This blog post was authored by HMA Principal Bren Manaugh, LCSW-S, CPHQ and Senior Consultant Laquisha Grant, MPA.
We have all seen the headlines about jails and prisons becoming the largest de facto mental healthcare providers in the country. Nationally, 14 to 17 percent of inmates have a serious mental illness, 53 to 68 percent have a substance use disorder, and up to 72 percent of jail inmates have both a mental illness and substance use disorder. The overrepresentation of individuals with mental illness and substance use disorder did not happen overnight — and it is not a result of one system or issue.
The federal government has made huge investments to address this issue, and many states and counties have participated in initiatives aimed at decreasing these numbers and improving the lives of individuals incarcerated because of their behavioral health conditions. Nevertheless, hospital systems, law enforcement and local administrators are challenged to balance available resources with the demand of meeting the needs of individuals with mental illness and addiction in jails and the criminal justice system.
We know that police training, jail diversion and problem-solving courts have proven successful in some counties, but not in others. And, we know that while training law enforcement officers in de-escalation is part of the solution, effectively diverting people with mental illness from jail requires more complex strategies. At HMA, we help clients address this systemic problem with an accountable system of care approach that works because it is person-centered. From any point of involvement – diversion, crisis services or jail-based healthcare – the system of care approach meets people where they are and ensures they have access to services and supports they need to avoid detention and attain stability in the community. At the same time, this flexible framework informs individualized approaches for counties, law enforcement, hospitals, mental health providers and others.
With so much attention on criminal justice reform, there is tremendous opportunity for health plans and healthcare providers to partner with law enforcement and judges in ways that nurture innovation and improve care for individuals with mental illness and substance use disorders. Our community collaborative accountable system of care model is not a medical model, a social services model, or co-location or integration – it is a person-centered system of care driven by value. It places the individual as the focal point of the entire system of medical and social services providers and health plans. Criminal justice entities and health systems collaborate within the system to ensure all patient needs are met. Additionally, member-facing health plans link members to services through outreach, screening and linkage to services for unmet health-related social needs. In this accountable system of care, community-based organizations (CBOs) that provide links to housing, food, transportation and employment are critical.
Not only are people with criminal justice involvement likely to have chronic untreated health problems or unmet social needs, they are also likely to have a history of trauma, and through previous encounters, may have developed a mistrust for the health and criminal justice systems. To be effective in changing negative patterns and linking these individuals to the services they need, providers and law enforcement must approach every encounter through a person-centered lens. In transitioning from the old paradigm of volume-based health service delivery to a person-centered system of care, it is critical to think about engagement – the way we connect with community members and involve them in their own care – before interventions. Engagement must be based on empathy, dignity and respect as the foundation of every encounter, interaction and touch point within the system.
Systemic changes will include: a) building out the capacity of healthcare providers, law enforcement and supportive services providers to share and apply common data sets when treating or assisting the target population; b) establishing a community-wide, longitudinal dataset to coordinate care across sectors; c) using population health management tools to track and report indicators of community health and well-being; d) disseminating findings about what works in the care and treatment of high-utilizers; e) creating solutions for lagging indicators; and, f) distributing actionable data to stakeholders to stimulate sustainable investments in proven methodologies.
Each community will have its own priorities for outcomes measurement that should be developed collaboratively to capture the goals and priorities of community partners. The following are examples of effective metrics. Because they are outcomes rather than process measures, they provide a true picture of return on investment:
- Emergency department (ED) utilization
- Behavioral health-related hospitalizations
- Recidivism: re-arrests and re-booking
- Jail days
- Behavioral health crisis encounters
Successful collaborative care models are built from strong community partnerships composed of many organizational components including city, county and state government; law enforcement and criminal/civil courts; hospitals and community-based mental health providers; and other service providers.
Designing, implementing, operating and evaluating systems that promote criminal justice diversion and community reentry strategies requires strong leadership, skillful stakeholder engagement, and technical knowledge of criminal justice, clinical and financing issues. Whatever the current status of your community in planning for or addressing diversion, HMA can work with you to advance your efforts in improving care for justice-involved individuals and reducing incarceration of people struggling with mental illness or addiction. To learn more about HMA’s Community Collaborative framework for jail diversion, click here. Also, this recent webinar highlights our work in this area in more detail.
We’re ready to discuss how we can help support this important work in your community. Email firstname.lastname@example.org to reach our team of diversion and correctional health experts.
 Steadman, H. J., Osher, F., Robbins, P.C., Case, B., & Samuels, S. (2009). Prevalence of Serious Mental Illness Among Jail Inmates. Psychiatric Services, 60: 761–65. Retrieved from http://www.csgjusticecenter.org/wp-content/uploads/2014/12/Prevalence-of-Serious-Mental-Illness-among-Jail-Inmates.pdf
 Belenko, S., Hiller, M., & Hamilton, L. (2013). Treating Substance Use Disorders in the Criminal Justice System. Current Psychiatry Reports, 15(11). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859122/; Karberg, J. C., & James, D. J. (2005). Special Report Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002. Retrieved from https://static.prisonpolicy.org/scans/bjs/sdatji02.pdf
 Cloud, D. (2014). On Life Support: Public Health in the Age of Mass Incarceration.
Vera Institute of Justice. Retrieved from http://archive.vera.org/sites/default/files/resources/downloads/on-life-support-public-health-mass-incarceration-report.pdf