Model Community-Based Treatment Program Reduces Hospitalization and Jail Time Among People with Mental Illness and Substance Abuse
Project Link, directed by Steven Lamberti, M.D., is a consortium of six community service organizations (see Appendix 2) in Monroe County, N.Y., working to reduce repeated hospitalizations and incarcerations among a population of clients with the dual diagnoses of severe mental illness and substance abuse. The lead agency is the University of Rochester Strong Ties Community Support Program.
From August 1997 to July 2002, Project Link established a Mobile Treatment Team, which treated 83 patients during the funding period, and a Mental Illness and Chemical Abuse (MICA) Treatment Residence, which treated 41 of those patients.
The project was part of the Robert Wood Johnson Foundation Local Funding Partnerships (LFP) program (for more information see Grant Results). LFP is a national matching-grant program that seeks to stimulate innovative, community-based projects to improve the health and health care of underserved and vulnerable populations.
Project Link staff conducted an evaluation of the program by studying a subgroup of 44 clients who had completed one full year in Project Link. It found:
- A mean reduction in yearly hospital days per client to 88 days from 114.
- A mean reduction in yearly jail days per client to 45 days from 104 days.
- An average reduction in direct service and residential costs per client to $34,360 after a year of enrollment in Project Link from $73,878 in the year before Project Link.
The Robert Wood Johnson Foundation (RWJF) provided $269,129 to Project Link.
People suffering from severe mental disorders and substance abuse are overrepresented in the nation's jails and prisons. They also undergo multiple hospitalizations and experience homelessness and a lack of access to community services. Lack of coordination among these services and the criminal justice system contributes to the problem (Lamberti, Psychiatric Quarterly, 72: 6377).
A 1993 study by the Monroe County Office of Mental Health identified 126 individuals with severe mental illness who had experienced multiple jail and hospital stays over the previous three years. Most of these individuals were young African-American or Latino males who:
- Suffered from a combination of schizophrenia and drug addiction.
- Lacked stable housing.
Costs for their mental health services and competency evaluations in 1993 alone totaled $628,000 (Lamberti, Psychiatric Services, 50: 14771480).
To address this need, the University of Rochester and five community agencies that serve the inner-city population formed Project Link. See Appendix 2 for descriptions of the organizations.
Initially, five bachelor's level case advocates worked to prevent jail and hospital recidivism by linking their clients to psychiatric, medical, residential and social services in the community. The advocates faced three major barriers:
- Clients who refused treatment altogether.
- Clients who refused to go to clinics for treatment.
- Clients who repeatedly were evicted from available housing.
Project Link Director Steven Lamberti, M.D., and staff from the community partner agencies proposed two changes to address these barriers:
- A mobile team that would offer treatment in the client's natural environment (even if on the street or under a bridge).
- Residential housing from which clients could not be evicted.
Project Link used RWJF funds to establish a Mobile Treatment Team and a Mental Illness and Chemical Abuse (MICA) Treatment Residence.
With the addition of these two new elements, Project Link aimed to:
- Reduce the frequency of arrests and incarcerations.
- Reduce utilization of inpatient and emergency room services.
- Decrease the use of illegal drugs and alcohol.
- Improve the quality of life, social functioning and satisfaction among clients.
- Reduce overall costs of services.
The University of Rochester's Strong Ties Community Support System was the lead agency and headquarters for Project Link. Lamberti was also its director.
A representative of each of the community partner agencies made up the management team. The team members were required to have sufficient authority within their organizations to effect changes in the interest of serving the target population. The team met on a regular basis during the grant period for collaborative planning and problem solving.
The team also conducted consumer satisfaction surveys about service gaps with people served by the program. Some of the people served by Project Link also participated in an RWJF site visit and provided feedback about the effectiveness of the program.
Mobile Treatment Team
The Mobile Treatment Team provided health services to Project Link enrollees who were in the greatest need of assistance. RWJF funds paid for a forensic psychiatrist and a psychiatric nurse practitioner, who joined the existing team of five case advocates.
Services included extended, intensive treatment and stabilization, as well as crisis intervention. All team members were available around the clock. The team members used intensive outreach efforts and brought treatment to the clients in their natural environments, rather than bringing clients to clinics. This is the assertive community treatment model.
Forensic psychiatrist Robert Weisman, M.D., led the Mobile Treatment Team and worked closely with representatives of parts of the criminal justice system (jails, prisons, parole and probations offices and courts). His knowledge of the criminal justice system was critical in enabling the assignment of mentally ill clients to Project Link as an alternative to incarceration or as a condition of release.
Weisman became director of Project Link in 2001 when Lamberti became associate chairman of the Department of Psychiatry at the University of Rochester Medical Center.
During the grant period, Project Link staff worked with Monroe County Judge Patricia Marks to develop the area's first mental health court. The court began operations in 2003 (see After the Grant for more information).
Mental Illness and Chemical Abuse (MICA) Treatment Residence
The treatment residence for clients with mental illness and chemical dependency, an intermediate-level residential service, originally used a 10-bed facility managed by DePaul Residential Services.
RWJF funds expanded the staff of this facility, including the addition of a certified addictions counselor. The treatment residence was staffed around the clock. It offered four levels of care, ranging from total supervision to acquisition of skills required for independent living.
DePaul found subsequent levels of housing for clients who completed the MICA Treatment Residence program. The housing, based on client needs and readiness, ranged from supervised group residences to totally independent apartments.
Project Link staff published a book chapter and several articles about the project and made some 45 presentations at local, state, national and international conferences. See the Bibliography.
The American Psychiatric Association awarded Project Link its Services Achievement Gold Award on October 29, 1999. The Gold Award paper was published in Psychiatric Services in 1999, bringing national attention to Project Link. In the same year, Project Link placed second in the Clinical Medicine Category of the 1999 Lilly Schizophrenia Reintegration Award Competition.
RWJF provided communications planning and media training to Project Link staff. "I went to medical school and business school," said Lamberti. "But this was the first time anyone taught me how to work with the media." ABC and CBS affiliates, as well as radio, print and Web media, covered the Project Link story. The training was valuable in handling diverse media opportunities, according to the project director. See Lessons Learned for more information.
From August 1997 to July 2001, a total of 83 of the most impaired patients were admitted by referral to Project Link's Mobile Treatment Team. Admission criteria were:
- Age 18 or older.
- Severe mental illness.
- At least one previous arrest.
- History of nonadherence to outpatient treatment.
Project staff collected criminal justice and mental health service utilization data on the first 44 clients to complete one year of enrollment in Project Link. Data came from multiple sources, including hospital charts, jail records, probation and parole records, and interviews with clients.
The studies looked at substance use, service utilization, functioning ability and costs in the year before enrollment and after one year of enrollment in the program. For details on Methodology and Limitations, see Appendix 4.
Project staff reported these findings from the evaluation in the Spring 2004 issue of Psychiatric Quarterly (see Weisman et al. in the Bibliography):
- Mean yearly jail days per client dropped to 45 days from 104 days.
- Mean yearly hospital days per client dropped to 88 days from 114 days.
- There was significant improvement in clients' adjustment to the community and in their engagement in substance abuse treatment.
- The average cost of jail and hospital services per client dropped to $34,360 for the year after enrollment in Project Link from $73,878 for the year before Project Link.
SIGNIFICANCE TO THE FIELD
According to Lamberti, the project director:
- Project Link was among the first programs in the nation to show that it is possible to engage and treat patients who suffer from severe mental illness, drug addiction, homelessness and jail recidivism.
- Project Link was a prototype for an emerging new model of care called Forensic Assertive Community Treatment, which combines jail diversion and assertive community treatment to engage high-risk individuals in care.
- A preliminary cost analysis suggested a significant reduction in hospitalization, incarceration and outpatient costs among patients served by programs similar to Project Link.
- Collaboration with the criminal justice system is critical to the operation of a program such as Project Link. "Every program should have someone knowledgeable about the criminal justice system," said Lamberti. "It does not necessarily have to be a forensic psychiatrist, as we had in Project Link, but someone who knows the system and how to make appropriate contacts within it." (Project Director)
- Knowing how to interact with the media and respond promptly with a planned and focused message was essential to disseminating Project Link results. The media training provided by RWJF proved valuable on many occasions. For example, PBS contacted Project Link after the Virginia Tech massacre. It wanted to know if programs such as Project Link could help prevent such tragedies in the future. RWJF had provided media training to Project Link staff members, and they were prepared to describe the project briefly and explain its potential impact. (Project Director)
- Strategic communication planning is important to promoting the growth and development of a project. For example, the Ibero-American Action League, a Project Link partner agency, is the largest advocacy organization for Hispanics in the Monroe County area. Gladys Santiago, its representative, attended training provided by RWJF and learned how to frame the league's mission and message. She said that this enabled the league to obtain community grants to start a bilingual, bicultural version of Project Link (Lazos Furetes) in the heart of the area's Hispanic community. (Project Director)
AFTER THE GRANT
The Monroe County Office of Mental Health continued to fund Project Link after the RWJF grant ended.
The Monroe County, N.Y., Mental Health Court was established in 2003 to handle cases involving nonviolent offenders with mental health problems. It works with Project Link to identify patients with mental illnesses who could be treated in the community as an alternative to incarceration.
Weisman received a small RWJF grant (ID# 045915) to develop the Safety and Violence Education (SAVE) curriculum, which offers safety training to community staff working with high-risk populations. The SAVE DVD has been disseminated throughout the state of New York.
Project Link staff has responded to many requests for technical assistance, from Portland, Maine, to Hawaii and Alaska. Representatives of the MacArthur Foundation, the University of Medicine and Dentistry of New Jersey, and the New Jersey State Parole Board have visited Project Link.
Lamberti conducted a survey of the National Association of County Behavioral Health Directors to determine whether other programs were developing along the lines of Project Link. He identified 16 programs in nine states, enabling him to propose the Forensic Assertive Community Treatment model as an emerging model of care. (See Psychiatric Services, November 2004.)
Lamberti has received a grant from the National Institute of Mental Health for a prospective study that will resolve some of the limitations noted in the Project Link evaluation.
GRANT DETAILS & CONTACT INFORMATION
Establishing a Forensic Psychiatry Clinic and Transitional Housing for People With Chronic Mental Illness and Chemical Abuse
University of Rochester Medical Center (Rochester, NY)
Dates: August 1997 to July 2002
J. Steven Lamberti, M.D.
Project Link Funding Partners
- University of Rochester Medical Center (lead agency)
- Coordinated Care Services
- Eli Lilly and Company
- Monroe County Office of Mental Health
- United Way of Greater Rochester
Project Link Community Partners
Strong Ties Community Support Program (lead agency)
Strong Ties is a program of the University of Rochester Medical Center Psychiatry Department. It includes an outpatient clinic and a day treatment program that offer individual, group and family services. It is the only area program that focuses exclusively on the treatment of severe mental illness in adults. A multidisciplinary team, including psychiatrists, nurse practitioners, social workers, certified substance abuse counselors and case managers, provides services. Strong Ties is the headquarters for Project Link.
Action for a Better Community
Since 1965, Action for a Better Community has helped develop self-sufficiency among low-income families in Monroe County. Its programs encompass health, education, safety, employment and housing services. Examples include prison outreach, counseling, assistance in moving from welfare to work and a full-service outpatient clinic for those whose primary addiction is alcohol.
DePaul Mental Health Residential Services
DePaul, a nonprofit organization founded in 1958, provides residential treatment and rehabilitation services to people with mental illnesses, people in addictions recovery and those with a history of homelessness. It offers supervised community residences, treatment apartment programs (a preparatory step before independent living) and single room occupancy programs (for adults with serious and persistent mental illnesses). Services, ranging from on-site staffing to routine visits, accompany each level of residency. Staff members are available 24 hours a day in case of emergency.
Ibero-American Action League
The league provides advocacy and culturally sensitive programs and services to its Hispanic constituents in the Rochester, N.Y., area. Services cover children, youth and seniors and include education, employment, housing, mental health and emergency services. The intent is to raise socioeconomic status, well-being and citizenship awareness.
Monroe County Mental Health Clinic Socio-Legal Center
The center coordinates and facilitates services for people with mental illnesses in the criminal justice system. It offers mental health evaluations and consultations to Monroe County's courts and other criminal justice agencies. It provides transition services to assist people with serious mental illnesses to connect with treatment and supportive services after release from the Monroe County Jail.
Unity Health System
Unity is a 681-bed health care network that serves the city of Rochester and western Monroe County. It offers a wide range of specialty programs and services at Unity Hospital and more than 50 other sites. Beyond regular hospital inpatient and outpatient services, programs include after-hours care, chemical dependency treatment and community outreach.
Case advocate: A case manager with greater flexibility than traditional case managers. A case advocate can follow the assertive community treatment model, deal with high-risk individuals and interact with the criminal justice system as part of the Project Link Mobile Treatment Team. The Monroe County Office of Mental Health designated the term for Project Link staff. In New York State, case managers are unlicensed providers without formal social work, nursing or other health care training, who provide the assistance necessary to enable severely mentally ill adults to live successfully in the community. Services may include help with transportation, finances and daily living. State regulations require a mandatory number of patient contacts per week.
Forensic assertive community treatment (FACT): An emerging approach to the prevention of arrests, incarceration and recidivism among adults with severe mental illnesses who have substance abuse histories and/or involvement with the criminal justice system (hence, the term forensic). Interaction with the criminal justice system can promote alternatives to incarceration, such as community treatment, for these populations. FACT develops deliberately integrated mental health and criminal justice service systems, rather than using existing, but not necessarily related, services. The extent and nature of mental health and criminal justice integration vary among programs. Lamberti proposed the term FACT after reviewing 16 programs whose approaches were similar to those used by Project Link (see Lamberti in Psychiatric Services, 55: 12851293).
Mental health court: A specialty court that processes criminal cases involving people with severe mental illnesses. It tries to reduce incarceration and recidivism by linking offenders with appropriate mental health services and support systems.
Project Link staff collected criminal justice and mental health service utilization data on the first 44 clients to complete one year of enrollment in Project Link. Data came from multiple sources, including hospital charts, jail records, probation and parole records, and interviews with clients.
The studies looked at substance use, service utilization, functioning ability and costs in the year before enrollment and after one year of enrollment in Project Link. Project staff:
- Calculated jail use, inpatient hospital use, emergency room use and arrests for each client, and compared the mean rates.
- Examined differences in service rates for the year before and the year after admission to Project Link to determine statistical significance.
- Calculated all direct service costs, including inpatient, outpatient emergency room and testing costs.
- Hospital costs were based on the cost for one day in Strong Memorial Hospital's inpatient psychiatry unit ($578), and jail costs were based on one day in the Monroe County Jail ($77). Project staff multiplied these figures by the frequency of jail and hospital use during the year before and the year after entry into the Project Link program, based on the first 44 patients enrolled.
- Residential costs were calculated by assigning a monthly charge of $1,974.35 to all Project Link patients after enrollment, minus days spent in jail or in the hospital.
The project director noted the following limitations to the studies:
- A pre-post design and the lack of a control group.
- The elimination of clients who did not complete the program.
- Small sample size.
- Retrospective acquisition of pre-enrollment data.
- Estimated, rather than actual, room and board costs. The same estimated monthly charge was assigned to all subjects after enrollment, and days spent in jail or in the hospital were deducted.
See Weisman RL, Lamberti JS and Price N. "Integrating Criminal Justice, Community Healthcare, and Support Services for Adults with Severe Mental Disorders." Psychiatric Quarterly, 75(1): 7185, 2004.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Lamberti JS and Weisman RL. "Preventing Incarceration of Adults with Severe Mental Illness: Project Link." In Treating Mentally Ill Offenders: Challenges and Opportunities for Mental Health Professionals, Landsberg G, Rock M, Berg L et al. (eds.). New York: Springer Publishing Co., 2002.
Lamberti JS (Gold Award Paper). "Prevention of Jail and Hospital Recidivism Among Persons With Severe Mental Illness. Project Link, Department of Psychiatry, Rochester, New York." Psychiatric Services, 50: 14771480, 1999.
Lamberti, JS. "New Approaches to Preventing Incarceration of Severely Mentally Ill Adults." Psychiatric Times, 21(7): 3338, 2004.
Lamberti JS and Weisman RL. "Persons with Severe Mental Disorders in the Criminal Justice System: Challenges and Opportunities." Psychiatric Quarterly, 75(2): 151164, 2004.
Lamberti JS and Weisman RL. "Preventing Incarceration of Adults with Severe Mental Illness: Project Link." In Serving Mentally Ill Offenders, Landsberg G, Rock M, Berg L et al. (eds.). New York: Springer Publishing Co., 2002.
Lamberti JS, Weisman RL and Faden DI. "Forensic Assertive Community Treatment: Preventing Incarceration of Adults With Severe Mental Illness." Psychiatric Services, 55(11): 12851293, 2004.
Lamberti JS, Weisman RL, Schwarzkopf SB et al. "The Mentally Ill in Jails and Prisons: Towards an Integrated Model of Prevention." Psychiatric Quarterly, 72(1): 6377, 2001.
Weisman RL and Lamberti JS. "Violence Prevention and Safety Training for Case Management Services." Community Mental Health Journal, 38(4): 339348, 2002.
Weisman RL, Lamberti JS and Price N. "Integrating Criminal Justice, Community Healthcare, and Support Services for Adults with Severe Mental Disorders." Psychiatric Quarterly, 75(1): 7185, 2004.
Report prepared by: Nina Berlin
Reviewed by: Kelsey Menehan
Reviewed by: Molly McKaughan
Program Officer: Jane Isaacs Lowe