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Feb 17 2014
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Recommended Reading: ‘Inside a Mental Hospital Called Jail’

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A recent essay by columnist Nicholas Kristof of The New York Times looked at a critical problem faced by jails across the country, which often double as behavioral health treatment centers. For many inmates, mental health problems have been the significant factor in committing a crime, with some even purposely flouting the law in the hopes of getting into jail where they can get free treatment. As a result, the United States has a national inmate population where half of all male inmates and three quarters of all female inmates have a behavioral health condition.

Solutions are beginning to emerge, though critical problems remain. At a recent health initiatives forum convened by the National Association of Counties and held in San Diego, county health officials talked about the promise of the Affordable Care Act, which will allow jail health specialists to help enroll inmates in coverage in advance of their discharge to help continue care—behavioral and physical—outside of jail.

Read the full column here.

>>Bonus Link: Read NewPublicHealth’s coverage of the recent NACo Health Initiatives Forum.

Feb 4 2014
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AcademyHealth National Policy Conference: Integrating Behavioral and Physical Health

While behavioral and physical health have generally been separate entities in the United States, new rules under the Affordable Care Act are bringing them together—both to reduce costs and to integrate care in millions of people who face behavioral and physical health issues.

Experts at last week’s Healthy Communities Initiative forum, convened by the National Association of Counties (NACo), and this week’s AcademyHealth National Policy Conference, meeting in Washington D.C., presented strategies for combining the two. Some pilot projects are beginning. The pace is picking up largely because many people now covered under the states that have created Medicaid expansion have a range of behavioral and physical health needs. They will benefit from integration because the two are often connected—for example, diabetes has been linked to depression—and because connecting the two can reduce health care costs and reduce the number of provider visits a patient has to make.

“Behavioral health is a driving force in why people don’t get where they want to be,” said Donna Skoda, ​ Assistant Health Commissioner of Summit County, Ohio, who spoke at the NACo forum.

Several public health officers at the forum presented ideas of what works in their communities, including:

  • Hiring nurses to be care providers to assess both behavioral and physical health needs
  • Retraining behavioral health specialists, including psychiatrists, to use blood pressure cuffs and other medical equipment
  • Integrating patient files with information on mental and physical health baselines and changes
  • Opting, when possible, to deliver care in physical health offices rather than counseling offices, since physical practitioner clinics already have devices needed such as scales

Presenters at the AcademyHealth policy conference stressed cost savings. For example, Washington state will participate in a federal demonstration project for beneficiaries dually eligible for Medicare and Medicaid. Under the demonstration, the health plans will be responsible for a full range of services—including mental health; chemical dependency; long-term services and supports; and medical care—under a single capped rate.

“Integrated care needs to be the rule, not the exception,” said Charlene Le Fauve, a deputy director of the National Institute of Mental Health.

Le Fauve said new technologies can be an important factor in delivering care including mobile devices and internet tools, which can be used at provider offices, clinics, and in homes if communities provide those services.

Other ideas being funded include training community workers for brief interventions which may be able to keep many people with mental illness out of both the emergency room and the hospital. Phone intervention is also being studied, said Le Fauve.

Feb 3 2014
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NACo Conference: Transitioning Jail Inmates to Community Care

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A key session at the National Association of Counties (NACo) Health Initiatives Forum held last week in San Diego focused on the opportunities and implementation challenges of the Affordable Care Act for inmates of county jails.

Most county jail inmates are there awaiting trial because they can’t afford bail, and a large percentage have physical and/or mental health problems. While in jail, the cost for their health care falls to the county; Medicaid and other benefits inmates have in the community end once they enter the jail system, and many have no benefits. Typically, the care inmates received in jail ends on release since there is generally no entity to help them transition to community benefits and care.

And benefits under the Affordable Care Act are generally elusive for inmates—and counties—desperate for care and a break on the high cost of health care for inmates. While just about all inmates would qualify for coverage under the Affordable Care Act either through health insurance marketplaces or Medicaid expansions in those states that have changed their Medicaid rules under the health law—expanding Medicaid benefits to those without children who qualify financially because of low incomes—current laws do not permit inmates to be covered for health care costs under Medicaid while in jail, except for hospitalizations while they’re incarcerated.

Many counties in states that have expanded Medicaid to include low-income adults without children have petitioned their state Medicaid offices to amend current rules and allow coverage for health care under Medicaid during incarceration.

However, counties are taking initiative to help inmates sign up for coverage that will kick in on their release, reducing the chance for recidivism and improving the chance for healthier and more productive lives. For example, last week in San Francisco the city sheriff sent a bill to the city’s Board of Supervisors that would make the sheriff’s office responsible for helping inmates sign up for the Affordable Care Act.

At the NACo meeting, Farrah McDaid Ting, Associate Legislative Representative for Health and Human Services at the California State Association of Counties, said a key issue both for county budgets and for the health of people released from jail into the community is that without benefits and a transition to care, often care was only sought afterward and delivered when there is a crisis. Ting says among the requests being made in California is to have Medicaid suspended rather than terminated for people in jail under a year, which would allow a person to transition back to care immediately on release.

Another critical need in jail is technology infrastructure to allow inmates to be signed up. Some counties in California, according to Ting, are using outside nonprofit groups to sign up eligible inmates before release.

“What we want to reduce is that person ending up back in jail,” said Ting.

Jan 31 2014
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In San Diego, a Big Push for Better Health

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Many of the sessions at the National Association of Counties (NACo) Health Initiatives Forum meeting in San Diego this week have been moderated by Nick Macchione, director of San Diego’s Health and Human Services Agency and vice chair of the Healthy Counties Initiative Advisory Board. Macchione is a key architect of Live Well San Diego, a program voted in by the San Diego Board of Supervisors that is a long term, comprehensive and innovative strategy on wellness with a goal of helping all San Diego County residents become healthy, safe and thriving.

NewPublicHealth spoke with Nick Macchione ahead of the forum. Senior Policy Advisor Julie Howell and Dale Fleming, director of strategic planning and operational support, joined the conversation.

NewPublicHealth: The buzz about San Diego is that you’re working hard toward population health improvement.

Nick Macchione: I think the excitement about San Diego is that we have earned a reputation as a health innovation zone by having a collective impact on health and wellness. Our deeds demonstrate our words because over the past decade there have been five major broad-based population health improvements: reduction of heart disease and stroke; reduction of cancer rates; reduction of childhood obesity; reduction of infant mortality; and reduction of children in foster care. That reduction is extremely important to population health because we also look at the social determinants of health and not just pure health care.

We've taken an ecological approach to population health—working with partners across all sectors and coming together not just from traditional health care but beyond that to public health, social services, business, community, schools and the faith community.

And we’ve done that in the context of optimizing existing resources to improve outcomes. We’ve been blessed with a lot of competitive federal grants and philanthropy investments, but really the framework is how we leverage and optimize what we have first before we go and seek to augment with other resources. That has worked exceptionally well and that’s earned us that innovation zone reputation.

NPH: Tell us about Live Well San Diego.

Macchione: Live Well San Diego is a comprehensive public health initiative that involves widespread community partnerships to address the root causes of illness and rising health care costs. The tagline is healthy, safe and thriving. We think it’s a great template that communities can use, it’s transferable because San Diego has every imaginable bio-climate except a tropical rainforest. So we have desert towns, we have rural communities, we have mountain villages, we have beach towns and everything in between urban core. We also call it Project 1 Percent because 1 percent of San Diego represents the nation both in its diversity and its population. So, if we can achieve what we're achieving on advancing population based health in a broad scale it can be demonstrated throughout the country.

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Jan 31 2014
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Atlanta Needs Resiliency Lessons Before the Next Crisis

The fallout from this week’s snowstorm in Atlanta was a hot topic among many of the county officials attending the National Association of Counties (NACo) Health Initiative Forum in San Diego. Many have had to make tough decisions on crises in their communities—from flu to flooding to snow to shootings—and the consensus was that the snarled traffic, kids left to stay overnight in schools and thousands of cars abandoned marked a failure not of adequate preparation, but of communication and preparedness.

“You can’t know what disaster might hit, so you have to be prepared for everything,” said Linda Langston, NACo’s president and the supervisor of Linn County, Iowa, who has chosen resilient counties as her President’s initiative.

Langston said several steps can help reduce the trauma from disasters, including designating someone in each community to coordinate response, to stay up to date on dealing with emergencies, to building relationships among intersecting communities so that people trust each other in a disaster and to convening meetings with all sectors at the table. Langston pointed out that while schools and businesses don’t typically plan together, in the case of Atlanta’s snow storm most students and workers left the city for the suburbs at the same time of day, increasing traffic at the height of icy conditions. That might have been avoided by having a large pool of participants at the planning table.

“By inviting a member of the chamber of commerce, for example, to preparedness meetings and exercises, decisions can be made on traffic flow and other crowd control issues in the event of an emergency,” she said.

Langston, whose community saw devastating flooding in 2008, said recent preparations for possible flooding (that thankfully never happened) made city managers and the sheriff’s department—which controls the jail—realize they needed to coordinate on evacuation plans in the event of an emergency.

“And if the emergency never occurs, all those planning exercises create a more cohesive community, able to deal with run of the mill disasters like budget cuts, “ said Langston.

Jan 30 2014
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NewPublicHealth Q&A: James McDonough, Chair of NACo's Healthy Counties Initiative

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NewPublicHealth is on the ground at the NACo 2014 Healthy Counties Initiative Forum. The theme of the forum this year is “Improving Health in a Climate of Change.” Ahead of the meeting we spoke with James McDonough, county commissioner in Ramsey, Minn., and chair of the Healthy Counties initiative about the meeting and the health changes he is seeing at the county level.

NewPublicHealth: Can you tell us how the NACo Healthy Counties Initiative got its start?

James McDonough: Three years ago the president of NACo at that time, Lenny Eliason, from Athens County, Ohio, really was concerned about how the majority of health care dollars were being spent on treating preventable conditions and the whole issue of the wellbeing of our constituents and our employees. So he elevated the issue of wellness and health in counties as a presidential initiative. Typically those are short term and last for a year or two, but NACo has embraced this and has continued this on as a task force to really embed it in the work that we do—elevating how counties can have an impact on wellness in communities.

NPH: What are the current goals?

McDonough: To really elevate and get the county commissioners and county managers throughout the country to just pause and take a look at what they're doing and what they could be doing. We’ve been talking about how we can do a better job supporting counties that are already doing great work in this area and helping share those best practices, and then helping counties that haven’t really taken a look at what their role is. That can help us have a better impact on getting ahead of some of the major preventable diseases in our communities.

NPH: How important is county-level action when it comes to health?

McDonough: For the most part, counties really are responsible for the public health departments within their communities. Throughout the country we operate almost 1,000 county hospitals and close to 700 county nursing homes, so we have a lot of responsibility for public health and—just as important—we employ more than 30 million people throughout the country.

Action, responsibility and efforts vary county to county, but for example, in Ramsey County, Minnesota, where I’m the County Commissioner, we run the public health department working with our cities, the state and with the federal government. So for us it’s a really big opportunity to be the convener as well to lead the Healthy Cities Initiatives as well to a larger regional more focused and concentrated effort.

NPH: The focus of the forum includes some critical topics such as behavioral health and key health issues in jails. How much of a financial burden do these health issues place on counties?

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Jan 29 2014
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NewPublicHealth Q&A: Linda Langston, National Association of Counties

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This week the National Association of Counties (NACo) will hold the fourth Healthy Communities Initiative Forum, in San Diego, bringing together county health directors and staff to share best practices to improve community health. The NACo Healthy Counties Initiative supports innovative public-private partnerships to enhance community health.

Ahead of the conference, NewPublicHealth spoke with Linda Langston, president of NACo and Supervisor of Linn County, Iowa, who will be attending and presenting at the conference.

NewPublicHealth: Tell us about the Healthy Counties Initiative.

Linda Langston: I was the first chair of the initiative when it came into being four years ago. We modeled it after what we had done with our Green Government initiative—we had local government elected officials and staff connected to various areas of health, and then we also populated the committee with some of our corporate sponsors that were ultimately working toward very similar kinds of goals and trying to figure out how we could work affectively together.

We're also helping people understand upcoming issues and ideas they may know about.

NPH: What are the key health issues that counties face in 2014 and how is NACo generally helping counties with those issues?

Langston: Many counties are responsible for safety-net services and virtually every county in the nation has a jail. We’ve learned that many people, including many federal legislators, don’t understand the difference between jails and prisons. Jails are unique to local government, at the county level, and are often where people who have been arrested but can’t afford bail wait until their trial dates. Our challenges include providing health care in the jails, as well as connecting those released to health services in the community, with a goal of continuity for such services as mental health care and treatment for substance abuse.

We are also employers and very often, particularly in small-to-medium-sized counties, we are the largest employer in the area. So we have a lot of employees who need our best efforts, such as looking at how to incentivize people to make good decisions about their own health. And, of course, we also have the community public health responsibility. So we're pretty effectively placed to deal with all things related to health.

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