Strategic Plan Goal 3 – Re-entry Initiatives

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Help institutionalized individuals to re-enter and reintegrate into community.

Goals 1 and 2 of this Strategic Plan propose significant investment and fundamental changes to the system of care in LA County that, when fully realized, will dramatically reduce the number of individuals with serious mental illness and youth with a serious emotional disturbance who fall out of their community and into the institutions of deep isolation, the street, prolonged or repeated child welfare involvement, juvenile probation and jail.

DMH InstitutionsUnfortunately, these interventions will take time during which we cannot ever give up on those already living in, or likely to enter, the institutions. Goal 3 is framed around aggressive strategies to safely and humanely get individuals living with serious mental illness, including youth living with a serious emotional disturbance, out of institutions and back into community, which will often require a pit stop in the hospital or other element of the Crisis System. As above, Goal 3 targets individuals who are not connected to community, were missed by the Crisis System and have fallen into deep isolation (Strategy 3.1), homelessness, prolonged or repeated child welfare involvement and/or involvement in the justice system (Strategy 3.2). A portion of these individuals will require involuntary treatment as part of their recovery journey, but we must ensure they do not languish in involuntary settings (Strategy 3.3).

Identifying and Connecting with the Deeply Isolated (Strategy 3.1)

Reach out to and engage individuals who are living in isolation and cut off from community.

  • Deploy tactics for reaching out to and engaging individuals who are isolated
    • Bring these individuals back into community and give them the chance to flourish, which is key to stability and successful re-entry
  • Evaluate any systemic issues within DMH that may be promoting or enabling the isolation
    • Train front-line and clinical staff in cultural humility and sensitivity in order to better demonstrate empathy for increased cultural competency
  • Identify co-occurring disorders that may be further isolating individuals
    • Train staff to understand the associated stigmas attached to co-occurring disorders and inter-generational trauma within the cultures represented
    • Understand the various healing practices different cultural groups observe and incorporate those into how DMH delivers services
  • Identify and address the systemic issues which put children at risk for being involved in the justice and child welfare systems (e.g., early and repeated suspensions and expulsions)

Outreach on the Streets and In-reach to Justice Systems (Strategy 3.2)

Reach out to and engage individuals who are living on the streets or unstably housed, as well as those currently in jail and juvenile justice, to ensure successful community re-entry.

  • Coordinate and integrate outreach/in-reach efforts with partner organizations
    • Develop and deploy robust outreach and engagement efforts to individuals living with serious mental illness, including youth living with a serious emotional disturbance, who are homeless, unstably housed and/or involved with the justice system
    • Enhance alignment and collaboration with relevant partner agencies in the County, e.g., Departments of Public Health, Health Services and Children and Family Services
  • Recognize and take responsibility for care and support for homeless individuals with serious mental illness
    • Prioritize resources, connection and care delivery for this population in order to move them to stable housing
  • Help improve systems of diversion from justice systems
    • Ensure navigation for individuals who are justice-involved because of serious mental illness or serious emotional disturbance to more appropriate care settings
  • Develop new care facilities that focus on a recovery-oriented approach
    • Address the mental health needs of the justice-involved population in a more ethical manner than historical approaches
  • Create and train multidisciplinary teams, including peers, for homeless outreach
    • Build relationships with individuals who are homeless and/or have justice involvement and get them the resources they need to successfully integrate back into community through expanded in-person outreach

Involuntary Care – Conservatorship (Strategy 3.3)

Expand capacity for engaging and resourcing care of individuals who meet criteria for grave disability.

  • Recognize and more effectively engage individuals who require surrogate decision makers
    • Utilize the conservatorship option with discretion but fully and intentionally, when needed, so as to restore decision-making and empower recovery as quickly as possible
  • Commit resources that address both clinical needs and social determinants of health
    • Help promote a holistic recovery for our consumers in need of mental health conservatorships
  • Right-size all needed services for conservatees
    • Align with conservatees’ more-intensive needs and ensure that the full suite of resources accompanies all mental health conservatorships
    • Provide support to parents needing to have their children go through this process, so they can more effectively advocate for their child

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