Pinellas County has a long history of using data from across systems to understand the characteristics of people who use services, what puts them at risk for an escalation in their service needs and how it can improve service delivery. Due to limited state funding for behavioral health and the high cost of frequent utilizers on systems, Pinellas County is prioritizing stabilizing these individuals. In addition to working to reduce wait times for receiving behavioral health services, determining gaps in the continuum of care and developing solutions that meet the needs of the community, Pinellas County created the Pinellas County Empowerment Team (PCET) to assist people who have mental illnesses and substance use disorders access and receive care that will reduce recidivism and improve and support well-being.

Pinellas County Empowerment Team

Pinellas County established the PCET in May 2015. Its purpose is to identify the most frequent utilizers of the county’s crisis stabilization unit (CSU) and jail and provide an intensive level of treatment and services that will break the cycle of crisis and eventually
reduce the need for interventions by helping people improve their health and well-being. Under state law, the CSU receives and evaluates people who are a danger to themselves or others.

The county initially identified the top 30 highest users of the CSU and jail for planning and research purposes. Identifying this first cohort allowed the county to develop a better understanding of the population and its needs. Paranoid schizophrenia, bipolar disorder and schizoaffective disorder are common diagnoses. In addition to mental illnesses and substance use disorders, childhood trauma, victimization and homelessness are also very common within this population. Through this match of behavioral health and justice data, the project helped the county realize that it was spending more than $2 million on these 30 people.

Taking what it learned from its research on the top 30 frequent utilizers, the county was ready to implement a PCET pilot project. It identified a new top 30 cohort with a target population that includes not only the most frequent users of the CSU but also people who are most frequently referred from the county jail to CSU. The project leverages existing services and depends on a new network of personnel, including a case manager, psychiatrist, therapist, licensed practical nurse (LPN) and law enforcement officer to optimize the delivery of care. Because coordination and a commitment to client engagement are at the heart of the pilot, the strategy is intended to be a more cost-efficient approach to meeting the needs of the top 30. The Board of County Commissioners provided $964,442 to support PCET, which covers personnel and other operational costs, and is a 62 percent reduction in what the county was paying for the first top 30 cohort it researched.

PCET depends on repeated and frequent engagement with participants to build trust. Symptoms of medical conditions such as  schizophrenia can make the process of developing trust even more challenging. The key is to make people understand that there is a case worker who can help them when they are ready, along with good customer service, including warm connections to providers, to keep  people engaged.

The pilot is aligned with the county’s motto, “With partners, we do more,” as it emphasizes the importance of  collaboration to meet the needs of frequent utilizers, bridge gaps in resources and build the continuum of care. Partners include hospitals, homeless shelters and housing providers, the public defender’s office, law enforcement, advocacy groups and behavioral health treatment and service providers. These partners meet on a regular basis to discuss how the pilot is operating, including challenges, progress and strategies to improve the system of care.

Outcomes & Next Steps

Pinellas County contracted with the University of South Florida’s Florida Mental Health Institute to evaluate the PCET pilot project. The county is interested in the effect of the project on reducing utilization rates of the CSU, jail, detox and hospitalization. It also wants to take a qualitative approach to examining the results of the pilot, including collecting staff and participants’ perceptions of what was successful and where there were barriers.

Preliminary data indicate that PCET is effectively connecting the top 30 in the pilot to services and into treatment plans. Since participants enter the pilot on a rolling basis as they are located and engaged, the baseline measures account for these individual differences. Additionally, outcome measures are based on one full year of participation, which varies for each person. The comparisons span from July 2015 to December 2017.

Eleven of the participants had no CSU visits within the year following their entry into the pilot. The Pinellas County Sheriff’s Office reported that there were fewer arrests and less severe offenses for the top 30, and jail bed days have been reduced by almost half from 1,816 days to 968 days. In addition, county jail costs went from a total of $227,000 to $108,125. The cost of Medicaid-covered services decreased from a total of $534,456 to $216,452, and emergency room visit costs from around $30,000 to slightly more than $15,000. Eight-two percent of the participants who were homeless at entry into the pilot have been housed. By working with partners to leverage existing resources and provide intensive case management, only 69 percent of the funding allocated by the Board of Commissioners for PCET was expended during year one.

For the second year of the project, the county will focus on developing and implementing solutions to challenges it has identified with how services are coordinated. The county is also working towards creating a transition plan for those individuals that are ready to move out of intensive case management.

In collaboration with the Stepping Up initiative, the Data-Driven Justice initiative and the John D. and Catherine T. MacArthur  Foundation’s Safety and Justice Challenge, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a
Best Practices Implementation Academy to Reduce the Number of People with Mental Illnesses and Substance Use Disorders in Jails (BPIA) in April 2018 in Alexandria, Va. At the BPIA, delegations from 24 jurisdictions involved in one or more of the three initiatives met to showcase best practice strategies and advance implementation efforts to prevent or reduce the jail involvement of individuals with mental illnesses and substance use disorders.

This case study is part of a series highlighting the six counties that constituted the “Best Practices” teams representing the Data-Driven Justice initiative and the Stepping Up initiative at the BPIA.

SAMHSA contracted with Policy Research Associates (PRA), which operates SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation, to facilitate the BPIA. Additional partners included the lead organizations of the Stepping Up initiative (the National Association of Counties, the American Psychiatric Association Foundation and The Council of State Governments Justice Center), the Data-Driven Justice initiative (the National Association of Counties and the Laura and John Arnold Foundation) and the John D. and Catherine T. MacArthur Foundation’s Safety and Justice Challenge.

Integrating Justice and Human Services Data

The Allegheny County data warehouse was created in the early 2000s by consolidating publicly funded human services data, including behavioral health, child welfare, intellectual disability, homelessness and aging. Since then, it has expanded to include 21 categories of data. Whereas the county owns much of the data that goes into the warehouse, some information is shared from external sources such as school districts, public benefits and the Pennsylvania Department of Labor and Industry. The data warehouse is part of the county’s commitment to building a data-driven system that improves service delivery, decision-making and communication with the public. The county’s data warehouse is a critical resource in its efforts to improve public safety through the Allegheny County Jail Collaborative (ACJC). Formed in 2000, the ACJC represents a group of county government agencies, not-for-profit organizations and other stakeholders from the community that meet monthly to identify and implement innovative approaches to preventing people from returning to jail. Developing and implementing a comprehensive plan to divert, treat and support people with behavioral health conditions is one of the ACJC’s strategies for reducing recidivism.

Legal Foundation

The data warehouse is managed by the county’s Department of Human Services (DHS). DHS provides a range of services that include but are not limited to mental health treatment, substance use and alcohol treatment and emergency shelter. Many of DHS’s services are delivered through a network of contracted service providers. The data warehouse includes protected health information (PHI) and other information subject to privacy laws and ethical practices. DHS is one of several departments within Allegheny County government that must comply with the privacy and confidentiality requirements of the Health Insurance Portability and Accountability Act (HIPAA). Because it pays for services and wants to ensure the quality, coordination and continuity of those services, DHS is considered a “covered component” within the county umbrella. DHS approaches information sharing as an essential component of its provision of care. As a payor and an oversight entity, it can require its contracted providers to share relevant client information.

Behavioral health service providers are permitted by HIPAA and state law to share without consent for purposes of treatment and related payment and operational activities. Similar to DHS, these providers are required to comply with HIPAA regulations that they provide a notice of privacy practices to their clients. This notice outlines how their information may be shared and for what purposes. Not all DHS services are strictly governed by these rules, but as a best practice, and in instances when the law requires it, the county encourages obtaining informed consent from clients whenever possible. DHS providers typically obtain releases that permit the sharing of client information with DHS and for facilitating client care.

Formal agreements or memoranda of understanding were not required for data sharing between county programs (e.g., sharing between DHS and the county health department or medical examiner), because all county departments fall under the supervision of the county executive and thus are part of the same organizational and reporting structure. With the county executive having ultimate oversight and authority to enter into agreements, it did not make practical sense for departments to enter into agreements when the executive would  authorize the agreement for both sides. In addition to maintaining quarterly audit procedures, annual trainings and routine monitoring of the technology’s security, the county is continuously looking at ways to improve on procedures that promote good data stewardship.

Using Data to Analyze Services and Outcomes

Analytic tools have been developed to support use of the integrated data. Some of these tools are publicly available while others are available only to authorized users, including providers and DHS staff.

One of the publicly available tools is called “QuickCount.” This tool aggregates client data and allows for queries about participation in a wide range of services, including comparisons of the number of people who participate in more than one service. Users can limit the count to a period of time and can break down populations by sex, age, race, state legislative district, county council district, school district and zip code. For example, the public can use the tool to understand the cross-system involvement of people booked in the jail who also received publicly-funded mental health services. Specifically, using the filters, users could find that of all people booked in the jail in 2017, 68 percent previously received publicly funded mental health services. Three-quarters of women booked in the jail received mental health services compared to 67 percent of men. Several data dashboards and visualizations are also publicly available at the Allegheny County Analytics website (www.alleghenycountyanalytics.us).

“Client View,” a tool that is accessible only with authorization and log-in credentials, provides information about individual DHS clients and their service involvement, including across multiple DHS program offices. Accessible information includes service plans and assessments. The timeline view allows users to view service involvement over months or years, and also provides some context for that information by showing life events such as the birth of a child.

The “Outcomes Tool” allows authorized users within DHS to see how programs are performing. Right now, this tool works only for the education, justice and child welfare systems but it gives DHS staff the ability to analyze a segment of a population that is involved in one of these systems—such as a cohort of people who have been in the jail and meet other criteria of interest like a history of receiving emergency shelter services and mental health treatment—and then monitor their outcomes, like reconviction or rebooking.

In collaboration with the Stepping Up initiative, the Data-Driven Justice initiative and the John D. and Catherine T. MacArthur  Foundation’s Safety and Justice Challenge, the Substance Abuse and Mental Health Services Administration (SAMHSA) convened a  Best Practices Implementation Academy to Reduce the Number of People with Mental Illnesses and Substance Use Disorders in Jails  BPIA) in April 2018 in Alexandria, Va. At the BPIA, delegations from 24 jurisdictions involved in one or more of the three initiatives met to showcase best practice strategies and advance implementation efforts to prevent or reduce the jail involvement of individuals with mental illnesses and substance use disorders. 

This case study is part of a series highlighting the six counties that constituted the “Best Practices” teams representing the Data-Driven Justice initiative and the Stepping Up initiative at the BPIA.

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In September 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of Counties (NACo) and the Laura and John Arnold Foundation (LJAF) hosted the Data-Driven Justice and Behavioral Health Design Institute (Design Institute) in Rockville, Md. The Design Institute convened 13 teams committed to the Data-Driven Justice (DDJ) initiative. Teams were selected through a competitive process to work directly with expert faculty in facilitated sessions and workshops to create action plans for developing and using integrated data systems that would aid their jurisdictions in identifying high utilizers of jails and crisis services. This case study is part of a series highlighting counties that participated in the Design Institute.

When the county attended the Design Institute it identified two priorities. The first priority was to gather the data necessary to understand the delivery and consumption of behavioral health, emergency and criminal justice services. The second was to identify the appropriate measures for determining the effectiveness or success of each service. In order to address these priorities, the county is creating a map of its data systems, including data elements that are stored within existing databases, developing a data governance strategy and identifying a technology solution that would allow data owners to share deidentified datasets with other stakeholders in order to identify high utilizers—also called frequent utilizers—with cross-system interactions. The priorities identified and action plan developed by the Berks County team at the Design Institute support the CJAB’s goals to use data and technology to better understand, design and implement effective and appropriate services for people with mental illnesses.

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In September 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of Counties (NACo) and the Laura and John Arnold Foundation (LJAF) hosted the Data-Driven Justice and Behavioral Health Design Institute (Design Institute) in Rockville, Md. The Design Institute convened 13 teams committed to the Data-Driven Justice (DDJ) Initiative. Teams were selected through a competitive process to work directly with expert faculty in facilitated sessions and workshops to develop actions plans for developing and using integrated data systems that would aid jurisdictions in identifying high utilizers of jails and crisis services. This case study is part of a series highlighting counties that participated in the Design Institute.

By attending the Design Institute, Lucas County identified two priorities that will help leaders build a system of diversion and advance their efforts on DDJ, a national initiative involving over 140 county, city and state governments working to reduce the frequent and repeat cycling of high utilizers—also called frequent utilizers—with mental illnesses, substance abuse disorders and chronic health conditions through jails, emergency rooms, homeless shelters and other crisis services. The county’s top priority is to engage stakeholders and develop the networks and partnerships that are foundational for bringing together the justice and behavioral health systems. The second priority the county identified is to do a “deep dive” into its systems and develop an understanding of how high utilizers interact with and use the various service and resource systems.

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In September 2017, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Association of Counties (NACo) and the Laura and John Arnold Foundation (LJAF) hosted the Data-Driven Justice and Behavioral Health Design Institute (Design Institute) in Rockville, Md. The Design Institute convened 13 teams committed to the Data-Driven Justice (DDJ) initiative. Teams were selected through a competitive process to work directly with expert faculty in facilitated sessions and workshops to create action plans for developing and using integrated data systems that would aid their jurisdictions in identifying high utilizers of jails and crisis services. This case study is part of a series highlighting counties that participated in the Design Institute.

To improve the quality of life for high utilizers, the county identified two interrelated priorities while attending the Design Institute. First, Polk County leaders are focusing efforts on enhancing the county’s data collection and tracking abilities by identifying a technology solution that would allow them to pull and analyze data from multiple health and social services systems in order to uncover high utilizers with multiple system interactions. Second, although Polk County already has robust behavioral health services in place, leaders are emphasizing a data-driven approach toward identifying what services and supports best meet the needs of high utilizers and any gaps in resources available in the community. For example, the county funds intense services models including assertive community treatment, forensic assertive community treatment and wraparound service programs, but continues to assess whether such services are working for a high utilizer population that has not been connected in the past or stayed engaged with programs previously offered. Through its DDJ efforts, Polk County is positioning itself to understand what service approaches will work for people with high needs before their situations escalate and become more critical.

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Franklin County, Pennsylvania

Population: 153,000¹

Urban/Rural Population (Percent): 59.65/40.35²

Jail Population: 504³

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BACKGROUND

Franklin County, Pa., has committed to using data-driven strategies to divert low-level offenders with mental illness out of its criminal justice system. The county is using data-driven solutions, including data sharing and matching, to identify individuals who are high-utilizers of justice and health systems. This has resulted in the development of new practices and programs that strategically invest county dollars to protect and enhance public safety and improve health and treatment outcomes.

How is Franklin County using and sharing data to optimize its justice work?

Franklin County is combining data from the health and justice systems to identify the highest utilizers of multiple services. Because the county operates the health and justice systems, data sharing is a streamlined process that did not require a Memorandum of Understanding. The county uses a combination of social security numbers and dates of birth to generate unique identifiers and match individuals between systems. The county’s IT department receives the data, matches individuals and sends notifications to the appropriate agencies.

Who are the stakeholders in your data-driven justice (DDJ) work?

The success of efforts in Franklin County is backed by strong interagency collaboration and depends on the involvement of non-traditional stakeholders. For example, the Greater Area Chambersburg Chamber of Commerce spearheaded a collaborative effort to collect secondary data to identify county assets and gaps in resources. This data was utilized to develop programs to help individuals reentering the community build work skills. The district attorney received grant funding to lead the implementation of a diversion program similar to the Law Enforcement Assisted Diversion (LEAD) program that will focus on assessment and drug and alcohol treatment in lieu of charges. In addition, the county’s geographic information system department played a key role in identifying “hot spots” of mental health-related 911 calls. As a result, local law enforcement deploy officers with crisis intervention training (CIT) to high-need areas. In addition, groups like Healthy Franklin Coalition and the newly formed Reentry Coalition use data from the Community Health Needs Assessment to set and address priorities, including mental health and access to care.

What populations are the focus of the county’s DDJ work?

Franklin County has focused its DDJ work on the populations that were driving the jail population. The county identified individuals with mental illnesses and substance use disorders as large contributors to the jail population, and to county costs. The Honorable Robert Thomas, Franklin County Commissioner, noted that using data leads to better county investments and use of resources.

How did the county use data to identify these populations?

The county tracks many health-related factors related to in the jail population. To better identify and coordinate services for individuals with serious mental illnesses in the jail, the county established a system-wide definition of serious mental illness. In 2016, 16 percent of the inmates had a serious mental illness.  The county also tracks inmates who have substance use disorders or alcohol dependence. In 2016, 36 percent of detainees required a detox protocol upon booking. Seventy percent of sentenced inmates have substance use disorders as identified by jail staff using the Texas Christian University Drug Screen. Data also revealed that many individuals lack health insurance post-release, leading the county to implement a Medicaid Navigators program. As a result, in 2016, 46 percent of inmates identified as needing Medicaid for any reason were enrolled with this coverage upon release from the county jail.  Of those who needed inpatient treatment post-release, 100 percent received coverage on day one.

What programs does the county have in place for these populations?

In response to mental illness in the jail population, the county now has a forensic case manager that communicates with the jail and community-based behavioral health systems to coordinate services for individuals with mental illnesses in jail. In addition, a county-funded recovery support specialist, as well as Alcoholics Anonymous and Narcotics Anonymous groups, are available to inmates. Franklin County also implemented a program in the jail that combines Vivitrol, a medication to combat opioid dependence, with substance use treatment. Although the program begins in jail, individuals continue to receive treatment post-incarceration. Funding for the Vivitrol program in the county has come mainly from the state and federal pass-through dollars.

Additionally, law enforcement officers are equipped with the tools critical to addressing the immediate needs of individuals with mental illnesses. In addition to resource cards that help law enforcement divert to community-based resources, the county also provides a 24/7 crisis phone number and maintains an intervention office. A person in crisis can be seen immediately to determine if he or she needs assessment, treatment or to be admitted to the hospital.

The county’s response is not just focused on the justice system, but also on proactively working with individuals with mental illnesses or substance use disorders. Franklin County’s Drug and Alcohol Department has a case manager at the hospital to create a warm handoff and connect individuals to treatment after they are discharged from the hospital.

How is your jurisdiction using data to measure success/ensure long-term sustainability?

Program sustainability is critical but also a challenge. The county is using data as a conversation starter to obtain buy-in from key stakeholders. Demonstrating a problem or idea using data not only results in a quicker response, but also encourages the collection of better data, supports federal and state grant applications and allows for professional evaluation of programs. Many times, stakeholders are not willing to commit to an idea or program out of fear of lack of sustainability and long-term success. Having data allows the county to obtain critical buy-in from stakeholders, in turn contributing to a system that is better positioned to be sustained.

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NACo would like to thank Franklin County Commissioner Robert Thomas, County Administrator Carrie Gray, Assistant County Administrator Steve Nevada, Mental Health Program Specialist Cori Seilhamer and Grants Manager and Criminal Justice Advisory Board Director Shalom Black for sharing Franklin County’s work.

References:

¹ http://www.healthyfranklincounty.org/urban-and-rural-population

² http://www.healthyfranklincounty.org/urban-and-rural-population

³ One-day population count on February 20, 2017. Email communication with Franklin County, Pa., February 21, 2017.