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.