Evolution of Correctional Institutes into Behavioral Health - PDF document

10/27/2016 ADDRESSING LOUISIANA’S BEHAVIORAL HEALTH CRISIS THROUGH THE CRIMINAL JUSTICE SYSTEM Louisiana Judicial College Rural Courts Seminar October 27, 2016 Raman Singh, M.D. Medical/ Mental Health Director Louisiana Department of Public Safety and Corrections Evolution of Correctional Institutes into Behavioral Health Hospitals • Deinstitutionalization • Closure of large state behavioral health institutions with the promise of putting those fiscal savings into outpatient behavioral health services for those with SMI who lost housing/treatment • Cost of inpatient behavioral health • Overcrowding and deterioration of hospitals • New meds that significantly improved the symptoms of about half of patients • Failure to understand that the most ill were unable to make informed decisions about their own medication needs • Trans-Institutionalization • Deinstitutionalization of state behavioral health system  mentally ill increasingly incarcerated during the past 3 decades • Early 1970s: It was becoming evident that the emptying of the state behavioral hospitals had resulted in a marked increase in the number of mentally ill in jails and prisons • 1973: “A good deal of mental illness is now being interpreted as criminality…” – San Joaquin County sheriff @ CA State Senate meeting 1

10/27/2016 Correctional Institutions: De Facto Behavioral Health Hospitals Cook County Jail: America’s Largest Behavioral Health Institution Criminal Justice & Behavioral Health • We have now returned to the conditions of the 1840s by putting large numbers of mentally ill persons back into jails and prisons • Physical Health V. Behavioral Health • Impression that mental illness is a character flaw, especially substance use disorder • Medical Perception: Hospice patient creates a specific image in your mind • Behavioral Health Perception: A schizophrenic patient creates what image? • Behavioral health experts lack objective diagnostic tools to aid in the diagnosis of a mental illness – Medical experts have these: • Scans – CT & MRI • Blood & urine tests • X-Rays • Biopsies • Ultrasounds • Anyone can be diagnosed as having a mental illness… or overlooked. • Mentally ill do not get a response from behavioral health experts in the way that physically ill get a response from medical health experts (nurses, doctors, etc). Behavioral health has become a law enforcement issue. 2

10/27/2016 Physical Health V. Behavioral Health • Dominance of the “Physical Medicine” Model • 20% or 90% Block in the Artery Model • ER Model • Urgent Care Model • While the medical world has objective criterion to diagnose and then stage a disease, the behavioral health world does not. • Steve Jobs • Patrick Swayze • Robin Williams • Must create a behavioral health model to clearly define the stages of the disease processes in mental disorders, but… • The absence of objective criterion makes creating a behavioral health model with gradations of mental illness a very difficult task • The way that we think and talk about psychiatric illness has implications for all of us – not only behavioral health professionals and their patients, but anyone with affected friends and family members and policymakers. Relationship between Criminal Justice & Behavioral Health • The relationship between the criminal justice system and behavioral health is not a new one – This crisis has been brewing for decades and has become a law enforcement issue. • People with a SMI are cycling in and out of the criminal justice system and are incarcerated at a rate of 3 – 4x that of the general public • Higher rates of recidivism in SMI offenders • Of the mentally ill in society, >40% have been arrested • The majority of these are brought in for minor offenses • 7.5% of crimes committed were found to be directly related to mental illness (APA) • Taxpayers spend as much as $300-$400 per day supporting offenders with a mental illness 3

10/27/2016 Jails and Prisons as Behavioral Health Care Facilities? • Our Criminal Justice System: • Not purposed to handle people who are mentally ill • Behavioral health treatment is not the core mission of any CJS • The Incarceration of the Mentally Ill: • Generally ends in a negative result in terms of the offender’s behavioral health • Rarely does incarceration of the mentally ill lead to an improvement in their mental status. • DPS&C and local jails are not behavioral health institutions. • DPS&C and P&P are not behavioral health experts • Jails are not conducive to effective treatment • Jails are not equipped to treat offenders with SMIs “ We hav We have a a crim crimina inal just justice e syst system em which has which has a a ver very clea clear purp purpose: e: You You get arr get arrested ed. We We want just nt justic ice. We We try try you, and u, and just justice hope hopefull lly prev prevails. It It was s nev never built built to to hand handle le peop people le that were very, very ill, that were very , very ill, at at lea least with menta t with mental illness illness .” .” – Judge Steve Leifman (Miami-Dade County) Lack of Access to Care  Prisons = Ultimate Safety Net for Mentally Ill • Incarcerating Mentally Ill… • Is an immediate solution. • Often is the only solution present at the time. • But it is not a sustainable solution. • Families/Parents Having Children Arrested Because There Is No Other Option for Treatment • They believe their loved one and/or themselves will be safer in prison than elsewhere • They can get their loved one safety and immediate healthcare by making a call • Incarceration of mentally ill exacerbates symptoms of mental illness • This does not help the patient in the long run and starts the recycling within criminal justice system. 4

10/27/2016 Lack of Access to Care  Prisons = Ultimate Safety Net for Mentally Ill • Recycling of Mentally Ill • Mentally ill tend to get caught up in a viscous cycle by relapse and an inability to comply with the requirements of their incarceration, supervision, and release. • Incarceration rates of mentally ill and recidivism rates for mentally ill who are released from jails/ prisons is disproportionately high • When mentally ill are released back into the community from prisons, not behavioral health facilities = recidivism. • How many justice-involved individuals are released back into the community from prisons? • 95% of all DOC state offenders will be released to the community Lack of Access to Care in Society Released Back Placement in to Society Jails/ Prisons Lack of Treatment, Exacerbation of Symptoms, Declining Behavioral Health 5

10/27/2016 Economics: Private Health Insurance • Private Health Insurance • Health insurance via full-time employment (difficult for mentally ill to sustain)  Lapse in behavioral health care  Increased likelihood to commit crime/substance use  Arrest and incarceration  Inappropriate behavioral health care & eventual release with inappropriate resources • Health plan applications for private insurance are often rejected for adults with pre-existing conditions, such as SMI • Even people with health insurance face unequal or no benefits for behavioral health or substance use care. Economics: Pre-Medicaid Expansion Public Health Insurance • Public Health Insurance Pre: Medicaid Expansion • Medicaid pays health care costs for low-income Americans, but in most states adults with no children cannot get Medicaid unless they are on disability (SSI, Supplemental Security Income). • Medicaid for unemployed/disabled doesn’t have near adequate behavioral health coverage • Process of acquiring Medicaid coverage can be an intricate, lengthy process – Rely on mentally ill to take this initiative and successfully complete it? 6

10/27/2016 Economics: Post-Medicaid Expansion Public Health Insurance • Expanding Medicaid will improve health and save lives by providing health insurance to more than 300,000 Louisianans who could not otherwise afford it • Incarceration is no longer the only solution present to get care and treatment for yourself or your loved ones • Gives LA an enhanced capacity to meet the needs of those previously uninsured people with a mental illness • The best way to reduce mental illness and stigma is through better access to health coverage and timely, effective services. Eliminating access barriers involves fully implementing the new expansion initiative. Economics: Post-Medicaid Expansion Public Health Insurance • Healthy Louisiana • Louisiana’s Medicaid program (formerly Bayou Health) • The new expansion program is open to adults without children as well as many others • Who can get Medicaid now? • All low-income adults will be able to get Medicaid. In other words – Every person that falls between 0% and 138% of the Federal Poverty Level. (In addition to the elderly, blind, or disabled, which has not been changed.) • An adult is considered “low-income” if his/her household income is less than 138% of the federal poverty level. Household Size Weekly Monthly Yearly 1 $316 $1,367 $16,395 2 $426 $1,843 $21,108 3 $536 $2,319 $27,821 4 $645 $2,795 $33,534 5 $755 $3,271 $39,248 6 $865 $3,747 $44,961 7