Four Key Projects

Background

There is a vital need to develop suicide risk care pathways between jails and healthcare systems to offer immediate access to life-saving services. Currently, there are major barriers in the linkage of data and clinical information between jails and health systems, preventing effective care coordination between these community sectors. Health systems rarely become aware when their patients are released from jail, and jails are frequently unaware of how to connect individuals with new services upon release.

This project aims to fill this major gap by developing a generalizable data and clinical linkage infrastructure to facilitate rapid identification of at-risk individuals upon release from jail and create a systematic process to notify healthcare systems of their release, which can lead to opportunities for immediate intervention. This study will also test a comprehensive multi- level intervention for those identified as at-risk for suicide. Findings on suicide attempt and death outcomes, healthcare utilization mechanisms, cost-effectiveness, and implementation factors will inform future fully-scaled implementation trials and widespread adoption in community settings.

Project Details

Project 1 will harmonize publicly available jail booking and release data with healthcare records at two large healthcare systems in Minnesota (HealthPartners) and Michigan (Henry Ford Health System) to identify health system-affiliated individuals at the time of release from jail. Once identified, 1,050 individuals will be randomly selected into a multi-level intervention group (i.e., suicide care pathway) across both sites. The remaining eligible individuals (n=60,000) will comprise a “no contact” comparison group.

Both groups will be eligible to receive usual care, while the intervention group will also be eligible for the additional package of evidence-based services offered in the suicide care pathway, which includes immediate linkage to care coordination with universal screening, safety planning, and caring contacts coupled with a telehealth-delivered suicide prevention clinical intervention (the Coping Long-Term with Active Suicide Program; CLASP) for those identified as at-risk for suicide.

Background

Beginning in 2018, a large managed care organization (CareSource) and a justice data vendor partnered to track county jail booking and release data for Ohio CareSource through an algorithm that uses publicly available data that can be generalized to other healthcare/MCO systems. The goal was to help CareSource ensure that their subscribers who spent time in jail (~43,000) were connected to needed community care following jail release and to minimize disruptions of any existing care due to jail detention. Managed Care Organizations are ideal to help address system fragmentation because they span multiple behavioral health care systems (400 in Ohio alone) and multiple county jails (~88 in Ohio alone). This Jail-Medicaid data linking system arose naturalistically to meet a clinical care demand.

Project Details

Project 2 will track suicide-related and service linkage outcomes for all 43,000 subscribers passing through jail for the 12 months prior to and 6 months following jail release, using claims data algorithms developed by the Mental Health Research Network for large-scale suicide prevention research. The project includes two studies of evidence-based suicide prevention practices triggered by their jail detention/release notifications:

• The first study will randomize the ~43,000 Ohio CareSource subscribers who pass through jails over 12 months to receive Caring Contact (CC) letters sent by CareSource or to Care as Usual (CAU).
• The second study will involve a subset of ~6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 large behavioral health agencies in the 6 months prior to jail detention. Agencies will receive: (a) notifications of client’s jail detention/release, (b) instructions for re-engaging these clients and training in suicide risk assessment to use at re-engagement; (c) training in the Safety Planning Intervention (SPI) plus notification to use SPI when a client with past medically treated suicide attempts (study outcomes are identified by CareSource through claims data) is released from jail.

Background

Suicide screening in jails is often insufficient, given that individuals booked into jails may not be comfortable sharing feelings with corrections officials and access to an individual’s medical records and prior history is limited. Many jails don’t have the capacity to incorporate evidence-based screening and assessment tools. A more robust and automated process, that ‘flags’ risk of suicide, could improve identification, early intervention, and linkage to care while reducing adverse impacts that suicide has on detainees, families, correctional staff, and communities.

This project seeks to enhance suicide-risk identification during jail booking in a way that is more accurate and involves less work for staff (i.e., is potentially more scalable). The Mental Health Research Network (MHRN) has developed a mathematical model that uses past Medicaid claims data to predict suicide risk in the community. Michigan is currently making efforts to give jails access to Medicaid claims data. This project tests; (1) whether the MHRN model also works for predicting suicide risks in jails and after jail release, and (2) whether it works as well as/better than current screening approaches.

Project Details

The MHRN model has been shown to be effective in community samples, with the top 5% of risk scores predicting over 43% of attempts and deaths 90-days following a healthcare visit. However, it has not been tested solely on a jail population.

This project seeks to validate the MHRN suicide risk prediction model using Medicaid claims with a jail population of ~6,000 individuals booked into three Michigan jails and compare it to current and best feasible practice for predicting suicide attempts and deaths: (1) in jail, and (2) after jail release.

Background

There is increased concern that individuals with mental illness are involved with the criminal justice system too frequently and that these encounters may lead to the exacerbation of mental health symptoms, including suicide attempts. Understanding the intersection between mental health treatment, Emergency Department (ED) use, and criminal justice involvement is crucial to supporting individuals with mental illness. Criminal justice liaison and diversion services can provide an opportunity to identify individuals with mental disorders and connect them to appropriate services, but multi-system interventions are hampered by a lack of training of law enforcement, poor communication, different priorities between healthcare providers and law enforcement, and well-known and persistent silos between criminal justice, emergency services, and inpatient and outpatient psychiatric services.

In response, the Cambridge Police Department (CPD), Massachusetts, has developed the Family and Social Justice Section (FSJS) intervention, a police-based multi-system intervention to train patrol officers in mental health first aid and trauma-informed policing, link community and healthcare services, and follow-up on mental health-related calls with police department-based case management using a team of specialty mental health resource officers and mental health clinicians. The FSJS is a team-based, multidisciplinary approach delivered at Intercepts 0 and 1 of the Sequential Intercept Model (community services and contact with law enforcement) intended to reduce arrest, court involvement, ED visits and calls for service by police for individuals in mental health (including suicide) crisis.

While preliminary qualitative evaluation of the FSJS intervention demonstrated some success in pre-adjudication diversion, it also identified a disconnect in information-sharing across systems.

Project Details

Project 4 will compare three study conditions among justice-involved individuals in mental health crises transported to the ED (voluntarily or involuntarily) by the police. Most such individuals present with suicide-related concerns.

The three conditions include:

• The FSJS+Navigator arm includes eligible individuals (n=40) transported to ED by CPD and recruited in the ED. This intervention will employ a system navigator to coordinate and build relationships among CPD and two Cambridge EDs, to update the team with data-driven feedback (to the extent allowed by law) on each patient’s clinical, legal, and community situation to ensure coordination of care, and to provide outreach and assistance to each patient in accessing follow-up clinical and community services. The Navigator solves the identified problem by assigning a lead case manager/patient advocate who communicates across healthcare and legal systems and coordinates information-sharing.
• The FSJS arm includes eligible individuals identified in chart reviews as having FSJS contact resulting from the same two Cambridge EDs visiting for substantial risk to self or others (n=200) during the study period. Individuals in this condition will be: (a) brought in by CPD (vs. control cities), and (b) not enrolled in FSJS+Navigator (i.e., presenting when research staff is unavailable).
• The treatment as usual (TAU) arm patients will include 800 eligible individuals bought to the same EDs from control cities (Everett, Chelsea, Somerville, Medford, Malden) that are similar in size and demographics to Cambridge. TAU patients will be identified using targeted, limited chart review methods used in our prior studies, “scraping” clinical notes in the EHR for criminal justice involvement and ED use.

The research team will use a data warehouse that merges data from CPD, Corrections, ED electronic health records, claims, and area-level socio-contextual data to guide Navigator follow-up and outreach and to evaluate intervention outcomes. All three samples will be collected prospectively and analyzed using a propensity score-weighted difference-in- difference design. Outcomes include medically treated suicide attempts (primary), mental health and service use outcomes, and arrests (secondary).