BALTIMORE CITY S INTEGRATED DUAL DISORDERS TREATMENT (IDDT) INITIATIVE FISCAL YEAR 2013 ANNUAL REPORT NOVEMBER 2013

BALTIMORE CITY S INTEGRATED DUAL DISORDERS TREATMENT (IDDT) INITIATIVE FISCAL YEAR 2013 ANNUAL REPORT NOVEMBER 2013 Behavioral Health System Baltimore was created on October 1, 2013 by the merger of Baltimore Substance Abuse Systems, Inc. (BSAS) and Baltimore Mental Health Systems, Inc. (BMHS) One N. Charles St., Suite 1600 Baltimore, MD 21201-3718 www.bhsbaltimore.org

Table of Contents Executive Summary... 3 Background... 4 Data Sources... 5 Goals and Targets... 5 Accomplishments... 6 Team Formation... 6 Training... 6 Marketing... 7 Data Collection and Reporting... 8 Pooling and matching data across multiple databases... 8 Establishing Baseline Parameters... 9 Process Measures:... 9 Outcome Measures:... 13 IDDT Initiative Participant Voices... 18 2 IDDT FY13 Annual Report

Executive Summary Baltimore City s Integrated Dual Disorders Treatment (IDDT) Initiative began its initial full year on July 1, 2012 after a long planning period between Baltimore Substance Abuse Systems, Inc. (BSAS) and its partner agency, Baltimore Mental Health System, Inc. (BMHS). Focused on criminal-justice involved, dually diagnosed individuals in Baltimore City and Baltimore County, the Initiative aims to provide necessary support to this population by establishing integrated, community-based treatment services at both high- and lower-intensity levels. The Initiative selected three providers across Baltimore City to provide these two levels of service: the Bon Secours IDDT Intensive Team serves individuals meeting medical necessity criteria for Assertive Community Treatment (ACT); and two IDDT Clinic Teams at Maryland Treatment Centers and Family Health Centers of Baltimore, respectively, serve lower severity individuals. Activities in this first year centered on training, marketing, development of valid data collection and reporting systems, and establishment of baseline process and outcome measures for subsequent years. In its first year, the Initiative referred 188 eligible individuals to the three providers, of whom 133 (85%) were subsequently admitted for treatment. Referral sources included many parts of the criminal justice system as well as within the IDDT providers themselves, reflecting the nature of behavioral health treatment populations in Baltimore City. Having an alternative plan pursued was the primary reason why an eligible individual was not admitted to an IDDT provider. The demographic characteristics of the 133 admitted individuals reflect the geographic locations of the three IDDT providers, the criminal justice involved population in Baltimore City, and baseline expertise of each provider. Each IDDT provider experienced higher than expected increases in their first year fidelity score for implementation of the IDDT model. The reincarceration rate of 18% is well below Maryland s overall rate of offenders returning to prison/jail. The majority of emergency department visits and hospitalizations were mental health related and will serve as a baseline for future years. At the end of year 1, 82% of participants remained in care, 19% of those who were unstably housed had achieved permanent housing, and 8% of those who were unemployed on admission had become gainfully employed at some point during the year. In focus groups, participants expressed satisfaction with their IDDT provider and saw tangible benefits from the integrated treatment. 3 IDDT FY13 Annual Report

Background Individuals diagnosed with dual disorders 1 often experience higher rates of negative outcomes such as relapse, hospitalization, homelessness and incarceration. Treating both disorders in a coordinated manner and in an integrated setting has been shown to be the most effective approach for helping individuals manage both illnesses. However, historically separate funding streams and regulatory oversight have been significant barriers to integrated care. One consequence of these disparate service systems has been increased lengths of stay in courtordered ( 8-507) residential addiction treatment programs in Baltimore City, due in part to a lack of integrated treatment services available upon discharge. As a result, individuals with dual disorders stay in residential treatment longer, which in turn lengthens jail time for individuals waiting for residential care. Based on a random chart review of 329 individuals assessed in Baltimore City in Fiscal Year 2009 under the 8-507 legal process, 43% had both substance abuse and mental health disorders, representing a significant population who could benefit from better integrated care. To address this gap, the Baltimore Substance Abuse Systems, Inc. (BSAS) and the Baltimore Mental Health System, Inc. (BMHS) began an intensive joint planning and development process in 2009 for the Integrated Dual Disorders Treatment Initiative (IDDT) which was launched in April 2012 with three Baltimore City behavioral health providers. The Initiative aims to provide the support individuals with co-occurring disorders and criminal justice system involvement need by establishing integrated, community-based treatment services using the evidence-based treatment model, Integrated Dual Disorders Treatment (IDDT). To meet the varying needs of individuals with co-occurring disorders, the Initiative includes two levels of service of different intensities. Individuals with high-level needs have access to a community-based IDDT Team that provides mobile, intensive, wrap-around mental health and substance use disorder treatment, and support services. Individuals with lower level needs have access to two IDDT outpatient clinics (IDDT Clinics), one originating in the public mental health system and one coming from the publicly funded substance use disorder treatment system. These clinics provide less intensive, integrated, co-occurring services in an outpatient setting. To oversee and manage the Initiative at a local systems level, BSAS and BMHS formed the IDDT Operations Team consisting of key senior leaders from both organizations who meet regularly to plan, monitor, and oversee the implementation of the project. The Operations Team is supported by work of the IDDT Evaluation Team and the IDDT Advisory Workgroup that includes key stakeholders from criminal justice, social services, and the IDDT providers. This report presents outcome results and lessons learned from the first full fiscal year of the Initiative, July 1, 2012 through June 30, 2013. 1 In this document, dual disorders refer to co-occurring substance use and mental health disorders. 4 IDDT FY13 Annual Report

Data Sources Data sources for this report include: 1. BSAS Criminal Justice database 2. Statewide Maryland Automated Record Tracking (SMART) system 3. Mobile Treatment Outcomes (MTO) system 4. The online version of the Maryland Victim Notification and Notification Every day (VINELink) system 5. The online version of the Maryland Judiciary Case Search In addition, we draw from baseline and annual fidelity reviews conducted by the Case Western University Center for Excellence that has served as a consultant to the Initiative. Baltimore City Department of Parole and Probation provided courtesy work to identify the number of individuals on probation or parole. To develop a richer picture of the Initiative, its impact and ongoing areas for focus, we also include results from focus groups with Initiative participants and themes from interviews with key administrators across the three IDDT providers. All focus groups and interviews were held in July and August of 2013. 1. 3 IDDT participant focus groups with a total of 25 participants a. 10 participants from the IDDT Intensive Team b. 15 participants from the two IDDT Clinic Teams 2. Interviews with 3 IDDT administrators Goals and Targets The target number of individuals admitted to each of the IDDT providers during the first year of the Initiative is 55. With implementation of a new service delivery model and an expected rampup period, the focus of the Initiative s initial year has been on the adequacy of referrals and admissions. This focus has guided the majority of the activities completed over the past year. 5 IDDT FY13 Annual Report

Accomplishments Team Formation By July 1, 2012, three Baltimore City providers had received IDDT grant awards and formed IDDT teams. Bon Secours Assertive Community Treatment (ACT) team in central West Baltimore used funds to transform their existing ACT team into the IDDT Intensive Team. The two IDDT Clinic teams originated in the Outpatient Mental Health Clinic (OMHC) at Maryland Treatment Centers (MTC) in West Baltimore and the outpatient substance use disorder treatment program at Family Health Centers (FHC), a federally qualified community health center in South Baltimore. In identifying members for their respective teams, each provider organization built on existing staff and used grant funds to fill in where they each identified a need. For example, MTC identified needing a full-time team leader while FHC sought a mental health therapist. Bon Secours initially identified existing staff but increased the hours of several positions and then added a second team leader. Training In planning Baltimore City s IDDT Initiative, the IDDT Operations Team recognized that training would be an on-going area for focus throughout the three year pilot project, and would change depending on individual provider need and stage of the Initiative. In this first year, the IDDT providers have completed key trainings in areas common to all three with focus on those that would allow for initiation of services. July 10-13, 2012: All IDDT providers completed intensive in-depth IDDT training with Case Western Reserve University. August 2012: All three IDDT providers completed SMART database training. November 7, 2012: Forensic Alternative Services Team (FAST) provided training to the IDDT providers to familiarize them with the judiciary and treating forensic involved patients. FAST provided follow-up training on February 8, 2013. January 22-24, 2012: Case Western Reserve University provided on-site technical assistance (TA) for each IDDT provider, with a follow-up conference call with each provider on February 6, 2013. The Bon Secours IDDT Intensive Team received an additional TA session with Case Western on April 26, 2013. Case Western has continued to provide regular TA to each IDDT provider by phone and electronic media. October and December 2012 and February 2013: All-IDDT Provider Roundtable meetings 6 IDDT FY13 Annual Report

Marketing As a new service delivery model for criminally justice involved individuals with dual-diagnoses, the IDDT Operations team and the providers identified marketing and education of key stakeholders and potential referral sources as a critical area for focus in the initial stages of the Initiative. The initial marketing and education strategy involved having the IDDT Operations Team take on a larger role in this area than the IDDT providers, for several reasons: The criminal justice component of the target population required involvement of BSAS as the local entity responsible for monitoring many of the Initiative s participants. A centralized referral mechanism was felt necessary to ensure appropriate triage to the two different levels of service intensity. With oversight of the entire initiative, the IDDT Operations Team could speak to the project at both a systems and service delivery level. The IDDT Operations Team served as a conduit for introducing the IDDT providers to the various criminal justice stakeholders, allowing them to then move forward with building relationships with referral sources as appropriate to their geographic locations. Over the course of FY13, the IDDT Operations Team and individual IDDT providers developed fact sheets, pamphlets, and held numerous meetings to disseminate the availability of IDDT services. Some key meetings include: July through October 2012: The IDDT Operations Team (both with and without the IDDT providers) met with the District and Circuit court specialty mental health and drug courts, District and Circuit judiciary, the state hospitals, Parole and Probation, and residential substance use disorder treatment providers. October 2012 and April 2013: IDDT Operations Team met with leadership from ADAA, MHA, and the Deputy Secretary for Behavioral Health. January through March 2013: IDDT Operations Staff met in follow-up with state hospitals and residential substance use disorder treatment providers, and met with leadership and case managers from ValueOptions, the Administrative Services Organization for Maryland s Public Mental Health System. March through May 2013: IDDT Operations Team and providers met with District Drug Court, and Parole and Probation, to problem solve systemic communication issues between the criminal justice system and providers and further promote IDDT services. 7 IDDT FY13 Annual Report

Data Collection and Reporting The focus of this year for data collection has been two-fold: 1) develop an effective method for pooling and matching data collected across multiple databases; and 2) establishing baseline parameters for a number of process and outcome measures in order to assess the Initiative s impact as change over time. Pooling and matching data across multiple databases The IDDT Evaluation Team, composed of key staff and leadership from BSAS and BMHS, met almost weekly during the year to: develop an evaluation plan review and learn about the three main databases (BSAS Criminal Justice database, SMART, and MTO) problem solve data linking processes and discrepancies in data outputs The team proceeded through several different steps and learned key lessons as part of its work: Initial review of each database revealed several overlapping variables, particularly between SMART and MTO. However, each database defined many of these variables, such as housing and employment, differently. The IDDT Evaluation Team compared each of these variables in detail, with final consensus reached on which definition to use for evaluation purposes. The team documented all the variables, their definitions, and their database of origin in a written evaluation plan that serves as the basis for each type of report generated. Although attempts were made to minimize the amount of double data entry required by the IDDT providers, some was unavoidable because of both the unique and overlapping variables within each database. The Evaluation Team needed to add several variables specific to the IDDT initiative to each of the databases in order to identify and track IDDT participants apart from the larger population of individuals in each system. These changes were made in collaboration with the Maryland Alcohol and Drug Abuse Administration for SMART and the Mental Hygiene Administration for MTO. Because of both unique and overlapping variables, a need for a linked, centralized repository for all the data across the three databases was identified. As there was no common variable to match data across the three databases, the team created a common unique identifier. While this unique identifier enabled matching, it revealed a significant number of data entry errors that initially limited the percentage of records effectively linked. With significant data cleaning in conjunction with the IDDT providers and using regular, standardized data error reports, the percentage of matched records dramatically increased. 8 IDDT FY13 Annual Report

Establishing Baseline Parameters The IDDT Evaluation Team considered several options for a control population to compare with the IDDT participant group. Given the challenges of data collection across different systems, the pilot project approach to implementation, and the differences between the providers at baseline, the team opted to use a prospective, intra-group approach to the evaluation, with change over time in key process and outcome measures as the comparison. This first year of the Initiative thus serves as the baseline. Process Measures: a. Flow of individuals into the Initiative Figure 1 describes the flow of individuals into the Initiative and corresponding referral sources. District Court Drug Court 1 District Court Mental Health Court 3 Diversion Programs 5 Parole and Probation 16 8-507 10 Sate Hospitals 2 Circuit Court Drug Court 23 Other SUD treatment providers 2 Circuit Court Medical Services and FAST 3 IDDT Intensive Team 30 Circuit Court FDI 1 IDDT eligible individuals 188* IDDT Clinic Teams 91 *Referral source missing for one individual Figure 1: Referral Sources and Number of Referrals for July 1, 2012 through June 30, 2013 Several points are important to note regarding the flow of individuals into the Initiative: Given the diversity of referral sources and the complexity of tracking people through the criminal justice system, at this point it is impossible to identify the total universe of people from whom these 188 IDDT eligible individuals emerge. Since assessments for potential dual diagnoses occur at multiple different points in the system by different entities using different tools, it is impossible to describe the total pool of individuals with co-occurring disorders that may be eligible for IDDT services. 9 IDDT FY13 Annual Report

We can identify the total number of individuals who were court mandated to treatment through the 8-507 legal process since BSAS is required to track and monitor this. o For FY13, a total of 78 individuals received such an order. o Of these, 13% met eligibility criteria for an assessment for IDDT services after BSAS reviewed its 8-507 database (Figure 1). This likely represents an underestimate of potentially eligible individuals for IDDT services who are involved in the 8-507 legal process since other areas that are represented in the figure can have 8-507 involved individuals that are not identified as such. To minimize duplication of data, we elected to categorize referrals according to the most immediate referral source, acknowledging that this might mask individuals court mandated to treatment by an 8-507 order. A large proportion of referrals originated within the IDDT providers themselves. o This reflects the nature of individuals receiving treatment services in Baltimore City but also includes individuals who were referred directly to the IDDT providers from criminal justice sources. o This latter referral mechanism illustrates the work the IDDT providers have done over the past year to cultivate strong collaborations with their referral sources and will foster sustainability. b. Distribution of referrals and admissions Figure 2 illustrates the distribution of referrals and admission rates across the IDDT providers. Figure 2: Distribution of IDDT eligible individuals assigned to IDDT providers for assessment and subsequent admission, July 1, 2012 through June 30, 2013 10 IDDT FY13 Annual Report

Overall, 86% of the 185 eligible IDDT individuals referred to IDDT providers were admitted during this initial year of the project. None of the providers met the target goal of 55 admissions for the year, but all of them surpassed the 50% mark. MTC IDDT Clinic Team at 94.5% of target FHC IDDT Clinic Team at 85% of target Bon Secours IDDT Intensive Team at 62% of target It is important to note that the medical necessity criteria for admission to the IDDT Intensive Team requires higher severity of psychiatric symptoms than for the two IDDT Clinic Teams. This may explain the lower admission rate to the IDDT Intensive Team. c. Description of referral sources for individuals admitted to the Initiative To better understand the flow from assessment through admission, and shed light on the different admission rates across providers, we analyzed the referral sources for those individuals admitted to the Initiative (Table 1) and reasons why eligible individuals were not admitted (Table 2). Table 1: Referral Sources for Individuals Admitted to IDDT From July 1, 2012 Through June 30, 2013, By Provider (N=133) Referral Source Circuit Court Medical Services and FAST Bon Secours IDDT Intensive Team MTC IDDT Clinic Team Family Health Centers IDDT Clinic Team 1 0 0 Circuit Court Drug Court 3 0 2 8-507 2 0 0 District Court Mental Health Court 2 0 0 Diversion Programs 1 0 0 Parole and Probation 0 5 2 State Hospitals 2 0 0 IDDT Intensive Team 23 0 0 IDDT Clinic Teams 0 46 43 Total Admissions 34 52* 47 *One admission had a missing referral source 11 IDDT FY13 Annual Report

Although the 8-507 fewer than anticipated participants entered through this mechanism population received preference in referral and admission to the Initiative, This analysis also highlights the difference between the IDDT Intensive Team and the two IDDT Clinic Teams in their connections to the criminal justice system. To some extent, this likely reflects the differences in psychiatric severity for people involved in state hospitals, for example. Again, note is made of the large number of individuals identified internally by each IDDT provider as meeting eligibility for services. Table 2: Reasons for Individuals Not Being Admitted to IDDT From July 1, 2012 Through June 30, 2013, By Provider (N=133) Reasons for No Admission Bon Secours IDDT Intensive Team MTC IDDT Clinic Team Family Health Centers IDDT Clinic Team Refused IDDT Services 1 1 1 Absconded/No show for treatment 6 1 3 Different Plan Pursued 11 4 6 Already in treatment with non-iddt provider 2 0 0 Not assessed 7 1 3 Missing outcome 4 0 1 Total Admissions 34 52 47 Total Assigned 65 59 61 The reasons for referred individuals not receiving an IDDT assessment vary depending on the referral source. For example, early in the Initiative, the Initiative experienced challenges for people referred from Drug Court. Primarily, this was related to challenging in coordinating timely and effective connections between jailed individuals and the IDDT providers. For people referred from Parole and Probation, the reasons individuals did not receive an IDDT assessment relate more to them either not showing up for several assessment appointments or not being at home when an IDDT provider staff member came to conduct the assessment. 12 IDDT FY13 Annual Report

Outcome Measures: a. Fidelity Reviews One of the key outcome measures to implementing an evidence-based practice like IDDT is how close to maximal fidelity to the model a new initiative or provider comes. In behavioral health service delivery, it is expected that providers and systems need several years before high fidelity is reached. Prior to that, the outcome measure of interest is how much change has occurred from year to year as providers and systems learn and modify their practices. According to the Case Western Reserve University Center for Evidence-Based Practices, an expected amount of change for the IDDT model from one year to the next is an increase of 0.5 on the total IDDT fidelity scale. An overall total score of 4.0 reflects moderate implementation of the model while 5.0 indicates full implementation of IDDT. For the three IDDT providers in Baltimore City, their baseline to first annual fidelity scores ranged as follows: 1. Bon Secours IDDT Intensive Team: Increase of 0.8 Baseline fidelity score = 2.2 First annual fidelity score = 3.0 2. Maryland Treatment Centers IDDT Clinic Team: Increase of 1.9 Baseline fidelity score = 1.3 First annual fidelity score = 3.2 3. Family Health Centers IDDT Clinic Team: Increase of 1.5 Baseline fidelity score = 1.5 First annual fidelity score = 3.0 b. Demographic Characteristics and Other Outcome Measures Because of the complexity of the data collection and matching processes required across multiple data systems, outcome measures, including descriptive statistics, for the Initiative focus only on the group of 133 admitted individuals. Table 3 describes the demographic profile of those admitted to any of the three IDDT providers. 13 IDDT FY13 Annual Report

Table 3: Demographic Characteristics of Individuals Admitted to the IDDT Initiative From July 1, 2012 through June 30, 2013 Characteristic Bon Secours IDDT Intensive Team (N=34) MTC IDDT Clinic Team (N=52) Family Health Centers IDDT Clinic Team (N=47) Total Initiative (N=133) Age, mean (range) 38 (19-60) 39 (21-61) 39 (20-64) 39 (19-64) Male Gender, n (%) 26 (76%) 36 (69%) 37 (79%) 99 (74%) Race/ethnicity, n (%) Black 24 (71) 31 (60) 24 (51) 79 (59) White/Caucasian 9 (26) 19 (36) 21 (45) 49 (37) Asian/Pacific Islander 0 (0) 1 (2) 1 (2) 2 (2) Other 1 (3) 1 (2) 1 (2) 3 (2) Marital Status, n (%)* Married 1 (3) 8 (15) 3 (6) 12 (9) Never married 27 (79) 29 (56) 28 (60) 84 (63) Divorced/separated 4 (12) 4 (8) 14 (30) 22 (17) Widowed 2 (6) 1 (2) 0 (0) 3 (7) Income Level, n (%)* <$5,000 22 (65) 22 (42) 34 (72) 78 (59) $5,000 - $9,999 12 (35) 11 (21) 3 (6) 26 (19.5) $10,000 - $19,999 0 (0) 9 (17) 5 (11) 14 (10.5) $20,000 - $39,999 0 (0) 8 (15) 4 (9) 12 (9) $40,000 - $50,000 0 (0) 0 (0) 1 (2) 1 (0.5) >$50,000 0 (0) 2 (4) 0 (0) 2 (1.5) SUD Disorders, n (%)** Alcohol 14 (41) 8 (15) 4 (9) 26 (19.5) Cannabis 9 (26) 5 (10) 6 (13) 20 (15) Cocaine 7 (21) 3 (6) 3 (6) 13 (10) Opioid 3 (9) 34 (65) 34 (72) 71 (53) Other 1 (3) 1 (2) 0 (0) 2 (1.5) MH Disorders, n (%) & Major Depressive Disorder 6 (18) 32 (62) 20 (43) 58 (44) Depression/Dysthymic Disorder 4 (12) 5 (10) 8 (17) 17 (13) Bipolar Disorder 11 (32) 9 (17) 11 (23) 31 (23) Anxiety/Panic Disorder 0 (0) 2 (4) 2 (4) 4 (3) PTSD 0 (0) 0 (0) 3 (6.5) 3 (2) Schizophrenia/schizoaffective Disorder 13 (38) 3 (6) 3 (6.5) 17 (13) *Total of 12 individuals with missing data: 10 from MTC and 2 from FHC **Total of 1 individual with missing data admitted to MTC & Total of 1 individual with missing data admitted to MTC 14 IDDT FY13 Annual Report

Several demographic characteristics are worth noting specifically: The majority of the individuals admitted to the IDDT Initiative are men in their late 30 s. Overall, there was a preponderance of African-Americans admitted to the overall project, but the racial distribution varied across the three providers, with Family Health Centers in Cherry Hill having the narrowest gap between Black and Caucasian. Very few other minorities were represented by any provider. Over three-quarters of participants fall below the federal poverty level for a single person, which in 2013 was $11,490. 2 With the exception of the Bon Secours IDDT Intensive Team, the most common substance use disorder diagnosed was opioid use disorder, followed by alcohol and cannabis. Individuals admitted to the Bon Secours IDDT Intensive Team had a wider range of SUDs, including alcohol, cannabis, and cocaine, rather than opioid use disorders. While the reasons for this are not entirely clear, it may be related to the longer experience the two IDDT clinic teams have had with treating opioid use disorders with buprenorphine/naloxone. Both FHC and MTC have integrated medication-assisted treatment into their clinical processes and protocols which the Bon Secours team has not had. As would be expected given the differences in medical necessity criteria between the IDDT Intensive Team and the Clinic Teams, a higher percentage of individuals with schizophrenia and schizoaffective disorder were admitted to Bon Secours than either MTC or FHC. Interestingly, the two IDDT Clinic Teams admitted higher percentages of people with major depression than Bon Secours. The latter team admitted a higher percentage of individuals with bipolar disorder. The percentage of individuals with an anxiety disorder admitted to any of the IDDT providers was low, likely reflecting that Maryland s Public Mental Health System priority population excludes PTSD and anxiety disorders. Table 4 details the identified outcome measures for the Initiative. 2 http://useconomy.about.com/od/glossary/g/federal_poverty_level.htm 15 IDDT FY13 Annual Report

Table 4: Outcome Measures for Individuals Admitted to the IDDT Initiative From July 1, 2012 through June 30, 2013 Outcome Measure Criminal Justice Outcomes Bon Secours IDDT Intensive Team (N=34) MTC IDDT Clinic Team (N=52) Family Health Centers IDDT Clinic Team (N=47) Total Initiative (N=133) Participants on parole or probation 7 (20.5) 10 (19) 4 (8.5) 21 (16%) Participants re-arrested after admission, n (%) 7 (20.5) 11 (21) 0 (0) 18 (13.5) Participants incarcerated after admission, n (%) 8 (23.5) 5 (10) 11 (23) 24 (18) Hospital Utilization Outcomes Emergency Department Visits, N 26 27 34 87 SUD-related visits 1/26 (4%) 6/27 (22%) 0/34 (0%) 7/87 (8%) Mental health-related visits 17/26 (65%) 7/27 (26%) 29/34 (85%) 53/87 (61%) Somatic care-related visits 8/26 (31%) 14/27 (52%) 5/34 (15%) 2787 (31%) Hospitalizations, N 19 29 16 64 SUD-related hospitalizations 0/19 (0%) 11/29 (38%) 0/16 (0%) 11/64 (17%) Mental health-related hospitalizations 19/19 (100%) 9/29 (31%) 4/16 (25%) 32/64 (50%) Somatic care-related hospitalizations 0/19 (0%) 9/29 (31%) 12/16 (75%) 21/64 (33%) Recovery-related Outcomes Unemployed at admission, n (%)* 33 (97) 44 (85) 43 (91) 120 (90) Unemployed at admission who became 2/33 (6%) 4/44 (9%) 4/43 (9%) 10/120 (8%) employed at some point during the year Unstable housing at admission, n (%)** 29 (85) 2 (4) 5 (11) 36 (27) Unstable housing at admission who 6/29 (21%) 1/2 (50%) 0/5 (0%) 7/36 (19%) obtained permanent housing at some point during the year Number of participants still in treatment as 34 (100) 52 (100) 23 (49) 109 (82) of June 30, 2013, n (%) & Length of stay for participants in treatment as of June 30, 2013, mean days (range) 140 (5-311) 181 (4-314) 87 (4-353) 148 (4-353) *Total of 2 individuals with missing data: 1 from FHC and 1 from Bon Secours **Total of 2 individuals with missing data: 1 from FHC and 1 from Bon Secours & A total of 24 participants were discharged from MTC between July 1, 2012 and June 30, 2013 16 IDDT FY13 Annual Report

While many of these outcomes will serve as baseline measures for the IDDT Initiative, several of them deserve specific note and comment: The 18% re-incarceration rate overall stands well below the 40.5% return to prison or probation rate reported by the Maryland Department of Public Safety and Correctional services. 3 Twenty-six (26) participants, or 19.5% of all IDDT clients, accounted for the 87 total Emergency Department (ED) visits. o This averages to about 3 ED visits per person in the 12 month reporting period. o Of the 26 individuals visiting the ED, 19 (73%) had more than one visit. Participants in the FHC Clinic Team had the highest percentage of ED visits for mental health reasons (85%) among the three IDDT providers but the lowest percentage of substance use (0%) and somatic-related visits (15%). This team also saw the highest percentage of somatic-related hospitalizations (75%) and the lowest percentage of mental-health related hospital admissions (25%) of the Initiative. This likely reflects the background of the FHC clinic team as an original substance use disorder treatment provider integrated into a federally qualified community health center. The clinical expertise of the team that includes a family medicine physician specializing in addiction medicine probably allows for effective identification, triage, and intervention of substance use or somatic health concerns such that participants are steered towards hospitals for admission, not just an ED visit, when their symptoms are such that they cannot be managed in an ambulatory setting. However, because mental health care is the newest component for this team, it may rely on the ED more heavily at this point to assist in addressing challenging psychiatric symptoms. The Bon Secours IDDT Intensive Team also experienced a high utilization of hospital resources, both ED and inpatient, for mental health-related issues. Rather than reflecting the composition and expertise of the clinical team, these statistics likely primarily reflect the severity of the mental illnesses of IDDT Intensive Team participants with recognition by an experienced staff as to when hospital admission is needed. Not surprisingly, a higher percentage of IDDT Intensive Team participants were unstably housed at admission compared with participants in either of the IDDT Clinic Teams. The only discharges from the Initiative came from the FHC clinic team. This likely reflects the different regulations and cultures underlying treatment that have historically viewed mental health care from a time-unlimited, chronic illness perspective versus the acute disease approach of substance use disorder treatment where non-adherence to care results in discharge from treatment rather than intensification of care. 3 George J. State s recidivism rate drops in a decade. The Baltimore Sun, Tuesday, October 1, 2013. P. 8. 17 IDDT FY13 Annual Report

IDDT Initiative Participant Voices Here are a few snapshots of what IDDT participants have said about their experience so far, from a July 2013 focus group Perspectives on their health conditions: I no longer look at mental health as a stigma I have a better understanding of my mental illness and have better insight. I am more peaceful and balanced. Satisfaction with their IDDT service provider: I have a good counselor that helps me. Supportive. Surprisingly interesting. I love this place! Their general outlook: I m alive again. A life changing gift. I m no longer afraid. 18 IDDT FY13 Annual Report