington Circle performance measures associated with decreased criminal activity following treatment?” Journal of Substance Abuse Treatment 33(4): 341-52.
ⁱⁱ Adapted from Garnick, D.W., Lee, M.T., Horgan, C.M., Acevedo, A., Washington Circle Public Sector Workgroup (2009). Adapting Washington Circle Performance Measures for Public Sector Substance Abuse Treatment Systems, Journal of Substance Abuse Treatment, 36(3): 265-277.
ⁱⁱⁱ Adapted from SAMSHA (2010). National Outcome Measures. Rockville, MD: SAMSHA. Doi 122214/http://integratedrecovery.org/wp-content/uploads/2010/08/SAMHSA-National-Outcome-Measures.pdf.

Behavioral health treatment services for people with substance use disorders, mental disorders, and co-occurring substance use and mental disorders are still only available to a small percentage of those involved in the criminal justice system who need them. According to a 2007 study, approximately 10 percent of the daily prison or jail population—and even fewer of those involved with community corrections—have access to services.

The long-standing need to provide appropriate and adequate services drives this publication. It is part of Access to Treatment, a larger CSG Justice Center project funded by the U.S. Department of Justice’s Bureau of Justice Assistance. The first part of the project focused on bringing the University of Wisconsin’s Center for Health Enhancement Systems Studies’ NIATx model for process improvement to criminal justice settings.

Three pilot sites (DeKalb County, Georgia; Durham County, North Carolina; and the state of Maryland) were selected to use the NIATx model as a guide to improve transitions between the criminal justice system and community substance use disorder treatment organizations. Specific process measures were then developed following lessons learned from the pilot sites to help guide the interaction between the behavioral health and criminal justice systems.

These process measures are intended to help gauge how well criminal justice and behavioral health systems are working together to effectively screen, assess, refer, and treat individuals, while better facilitating access, initiation, and engagement in behavioral health services at the points where the criminal justice and behavioral health systems can and should interact. The goal is to advance the use of behavioral health services to reduce recidivism and reduce relapse rates.