Transcript Who are they and why are they there? The Youth of Texas

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
•
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
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.
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
Correctional Managed Care (CMC)
 CMC is a division of the
 Provides medical, dental,
 CMC divided into two
 Provides medical, dental,
University of Texas
Medical Branch (UTMB)
community health
services, established in
1994.
sectors: TDCJ offenders
served by UTMB (80% of
population) and Texas
Tech (20% of population).
nursing, and mental health
services to offenders within
the Texas Department of
Criminal Justice (TDCJ)
nursing and psychiatric
services to juvenile
offenders in custody of the
Texas Juvenile Justice
Department (formerly
TYC)
5
6
Adult and Juvenile Correctional Units Served
by UTMB-CMC
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
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 offsite consultations
 Clinical/case consultations
 Psychopharmacological
consultation
 Psychotropic oncall/emergency services
available statewide 24/7
 Discharge planning
 Staff training and
development on mental
health issues
Juvenile Justice Population
in Texas
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
1,161,830 million arrests of juveniles in 2009
2008 Juvenile Arrests in Texas
Age Groups
16 yrs*
Females
15 yrs
Males
13-14 yrs
134,575 youthful arrests in Texas In 2008
10-12 yrs
Under 10
99,114 youthful arrests in Texas in 2011
0
5
10
15
20
25
30
35
40
Number of Arrests in Thousands
www.txdps.sate.tx.us/crimereports
*In TX, a juvenile is legally defined as a person under seventeen
Texas Juvenile Justice Department
TJJD Facilities
Statewide:
-6 hardware secure facilities
• 3 closures in 2011
-9 Halfway Houses
Juvenile Justice in TX
Youth Committed to TJJD Custody
FY 2007-FY 2011
3000
2500
2,498
2000
1,696
1500
1,596
1,120
1000
991
500
2007
2008
2009
2010
2011
www.tyc.state.tx.us/research
Youth
Movement
in System
TJJD Youth
 89% Males
Caucasian
 Median Age at Commitment: 16
18%
 84% of youth’s parents were never
married, or divorced or separated
 43% come from families with
histories of criminal behavior
48%
32%
Hispanic*
African American
 44% admitted gang members
 35% had >1 felony adjudication
•Country of Origin: Greatest percentage from
Mexico, Honduras, El Salvador
-TJJD, 2011
 Median grade completed- 8th grade
 Median reading level- 6th 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
Reasons for Commitment to TYC in FY 2009
www.tyc.state.tx.us/research
Reasons for Commitment
2009
2012
 Burglary-23% (334)
 Burglary-22% (190)
 Aggravated Robbery-10% (152)
 Simple Assault-11% (93)
 Aggravated Assault-9% (133)
 Aggravated Assault-10% (85)
 Drug Offense-8% (118)
 Aggravated Robbery-10% (82)
 Simple Assault-8% (114)
 Sexual Assault-8% (70)
 Sexual Assault-7% (107)
 Drug Offense-6% (52)
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
Prevalence of Mental Illness in the Juvenile
Justice System in the U.S.
 Even higher rates of comorbidity
for females
 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
 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

Veysey, 2003; Wasserman, et al., 2003;
Grisso, 2004; Grisso & Underwood, 2004;
Teplin et al., 2002, 2004; OJJDP, 2006
Prevalence Studies: Recent Meta-analyses
Colins, et al., 2010
Fazel, et al., 2008
 15 studies using structured
 25 psychiatric surveys
diagnostic interviews
 Multicountry (10), detained
male adolescents (N=3401)
 70% met criteria for >1
disorder
 Mean prevalence for CD46.4%, SUD-45.1%, ODD
19.8%, ADHD-13.5%, MDD12%; SAD-10.7%; PTSD-10%,
psychotic disorders-1.4%
 Multicountry (8),
detained males (N=13,778)
& females (N=2,972)
 Mean prevalence for CD52.8% both, ADHD-11.7%
boys, 18.5% girls, MDD10.6% boys/29.2% girls;
psychotic disorders- 3%
both
Karnik et al., 2010
 650 males/140 females
 Incarcerated 9 months in California DJJ
 Used SCID, DICA & SIDP-IV
 Any psychiatric disorder:
 Boys < 16: 97%
Boys >17: 98%
 Girls < 16: 100% Girls > 17: 97%
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)
What is the Prevalence of Psychiatric Disorders
Among Youth Incarcerated Statewide?
How Does Texas Compare?
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
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

 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
Average number of
referrals:7.5
-Harzke et al., 2012
Prevalence of Psychiatric Disorders Among TJJD Youth
Any Psycho c Disorder
Females
2.80%
1.90%
Males
13.80%
12.30%
Disrup ve Disorder NOS
ODD
2.60%
1.20%
83.00%
83.30%
CD
15.30%
18.60%
ADHD
76.50%
75.50%
Any Substance Use Disorder
PTSD
Any Anxiety Disorder*
Any Bipolar Disorder
Any Depressive Disorder
Any Psychiatric Disorder
*excludes PTSD
18.80%
4.20%
7%
3.20%
40.60%
17.10%
25%
11.30%
99.60%
98.20%
 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
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
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
Electronic Medical Record
 On system-wide servers
 Pearl – Web based
 Evaluations
 Progress notes
 Consults
 Medical care
 Labs
 Orders
 Email
 Scheduled Patients
 System Reports
Pharmacy Services
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
Medication Delivery System
•
•
•
•
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.
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
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
Pharmacy Youth Services-FY 12
 Number of facilities at year end
 Average number of patients per month
 Number of prescriptions
 Average number of prescriptions per month
 Average number of prescriptions per day
15
1,394
46,873
3,906
185
Number of Prescriptions
per Member per Year
5,000
33.6
31.2
4,000
28.1
30
3,500
25
3,000
20.3
20
2,500
15
15
4,500
12.7
12.6
12.7
11.6
11.4
11.8
2,000
12.9
1,500
10
1,000
Fiscal Year
# RX PMPY
Average Census
FY12
FY11
FY10
FY09
FY08
FY07
FY06
FY05
0
FY04
0
FY03
500
FY02
5
Number of Patients
35
FY01
Number of Prescriptions
per Member per Year
40
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
6,623,366 under 18
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
Total TJJD CMC Healthcare Encounters-2012
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
Total: 64,662
ADP: 1,281
Nursing
Medical
Psychiatry
Dental
Specialty
Clinics*
41,602
9,654
7,503
4,800
1,103
ADP: 2008-2,468 2009-2,027
*optometry, orthopedic highest
2010-1,695
2011-1,399
-TJJD, 2012
Psychiatric Encounters
12,000
10,000
8,000
6,000
4,000
2,000
0
Psychiatric
2008
2009
2010
2011
Projected 2012
10,910
10,080
9,249
8,208
7,530
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
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
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
References
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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
U.S. Census Bureau. (2011, June 3). State & county Quickfacts: Texas. Retrieved July 8, 2011, from
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.
Contact info:
Ohiana Torrealday, PhD CCHP
[email protected]
(512) 374-9308