Ensuring Access to Medicaid for Inmates with Mental Illnesses Who Are Re-Entering Their Communities in Oklahoma

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Ensuring Access to Medicaid for Inmates with
Mental Illnesses Who Are Re-Entering Their
Communities in Oklahoma
Henry Ireys Presented at the Disability Policy
Research Forum Washington, DC October 21, 2010
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Overview

• Policies affecting prisoners with mental
  illnesses
• Oklahomas increase in offenders with mental
  illnesses
• A program implemented in 2006 to improve
  discharge planning for inmates with mental
  illnesses
• Findings from an evaluation of the program

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No Medicaid Coverage in Prisons

• States cannot obtain federal financial
  participation for Medicaid services provided to
  individuals in correctional facilities
• Most states
• Consider these adults to be ineligible for
  Medicaid
• Will not accept Medicaid applications until after
  discharge

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Access to Services After Discharge

• Low-income, working-age adults with mental
  illness who are leaving correctional facilities
  need access to care
• Medicaid coverage as their only option
• Majority must obtain federal disability benefits
  to become eligible for Medicaid
• In some states (such as Oklahoma), receipt of
  disability benefits does not automatically confer
  Medicaid coverage
• Significant application barriers, delays in
  coverage

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Psychiatric Hospital Commitments and Offenders in
Prison, Oklahoma, 19602005
Per 100,000 Oklahomans
All Patientsin Psychiatric Hospitals
All Offendersin Prison
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Offenders in Oklahoma with Mental Illness, 2008

• About 50 percent of incarcerated offenders (about
  12,000) had a history of or exhibited mental
  illness
• Female offenders 79 percent (2,050)
• Male offenders 46 percent (9,840)
• About 27 percent (about 6,400) either received
  treatment for serious mental illness or needed
  treatment and refused it

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Offenders in Oklahoma with Mental Illness, 2008
(contd.)

• About 19 percent (4,500) were taking psychotropic
  medications
• Approximately 1,000 offenders who needed
  treatment for, or had current symptoms of, a
  serious mental illness were discharged to
• Probation/parole supervision
• Directly to street without supervision

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How to Respond?

• Collaborative efforts to implement better
  discharge planning involved many stakeholders
• Department of Corrections (DOC)
• Department of Mental Health and Substance Abuse
  Services (DMHSAS)
• Oklahoma Health Care Authority (Medicaid)
• Department of Human Services (Medicaid
  eligibility)
• Social Security Administration (SSA), State
  Office
• Division of Disability Determination in the
  Department of Rehabilitation Services

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Oklahomas New Program Integrated Services
Discharge Managers

• Discharge managers as boundary spanners
• Employees of the DMHSAS central office, based in
  correctional facilities
• Have credibility with DOC and community mental
  health staff
• Discharge managers with resources
• Receive all training required by departments of
  corrections and mental health
• Receive SSI/SSDI Outreach, Access, and Recovery
  (SOAR) training
• Have funds ready to assist with offenders needs

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Integrated Services Discharge Managers Specific
Activities

• Participate in prisons interdisciplinary team
• Interview clients to develop consumer-directed,
  person-centered transition planning
• Coordinate discharge planning and referrals to
  community services
• Work with existing community-based
  agencies/care-coordination teams to provide
  post-discharge support and services

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Discharge Managers Help Eligible Inmates Enroll
in Medicaid at Discharge
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Disability Determinations

• Federal disability benefits SSI or SSDI
• Average time until decision three to five months
  (excluding consultative exam)
• Anecdotal reports Adults with MI take longer
• For SSI/SSDI applicants
• Consent forms
• Gathering of information regarding medical,
  functional status
• Consultative exam, if needed

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Is the New Program Working?

• Primary evaluation question
• Will Oklahomas program of enhanced discharge
  planning improve enrollment into Medicaid for
  eligible inmates with serious mental illness?
• Other questions
• Does the program enhance service use?
• Does it reduce recidivism?

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Evaluation Design

• Comparison of program participants with
• Similar inmates at the same three institutions
  two years before the new program
  pre-intervention comparison group
• Similar inmates who were discharged from other
  institutions during the same period
  contemporaneous comparison group
• Study period July 2007March 2008

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SSI/SSDI Application Results
Source Oklahoma Department of Rehabilitative
Services, Disabilities Determination Division
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Did Discharge Managers Help Inmates Enroll in
Medicaid?
All Participants Screened Participants
Number 77 53
Percentage Enrolled
At discharge 24.7 32.1
Within 30 days 28.6 37.7
Within 90 days 37.7 47.2
Source Mathematicas analyses of project data
compiled from Oklahomas DMHSAS, DOC, OSBI, and
OESC administrative records.
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How Did the Intervention GroupCompare with Other
Groups?
Intervention Pre-Intervention Contemporaneous
Number 77 195 130
Percentage Enrolled in Medicaid
At discharge 24.7 8.2 3.1
Within 30 days 28.6 14.4 6.2
Within 90 days 37.7 16.9 9.2
Percentage Using Services
Within 90 days 62.3 46.7 35.4
Source Mathematicas analyses of project data
compiled from Oklahomas DMHSAS, DOC, OSBI, and
OESC administrative records.
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What Specific ChangesLed to Positive Outcomes?

• Dedicated, trained staff
• New, revised memoranda of understanding between
• Correctional facilities and local SSA offices
• Corrections and mental health departments
• New procedures within local DDS offices for
  flagging applications from persons with
  disabilities
• Dropped requirement for in-person interviews for
  program participants

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Summary

• Oklahoma designed and implemented a comprehensive
  re-entry program for offenders with mental
  illness
• Focused discharge planning for selected,
  high-risk offenders
• Program integrated into ongoing efforts via
  interagency collaboration

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Summary (contd.)

• Analyses suggest that
• The intervention significantly increased Medicaid
  enrollment and service use
• Specific administrative changes at local and
  state levels contributed to program success

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Full Report Available

• Establishing and Maintaining Medicaid
  Eligibility Upon Release from Public Institutions
• Copies are available on a table near the front
  desk
• Also see the Substance Abuse and Mental Health
  Services Administration (SAMHSA) website
  http//www.samhsa.gov

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Acknowledgments

• Many thanks to
• Judith Teich and Jeff Buck (project officers at
  SAMHSA)
• Robert Mann (coordinator of clinical social work,
  Oklahoma DOC) and many others in Oklahoma
• Audra Wenzlow, Carol Irvin, and Matthew Hodges
  (colleagues at Mathematica)

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For More Information

• Please contact
• Henry T. Ireys
• [phone]
• hireys_at_mathematica-mpr.com