Improving Access to Healthcare for Youth in the Juvenile Justice System Prepared by

1. Improving Access to Healthcare for Youth in the Juvenile Justice System Prepared by Prepared for Presentation to California Association of Probation Institution Administrators (CAPIA) Annual Meeting September 2012

2. Connecting to Treatment • Health Reform creates increased access to health care for Californians – through expanded eligibility and new benefits that include behavioral health care. • Juvenile offenders are a high-risk, hard-to-reach population, and the time spent in detention creates an opportunity to connect them to traditional and new community-based health care services.

3. Knowing Your Options • Jurisdictions that research and develop their options for health care treatment for the youth under their supervision or custody can provide smart health care for their specific needs and culture. • Providing smart health care can save the jurisdiction money by shifting or sharing costs, and, ultimately, by reducing recidivism.

4. Participation in Medi-Cal and HBEX • Across the state, Medi-Cal eligibility for youth brought to detention averages about 65%. • It is estimated that nearly all of the remaining youth will be eligible for coverage in 2014 under the federally subsidized Health Benefit Exchange (HBEX) or Medi-Cal expansion. • In 2014, there will be near universal health care eligibility among documented youth brought to detention.

5. Changes to the Inmate Exception • Health Reform creates a significant new opportunity to serve youth whose families are eligible for federal subsidies through the HBEX. • These youth will be able to receive covered services while detained in a correctional facility while awaiting adjudication of charges. • The Inmate Exception will still limit Federal Financial Participation for youth receiving health care while sentenced to time in detention or camp.

6. Improved Access to Behavioral Healthcare • Health Reform requires parity between medical and behavioral healthcare benefits. • Justice system-involved youth have high rates of substance use and mental illness compared to the general population, which creates security risk, staff pressures, and added environmental stress in the detention setting. • Improved access to behavioral healthcare in the community and, when possible, in detention, could have a significant positive impact on this population.

7. Connecting to Treatment • There are opportunities to connect youth who are engaged by law enforcement to treatment at: • The front end, prior to admission to a detention facility • During detention • Upon release

8. Connecting to Treatment: Enrollment and Coverage • For all the options described on the next slides, ensuring that youth are enrolled in a health plan and that services are delivered according to the rules of the plan will be the key determinants to increasing access to care and collecting reimbursement for services delivered through probation programs or in the community.

9. Connecting to Treatment: Enrollment Challenges to achieving enrollment in a detention center setting: • Who verifies eligibility and enrollment status? When? • Who assists with enrollment? When? Where? • Parental consent? Probation authority? • Data requirements for enrollment

10. “Front End” Connection to Treatment: Law Enforcement • Youth are most vulnerable at the time of their encounter with law enforcement. • This is especially true for the first or second arrest, before they become “system involved.” • We also know that once a youth is booked into a detention facility, the likelihood of a return stay multiplies.

11. “Front End” Connection to Treatment: Law Enforcement • Crisis Intervention on the part of law enforcement could keep some youth out of detention. • The National Alliance on Mental Illness provides resources and manuals for Crisis Intervention Teams (CIT) for Youth. • NAMI CIT for Youth Resource Center: http://www.nami.org/Content/NavigationMenu/Find_Support/Child_and_Teen_Support/CIT_for_Youth/CIT_for_Youth.htm

12. “Front End” Connection to Treatment: Release with Court Date • Many youth are picked up on a suspected violation and then released with a “notice to appear” issued by the officer at the scene, or at the detention center because they do not meet the risk assessment criteria.

13. “Front End” Connection to Treatment: Release with Court Date • Probation has an opportunity to refer youth to (and perhaps even make an appointment for) treatment or programming at this “teachable moment” - especially if there is the assurance that the court will look favorably upon participation and compliance.

14. “Front End” Connection to Treatment: Pre-booking Assessments • The brief health history and physical exam (”Safe to Detain Assessment”) conducted prior to booking into the detention center could be a billable service. • A facility that can re-engineer its systems to conduct assessments by an eligible provider prior to booking may reduce its medical expenses for those exams. • Mental health risk assessments may also qualify for billing if conducted prior to booking by an eligible provider.

15. “Front End” Connection to Treatment: ER Care Before Booking • Sharp Decision – law enforcement and probation are not responsible for emergency department care or hospitalization for youth who are transported for treatment prior to booking. (Sharp Healthcare vs County of San Diego, Nov 15, 2007) • Health insurance status is irrelevant to probation in this context, as the financial responsibility rests with the hospital.

16. Post-Booking Connection to Treatment: New Health Reform Provision • Youth enrolled for coverage under the HBEX will be able to receive covered services while detained in a correctional facility awaiting adjudication of charges. • Youth must be enrolled for coverage, and eligible health service providers in the detention center must provide covered services.

17. Post-Booking Connection to Treatment: In-patient Hospitalization • Detention centers routinely transport youth in need of inpatient care to off-site medical facilities that have the necessary treatment capacity. • Probation traditionally has been on the hook to pay hospital charges for inpatient stays. • In California, transaction prices for a day in the hospital paid by commercial insurers increased by more than 150 percent between 2000 and 2009 (an average annual growth rate of 11 percent per year).

18. Post-Booking Connection to Treatment: In-patient Hospitalization • “The 24-hour Rule” allows jurisdictions to shift the cost of inpatient acute care to Medi-Cal (AB 396 Mitchell). • Youth must be enrolled for coverage, and hospitals often carry that burden. • Funding would be FFP to the extent possible.

19. Post-Release Connection to Treatment: Connectivity • Most youth who enter juvenile detention lack a stable relationship with medical providers in their communities. • The time a youth spends in detention creates an opportunity to connect him/her to community-based health services. • It the youth remain connected to community-based health care providers upon release, their prospects for continuing care will likely improve.

20. Post-Release Connection to Treatment: Connectivity • Many jurisdictions provide case management and aftercare to youth when they are released from a long term commitment program or camp. • In contrast, youth released directly from detention upon adjudication frequently are not connected to the services that could help them avoid re-arrest.

21. Post-Release Connection to Treatment: Connectivity • Transition or reentry programs that connect youth and their families to services may reduce recidivism. • Access to/assistance with Social Services for Medi-Cal / HBEX enrollment • Appointments with community-based medical and behavioral health systems • Placement in supportive, appropriate educational or job training program • Meeting with assigned PO to clarify terms of release

22. Post-Release Connection to Treatment: Day and Evening Reporting Centers • Healthcare services delivered at a Day or Evening Reporting Center may be eligible for reimbursement because the youth are not confined to an institution. • Behavioral health services delivered by qualified providers will be covered under new Health Reform parity rules that allow for out-patient substance use and mental health treatment.

23. General Advice • Partnering with local behavioral health care providers, social services, and schools is essential to creating connectivity to care for youth. • Billing for services delivered in a detention center requires that the youth be enrolled, health care providers be eligible, and services be included in the benefit package. • Engaging the court and county governance in the early stages of developing new approaches and/or systems will help ensure success.

24. Specific Advice • To the extent possible, facilities that can create systems to determine eligibility and enrollment status in a health plan, and to facilitate the enrollment of youth and/or their families, maybe able to offset some of their medical costs.

25. BSCC Proposed Regulation • Proposed inclusion in the 2012-14 BSCC Title 15 regulations: 1324 Procedures: “establish procedures for the collection of MediCal eligibility information and enrollment of eligible youth (W&I Code 12029.5).”

26. JOCHS Monterey • Juvenile Offenders Community Health Project (JOCHS) • In Monterey County, we worked with Probation to develop a transition program that appears to be generating some positive results. • Jose Ramirez, Probation Division Director for Juvenile Hall, will tell us more about that project.

27. Community Oriented Correctional Health Services (COCHS) • Website: www.cochs.org • Steve Rosenberg: srosenberg@cochs.org • Nancy Torrey: ntorrey@cochs.org