Initial Tax Sharing Agreement Made Easy

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- [Richard] Good day and welcome to today's webinar. We will get started in just a moment. Welcome, everyone. This webinar is being hosted by SAMHSA's GAINS Center. Today, a panel of experts will be sharing information as part of an ongoing Virtual Learning Community. This being the second session on data sharing agreements and confidentiality concerns across Criminal justice and Behavioral health partners. I'm Richard Van Dorn, I'm a Senior Research Associate in the GAINS Center and I will be serving as the moderator for this event. Before we get started, I'd like to share the following disclaimer. The views opinions and content expressed in this presentation and discussion do not necessarily reflect the views, opinions or policies of the Center for Mental Health Services, the Center for Substance Abuse Treatment, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services. This Virtual Learning Community on information and data sharing has been structured as a one hour presentation webinar with a one hour open discussion group which follows immediately. A number of you have submitted questions for discussion will be registered and we will address those during the discussion group portion of this event. Additional questions can be posed by typing your questions into the Q&A pod on the right side of your screen. A few more reminders. First, this webinar is being recorded. Slides will be available in a few days. A downloadable certificate of attendance will be available at the end of the webinar. This slide provides the agenda for today's events. Dr. Victoria Chau from SAMHSA's Office of Behavioral Health Equity and Justice-Involved, is with us today to welcome registrants and provide additional information about the information and data sharing Virtual Learning Community series. After her welcome, I will introduce our webinar presenters and discussion group expert participants. Victoria, I'll now hand the microphone over to you. - Also known as SAMHSA, welcome to the data and information sharing Virtual Learning Community hosted by SAMHSA's GAINS Center. The GAINS Center it answers National Technical Assistance Centers focused on expanding access to services for people with mental and, or substance use disorders who come into contact with the justice system. Today, people living with mental and substance use disorders are at their most vulnerable state. This includes people who are involved in the criminal and juvenile justice system. Behavioral health crises in concerns are mounting in today's current environment, where COVID-19, unemployment and closing of businesses and behavioral health services, racism and excessive force against communities of color and subsequent civil unrest are converging into a confluence of stress. And the U.S, prisons and jails are over represented with individuals who have mental and substance use disorders. In alignment with Stanford's mission to reduce the impact of substance abuse and mental illness on America's communities, SAMHSA recognizes the need for mental and substance use disorder treatment for individuals in contact with the justice system. SAMHSA continues to promote collaboration and partnerships across disciplines and sectors to better serve individuals with mental and, or substance use disorders and who are at risk for, or who are already incarcerated. In this intersection of Criminal justice and Behavioral health, SAMHSA continues to promote the identification of individuals with mental and, or substance use disorders. Use of evidence based screening and assessment during pre and post adjudication, diversion of individuals from the justice system into home and community based treatment, provision of training and technical assistance for law enforcement officers, juvenile and family court judges, probation officers and other judicial decision makers, and the assurance of equitable opportunities for diversion and linkage to community services and supports for all populations in order to decrease disproportionate minority contact with the justice system. Today's webinar titled, Data Sharing Among Criminal Justice and Behavioral Health Partners, addressing data sharing agreements and confidentiality concerns, is the second of three webinars for this Virtual Learning Community. Today's webinar will be followed by a third and final webinar in this series on July 28th, focused on mechanisms and platforms for efficient data and information sharing. During these challenging times and this current environment, SAMHSA would like to thank the GAINS Center, the speakers and the participants on this webinar for your participation in this Virtual Learning Community and your continued dedication to improving the Behavioral health of individuals incarcerated in the Criminal justice system. Richard, back to you. - [Richard] Perfect, thank you, Dr. Chau. Following up on Victoria's remarks, the Virtual Learning Community, and this May, June, July, topics were born out of the recognition that many jurisdictions are seeking assistance with our efforts to use data to improve outcomes for people with mental health and substance use concerns. And with good reason. Across system information and data sharing allow for individual level information to better understand and inform immediate and long term community needs, improve services, interventions, systems and policies. However, there are challenges including legal and information security issues that will be discussed today as they relate to data sharing agreements and confidentiality concerns. And a quick plug for the July VLC webinar is going to be on July 28th, and that one will be addressing mechanisms and platforms for efficient data and information sharing. So today we have three panelists, who will be sharing information and experiences about programs, lessons learned, and lessons learned from implementing information and data sharing initiatives in their local jurisdictions. Keith Brennan is Assistant Counsel at the New York State Office of Mental Health, representing the agency and matters of regulatory enforcement, development and implementation of new regulations and institutional reform litigation. In his time with OMH, Mr. Brennan has been involved in legislation related to outpatient commitments and gun control. Finally, Mr. Brennan provides technical assistance to Behavioral health providers, local government officials, patient advocates and law enforcement. Next, we will have Andrew Brown speaking. Andrew is Program Coordinator of the Ottawa County Recovery Courts in Michigan, which is currently one of the National Association of Drug Court Professionals' eight national mentor courts in the U.S. Mr. Brown holds master's degrees in public administration and social work and is a graduate of the National Center for State Courts Fellows Program. Our third presenter is Dayna Fondell. Ms. Fondell is Senior Clinical Manager of the Clinical Redesign Initiatives team at Camden Coalition of Health Care Providers in New Jersey. Ms. Fondell works with clinical providers to design pilots and activate workflows to serve complex patients, including the expansion of Medicaid, medication-assisted treatments and the activation of Health Information Exchange data for clinical care. Ms. Fondell began her healthcare career researching harm reduction models and became a registered nurse and eventually transitioned into health systems work as a program manager and strategic planning consultant. After the webinar portion of today's event, Keith, Andrew and Dayna will be joined by Aaron Truchil as discusses during the discussion group components of the session. Mr. Truchil is Director of Analytics and Informatics at Camden Coalition where he supports the organization's data and research activities. Specifically, he supports the integration of individual level data across health, Criminal justice and other sectors. And he worked previously as a program manager at CamConnect, a non-profit data warehouse in Camden, New Jersey, that analyzes and reports on data on the city of Camden's revitalization. So very exciting for today's webinar, followed by the one hour discussion. So I would like to know, now hand things off to Keith Brennan, Keith, take it away. - [Keith] Thank you, Richard. Hello, everyone. So I'm gonna start off talking about, I guess what you would call some of the technical features of information sharing. I guess I get to do that, because I'm the lawyer. And, I think sometimes, I've had many conversations with some of my clients at the agency, and folks from providers over the years and I have often observed a lot of trepidation about, how we overcome what we see as obstacles to information sharing, because it seems to be an arbitrary, huge body of arbitrary rules that don't seem to make a lot of sense. But what I would urge you to look at much differently than that, as a problem solving exercise, I'm gonna start off with a metaphor. And it's like, if we see an apple, we don't know what apples are, and if we try to swallow an apple hole, we will choke. So what we do is, we just eat the apple one bite at a time. And I think, if you think about what I'm gonna share with you over the next 10 or 15 minutes in terms of just taking one bite of the apple at the time, you kind of have a framework for problem solving. And the way I do it, is to treat these things as a transaction, because that's really what they are. Someone has information and someone else wants or needs the information. So that's the way I'm gonna explain how we can work through some of this stuff. And then, you just plug in the pieces parts of your particular situation, and hopefully that'll lead you to some helpful solutions, slide please. So, we're gonna start off, like dealing with the basics. So break it down. What is it? Who has it? And who wants it? And the what is it, is very important because that's gonna help us decide which rules apply, and it's gonna also kinda make us focus on doing what we need to do, and no more and no less. And by that I mean, basic things like that we all know. We're gonna share information that's necessary, and only that which is necessary. And who has it, that's important because some people are subject to certain rules, other people aren't. And we wanna know that going forward. And who wants it, the same thing is true. And when we look at this, we're gonna even break it down a little more, because the who has it and who wants it, we're not really gonna look at what we call each other, but what our roles are, because for example, law enforcement, may have a certain law they need be, for example, monitoring treatment that's part of some kind of community supervision plan, or law enforcement may be involved in a ongoing investigation of a criminal matter. So, how we wanna move forward, it's gonna really depend on who wants and who has in terms of the roles that folks have. Okay, slide please. Okay, so the what is it? So usually we're talking about a clinical record, and the clinical record is covered by HIPAA. And this is important for us to remember also, that it's also gonna be something we're gonna have to exchange information away that comports with state requirements. And I know in New York State, for example, there are provisions of the mental hygiene law that govern exchange of information. They are often superseded by HIPAA. And the rule about that is, whichever is the strictest, and by strictest, what I mean is whatever is the rule that protects, provides the greatest amount of protection to the information, and that is going to govern, but it's something you need to be aware of. Because in your state, you wanna make sure that not only are we complying with CMS regulations and HIPAA, that we're not running afoul of state requirements. Drug and Alcohol Treatment Records, we know that they are treated differently than, HIPAA records. Although we also all know that a lot of times both of these types of records might be in the clinical record. So we wanna make sure that we're being very careful about the exchange of information. And we know exactly what we're asking for, what we're sharing and what we're receiving. HIV records, this is another category of information, which is subject to additional protections. So if the records that you're sharing include information that would identify someone, someone's HIV status. You may need to make sure that you're complying with the prohibitions and the protections that pertain to those records. And the important thing here is once again, clinical record for a particular person may have a mishmash of records that are governed by these different laws or all of them. And lastly, I added this just so that, to be a completist. But criminal record information is covered by the U.S. Department of Justice Information Services Security Policy, and this probably is gonna impact your activities less in terms of what we're talking about today. But you should know what's out there, because there may be instances where the information, the clinical record of the file, or whatever it is, could potentially include records that are governed by this additional set of rules. Slide, please. Okay, the Security Rule. And this is the main thing that we're talking about with respect to HIPAA, and ensures confidentiality, integrity and availability of protected health information created, received, maintained or transmitted. So that's very encompassing, and we should look at it that way. Confidentiality applies to the clinical record, of course, but more broadly, it applies to any information which would tend to identify the person as a recipient of services. And that's kind of a broad general definition, but it also pertains to all of these records. So if it's a part two record or it's a HIPAA record, the test is gonna be whether it was shared, it would identify an individual as a recipient of these types of services to a third person. The Security Rule protects against reasonably anticipated threats to security and ensures compliance by the workforce. And then, for business associates, the Health Tech Information Technology for Economic and Clinical Health, that's a mouthful. High tech really pertains to the processes and mechanisms by which we share information. And we all know that we've had to, over the past 10 years look very closely as technology has evolved to the ways that we share information. And for a long time, it was a challenge for entities to share information because data needs to be encrypted, for example. High tech would also pertain to, can we share information on a telephone? Do we need to use a facsimile? And I would point out that any of you that are currently involved in this kind of work, you've probably been spending a lot of time with high tech related issues because during the COVID-19 crisis, CMS and also where I live, New York State, has created emergency executive orders and regulatory changes and waivers to allow for easier exchange of information, because people can't be face to face, patients can go into doctor's office and so on. So we've seen a temporary expansion, for example, from the requirement that information must be exchanged digitally through in an encrypted way to a more broadening allowance that permits, Zoom and Skype and FaceTime, and even recently, and this is probably short lived, but the exchange of clinical information over the telephone. And so these are temporary things, but I point them out because they really help to illustrate what the high tech is about. It's not, going back to my earlier slides, it's not the who or what, it's really the how. So these are all things that we wanna keep in mind when we're dealing with requests for information, whether we're the one making the request, or we're the one receiving a request. Slide, please. Okay, Protected Health Information. Okay, to protect an individual's right to privacy includes anything which would tend to identify the individual as recipient of care. And I kind of just explain that a little bit. But really, it's more than just a document. It could be and I use this example and it's a little bit of an exaggeration, but it's also technically correct, and I find it illustrative where, if you are somewhere in public, you are in a restaurant, you are your child's soccer game, you're at the grocery store, and you would vote your friends, and you see someone and your friends know that you work at a Mental health clinic, for example, and you say hi to the person in the vegetable aisle, and your friend says who's that? And you say, that's a person, that's a client of mine from work and you just really share protected health information about the individual in a way that's prohibited. And like I said, that's a bit of an exaggeration, but I think it's good to keep in mind that really what we're not talking about is, just the documents, we're talking about information. So we should always keep in mind when we're sharing information that these rules apply, and that they go beyond just what is included in the paper file or the digital file, which we would often refer to as the clinical record. Now, the covered entity is a person or entity subject to the privacy rule. Who's subject to the privacy rule? Well, basically, the person subject to the privacy rule would be anyone who is involved in the medicare system, because the privacy rule is a CMS promulgated enforced rule. And in addition, and on my state, in most states, incorporated by reference into the licensing schemes is the privacy rule. And like I'd mentioned before, New York happens to have a statute that also creates privacy. But, and, so the covered entity it's probably anyone in healthcare, or anyone who deals with folks in healthcare, and with as part of their job be exchanging information. Okay, the pro tools designed to be flexible, and comprehensive to cover the variety of uses and disclosures that need to be addressed. Now, this is very important. And this is important because the rule is designed to protect the individual's right to privacy, but also to let us all do what we need to do to provide care to the individual, to manage the care for the individual. Often to bill and provide revenues based on the provision of care to individuals. So sometimes we think of the rules as overly onerous, but I think it's helpful to keep in the back of our minds the fact that the rule is designed to allow us to do what we need to do. We just need to do it in a certain way that protects the interests and privacy interests, have patience. Next slide, please. Okay, HIPAA, okay information can be shared for treatment purposes. That's an exception to HIPAA. They use as an example of what I'm talking about in terms of the flexibility. So we see HIPAA as a barrier, but HIPAA is also an opportunity. So HIPAA says, if you're doing these things, you're permitted to share information. So you can share information for treatment purposes. In many instances, the referral of care falls within the definition of treatment. And that's important to remember. And then I would add to that, like I mentioned at the very beginning. So for treatment purposes, if you're a treating physician or a clinician or a clinic or a provider, you may need the entire clinical record. And I think HIPAA allows for the sharing of information for you to do what you need to do. If it's a referral, if you think about it, probably on a referral basis, the entire record doesn't need to be shared. So what needs to be shared? Often is referred to as a referral package. So it's the basic information that would help a provider analyze whether, their level of care or their care environment would be appropriate for the patient. So every instance of appropriate sharing and every instance of an exemption under HIPAA doesn't necessarily permit the same amount of sharing. So the sharing really needs to be tailored to the purpose. Okay, a general consent with an opportunity object. This is really the silver bullet for managing information sharing, it's not always possible, but general consent and, often the most efficient way to do this is to think hard about your in process zoom documents. So when someone comes in, and they're accepted as patient to a clinic or to an outpatient program or to a residential program, there's gonna be a lot of paperwork and a lot of information that's shared with the patient at the time, and the contents really should be part of that effort and that activity. A general consent for HIPAA, can be shared with providers and so on and so forth. It can be limited. But I know that HIPAA doesn't, HIPAA prevents, for example, the sharing of information with an adult person's family, absent, unless they are the guardian, or some surrogate decision maker, so general consent probably wouldn't include that. But it may include consents, for the sharing of information with a managed health care plan, for example, and often it will include consents, for the sharing of information between providers in a system. A hospital system and we see this more and more with electronic records, that the consent at the beginning when the person is in process will be basic language. There's an opportunity object that allows the system, a hospital system or the system of care to create electronic medical record that's accessible by all providers. So that if you're general, if your in clinic, and then you need to go to the specialist, they will have access to all the information about you. Because the idea is, and I think we would all agree this is true that really leads to better outcomes when providers have more information about patients. Now 42 CFR Part Two, is really a different ballgame all together. The sharing of substance, alcohol and substance abuse treatment records are a lot more strictly protected. And disclosures without patient consent, are a lot more problematic. There aren't the same extent options for part two, that there are for HIPAA. So really, the idea that we're gonna try to achieve consent from the patient is much more important with respect to the sharing of Part Two records, because it's really the best and in a lot of cases, unfortunately, the only way of sharing information. Now, both HIPAA and Part Two have provisions that allow sharing after court proceeding. And if there's a court order, then information can be shared, there's rules that pertain to how a court order is obtained. And there's also exceptions in both of them for information sharing that is required by law. So there may be statutes in your jurisdiction, or depending on your activity, there may be federal statutes which themselves permit the sharing, or may require the sharing of information. And so, those are things that we wanna look at, when we're thinking about the challenge of information sharing. A Court Ordered Disclosure, what could this mean? This could mean a subpoena or some kind of individual, a person or entity files a request to the court. It could be a subpoena, it could be a Show Cause Order would really depend on your jurisdiction, or a Court Ordered Disclosure could be more broad. There could be a class action suit, for example, I was involved with some of my colleagues at PRA, in the implementation of a class action suit in the state of Washington. And part of that, really required the sharing of information for the remedy, the court order solution to the case, for the remedy to be achieved. So in that case, you have a court order that doesn't really, it's not really one person asking the judge to tell another person to share information. It really creates the authority for all the people that are members of that class. And with respect to those individuals, certain information could be shared, in fact had to be shared. Next slide, please. Okay, so consents are time limited. And that's an important feature of consent. And it in terms of, if the consent has expired, well, then it's worthless at that point. And if the consent does not have the time limitation, then it's not valid from the get go, at the same time. So, I think that it's important when we put together for example, in processing documents, like I talked about before, that we create, a rational way to create, time limitations, that they're clear in the documents, and then we have a way of tracking them or at least, figuring out when we need to, execute new documents. Sometimes time limitations are derived from a different source. For example, if someone's in community supervision, they're on parole, or probation, and part of their parole and probation requires them to attend certain treatment, for example, well, the time and then they consent as part of their parole or probation, they consent to the sharing of information for that purpose. Well, in that case, the consent is really time limited to the term of whatever, the probation or parole would be. They're subject to revocation by a patient. This is true, and maybe less true. And those unique examples that I just mentioned, for example, if you are on parole, and you have to attend certain types of treatments, and part of that includes the sharing by the treatment provider where the parole authorities, information about the treatment. In those cases, there may be instances where revocation doesn't act the same way that it does for a person in the civil context. Consented disclosure is for a specific user purpose. So, this is very important because it may be pretreatment or maybe, for example, there are ways that information can be shared as part of a criminal investigation. And those are very narrow, but even in those cases, let's be very specific information need and then if the information is shared, it really can't be used outside of that specific need which provided the basis for, for example, the process which resulted in a court order requiring the disclosure of the information. So the specific use is very important. A lot of times in just the normal health delivery context, if the purpose is for treatment by other providers, there's really nothing controversial ambiguous about that. But there are a lot of outlying scenarios which we wanna be aware of. So sharing for specific purpose should be included in your consent. And once again, the last we wanna do is have a challenge to our documents, for example, we spent a lot of time to develop a consent form. And the consent form, we use it for all of our patients, and we use it for a lot of different purposes, for the care in our clinic and the care in our residential program and so on and so forth. Well, we don't wanna have a technical flaw in the form itself, put in jeopardy, our efforts to achieve consent from patients. Prohibition pertained to redisclosure. This is something that we need to keep in mind that just because the initial sharing of information was appropriate, could have been by consent, it could have been because there was an exception in HIPAA or Part Two that pertained to the information. So the initial sharing was appropriate. But the redisclosure of that information is not permitted by HIPAA or by Part Two. So we wanna make sure that if we're on either end of that transaction, that we are cognizant of the fact that although other people may need the information, we may need to kinda have another iteration of our consent process, or may have to identify an additional exemption that applies to that redisclosure. Or there may need to be, a court proceeding to achieve the redisclosure and surrogate decision making. Surrogate decision making, this operates in the most formal sense. So, like I said before, someone who's 18 or 19, or 20, is reached age majority, they are an adult. Their parents may not believe that, but their parents are not their surrogate decision maker anymore. And so they do not stand in the shoes of the patient in terms of giving consent, unless they are the surrogate decision maker. And how do we know someone's a decision maker? Well, if there has been a court proceeding that appoints them as a guardian, that's an example of how someone formally becomes a surrogate decision maker. And so, we wanna be careful that we recognize, we honor the rights of surrogate decision makers. Sometimes a court can appoint someone to be a surrogate decision maker. That happens a lot in New York in the Mental Health and Developmental Disability context where there's a lot of mechanisms to appoint a surrogate decision maker. Now, the surrogate decision maker can, agree and consent to the sharing of information. But for example, if you're gonna share information with such a person, and they were gonna sign a consent on behalf of a patient, I think what we'd wanna do is we wanna, it's just as simple. You see copies of the circuit court's order appointing them a surrogate decision maker, and so on. So, I guess to wrap it up here. What we wanna do is, we wanna look at this as an opportunity to share information. It's very important not to be obsessed or focus too much on the obstacles. If it was an obstacle that's true and Part Two access an obstacle. But we wanna focus on the path through what are the things that are gonna help us, have a valid and legal sharing of information, rather than focus on the things that prevent that. We wanna look for the exceptions in the law, is this fall within a public health exemption? Is it for treatment or referral purposes? And so on. And then if need be, we're gonna go to court, and if we go to court, we wanna know exactly what the standards are. Is the person that's gonna be receiving it, are they gonna be using it for their law enforcement? Are they going to be like I mentioned before, are they going to be investigating a crime? Or are they really just verifying performance of obligations under probation or other community supervision order? So that's the framework for problem solving that I hope it's helpful to you. And now I think I'm gonna hand it off to Andrew Brown, who's gonna pick it up from here. - [Andrew] Thanks, Keith. And good afternoon, everybody. My name is Andy Brown. I am the Recovery Court Coordinator over in Ottawa County, Michigan. And in my role, I've been heavily involved in program evaluation over the past several years, particularly as it relates to specialty courts. But there are some lessons learned that we're gonna be talking about here in my presentation that apply to any type of probation program or Criminal justice intervention, whether that's adults, or juveniles. And what I'll be talking about I think is going to be more of an evaluation planning and data collection experience. It's probably gonna be more common to a lot of the jurisdictions and a lot of the callers that are participating in our call today, and that is, we're trying to get data, we're trying to do evaluation planning or we're thinking about doing it. And we're doing it in a very fragmented system. And we kind of heard that in Keith's presentation that one, there's a lot of barriers to work through, and getting data. And where that data comes from, and we got hoops that need to be prepared and accounted for. And sometimes it just means you have to approach a lot of different agencies separately to get data. And I think that's a common experience for a lot of jurisdictions. But we're gonna hear in the next presentation from Dayna, is what really robust collaboration looks like. And I think the Camden Coalition really sets kind of a national standard of what community level integrated data sharing. So we're here to really complimentary presentations here. But what we, and so to get going, I wanna just kinda emphasize and help people understand why we need good data. It's kind of an obvious answer there. How would you go about planning for data collection and budgeting and planning for evaluation? So why do we need good data? Well, obviously bad data is going to yield unreliable results as the same goes ego, garbage in, garbage out. At the end of the day, we wanna know why. If our programs work, and we wanna understand how they work, and for those who are working in a drug court or a veterans court, Mental health court, any of the specialty courts, chances are your program is grant funded. And somewhere down the road you would like for your local funding unit to pick up the personnel costs or the program costs. That's absolutely the position that we're in here in Ottawa County. And our ability to make funding requests hinged directly on good valuation and the outcomes of the evaluation of our drug court. And the second thing is bad data. If you don't have complete data, if you have lots of missing data, you don't have a key variables that are needed to run the tests, it's just going to result in limited testing that can be done. So good data, it gives more opportunity for more rigorous statistical testing. You can maximize evaluation design and work with your evaluator to get more robust testing that's going to be done. And that's the difference between what we call descriptive statistics which a lot of us are familiar with, that's going to be your pie charts and bar graphs saying, hey, we had 50 people on our drug court who were opiate users and 30 people who were crack cocaine users. But what we wanna know and with good data, what you can start to do and maximizing your evaluation design to start asking more inferential questions. And what that looks like is, hey, we have a 24 year old Caucasian male with three prior felony charges, who's a crack cocaine addict and received 30 hours of treatment in our program. What were the odds of him completing the program? And start extrapolating outcomes. And the more data you have, the more you can get into those inferential statistics. And again, the more data the more robust you have, the more value you're going to get for your money purchasing evaluation services. 'Cause the evaluators that you're going to be contracting with or working with, again, they can only test the data that you give them. And if it's poor quality data, or it's a limited data, you're just not going to get as much. So a few truth about data, data is difficult to obtain. There's, sometimes there's no way around that. First, we have a lot of illegal challenges. And we heard Keith talk about that and how to navigate some of those. But what agencies are we getting data from? I can speak from my experience here, we have two treatment providers. So that's two different relationships that need to be maintained, those two different requests just to get clinical data. We have six law enforcement agencies in our palette in our county, none of whom communicate together or share same database. So, if we need to get a recipe that six different law enforcement agencies, you have to go to, the jail, we give booking and length of stay in the jail. We're the court or the third branch of government, the sheriff's department is the second branch, executive branch so you have to make a separate request to the jail. And if we wanna get data for felony population, through the Department of Corrections, we need to make an approach to the Department of Corrections. So lots of different requests, lots of different challenges, we wanna be able to get primary source data, from these agencies, but it's all individual separate requests. Each of those agencies has their confidentiality concerns and requirements and releasing data and that needs to be planned for. But let's say we'd start to get all that data. The next question is the data that we're getting, how good is the data? And at the end of the day, data is only as good as the person who inputted it, or entered it into the system. So also, as you're making the data requests and thinking about planning this data, look at what are the data sources, but then also be asking what are the limitations of the data. An example of this would be in the state of Michigan. We have two criminal record repositories, one that's maintained by the state court of administrative office and one that's maintained by the Michigan State Police. Not all courts and not all law enforcement jurisdictions upload their data into either of these systems. And interestingly enough, the second largest court jurisdiction in the state of Michigan doesn't upload their disposition data into the state court administrator's, repository. So there's about a half a million people in this second largest jurisdiction. And for those that are involved in that local court system, none of that criminal history data is available in the state. So, again, being aware of the limitations, what agencies are uploading data, things like that are really important. So if you start to plan and think about doing your evaluation, your data collection, really spend some time if you already have an evaluator, perhaps on staff or in your local municipality, that does program evaluation, or if you have a contract with someone, take the time to do a good planning process up front. So what do you evaluate? Are we looking at a quality process evaluation? Are we trying to do an outcome measures like a recidivism study, or we're trying to evaluate cost, or the impact? What program elements influence, successful completion? Are the outcomes from our program? Drill down and answer the question, what are we evaluating? What do we want to know? What are the questions that we're trying to answer? And that's where the data going to come from? List out the data points from the data elements that you need, create an inventory of that, and identify the agency or agencies that you're going to need to approach and partner with, to get that data. And who's going to collect the data? What staff are going to be assigned to this? And how long is it the data collection process is going to take? And it can take a long time. Sometimes you might get a data dump is kind of the jargon that's used. And that is, hey, the Department of Corrections can send you one big Excel file with all the information you need. Sometimes getting the data, like in our experience with our treatment episode data for our participants, we have to go through the billing records by hand, to get that data, because there's no aggregate report that can be generated. So if you're having to get your data and collect that data and get it entered by hand versus an Excel or CSV file that comes down, big differences in the time commitment for you as you go through that. And the next thing with data is, as we've been talking about data coming from all of these different sources, so it's great if you can get the criminal history data from the Michigan State Police and you can get criminal history data from the state court administrative office, and you can get the clinical records from your two or three treatment providers, and you can get the jail records from your jail. So now you have these two data sets from all these agencies. How do you combine them? How do you bring them so John Smith, who has case information of all of those data sets, you can put all of that together? And it's critical that there's a set of common identifiers between each data set. And if you don't have that, it's not possible to merge that data. You're sitting on siloed information from all of these different agencies. So spend time in that planning process as well. What are the common identifiers that you can use to link the datasets from all of your different sources? And for Criminal justice practitioners that might look like a driver's license number, in Michigan, we have what's called the state ID number. It could be date of birth, maybe the last four, six digits of a social security number, really put thought into what identifiers are common between all of the agencies. Because if you're working really hard to get all this data, you wanna be able to use it all as well. And the other thing to keep in mind as well, the most rigorous research design that can be carried out is what's called the randomized control trial. And particularly in criminal justice research, it's really tough to pull off a randomized control trial. So often, and basically the idea of a randomized control trial, let's say somebody's coming into a drug court program, and you have two applicants and they meet all the eligibility for coming into drug court, you're going to flip a quarter, and if it's heads, one person is going to go into drug court and if it tails one person's going to go under regular probation, and then you go to measure the outcomes one, two or three years down the road. You just don't know how people are going to perform. But we often just can't do those types of research designs. So we use what's called the quasi experimental research design. That is we create a matched group of drug court people to a group of regular probationers with similar characteristics. They've already completed probation. But we wanna try and determine, did drug court outperform regular probation? And there's statistical methods for doing that. But to really be able to do a good quasi experimental research design where we can compare the outcomes of drug court to regular probation, that takes a lot of data. And you need the same data for your drug court people as you do for your matched comparison group, for regular probationers. So you wanna be able to ask them that research design is the data available or the same data available for both groups, because you need to measure the same thing. You wouldn't wanna measure all arrests for the drug court people and then all guilty pleas or convictions only, for the match comparison group. You need to measure arrests to arrest for both groups that have valid outcome results that you can use. So again, as part of that data collection process, what data are you able to get for your participants? And can you get that equivalent data for your matched comparison group? And, again, that data and some of the key data you're going to want to look at, would be budgeting costs, data, overhead personnel costs, court case flow data. All of your program level data, units of treatment, how many drug tests, who have positive drug tests, how many case manager contacts, surveillance contacts, it becomes important information. And then of course, criminal history, when we're trying to measure recidivism. Annoying, can we get the arrest data? Can we get conviction data? Where are we going to get that data? Ideally, you wanna be able to get data from across your state or if you can get across the country even better. But again, can you get that equivalent data, not only for your program participants, but for that match comparison group? And as we start to wrap up here, and we'll talk more about this in the Q&A section of things for those that stick around, evaluation is a time consuming process. And it's an expensive process, and it's an investment. One of the best ways for Criminal justice programs to fund them, are the Department of Justice through the BGA grants. Definitely support evaluation, SAMHSA supports evaluation with their drug court enhancement grants as well. So grants are a great opportunity to fund evaluation that way. But now that, it can be very expensive, it's not uncommon to see a six figure price tag for pricing that's over $100,000 for an evaluation, depending on the research design and the level of effort that goes into it. And evaluations, it's time-intensive. Think of all that data collection and the planning process. So you wanna be able to account for that time to do the data, and for the evaluators to clean it up and do the analysis. And it's reasonable to expect that it's a 12 to 24 month process. And it can be done faster as well, but definitely expect a 12 to 24 month process. And that wraps up my presentation, we're going to hear from Dayna Fondell now. - [Dayna] Hello, it's nice to join you all. So I'm gonna be talking today about how do you use cross sector data exchange to improve coordination of services for patients that are experiencing complex needs. And what we're really gonna focus on is kind of specifically how we use relationships with community partners to deepen our ability, to implement cross sector data sharing, and really looking at how is this grounded in optimizing care at the patient level. So have you build out use cases and engage staff to really activate the data in a way that improves care for patients? And clarifies the next steps as a community for where you can move forward within your data sharing process. Throughout the presentation, I'm not gonna specifically highlight each intercept that we talked about, but we really feel like the work that we're doing in Camden touches on intercept, two, three and four from the Sequential Intercept Model. So at the Camden Coalition, we are an organization that is focused on how do we transform the healthcare system that we work within, in order to provide a more holistic care for patients with complex health and social needs. And this overall mission has really, from the beginning, had us really take kind of a wide view about the types of partnerships that we needed, and the types of providers that we think of, when we look at how to best serve these patients. So just to give you a little bit of context about the area that we're doing our work. Camden is a small city. There's about 71,000 people. And while New Jersey is one of the wealthiest states in the country, with a median household income of 72,000, Camden, medium household income is closer to 26,000 and about 60% of individuals in our community on some type of public insurance, with Medicaid being the most common. And another kind of context around our work is that Camden city tends to have the worst health outcomes in the state, and ranks in the bottom five across most health indicators across the 21 counties. So in our initial work, we really, from the beginning, as an organization have focused on clinical observation and data analysis. So what you're seeing on this slide is a representation of some of our initial work, where we really started looking at patients that had the most frequent utilization of our health care systems, and really revealing that 1% of patients were accounting for about 30% of the hospital costs in Camden. And this became really relevant for kind of informing a lot of our work around this aspect of hotspotting. So how do we use data to target evidence-based services to patients that have complex means. And from the beginning, I guess our work has focused on both this access to data and then how you bring together providers to look at that data in order to inform the next steps that they take. And over the years, we've run a variety of different interventions. But really, throughout all of our interventions, there's a focus on connecting patients across sectors. So because we're looking at this intersection of complex health and social needs, we've worked across social service, Criminal justice, legal system, Behavioral health and medical settings, because those are the needs that are emerging within our patients. Our current work and care teams really reflects that focus and we have multidisciplinary teams and program offerings such as a housing first program and a medical legal partnership. So in addition to our work that we do with patients, we closely work with a variety of community partners to implement new programs, workflows and kind of activation of that cross sector data. And our both our patient and our systems work is facilitated by our Health Information Exchange, which is the Regional Health Information Exchange, as well as our data analytics team, which uses data from a variety of sources to both inform our work and the work of our partners, but also to help evaluate our efforts through some of the types of complex evaluation, that Andy was just referring to. Finally we are a coalition. So a big part of our work is convening partners. And then we work to synthesize these learnings from our patient and systems work into our policy and advocacy approaches. So for this presentation, we wanna focus on several specific relationships that we've worked to build out over a number of years, and those are the relationships that we have with the Camden County Jail, as well as their clinical services provider. So, our relationship with the county jail has allowed us to build out a number of collaborative programs and to receive datasets that help with our population level analysis. So, Andrew just went over a lot of work and considerations at the population level. So as he said, we're gonna focus our work on the patient level. But my colleague Aaron, who is our Director of Analytics will be joining us in the discussion panel, and he'll be available to answer questions about them about population level work, which is the Camden ARISE data set. And this dataset combines information with our cross sector data sits, from across sector data systems to create a multi dimensional picture of city wide challenges, which helped drive better decision than allocation of resources, as well as some city wide conversations about the root causes of some of the different public problems that we see in our community. In addition to the work that they've done at the population level, our relationship with the county jail has allowed us to actually pilot patient specific programs, which I'm gonna talk about a little bit, and then build on those programs and to help them expand the offerings that they have within the Camden County Jail. Our relationship with their clinical provider has really focused on another data sharing mechanism which we use, which is our Health Information Exchange. And so they were actually one of the first users of our Health Information Exchange when we launched it in 2010. And our relationship with them has really expanded over the years which has grown to a bi-directional data sharing agreement where they are actually pushing summaries of their care into our Health Information Exchange. And they began expanding their offerings of medications for addiction treatment as a part of their primary care services. So they don't have a separate MAT program, they've actually integrated it in to their primary health care approach, which, as Keith alluded to, with some of the considerations around 42 CFR concerns and different data sharing sites, depending on how different contributing providers integrate their services. It does open up some opportunities to really look at whether or not data is considered 42 CFR and that really is a provider to provider consideration on which he spoke to, but we just wanna acknowledge that this is a part of the primary care offering within the jail which gives us a little bit more flexibility. And then in 2020, we began a collaborative process with them to really augment their MAT services. And so I wanna really highlight that these relationships are symbiotic. So as we move forward with one, it really helps reinforce the other relationship. For example, as the county shared more data with us and saw more value in this data, collaboration and exchange, they decided that to make, to actually add it into their contractual requirements with their clinical provider, so the clinical provider have the ability to contribute data into our Health Information Exchange. So we really see these two areas as definitely like a symbiotic approach. So the final thing that I wanna say and before I go into our HIE is one of the things is that our approach is really based on what Keith said earlier around taking a bite at a time. So we're really focused on how do we share minimum levels of data and then build from there and really make sure that we're taking advantage from a workflow perspective of the data that we have available. And then as we establish trust and build out really defined use cases, we can look at what additional data sharing is needed and will be beneficial to all parties. So our Health Information Exchange is a patient level data exchange. And that is not exhaustive. So there are a number of different Behavioral health and substance use provider facilities that don't contribute data, but are able to access the data from the medical side and from other organizations that are not 42 CFR designated location. And this data on this work with the Health Information Exchange has allowed us to better activate the use of data that's coming in, from the emergency department, inpatient and outpatient settings in order to improve the intake process and for the jail's Behavioral health and substance use disorder programs, as well as help coordinate care post release to support kind of better continuity of care across the system. So, in our previous work when we were doing a patient facing program within the Camden County Jail, we ran a partnership in, we ran a program in partnership with other providers in the Reentry space. So we use the Health Information Exchange to help identify patients that we should triage for programs and to verify their eligibility. And then with patient permission to provide ongoing monitoring through use of admission, discharge and transfer notifications within the HIE to help our care team be able to stay in contact with patients as they moved across different systems. But what's important to highlight is that while the HIE really provided a foundation for that, we really supplemented our care coordination work by establishing relationships with the staff directly in the jail. And this involves having individual care coordination conversations between nurses and social workers, as well as engaging in regular contact with some of the different community partners that were crucial post relief, such as mental health and substance use treatment providers. As you can see on the slide, a high percentage of the panel had Mental health and substance use diagnosis. And so with patients consent, our teams were able to share out the medical, Mental health and medical information from the jail directly to the providers that were taking over their care upon release. And with those groups, we also found it really crucial to have a consistent touchpoints to really keep those relationships active. So our pilot ended in 2019, but building on the lessons learned from the population data analysis that the Camden County Jail had participated in, as well as the programs that we were doing with them, the jail has really worked to expand existing programming to support increased access to Mental health and substance use treatment within the jail, and their work and the work of their community partner has really been amazing. I mean, I think that all of the work that we do is really in collaboration and because of the amazing partners that we have in Camden. And so the Camden County Jail is now providing MAT to as a standard part of their intake and as a standard part of their primary care offering. In 2019, 900 patients were released from the jail as a part of an active MAT program. And they've really built out, also extensive resources around providing additional support for patients with co-occurring and diagnoses. So, as our program ended, even out of the jail and their medical provider have really built out their services. Our role has transitioned from providing direct services to supporting the programs that the jail and the medical provider argue in. So we now are involved in helping support their improved data coordination, both within the jail between internal data systems, as well as their ability to do coordination with external partners. And so what this looks like is that the jail administrators and clinicians use the HIE as a part of their standard intake process to understand the patient history, as well as identify and verify patients with diagnoses that would qualify them for additional support groups, and to help the jail providers understand where to go next for more detailed information about patients. And the external providers are then able to access summaries of care, and that include medications but no treatment notes to help coordinate care for ongoing treatment post release, as well as know that their patients are receiving services when incarcerated. So we have regular touchpoints with the external providers to gather information from them about how the jail data is being used and opportunities for workflow and data improvement. So how does this work? The patient consent process is currently built into the consent process at all of our providers. So our approach is based on every individual accessing the HIE, having a treating relationship with the patient. So as a part of their intake process to any of their settings, the HIE consent is a part of that general intake with all of our providers, which gives an option for patients to either, request that their data is not accessed or just to let their provider know that they no longer want their data to be available in HIE. Which then each clinical provider can connect to a patient to have that data removed. And then patients in the jail setting do consent to their Behavioral health and substance use data being shared, but we're really focused on activating data that is operating under HIPAA protections rather than 42 CFR and optimizing those workflows. And then we've been able to build out specific use cases where additional data may need to be shared, but we're working on specific piloting those workflows between a limited number of providers versus total visibility within any treating provider within the HIE. So we've basically been able to set a strong foundation, which then we're building off for specific use cases. So how do we identify these different gaps in areas where we need additional data sharing? With the advice of our partners and with different interdisciplinary teams, we really work on engaging in workflow mapping to understand the specific data points that are needed, both in order to strengthen the ability to track data within a contained program within the jail, but also between the jail and external partners. And the same thing that, the same methods that we use with our patient work, regular meetings, clarifying needs, and having frontline staff and partner agencies talk directly, really apply to the system things. So we really wanna get frontline staff in the room, we really wanna connect agencies directly to each other to talk through their data sharing knees. And what this works for, is to help us identify what are the minimum data sharing points that are useful? So we found that minimum amounts of information such as just knowing where a patient has received services or is receiving services has a huge impact and clinicians being able to coordinate with each other. It also has helped us identify kind of how we would layer on additional information such as diagnoses, medication and dose, and to coordinate care which is being done between some of our different participants. But it's also really clarified for us but we don't need to share treatment now, we really have aligned as a community is saying that those are things that are even with 42 CFR protections in place are not necessary to be transported through the Health Information Exchange. So it's really helped us clarify, not only what can we share, but also what do we think we should share, and what do we really have use cases for. Around who specifically views which pieces of data. And I think what's nice for this, is that it's allowed us to have clear use cases for providers to also be able to explain to patients, to ask what their data would be used for. So it's leading us to a place where we can really continue to have a more and more patient centered consent process, where they really understand exactly how their data would be used with specific care coordination examples. Finally, it's helping us assess what evaluation metrics are needed to improve care, so that we can be looking at what actually relates to our ability to improve the services we provide, and have kind of metrics that we're looking at, that are really informed from the lessons on the ground. So we have a few lessons learned, which I just highlighted, which is, looking for, acknowledging the complications of 42 CFR and the need for ongoing conversations and clarifying which parts of the data are protected and which parts aren't. And then which parts of the data may not be protected, but we still from a patient autonomy and understanding the role of stigma where you want to protect. And it's created space for us as a community to look at an external layers that we may wanna add on such as online vendors and help manage consent interface, and so that we can be on parsing, medical, Behavioral health, substance use data, so that patients don't have to redact their whole HIE participation, they could choose to restrict one area of care or another. And then it also, helping us look at how, overall how we build these relationships and really grounding them in patient care. Allows us to play a more neutral role to keep a lot of different providers at the table. So key takeaways are, this aspect of relationships take time, and we have benefited from being in the community for a long time and having a lot of long standing partnerships. But we really wanna highlight it, start where you can and then build how you can. And ongoing feedback about the value that each person is providing really helps keep people at the table. So thank you all so much for your time and we're excited to answer questions in the discussion portion. - [Richard] Thank you all, this is Richard Van Dorn again. I realized that we ran over our one hour allotment. For the webinar presentation, we are still going to go into the Q&A in a couple of moments. But we're still going to end that at four o'clock. So I'll be brief in my wrap up here. The Q&A, if you want to submit any final questions, please do so. There will be a certificate of, there will be a certificate of attendance that is downloadable. And a quick reminder, this is not a CEU, it's for portfolio use only. So feel free to download that. Also there's a webinar supporting documents that might be useful but I'd like to point out it is entitled data collection across the Sequential Intercept Model. You heard Dayna mention intercepts two, three and four. These are central measures webinar supporting document identifies measures across the intercepts that you can consider in building your data sharing program or primary and secondary data collection strategies. To learn more about subsequent events in this series, including July's webinar, which will focus on, again on, mechanisms and platforms for information and data sharing, as well as other offerings from the GAINS Center. We encourage you to subscribe to the GAINS Center's listserv. Also note the contact information for SAMHSA and SAMHSA's GAINS Center and again, the phone number for the GAINS Center where you can call or phone based technical assistance. And finally, in closing for this event, thank you for your time and participation. We encourage you to join Keith, Andrew, Dayna and Aaron for the discussion group that is taking place next. We will head over now to the Adobe Connect platform and join in that discussion. And we'll see you all over there shortly, thank you.