There’s going to be a need for greater public health education with this population. These are folks who generally get their care in emergency rooms and jails if at all. So, they’re not used to utilizing services, and we have to help them understand what their new rights and capacities are. There’s also an interest particularly in substance abuse and mental health services conversation about actually physically integrating care so that substance abuse and mental health services and primary care are provided alongside each other. There may lots of reasons why that’s a challenge, but it is a long term goal in terms of the health care system of the future.
We’re also going to see some new work force issues starting with this change particularly related to what services clinicians are credentialed to provide. Are the clinicians that we’re used to working with in substance abuse and mental health systems today going to be able to get reimbursed for care in the future? Lately, we’ve been hearing some very favorable conversations on the federal level about assuring how this happens. That’s going to need to carry through at the state level. We at TASC have the opinion that the behavioral health work force of the future needs to include layers of staffing on teams that can include a health care provider like a nurse, a licensed counselor, a certified substance abuse counselor, and recovery support specialist in different combinations for different populations.
So, for some states, that is reimbursable today, and for others, it’s not. So, how we think this through together is important. Many states have venues for this. In Illinois, there’s a work force committee that is being led by the Illinois Department of Public Health. My understanding is that hasn’t kicked off yet, but when it does, it’s going to be an important venue to have this conversation.
So, the last section of the webinar is talking about planning options. So, why don’t I just take a last break here, Monica, and see if there’s anything that anybody wants to ask about.
Monica:
You know, we have two questions. We may only have time for one.
Maureen:
I’ll let you be the screener then because I can’t see them.
Monica:
Right. Carlo, your hand is still raised. Hello?
Carlo:
Hello.
Monica:
Do you have a question?
Carlo:
Yes, I have a question. This is going back to the potential impact of the broad re-entry program, that hypothetical jail model. There was a statistic on there about a 10% reduction in jail days would yield over $1 million in savings. I wanted to expand on that. Is that presupposing that jails might want to reduce that time? Is there a vested interest? I ask that because there’s revenues from fines, court costs, fees, the fees mandated pictures such as a substance abuse assessment, victim impact panels, urine drops. So, people are getting charged for each and everything. It’s a big source of revenue. So, I question, really, if there’s a motivation to reduce those number of days or inmates in jail.
Maureen:
I think that’s a very perceptive question, and there are a lot of market influences that would reinforce what you’re saying. I don’t know that, on their own, the sheriffs and jail administrators whose funding comes from that would necessarily go there. There are certainly a lot of folks who run correction institutes who do have a strong commitment to re-entry services. So, I think it’s a mix. I do think that the person in your community who has the biggest interest are the people who manage the county budget, and so, it may be a question of having the conversation with the right folks.
I know that we’re very concerned about if there’s a substantial reduction in incarceration and what you do with those jobs. There’s a number of issues related to that, but we think that there’s a lot of potential for those jobs for community supervision. As part of this alternative, you have to rethink how you’re going to use your work force in a different way. So, certainly, these are sensitive issues and controversial issues, and there’s a lot of both economics and politics at play, but I think the communities who are determined to take advantage of this situation really can.
Ten percent reduction may not be politically [01:32:50]. So, that’s why I didn’t say, “What’s a 25% reduction?” We started with 10% because we thought it was more palatable for the stakeholders.
Carlo:
Okay. Thank you.
Maureen:
Sure.
Monica:
Okay. We can continue, and I have the names of the other people who had their hands raised so we can probably take that at the end of the webinar.
Maureen:
Okay, great. Thank you for being the producer. Alright, good.
The first opportunity and I’ve talked extensively about different aspects of this but just to pull it together, the first opportunity is earlier interventions and sustained services identified by broad based screening, screening everyone who comes into the system, intervening before conditions become deeply entrenched and chronic. In the progression of a chronic disease like diabetes, the earlier you start to intervene, the less the complications are going to be and the less expensive it’s going to be and the better the outcome is going to be.
The same is true for substance abuse and mental health care as well. So, the sooner that we can get the people, the better. The more overall expansion certainly the more it incorporates practices that we know produce reliable results, the better results are going to be.
Opportunity number two is implement protocols for screening, and this is inside the justice system. So, the justice system is determining to what extent you want to employ screening tools to determine eligibility. Eligibility is not the right word here but screening tools to determine need for the kind of services that now the care’s is going to be extended for and also implementing the enrollment.
There should be a process to assess clinical need and public safety risk, and there are an increasing number of tools even very short tools that can give some guidance about that. In a busy jail, when you want to be able to determine who it is a good idea for me send for treatment in the community instead of being here, you want to take that into account. It’s actually important. There are some good tools that can be used both for the screening and the public safety assessment. I guess I would add on National Institute of Corrections on here, which I will do for the next time I give this. An early screening also informs what participation people can make in many treatment alternatives.
The third opportunity is the justice system as a Medicaid enrollment partner. The more streamline the state’s process for enrollment is on eligibility verification is, the easier it’s going to be to enroll people in jail. Most people, when they get arrested, don’t have a lot of identification and documentation on them. Their ongoing use and/or psychiatric disorders may make it difficult for them to go through an extended application process and just a lack of familiarity.
So, state Medicaid directors and insurance directors, because it’s usually the two together who are doing this work, play an important role in establishing procedures. So, in Illinois, we’ve gone to these folks and said, “Look at the number of people we’re talking about here when you take into account all the people in jails, all the people on probation, all the people coming out of prison. This is a significant group of your likely new enrollees, and we need to have smart systems that really help create the kind of health outcomes and cost reduction outcomes you’re looking for because if these folks continue to show up in emergency rooms and get really very expensive care, this isn’t the best situation for anybody.”
There’s been a little bit of work done on this by the Kaiser Family Foundation not specific to incarceration but specific to outreach to newly eligible populations, and they’ve identified what some of the barriers are. Again, I mentioned electronic medical records earlier, but the capacity for people to leave with medical information and leave with valid Medicaid cards, that’s an incredible change in the system.
The fourth opportunity is really balancing clinical intervention and public safety at each point. We’ve talked about how these resources can provide the basis for very broad expansion of diversion and re-entry and community supervision, which requires that people participate in substance abuse and mental health treatment virtually all the way across the criminal justice system. Some of the things that need to be done preferably by the criminal justice system in combination with the community treatment providers is developing legal eligibility criteria for diversion or specialty supervision programs, developing the community supervision requirements, using both to inform the scope and scale of likely population demands for services for providers, using validated risk tools and evidence-based practices, and also avoiding net widening. That’s the caution here is we don’t want to make any of the requirements at the risk that a lot of people wind up getting incarcerated as a result of participating.
There is an interesting thing that people need to be aware of which is a requirement in Medicaid for patient choice of providers. It may seem a little apathetical in the criminal justice system where you’re used to saying, “You’re going to treatment, and it’s at this provider. Here’s intake date. Go,” and what Medicaid requires is a choice among appropriate service providers.
So, one of the things that we did was an access to recovery initiative here in Illinois. We piloted this. So, what we did was we did the enrollment and referrals to treatment. We said to people, “You have to go to this level of care because this is what’s warranted based on your symptomatology, your history, everything, but here are the providers you can choose from who are in your area,” and if they didn’t want any of this, “Here are the ones outside your area.”
We found that there was quite a positive response. People were absolutely overwhelmed that they got to choose their provider. They got their preference to result in better engagement. They were very pleased with how that turned out. So, it may seem like it couldn’t work, but it actually worked really well.
A little bit more on net widening in this slide just to specify the issues we want to avoid, additional technical violations we want to avoid, lower risk offenders placed into more intensive supervision just to get access to care. We want to have a good partnership between providers and criminal justice professionals on this issue.
In terms of planning, I mentioned a few times the process of planning process we’re doing in Illinois. Different states, because of the relationship of their state to the national health care reform law, may be in different spots on this. Illinois is very supportive and going right down this road. Other states are holding back, and that’s every prerogative to make their decision.
In states where it’s possible, this can be done at the state level, but it can also be done at the community level. So, this is to think about your local politics and how things fall out, but if your criminal justice system is already engaged in behavioral health treatment and your community health providers work with the criminal justice system, you have the building blocks. There’s just some additional partners like Medicaid and insurance that needs to be brought into the conversation.
So, in terms of recommendation, we certainly recommend that you take a systems approach, incorporating the essential elements that are required to build recovery, balance the sanctions and rewards process in the criminal justice system to promote engagement, promoting client recovery from substance abuse and mental health conditions, and involving the community where offenders come from and almost all of them will be returning to.
Some of the components of care continuity for justice populations are on this slide: Screening, comprehensive clinical assessment, placement in community substance abuse and mental health services, ongoing care management to support engagement and retention, and to report regularly on compliance to the criminal justice system.
Important elements of the infrastructure that try to get the whole focus to shift from an acute, episodic treatment to sustained, chronic disease management and support long term, durable recovery not just the cessation of use.
Often today, we only have access to enough treatments or get people to managing that acute use, but really there’s a much larger goal here. Building community recovery capacity is also valuable. It will probably not be funded by the Medicaid expansion, but it is definitely something to take up in the context of all this planning, good planning that we’re going to do anyway.