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Practical Innovations in Large
Jail Health Care
Brent R. Gibson, MD, MPH, FACPM,
CCHP-P
Chief Health Officer
NCCHC
Disclosure
• I am a full time employee of the National
Commission on Correctional Health Care
Learning Objectives
Participants will gain up-to-date knowledge
of the Affordable Care Act
implementation in large jails.
Participants will be able to list and explain
strategies used by large jails in
managing mentally ill inmates.
Learning Objectives
Participants will understand the role of
not-for-profit national accrediting
bodies in providing linkages among
jails with respect to disseminating
knowledge of best practices and
innovations.
Update on the Affordable Care Act
2014 GAO Report
• Large increase in number of eligible persons
– 27 Medicaid expansion states
– New York and Colorado vs. North Carolina
http://www.gao.gov/products/GAO-14-752R
2014 GAO Report
• However, Medicaid matching (federal) funds
are not available in most cases
– 1.0-2.3% of eligible inmates received allowable
inpatient services (four state survey)
•
•
•
•
California
Pennsylvania
Washington
North Carolina
http://www.gao.gov/products/GAO-14-752R
2014 GAO Report
• And the proportion of Medicaid funds that are
used for inmate care (inpatient) is small
– $1.3-38.5M or 0.1-2.3%
http://www.gao.gov/products/GAO-14-752R
Suspension vs. Termination
• 38 states and the District of Columbia
terminate Medicaid eligibility upon
incarceration
• Federal government encourages suspension in
order to reduce delays in receiving services
upon release
http://www.naco.org/newsroom/pubs/Documents/Health,
Human Services and Justice/Suspensiontermination_2015.pdf
Mapping the Justice System
• National Institute of Corrections June 2014
Report
Mapping the Criminal Justice System to Connect
Justice-Involved Individuals with Treatment and
Health Care under the Affordable Care Act
https://s3.amazonaws.com/static.nicic.gov/Library/028222.pdf
Mapping the Justice System
• National Institute of Corrections June 2014
Report
– Use a systems mapping process to
• Ensure the incarcerated population id given attention
• Costs are appropriately shifted to Medicaid
• All opportunities for enrollment, referral and treatment
are identified.
https://s3.amazonaws.com/static.nicic.gov/Library/028222.pdf
Key ACA takeaways…
• While progress has been made in getting
detainees enrolled in coverage at release,
a card is just a card.
• The far bigger challenge is establishing a
medical home for community-based
care.
Key ACA takeaways…
• Communities vary widely in progress
toward this goal, but where it is effective,
the changes that we have anticipated are
occurring.
Courtesy of Donna Strugar-Fritsch, BSN, MBA, CCHP
Health Management Associates
Key ACA takeaways…
• As health care reform continues to take root in
the expansion states, the health care
continuum is becoming a smaller and tighter
circle with fewer gaps in care.
• Jails will receive detainees from a known
source of care, and be a “stop on the ride”
instead of on the outside. This will expedite
care and reduce gaps, risk, and cost.
Key ACA takeaways…
• Jails will receive detainees from a known
source of care, and be a “stop on the ride”
instead of on the outside.
• This will expedite care and reduce gaps, risk,
and cost.
Courtesy of Donna Strugar-Fritsch, BSN, MBA, CCHP
Health Management Associates
Key ACA takeaways…
• Not much progress has been made yet on
accessing pre-adjudicated detainee benefits
from exchange plans, but work is starting and
there will be much to share in the next 18
months or so.
Courtesy of Donna Strugar-Fritsch, BSN, MBA, CCHP
Health Management Associates
Key ACA takeaways…
Medicaid Expansion and Inm
Three Jails Solve the Puzzle
• CorrectCare, Winter 2016 issue
– Judith Cox and Jaime Shimkus
– http://www.ncchc.org/correctcare
El Paso County, Colorado
El Paso County, Colorado
• ADP - 1428
• Daily intake – 64
• What works:
– First jail in Colorado to be an official Medicaid
enrollment site
– Partnership with the Sheriff’s Office
– Dept. of Human Services staff work within jail to
screen and enroll
El Paso County, Colorado
• Results
– In the first three months there were 440 people
enrolled
– $527,000 in hospital inpatient expenses paid my
Medicaid
Multnomah County, Oregon
Multnomah County, Oregon
• ADP – 1,280
• Daily Intake – 100
• What works
– Screening at admission by jail staff
– By law, Medicaid benefits are suspended (<1yr) or
terminated
– Health staff work right away to reenroll or
reinstate prior to release
Multnomah County, Oregon
• What works (cont.)
– Jail Eligibility Specialists (1.5 FTE)
• Medicaid
• Private insurance
– Inmates identified based on
•
•
•
•
Initial screening
Sign-up
Roster cross-checks
Medical record review
Multnomah County, Oregon
• Results
– 4,000 individual enrolled through the jail since this
has been tracked.
– $1M in cost savings via billing Medicaid for
hospital stays.
Monroe County, New York
Monroe County, New York
• ADP – 1,400
• Daily intake – 52
• What works
– Screening at admission
– By law, Medicaid is suspended
– DHS staff screens census (remotely) to cross check
with Medicaid rolls
– Reinstate upon release
Monroe County, New York
• What works (cont.)
– Identifying un-enrolled at intake
• Jail personnel augmented by state Navigators (DHS)
• Exchange enrollment program (prior to release)
– Hospitalization
• Private insurance billed
• Medicaid billed
• 23:59 patients and those in “obsersvation”
Monroe County, New York
• Results
– “Substantial savings”
– Direct impact on subsequent health care vendor
contract
Overview of 2015 Mental Health
Revisions
Overview of Revisions
2015 Standards for Mental Health Services in Correctional
Facilities
• Summary of important changes
• Standards with no changes or only minor
editorial changes not discussed
New 2015 MH Standards
 New 2015 Standards
-B-05 Response to Sexual Abuse
-G-07 Counseling and Care of the
Pregnant Inmate
Examples Changes from 2008
• A-06 CQI Program
• B-02 Patient Safety
• C-02 Clinical Performance
Enhancement
• C-08 Mental Health
Liaison
• D-02 Medication Services
• D-05 Inpatient Psychiatric
Care
• E-04 Mental Health
Assessment and
Evaluation
• E-05 Nonemergency Mental
Health Care Requests and
Services
• E-9 Continuity and
Coordination of Mental Health
Care During Incarceration
• J-G-04 Suicide Prevention
Program
• J-I-01 Restraint and Seclusion
• J-I-02 Emergency Psychotropic
Medication
Section A – Governance and
Administration
• A-06 Continuous Quality Improvement Program (E)
– The committee must:
• Identify mental health care aspects to be monitored and establishes
thresholds
• Designs quality improvement monitoring activities
• Analyzes results for factors that may have contributed to less than threshold
performance
• Designs and implements improvement strategies to correct the problem
• Remonitors the performance after implementation of improvement
strategies
• Meets quarterly
– Responsible mental health is involved in the CQI program
– When problem is identified from monitoring a process and/or outcome study is
initiated and documented
Section B - Safety
• B-02 Patient Safety (I)
– Changed “error reporting system” to “reporting system”
– Includes adverse and near-miss events, not just errors
• B-05 Response to Sexual Abuse (I)
– New Standard
– Mental health staff must be trained in how to detect,
assess and respond to sexual abuse and harassment
including preservation of physical evidence
– In all cases a MH evaluation is needed and a report is
given to correctional authorities
Section C – Personnel and Training
• C-02 Clinical Performance Enhancement (I)
– Requires clinical performance enhancement of all qualified MH
professionals, Mental Health RNs and LPNs in addition to
clinicians
– “Licensed mental health professional” changed to “direct patient
care clinicians”
• C-08 Mental Health Liaison (I)
– Required on days when no qualified mental health care
professionals available for 24 hours
– MHL instructed in role and responsibilities by responsible
physician or designee
– Must have plan in place to tell custody staff what to do when
health staff not present
– MHL must receive instruction in and maintain confidentiality
Section D – Health Care Services and
Support
• D-02 Medication Services (E)
– Medications must be delivered in a timely fashion
– Policy to identify expected time frames from ordering to
delivery and backup plan if time frames can’t be met
– Notification of impending expiration of an order moved to CI
#7 from D-01
Section D – Health Care Services and
Support
• D-05 Inpatient Psychiatric Care (E)
– Contract not required in CIs
– Written agreement now a recommendation
– Evidence must demonstrate access to hospital and
specialty care and summaries provided
– Compliance changed from important to essential
Section E – Patient Care and
Treatment
• E-04 Mental Health Assessment and Evaluation (E)
– Additional inquiries during structured interview
• Substance use hospitalization
• Detoxification and outpatient treatment
Section E – Patient Care and
Treatment
• E-05 Nonemergency Mental Health Care Requests and
Services (E)
– Moving away from term “sick call”; replaced with
“respond to mental health service requests”
– Changed one word in CI #2 from “received” to “picked
up” - intent is that COs do not handle health service
requests
– The requirement for face-to-face encounter within 24
hours after triage hours is now a compliance indicator
Section E – Patient Care and
Treatment
• E-09 Continuity and Coordination of Care
During Incarceration (E)
– Almost entire standard rewritten
– More patient-centered focus
Section E – Patient Care and
Treatment
• E-9 Continuity and Coordination of Care During
Incarceration (cont.)
– Clinician interventions are consistent with current
standards of practice.
– Deviations from standards of practice clinically
justified, documented, shared w/patient
– Evaluations (e.g. neurological and neuropsychological)
and other specialty consultations are completed in a
time manner with evidence of review
– Treatment plans modified by diagnostic and treatment
results
Section E – Patient Care and
Treatment
• E-9 Continuity and Coordination of Care
During Incarceration (cont.)
– Patients seen by mental health professional upon
return from hospital/ER to implement discharge
orders and follow-up
– Recommendations from specialists reviewed and
acted upon by clinician in timely manner
– If changes in treatment plan indicated,
justification documented and shared with patient
– Chart reviews done to assure appropriate care
ordered, implemented and coordinated by all staff
Section G – Special Needs and
Services
• G-04 Suicide Prevention Program (E)
– “Actively” suicidal changed to “acutely” suicidal
– “Potentially” suicidal changed to “non-acutely”
suicidal
– “Irregular” checks changed to “unpredictable”
– Defined acutely suicidal and non-acutely suicidal
Section G – Special Needs and
Services
• G-07 Counseling and Care of the Pregnant Inmate (E)
– Counseling and assistance are provided
– Prenatal care
• Medical exams
• Laboratory diagnostics
• Advice on activity, safety, alcohol and drug avoidance, nutrition
– Restraints are not used during active labor and delivery
– Documentation on appropriate post-partum care
– List of pregnancies and outcomes
Section I – Medical-Legal Issues
• I-01 Restraint and Seclusion (E)
– Health staff order clinical restraints and seclusions
only for patients exhibiting behavior dangerous to
self or others as a result of medical or mental
illness. Except for monitoring their health status,
the health services staff does not participate in the
restraint of inmates ordered by custody staff.
– Clarified under definition of clinical seclusion that
communicable disease isolation is not considered
seclusion for the purpose of this standard
Section I – Medical-Legal Issues
• I-02 Emergency Psychotropic Medication (E)
– New CI #3 - When medication is forced there is
appropriate follow-up care
– New CI #4 - Follow-up documentation is made by
nursing staff within the first hour of administration and
again within 24 hours of administration
– Discussion expanded significantly to explain elements
required for appropriate f/u care
Reducing the numbers of
mentally ill in jails….
Mental Illness in our
Communities
• Mental illness has become elevated to
a national concern, if not a crisis
• Sheriff’s Departments (including field
operations and detention) are now the
de facto providers of mental health and
mental health case management
services in many of our communities
Manifestations of the
Problem
• Progressively higher numbers of mentally ill
are in the criminal justice system and not in
appropriate treatment settings (Bureau of
Justice Statistics, 2005)
• Longer sentences served by mentally ill as
compared to non-mentally ill, even for
identical crimes (Stanford Law School, Three
Strikes Project, 2015)
• Mentally ill recidivate at higher rates than nonmentally ill (Stewart, LA & Wilton, G., 2014)
The nation’s largest mental hospitals are
jails
Bexar County Sheriff
Cook County Sheriff
Hennepin County Sheriff
Hillsborough County Sheriff
Jefferson County Sheriff
Los Angeles County Sheriff
Ventura County Sheriff
% of population
22%
902
23%
2000
28%
200
27%
4100
710
780
26%312
8,750
2945
1201
24%
4,050
16,700
21% 342
1611
No. of Inmates with Mental Illness
Avg. Daily Population
Cost Comparison
Inmate without mental health needs
$171
$1,475
$70 0
Inmate with mental health
needs
$210
$513
$748
$8,768
Medical Care
Dental Care
Food
Clothing
Faith-based Services
*Estimated cost per year, not accounting for facilities, security, operations or
administration. (LAO – 2008-09)
$2,994
$5,784
$2,244
Total Cost:
$11,232
$4,425
$26,304
Total Cost:
$42,474
Medical Care
Dental Care
Psychiatric Services
Clothing
Faith Based Services
Food
Survey of MCSA Members
• Surveyed seventy-eight (78) Sheriff’s
Offices throughout the United States
– Forty (40) agencies responded
• Surveys included three (3) tracks:
– Sheriff or elected official
– Jails
– Motor Patrol/Operations
• We achieved a 58% response rate
Sheriff Richard
Stanek
Hennepin
County, MN
Sheriff Michael
Chapman
Loudoun
County, VA
Sheriff Sandra
Hutchens
Orange County,
CA
Significant Survey Findings
Respondents identified significant events causing a
need to focus on mental illness. They involved:
–
–
–
–
–
In-custody death
Barricaded subject resulting in line of duty death
Closure of mental health facilities
Exposure to mental health programs (CIT and PERT)
Significant number of self-identified with mental
health
Common Wants and Needs
If sufficient resources were available, Sheriffs
would:
– Invest in dedicated drop-off centers
– Include CIT/PERT as part of the law enforcement
academy training
– Utilize extensive and long term case management
– Collaborate with mental health transition centers
Additional Findings from
Survey
Respondents are:
– Better at identifying individuals with special mental health
needs
– Assessing the level of care needed to treat, not manage, illness
– Utilizing new and successful approaches in criminal justice
systems
• Pre-trial Diversion, Collaborative Courts
Psychologist determined:
– Inmates with special mental health needs spend three (3)
times the number of days in jail per booking
– Have three (3) times the number of bookings than inmates
without special mental health needs
• Ventura County statistic
Sheriffs are…
• Engaging community mental health
programs
• Working with hospitals and mental health
facilities
• Collaborating with the courts
• Identifying elements needed to achieve
success:
– More community services
– Continued training on MH needs
– Reinvesting savings into the successful
programs
Common Themes Recognized
• Sheriff is the champion of the initiative
• Discharge planning begins at booking
• Robust Crisis Intervention Training (CIT)
– Models may vary to fit agency’s needs
– Statistics have shown that CIT Deputies have
lower use of force incidents
– Mental Evaluation Teams are becoming mobile
• Collaboration of community and government
entities
• Families are involved in recovery/resource
process
Individual Success of our
Members
• Bexar County, Texas – Building new video visitation center
• Cook County, Illinois – Hiring a psychologist to run jail
• Hennepin County, Minnesota – Civil commitment from jail in 48
hrs.
• Hillsborough County, Florida – Pre-arrest intercept model
• Jefferson County, Colorado – Case managers co-located near
patrol
• Los Angeles County, California – Active deployment of MET
teams
• Ventura County, California – RISE team in the field & smart
phones
What’s next?
Sheriffs
Courts
Communi
ty
Organizat
ions
Mental Health
Professionals
Prosec
utor
Shelters
• Build a coalition
between our members
and continue to share
ideas and visions
• Work with stakeholders
within our community
• Have MCSA Sheriffs sign
on to the Stepping Up
initiative
Perspective from the NCCHC
• NCCHC serves nearly 500 facilities around the
nation.
• The recognized experts in the field of medical
and mental health care in jails and prisons
• The 2015 Standards for Mental Health Services
in Correctional Facilities are dedicate to mental
health and provide a critical resource to law
enforcement and health care organizations
across the nation
• Accreditation in mental health is available
Standards for Health Services in Jail
The NCCHC Jail standards also include
standards on mental illness:
– Mental health screening
and evaluation
– Nonemergency health care
requests and services
– Segregated inmates
– Continuity and coordination
of care during incarceration
– Chronic disease services
– Patients with special health
needs
– Basic mental health
– Suicide prevention program
– Patients with alcohol and
other drug problems
– Restraint and seclusion
– Emergency psychotropic
medication
2015 NCCHC Statistic
• During the last year alone, we surveyed over 120
facilities and found that agencies across the nation
are addressing mental illness in their facilities
• Regardless of facility type or size, basic on-site
services are essential. These include: identification,
crisis intervention, medication management,
counseling, treatment, and proper documentation
and follow-up
• On initial review, only a small portion (5%) of the
facilities we surveyed required corrective action on
the essential aspects of mental health services
Dedication to Correctional Mental
Health Care
• After reviewing the data from MCSA mental health
surveys, we recognized that the issues raised are
very similar to what we encounter in our
accreditation mission
• Many of the mental health concerns encountered by
MCSA Sheriffs are addressed in the standards
• We are all working together toward the goal of
providing quality mental health services to those we
serve
– It is good law enforcement practice
– It is good health care practice
Observations
• Based on our survey of MCSA members, all
respondents are doing well in identifying,
assessing and intervening with those with
mental illness in their communities and in
their criminal justice systems
Observations
• All of our survey respondents demonstrated
creative and effective approaches to
addressing issues related to those with mental
illness who become involved in some aspect
of the criminal justice system
Observations
• NCCHC’s project with MCSA reveals that the
criminal justice system is encountering people
with mental illness in increasing numbers,
and individuals with mental illness are
continuing to penetrate deeper into the
criminal justice system
Observations
• Reducing arrests and incarceration of those
with mental illness, and assisting those with
mental illness who are incarcerated with
successful re-entry to the community is critical
to appropriately addressing mental illness in
our communities
Observations
• Available resources continue to fall short of
meeting the assessment, intervention and
treatment needs of individuals with mental
illness in our communities, and fall short of
adequately addressing issues of mental illness
for those who become involved in the criminal
justice system
Observations
• Respondents to our survey stated that there
was a significant event that occurred within
their agency that resulted in the need for a
better understanding of mental health needs.
They included:
– In custody death.
– Barricaded subject, suffering from mental illness
that resulted in a death of one deputy and two
more were wounded.
Observations
(CONT)
– Closures of Mental Health Facilities pushed those
with mental illness into the Jails.
– Exposure to known mental health programs like
CIT and PERT.
– Significant number of those arrested selfidentified themselves as being mentally ill.
Observations
• Agencies are engaging with Community
Mental Health Professionals, Hospitals and
other medical/mental health facilities, the
Courts and the Prosecutors the most
Observations
• The most common wants/needs that will help
agencies continue with program success
include:
– More community services
– Continued training on mental health needs
– Funding
– Treatment vs. Incarceration
Observations
• If agencies had sufficient resources to
effectively deal with those with mental health
needs in their Jails and in encounters with law
enforcement in the field, they identified the
following stakeholders as vital for the effort:
– Dedicated Drop-Off Center
– CIT/PERT as part of the training at the Law
Enforcement Academy
Observations
(CONT)
– Extensive and long term case management
– Mental Health Transition Centers
• Most mental health screenings occur during
the booking process.
Observations
• The top three methods of identifying
individuals with mental needs are:
– Identified through those who receive medication
for psychiatric illnesses
– Individuals who are identified during an
assessment
– Individuals who received mental health
treatments
What is NCCHC?
• A 501 (c)(3) whose sole mission is to improve the
health care delivery system in jails, prisons, and
juvenile detention and confinement facilities.
• As an AMA project, we worked in the early 1970s to
develop standards and an auditing tool.
• Today, our board has 37 professional organizations
representing the fields of criminal justice, law, and
health.
Major Court Decisions
• Supreme Court rule that prisoners have a right
to be free of “deliberate indifference to their
serious health care needs ”
» US Supreme Court: 1976 Estelle v. Gamble
• “We see no underlying distinction between
the right to medical care for physical ills and
its psychological counterpart.”
» 4th Circuit Court: 1979 Bowring v. Godwin
• It extended the Estelle decision to mental
health care.
Deliberate Indifference
• Conscious or reckless disregard of the
consequences of one’s acts or omissions
• Professional knows of and disregards an
excessive risk to an inmate’s health or
safety
In the hundreds of cases following Estelle v.
Gamble three basic rights have emerged:
• Right to access to care
• Right to care that is ordered
• Right to a professional medical judgment
Standards that support the right to
Access to Care
• Access to Care
• Hospital and Specialty
Care
• Information on Health
Services
• Receiving Screening
• Oral Care
• Nonemergency Health
Care Requests and
Services
• Emergency Services
• Segregated Inmates
• Patient Escort
• Basic Mental Health
Services
Standards that support the right to
Care that is Ordered
• Medical Autonomy
• Policies and Procedures
• Grievance Mechanism
for Health Complaints
• Medication Services
• Clinic Space, Equipment
and Supplies
• Diagnostic Services
• Continuity of Care
• Chronic Disease
Services
• Patients with Special
Health Needs
• Care of the Pregnant
Inmate
Standards that support the right to
Professional Medical Judgment
•
•
•
•
•
Responsible Health Authority
Credentialing
Clinical Performance Enhancement
Staffing
Health Care Liaison
NCCHC Today
• Accredits many hundreds of correctional
facilities across the nation,
• Certifies thousands of correctional health
professionals
• The largest provider of correctional health
care education in the world
NCCHC Standards for Health Services
• Represents NCCHC’s recommended standards for
health care delivery systems in jails
•
Are based on constitutional requirements and
subsequent court decisions/interpretations
•
Require that treatment is provided based on
nationally accepted clinical guidelines (although
standards are not clinical guidelines)
•
Require that health professionals work within their
scope of practice
•
Are supplemental to discipline-specific directives
NCCHC
Standards
Employee
CCHP
Certified
Nationally
recognized
best practices
Best-case scenario:
Employees &
Facility operating by
the Standards
Facility
NCCHC
Accredited
What is NCCHC Accreditation?
• Validation that the facility meets:
• 100% of applicable essential
• and at least 85% of applicable important Standards for
Health Services
• Can lead to:
•
•
•
•
increased efficiency of health services delivery
greater organizational effectiveness
better overall health protection for patients
reduced risk of adverse legal judgments
• Supports consistency of health services
• Promotes morale and professional excellence
• Allows for participation in a national forum
Accreditation Community
• In 2014 nearly 500 facilities participated in
accreditation
• Accredited facilities are in 47 states and the District
of Columbia
• Over ½ are jails and over ¼ are prisons
• The remainder are juvenile confinement facilities
• On any given day, there were nearly 500,000
persons incarcerated in NCCHC accredited facilities
• Facility sizes range from a juvenile facility with an
average daily population (ADP) of 10 to a mega-jail
with an ADP of nearly 9,300
91
Certification
• NCCHC pioneered corrections-oriented certification and
administers the largest certification program in
correctional health care: the Certified Correctional
Health Professional (CCHP) .
• The CCHP is the most widely held correctional health
care credential in the world, with more than 3,000
individuals currently certified.
Certification
• It shows mastery of national standards and the
knowledge expected of leaders in this specialized field
and raises the bar on quality and clearly delineates
expectations and best practices.
• NCCHC now offers specialty certifications
• Advanced – CCHP-A
• Nursing – CCHP-RN
• Mental Health – CCHP-MH
• Physician – CCHP-P
Education
• For more than 35 years, NCCHC has emphasized the
importance of professional development and staff
training, with a strong focus on best practices.
• The National Conference on Correctional Health Care
has grown from a gathering of 80 pioneers into the
must-attend event of the year for thousands of
professionals.
• There are now four distinct conferences and numerous
other educational services
NCCHC Resources, Inc.
• 501(c)(3) not-for-profit providing:
–Technical assistance
– Correctional health care education
– Experts in the field of correctional health care
Where to Go for Help
•
Spring Conference on Correctional Health Care
April 9-12, 2016
Gaylord Opryland Resort & Convention Center, Nashville, TN
•
Correctional Health Care Leadership Institutes
July 15-16, 2016
The Westin Copley Place, Boston, MA
•
Correctional Mental Health Care Conference
July 17-18, 2106
The Westin Copley Place, Boston, MA
•
National Conference on Correctional Health Care
October 22-26, 2016
Paris Hotel, Las Vegas, NV
Where to Go for Help
• Submit technical assistance requests to NCCHC
Resources, Inc.
[email protected]
• Call or write:
Brent Gibson, MD, MPH, FACPM, CCHP-P
Chief Health Officer
(773) 880-1460
[email protected]