August 7, Via Members of the Los Angeles County Board of Supervisors 500 West Temple Street Los Angeles, CA

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1 Via Members of the Los Angeles County Board of Supervisors 500 West Temple Street Los Angeles, CA Re: HMA Report Dear Honorable Members of the Board: We write on behalf of the Judge David L. Bazelon Center for Mental Health Law, the ACLU of Southern California, NAMI - Los Angeles County Chapters, Mental Health America Los Angeles and other organizations, which are Department of Mental Health Full Service Partners (FSPs), and/or provide mental health and other related services to, legal services for, or advocate on behalf of, people with mental illness who become involved in the criminal justice system and their families. We question and disagree with the analysis and findings of Health Management Associates and Pulitzer Bogard & Associates in their report, recently submitted to the Board, entitled Los Angeles County Consolidated Correctional Treatment Facility Population Analysis and Community Health Care Continuum (hereinafter CCTF and The HMA Report ). We believe the HMA Report fails to correctly address some of the questions the Board asked, contains faulty analysis, and as a result provides misguided advice particularly with respect to its projections of the growth in the population of inmates with mental illness and the needed capacity for any CCTF. We urge you (1) not to take any action based on the HMA Report until you have its analysis and findings reviewed by qualified professionals; and (2) that you not take any action on the proposed CCTF until you have answered the important questions the Report does not address, namely: a) How many people currently in or cycling in and out of LA s jails could be safely and successfully served in community settings through intensive mental health services like Assertive Community Treatment (ACT), which Full Service Partnerships (FSPs) are intended to provide, and supportive housing? and

2 Page 2 b) What would be the cost of expanding such intensive community mental health services so as to reduce the number of needed mental health beds in LA s jails, including what is needed to achieve the maximum reduction, and how much of the cost could be financed through additional state and federal Medicaid dollars? We are confident that an assessment that properly addresses these questions would yield a far lower number of people with mental illness who need to be in jail for safety reasons than does the HMA Report s cursory analysis. This letter both critiques the HMA Report s approach and describes in more detail how an appropriate analysis might be accomplished The HMA Report does not directly or correctly answer some of the specific questions the Board asked. The Board at its June 9, 2015 meeting, instructed the Interim Chief Executive Officer to: 1. Provide an independent analysis of the actual number of treatment beds and other beds needed at the new CCTF, including the likely impacts to the County jail population of District Attorney Lacey s diversion program, and any other legislative or significant programmatic development that occurred after the Board s adoption of Option 1B; 2. Conduct a capacity assessment of all community-based alternative options for treatment including, but not limited to, mental health and substance abuse treatment[.] a. Despite the Board s specific request, the HMA Report gives diversion programs short shrift. The HMA Report does not evaluate the likely impacts to the County jail population of District Attorney Lacey s diversion program... or the impacts of the County making a substantial investment in diversion. Diversion is mentioned only in passing. The Report acknowledges (at page 48) that expansion of diversion programs certainly has the potential to reduce the number of mental health beds at the CCTF over the longer term. However, according to the Report, in order to estimate this impact, a more detailed analysis [than it did] would be required. We agree. The authors of the HMA Report did not conduct the analysis the Board requested. We believe it is essential that more time and attention be devoted to studying this critical issue. b. The HMA Report does not properly identify how many individuals currently in, or cycling in and out of, LA s jails could be safely and successfully served in community settings through intensive mental health services like ACT and supportive housing. 1 Nothing in this letter is intended to suggest that we believe the conditions in Men s Central Jail or Twin Towers are appropriate to the proper housing and treatment of inmates with mental illness who cannot be safely treated in the community. However, we strongly believe that building an overly large CCTF will reduce the growing commitment to diversion and will siphon off necessary resources from that goal.

3 Page 3 The HMA Report purports to provide [a]n assessment on [sic] the number of inmates that can be successfully placed into an outside facility (community based) for Mental health/substance Abuse Treatment. (At page 1.) However, it is clear from the Report that the authors did not meaningfully conduct such an analysis. There is a virtual consensus among mental health experts, including the nation s preeminent forensic mental health professionals, that large numbers of individuals with mental illness could safely be diverted from jail if they received appropriate community services. But the HMA Report concludes, in effect, that this is not the case in Los Angeles. We entirely and strongly disagree. And we note that treatment in jail is more expensive and less effective, including in reducing recidivism an essential component of protecting public safety than is community care. According to the Report, 81% of inmates with mental illness are classified by the Jail as low or medium security. (At page 82.) While security levels are not the ideal measure of someone s ability to be safely treated in the community (we explain the appropriate way to do that assessment below), they are a sufficient measure of risk to suggest that a very substantial percentage of prisoners with mental illness could have been diverted from jail if the right kind of community services were in place. Somewhat inconsistently, the HMA Report on the one hand acknowledges that [d]etainees who could currently be appropriate for community mental health and/or SUD services cannot be sufficiently served by the existing community treatment network, because the current network is sized to serve the population currently funded and is insufficient for the actual need in the community. (At page 64.) The Report advises that [a] concerted effort to grow the desired community capacity is a wise investment. (Id.) But the Report then undercuts this point by warning that growing community capacity will take time and will require some new community services tailored to the justice involved population. (Id.) However, constructing a new jail will take time as well likely eight to ten years. Substantial new diversion capacity could easily be brought on line years before a new jail is finished. The provider community is willing and able to expand their offerings and tailor them to the needs of the justice-involved population, as the HMA Report notes. c. The HMA Report does not provide an evaluation of community capacity. The Board asked for a capacity assessment of all community-based alternative options for treatment including, but not limited to, mental health and substance abuse treatment. However, [d]ue to the aggressive timeline identified to complete this scope of work, [a] comprehensive capacity analysis is not possible with the data we [the Report s authors] were able to obtain and in the timeframe provided for the study. (At page 57.) Thus the Report provides only a high level environmental scan and inventory of system services and general capacity. (At page 47.)

4 Page 4 2. The HMA Report simply projects the status quo into the future. The HMA Report makes inmate population projections over the next several years, including projections for those with Mental Health disorders. (At page 1.) Indeed, the bulk of the Report appears devoted to making such projections through the year Unsurprisingly, therefore, the Report concludes: The total number estimated mental health beds in the Consolidated Correctional Treatment Facility will be approximately 3,640 to 3,960. This estimate is essentially the current volume of patient-inmates with mental illness in the LASD. These projections, as the authors acknowledge, are based on their faulty assessment of current trends and, as described above, do not meaningfully take into account the impact of new diversion programs. 2 The Report s estimate also fails to take into account the dramatic undercounting by LASD and DMH of the population of jail inmates with mental illness that was a major problem in 2008, 2009, and 2010 but has dramatically declined more recently, in part because of pressure from DOJ. It is changes in screening that have led to LASD and DMH s reporting a rise in the jail population of inmates with mental illness, not an actual rise in that population. Indeed, the 14% figure for 2010 is out of line with the general consensus about the make-up of large urban jails. Yet the HMA Report uses this illusory rise between 2010 and 2015 to project outward a sharply rising mental health population in a linear fashion to 2035 without any apparent saturation point. (See, generally, page 34, et seq.) The Report s faulty assessment that the percentage of inmates with mental illness will rise sharply over the coming years leads to a faulty recommendation for the size of the CCTF. 3. The Board must answer the two important questions that the HMA Report neglects. Two fundamental questions must be answered before the Board can take action on the CCTF: a) How many people currently in or cycling in and out of LA s jails could be safely and successfully served in community settings through intensive mental health services like ACT, which FSPs are intended to provide, and supportive housing? and b) What would be the cost of expanding such intensive community mental health services so as to reduce the number of needed mental health beds in LA s jails, including what is needed to achieve the maximum reduction, and how much of the cost could be financed through additional state and federal Medicaid dollars? There is a proven way to answer the first question, which unfortunately the HMA Report does not pursue. Experts familiar with effective community services for justice involved people with 2 While this letter focuses on the HMA Report s analysis of the justice-involved population of inmates with mental illness, due to our expertise in that area, we also could not help but note that the Report gives no consideration to the possibility of LA s implementing a robust risk-based pretrial release program to address what the Vera Institute for Justice has identified as a significant over-incarceration of low-risk pretrial detainees in the LA County jails.

5 Page 5 mental illness could analyze a sample of LA jail inmates with mental illness. The analysis would collect data on the individuals current level of psychiatric impairment, personal strengths, network of support if any, arrest and conviction records, time spent in jail and precipitating events or reasons, time spent in emergency rooms and inpatient psychiatric facilities and precipitating events or reasons, the community services the individuals have received, the community services the individuals want or have sought but not received (e.g., housing, substance abuse treatment), and the services the individuals have refused or failed to consistently use and the reasons for those refusals. The expert would then compare the inmates in the sample to individuals with mental illness being served successfully in the community in Los Angeles or in other parts of the country. As the experts would explain, to the extent the inmates in the sample have needs, strengths and histories similar to the individuals being served successfully now in the community in Los Angeles or elsewhere, they could be successfully diverted from LA s jails. The analysis could also identify the number of individuals who, before they are able to be successfully served in the community, need a brief stay in a hospital to be stabilized on medication and/or detox from substances. As part of their analysis, the experts would identify red flag circumstances that raise a safety concern, and counsel against serving individuals with those red flags in the community. For example: certain kinds of criminal histories, especially if there is recent bad conduct, could be a red flag (e.g., a recent history of fire-setting); being actively psychotic and needing a stay in a hospital or crisis stabilization unit might be a red flag, although it may be possible to reliably predict that the person could be cared for successfully in the community after being stabilized in a hospital or stabilization unit; and another red flag might be conditions that cannot be costeffectively addressed in the community, such as having a severe cognitive impairment or requiring a significant amount of skilled nursing care. The experts could also offer possible financing strategies. For example, 100% federal funding is available for community mental health services to individuals who are newly eligible for Medicaid as a result of the Affordable Care Act. We think it is essential that the experts who conduct both analyses have a good grasp of who (among those with challenging conditions) can be, and are being, served safely and successfully in community settings throughout the country, and with what kinds of services (e.g., ACT, intensive case management, supported housing). The experts must also have extensive experience actually providing effective community mental health services to individuals like those in LA s jails. * * * The Board cannot make informed decisions about how to properly size the CCTF until the assessment we lay out above is done. We believe that a proper assessment of the issues will demonstrate a need to increase resources committed to community treatment and will also likely show that the HMA Report s recommendation for the size of any CCTF is far too large. We

6 Page 6 urge the Board not to build a CCTF facility whose size is pegged to the flawed HMA Report, and not to commit to a specific capacity for any CCTF until the fundamental questions we lay out above are answered. Sincerely, Ira A. Burnim Legal Director Emily B. Read Senior Staff Attorney Judge David L. Bazelon Center for Mental Health Law Brittney Weissman NAMI Los Angeles County Council Dave Pilon, PhD, CPRP President and CEO Mental Health America of Los Angeles Jonathan E. Sherin, M.D., Ph.D. Executive Vice President for Military Communities and Chief Medical Officer Volunteers of America Peter J. Eliasberg Legal Director ACLU of Southern California Chuck Ingoglia, MSW Senior Vice President Public Policy & Practice Improvement National Council for Behavioral Health Dr. Kita Curry, Ph.D. President/CEO Didi Hirsch Mental Health Services James Preis Mental Health Advocacy Services Mark Faucette Community and Gov t. Relations Director Amity Foundation Anne Richardson Associate Director Public Counsel Opportunity Under Law Adam Murray Inner City Law Center Janlee Wong California Chapter of National Association of Social Workers