Data on Justice-Involved Populations Targets SDOH, Cuts Recidivism

Clocking in at around $150,000 in a single state annually, recidivism is a costly problem for the American taxpayer, and yet one of the most poignant examples of where concerted care coordination and social determinants of health work can help.

Figures show recently jailed people experience a slate of health problems at a higher rate than individuals with no criminal justice involvement. They’re about three times more likely to have HIV/AIDS, are seven times more likely to have Hepatitis C, and they are at higher risk for all-cause morbidity and mortality.

What’s more, justice-involved populations see high rates of behavioral and mental health issues. Between 15 and 25 percent of incarcerated people in the US have some form of mental illness, while just 5 percent of the general population do.

For CareSource, a managed care organization serving Medicaid members in Ohio, those problems are especially pressing. After all, about one in 12 Medicaid beneficiaries will have at least one jail booking in their lifetimes, with the risk of recidivism high when their social needs aren’t met.

Among CareSource beneficiaries specifically, substance use disorder is an issue for 50 percent of those members who have been incarcerated, while 15 percent suffer from severe or ongoing mental illness.

“Upwards of 60 to 65 percent of individuals in jail have a substance use disorder,” Kieran Hurley, the director of criminal justice services at CareSource, told PatientEngagementHIT.

“We also know with substance use disorder that it's one of the criminogenic risk factors that are relevant. There are a bunch of factors that contribute to criminogenic risk, but we know from a behavioral health perspective that substance use disorders, if untreated, continue people on a path of continued criminal justice involvement.”

The link between mental health and justice involvement is more tenuous, Hurley explained, but it’s generally accepted fact that individuals with mental illness are significantly more likely to become incarcerated at some point than those without.

There are serious opportunities to mitigate these behavioral health challenges, something that can be exciting for healthcare professionals. The healthcare industry has come a long way in building out mental health services as well as effective substance use disorder treatments that have the potential to mitigate the risk of recidivism among previously jailed populations.

“That starts to speak to the question around social determinants of health, because we also know this population experiences much larger incidence of homelessness, food insecurity, lack of family and social supports. And so again, what precedes the other? What is the linkage?” Hurley posited.

“The reality is those populations we know have not only higher rates of incarceration, but they also repeat and reenter into incarceration at much higher rates,” he continued. “So addressing things like substance use disorder, which we know to be a criminogenic risk factor, and addressing all the myriad of social determinants of health and the needs around stability in the community, stability with social systems and supports, is super important to meeting the needs of individuals and changing the dynamic of justice involvement.”

The only problem, most experts are finding, is the data around who’s being jailed and who has SDOH needs isn’t very accessible. The healthcare, social services, and criminal justice systems are pretty siloed, and the onus isn’t exactly on one entity to take ownership of this problem.

“What we know about our incarceration data is that the federal/state government doesn't have the kind of repository we do to look at coverage across the nation,” Cheston Newhall, a senior market manager at Appriss Insights, a data analytics company that provides information about recently incarcerated or jailed individuals to health payers like CareSource, said in a separate call.

“The missing puzzle pieces here really are understanding a history of an individual, beyond what the doctor knows when I'm showing up for an emergency visit, and then also the timing.”

Those lapses in data are causing huge problems, Hurley noted. In addition to not knowing who, exactly, might have a behavioral health or SDOH need, limited information about justice-involved people makes it hard for health payers and providers to facilitate re-entry and re-engage individuals with the traditional health system that serves them outside of prison or jail.

Put simply, CareSource could be in the dark about which members are going in and out of the criminal justice system and which have social needs to supplement medical care. And that could keep those individuals from getting any care coordination at all.

“As a managed care organization working with the Medicaid population, while we don't pay for services today inside jails or prisons, certainly the impact of that disruption causes potentially serious impact to the health of our members because of that discontinuity of care,” Hurley stated.

“Trying to bridge those gaps during that time of entry and re-entry from incarceration, from a CareSource perspective, is key to our members' health and key to the long-term health utilization and access to treatment.”

CareSource recently partnered with Appriss Insights, giving the managed care organization a more granular view of the specific needs among its about 7,000 justice-involved beneficiaries. In addition to the findings about behavioral health—55 percent have substance use disorder or severe mental illness—CareSource determined critical medical needs. About a quarter of justice-involved members have a physical chronic illness, while 10 percent are pregnant.

Having access to that breadth of data has helped Hurley and his team at CareSource better focus interventions that will benefit recently incarcerated individuals, while also assisting providers who serve CareSource’s members.

“We’re able to not just to say, ‘Hey, 60 percent plus of individuals have a SUD need,’” Hurley noted. “We can now actually identify who those individual members are. And so we can talk about developing the interventions to change how we serve our members.”

Broadly, CareSource said this data has helped it prioritize a population that has a history of significant care access barriers. Hurley said the managed care organization has been able to actually utilize the fact of an incarceration as an opportunity to engage with an individual who is usually unengaged with the community and the healthcare industry.

“We've done a lot of work there and do outreach and engagement with those members during that critical time,” Hurley said of the point where an individual would re-enter society following incarceration. “We are not waiting for them to show up in the ED or in an inpatient hospitalization, but being proactive in outreach to those individuals. It seems basic, but it is not happening for the vast majority of people experiencing incarceration.”

CareSource has guided its provider partners in doing the same.

“How can we assist our providers to better identify and engage with our members in kind of critical times at re-entry?” Hurley queried. “When we think about the population with substance use and specifically opioid use disorder, we know they are at 12 times the risk of overdose and death post-release. Assisting our providers in understanding when their clients have entered or are exiting from incarceration so that they can engage those members as well.”

The granular data into who experiences substance use disorder or mental illness has also allowed CareSource to tailor member-specific interventions. After engaging the patient upon re-entry, CareSource can refer them to community health programs that address specific issues.

Of course, just having the data is not a panacea, Hurley asserted. Patient trust is a serious issue, and it’s an uphill battle when CareSource works to engage its recently incarcerated members.

“One of the most difficult realities when trying to engage people, whether it's in healthcare, whether it's in community-based resources and services, employment services, is trust,” Hurley stated. “Systemically, a lot of individuals in the criminal justice system don't trust the criminal justice system. They don't trust or understand necessarily the healthcare system, especially in states with recent expansion where many more people are now eligible for Medicaid.”

Low patient health literacy and limited understanding of how the medical system is working to help people is a serious roadblock, Hurley said. Generally speaking, people withhold their trust because they do not necessarily believe someone has their best interests in mind. That, plus the extreme complexities of healthcare and health insurance, can be very off-putting for recently jailed individuals.

Hurley said organizations like CareSource can build better trust by helping recently incarcerated individuals understand how these systems work.

“We need to take a very directed effort at education around healthcare, how insurance works, how healthcare works,” Hurley said.

But simply explaining how healthcare works won’t necessarily convince someone to engage with it. Like other efforts to build patient trust in healthcare, Hurley said groups working with justice-involved people need to be ever-present.

“We also need to be one-to-one present with individuals either through our employees or through our provider communities and through the broader network of social resources,” Hurley advised. “For example, promoting that our community providers engage with justice-involved members in court and jail settings. That can be a challenge, but ultimately it is what drives better engagement in ongoing health care and treatment.”

This approach can be replicated nationwide if only key entities have access to the data necessary for risk stratifying and tailoring interventions. As healthcare, taxpayers, and other related groups come up against the costs of recidivism—both literal costs and human costs—the urgency of meeting social and medical needs contributing to justice involvement may grow.

In order to meet that moment, the data breakdowns between healthcare, the criminal justice system, and social services will need to be bridged. It’s a tall order, but as shown in the CareSource case study, it can lead to focused intervention.