Cascade of care for substance use and mental health disorders for justice-involved populations.

INTRODUCTION: Justice-involved populations have dramatically higher rates of substance use disorders (SUD) and mental health disorders (MHD) compared to the general population. Despite high rates of SUD and MHD, treatment for this population is often limited and not evidence-based. The cascade of care model estimates drop-offs in the continuum of care from screening to identification of need, referral, care initiation, care engagement, and care completion. Recently, healthcare providers have utilized the cascade of care to improve the continuity of care for people with SUD and MHD in justice settings. The purpose of the current study is to 1) identify typologies that explain the proportion of new intakes that pass through each level of the cascade of care for SUD and MHD, and 2) describe agency-level factors that predict typology assignments and agency ability to assess client flow through the levels of the care cascade. METHOD: Using Latent Class Analysis, we classify 791 agencies serving justice-involved individuals into typologies according to utilization of each stage in the mental health and substance cascades of care. Then, we examined county and agency characteristics that affect three stages of the cascade process: identification of need for behavioral health services, referrals to appropriate services, and treatment initiation. We build on previous work by exploring these patterns for both SUD and MHD treatment. RESULTS: The study identified four SUD/MHD treatment patterns: Low Access, SUD-Focused, High Need-High Access, and Lower Need-High Access classes. Factors influencing typology alignment include location, specialized staff availability, warm hand-off coordination, Medicaid reimbursement, and performance measure tracking. Thirty-nine percent (39 %) of agencies could not be classified because they were unable to report their rate of care along the cascade measures. CONCLUSION: Focusing on factors influencing typology assignment can help counties in assessing service delivery, identifying barriers, and targeting areas for improvements in policies and practices, potentially facilitating long-term changes and overall improvement in the care of individuals with mental health and substance use disorders. Identification of these factors and typologies can improve mental health treatment and access in counties and agencies with large resource barriers or limited attention to mental health treatment.

Recommended Mental Health Practices for Individuals Interacting With U.S. Police, Court, Jail, Probation, and Parole Systems.

OBJECTIVE: Tens of millions of individuals with mental health problems interact with the U.S. criminal legal system (including 911, police, jail detention and sentences, courts, and probation and parole) each year. The authors sought to identify recommended mental health practices for criminal legal system-involved individuals and report the percentages of U.S. counties and of the U.S. population living in counties in which each recommended practice is present. METHODS: Recommended practices for criminal legal-involved individuals with mental health problems were identified from meta-analyses, reviews, and best practice recommendations. Up to four respondents per county (i.e., jail, probation, community mental health, and community substance use treatment administrators) from 950 counties were asked whether each recommended practice was present for criminal legal-involved individuals. Weighted percentages of U.S. counties using recommended practices and of the U.S. population living in counties with each recommended practice are reported. RESULTS: Fifty-nine recommended practices, including general mental health approaches (e.g., permanent supportive housing, Medicaid continuity) and diagnosis-specific mental health treatments (including medications and psychotherapies), were identified. Weighted data from respondents (N=791 from 519 counties) indicated that each recommended practice was present for criminal legal-involved individuals in only 21.9%-43.0% of U.S. counties. CONCLUSIONS: These results inform implementation efforts by indicating the presence of recommended care practices for criminal legal-involved individuals with mental health problems in counties nationwide. Because supportive housing, access to Medicaid reactivation in jails, and psychosocial interventions for physical pain have low presence but high importance for recovery, implementation efforts might first target these approaches.

Delinquency, Substance Use, and Risky Sexual Behaviors among Youth who are involved in the Justice System and Predominantly Reside in Rural Communities: Patterns and Associated Risk Factors.

There is a significant gap in research examining the prevalence of problem behaviors among youth involved in the juvenile justice system in rural areas. The current study sought to address this gap by exploring the behavioral patterns of 210 youth who were on juvenile probation in predominantly rural counties and who were identified as having a substance use disorder. First, we examined the correlation among 7 problem behaviors representing different forms of substance use, delinquency, and sexual risk-taking and 8 risk factors related to recent service utilization, internalizing and externalizing difficulties, and social support networks. Then, we used latent class analysis (LCA) to identify distinct behavioral profiles based on the observed problem behaviors. LCA identified a 3-class model representing distinct groups labeled Experimenting (70%), Polysubstance Use + Delinquent Behaviors (24%), and Diverse Delinquent Behaviors (6%). Finally, we assessed differences (i.e., ANOVA, χ2) in each risk factor across the behavioral profiles. Important similarities and differences in the association among the problem behaviors, behavioral profiles, and the risk factors were revealed. These findings underscore the need for an interconnected behavioral health model within rural juvenile justice systems that is able to address youths' multidimensional needs including criminogenic, behavioral, and physical health needs.

Individual Characteristics and Organizational Attributes: An Assessment of Probation Officer Burnout and Turnover Intent.

In recent years, Western and non-Western countries have experience increased reliance on probation services. However, prior research indicates that high job demands and ambiguous role responsibilities invoke feelings of stress and suggest the importance of understanding the relationship between stress and burnout and turnover. While past efforts largely focused on correctional officers (COs), less is known about how probation officers (POs) experience burnout and how organizational attributes may influence this relationship. Using survey data of federal POs (N = 80) across eight offices in a southern state, the current study examines the influence of individual characteristics and organizational attributes in predicting burnout and turnover intent. To answer our research questions, we perform a series of linear regression models. Findings suggest the importance of affective commitment for reducing POs' feelings of burnout and turnover intent. Implications of these findings and directions of future research are discussed.

COVID-19 and Juvenile Probation: A Qualitative Examination of Emergent Challenges and Useful Strategies.

The emergence of COVID-19 placed immediate pressure on the juvenile justice system to adapt to changes in case processing and decision-making practices. Juvenile probation agencies were tasked with quickly altering their policies and practice to abide by local public health measures. As probation supervision is the most common disposition in the juvenile justice system, there is both an empirical and practical need to understand the impact that COVID-19 has on a variety of issues surrounding the supervision and provision of services for juveniles. Using self-report survey data from juvenile probation directors across the United States, the current study examines (a) the biggest challenges faced by juvenile probation agencies during the pandemic, (b) the strategies implemented in response to these challenges, and (c) the most pressing issues currently facing the field of juvenile community corrections. Results have the potential to inform future agency decision-making when adjusting juvenile probation policy and practice.

Examining the measurement precision of behavior problems among a sample of primarily rural youth on juvenile probation and their parents.

Accurate and timely intervention in the justice system is particularly critical in rural communities, given documented barriers to accessible, evidence-based services for youth. As youth in the juvenile justice system have a high prevalence of behavioral health needs, accurate assessment of those needs is a critical first step in linking youth to appropriate care. The goal of the current study is to examine the reliability of a brief assessment (the Brief Problem Checklist [BPC]) among a sample of 222 justice-involved youth and their caregivers who primarily reside in rural communities in the United States. Using a series of reliability analyses and tests of agreement, we examined whether youth and caregiver BPC produces reliable scales, the strength of the convergence among each of the BPC scales, and youth and caregiver agreement on the BPC scales. Findings support the reliability of the BPC, but not inter-rater reliability. Poor agreement between youth and caregiver reports exists for both youth internalizing and externalizing problems. Additionally, the BPC was significantly related to several theoretically relevant constructs, including treatment, substance use disorder severity, and family history of substance use. These findings lend merit to discussions about the need for more research on the reliability and validity of assessment instruments before their widespread use in guiding youth- and agency case planning decisions, along with informing conclusions about program effectiveness.

The relationship between community public health, behavioral health service accessibility, and mass incarceration.

BACKGROUND: The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge. METHODS: The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute's incarceration database, Robert Wood Johnson Foundation's County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census. RESULTS: Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate. CONCLUSIONS: Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.

Protocol for a quasi-experimental, 950 county study examining implementation outcomes and mechanisms of Stepping Up, a national policy effort to improve mental health and substance use services for justice-involved individuals.

BACKGROUND: The criminal justice system is the largest provider of mental health services in the USA. Many jurisdictions are interested in reducing the use of the justice system for mental health problems. The national Stepping Up Initiative helps agencies within counties work together more effectively to reduce the number of individuals with mental illness in jails and to improve access to mental health services in the community. This study will compare Stepping Up counties to matched comparison counties over time to (1) examine the effectiveness of Stepping Up and (2) test hypothesized implementation mechanisms to inform multi-agency implementation efforts more broadly. METHODS: The study will survey 950 counties at baseline, 18 months, and 36 months in a quasi-experimental design comparing implementation mechanisms and outcomes between 475 Stepping Up counties and 475 matched comparison counties. Surveys will be sent to up to four respondents per county including administrators of jail, probation, community mental health services, and community substance use treatment services (3800 total respondents). We will examine whether Stepping Up counties show faster improvements in implementation outcomes (number of justice-involved clients receiving behavioral health services, number of behavioral health evidence-based practices and policies [EBPPs] available to justice-involved individuals, and resources for behavioral health EBPP for justice-involved individuals) than do matched comparison counties. We will also evaluate whether engagement of hypothesized mechanisms explains differences in implementation outcomes. Implementation target mechanisms include (1) use of and capacity for performance monitoring, (2) use and functioning of interagency teams, (3) common goals and mission across agencies, and (4) system integration (i.e., building an integrated system of care rather than adding one program or training). Finally, we will characterize implementation processes and critical incidents using survey responses and qualitative interviews. DISCUSSION: There are few rigorous, prospective studies examining implementation mechanisms and their relationship with behavioral health implementation outcomes in justice and associated community behavioral health settings. There is also limited understanding of implementation mechanisms that occur across systems with multiple goals. This study will describe implementation outcomes of Stepping Up and will elucidate target mechanisms that are effective in multi-goal, multi-agency systems.

Core Correctional Practices in Community Supervision: An Evaluation of a Policy Mandate to Increase Probation Officer Use of Skills.

Community supervision officer training programs aim to translate core correctional practices into routine practice. These training programs emphasize skill-building designed to shift supervision strategies from law enforcement/compliance-oriented to a focus on promoting and supporting behavior change. Despite evidence of their effectiveness, research finds trained officers use newly learned skills infrequently. The current study examined the impact of a policy, implemented post-training, designed to encourage trained officers to use skills emphasized by the Staff Training Aimed at Reducing Rearrest (STARR) training program more frequently. The current study examined the effectiveness of this policy on the frequency and type of skills used by officers in their interactions with individuals on their caseload. Analyses suggested the policy mandate was effective in increasing skill use, however officers still used trained skills in less than half of their interactions. Implications and considerations for increasing the use of skills are discussed.

Juvenile probation officers' perceptions on youth substance use varies from task-shifting to family-based contingency management.

The majority of justice-involved youth have problems with substance use, but juvenile justice agencies face numerous barriers to providing evidence-based treatments for these youth. Task-shifting is one strategy for increasing access to such treatments. That is, training juvenile probation officers (JPOs) to deliver substance use treatments, such as contingency management (CM) could improve youths' motivation and behavioral outcomes. However, probation traditionally emphasizes sanctions over incentives, so JPOs must alter their perspectives to accept protocols such as CM for substance use. Using mixed focus group and survey methods at baseline and one year later, this randomized study examined heretofore unstudied JPO perceptions during a task-shifting experiment in which JPOs were asked to start delivering CM for youth substance use, compared to a control group of JPOs who did not change their practices. At baseline, JPOs expressed a perception of hopelessness about their work with substance-using youth and their parents, but they generally held positive views toward use of tangible incentives. One year after randomization to participate in CM training and delivery, JPO perceptions changed positively about working with youth and their parents, substance use programs and resources, and whether they believed tangible incentive programs were worthwhile. Over the same time, there was a perceptual stasis in hopelessness for JPOs randomized to deliver probation services as usual, and there was degradation in their previously positive perception toward tangible incentives. The study advances thinking regarding tools that JPOs can use for working with youth and families and the role that task-shifting can play in both increasing access to evidence-based treatments and improving attitudinal outcomes of JPOs.

Multilevel Matching in Natural Experimental Studies: Application to Stepping up Counties.

Among many approaches for selecting match control cases, few methods exist for natural experiments (Li, Zaslavsky & Landrum, 2007), especially when studying clustered or hierarchical data. The lack of randomization of treatment exposure gives importance to using proper statistical procedures that control for individual differences. In this natural experimental study, which has a hierarchical structure, we plan to evaluate the efforts of 455 counties across the United States to make targeted efforts to improve mental health services and reduce jail utilization over time. Nested within states, counties are clustered on health and social indicators, which affect the likelihood of making improvements in these areas. Similar to a randomized trial, prior to collecting survey data, it is necessary to identify matched control counties as study sites based on an array of state and county covariates. Accounting for the hierarchal structure of data, a blend of various probability-based models are presented to achieve this goal. Methods include multivariable models that control for observed differences among treatment and control groups, shrinkage based LASSO as a variable selection technique, and logistic models.

A Multi-Level Examination of Organizational Context on Adult Probation Officer Attitudes Toward Evidence-Based Practice.

Currently, both researchers and criminal justice agencies recognize the need to consider evidence-based practices (EBPs) as means to provide effective supervision and reduce recidivism rates. Research documents the importance of organizational characteristics in relation to EBP adoption and implementation, including organizational climate, commitment to the organization, and cynicism for change. Using data collected through surveys of 251 probation staff nested within 12 probation agencies in the United States, the current study utilizes Hierarchical Linear Modeling to examine the association of these important organizational characteristics with probation staff reported attitudes toward EBPs. These findings are critical for understanding how probation staff perceptions relate to the transportability of EBPs and which/how contextual factors influence attitudes toward best practices.

Organizational Factors and Probation Officer Use of Evidence-Based Practices: A Multilevel Examination.

Growing evidence pointing to the ineffectiveness of control-oriented supervision practices has led to an emphasis on evidence-based practices (EBPs), or practices that are empirically tied to recidivism reduction. Research on EBPs in probation highlights the importance of case management-oriented supervision and provision of proactive, appropriate program referrals. Despite research support, challenges exist regarding implementing EBPs in real-world practice. Utilizing survey data from 813 adult probation officers across 43 agencies, the current study examined variation in use of case management and proactive referral practices. Findings highlight the important role organizational commitment plays in supporting implementation efforts. Implications suggest a need for probation agencies to promote and sustain staff commitment to their agency before embarking on significant reform efforts.

Community correctional agents' views of medication-assisted treatment: Examining their influence on treatment referrals and community supervision practices.

BACKGROUND: Alcohol and opioid use disorders are common among adults under community supervision. Although several medications (medication-assisted treatment or MAT) are Food and Drug Administration (FDA)-approved to treat such disorders, they are underutilized with this population despite established effectiveness at decreasing substance use. This paper examines how community correctional agents' understanding of addiction and views of MAT influence their professional actions regarding addiction medications. METHODS: A total of 118 semistructured qualitative interviews were conducted with community correctional agents taking part in the CJ-DATS MATICCE implementation study across 20 parole/probation offices in 9 US states. Using grounded theory methodology and an iterative analytic approach, issues of role perception, views of MAT, current treatment referral, and community supervision practices were explored. RESULTS: Agents often had limited autonomy to make direct treatment referrals, regardless of their views of MAT, as they were required to follow court orders and their organization's policies and procedures. Within some organizations, community correctional agents held sufficient autonomy to make direct treatment referrals, with agents struggling to reconcile their desire to support their clients who needed MAT with concerns about the abuse potential of opioid agonist medications. Viewing MAT as a "treatment of last resort" was counterbalanced by the view that it was an effective evidence-based practice. Agents described how MAT impacted their ability to supervise clients and how their knowledge and understanding of MAT was directly influenced by watching their clients who were successful or unsuccessful on MAT. Even those agents who were more accepting of MAT were largely unsupportive of it long-term use. CONCLUSIONS: Community correctional agents' views of MAT were influenced by their understanding of addiction as well as their experiences supervising clients receiving treatment with medications, but whether or not MAT referrals were made was not always within their control.

Front-Stage Stars and Backstage Producers: The Role of Judges in Problem-Solving Courts().

In problem-solving courts judges are no longer neutral arbitrators in adversarial justice processes. Instead, judges directly engage with court participants. The movement towards problem-solving court models emerges from a collaborative therapeutic jurisprudence framework. While most scholars argue judges are the central courtroom actors within problem-solving courts, we find judges are the stars front-stage, but play a more supporting role backstage. We use Goffman's front-stage-backstage framework to analyze 350 hours of ethnographic fieldwork within five problem-solving courts. Problem-solving courts are collaborative organizations with shifting leadership, based on forum. Understanding how the roles of courtroom workgroup actors adapt under the new court model is foundational for effective implementation of these justice processes.