Evolution of Correctional Institutes into Behavioral Health - - PDF document

10/27/2016 1

ADDRESSING LOUISIANA’S BEHAVIORAL HEALTH CRISIS THROUGH THE CRIMINAL JUSTICE SYSTEM

Louisiana Judicial College Rural Courts Seminar October 27, 2016 Raman Singh, M.D. Medical/ Mental Health Director Louisiana Department of Public Safety and Corrections

Evolution of Correctional Institutes into Behavioral Health Hospitals

• Deinstitutionalization
• Closure of large state behavioral health institutions with the promise of putting

those fiscal savings into outpatient behavioral health services for those with SMI who lost housing/treatment

• Cost of inpatient behavioral health
• Overcrowding and deterioration of hospitals
• New meds that significantly improved the symptoms of about half of patients
• Failure to understand that the most ill were unable to make informed

decisions about their own medication needs

• Trans-Institutionalization
• Deinstitutionalization of state behavioral health system 

mentally ill increasingly incarcerated during the past 3 decades

• Early 1970s: It was becoming evident that the emptying of the state behavioral

hospitals had resulted in a marked increase in the number of mentally ill in jails and prisons

• 1973: “A good deal of mental illness is now being interpreted as criminality…” –

San Joaquin County sheriff @ CA State Senate meeting

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Correctional Institutions: De Facto Behavioral Health Hospitals

Cook County Jail: America’s Largest Behavioral Health Institution

Criminal Justice & Behavioral Health

• We have now returned to the conditions of the 1840s by putting large numbers
• f mentally ill persons back into jails and prisons
• Physical Health V. Behavioral Health
• Impression that mental illness is a character flaw, especially substance use

disorder

• Medical Perception: Hospice patient creates a specific image in your mind
• Behavioral Health Perception: A schizophrenic patient creates what image?
• Behavioral health experts lack objective diagnostic tools to aid in the

diagnosis of a mental illness – Medical experts have these:

• Scans – CT & MRI
• Blood & urine tests
• X-Rays
• Biopsies
• Ultrasounds
• Anyone can be diagnosed as having a mental illness… or overlooked.
• Mentally ill do not get a response from behavioral health experts in the way

that physically ill get a response from medical health experts (nurses, doctors, etc). Behavioral health has become a law enforcement issue.

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Physical Health V. Behavioral Health

• Dominance of the “Physical Medicine” Model
• 20% or 90% Block in the Artery Model
• ER Model
• Urgent Care Model
• While the medical world has objective criterion to diagnose and then stage a

disease, the behavioral health world does not.

• Steve Jobs
• Patrick Swayze
• Robin Williams
• Must create a behavioral health model to clearly define the stages of the

disease processes in mental disorders, but…

• The absence of objective criterion makes creating a behavioral health

model with gradations of mental illness a very difficult task

• The way that we think and talk about psychiatric illness has implications for

all of us – not only behavioral health professionals and their patients, but anyone with affected friends and family members and policymakers.

Relationship between Criminal Justice & Behavioral Health

• The relationship between the criminal justice system and behavioral

health is not a new one – This crisis has been brewing for decades and has become a law enforcement issue.

• People with a SMI are cycling in and out of the criminal justice system

and are incarcerated at a rate of 3 – 4x that of the general public

• Higher rates of recidivism in SMI offenders
• Of the mentally ill in society, >40% have been arrested
• The majority of these are brought in for minor offenses
• 7.5% of crimes committed were found to be directly related to mental

illness (APA)

• Taxpayers spend as much as $300-$400 per day supporting offenders

with a mental illness

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Jails and Prisons as Behavioral Health Care Facilities?

• Our Criminal Justice System:
• Not purposed to handle people who are mentally ill
• Behavioral health treatment is not the core mission of any CJS
• The Incarceration of the Mentally Ill:
• Generally ends in a negative result in terms of the offender’s behavioral health
• Rarely does incarceration of the mentally ill lead to an improvement in their

mental status.

• DPS&C and local jails are not behavioral health institutions.
• DPS&C and P&P are not behavioral health experts
• Jails are not conducive to effective treatment
• Jails are not equipped to treat offenders with SMIs

“We hav We have a a crim crimina inal just justice e syst system em which has which has a a ver very clea clear purp purpose: e: You You get arr get arrested

• ed. We

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• prevails. It

It was s nev never built built to to hand handle le peop people le that were very that were very, very ill, , very ill, at at lea least with menta t with mental illness illness.” .” – Judge Steve Leifman (Miami-Dade County)

Lack of Access to Care  Prisons = Ultimate Safety Net for Mentally Ill

• Incarcerating Mentally Ill…
• Is an immediate solution.
• Often is the only solution present at the time.
• But it is not a sustainable solution.
• Families/Parents Having Children Arrested Because There Is No Other

Option for Treatment

• They believe their loved one and/or themselves will be safer in prison

than elsewhere

• They can get their loved one safety and immediate healthcare by

making a call

• Incarceration of mentally ill exacerbates symptoms of mental illness
• This does not help the patient in the long run and starts the recycling

within criminal justice system.

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Lack of Access to Care  Prisons = Ultimate Safety Net for Mentally Ill

• Recycling of Mentally Ill
• Mentally ill tend to get caught up in a viscous cycle by relapse and

an inability to comply with the requirements of their incarceration, supervision, and release.

• Incarceration rates of mentally ill and recidivism rates for mentally ill

who are released from jails/ prisons is disproportionately high

• When mentally ill are released back into the community from

prisons, not behavioral health facilities = recidivism.

• How many justice-involved individuals are released back into the

community from prisons?

• 95% of all DOC state offenders will be released to the community

Lack of Access to Care in Society Placement in Jails/ Prisons Lack of Treatment, Exacerbation of Symptoms, Declining Behavioral Health Released Back to Society

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Economics: Private Health Insurance

• Private Health Insurance
• Health insurance via full-time employment (difficult for mentally ill to

sustain)  Lapse in behavioral health care  Increased likelihood to commit crime/substance use  Arrest and incarceration  Inappropriate behavioral health care & eventual release with inappropriate resources

• Health plan applications for private insurance are often rejected for

adults with pre-existing conditions, such as SMI

• Even people with health insurance face unequal or no benefits for

behavioral health or substance use care.

Economics: Pre-Medicaid Expansion Public Health Insurance

• Public Health Insurance Pre: Medicaid Expansion
• Medicaid pays health care costs for low-income Americans, but in

most states adults with no children cannot get Medicaid unless they are on disability (SSI, Supplemental Security Income).

• Medicaid for unemployed/disabled doesn’t have near adequate

behavioral health coverage

• Process of acquiring Medicaid coverage can be an intricate,

lengthy process – Rely on mentally ill to take this initiative and successfully complete it?

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Economics: Post-Medicaid Expansion Public Health Insurance

• Expanding Medicaid will improve health and save lives by providing

health insurance to more than 300,000 Louisianans who could not

• therwise afford it
• Incarceration is no longer the only solution present to get care and

treatment for yourself or your loved ones

• Gives LA an enhanced capacity to meet the needs of those previously

uninsured people with a mental illness

• The best way to reduce mental illness and stigma is through better

access to health coverage and timely, effective services. Eliminating access barriers involves fully implementing the new expansion initiative.

Economics: Post-Medicaid Expansion Public Health Insurance

• Healthy Louisiana
• Louisiana’s Medicaid program (formerly Bayou Health)
• The new expansion program is open to adults without children as well as many
• thers
• Who can get Medicaid now?
• All low-income adults will be able to get Medicaid. In other words – Every

person that falls between 0% and 138% of the Federal Poverty Level. (In addition to the elderly, blind, or disabled, which has not been changed.)

• An adult is considered “low-income” if his/her household income is less than

138% of the federal poverty level.

Household Size Weekly Monthly Yearly 1 $316 $1,367 $16,395 2 $426 $1,843 $21,108 3 $536 $2,319 $27,821 4 $645 $2,795 $33,534 5 $755 $3,271 $39,248 6 $865 $3,747 $44,961

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Economics: Post-Medicaid Expansion Public Health Insurance

• Wrap Around Services
• Transportation
• Supportive Housing
• No monthly premiums
• Costs individual $0
• All services minimum cost to tax

payers

• 90% of funds are from the

federal government

• 10% of funds are from LA
• All other eligibility criteria

removed

• Not required to have a

disability, cancer, pregnant, etc

• Access to Health Care

▫ Emergency Room ▫ Chronic Care ▫ Primary Care ▫ Dental ▫ Vision ▫ Chiropractic Care ▫ Behavioral Health Services ▫ Substance Use Services ▫ Prescriptions ▫ Labs and X-Rays

• Case Management Services

▫ Coordinates Care for High- Need Group

Economics: Post-Medicaid Expansion Public Health Insurance

• Overarching Result:
• Healthier and Safer Louisiana
• Re-entry Efforts in Local Jails and State Prisons
• Jails and prisons will benefit from Medicaid expansion by reducing

recidivism in the high-need populations – Offenders with medical and behavioral health needs that a jail and prisons are not meant to handle

• Change demographic for healthy population while sick stay out of

prison

• Individualized Customized Process for Jails
• It is clear that each local jail is a different and unique revolving door –

“One size fits all” will not work with Medicaid implementation in local jails

• 2 Steps for DOC Facilities and Local Jails:
• Educate offender regarding Medicaid
• Assist offender in enrolling for Medicaid

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Economics: Post-Medicaid Expansion Public Health Insurance

Enroll Offender in Medicaid Suspend Offender’s Medicaid  Inpatient Stay

•  Discharge

Unsuspend Offender’s Medicaid

Economics: Post-Medicaid Expansion Public Health Insurance

• Overall, 43% of the entire eligible Medicaid Expansion population in

Louisiana has a behavioral health condition (American Mental Health Counselors Association, 2014)

• Severe Mental Illness

7.4%

• Serious Psychological Distress

16.5%

• Substance Use Disorder

18.8% Simply put: The new expansion effort will save lives, improve the quality of life, and improve the health status for the thousands of uninsured Louisianans with mental illness.

• J. Miller,

Senior Director of Policy and Healthcare Reform, National Association of State Mental Health Program Directors

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How Much will Louisiana’s Justice-Involved Population Benefit from Medicaid Expansion?

• LA’s jails and prisons have a

disproportionately high number of high-need

• ffenders – Offenders with

medical and behavioral health needs

• Rising Healthcare Costs
• From 2001 to 2008 health

care cost per offender increased nationally by an

• avg. of 28% (Pew

Charitable Trusts)

• In 2011, states spent $7.7

billion (20% of total budget) to provide health care to U.S. prisoners (Bureau of Justice Statistics)

Need Requiring Additional Resources % of DOC Population Mental Illness 21% Serious Mental Illness 11% Substance Use Disorder 75% HIV/ AIDS 4% Cancer 2% Routine Sick Call 19% Hypertension 33% Hepatitis C 10% Geriatric (50+) 20%

The Medicaid Expansion “Waterfall Effect”

 Multi-Level Cascading Impact on Uninsured People with a Mental Illness 1.

Expanding health insurance coverage…

• to millions of uninsured people with behavioral health conditions – or at risk
• f developing such illnesses.

2.

Increasing health insurance behavioral health and medical benefits…

• through the implementation of an “essential health benefits” package,

which includes “mental health, substance abuse and behavioral services” that Americans will receive through the Medicaid expansion and state health insurance marketplaces.

3.

Providing behavioral health benefits at “parity”…

• which means that behavioral health coverage and benefits must have

similar provisions as medical services.

4.

Growing the country’s behavioral health workforce…

• by encouraging new medical and related personnel to enter the behavioral

health field through new incentive programs.

5.

Reinventing and redesigning state behavioral health systems…

• by enabling states and federal agencies to test and evaluate improved

financial and organizational tools, in order to address the fragmentation of behavioral health services that lead to poor quality and high cost.

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The Medicaid Expansion “Waterfall Effect”

 Multi-Level Cascading Impact on Uninsured People with a Mental Illness 6.

Promoting early screening & intervention...

• f mental illness for children & young adults – and adults – and referring

individuals to the right providers; to effectively reduce the burden of disease on children, their families & communities.

7.

Integrating behavioral health care into primary and health care services…

• as we have an opportunity to address this long-standing problem because

many people with these conditions will now have health insurance coverage.

8.

Integrating behavioral health and substance use services…

• which has been a persistent deterrent to appropriate care, but the

Medicaid expansion provides numerous opportunities to better address this issue.

9.

Implementing evidence-based treatments and support services…

• that contribute to high levels of social functioning and recovery but are
• ften not used in the care of people suffering from behavioral health

conditions.

10.

Ensuring that services and programs are person-centered and…

• support health, recovery and resilience and healing for individuals and

their families who experience behavioral health disorders.

• J. Miller, Senior Director of Policy and Healthcare Reform, National Association of State Mental Health Program Directors

Next Steps

• Goals should be realistic rather than idealistic
• Over the past decades, the issue of placement and treatment for

mentally ill has turned from a problem to a crisis

• No one should go to a jail for treatment or supervised housing
• Most of the incarcerated mentally ill will be released back in the

community

• Need a better safety net in the community
• This crisis will not be solved unless a comprehensive solution is

implemented to provide treatment to those who need it – Must be careful not to repeat the same mistake.

• Moving mentally ill out of behavioral health institutions with no where

to go  mentally ill in prisons

• Move the mentally ill out of prisons with no where to go = ??
• What Can WE Do?

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Judges Potential for behavioral Health Reform in CJS: Influential Position

• Louisiana’s Judges In a Unique Leadership Position
• To convene stakeholders and promote alternatives to traditional

processing

• As a catalysts to improve the response to people with mental illness

who become involved in the criminal justice system

• To spread knowledge amongst peers that trying a defendant with an

SMI doesn’t equate to less/no accountability – Goal is to both acknowledge MI and still hold them accountable for crimes

• Determine how individual cases will proceed and whether alternatives

to incarceration should be considered

Judges Potential for Behavioral Health Reform in CJS: Collaboration

• Judges Leadership Initiative (JLI)
• Supports and enhances the efforts of judges who have already taken

leadership roles on criminal justice/ behavioral heath issues in their communities

• Promotes leadership among more judges to spearhead initiatives that will

improve the response to people with mental illness in the criminal justice system

• Funding by JEHT Foundation, US DOJ, and US DHH
• Behavioral Health References For Judges
• Judges’ Guide to Mental Health Diversion
• Tabbed, reference guide for judges interested in developing,

implementing, or expanding jail diversion programs for people with mental illness

• Judges’ Guide to Mental Health Jargon
• Tabbed, quick reference guide to the mental health terms most often

encountered in criminal justice settings

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Judges Potential for behavioral Health Reform in CJS: Medicaid Expansion

• Medicaid Expansion in Louisiana will be one of the largest catalyst that has

been seen in corrections in terms of having the ability to change lives of justice-involved individuals.

• United with a common goal of changing the way justice-involved

populations access health care in the community.

• Being able to secure public health insurance coverage (Medicaid) or

private health insurance coverage (through the Marketplace or employment) increases access to health care, including behavioral health programs that will improve health outcomes and reduce recidivism rates.

• Having public or private health insurance coverage will augment the

chance of successful reentry, which is why efforts to enhance access to health insurance and community based services should be an integral part of reentry programs.

• The change in Medicaid coverage is more than an opportunity to link

individuals with health care services in the community; it is the responsibility of professionals working with justice-involved populations

Judges Potential for behavioral Health Reform in CJS: Medicaid Expansion

• Community and Law Enforcement
• For justice-involved individuals who are permitted to remain in the

community during the pretrial phase, Medicaid and Marketplace benefits do not change. This will have a significant impact on the individual’s ability to access and obtain health services, including treatment for behavioral health or substance use disorders.

• Even after sentencing, if the justice-involved individual can be safely

managed in the community, their health care benefits do not change.

• While this will not be applicable in all cases, when judges can utilize

this option, continuing access to services would have a positive impact for the individual and the community.

• References:
• A Culture of Coverage for the Justice-Involved Adults in Illinois
• Even though this was written for Illinois, it contains valuable

information that could assist jurisdictions in Louisiana

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Judges Potential for behavioral Health Reform in CJS: Medicaid Expansion

• Arrest and Initial Detention/ Court Hearing
• During the initial detention, pretrial, or booking process, there are
• pportunities to gather additional information without delaying these
• processes. It is critical to obtain information about health insurance

and other benefits somewhere during the initial processing of the justice-involved individual.

• Are you or have you been enrolled in Medicaid
• If not Medicaid, do you have some other type of health insurance?
• If you have Marketplace health insurance, do you have private

insurance or is your coverage employer-based?

• Have you been receiving disability benefits?
• If pre-trail services are not available, it may be important for public

defenders or prosecutors to ask this additional information.

Judges Potential for behavioral Health Reform in CJS: Medicaid Expansion

• Arrest and Initial Detention/ Court Hearing
• For example, if the individual being arraigned has Medicaid benefits and

remains in the community, nothing changes in their ability to access health care services.

• Remaining in the community would also ensure that SSI and

Marketplace insurance coverage will not be suspended or terminated. This might be particularly helpful with diversion or specialty courts.

• If the individual does not have Medicaid, but could be eligible, then a

referral to an enrollment assister could be valuable and provide an

• pportunity to obtain needed services.
• Ideally this would be done prior to the individual leaving the courthouse.

If not, then providing information about possible enrollment mechanisms will be important.

• Local Medicaid staff
• Contracted groups doing enrollment work, perhaps through the

Marketplace

• Volunteers from non-profits such as Enroll America

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Judges Potential for behavioral Health Reform in CJS: Creating a “YES” Place

• Outpatient Behavioral Health Care
• By regularly treating people with a mental illness, we can prevent

unnecessary incarceration, which would reduce the cost to the American public, overcrowding of facilities, and utilization of local resources

• Rapid Stabilization Centers
• Rapid access to intake/stabilization services
• Provides very brief say to relieve acute symptomatology & restore an

individual’s ability to function in a less restrictive setting

• Reduces use of ERs and possibly jails
• Forensic Assertive Community Treatment Programs
• An emerging model for preventing arrest and incarceration of adults with

SMI who have histories of involvement with the criminal justice system

• Need further research to establish the structure, function, and

effectiveness of this developing model of service delivery

Judges Potential for behavioral Health Reform in CJS: Alternatives to Incarceration

• Forensic Diversion Facility
• Provides a sentencing alternative for offenders with behavioral health

issues who have committed a minor crime

• Enter in a higher-security area (more like a prison) and once stabilized

move to a different part of the building for treatment. The offender will continue to step down until he is truly ready to reenter the community.

• Run on a “clubhouse model,” meaning people with mental illness take an

active role in planning activities

• Won’t keep everyone with mental illness out of prisons, but keeping even

half of SMI offenders entering prison with SMI will make a huge dent

• And remember, in LA this is only 16% of DOC population – Low

Hanging Fruit

• Behavioral Health Legislation
• For judges to divert non-violent offenders with SMI away from

incarceration and into appropriate treatment

• Enable courts to tailor a cost-effective sentence that fits the offender and

the crime, protects the public, and provides rehabilitation

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Judges Potential for behavioral Health Reform in CJS: Education and Training

• For Those Within the Court System
• Judges, Commissioners, Clerks Of Court, Court Administrators, Court

Security, Legal Staff, Judges Support Staff, Juvenile Officers

• Mental health jargon and diagnoses
• Recognize signs and symptoms of behavioral health disorders/ SMIs
• For Officers - The “First-Responders”
• Local police officers and state troopers – These are our people who

have direct, and usually the first, contact with people with MI & SMI in the community

• Recognize signs and symptoms of MI & SMI
• Distinguish signs and symptoms of MI & SMI from criminal conduct

and belligerence

• Respond effectively and appropriately – Does this person need to be

in behavioral health system or corrections system?

• Stay aware and up-to-date on current treatment resources and

benefits available to mentally ill

This is a REAL problem. This is TODAY’S problem. Louisiana needs YOUR help.

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Questions or Comments