CalAIM Explained: Caring for Californians Leaving Incarceration Liz Buck, Olivia Randi, Dan Mistak, and Kathy Moses CalAIM Explained: Caring for Californians Leaving Incarceration INTRODUCTION Every year, hundreds of thousands of people leave California jails and prisons and return to the community, including many who cycle in and out of the system repeatedly.1 A disproportionate number of these people have multiple chronic physical and behavioral health conditions and need services upon reentry to the community.2 In addition to immediate health care needs, people leaving correctional systems face myriad challenges made more difficult by having a criminal record, including reintegrating into their community, accessing benefits, securing a job, and finding housing. Coordination of health and social services at reentry is critical to improving health outcomes, advancing health equity, and reducing recidivism.3 Because of Medicaid expansion through the Affordable Care Act, most people leaving California jails and prisons are eligible for Medi-Cal. However, the longstanding inmate exclusion policy, which prohibits Medicaid spending for people who are incarcerated (except for hospitalization for more than a day), has contributed to challenges in accessing needed health care services when people leave correctional systems and reenter the community. CalAIM (California Advancing and Innovating Medi-Cal) creates an opportunity to change this and enables Medi-Cal spending for select services in the 90 days before release. This brief can help health care stakeholders understand the reentry process and maximize opportunities to best serve this population, both during reentry (before release from incarceration) and in the community. California Health Care Foundation | www.chcf.org 2 CalAIM Explained: Caring for Californians Leaving Incarceration WHAT TO EXPECT FROM THIS BRIEF This brief can help health care stakeholders understand how the correctional system works, with a focus on community reentry. It also outlines practical suggestions on how to participate in community-based reentry planning processes in CalAIM. What's Included The brief includes key foundational information and suggested actions to empower health care providers and other stakeholders to take the first steps to collaborate with their communities' correctional systems on reentry. Sections address: • The case for cross-system collaboration • Correctional system basics • Opportunities in California for collaboration around reentry • How to get started: examples of successful correctional and health care partnerships around reentry What's Not Included • A lot of technical details about correctional systems, operations, and funding that often vary from one community to another • An expansive description on another important issue - diversion or deflection, or opportunities to minimize initial interaction with the criminal legal system California Health Care Foundation | www.chcf.org 3 CalAIM Explained: Caring for Californians Leaving Incarceration THE CASE FOR CROSS-SYSTEM COLLABORATION In California, most people leaving correctional systems are eligible for health insurance through Medicaid expansion under the Affordable Care Act. However, even though these actions have expanded eligibility, many people are not connected to coverage or care when leaving correctional facilities. Identifying and addressing health and social needs through cross-sector collaboration to coordinate prerelease planning and connection to coverage and community-based health services is critical to improving the health of this population for these reasons: • People entering and leaving jail and high rates of homelessness - up to 39% of all prison often have significant physical and people entering parole from California prisons behavioral health needs compared to the report "moderate to high rental instability."8 In general population. People with behavioral addition, transition care planning - including health needs are more likely to interact with scheduling initial appointments and sharing the criminal legal system for a complex set important medical information, such as of interconnected reasons including limited prescribed medications from correctional health behavioral health treatment options and services to community-based providers - has shortages of low-barrier housing.4 As a result, been rare and not comprehensive. As a result, people with behavioral health conditions are people leaving incarceration face higher rates overrepresented in California's jails and prisons. of hospitalizations,9 a risk of death in the two Nationally, 64% of people leaving jails5 and 43% weeks after release that is 12 times higher than of people in state prison6 have a behavioral the general population,10 and a risk for overdose health condition. In addition, the percentage of death that is a staggering 129 times higher than older adults in prison has also grown - between the non-justice-involved population.11 2000 and 2017, the share of prisoners in California age 50 or older rose from 4% to 23%.7 • Providing integrated, person-centered care This group faces higher rates of chronic medical for people involved in the criminal legal needs when they reenter the community. system is a health equity issue. Structural and institutional racism contribute to • Leaving correctional facilities is often a disproportionate rates of criminal legal system challenging transition, particularly for people involvement for people of color. In California, managing complex health and social needs. 28.5% of incarcerated males are Black, while Even short stays in jail can have a significant Black men make up only 5.6% of the state's impact on someone's life, including loss of a job, total population. Black women, Latino men, housing, access to community providers and and Latina women are also overrepresented in treatment, and the exacerbation of physical or California jails and prisons.12 behavioral health conditions. In addition, people entering and leaving jails and prisons have California Health Care Foundation | www.chcf.org 4 CalAIM Explained: Caring for Californians Leaving Incarceration CRIMINAL LEGAL SYSTEM BASICS Understanding the criminal legal system is a key first step for health care stakeholders seeking to improve access to health care and social services for the reentry population. This section describes basic information about jails, prisons, and community supervision and Figure 1 describes how people move through the system. Key Terms Law enforcement Local agencies that employ people, such as police officers, who enforce laws, investigate crimes, and make arrests. Jails County correctional facilities managed by elected sheriffs and funded through county budgets. Judiciary System of courts that interprets and applies the law. Prisons State or federal correctional facilities. In California, the California Department of Corrections and Reentry oversees state prisons. Community Supervision - Parole Supervision in the community administered at the state level. - Probation Supervision in the community administered at the county level. California Health Care Foundation | www.chcf.org 5 CalAIM Explained: Caring for Californians Leaving Incarceration CRIMINAL LEGAL SYSTEM BASICS Other Important Terms Correctional systems Also called correctional agencies and facilities, refers to jails and prisons. Criminal legal system Refers to "policing, prosecution, courts, and corrections in the United States."13 Deflection An intervention connecting people who have mental health needs to community-based treatment and services prearrest.14 Diversion Programs that connect people to community-based interventions while avoiding traditional sentencing, further criminal legal involvement, and incarceration.15 Reentry The transition period between custody in jail or prison and the community. The reentry process can vary by facility and availability of community-based programs but can include help finding employment, housing, and health care.16 California Health Care Foundation | www.chcf.org 6 CalAIM Explained: Caring for Californians Leaving Incarceration CRIMINAL LEGAL SYSTEM BASICS Figure 1: How People Who Are Arrested Move Through Correctional Systems ILLUSTRATIVE - BOX SIZES APPROXIMATE THE VOLUME OF PEOPLE IN EACH PHASE Law Enforcement Jail Judiciary Prison Probation/Parole Community Law Enforcement (e.g., Arrest and Booking) Jail (Presentencing) Judiciary (Initial Hearing, Trial) Jail (Postsentencing) Community Probation/ Parole Source: Author analysis of publicly available data from the technical appendix, Heather Harris, Pandemic Policymaking and Changed Outcomes in Criminal Courts, Public Policy Institute of California, April 2023. Note: Community in this instance is defined as a setting outside jail or prison without supervision from parole or probation. Once booked into jail, everyone receives a preliminary hearing. While many people spend time in jail prior to sentencing, only a small minority are ultimately sentenced to jail or prison. Improving reentry outcomes will require developing workflows that address both the large volume of people who have short stays in jail and the small volume of people who return to the community after a long prison sentence. California Health Care Foundation | www.chcf.org 7 CalAIM Explained: Caring for Californians Leaving Incarceration LAW ENFORCEMENT, JAILS, AND THE JUDICIARY Law Enforcement In most California counties, there are multiple law enforcement agencies, including agencies operated by the city, county, public transit, and educational institutions. A person typically enters the criminal legal system through an arrest by a law enforcement officer. After being arrested, they may be booked into jail. Jails Jails are county correctional entities managed by elected sheriffs and funded through county budgets. Across California, 115 county jails operate across 56 counties. A high volume of people enter and leave jails with relatively short stays of hours or days. Many jails screen people at booking for physical and behavioral health needs. The primary reason jails conduct these screenings is to ensure safety for staff and people in custody, with a focus on determining possible substance use disorder withdrawal, suicide risk, and risk of potential danger they may present to others. Judiciary The judiciary plays a large role in determining outcomes for people being processed through hearings in the criminal legal system. While prosecutors determine whether to press charges and what charges to pursue, judges have significant discretion about how a case can proceed in their court, are powerful voices for how criminal legal systems are structured, and have some discretion about sentencing. California's correctional system operates differently than most other states. In general, people convicted of a serious, violent, or registerable sex offense (with some exclusions) serve their sentence in prison. People convicted of nonviolent, nonserious, nonregisterable sex offenses typically serve their sentence in a county jail. California Health Care Foundation | www.chcf.org 8 CalAIM Explained: Caring for Californians Leaving Incarceration KEY THINGS TO KNOW ABOUT JAILS 1 California jail population. On any day in California, about 60,000 people are in jail.17 About 75% of them are awaiting trial and have not yet been convicted of a crime.18 2 Primary focus. The primary focus of jail is securely facilitating the legal process (e.g., getting people to court safely). This can impact how health care services are delivered in these facilities. For example, if an incarcerated person has a routine medical appointment or treatment, assuring the person appears in court will take priority over these types of health care services. Jail staffing affects how much attention and support are dedicated to health care service delivery. 3 Average length of stay. In California, the average time spent in jail is 37.6 days.19 However, nearly two-thirds of people released from jails (62%) are incarcerated for a week or less.20 There are notable exceptions to this, with many people awaiting trial in jail because they cannot afford bail. There are several more reasons people can have much longer lengths of stay, including mental health conditions that delay trials. 4 Leadership and budget. Elected sheriffs oversee county jail systems, including oversight, and often have some financial responsibility for correctional health services. 5 Health care provision. Many counties provide direct correctional health services in jails while others contract out some or all services to private health care providers. A few examples of private correctional health services providers include Centurion Health, Wellpath, and YesCare. 6 Transitions from jail. People have several pathways to leave jails. For example, people can be sentenced to prison, transitioned to state hospitals due to illness or lack of competency to stand trial, or moved into the community with the requirement of supervision (commonly known as probation). 7 Reentry considerations. People enter or leave jails at all hours of the day and night, complicating reentry planning. California Health Care Foundation | www.chcf.org 9 CalAIM Explained: Caring for Californians Leaving Incarceration KEY THINGS TO KNOW ABOUT PRISONS The California Department of Corrections and Reentry (CDCR) runs 34 men's and women's prisons, three youth facilities, and one camp. Key points to know about prisons include: 1 California prison population. As of 6 Transitions from prison. People 2019, this population was about 95,460 can be transferred between prisons, (down from a peak of 173,000 in 2006), sometimes back to jail (less common), with 30,000 releases per year and 50% of or released to community supervision. people being released to parole.21 People with significant medical needs can be put on medical parole, and 2 Primary focus. A primary focus of prisons those with terminal illnesses are is safety and security of staff and people sometimes given compassionate in custody. This can impact how health release without a requirement of care services are delivered in these community supervision. facilities (e.g., who can enter facilities to provide services). 7 Reentry considerations. Compared to jails, prisons are more likely to 3 Average length of stay. In California, have formal reentry processes, and it the average length of a prison stay is can be easier to coordinate services three years. prerelease due to the longer lengths of stay and greater predictability of 4 Leadership and budget. In California, release dates. However, most people CDCR leadership is appointed by leaving a CDCR facility return to a the governor, and the agency is different county than where they were predominantly state funded. serving their prison sentence, meaning that prerelease planning requires 5 Health care provision. Health care is collaboration with local stakeholders provided by the California Correctional in many counties. Health Care Services within CDCR. California Health Care Foundation | www.chcf.org 10 CalAIM Explained: Caring for Californians Leaving Incarceration KEY THINGS TO KNOW ABOUT COMMUNITY SUPERVISION The criminal legal system has a variety of options at its disposal to avoid incarceration in the first place or to return people to the community while they remain under supervision. People can be on community supervision as a condition of pretrial release from jail. People can also be offered community supervision rather than be sentenced to time in jail or prison or offered a split sentence, with some time in jail or prison followed by some time under community supervision. Anyone who fails to meet the conditions of their community supervision may face jail or prison time. Probation is community supervision administered by the county, while parole is community supervision administered by the state. Community supervision agencies can be important partners in engaging people in health care services. Key Things to Know About Probation and Parole PROBATION PAROLE 1 Population 199,313 people were on probation in On March 22, 2023, the point-in-time California in 2019.22 count for the population on parole in California was 37,370.23 2 Primary Focus Monitoring compliance with conditions of release, identifying housing and treatment services for people under their supervision, and overseeing caseloads. 3 Average Time Varies by charge, up to two years Three years 4 Leadership Counties State (CDCR) and Budget 5 Health Care Predominantly community-based providers. Provision 6 Transitions If the person on community supervision fails to meet the conditions or requirements of their supervision, they may return to jail or prison. 7 Reentry Mental health and substance use treatment may be a requirement of community Considerations supervision. Depending on the conditions of release, people who miss appointments can be taken back to jail or prison. People on community supervision may have travel restrictions that impact where they can access services. California Health Care Foundation | www.chcf.org 11 CalAIM Explained: Caring for Californians Leaving Incarceration OPPORTUNITIES IN CALIFORNIA FOR COLLABORATION AROUND REENTRY California is taking steps to ensure better transitions and access to care for people leaving jails and prisons that will more directly involve health care partners. These efforts fall under the CalAIM Justice- Involved Initiative, which includes these opportunities to better meet the health needs of people leaving incarceration: Enrolling eligible people in Medi-Cal before release from prison, jail, or juvenile justice Prerelease services for youth and eligible adults Coordination with and connection to health and behavioral health services postrelease Coordination of community-based services, including through Enhanced Care Management Community Supports if offered by an enrollee's managed care plan Providing Access and Transforming Health (PATH) Justice-Involved Capacity Building Program that offers capacity building grants to correctional facilities and key implementation partners California Health Care Foundation | www.chcf.org 12 CalAIM Explained: Caring for Californians Leaving Incarceration OPPORTUNITIES IN CALIFORNIA FOR COLLABORATION AROUND REENTRY Medi-Cal enrollment for all youth and adults leaving jails and prisons. State legislation required that all counties must implement prerelease Medi-Cal application processes in county jails and youth correctional facilities by January 1, 2023, with the goal of ensuring that everyone eligible leaves jail or prison with Medi-Cal coverage and is connected to care as needed.24 This was already required in juvenile facilities as of October 1, 2020.25 DHCS guidance clarifies that CDCR prisoners are eligible for enrollment in Medi-Cal and describes the process of Medicaid suspension status for people leaving prisons.26 Additional DHCS guidance outlines key details for county welfare directors and county correctional agencies regarding prerelease applications27 and Medi-Cal suspension guidelines.28 Note that legislation from 2013 already required prisons and jails to suspend, rather than terminate, Medi-Cal benefits for up to one year.29 Prerelease services for up to 90 days for people eligible for CHIP and Medi-Cal leaving jails and prisons. On January 26, 2023, California became the first state in the nation to get approval to spend federal Medicaid dollars on a set of targeted prerelease services for youth and adults leaving state prisons, county jails, and youth correctional facilities 90 days before release. Correctional facilities will be required to implement prerelease services no sooner than April 1, 2024, and no later than March 31, 2026.30 For people leaving prison or jail, the managed care plan enrollment process will be started before release, and managed care plans will be responsible for coordinating services provided to enrollees after they leave prison or jail. Prerelease services, however, will be paid for on a fee-for- service basis by the state.31 California Health Care Foundation | www.chcf.org 13 CalAIM Explained: Caring for Californians Leaving Incarceration OPPORTUNITIES IN CALIFORNIA FOR COLLABORATION AROUND REENTRY Table 1. California's Prerelease Services at a Glance QUESTION WAIVER PROVISION Over what period will Ninety days before expected release date services be provided? What facilities are eligible State prisons, county jails, and juvenile justice facilities to provide services? Who is eligible to receive • All youth in juvenile justice facilities prerelease services? • Medi-Cal-eligible adults in prisons and jails with a qualifying condition including health and mental health conditions, HIV/AIDS, intellectual or developmental disability, substance use disorder, and pregnancy through 12 months postpartum What services will be Services provided before release: available to enrollees? • Prerelease case management • Physical and behavioral health clinical consultation to diagnose conditions, provide treatment, and develop discharge plan and postrelease treatment plan • Laboratory/radiology testing • Medi-Cal-covered prescription and over-the-counter drugs and administration • Medication-assisted treatment for opioid use disorder and alcohol use disorder (including counseling) • Services provided by community health workers with lived experience At time of release: • A minimum 30-day supply of medication, as clinically appropriate, consistent with approved Medicaid State Plan • Durable medical equipment Postrelease • All community-based services available to enrollees under California's Medicaid state plan Source: Margot Cronin-Furman et al., Breaking Ground: How California Is Using Medicaid to Improve the Health of People Leaving Incarceration, Health and Reentry Project, May 2023. California Health Care Foundation | www.chcf.org 14 CalAIM Explained: Caring for Californians Leaving Incarceration OPPORTUNITIES IN CALIFORNIA FOR COLLABORATION AROUND REENTRY Behavioral health linkages and warm handoffs are requirements for correctional facilities. To improve connections to care for people with behavioral health needs, correctional facilities will be required to facilitate referrals to physical and behavioral health providers postrelease and share health information with the person's managed care plans (managed care plan, specialty mental health plan, and Drug Medi-Cal Organized Delivery System). Enhanced Care Management (ECM). ECM is a whole-person, interdisciplinary approach offered through CalAIM to address the clinical and nonclinical needs of those with the most complex medical and social needs. ECM systematically coordinates all care and services through comprehensive care management across physical health, behavioral health, and social service systems. Starting January 2024, managed care plans are required to implement ECM for all youth and most adults leaving jails and prisons. Community Supports, which address broader health-related social needs, are an option for Medi-Cal managed care plans under CalAIM. For people leaving correctional systems, many of these services can be critical including housing deposits, housing tenancy and sustaining services, housing navigation, and transition to assisted living for older adults needing support with mobility or activities of daily living. Additional funding under the Providing Access and Transforming Health (PATH) initiative provides support for criminal legal system implementation of prerelease Medi- Cal application and suspension processes as well as broader capacity and infrastructure support of CalAIM. • The Justice-Involved Capacity Building Program provides funding to support planning and implementation of prerelease Medi-Cal application and suspension processes and prerelease services.32 It also supports county behavioral health agencies to implement behavioral health linkages.33 • PATH Capacity and Infrastructure Transition, Expansion, and Development (CITED) can also support workforce and infrastructure to implement ECM and other Community Supports that include a reentry population.34 • Collaborative Planning and Implementation groups help with local, county-based efforts to support implementation of ECM and Community Supports.35 California Health Care Foundation | www.chcf.org 15 CalAIM Explained: Caring for Californians Leaving Incarceration WHAT THIS MEANS FOR HEALTH CARE STAKEHOLDERS Significant new opportunities exist for health care providers, including behavioral health and managed care plans, to partner with criminal legal partners, including sheriffs, jail staff, probation and parole agencies, and correctional health providers, to: • Establish Medi-Cal enrollment workflows to make sure upon release, everyone eligible leaves with active Medi-Cal benefits and has selected a managed care plan • Work with the judiciary to identify opportunities for diversion • Support prerelease planning in prisons and jails, including collaboration on care plans and connecting those leaving incarceration to primary care and behavioral health care in the community • Collaborate with community supervision and engage providers who can deliver ECM and Community Supports for people with complex health and social needs who are reentering the community. Consider partnering with reentry organizations and people with lived experience, including community health workers • Work with behavioral health providers and others to work upstream beyond reentry, identifying opportunities to reduce the total number of people entering jails and prison in the first place California Health Care Foundation | www.chcf.org 16 CalAIM Explained: Caring for Californians Leaving Incarceration HOW TO GET STARTED Several existing examples of effective partnerships between corrections and health care organizations can inform new efforts under CalAIM. For example, among California's Whole Person Care pilots, four that are primarily focused on serving reentry populations - including Kern, Los Angeles, Placer, and Riverside Counties - can provide insights for implementing and scaling reentry models that involve health care organizations.36 In addition, several other existing partnerships and care delivery models, highlighted below, also can inform the design of effective care models in the correctional system, for care transitions, and in the community. Enrollment California suspends rather than terminates Medicaid benefits for people entering adult and juvenile correctional facilities, to provide a bridge for coverage continuity upon release. To further improve access to care for people leaving correctional facilities, the state required counties to implement prerelease application processes in county jails and youth correctional facilities by January 1, 2023. To support this application process, the California Department of Health Care Services published a guide outlining best practices related to Medi-Cal enrollment in county jails.37 One best practice for counties implementing enrollment processes is developing strong interagency partnerships between Medi-Cal and corrections agencies for implementation planning and tracking. Successful counties developed robust partnerships between eligibility teams and sheriff's offices that worked together either through a working group or task force that met regularly to develop a strong suspension and enrollment process. In Santa Clara County, the sheriff's office provides a list of people being released to the county eligibility office. The county identifies who is not enrolled in Medi-Cal and sends the list back to rehabilitation officers in the sheriff's office to complete Medi-Cal applications. The rehabilitation officers send completed Medi-Cal applications to county eligibility workers specifically assigned applications for people who are justice involved. A goal for the county is to have a paper benefit identification card available upon the enrollee's release from jail. Other states have implemented data exchanges between health care and the criminal legal system to support Medicaid enrollment. For example, in Arizona, the state Medicaid agency automatically receives information on people who were booked and released from jails and prisons daily through the state's data exchange system. This information is used to suspend and reinstate coverage and coordinate with managed care plans, as well as identify those who are not enrolled in Medicaid but who may be eligible.38 California Health Care Foundation | www.chcf.org 17 CalAIM Explained: Caring for Californians Leaving Incarceration HOW TO GET STARTED (continued) Collaboration with the Judiciary Collaborative courts - also known as problem-solving courts for specific populations, including people with behavioral health needs - combine supervision and treatment requirements. Some commonly used examples of these include drug courts, mental health courts, and homeless courts. One of the main goals of the collaborative court system is to reduce the number of people with mental illness who are incarcerated. For example, in Santa Clara County, the collaborative court system includes courts focused on serving adults and youth with mental health and substance use needs, those reentering the community from prison, and veterans, among others. This system serves about 2,000 program participants per year and includes a focus on mental health treatment. The court also oversees diversion cases, which has allowed nearly 700 people to avoid misdemeanor or felony charges. When a person is identified as having a mental illness, the judge overseeing the case can refer them to the collaborative court system for support in accessing treatment. This includes both those who are in the jail and in the community, and those who have and have not been sentenced. Behavioral health clinicians assess people at court using the American Society of Addiction Medicine Criteria39 and where possible, divert people out of the court system and connect them to services, including transitional or permanent housing as needed. Other providers are located on site at courts to offer services, such as psychiatrists available to refill medications. Due to their countywide collaboration across criminal legal agencies and behavioral health services, Santa Clara County has developed multiple intervention points at the pretrial, jail, and state prison setting to refer people to behavioral health treatment. Prerelease Planning and Coordination Health partners can make sure people leaving incarceration have medical and behavioral health services available, as well as connections to resources that address health-related social needs. As people leave incarceration, they may need timely access to medications such as insulin, medications for opioid use disorder, or antiretroviral or psychotropic medications that stabilize an individual's health status. Since many people leave jails after short stays and are released into the community with less notice, health care partners need to work with sheriffs and jail staff to ensure coordination. In Los Angeles County, the Department of Health Services' Whole Person Care pilot focused on the pretrial population to provide release planning in the jails and to link to community services upon release through medical case workers, community health workers (CHWs), and others. These staff start by conducting a needs assessment and develop release plans that may include linking to interim housing and substance use disorder treatment, reinstating Medi-Cal California Health Care Foundation | www.chcf.org 18 CalAIM Explained: Caring for Californians Leaving Incarceration HOW TO GET STARTED (continued) soon after release, setting up appointments for medical and mental health care, applying for a replacement ID, arranging transportation, and other services. The program connects participants to a network of contracted community-based partners that have hired CHWs with lived experience of past incarceration. These CHWs work with participants after their return to the community to provide navigation assistance, mentoring, accompaniment to appointments, and other services as needed. The county originally intended to have CHWs work within the jails to engage people as early as possible before release but were constrained by requirements related to who can work in correctional facilities. The pilot also explored virtual meetings between CHWs and people detained in the jail, but faced barriers due to limited technology infrastructure. Instead, a subset of CHWs stationed in the jails engage people both while they are in the jail and in the community, which helps in building trust and ongoing engagement. Given the reality of uncertain release dates, the LA County Whole Person Care pilot also established a "release desk" where people can stop before release to talk to a case manager and finalize their release plans. Other point- of-release services include a 30-day supply of medication and availability of naloxone, hygiene kits, transit cards, and car or van transportation as applicable. While this Los Angeles pilot served about 20% of people leaving the jail, the state estimates that, under the new CalAIM provisions, an estimated 70%–80% of this population will be eligible for ECM. One challenge is that people being released from jail are returning to the same community-based services that have often failed them in the first place. Effective reentry planning - including in-reach and warm handoffs - is critical to shifting this dynamic, and the transition to CalAIM and ECM may be an avenue for providers to do so. Collaboration with Probation and Parole There are many models of community supervision, but they all rely on some form of case management. Health care organizations can partner with probation and parole by implementing screenings and connecting to health care services in the community, all of which reduce returns to jail and prison. Building strong cross-sector partnerships and buy-in between health care partners and the county probation department was critical to success in the Riverside County Whole Person Care pilot. The pilot (led by the Riverside Health Department) engaged its probation department early in the planning process. Leadership in the probation agency, who were used to struggling to connect people to health services and treatment, were motivated to participate in the Whole Person Care California Health Care Foundation | www.chcf.org 19 CalAIM Explained: Caring for Californians Leaving Incarceration HOW TO GET STARTED (continued) pilot and develop new relationships with health care providers. The resulting partnership included a team of nurses, care managers, housing specialists, and a CHW. Nurses trained in case management were colocated in the probation agencies and engaged with clients directly when they appeared for their scheduled appointment with their parole officer. The team also developed a new screening form to better assess the behavioral health needs of people involved with probation and to connect them to needed services. Based on a survey the county administered before beginning the pilot, only 5% of people on probation had active Medi-Cal. This rate increased to 65% after the pilot had been implemented. Data also showed reductions in recidivism rates among people on probation. While Riverside County's Whole Person Care pilot placed nurse case managers in the probation department, Kern County Probation Department (KCPD) connects people on community supervision to community-based services, including social services, by strategically training probation officers. In July 2016, KCPD became one of the few probation departments in the state to implement targeted case management (TCM). Before this, probation officers in the county received basic case management training. As part of TCM, probation officers are trained to implement a robust case management approach billable through Medi-Cal for people under community supervision. This approach has strengthened and streamlined service delivery, leading to stronger partnerships with community-based providers, more individualized care, and an improved assessment that includes questions about food security and nutrition as well as behavioral health needs. KCPD also works with Garden Pathways, a community-based organization, to enroll people in Medi-Cal right after release. KCPD's experience shows an example of how probation agencies can better connect people under community supervision to health and health- related services and bill for different aspects of case management services. California Health Care Foundation | www.chcf.org 20 CalAIM Explained: Caring for Californians Leaving Incarceration NEXT STEPS There are many opportunities for health care organizations across California to collaborate with criminal legal partners. The success of the criminal legal and health partnership examples described in this brief relied largely on champions at specific agencies. It may take time to understand existing collaborative work and identify the right contacts and local champions in the criminal legal system. Places to start might include local judges who oversee collaborative courts,40 clinical leaders providing correctional health services, sheriffs who oversee local jails, or probation leadership. Reentry councils, community-based organizations, and existing health care models with success serving reentry populations, including the Transitions Clinic Network, can be excellent local champions and prospective partners.41 One way to engage with criminal legal systems is through the Sequential Intercept Model (SIM) planning process. The SIM model, developed by the Substance Abuse and Mental Health Services Administration, provides a framework for health care partners, historically behavioral health agencies and providers, to understand opportunities for engagement and collaboration alongside criminal legal stakeholders. Figure 2 shows an example of a SIM. Figure 2. The Sequential Intercept Model Intercept 0 Intercept 1 Intercept 2 Intercept 3 Intercept 4 Intercept 5 Community Services Law Enforcement Initial Detention/ Jails/Courts Reentry Community Corrections Initial Court Hearings Crisis Lines 911 Speciality COMMUNITY Prison COMMUNITY Court Parole Reentry Violation Arrest Crisis Care Local Law Initial First Court Dispositional Jail Probation Jail Violation Continuum Enforcement Detention Appearance Court Reentry Source: "The Sequential Intercept Model (SIM)," Substance Use and Mental Health Services Administration, accessed May 2023. Each county is unique, and specific opportunities to partner may vary - for example, some correctional facilities may want community providers to play a greater role in prerelease planning in the facility or via telehealth, while others may want to use Medi-Cal resources to expand their in-house teams. Some correctional facilities may prefer telehealth consultations, while others may prefer colocation. It is important to maintain an open mind and understand that the practices we take for granted in the community, like a "contact visit" not mediated by glass and telephone, may require more correctional staff resources than a jail is initially willing to provide. Similarly, a community best practice "warm handoff" of two clinicians meeting with the patient all in the same room may not be realistic for people reentering from a prison in a distant county. Meeting the health needs of this population requires building new and strengthening existing relationships between criminal legal partners and health care. CalAIM creates new opportunities to impact the health care outcomes of people leaving the criminal legal system, and with it, a real promise to advance health equity in California. California Health Care Foundation | www.chcf.org 21 CalAIM Explained: Caring for Californians Leaving Incarceration ABOUT THE AUTHORS Liz Buck, MPA, is a senior program officer at the Center for Health Care Strategies; Olivia Randi, MPP, is a program officer at the Center for Health Care Strategies; and Kathy Moses, MPH, is a senior fellow at the Center for Health Care Strategies. Dan Mistak, JD, MA, MS, is the acting president and director of Health Care Initiatives for Justice-Involved Populations at Community Oriented Correctional Health Services (COCHS). The Center for Health Care Strategies is a policy design and implementation partner devoted to improving outcomes for people enrolled in Medicaid. We support partners across sectors and disciplines to make more effective, efficient, and equitable care possible for millions of people across the nation. COCHS works to bridge the gap between correctional and community providers. COCHS's major emphasis is to reframe jail health care not as a place separate from the rest of the community but as another health care delivery site within the community. ABOUT THE FOUNDATION The California Health Care Foundation (CHCF) is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus especially on making sure the system works for Californians with low incomes and for communities that have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a complex system. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. California Health Care Foundation | www.chcf.org 22 CalAIM Explained: Caring for Californians Leaving Incarceration ENDNOTES 1 Heather Harris, Pandemic Policymaking and Changed Outcomes in Criminal Courts, Public Policy Institute of California, April 2023. 2 Laura M. Maruschak, Marcus Berzofsky, and Jennifer Unangst, Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12 (PDF), US Dept. of Justice (DOJ), February 2015. 3 Emily A. Wang et al., "Propensity-Matched Study of Enhanced Primary Care on Contact with the Criminal Justice System Among Individuals Recently Released from Prison to New Haven," BMJ Open 9, no. 5 (2019): e028097. 4 Lucius Couloute, "Nowhere to Go: Homelessness Among Formerly Incarcerated People," Prison Policy Initiative, August 2018. 5 Doris J. James and Lauren E. Glaze, Mental Health Problems of Prison and Jail Inmates (PDF), DOJ, last revised December 14, 2006. 6 Laura M. Maruschak, Jennifer Bronson, and Mariel Alper, Indicators of Mental Health Problems Reported by Prisoners (PDF), DOJ, June 2021. 7 Joseph Hayes et al., California's Prison Population, Public Policy Institute of California, July 2019. 8 Charles Francis, Thomas Coyne, and Katie Herman, Reducing Homelessness for People with Behavioral Health Needs Leaving Prisons and Jails (PDF), Council of State Governments Justice Center, February 2021. 9 Emily A. Wang, Yongfei Wang, and Harlan M. Krumholz, "A High Risk of Hospitalization Following Release from Correctional Facilities in Medicare Beneficiaries," JAMA Internal Medicine 173, no. 17 (2013): 1621–28. 10 Ingrid A. Binswanger et al., "Release from Prison - A High Risk of Death for Former Inmates," New England Journal of Medicine 356, no. 2 (Jan. 11, 2007): 157–65. 11 "National Trends and Racial Disparities," Vera Institute of Justice, accessed March 27, 2023. 12 Hayes, California's Prison Population. 13 Erica Bryant, "Why We Say 'Criminal Legal System,' Not 'Criminal Justice System,'" Vera Institute of Justice, December 1, 2021. 14 Jac Charlier and Jessica Reichert, "Introduction: Deflection: Police-Led Responses to Behavioral Health Challenges," Journal for Advancing Justice, vol. 3, Emerging Best Practices in Law Enforcement Deflection and Community Supervision Programs, 2020, 1. 15 "Diversion," Center for Justice Innovation, accessed April 13, 2023. 16 COCHS Glossary: Speaking the Same Language: Criminal Justice, Health Care, and Information Technology, Second Edition, Community Oriented Correctional Health Services, April 2014. 17 "Jail Population Trends," California Board of State and Community Corrections, updated February 10, 2023. California Health Care Foundation | www.chcf.org 23 CalAIM Explained: Caring for Californians Leaving Incarceration ENDNOTES 18 Robert Lewis, "Waiting for Justice," CalMatters, March 31, 2021. 19 "Length of Stay," California Board of State and Community Corrections, last updated February 10, 2023. 20 Small but Growing Group Incarcerated for a Month or More Has Kept Jail Populations High, Pew Charitable Trusts, June 23, 2020. 21 "California 2019," National Institute of Corrections (NIC), 2019. 22 "California 2019," NIC. 23 Weekly Report of Population (PDF), California Dept. of Corrections and Rehabilitation, March 22, 2023. 24 A.B. 133, 2021–22 Leg., Reg. Sess. (Cal. 2021). 25 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018, Pub. L. No. 115-271, 3894 Stat. 132 (2018). 26 Sandra Williams (chief, Medi-Cal Eligibility Div.) to all county welfare directors et al., "Updated Policy Guidance Regarding Me- di-Cal Applications Received from Participants and Residents of CCTRP and MCRP Facilities" (PDF), Medi-Cal Eligibility Division Information Letter I 22-15, April 28, 2022. 27 Sandra Williams (chief, Medi-Cal Eligibility Div.) to all county welfare directors et al., "CalAIM Mandatory Pre-release Medi-Cal Application Process for Inmates and Youth of County Correctional Facility and County Youth Correctional Facilities" (PDF), Medi-Cal Eligibility Division Information Letter 22-27, November 10, 2022. 28 Sandra Williams (chief, Medi-Cal Eligibility Div.) to all county welfare directors et al., "Implementation of Senate Bill (SB) 184 - Extension of the Suspension of Medi-Cal Benefits for Adult Inmates, Redetermination Requirements, and Suspension Timeline Guidelines" (PDF), Medi-Cal Eligibility Division Information Letter 22-26, October 28, 2022. 29 A.B. 720, 2013–14 Leg., Reg. Sess. (Cal. 2013). 30 California Advancing and Innovating Medi-Cal (Cal-AIM) Justice-Impacted Advisory Group (PDF), California Dept. of Health Care Services (DHCS), February 2023. 31 "California Advancing and Innovating Medi-Cal (CalAIM) Justice-Involved Advisory Group: Review of Justice-Involved Initia- tive Policy and Operational Process Expectations" (PDF) (DHCS Justice-Involved Advisory Group meeting, July 28, 2022, virtual). 32 "Justice-Involved Capacity Building Program," DHCS; and "PATH Justice-Involved Capacity Building Program," DHCS. 33 "Justice-Involved Program," DHCS. 34 "Capacity and Infrastructure Transition, Expansion and Development (CITED)," DHCS. California Health Care Foundation | www.chcf.org 24 CalAIM Explained: Caring for Californians Leaving Incarceration ENDNOTES 35 "Collaborative Planning and Implementation," DHCS. 36 Whole Person Care pilots with primary target populations for justice-involved populations include Kern, Los Angeles, Placer, and Riverside Counties. 37 Strategies for Conducting Pre-release Medi-Cal Enrollment in County Jails (PDF), DHCS, last updated August 9, 2022. 38 Jane B. Wishner and Jesse Jannetta, Connecting Criminal Justice-Involved People with Medicaid Coverage and Services (PDF), Urban Institute, March 2018. 39 "About the ASAM Criteria," Amer. Society of Addiction Medicine. 40 "Collaborative Justice Courts," California Courts. 41 Transitions Clinic Network. California Health Care Foundation | www.chcf.org 25