Yellow Line Project 2017 Quarter 1 Report

This information contained in this report is a summary of Blue Earth County’s Yellow Line Project for the dates of January 1, 2017 through March 31, 2017. 

Introduction

The Yellow Line Project is designed to provide an early response to individuals with acute or chronic mental or chemical health problems who have become involved with law enforcement and are not a risk to the community. The Yellow Line Project enhances the resources and tools available to law enforcement so that residents of Blue Earth County get the right services at the right time and have strong incentives to participate in those services. The project has received funding from the state of Minnesota to test the effectiveness of the model.

While there is a substantial amount of data collected for this project, the format in which it is being collected in is currently being reviewed and redesigned. Capturing aggregate baseline data was the original goal, which has been satisfactorily achieved. As we look to future needs surrounding data we are adjusting our collection methods to satisfy the needs of our day to day operations and to communicate short term and long term project impacts to stakeholders and the community. For the purposes of this report, a combination of aggregate data and individual-level data will be used. Due to the timing of the contract signing, collection of some data elements requested by DHS were not able to be captured. We are assessing how we might be able to include this data in future reports. 

Historical Context

This project has been underway since September 2015. This project is focused on building a model of care versus implementing an existing model. To provide historical context, we’ve categorized our build out in years (see Project Timeline).

The last quarter of 2015 focused an effort to “Define the Mission.” A leadership team was established that consisted of top leaders from Human Services and the Sheriff’s Office. A meeting was held with Assistant Commissioner Jennifer DeCubellis to discuss how the vision for our project may intersect with the department’s vision for the state surrounding mental and chemical health services for legally involved individuals. A gaps analysis was completed, and long-range project goals were established.

The entire year of 2016 was dedicated to “Research & Design: Model & Data.” Initial steps to understand the practices of law enforcement and human services resulted in staff collaborating on an individual basis to problem-solve the needs of a few individuals in the jail that had been identified as “stuck” in jail due to individual mental or chemical health needs.  A request for funding was submitted to DHS, and was subsequently awarded for 2016 with the understanding that the model formed could be replicable to other counties or regions. With a lofty vision in mind, an Operations Team was formed, consisting of leadership and direct service staff from the Sheriff’s Office and Human Services in order to carry out the mission set forth. A project management platform was developed due to the many individual projects underway, as a way to standardize communication, assure accountability, and track the project’s progress. Significant research was being conducted to find a model that could be integrated with the vision of our project. A state and national search for models indicated that many jurisdictions were investing heavily in crisis intervention training, pre-trial and re-entry programs, with none focusing on post-arrest diversions. Individual development projects began to take shape throughout 2016, with investments in technology, information systems, and staffing. The Blue Earth County Board also passed a resolution to be involved in the National Association of Counties’ “Stepping Up” Initiative. This has given us an opportunity to connect with projects across the nation.

On June 1, 2016, a human services staff person was dedicated to the person-level needs of this project on a full time basis. It was identified that there was a link between AMRTC and our jail, given that the majority of individuals being served by AMRTC for our county had been in our jail prior to hospitalization. These are also the individuals who struggled to be discharged effectively from AMRTC, resulting in many Does Not Meet Criteria (DNMC) days. The project worked with AMRTC staff to set up a regular briefing to coordinate care, and this staff acted in the capacity of a Liaison Case Manager. Although this was cumbersome to initially coordinate with AMRTC staff (due to many internal AMRTC changes and miscommunication), the development of this relationship has been highly beneficial to our county and the people we serve (see AMRTC Cost of Care chart). We attribute the decrease in AMRTC expenses to be directly related to implementation of this model of care coordination.

At this same time, the same staff person was instructed to dedicate time becoming familiar with jail practices and the needs of individuals in the jail. Although the goal was to become as proactive as possible, establishing credibility of this worker within the jail system was essential. Relationships with inmates and with jail staff were built, and common languages were developed. It was obvious that the chemical health needs of many inmates were not being addressed, and work was done to bring in additional resources to begin to address some of these needs. 169 individuals in jail were served by this worker during 2016.

Work on establishing a model of care the focused on post-arrest diversion to prevent unnecessary incarceration continued. A pilot night was conducted in the jail to see first-hand the flow of booking and learn about potential ways to divert to community-based options. Although it was the intention to only observe and practice the screening tools that had been developed, a full diversion was conducted that evening. Weeks prior, this individual had dropped out of college, had lost her family support, received inpatient psychiatric care for a suicide attempt, and had just been introduced to IV drugs by a new peer group. This peer group was the subject of a drug task force raid, and this individual was also arrested, with no prior criminal history. This person refused to cooperate with law enforcement, but although scared, did allow our human services staff to create a plan for diversion to which law enforcement agreed. This person was served at the South Central Crisis Center for a few days and then entered an inpatient chemical dependency treatment program. Aftercare was provided through a halfway house, targeted case management services were provided, and months after the pilot night, this individual has reconnected with a healthy support system and is gainfully employed.

Blue Earth County has the pleasure of hosting a full day meeting with Commissioner Piper, Assistant Commissioner Wilson, and Program Consultant Faye Bernstein regarding the progress of the project. A tour of the South Central Crisis Center was given, and a discussion was held stressing the importance of public-private partnerships. A tour of the jail was given, focusing on the pre-booking and intake areas of the jail, signifying the value of the space where negotiations for community diversions can occur. Having just completed the pilot night, the discussion focused on our profound learnings, and a vision for the future was conveyed. A request was made for funding for one more year, as a proof-of-concept year.

The Yellow Line name was adopted in late 2016, signifying the yellow line that exists between the pre-booking area and the intake area of the jail. This line is significant, as crossing this line indicates a change in a person’s constitutional rights, or incarceration. Simply stated, the project’s goal is to frontload services ahead of the yellow line so that law enforcement and individuals may be able to consider alternatives to crossing the yellow line. Once crossed, services come in the form of pre-trial, jail-based services and re-entry services. Research has shown that no two jurisdictions look the same when it comes to programming and services. A model was created as part of the Yellow Line Project to indicate the plethora of options that jurisdictions can work with in order to expand the full continuum of care. The Yellow Line Project exists in a space where no services have been prior, in the Pre-booking, Screening and Triage column. (See Continuum of Care graphic, attached)

Many individual community outreach meetings occurred early in this project to solicit feedback and buy-in. Discussions were held with county commissioners, county administration, corrections, the county attorney, community providers, the hospital, public defender, Brown County Evaluation Center, Mankato Public Safety, the South Central Community Based Initiative, and our Mental Health Center. A large scale community meeting was held on December 2, 2016 to introduce the project to a wider audience and to provide an update to all interested parties. Approximately 60 people were in attendance, which included many other county human services and/or sheriff’s departments, and local legislators.

Major Project Milestones

Many project milestones were reached during the first quarter of 2017. This is a brief listng of the key milestones:

• Integration of Mobile Services and Mankato Department of Public Safety: The leadership team and Operations team was expanded early in 2017. Following the December community meeting, leadership from both entities approached the Yellow Line Leadership about joining the mission. This was an extremely important milestone, as it created a natural buy-in for the organizations to embrace this new way of thinking and practicing. Significant resources from both of these entities have been dedicated to this project.
• Mobile Services Clarification: One early challenge was the integration of mobile philosophies with the YLP. The first few months of 2017 represented a time of significant exploration occurred regarding mobile services in Blue Earth County and the region, as to what it is and also what it could be. Upon receipt of the grant funds in 2016, part of the unofficial agreement was to assure that we were not building a service system that was separate from the mobile crisis team. Early data collection and analysis showed that the SCCBI’s mobile crisis team was not being utilized to a great extent. Conversations with leadership occurred regarding this reality, and planning for future marketing, relationships, workflows, and intersection with the YLP began. YLP leadership, including Horizon Homes’ leadership, began to see how critical a singular continuum of care is to the community acceptance of mobile services. Mobile statistics had historically shown a very low referral rate for services coming from law enforcement. Initial efforts were made to educate law enforcement through the YLP project regarding the potential role of mobile crisis services. A March 2nd work session with a few individuals from law enforcement was held to educate them on the basic principles of the YLP. Actual call scenarios over the last few months were recapped, and officers discussed the traditional responses. Education on YLP and mobile services (as one continuum) was given, and the scenarios were again discussed, and many alternatives surfaced. The following weekend resulted in more calls from law enforcement to the mobile team than has ever occurred, in total, since the team was formed years ago. This solidified our need to receive the department’s support for mobile services to be integrated within the YLP, to do the services they are already doing but within a larger project. Discussions with the department began during this quarter.
• Community Based Coordinator: In the early stages of this project, we identified the social worker role as a “Liaison Case Manager”. Conversations with DHS Case Management leadership occurred about the titling of this position, and the pros and cons of this name. The term “Community Based Coordinator” (CBC) became the agreed upon title, so as to not create confusion regarding the type of care provided (different than targeted case management, or other case management services). The social worker that was located in the jail in 2016 was instructed to begin transitioning her work ahead of the yellow line, into the pre-booking area, with the goal to be solely “ahead of the yellow line” as of 4/1. This move signified a continued investment in moving diversion as far upstream in the process as possible. This move didn’t come without its pains, however, as the need for jail services became very apparent. Conversations with law enforcement, the county attorney’s office, probation, and human services continue regarding the gap that has shown itself in the continuum of care.
• 24/7 Preparations: During the first quarter, the CBC conducted a series of pilots to continually test the tools that were being developed. Administration conducted searches for staff with nursing or social work experience to augment the staffing needs of the YLP in order for the screening and diversion component to be available 24-hours per day, 7-days per week. Hiring such positions proved to be a challenge, given the specific requirements, location, and hours. Work to move to 24/7 continues into the second quarter.
• Stabilization Bed Planning: The need for short-term stabilization options is high with this project. In situations where a person cannot immediately return home, but is able to be diverted from incarceration, our local system of care needs to have options available to consider for short term placement. Working with Horizon Homes, Inc., our local crisis residential provider and provider of other mental health services, we are planning for an expansion of beds for mental and chemical health needs. Horizon Homes kicked off a strategic planning process in order to determine what type of service is most needed in the community. Given that their current crisis residential facility is licensed for 12-beds, but routinely closes admissions at 6 individuals (due to double occupancy rooms), it was apparent that this was the place to begin planning efforts. Initial conversations with regional partners as well as with a property developer began. This process will continue into the coming quarters, and will also include planning for other types of beds and/or services.
• Use of Consultants: Within the first quarter, the use of outside consultants was a strategy employed to bring additional dimension and horsepower to our project analysis. A contract with Houlton Consulting was sought for the purposes of providing a road map for data collection relevant to the key project goals. Nancy Houlton worked exclusively with our project team to identify the key performance indicators for the project, and provide a plan for data collection and dissemination. Most of this work occurred during the first quarter, and is due to wrap up early within the second quarter of 2017. An additional contract was explored with LaForce Teamwork Services to work directly with the Mobile Crisis Team during this time of change and growth, as a way to provide support to leadership and the team. Prior to work starting with Tom LaForce, it was determined that the Mobile Crisis Team had already engaged a plan to meet the goals, therefore the full contract was not needed.
• Post-Arrest Community Based Coordination: As a means to project financial stability, and to further the replicability of this project to other counties, it was clear that a financial model needed to be created that involved both cost savings and revenue production. Exploration of various forms of billable services occurred, and it was determined that the model that most closely supports the CBC role is that of Hospital In-Reach Service Coordination, a service within the MA benefit set. Local legislators had already endorsed the project, and were therefore very interested in ways to continue the innovation. Senator Julie Rosen authored a bill in the Senate to create a new MA service called Post-Arrest Community Based Coordination. Senate authors also included Sens. Senjem, Pappas, and Benson. Representative Tony Cornish authored the companion bill in the House. House authors also included Considine and C. Johnson. DHS legislative staff worked directly with us and the authors to come to compromise language. At the end of the first quarter, the bill remains active in both the Senate and the House. NAMI has vocalized support for this project and this bill, and has encouraged other regions to look closely at this model.
• Operational Toolkit: Forms, policies and procedures were created to support the needs of the community based coordinator doing post-arrest jail diversions. This includes the development of the following items:
  • Project Offense List
  • Specialized Releases of Information
  • Data Sharing Practices Policy
  • Notice of Privacy Practices
  • Database Investigation Checklist
  • Officer Intake Report
  • Detainee Intake Assessment (demographics, mental/chemical/physical health screening)
  • Yellow Line Participation Agreement
  • Yellow Line Participation Standards
  • Yellow Line Treatment Plan
  • TransportaDon Menu
  • Brief Stability Placement Menu
  • Treatment and Services Menu
  • CompleDon/Non-CompleDon NoDficaDon to Law Enforcement
  • CompleDon/Non-CompleDon NoDficaDon to ParDcipant
  • Release of Liability – Alcohol/Drug
• Systematic Placement Database: An electronic database was created through a survey of licensed facilities across the state, which indicates what type of services are provided and to what type of individual based on need. Staff are able to do a statewide search of mental health and chemical health programs and facilities across the state by selecting categories of need. This has significantly shortened the time it takes for case management staff to find placements, and has encouraged the use of facilities that some staff have been unfamiliar with. Providers have expressed interest in this program’s use to be broadened to other counties.
• Flagged Booking System: An automated information system was designed and deployed to cross reference the daily jail booking list with human services information systems. This program is available only to human services staff with proper credentialing. If a person is booked into jail, the following morning at 8 AM a notification is provided to human services if there is any current or past (up to 6 months) involvement of any human services program. This allows staff (case managers, nursing, other) to immediately make contact with the individual and prioritize this contact. It also is an automated system to build upon for future use by our human services staff providing services in the jail.
• March 20th Community meeting: As a follow up to the December meeting, we held a community meeting on March 20th. Sixty-two people were in attendance at this meeting, including interested leaders from as far away as the Arrowhead Region.

Program Data

Total # of individuals screened: 81

Screened at Pre-booking: 6

Screened within the jail: 75

Community Services that were accessed:

*Note: jail staff indicate that prior to CBC in the jail, or jail pre-booking, no referrals were made to these community services.

To understand the individual impact, a selection of personal stories are included:

Person #1 – 29 year old male, charged with DWI (Gross Mis.), came in under the influence, assessed while in custody for a Rule 25, provided on-going face to face contact while in custody and waiting for an inpatient dual diagnosis program. Person was released early to treatment, total stay was 29 days, while court ordered to serve 55. Person was released 26 days early due to the rapid response of screening, Rule 25 provider and coordination of services. Person successfully completed the short term chemical dependency program and is now in the long term (13 month) program at MN Adult and Teen challenge.

Person #2 – 36 year old male, charged with 4th degree Assault on a Peace Officer, Theft of Motor Vehicle, Receiving Stolen Property, DWI, Attempt to Disarm, Obstruction with Force, and Damage to Property. Person came in under the influence and was experiencing delusions. CBC met with client to complete screening, consulted with medical and was then treated for withdrawal. A Rule 25 was requested and completed the next day. A recommendation was made for inpatient CD treatment by CBC, who then made referrals for inpatient and presented a plan to the public defender. A hearing was requested and the condition of the court would vacate bail if defendant goes to inpatient treatment. Furlough from BEC Jail to take care of Nicollet Co Warrant. BEC jail Drug testing condition will be vacated if inpatient treatment entered into. Person was released early from jail to enter treatment on March 16, 2017 and remains there.

Person #3 – Middle-aged male was arrested and incarcerated due to Order for Protection violation. OFP was related to a former girlfriend. OFP violation was a result of the individual walking to girlfriend’s home. Girlfriend notified police due to the man’s unusual behavior (not disruptive, but acting strangely), and was concerned something was wrong. Due to OFP violation, man was brought to jail. While incarcerated, jail staff had to intervene with the individual multiple times due to “behaviors” over the course of many days. CBC was consulted, and person agreed to be screened by CBC. CBC immediately flagged possible cognitive/medical concerns. Further information search within human services systems indicated no history with these symptoms. Emergent medical care was sought, and person was diagnosed as having had multiple strokes. Treatment began by medical team. CBC worked with legal team to coordinate a community care plan, engaged a MNChoices screening, and facilitated placement at an assisted living facility, versus remaining in jail. Legal team indicated the alternative route would have resulted in being released from court, to the community with no medical intervention, which would likely have resulted in further OFP violations.

Person #4 – Middle-aged, developmentally-disabled male was arrested and incarcerated following a physical altercation with a police officer. Person was living in the community, independently, since 1999, and prior to that had been raised in an institution since the age of 6. Has been under guardianship since 1975, and receives case management services from Jackson County. No prior criminal history. Jackson County indicated concerns with his behavior recently, and during a welfare check a police offer was bi[en by this individual. Person was taken to the hospital for evaluation. Parties did not want this person to return home without a plan for care. A series of miscommunications occurred between law enforcement, the case manager, and hospital staff in which resulted in charges filed related to the biting incident. Individual was then taken to jail and incarcerated. CBC was immediately consulted, and worked with county case manager and guardian to navigate the options for this individual who was highly stressed and confused about being in jail. CBC coordinated an urgent care appointment with Blue Earth County’s mental health center to address mental health needs, within hours. Judge agreed to release individual once an appropriate plan of care was in place. Person went to the local crisis center for a few days and was then placed in an assisted living in Jackson, closer to family and per his request. Legal and jail teams indicated that without the CBC, this individual may have remained in jail for months otherwise.

Successes

Due to the ongoing nature of this pilot, many of the learnings are also considered successes. Additionally, many of the failures are spun to be seen as successes, because we have learned more about something that we didn’t know about prior.

Many of the milestones above correlate with project successes. However, the themes that have resonated this past quarter are as follows:

• There is significant buy-in from our team, our partners, the community, our elected officials, and the individuals we’ve worked directly with. This seems to be something “new and innovative,” yet completely replicable within other jurisdictions. The excitement of the project is unable to be contained, and we are beginning to receive requests for speaking engagements from a wide audience who is interested in learning more. Oddly, this is coming prior to us having a 24/7 model, or having all of the “kinks” worked out. This speaks to just how significant of a systemic problem that mental and chemical health needs in jails are, and how hungry others are for solutions or ideas.
• This quarter, significant resources were put into creating a standard of practice from which the YLP operates. The Operational Toolkit is nearing completion, and it will be a resource for any other project to use when considering the workflows and practices. Additionally, all of the other pieces that are coming together to move to 24/7 coverage are continually helping to shape our project expectations and practices.
• We do not pretend to believe that we are the first to come across this conclusion, but once experienced you fully appreciate the magnitude of the benefit. Having a social worker (or CBC) in the jail to navigate the community-based systems of care within the legal realm has positive impacts across our entire service system within Human Services. The cultural growing moments are aplenty, and we’ve just begun. We have learned from both Leadership Design Team and Operations Teams that the members are beginning to assimilate with one another, and have an even greater appreciation for the necessity of our roles. Operating under the premise that we are not converting a social worker to practice as a police officer, and we are not expecting our police officers to act as a social worker, we’ve begun to chip away at the cultural barrier that naturally exists and limits creativity and potential positive outcomes.
• Taking a risk to try something new is not easy. This is what we’ve tried to do with the pilot times, as we prepare to move to a 24/7 model. This is the environment where we’ve learned what works, and what doesn’t. We’ve had very little resistance from the people we are working with, and they are usually motivated to work with us versus against us. We spend time at each of our Operations Team meetings discussing actual individual stories, to discuss what worked, what didn’t, and other potential creative options. It also provides us fuel to continue moving forward with this mission.

Barriers

• Integrating with our provider of mobile services has not been challenging, as they’ve shared excitement for the project all along. However, coming together as the County, the Region, the Provider, and the Department of Human Services with a mutual understanding of mobile services has been a barrier we continue to work through. We’ve determined that the screening conducted by the CBC is almost identical to the screening conducted by the mobile team. Coupling that finding with what we believe to be an aligned mission, and a desire to not duplicate or work around an existing service, we look for reassurance from the Department to integrate the mobile team within a segment of the YLP. The County and the Region believe the work falls well within the bounds of what statute defines as mobile crisis services, but the Provider also understands that this is an advancement to the already submitted crisis grant application. Receiving confirmation from the department that these practices are indeed aligned within the community-based care delivery model was necessary to validate all parties and move forward with continued integration. (*Note, at the close of the quarter this was not yet clarified, but into 2nd quarter this has since been resolved.)
• One project that seems to be slower to move than others is the development of a Jail Clinical Services model. From the onset, there has been interest by both the Sheriff’s Office and Human Services to align our staff more closely so the jail may utilize specialized clinical services from our mental health center. This is a heavier “lift” than originally suspected. The jail currently has a menu of medical services, although not chemical or mental health specialty services. There are many pieces that need to occur, in a particular order, to achieve the project’s end goal, however the first step may not occur until the details of the final step are known and assured. This is only further complicated by contracting issues, acquiring approval for hiring, role definition, and transfers of liability. We hope to move on this further during the second quarter.
• As noted above, the YLP has gained significant attention and expressed interest by many parties. One challenge has been to keep the design team limited in population. Many leaders from other areas have lobbied to be a part of this project, but hesitantly, their participation has been halted from the vision-setting group. We have continued to work with these many partners in other, more operational, ways. As leaders who want to promote inclusivity and reward buy-in, this has been difficult, and almost counter-intuitive, to do. We are confident that keeping the design and governance small and limited is what has allowed us to continue to push such a project in our collective environments.
• We do struggle with how to best communicate about the project. We spend hours each week on communications, as the dynamic nature of this project means we have much to share. Our community meetings, standing leadership and operations meetings, presentations, emails, and other communication strategies have worked to a degree, but we do need to strategize on how to be[er meet our needs in this regard.

Plan for Next Quarter

The second quarter of 2017 is likely to be the most dynamic yet. We hope to move to having 24/7 staffing available in the pre-booking area of the jail mid-second quarter. Most of our work will center on hiring, training, communications, and finalizing practice standards and the operational toolkit. Additionally, we hope to continue to work on the Post Arrest Community Based Care Coordination with the Legislature for inclusion in the Medical Assistance benefit set. Finalizing a set of data and performance metrics will be essential in the coming months, as we’ve established baseline data and now need to gather the most important data to show and track progress. Finally, we have been asked to present to the Association of Minnesota County’s Future’s Committee, which will certainly be a test to the viability and interest of this project on a statewide platform.