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DATE: |
February 28, 2023 |
20 |
SUBJECT
Title
SUPPORTING CARE COORDINATION FOR JUSTICE-INVOLVED INDIVIDUALS: REPORT ON POTENTIAL OPPORTUNITIES AND CHALLENGES IMPACTING DATA SHARING (DISTRICTS: ALL)
Body
OVERVIEW
Individuals who are justice-involved experience adverse health and socioeconomic outcomes at greater rates than the general population. Data shows that rates of chronic conditions among incarcerated individuals are more than double that of the general population and nearly two-thirds of jail inmates have substance use disorders, as compared to 5% of the general adult population. Those who are justice-involved face a higher burden of health and socioeconomic disparities, and many individuals cycle between the community and jail. Care coordination is essential to address the needs of this population. However, without an integrated data infrastructure to support care coordination, navigating the complex health and social care systems can be a lengthy, frustrating, or disjointed process. Recognizing the challenges justice-involved individuals encounter, the San Diego County Board of Supervisors (Board) has made it a priority to take actionable steps to address the needs of this population.
On October 19, 2021 (3), the Board approved A Data-Driven Approach to Protecting Public Safety, Improving and Expanding Rehabilitative Treatment and Services, and Advancing Equity Through Alternatives to Incarceration: Building on Lessons Learned During the COVID-19 Pandemic. This action directed staff to conduct a data-driven analysis on use of jails with a focus on identifying policy interventions that would most effectively and safely reduce the San Diego jail populations, and better protect public safety through alternatives to incarceration. Initial findings highlighted care coordination as a challenge due to the need for a data governance structure and data sharing between programs for this population.
In response to these findings, on May 10, 2022 (3), the Board approved Supporting Care Coordination for Justice-Involved Individuals Through Funding and Integrated Data Infrastructure, further demonstrating their commitment to addressing inequities and health disparities that impact individuals who are involved with the justice system. This Board action acknowledged the challenge of coordinating care across justice, health and social service sectors without an integrated data system and highlighted the need to identify opportunities and challenges at the local, State, and federal levels in the areas of regulation; policy and procedure; infrastructure; and funding that impact creating an integrated data infrastructure to support care coordination for justice-involved individuals. The Board directed County staff to report back on the status of this ongoing project at specified intervals.
Today’s action requests the Board receive a report on identifying the challenges and potential opportunities to create an integrated data strategy and infrastructure to support care coordination, which will more seamlessly connect justice-involved individuals with the services they need and allow case managers, providers, and others to be more connected with multiple aspects of their care. This will have a positive impact by reducing health disparities and inequalities impacting justice-involved individuals in line with the regional Live Well San Diego vision of healthy, safe, and thriving communities. Additionally, this action supports the County’s vision of a just, sustainable, and resilient future for all, specifically, those communities and populations in San Diego County that have been historically left behind, as this collaborative effort will support coordination of care, which may ultimately lead to improved health and well-being outcomes, for the unique needs of those involved with the justice system.
RECOMMENDATION(S)
CHIEF ADMINISTRATIVE OFFICER
1. Receive report entitled Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Report on Potential Opportunities and Challenges Impacting Data Sharing.
EQUITY IMPACT STATEMENT
On January 12, 2021 (8), the San Diego County Board of Supervisors (Board) issued a resolution declaring racism a public health crisis. Recognizing that racism underpins health inequities throughout the region and has a substantial correlation to poor outcomes and social, economic, and criminal justice disparities, the Board has taken bold action to tackle this issue and improve the overall health and well-being of our residents. Identifying and addressing data sharing opportunities and challenges at the local, State, and federal levels to enhance care coordination for justice-involved individuals further supports this mission. In San Diego County, Black and Hispanic individuals were overrepresented in all arrest categories in 2021, compared to their proportion of the population, while White individuals and those who represented Other races/ethnicities were underrepresented. This and other race and ethnic-based disparities within the criminal legal system, and their correlation to poor health, social and economic outcomes, underpin the importance of data collection and sharing for addressing these trends, dismantling systemic contributors to these disparities, and improving public health outcomes for all.
Additionally, addressing data sharing for care coordination of justice-involved individuals and finding solutions to enhance this essential service is an important step toward ensuring this population can access and receive the same types of services as any other member of San Diego County. Additionally, it is important to consider how policy, procedures, and systems impact the justice-involved population. Reaching equity requires addressing the social, political, and economic factors that impact a justice-involved individual’s ability to access care. An integrated data infrastructure, as part of a data integration strategy to support care coordination of this population may increase opportunities for monitoring outcomes with an equity lens and facilitate the exchanging of information to enhance an individual’s access to the care and services they need, with a goal of improving the social and economic situations in which this population may find themselves. However, it will also require considerations of how policy and system designs impact this population, providing the opportunity to include justice-involved individuals in the decision-making process to ensure solutions meet the need.
SUSTAINABILITY IMPACT STATEMENT
Identifying challenges and opportunities at the local, State, and federal levels in the areas of regulations, policy, infrastructure, and funding is an initial step toward creating an integrated data infrastructure to support care coordination for justice-involved individuals. This infrastructure will also support strategic planning, operations, and evaluation, and facilitate sharing data publicly to support engagement with the community around this important topic.
Supporting care coordination for justice-involved individuals supports the County of San Diego Sustainability Goal #2 of providing just and equitable access, as it contributes to care to protect health and well-being by creating a system for data sharing to enhance care coordination, connecting individuals with services and supports more quickly and ensure needs are addressed. These efforts collectively help improved connection to services that reduce recidivism and promote health and well-being.
FISCAL IMPACT
There is no fiscal impact associated with this action. There will be no change in net General Fund costs and no additional staff years.
BUSINESS IMPACT STATEMENT
N/A
Details
ADVISORY BOARD STATEMENT
The Health Services Advisory Board voted to support the recommendation during its regular meeting on February 7, 2023. An informational presentation on the Board Letter was provided to the Behavioral Health Advisory Board during its meeting on February 2, 2023.
BACKGROUND
The health disparities experienced by individuals who are justice-involved are vast and well documented. Data indicates this population is among the most underserved in society, which contributes to poor health and social outcomes, such as significantly higher rates of infectious disease, chronic health conditions and homelessness. Compared to the general public, the incarcerated population contends with drastically higher rates of diseases such as HIV, tuberculosis and hepatitis C virus. With the increase in the proportion of older adults who are incarcerated and the growing numbers of individuals diagnosed with chronic disease, the justice-involved population faces increasingly higher rates of diabetes, hypertension and asthma compared to the general population. In addition, rates of mental health disorders have been found to be nearly four times higher among individuals in jail compared to the general population, and substance use disorders were found among more than 50% of the inmate population. A recent study of Sacramento County’s jail found that nearly 60% of the population had some combination of mental health needs and substance use, as well as a range of complex health conditions.
Some of the justice-involved population cycle between jail and the community, so health conditions may require treatment while incarcerated and when returning to their community. Individuals involved in the justice system may also be facing challenges such as homelessness, lack of health insurance, and difficulty accessing and adhering to health and social service programs, which often present a challenge to ongoing care and treatment of health conditions. This underscores the importance of care coordination for the justice-involved population and pursuing all actions that support enhancing the ability to provide optimal care coordination.
On October 19, 2021 (3), the San Diego County Board of Supervisors (Board) approved A Data-Driven Approach to Protecting Public Safety, Improving and Expanding Rehabilitative Treatment and Services, and Advancing Equity Through Alternatives to Incarceration: Building on Lessons Learned During the COVID-19 Pandemic to direct staff to conduct a data-driven analysis to public safety and to identify service gaps across the delivery system. Initial findings highlighted care coordination as a challenge due to the need for a data governance structure and data sharing between programs for this population.
In response to these findings, on May 10, 2022 (3) the Board approved Supporting Care Coordination for Justice-Involved Individuals Through Funding and Integrated Data Infrastructure, further demonstrating the Board’s commitment to address inequities and health disparities that impact the justice-involved population. This action acknowledged the challenge of coordinating care across justice, health and social service sectors without an integrated data system and highlighted the need to identify opportunities and challenges at the local, State, and federal levels in the areas of regulation, policy and procedure, infrastructure, and funding that impact creating an integrated data infrastructure to support care coordination for justice-involved individuals. The Board directed County staff to report back on the status of this ongoing project at specified intervals.
To address the May 10, 2022 (3) Board action, a Strategic Planning Workgroup (Workgroup) was formed with representatives from across the County of San Diego (County) enterprise to conduct a comprehensive assessment of challenges and opportunities related to an integrated data infrastructure. The Workgroup convened multiple times between June 2022 and January 2023 for project planning and conducted numerous assessments to gather the information presented in today’s item. A Memorandum was submitted to the Board on August 17, 2022, describing formation of the workgroup and the project plan. A second update followed via Memorandum on December 30, 2022, which described updates to the project plan, forums in which feedback was gathered, and initial assessment findings. Attachment A includes a list of Workgroup members as well as additional information on the project plan and the methodology and scope of the assessment.
A care coordination use case found in Attachment A provides an example of how accessing information on a justice-involved individual being released from jail may be impacted by regulation, infrastructure, and/or funding. The case highlights some of the difficulties experienced by case managers, providers, and individuals involved with the justice system. It also highlights how an integrated data infrastructure can support strategic planning, operations, and evaluation.
Today’s update identifies the challenges and potential opportunities at the local, State, and federal levels in the areas of regulation, policy and procedure, infrastructure, and funding that impact the ability to share data to support care coordination for justice-involved individuals and highlights how the County may approach developing a data integration strategy.
Regulation
Ideal care coordination for justice-involved individuals would include selected information sharing between criminal justice, health care, and social services programs. However, numerous regulations designed to protect individuals and their privacy are in place that restrict data sharing. These regulations are not uniform across the various disciplines involved with care coordination of justice-involved individuals, requiring that each regulation is thoroughly understood and applied appropriately. Also, these regulations may not be uniformly interpreted and applied, which creates additional challenges when working to share data between entities.
While no local regulations govern data sharing, several State and federal regulations were identified. The regulations listed below highlighted as the most crucial for understanding the challenges and opportunities around data sharing for the purpose of care coordination, strategic planning, operations, and evaluation:
• Criminal Justice Information Related Regulations: Criminal justice information refers to all criminal offender record information, data, and the systems that house this information. This includes, but is not limited to, summary of arrests, proceedings, nature, and disposition of criminal charges, sentencing, incarceration, and rehabilitation.
• Health Care Data Related Regulations: The federal Health Insurance Portability and Accountability Act (HIPAA) sets national standards around patient data sharing for health care providers, health plans, and others in the health care space. HIPAA defines the scope of how, when, and for what purposes patient data may be shared.
• Social Services Data Related Regulations: Rules related to sharing individual-level data related to social services differ from health care related regulation. Unlike HIPAA, there is no law that covers all aspects of social services data, therefore, separate regulations must be considered for each type of program.
Identifying the impacts State and federal regulations have on data sharing are essential for understanding the challenges and opportunities that exist when developing a data integration strategy. Tables depicting challenges and opportunities presented by specific regulations in each of these areas are included in Attachment A.
Two overarching opportunities to address State and federal regulations impacting data sharing are the Board’s Legislative Agenda and California Assembly Bill 133. On December 13, 2022 (20), the Board approved their 2023 Legislative Agenda which includes Data Infrastructure as a Priority Issue. This provides the policy direction and authority to pursue and advocate changes to legislation. Additionally, California Assembly Bill 133 established programs and data sharing strategies in which organizations that may not have shared data previously are now encouraged to do so, creating opportunities to enhance care coordination through data exchange.
Policy and Procedure
There are various policy- and procedure-related challenges and opportunities that impact the ability to develop, implement and utilize an integrated data infrastructure to support care coordination for justice-involved individuals.
Key areas to consider, which are discussed in more detail in Attachment A, include:
• Agreements: Update County practice of requiring a Memorandum of Understanding or Memorandum of Agreement each time a new project or purpose for data sharing arises to a less time-consuming process of using project agreements.
• Community Representation: Need for inclusion of community representatives and individuals with lived experience in policy and programmatic decision making in a manner that compensates individuals for time and efforts and ensures concepts of social equity are honored.
• Link to Initiatives Addressing Homelessness: Development of a consistent local methodology for demographic definitions across programs and services to be utilized by the County and community and explore solutions for accessing data with the most comprehensive source of information on individuals experiencing homelessness.
• Consent: Need for clear and consistent policies, procedures, and education for care coordinators to follow and provide to their clients, which may result in more consents for data sharing.
Infrastructure
Potential opportunities and challenges for infrastructure focused on the categories of Data, Staffing, Data Governance and Technology, which are listed below:
• Data: The Workgroup conducted an initial assessment in Fall 2022 and identified thirteen County data sources that fall within the scope of the project. Establishing a data integration strategy will set the foundation for improving collaboration and coordination and allow for a comprehensive look at the types of data used within the County while developing the best solution for integration across platforms and applications.
• Staffing: In an infrastructure assessment conducted for this project, several County departments responded they would benefit from additional support to manage data systems, specifically staffing with expertise in working with large data systems and integrations.
• Data Governance: An assessment of existing County data governance policies related to justice-involved individuals identified 29 policies, four of which specifically refer to justice-involved individual data. A comprehensive structure is not currently in place to govern data integration for care coordination of justice-involved individuals. An update will be presented to the Board in May 2023 in response to the Board’s action on May 10, 2022 (3), which directed County staff to develop a data governance and management system.
• Technology: Technology solutions for data sharing vary depending on the purpose. Transactional data systems are necessary for care coordination so that data present in one system can quickly be made available to view in another system. Sharing data for the purposes of strategic planning, operations, and evaluation can be accomplished through a data warehouse, where the data can be stored and updated at regular intervals. A solution for care coordination will need to be identified, whereas data warehousing solutions currently exist within the County and are in process of being expanded. The region’s Health Information Exchange and/or Community Information Exchange may also be considered in addressing the County’s needs.
Funding
Under California Advancing and Innovating Medi-Cal, Providing Access and Transforming Health (PATH) is a five-year funding strategy to build the capacity and infrastructure of on-the-ground partners, such as community-based organizations, public hospitals, county agencies, tribes, and others, to successfully participate in the Medi-Cal delivery system. One component of PATH is Justice Involved Capacity Building (PATH JI), a $561 million program to support implementation of the pre-release enrollment processes as well as the targeted pre-release and reentry services.
The County was awarded $250,000 in August 2022 through the first round of PATH JI to prepare for the implementation of the pre-release Medi-Cal enrollment process. In March 2023, the County will apply for up to $5.75 million during the second round of PATH JI. If awarded, the funding will be used to implement an enhanced pre-released Medi-Cal enrollment process, including funding information technology modifications, and staffing for the San Diego County Sheriff’s Department, Probation Department, and the Health and Human Services Agency. A third and fourth round of PATH JI funding will support the development and implementation of pre-release and reentry planning services in the 90 days prior to an inmate’s release, which the County also intends to apply for upon the release of the applications.
Today’s action is a critical step in creating a data integration strategy and data infrastructure to address supporting care coordination of justice-involved individuals through assessing existing challenges and opportunities. Supporting care coordination for justice-involved individuals through an integrated data infrastructure should not only enhance interactions with clients but also increase efficiencies and reduce administrative burden. Determining how to integrate with community-based organizations, hospitals, emergency departments, and outpatient clinics who also provide services to justice-involved individuals will be an essential part of a data integration strategy.
LINKAGE TO THE COUNTY OF SAN DIEGO STRATEGIC PLAN
Today’s action aligns with the County of San Diego Fiscal Year 2023-2028 Strategic Plan initiatives of Equity (Health), Empower (Workforce, Innovation), and Community (Engagement, Quality of Life, Partnership). Supporting care coordination for justice-involved individuals creates a structure that will reduce the burden on individuals as they try to navigate complex health and social care systems and enhance providers’ abilities to connect clients to services. Today’s action also describes the challenges and opportunities to share data for care coordination, which will allow County staff to be innovative while implementing best practices and investing in a system that supports staff, contractors, and the community.
Respectfully submitted,
HELEN N. ROBBINS-MEYER
Chief Administrative Officer
ATTACHMENT(S)
Attachment A - Supporting Care Coordination for Justice-Involved Individuals through Funding and Integrated Data Infrastructure: Report on Potential Opportunities and Challenges Impacting Data Sharing