For San Diego dentist Dr. Daniel Vinograd, focusing on both the big picture and the small one is essential. This commitment to details and to overall health is why many consider him the best holistic dentist San Diego has.

 

Attention To Detail

For a dentist, details are essential. Fillings must not be too shallow or built up too much. Crowns must fit exactly. Dentures and dental implants must align properly or the patient will experience pain, problems eating and never be completely satisfied.

While a mouth may be generally healthy, a single tooth can need careful attention. Just for a moment, then, all efforts and attention must turn toward restoring that single tooth so that complete health and wholeness is possible. And a biocompatible dentist makes sure everything used for every restoration is okay for usage in the mouth.

 

The Bigger Picture

But a holistic dentist like Dr. Vinograd is concerned with much more than just teeth and oral health. A good holistic dentist understands that oral health and the overall health of the patient are intertwined. The bacteria that decays teeth can also cause heart disease. An acid mouth means an acidic body, and there are health implications from that. An infection in the mouth can spread, and ill health elsewhere in the body can lead to a decline in oral health.

It simply isn’t possible to treat the mouth without considering the whole body. That’s how Dr. Vinograd has established a reputation as the dentist San Diego residents trust above all others: he treats every patient as a whole person, not just a mouth.

In fact, that’s what holistic dentistry is: a focus on a healthy body and its connection to a healthy mouth. Doesn’t that seem like a smart approach to dentistry?

 

If you want the best toothpaste for your money and for your family’s health, you’ll have to look beyond the most common brands to smaller, less-well-known brands that are more careful what they put in their products.

You can find Sodium Lauryl Sulfate, Carrageean and Sorbitol in some brands. And most brands include Sodium Saccharin, a questionable artificial sweetener that’s the same thing as those pink packets some people once used in their tea or coffee before better alternatives were available.

Worst of all the chemicals found in big-name toothpastes is Sodium Fluoride and the other forms or Fluoride. While this was once considered essential to healthy teeth, there are better choices now that are non-toxic and don’t have the side effects. If you want the best toothpaste available, you want a fluoride-free toothpaste.

So which brands can be trusted? You need to carefully read the label of any product you’re considering, but you can trust some products from Tom’s of Maine, now made by Colgate, Jason and Kiss My Face.

Other brands you may be able to trust are:

• Dr. Ken’s
• The Natural Dentist
• Tea Tree Therapy
• Vicco
• Desert Essence
• Weleda, and
• Spry.

Reading labels and staying vigilant is as essential when choosing a toothpaste as it is when choosing vegetables, packaged foods and other products for your family. It’s so important to choose the right toothpaste because it goes into your mouth every day, is absorbed through your gums and some of it is inevitably swallowed, especially by children who don’t know any better.

Remember that even trusted makers change their formulas all the time, so a product that’s acceptable one week could be bad for you the next. Remember also that some products from trusted makers are better than others. Not every choice is a fluoride-free toothpaste that deserves to be called the best toothpaste for your precious family.

If you are willing to put in the time, here is a health homemade toothpaste recipe.

 

Doug:

Okay.  Good.

 

Monica:

I want to chime in as well.  This is Monica.  We here, at Great Lakes ATTC, we also provide workshops on trauma-informed care and actually have projects.  Next week, we’ll be at the Michigan Substance Abuse Disorder Conference, and we’re actually having a workshop on strength-based approach towards common treatment and recovery support for women.

So, if you’re interested, I can send you more information, and I’ll make an announcement.  I’ll send some information through e-mail as well where you can get some of our resources.  If you’re interested in any of our workshops in our four state region, I can send you that, and then, I can also provide national contacts for those who are not in our four state region.

 

Doug:

Okay, fine.  That will be on your website, right?

 

Monica:

Yeah.

 

Doug:

Okay, very good.

 

Maureen:

Thanks for adding that, Monica.  Now, to address the second part of your question which was, “Where do evil capitalist fit into this situation?”  I would say it depends on what opportunity they see.  There’s going to be the potential for tremendous expansion in capacity of care for medical care, for substance abuse, and for mental health care created by this insuring of people who haven’t been insured before.

The studies that have been done by the National Association of State Alcohol and Drug Abuse Doctors looked at the impact of substance abuse care, the expansion of coverage for low income people in Massachusetts, Vermont, and Maine.  They saw quite a range, but in Massachusetts, there was a 20% expansion in demand for substance abuse treatment.  The other states were quite a bit larger.  A single state agency director from Massachusetts always reminds me that they already had a pretty high level of insurance coverage in Massachusetts before they did their health care reform.  So, that 20%, if it is applied to a state like Illinois, is going to be much larger.

So, there’s going to be a lot of need for new players, new partners, and so, this is the time for people who are serious about providing good care to think about who you want to be serving in the next three to five years.  In a state like Illinois, there’s also going to be a great expansion in Medicaid managed care.  The state legislature passed the law.  The governor signed it in January.  It is going to happen.  So, there is a big expansion in the insurance world as well.  So, I’m not sure who you were thinking about, but that’s in terms of…

 

Doug:

Well, it seems to be that it’s going to be more focused towards fee for service versus block grant, which is the way the private insurance market works currently.

 

Maureen:

Yes, that is very likely.

 

Doug:

Alright.  I think I understand.  I’ve got it.

 

Maureen:

The only thing I would add to that is not necessarily only fee for service because there’s a lot of discussion about capitation, bundle payment.  There are a lot of initiatives through the Center for Medicaid Medicated Services on payment bundling, accountable care organization, and we’re going to see a lot more of that. I know we’re going to see a lot more of that in Illinois.  I’m not as familiar with the path that the states of Ohio, Indiana, and Michigan are taking, but we’re all facing the same pressures.

 

Doug:

Okay.  Thank you.

 

Maureen:

You’re very welcome.

I’m going to move into some of what will change.  The person who just asked that question previewed a lot of that for you because we’re looking at a lot of changes for funding and billing mechanisms.  Medicaid will be the dominant payer for people whose economic situation is below 133% of the federal poverty level.  Insurance companies who are operating products on the exchanges, the health insurance exchanges, and those premiums being subsidized by the federal government on a sliding scale, those will be the dominant payers for people above 133% of the poverty level to the extent that Medicaid managed care expansion.  That will be the expansion of companies into the below 133% population.

Particularly for the lowest income population, which tends to be very much affected by the criminal justice system, we’re looking at Medicaid as a dominant payer, and their funding rules will govern how substance abuse and mental health is structured, reviewed, and approved on an aggregate level and on an individual case level.  The state Medicaid authority will be the primary funder and overseer of the rules around them.  Providers will have to be and currently are in the process of implementing or upgrading their Medicaid-compatible fee for service billing structures.  Also, thinking about how they’ve been in decapitated care arrangements, which is a way to help manage the risks, the potential upside and downside, states are very much interested on who can participate in those arrangements.

There are specific Medicaid certificate requirements.  They vary by state agency departments and also the capacity to participate in health information exchange, health information technology, and sharing of electronic information and health records.  These are all things that will be required in a new environment.  States have different timelines for implementing them, and providers are in the process of figuring out how they’ll comply with those.

The providers who are used to receiving block grants that provides a majority of their funding will definitely by shifting funding sources.  We actually don’t know what state general revenues will look like in the future for substance abuse treatment to the extent that the federal block grant, how that will be used.  The National Association of State Alcohol and Drug Abuse Doctors has really done some good advocacy on having the federal block grants continue to be available to cover some very important services that Medicaid will likely not cover and also to cover some people who come into treatment uninsured.

I’m not familiar with the same advocacy on the mental health side, but there is a National Association of State Mental Health Directors.  They’re also very active in this area.  So, I need to look into that, but the potential loss of block grants and state revenue dollars, which providers currently have as majority of their funding, is what’s going to initiate this big shift.  We find that some providers are already there.  They’re already working extensive with Medicaid and insurance.  There are providers that have it, but it is not their primary funding.  So, there’s a big shift involved and some who are really starting at the beginning.

So, what we’ve been suggesting to people in the criminal justice system is to start talking to the providers now.  There’s no reason to wait until 2014.  They have a long list of things they need to do to be ready to expand services to meet the demands starting in 2014, and it’s very helpful for them.  They think of you as their customers.  So, it’s very helpful for them to hear from you that this is important because if they’re having resistance from their board or from staff who don’t want to do it, it helps them overcome some of that resistance and just get focused on doing what they need to do.

The second change I’m going to mention is reimbursement based on medical necessity. Medicaid billing requires authorization based on medical necessity, and each state Medicaid authority and state laws put into plays processes for that determination and the guidance for those determinations.  A lot of those determinations are made by managed care, whether it’s the Medicaid or the insurance side, and substance abuse and mental health providers will need to understand these provisions and do advocacy because around how they’re categorized.

The criminal justice system will also need to be thinking about this.  Just to give a couple of examples of what we’re dealing with here.  When you think about someone who’s been in jail or prison, incarceration generally has the effect of suppressing use, and while substance dependence is chronic and this true whether someone has a primary mental health condition along with their substance abuse or not, their symptoms may disappear temporarily, meaning their use, and are likely to reappear after their release.  So, there’s disconnect with how medical necessity is traditionally determined and what this means in a justice setting.

So, clinical treatment is still necessary to prevent return to use and build recovery, but we’re going to have to figure out how that’s actually worked through in a medically necessary treatment context.  We had some success in Illinois.  The state adopted a law that was the implementation of a mental health and substance abuse charity rule that put the American Society for Addiction for Medicine criteria in place as the criteria for determining medical necessity.  We don’t know yet how that ball is going to play out, but we saw that as a very helpful sign.

We definitely see increased demand for people needing substance abuse and mental health services.  I gave these statistics earlier in terms of utilization expansion in those three states, and there’s a real need to build a community treatment capacity to accommodate this increase in demand.  Joint planning between community substance abuse and mental health service providers and criminal justice systems can help the providers to accurately anticipate and build some certainty around how much capacity should be built.  We’re not just talking about building a building but building the capacity to provide the outpatient groups how many more counselors, the qualifications of these counselors so that it can be drawn from the Medicaid dollars.  There’s a lot of planning that needs to go into this.  So, it’s really not too early to start.

We may see a shift in the supply of services.  Again, the supply of services will be dictated by what will be covered in Medicaid and by the federal essential benefits.  The determination, we’re expecting to see that sometime in the next year.  We may see a situation wherein the depth of care is somewhat reduced.  The forces at work that I’ve described already may organize to push this away from more of an acute care to model to a long term recovery support model which fundamentally is a good thing but may result in less utilization of residential treatment.  Part of the reason that I mention it is because residential treatment is a particularly attractive thing for the criminal justice system to refer patients to if there’s a sense that it’s more structured, it’s safer, that person has more supervision even though it’s not a locked facility.  We want to be able to help the criminal justice system make this transition and also start to advocate, but what are we talking about?  We’re talking about long term recovery support.

Again, this is a very fertile area for providers in the community and the criminal justice system to talk about.  We may see some expansion of services that are less expensive than residential treatments.  Brief interventions, which are for people who are not substance use dependent and expansion of outpatient treatment, day treatment, partial hospitalization, and possibly medication-assisted treatment as well for the community where there are medications indicated that are useful.

There is also a focus on the integration of substance abuse and mental health with primary care, and that integration of care is designed to both improve access and improve coordination and result in fewer acute care episodes.  So, one of the big players in communities when we’re looking at the low income population will be federally-qualified community health centers.  It’s worthwhile to get acquainted with those folks if you don’t work with them now.  They are likely to become important as parts of your networks of care.  This is true for both substance abuse and mental health treatment providers and the criminal justice system.

Some of the things that would be incredibly productive in the integration process if we could plan successfully would be the transfer of prescriptions between corrections health care providers and community providers so basically we’re not starting over once they go to a community system.  That would expedite and provide for far less gaps in care.  The integration of electronic health records would be enormously helpful so that the correctional health care records could follow a person into the community.  Again, less gaps, less starting over.

Now, we’re going to talk about specific opportunities for probation, and the biggest opportunity in probation is reduction in probation violations that are due to untreated substance use and psychiatric disorders.  We know that people who are continuing to use have both violations for new cases as well as many, many technical violations, and that has a big impact on how probation officers have to spend their time.  Many of those people wind up incarcerated as a result of repeated violation.

So, being able address what is, today, untreated substance abuse and psychiatric disorders can have a big impact for probation officers and probation departments.  It’ll be possible to gain these results across all probationers not just in smaller demonstration programs or specialty supervision units or specialty courts.  Then, for the specialty courts, specifically, they’ll certainly have better access to timely treatments.

A lot of specialty courts do their best to leverage existing resources.  They may have small amounts of grant dollars that pay for treatment. They may have the county dollars that they are able to use, but straightforward across the board access for everyone will make it much more manageable and hopefully much more timely manner to get into treatment.  There’s also an opportunity to focus on the high risk, high need probationers in the specialty court if everyone who’s on probation supervision is referred to treatment that specialty courts can be used to prioritize the people who need the more structured supervision, which we talked about earlier, Doug Marlow’s research.  This is a one way to apply it in this new environment starting in 2014.

A lot of the things that are needed to gain these results are similar to what’s needed in the jails, but’s a different twist because probation supervision provides different opportunities.  Timely enrollment in Medicaid and insurance is definitely very important.  A number of people who come into probation have spent time in jail.  So, if they get enrolled there, then that burden doesn’t shift to probation officers, but if probation officers can facilitate that timely enrollment, that’s great.  It could also be done by community substance abuse and mental health providers in partnership with probation departments.

Universal screening early in the criminal justice process will help determine who needs what because we know that the epidemiological information is all of this, substance abuse and mental health issues, are everywhere, but everyone has it in a different combination and in a different history.  So, everyone’s treatment plan is a little different.  So, universal screening could figure out what each person needs to expedite getting to everybody in a different way than we do today.

Certainly matching to appropriate services is very important.  There are people, the low risk, low need people you want to send to drug education programs and to early intervention programs, not necessarily to structured treatment services.  Intensive outpatient residential treatment are certainly for substance abuse side, which has very extensive needs.  The continuum on the mental health side, also will expand to [01:02:19].  I’m not as familiar with all the gradations along the way, but, certainly, it’s a high end community treatment services.  At the lower end, outpatient counseling that does a great deal of what it does in substance abuse treatment and everything in between.

So, there may be new modalities like an expansion of partial hospitalization.  That becomes available, and we’ll have to see how that plays out.  Certainly, the funding will come on board, and the providers need to get in planning the capacity, how much, how many, who, where, when.  Our suggestion is to do that planning in concert with the criminal justice system so that the providers are creating the capacity that the criminal justice system wants to use, and the criminal justice system will know which providers do what.  This whole system can be much more broad and robust and dynamic than is possible for it to be now.

It’s almost very important when you think about this kind of expanded act and expanded referral that we think about what universal reporting and sanctions process should look like.  We don’t want to generate an unmanageable burden for probation officers.  We don’t want to have a sanctions process that’s so aggressive that it actually results in more people violating and going to prison.  That’s the reverse of what we’re trying to make happen here.  So, we need to be really thoughtful about that, and the phrase for that in the criminal justice literature is net widening, when you set up a program and it’s intended consequence is that actually more people go to prison.  That’s widening of the net or more people are intensively involved in criminal justice supervision than you would expect.  So, we definitely want to avoid that.

Moving on to opportunities for parole.  There are, again, similarities and differences.  So, the opportunity in parole is to develop structured re-entry services for parolees who have had treatment inside correctional centers.  There’s many, many years of research that demonstrates that pre- and post-release treatment together have the greatest impact and subsequent reductions in recidivism.

There’s also the opportunity to reduce parole violations even for people who haven’t had treatment in an incarcerated setting to reduce violation due to untreated substance abuse and psychiatric disorders.  Increased access to treatment.  Increased ready-access to treatment as an alternative to re-incarceration when someone is about to be evaluated; is it a big deal for the criminal justice system?  Also, the expansion of routine access to treatment created that in a process of an interview, a parolee mentioned, “I used to have this problem.  I’m concerned about starting again/ I have started again.  I don’t want it to get worse.”

An easy access to the system in the community will make it much more viable for a parole officer to write that instead of waiting for the problem to get worse.  It may also make it easier for a parolee just to walk into treatment on their own, but I think we’re looking at a population that often needs a little encouragement.  So, this is helpful.

Also, there’s also a possibility of gaining these results across all parolees not just as earlier in the smaller demonstration programs or specialty supervision units.  The key is the creation of universal access to substance abuse and mental health services on release.

So, what’s needed for parole officers?  Again, timely enrollment in Medicaid and insurance.  We’re doing a planning process here in Illinois for connecting the criminal justice system and the substance abuse and alcohol treatment providers and Medicaid, which will be the big funder for our population in 2014 in planning how you would do this.  How can you facilitate timely enrollment prior to release from prison, prior to release from jail?  Looking at a number of technical options as well as how this would be staffed, workload expectations, and so forth, but I think we’re going to get there.  I think we’re going to see a good penetration of enrollment in an incarcerated setting.

As with probationers and people in jail, universal screening early in the justice process so you know who needs what.  Matching to appropriate services and expanding capacities and the same issues with avoiding net widening in the sanctions process and the reporting process.  The last thing we want to do is make this treatment expansion and significantly increase the number of people who are imprisoned or jailed as a result.

I’m going to take another pause here, and Monica, if you want to look if there’s any hands up.  The next section is going to be about the changes in the substance abuse and mental health treatment systems that are coming in health care reform and what the criminal justice system needs to know about that.

 

Monica:

Alright.  If we do someone raise your hand.  Okay, Taz?

 

Taz:

Hi.  I just had a question about a brief note about real jails and the correctional facilities and how they’re becoming the default settings for mental health and abuse health needs that are available in those communities. I was wondering if you meant that those are those only places where it’s available, or are there people who aren’t incarcerated who are actually attempting to access those?

 

Maureen:

That’s a really great question, and I’m glad you asked for clarification there.  What I meant was not that people are trying to get into jail to get services although once in a while you do hear an anecdotal story like that.  Really, it’s more than because there isn’t the capacity to provide treatment in the community for mental health and substance abuses, you got people with lots of untreated addictions. Their behavior gets them the attention of the criminal justice system, whether it’s because they’re arrested for possession or they’re arrested for a crime that they used to gain the resources to continue using or sometimes trespassing or disorderly conduct or a number of misdemeanor charges that people with serious mental health issues often brings them to the attention of the criminal justice system.

So, it’s certainly isn’t an intentional situation.  It’s just that the criminal justice system and the emergency room are two no decline systems, and that’s where the current situation is brought up.  Does that make sense?

 

Taz:

Yeah.  It does.  Thank you.

 

Maureen:

Sure, no problem.

 

Monica:
Okay, we have another question from Doug.

 

Doug:

Yeah, hi.  I have two questions actually.  You put out a term there that I haven’t seen before.  Trauma-informed care in one category, if you could explain that.  Then, the next question would be where and how do private agencies fit into the overall scheme treatment providers?

 

Maureen:

When you say private agencies are you thinking about private non-profits or private for profits or a combination?

 

Doug:

Abled capitalist.

 

Maureen:

Okay.  Let me take these questions one at a time, then.  In terms of trauma-informed care, that is a term that’s become more common in the substance abuse and mental health world in the last five to eight years I would say, and there’s some really good work being done on what this means in substance abuse treatment, what this means in mental health treatment, and what this means in the criminal justice setting.

So, the broadest notion of trauma-informed care is that, especially in any of those setting because the resource suggested is nearly universal, you assume that the people in front of you have had some significant issues, whether it’s domestic violence, being beaten up, sexual abuse in childhood.  There’s a long list of the kinds of things that create this response in the nervous system that suggests accelerated fight-or-flight response.

So, if you approach someone with a serious trauma history in a particular way and you get a very unexpected reaction from them, you know it’s active.  You know you need to deal with.  So, trauma-informed care practices, the research I’ve seen on this in criminal justice settings where they’ve done this systematically, they did a lot of this in Maryland in the prisons and the jails, has reduced the officer injuries.  It’s increased safety rates.  It’s had a lot of good effects for officers as well because we’re just a little bit more informed about who’s in front of us and how to handle them.

On the treatment side, how do you get out these issues in a way that’s appropriate for the setting?  So, you don’t want to push somebody into dealing with a level of their trauma history that they’re not ready for.  Yet, at the same time, you want to bring it to their awareness that they can start to integrate that into their thinking about why they’re using because, often, the heavier the use, the more likely use of opiates is a very high sign that there’s something going on because they’re using heavy pain killers.  It kills emotional pain or decreases emotional pain.

 

Doug:

Right.  Okay.

 

Maureen:

Okay.  So, good.  So, there’s a lot of work out on this.  If you Google trauma-informed care, you’ll start to find that there’s some good models for treatment like [01:13:00].  There’s a bunch of stuff out there.

The evidence-based practice has evolved.  There has been a lot of focus lately on trauma-informed care.  We know that there’s a lot of both childhood and current life trauma that’s common in the justice population, and those trauma are associated with very high rates of psychiatric and substance use disorders.  This may be part of the mechanism that we’re seeing in this population that we now have the opportunity to intervene with.  We certainly know that unaddressed trauma impedes treatment and recovery.

We have, just in our own clients, we link them to treatment.  We ask them to stop using and then what happens. All their trauma that they’ve been self-medicating with their heavy drug and alcohol use comes up, and because of the funding situation, we’re not able to send them directly to care for that.  Individual or group treatment psychotherapy is a horrible situation.  So, this is one of the big changes I think we can see once we have the funding in place.

I was speaking with a man who’s a coordinator for the Brooklyn Drug Court, which is a very mature program, one of the earliest developed programs.  They have about 500 people under supervision at any one time, and because New York has expanded their Medicaid coverage to cover single adults, they’re able to access substance abuse and mental health services much more extensively that, for example, we are here in Illinois.  They routinely send people for trauma interventions, and it was a very inspiring conversation for me and underlines the sadness of the current situation.  Again, this is a way that we can expand bills and strengthen the system of care.  Really, 2014 isn’t as far away as it sounds.

When you’re thinking about evidence-based practices, you want to think about aligning with the target population, where they are in their justice involvement meaning you would do something with a probationer than you would do with somebody who’s just getting out of jail without further criminal justice supervision, what their health needs are and certainly what risks they have, public safety risk and criminogenic risk.

Aligning the evidence-based practice with the overall goals of the health system with the program, you’re thinking of reducing costs, what kind of supervision is available on the correction side, what’s the goal in terms of reducing symptoms and improving their clinical status, and establishing a stable, durable recovery.  Then, aligning the evidence-based practice with the system capacity and design of the programs that you’re looking at.  So, evidence-based practices aren’t to fill the bullet.  They’re just practices that we know have proven reliably to demonstrate a consistent effect across setting, and, depending on the kind of research that was done, that is extremely valuable knowledge.

So, when we look at the Affordable Care Act and its potential to reduce costs in the criminal justice system, we’re looking at a board expansion of funding, more opportunities for diversion and intervention at every point in the justice system, the expansion of access that’s needed in the community substance abuse and mental health system that’s needed in order to meet this previously unmet demand from the justice system, bringing to scale programs that are already in place that show great results but don’t have the funding basis to expand and incorporating the proven models, which is the evidence-based practices.

So, what happens when one state gets this?  Washington State, in the beginning part of the last decade, made a major shift of resources from their correction system to funding substance abuse services particularly in the community.  They have some of the best data.  We just all really want to have this kind of data in Illinois, but we don’t have it because we don’t have a way to collect it and a process for it.

In Washing State, they established a public policy institute to do a lot of research at the time of the state policy shift.  So, they were able to document consistently that there was a 33% reduction in arrest after people went to substance abuse treatment, and that was without any criminal justice leverage at it.  They didn’t really do anything different on the criminal justice side to more strongly encourage people in treatment, to require that they participate in treatment, and to have a graduated sanction process, which we know improves participation and attention.

So, that’s just participation and treatment.  So, we think there is a potentially much greater reduction in recidivism possible when you combine the criminal justice leverage with the treatment. In fact, there are many other programs in the country that have demonstrated a more powerful reduction, including projects like the Sheridan Correctional Project that I mentioned earlier.

So, now we’re going to talk a little bit about the different opportunities in the criminal justice system.  I’m going to talk about for sheriffs, jail administrators.  I’m going to talk about probation officers, for probation and parole departments. That’s certainly now everybody along the full continuum, but it is where the large volumes of people tend to reside.  If people have questions about other parts of the criminal justice system, I’d be happy to take those.

So, first, in terms of specific opportunities for sheriffs and jail administrators, there are a lot of people who repeatedly appear in jail due to their substance use and their psychiatric disorders.  They are often called “frequent fliers” or “frequent users”.  They often use a lot of resources at high levels.  They need emergency room resources, especially for people with mental disorders.  They’re using homeless shelters a lot and cycling through those.  So, we’re spending an awful lot of money on them but not really moving them forward while we’re doing it.

So, there’s an opportunity to reduce this frequent flier situation by providing appropriate treatment both in jail but especially in the community and also to reduce health care expenditure related to condition.  So, if there is a way to divert people in jail to treatment in the community that reduces the number of people who require that kind of health care expenditure.  Certainly, if people come in in better shape because they’re getting better treatment in the community, then, the jails aren’t going to be in the constant situation of dealing with a huge flare up with a chronic condition because it is extraordinarily expensive to deal with and much more expensive than it needs to be.

There’s also the potential opportunity to reduce incarceration through increased diversion.  So, that’s one of the mechanisms that sheriffs and jail administrators have.  What I left off this list is actually the opportunity to reduce rebounding through good re-entry services.  That’s the other opportunity.  It’s post-jail.  You’ve got pre-jail, diversion from jail, and then post-jail you’ve got re-entry services to help reduce the next number of people who come back the next time.

We took a little look at a hypothetical moderate-sized county jail to see what the impact of this could be.  This is our economic scenario for illustration purposes only, but you can certainly apply this kind of logic to your own situation.  If a jail has 500 beds and you assume an average length of stay of about two weeks, which includes people who are only there overnight, people who actually served time in the jail as a result of a misdemeanor offense, and everybody in between.  If you take that as the length of stay and apply it to the 500 bed jail, you get about 13,000 detainees who cycle through that jail every year.

Applying national statistics, two-thirds of them report using drugs regularly.  That’s over 8,500, and if a jail has a treatment program, they probably only have the capacity to treat several hundred people a year.  If you apply the 15.4% jail figure for people with psychiatric disorders, you get about 1,800, almost 1,900 people with psychiatric disorders cycling through that disorder in a year.  You may have more repeaters among that group in the psychiatric disorders, but still, that’s a really large number.  Most of them will benefit from treatment in jail and especially from treatment in the community.  So, we said what if you didn’t get to all those people, but what if you just had a 10% reduction in the number of detainees?  Even that would result in significant cost-saving.

We used the figure of $70 per day for jails.  Some jails are more.  Some jails are less expensive, but that’s an average national number.  A 10% reduction in number saves, based on the drug using and psychiatric disorder population, would yield over $1 million in savings every year.  There aren’t many counties that would turn a blind eye in a million dollar savings that could come to them, especially when the most expensive parts of it, the community-based treatment, don’t need to be paid for by the county.  They will be paid for in part by the federal government and in part by the state government through the Medicaid expansion.

So, there’s a big potential payoff here, and we’re definitely encouraging people who plan county budgets and county criminal justice and health services to take a look at this.  Jails are very expensive.  The $70 a day jail cost is just a cost of feeding the person, housing them.  The cost of the staff in the jail, the correctional officers, anybody who’s on a medication, that’s more.  A lot of the psychiatric medications are very expensive.  So, there’s very big cost incentives to get people treated in the community.  We know that people, in general, do better in the community, certainly, if they meet that low risk criteria.  That’s a good decision all-around.

So, what will be needed starting in 2014 to gain these results?  A number of things are needed, and different people will play different roles.  One thing that’s needed is enrollment in Medicaid or subsidized insurance during incarceration.  The reason that’s important is because we want people to be able to walk out of the jail and to walk into community treatment setting without a big gap.  We know that if there’s a gap between incarceration and treatment in the community, people return to use.  Their psychiatric symptoms accelerate.  Whatever is going on in their lives if they may have lost their housing or they may have lost a job if they had one, all these various destabilizing factors come into play and result in very serious consequences and not in what we’re looking for, which is establishing getting into treatment, establishing stable recovery.

So, while the Medicaid and insurance wouldn’t have impact until people are released because health care reform will not pay for treatment in an incarcerated setting through Medicaid and insurance expansion, but once those services are available in the community, we want that enrollment to take place before people will be in the incarcerated setting.  We also want to see universal screening in jail for substance abuse conditions, psychiatric disorders, and chronic medical conditions because these are folks who need to get into services.  There are a couple of good methods to do this.  We just got some funding to pilot in the courts and here in the jails here in Chicago, using an adaptation of the expert intervention, the screening brief intervention and referral to treatment modified for the criminal justice population and modified for the setting as a way to identify people, motivate them to participate in whatever treatment they need, and ideally, though we can’t do it today, enroll people right there all in one intervention.  So, we’re hopeful that something like that can become common practice around the country.

Another important thing that should be done as part of this expert intervention is matching people to their appropriate services.  So, even if they’re just leaving the jail with no community supervision as a follow-up, you can tell them, “This is where you need to go, and these are good places that are available to you that will take your insurance.  You can go.”  This is after 2014, of course, but those are the treatment that needs to happen in order to get there.  If the criminal justice system chooses to add some restructured re-entry support to that it will only make it more effective.  Sorry, I didn’t have that slide up, but it will be on the webinar on the website.

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.