THE OPPORTUNITY FOR CHANGE

Located on more than eight city blocks in Chicago, the Cook County Jail is one of the largest single site county jails in the United States, with 10 divisions, a health services facility, two education departments and more. The jail primarily holds pretrial detainees, admitting approximately 200-300 people every day.

Many individuals in the jail could benefit from expanded access to Medicaid, particularly those with behavioral health needs, and leaders from the courts, jail and health care systems in Cook County, Ill. all recognized this early on. Approximately 15-30 percent of individuals in the Cook County Jail are estimated to have a serious mental illness, and county leaders cite a growing understanding, locally as well as nationally, of the drivers that can cause individuals with mental health and substance abuse issues to enter into the criminal justice system. In anticipation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA), in October 2012 Illinois obtained approval from the Centers for Medicare & Medicaid Services to get an early start on Medicaid expansion for adults in Cook County. Initial planning began in late 2011, and in 2012 the Justice & Health Initiative steering committee was formed that included high-level members from the Sheriff’s Office, Cook County Health & Hospitals System (CCHHS), the courts, probation and other related agencies. Cook County’s application enrollment process began in the jail in April 2013, through a partnership with CCHHS, the jail and Treatment Alternatives for Safe Communities, (TASC), which is a local provider of case management services for people with histories of drug problems, health conditions and involvement in the justice system. Because the jail sees such a large number of individuals, it was crucial that the enrollment process be quick.

COOK COUNTY’S MODEL

The Justice & Health Initiative worked together to evaluate justice enrollment priority locations. The goals were to maximize the number of applicants that got covered and get to them as early after arrest as possible. They looked at many spots, including probation intake, but determined that the largest number of likely eligible/high need people were passing through the jail. Since 25 percent of detainees leave the jail within 24 hours, they determined that intake was the place where they would reach the largest number of people. This met the goals of the health system (to maximize enrollment of the newly eligible population) and the justice system (to put in the hands of the most people the tools to avoid future arrests).

TASC staff is stationed in the jail intake area for eight hours a day, seven days a week. These application assisters meet with individuals one at a time to complete a brief screening to determine Medicaid eligibility as the detainees wait for their health and mental health assessments. The process is voluntary, but a large proportion of eligible detainees have chosen to enroll. “If you think about where an individual is at this point in time—they’ve been arrested, they’ve been at the police department for a while, they’ve been transported to the jail, they’re now turning in their personal belongings, getting health screenings, etc.—and we’re asking them, ‘Oh, while you’re at it, are you interested in signing up for health insurance?’ It sounds crazy. But the answer has been a resounding, ‘Yes!’” says Steven Glass, executive director of managed care at CCHHS.

TASC staff ensures that individuals meet eligibility requirements like residency and citizenship, and then verifies identity using fingerprint-based information already on file with the Sheriff. This has proven critical to completing applications in a timely manner, typically in about 10 minutes per person. Cook County worked with the Illinois Department of Human Services to allow this identity verification instead of the usual requirements such as a driver’s license or piece of mail for their work in reviewing applications. 

Cook County is not just focused on enrolling individuals, but is also now working to connect these individuals with care as they return to the community. “It’s incredible how disjointed the discharge process is,” Glass says. “It’s uncoordinated, and there’s been no systemic approach. It’s incredibly hard to maneuver and at the end of the day becomes incredibly detrimental to coordination of care.” A local foundation provided seed funding to TASC, in partnership with the jail, to establish immediate pre-release services for people with serious mental illness in the jail’s “discharge lounge.” Based on classifications related to housing and medical and/or mental health needs, some individuals are sent to the lounge upon discharge, where TASC staff works with them to set up connections to housing, doctors’ appointments, prescription pickup and more. CCHHS is now providing funding and other infrastructure support to add a second shift of discharge workers and expand the program.

SUCCESSES AND OUTCOMES

County leaders are proud of the success of their collaboration and continue to focus on the intersection between health and justice. “Someone once told me that we should think about intake into a county jail as no different than an intake into an inpatient or emergency room health setting, and that really stuck with me, and it’s how we are working to operate in Cook County,” Glass says. Similarly, county justice and health stakeholders emphasize that regardless of how a person comes into the health plan—through the jail or through some other route—all individuals are treated the same.

Since beginning the jail enrollment process in Cook County, they’ve seen the following outcomes:

• Approximately 12,000 individuals have had their applications initiated in the jail and obtained coverage under the county-run managed care plan, CountyCare, or another Medicaid plan.
• Another 1,232 individuals have been served in the first 9 months of the discharge lounge.

LESSONS LEARNED

CONSIDER THE CULTURE AND NEEDS OF YOUR SYSTEM:

Glass attributes much of Cook County’s enrollment success to the fact that the sheriff’s deputies are staffed at intake permanently, as opposed to rotating throughout the jail. This allowed them to get to know many of the arrestees who cycle in and out of the jail and they encouraged individuals to enroll. “The culture in the jail was that the sheriffs knew these men and women almost personally,” Glass explains. “Their support is instrumental in making this program successful.”

DON’T HESITATE TO APPROACH THE STATE WITH A BETTER WAY OF DOING THINGS

As mentioned above, Cook County worked with the Illinois Department of Human Services to allow the jail’s identification information to be used for eligibility determination. “Think about the things already going on in your jail that might make getting complete information easier, and let the state know about it,” Glass recommends.