Six Necessary Principles for Successful Decarceration

Over the past several commentaries, I have been advocating changes in federal legislation that are needed to make the Medicaid program more adaptable to our current efforts to decarcerate county and city jails. Specifically, we hope to extend federal Medicaid to persons who actually are in jails cells, but who are pre-adjudicated. Thus, we are seeking to remove the “inmate exclusion” for these persons.

This effort is underway within a context for which considerable progress already has been achieved. In 2016, CMS removed the Institution for Mental Disease (IMD) exclusion for care of persons with substance use conditions; in 2018, this exclusion also was removed for persons with mental health conditions. In 2017, the Centers for Medicare and Medicaid Services (CMS) extended federal Medicaid to persons who are involved with the criminal justice system, but who are not actually in a cell, e.g., persons on home detention or persons on probation or parole.

As we develop the capacity to promote more effective decarceration practices, it also will be important to be very clear about how we undertake this work. Below, I suggest some necessary principles for this effort. Several are from me; others, from leaders in our field.

The decarceration principles are:

• Divert from jail, and divert as early as possible. Clearly, jail should never be the site of choice or default for treatment of a behavioral health or I/DD condition. Diversion should occur via actions in the community, long before the police are involved, i.e., at Intercept “0.” The treatment site of choice is the community, within a county or city program that offers a good service array and good care coordination.
• Move away from the 911 culture toward a new call code not directly associated with the police, e.g., 611. The 911 culture screams crisis, police response and jail. We need to change this culture to one that is more routinized, less threatening, and more compatible with de-escalation and good quality care.
• Use systems other than the police when an emergency arises. Once the police are involved, the only choices are transportation to jail or to a diversion site, if one exists. Use other systems, such as the Emergency Medical System (EMS), particularly in conjunction with a mobile crisis response team. This will increase the range of options to pursue, such as direct de-escalation in the community and direct linkage with a care coordinator. 
• Use county or city community providers to deliver care, even in a jail setting. Building a separate behavioral health or I/DD care system in the jail simply is the wrong answer to the incarceration problem. Use of community providers is particularly important to prevent jail entry in the first place, but also to facilitate community re-entry if a person becomes incarcerated and to prevent recidivism.
• Integrate care as much as possible. Different drug formularies between county behavioral health and county jail systems; different care requirements across these systems; unclear care responsibilities in different county offices; and confusing funding streams all will lead to major difficulties in care delivery for persons at risk of becoming incarcerated or who actually are incarcerated. We need to identify these obstacles in county and city programs and eliminate them.
• Work across governmental levels. It is becoming increasingly clear that counties and cities must work with state governments and state associations to solve the incarceration problem. Similarly, states must work with federal partners. Although not new, this way of collaborating has not been very prevalent in our decarceration efforts.

As you seek to address the inappropriate incarceration of persons with behavioral health and I/DD conditions in our county and city jails, I hope that you will implement these key principles. At the outset, you may be able to accomplish only one of two of them. That is okay. Don’t lose heart. Implementation of one or two will facilitate the implementation of others until you have done all of them.