2003 APA Awards: Silver and Bronze Achievement Awards

Children and adolescents who have both mental disorders and developmental disabilities have unique needs that are all too often neglected. In the state of Kentucky, before the introduction of two special programs of CARITAS Peace Center in Louisville, services for this patient population simply did not exist—children and adolescents with coexisting disorders had to be placed in institutions outside Kentucky, far from family and community support systems.

CARITAS Peace Center is one of the nation's leading psychiatric facilities offering specialized programs for persons with emotional, behavioral, or psychiatric disorders or chemical dependencies. With a licensed bed capacity of 416 and a current operating capacity of 227 beds, it is one of the largest private psychiatric hospitals in the United States and is unique in both the volume of patients it serves and the range of programs it provides. More than 85 percent of the hospital's patients are children and adolescents, many of whom are indigent or are wards of the state. CARITAS serves individuals and families from the Louisville metropolitan area and throughout the Commonwealth of Kentucky as well as patients from Indiana, Ohio, Iowa, and other states. Approximately 2,500 inpatient and 23,000 outpatient visits are expected during 2003.

Starting in October 1997, the CARITAS Peace Center established Innovations and the Neurobehavioral Center, programs that offer effective, least-restrictive treatment for children and adolescents with both a psychiatric condition and a developmental disability. The programs' creators chose this name to set the programs apart from traditional programs for children and adolescents with this special combination of problems. As a result of continued success with patient outcomes, the programs have grown from a single 22-bed unit to three units capable of serving up to 67 children and adolescents. The units remain at or near capacity, an indication of the demand for this type of service. For their efforts to address the needs of a very challenging patient population, Innovations and the Neurobehavioral Center were awarded one of two APA Silver Achievement Awards for 2003.

The programs' establishment followed intensive lobbying by families, CARITAS, and others in the mental health community for in-state care for this special population. State legislation was changed in 1997 to prohibit Medicaid reimbursement for placements out of state when a willing in-state provider can provide care at comparable cost. In 1996, before the programs were implemented, more than 350 Kentucky children were treated in out-of-state facilities; 40 to 80 of these children had a diagnosis of mental retardation, autism, or brain injury and required intensive specialized care. Four years later, fewer than 25 Kentucky children were receiving out-of-state treatment.

The mission of Innovations and the Neurobehavioral Center is to provide cutting-edge treatment for children and adolescents with developmental disabilities who present significant behavioral challenges that impede meaningful family, social, and community integration. The primary purpose of the treatment provided is to help patients live as autonomously as possible within the parameters of their preferences, the preferences of persons who help them make decisions, and relevant concerns related to quality of life.

Given the challenging nature of their patient population, Innovations and the Neurobehavioral Center have combined the use of relevant scientific literature, original ideas, adherence to best practices, and data-based decision making to continually improve the programs. The centers' programming is driven by empirically based disciplines that have proven positive outcomes, such as applied behavior analysis. This approach as well as other key disciplines of occupational therapy and speech-language pathology have been successfully combined with a more traditional psychiatric hospital.

Treatment provided through the programs is individualized and data driven. Assessment of the patient's behavior is based on direct observation and data collection—as often as every 15 minutes—and scientific manipulation of environmental variables. Data are reviewed daily for the purposes of continuous quality improvement.

Community-based interventions are another important aspect of the programs. Patients have access to a variety of community settings—such as parks, shopping centers, community sports arenas, and movie theaters—on an almost daily basis, which provides opportunities to practice new skills in alternative settings and to increase generalization from an inpatient treatment setting to the community. Patients' community involvement is progressively expanded as prescribed in individual treatment plans. For some patients, the community-based services have eliminated the need for inpatient treatment.

The clinical director is a psychiatrist who provides leadership along with the nurse manager and the program director, who is one of the team's behavior analysts. Key staff include six behavior analysts, 22 nurses, six social workers, nine teachers, four recreation therapists, two speech and language pathologists, two occupational therapists, eight specialized staff trainers, and 58 direct care staff. Most of the staff members are full-time. The behavior analysts conduct functional assessment of patients' behavior and develop an individualized personal intervention plan that specifies target behaviors for reduction, replacement behaviors for development, reinforcement-based procedures for staff and family members to implement, and crisis intervention procedures. The speech pathologist and occupational therapist screen all patients and, when indicated, contribute to the personal intervention plan or develop specific speech or occupational therapy plans. The bachelor's-level staff trainers cross over to all shifts and to weekends to ensure that all staff members are trained on intervention plans and to ensure continuity of services. The nurse is the shift supervisor and assigns tasks to all direct care staff. The teachers provide year-round schooling, and the recreation therapist develops the evening and weekend schedule of activities, including community outings.

Family members, caregivers, and other community support systems are involved in treatment on an ongoing basis, learning and applying reinforcement methods. Parents and guardians are encouraged to attend therapy sessions as often as possible, but at least weekly.

These units serve approximately 85 children and adolescents per year; approximately 342 have been served over the four years that all three units have been in operation. The average length of stay is three to four months. A study was conducted to assess the impact of the centers' treatment approach on functional outcomes over the first three years. Data were collected for 165 program participants at preadmission and discharge, with 135 participants available for follow-up at three months, 124 at six months, and 87 at 12 months. All the participants were children between the ages of three and 19 years with a preadmission diagnosis of a developmental disability, such as mental retardation or autism, and a psychiatric disorder, such as conduct disorder, obsessive-compulsive disorder, or oppositional defiant disorder, and an average length of stay in the hospital of 122 days.

Analysis of the data indicated that 99 percent of the study participants improved in safety and risk status, 62 percent improved in residential status, 84 percent improved in social and community participation, and 82 percent improved in environmental and support status from admission to discharge. One of the most significant indicators of success was that a majority of participants (58 to 98 percent, depending on the outcome area) maintained or improved on all five outcome areas across all three follow-up intervals.

Innovations and the Neurobehavioral Center continue to face various challenges, including the challenge of fiscal management. The programs work hard to attract funding from diverse sources to provide a solid but flexible base: Title XIX Medicaid ($7.4 million), the federal Early Periodic Screening Diagnosis and Treatment program ($1.9 million), Medicaid Impact Plus community wraparound funds (partial and outpatient), the Indiana Department of Education, a specialized Medicaid carve-out with individual counties, private commercial insurers, CHAMPUS (federal military), and disproportionate share funds, for a total budget of around $10 million. When all other avenues of funding have been exhausted, charity funding has been made available.

Staff turnover was initially a challenge as well, given that the programs' patient population requires a unique approach to treatment. Now, all job candidates are given a tour of the units and a description of the programs before they formally apply for a position on the staff. Newly hired mental health workers receive one and a half weeks of classroom instruction, including safe crisis management, in addition to four weeks of orientation during which they work alongside an established staff member before being assigned a shift of their own. Within the first 60 days of employment, new staff members are provided with small-group inservices with the clinical director, behavior analysts, speech-language pathologists, and occupational therapists for additional training on strategies for working with this patient population. As a result of these kinds of approaches, staff turnover has declined from more than 30 percent in 2001 to about 20 percent currently.

Beginning in June 2003, a new staff training program that specifies monthly staff training requirements on individualized personal intervention plans was implemented. If staff meet the required training goal, they receive an extra dollar per hour for every hour they work during that month. This system has increased the percentage of staff trained by the deadline on these monthly required plans from an average of 68 percent of staff trained to 93 percent of staff trained within the first month of its implementation.

The treatment teams of Innovations and the Neurobehavioral Center are frequently invited to lead site visits and to present results of their data-driven research to professional groups, training institutes, and conferences—for example, the Association for Behavior Analysis, the Brain Injury Association of Kentucky, and the Kentucky Mental Health Institute. Curricula of the staff training programs are available on request for distribution to programs throughout the United States. Through such activities, the treatment team is increasing public awareness of the needs of and treatment methodologies for the centers' special patient population. Innovations and the Neurobehavioral Center are model programs that have combined empirically based treatment components, core disciplines, a proactive approach, and positive reinforcement to produce positive, cost-effective outcomes.

The recently released report of the President's New Freedom Commission on Mental Health calls for a transformed system that is recovery oriented and driven by the needs of consumers and in which multiple systems collaborate to make the best use of resources. In rural Colorado over the past seven years, Southeast Mental Health Services (SEMHS) has undertaken a process of planning and vision to achieve such a transformation.

By shifting from a deficit-based program model to a consumer-driven recovery model and drawing on the frontier ethos of people helping each other, SEMHS has created an environment of stability and safety for both consumers and staff. Since the new model was implemented, consumers with serious mental illness are getting and keeping jobs, returning to school, and reporting significant positive changes in their lives. People who were once considered marginal are achieving a level of success that was never thought possible.

In recognition of the difficulties involved in realizing such a culture change and the success of the change process, APA has awarded a 2003 Silver Achievement Award to SEMHS.

SEMHS is a private nonprofit corporation founded in 1957 that provides mental health services to children, adults, couples, and families in six rural and frontier counties. The counties cover nearly 10,000 square miles and account for about 10 percent of Colorado's landmass but only 1 percent of its total population—about 52,500 people. About 25 percent of its residents are Hispanic, 73 percent are white, and 2 percent are either African American or Native American. The median family income is significantly lower than the income for the state as a whole.

When Robert Whaley, M.B.A., became executive director of SEMHS in 1998, several factors were already in place that would help him guide the culture change that he envisioned. In 1995, the state of Colorado capitated the provision of mental health services for its Medicaid-eligible population. Moving to a capitated model enabled SEMHS to expand the array of services and tailor them to individual and community needs. In 1997 SEMHS staff began training in the Boston University model of psychiatric rehabilitation under the guiding inspiration of Ed Knight, Ph.D., vice-president for recovery, rehabilitation, and mutual support at ValueOptions and a consumer with schizophrenia who has lived as a homeless person. Along with the training came the recognition among staff that a culture shift was necessary to ensure success.

A detailed plan for implementing the change was formulated. First, the mission statement was changed. References to mental illness and symptoms were removed, and the statement was focused on "the success of individuals." Programs were redesigned and job descriptions were redefined, empowering both staff and consumers to make decisions about treatment. SEMHS developed a consumer-driven service model with a service menu from which consumers could choose. Programs include social skills and work training, daily living skills training, and education about mental illness and the importance of medication, symptom management, and therapy to help people deal with the trauma of having a serious mental disorder.

Specific program changes that moved SEMHS to a recovery model included increased use of atypical medications. Donald Johnston, M.D., made atypicals the medications of first choice, rather than the last resort for consumers who did not respond well to other medications. Group homes in which consumers had been isolated were closed, and consumers moved into apartment complexes in the community. Five or six consumers decided to live in the same complexes alongside other residents. Such clustered housing in community settings allowed consumers to establish informal support groups and natural support networks. In addition, instead of being assigned to a clinician, consumers were allowed to choose their own therapist and to determine the duration and topic of their therapy. Sessions were no longer mandatory. All day treatment programs were closed.

Paul Sedillo led the community support services team through changes that deeply affected team members' daily routines and relationships with consumers and required staff to examine their beliefs about consumers' abilities. In addition, home health care aides were hired to help consumers manage their homes, finances, and lives. Consumers' expectations about what they can achieve have been raised, and they are expected to take responsibility for their own well-being and inform their case manager if conditions in their lives deteriorate. In June 2001 SEMHS opened an 11-bed crisis hostel that is available to consumers 24 hours a day, seven days a week. The hostel is staffed by professionals and consumers, and consumers use the hostel voluntarily for support. Unlike other crisis or acute treatment programs, a predetermined threshold of dangerousness or distress is not required. Consumers stay at the hostel as long as they feel the need to.

Another important factor in the successful culture change was public education. Because SEMHS is located in a rural community, consumers do not have the advantage of anonymity. For reintegration to be successful, SEMHS recognized that it was critical that the community did not discriminate against people with serious mental illness. The center undertook an aggressive campaign to educate the community about mental illness. It hired a professional public relations firm to develop a marketing campaign that would make its name and "product" more visible in the community. In addition, all staff members conduct community education programs on a rotating basis.

SEMHS increasingly focused on jobs and education for consumers who selected these goals. Through its community modeling and education efforts, SEMHS developed relationships with local employers to increase the pool of jobs available to consumers. It also helped employers by providing a labor pool that was flexible and willing to work part-time or nonstandard hours.

A new position was created specifically to build community partnerships. Before the shift, other community agencies were isolated and territorial. Now, agency staff sit on each other's boards, attend each other's meetings, and share office space and in-kind training. It is a more efficient use of resources and helps to build networking partnerships. Formal and informal collaborative relationships have been developed with primary care physicians, hospitals, law enforcement agencies, a local junior college, substance abuse treatment services, Planned Parenthood, and banks. In addition, staff who did not have master's-level certifications were trained to coordinate services, a change that was well received by both consumers and other staff.

SEMHS has addressed several barriers throughout the transition. The area it serves does not have widespread public transportation. Transporting consumers took valuable clinical and case management time. To solve this dilemma, SEMHS obtained transportation services via a contract. Another problem faced by many rural service agencies is turnover and recruitment of trained staff. When the change was implemented, the management team recognized that many staff members would be reluctant or even unwilling to change their treatment philosophy and might leave the organization. To ensure staff commitment, several inservice training sessions on organizational change were conducted, and staff members were required to do outside reading on the change process. Staff also had input into the process, and their concerns were addressed formally in meetings with the director and informally with their supervisors.

In addition, rural mental health centers are typically underfunded, and SEMHS is no exception. It receives 79 percent of its funding (about $3 million) through its capitated Medicaid contract with the state, 15 percent ($570,000) through state general funds and block grants, and 6 percent ($230,000) from fees and other income. The "one-size-fits-all" approach meant that many clients received unnecessary services, which was inefficient and fostered dependency. The move to a recovery-oriented system of care has allowed SEMHS not only to improve outcomes but to use its already stretched resources more effectively.

Currently, SEMHS serves 120 consumers with serious mental illness. According to research by Dr. Knight, about 40 percent of them are working, volunteering, or going to school. A pre-post evaluation conducted in 2000 for 50 clients showed a dramatic increase in level of functioning of more than one point (on a 5-point scale). This increase moved the group from a below-average rating to an average rating. On a similar scale, problem severity scores have also improved by more than one full point, from below average to average. Evaluation of other areas, including overall strengths and resources, reflect a similar pattern of positive change.

Services also changed dramatically. Although the overall number of units of service for consumers with serious mental illness stayed relatively flat, the mix of services changed. Under the new model, consumers receive fewer restrictive services, such as residential and day treatment, and more integrative services, such as vocational and case management.

A great deal of research has been conducted to describe, define, and quantify recovery. Although a number of recovery models have evolved and many are being replicated successfully, most research has been conducted in urban areas, which have far greater resources and vastly different cultures. In addition, most of the widely recognized systems of care for people with serious mental illness have been designed and researched in urban areas. Through a process of planning and vision, SEMHS has created a strengths-based program that incorporates elements from several models to help rural consumers find a meaningful niche in their community. The ultimate accomplishment of the program is best described in the words of an SEMHS board member: "What we have here is a planned and controlled liberation of people diagnosed with mental illness."

Patients who have both a mental illness and a substance use disorder often do not receive coordinated treatment for their co-occurring conditions. Effective care for this group of consumers is significantly impeded by the fact that services to persons with dual diagnoses are provided through two separate funding streams, often through two or more different agencies within a geographic area. It is not unusual for the two agencies to provide services through distinct "silos" of care, requiring two separate intake processes, for example. It has been well documented that, under such a system, the individual agencies frequently have difficulty providing concurrent services to patients with dual diagnoses.

Sinnissippi Centers, Inc., a private, nonprofit four-county behavioral health care agency located in rural northwestern Illinois, provides 24-hour emergency services seven days a week in addition to a full range of behavioral health services for persons with serious mental illness and substance abuse and for families, children, and adolescents experiencing mental health-related problems. In July 2000, Sinnissippi—which has been in existence since 1966—undertook a project to identify barriers to the receipt of services by persons with both mental illness and substance abuse and to address these barriers by enhancing services to this group.

The project, which was selected as one of two winners of an APA Bronze Achievement Award for 2003, began as a joint venture between two of the agency's treatment centers: substance abuse services and clinical services. The clinical leadership of these two centers invited interested staff to participate in a statewide conference about the co-occurrence of mental illness and substance abuse. Subsequently, a performance improvement team was formed and was given the tasks of identifying barriers to integrated treatment services for this consumer group and developing recommendations for removing those barriers. The dedicated members of this team devoted much of their time without pay to open the lines of communication between two separate treatment centers.

Specific barriers identified were organizational barriers, including staff specialization; separate and distinct funding sources requiring different types of staff credentials, different sets of documentation, different completion time frames, and different signature and authorization procedures; lack of a protocol for dealing with the full range of problems experienced by patients with dual diagnoses; lack of a protocol for diagnostic consultation between service areas; lack of directives in relation to case managers' responsibilities; and an insufficient number of treatment groups specifically for persons with both mental illness and substance abuse.

Each of these barriers was addressed through approaches such as cross-training staff to complete the appropriate documentation for both types of disorders; training staff in the philosophy of integrated service provision; developing an integrated assessment instrument for securing funding; developing a specific best-practice decision tree for patients with dual diagnoses; developing a more specialized assessment and consultation process whereby a member of one treatment team could request a more comprehensive assessment or further consultation from the other team; developing a best-practice treatment protocol for case managers; and introducing a treatment group specifically for patients with both mental illness and substance abuse.

The first treatment group specifically for persons with dual diagnoses was initiated in July 2000, with 18 consumers. Currently, the agency serves approximately 1,200 consumers with both mental illness and substance abuse with various aspects of the redesigned service model.

Sinnissippi's treatment approach involves multiple assessment measures as a means of increasing the likelihood that the consumer will receive an accurate diagnosis, which allows a greater number of consumers to receive appropriate services specifically for persons with dual diagnoses. This approach has in turn allowed Sinnissippi to track the response of other disorders to specific treatment processes. Sinnissippi's chief psychiatrist is a proponent of the idea that psychotropic medication is a useful primary therapeutic intervention for patients with dual diagnoses. The psychiatrist has also developed a protocol to decrease the probability that inappropriate medications will be prescribed to consumers with addiction.

The process of identifying and eliminating treatment barriers has been multidisciplinary in both design and implementation. The staff involved in the planning and implementation of the initiative included management, supervisors, and frontline clinicians representing licensed clinical social workers, licensed clinical professional counselors, certified addiction and drug abuse counselors, registered nurses and certified psychiatric nurses, and nonlicensed, noncertified staff. All staff had numerous years of experience in working with populations with serious mental illness and substance abuse. Currently the staff working specifically with this patient group comprises two management staff (one for addiction and one for quality assurance), one supervisor (mental illness), one master's-level nurse with certification in the field of mental illness, two bachelor's-level frontline staff who work in the area of mental illness, and one frontline staff member certified in the area of addictions.

Data for 18 months before and after service enhancement were compared to examine correlations between the services provided and patient outcomes. The research included a matched comparison group of 18 patients with dual diagnoses who were not treated with protocols specific to the service enhancement program. Results of the evaluation include a dramatically lower dropout rate in the intervention group (5.5 percent compared with 65 percent), higher functioning in the intervention group (average score of 6.8 compared with 4.19 on a scale of 1 to 10, with higher scores indicating better functioning), drastically reduced use of emergency services after the service enhancement initiative (1.16 events per consumer compared with 5.05 events), and a greatly improved rate of sobriety after the initiative (67 percent after the initiative compared with 28 percent before).

The mental illness and substance abuse service enhancement program did not receive funding from any source other than Sinnissippi Centers, Inc. Program development expenses were supported by the organization's case reserves, and operational processes were improved so that direct service expenses could be appropriately billed to existing funding sources, such as the Illinois Office of Mental Health. The program's initial operating cost was around $40,000, which includes $17,000 for program development and $23,000 in direct service expenditures. Sinnissippi Centers, Inc., has a 2003 budget of $7.7 million, funded through state and county grants, purchase of service contracts, insurance, and private payments.

For the past two years or so, the state of Illinois has been attempting to get many behavioral health centers throughout the state to work together more closely and integrate mental health and substance abuse assessments, with little success in many cases. Sinnissippi began implementing these ideals well before these efforts on the part of the state and is now at the forefront in this quest to blend mental health and substance abuse services in a more seamless way.

The program won the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO's) 2002 Codman Award in the behavioral health care category. Since receiving the award, Sinnissippi has been contacted by agencies from across the nation seeking information about the initiative. In the words of Mary Cesare-Murphy, Ph.D., executive director of JCAHO's behavioral health care evaluation program, Sinnissippi "was able to succeed where programs around the United States have failed—or not even tried—in eliminating service barriers that are shared by all such programs."

Over the past three years, the likelihood of incarceration of persons with serious mental illness who live in and around Akron, Ohio, has been greatly reduced by a comprehensive program that has strengthened existing bonds between the county's mental health and criminal justice systems and united many individuals in a common goal. For its systematic and successful efforts on multiple fronts to counter the serious problem of criminalization of persons with mental illness, the Summit County Alcohol, Drug Addiction, and Mental Health Services Board (ADM) has been awarded a 2003 Bronze Achievement Award by the American Psychiatric Association.

Although the Summit County ADM has for many years operated individual programs to prevent inappropriate incarceration, it dates the full implementation of its systematic decriminalization program to the creation of the Summit County Mental Health/Criminal Justice Forum in April 2000. The forum, which resulted from a 1999 consultation with the National GAINS Center, includes all the major stakeholders in the county in mental health and addiction treatment and prevention and criminal justice. Two major achievements have emerged from the GAINS consultation and the forum: the adoption of the sequential intercept model as a systematic approach to decriminalization and the implementation of three specific programs consistent with the model—an integrated co-occurring disorders assertive community treatment team (SAMI-PACT), a crisis intervention team (CIT) with the Akron Police Department and the Summit County Sheriff's Office, and the Akron Municipal Mental Health Court. These efforts build on existing programs, including a behavioral health assessment and treatment program at the county jail, a linkage program between the municipal courts and the mental health and substance abuse treatment systems, and a residential program for individuals with co-occurring disorders who are released from correctional settings or diverted by the courts.

The sequential intercept model recognizes that because the criminalization phenomenon results from multiple factors, multiple solutions are needed. The model attacks the problem at four levels. Each level is a point at which a mentally ill person can be "intercepted" and kept from going further into the criminal justice system. Intercept 1 is the level of best clinical practices, in which an accessible mental health system provides treatment and recovery interventions that have been shown to be effective. Intercept 2 is the level of prearrest diversion, where the focus is primarily on law enforcement. At the intercept 3 level are postarrest diversion efforts that primarily target judges, prosecuting and defense attorneys, and the probation system. Intercept 4 is treatment within correctional settings and postrelease linkage to the treatment system.

Using this model, the Summit County ADM developed new programs at each of the first three intercept levels to complement existing programs at intercept 4. The SAMI-PACT team, which follows the Dartmouth-New Hampshire model, is an integrated treatment program for persons with schizophrenia, schizoaffective disorder, or bipolar disorder and co-occurring substance abuse. It is a joint effort of two ADM agencies: Community Support Services (CSS), which serves the seriously mentally ill population, and Community Health Services, which serves people with addictions. Most persons assigned to the team have extensive histories of involvement with the criminal justice system.

The Akron CIT is an adaptation of the Memphis CIT model program, in which the mental health system enlists family members, consumers, and mental health professionals to provide a week-long training program to volunteer patrol officers who are then available on all shifts to respond to calls that are thought to involve persons with mental illness. Deescalation skills are emphasized, and officers are encouraged to refer people for treatment as an alternative to arrest.

The Akron Municipal Mental Health Court is a misdemeanor court in which competent individuals with serious mental illness, after assessment by the CSS psychiatrist at the county jail, are offered a chance to plead guilty and to be sentenced to two years of supervision. The supervision plan essentially is a mental health treatment plan created by an intensive case management team from CSS. The team's case managers collaborate closely with the judge and the mental health probation officer. Graduated sanctions and rewards are used. When participants successfully complete the two-year program, charges may be expunged, after which participants continue in treatment at CSS. Akron is believed to be the second U.S. city after Seattle to have both CIT and mental health court programs.

Summit County's systematic decriminalization program serves as a model for the state of Ohio. In recognition of the innovative array of services in Summit County, the Ohio Department of Mental Health designated the Summit County ADM as a Coordinating Center of Excellence in Mental Health Criminal Justice Jail Diversion Alternatives. The ADM contracted with the Northeastern Ohio Universities College of Medicine to operate the center, which is charged with helping other counties in Ohio develop jail diversion programs. Center staff work closely with the Ohio Supreme Court's Mental Health Initiative, a unique effort by that court to promote jail diversion programs. Center staff have made presentations at national, state, and local meetings in an effort to disseminate the sequential intercept model and to encourage others to replicate the CIT and mental health court programs. Mental health and law enforcement teams come to Akron to participate in CIT training, and six urban and several rural Ohio counties have or are developing their own CIT programs

Each component program has required unprecedented collaboration, which has been given momentum by the Mental Health/Criminal Justice Forum. The SAMI-PACT team is coadministered by a mental health agency and an addiction agency, which have different certification standards, billing systems, medical record-keeping procedures, philosophies, and cultures. The CIT program attributes its success to the willingness of mental health staff and police officers to become sensitized to each other's world: mental health staff go on "ride-alongs" as civilian observers with police officers and police officers work as "moonlighters," providing security at the psychiatric emergency service. The most challenging collaboration has been between the CSS mental health team and the Summit County Municipal Court. Clarifying the appropriate roles of the mental health case managers, the mental health probation officer, and an activist judge has required ongoing discussion and compromise.

The Summit County ADM has received few additional funds to support these programs. Funding has come largely from reallocation of existing resources. The SAMI-PACT team was partially funded by the state for its first three years. The CIT program was fully supported by the Summit County ADM and now receives partial support from the Center of Excellence grant. The mental health court, which started with ADM funding, has received grant support for two new positions. The Summit County ADM remains committed to maintaining these programs, because it believes that persons with serious mental illness who are at risk of incarceration are the highest priority group for service provision.