Evaluation and Program Planning 48 (2015) 57–62
Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
The cost of implementing a jail diversion program for people with mental illness in San Antonio, Texas Alexander J. Cowell *, Jesse M. Hinde 1, Nahama Broner 2, Arnie P. Aldridge 3 RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 February 2014 Received in revised form 19 June 2014 Accepted 22 September 2014 Available online 30 September 2014
Jail diversion programs for people with mental illness are designed to redirect offenders with mental illness into community treatment. Although much has been published about program models and their successes, little detail is available to policy makers and community stakeholders on the resources required to start and implement a jail diversion program and which agencies bear how much of the burden. The current study used data on a model jail diversion program in San Antonio, Texas, to address this research gap. Data on staff costs, client contacts, planning, and implementation were collected for three types of diversion: pre-booking police, post-booking bond, and post-booking docket. An activitybased costing algorithm was developed to which parameter values were applied. The start-up cost for the program was $556,638.69. Pre-booking diversion cost $370 per person; 90% of costs were incurred by community mental health agencies for short-term monitoring and screening (>80% of activities). Postbooking bond and docket diversion cost $238 and $205 per person, respectively; the majority of costs were incurred by the courts for court decisions. Developing a multiple-intercept jail diversion program requires significant up-front investment. The share of costs varies greatly depending on the type of diversion. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Jail diversion Mentally ill offenders Cost
1. Introduction Jail diversion for people with mental illness is a formal process of identification, enrollment, and recommendation for adjudication and treatment for those in contact with the criminal justice system (Naples, Morris, & Steadman, 2007). Diversion requires collaboration among a variety of stakeholders, primarily in the community mental health and criminal justice systems, all of
Abbreviations: ACC, Acute Care Center; CHCS, Bexar County Center for Health Care Services; DMOT, Deputy Mobile Outreach Team; PTS, Pre-Trial Services; SAPD, San Antonio Police Department. * Corresponding author at: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 541 8754; fax: +1 919 485 5555. E-mail addresses: [email protected] (A.J. Cowell), [email protected] (J.M. Hinde), [email protected] (N. Broner), [email protected] (A.P. Aldridge). 1 Address: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 541 1209; fax: +1 919 485 5555. 2 Address: New York University, 915 Broadway, Suite 1200, New York, NY 10010, USA. Tel.: +1 646 236 2043. 3 Address: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 990 8389; fax: +1 919 485 5555. http://dx.doi.org/10.1016/j.evalprogplan.2014.09.004 0149-7189/ß 2014 Elsevier Ltd. All rights reserved.
whom rely on disparate public funding streams. Decision makers seeking to start, expand, or continue a program must budget for resources, and this in turn requires detailed estimates of program costs across stakeholders and for specific activities. Although a considerable body of literature recommends widespread adoption and refinement of diversion for people with mental illness limited information is available on the value of resources required to conduct diversion (Ryan, Brown, & Watanabe-Galloway, 2010). More specifically, to our knowledge, no published study estimates diversion costs disaggregated by stakeholder agency and by activity. The first economic evaluation of jail diversion, a cost-effectiveness analysis connected to a crosssite evaluation (Cowell, Broner, & Dupont, 2004), provides a rigorous economic evaluation, comparing the aggregate cost of diversion to its effectiveness, but it does not separate resources used for the formal diversion program from those used for activities occurring before or after diversion. The formal diversion program is defined as activities occurring from the point of client identification through recommendation for criminal justice action or clinical services. These resources do not include, for example, the cost of time spent in jail or treatment in the community after release from the program. One study to our knowledge suggests
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A.J. Cowell et al. / Evaluation and Program Planning 48 (2015) 57–62
that significant resources may be needed to conduct diversion because of the pre-diversion referral, screening, and acceptance process (Naples et al., 2007). However, that study did not place a dollar value on the activities being evaluated. Two recent studies (Cowell, Hinde, Broner, & Aldridge, 2013; Hughes, Steadman, Case, Griffin, & Leff, 2012) use data from Texas—the former on the program examined in the current study—and include program costs in an assessment of the costs of treatment, arrest, and incarceration. Neither study disaggregates the program costs by the activities conducted or by the agencies performing those activities. The current study uses data from a jail diversion program in Bexar County (San Antonio) to analyze its costs. The specific research aims are to estimate the costs of starting the program, assess the cost per client of implementing the program, and analyze how the cost per client is shared among stakeholder agencies and across diversion activities. Starting the program involves using resources on a one-time basis to put in place processes and staff; the program serves no or very few clients while it is being built. Implementation involves serving clients on an ongoing basis by means of a staffed and functioning program. The findings from this program are relevant to other jurisdictions because it serves a large population, is nationally recognized, follows best practices, and contains several common forms of diversion. The program serves the seventh largest city in the United States (U.S. Census Bureau, 2008) and in 2006 won the American Psychiatric Association’s Gold Award (Evans, 2006). It has implemented specific practices required for successful diversion, including incorporating three sequential intercept points (Munetz & Griffin, 2006). Intercept point is defined as an opportunity ‘‘in which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system’’ (Munetz & Griffin, 2006, p. 544). Many programs traditionally have only one intercept point (Broner, Lattimore, Cowell, & Schlenger, 2004). The community mental health agency, the Center for Health Care Services (CHCS), first directed resources toward the program in 2000, and the program became fully functional in 2003. From its beginning, the program had a full-time director, a ‘‘boundary spanner’’ (Steadman, Morris, & Dennis, 1995), a clinical psychologist with program management and criminal justice experience. The boundary spanner solicited the collaboration of agencies with different missions (such as the police department and community mental health), coordinated the diversion efforts of these agencies, cultivated program resources, developed training, staffed the program, oversaw its implementation, and developed dissemination and sustainability plans. Program eligibility was restricted to people with serious mental illness, operationalized as a diagnosis of bipolar, major depression, schizophrenia, or schizoaffective disorder, and a misdemeanor offense. The program had three components that are defined by intercept points along the spectrum of involvement with the criminal justice system. The first intercept point is pre-booking police diversion, whereby persons with mental disorders engaging in a low-level offense are diverted before formal booking. Identification is done by specially trained Crisis Intervention Team dispatch and peace officers (Steadman et al., 2001) who transfer custody at enrollment. Enrollment and recommendation processes are managed by caregivers at a centralized facility, the Crisis Care Center, which provides medical clearance and psychiatric assessment, short-term (
Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
The cost of implementing a jail diversion program for people with mental illness in San Antonio, Texas Alexander J. Cowell *, Jesse M. Hinde 1, Nahama Broner 2, Arnie P. Aldridge 3 RTI International, 3040 E. Cornwallis Road, Research Triangle Park, NC 27709, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 4 February 2014 Received in revised form 19 June 2014 Accepted 22 September 2014 Available online 30 September 2014
Jail diversion programs for people with mental illness are designed to redirect offenders with mental illness into community treatment. Although much has been published about program models and their successes, little detail is available to policy makers and community stakeholders on the resources required to start and implement a jail diversion program and which agencies bear how much of the burden. The current study used data on a model jail diversion program in San Antonio, Texas, to address this research gap. Data on staff costs, client contacts, planning, and implementation were collected for three types of diversion: pre-booking police, post-booking bond, and post-booking docket. An activitybased costing algorithm was developed to which parameter values were applied. The start-up cost for the program was $556,638.69. Pre-booking diversion cost $370 per person; 90% of costs were incurred by community mental health agencies for short-term monitoring and screening (>80% of activities). Postbooking bond and docket diversion cost $238 and $205 per person, respectively; the majority of costs were incurred by the courts for court decisions. Developing a multiple-intercept jail diversion program requires significant up-front investment. The share of costs varies greatly depending on the type of diversion. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Jail diversion Mentally ill offenders Cost
1. Introduction Jail diversion for people with mental illness is a formal process of identification, enrollment, and recommendation for adjudication and treatment for those in contact with the criminal justice system (Naples, Morris, & Steadman, 2007). Diversion requires collaboration among a variety of stakeholders, primarily in the community mental health and criminal justice systems, all of
Abbreviations: ACC, Acute Care Center; CHCS, Bexar County Center for Health Care Services; DMOT, Deputy Mobile Outreach Team; PTS, Pre-Trial Services; SAPD, San Antonio Police Department. * Corresponding author at: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 541 8754; fax: +1 919 485 5555. E-mail addresses: [email protected] (A.J. Cowell), [email protected] (J.M. Hinde), [email protected] (N. Broner), [email protected] (A.P. Aldridge). 1 Address: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 541 1209; fax: +1 919 485 5555. 2 Address: New York University, 915 Broadway, Suite 1200, New York, NY 10010, USA. Tel.: +1 646 236 2043. 3 Address: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709, USA. Tel.: +1 919 990 8389; fax: +1 919 485 5555. http://dx.doi.org/10.1016/j.evalprogplan.2014.09.004 0149-7189/ß 2014 Elsevier Ltd. All rights reserved.
whom rely on disparate public funding streams. Decision makers seeking to start, expand, or continue a program must budget for resources, and this in turn requires detailed estimates of program costs across stakeholders and for specific activities. Although a considerable body of literature recommends widespread adoption and refinement of diversion for people with mental illness limited information is available on the value of resources required to conduct diversion (Ryan, Brown, & Watanabe-Galloway, 2010). More specifically, to our knowledge, no published study estimates diversion costs disaggregated by stakeholder agency and by activity. The first economic evaluation of jail diversion, a cost-effectiveness analysis connected to a crosssite evaluation (Cowell, Broner, & Dupont, 2004), provides a rigorous economic evaluation, comparing the aggregate cost of diversion to its effectiveness, but it does not separate resources used for the formal diversion program from those used for activities occurring before or after diversion. The formal diversion program is defined as activities occurring from the point of client identification through recommendation for criminal justice action or clinical services. These resources do not include, for example, the cost of time spent in jail or treatment in the community after release from the program. One study to our knowledge suggests
58
A.J. Cowell et al. / Evaluation and Program Planning 48 (2015) 57–62
that significant resources may be needed to conduct diversion because of the pre-diversion referral, screening, and acceptance process (Naples et al., 2007). However, that study did not place a dollar value on the activities being evaluated. Two recent studies (Cowell, Hinde, Broner, & Aldridge, 2013; Hughes, Steadman, Case, Griffin, & Leff, 2012) use data from Texas—the former on the program examined in the current study—and include program costs in an assessment of the costs of treatment, arrest, and incarceration. Neither study disaggregates the program costs by the activities conducted or by the agencies performing those activities. The current study uses data from a jail diversion program in Bexar County (San Antonio) to analyze its costs. The specific research aims are to estimate the costs of starting the program, assess the cost per client of implementing the program, and analyze how the cost per client is shared among stakeholder agencies and across diversion activities. Starting the program involves using resources on a one-time basis to put in place processes and staff; the program serves no or very few clients while it is being built. Implementation involves serving clients on an ongoing basis by means of a staffed and functioning program. The findings from this program are relevant to other jurisdictions because it serves a large population, is nationally recognized, follows best practices, and contains several common forms of diversion. The program serves the seventh largest city in the United States (U.S. Census Bureau, 2008) and in 2006 won the American Psychiatric Association’s Gold Award (Evans, 2006). It has implemented specific practices required for successful diversion, including incorporating three sequential intercept points (Munetz & Griffin, 2006). Intercept point is defined as an opportunity ‘‘in which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system’’ (Munetz & Griffin, 2006, p. 544). Many programs traditionally have only one intercept point (Broner, Lattimore, Cowell, & Schlenger, 2004). The community mental health agency, the Center for Health Care Services (CHCS), first directed resources toward the program in 2000, and the program became fully functional in 2003. From its beginning, the program had a full-time director, a ‘‘boundary spanner’’ (Steadman, Morris, & Dennis, 1995), a clinical psychologist with program management and criminal justice experience. The boundary spanner solicited the collaboration of agencies with different missions (such as the police department and community mental health), coordinated the diversion efforts of these agencies, cultivated program resources, developed training, staffed the program, oversaw its implementation, and developed dissemination and sustainability plans. Program eligibility was restricted to people with serious mental illness, operationalized as a diagnosis of bipolar, major depression, schizophrenia, or schizoaffective disorder, and a misdemeanor offense. The program had three components that are defined by intercept points along the spectrum of involvement with the criminal justice system. The first intercept point is pre-booking police diversion, whereby persons with mental disorders engaging in a low-level offense are diverted before formal booking. Identification is done by specially trained Crisis Intervention Team dispatch and peace officers (Steadman et al., 2001) who transfer custody at enrollment. Enrollment and recommendation processes are managed by caregivers at a centralized facility, the Crisis Care Center, which provides medical clearance and psychiatric assessment, short-term (
