Gold Award: Prevention of Jail and Hospital Recidivism Among Persons With Severe Mental Illness

Project Link developed from a 1993 survey of the county jail conducted by the Monroe County Office of Mental Health. The survey identified a group of 126 individuals with severe mental illness who had experienced multiple jail and hospital stays during the previous three years. Most of these individuals were young men of African-American or Latino heritage who suffered from a combination of schizophrenia and drug addiction and who lacked stable housing. Costs for their mental health services and competency evaluations in 1993 alone totaled $628,000.

Based on these findings, the Office of Mental Health issued a request for proposals in 1995. The department of psychiatry of the University of Rochester responded in partnership with five community agencies to form Project Link. Project Link began as a team of bachelor's-level case advocates and a master's-level coordinator, with one case advocate employed at each of the community agencies. Currently the project employs five case advocates from these agencies.

The role of the case advocate is to prevent jail and hospital recidivism by linking consumers to psychiatric, medical, residential, and social services in the community. Each case advocate carries a caseload of 20 consumers, and the team is available seven days a week, 24 hours a day. Case advocates receive supervision and clinical support through the Project Link coordinator, a nurse with mental health and chemical dependency treatment experience. In addition, the coordinator directs community education efforts and represents the case advocates on Project Link's collaborative management team.

Admission criteria for Project Link include the presence of a severe and persistent mental illness and a history of involvement with the criminal justice system. Consumers are enrolled from a wide variety of sources, including state correctional facilities, the local jail, local police departments, the public defender's office, hospitals, and emergency rooms. Project Link places a special emphasis on engaging consumers who are members of minority populations. To effectively bridge barriers related to differences in culture, ethnicity, and language, Project Link features a diverse staff including African-American and Latino case advocates. In addition, all clinical and administrative staff of Project Link have received cultural competence training provided through the Urban League of Rochester. The case advocate team's workload has grown steadily since the project began. Case advocates logged 2,715 contact hours in 1996, 4,340 hours in 1997, and 5,712 hours in 1998.

Although Project Link was initially effective in engaging the target population, the case advocates encountered serious barriers to obtaining appropriate housing for some of the most impaired clients. Those with active drug abuse, multiple arrests, and felony convictions were usually denied admission to group homes or supervised apartments. Case advocates often had to house these consumers in single-room apartments or cheap hotels, which were typically located in drug-infested neighborhoods. In addition to housing problems, the case advocates reported serious difficulty gaining and maintaining access to outpatient health services because psychiatric and medical clinics did not provide the outreach necessary to engage this challenging group.

After a series of discussions that included consumers, case advocates, and staff of the partner agencies, Project Link applied for a Local Initiative Funding Partners grant from the Robert Wood Johnson Foundation in 1997. This effort was led by project director Steve Lamberti, M.D., and the goal was to obtain funds to address the clinical and residential service barriers that case advocates had encountered. The LIFP program was designed to match local dollars, and the administrative staff of Project Link raised a total of $278,000 from multiple sources to qualify for grant funding. Funding partners include the New York State Office of Mental Health, the Monroe County Office of Mental Health, Coordinated Care Services, Inc., Eli Lilly and Company, and Janssen Pharmaceuticals. Project Link was given a four-year grant totaling $557,000. The funds were used to develop a mobile treatment team and treatment residence for clients with severe mental illness and chemical addiction.

To examine the project's effectiveness, Project Link looked at the experiences of the 46 persons with severe and persistent mental illness who were admitted to Project Link's mobile treatment team between October 1, 1997, and December 1, 1998. The mean length of stay in the project for this group was 278 days. The largest referral sources were the jails and prisons (30 percent) and the local state hospital (28 percent).

Thirty-seven of these consumers were men, and their mean age at enrollment was 34 years. Thirty-three consumers were African American, seven were Caucasian, three were Hispanic, two were Native American, and one was Asian. At enrollment, 13 consumers were homeless. Thirty-seven failed to graduate from high school.

Twenty-one of the 46 consumers had a DSM-IV diagnosis of schizophrenia, 12 had a psychotic disorder not otherwise specified, six had schizoaffective disorder, four had bipolar disorder, and three had other diagnoses. Thirty-eight of the 46 consumers had histories of comorbid substance abuse or addiction. At enrollment, their mean score on the Global Assessment of Functioning Scale was 39.

Twenty-three consumers were on parole or probation at the time of enrollment, and charges were pending for an additional five consumers. Twenty had previous felony convictions. Compared with the year before enrollment in Project Link, the mean number of days spent in jail per month for the group of 46 consumers dropped from 9.1 to 2.1 per consumer, and the mean number of hospital days per month dropped from 8.3 to .3. Significant reductions were also noted in the total numbers of incarcerations and hospital admissions for the group.

A preliminary evaluation of the costs incurred by the group of 46 consumers revealed that average monthly jail costs for the entire group dropped from $30,908 to $7,235, or from $672 to $157 per consumer. Average monthly hospital and outpatient costs, including costs for services provided by Project Link, dropped from $197,899 to $42,247 for the group, or from $4,302 to $918 per consumer.

Consumer's ratings of satisfaction with the program yielded a mean of 4.6, with 5 indicating the highest level of satisfaction. In addition, 35 of the 46 consumers reported that Project Link helped them cut down on their use of illegal drugs and alcohol. No assaults, suicide attempts, or other reportable incidents have occurred in the group of 46 consumers since their enrollment in Project Link.

Several aspects of Project Link represent much-needed innovations and important contributions in serving persons with severe mental illness who have a history of involvement with the criminal justice system. The project has created critical links between health care, social service, and criminal justice systems. The coordinated efforts of several agencies are necessary to address the many problems of this consumer group. The project's emphasis on bridging cultural and language barriers and in providing cultural competence training to all team members has made it especially effective in engaging consumers and in gaining community support.

Although conventional assertive community treatment and intensive case management models have been used with similar populations, most studies show little effect of these approaches on time spent in jail. Project Link has made a significant contribution in reducing incarceration among consumers in Monroe County. As a result, Project Link has been used by the Monroe County Office of Mental Health as a model for other programs that serve populations at risk for arrest and incarceration. Project Link is regarded as a statewide model in New York. To promote the model, Project Link staff made a presentation in January 1999 to the commissioner's cabinet of the New York State Office of Mental Health. Project Link recently received national recognition when it was awarded second place in the clinical medicine category of the 1998 Lilly Schizophrenia Reintegration Award.

The 1998-1999 operating budget for Project Link was $681,455, of which $430,000 was associated with case advocacy services and $251,455 with the mobile treatment team and the treatment residence. The New York State Office of Mental Health provided the bulk of the funding for these programs, a total of $471,953. Other sources of funding were the Monroe County Office of Mental Health ($30,000) and the Robert Wood Johnson Foundation ($74,805). Direct service revenue accounted for $43,661, and hospital support accounted for $61,063.

A major obstacle facing Project Link is to establish ongoing funding after termination of the Robert Wood Johnson grant in 2001. To address the issue, directors of the Monroe County and New York State offices of mental health and the New York State Division of Criminal Justice were invited to participate in a Robert Wood Johnson Foundation site visit in November 1998. Based on review of clinical and cost data presented at the visit, state and county officials agreed to consider Project Link for possible continuation funding after expiration of the grant from the Robert Wood Johnson Foundation.

The staff of Project Link are encouraged by its record of success in creating and maintaining critical collaborations among community systems and by the results seen daily among consumers who are living in their community and avoiding jails and hospitals. Project staff will continue to develop and evaluate the program as a model to serve a highly vulnerable group of persons with severe mental illness in urban communities across the nation.