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BEHAVIORAL HEALTH AND CRIMINAL JUSTICE: CHALLENGES AND

OPPORTUNITIES

Pamela S. Hyde, J.D.SAMHSA Administrator

American Correctional AssociationDenver, CO • July 21, 2012

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INTERSECTION:BEHAVIORAL HEALTH AND CRIMINAL JUSTICE

1/2 of Incarcerated People Have MH Problems

60 Percent Have SUDs

1/3 Have Both

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CORRECTIONAL BEHAVIORAL HEALTH IS COMMUNITY HEALTH

~ ⅔ of People in Prison Meet Criteria for SUDs, Yet < 15 Percent Receive Treatment After Admission

24 Percent of Individuals in State Prisons Have Recent History of MI, Yet Only 34 Percent Receive Treatment After Admission

~ 700,000 Federal and State Prisoners Released to Communities in U.S. Every Year

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BEHAVIORAL HEALTHIMPACT ON PHYSICAL HEALTH

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PREVALENCE OF BH CO-MORBIDITIES(MEDICAID-ONLY BENEFICIARIES W/DISABILITIES)

6Boyd, C., Clark, R., Leff, B., Richards, T., Weiss, C., Wolff, J. (2011, August). Clarifying Multimorbidity for Medicaid Programs to Improve Targeting and Delivering Clinical Services. Presented to SAMHSA, Rockville, MD.

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PREMATURE DEATH AND DISABILITY

People with M/SUDs are nearly 2x as likely as general population to die prematurely, (8.2 years younger) often of preventable or treatable causes (95.4% medical causes)

More deaths from M/SUDs than HIV, traffic accidents , and breast cancer combined

More deaths from suicide than from HIV or homicides

Half the deaths from tobacco use are among persons with M/SUDs

CDC, National Vital Statistics Report

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HEALTH REFORM: THE JUSTICE POPULATION

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2014 – MORE AMERICANS WILL HAVE HEALTH COVERAGE OPPORTUNITIES

Currently, 37.9 million are uninsured <400% FPL*

• 18.0 M – Medicaid expansion eligible • 19.9 M – ACA exchange eligible**• 11.019 M (29%) – Have BH condition(s)

* Source: 2010 NSDUH**Eligible for premium tax credits and not eligible for Medicaid

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ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES

1) Ambulatory patient services

2) Emergency services3) Hospitalization4) Maternity and newborn

care5)5) Mental health and Mental health and

substance use disorder substance use disorder services, including services, including behavioral health behavioral health treatmenttreatment

6) Prescription drugs7) Rehabilitative and

habilitative services and devices

8) Laboratory services9) Preventive and wellness

services and chronic disease management

10) Pediatric services, including oral and vision care

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ACA & JUSTICE INVOLVED POPULATIONS ①

Coverage expansion means individuals in/after jails and prisons (generally w/o health insurance) will now have more opportunity for coverage – exchanges while in; Medicaid expansion upon re-entry

CJ population w/ comparatively high rates of M/SUDs = opportunity to coordinate new health coverage w/other efforts to ↑ successful transitions

Addressing BH needs can ↓ recidivism and ↓ expenditures in CJ system while ↑ public health and safety outcomes

SAMHSA and partners working to develop standards and improve coordination around coverage expansions

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FOCUS: ENROLLMENT ACTIVITIES

Consumer Enrollment Assistance (thru BRSS TACS)• Outreach/public education• Enrollment/re-determination assistance• Plan comparison and selection• Grievance procedures• Eligibility/enrollment communication materials

Enrollment Assistance Best Practices TA – Toolkits

Communication Strategy – Message Testing, Outreach to Stakeholder Groups, Webinars/Training Opportunities

SOAR Changes to Address New Environment

Data Work with ASPE and CMS

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TRAUMA-INFORMED SYSTEMS

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UNDERSTANDING TRAUMA

Event(s)• Exposure to violence, victimization including sexual, physical

abuse, severe neglect, loss, domestic violence, witnessing of violence, disasters

Experience• Intense fear of/ threat to physical or psychological safety and

integrity, helplessness; intense emotional pain and distress

Effects• Stress that overwhelms capacity to cope and manifests in

physical, psychological, and neuro-physiological responses

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PREVALENCE OF TRAUMA IN JUSTICE-INVOLVED POPULATIONS

About ¼ of State Prisoners (27 Percent) and Jail Inmates (24 Percent) w/ MH Problems Reported Past Physical or Sexual Abuse

Youth in Residential Treatment – 70 Percent Have Past Traumatic Experience With 30 Percent Physical and/or Sexual Abuse (OJJDP)

43-80 Percent of Individuals in Psychiatric Hospitals Have Experienced Physical or Sexual Abuse

51-90 Percent Public MH Clients Exposed to Trauma⅔ Adults in SUD Treatment Report Child Abuse/Neglect

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TRAUMA-INFORMED SERVICES IN THE JUSTICE SYSTEM (GAINS Center)

Align Opportunities for Change at Each of 5-Intercept Points:

1. Law Enforcement (Crisis intervention training, avoid re-traumatizing, e.g., de-escalation; strip searches)

2. Initial Detention/Court Hearings (screen for trauma; gather trauma histories; what happened to you?)

3. Jails/Courts (avoid re-traumatizing behaviors; demeaning, disempowering; personnel training on trauma; provide trauma-specific tx )

4. Reentry (ensure trauma-informed peer support, transition planning with trauma interventions)

5. Community Corrections (trauma training for parole and probation officers; link with community trauma services/supports)

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PREVENTION

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YOUTH, JUVENILE JUSTICE AND BEHAVIORAL HEALTH

~2 million Youth Arrested Each Year600,000 Through Juvenile Detention Centers; more

than 93,000 Put in Secure Juvenile Correction FacilitiesMajority Have M/SUDsPrevalence Rates as High as 66 Percent w/ 95 Percent

Experiencing Functional Impairment56 Percent of Boys and 40 Percent of Girls Tested

Positive for Drug Use at Time of Arrest (NIDA)

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EARLY INTERVENTION REDUCES IMPACT

½ of All Lifetime Cases of Mental Illness Begin by Age 14; ¾ by Age 24

On Average, > 6 Years from Onset of Symptoms of M/Suds to Treatment

Effective Multi-Sectoral Interventions & Treatments Exist

Need Treatment and Support Earlier• Screening• Brief interventions• Coordinated referrals

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SAMHSA PREVENTION PRIORITIES

SA Prevention & Emotional Health Development

Suicide

Underage Drinking

Prescription Drug Abuse

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DIVERSION

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JAIL DIVERSION: GETTING RESULTS

Jail Diversion Works – Those Diverted: • Use less alcohol and drugs (last 30 days)

• Any alcohol use: baseline 59 percent vs. 6 months 28 percent • Alcohol to intoxication: baseline 38 percent vs. 6 months 13 percent • Illegal drug use: baseline 58 percent vs. 6 months 17 percent

• Fewer arrests after diversion compared to 12 months before (2.4 v 1.3)• Fewer jail days (52 vs 41)• Improved quality of life with fewer symptoms

¾ Jail Diversion Programs Keep Operating After Federal $Courts = Post-Arrest or Post-Conviction Diversion

• ~ 2400 Drug Cts, 300 MH Cts, 80 Veterans Cts

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GETTING UPSTREAM: PRE-BOOKING DIVERSION

Identified for Diversion by Police; Before Formal Charges

Occurs at Point of Contact w/ Law Enforcement Officers

Relies Heavily on Effective Interactions Between Police and Community MH/SA Services

Characterized by Specialized Training for Police Officers and a 24-hour Crisis Drop-off Center with No-refusal Policy

Crisis Intervention Team (CIT) Model

Collaboration Between Police and Specially-trained MH Providers Who Co-Respond to Calls Involving a Potential MH Health Crisis

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EXAMPLE: PRE-BOOKING DIVERSION PROGRAM

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ACCOLADES: BEXAR COUNTY JAIL DIVERSION PROGRAM IN SAN ANTONIO, TX (2002)

Received SAMHSA TCE Jail Diversion grant and Jail Diversion and Trauma Recovery Program – Priority to Veterans Grant

Replication and/or Consultation Underway in All 50 States and in China, Mexico, Australia, England, and Canada

Received Gold Achievement Award for Community-Based Programs from American Psychiatric Association

Received Program for Service Excellence Award from National Council for Community Behavioral Healthcare

A SAMHSA National Model Program

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BEXAR COUNTY PARTNERS

Consumers and families City, State and County Government County Hospital District University, Local and Private Hospitals Criminal /Civil Courts, including Probation Departments Advocacy – NAMI San Antonio State Hospital Mental Health Partners Adult Protective Services Child Protective Services Military Entities EMS System

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TOOLKITgainscenter.samhsa.gov

Blueprint for Success: The Bexar County Model

How to set up a jail diversion program in your community

• Impacts/Influences CJ/MH System at 46 Intervention Points – “No Wrong Door”

• Trains Practitioners; Educates Policy Makers, Defense Attorneys Community

• Shares Resources – 34 Different Partners

Judges, County Sheriffs Office, Police Department, Health Care Providers, Adult Detention Centers, and Community Stakeholders

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HIGHLIGHTS: BEXAR COUNTY MODEL

Tools/Resources• Crisis Intervention Team Training (CIT); >50 percent of law

enforcement officers currently trained• Deputy Mobile Outreach Team (DMOT) - one MH professional

and two deputy sheriffs • Crisis Care Center (MH services)• Restoration Center (SA services)

Services – Booking to Court Appearance to Probation, Jail/Prison to Release

At Release, Coordinated Care – Genesis House Program• Intensive Case Management, Psychiatric Services and

Rehabilitation for Offenders on Parole/Probation

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HIGHLIGHTS: OUTCOMES AND COSTS

~ 13,200 Individuals Diverted (from Jails/Prisons, ERs and Homeless Shelters) Annually

Cost Savings• Jails: ~ $65 M Annually• Cost Savings Emergency Rooms: ~ $52 M Annually

2003 Texas Jail Standards Commission Advised Bexar County Jail Would Need 1,000 New Beds; Today the Jail Currently Has 900 Empty Beds w/o Expansion

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REENTRY

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REENTRY CHALLENGES

9 Million Individuals Cycle Through Jails Each Year

> 700,000 Prison Offenders Reenter Communities Annually

2/3 State Prisoners Rearrested Within 3 Years Of Release

Reentering Offenders Represent:• ¼ of general population living with HIV/AIDS• Almost 1/3 of those with Hep C• Almost 40 percent of people with TB

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REENTRY: KEY ISSUES

Employment: Incarceration decreases annual employment by > 2 months and yearly earnings by 40 percent

Homelessness: Direct relationship between incarceration and homelessness; challenges in securing housing upon reentry

Education: > 40 percent of prison and jail inmates lack a high school diploma or GED compared w/ 18 percent general population

Social Connection & Treatment: Uncertainty about Parole, Housing Arrangements, Employment, Family Reunification, Health/BH Care as Well as How to Function on Outside Can Elevate Stress and Trigger/Exasperate M/SUD Conditions

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ATTORNEY GENERAL’S REENTRY COUNCIL

Cabinet-Level Council Led by AG Identify Research And EBP To Advance Reentry And Community

Safety Identify Federal Policy Opportunities and Barriers to Improving

OutcomesPromote Federal Policy and Practice Change to Improve Well-

being of Formerly Incarcerated Individuals and Their FamiliesSupport Initiatives in Education, Employment, Housing, Health ,

Faith, BH TreatmentCoordinate Messaging and Communications Re Prisoner ReentryRemoving Barriers to Employment, Access to Benefits Such As

TANF, Food Assistance, Health Care, Etc.

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CHANGING THE CONVERSATION

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A BOLDER VISION?

Can We Imagine:• A generation without one new case of trauma-

related mental or substance use disorder?• A generation without a death by suicide?• A generation without one person being jailed or

living without a home because they have an addiction or mental illness?

• A generation without one youth being bullied or rejected because they are LGBT?

• A generation in which no one in recovery struggles to find a job?

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SAMHSA’S VISION

A Nation that Acts on the Knowledge that:• Behavioral health is essential to health• Prevention works• Treatment is effective• People recover

A nation/community free of substance abuse and mental illness and fully capable of addressing

behavioral health issues that arise from events or physical conditions