For nearly 20 years, Miami-Dade Circuit Judge Steven Leifman has coordinated the work of state and local agencies in diverting mentally ill people from the jail system and getting them into comprehensive residential and outpatient recovery services. He was a top contender for the new HHS assistant secretary position in charge of mental health and substance abuse policy. In an interview with Modern Healthcare senior reporter Harris Meyer, Leifman described the structural reforms he believes are needed in mental healthcare and what the federal government must do to achieve those improvements. The following is an edited transcript.
Modern Healthcare: Please describe the reforms you spearheaded in Miami-Dade.
Steven Leifman: I started the project in Miami about 17 years ago primarily because of a defendant I had in my courtroom who turned out to be a Harvard-educated psychiatrist. He had late-onset schizophrenia, became homeless, and was recycling through the criminal justice system. At the time, if you got arrested in Miami on a misdemeanor, there was little we could do except put you right back out on the street, which was ridiculous.
We looked at the entire system to see what kind of systematic changes we could make in the community so we could reduce the number of people with serious mental illness coming into the criminal justice system who didn't need to be handled by that system. We looked at ways to determine who should and shouldn't be in jail, and divert those who didn't need to be in the criminal justice system into treatment.
We looked at why the police were arresting so many people with a serious mental illness. It turned out Miami-Dade County has the largest percentage of people with mental illnesses of any urban area in the U.S., two to three times the national average, while Florida offers very low-per-capita funding for mental healthcare. Like in most communities, the criminal justice system had become a primary gateway for people with serious mental illness.
MH: What changes did you implement?
Leifman: We found what we consider to be the best training for law enforcement, called crisis intervention team policing. It helps officers identify people who are in serious mental health crisis and how to de-escalate and avoid violence, then where to take people as opposed to arresting them.
We worked with the county jail to develop a better assessment tool for identifying people coming in with mental illness. Now, if a person with serious mental illness gets arrested, usually within three days we divert them out of the jail into a locked crisis stabilization unit.
Because they're on a criminal hold, the 72-hour civil commitment limit doesn't apply. We generally set the case for hearing in about two weeks, allowing the person to become stabilized. During that period, someone from our staff meets with the individual and offers him or her the opportunity to go into our program.
The program is about helping them get into and stay in recovery. We get them their appointments, transportation, benefits, housing, clothes, whatever they need for recovery. About 70% to 80% of the people who are offered the program accept it.
They are taken directly from the stabilization facility back to the courtroom, where a peer specialist is waiting for them. Four of our seven peer specialists graduated from our program. That same day, we transport them by car to where they need to go for services. So it's a warm handoff into the system of care they need for their recovery.
MH: What kind of results have you achieved?
Leifman: It's been phenomenal. From 2010 through 2016, the city of Miami Police Department and the Miami-Dade County Police Department handled 71,628 mental health calls and made only 138 arrests. Our jail audit plummeted from around 7,300 to about 4,000 today. It allowed us to close one of our local jails, saving $12 million a year.
Recidivism for the misdemeanor population dropped from about 75% to 20%. It worked so well that with our state's attorney, we were allowed to expand the program to people with serious mental illness who are charged with nonviolent felonies. Seventy percent of people who go into the program successfully complete it, with only a 6% recidivism rate. Over the last four to five years, that program alone has saved the county more than 68 years of jail bed days.
MH: What are you doing to reduce the flow into hospital emergency departments?
Leifman: We are in the process of establishing a first-of-its-kind forensic diversion facility, which we estimate will save the county hospital and its ER at least about $8 million a year by keeping people with serious mental illness who are repeat users in this other facility that will have both primary-care and psychiatric services under one roof.
MH: What does it take to get the healthcare, the law enforcement, behavioral health and the political system to collaborate on successful structural changes?
Leifman: It's very doable, and it's starting to happen all around the country. I'm part of an initiative called Stepping Up, which is a coalition involving the Council of State Governments, the National Association of Counties, the American Psychiatric Association Foundation, the U.S. Department of Justice, the National Alliance for Mental Illness, and the Sheriffs' Association. It's designed to develop collaborations and make structural changes. Over 300 large counties have passed resolutions to set up these types of programs to help people with these illnesses stay out of the criminal system.
The main factor driving this is counties are spending over $80 billion a year just on correctional costs, and that's making it hard for communities to invest in hospitals, schools and infrastructure. Too much money is going into correctional costs for people with untreated mental illness. The counties have realized we cannot lock people up and expect the problem to go away.
We've come to understand the way to the solve the problem is to use a population health model, as opposed to a criminal justice model, to help get people services. When you do that, you're going to see better recovery. People tend to forget that these are illnesses, just like heart disease.
MH: What is the role of the federal government in reforming the mental health system?
Leifman: The main role for the new HHS assistant secretary in charge of mental health and substance abuse is to help all the different agencies end the fragmentation of the community mental health system. One of the biggest problems people have is trying to navigate this complex system of care that makes it really hard for people to get the treatment they need. A lot of money gets wasted because people aren't getting the level of services that they need.
Another issue is there is a huge gap between the science and medicine of mental health and substance abuse and what's actually delivered in the communities. Half a dozen states do a good job disseminating information and training people on how to deliver the most effective treatments to people, including working with the courts and all the other stakeholders. I would encourage all states to set up centers of excellence so that the information can be more effectively delivered into the community.
MH: Are health insurers adequately covering treatment for mental health and substance abuse disorders?
Leifman: No, not at all. We have to keep the insurance industry's feet to the fire, and make sure they are delivering the level of services that they're supposed to be offering, so people aren't pushed into more expensive acute systems, such as the emergency room or the jail, where they get sicker.
MH: What do you think about the get-tougher-on-drugs rhetoric from Attorney General Jeff Sessions?
Leifman: I am hopeful that they will treat this primarily as a medical issue, which it is. Jail should be the last resort for services, not the primary place for people to go. We have to reverse what we are doing today.