How One Community Comes Together To Treat, Not Jail, the Mentally Ill

March 13, 2000

They're among the toughest-to-treat patients: mentally ill people who have become entangled in the criminal justice system. For many, the final destination is a jail cell.

Now Project Link, a program created by several Rochester community organizations and the University of Rochester Medical Center, is showing unprecedented success in treating this swath of patients, who oftentimes bounce from jail to the hospital to the streets with no successful treatment.

"Jails and prisons have become the final destination for the mentally ill in America-it's the most pressing issue facing psychiatry today," says psychiatrist J. Steven Lamberti, M.D., director of Project Link. "The Los Angeles County Jail has become the nation's largest mental institution. It holds more people suffering from severe mental illness than any hospital in the country. The problem has received a lot of attention, but there have been few proposed solutions. We've found one promising approach."

Project Link combines a number of innovative treatments, including a culturally diverse staff, close cooperation with the criminal justice system, a mobile treatment team, and a residence for patients with mental illness and addiction. Most important, several community-based organizations are partners, including Action for a Better Community, the Ibero-American Action League, Monroe County Clinic for Socio-Legal Services, Unity Health System, and the Urban League of Rochester. A representative from each is part of the project's management team, bringing together very different groups who share the goal of improving patients' lives.

"This program is a prime example of an innovative and much-needed service for persons with serious mental illness involved with the criminal justice system," says James L. Stone, New York State commissioner of mental health. "Project Link has achieved significant reductions in jail and hospital lengths of stay and is making a significant contribution both to the individual clients and to the local mental health community."

The program is aimed at people who have a severe and persistent mental illness and a history of involvement with the criminal justice system. Of the current participants, two-thirds never graduated from high school, one-third were homeless, and nearly half have felony convictions. About 85 percent have either schizophrenia or another psychotic disorder, and more than 80 percent reported using drugs or alcohol. Most are African-American or Hispanic men.

Project Link was recently recognized by the American Psychiatric Association as winner of the prestigious Gold Achievement Award for the most outstanding university-run clinical psychiatric program for the mentally ill in the country.

A recent study compared the experiences of 54 participants in the year prior to entering Project Link with their circumstances during the first year in the project. In the year before the program, these individuals spent an average of 109 days in jail and 105 days in the hospital. In Project Link, those numbers plummeted: Participants spent an average of just 40 days in jail and 14 days in the hospital. The average cost of caring for a participant fell as well, from $62,500 per person to about $14,500 per person, including the cost of the program. And the patients improved dramatically in their ability to take care of themselves: They managed money better, their personal hygiene improved, and they cut down their use of drugs and alcohol.

Very often, says Lamberti, mental health professionals, police and social service workers clash in their attempts to help such patients or protect society. "Before this program, it was as if these patients were lost in the Bermuda triangle: They bounced from jail to the hospital to the street with no hope of finding their way out."

To break the cycle, Lamberti initiated a program five years ago that evolved into Project Link. The first step was to hook up with key community-service agencies, whose leaders assumed a central role in the program. Thus the project is managed by Lamberti, director of the University's Strong Ties Community Support Program, along with five community leaders, one from each of the agencies directly involved. Through extensive dialogue, this culturally diverse team sets the project's policies, and the actual hiring of case advocates-the people closest to the clients-was put in the hands of the agencies.

"The diversity of the partnership and the diversity of the staff is what makes this work," says Gladys Santiago, a member of Project Link's management team and senior vice president of the Ibero-American Action League of Rochester. "Case managers need to know the culture and the language of the people they serve-it's a fact of life."

Robert Laird, who helps to manage the project as part of his job as deputy director for community services at Action for a Better Community, makes the same point. "We want to be sure we're culturally representing the population we're serving," he says. "Cultural diversity is embodied in our recruitment process, from the directors of the program down to the case advocates."

Laird says it's unique for community agencies to be part of a group working closely with the criminal justice system and the medical community. In particular, Project Link includes input from police, judges, and parole and probation officers, most of whom were skeptical when the program began.

Among Project Link's clients: a man who attacked his case manager, a man who set his house on fire after locking his family inside, as well as drug addicts, arsonists, and other felons. Rochester judges recognize many of these individuals, who had cycled through various programs and jails for years.

"There was lots of skepticism from potential funders, too," says Robert Weisman, D.O., the forensic psychiatrist who heads Project Link's mobile team that treats individuals in crack houses, homeless shelters, jails, and hospitals. "One visitor came through and said, 'Where I'm from, we lock these people up and throw away the key.' That summarizes what a lot of people think. But we've developed a system to treat these individuals successfully, and it saves taxpayers money in the process.

"Our clients are the folks who tend to fall through the cracks," Weisman adds. "We're the last stop for a lot of clients who have no other place to go. With traditional services, if they miss their first appointment, they're lucky to get a second one. Our program provides a third chance, a fourth chance, a fifth chance."

Much of the program's interaction with the criminal justice system happens through Weisman and a psychiatric nurse practitioner, Nancy Price, M.S., R.N., as well as Rudo Munondo-Ashton, M.S. R.N., project coordinator. The team tracks down and visits clients wherever necessary, sometimes treating them with medication, sometimes putting them back in touch with case managers. They're present if a client is brought in for breaking the law, and they're frequently in courtrooms and jails, talking with judges, public defenders, police, and lawyers.

The hands-on approach goes a long way toward bridging the gap between medicine and the criminal justice system. The team works closely with jail officials, often to make sure that clients agree to treatment as a condition of parole or probation. "Most treatment teams are based in the mental-health world, and clients disappear when they go into jail," says Lamberti, who is associate professor of psychiatry at the Medical Center. "Our team is part of both worlds; they're as comfortable in the jails as they are in the hospitals."

The initial funding for Project Link came from the Monroe County Health Department and the New York State Office of Mental Health, which has held up the program as a model for other communities. Two years ago the program received a four-year grant from the Robert Wood Johnson Foundation, which co-funded the program along with Coordinated Care Services Inc., Eli Lilly and Co., and Janssen Pharmaceuticals. Also contributing to Project Link is the University's Department of Psychiatry, which runs Strong Ties, and DePaul Residential Services, which operates the residential facility.

"Project Link has had a noticeable impact on the life of our community," says Stephen Dungan, C.S.W., director of the Monroe County Department of Mental Health. "We see fewer mentally ill individuals in our jails, fewer psychiatric hospitalizations from our jails, and more appropriate use of our county's services, all in a context which seems likely to reduce our community's expenditures. Plus the culturally diverse staff has gained acceptance into all areas of our community, enhanced the credibility of the program, and achieved respect on the streets.

"Project Link is an innovative program of care which unites our teaching hospital, its outpatient department, community agencies and local government," adds Dungan. "The program offers a different way to look at the interaction between mental health service providers, community service agencies, and the criminal justice system. Our experience in Monroe County suggests that Project Link is an excellent model of assertive service delivery and is well worth replicating in other communities."

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