«From Inception to Implementation: How SACPA has affected the Case Processing and Sentencing of Drug Offenders in One California County DISSERTATION ...»
Despite these obstacles, core stakeholders had to figure out how to put a system into place that facilitated the flow of information between the various entities responsible for supervising and/or providing services to these offenders. By default this burden fell disproportionately on the probation department (as the legislation placed the information sharing responsibility on them) and to some degree, HCA (as they were entirely responsible for treatment activities). According to the law, it was the probation department’s responsibility to ensure that the Prop36 probationer enrolled in treatment within a specified time period and to report that information back to the court, as well as to provide quarterly updates to the court on the individual’s progress. According to Section 5, subdivision (c) of SACPA, the probation department must notify the drug treatment provider designated to provide drug treatment of court ordered probation and treatment within seven days; and the drug treatment provider must prepare a treatment plan and forward it to the probation department within 30 days. Furthermore, the drug treatment provider must prepare progress reports on a quarterly basis and forward those on to probation, which then forwards them to the court.
In order to assure compliance with state and federal confidentiality laws (ex.
42CFR and HIPAA), the core stakeholder group created a “release of information” form that all Proposition 36 clients signed in court immediately upon acceptance of Proposition 36 diversion. This proved to be very important, as many offenders fell out of the system before reporting to probation or treatment. Having the waiver signed immediately protected the county from potential lawsuits and allowed agencies to communicate with one another and share basic information regarding program compliance right away. Eventually a high court ruled that such waivers were unnecessary and permission to share information was automatically granted by offenders upon acceptance of Proposition 36 diversion (Confidential Informant).
However, as will be discussed below, some client information is still subject to stricter regulation.
Both criminal history records and substance abuse treatment records are governed by “right to know and need to know” laws. Only individuals who have a “right to know” (for instance as part of their employment) and a “need to know” (justified by current assignment and task) can access these types of records. In terms of Proposition 36 this means that most treatment providers have a “right to know and a need to know” treatment information about their clients (how many meetings they have attended, dates and results of drug testing, etc.); however they do not have a “right to know and a need to know” criminal justice information about their clients.
The same issue exists for probation officers, district attorneys, public defenders, and court staff. This means that most practitioners who work with Proposition 36 offenders generally will not have a “right to know” and a “need to know” both criminal justice and treatment information. This issue posed considerable problems for Orange County’s core stakeholders as they attempted to build a database to share information.
In many ways Orange County was unique in its approach to Proposition 36.
One thing that Orange County did that other counties did not do (at least not right away) was to use some of their initial allocation of SACPA funds from the state to create a shared database that all practitioners could use to view current information on Proposition 36 clients. The “vision was to have a shared database where probation could go in and keep track of cases and other entities could and we could just see what’s going on with the case” (Confidential Informant DDA, personal communication). However, the process was very tedious because there was no prototype for this type of information sharing, “we designed it from scratch, from the ground up”. Core stakeholders, specifically the ones who served on this subcommittee, had to “literally walk through the process of what the probation department does when [they] get new cases and to some degree what the healthcare agency does [when it gets new cases]” (Confidential Informant). Core stakeholders had to figure out a way to capture information from multiple agencies (including each and every approved treatment provider) located at multiple sites throughout the county.
The database was designed to allow multiple users to input information on a single individual, so information would always be up-to-date and correct. Probation department staff, health care agency staff and individual treatment providers are responsible for inputting case management information and updating the information on their cases as necessary. Depending on the module, information can be viewed by staff at those agencies as well as Prop36 court staff and attorneys. The database contains a multitude of information on each person assigned to Proposition 36 probation. For example, information on conviction date and offense information, offender contact information, date reported to probation, probation case number, probation officer, and dates of meetings with probation officer and relevant notes, treatment provider information, results of treatment severity index (at treatment intake interview), treatment progress including dates of meetings, test dates and results, court appearance information, progress reports and other pertinent information. In order to comply with confidentiality laws, data modules are separated and can only be accessed by individuals with the proper “clearance.” In addition to the strict confidentiality laws that had to be navigated, other hurdles emerged. For example, not all treatment providers had computer systems (and therefore were not be able to access the shared database that core stakeholders spent so much time and effort creating). “Once we got the computer system going, getting the providers to use the database was huge. They definitely struggled with that. It was something that wasn’t anticipated I think as to how hard it was going to be” (Confidential Informant). “There was a huge learning curve for them (treatment providers)…trying to understand what their role was and how to work it (the database)” (Confidential Informant).
Deciding on the scope and duration of treatment that would be provided to Prop36 offenders was also a major task. The legislation limited the duration of treatment to no more than 12 months plus up to six months of aftercare. It did not dictate, however, the type or length of treatment that was required to be provided by counties. Given that each county received a set amount of funding for all Prop36 related expenses (treatment and criminal justice); core stakeholders had to make difficult decisions regarding the intensity, duration, and types of treatment that would be offered. Several factors were considered, including: best practices in substance abuse treatment (treatment modality, duration, etc), capacity of current treatment providers, ability to expand treatment capacity within a short time period, expected number of offenders, expected treatment severity of enrolled offenders, cost of criminal justice and other necessary expenditures, in addition to philosophical discussions about where core stakeholders believed SACPA funds should be primarily spent (supervision or treatment).
Orange County was unique in that core stakeholders chose to provide clients with treatment for the maximum duration allowed by law, one year plus aftercare treatment – this was significantly longer than neighboring counties and was more than most counties in the state offered. This decision was grounded in best practices research that finds the longer a person is in treatment, the better the outcomes.
Toward this end, Orange County HCA attempted to create a menu of treatment options that would apply to the vast majority of clients they expected to encounter.
Originally HCA offered six levels of care for Prop36 clients: educational services, medical model inpatient detoxification, social model residential detoxification, methadone maintenance, outpatient treatment (three levels) and residential treatment (90 days)40. Offering three levels of outpatient treatment was somewhat distinctive to Orange County in that most other counties only offered one level of outpatient treatment (Confidential Informant).
Unfortunately, Orange County found itself dealing disproportionately with offenders with severe addictions and other co-occurring disorders, which impacted the treatment the County required and the treatment that the County was able to and could afford to provide. As a result of system constraints (an unexpectedly large number of offenders with more severe addictions than anticipated combined with inadequate funding) treatment durations were shortened. “We were constantly having to adjust Orange County HCA has since added a perinatal program as well as a 30-day sober living option.
the program requirements as to how long people would be in. The model, your best practices says the longer the better. We had to keep shortening [the time clients could spend in treatment]” (Confidential Informant). For example, level one outpatient treatment was originally six months long but was reduced to four months, level two was reduced from nine to six months, and level three was reduced from 12 to nine months. “We realized that if we funded those people for all that time, we’re going to run out of money” (Confidential Informant). Furthermore, the number of clients requiring residential treatment constrained the system.
What we didn’t anticipate was how many people needed residential (treatment). We expected it to be kind of like a bell curve, so the levels and the way the providers were selected was (sic) kind of designed around that idea – that the majority of the people would be in the middle. Really, the number of people that needed residential surpassed what we expected.
Moreover, residential treatment capacity was not easily increased. “If you put all those people in residential, the money was (sic) gone” (Confidential Informant).
Despite the desire to provide clients with the most appropriate treatment for their addiction need, Orange County was not able to do so consistently due to budget and system constraints.
Proposition 36 allocated $60 million to be split between California’s 58 counties to cover implementation and operating expenses from July 1, 2001 to December 31, 2001. It allocated $120 million annually for additional operating expenses for the years 2002 – 2004. It was stipulated in the legislation that California State Department of Alcohol and Drug Programs (ADP) would be responsible for overseeing the implementation of SACPA state-wide, including the distribution of funds. In order to receive funds, ADP required counties to designate a lead agency.
Originally Orange County designated the Health Care Agency as the lead implementation agency and the County Executive Office (CEO) to be the receiver of funds from the state and distributor of funds to county agencies. Eventually HCA became the lead agency for all implementation related activities (including distribution of funds).
As would be expected, money was a hotly debated issue. Beyond substance abuse treatment and case management/criminal justice activities, counties could spend SACPA funds on other types of services for offenders, such as: literacy training, family counseling, vocational training, or similar types of services. In order to determine how Orange County’s share of SACPA funds would be dispersed, each agency had to argue their case to the CEO. Each agency had to estimate the extent to which they would be impacted by Proposition 36 and approximate the additional cost associated with supervising, monitoring, or serving those offenders. HCA received the bulk of Orange County’s allocation (approximately 80%), the probation department received approximately 17% of the funding during the first year and the other agencies (DA, PD, SC) shared the small amount that was left. It was agreed by every stakeholder interviewed that funding was (and continues to be) inadequate for the number of offenders in Proposition 36 and the services they require. Insufficient funding drastically limited the case management and treatment services the county was actually able to provide. Services needed to be cut due to funding shortfalls.
We had some really intense, very intense, discussions at that meeting when it came time to cut services. At one point we cut back some treatment services. We had to cut back some probation services. When it was time to cut, and where to make those cuts, a lot of good old fashioned backdoor arm-twisting, and politicizing, and things like that would take place…. if you’re familiar with the dynamic where you’re all around the table and everybody’s got their polite faces on, but when the meetings are broken up, then everybody’s calling and or they’re emailing and saying ‘I want your support on this’, or ‘I want your support on that’ that sort of thing happened.
As one stakeholder said, “everybody was dedicating resources specifically to deal with this Prop36 population, but the funding wasn’t there for the level of resources it was taking. Pretty soon it was so overwhelming that people just started backing off and saying ‘we can’t give you any more people. You got what you got’” (Confidential Informant). In response to the unexpectedly large volume of offenders, there were discussions about adding additional Prop36 courtrooms. However, agencies were spread too thin and “nobody could fund all those specific attorneys just to handle [Prop36 cases]. It [was] very difficult in terms of the resources that it was sucking up in compensation to the individual agencies” (Confidential Informant).
Agencies could not increase capacity and many services had to be cut because there was no SACPA money available and the CEO refused to use non-SACPA county funds for SACPA clients. The county simply could not afford their vision with the number and the addiction severity of the offenders in the program.