So, people have to be pretty extensively disabled in order to benefit.  Often, people in the criminal justice system are not quite that disabled.  So, there’s this gap where people can’t get access to care, and it creates the same kind of ongoing, untreated addiction and mental health issues that basically have us where we are today.

So, under the current justice and healthcare structures, there are multiple and interconnected barriers to providing coordinated and effective care.  This is especially pronounced with behavioral health issues, and there are some challenges related to divergent goals between the substance abuse and mental health and criminal justice system, insufficient or fragmented funding, lack of health insurance coverage, insufficient care because of the previous health issues, and the lack of coordination, which makes it hard to accomplish large overall goals across the system.

In terms of divergent goals, the way we tend to think about this is the primary responsibility of the justice system is public safety and reducing recidivism.  The primary responsibility in the health care system including behavioral health is to protect or improve in individual and community health. These things do align, but it’s not necessarily always obvious how to make them align.

There’s certainly a mutual objective in cost containment.  There’s certainly different costs, but at the place, people can align.  The justice system is definitely not designed to be a provider of health care but often obliged to assume that role as a default setting because the capacity in the community system that’s needed isn’t available.

In terms of insufficient and inadequate treatment, the demand for community-based substance abuse and mental health treatment in most states way exceeds it availability.  Justice-based treatment programs rarely reach all individuals who are legally eligible.  Just to give you an example from the mental health core program that I worked on building earlier in this decade here in Crook County, Chicago.

There are about 20,000 people on probation today in Crook County, and based on the epidemiological estimates we got, we think 10% of those folks have persistent mental illness.  Well, we built a mental health core program that started at 25 people and had an ambitious goal of getting to 100 people and an outrageous goal of getting to 250 people because we’re building this with grants and we were basically borrowing money to pay for these services like the patchwork of a quilt. Those of you who do this work know what I’m talking about.

So, in our most outrageous goal, we were going to get to about 10% or over 10% of the people we knew needed intervention.  So, that scenario is repeated over and over again. We are hopefully in a moment where that could change.  For now, we lack the resources to expand models that we know work.

For those who haven’t had the pleasure of learning about the financing of substance abuse and mental health treatments and intervention services, I just want to get a little bit of information about that by way of background to understand the current situation.  Public substance abuse and mental health services are supported largely be federal block grants and categorical Medicaid eligibility.  By that I mean in most states, not all states, Medicaid eligibility is a combination of low income and low assets and a particular category of disability.  For example, in most states, people who have significant mental illness who are significantly disabled by that condition are eligible for disability, which makes them eligible for Medicaid funds for their care.

So, that I very good for people who have that access, but they are often very difficult to get.  It’s because it’s difficult to meet those criteria.  The application process takes a long time, and most folks whose lives are significantly disordered because of serious mental condition aren’t going to get through that application process on their own.  So, it’s a big challenge.  The challenge is the same on the substance abuse side, and those limitations have been enduring for as long as I’ve been in this field.

There are some federal funds, the block-grant funds that fund demonstration programs, initiatives that help.  They can provide evaluation money in those projects that help us to provide evidence that what we’re doing works, and those are helpful but pretty small in terms of the dollar amount.  They’re time-limited as well.  The largest dollar amount that goes into funding substance abuse and mental health services are actually state and county level funding like the state general revenue funds, county funds.  In some states, communities at the county level have the opportunity to have additional and small additional sales tax or other property tax added on that can fund some services. That is by far the largest amount of money spent nationally, but, again, it varies state by state and is certainly not enough to meet the need.

So, the pursuing of grant funding requires long processes for a somewhat incremental outcomes.  It is a very worthwhile and a strategy that we use all, but it’s a very laboring task.  Further, the larger, uncoordinated funding creates isolated pockets of service and not seamless continuums of care.  So, those are some of the things we think can be made to happen beginning in 2014.

So, what’s the impact of all of that?  Substance abuse and mental health conditions are chronic conditions that require ongoing long-term treatment and management. We know that for substance abuse, the National Institute on Drug Abuse has established that at least three months in treatment is needed to stop or curtail use.  That does not have to be residential treatment, maybe a short period of residential then some intensive outpatient or outpatient care, but there needs to be a sustained period of about three months to get things started well.  Durable recovery, meaning something that can last a lifetime and keep the people on a very different track in their lives, requires multiple episodes of are over many years.

Acute care treatment in justice setting just really cannot address these chronic conditions sufficiently.  They’re very important building blocks to getting to durable recovery, but they’re not enough in themselves.  So, that’s the trick here.  We’re trying to figure out how to extend the care in the community.

I talked before about the lack of insurance in this population.  There are about 12 of the 50 states that have expanded their Medicaid coverage to include single adults who do not have otherwise qualify through disability or parenting status.  None of the states in this four-state region have done that although I know many have considered it as a way to try to address this specific issue.  So, basically, we’re left with the 2014 option.

I want to acknowledge this because the Midwestern states in the [38:36] Region certainly have very large rural areas, and the rural jail and correction system have also become default settings for health and social services that don’t exist in the community through the lack of insurance or other funding and, in a lot of ways, hit those jails even harder.  If you’re operating a 45-person jail and you have enormously big health claim that can wipe out the budget for the whole year, let alone the capacity to provide the ongoing, constitutionally required care at an appropriate level.  So, a big opportunity with this funding coming is to think about how to use the resources that people, then, have as part of the individual insurance to bolster the health care systems in rural communities.

So, health care reform won’t solve all these challenges, but just to sum up, there are some very unique opportunities that are created for change on a broad scale.  Health care reform will create nearly universal coverage, meaning it does not include anyone who’s undocumented, and this affects a lot of communities differently.  The last testament I’ve seen suggests that health care reform will get about 94% of people covered nationwide, and that’s up quite a bit from where we are right now.  So, when I talk about near universal coverage, that’s what I mean with that limitation.

Potentially eliminating waiting lists for care is care in the community becomes more available and service capacity is expanded to absorb people who are now coming without dollars attached to them to pay for their care.  We have the potential to address gaps in services and build more continuum systems in the community and between jails and prisons and communities because that’s often where there’s a big juncture of mobility that creates a tremendous public challenge and a public safety challenge, that release piece.  Hopefully, ending the piecemeal approach to public funding, hopefully we won’t have to have to write the same type of grant proposals we’ve been writing for years as well.

So, this is another place for a good pause, Monica, if you want to look to see if we have any hands raised.

 

Monica:

Let’s see.  We don’t have anyone raising their hands, and at the end of the webinar, if you want to ask a question, we can provide Maureen’s e-mail.

 

Maureen:

Sure, and we’ll have time for questions at the end, too.

 

Monica:

Okay.  You can continue.

 

Maureen:

Okay.  Then, I’m going to continue.

So, now we’re going to shift to talking about thinking about health care reform in 2014 and its expansion of coverage in applying what works, applying what we know from 30 years of research from this field actually makes a difference in reducing recidivism, improving public safety, and building recovery.  So, rather than outline a number of specific practices, I wanted to talk about the frames of reference and the frames of research where all this stuff has been gathered.  All this stuff is easily available on the internet at the different national agencies.

So, the National Institute of Drug Abuse has “Principles of Drug Abuse Treatment for Criminal Justice Populations.  It’s very helpful and very helpful in thinking through what the system of care should be built around.  They definitely emphasize the matter of continuity between incarcerated situations and community treatment as a high priority with this group.

SAMHSA has a number of useful things including a more recent TIP, “Treatment Improvement Protocol 44:  Substance Abuse Treatment for Adults in the Criminal Justice System”.  That addresses both criminal justice system issues and also clinical issues.  So, it can be very helpful.  SAMHSA also has a National Registry of Evidence-based Programs and Practices.  SAMHSA is National or Federal Substance Abuse and Mental Health Services Administration.  So, they’re responsible for federal level funding of substance abuse and mental health treatment and prevention.

SAMHSA also has an organization called the GAINS Center that they’ve funded extensively that they’ve funded through the last 10 to 15 years, and they’ve identified six evidence-based practice treatments in mental health treatment that should be adopted in justice settings.  They have a great website.  If you Google the Gains Center Mental Health, you’ll find them, and they have really great sources available for all kinds of planning issues from screen to subsequent treatment into treatment in the community and continuity of care as well.

The National Institute of Corrections has published a number of documents and guidelines on evidence-based practice that should reduce recidivism, which includes substance abuse and mental health treatment but aren’t restricted to that.  They also have guidelines for implementing evidence-based practices in community corrections.

So, depending on who you are and where you work, different pieces of this might be of most interest to you, but they are all quite valuable.  They summarize the last 30 years of research because we really do know what words.