Serving Newly Eligible Beneficiaries with Special Needs: Individuals Reentering Communities from the Criminal Justice System

Transcription

1 Serving Newly Eligible Beneficiaries with Special Needs: Individuals Reentering Communities from the Criminal Justice System Prepared by John Connolly October 22, 2014 Executive Summary The role of the Medi-Cal program in providing health care to Californians reentering the community from the criminal justice system expanded substantially in All citizens and legal permanent residents with incomes up to 138% FPL are now eligible, 1 and many individuals without minor dependent children in their households will become eligible for Medi-Cal when they are released from incarceration. 2 This population has a quite different health and social profile than the groups who have historically been enrolled in Medi-Cal. Individuals who are incarcerated in California are more likely to have HIV, hepatitis, tuberculosis, and hypertension. Around half have a mental illness, and roughly two thirds are engaged in substance use. 3 In fact, many inmates also do not receive needed treatment while they are in prison or jail. 4 Although managed care plans may be skilled at serving parents and children, the needs of many newly eligible adults call for new outreach, service delivery, and care management models that allow Medi-Cal providers and managed care plans to offer high-quality, cost-efficient care to all beneficiaries. 5 At the same time, several other important policy changes to health and criminal justice programs in recent years make the present an ideal time to build strategies to serve newly eligible groups with special needs. The 2011 realignment of certain criminal justice responsibilities from the state to the counties creates a window of opportunity to improve and coordinate health and social services for this population at the local level. The State has also made, and continues to make, many changes to Medi-Cal behavioral health programs. Realignment in 2011 also transferred financial responsibility for the Drug Medi-Cal (DMC) program from the state to the counties. In addition, when California expanded eligibility for Medi- Cal through the ACA, the state included an expansion of mental heath and substance use disorder services in managed care plans. A DHCS initiative to further organize and improve the DMC program though a federal Medicaid waiver is also ongoing. All of these policy changes have increased local control of a range of important services that the reentry population frequently needs. Individuals leaving county jails can now immediately enroll in Medi-Cal managed care plans. With greater alignment among criminal justice stakeholders, health plans, and county departments responsible for behavioral health and social services, counties and managed care plans could connect beneficiaries with a range of service providers right at the point of discharge. In particular, the substantial need for substance use and mental health services among the reentry population requires effective and coordinated delivery of these benefits. These linkages could enable many individuals to make large strides toward better health and quality of life, while also reducing recidivism. 6, 7 In sum, county departments and health plans should leverage their increased programmatic flexibility and funding streams to reach these aims. We recommend the following local policy actions: 1 Around $16,000 for an individual and $32,000 for a family of four. 2 Cuellar AE, Cheema J As Roughly 700,000 Prisoners Are Released Annually, about Half Will Gain Health Coverage and Care under Federal Laws. Health Affairs 31(5): Davis et al Understanding the Public Health Implications of Prisoner Reentry in California. RAND Corporation 4 Rich JD, Wakeman, SE, Dickman SL Medicine and the Epidemic of Incarceration in the United States. New England Journal of Medicine 364(22): Boutwell AE, Freedman J Coverage Expansion and the Criminal Justice-Involved Population: Implications for Plans Service Connectivity. Health Affairs 33(3): Wallace D, Papachristos A Recidivism and the Availability of Health Care Organizations. Justice Quarterly. First published online July 9. Available at: 7 Morrissey JP et al The Role of Medicaid Enrollment and Outpatient Service Use in Jail Recidivism among Persons with Severe Mental Illness. Psychiatric Services 58(6). Available at:

2 1) Counties should station personnel in jails to assist individuals with enrollment in Medi-Cal at the point of discharge. 2) Sheriffs departments and Medi-Cal managed care plans should build partnerships to share information and ensure continuity of care after release. 3) County officials in sheriffs and probation departments and county departments responsible for behavioral health should also build strong, collaborative relationships to continue treatments and connect individuals with providers in the community. 4) Health stakeholders should collaborate with district attorneys to maximize the appropriate use of split sentencing to allow for more comprehensive rehabilitation and treatment in the community. 5) Counties should align AB 109 funds and Medi-Cal services to create more innovative and comprehensive community rehabilitation and reentry programs that incorporate a range of physical health, behavioral health, educational, employment, and other social services. 6) Counties should dedicate AB 109 funds and staff resources to data collection and evaluation of reentry, rehabilitation, and treatment programs. 2

3 Background: AB 109 and the Community Reentry Population The Public Safety Realignment Act of 2011 (Assembly Bill 109, commonly known as AB 109) transferred responsibility for most low-level offenders from state prisons to county jails. AB 109 was a response to the Brown v. Plata decision in which the U.S. Supreme Court found California in violation of the Eighth Amendment and ordered the state to reduce overcrowding in its state prisons. AB 109 also stipulates that individuals who violate the terms of community supervision will now serve additional time in county jails, not prisons. 8 As a consequence of these changes, the proportion of California adult offenders under the supervision of the counties has increased from 59% in 2010 to 73% in And both the proportion and overall number of incarcerated California adults who are on probation have increased markedly. 9 Importantly, AB 109 similarly transferred supervision of current parolees incarcerated for lower-level offenses from state parole officers to county probation officers. 10 Moving both incarceration and community supervision from the state to the county presents a great deal of opportunity to coordinate, innovate, and improve health services, behavioral health treatment, and other important supports for individuals reintegrating into communities. With the expansion of Medi-Cal coverage and AB 109, the administration and funding for many of the key services for the reentry population now lie in the counties. These shifts have very meaningful consequences for the counties ability to create community supervision and reentry programs that are more rehabilitative and help individuals to avoid future incarceration. AB 109 allows counties a considerable degree of flexibility in allocating the $4.4 billion in realignment funds they are projected to receive through FY , 12 They can dedicate the funds to a range of different programs and activities focused on both law enforcement and rehabilitation. 13 If counties and health plans proactively collaborate to create more comprehensive and rehabilitative programming during individuals sentences and at reentry, counties could have an impact on health outcomes during post-release community supervision and, ultimately, rates of recidivism. In sum, this confluence of policy changes has placed an increasingly large set of responsibilities in the counties, and it presents a great deal of opportunity to improve and create new programs. Many county departments may need to build connections with other county departments and health plans with which they may not have historically had strong relationships. Nevertheless, the possibilities for very positive change should motivate new partnerships aimed at improving lives, and making communities healthier and safer outcomes that all stakeholders and citizens would like to see. The remainder of this paper outlines recommendations for reaching these objectives through expanded Medi-Cal coverage and strong, innovative partnerships in the counties. Coordination between the Sheriffs Department, Medi-Cal Managed Care Plans, and County Departments Responsible for Behavioral Health To ensure that individuals reentering communities receive the services that they need, counties must take the fundamental step of making sure that they get enrolled in Medi-Cal. Encouragingly, a recent survey by Californians for Safety and Justice and the California State Association of Counties (CSAC) revealed that most counties have taken meaningful steps toward this goal. As of the summer of 2014, 31 of the 44 responding counties reported that they were already offering Medi-Cal enrollment assistance in their 8 Quan LT, Abarbanel S, Mukamal D Reallocation of Responsibility: Changes to the Correctional Control System in California Post-Realignment. Realignment in Review (4). Stanford Law School, Stanford Criminal Justice Center Petersilia J Voices from the Field: California Prison Downsizing and Its Impact on Local Criminal Justice Systems. Harvard Law and Policy Review 8: (Forthcoming). 11 Brown B, et al The Budget: The 2011 Realignment of Adult Offenders An Update. Legislative Analyst s Office. Available at: 12 Lin J, Petersilia J Follow the Money: How California s Counties Are Spending their Public Safety Realignment Funds. Realignment in Review (3). Stanford Law School, Stanford Criminal Justice Center. 13 3

4 jails. 14 An additional 10 counties reported that they would begin these activities by the end of 2014, and another 3 said they would do so in Moreover, roughly 70% of the counties that offer enrollment services are using their AB 109 funds to support those initiatives. The relationship between Medi-Cal managed care plans and the county sheriffs departments will be increasingly important to enabling more successful reentries. Now that many of the reentering individuals are likely eligible for Medi-Cal, managed care plans have an interest in not only enrolling them, but also managing their care skillfully. At the same time, sheriffs departments want to see individuals successfully reintegrate into communities and remain out of jail or prison for the rest of their lives. The Ohio Department of Medicaid designed a program in collaboration with the Ohio Department of Rehabilitation and Corrections, and the aim is to identify individuals eligible for Medicaid upon leaving prison, and to engage them in enrollment and plan selection 90 to 120 days before their discharge. 16 Ohio Medicaid managed care additionally plans to engage new enrollees with case managers to create a transition plan that accommodates each beneficiary s needs. Importantly, the program offers incentive payments to case managers who meet defined outcomes benchmarks. 17 Building partnerships that allow for a much smoother handoff from jail health services to Medi-Cal managed care will be central to achieving health and public safety goals for a number of reasons. Receiving health services is very important to many individuals reentering communities because of their increased risk of having many conditions. Also, evidence suggests that receiving health services at the time of community reentry may reduce the risk of recidivism, which the California Department of Corrections and Rehabilitation (CDCR) reports is around 64%. 18, 19, 20 Sheriffs departments could be very helpful partners to health plans as they develop new service strategies to effectively meet the needs of this group. Data Sharing and Treatment Planning Collaborative planning and data sharing will be very important to ensuring effective Medi-Cal enrollment and provider connections when individuals leave jails. 21 Discharge counseling should not only assist individuals with enrollment, but also the process of health plan selection, education about available services, providers, choosing a primary care provider, and how to use coverage and plan services. This kind of counseling would ideally help reentrants make connections with providers for a range of needed services, and even schedule appointments for needed services or initial consultations. In many cases, inmates with health conditions will have existing treatment plans with jail health services when they are discharged. Transferring key information about patients to managed care plans (with patient consent) would allow for continuity of care and the most informed treatment plan in the community. For example, information from jail health services would allow plans to connect individuals to geographically accessible service providers that deliver appropriate, culturally competent treatment. Health plans and county jails could collaboratively develop consent forms to allow individuals to permit jails to share their health information with health plans. Plans would then have the ability to arrange new enrollees care almost immediately. 14 Californians for Safety and Justice Health Coverage Enrollment of California s Local Criminal Justice Populations. Available at: National Association of Medicaid Directors Ohio s Medicaid Managed Care Prison Transition Program. Available at: Wallace D, Papachristos A. Op cit. 19 Morrissey JP et al. Op cit. 20 California Department of Corrections and Rehabilitation Outcome Evaluation Report 13. Available at: 2.pdf 21 Boutwell AE, Freedman J. Op cit. 4

5 Implementing electronic health records in county jails could also be an effective use of AB 109 funds, both to improve the quality of health care while individuals are incarcerated, and to enable the efficient transfer of data from jails to Medi-Cal health plans. 22 This electronic tool could be a valuable investment for counties to improve suboptimal care that might lead to worsened health conditions and poor outcomes. Counties have an interest in preventing this outcome because avoidable health problems will become the inherited responsibility of county departments of health, mental health, and public health, as well as Medi-Cal managed care plans. 23 To enable continuity of treatment, EHRs ought to be compatible with those of providers in Medi-Cal managed care plans networks. Connecting to Care in the Community Both sheriffs departments and managed care plans should additionally strengthen relationships with county departments that administer carved-out behavioral health benefits. These partnerships would enable swift delivery of treatment after the individuals are discharged. For example, the LA County Sheriff s Department, Department of Mental Health, Department of Public Health (Substance Abuse Prevention and Control), and Department of Health Services are considering how to design discharge counseling appointments to both enroll individuals in coverage, as well as provide and connect individuals to community treatment providers. Representatives of the departments have discussed offering an initial dose of Vivitrol for inmates with opiate addiction, and the establishment of transition clinics for individuals reentering communities. 24 The departments are also discussing the possibility of providing medication-assisted treatments for addiction, and detoxification services onsite in jail to increase the odds of rehabilitation and a more successful community reentry. 25 Counties behavioral health administrators could be particularly helpful in assisting clients with finding providers who are most able to serve them in the community, as well as in transferring important client and treatment information (again, with consent) to those providers. Sacramento County officials report that probation officers are collaborating with public health nurses to assess individuals and link them to appropriate community providers when they leave jail. Similarly, the Alameda County health services department has contracted with community clinics for this purpose. 26 These steps are central to adequately responding to the health needs of individuals as they leave county jails, and throughout community supervision periods. Bridges between jail services and community providers will help to achieve continuity of services that can be important to a successful reentry. By receiving the supports necessary to keep conditions stable, individuals are more likely to reenter society in a healthy and productive manner, and states and counties could realize cost savings through reduced recidivism and lower health spending. 27 For these reasons, counseling at release should also connect individuals with other needed social services agencies that may offer assistance with housing, job placement, transportation, and education effectively providing a range of needed services through a comprehensive discharge plan. 28 AB 109 Split Sentencing AB 109 allows judges to split offenders sentences between jail time and community supervision, which would ideally include rehabilitation and treatment programs. 29 Judges and district attorneys can increasingly incorporate needed mental health or substance use treatment, and connection with social service providers as required elements of probation or community supervision. 30 In fact, the FY Rich, JD et al Personal communication with ITUP behavioral health workgroup participants, July 11, Californians for Safety and Justice. Op cit. 27 Patel K et al Integrating Correctional and Community Health Care for Formerly Incarcerated People Who Are Eligible for Medicaid. Health Affairs 33(3): Petersilia J. Op cit. 30 Boutwell AE, Freedman J. Op cit. 5

6 California budget also establishes split sentences as the default for low-level offenders, except in cases when a judge deems it inappropriate. 31 These provisions of AB 109 and the recently enacted budget provide a constructive alternative to a longer sentence, and enable individuals to engage with needed services and treatment in the community, often referred to as aftercare. 32 Prior to AB 109, California spent more per inmate on medical care (approximately $16,000) than any other state, 33 and the unconstitutional quality of services was poor enough to be a major reason for the Plata Supreme Court decision. 34 Requiring treatment as a condition of community supervision or probation would help to increase the quality, effectiveness, and continuity of services. 35 With counties new flexibility with correctional realignment funds, sentencing, and defining the terms of community supervision, individuals could be required to seek behavioral health treatments that can stabilize conditions. Research demonstrates that community supervision combined with needed treatment is more effective in reducing recidivism than probation alone. 36 Controlling or managing chronic conditions can often be a crucial and more cost-effective step to enabling individuals to rehabilitate and reintegrate into communities (e.g., through social networks and employment). While the statewide split sentencing rate is 28%, Contra Costa County has one of the highest rates of split sentencing in California (94%). 37 The strong reputation of the county s probation department among local criminal justice stakeholders explains some of the willingness of the district attorney to seek, and the courts to render split sentences. 38 The sentencing policy has allowed Contra Costa to keep its county jail population flat, despite the implementation of public safety realignment. By contrast, Los Angeles County has one of the lowest split sentencing rates (6%) in the state, and has experienced one of the largest increases in its jail population (24%). Yet, Los Angeles County District Attorney Jackie Lacey recently said that she supports the use of split sentencing, and the county will launch a diversion program for mentally ill offenders (more about this model in the following section) with her support and funding made available by Supervisor Zev Yaroslavsky. 39 Split sentencing also has the potential to produce cost savings for counties. 40 Counties fund health services provided to inmates while they are incarcerated, but many of these individuals would be eligible for Medi-Cal if they were in the community. While the federal government may cover 50% of the cost of care for individuals who were previously eligible for Medi-Cal (e.g., those with a disability), the federal government will cover 100% of the cost of individuals who are newly eligible through the Medi-Cal expansion. This financing rate extends through 2016, descends to 90% by 2020, and remains at that level thereafter. In sum, drawing on federal support for health services and treatment for offenders while they are serving their sentences in the community could produce savings for county governments managing larger inmate populations. 31 California Department of Finance Enacted FY Budget: Public Safety. Available at: 32 Petersilia J. Op cit. 33 California Legislative Analyst s Office Providing Constitutional and Cost-Effective Inmate Medical Care. Available at: 34 The full text of the Plata decision is available at: 35 Liebowitz et al A Way Forward: Diverting People with Mental Illness from Inhumane and Expensive Jails into Community-Based Treatment that Works. ACLU of Southern California and the Bazelon Center for Mental Health Law. Available at: REPORT.pdf 36 Gies SV Juvenile Justice Series: Aftercare Services. Office of Juvenile Justice & Delinquency Prevention. Available at: 37 Austin J, Allen R, Ocker R Contra Costa County: A Model for Managing Local Corrections. JFA Institute. Available at: Palta R LA County s Top Prosecutor Embraces Split Sentencing. KPCC. Available at: 40 Liebowitz et al. Op cit. 6

7 Innovative Community-Based Rehabilitation Models Across the Counties Counties with stronger rehabilitation programs that include robust treatments and community supports will have a greater chance of achieving more successful community reentries and lowering recidivism. County behavioral health services and Medi-Cal managed care plans could be very valuable partners to county sheriffs in program development. One study of the effects of AB 109 reported that local judges often cited a concern that counties do not have effective treatment and support programs that would make a split sentence meaningful. 41 Again, the experience of Contra Costa suggests that strong probation and rehabilitation services would build confidence in this approach among criminal justice stakeholders. To encourage judges to take advantage of the split sentencing options available to them, county sheriffs and departments responsible for behavioral health, including local managed care plans, ought to be proactive in designing rehabilitation programs. Again, much of these programs development may require relationship building between entities that have not previously worked together; nonetheless, reduced recidivism and better health outcomes are in all stakeholders interests. Diversion Programs and Community-Based Treatment People with mental illness are a group that would particularly benefit from expanded community-based treatment. Assertive Community Treatment (ACT) is an approach of providing a range of needed services and treatments in the community with an intensive team of providers. A program with ACT for offenders with mental illness has a great deal of potential to provide mental health treatments that are actually effective, and without inmate isolation and the threat of violence. 42 Further, community treatment programs in New York City, Chicago, Seattle, and Miami have all seen reductions in recidivism among their clients. 43, 44, 45, 46 As mentioned above, community-based treatment can also lower the cost of rehabilitation, and a number of cities and counties demonstrate that effect. The average cost of a year of incarceration for an inmate in Los Angeles County is approximately $38,000, and that amount is for an individual without a behavioral health condition or other special medical needs. 47, 48 By comparison, a year of treatment in a communitybased treatment for an individual with a mental health condition costs around $20,000 in Los Angeles. 49 The real possibility of better outcomes in terms of treatment and recidivism, while reducing spending, presents a strong argument for implementing more diversion programs that offer mental health services outside of jails through community supervision programs Petersilia J. Op cit. 42 Liebowitz et al. Op cit. 43 CASES. Nathaniel ACT ATI Program: ACT or FACT? Available at: 44 Thresholds. Justice Program. Available at: 45 Rowe G, Sylla L Evaluation of the Forensic Assertive Community Treatment Program. Department of Community and Human Services; Mental Health, Chemical Abuse and Dependency Services Division. Available at: 46 Eleventh Judicial Circuit of Florida Eleventh Judicial Circuit Criminal Mental Health Project. Available at: %20January% doc 47 Vera Institute of Justice Los Angeles County Jail Overcrowding Project. Available at: 48 Liebowitz et al. Op cit. 49 Flaming D, Matsunaga M, Burns P Where We Sleep: The Cost of Housing and Homelessness in Los Angeles. Economic Roundtable. 50 California Administrative Office of the Courts Task Force for Criminal Justice Collaboration on Mental Health Issues: Final Report. Available at: 7

8 San Francisco has operated a diversion program for individuals with mental illness since The program has a dedicated behavioral health court, to which judges, prosecutors, police, and jail psychiatric workers can refer defendants. 52 Individuals develop a treatment plan with a case manager, and judges supervise their progress in the community. After at least one year, judges can reassess whether or not to release offenders from the program. 53 The recently announced Los Angeles County diversion program for individuals with mental illness would provide housing, health services, and job search assistance instead of incarceration. 54 The program represents an important turning point for the state s largest county, with a county supervisor, the district attorney, the public defender, the Los Angeles city attorney, and the Superior Court collaborating to enable the project. 55 Split and alternative sentencing programs of this kind, while limited in size (beginning with 50 inmates) and scope (one location in Van Nuys), could demonstrate more effective ways to address public safety and rehabilitation with the available public funds. If the results are positive, Supervisor Yaroslavsky is hopeful that the County can replicate the model in other areas. Day Reporting Centers Day Reporting Centers (DRCs) offer another important model for delivering a range of services to individuals in community supervision programs. DRCs provide a range of services that individuals often need to successfully reintegrate into communities. DRCs are operational bases for county probation officers, often joined by therapists offering mental health and substance use treatment, and employment counselors. The California State Association of Counties (CSAC) highlights innovative programs that counties have created to rehabilitate low-level offenders with financial support from AB 109. The series features San Bernardino County s DRC, which offers GED classes and assistance with applying for CalFresh and obtaining bus passes, in addition to the services mentioned above. 56 San Bernardino also colocates Department of Behavioral Health practitioners within these facilities, with an outpatient mental health clinic at each location. Importantly, these facilities are certified Medi-Cal providers, allowing the counties to access newly available federal funds through the Medi-Cal expansion. 57 San Joaquin County also operates a DRC where reentering individuals go through a risk and needs assessment and can access many of the same services. Professionals from different county departments and community-based organizations are co-located within the San Joaquin facility. Staff from the different organizations work together collaboratively and provide a range of services. 58 According to a recent scan of AB 109 programs in the counties, twenty-five California counties now have DRCs, virtually all of them receiving some AB 109 funding Superior Court of California, County of San Francisco Behavioral Health Court. Available at: 52 Liebowitz et al. Op cit. 53 Superior Court of California, County of San Francisco. Op cit. 54 Gerber M Mental Illness Program Could Transform L.A. County Justice System. LA Times. Available at: 55 Yaroslavsky Z Piloting a Path away from Jail. Zev s Blog. Available at: 56 California State Association of Counties California Counties Practice Smart Justice. Available at: 57 Californians for Safety and Justice Promising Models: Leveraging the Affordable Care Act. Available at: Petersilia J. Op cit. 8

9 Intensive Case Management and Recovery Coaches With a strong focus on case management, Marin County created a Recovery Coach Program in which recovery coaches act as sponsors or mentors to assist individuals with the full range of rehabilitative services that they need. 60 A rehabilitative caseworker, working alongside county probation officers, could be a promising model for counties. Recovery coaches could serve a similar purpose to a care coordinator in a managed care setting, yet the recovery coach could be a more effective primary caseworker because the reach of their services would be much broader than Medi-Cal, often including housing and employment issues. In any case, these individuals ought to collaborate closely with case managers in both managed care plans and carved out behavioral health services to coordinate and maximize the impact of all services for the beneficiary. Peer Support and Mutual Aid San Bernardino County BRIDGES Program The San Bernardino County Bridging Reentry Integration by Driving Goal-Oriented Effective Strategies (BRIDGES) Program uses Second Chance Act Adult Offender Reentry Planning Program Grant from the U.S. Department of Justice. BRIDGES is a multiagency project of the San Bernardino County Reentry Collaborative to develop a set of comprehensive strategies to enhance public safety and reduce recidivism though rehabilitation and reentry services. Components of BRIDGES include intensive case management by Reentry Peer Advocates, which starts three months prior to release. Case managers also assist with pre-enrollment in CalFRESH and Medi-Cal, and link to housing resources. The assistance also continues for 6 months after discharge from jail. Once individuals leave jail and begin Post-Release Community Supervision, the county offers cognitive behavioral classes and mental health and substance use treatment at county Day Reporting Centers (discussed above). Peer support and mutual aid (self-help) offer additional options for helping individuals to reintegrate into communities from the criminal justice system. Studies have indicated a range of positive effects of peer support services for individuals with severe mental illnesses, and the improved outcomes range from clients views about themselves and their level of belonging in the community, to their utilization and clinical outcomes. 61 Mutual aid has also been demonstrated to have positive effects for individuals struggling with substance use conditions, and they may be helpful for individuals with a range of special needs. 62 When considering how to organize these services for newly eligible Medi-Cal beneficiaries who are transitioning from the criminal justice system, the The program also engages and provides training to faith-based and community organizations to familiarize them with evidence-based practices for serving individuals reentering the community. Since these organizations offer major source of support for many reentrants, this aspect of the program holds promise for more effectively engaging and supporting program participants. Finally, the program has a robust evaluation component with Cal State San Bernardino conducting the analysis. Source: San Bernardino County Reentry Collaborative. Available at: BCRC%20Strategic%20Plan.pdf county departments of mental health can deliver peer support services through Short-Doyle Medi-Cal for individuals who qualify for specialty mental health services. 63 Medi-Cal managed care plans also ought to consider increasing the availability of peer support and mutual aid services for this group. Under the 60 California State Association of Counties Smart Justice in Marin County. Available at: 61 Davidson L, et al Peer Support among Persons with Severe Mental Illnesses: A Review of Evidence and Experience. World Psychiatry 11(2): Magura S Effectiveness of Dual Focus Mutual Aid for Co-Occurring Substance Use and Mental Health Disorders: A Review and Synthesis of the Double Trouble in recovery Evaluation. Substance Use & Misuse 43(12-13): Linkins KW et al Peer Models and Usage in California Behavioral Health and Primary Care Settings. Integrated Behavioral Health Project. Available at: 9

10 health plans capitated payment structure, they have the flexibility to offer the service, and it may measurably improve both health and social outcomes for beneficiaries at a fairly modest cost. Again, now that the Medi-Cal program has expanded to cover adults without minor children at home, many mental health and substance use disorder services now have a source of payment. With AB 109 funds, counties can wrap around Medi-Cal services to offer a more comprehensive set of rehabilitative services and case management to assist individuals in securing housing, CalFresh, transportation assistance, employment, and further training or education. Vocational Skills Development Tehama County Sheriff Dave Hencratt created one of the more unique programs for offenders under community supervision. To reduce recidivism and offer job skills training, Tehama County created an auto repair shop staffed by individuals under the Sheriff s supervision. 64 Participants in the program live outside of the jail and wear ankle monitors with GPS tracking capability; this arrangement creates more space in the county jails for higher-risk offenders. 65 While the program is relatively small, with around 10 inmates, the Sheriff s Department reports that the program has saved around $98,000 in vehicle maintenance costs during its first year. 66 Given the Tehama auto shop s success, other counties around the state may be able to replicate and implement this work release model on a larger scale and with multiple vocations. Rethinking County Jails and Detention Centers Counties are also rethinking the experience of inmates while they are incarcerated in county facilities to increase the success of the community reentry process. Santa Barbara County plans to build a reentry facility, called the Sheriff s Transition and Recovery (STAR) Complex, adjacent to the planned North Branch Jail. In January 2014, the Board of State and Community Corrections awarded the County nearly $39 million for the project. The facility will be designed to provide programming education, life skills, and substance use disorder treatment for inmates nearing the end of incarceration with the ability to prepare them for discharge and community reentry. 67 San Diego County also reorganized and renamed one of its detention facilities, the East Mesa Reentry Facility (EMRF), to offer more rehabilitative programming for inmates serving the last two years of their sentences. 68 EMRF offers programs in cognitive behavioral therapy, vocational skills, and personal skills (e.g., anger management, parenting, and English as a second language). The facility also offers assistance with employment searches, finding substance use disorder services, and social support programs. 69 This type of facility reorientation and programming may hold promise by providing some skills and supports that individuals need to have better outcomes when they leave incarceration. Ideally, counties ought to design incarceration-based rehabilitation and treatment programs that provide continuity through the point of release into life in the community. Continuity in reentry programming would allow individuals to continue to access services and support systems that are very likely to be quite central to their lives in the community. Further, data sharing between county detention facilities and community providers would improve providers ability to accommodate individual clients needs as seamlessly as possible. 64 Tehama County. Available at: file:///users/johnconnolly/downloads/snapshot-4739.pdf 65 Californians for Safety and Justice Available at: Models/Community-Corrections Santa Barbara County Sheriff s Office Santa Barbara County Awarded $38.9 Million in Jail Funding. Available at: 68 San Diego County Sheriff s Department Listing of Detention Facilities. Available at: 69 San Diego County Grand Jury San Diego County Detention Facilities and Management. Available at: 10

11 Data Collection and Evaluation As counties launch a range of new strategies, programs, and facilities to improve the community reentry process, data collection and analysis are vital to understanding which initiatives are effective and which are not. Measurement of key statistics recidivism, jail populations, probation violations, joblessness among the reentering population, and communities crime rates, for example will allow policymakers to evaluate which approaches are most successful. These assessments ought to be prospectively planned and provided adequate funding and staff power. Proper evaluation will allow state and county policymakers, stakeholders, and the public to identify and disseminate promising models across the state. With the influx of federal and state funds, counties should seize the opportunity to design and carefully assess programs that achieve better outcomes for communities. San Francisco District Attorney George Gascón established a Sentencing Commission to examine the outcomes of offenders who received different types of sentences, with aim of increasing public safety, reducing recidivism, and improving reentry programs. 70 Counties ought to set aside some of their AB 109 resources for the purpose of recording and assessing the relative impact of their reentry programs, criminal justice policies, and overall use of public safety funds. Further, many observers and advocates who have studied and implemented California s public safety realignment have argued for the need for new legislation that would require statewide data collection and measurement activities to evaluate the impact of AB 109 across the counties. 71 The creation of datareporting requirements for counties and a state-level office to collect, analyze, and disseminate the data would be very valuable for policymakers. Attorney General Kamala Harris office could be an appropriate place to house such a unit. Harris created the Division of Recidivism Reduction and Re-Entry in 2013 and has partnered with the LA County Sheriff s Department to launch Back on Track LA, an education and comprehensive reentry services pilot program. 72 Ultimately, the ability to collect and analyze data will ensure that counties are implementing best practices and that public money is being dedicated to the most effective interventions Waiver Renewal The upcoming 1115 waiver renewal in 2015 could offer an important opportunity to coordinate and improve many delivery systems that serve the AB 109 population. While both Medi-Cal and AB 109 offer financial support for new, innovative, and more comprehensive rehabilitation, treatment, and reentry programs, the waiver could offer support for the development, coordination, and infrastructure of provider networks. The Department of Health Care Services indicated that it would like to create an incentive program for integrating physical and behavioral health, 73 and Medi-Cal services that are important to counties community reentry programs should absolutely be incorporated into these incentives. For example, the comprehensive case managers like those in Marin County s reentry program, as well as the comprehensive services offered at the day reporting centers in both San Bernardino and San Joaquin could receive support from these incentive programs that the State would like to aim at coordinating services and reducing costs. Looking Forward The recent changes both to California s criminal justice system and to the Medi-Cal program provide a substantial opportunity to align these systems to better serve individuals under community supervision, 70 Office of the District Attorney of the City and County of San Francisco. Available at: 71 Petersilia J, Op cit. 72 Office of the Attorney General of California Available at: 73 California Department of Health Care Services Concepts for California s Next Medicaid Waiver Renewal. Available at: July_2014.pdf 11

12 on probation, or reentering communities from incarceration. California s counties now have greater administrative responsibility and funding for public safety systems and Medi-Cal delivery systems. County administrators should take advantage of these opportunities by collaborating to create more comprehensive, rehabilitative, and cost-effective community reentry and supervision programs. Transitions from incarceration can be very difficult for offenders and their families and friends. Many offenders struggle to reestablish themselves emotionally, socially, and financially after sometimes long, and often jarring absences. Yet, stronger treatment programs and community supports would increase the chances that individuals can rebuild their lives and reconnect with their communities. Ultimately, more successful community reentries would reduce recidivism and improve health outcomes, making communities safer and healthier in the long run. 12