Expanding Medicaid and CHIP's Role in Corrections: Implementing Section 5121 New Continuity of Care Requirements for Youth and Young Adults

Heather Tubman-Carbone: Good afternoon, everyone. I want to start by saying thank you for joining us at this Bureau of Justice Assistance, or BJA as you may know us, webinar on section 5121 of the 2023 Consolidated Appropriations Act. We are thrilled to have you all here and to be joined by our partners at the BJA National Training and Technical Assistance Center, also known as NTTAC and the Health and Reentry Project or HARP.

We cannot do the work that we do without our partners at HARP and NTTAC, and they've been instrumental to getting partners closer to implementation around 5121. So our sincere thanks to both organizations.

We are also delighted to be joined for a panel discussion by valuable partners in the field who are attempting to implement. Section 5121 requirements at the state and local levels.

Our sincere thanks to Sheriff Jerry Clayton, Emily Eisenman, Melissa Pierson, and Secretary Kelly Wasko, for giving their time and expertise today.

For those unfamiliar with BJA, our mission is to provide leadership and services in grant administration and criminal justice policy development to support state, local, and tribal justice strategies to achieve safer communities.

In our day-to-day work, it's partnering with leaders like you all at the county level regarding issues and corrections in particular, to partner, to reduce and prevent crime, reduce recidivism, and promote a fair and safe criminal justice system.

All of that, to say, at first blush, it may seem odd to have leaders in corrections and criminal justice gathered to discuss Medicaid laws.

Believe me, I thought it was very odd, too, but the reality is, particularly for those of us on this webinar, we know firsthand at BJA that people in prisons and jails need some help, and that includes young people and leveraging Medicaid is a way to get him. That, excuse me, a way to get them that help.

The over-representation of people with mental illnesses, substance use conditions, chronic physical health challenges, and more in jails across our country is no surprise to anyone on this call.

One recent study showed that in the 2 weeks after release, people leaving incarceration were 12 times more likely to die than the general population. 12 times. And they were 129 more times more likely, excuse me, to die of an opioid overdose.

Losing Medicaid coverage is associated with higher rates of criminal behavior and incarceration among our young men, and poor access to coverage can result in costly visits to the emergency room hospitalizations and reincarceration.

Fortunately, we know the factors that drive incarceration and recidivism, and we have to do what we can to address those factors.

Providing quality care and ensuring continuity of care during a person's period of incarceration is our duty as correctional professionals and leaders. For many with criminal justice involvement, the lack of health insurance is a barrier to safe reentry and a factor that impacts recidivism. By expanding access to coverage through Medicaid, we're acting to reduce or eliminate that barrier for a sizable portion of the population.

The Medicaid changes that you'll hear about today are an important step in that direction. For years there was not much interaction between corrections and the Medicaid system at the State, federal, and local levels. However, that dynamic has been changing. Many States have moved from terminating a person's Medicaid coverage upon intake to suspending it and to reinstating coverage upon release.

I'll let my friends at HARP get into the weeds on Section 5121 with you all. But I wanted to underscore why we at BJA think this provision around youth is incredibly important.

While BJA does not have a direct hand in implementing this law and the related rules, given that the requirements apply to prisons and jails in every State, we are dedicated to helping raise awareness around this work through engagements like this one and encouraging preparatory efforts to be collaborative across corrections and Medicaid.

We have worked over the last year with national stakeholders and our partners at HARP to raise awareness, and we also spent this fall listening directly to jurisdictions at the Department of Corrections and jail level around what you need to carry out those requirements.

The suite of materials, the checklists, the FAQs, and the getting ready guides which are released today, that David at HARP will go in into depth on, they are the direct result from hearing all of from all of you what was needed. 

If you haven't seen these materials yet, we will put links to them in the chat.

While we still have many challenges to tackle, I want to underscore that this is a change that will mean many more people are linked to the care and services they need. That is important. Our hope and our expectation is that these new approaches will have an impact on the health and safety of our communities.

You'll hear from Jeff Locke at the end of the Webinar today. He's a senior policy advisor at BJA and responsible for all of this emerging work in addition to a large standing portfolio.

I'll turn now to my colleague, David Ryan, Senior Director of Criminal Justice at the Health and Reentry Project. Thank you all.

David Ryan: Thank you, Heather, appreciate that, and thank you to the Bureau of Justice, Assistance and BJA NTACC for all their efforts in getting us here today and for their collaboration. On these resources that we've been developing for the fields as well as for inviting us to present here today. Just wanted to provide a little bit of background on the Health and Reentry Project or HARP. We are a small national nonprofit.

Our goal is to help individuals return healthy and whole to the community from incarceration. So how do we do that? It's through education and analysis that we work to strengthen policy and expand access to care. There's two main areas of focus where HARP is working. One is obviously in the youth provisions which we're going to do a deep dive on today as well as the 1115 Medicaid demonstration opportunities, which I can touch on briefly as well. But HARP works to advance implementation of these new policies by working with State and local agencies which we're doing in California in around 12 counties. We're also working with 7 States with our partner, the National Academy of State Health policy to help in the implementation process as well. We also do a lot of translational work where we take what we are hearing from our Federal partners, could be from CMS, in the form of guidance. There was obviously guidance put out in around these youth provisions, and we translate those and then push resources out to the field. We also listen to our state and local partners, and we push that information up to our Federal partners as well.

Lastly, we also see ourselves as conveners. It's how HARP cut their teeth as we assembled when we first launched back in 2022 around 70 stakeholders around the table, because we knew that we had a pathway forward, but we wanted insight from a diverse set of stakeholders in order to inform that process. And that's also something that we rely on to this day, where we continue to reach out to different stakeholders. Because I think, as we all know, that we have justice in the state offices of Medicaid that are coming together, that may not always speak the same language or have a long history of working together. So we try and get the right folks around the table so we can carve a path forward together.

So just to do a bit of level setting here, and I'm sure that there's many folks that are on this webinar that are aware of this. But we thought we would take a moment just to highlight the fact that Federal law prohibits Medicaid from paying for any services for people who are inmates of a public institution. So, with these new provisions that are coming into place in January 1. This is the first change since 1965 that we're seeing to these policies this inmate exclusion is being reexamined at both the Federal and the State level as we work towards implementation, and these recent changes aim to bolster continuum of care and enhance the public safety.

So just wanted to also take a minute to discuss how Medicaid is a lever for change.

The first instance here is the ability to scale. Obviously, the Medicaid program has both a State and national reach in the resources to drive that change to scale.

Secondly, sustainability, predictability, ongoing finance source through Medicaid is key. Also, we're ripe for change, an opportunity to drastically expand access for millions of individuals to care.

Quality and accountability standards and processes that are in place to drive quality and access and oversight are part of the Medicaid program. Also evidence, data and evaluation tools that are going to be part of this process so that we can measure our performance moving forward.

So, getting to the meat of it today. First and foremost, the effective date. Starting in January 2025, states are required to use Medicaid and CHIP to cover limited services for incarcerated youth who are soon to be released. This applies to all Medicaid beneficiaries in custody following adjudication (that's an important note following adjudication), who are under age 21 or former foster youth under the age of 26.

This policy requires that all states provide screening and diagnostic services, referrals for youth in 30 days prior to release or shortly after release and also to provide case management or targeted case management 30 days prior to release and for at least 30 days following release. This applies to all state, local and tribal facilities where youth are incarcerated. Again, post adjudication. So that's prisons, jails, juvenile justice, youth corrections, and tribal facilities. Additional state option to use Medicaid to cover comprehensive services for youth pending disposition, also known as 5122, is an option for states as well, which I'll get into on another slide. But just to note, to date we know of conversations that are happening at the state level, but we are not aware of any states that have currently taken up the option of 5122, which is obviously different from the provisions outlined in 5121.

So that's a lot of information so we wanted to pause for a second to walk through the who, what and when? Looking first and foremost at the focus population for these provisions. So again, we're looking at folks that are eligible for Medicaid and CHIP under 21 and under age 26 and former foster care youth.

It's post adjudicated, and it's within 30 days of release. Prior to joining HARP back in April I spent 11 years working in a local jail. When I first saw this signed into law, I said, “Oh, okay, I don't have to worry about this, because this is juveniles.” No, because it's obviously under 21 or under age 26 for former foster age youth is part of the eligibility. So that's where it obviously brings in jails and prisons as well. So on the what: screening and diagnostic screening and diagnostic services, including physical, dental and behavioral health.

Moving over to the when, that's 30 days prior to release or shortly thereafter within the community.

Also, as we highlighted earlier targeted case management, including referrals to the appropriate services. And that's 30 days prior to release and for at least 30 days within the community.

So, this is the state option that I described earlier. So, starting in January, states have the option to offer some Medicaid covered services to youth that are pending disposition of charges. So, like I said earlier, we are aware of conversations that are happening in states, but no state that we're aware of that's going to be pursuing this option as of January 1. But, we will continue to monitor those pieces.

So, wanted to pivot a little bit into the implementation pieces of it. I think a lot of folks on this call are aware of some of the challenges in and around implementing some of these provisions. Obviously, we have high rates of behavioral health and chronic health among this population.

Obviously, in my experience, working in a jail, if you've seen one jail, you've seen one jail. But also, there is the challenge in and around short stays in uncertain release dates. But we do have a lot of opportunities as well to connect individuals with care and to prevent the cycle or the churn into our facilities, also an opportunity to improve health outcomes and decrease future law enforcement interactions.

Also, an opportunity to implement upstream prevention to get folks the services they need earlier than originally possible, and also to enhance connections to community health and social services for individuals.

So again, we’ve given you a lot of information. So, we wanted to take a moment to talk a little bit about where to start. And that's information gathering. Again, back when I was working in the jail, once we realized that this impacted us, we wanted to take a look at our census data. And so that's one of the first recommendations, and a lot of this is outlined in the documents that were released today to walk through. So, this will obviously be available afterwards. But also, a lot of this we captured in the documents that were released today, but doing a review of those folks that are under 21, and then starting to get your hands around identifying those individuals who are former foster care youth under age 26 will get obviously give you an idea of the size of the population that you're going to have to point services to. The second piece of this is understanding how your facility tracks data, what current data collection activities that you currently have in place and where enhancements may be needed to be able to capture some of this information.

Also identify what Medicaid enrollment processes that currently exist in your facility.

You know, back when I was working in the jail, we had an enrollment process for individuals prior to release where we would help them fill out the application so that that was active upon release. But you're gonna want to do a review of your current activities, so that you can make sure that they're aligning with these new provisions.

In addition to that, taking a look at what screening and diagnostic services you already provide, and making sure to reach out to your state office of Medicaid to make sure that those screening and diagnostic requirements align with what is needed under these new provisions.

So just to continue on, where to start in the information gathering.

Part of this, as I mentioned earlier, is targeted case management. There's a lot of facilities that are doing case management pieces, but you're gonna want to make sure in talking to your state office of Medicaid that what your current activities are for case management align with the definition for targeted case management moving forward so that you'll be able to build for those services.

Second, you want to explore methods for tracking performance metrics post release because you're going to want to be able to measure improvements in health outcome but also for the correctional facilities. Looking at recidivism as well as something that facilities could consider as they're tracking this information post release.

And then another key component to this is identifying what your technological infrastructure looks like. For example, if you wanted to utilize telehealth services, you would need to obviously do a review of what your technological capabilities are in that area, and also your data systems as well, which I'll actually get into a little bit later. And then, the other piece of this is obviously staffing, developing a staffing matrix in and around this and trying to determine how many staff you're going to need in order to implement these provisions.

So, another key component to the where to start is obviously stakeholder engagement. I mentioned this a few times, and not to belabor the point, but starting a discussion with your state office of Medicaid around these provisions, but also what their activities are in and around 1115 waivers is an important discussion to have. And also something that we'll get into a little bit later is a notice of funding that is out from CMS currently to the tune of 100 million dollars, which are in the form of State planning grants. You want to start those conversations with your state office of Medicaid in and around the implementation efforts. Also reaching out to your facility medical providers and what their thoughts are in and around the implementation of these provisions, because correctional facilities will have a choice of whether or not they want to enroll as a Medicaid provider to provide these services or have someone else come in who's already a Medicaid provider to do the screening diagnostic and the case management services. Also, you want to expand the level of stakeholder involvement with your community providers, because you're going to be talking about, obviously, folks that are reentering and connecting them to those community providers in order for continuity of care.

In addition to that, and this is what a lot of folks are already doing, is connecting with their peers in and around what promising practices are in place for the implementation of the provisions. In addition to that, reaching out to your state and national member organizations to also discuss with leadership and other members what promising practices they have identified as well, and also to be able to share those across the membership.

So more on where to start and getting ready. And again, this is outlined in the documents that were released today, so you can refer back to them after the webinar, if you like. But the first one is organizing your agency and establishing, excuse me, initial plans. You want to identify a leader, a point of contact, who is going to be running the implementation pieces of that roles and responsibilities, defining what those are going to look like, are going to be important to a successful implementation and also developing a plan of how your facility will carry out the required services.

Also for eligibility enrollment, we talked a little bit about this, but assessing what your current activities are in and around determining eligibility in enrollment. I think it is important to note that the state office of Medicaid determines eligibility. But you're, again, you're going to want to talk with your State office of Medicaid for setting up those processes for determining eligibility of the individuals that are in your custody.

Also, preparing staff.

You're like, I said earlier, you're gonna want to develop a staffing matrix in and around this. But also, you're going to want to develop a training curriculum. What we did in earlier iterations when I was at the jail is that we would do something for our basic training, but also we would implement that into our 40 h training, just because it was important that everyone was aware at a high level of what was included in these provisions as they move forward.

Some other considerations around getting ready. One thing that we would do is that we would incorporate new information into our orientation materials for folks that are entering our custody, so that they are aware. Also understanding how your facility tracks and communicates release dates is going to be important, especially on the post release navigation. That's going to be happening in the community with the case managers. And also, assessing any security or physical plant challenges.

As I mentioned earlier, you may want to utilize telehealth for some of these services. But taking a look at your physical plant restrictions, possibly, and expanding telehealth services as well as your technological capabilities. But that's going to be an important part of this as well as the administrative processes, coordinating with your State office of Medicaid to enroll as a provider, if that's what you choose to do, or bringing in someone else to provide those services who's already a Medicaid provider. Identifying administrative infrastructure needs. 

As folks on this call are also aware, you're going to have to develop new policies and procedures, administrative policies and procedures in and around this which, obviously getting a jump on that would be obviously helpful in building your operational plan and also on your data and systems identifying and developing the data and technologies or assessing what those needs are in order to carry out these requirements.

So, we wanted to take a moment on one area and do like a little bit of a deeper dive, because this is one that takes a bit more consideration. And again, folks on this call are well aware. But it's your data systems and the planning that's going to be necessary for this. So 4 key areas that we're looking to highlight, which is governance, privacy and legal systems, integration and workflows, and infrastructure.

So on the governance side we're talking about the development of data sharing agreements, memorandum of understanding data, utilization agreements. It’s also a consideration of possibly bringing in outside expertise in order to develop those necessary data sharing agreements in order to share information across systems.

As we all know, that is not the easiest lift, and so that will take some time to put those agreements in place so that you can coordinate care for the individuals that are returning to community. But you're going to want to be able to share that information across those systems. For example, the the correction side of the house will want to be able to share that information with a community provider for cognitive care purposes. Systems, integration and workflows.

Process and timing for data sharing. Part of this is also the suspension of Medicaid benefits which I will talk about later in the deck.

But that process, and the timing of suspending an individual's Medicaid benefits while they are incarcerated, is something that has to be considered. And also again, training and education for staff that are going to be handling this information is going to be important, because there are certain obviously privacy and and technological considerations that need to be considered.

And obviously on the privacy and legal side, I think, again, everyone on this call is aware, but we have HIPAA and 42 CFR Part 2. Also, as you know, there's going to be criminal history information that's going to be shared. You have FERPA. And also developing the necessary documents for consent and the release of information are all key considerations for facilities to start out to have those discussions internally.

And then this is just the infrastructure, or I call it like the guts of like what is your EHR look like right now? Can it communicate with a EHR that is in the community? And that's an electronic health record. Again, in order to facilitate the continuity of care and the care coordination, it's going to be important for sharing of information. So doing that capacity review of your current systems and those systems that are within the community for the sharing of information is going to be key to this.

Like I highlighted earlier on the suspension piece as well, you're going to have to be coordinating with your state office of Medicaid in and around the suspension activities. And what is that going to look like? Is that going to be a file match? Is that going to be a file share of a secured excel spreadsheet? Is that going to be automated? So, starting to have those conversations about what the necessary infrastructure is going to be needed for the sharing of information.

So also wanted to just take a moment to walk through where we've been and where we're going. In April of 2023, CMS released its guidance to states on the new reentry, 1115 waiver opportunity. And then in April of 2024, and now we're starting to see, as of this week I believe, a lot of these grants that are being released by the Federal Government to the tune of 50 million dollars for community health centers who are going to be able to use these new resources to help folks that are transitioning back into the community to connect to care at the local level and at the community health centers. So, there's been a lot of news in and around that. Those awards are starting to come out, and that is really critical. I remember back when I was working at the jail, we worked very closely with our local community health center, especially for folks that were returning on mat to the community. January 2025, I think that we've hit on this one. But not to belabor the point, but January 1 is the due date for these new requirements that go into effect, and then March of 2025, and I'll go into this a little bit later as well and I did touch on it earlier, is there's over 100 million dollars in state planning grants to support cross sector operations and systems building in and around. And we can drop this in the chat, the notice of funding opportunity or NOFO outlines all the requirements for submitting an application, and it's actually going to be in 2 tranches. But, we'll get into a little bit more detail on that later. And then the last thing to note is January 2026, a national requirement that Medicaid suspend and not terminate individuals’ Medicaid benefits while they are incarcerated. That is a new change. There's probably a handful or more states that still currently terminate, but as of January 2026, all states will have to suspend benefits for folks during incarceration.

Okay, the future of Medicaid and reentry looking forward.

So reentry waivers and the new youth requirements are becoming a major vehicle for improving health and safety. We have an opportunity here in that, if folks have the coverage that they need upon reentry and then that connection to care, the hope is that they'll have a decrease in recidivism rates in future law enforcement interactions. Implementation for this is going to be complex. It's going to require a dedicated investment and attention. And it will take time.

In addition to that, like I stated earlier, bringing together health and criminal justice government agencies as well as external stakeholders is going to be critical to this. Having both corrections and state office of Medicaid at the table. To walk through what the key considerations are on both sides is really going to be important in order to implement this successfully. And people who are directly impacted by these services, soliciting their input into this process is also going to be critical. One thing that we did back when I was working at the jail is we sat down with a group of individuals in a focus group and asked them what services would be helpful to incorporate into your reentry plan as folks are reentering, and that was an extremely helpful exercise, because we were able to fold a lot of that input into the proposal that we put into CMS. And the impact on people and communities, it will have to build over time. And we will be making improvements along the way. Again, this will take time, but we're going to assess along the way and make the necessary changes for the successful implementation.

So, like I stated earlier, back in October, CMS released a notice of funding for over 100 million dollars in planning grants to support implementation of the new youth requirements. Below, you'll see the deadlines there. It's going to be in 2 tranches. The first cohort is November 26th 2024. So, if you haven't already inquire with your State office of Medicaid on their plans for applying for these for these monies. It is only the state office of Medicaid and CHIP agencies that can receive these monies, but from a correctional perspective, it would be important to reach out to determine whether or not they are going to be submitting an application to receive these funds. The second cohort is going to be on March 17th of 2025.

New resources. As we stated earlier today, we have released a suite of resources for adult corrections. We have FAQs, frequently asked questions, for both prisons and jails. We have our getting ready document, which is key elements for implementation for section 5121. And we also have an operational checklist.

So we wanted to provide the fields with the more comprehensive FAQs, there’s about 20 that are in there, and then we wanted to have our 7 key elements, but also, once folks have sort of, you know, walked through those, that you just had quick one pager to look at that provides you with a checklist of all the key considerations so that you had what I like to call the accordion, a more comprehensive resource, but also we tried to just get it down to one page for just those key considerations in and around the implementation.

So at this point, I'm gonna pass it over to HARP's executive director, Vikki Wachino.

Vikki Wachino: David, thank you so much for the presentation and for your role in leading the new materials that HARP is so happy to release today with BJA. And thank you Heather and Jeff and team at BJA as well as BJA NTTAC for your partnership in this work. I am really happy now to take the issues that David laid out so clearly and be joined by a panel of State and local leaders from across the country for them to share their observations about how they will be implementing the new youth continuity of care requirements. We can pull them up on screen now, and I'm going to ask each of our 4 panelists to briefly introduce themselves. Sheriff Clayton, let's start with you.

Sheriff Jerry Clayton: Good afternoon. I'm happy to be to join this this great panel and and discuss this issue. My name is Jerry Clayton. I have the honor of serving as the sheriff of Washtenaw County, which is Ann Arbor, Michigan.

Vikki Wachino: Secretary, Wasko, you're next on my screen.

Kellie Wasko: Thank you very much, Vikki. I appreciate it. My name is Kelly Wasko, and I am the Secretary of Corrections here in South Dakota. I've been here for almost 3 years.

Vikki Wachino: Next up we have Emily Eisenman.

Emily Eisenman: Good afternoon, very excited to join you all. I'm Emily Eisenman. I am a Deputy Division Director with our Texas Department of Criminal Justice in our rehabilitation and reentry, and I also serve as our Deputy Director with the Texas Correctional office for offenders with medical and mental impairments.

Vikki Wachino: And finally Melissa Pierson.

Melissa Pierson: Good afternoon, everyone, and thank you for being here and inviting me to be here. My name is Melissa Pierson. I'm the Chief Operating Officer with the Franklin County Office of Justice Policy and Programs. We are the administrative agency to the criminal justice, Local Criminal Justice Planning Council, which is responsible for resource, allocation, provision of technical assistance, and strategic planning. We've also stood up quite a few programs inside our local jail, so we work closely with our sheriff's office.

Vikki Wachino: Thanks to all of you for being here. I know you're all incredibly busy, and we so appreciate your taking time out on this holiday week to share some thoughts with the audience.

You've just heard, David, outline the importance of these new youth continuity of care requirements as well as to offer HARP's take on how correctional administrators can get implementation more fully underway. I thought we could kick off the panel by just asking each of you to offer one reflection or piece of advice for the field as they turn their attention to implementation.

Sheriff Clayton, we'll go ahead and start with you if that's okay.

Sheriff Jerry Clayton: Sure, ask a lot of questions I find out and join webinars like this quite frankly. David has done a wonderful job of just laying out what needs to be done, and I know one of the questions I'll get at some point is what have we done? And every time I hear David talk. I I clearly understand we haven't done enough. There's a whole lot to do so, I think ask questions and and not not be afraid of partnering. And so it will be the collaboration that will make a difference here.

Vikki Wachino: Emily, how about you? What piece of advice would you offer from your experience in Texas? So far.

Emily Eisenman: Our the biggest piece of advice that I can advise is, if you are mainly on that adult focused area, bring your juvenile justice partners to that table with you, because many of them have already started some elements of work.

And so, just kind of leveraging some of that communication that they already have with your local Medicaid office and processes that they may have established where you could even join their MOUs, or some other things, has been very helpful and beneficial.

Vikki Wachino: Great secretary, Wasko. Let's turn to you for a piece of advice from your work in South Dakota.

Kellie Wasko: I'm with the sheriff. There's a ton of questions that need to be asked, but have great patience and collaboration because we're all going through this together. So, I think my one piece of advice is just, you know what, lean into each other and collaborate, and just have a little bit of patience, and we'll get through it.

Vikki Wachino: Fantastic. And, Melissa, what would you add to the advice mix?

Melissa Pierson: Well, there's not a whole lot more that I can lend. But I will say this from a local perspective, I would say don't wait. I know the state offices are doing what they can to put these implementation plans together, but don't wait at the local level to convene the partners go ahead and start getting them used to the legislation language. And you know, starting to ask the right questions, so that when the State is ready to convene with us, we’re ready to go as well, so just don't wait and take one bite out of the elephant or apple at a time.

Vikki Wachino: That's a great way to kick us off. Sheriff Clayton, as you suspected, I did want to turn to you and hear a little bit more about how the sheriff's office there in Michigan is implementing these new requirements. And since we've already heard from some of your co-panelists the emphasis on collaboration, wondering if, as part of that, you could tell us a little bit about who's sitting at the table to make these changes.

Sheriff Jerry Clayton: Sure, sure. So you know, interestingly enough, I didn't know as much as I should have known about this until sitting in a panel with you and David and Carrie Hill with some sheriffs really starting to lay this out. So, I didn't panic. I went right to my staff, who was on the ground operationally responsible, and just asked them because they're always connected. So, what do we know? And what have you done? So, here's what they laid out for me.

So, what they laid out is, look we already had connected with our medical care providers, so Well Path is the medical care provider, to start to understand what do they do.

What are they doing? Have they made to try contacts? And one of the things Well Path has already started doing is, although you know, our State has petitioned to to be a part of this is starting to build the proper coding.

So when we, when we have the medical records, we're prepared to start to put in the right kind of information. I think Emily talked about bringing our juvenile partners to the table.

We reached immediately out to our juvenile detention folks first to see what they knew and then to understand where is that collaboration for us? So we know that they're for the youth, but are there systems that we could put in place on the adult side that can be leveraged for the juveniles and vice versa. Let's not duplicate it in the county. Let's make sure there's some continuity.

We looked internally at some of the processes we've already had in in place. So we already have a very robust reentry architecture. And we know that's gonna be part of it. So you know, we wanted to verify our current system, Are we already providing a lot of the care that's going to be required? Physical, dental, behavioral health, the screening, the diagnostic services? What do we already have in place? And as we learn more, as our state learns more and communicates to us, what do we have to add to what is already there that'll streamline and make sure that we're hitting the ground to be a lot more efficient, a lot quicker?

We verify our current system for our pre-release case management to make sure that we're meeting needs. And then we verify the reentry process. Again, you know this warm handoff that David talked about making sure that as people leave our facility and go into and contact our community partners, do we already have systems in place to facilitate that warm handoff?

As I said before, we have a very robust reentry strategy, so that was all taken care of. And let me back up and and talk about on the front end.

We looked at our screening all of our screening processes for intake and moving forward and making sure you know, what questions are we already asking? What questions do we need to add to make sure that we identify people that are eligible to meet that criteria? So right now, what our staff has really done more than anything else is let's assess our current architecture. Let's see what we already have.

And so we'll have a plan for what we need to put in place to make sure when the time is right, we can actually meet the needs without a lot of gap in terms of services and processes.

Vikki Wachino: That's a great perspective and very hands-on advice in terms of looking both at reentry and the process starting at entry. But I particularly appreciated that you started with don't panic, because some days I feel like we should have that printed on T-shirts like we can do this. Sheriff Clayton, just sticking with it a little bit with you. I wonder, you heard from Heather at the outset of some of the health outcomes that are very negative and that's part of what's motivating the creation of these new policies, I wonder if you could just speak to like what is the upshot from a public safety perspective of some of this continuity of care.

Sheriff Jerry Clayton: Oh, without a doubt, that's a great question. And I think for us it's a direct alignment. So, part of our mission statement is co-creating community wellness and safety. And what we've always what we've recognized is you really can't have public safety without having community wellness. And that actually occurs one individual at a time. So so this is a great opportunity to engage people where they are to address needs where we start to break the cycle. And I love the fact that the focus is on our young folks because if we're really talking about breaking cycles, if we're really talking about achieving community wellness, we really have to start at our youngest population and make sure that we are positioning ourselves to meet their needs upfront. And for those that we can't get to, that we can't deflect that we can't, you know ones that we're trying to divert, those that go through reentry, the more we can help them address their needs.

When they leave our facilities, they facilitate those warm handoffs. If we can start to get them in the right place for that individual wellness, I think that contributes to community wellness. And that's where we start to achieve public safety.

And and and in in all of this we're doing it without that enforcement piece, right?

That is the key part. Enforcement's already going to always going to be there. But I love the fact that we're paying attention on this side. Because that's where I think we get the best impact in our communities.

Vikki Wachino: That's great. Emily, I'd love to turn to you now and hear a little bit about how the Texas Department of Criminal Justice is tackling the implementation of these new provisions.

Emily Eisenman: Yeah. So currently, we kind of started with an initial reach out just to our Medicaid office. We were really focused mostly on 1115, and as an adult system reaching out, they went “Oh, we are so excited you called. We didn't know a person over there in the adult system. But we've got this other thing that's youth, and we think you've got some of that population.”

And so it was kind of a very easy and immediate jump for us. I'd mentioned during my introduction, I'm I also serve within our Texas correctional office on offenders with medical and mental impairments, and that office spans adult and juvenile county up to kind of that state element of criminal justice and just functions in an advisory capacity.

And we've got multiple different advisory board members that participate from judges to sheriffs to our local mental health behavioral authority agencies. Nami sits with us as well. So we really kind of sat there and said, “Okay, so we know that we've got this conversation.”

I don't know how many other adult systems, especially, are necessarily as aware. Our juvenile side in Texas is lucky to some degree that that formal State prison element down to their detention centers is all kind of one chain. Whereas on the adult side, those county jails and the prison system are very separate, and we've got 254 counties in our State, so lots and lots of variation.

But what we did was, we asked Medicaid to kind of come to that table and really offer a presentation, and they did that presentation in line with our Texas Juvenile Justice Department to kind of talk about what they were hoping to accomplish, what they were seeking, and where some of their system gaps exist already, because they had gone a lot further in that mapping of where that Medicaid eligibility was.

Vikki Wachino: That's great. So you called the Medicaid Agency. You got a warm reception, and then you sat down and joined the the and and expanded on the thinking that they already had underway. That's terrific.

Emily. I'm going to get a little bit into the nitty gritty now. One of the first questions that comes up in implementation from correctional administrators is frequently, “how are we going to identify these former foster care youth who are eligible for Medicaid? So we hear you Federal Government, that we want to get services to these people. But how do we know who they are?” My understanding is that Texas has been ahead of the

on this issue, and actually has some legislation, and I'd love to hear a little bit about that.

Emily Eisenman: We do. Yeah, when we read that we went, “wait, what was that, bill?” And we all kind of had to go backwards a little bit in our minds, just because it had kind of sat with an executive services area, with a very small reentry tie in. But in 2013 we had House Bill 2719, and it added language to kind of our correctional statutes about collecting formal as well as self-reported data during our intake and diagnostic process about prior conservatorship or foster care involvement. The interest at that time in 2013 was really about trauma and system gaps of where support could be, with the ultimate goal being to develop resources and programs that would further build skill sets in that foster, former foster youth, participant kind of category, and then avoid any further return or entry into criminal justice as it sat. 2019, they added a little additional language, as well about a comparison between non incarcerated former foster youth and foster youth that are just kind of in our system. Since that bill enrollment in 2013, our agency produces an annual summary of the number of inmates we have in our custody that have had prior engagement.

We drafted an MOU between ourselves and the department of family and protective services, which is where foster care sits for us.

And in 2020, that that data exchange went from being, “Hey, we're going to securely email, you an excel document, you securely email Us back an Excel document,” and we're doing manual data matching, to in 2020, we actually have a formal data exchange process that has been worked out.

So it saves on a lot of man hours to match that up. And we know as of right now we've got about, you know, 6.1% of our annual received population has had some sort of engagement with that foster youth system. Now, not all of those are obviously that age 26 and below. But, yeah.

Vikki Wachino: That's that's great background and congratulations for taking that step to automation. I know a lot of places across the country are are working on that. Secretary Wasko, you know so well that for the first time we're bringing these 2 systems together, corrections and health and Medicaid. And these systems just don't have a history of collaboration, and that's what we're trying to change. I wonder, as you think about tackling implementation, what are some of the systems disconnects that most need to be bridged as part of doing this work?

Kellie Wasko: Thank you, Vicki, you're absolutely right. This is a time where we've not seen this kind of direct collaboration, you know, for usually there's an alternative purpose if the DOC and our Medicaid offices are getting involved. And now we have so many avenues coming out of CMS that are requiring us to, you know, to communicate and identify gaps and opportunities to make these, you know, returning citizens successful. And I I think the strongest variables right now is that not everybody is in the same place for preparation. I think we've all seen even that there are there are some entities that just 2 weeks ago said, “We got to do what by when?”

So they're still finding out about these about these requirements when you think about prisons and jails and juvenile detention. And then Medicaid offices themselves, my State is a recent expansion state of just a year ago.

And so, still learning the you know, the ins and outs of expansion standing up Medicaid office. And then, you know, here we come with additional asks. So I think some of the most obvious disconnects that we've found is, you know, they've been brought up here, and we speak of them, you know, just kind of matter of factly, but when we, when we look at the actual operationalizing of, you know, something so simple as termination versus suspension, you know, that's a system issue. That's something that's built into systems. Or when we start talking about electronic health records. You know, there's hundreds of different electronic health records all over the United States. And we're going to be these screenings. You know, I've heard people say, “Oh, yeah, we do those screenings.” But how do you communicate them? How are they getting into the right hands that are going to meet the needs of the model that CMS has outlined? Or you know, the big one especially, you know, targeted case management and the resources it's going to take to support, you know, the in reach and outreach. When I when I hear, when I first heard of the requirements of 5121 on the prison side, I was like, “Oh, gosh! You know what adult corrections, you know. In about 10 years we figured out in reach,” which is, you know, bringing those services in 30 to 45 days before they get out.

Kellie Wasko: But that's not true for everywhere, that's not an opportunity that everywhere has. And when you look at some of these states with you know these parolees that are going to be returning back into the community that are going to rural areas. So, the reality becomes, you know that telehealth. Not only do you have to have broadband, but you've got to have the connectivity. You've got to have the right software, you know. And what does that, what does that do for us to be able to have that continuity of care if we have all of this infrastructure that we don't quite have the foundation for yet?

Vikki Wachino: That's great and infrastructure exactly where I wanted to go next. As we think about building the bridge, there are some actual infrastructure that needs to be put in place. What is it that you think already exists, and what do we need to be building for the first time or building better?

Kellie Wasko: So I think that something that exists, at least in my system, and I think that corrections as a whole, whether it's, you know, detention through jails or long-term incarceration through prisons, one of the things that we've figured out is, you know, these these kids, and that's what they are, I mean, they're young, youthful, many times kids, they're coming into us from a society where, you know they they they need an exponential amount of resources. They need the substance use disorder resources, the mental health resources. I mean, I could just go on and on on the continuity of care side, but once once they get inside, you know, do we have the outreach? Do we have the infrastructure of resources that when we're releasing them into the communities, do we have.

You know, one thing we found here in South Dakota was, do we have providers that have programs such as strengthening families? Do we have all of the evidence-based programs in place around us that we know make make these youth successful, or contribute to successful reintegration? And then the other pieces. Do we have those technological interfaces, not just with the telehealth, but with our Medicaid offices?

You know, before, things we did with a phone call, or we shot over an email are now needing we need the efficiencies of those interfaces with Medicaid offices. And then a lot more on the case management education side.

I think you know, clinicians know how to do the counseling, and they know how to to provide the treatment plans, and those in the community know how to receive them. And but that actual handoff, that case management handoff, you know, what what more can we contribute? And those are just some of the high-level ones that come to mind for me, Vikki.

Vikki Wachino: Great. That's excellent. Melissa, we're going to turn to you next, and I'm realizing that we're we're chewing through time a little more quickly than we planned, but I want to be sure to hear from you, especially given Franklin County's long history, as you noted in your intro, of leading from the from the local level. I mean, when you, when you think about implementing the youth, continuity of care, knowing that so many places are really starting from from square one, how do you think about a coalition and the partnerships and the table that needs to be built to do this work?

Melissa Pierson: Thank you for that, yeah. And it's so interesting because there's so many different systems that are rolling this out at the same time. I think of the challenges for the states. I think then you go to the local levels and and we have a very different population, a very transient population that's in and out. So, it's going to be interesting to see how we're all building this out. But when I think about what we're going to do here in Franklin County, you’re right, we are, we do have some advantages because we have that local justice coordinating council, and I hope everyone on the call considers putting one of those together because it really has set us up for a lot of great initiatives like the Justice Counts initiative, which is essentially a data sharing, information sharing initiative. So we've got some of that infrastructure in place.

But for this, we have to really step outside of our silos and really think about partners that we haven't traditionally brought to the table. So when I think about those partners that we don't just obviously always think about, for us it'll be bringing children services to the table. It will be about bringing our local Adam board to the table, an academic partner to the table, a technology apartment partner, even our public facilities management because we, as we think about the logistics of how this will operate in our jails, there may be some, some reconfiguring of our of our space. So we're really trying to think about who needs to be at the table, and really, probably more importantly, not just who, but when.

I think everybody needs to be brought in at the ground level, and I think that's really important for trust and establishing credibility. I don't want to bring in a partner after the fact, after we've already developed some plans. I think that's a a great way to say, “Hey, you were an afterthought. We're bringing you in, and we need you to, you know, configure your response to how we've already rolled out some of the solutions.” I want to bring everyone in at the beginning.

And if they decide later down the road that they don't belong as part of the coalition and the work group, then that's okay. But they were there, and they were asked to be at the table. So again, it's going to be bringing in for us an academic or a research partner. I know that's going to be really, really important, important for us to do that right from the beginning. We want to make sure that we're tracking all these very important outcomes, the reason why we're even rolling out this important legislation. So, we'll be bringing on a research partner. And then the last thing I want to just say is here in Franklin County we have a slogan, and it sounds like a cliche, but it is it's a principle that we operate. “It's nothing about us without us.” And so, as we roll out some of this really important, these changes that are going to affect all of us system partners. But let's remember who it's really about. It's about the clients, it's about the individuals and their families. So from the beginning, I want to have a plan, for how are we making sure that this information is getting out there to the individuals that are incarcerated so that they know these services are now available. And so really bringing them together. And we're going to be probably from the beginning, we're going to host some focus groups. We'll be conducting interviews within the first 6 months of rollout, just to make sure that what we intended to happen is actually happening the way we all wanted it to, and that we are seeing some of those outcomes as intended. So those are some of the the partners that we don't traditionally, we always try to get the feedback from the clients and those who are most affected, but having them there at the beginning, as we roll out some of our plans, I think, are going to be really, really critical.

Vikki Wachino: Fantastic, although I'm sorry that we don't have more time to delve even more deeply with you really exceptional leaders. That's a great note to end on, Melissa. So thank you for that. As I transition to Jeff, I'll just say, on behalf of the HARP team, we are going to continue our work on youth implementation. We would really love to hear from you in the field about what your implementation needs are. And as you've absorbed these new products, please let us know what else you need in order to be successful leaders. Have a happy Thanksgiving everyone, thanks for joining us, and I'll leave it to Jeff to close us out.

Jeff Locke: Yeah, thanks, Vikki. I'll be quick. Just on behalf of BJA, I want to just echo Vikki's thanks and appreciation to Secretary Wasko, Sheriff Clayton, Emily, and Melissa for joining us today. We also want to thank our partners at NTTAC and HARP for this critical work around  Section 5121. We have an evaluation that you should all see that has just popped up for today's webinar. Please click on that link and tell us whether and how this is helpful.

Thank you to everyone who joined. Please reach out to us with any questions, and how we might be able to better help your jurisdiction with respect to Section 5121. As Vicki noted, have a good rest of your week and a safe and happy Thanksgiving. Thanks again.