Leveraging Support from County and State Funding Sources

1. Leveraging Support from County and State Funding Sources Leon Evans Henry Ireys Art Wallenstein Moderator: Ron Wiborg Smart Responses in Tough Times: Achieving Better Outcomes for People with Mental Illnesses Involved in the Criminal Justice System July 15-17, 2009

2. A Community ApproachTo Leveraging Support from County and State Funding Sources*Bexar County Diversion Initiatives*Achieving Better Outcomes for People with Mental Illness involved in the Criminal Justice SystemLeon EvansPresident and Chief Executive OfficerThe Center for Health Care ServicesSan Antonio, Texas www.chcsbc.org

3. Collaboration: It’s an unnatural act between… …two or more unconsenting adults.

4. Bexar County Commissioner’s Court Criminal Justice University of Texas Criminal Courts Consumers And Families Connecting Community GI Forum DSHS Probate Courts Adult Probation Texas A&M SASH Mental Health Partners Sheriff’s Office NAMI Medical Directors Roundtable Area Hospitals CPS Metro Health SAPD Juvenile Probation FIRE APS University Health System Children's Diversion Collaborative CHCS County Judge Patrician Movement DA EMS Magistration Facility Law Enforcement Leveraging Outcomes SAMM Ministries Veterans Administration DAPA Pre Trial Services City of San Antonio Graphic by Seth Godin

5. Civil and Criminal System County City-wide Entry Points Judicial/Courts Magistrate, County, District System Level City-wide County Law Enforcement Detention/Jail CIT Crisis Care Center Jail Diversion Psychiatric and Medical Clearance Specialty Offender Services Mental Health Public and Private Providers Police, Sheriff Probation, Parole Treatment Continuity of Care Emergency Services Community • Data exchange through • Community Collaborative • Crisis Care Center • CIT/DMOT • Jail and Juvenile Detention • Statewide CARE Match Dynamic Crisis Jail Diversion Information Exchange

6. The Crisis Care Center Psychiatric Screening Minor Medical Clearance 24/7 Access for Law Enforcement

7. Impact on WAIT TIME for LAW ENFORCEMENT • Now • The wait time for Medical Clearance/ Screening at the Crisis Care Center is 45 minutes. • Wait time for Medical Clearance/Screening and Psychiatric Evaluation is 60-65 minutes. • Then (prior to Sept 2005) • Wait times for Medical • Clearance/ Screening at • UHS ER - 9 hours, 18 min. • Wait times for Medical • Clearance/ Screening and Psychiatric Evaluation was between 12 and 14 hours.

8. CIT School Itinerary MONDAY Purpose and History Officer Safety and Tactics Introduction to CIT Active Listening Role Play TUESDAY Introduction to Mental Illness Psychosis & Schizophrenia Psychotropic Medications Developmental Disorders Alzheimer's Role Players Psychosis WEDNESDAY Substance Abuse and Dual Diagnosis Child & Adolescent Issues Community Resources Depression & Suicide Role Play Suicide THURSDAY Legal Issues Guidelines Consumer’s Perspective Family’s Perspective Mental Retardation FRIDAY TEST DAY Written and Role Plays

9. Public Safety Triage Facility Restoration Center Grand Opening April 15th, 2008 • Detox Facility • Community Court • Outpatient Substance • Abuse Services

10. Restoration Center • Public Safety Triage • Detox Facility • Outpatient Substance • Abuse Services • Community Court

11. San Antonio Express News “The immediate availability of detoxification services is priceless….” “Providing treatment to those who desperately need help will save taxpayers millions of dollars over the long run.”  Gloria Padilla, Express News 9/13/2008

12. Haven for Hope To increase the community capacity for mental health, substance abuse and detoxification services The Community Wide InitiativeHaven for Hope and CHCS collaboration Goal:

13. Title of new section

14. Behavioral Healthcare Integration with Primary and Specialty Medical Care • The patients served by the Center and by the local Hospital District (UHS) are the same individuals • We combine functions to integrate care for these individuals • Functional integration is the foundation of the best healthcare possible for the people we both serve

15. New Generation Medication Program • Contract with UHS initiated in 2002 • CareLink Patients NGM Cost paid by CHCS with General Revenue • CareLink Patients other Medication costs borne by UHS • Savings to CHCS of between $2.4 & $2.6 million • Savings funded the Crisis Services and Jail Diversion Initiative

16. Show me the DATA !!!

17. Total = 8,758 Total = 991

18. Total = 696 Total = 2,002

19. Total = 953 Total = 492

20. Total = 506 Total = 519

21. Alternatives to Incarceration • Crisis Care Center and Restoration Center • Involuntary Outpatient • Commitment (IOPC) • Outpatient Competency Restoration • Mental Health and Drug Courts • Veterans Initiatives • Adult Parole/Probation • Partnerships

22. Thank you ! www.chcsbc.org Leon Evans, President and Chief Executive Officer, The Center for Health Care Services San Antonio, Texas For additional information contact: Leon Evans, Ph. 210 731-1300 Email levans@chcsbc.org

23. Medicaid Eligibility At Prison Discharge: Lessons Learned from a Model Program in OklahomaHenry T. Ireys, PhDSenior Fellow, Mathematica Policy Research

24. The Problem • States cannot obtain federal financial participation (FFP) for Medicaid services provided to individuals in correctional facilities • Most states • Consider these adults as ineligible for Medicaid • Will not accept Medicaid applications until after discharge

25. The Problem (continued) • Working-age adults with mental illness and little income leaving correctional facilities need access to care: • Medicaid coverage as their only option • May be eligible for Medicaid or federal disability benefits but face significant application barriers, delays in coverage • Are at high risk for re-entry

26. Project Goals • Minimize gap between discharge from correctional facility and Medicaid enrollment • Improve access to treatment for individuals with mental illness by helping those eligible for Medicaid • Decrease recidivism

27. Key Stakeholders in Oklahoma • Department of Mental Health and Substance Abuse Services (ODMHSAS) • Department of Corrections (DOC) • Oklahoma Health Care Authority (OHCA) • Department of Human Services (DHS) • Social Security Administration (SSA), State Office • Division of Disability Determination (DDD) in Department of Rehabilitation Services

28. Disability Determinations • Average time to decision: 4 months (excluding consultative exam) - Anecdotal reports: Adults with MI take longer • For SSI/SSDI applicants - Consent forms - Gathering of information re medical and functional status - Consultative exam if needed

29. Operational Challenges • Dramatic, rapid rise in number of inmates with serious mental illness since late 1990 • Since 2000: 300% increase in inmates receiving psychotropic medications • Problems in initiating, tracking SSA applications • Busy clinical staff, lack of training • Other priorities for discharge • Hard to track applications • Pre-release procedures: in place but not used • Need for new links with local SSA, DHS offices

30. Inmates with Mental Illness Entering DOC Facilities, FY2004 Number Percent Total 1,482 100 Medicaid enrolled 226 15 Not enrolled, probably eligible 942 63 Not enrolled, probably not eligible 314 21 Sources: ICIS, MMIS, OESC, OMS

31. Program Overview:DOC Facilities Intervention Time: Nine Months 120 days from release: Start SSI/SSDI application Monitor application status 6–9 months from release: Identify target population Screen for income, resource eligibility Request consents 60 days from release: Start Medicaid application Day of release: Direct person to local SSA office Fax certificate of release to local DHS office 45 days from release: Submit Medicaid application

32. Post-Discharge Medicaid Enrollment of Study Inmates Adjusted Difference-in-Differences Effect Estimate Unadjusted Percent Enrolled

33. Summary • SAMHSA-funded project helped build momentum for a comprehensive, collaborative mental health reentry program • Analyses suggest: - The intervention significantly increased Medicaid enrollment for inmates with mental illness - Implementing better discharge planning led to better information sharing between DOC and SSA and increased the likelihood for SSI/SSDI approval

34. Questions or Comments? Contact: Henry T. Ireys 202-554-7536 hireys@mathematica-mpr.com The report on this project should be available on the SAMHSA and the MPR websites by late August, 2009

35. Thank you For further information & conference presentations please visit www.consensusproject.org This material was developed by presenters for the July 2009 event: “Smart Responses in Tough Times: Achieving Better Outcomes for People with Mental Illnesses Involved in the Criminal Justice System.” Presentations are not externally reviewed for form or content and as such, the statements within reflect the views of the authors and should not be considered the official position of the Bureau of Justice Assistance, Justice Center, the members of the Council of State Governments, or funding agencies supporting the work.