One day, early on in my career, I recall a conversation with a manufacturing manager, whose team built a very complicated piece of telecommunications circuitry-the core product of a fast-growing business. My question was simple: “How do you do it?”
He looked at me, years of experience in his eyes, and said simply, “You know, this just barely works.” I realized then that his team's success depended on managing a thousand things that could go wrong every day-but didn't.
In our field, things are much the same. It is difficult to develop and then replicate methods and practices that consistently deliver great outcomes. Consistency in outcome demands consistency throughout and great attention to detail. Sometimes, our efforts seem so fragile, so difficult to explain, as though they just barely work.
But then, people like our 2011 Behavioral Healthcare Champions help us break through and show us how programs that master the details can make a powerful difference. Take, for example, the criminal justice work done by one of our 2011 Champions, Leon Evans of San Antonio, Tex. He champions a system in which police are trained to recognize that about one in five individuals placed under arrest has a mental health or substance use problem that needs specialized (but not ER) treatment, followed by adjudication to community correctional or transitional housing (not jail or prison) and ongoing community supports.
The process by which this is done is no secret (see Leon's profile page). The savings to governments, law enforcement, hospitals, jails, and other community resources are remarkable in cities like San Antonio, where effective justice reforms are in place. And, with the help of reentry programs, some cities are helping to reduce recidivism and other social costs for the many released from incarceration each year.
Yet, the battle for would-be champions of criminal justice reforms remains difficult, dogged by skepticism and dwindling federal and state resources. In too many counties, non-violent offenders (NVOs) with behavioral health problems aren't properly treated until long after their arrest, after weeks in jail, a visit to court, and perhaps, imprisonment. This occurs despite the fact that effective jail diversion, community-based corrections, treatment, housing, and community support programs can help NVOs and reduce recidivism for a fraction of the cost of jail or prison.
The federal government, which normally champions civil rights, does little to help. In fact, its first action to those who go behind bars is to withdraw their federal entitlement eligibility. CMS mandates this under the 46-year-old “IMD exclusion,” a rule that bans federal match funds from flowing to state “institutions for mental disorders,” a category that covers psychiatric hospitals, jails and prisons.
So, many new defendants, though presumed innocent under law, face the loss of Medicaid eligibility-for many, a key link to treatment-while they await criminal trial. Many counties spend heavily to fill this treatment void, but the break in continuity of care is costly and disruptive. And, this exclusion, which starts on the first day of an individual's incarceration, rarely ends on the last due to varying state systems. Some states “terminate” benefits and require those incarcerated to reapply, while others “suspend” benefits (what CMS recommends) so eligibility can be re-established upon release. But, the process often doesn't go smoothly. For individuals with mental health or substance use disorders, the time involved can be the difference between reconnecting to help and avoiding arrest, or starting the sorry cycle of arrest and incarceration again.
With healthcare reform's 2014 insurance expansion looming, organizations like the National Association of County Behavioral Health and Developmental Disabilities Directors (NACBHDD) are reviving efforts to get more effective criminal justice reforms in place for incarcerated individuals with behavioral health problems. Reforms that, in all states, would favor treatment over incarceration for NVOs, ensure continuity of care for the innocent and the incarcerated, and ensure adequate reentry resources for the newly released. There are a lot of details, to be sure, but successfully managing this complexity is the difference between criminal justice that fails often at great expense and justice that works consistently—even if just barely-at a much lower cost to society.
Dennis G. Grantham, Editor-in-Chief