Project 2: Managed care updates of subscriber justice system involvement for suicide prevention

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Abstract (PROJECT 2: Managed Care Updates) More than 10 million people pass through US jails each year. Suicide risk is especially high at jail release. Individuals are often arrested when they are out of care and experiencing worsening symptoms. Jail detention may disrupt existing care and provide additional stressors. However, high jail admission and discharge volumes (>10,000,000 per year), jail stays that only last a few days, and understaffing mean that most of the U.S.’s ~3,100 county and local jails do not have the capacity to coordinate care. Outside jail, many justice-involved individuals are supported by professionals in publicly funded systems, who are typically unaware that their client was in jail and may drop the client for missing appointments. The resulting lack of care or fragmented care leads to unnecessary cycling in and out of jail and suicide-related morbidity and mortality. Better coordination of care between county jails and healthcare systems is widely acknowledged as crucial but difficult to achieve at scale. To address this problem, a large Medicaid managed care organization (MCO; CareSource) and a justice data vendor partnered to track county jail booking and release data for Ohio CareSource through an algorithm using publicly available data, generalizable to other healthcare/MCOs. The goal was to help CareSource ensure that subscribers were connected to needed community care following jail release and to minimize disruptions of any existing care due to jail detention. MCOs like CareSource are ideal organizations to help address system fragmentation because they span multiple behavioral health (BH) care systems (400 in Ohio alone) and multiple county jails (~88 in Ohio alone). In 2019, 43,000 (5.4%) of CareSource’s 800,000 total adult subscribers in Ohio, including 2,306 pregnant women, spent time in jail. CareSource is exploring ways to ensure that these subscribers receive needed care. This proposal involves two studies of evidence-based suicide prevention practices triggered by CareSource justice notifications, in a 2x2 factorial design. The first study will randomize CareSource’s ~43,000 Ohio subscribers who pass through jails over 12 months to receive Caring Contact letters sent by CareSource or to Care as Usual. The second study (running simultaneously) will involve a subset of ~6,000 of the 43,000 subscribers passing through jail who were seen in one of 12 large BH agencies in the 6 months prior to jail detention. Using a stepped wedge design, the 12 agencies will be brought online over time, receiving (a) notifications of jail detentions/releases with instructions for re-engaging clients in services; and (b) training in the Safety Planning Intervention plus notification to use it when a subscriber with past medically treated suicide attempts (identified by CareSource through claims data) is released from jail. Outcomes include medically treated suicide attempts, all-cause injury and poisoning, service utilization, cost-effectiveness, and implementation data. This Hybrid Type I 2-year “Exploratory” Center project is fully powered, yielding definitive effectiveness results that can be scaled immediately to improve suicide prevention nationally.