Best Practices: Recommendations for Criminal Justice Behavioral Health Spending

Counties have flexibility in using public safety realignment funds to support behavioral health services in their communities. This flexibility allows counties to tailor local services but puts the burden of identifying and selecting the best available programs and practices on the counties. In this brief, we provide a high-level overview of practices, along with evidence supporting their value to this population. California counties can utilize this information in their planning and provision of services to improve quality of life and increase connections to care. In addition, we highlight several major California behavioral health initiatives that can be leveraged to support these practices.

Understanding the Sequential Intercept Model

The Sequential Intercept Model (SIM) was created in 1999 by Mark R. Munetz and Patricia A. Griffin. SIM is a comprehensive framework designed to address the intersection of the criminal justice system and mental health services. In California, 37 out of 58 counties have adopted resolutions committing to the Stepping Up Initiative, a national effort focused on reducing over-incarceration of people with mental illnesses. As part of this initiative, SIM is a key tool in assessing county systems, determining gaps, and investing resources. 

The California Advancing and Innovating Medi-Cal (CalAIM) initiative requires counties to create re-entry planning strategies for people with behavioral health issues and services before release. It also provides grant funding to develop the capacity for doing so. SIM is a useful framework for counties to consider in CalAIM implementation. SIM highlights five key interception points where individuals with behavioral health needs can be redirected from entering or advancing deeper into the criminal justice system. These points, illustrated in the figure below, span from the first law enforcement contact (intercept 1) to community re-entry after incarceration (intercept 5). 

Communities can develop targeted strategies by pinpointing these overlapping areas to improve outcomes for individuals with behavioral health issues involved in the criminal justice system.

SAMHSA's 5 Intercepts

Mobile Crisis Response Teams (MCRT)s

SIM Intercept 0: Community Services
SIM Intercept 0: Community Services

Mobile crisis response teams (MCRTs) focus on the initial interaction between individuals with behavioral health disorders and the criminal justice system. MCRTs address behavioral health crises in the community using a team of mental health professionals (counselors, social workers, peers/case managers) .

Beginning in January 2024, every county in California is required (through a new Medi-Cal benefit) to provide 24/7 non-law enforcement mobile crisis services. For situations deemed safe by 911 dispatch, a clinician and case manager are dispatched to where the crisis occurs (on-the-spot care) to provide immediate de-escalation techniques to keep a situation from escalating further. Additionally, teams are often trained to conduct assessments, connect individuals with appropriate behavioral health services, and create safety plans to prevent repeat episodes. The new Medi-Cal benefit for mobile crisis services includes these provisions.

Deflection and Diversion Centers

SIM Intercept 0: Community Services
SIM Intercept 0: Community Services

Deflection and diversion programs are critical components in the evolving landscape of criminal justice and public health, providing alternative pathways for individuals who might otherwise enter the traditional criminal justice system. In California, Medi-Cal covers stays in crisis receiving centers, and the implementation of a new benefit covering stays in sobering centers is underway. These provide key alternative pathways away from the traditional criminal justice system. In addition, the new 988 crisis lifeline offers a path away from conventional 911 calls. The goal is to divert individuals with behavioral health needs away from the criminal justice system and into community-based treatment programs that can better address their underlying health needs.

Court-Based Diversion Programs

SIM Intercept 2 : Initial Detention/Initial Court Appearance
SIM Intercept 3: Jails/Courts

This model recognizes that many people with behavioral health needs enter the criminal justice system due to behaviors related to their untreated or inadequately managed conditions rather than criminal intent. This includes varying levels of severity. 

For example, in California, the rising numbers of individuals found incompetent to stand trial have led to significant investments in diversion programs. Evaluations of these programs indicate that successful elements often include strong multi-agency collaboration, personalized treatment plans, and comprehensive support services. 

Challenges frequently involve funding constraints, integration of services, and the need for broader eligibility criteria. A starting guide to implementing a mental health diversion program is available here.

Mental Health Courts

SIM Intercept 2 : Initial Detention/Initial Court Appearance
SIM Intercept 3: Jails/Courts

Mental health courts serve as critical points for diversion and operate on the premise that individuals with mental health needs can benefit more from treatment programs than from traditional court proceedings. Mental health courts aim to address underlying behavioral health issues that may have contributed to justice involvement, with the ultimate goal of reducing recidivism and promoting long-term recovery and stability. 

The typical structure is that legal system personnel (judges, prosecutors, defense attorneys, and law enforcement officers) collaborate closely with the area’s mental health system, including mental health professionals, addiction counselors, and social workers. Mental health and drug courts have existed since the 1990s. However, significant variation exists in eligibility criteria, program structure, length, and goals. Therefore, evidence is limited on the overall impact, although evidence tends to support a positive effect on both recidivism and treatment of behavioral health needs. 

California currently has more than 40 counties that offer mental health courts, sometimes in conjunction with substance use and co-occurring disorders, designed for individuals with mental health needs. Other established mental health court examples include Miami-Dade’s Criminal Mental Health Project (CMHP) and King County District Court Regional Mental Health Court

The types of diversion opportunities in each county in California are available in the California Civil and Criminal Court dashboard from O’Connell Research.

California Civil and Criminal Cout Map

Assisted Outpatient Treatment (AOT)

SIM Intercept 2 : Initial Detention/Initial Court Appearance
SIM Intercept 3: Jails/Courts

Assisted Outpatient Treatment (AOT) programs are designed for individuals who have a history of repeated hospitalizations and/or arrests and difficulty engaging with voluntary treatment programs due to the nature of their illness. 

These programs operate under court orders that mandate the individual to comply with a specific outpatient treatment plan, typically after a finding that the person is unlikely to be safe in the community without supervision. While mental health courts provide care for people facing criminal charges in the justice system, AOT programs focus on people who may not be in the criminal justice system but are deemed to be at high risk of harm to themselves or others due to behavioral health disorders. 

AOT can lead to reduced hospitalization rates, improved treatment adherence, and lower incidences of harmful behaviors or interactions with the criminal justice system for individuals with severe mental illness. AOT programs can also provide a structured pathway for justice-involved individuals with severe mental illness to receive consistent and coordinated care in the community, potentially reducing recidivism and improving public safety. 

Successful AOT programs require robust community mental health services, and they should be implemented as part of a comprehensive approach to treating severe mental illness, with an emphasis on respecting individual rights and promoting recovery. Just over half of the counties in California (31 of 58; 53%) currently have AOT available.

Forensic Assertive Community Treatment (FACT)

SIM Intercept 4: Reentry
SIM Intercept 5: Community Corrections and Community Support Services

Assertive Community Treatment (ACT) teams started in the early 1970s, with the FACT model emerging as an adaptation in the early 1990s to specifically address the needs of individuals involved in the criminal justice system with mental health needs and medium to high criminogenic risk. 

FACT teams consist of a team of professionals, usually including psychiatrists or other behavioral health professionals, social workers, nurses, case managers, and criminal justice partners. These teams provide personalized and comprehensive around-the-clock support to individuals with severe mental illness. 

By combining intensive community-based support with mental health treatment, substance abuse services, and case management, FACT teams aim to reduce recidivism and improve the overall well-being of this population. Programs often differ by target population & eligibility criteria, making robust research on FACT difficult. Few evaluations have been conducted on the effectiveness of FACT. Yet, results so far show that FACT can positively impact clients’ criminal justice-related outcomes (reduced recidivism and probation/parole violations, improved quality of life, decreased medical utilization, and reduced homelessness). 

The state aims to incentivize FACT by making this practice a covered Medi-Cal benefit under the upcoming California Behavioral Health Community-Based Organized Networks of Equitable Care and Treatment (BH-CONNECT) Demonstration. In addition, Proposition 1 (on the March 2024) ballot intends to focus resources on Full-Service Partnerships, which may be provided with fidelity to FACT.

Permanent Supportive Housing (PSH)

SIM Intercept 4: Reentry
SIM Intercept 5: Community Corrections and Community Support Services

Permanent Supportive Housing (PSH) represents a key strategy in addressing homelessness, improving health outcomes, and reducing recidivism among justice-involved individuals with SMI. By providing stable housing and integrated support services, PSH can help individuals with SMI lead more stable and healthy lives. PSH combines affordable housing with supportive services, which is critical for individuals with significant behavioral health challenges. 

PSH is particularly beneficial for justice-involved individuals with SMI. This population often faces multiple challenges, including higher rates of homelessness, difficulty accessing and maintaining treatment, and a higher likelihood of repeated interactions with the criminal justice system. PSH can play a crucial role in addressing these challenges by providing stable housing coupled with supportive services tailored to the needs of this population, thereby facilitating their reintegration into the community and reducing recidivism. 

In California, the No Place Like Home (NPLH) Program earmarked $2 billion in 2018 for PSH across the state, and Proposition 1 aims to focus additional resources on PSH going forward. A toolkit for PSH evidence-based practices is available here.

Integrated Dual Disorder Treatment (IDDT)

SIM Intercepts 1-5

Unlike the programs and models mentioned previously, Integrated Dual Disorder Treatment (IDDT) supports adults across all the intercepts of the SIM. IDDT is an evidence-based practice specifically designed to address the needs of individuals who have co-occurring mental health and substance use disorders (dual diagnoses). 

The core principle of IDDT is the integration of mental health and substance abuse services into a single, coherent treatment approach rather than treating each disorder with separate services or sequentially. This model is based on the understanding that both disorders are interrelated and require a coordinated treatment plan to address the complex needs of the individual effectively. 

For justice-involved individuals with co-occurring disorders, IDDT can reduce the cycle of incarceration, improve mental health and substance use outcomes, and support successful community reintegration. It represents a shift from traditional, siloed treatment models toward a more integrated, holistic approach to complex behavioral health needs for this population. A toolkit for IDDT evidence-based practices is available here.

Vision 2030 logo

Goal: Reduce the number of people with mental illness entering our criminal justice system by half

More than a third of people who make up the California prison population live with a mental health and/or substance use condition, and many of those individuals become involved in the justice system because of a lack of access to adequate community mental health care. The Steinberg Institute’s research in this focus area will examine the mental illness-to-prison pipeline and identify effective diversion strategies.
Read more about Vision 2030 at steinberginstitute.org/vision-2030

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