Strengthening community services to keep individuals with mental illness out of jail: a qualitative analysis of implementation mechanisms in 52 U.S. Counties.

backgroundIdentifying mechanisms of implementation approaches helps improve them. This qualitative analysis examined how hypothesized mechanisms (performance monitoring, interagency teams, common goals/mission across agencies, and system integration) influenced implementation outcomes (number of evidence-based services [adoption], people served [reach], and resources to support evidence-based services [component of sustainment]) in county-level efforts to improve community services to keep people with mental illness out of jails.

methodsOur study statistician chose a representative sample of 60 U.S. counties and respondents from a sampling frame consisting of community mental health, community substance use, jail, and probation administrators in 950 U.S. counties. We reached and interviewed representatives from 52 of 60 counties (68 respondents in 52 interviews). Interviews were recorded, transcribed, de-identified, and coded using thematic analysis with deductive codes. Study team members created analysis summaries for each mechanism, which were reviewed and verified by other team members.

resultsAdministrators viewed all hypothesized implementation mechanisms as helpful for at least one outcome. They viewed performance monitoring (tracking metrics over time) as helping counties obtain resources to provide services, re-allocate existing services to better meet clients’ needs, and provided feedback needed to improve services. Interagency teams (i.e., regular meetings with multiple agencies) increased integration and continuity of care across treatment and jail/probation settings, improved client mental health and substance use outcomes, provided access to additional trainings and programs, and helped to change attitudes and policies to support evidence-based practices. Agreement on goals and mission across agencies improved availability of evidence-based practices, client outcomes, and collaboration between community providers and criminal justice partners, and facilitated interagency problem-solving. Integration of care across agencies helped get clients faster, more appropriate care, eliminating unnecessary frustration, illness, incarceration, and suffering. The presence of one mechanism tended to support use of other mechanisms. Representatives from small and medium/large population counties viewed mechanisms as similarly helpful. However, medium/large counties were often further along enacting the mechanisms.

conclusionRespondents described performance monitoring, interagency teams, common goals across agencies, and system integration improving number of evidence-based services, people served, and resources for improving community services to keep people with mental illness out of jails.