1. Academic & Health Policy Conference on Correctional Health Chicago March 22, 2013 Ohiana Torrealday, PhD CCHP Administrative Director, Mental Health-Youth Services University of Texas Medical Branch-Correctional Managed Care Joseph Penn, MD CCHP Director of Mental Health University of Texas Medical Branch-Correctional Managed Care

2. University of Texas Medical Branch-Correctional Managed Care (CMC) Youth Services Pharmacy Services-University of Texas Medical Branch-CMC Amy Jo Harzke, DrPH, Jacques Baillargeon, PhD, Gwen Baillargeon, MS, Joseph Penn, MD (UTMB-CMC) Texas Juvenile Justice Department No Financial Disclosures

3. Objectives Discuss public health issues, medical and mental health care evaluation and treatment needs of “high risk” youth who enter the juvenile correctional system; Discuss increased challenge of covering a large geographic area while maintaining a high level of care and follow best practice in a cost-effective/conscious manner; Discuss opportunities and challenges in the implementation of a statewide correctional health care system utilizing an academic and state agency partnership and funding model.

4. Correctional Managed Care  A Strategic Partnership between:  The Texas Department of Criminal Justice  The University of Texas Medical Branch at Galveston  Texas Tech University Health Sciences Center  Focused upon a shared Mission:  To develop a statewide health care network that provides TDCJ offenders with timely access to a constitutional level of health care while also controlling costs  Managed by a statutorily established body:  The Correctional Managed Health Care Committee

5. Correctional Managed Care (CMC) CMC is a division of the University of Texas Medical Branch (UTMB) community health services, established in 1994. CMC divided into two sectors: TDCJ offenders served by UTMB (80% of population) and Texas Tech (20% of population). Provides medical, dental, nursing, and mental health services to offenders within the Texas Department of Criminal Justice (TDCJ) Provides medical, dental, nursing and psychiatric services to juvenile offenders in custody of the Texas Juvenile Justice Department (formerly TYC) 5

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7. Adult and Juvenile Correctional Units Served by UTMB-CMC

8. Advantages for the Criminal and Juvenile Justice Systems Provides statewide network of providers to cope with prison system expansion Provides access to credible, quality health care Assures medical management standards Provides cost-effective services Sharing of risk

9. Correctional Managed Care (CMC)-Youth Services Mental Health Services Overview Psychiatric diagnostic evaluations Psychotropic medication management Telepsychiatry Evaluation for CSU admission Emergency state hospital commitment evaluations Unit, school based and off- site consultations Clinical/case consultations Psychopharmacological consultation Psychotropic on- call/emergency services available statewide 24/7 Discharge planning Staff training and development on mental health issues

11. Juvenile Justice Population in Texas

12. U.S. vs. Texas U.S. Juvenile Arrest Rates for All Crimes 6,318 arrests for every 100,000 youth 2.11 million arrests of juveniles in 2008 134,575 youthful arrests in Texas In 2008 99,114 youthful arrests in Texas in 2011 *In TX, a juvenile is legally defined as a person under seventeen www.txdps.sate.tx.us/crimereports 6,318 arrests for every 100,000 youth 2.11 million arrests of juveniles in 2008 1,161,830 million arrests of juveniles in 2009

13. Texas Juvenile Justice Department

14. TJJD Facilities Statewide: -6 hardware secure facilities 3 closures in 2011 -9 Halfway Houses

15. Juvenile Justice in TX

16. www.tyc.state.tx.us/research

17. Youth Movement in System

19. TJJD Youth Country of Origin: Greatest percentage from Mexico, Honduras, El Salvador  89% Males  Median Age at Commitment: 16  84% of youth’s parents were never married, or divorced or separated  43% come from families with histories of criminal behavior  44% admitted gang members  35% had >1 felony adjudication -TJJD, 2011 Hispanic* African American Caucasian

20.  Median grade completed- 8 th grade  Median reading level- 6 th grade  35% special education eligible  44% in need of mental health treatment  38% had documented history of abuse/neglect  72% in need of alcohol or other drug treatment

21. Reasons for Commitment to TYC in FY 2009 www.tyc.state.tx.us/research

22. Reasons for Commitment 2009 2012 Burglary-23% (334) Aggravated Robbery-10% (152) Aggravated Assault-9% (133) Drug Offense-8% (118) Simple Assault-8% (114) Sexual Assault-7% (107) Burglary-22% (190) Simple Assault-11% (93) Aggravated Assault-10% (85) Aggravated Robbery-10% (82) Sexual Assault-8% (70) Drug Offense-6% (52)

23. Prevalence of Mental Illness in the U.S. Juvenile Justice System 65-70% of youth meet criteria for > 1 disorder Shufelt & Cocozza, 2006; Teplin et al., 2006; Wasserman et al., 2002; Wasserman et al., 2004 Many enter the Juvenile Justice system without having been diagnosed or treated Studies examining rates of psychopathology have been inconsistent: Major affective disorders 5 to 88% Substance use disorders 20 to 88% Psychosis 12 to 45% Teplin et al, 2006

24. Prevalence of Mental Illness in the Juvenile Justice System in the U.S. Even higher rates of comorbidity for females Studies range from 79-99% (virtually all females) Females have higher rates of any single and comorbid psychiatric disorders including: major depressive episodes some anxiety disorders PTSD somatization disorders borderline personality disorder substance use disorder other than alcohol and marijuana PTSD among youth in juvenile justice similar to youth in mental health and substance abuse systems (3-50%) BUT up to 8x higher than same aged youth in the community population Veysey, 2003; Wasserman, et al., 2003; Grisso, 2004; Grisso & Underwood, 2004; Teplin et al., 2002, 2004; OJJDP, 2006

25. Prevalence Studies: Recent Meta-analyses Colins, et al., 2010 15 studies using structured diagnostic interviews Multicountry (10), detained male adolescents (N=3401) 70% met criteria for >1 disorder Mean prevalence for CD- 46.4%, SUD-45.1%, ODD 19.8%, ADHD-13.5%, MDD- 12%; SAD-10.7%; PTSD-10%, psychotic disorders-1.4% Fazel, et al., 2008 25 psychiatric surveys Multicountry (8), detained males (N=13,778) & females (N=2,972) Mean prevalence for CD- 52.8% both, ADHD-11.7% boys, 18.5% girls, MDD- 10.6% boys/29.2% girls; psychotic disorders- 3% both

26. Karnik et al., 2010 650 males/140 females Incarcerated 9 months in California DJJ Used SCID, DICA & SIDP-IV Any psychiatric disorder: Boys 17: 98% Girls 17: 97%

27. Unfortunate Reality “ The juvenile justice system has become the default placement for many youth with mental health disorders who are not receiving appropriate psychological and psychiatric treatment in the community. ” - Boesky, L. M. (2002) “ …the juvenile justice system is becoming the dumping ground for these kids. ” –Cocozza, cited in Bender (2002)

28. How Does Texas Compare? What is the Prevalence of Psychiatric Disorders Among Youth Incarcerated Statewide?

29. Prevalence Study of Texas Juvenile Justice Incarcerated Population Study Period: January 1, 2004- December 31, 2008 Retrospective analysis of data from UTMB-CMC Electronic Medical Record & TYC Information System All youth committed to TYC secure facilities from 10-21 years of age Sample size of 11,603 youth -Harzke et al., 2012

30. Population Characteristics Total population: 11,603 youth 90.2% Male 71.3% > 16 years at time of commitment 34% African American & 42.6% Hispanic Nearly half of first referred to Probation when <13 years Average number of referrals:7.5 94% had only one commitment during study period (5 years) Almost 66% not committed to TYC until age 16 or older 36% committed for violent offense Median length of sentence: 9 months -Harzke et al., 2012

31. *excludes PTSD Prevalence of Psychiatric Disorders Among TJJD Youth

32. Comparable prevalence estimates to other samples of incarcerated youth Much higher than estimates from youth in different juvenile justice settings (detention or probation) Prevalence of any psychiatric disorder slightly higher among females (99 vs. 98%) Substantially higher prevalence estimates among females for any depressive disorder, any adjustment disorder, any bipolar disorder, any anxiety disorder, & PTSD

33. System Challenges Expansive area-268,581 square miles Units located in remote and underserved areas Unified statewide service system Shortage of qualified child providers Increased outside entities/advocate involvement

34. Our Approach Statewide Electronic Medical Record Centralized pharmacy Telepsychiatry services Telehealth HUBs Secure facilities and Halfway Houses Academic partnership with Psychiatry Department Engage in initial conversation & gatekeeping

35. Electronic Medical Record On system-wide servers Pearl – Web based Evaluations Progress notes Consults Medical care Labs Orders Email Scheduled Patients System Reports

36. Pharmacy Services

37. Overview of Operations Pharmacy procurement and distribution provided by UTMB Correctional Pharmacy statewide Clinical pharmacy services and consultation Medications prescribed, filled and distributed using computerized systems Pharmacy and Therapeutics Committee provides oversight CMC Formulary Disease Management Guidelines

38. Medication Delivery System Provider Order entry (Transmitted electronically to Pharmacy) Centralized Pharmacy reviews, dispenses and ships order (generally within 24 hour turn-around time) Medication order Received by the Facility Medication administered to patient Computerized ordering system (PRS) provides a template for each medication with normal dose and frequency to reduce order entry errors. Computer system flags potential drug-drug interactions at the time of prescribing. A copy of all current active medications placed in the patient’s EMR record so that each provider is aware of all medications being taken by the patient. Access to automated prescribing system is restricted to licensed providers through use of identification security.

39. Pharmacy Services Strategies implemented to maximize pharmacy services: Computerization (physician electronic order entry) Centralization of drug distribution services Automation of drug distribution services Purchasing initiatives Development of formulary management program

40. Pharmacy Youth Services-FY 12  Number of facilities at year end15  Average number of patients per month1,394  Number of prescriptions46,873  Average number of prescriptions per month3,906  Average number of prescriptions per day185

41. Number of Prescriptions per Member per Year

42. Telemedicine/Telepsychiatry Response to system need Tele-Health provides specialty care to correctional facilities in rural areas where providers are scarce and difficult to recruit Quick and easy access to collaborating physicians and peers to discuss/staff challenging patients and situations Allows for greater continuity of care Cost effective alternative

43. 6,623,366 under 18

45. The Virtual Provider Office Links providers with patients regardless of location Uses the same telecommunications link as the electronic medical record system, limiting costs Utilizes high resolution cameras to enhance diagnostic capabilities Serves as a unified workplace for providers and resources

46. Total TJJD CMC Healthcare Encounters-2012 -TJJD, 2012 *optometry, orthopedic highest ADP: 2008-2,468 2009-2,027 2010-1,695 2011-1,399

48. Academic Partnerships Collaboration/MOU with UTMB Department of Psychiatry and Behavioral Sciences since 2009 Academic and clinical partnership Specialized professional service Child Psychiatry Faculty Providers and Supervisors Child Psychiatry Fellows Unique training opportunity Recruitment effort

49. Advocate/Outside Involvement Due to increased involvement by advocacy groups, parents, attorneys:  Gatekeeping efforts by Administration  Proactive engagement in initial conversation with advocacy groups  Education, information gathering  Parent/Guardian Notification  Creation of Clinical Case Managers-RNs  Point of contact for health care services received by youth  Coordination of care-record gathering, clinical staffings, MDTs, discharge planning

50. Summary Despite decrease in population size, continued increased need for mental health and other health services Despite challenges, system must respond and provide quality health care Technology and collaborative partnerships address needs and challenges of large systems

51. References Bender, E. (2002). Justice system ill equipped to treat mentally ill youth. Psychiatric News, 37(23), 17. Boesky, L. M (2002). Juvenile Offenders with Mental Health Disorders: Who They Are and What Do We Do with Them? Washington, DC: American Correctional Association. Harzke, A. J., Baillargeon, J., Baillargeon, G., Henry, J., Olvera, R., Torrealday, O., Penn, J. & Parikh, R. (2012). Prevalence of psychiatric disorders in youth committed to juvenile correctional facilities in Texas. Journal of Correctional Health Care, 18(2) 140-152.. Karnik, S. N., Soller, M. V., Redlich, A., Silverman, M. A., Kraemer, H. C., Haapenan, R., & Steiner, H. (2010). Prevalence differences of psychiatric disorders among youth after nine months or more of incarceration by race/ethnicity and age. Journal of Health Care for the poor and Underserved, 21, 237-250. Shufelt, J.L., & Cocozza, J. J. (2006). Youth with mental health disorders in the juvenile justice system: Results from a multi-state prevalence study. Research and Program Brief. National Center for Mental Health and Juvenile Justice. Snyder, H. N, & Sickmund, M. (2006). Juvenile Offenders and Victims: 2006 National Report. Washington, DC: US Department of Justice, Office of Juvenile Justice and Delinquency Prevention. Teplin, L. A., Abram, K. M., McClelland, G. M., Mericle, A. A., Dulcan, M. K., & Washburn, J. J. (2006). Juvenile Justice Bulletin: Psychiatric Disorders of Youth in Detention. Washington, DC: US Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. www.tyc.state.tx.us/research www.tyc.state.tx.us/research www.tyc.state.tx.us/research U.S. Census Bureau. (2011, June 3). State & county Quickfacts: Texas. Retrieved July 8, 2011, from http://quickfacts.census.gov http://quickfacts.census.gov Wasserman, G. A., Jensen, P. S., Ko, S. J., Cocozza, J., Trupin, E., Angold,A., Cauffman, E., & Grisso, T. (2003). Mental health assessment in juvenile justice: Report on the consensus conference. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (7), 752-761. Wasserman, G., McReynolds, L., Ko, S., Katz, L., Cauffman, E., Haxton, W., & Lucas, C. (2004). Screening for emergent risk and service needs among incarcerated youth: Comparing MAYSI-2 and Voice DISC-IV. Journal of the American Academy of Adolescent Psychiatry, 43, 629-639. Wasserman, G., McReynolds, L., Lucas, C., Fisher, P., & Santos, L. (2002). The voice DISC-IV with incarcerated male youths: Prevalence of disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 314-321.

52. Contact info: Ohiana Torrealday, PhD CCHP ohtorrea@utmb.edu (512) 374-9308