Revisiting Million Dollar Murray A Better Plan Larke

Revisiting “Million Dollar Murray: ” A Better Plan Larke Nahme Huang, Ph. D. Director, Office of Behavioral Health Equity Lead, Trauma and Justice Strategic Initiative Jennie Simpson, Ph. D. Staff Lead, Criminal Justice Initiative Office of Policy, Planning and Innovation Criminal Justice-Behavioral Health- Partnerships Promoting Integrated Healthcare IBHI and CHCS Conference San Antonio, TX – January 29, 2017

SAMHSA’s Trauma and Justice Strategic Initiative 2 • Integrating a trauma informed approach throughout health, behavioral health and related systems in order to reduce the harmful effects of trauma and violence on individuals, families and communities. • Utilizing innovative strategies to reduce the involvement of individuals with trauma and behavioral health issues in the criminal and juvenile justice systems.

Who is Million Dollar Murray?

What Creates Health? Determinants of Health Genes and Biology Physical Environment Clinical Care 10% Social and Economic Factors 40% 10% Necessary conditions for health (WHO) Health Behaviors 30% Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896: 281 -93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081 -2083. World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17 -21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at http: //www. who. int/hpr/archive/docs/ottawa. html. Shelter Education Food Income Stable eco-system Sustainable resources Mobility Health Care Social justice and equity Trauma Reduction

Key Data Points (Bureau of Justice Statistics, 2006)

Criminal justice involvement among noninstitutionalized adults with and without serious mental illness Alene Kennedy-Hendricks et al. Health Affairs 2016; 35: 1076 -1083 Substance Abuse and Mental Health Services Administration National Survey of Drug Use and Health

Ten medical conditions with the highest estimated spending in 2013 Charles Roehrig Health Aff

Combined spending by private insurance, Medicaid, and Medicare as a share of all spending for mental health and substance use disorder treatment Tami L. Mark et al. Health Aff 2016; 35: 958 -965

Trends in substance use disorder and criminal justice involvement Brendan Saloner et al. Health Aff 2016; 35: 1058 -1066 Substance Abuse and Mental Health Services Administration National Survey of Drug Use and Data

Selected Federal and National Initiatives Policy Initiatives Grant Programs Partnerships • 21 st Century Cures Act • Affordable Care Act • HIPAA • MAT • Health Homes • Public Health 3. 0 • Criminal Justice Programs • Certified Behavioral Health Clinics • Opioid State Grants • Re. CAST • • Data Driven Justice Stepping Up One Mind SPARK

21 st Century Cures Act and Mental Health Reform Bill- Selected Provisions Title 9, Promoting Access to Mental Health and Substance Use Disorder Care – • Authorizes programs for Adult Suicide Prevention, Assertive Community Treatment, Crisis response, Jail Diversion, Assisted Outpatient Tx Title 12, Medicaid Mental Health Coverage: • Clarifies that Medicaid does not prohibit same day payment for mental health and primary care services Sec 1003, Account for State Response to Opioid Abuses Crisis: $1 B over 2 years to address treatment gap for States Title XIV, Mental Health and Safe Communities • Increases for Law Enforcement Training on crisis response; Amends COPS-crisis training; court-ordered AOT; Forensic ACT, Law Enforcement-School MH Crisis Intervention Team

Affordable Care Act: Benefits and Medicaid Expansion • • • Essential Benefits Package Medicaid expansion – 31 states and D. C. People recently incarcerated – ~ 10% of Medicaid expansion population Before ACA – 80% of people recently released from prison were uninsured. ~ 80% CJ-involved may qualify for Medicaid in expansion states New Medicaid guidance (April 2016) – Clarifies that individuals who are currently on probation, parole or in home confinement are not considered inmates of a public institution. – Extends coverage to Medicaid-eligible individuals living in community halfway houses where they have freedom of movement

Disparities in Coverage: Example African Americans (Snowden, 2016) 13 Medicaid Non-Expansion States with Highest Proportion of African Americans

ACA: Aligning New Service Delivery and Payment Models • Health Home Option with Enhanced FMAP • Improves care coordination and service linkage for people with chronic conditions • 19 States and DC (SPA) • New York: – Piloting CJ Program in Health Homes – Established Complex Trauma as Chronic Condition

HIPAA Guidance (2016) • Clarifies if a covered entity may collect, use, and disclose criminal justice data under HIPAA https: //www. hhs. gov/hipaa/forprofessionals/faq/2073/may-coveredentity-collect-use-disclose-criminal-dataunder-hipaa. html

Medication Assisted Treatment: New Buprenorphine Regulation July 2016: Final rule, “Medication Assisted Treatment for Opioid Use Disorders. ” – Allows physicians with waiver to prescribe buprenorphine for up to 100 patients for a year or more to obtain a waiver to treat up to 275 patients. – Early 2017: Nurse practitioners (NPs) and physician assistants (PAs) able to submit applications to become buprenorphine waived as of early 2017.

Sequential Intercept Model – Organizing Framework for SAMHSA Grants Early Diversion BH Treatment Court Collaboratives Treatment Drug Courts Offender Reentry Program

Starting at Intercept 0: Law Enforcement & Behavioral Health Partnerships for Early Diversion • Three grantees: – Boulder County Sheriff’s Department – The Connecticut Department of Mental Health and Addiction Services (DMHAS) – Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS) • • • Best practices in police response– combines craft knowledge, training, and community policing EB treatment – combines best clinical judgment and science Warm hand-offs Community services: behavioral health, social and human services gains for public health and public safety

Intercept 2 and 3: Treatment Courts • Use of MAT – SAMHSA Treatment Drug Court grantees are encouraged to use up to 20% grant award for MAT • • Behavioral Health Treatment Court Collaboratives Adult Treatment Courts Adult Tribal Healing to Wellness Juvenile Treatment Drug Court • Trauma Informed Approaches with Justice-Involved Individuals

Mental Health Indicators among Adults Aged 18 or Older, by Lifetime Trauma Exposure: MHSS Clinical Study, 2008 -2012 (n = 5, 653) 25 23. 2 Lifetime Trauma Exposure No Lifetime Trauma Exposure Percent 20 15 17. 8 14. 4 14. 3 10. 4 10. 1 10 8. 1 6. 1 4. 3 5 2. 4 4. 4 3. 1 0 Any Mental Illness Serious Psychological Distress CBHSQ Data Review, April 2016 Major Depressive Episode Suicidal Thoughts Received Mental Health Treatment/ Counseling

Intercept 4: Offender Reentry Program • Substance use treatment services & recovery supports for individuals reintegrating into communities • Includes funding for MAT & Trauma Informed Approaches with Justice. Involved Individuals

State Targeted Response to the Opioid Crisis Grants • Announced on December 21, 2016 • For: All 50 states and territories • Purpose: Address the opioid crisis by: – increasing access to treatment, – reducing unmet treatment need, and – reducing opioid overdose related deaths through the provision of prevention, treatment and recovery activities for opioid use disorder • Goal: Expand prevention, treatment, and recovery services as well as expand efforts to reduce deaths from opioid-related causes.

Certified Community Behavioral Health Centers • Protecting Access to Medicare Act of 2014 – Section 223: Establishes a national demonstration program that provides an opportunity for states to improve and pay for the behavioral health of their residents by improving access to high quality community-based mental and substance use disorder treatment through CCBHCs. – Twenty-five states were awarded planning grants to prepare for the demonstration program. • Eight demonstration states: Minnesota, Missouri, New York, New Jersey, Nevada, Oklahoma, Oregon and Pennsylvania

Re. CAST Grant: Resiliency in Communities After Stress and Trauma • For: Communities experiencing civil unrest • Purpose: – Assist high-risk youth and families – Promote resilience and equity in communities – Use violence prevention/community youth engagement programs – Link with trauma-informed services • Goal: local community entities and government (law enforcement, education, etc. ) agencies to work together to improve behavioral health, empower community residents and reduce trauma • http: //www. samhsa. gov/grants/grantannouncements/sm-16 -012

Emerging Framework for Service Delivery and Payment Models Karen De. Salvo, MD, MPH; Assistant Secretary for Health, DHHS

Public Health 3. 0 Components “emphasizes cross- sector environmental, policyand systems- level actions that directly affect the SDOH. ” FLEXIBLE & SUSTAINABL E FUNDING DATA, ANALYTIC S& METRICS LEADERSHIP & WORKFORCE ESSENTIAL INFRASTRUCTURE STRATEGIC PARTNERSHIPS

CMS: Center for Medicare and Medicaid Innovation- Accountable Health Communities • Based on emerging evidence that addressing health-related social needs through enhanced clinicalcommunity linkages can improve health outcomes and reduce costs. • Model promotes clinicalcommunity collaboration through: – Screening to identify certain unmet healthrelated social needs; – Referral to community social services; – Provision of navigation services – Alignment between clinical and community services

What if we consider the social determinants of justice involvement- Public Safety 3. 0? Historical and community trauma Access to affordable housing Police, court, and correction practices Health and Behavioral Health Access to employment Neighborhood instability

Partnering with National Initiatives • • Data Drive Justice Stepping Up One Mind Spark - Optum

Resources • GAINS Center • Federal Interagency Reentry Council • US Interagency Council on Homelessness • National Institute of Corrections