2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Commentary on Treating Vulnerable, Mentally Ill Patients

Dr. Falconer effectively drives home the travesty of the disproportionate representation of those with serious behavioral health issues behind bars. Alarming, but not new, the “trans-institutionalization” of the 80’s and 90’s continues unabated to its tragic conclusion. She cogently captures the history, challenges and emerging strategies related to inordinately high rates of recidivism that characterize the experience of these individuals, an unconscionable experience that begs for reform. Re-enter Dorothea Dix, stage left, 1854, inspiring calls for a return to Asylum. (See, “Improving Long-term Psychiatric Care, Bring Back the Asylum,” Journal of the American Medical Association (January 21, 2015).

Not so fast…Indeed, the lack of progress in the face of these unconscionable realities, fifty years beyond the public mental health priorities and unfulfilled promises of the last century, is hard to accept. However successful, compassionate and replicable alternatives exist, such as Judge Leifman’s Miami Dade and the Leon Evans-led reforms in Bexar County. Those successes turn on redoubled collaboration among public safety, health and human services leadership and (wouldn’t you know it!) much welcomed federal financial participation in the cost of these desperately needed treatment strategies. Ironically, the now sun setting ACA-driven potential for offsetting state and county costs of correction with federally subsidized community-based services and supports, may soon elude us. (Under the provisions of the ACA “more than half of the 730,000 federal and state prisoners reentering the community each year are estimated to have been eligible for either Medicaid funded services or federal subsidization of their purchase of vitally important health coverage”1).

Dr. Falconer also gets it right in her identification of those individuals who are most likely to be incarcerated and the behavioral, medical, and social determinants of care that drive their inevitable relapse, recidivism and a tenfold increase in the likelihood of their death by overdose following an under-planned, and uncoordinated release This lack of post-release treatment, case management and social supports, including housing, are the major contributors to our unconscionable levels of recidivism, just as they are the main factors that drive unacceptably high rates of preventable hospital readmissions to general care beds, invariably by patients with one or more behavioral health diagnoses.

So, I suggest: (1) The best re-entry is no-entry. To that end, it is critically important to identify and divert those at greatest risk to responsive care management and treatment alternatives to incarceration. (2) Law enforcement and the courts need assured access to alternative dispositions that will obviate their current reliance on lock ups and overcrowded ER’s. (3) Even in the best resourced service environments, it takes exceptional community providers, well linked to essential cross system supports and well supported by aggressive and effective case management, to produce the results we seek. (4) Many offenders living with mental illnesses have committed an offense that is often a manifestation of their illness rather than the result of criminal intent. (5) Our ability to translate that understanding into a clinical direction of trauma-informed, person-centered care is essential. (6) Leading edge analytic tools are required to optimally inform our targeted strategies and sharpen the focus of our clinical models. (7) Value based purchasing must support and ensure the viability of our specially capacitated community partners as they drive the systems reforms leading to the desired outcomes of community stabilization and recovery. (8) Not generally embedded in the comfort zone of most health care payers or providers, these required cross systems challenges are indeed daunting. But know that they reflect the emerging expectations of Federal, State and local leadership that call for: Diversion, Jail In-Reach Service Planning, Data Sharing, Care Coordination and Re-Entry strategies replete with systems oversight and accountability.

In closing, let us continue to honor Dorothea Dix, but avoid the temptation of a return to the failed policies of the last few decades. Let us redouble our collaborative efforts to advance inextricably linked health care and criminal justice reform by attacking the challenge of mass incarceration associated with the preventable arrest and recidivism of those with significant behavioral health challenges. In doing so, we will strengthen our communities as we strengthen our families, minimize victimization, and empower individuals to live meaningful and fulfilling lives.

White House Fact Sheet: Launching the Data Driven Justice Initiative: Disrupting the Cycle of Incarceration (June 30, 2016).

Richard Sheola can be contacted at richard.sheola@healthandjusticestrategies.com.

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