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Agenda 06/05/2018 WCOLLIER COUNTY Board of County Commissioners MENTAL HEALTH WORKSHOP AGENDA Board of County Commission Chambers Collier County Government Center 3299 Tamiami Trail East, 3rd Floor Naples, FL 34112 June 05, 2018 9:00 AM Commissioner Andy Solis, District 2 - BCC Chair Commissioner William L. McDaniel, Jr., District 5 - BCC Vice-Chair; CRAB Co-Chair Commissioner Donna Fiala, District 1; CRAB Co-Chair Commissioner Burt Saunders, District 3 Commissioner Penny Taylor, District 4 Notice: All persons wishing to speak must turn in a speaker slip. Each speaker will receive no more than three (3) minutes. Collier County Ordinance No. 2003-53 as amended by Ordinance 2004-05 and 2007-24, requires that all lobbyists shall, before engaging in any lobbying activities (including but not limited to, addressing the Board of County Commissioners), register with the Clerk to the Board at the Board Minutes and Records Department. 1. PLEDGE OF ALLEGIANCE 2. WORKSHOP TOPICS 2.A. Agenda and Strategic Plan 3. PUBLIC COMMENTS 4. ADJOURN Inquiries concerning changes to the Board’s Agenda should be made to the County Manager’s Office at 252-8383. 06/05/2018 COLLIER COUNTY Board of County Commissioners Item Number: 2.A Item Summary: Agenda and Strategic Plan Meeting Date: 06/05/2018 Prepared by: Title: Operations Analyst – County Manager's Office Name: Geoffrey Willig 05/29/2018 4:32 PM Submitted by: Title: County Manager – County Manager's Office Name: Leo E. Ochs 05/29/2018 4:32 PM Approved By: Review: Operations & Veteran Services Sean Callahan Additional Reviewer Completed 05/29/2018 4:57 PM County Manager's Office Geoffrey Willig County Manager Review Completed 05/29/2018 5:00 PM Board of County Commissioners MaryJo Brock Meeting Pending 06/05/2018 9:00 AM 2.A Packet Pg. 3 2018 Mental Health and Addiction Workshop June 5, 2018 Agenda Board of County Commission Chambers Collier County Government Center 3299 Tamiami Trail East, 3rd floor Naples, FL 34112 9:00 am Welcome and Pledge of Allegiance – Chairman Andy Solis 9:05 am How We Got Here and Why – Chairman Andy Solis 9:10 am Brief Update and Review of the Last Year Treatment Courts – Judge Janeice Martin David Lawrence Center – Scott Burgess, CEO National Association for the Mentally Ill – Pam Baker, CEO Collier County Sheriff’s Office – Sgt. Leslie Weidenhammer & Cptn. Chris Roberts, Mental Health Intervention Team; Katina Bouza, Inmate Service Bureau Manager Collier County Public Schools – Karen Stelmacki, Executive Director, Exceptional Education & Student Support Services 9:40 am Criminal Justice, Mental Health & Substance Abuse Planning Council Strategic Planning Sessions – Review and Identified Priorities with their Champions: Centralized Receiving System / Addiction Receiving and Baker Act Receiving Facility – Scott Burgess, CEO David Lawrence Center; Allan Weiss, CEO Naples Community Hospital Permanent Supportive Housing (Scattered Sites & Supportive Services) – Pam Baker, CEO NAMI, and Beverly Belli, DLC Behavioral Health Data Collaborative – Chairman Andy Solis Increase Use of Evidence-based Practices – Nancy Dauphinais, COO David Lawrence Center Increase Effectiveness and Capacity of Treatment Courts – Judge Janeice Martin and Beverly Belli, DLC Baker Act / Marchman Act Transportation – Sgt. Leslie Weidenhammer, CCSO Build Sustainability for Criminal Justice, Mental Health & Substance Reinvestment Grant – CJMHSA Planning Council 10:30 am Break 10:45 am Public Comment & Commissioner Discussion 11:30 am Next Steps Moving Forward – Chairman Andy Solis 2.A.1 Packet Pg. 4 Attachment: June 5 2018 Workshop Agenda (5797 : Agenda and Strategic Plan) 1 Mental Health and Substance Abuse Strategic Plan 2018-2021 Mission: To collaboratively plan for and coordinate a full array of effective services and supports to improve the lives of individuals with mental health and substance use conditions and overall quality of life in the Collier County community. Overview and Purpose In June of 2017, Collier County Commissioners held a workshop to elicit community wide input regarding the urgent and growing need for expanded mental health and substance use (behavioral health) services in our community. Workshop stakeholders, including behavioral health providers, law enforcement, judiciary, and family members, presented the current description, status, successes, challenges, gaps, and opportunities within the local system of care. While all acknowledge that current collaboration among local stakeholders is impressive, the issue is becoming more urgent as the overall local population is rapidly expanding with no plan, or dedicated resources in place, to expand essential mental health and substance use treatment services. Since 2010, the Criminal Justice, Mental Health and Substance Abuse (CJMHSA) Planning Council has maintained strategic plans specifically outlining coordinated local approaches for the population of persons with serious mental illness who are in the criminal justice system. However, there is no such coordinating plan for the much larger population of people with mental health and substance use problems who do not fall into that category—though all are at risk. The conclusion of the June workshop was that a community-wide, integrated strategic plan was needed to coordinate local responses and maximize scarce resources. To facilitate the plan, in November 2017 and again in May 2018, Mark Engelhardt, MSW, Director of the CHMHSA Technical Assistance Center at University of South Florida’s Florida Mental Health Institute, facilitated community-wide strategic planning sessions. Between and following those meetings, informal groups have been meeting monthly to provide additional input. The current strategic plan was completed using information from these meetings along with several other sources, including CJMHSA Planning Council input, best practices in the behavioral health field, and relevant aspects of partners’ agency- specific strategic plans to ensure cohesion among plans and coordinated community 2.A.2 Packet Pg. 5 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 2 planning efforts. This plan focuses on the adult (18 years of age and older) population with behavioral health care needs. A current local process for children’s behavioral health is in place through the Naples Children & Education Foundation. The Richard M. Schulze Family Foundation conducted a Collier County Needs and Assets Assessment in 2017 which included significant input from community-wide surveys and focus groups. Key points cited in the report include: “A lack of affordable assisted living, residential options for elderly, and for those with mental health issues and disabilities continues to be a problem in the area”. “Residents are worried about the lack of mental health care and addiction treatment availability. Though the number of providers has increased in recent years, gaps in services remain”. General Considerations Mental health and substance use conditions require a wide array of services and supports to fully address their complex biopsychosocial nature. Optimally, comprehensive community services help to ensure that people with mental illnesses do not enter either the criminal justice system or institutional settings such as state mental hospitals. Incarceration, and deep-end, acute care programs are expensive but are needed when community-based treatment and recovery-oriented supports do not work. We know that evidence-based treatment and recovery practices, when used, are effective in helping people recover to lead full and productive lives in the community. Some behavioral health services are paid for through Medicaid and sometimes Medicare for people on disability due to serious mental illnesses. For those without a means to pay (i.e., indigent), state and federal behavioral health funds are contracted to local community mental health centers, such as the David Lawrence Center, which is then required to provide people with treatment regardless of their ability to pay. However, these state funds are not at all adequate to pay for all in need. Depending upon the source, Florida reportedly ranks 49th or 50th among states with regards to per capita state funding appropriated for mental health care. In addition, Florida opted out of the recent Medicaid expansion program which would have expanded the Medicaid-eligible population and infused additional federal Medicaid dollars to pay for behavioral health care. Under Florida statute, local jurisdictions are required to provide funding as match to the state mental health and substance use contracts. Collier County currently meets and exceeds these requirements. Without adequate funding for community-based services, counties must often foot the bill for citizens in need of care beyond the 2.A.2 Packet Pg. 6 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 3 required local share of cost—often in jails— not because people with mental illnesses and addictions tend to be criminals, but because their criminal offenses are often committed as a function of their untreated, or inadequately treated, mental illness or addiction. Population Growth. Collier County alone is projected to grow by roughly 40,000 people over the next five years. With a current population estimate of 372,880, by 2030, the county will be home to roughly a half million people when adding the roughly 90,000 seasonal residents who stay through the winter months. Any increase in population will negatively affect the local behavioral health system to meet the needs of citizens, especially since the system is at or over capacity at present. Behavioral Health System Map. The University of South Florida assisted the State of Florida in the creation of a Community Behavioral Health System Access and Process Mapping document which gives a visual depiction of service types, access points and relationships to services within any given mental health system in the state. It highlights the complexities of such systems, and includes potential services that are not in place locally, such as an addiction receiving facility or peer- run crisis center. The map provides a visual tool for the overall local strategic planning. 2.A.2 Packet Pg. 7 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 4 Figure 1. Behavioral Health System 1 Brown, R; McLean, C., Engelhardt, M., & Armstrong, M. (2015). Behavioral Health Systems Design Recommendations. University of South Florida, September 2015 Current Resources and Challenges Law Enforcement: Mental Health Unit The CCSO’s Mental Health Unit recently implemented a new strategy, called the Mental Health Intervention Team (MHIT). The MHIT includes CCSO deputies along with a licensed clinician contracted through the David Lawrence Center. The team focuses on responses to persons considered ‘high risk, high utilizers’ of services, often conducting wellness checks in the community to ensure the person has the resources and supports they need so they do not re-enter jail or hospitals Civil Court Involuntary Order Professional Certificate Minor Alternative Assessment Protective Custody Voluntary Application Screening, Assessment and/or Intake Crisis Stabilization Unit -secure Addictions Receiving Facility - secure Residential Detoxification (nonsecure) Hospital Outpatient Services Residential/ Supportive Housing Medication Assisted Therapy Outpatient Detoxification Room and Board Facility Social Setting Detoxification Inpatient Inpatient Residential/ Supportive Housing Residential/ Supportive Housing Outpatient Outpatient Involuntary Inpatient State Hospital or SRT Involuntary Residential Involuntary Outpatient Initial Petitions Renewal & Termination Petition Community Behavioral Health System Access and Process Mapping Consumer Choice Diversion Involuntary Placement Non-Secure Involuntary Placement Secure Petition (Initial, Renewal) Initiating Involuntary Process EXIT EXIT EXIT EXIT EXIT EXIT Home Mobile Crisis Teams Peer-Run Crisis Centers CIT-Trained Law Enforcement Hospital/ER In-Reach SAMH Primary Care A B C D E F Community Routes of Access Triage Functions/Acute Care Court Rulings Involuntary Interventions to Care Receiving Facilities Placements 2.A.2 Packet Pg. 8 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 5 unnecessarily. The inclusion of a DLC clinical staff person allows the team to access historical data and expand the continuity of care for individuals in crisis. (Appendix II) Crisis Intervention Team (CIT) training is a best practice that helps to train first responders in effective ways to de-escalate crises with people with behavioral health problems, diverting them from the criminal justice system and into the mental health system. Importantly, CIT saves lives and averts cost to the local criminal justice system. Coordinated by the Collier County Sheriff’s Mental Health Unit, Collier County has a robust Crisis Intervention Team (CIT) training program, with a goal of training 100% of all law enforcement, including state and county probation, and most recently added fire and EMS staff as trainees. The 40-hour classes are led by the Collier County Sheriff’s Office (CCSO) and Naples Police Department and are held at National Alliance on Mental Illness (NAMI) of Collier County five times per year. Collier County is the only Gold Standard CIT program in the state, as designated by the Florida CIT Coalition. In 2018, CCSO began a method of collecting valuable CIT data on numbers of persons diverted and disposition using a new signal and code. This will allow tracking of law-enforcement assisted jail/criminal justice diversions. Law Enforcement Assisted Diversion (LEAD) is an innovative diversion program developed through a partnership between the Collier County Sheriff’s Office and David Lawrence Center. The LEAD program allows law enforcement officers discretionary authority to redirect certain drug-related activity to community-based treatment services, instead of jail and prosecution. By diverting eligible individuals to services, LEAD is committed to saving lives, and improving public safety and public order. (Appendix III) Law Enforcement: Corrections Department The Collier County Sheriff contracts for its medical services for inmates, including limited mental health and addictions care, with Armor Correctional Health Services (Armor), a for-profit entity which specializes in institutional care. As Armor is not a community-based provider, this sometimes creates communication issues among parties responsible for discharge planning and continuity of care, for example with medications. Notably, since the 1990’s Collier County’s jail, through Armor and its predecessors, has provided in-jail substance use treatment services, called the Project Recovery Program (PRP), to those in need. PRP can help facilitate early release of successful program graduates, who, as a result are less likely to return to jail in the future. Each of these strategies employed by local law enforcement are relatively low cost, but high-impact resources for the mental health and substance use population. 2.A.2 Packet Pg. 9 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 6 Acute Care David Lawrence Center (DLC) operates Collier County’s only public Baker Act receiving facility. It is licensed and designated under Chapter 394, F.S. as a Crisis Stabilization Unit (CSU). Crisis Stabilization Units, which may be no larger than 30 beds per license, provide brief (72 hour) psychiatric evaluation primarily for low- income individuals with acute/emergent psychiatric conditions. The DLC CSU adult CSU has a 22-bed capacity, and 8 designated beds for children. However, the 30 beds may be used in a flexible manner, serving additional or fewer adults or children as needed due to demand. The generally recognized ‘rule of thumb’ for adequate mental health care, where the needs of a community are considered met, is 30 adult acute care beds per 100,000 of population. That means Collier County, at 372,880 population and only 22 beds, falls far short of the benchmark. There should currently be over 100 of these beds. By 2020, with the projected population growth, Collier should have over 120 crisis beds. Acute care services are paid for by insurance when available, and with public dollars when an individual lacks insurance. Public support is provided through the State of Florida and partly through county matching funds. Utilization of David Lawrence Center’s Crisis Stabilization Unit nearly quadrupled over the past 10 years. Last year, at least 38% of people in need of mental health crisis care under the Baker Act were sent to facilities in other counties due to lack of local capacity-- particularly for individuals with Medicare or who are medically compromised and need a hospital environment. The overall payor mix for the CSU is 50% indigent, 25% insurance, and 25% Medicaid. The reimbursement from Medicaid does not adequately cover the cost of care. A mobile crisis team or mobile crisis response service is a nonresidential crisis service attached to a public receiving facility and available 24 hours a day, 7 days a week, through which immediate intensive assessments and interventions are provided, including screening for admission into a receiving facility. David Lawrence Center as the county’s only public receiving facility does not currently offer this service--which can be quite costly due to the need for 24/7 clinical staff availability for off-site screenings. The Mental Health Intervention Team operated by CCSO is not a mobile crisis team. For substance use acute care, David Lawrence Center operates a 12-bed, voluntary detox unit. Additionally, Naples Community Hospital also has 12 voluntary beds for people with co-occurring mental health and substance use problems. No other local hospital has services available for the population. Collier County does not have a designated Addiction Receiving Facility (ARF), a locked unit for persons in custody under the Marchman Act for substance use disorders. 2.A.2 Packet Pg. 10 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 7 Centralized Receiving Systems (CRS). A central receiving system consists of a state-designated central receiving facility for both Baker Act and Marchman Act that serve as a single point or a coordinated system of entry for individuals needing evaluation or stabilization for mental health or substance use disorders. The model is currently in use in several Florida communities, and has been shown to:  Reduce the inappropriate utilization of emergency rooms;  Increase the quality and quantity of services through coordination of care and recovery support services; and  Improve access and reduce processing time for law enforcement officials transporting individuals needing behavioral health services. New building and/or renovation of current space would be needed locally to accommodate both an increase in Baker Act and Marchman Act capacity and space for a functional CRS. (Appendix IV). Collier County does not have a private Baker Act receiving facility. Private Baker Act receiving facilities are licensed under Florida Statutes Chapter 395 as either free- standing or connected to general medical hospitals. Funding is largely provided by billing to Medicare and private insurances. In some instances, private receiving facilities also contract with the State for public mental health funds to serve uninsured persons. Private receiving facilities are available in both Lee (Park Royal Hospital) and Charlotte Counties (Riverside Behavioral Health). In fact, most Florida counties the size of Collier have at least one private receiving facility. The absence of such a facility in Collier County requires older adults on Medicare, or who have private insurance, and are in need of acute care to go to the facilities in nearby Lee and Charlotte Counties, away from their family and support system. Baker Act Transportation The duty for primary transport to a receiving facility for persons on involuntary status lies with law enforcement. Law enforcement has the authority and responsibility to provide the transport and can decline only under limited circumstances specified in the law. However, if the county has a contract with a medical transporter to provide this transport on behalf of law enforcement, it can seek reimbursement from the patient or an insurer. Several models may be considered for this purpose. To ensure care is available to the indigent/publicly funded population at David Lawrence Center’s CSU, Collier has a county- and state- approved transportation exception plan which allows persons under the Baker Act to be transported to facilities, as ‘exceptions’ to the ‘nearest receiving facility’ as required by the Baker 2.A.2 Packet Pg. 11 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 8 Act statute. These are generally people with Medicare or private insurance, or who have complex medical needs beyond the scope of a CSU. Often, the hospital / NCH is responsible for transporting people from its facility to DLC or to out of county facilities. In addition, many Baker Act transports from NCH and Physician’s Reginal Medical Center are completed by CCSO under an MOU between the Sheriff and DLC. The hospital pays for its costs via contract with medical transportation company. Within county transports completed by medical transport are $550 per trip. Out of county costs are considerably higher. There may be opportunities for cost savings and improved coordination for these types of transportation needs. Outpatient Services David Lawrence Center’s community Access Center can provide assessments on a walk-in basis, 24 hours a day, 7 days a week. This often helps to avert unnecessary Crisis Unit admissions as people may be able to get their urgent needs taken care of in an outpatient setting before they turn into emergencies. Capacity for publicly funded, office-based outpatient therapy and psychiatric care is currently adequate, with minimal wait lists. That having been stated, DLC consistently provides more of these services than is supported by public resources and is challenged to continue to financially sustain such. Additionally, waiting lists do exist for specialized treatment such as Dialectical Behavior Therapy (DBT) or Traumatic Incident Reduction (TIR). NCH recently opened a small outpatient mental health office, staffed with a psychiatric Advanced Registered Nurse Practitioner (ARNP). This new service should help provide additional choice of provider and, to some extent, reduce pressure on DLC’s outpatient department. One recent occurrence that will negatively impact outpatient care capacity for addictions is a reduction of $250,000 in state adult substance abuse outpatient funding in the David Lawrence Center’s contract. Integrated Health Care A significant strength locally is the on-site DLC location of the local Federally Qualified Health Center (FQHC), Healthcare Network of Southwest Florida (HCNSWF). This model of integrated health care ensures that people with serious mental illnesses receiving psychiatric care at DLC, who are at high risk for certain medical conditions, can receive their care in a coordinated manner in one place. In addition, another form of integrated health and behavioral health care is on site at the Health Care Network. Behavioral health services are available organization- wide, resulting in 18,000 visits annually. Approximately 40% of those are adult visits. Nationally, as many as 70% of primary care visits are related to behavioral health needs and over 80% of all psychotropic medications in the U.S. are 2.A.2 Packet Pg. 12 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 9 prescribed by primary care physicians. Primary care is often the default entry point for many in need of mental health care, but generally does not provide the specialty care (e.g. case management, supported employment) needed for persons with serious mental illnesses. Health centers across the nation are being encouraged to provide more behavioral health services for reasons cited above. This also is going to apply to substance abuse services. In 2017, DLC opened a pharmacy on its main campus, operated by Genoa Healthcare. As such, DLC clients can conclude their mental health appointments and walk immediately over to the on-site pharmacy to receive their prescribed medications. This helps to reduce potential barriers to use of psychotropic and other prescription medications. Opioid Crisis In response to the nationwide opioid crisis, local efforts include significantly expanded access at David Lawrence Center to effective interventions including:  Narcan (opioid overdose reversal kits)  Medication Assisted Treatments (MAT) including Vivitrol and Suboxone  Case management services for individuals receiving MAT  Expanded MAT education and support in problem solving courts Problem-Solving Courts Collier County currently offers three Problem-Solving Courts for legally and clinically appropriate adults facing criminal charges. They are Drug Court, Mental Health Court and Veterans Treatment Court, each of which operates in a similar fashion. These courts are run by a unified multidisciplinary team, which includes a dedicated judge, dedicated prosecutor, dedicated public defender, dedicated probation officers, as well as the Sgt. from the CCSO Mental Health Unit, and clinicians and case managers from the David Lawrence Center. Beyond these, partnerships with the Jail and its medical provider, St. Matthew’s House, NAMI, The Shelter, the FACT Team, Gulf Coast Runners, the Neighborhood Health Clinic, and many others are crucial to the success of these courts. Participants in each court are afforded an individualized treatment plan aimed at addressing the full behavioral health picture for that individual. This may include any combination of group and individual therapy, medication, trauma treatment and collateral support. Participants are held to high standards of intensive supervision, rigorous honesty, and personal accountability. They are connected with long-term peer supports, they make restitution to their victims, and are 2.A.2 Packet Pg. 13 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 10 supported in securing the housing, education, healthcare and employment needed to maintain their recovery. In 2017, Collier County provided resources to add staff to the team in order to (1) expedite identification and connection of appropriate defendants to these programs, and (2) track data that may be used to measure outcomes and secure sustainable funding. National data suggests these courts are highly effective at improving outcomes for recovery, thereby reducing recidivism, improving public safety, saving tax dollars and restoring individuals to productive lives with their families, businesses and communities. Criminal Justice Reintegration The Forensic Intensive Reintegration Support Team (FIRST) is a jail reentry program providing an intensive, multidisciplinary, case management team from Collier County jail reintegration specialists, David Lawrence Center case managers, and a NAMI peer specialist to assist individuals with community reentry after a period of incarceration. Many participants had multiple arrests prior to admission into the program. The program’s ultimate goal is to improve the person’s probability of success in the community and reduce their chances of re- arrest/recidivism. The FIRST team has demonstrated success at lowering the rate of recidivism among participants to just 22%. For the grant period 2014-2017, the FIRST served 313 people. Of those only 69, or 22% we re-arrested. Reintegration Grant. Implemented in 2010, the Collier County Criminal Justice, Mental Health and Substance Abuse Reintegration grant is in the first year of its third, three-year grant cycle. Supporting the FIRST program, the grant is provided through the Florida Department of Children & Families’ Substance Abuse & Mental Health state headquarters office through Memorandum of Agreement with Collier County. The current grant funding (July 2017 through June 2020) is $1,042,506 with county/partner agency match of $1,052,300 for a total of $2,094,806. The state also pays for significant assistance from the USF Technical Assistance Center throughout the grant cycle. This project demonstrates significant state funding and support for a local project, and stakeholders want to ensure continuation of the FIRST program. Housing Strategic planning participants agreed that housing is perhaps the most daunting issue to address regarding people with behavioral health needs in Collier County. Many residents have a hard time finding affordable housing. Affordable housing is considered housing that consumes 30 percent or less of a household’s income. It includes income target levels starting at “very low,” those making less than 30 2.A.2 Packet Pg. 14 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 11 percent of the $75,000 Collier County median income, up to “moderate income” and “gap income.” Table 1. Fair Market Rent Naples Marco Island, 2018 The average single-family home value in Collier County is estimated at $573,519, which is much higher than the state average of $219,681. About 40% of Collier residents are considered ‘cost burdened’, meaning they spend at least 30% or more of their income on housing, and 20% pay more than 50% of their income for housing. Individuals with mental illnesses are even further priced out of the housing market, many of whom rely on Supplemental Security Income (SSI) due to disability. SSI is currently $750 per month or just $9,000 per year, that is 14.5% of the median income. For individuals with disabilities living solely on SSI, renting even an efficiency at the fair market rent would require more than 100% of their monthly income. Rental units at or below fair market rent in Collier County are extremely scarce. The problem was compounded by Hurricane Irma in September of 2017, which devastated the stock of affordable housing throughout the county, often mobile homes, which will take time to replace. Also, there are higher costs of applying for rentals and high deposits for rent and utilities which complicate renting properties for lower income households. Securing affordable housing for people with convictions and substance abuse issues is even more difficult due to increased use of background checks. The lack of safe and affordable housing is one of the most powerful barriers to recovery. When this basic need isn’t met, people cycle in and out of homelessness, jails, shelters, and hospitals. Supportive housing provides an essential platform for the delivery of services that lead to improved health and stability. At the most basic level, housing provides physical safety, protection, and access to basic needs. HUD FY 2018 Fair Market Rents by Unit Bedrooms Year Efficiency One- Bedroom Two- Bedroom Three- Bedroom Four- Bedroom FY 2018 FMR $778 $996 $1,220 $1,630 $1,978 MYTH: “Housing is a Privilege” Everyone has a right to a standard of living adequate for the health of them and their family including food, clothing, housing, medical care, and necessary social services. --Article 25 of the Universal Declaration of Human Rights 2.A.2 Packet Pg. 15 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 12 Supportive housing improves access to quality health care by providing a physical space for service delivery staff (e.g., case management, FACT) that directly provide or link tenants to community-based social, mental health, substance abuse and primary/specialty medical care services. Local supportive housing options operated by non-profit agencies include David Lawrence Center and Community Assisted Supported Living (CASL). There are generally wait lists for these. NAMI has a HUD grant administered through the county for a small amount of rental assistance for people who are homeless. However, securing willing and benevolent landlords along with affordable units has proven virtually impossible. Some supportive housing models may be helpful in addressing barriers to housing for the target population. These include sites for which behavioral health providers hold a ‘Master Lease’; Florida Assertive Community Treatment teams; Housing First; and the Dave’s House or Jerry’s House model. (Appendix V). Peer Run Services Peer-run services provide a safe and supportive environment for self-help, mutual support, and employment opportunities for people with disabilities. A peer is a person who has experienced mental illness personally, and who has received special training in how to use that experience to support others facing similar challenges from mental illnesses. Along with medication and therapy, peer supports are proven to be effective in helping individuals recover from mental illnesses and addictions. NAMI Collier’s Sarah Ann Drop in Center (SAC) is a peer-operated program for adults with serious mental illnesses. The Sarah Ann Center is open Monday through Saturday and offers socialization and support groups for persons who may otherwise be isolated. Many wellness supports are available for participants via volunteers including yoga, nutrition education, mindfulness practice, and therapist- facilitated improvisational comedy exercises. Drop-in centers often appeal to people who have been disenfranchised or who wish avoid the traditional mental health system. The centers are accessible; provide safe, nonjudgmental, and informal environments; and put few demands on clients. In addition to the Sarah Ann Center, NAMI’s COPE, Community Outreach Peer Education, provides a variety of individual and group peer supports through Certified Recovery Peer Specialists (CRPS). NAMI also operates a state-wide, peer- run Warm Line to provide telephone support when people are isolated and need an experienced, empathic ear. Some communities operate peer-run respite homes. Non-emergent peer respites are voluntary, short-term, overnight programs that provide community-based, non- clinical crisis support to help people find new understanding and ways to move forward. They operate 24 hours per day in a homelike environment, and act as a diversion from high end psychiatric care when possible. 2.A.2 Packet Pg. 16 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 13 Evidence Based Practices Evidence-based practices (EBPs) are defined as treatments that have been researched academically or scientifically, been proven effective, and replicated by more than one investigation or study. Evidence-based treatment practices are meant to make treatment more effective for more people by using scientifically proven methods and research. Ultimately, because they are proven to be effective, the use of evidence-based practices saves money and lives. Whenever possible, local agencies will implement programs using evidence based practices. There are several evidence based practices recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) including but not limited to:  Early Intervention for First Episode Psychosis  Medication- Assisted Treatment (MAT) for Opioid Use Disorder  Peer Support Services in a Recovery-Oriented System of Care (ROSC)  Trauma- Informed Care  Dialectical Behavior Therapy  Supported Housing and Supported Employment Data: Collection, Compilation, Analysis and Sharing For each of the areas discussed above, there is a need for improvement of local data-driven decision making. In Collier County, there is a well-established tradition of health and behavioral health care organizations, county, law enforcement, judiciary, community partners, and concerned individuals collaboratively working toward local behavioral health solutions. Multiple sources collect internal data, and share with other entities in limited ways, but there is not a process for comprehensively collecting and using relevant data, both at the systems and clinical levels, to enhance and inform the planning and delivery of behavioral health care among all related community organizations. Figure 2 depicts the primary local mental health and substance use service array and relationships. 2.A.2 Packet Pg. 17 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 14 Figure 2. Collier County FL Behavioral Health Local Collaborative Relationships (June 2017).20 18services A centralized data collaborative could collect information from entities including DLC, hospitals, and courts, law enforcement, and homeless providers such as:  Number of days acute care units are at or over capacity  Disposition and impact of acute care overflow  What agencies are providing uncompensated care and to what extent?  Numbers and demographics of persons served in each type of service  Demonstration of cost avoidance in criminal justice through diversion activities  Individuals needing multiple types and levels of services The data may be aggregated in many ways to use for planning, quality improvement, program evaluation, and grant applications. A single person or repository would be needed to collect and disseminate multiple data points from multiple entities. Such data can then help better coordinate and target care among entities for people with high needs, and who frequently use multiple services throughout the county. 2.A.2 Packet Pg. 18 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 15 Local Priorities and Committee Leads Participants in the planning sessions agreed upon several priorities and identified a lead person (or persons) to oversee continued planning and execution of objectives and action steps for each priority. An Ad Hoc committee will be needed to oversee the process. # Priority Lead(s) 1 Centralized Receiving System/Addiction Receiving & Baker Act Receiving Facility Scott Burgess, DLC CEO 2 Permanent Supported Housing (Scattered Sites and Supportive Services) Pamela Baker, NAMI CEO; Beverly Belli, DLC 3 Behavioral Health Data Collaborative Commissioner Andy Solis; Sean Callahan, County Administration 4 Increase use of evidence-based practices, e.g. Early intervention for 1st time psychosis. Nancy Dauphinais, DLC COO 5 Increase effectiveness and capacity of Problem-Solving Courts Judge Janeice Martin; Beverly Belli, DLC 6 Baker Act / Marchman Act transportation Sgt. Leslie Weidenhammer, CCSO 7 Build sustainability for Criminal Justice, Mental Health & Substance Abuse Reinvestment grant. CJMHSA Planning Council Table 2. Strategic plan local priorities and lead person(s). 2.A.2 Packet Pg. 19 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 16 APPENDIX I State and National Resources Florida Criminal Justice Mental Health and Substance Abuse Technical Assistance Center www.floridatac.org Louis de la Parte Florida Mental Health Institute Department of Mental Health Law and Policy http://mhlp.fmhi.usf.edu Justice Center www.justicecenter.csg.org Policy Research Associates www.prainc.com National GAINS Center/ TAPA Center for Jail Diversion www.gainscenter.samhsa.gov National Law Center on Homelessness and Poverty https://www.nlchp.org/Simply_Unacce ptable Center for Mental Health Services http://beta.samhsa.gov/about- us/who-we- are/offices-centers/cmhs Center for Substance Abuse Prevention http://beta.samhsa.gov/about- us/who-we- are/offices-centers/csap Center for Substance Abuse Treatment http://beta.samhsa.gov/about- us/who-we- are/offices-centers/csat Council of State Governments Consensus Project www.consensusproject.org Florida Alcohol and Drug Abuse Association www.fadaa.org National Association of Drug Court Professionals www.nadcp.org National Alliance on Mental Illness www.nami.org National Center on Cultural Competence www11.georgetown.edu/research/gucc hd/nccc/ National Clearinghouse for Alcohol and Drug Information www.health.org National Criminal Justice Reference Service www.ncjrs.org National Institute of Corrections www.nicic.org National Institute on Drug Abuse www.nida.nih.gov Office of Justice Programs www.ojp.usdoj.gov Partners for Recovery www.partnersforrecovery.samhsa.gov Substance Abuse and Mental Health Services Administration www.samhsa.gov 2.A.2 Packet Pg. 20 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 17 APPENDIX II The M ent al Healt h Int ervent ion Team (M HIT) is a p art nership b et ween David Lawrence Cent er and t he Collier Count y Sheriff’s O ff ce (CCSO ). M HIT provides out reach and assist s wit h coordinat ion of ment al healt h services t o ind ivid uals in Collier Count y t hrough t he work of a licensed clinical social worker, who is co-located with CCSO. The MHIT pr ogram seeks to: •Divert individuals wit h ment al illness from t he criminal justice system •Red uce st igmatizat ion of persons wit h ment al illness •Link individuals with ment al illness t o app ropriat e treatment and resources in the community •Promot e safet y of t he communit y, including individuals in crisis, family members, and law enforcement off cers •Red uce concerns among family and friends of those with mental illness by pr oviding them with the knowledge that ther e are specially trained of f cers and clinicians who can de-escalate the situation CO MMUNITY MENTAL HEALTH SERVICES Mental Health Intervention Team (MHIT) MHIT IS COMPRISED OF: Certified Crisis Intervention Team (CIT) law enforcement deputies, support staff, a licensed clinical social worker, and liaisons from the local Fire Departments and Collier County EMS. 5/2018 MHIT also conducts follow-up and wellness check-ups for individuals who ar e at high-risk, or who are high-need or high-utilizer s of services. Additionally, the program provides assistance to individuals who may be in need of treatment, such as those frequently calling law enforcement fo r assistance with behavioral challenges. David Lawrence Center is a not-for-profit behavioral health provider dedicated to inspiring and creating li e-changing wellness for every individual through revention, intervention, and treatment services. CALL 239-455-8500 D avid LawrenceCent er.o rg 6075 Bathey Lane Naples, FL 34116 2.A.2 Packet Pg. 21 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 18 APPENDIX III 2.A.2 Packet Pg. 22 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 19 APPENDIX IV Receiving Facilities Baker Act, Marchman Act and Centralized Receiving Facilities The Baker Act (Florida Mental Health Act; F.S. Chapter 394 Part I), includes provisions for involuntary commitment if the person “exhibits substantial likelihood that without care or treatment the person will cause serious bodily harm to self or others in the near future, as evidenced by recent behavior”. Crisis Stabilization Unit (CSU): Also known in Florida as a Baker Act receiving facility, a CSU provides brief (72-hour hold) voluntary and involuntary psychiatric stabilization services in a secure, locked unit, for persons who are in a psychiatric crisis. The Marchman Act (F.S. Chapter 397.6744) essentially provides a means to care for an individual who has lost the power of self-control with regard to substance abuse and there exists the likelihood that the individual has the potential to inflict harm upon themselves or others unless they get help. Furthermore, it must also be demonstrated that the impaired individual is without the capacity to make rational decisions with regard to appreciating the need for treatment. Detoxification Program (Detox): A voluntary (non-secure), medically-managed program for adults who are in need of alcohol and/or drug detoxification services. Addiction Receiving Facility (ARF): Also known as a Marchman Act receiving facility, an ARF is similar to a detox program, but the ARF is secure/locked, and individuals can be legally held at the facility. The ARF provides higher levels of staffing and professional treatment than a detox facility. Centralized Receiving Facility: A Centralized Receiving Facility (CRF) is a single point of access for persons exhibiting challenges related to mental health or addiction-related issues. The CRF provides rapid assessment and linkage to the most appropriate level of care, every day, at any time of day, whether the person’s situation is emergent, urgent, or routine/non-emergent, and whether the issue is mental health or addictions-related. The gold standard for community behavioral health care is to have a Centralized Receiving Facility or System (CRF) to which ALL behavioral health needs can be directed. The CRF can be accessed 24/7 by citizens, their families, law enforcement, or any community member seeking help for a behavioral health need. Once accessed, the CRF diverts people to the appropriate care 2.A.2 Packet Pg. 23 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 20 inside. Typical components of a CRF include a Crisis Stabilization Unit (CSU) and an Addictions Receiving Facility (ARF). The CRF is referred to as a “No Wrong Door” approach in which families or law enforcement officers can bring an individual to one place, without having to predetermine whether the person meets criteria for mental health or substance abuse intervention. The triage and placement decisions are made at the CRF by mental health professionals. For emergent, (i.e. acute) levels of care, whether on a voluntary or involuntary basis, the CRF facilitates direct admission to a Crisis Stabilization Unit (CSU), or Baker Act Receiving Facility. For persons needing clinical intervention related to acute substance use disorders, the CRF facilitates admission to an Addiction Receiving Facility (ARF) or “Marchman Act” receiving facility.” For non-emergent situations, the CRF offers education and linkage to services as needed by the individual. This may include such services as outpatient psychiatric evaluation and medication management, residential substance use treatment, intensive outpatient therapy, case management, supported employment, or a variety of peer led recovery supports. NOTE: Centralized Receiving Systems (CRS) are a relatively new concept in Florida, and do not yet exist in most communities. Where they do exist, they are currently mostly in larger metropolitan areas. Some include a Centralized Receiving Facility. Centralized Receiving Systems are collaborative efforts of receiving facilities of several different provider organizations. In Collier County, aside from the David Lawrence Center, there are currently no other receiving facilities for mental health, and Collier County has never had an Addictions Receiving Facility. CRS’s can also employ additional interventions and responses to meet community mental health and addictions needs, such as Mobile Crisis Teams. 2.A.2 Packet Pg. 24 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 21 APPENDIX V HOUSING MODELS (Examples) Permanent Supportive Housing Permanent Supportive Housing (PSH) is a nationally recognized, proven, and cost- effective solution to the needs of vulnerable people with disabilities who are homeless, institutionalized, or at greatest risk of these conditions. The PSH approach integrates permanent, affordable rental housing with the best practice community-based supportive services needed to help people who are homeless and/or have serious and long-term disabilities - such as mental illnesses, developmental disabilities, physical disabilities, substance use disorders, and chronic health conditions - access and maintain stable housing in the community. Key components of PSH that facilitate successful housing tenure include:  Individually tailored and flexible supportive services that are voluntary, can be accessed 24 hours / day, 7 days / week, and are not a condition of ongoing tenancy  Leases that are held by the tenants without limits on length of stay  Ongoing collaboration between service providers, property managers, and tenants to preserve tenancy and resolve crisis situations that may arise. The evidence on PSH demonstrates that the housing preferences of homeless people and people with disabilities are consistent with the PSH model which provides independent housing that is integrated in the community; offering greater satisfaction and perceived choice to the individuals it serves. The expansion of PSH using innovative systems-level approaches such as those authorized in HUD's reformed Section 811 Program holds great promise for systematically expanding new integrated supportive housing opportunities in states and localities across the country. Integrated supportive housing approaches are responsive to the community integration mandates within the 1999 U.S. Supreme Court's Olmstead decision, a landmark disability rights case which affirms the right of people with disabilities under the Americans with Disabilities Act (ADA) to live in the most integrated setting appropriate to their needs. Reference: http://www.tacinc.org/knowledge-resources/topics/permanent-supportive- housing/ 2.A.2 Packet Pg. 25 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 22 An example of privately-funded supported housing program for people with mental illnesses is Dave’s House. The Traditional Home Model. Dave’s House has two different housing models. The Traditional Home Model, which began operating in 2008, serves to keep individuals from becoming homeless by placing four to five people in a single-family home with supportive services. Residents function as a modern family, supporting each other, sharing housekeeping duties and socializing. By living with others who struggle with the same illness, some residents are able to form meaningful friendships, often for the first time. The Housing First Model. In early 2016, Dave’s House launched a second program called Dave’s Housing First to take chronically homeless people with serious mental illnesses (SMI) off the streets and provide permanent housing in one-bedroom apartments scattered throughout Orlando. In both models, residents are given ongoing mental health services; 24-hour, 365- day-a-year crisis intervention; access to medical care; help applying for benefits; guidance in finding supportive employment for those who are able to work; and assistance in learning general life skills such as how to shop for groceries and use public transportation. Dave’s House partners with Pathway Homes, Aspire Health Partners, Henderson Behavioral Health and Hope South Florida to provide this level of encompassing support, which has proven to be the most successful way to allow individuals with SMI to live independent, fulfilling lives. Residents break the cycle of homelessness, incarceration and hospitalization, so that they may focus on improving themselves, contributing to their communities and realizing their dreams. Providing individuals with permanent supportive housing changes lives. Each individual has a story, hopes and the potential for positive contributions to society. The personal costs to the individual suffering from SMI when we allow them to become and remain homeless are immeasurable – unachieved individual goals as well as loss of familial connections and societal contribution. The costs to the community, however, are very measurable – and staggering and avoidable. 2.A.2 Packet Pg. 26 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 23 Initiated in 2017 by the Vanderhorst Family Foundation in collaboration with NAMI of Collier County, Jerry & Janet's House was inspired by and partially modeled on the Dave’s House concept. Jerry and Janet’s House is a privately- funded permanent supportive housing program for adults disabled by mental illnesses in SW Florida. Disability income falls short of providing even substandard housing in Collier County. While there are a few publicly-funded HUD units that can serve the population, wait lists of over two years prohibit people in need from ever participating. Without decent, safe, affordable housing, recovery from mental illness is not likely. Jerry and Janet’s House was created to help address this problem. Located in Bonita Springs, Jerry and Janet’s House is a large five-bedroom, 3 and 1/2 bath home that houses up to five individuals with serious mental illnesses. The residents receive supportive services from agencies such as Florida Assertive Community Treatment (FACT) team, and NAMI of Collier County’s Self-Directed Care and Community Outreach Peer Education (COPE) programs. A non-residential ‘property manager’, a master’s level counseling student, visits the home on a frequent basis, several times a week, working with residents on meal planning, budgeting, shopping, home maintenance, and mutually agreed upon social activities. Residents each sign their own lease and pay roughly one third of their income for rent and utilities. The ultimate goal is to improve their chances for a productive and meaningful life in a safe and supportive environment. 2.A.2 Packet Pg. 27 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 24 APPENDIX VI STRATEGIC PLANNING PARTICIPANTS Name Organization Commissioner Andy Solis Collier County Board of County Commissioners Judge Janeice Martin 20th Judicial Circuit Scott Burgess CEO, David Lawrence Center Dr. Emily Ptaszek COO, Healthcare Network of SW Florida Susan Kimper Naples Community Hospital Robert Tabor Central Florida Behavioral Healthcare Network Nicole Mirra State Attorney's Office Susan Vivonetto Collier County Sheriff's Office, CIT Sgt. Leslie Weidenhammer Collier County Sheriff's Office, CIT, MHIT Beverly Belli David Lawrence Center Tamara Glynn David Lawrence Center Sheila Forrester Collier County Sheriff's Office Kristen Metz Physicians Regional Medical Center Katina Bouza Collier County Sheriff's Office Nancy Dauphinas COO, David Lawrence Center Dr. Pamela Baker CEO, NAMI of Collier County Lisa Dean Park Royal Hospital Brenda Iliff CEO, Hazelden Bill Gonsalves Collier County Sheriff's Office, CIT Marlee Hartnett, RN Isle of Palms Recovery Center Dawn Whelan Collier County Community and Human Services Kristi Sonntag Collier County Community and Human Services Leanne Morrison Park Royal Hospital Katie Burrows David Lawrence Center Amanda Krause State Attorney's Office Dena Landry Collier County Public Schools Jim Ignelsi The Willough at Naples Doug Williams Collier County Sheriff's Office Monique Nagy Collier County Sheriff's Office Michael Lisboa Colllier County Sheriff's Office Angela Goodner Collier County Commission Zachary Ward Public Defenders Office Jeff Nichols Circuit 20 Court Administration Vann Ellison St. Matthews House Keri Miller David Lawrence Center/CCSO MHIT Tabitha Butcher Collier County Government 2.A.2 Packet Pg. 28 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan) 25 STRATEGIC PLANNING PARTICIPANTS (CONTINUED) Name Organization Brigette DaBiere Armor Correctional Marien Ruiz Collier County Sheriff's Office Shelley Forrester Collier County Sheriff's Office Dr. Lois Bolin Southwest Florida Veterans Alliance Mark Engelhardt USF FMHI CJMHSA Technical Assistance Center 2.A.2 Packet Pg. 29 Attachment: Strategic Plan Draft 5 29 (5797 : Agenda and Strategic Plan)