Demonstration to Maintain Independence and Employment by pengxuezhi

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									                                                                                       Revised -- November 30, 2006

        Demonstration to Maintain Independence and Employment (DMIE)
                                 State of Iowa

                                            PROBLEM STATEMENT

         Without access to medical services, the functional health status of mentally ill individuals

will decline, resulting in debilitating mental illness, inability to remain physically healthy,

inability to adhere to recommended plans of care, inability to meet employment obligations, and

increased likelihood to use SSI/SSDI funds.1

         Reflecting that “people with a mental illness have many strengths, talents, and abilities

that are often overlooked, including the ability and motivation to work, research has shown that

70% of adults with a severe mental illness desire work, and 60% or more of adults with a mental

illness can be successful at working when using supported employment.”2 Research has also

found that competitive work promotes an improved quality of life for persons with serious

mental illness.2 However, vocational success for this population depends on a two-pronged

approach—the provision of medical services and vocational rehabilitation.1

         Prisoners comprise a population that exhibits a high prevalence of mental illness. “In

1999, the U.S. Bureau of Justice Statistics estimated about 16.3% of state prison inmates, and

16% of probationers, were mentally ill, based on offenders’ self reports. In 2000, the American

Psychiatric Association reported research estimates that perhaps as many as one in five prisoners

were seriously mentally ill. The figures for Iowa inmates are higher than these estimates, with

over one-third (33.8%) of offenders identified as mentally ill.”3


1
 Substance Abuse and Mental Health Services Administration (SAMHSA), (2002). Employment: A workable option despite
mental illness. SAMHSA News, retrieved on 6/8/06 from http://www.samhsa.gov/SAMHSA_News/VolumeX_1/article3.htm
2
 Substance Abuse and Mental Health Services Administration (SAMHSA), (2006). Evidence-Based Practices: Shaping Mental
Health Services Toward Recovery, retrieved on 6/8/06 from http://www.mentalhealth.samhsa.gov/

3
  Iowa Department of Corrections (April, 2006). Mental Health: Report to the Board of Corrections. Retrieved on June 7, 2006
from http://www.doc.state.ia.us/Documents/BOCMentalIllnessReport.doc



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                                                                                                 Revised -- November 30, 2006

         Prisoners with mental illness have additional barriers to successful living upon their

release. For example, mentally ill prisoners in Iowa are more likely to recidivate and return to

prison within 3 three years following reentry into the community (Figure 1).

                                        Figure 1. Recidivism rates by mental health status
                                              Recidivism: Return to Prison Within 3 Years
                                                         By Mentally Ill or Not
                                     100%

                                     80%
                        % Returned




                                     60%                                               54%
                                                  44%
                                     40%                                                             31%
                                                           19%
                                     20%

                                      0%
                                                     Female                                   Male

                                                         Mentally Ill       No MI Diagnosis

                       Chart depicts three-year recidivism rates for offenders released in FY2003
                       Sources: Iowa Corrections Information System (ICON) and ICON-Medical Module

         Since it promotes management of their mental illness, the provision of basic medical

coverage coupled with vocational support and oversight can improve successful reintegration for

offenders with mental illness who are returning to the community.4 Iowa currently operates two

small community-based reentry programs that utilize a parole officer with specialized mental

health training to provide a wide range of services intended to help the offender remain in the

community. Although Iowa’s current mental health reentry pilot programs “were designed to

provide people with mental illnesses the support they need to successfully transition back into

the community upon their release from prison,”4 the provision of medical services and supported

employment has not been included. While successful in many aspects of offender reintegration in

the community, Iowa’s reentry programs recognize two key shortcomings:

             Lack of health insurance for 62% of the participants; and
             Low employment rate, with only 29% of participants employed.
4
 Council of State Governments (CSG). (June 2002). The Consensus Project Report, retrieved on 6/13/06 from
http://consensusproject.org/the_report/



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                                                                    Revised -- November 30, 2006

These figures are disproportionate in comparison to the high employment rate of all felons in

Iowa (69%), and the overall low unemployment rate in Iowa (3.6%). This means that there is

room to improve the employment for Iowa offenders with mental illness with appropriate

interventions.

       In summary, offenders leaving prison with mental health conditions are at risk for

becoming dependent on income assistance programs. They pose particularly difficult transition

challenges. There is not only the stigma of the felony conviction and incarceration, but also the

frequent needs related to the mental illness. Additional challenges include prescriptions for and

supplies of medications; treatment appointments at medical/mental health clinics, substance

abuse treatment centers and doctors/hospitals; financial support to fill entitlement gaps; and

structured time activities. The Iowa Demonstration to Maintain Independence and Employment

(DMIE) project has been designed to build upon the successful aspects of current programs and

address the deficiencies identified with the current system to help this population be successful in

maintaining employment and independence.

                                 DEMONSTRATION DESIGN

       The Iowa DMIE will address the first two priority areas of the solicitation by focusing on

individuals leaving state prison with job-threatening, serious mental illnesses. This

demonstration proposes early mental health screenings, assessments, and referrals using the Iowa

Medicaid intensive mental health care management program in coordination with new reentry

preparation programs and rapid employment efforts using the supported employment model.

This collaborative effort of the Iowa Department of Human Services (IDHS), the Iowa

Department of Corrections (IDOC) and the Iowa Workforce Development (IWD) will provide

mentally ill Iowa prisoners with new Life Skills training courses, vocational training courses,

supported employment activities, and benefits equivalent to those provided by Medicaid upon


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                                                                    Revised -- November 30, 2006

their reentry into the community to improve the likelihood of their being successfully employed

and remaining off of any disability programs.

       The primary objectives of this demonstration are:

          To decrease the proportion of prisoners who enroll in the SSI or SSDI programs or
           receive cash benefits from other public assistance programs upon reentry into the
           community (global objective)
          To improve the health and mental health status of chronic mentally ill prisoners upon
           reentry into the community (primarily associated with Medicaid and mental health
           care coordination intervention)
          To decrease the recidivism rates of prisoners following reentry into the community
           (primarily associated with supported employment and Life Skills interventions)

       The population for this demonstration includes male and female Iowa state prisoners,
       aged 19 through 50, who:

          Have a diagnosed, job-threatening, serious mental illness
          Have made positive progress under correctional supervision per evaluation of
           supervisors
          Are at risk of long-term dependence on SSDI or SSI without access to medical
           services
          Are employed, defined as having worked for at least 40 hours per month while in
           prison or on work release
          Are not otherwise eligible for full Medicaid benefits
          Will be in community supervision post-release from prison for at least six months in
           order to receive all IDOC programming. (Individuals with less than six months of
           community supervision will not be included in this demonstration)

       To address this problem, we are proposing a multi-pronged intervention that will address

the mental and physical health needs of prisoners, as well as offer life and employment supports

to improve the likelihood that this population will be employed, remain out of prison, and have a

higher quality of life than they would have without the intervention.




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                                                                       Revised -- November 30, 2006

Primary intervention

          As an overview, prisoners involved in the primary intervention will receive the following

programming, staffing and reentry assistance as part of the demonstration:

      1. Rapid supported employment beginning in prison and continuing following reentry into
         the community
      2. Life Skills training while in prison to improve reentry into the community
      3. Mental health care management beginning in prison and continuing upon reentry into the
         community
      4. The full package of Medicaid State Plan services, and the appropriate treatment, therapy
         and medications for mental and physical impairments following reentry
      5. The assistance of special mental health-trained parole officers, in coordination with
         supported employment personnel, to assist with reentry issues–such as housing–that can
         threaten a person’s ability to be employed
More detail about the primary intervention may be found in the Intervention section of this
proposal.

Participant identification

          The identification of mentally ill prisoners with the potential to be employed who meet

the eligibility criteria for the intervention will begin about 7 months prior to their scheduled time

for reentry into the community.

          First, we will identify prisoners for inclusion in this demonstration if they have a chronic

mental health condition defined as: a) a Global Assessment Functioning Scale (GAF) score of 50

or higher, which indicates a person appropriate for outpatient treatment with the ability to keep a

job and/or b) a diagnosis within the ICD-9 codes of 290-300 (includes psychotic disorders,

dementias, mood and anxiety disorders), or 308-312 (includes disorders of impulse control,

attention, and psychiatric manifestations of brain damage). The GAF score is an accepted

measure of a person’s mental health status and has good inter-rater reliability. 5




5
    www.bsu.edu/csh/ssrc/media/pdf/gafpage.pdf

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                                                                                  Revised -- November 30, 2006

          The mental health status of Iowa prisoners will be evaluated during their prison stay in

the following manner:

     1. Upon entry into prison, a mental health diagnosis will be determined using a full mental
          health assessment conducted by an on-site forensic psychologist. This assessment will
          include the determination of a provisional clinical diagnosis based on the results from
          two mental health screening instruments, the MINI and the TCU, and the calculation of a
          GAF score.
     2. The provisional diagnosis will be verified by a board certified psychiatrist in a full mental
          health evaluation, resulting in a DSM-IV TR with GAF score.
     3. At the time a prisoner is subject to an intra-institutional transfer, the MINI short
          screening instrument will be used to detect possible changes in mental health diagnosis.
     4. If indicated by the score on the MINI short screening at transfer, a second mental health
          evaluation will be conducted to verify the DSM-IV diagnosis.
     5. PhD psychologists will conduct other testing as appropriate during the stay in prison.
The diagnostic procedures for mental health diagnosis are summarized in Table 1.

         Table 1. Diagnostic procedures used to evaluate the mental health status of prisoners

                                    Reception and Retrospective Diagnostic Procedures
I. Admission Evaluation process                            Administration
   Full mental health appraisal/interview / provisional    Forensic psychologist, masters degree
   diagnosis with GAF score
   MINI short screening                                    Forensic psychologist, masters degree
   TCU screening                                           Forensic psychologist, masters degree
II. Evaluation (DSM IV-TR)
   DSM IV-TR with GAF score                                Board certified/ eligible psychiatrist
III. Intra-institutional transfer
   MINI short screening                                    Site psychologist
IV. Re-evaluation or follow-up
   DSM IV-TR with GAF scores                               Board eligible psychiatrists
                                                           Board eligible medical and psychiatric physician
                                                           Board eligible endocrinologist

V. Other testing as indicated                              PhD psychologist
                                                           (All clinicians utilize DSM IV-TR for reference and
                                                           diagnostics and functional GAF scores)




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                                                                      Revised -- November 30, 2006

       Second, the expected release date and length of post-release supervision will be evaluated

for the identified, mentally ill prisoners. Prisoners must have an expected post-release

supervision period of at least 6 months so that they could receive all necessary programming and

support during the transition period back into the community. Eligible participants will be

identified using data fields on estimated release date and time in supervision that will be newly

available for all Iowa prisoners beginning January 1, 2007 in the Iowa Corrections Offender

Network (ICON) database. Additional information about the ICON database is provided later in

this proposal.

       Third, the prison work history of these mentally ill prisoners will be evaluated using

information in the ICON database to ensure that they have worked at least 40 hours per month

while in prison. Work experience may include food service, janitorial, laundry,

maintenance/grounds, clerks, barbers, printing and general construction.

       Fourth, the prisoner will be informed about the program and enrollment requirements

using materials prepared by IDHS. Once a prisoner chooses to participate in the demonstration,

procedures for informed consent will be implemented. Consenting prisoners will then be

screened for Medicaid eligibility (if Medicaid-eligible, the prisoner will be denied participation

in this demonstration).

       Following enrollment in the program, participants will be transferred to one of three

locations-the North-Central Correctional Facility in Rockwell City, the Clarinda Correctional

Facility, or the Iowa Correctional Facility for Women in Mitchellville. They will remain at one

of those facilities until their time of reentry into the community. While at these facilities they

will receive the 15-week Life Skills training curriculum and will begin to receive supported

employment assistance and managed mental health care assistance. The coordination of Life

Skills, supported employment and mental health services will be facilitated by staffings with the


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                                                                    Revised -- November 30, 2006

mental health care manager, the parole officer and the IWD employment counselor that will

occur prior to release from prison with the assistance of on-site mental health release

coordinators, who will begin the transition planning for the offender.

       The release coordinators will also work with the local IDHS office nearest to where the

offender plans to be released to begin the application process for Medicaid. A Medicaid

application will be completed by the offender and directed to the local IDHS office to ensure

enrollment in the Medicaid portion of this demonstration. Upon reentry into the community, the

IWD Supported Employment Assistance and managed mental health care assistance will

continue to facilitate the search for and maintenance of employment.

       A flowchart summarizing the participant identification and intervention process is shown

in Figure 2.




                                                 8
                                                                Revised
Figure 2. Participant identification and primary intervention flowchart-- November 30, 2006

     TIME        1. SCREENING & TRANSFER
                 IDOC identifies prisoners with a) a mental health
 7 mos. to       diagnosis following clinical assessment by an IDOC
 reentry         psychiatrist, b) >6 months supervision, and c) the
                 potential to be employed while in prison; prisoner is
                 transferred to one of the three intervention facilities



                 2. DEMONSTRATION ELIGIBILITY DETERMINATION
                   a. Prisoner gives informed consent to participate
 6 mos. to
                   b. Screens for eligibility for full benefit Medicaid under
 reentry
                      DMIE (i.e. does not otherwise qualify for Medicaid)



                 3. PROGRAMMING
                 Participant receives intensive reentry programming,
                 including:
                   a. Life-skills training by IDOC mental health trained
                      release coordinator
                   b. Prison work or work release assignment (40
 3-6 mos. to
                      hrs/mo minimum)
 reentry
                   c. Iowa Workforce Development (IWD) Supported
                      employment counseling
                   d. Mental health assessment and treatment plan by
                      Magellan
                   e. Applies for eligibility for Medicaid



                 4. INDIVIDUAL PRISONER STAFFING
                 Prisoner is referred to Iowa Plan (Medicaid Mental
                 Health Provider), and assigned an intensive care
 Reentry into    manager who communicates with the IDOC’s release
 community       coordinator, IDOC’s parole officer and IWD’s
                 employment counselor to create individual reentry plan
                 (Note: This DMIE component does not include any
                 Medicaid payments.)


                 5. COMMUNITY REENTRY
                 IDOC/IWD/Medicaid intervention:
                   a. Mental health trained parole assistance
 Following         b. IWD supported employment counseling (ongoing
 reentry              from 3c)
                   c. Medicaid
                   d. Intensive mental health care management (MHCM)




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                                                                                          Revised -- November 30, 2006

Staffing and number of participants in the demonstration

           For this demonstration, the IDOC will add staff at the three correctional facilities to assist

with the Life Skills training and reentry into the community. One Life Skills training counselor

will be added at the women’s prison at Mitchellville and two counselors will be added at each of

the men’s prisons in Rockwell City and Clarinda. The total number of participants in the

demonstration will be limited by class size and the institutional capacity to conduct Life Skills

courses in the prisons. Each new IDOC counselor will conduct one 15-week Life Skills class

each trimester with 15 mentally ill participants in each class (Table 2). From 2005 ICON data, it

was determined that there were 735 mentally ill prisoners who had post-reentry supervision

periods of at least 6 months and met other eligibility criteria to qualify for this demonstration.

Thus, this program will be able to accommodate approximately one-third of the potential

participants each year.

                                Table 2. Number of participants in the intervention

Prison                   Number of new              Number of                   Number of                  Number of
                         mental health              prisoners per class         prisoners per              prisoners trained
                         officers                                               trimester                  per year
Mitchellville                       1                          15                         15                          45
Rockwell City                       2                          15                         30                          90
Clarinda                            2                          15                         30                          90
Total                               5                       15/class                      75                         225*
* This is one-third of the estimated 750 mentally ill prisoners each year with at least 6 months post-release supervision

To facilitate an understanding of the flow of the entire demonstration, a logic model of the

proposed demonstration is shown in Figure 3:




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                                                          Figure 3. Logic Model for Iowa DMIE                          Revised -- November 30, 2006
                                                                                                                      Outcomes –– Impact
Resources - Inputs                          Activities                          Outputs                       Short term                 Long term

Funding:                           Reentry Programming (prior       Life Skills curriculum results in:
CMS, DMIE grant                    to prison release)               Increased skills in time and financial     Increased access      Decrease in the
State matching funds                                                management, job attainment and             to health care and
                                     Conduct one, 15-week Life      retention, setting goals, personality
                                                                                                                                     proportion of
                                                                                                               continuous            prisoners who
                                     Skills courses per trimester   assessment, relapse prevention,
Partners/Collaborators               at each location                                                          treatment of          enroll in SSI or
                                                                    communication and computer literacy
Iowa Department of                                                                                             mental illness.       SSDI or receive
                                     Prison work or work release    Increased understanding of roles of
    Corrections (IDOC)
Iowa Department of Human
                                     assignment                     agencies and support services,                                   cash benefits from
    Services (IDHS)                  Customized rapid               changes in family and community                                  other public
Iowa Workforce Development           employment counseling          relationships following prison, and                              assistance
    (IWD)                            Mental health assessment       barriers to successful transition          Increased             programs
University of Iowa, Public           and treatment plan             Increased access to resources for          adherence to
    Policy Center (PPC)              Medicaid eligibility           transportation, housing, and health and    mental health
                                     determination                  wellness                                   treatment plan,
Facilities (for Primary
Intervention Components)                                                                                       including
                                   Individual Prisoner Staffing     Prison work/work release                   prescription
North Central Correctional                                          demonstrates the potential to be
     Facility (Rockwell City)      (prior to release)                                                          medications and
                                   Multi-agency staffing with       employed prior to release (40 hrs/mo.)
Clarinda Correctional Facility                                                                                 mental health care
Iowa Correctional Facility for     intensive mental health care                                                appointments
                                   manager (Iowa Plan), mental      Multi-agency staffing leads to                                   Improved physical
     Women (Mitchellville)                                          increased mental health care
                                   health trained -release                                                                           and mental health
                                   coordinator and -parole          coordination and increased inter-
New Staff (FTE)                                                                                                                      status and
                                   supervisor (IDOC), and           agency collaboration of transition
DOC – 1 administration, 9                                                                                                            improved quality
                                   supported employment             planning
   parole officers, 3 mental                                                                                                         of life following
   health release                  counselor (IWD)                                                             Job placement
                                                                    Supported rapid employment support                               reentry into the
   coordinators, 5 Life Skills
                                                                    results in:                                and employment        community
   instructors;                    Community Reentry services                                                  at minimum of 30
IDHS – 1 administration, 2         Medicaid coverage                Increased job placement using
                                                                                                               hours per week
   field eligibility workers;      Intensive mental health care     mentoring, job shadowing, and
                                                                    community-based work experience            within 3 months
IWD – 3 supported                  management
   employment specialists          Ongoing mental health trained    Employment focused person-
                                   parole assistance                centered planning that is goal-
Participants                                                        appropriate
Prisoners reentering the           Supported rapid employment
                                   counseling                       Increased connections and linkages         Decreased
community with a diagnosed                                          with employers in the community
mental illness that without                                                                                    incidence of          Decreased
assistance will likely result in   Program Evaluation                                                          parole violations     recidivism rates
a disability                       Experimental design              Medicaid coverage results in:              and other illegal
                                   comparing full intervention      Iowa Plan coverage including Intensive     behavior
                                   group with Medicaid-only         mental health care management and
                                   intervention group and           mental health services
                                   Control group                    Enhanced primary care case
                                                                    management
                                                                    Disease management
                                                                               11
                               PARTICIPANT RECRUITMENT

       Established target population criteria will be used in recruiting participants in all Iowa

correctional facilities (Appendix B). All individuals who are currently being treated or followed

by an IDOC psychiatrist for one of the included diagnoses (ICD-9 codes 290-300 and 308-312)

with an appropriate GAF score will be identified by IDOC staff seven months prior to planned

release as potential candidates for the program. IDOC staff will identify potential participants

using specified criteria, and then inform them about the program and the benefit of enrolling

using materials prepared by IDHS. Those wishing to enroll will be asked to sign informed

consent forms. Enrollment in the primary intervention group is expected to reach 225 in the first

full year of operation, with 225 new participants added each 12-month period.

Retention

       Retention efforts are an integral part of the program design. All participants will be

supervised and supported at the community level by Medicaid-funded mental health intensive

care managers (through the Iowa Plan), and participants who receive the primary intervention

will also be supported by mental health probation and parole officers and IWD supported

employment specialists. Their supervision and care management will include accountability for

criminal behavior and help accessing resources to address mental health and physical impairment

needs. Housing and employment issues will also be supported.

       Continued employment is an important goal of this demonstration project and

employment status will be monitored by the IDOC mental health officers, as well as by Iowa

Plan care managers. If a participant becomes unemployed, the Iowa Plan Intensive Care Manager

or IDOC parole officer will coordinate efforts with Iowa Workforce Development for rapid job

search, and with mental health providers to address treatment planning issues and supports to get




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them re-employed immediately. Participants who no longer meet employment criteria will be

disenrolled from the program.

                          DETERMINATION OF DISABLING CONDITION

           All prisoners enrolled in this study will have met the criteria of having a serious mental

illness, as defined in federal regulations.6 In summary, the definition includes:

          Adults age 18 and over, who currently or at any time during the past year have had a
           diagnosable mental, behavioral, or emotional disorder of sufficient duration to meet
           diagnostic criteria specified within DSM-IV that has resulted in functional impairment
           which substantially interferes with or limits one or more major life activities.

As indicated previously (see Table 1), determinations of a serious chronic mental illness will be

made based on a having a:

          Diagnosis within the ICD-9 codes of 290-300 (includes psychotic disorders, dementias,
           mood and anxiety disorders), 308-312 (includes disorders of impulse control, attention,
           and psychiatric manifestations of brain damage)
          GAF score of 50 or higher

      Substance abuse disorders are excluded unless they co-occur with another diagnosable

serious mental illness. Those whose only psychiatric diagnosis includes personality disorder,

alcohol or substance abuse/dependence, or sexual/gender identity disorder will not be eligible.

                                            PROJECT LOCATION

           The Iowa DMIE encompasses the entire state of Iowa. Iowa is divided into 99 counties,

with a total population of approximately 2,966,334. While offenders are released to supervision

across the state in a fairly equal geographic dispersion, the primary intervention programming for

participants will not be available in the North Central and Southwest judicial districts due to a

low volume of targeted offenders being released in these predominantly rural areas. However,

the Medicaid and intensive care management program will be available statewide.

6
    Federal Register, Vol. 58, No. 96, May 20, 1993


                                                      13
           In 2005, approximately 1,400 offenders with mental illness-only (N=711), medical

problem-only (N=241), or both (N=183) were released across the state. This is the total number

of mentally ill prisoners regardless of the length of their post reentry supervision period. Table 3

describes the employment status of these individuals following reentry.

             Table 3. Job status for parole/work release offenders (2005 from ICON database)

                              Employment status            Percent
                              Disabled                     8%
                              Full-time employed           49%
                              Part-time employed           10%
                              Retired                      1%
                              Seasonal                     1%
                              Spot job employment          2%
                              Student                      5%
                              Unemployed                   29%



           Iowa is a rural state, with 89% of its land put to use for agriculture. It ranks first in pork,

corn, and egg production, and second in soybean and red meat production.7 Iowa’s rural setting

creates barriers to employment related to the number of jobs available, as well as the number of

health care professionals available in any given county. Access and availability impact

transportation and time commitment to reach employment opportunities, employment support

services and health care services. For newly released inmates, the stigma of being a felon and

having a mental illness creates additional barriers.

           Program enrollees will be transferred to one of three locations: the North Central

Correctional Facility in Rockwell City, the Clarinda Correctional Facility, or the Iowa

Correctional Facility for Women in Mitchellville. They will remain at one of these facilities

through the time of planned reentry. Mentally ill inmates will then be released to a specific


7
    http://www.traveliowa.com/iowafacts/statistics.html


                                                          14
county but will be supervised across the state by the IDOC through one of eight judicial districts

(Appendix C).8 Each county has its own local IDHS office to perform eligibility determination.

The Medicaid program has a comprehensive network of over 36,000 individual providers located

in large and small communities throughout the state. IDOC release coordinators and reentry

program personnel will work jointly with the county IDHS office, Iowa Plan intensive care

managers, and community mental health parole officers to help offenders access necessary

services for health care and medication.

        In the Iowa DMIE primary intervention, the process of community reentry for mentally

ill offenders will be expanded so that all counties and each judicial district (with the exception of

the North-Central and Southwest judicial districts) will have mental health parole officers to

assist and support offenders in the community. This project will build upon the experience of the

two current IDOC mental health reentry projects. These initial grant-funded projects have been

operating in Cedar Rapids and Waterloo since 2001. While these programs have been successful

in terms of high rates of completion (67%) and keeping offenders in the community,

employment for program participants has remained low at approximately 29%. This is

disproportionate in comparison to the high employment rate of all felons in Iowa (69%), and the

overall low unemployment rate in Iowa (3.6%), indicating that with assistance and support, the

employment rate for mentally ill offenders can improve.




8
 Iowa Department of Corrections (April, 2006). Mental Health: Report to the Board of Corrections. Retrieved on
June 7, 2006 from http://www.doc.state.ia.us/Documents/BOCMentalIllnessReport.doc



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                                        INTERVENTION

       The Iowa DMIE is an integrated package of pre-release offender training, vocational

services, community-based mental health care management and specialized parole supervision

and supports. The primary intervention in this demonstration includes:

1) The full range of Medicaid State Plan services, specifically including intensive mental health
   care management and appropriate treatment, therapy and medications after reentry into the
   community
2) Intensive community reentry programming while in prison including: a) Life Skill training,
   b) mental health assessment, and c) supported employment services
3) Interdisciplinary team staffing for release planning and follow-up community support for
   each participant, lead by the mental health intensive care manager, and also including the
   prison release coordinator, the mental health-trained parole officer and the IWD workforce
   advisor

                                        Medicaid Services

       All members of the primary intervention group will receive the full range of Medicaid

benefits covered under Iowa’s Medicaid State Plan. The Iowa Medicaid program is administered

by the Iowa Department of Human Services Iowa Medicaid Enterprise (IME). Medicaid services

and eligibility determination will be provided through the existing IME and IDHS

administration, with additional staff resources provided by the grant (see Budget). The State Plan

services include, but are not limited to, inpatient and outpatient hospital services, physician

services, prescription drugs (under Iowa’s existing prior authorization and Preferred Drug List

policies), laboratory and x-ray services, ambulance services, and durable medical equipment and

medical supplies. Services will be available from the existing Iowa Medicaid provider network

that includes over 36,000 individual providers, such as hospitals, federally-qualified health

centers, clinics, physicians, and pharmacies. All existing Medicaid policies, including

reimbursement rates, appeals processes, co-payments, etc., will apply in the same manner to the

primary intervention population.



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Mental Health Services

       Through the Iowa Plan, a full continuum of mental health and substance abuse services is

available statewide to Medicaid enrollees. Service delivery is coordinated and overseen by a

single statewide contractor, Magellan Behavioral Health, with services provided by a broad

network of local providers. There is coordination with other funding streams, when applicable,

leading to comprehensive treatment planning and timely access to appropriate services. The Iowa

Plan also makes non-traditional community-based services available to members through the

care management provided under the contract and waiver.

       Services covered under the Iowa Plan include ambulance and emergency services for

psychiatric conditions available 24 hours per day; inpatient hospital care for psychiatric

conditions; and outpatient care for psychiatric conditions, including intensive outpatient services,

individual and group therapy, occupational therapy, medication administration, activity

therapies, family counseling, partial hospitalization, and day treatment. All other services

(prescriptions, hospital, etc.) are provided through Medicaid fee-for-service.

       The specialized needs of the mentally ill offender population are best met through

multifaceted services and supports. However, when several entities are involved, coordination of

providers and agency staff is vital. All primary intervention participants will receive Iowa Plan

intensive care management throughout their time in the demonstration. The Iowa Plan intensive

care management program has extensive experience providing this type of service for seriously

mentally ill Medicaid members. Since its inception in January of 1999, the Iowa Plan for

Behavioral Health has received national attention for its comprehensive service capabilities and

demonstration of a partnership between two agencies within a state government. This model has

been referenced by the Centers for Medicare and Medicaid Services (CMS) as a template for




                                                17
other states wishing to develop a comprehensive and coordinated plan for providing community-

based services for Medicaid members. The Iowa Plan intensive care managers will be the central

point of coordination in developing and monitoring the mental health assessments, treatment

planning, community providers, medication monitoring, IDOC reentry services and vocational

services for study participants. This will provide continuity for the participants as their

community-based parole services end when parole is completed. Four FTE positions will be

added for the Intensive Care Management under the Iowa Plan contract.

Physical Health Services

       IDOC data for 2005 indicates that up to 15% of the target population could have a

comorbid medical condition that could place them at risk for their condition to deteriorate to the

point of needing SSI/SSDI. Those medical conditions included cardiovascular, musculoskeletal,

neurological, and neoplastic disorders. Participants will receive services aimed at helping them

manage their chronic physical condition along with their mental illness.

       These individuals will have access to the Medicaid provider network and will be

encouraged to establish a “medical home.” If they meet high cost, high utilization criteria, they

can be referred to the Enhanced Primary Care Case Management (EPCCM) program. EPCCM

supports the role of the primary care provider through case management coordination of services

and communication among providers and with the member. Individuals with asthma, diabetes or

congestive heart failure may qualify for one of the IDHS disease management programs. Finally,

all participants will be eligible to receive a comprehensive wellness assessment (CWA) that

includes a physical assessment by their physician (if needed), an online personal health

assessment, and a resultant individualized health action plan. The goal of the CWA is to identify

health risks and current health status and to provide the participant with education to encourage




                                                 18
better self-management of health risks. IDHS can utilize the aggregate data from the online

assessment to better understand health trends in this population, both at baseline and over time.

Premiums

       Premiums will be charged on a sliding scale to Medicaid members with gross incomes

over 150% of the Federal Poverty Level and will begin at $27/month. A premium schedule is

included in Appendix A. Premium amounts, administration, and policy will mirror Iowa’s

existing Medicaid buy-in coverage group, Medicaid for Employed Persons with Disabilities

(MEPD). Existing Medicaid nominal co-payments will be applied. If premiums are applicable,

they must be paid before Medicaid coverage is given. When a premium is not received by the

due date, the client will be canceled. The premium amount will be established for six months at a

time. It is estimated that income from premiums will be less than $500,000 over the grant period.

                     Pre-Release Programming and Transition Planning

       The Iowa Department of Corrections has developed an intensive pre-release program to

help prepare offenders for reentry into the community that includes:

      Identification of individuals potentially eligible for the Iowa DMIE program at seven
       months prior to release. These individuals will be transferred to one of the three
       institutions with DMIE pre-release programming.
      Life Skills training - This 15-week curriculum was developed by the Des Moines Area
       Community College in response to a request from area businesses. Life Skills is designed
       to offer training in basic skills that businesses require in order for the offender to
       successfully perform job skills and customer service responsibilities. The training occurs
       during the last 90 days of incarceration. It emphasizes work skills, life/courtesy skills,
       and it prepares inmates to once again be part of a larger community (Appendix D). The
       curriculum is six hours a day, five days a week for eight weeks and is considered a work
       responsibility. An additional five Life Skills instructors would be added under the grant
       to specifically serve the DMIE population. Supported employment counselors will be
       added to the Life Skills training to help with employment transition issues.
      Community Transition Planning - Inmates will also receive the services of IDOC
       transition staff in setting up a release plan 60 days prior to their release. The release
       planning will address linkages to community supports for the offender and will include
       completion of the ANSA mental health assessment. The IDOC mental health release


                                                19
       coordinators have a specialized knowledge of the particular issues faced by offenders,
       while the Iowa Plan care managers bring clinical mental health expertise. The Iowa Plan
       care managers will use the ANSA information to lead a multi-party discharge/service
       planning meeting that will include the mental health release planner, parole officer and
       other DMIE project stakeholders to create a comprehensive plan for the participant. This
       team approach will continue into the community as needed.

       This pre-release program will be provided to the 225 participants in the primary

intervention who will receive IDOC services along with Medicaid services. The pre-release

program includes the following services:

1) Mental Health Community Reentry Supervision

       The purpose of the IDOC Reentry Case Management program is to provide support to

offenders who are transitioning from the prison setting to parole or work release programs. This

service component of the demonstration will build upon the experience of the two current IDOC

mental health reentry projects. They provide a high level of service, intensive supervision and

support for offenders who have been diagnosed with mental illness. Probation/parole officers

with specialized mental health training are paired with Community Accountability Boards that

bring a collaboration of professional and community volunteers from mental health treatment,

education, substance abuse treatment, housing services, law enforcement, family/individual

therapy and neighborhood support.

       This project will also build upon the design of the IDOC’s new reentry case management

system. Ninety-six percent of all Iowa offenders return to the community. The re-arrest rate is

56% within three years, of which 31% is for felonies. The current Reentry Case Management

System identifies “criminogenic” needs (those needs that will drive future criminal behavior)

when the offender is admitted to prison. Reentry transition planning begins to address those

needs during the anticipated period of incarceration and a community transition plan is




                                                20
developed. The budget requests one FTE release coordinator in each of the three institutions and

nine mental heath parole officers in the community corrections programs.

2) Supported Employment Services

       The vocational services provided through the DMIE program will be based on the

Supported Employment model. The intervention will be provided through a contract with Iowa

Workforce Development (IWD). IWD is the primary statewide labor and employment agency in

the state. It also operates Iowa’s Temporary Assistance for Needy Families (TANF)

employment assistance program, knows as “Promise Jobs” in Iowa, which includes workforce

placement, training, and other assistance needed to place TANF recipients in employment and

meet federal workforce participation requirements. Due to its role with TANF and other

recipients, IWD has experience working with people who are hard to place and often have

barriers to employment such as emotional and mental health issues. IWD operates 54 local

offices statewide and has developed a comprehensive workforce services network that provides a

package of vocational services for Iowans, including:

 Recruiting: IWD staff seeks to match job seekers with prospective employers, and to make
   appropriate referrals based on skills, training and labor market needs. No fees are charged.
   The Internet makes this matching easy. Job seekers can register online, employers can post
   their openings, and jobs listed with IWD are posted on several Internet sites. IWD workforce
   advisors are also available to provide personalized employment services upon request. This
   differs from other states, such as Minnesota, which do no matching between employers and
   job seekers.
 Outreach: Most areas of Iowa have a regional Business Services Representative to provide
   area employers assistance with recruitment needs, coordination of large-scale recruitment
   such as career and employment fairs, and marketing of IWD products and services.
 Resource Centers: All IWD offices feature resource centers with public access PCs
   available for job search assistance. These centers also have software for persons wanting to
   develop a resume, and career assessment tools. Many are equipped with specialized software
   and aids for the disabled.
 Career and Employment Fairs: Regularly scheduled career and employment fairs are held
   in all regions, offering employers and job seekers the opportunity to interact at a single
   location.


                                                21
 Veteran’s Services: IWD’s Disabled Veterans’ Outreach Program staff can provide
    specialized assistance for eligible military veterans.
 Services to Business: IWD has a network of Business Services Representatives that markets
    the services listed above to Iowa employers, as well as being a resource for questions on
    alien labor certification, employment issues, hiring individuals with disabilities, New Iowan
    Centers, program navigators, business tax credits, military activations and deployments,
    administrative rules, and unemployment. Most also coordinate their region’s Employer’s
    Council of Iowa, a group of employers committed to education and networking to meet the
    workforce needs of employers. They provide an employer perspective in advising IWD and
    other policy makers on the full range of workforce issues and topics of concern to employers.
    The special role of the state level Employers Council is to help gather and disseminate
    information about the activities of local councils, and to represent the local councils at the
    state and federal levels. IWD also maintains a business directory of employer websites on its
    family of websites, giving job seekers easy access to employer applications and business
    information.

The Iowa DMIE program will build upon the IWD expertise in helping participants get

employed and networking with businesses to find jobs.

        The vocational intervention will include three full-time workforce specialist positions

located at the three DMIE prison locations. The workforce specialists will be an integral part of

the interdisciplinary team, and will work with offenders on a one-on-one basis during the 3

months prior to their release. They will help participants both prepare for and find a job, with a

goal of the offender having a job when they leave prison. Specifically the three workforce

specialists will provide the following services at the Mitchellville, Rockwell City, and Clarinda

correctional facilities:

    1. Coordinate career assessment, job search, and retention strategies with the Life Skills
       instructors and release coordinators and counselors at each facility
    2. Develop an action plan for release which may include:
       a. Individual interest and skills inventory. Assist the participant in making career
           choices based on skills, knowledge, abilities and appropriate match based upon
           reason for incarceration
       b. Labor market information and information about available on-the-job training
       c. Job search assistance
       d. Resume preparation
       e. Interviewing skills


                                                 22
       f. Job application completion skills & techniques
       g. Job-keeping skills
       h. Job development in the community in which the participant will be released
       i. Job matching and referrals to existing jobs
       j. Facilitate job clubs, job fairs, and other job-finding strategies with the focus on
          securing an offer of employment prior to release
      k. Individualized “Iowa Advantage” workshops, covering the following topics:
           Your Successful Job Search
           Coping with Change
           Budgets & Finances
           Job & Career Options
      l. Provide information on community resources for the areas to which the participant
          will be released
      m. Coordinate with the assigned case manager and parole officer upon release and
          provide case notes and action plan for each participant
      n. In coordination with the case manager and parole officer, conduct follow-up and job
          retention counseling
      o. Coordinate with local IWD management to identify local staff contact(s) to work with
          the participant and case manager if not within the regions of the three facilities
      p. Coordinate service provision with appropriate PROMISE JOBS case manager in the
          event the participant is FIP eligible and regaining custody of children, or rejoining an
          existing FIP household
      q. Coordinate service provision with appropriate Veterans case manager in the event the
          participant is an honorably discharged military veteran
      r. Work Opportunity Tax Credit certification
   3. Participate in follow-up and case management as requested by the case manager and/or
      parole officer

       The guiding principal of the Iowa DMIE project is to conduct a “rapid job search” and to

provide individualized assistance to identify employment issues and get the issues addressed

prior to release from prison, and to find a job so that the offender can be employed immediately

upon release.

       In addition, the Iowa DMIE vocational intervention will include individualized case

management and follow-on supports by workforce specialists located in the offender’s

community. As mentioned above, IWD is the primary workforce and labor agency in the state


                                               23
and operates 54 local offices, which will provide the community-based supports for the offenders

coming out of prison. These services may include assistance in getting started in the job, job

coaching, and coordination with the employer and employee to identify issues early and facilitate

working them out to avoid terminations, etc. The community-based workforce specialist (case

managers) will be members of the interdisciplinary treatment team. They will also perform rapid

job search assistance when or if a member loses their employment.

          There is a great deal of literature and evidence for the efficacy of Supported Employment

for Mentally Ill individuals.9,10 Supported Employment includes six key principles:

      1. Eligibility is based on consumer choice. No one is excluded who wants to participate
      2. Supported employment is integrated with treatment. Employment specialists coordinate
         plans with the treatment team: the case manager, therapist, psychiatrist, etc.
      3. Competitive employment is the goal. The focus is community jobs anyone can apply for
         that pay at least minimum wage, including part-time and full-time jobs
      4. Job search starts soon after a participant expresses interest in working. There are no
         requirements for completing extensive pre-employment assessment and training, or
         intermediate work experiences (like prevocational work units, transitional employment,
         or sheltered workshops)
      5. Follow-along supports are continuous. Individualized supports to maintain employment
         continue as long as participant want the assistance
      6. participant preferences are important. Choices and decisions about work and support are
         individualized based on the person’s preferences, strengths, and experiences

          The Iowa DMIE vocational services fulfill all of the above concepts. Offenders will

choose whether or not they want to participate in the program. The Workforce Specialists (both

those located at the prisons and the community-based case managers) are members of the

interdisciplinary treatment team that includes the mental health case manager, mental health

providers, and the specialized mental health parole officer. Employment in a community-based,

“regular” job for a minimum of 30 hours per week is not only the goal; it is a requirement for

9
    US Department of Labor. http://www.dol.gov/odep/archives/fact/supportd.htm
10
    SAMHSA. Evidence-based practices.
    http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/employment/


                                                  24
participation in the program. The job search process and job preparation will begin months

before leaving prison, while the individual is also completing the Life Skills curriculum. The

integration of the job search, resume and other job-preparation activities along with the Life

Skills curriculum will provide comprehensive training for a future in community employment.

       Continuous follow-along supports will be provided through the community-based

workforce specialists, who will be helping members get started in their jobs through coordination

with the employer and job coaching, and will continue with the intensity of services, as needed.

It is expected that members would need intensive services to start and then less frequent services

over time. The involvement of the workforce staff will be based on member need and choice.

This activity will be coordinated with the other members of the interdisciplinary team to provide

the full range of supports necessary for the member to remain in the community.

       The primary intervention group will receive the full range of supported employment

services, meeting each of the six supported employment principles. As noted above, even regular

parole has a very heavy emphasis on employment, and there are other community-based

resources available to these individuals that will assist them in the community.

Potential Start-up Issues

       Two key issues could affect the success of the Iowa DMIE program. The first is lack of

coordination among the complex set of personnel and services; the second is that it will be

necessary for IDOC to implement a significant expansion of their current reentry and pre-release

programs. We have taken the following steps to forestall these problems:

    1. Made one entity the lead coordinator of services. Iowa Plan Intensive Care Managers are
       in the best position to be the lead entity because they will be assigned to all of the
       program participants and will be responsible for managing the individuals’ mental illness
       from pre-release to exit from the program.
    2. Limited the IDOC program to 225 participants at any time.



                                                25
                                  NON-FEDERAL FUNDING

       A state match of 38.02% will be required for all Medicaid services provided. It is

estimated that a total of $13,565,596 will be required to provide Medicaid medical and mental

health services for 450 new participants each year. Program enrollment is estimated to be 900 by

the end of the grant period. The state match requirement totals $5,242,572. The State of Iowa

Fiscal Year is from July 1 to June 30. The Iowa General Assembly will be requested to

appropriate the state match for the program. The following amounts in Table 4 will be requested

for the match (shown by State Fiscal Year, all other State match figures appearing in this grant

are based on Federal Fiscal Year):

                     Table 4. Amount requested for the Medicaid state match

                        Fiscal Year                         Dollar Match
                        State FY 2007 Supplemental             $       0
                        State FY 2008                           1,057,025
                        State FY 2009                           3,171,075
                        State FY 2010                           1,057,025
                         Total State Match Request             $5,242,572


                                      EVALUATION DESIGN

       To evaluate the effectiveness and long-term outcomes of this demonstration, we will

utilize a true experimental design, where mentally ill prisoners with at least 6 months of post-

reentry supervision will be randomly assigned into one of three groups: 1) a primary intervention

group (as described previously), 2) a Medicaid-only intervention group, and 3) a control group

that will receive no additional interventions beyond the usual services provided to mentally ill

prisoners in Iowa (Table 5).

       Because mentally ill prisoners are at risk of long-term dependence on SSDI or SSI

without access to medical services, a comparison group of mentally ill prisoners who will receive



                                                     26
only Medicaid coverage including mental health care management is being introduced to the

evaluation design. In this way, the outcomes for prisoners who participate in the primary

intervention will be compared to prisoners who receive only Medicaid health care coverage

(Medicaid-only group) to determine the relative impact of the Life Skills and supported

employment interventions for this population. The rationale for the Medicaid-only comparison

group is that the provision of medical services alone will have an important impact on the

participants’ ability to remain employed by managing their mental illness, and that the additional

provision of Life Skills training and employment support will further impact their ability to

obtain and maintain gainful employment and remain out of prison. A comparison of these two

intervention groups is shown in Figure 4.




                                                27
Figure 4. Primary and Medicaid Only Interventions




                                          28
           A third control group of prisoners that has characteristics similar to participants in the

primary and Medicaid-only interventions but will not receive any additional services provided in

either intervention has been added for an evaluation of the impact of both Medicaid health care

coverage and the Life Skills and supported employment activities. A description of all 3 groups

in this demonstration is shown in Table 5.

                          Table 5. Description of Treatment and Comparison groups

Treatment Groups
1.   Full Intervention Group
          Participants will receive in-prison programming; multi-agency staffing; supported employment; and
         intensive mental health care management as well as full Medicaid services with following reentry;
2.   Medicaid-only Intervention Group
          Participants will receive only the intensive mental health care management beginning in prison and will
         then receive Medicaid services following reentry as those in the full intervention group.
Comparison Group
3.   Control group
          Participants will not receive any of the services provided to participants of either intervention group.


           The use of an experimental design will allow us to evaluate and compare the outcomes

of: a) the full intervention (i.e., Life Skills training, supported employment and intensive mental

health care management with Medicaid health care coverage post-reentry), compared to b) the

intensive mental health care management with Medicaid health care coverage post-reentry alone

and c) no additional intervention, to answer the research questions detailed in Table 6.




                                                            29
                      Table 6. Research questions investigated with this experimental design
                         Research Questions                                              Comparison group
True experimental design
What is the impact of the full intervention on reliance on cash benefits,    Pre-test v. post-test of primary intervention
employment status, mental health status, recidivism and quality of            group;
life?                                                                        Primary intervention group v. Control
                                                                              group
What is the impact of prison programming and supported employment            Full intervention group v. Medicaid-only
on the probability of employment?                                             group


What is the impact of providing health care coverage including mental        Pre-test v. post-test of Medicaid-only
health care coordination through Medicaid on the health status, quality       group;
of life, and criminal recidivism of participants?                            Medicaid-only group v. Control group

Non-experimental design
What are the characteristics of participants in the DMIE?                      Descriptive
What are the health care costs among participants?                             Descriptive



Regular services provided to non-primary intervention participants

         Prisoners in the Medicaid-only and control groups will continue to receive all services

that mentally ill prisoners in Iowa have received in the past. For example, in a typical parole case

in Iowa, the offender’s housing has been investigated and approved prior to leaving prison.

Usually, the offender is scheduled to report to the assigned parole officer and sign the parole

agreement on the day of release, and arrives at the destination that same day. It might be the next

day if there are transportation issues that would prevent a same day sign-up. The standard parole

agreement has the following expectation regarding employment:

      E. I shall secure and maintain employment as directed by my supervising officer. I shall
     notify my supervising officer within twenty-four (24) hours if my employment is terminated. I
     shall seek employment if I am unemployed and shall report my efforts to find employment as
     directed by my supervising officer.

         Specific expectations will vary depending upon the parolee, the parole agent, and the

employment prospects of the community. The parole officer may give the offender suggestions,

such as starting at a “Temp” agency establish a work record. They might also give parolees the



                                                          30
names of employers who are currently hiring if they have such information. If the parolee is

having difficulty finding employment, the parole officer may refer the offender to Workforce

Development to register with that agency. If parole officers feel parolees are not making a good

faith effort to find employment, they may require them to keep log sheets detailing at least two

job-seeking contacts per day. In many cases, there is an expectation that the offender should be

able to find some employment within a one-month period of time, although this varies depending

upon circumstances. There is no set time-guideline policy. Fulltime employment is considered to

be 32 hours or more per week.

          An offender who is being treated for a mental health problem while in prison leaves

prison with a 30-day supply of medication, and a prescription renewal for another 30 days, which

can be re-filled at their own expense. The prison counselor or release coordinator will often set

up an appointment at the local mental health clinic prior to the offender leaving prison. The

average parole officer with a normal caseload may not know a great deal about accessing mental

health services, and would not have time to offer much assistance, other than making a referral to

a community agency. For a variety of reasons, parolees are often unable to secure timely

financing for continuing mental health treatment in the community, and offender follow-up may

also be lacking.

          The limited mental health care services available to newly released offenders severely

limits their ability to continue to treat their mental illness and access mental health care services.

It also underscores that this problem of accessing mental health care services could be improved

by providing Medicaid coverage to the target population so that care for their illness is not a

barrier to employment-a research question that will be answered by the proposed evaluation

design.




                                                  31
Number of participants in the demonstration

       As mentioned, it is estimated that 225 participants will receive the full intervention in

each year of the demonstration. Since it is also estimated from the 2005 ICON data that there

will be about 735 mentally ill prisoners who meet the criteria for this demonstration each year, it

will be possible to also have about the same number of prisoners in both the Medicaid-only and

control groups respectively, making for appropriate statistical comparisons of the results of the

demonstration.

Randomization of prisoners and experimental design

       A stratified random sample of eligible mentally ill prisoners in Iowa will be used to

create the three groups for this demonstration. Prisoners will be randomly selected after being

stratified into groups by sex and race to improve the likelihood that the two intervention groups

and the control group will have characteristics that resemble each other, as well as the population

of mentally ill prisoners in Iowa as a whole. Analysis of the ICON 2005 data indicates that this

should be possible (Figure 5). Among the 732 mentally ill prisoners in 2005, about one-fifth

were women and four-fifths were men. This matches the proportion of male and female mentally

ill prisoners that will be enrolled in the full intervention in the men’s and women’s prisons. The

racial proportions in the three groups will also be randomly selected to reflect the same

proportions as in the population of mentally ill prisoners as a whole.




                                                32
         Figure 5. Mentally ill prisoners in Iowa by sex and race in 2005 (ICON database)

                                             732
                                       Offenders with a
                                         mental health
                                        diagnosis & >6
                                        months reentry
                                      supervision in 2005
                       185                                        547
                      Women                                       Men




           24 (13%)            159 (86%)               58 (10%)         482 (88%)
            Black                White                  Black             White




Intervention timeline and enrollment of participants

       Because prisoners will be released throughout the year whenever their sentence is

complete (rather than all at once), the timing of the interventions, as well as the placement of

eligible prisoners into the three groups, will have to be coordinated. A tentative schedule of the

Life Skills/supported employment classes during the 2-year intervention, the number of prisoners

trained and the timing of their reentry into the community is given in Table 7.




                                                  33
          Table 7. Timeline for intervention and release of prisoners into the community
                                 during the demonstration period
           Class Start          Reentry into the                            Number of prisoners
              Date              Community Date
                                                                Full             Medicaid              Control
                                                        Men      Women         Men   Women    Men         Women
           April 2007         August-October 2007          60          15      60      15         60        15
          August 2007            December 2007-            60          15      60      15         60        15
                                  February 2008
           December              April-June 2008           60          15      60      15         60        15
             2007
           April 2008         August-October 2008          60          15      60      15         60        15
          August 2008            December 2008-            60          15      60      15         60        15
                                  February 2009
           December              April-June 2009           60          15      60      15         60        15
             2008
          April 2009*         August-October 2009          60          15      60      15         60        15
          August 2009*           December 2009-            60          15      60      15         60        15
                                  February 2010
              Total                                     480        120         480     120    480           120
         * Classes will be held pending ending date of the demonstration

Disenrollment Criteria

   Participants may be disenrolled from the demonstration if:

      They have a serious criminal justice violation following reentry
      They are not employed for an average of 120 hours per month within 90 days                                 Comment [e1]: CMS was concerned about this.
                                                                                                                  “If the key goal of the project is to assess the impact
      They do not pay their premium payment (if their income is over 150% of the federal                         of the intervention on employment, why would
                                                                                                                  theses individuals be disenrolled from the
       poverty level and a premium is required. See Appendix A)                                                   demonstration?” (See memo #3.1)
      They obtain employment that includes comprehensive health insurance comparable to                          Comment [e2]: Will we have an appendix with
       Medicaid coverage                                                                                          this response?


Data Collection

       This evaluation will use a combination of primary and secondary data sources depending

on the research question.

   Primary data collection

       Primary data collection will occur a three points in time: 1) two to three months prior to

reentry into the community (baseline), 2) six months after reentry, and 3) one year after release.



                                                      34
The primary data collection process will be conducted by staff of Magellan Behavioral Health,

the company that operates the Iowa Plan for Behavioral Health. They will collect all of the

baseline data at the time they are conducting the baseline ANSA and BASIS-24 assessments

(prior to their involvement in the participant staffing) and will collect all of the follow-up data at

the time they are collecting the second follow-up ANSA and BASIS-24 assessment. A detailed

list of the domains, items and source surveys for the primary data to be collected in this study

can be found in Appendix H.

           The outcome measures evaluated using primary data will be operationalized in the

following way:

Operationalization of employment outcomes: Employment outcomes will include information
     about the participants: 1) current employment (both in prison and post reentry), 2)
     attempts at employment (if unemployed during reentry), and 3) work history. This
     information will be obtained both from administrative data (ICON) and surveys
     conducted at baseline and follow-up. Questions and domains in the survey will be taken
     from the HPQ, and the Bridges to Employment in Iowa survey (e.g., hours worked/week,
     type of job, hourly wage, number of attempts to get a job, job satisfaction). Questions
     will also be asked about the effectiveness of the supported employment program such as
     type and adequacy of the support received and usefulness in terms of gaining
     employment.

Operationalization of mental health status: Objective assessment of mental health status will            Formatted
      be conducted at baseline and every six months post release using the ANSA mental
      health assessment instrument. The ANSA measures the following domains: 1) problem
      presentation, 2) functional status and 3) risk behaviors.
      Subjective measures of psychopathology will be assessed via the BASIS-24 instrument.
      Data collection with the BASIS-24 will also occur prior to baseline and six and 12
      months post reentry. The BASIS-24 includes assessments of the following domains: 1)
      depression, 2) difficulty with relationships, 3) self-harm ideation and behavior, 4)
      difficulty with emotional lability, and 5) difficulty with substance abuse. Both of these
      instruments will be used with the primary intervention and Medicaid-only groups (See
      Appendix E).

           Utilization of mental health outpatient and inpatient services will be operationalized
           using two HEDIS11 measures (See Appendix F): 1) mental health utilization–Inpatient
           discharges and Average Length of Stay and 2) mental health utilization–percentage of
           members receiving inpatient and intermediate care and ambulatory services. These
11
     HEDIS = Health Plan Employer Data and Information


                                                         35
        measures will be evaluated and compared for participants in the primary intervention and
        Medicaid-only groups and compared to results for Medicaid enrollees nationally,
        published by the National Committee for Quality Assurance (NCQA).

        The quality of the mental health care that participants receive will be operationalized
        using two other HEDIS measures: 1) follow-up after hospitalization for mental illness,
        and 2) antidepressant medication management. These measures will be evaluated and
        compared for participants in the primary intervention and Medicaid-only groups and
        compared to results for Medicaid enrollees nationally, published by the NCQA.

        Treatment adherence will be operationalized using the ANSA items measuring
        medication compliance and motivation for psychiatric care.

Operationalization of health status and quality of life:
      Quality of life will be measured by using the Quality of Life Inventory (QLI) developed
      by Frisch et al.12 It been shown to be a reliable and valid instrument with mentally ill
      populations. The data will be collected at baseline and follow-up with the primary
      intervention and Medicaid-only groups and at follow-up for the retrospective group.

        Health status indicators will be obtained using standardized survey assessment tools
        while in prison and one-year post release. The survey items will include the Global rating
        of overall health, the SF 12v.2, and items from the HPQ, including the list of chronic
        health conditions. The analysis will include a pre-post comparison of the health status of
        each participant, comparisons between the three groups, and comparisons with national
        benchmarks. Medicaid claims data will also be used to evaluate the 10 most frequent
        medical diagnoses found in this population.

Operationalization of health care utilization and cost:
      Utilization of medical care will also be evaluated after one year in the Medicaid
      program using questions from the HPQ, which will be compared to available
      benchmarks.

        Cost of medical care will be operationalized as the cost of all health care services paid
        for by the Medicaid program. Information will gathered from the Medicaid claims and
        encounter files for the entire enrollment period following reentry. Costs will be calculated
        for each service area (e.g., inpatient, outpatient, ambulatory, prescription drugs).

Operationalization of health care access and quality:
      Access to medical care will be evaluated at follow-up using a written survey instrument.
      The instrument will include questions from instruments that have been tested for
      reliability and validity including the CAHPS survey, the National Health Interview
      Survey, the WHO Quality of Life survey and the WHO Health and Work Survey known
      as the HPQ (See Appendix G). Results will be compared between groups and to national
      benchmarks. Retrospective information about health insurance coverage and unmet need
12
  Frisch, MB, Clark, MP, Rouse, SV, Rudd, MD, Paweleck, JK, Greenstone A, & Kopplin, DA. (2005). Predictive
and treatment validity of life satisfaction and the Quality of Life Inventory. Assessment, 12(1), 66-78.


                                                    36
        for care in the 12 months prior to the arrest that sent the participant to prison will also be
        determined in the baseline survey.

        Quality of medical care will be operationalized using both objective and subjective
        measures. An objective measure of the quality of the medical care received in the first
        year of reentry will be obtained by calculating HEDIS measures for receipt of ambulatory
        care for all those in the Medicaid program. Subjective quality measures will also be
        obtained using items from the CAHPS survey at follow-up. HEDIS rates will be
        compared between the primary intervention and Medicaid-only groups while the CAHPS
        items will be compared for all three.

        Coordination of care for participants with dual diagnoses (physical and mental health
        diagnoses) will be evaluated using questions from the CAHPS survey collected at follow-
        up and compared for all three groups.

        Operationalization of criminal justice outcomes:
        Recidivism will be measured in terms of the incidence and timing of the following
        indicators of deviant or criminal behavior: parole violations, re-arrests, re-admission to
        prison, new court commitments to the DOC for new offenses, and incarceration in local
        jails. Data will be obtained from the ICON and Justice Data Warehouse databases.
        Comparisons will be made between the primary intervention group, the Medicaid-only
        group and the retrospective group.

        Community Social Supports will be assessed via a survey asking participants about
        their contact with families, spouses, partners and friends. We will ask about frequency of
        contact, the types of social and economic supports that are offered by these others, and
        whether the participants perceive the support as helpful. We will also ask participants for
        their perceptions of how well they are becoming reintegrated into social groups in the
        community. Domains will be similar to those proposed by Jacoby and Kozie-Peak13 for
        evaluating social support with mentally ill offenders. Data will be collected at baseline
        and follow-up for all three groups.

        The sources for the survey questions/instruments that will be used in this evaluation are

identified in Table 8. A flowchart of the primary data and time of the data collection during the

demonstration is shown in Figure 6. These measures have all been published in the scientific

literature and have been tested for reliability and validity.




13
  Jacoby, JE & Kozie-Peak, B. (1997). The benefits of social support for mentally ill offenders: Prison-to-
community transitions. Behavioral Sciences and the Law, 15, 483-501.


                                                        37
        Table 8. Primary data topics and survey instrument sources at baseline and follow-up

                                            Primary data collection
                   Baseline (source)                               6 and 12 month follow-up (source)
   Health status and work before prison (HPQ)            Health status and work since reentry (HPQ)
   Mental health assessment (current and                         Mental health assessment (current)*
    retrospective) (ANSA and BASIS-24)                             (ANSA and BASIS-24)
   Functional health status (SF12v.2)                            Functional health status (SF12v.2)
   Access to care and health insurance coverage for 12           Access to care (CAHPS, NHIS, WHOQoL)
    months prior to prison (CAHPS, NHIS, WHOQoL)                  Recidivism issues (e.g., rearrest)
                                                                  Social support (Jacoby, Kozie-Peak)
   Quality of Life in prison (QOLI)                              Quality of Life post reentry (QOLI)
*Note: The ANSA and BASIS-24 will be conducted every 6 months post reentry while still in Medicaid
HPQ = Health and Performance Questionnaire (HPQ) employee version
         (www.hcp.med.harvard.edu/hpq/ftpdir/survey_employee_040621.pdf);
QOLI = Quality of Life Inventory (www.pearsonassessments.com/tests/qoli.htm)
SF-12v2 = SF-12v2™ Health Survey (www.sf-36.org/tools/pdf/SF-12v2_Standard_Sample.pdf)
WHOQOL-100 = World Health Organization Quality of Life Survey (www.who.int/evidence/assessment-
         instruments/qol/documents/WHOQOL-100.pdf)




                                                          38
Figure 6. Primary Intervention Flowchart

     TIME         1. SCREENING & TRANSFER                                          PRIMARY DATA
                  IDOC identifies prisoners with a) a mental health                COLLECTION*
 6 mos. to        diagnosis following clinical assessment by an IDOC
 reentry          psychiatrist, b) >6 months supervision, and c) the
                  potential to be employed while in prison; prisoner is
                  transferred to one of the three intervention facilities.



                  2. DEMONSTRATION ELIGIBILITY DETERMINATION
                    a. Prisoner gives informed consent to participate
 5-6 mos. to
                    b. Screens for eligibility for full benefit Medicaid under
 reentry
                       DMIE (does not otherwise qualify for Medicaid)


                                                                                      Pre-test:
                                                                                  History of cash
                  3. PROGRAMMING                                                   benefits,
                  Participant receives intensive reentry programming,              employment, &
                  including:                                                       health status
                    a. Life-skills training by IDOC mental health trained         Mental health
                       release coordinator                                         status;
 2-3 mos. to        b. Prison work or work release assignment (40                 Quality of life;
 reentry               hrs/mo minimum)                                            Health & well-
                    c. Iowa Workforce Development (IWD) supported                  being;
                       employment counseling                                      Medical care use
                    d. Mental health assessment and treatment plan by              before prison;
                       Magellan                                                   Health status
                    e. Applies for eligibility for Medicaid                        and work before
                                                                                   prison.

                  4. INDIVIDUAL PRISONER STAFFING
                  Prisoner is referred to Iowa Plan (Medicaid Mental
                  Health Provider), and assigned an intensive care
 Reentry into     manager who communicates with the IDOC’s release
 community        coordinator, IDOC’s parole officer and IWD’s
                  employment counselor to create individual reentry plan.              Post-test:
                  (Note: This DMIE component does not include any                  Reliance on
                  Medicaid payments.)                                               cash benefits
                                                                                   Employment
                                                                                    status
                  5. COMMUNITY REENTRY                                             Mental health
                  IDOC/IWD/Medicaid intervention:                                   status;
                    a. Mental health trained parole assistance;                    Quality of life;
 Following          b. IWD supported employment counseling (ongoing                Health & well-
 reentry               from 3c)                                                     being;
                    c. Medicaid                                                    Health status &
                    d. Intensive mental health case management                      work;
                       (MHCM)                                                      Access/ Quality
                                                                                    of Care;
 * Secondary data from Medicaid claims and enrollment files, ICON database,        Recidivism;
 and Justice Data Warehouse will be used to supplement primary data                Social support.
 collection measures.

Secondary Data Collection



                                                    39
       Secondary data sources for this evaluation will include: 1) the Iowa Medicaid

administrative claims and enrollment files, 2) the ICON database of prisoner information, and 3)

the Iowa Justice Data Warehouse. All individual-level information from these three databases

can be linked by Social Security Number, using appropriate safeguards to ensure confidentiality

of the information.

       Medicaid claims and enrollment files will be used for the following purposes in this

evaluation: 1) determining enrollment in the SSI and SSDI program post reentry for all three

groups, 2) describing the cost of care and health care use for those in Medicaid, and 3)

determining the HEDIS outcome measures for utilization and quality of mental health services

for those in Medicaid. The University of Iowa Public Policy Center (PPC) has extensive

experience using this data for program evaluation purposes for the Iowa Department of Human

Services, including determining HEDIS measures for the Iowa Medicaid managed care programs

on an annual basis. The database is housed at the PPC in a sequel server database, an

environment accessible to PPC researchers. The data are protected by an extensive computer

recognition and password protocol system.

       Administrative data regarding criminal offenses in Iowa, at the individual level, is

maintained in two databases: ICON and the Justice Data Warehouse. The ICON database

includes demographic information about each prisoner, as well as intake assessments, sentencing

characteristics, criminogenic needs of the prisoner and the associated interventions received

while in prison, medical care received while in prison, and reentry information such as type of

program upon release (e.g., parole vs. work release). The Justice Data Warehouse links with the

Iowa Court Information system and includes information about all criminal charges, convictions

and jail-type offenses.




                                                40
       The ultimate goal of this demonstration design is to provide the best understanding of the

outcomes under the Iowa DMIE and to allow cross-site comparisons and generalizability to other

states participating in this demonstration.


                        ORGANIZATIONAL PLAN AND STAFFING

       The Iowa DMIE will be managed by a partnership of three state agencies: the Iowa

Department of Human Services (IDHS), the Iowa Department of Corrections (IDOC) and the

Iowa Department of Workforce Development (Appendix I). IDHS, the state’s Medicaid agency,

is the lead agency and will add one FTE with 100% of time dedicated to administration of the

project and coordinating the work of the three agencies. Medicaid services will be provided

through the existing Medicaid provider network, 1915(b) waiver managed behavioral health plan

(Iowa Plan), and claims processing systems. In addition, two FTE (with resources spread across

a number of local offices) will be added for eligibility processing at the local level. Existing

claims processing, eligibility and data warehouse systems will be used, with additional funding

for systems and programming changes (See Budget). Four FTE will be added to the Intensive

Care Management under the Iowa Plan contract.

       The pre-release programming, Life Skills training, and community mental health parole

supervision, will be coordinated through IDOC. IDHS and IDOC will develop an interagency

agreement to define roles, responsibilities, and funding transfers for these services.

       To effectively deliver program services, IDOC will also add one FTE with 100% of time

committed to the project. This position will coordinate with the Medicaid grant administrator and

will manage the three IDOC mental health release coordinators, five Life Skills instructors, and

nine community-based mental health parole supervisors (100% of time dedicated to the grant).

All newly hired staff will be expected to complete three weeks of IDOC pre-service training. In



                                                 41
addition, specific training on mental health and community services will be provided. It is

expected that initial training requirements can be met in a one-month period. Training will be

ongoing for project staff. The Department of Workforce Development will also add three new

program staff with 100% of time dedicated to the project to be managed by an existing program

manager. In addition, a contract cost of $450,000 will be provided to IWD for the cost of

community-based workforce case management through their 54 local offices.

       The project will also be supported by existing state agency staff, including Jennifer

Vermeer, Assistant Medicaid Director (15% of time to the grant), Jeanette Bucklew, Deputy

Director, Department of Corrections (15% of time to the grant), and Lori Adams and Mike

Wilkinson, Iowa Workforce Development (15% of time to the grant). IDOC Mental Health

Director, Dr. Bruce Sieleni, and Research Director, Lettie Prell, will also participate as needed.

Their time will be provided as an in-kind contribution and will not be charged to the project.

       IDHS will contract with the PPC at the University of Iowa for independent evaluation of

the design and data collection. Dr. Peter Damiano (30% of time to the grant) of the PPC will

manage the evaluation of the project. The percentages are based on the amount of time spent on

the project during a one-year period.

Program Governance

       Effective oversight of the DMIE project will be provided by a blue ribbon governance

board comprised of seven community-based members. The principal duties and responsibilities

of the board will be to: 1) assess the feasibility of program plans; 2) approve deployment of

program interventions to achieve stated outcomes; 3) allocate resources to support component

programs of the collaboration; 4) evaluate program progress and outcome achievement; 5) link




                                                42
program and community resources; and, 6) correct to course program deployment to achieve

stated outcomes.

         The governance board will meet on a quarterly basis to monitor the progress of the

project, its deployment and the achievement of stated outcomes. It will closely coordinate its

work through administrative staff leadership for the program.

         The seven members of the board will be selected based upon their interest in the program

plan of DMIE and their proven record of leadership in health, business, employment

development or correctional service programs, along with their ability to fulfill the above stated

duties and responsibilities. The chair of the board will be distinguished in his/her leadership in

the health services field. The balance of the board members will also be non-government

employed individuals who play leadership roles the community and exhibit diversity in

background, interests, gender, ethnicity and formal education.

Program Planning

         The Iowa DMIE will commence immediately upon notification of award. Table 9

exhibits the planning timeline and Table 10 outlines the evaluation process by quarter year of the

project timeline.

                                      Table 9. Program Planning Timeline

                                                             July   Aug    Sept   Oct   Nov   Dec    Jan
                              Activity                        06     06     06    06     06   06      07
Attendance at mandatory grant meeting                         X
Contracts and Interagency agreements signed                         X
Governance Board Convened                                                   X
Project Coordinator hired (IDHS)                                                  X
Project Coordinator hired (IDOC)                                                  X
6 IDHS staff hired: (2 for eligibility processing
4 Intensive Care Managers)                                                        X
3 IDOC Mental Health Release Coordinators hired                                   X
5 Life Skills Instructors hired                                                   X
9 Community-based Mental Health Parole Supervisors hired                          X


                                                     43
3 Vocational Rehabilitation Consultants hired                                        X
Job training for IDOC staff complete                                                         X      X
Participant Enrollment Period                                                                                   X
                                                                                                             1/01/07 –
                                                                                                              9/30/09
Evaluation process initiated                                                         X



Table 10. Evaluation Process Timeline

     Time period                                                Activity

Quarters 1-2              Complete development of primary data collection instruments

Quarters 1-2              Meet with DHS/DOC/Voc Rehab staff to determine performance targets

Quarters 3-12             Collection of primary data

Quarter 2-12              Collection, management and linkage of secondary datasets

Quarters 5-6              Begin analysis of primary data
                          Preliminary report of demonstration evaluation including analysis of primary and
Quarters 8
                          secondary data
Quarters 13-16            Final compilation and analysis of primary data

Quarters 13-16            Final compilation and analysis of secondary data
                          Final report of demonstration outcomes including analysis of primary and secondary
Quarter 16
                          data




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