In Case You Missed It: Outcomes-Based Care for Justice-Involved Individuals

Justice-involved individuals often face mental health challenges without receiving the proper support or services. It is reported that 40% of individuals with serious mental illness have been in jail or prison at least once in their lives. Once they are released from detention, they are often reincarcerated at a later time in part because they do not receive the necessary behavioral health care and other life-changing services that could help prevent their re-entry into the justice system.

In a recent Netsmart webinar, Thriving Mind South Florida President and CEO John Newcomer MD, Bernalillo County Director of Department of Behavioral Health Services Margarita Chavez-Sanchez, MS and Netsmart Senior Director of Behavioral Health and Population Health, Julie Hiett, LMSW discuss how organizations can properly assist justice-involved individuals experiencing mental health issues both before and after incarceration through programs and technologies designed with social determinants of health (SDoH) and care coordination in mind.

Here are a few highlights from the webinar. 

Let’s talk numbers (2:20) In county jails and state and federal prisons, mental health is a big factor. Sixteen percent of inmates in jails and prisons have a serious mental illness. 45% of inmates have a co-occurring mental illness along with substance use disorders. And a whopping 75% of inmates with a mental illness also meet the criteria area for substance use or vice versa. Thinking about the juvenile justice population, 70% has one or more mental health disorders. As a result of these numbers, we see three things: higher rates of recidivism, higher costs (in many counties, jails are the largest budget item), and longer stays.

Letting the data drive initiatives (9:20) How can you look at individuals in a county or an area you are serving and identify persons that are highly likely to be justice involved, or those that have already been justice involved? Then take that information and baseline the data to see what's happening with those folks, as well as completing assessments and screening? That leads to creation of a care plan that is patient-centered – with the individual at the center and all providers and other entities coordinating care and sharing information accordingly for the best outcomes.

Connecting consumers to care (17:15) Care coordination comes in a few of different models. One is a healthcare provider-based care coordination process where care coordinators help link a person with services and navigate them within that healthcare provider agency. Another layer of care coordination is at the payer level. That’s what Thriving Mind does, navigating people between different healthcare provider agencies and across law enforcement, criminal justice and, housing resources in the community. It’s up at that level providers can see across the treetops and understand the full spectrum of patient needs.

Thriving Mind’s care coordination strategy (21:50) Their strategy for coordinated care includes a collaboration between payer and provider-level processes. People can enter the system at multiple different points, including through law enforcement, schools, the 211 Hotline or other points of entry. These are high need individuals who are utilizing a lot of services. Through these referrals, Thriving Mind can supervise and manage which services are necessary for the individual. The Miami Dade Police Department really picked up on that model of high need individual for persons who frequently made emergency calls for psychiatric issues. The department uses this collaborative model to place persons into Thriving Mind’s Threat Management Section (discussed at 13:00). This approach to care coordination helps reduce arrest and incarceration rates for individuals with existing mental health issues.

Programs designed to reduce recidivism (35:30 – 43:00) Bernalillo County (N.M) knew it needed to focus on four main areas to help reduce recidivism: crisis services, community supports, supportive housing and prevention, intervention and harm reduction. The county has built and funded programs within each of these buckets and created paths that span related services and care. This includes mobile crisis teams, Resource Re-Entry Center, law enforcement-assisted diversion, intensive case management, peer case management, and more. With this approach, they have established a model focused on continuity of care and mitigated significant gaps in the system. Bernalillo County also leverages community input to help reduce recidivism. This includes hearing from voices of those with lived experience, as well as working with technical advisors in the development in RFPs and project funding.

Resource Re-Entry Center (44:40) Upon incarceration discharge, individuals are required to walk through the Bernalillo Resource Re-Entry Center in order to get connected to services and be released back into the community. Staff introduce case managers along with all of the services available. The center offers sandwiches, coffee, and often most importantly, a phone charging station. The time it takes to charge their phone and call someone to pick them up is a prime opportunity for one of the county’s case managers to sit down and say “Do you have a plan? How can we help?” This provides an ideal venue for dialogue with clients who otherwise may not have felt comfortable having that conversation.

Planning a transition ahead of time (47:00) In addition to the Resource Re-entry Center, every inmate who comes to the jail at booking receives a screening that includes risk of recidivism, mental health needs, substance base needs, as well as a general needs assessment. Anyone who scores high to moderate risk on any of those screenings is assigned a transition planner. When the person arrives at the Resource Re-Entry Center upon their release from incarceration, the Resource Re-Entry Center case manager can open the transition plan that was created earlier and help guide the individual back into the community with the appropriate support services. Bernalillo County is also working within the jail to transition people into more stable supports when they are released into the community to avoid such a hard landing.

Technology as the key enabler (1:08:00) To plan and implement an effective care coordination plan for justice-involved individuals, providers need to utilize technology to gather data about the person’s entire care journey – for a full context. For example, knowing in advance of the conversation if the person was recently hospitalized or had an interaction with law enforcement is critical knowledge for the care coordinator. Finally, connecting systems together. Having the ability to integrate with any type of electronic health record (EHR) or other system, with secure direct messaging, and being able to share that data in as real-time with other providers is important to success when serving justice-involved individuals.

The presentation concluded with a Q&A session.