Medication Consistency (Senate Bill 17-019)

In 2017, the Colorado General Assembly passed Senate Bill (SB) 17-019 to improve access to effective medications for people who transfer in and out of criminal justice and mental health facilities, including institutes, jails and prisons. By having continuous access to the same set of effective medications, including psychotropic medications, individuals are more likely to maintain mental wellness and be successful transitioning between the criminal or juvenile justice system and mental health service providers.

The State is working to strengthen medication consistency across settings through the following efforts:

• Establishing an agreed upon medication formulary, in accordance with SB 17-019,
• Decreasing overall costs of treatment through cooperative purchasing agreements, and
• Piloting health information exchange systems in jails to facilitate data sharing so that caregivers are able to access their patients' critical health information.

Medication Consistency Formulary

Medication Consistency Program: What is the Psychotropic Medication Formulary? [Print]

Access the Medication Consistency Formulary Here A medication formulary is a continually updated list of both generic and brand-name prescription medications and related cost information, representing the approved recommendations of pharmacists, physicians, and other experts. Using a medication formulary ensures that all patients can access the medication that works for them.

Switching medications can cause a patient or inmate to escalate or have new symptoms. Maintaining consistency across providers saves costs related to urgent and emergency mental health needs, crisis care, transportation and staff time.

The State medication formulary is comprised of specific psychotropic medications that, if used appropriately, can increase medication continuity for individuals with behavioral health disorders in the criminal and juvenile justice systems. Click on the green button to access the Formulary.

Using the Formulary

The medication formulary is updated and reviewed annually and lists both generic and brand-name prescription medications and related cost information. It represents the approved recommendations of pharmacists, physicians, and other experts. The medications listed on this formulary comprise the preferred formulary used in community provider settings, including community mental health centers, and is available through the Medicaid benefit for individuals released from criminal justice systems. This specific medication formulary was created for the sole purpose of ensuring medication consistency for persons with mental health disorders in the criminal and juvenile justice systems in Colorado.

The Office of Behavioral Health understands that correctional institutions provide care to people with chronic conditions including serious mental illnesses and need access to a complete range of medications available. The formulary is not intended to restrict medications when a patient's needs warrant a different pharmaceutical. The formulary is a minimum set of medications that should be available, but does not encompass all medications that may be available to an individual in custody. The formulary is not designed to change the prescriber/patient relationship, rather, it is to promote a statewide approach to ensure individuals have the standardized protocols and medications to support their recovery to ensure a safe and successful return into the community.

Where to find the Formulary

This medication formulary should be kept and easily accessible to prescribers at federally qualified health care centers, clinics, community mental health centers, substance use treatment settings, institutions, acute treatment units and crisis stabilization units designated by the Office of Behavioral Health. All facilities designated by the Office of Behavioral Health are statutorily required to use the medication formulary when prescribing medications and are encouraged to leverage the standardized medications listed on the formulary to patients if the patients are already prescribed a medication.

Per Colorado Revised Statutes, §27-70-103 (2), this formulary will be regularly updated.

Cooperative Purchasing

Cooperative Purchasing [Print]
Getting medications at a reduced cost

Facilities can leverage opportunities to reduce costs of purchasing medications on the formulary and are able to participate in Colorado cooperative purchasing opportunities for medications and other pharmacy products and services. All Colorado county facilities, including jails and other local government entities are authorized to participate in cooperative purchasing. Purchases are made by using State Price Agreements.

• The State Purchasing & Contracts Office participates with a Group Purchasing Organization (GPO) operated by the State of Minnesota called the Minnesota Multistate Contracting Alliance for Pharmacy (MMCAP). Colorado was a founding MMCAP Participating State.
• All U.S. states participate in this free, voluntary GPO.
• In Colorado, all state-operated healthcare facilities, some institutions of higher education, and many local government entities are MMCAP members.

MMCAP has national account status with all of the major brand name and generic pharmaceutical manufacturers ensuring much lower prices to participating facilities. Overall, by becoming an MMCAP Member, your facility will save money on purchases of required formulary medications.

Buying other products and services as an MMCAP Member will further reduce the costs associated with providing healthcare to inmates. MMCAP members receive access to a full range of other healthcare products and services, such as medical supplies, influenza vaccines, dental supplies, and drug testing products and services.

To participate in the MMCAP, contact Amy Risley (contact information above). She will explain how the jail can become an MMCAP member, how to make purchases using the State Price Agreements and answer any other related questions you may have.

Colorado Cooperative Purchasing Contact

Amy Risley, MBA, CPPB
State Procurement Administrator
State Purchasing & Contracts Office
Colorado Department of Personnel and Administration
amy.risley@state.co.us | 303.866.5663

Technology and Health Information Exchange

Technology and Health Information Exchange [Print]
Accessing clients' critical health information

Technology and health are intersecting as more efforts are being made to create meaningful and improvement-driven strategies around behavioral health care. An integral component of this initiative includes the secure transmission of health information so that providers can better access and use patient information to achieve improved outcomes for this vulnerable population.

Primary care providers, specialists, and behavioral health professionals lack critical information about a person's diagnosis and relevant treatment history that can lead to delays in a treatment - or even create harmful consequences for the client... People with chronic physical and behavioral health treatment needs often suffer needlessly due to a lack of coordination and access to information from treatment providers.

OBH is piloting solutions to support jail health care provider's access to relevant health information and coordination of treatment across various treatment settings. Technology and Health Information Exchange (HIE) helps provider's better coordinate care for individuals by facilitating safe and secure transmission of health information - making information available when and where it's needed for medical care. HIE equips providers with a better understanding of the whole health of an individual so they can provide the safest and most effective treatment recommendations.

National Efforts to Support HIE

At the national level, the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology (ONC) is charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information. The demand for electronic health information exchange among care professionals is growing along with nationwide efforts to improve the quality, safety and efficiency of health care delivery.

The State of Colorado is at the forefront of national efforts and has been able to create innovative and meaningful initiatives that align with the national landscape. More importantly, Colorado is paving the way for our vulnerable populations to be offered the same health benefits as others through the use of technology and health information exchange practices across public and private providers. This momentum continues to demonstrate a need to engage providers and other entities that can benefit from the interoperability enhancements within the health IT system.

Additional Resources

• Visit ONC's website to learn more about how Colorado fits into the national Health IT landscape. (www.healthit.gov/)
• "Behavioral Health Integration and Data Exchange: Privacy and Exchange Considerations for Community Health Centers" by the National Association of Community Health Centers
• "HIPAA and Health Information Exchange" by CORHIO (Colorado Regional Health Information Organization)

 

State of Colorado Efforts

The State of Colorado has two HIEs: CORHIO (Colorado Regional Health Information Organization) and QHN (Quality Health Network). These entities house information that can be essential when individuals make the critical transition in or out of criminal justice settings by standardizing how their health information is shared and mitigating the potential for gaps in critical treatment opportunities. The goal of the HIE is to provide the technology to support the flow of health information between providers and other healthcare organizations, which will allow delivery of the right information to the right place at the right time, providing safer, more timely, efficient, patient-centered care.

CORHIO serves Denver and many of the surrounding geographical locations. QHN serves the western slope of Colorado and many of the surrounding geographical locations. You can find more information on the CORHIO website or the QHN website.

In 2019, CORHIO and QHN began implementing a "query-based" exchange pilot so that jails healthcare provider's caregivers) can access clinical health information data for individuals being booked into jails. In general this includes information on recent hospital or emergency room admissions and recent providers that are connected to the HIE. The outcome of the pilot will inform future efforts to broadly roll out access to query the HIE's for all remaining jails in the state.

CORHIO & QHN improve the quality of healthcare by:

• Reducing the need for repeat or duplicative diagnostic testing.
• Reducing the risk of adverse drug reactions.
• Minimizing errors caused by lack of access to needed health records, missing or hard-to-read paperwork.
• Allowing for easier specialty care and second opinions with simplified access to all current patient information.
• Improving emergent and urgent care by providing immediate access to critical, potentially lifesaving, and health information.
• Moderating the growing costs of healthcare by enabling providers to work more efficiently.
• Streamlined access to patients' medical history and lab results, saving valuable time searching through paper charts and faxes or making phone calls.
• Decreased costs as a result of reduced faxing, printing, mailing paper files, and other administrative tasks.

Both QHN and CORHIO are valuable partners in the Medication Consistency Pilot. By leveraging resources between the two HIE's, OBH will support delivery of interoperability features across the criminal justice system to allow for more secure data sharing, improved care transitions and ultimately better health outcomes for this vulnerable population.

Jails interested in having access to query the information in the HIEs should contact Danielle Culp with the Office of Behavioral Health at danielle.culp@state.co.us or at 303.866.7110.

The following dashboard represents the utilization of the 10 Jail Pilot Sites participating in the Medication Consistency Pilot Program. We have included three different utilization metrics: total # of searches, total # of unique patients accessed, and total # of clinical documents accessed. This dashboard is updated monthly as CORHIO and QHN submit monthly utilization reports to OBH.

HIEs and Health Information Privacy Law and Policy

HIE participation must comply with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, a federal privacy law that sets a baseline of protection for protected health information (PHI).

Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. The Office of the National Coordinator for Health Information Technology (ONC) offers the following guidance for ensuring HIE compliance. Visit the ONC website for more information. Or contact CORHIO or QHN for assistance.

What type of patient choice exists under HIPAA?

Health care providers and other covered entities that create, maintain or transmit PHI must follow the HIPAA regulations. HIPAA generally permits disclosure of PHI without consent for treatment, payment and health care operations.

While it is not required, health care providers may decide to offer patients a choice as to whether their health information may be exchanged electronically, either directly or through a Health Information Exchange Organization (HIE). That is, they may offer an "opt-in" or "opt-out" policy or a combination.

The U.S. Department of Health and Human Services (HHS)does not set out specific steps or requirements for obtaining a patient's choice whether to participate in an HIE. However, adequately informing patients of these new models for exchange and giving them the choice whether to participate is one means of ensuring that patients trust these systems. Providers are therefore encouraged to enable patients to make a "meaningful" consent choice rather than an uninformed one.

You can read more about patient choice and HIE in guidance released by the Office for Civil Rights (OCR): the HIPAA Privacy Rule and Electronic Health Information Exchange in a Networked Environment.

Are there privacy laws that require patient consent?

Yes. There are additional federal and state privacy laws that govern the disclosure of PHI. Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2 requires health care providers to obtain patients' written consent before they disclose their health information to other people and organizations, even for treatment and payment purposes. Many of these privacy laws protect information that is related to health conditions considered "sensitive" by most people.

How do CORHIO and QHN strive to continually improve the stability and integrity of data?

The HIEs review the data in their network and the processes to ensure high quality standards are being met. CORHIO has a Security Team, which consists of a Compliance Officer, a Privacy Officer and a Security Officer. They work together to review both privacy and security policies, train employees, review new security technologies, enforce the CORHIO security program and act as first responders to breaches and/or suspected breach notifications.

• Data Sender Interfaces - Regularly monitors the flow of information coming through data sender interfaces so that they can recognize when the flow has been interrupted or when data values have changed.
• User Monitoring - The Security Team utilizes sophisticated auditing and monitoring tools to ensure data security and that users are only accessing patient records for those which they have a clinical relationship.
• Internal Security - Performs monthly and random scans of servers to review vulnerabilities and open ports. All found vulnerabilities are resolved via internal resources and/or IT via monthly patching schedules.
• Annual Assessments - Performs annual third-party assessments and penetration tests.

If you have any questions about the HIE security procedures or data monitoring, please contact CORHIO representative or the Help Desk at helpdesk@corhio.org. You can also request a copy the CORHIO Security Overview document from CORHIO, which includes more details.

 

Steering Committee Recordings

Medication Consistency Steering Committee Meeting Recording - Jan. 6, 2022

Frequently Asked Questions

Q: What is the Medication Consistency Program?
A: The Colorado State Legislature recently passed Senate Bill (SB) 17-019 calling for enhanced medication consistency solutions and health information exchange. Strengthening the medication practices of jail staff is a key priority for Colorado, and the legislation has potential to positively impact the quality of care provided to individuals within Colorado's jail system.

Q: What is an HIE (Health Information Exchange)?
A: Electronic health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient's vital medical information electronically-improving the speed, quality, safety and cost of patient care. Colorado has twoHIEs (CORHIO- Colorado Regional Health Information Exchange Organization) and QHN (Quality Health Network).

Q: Do we have to be in the CORHIO territory to be selected for the pilot program?
A: No, both QHN (Quality Health Network) and CORHIO will be participating in this program.

Q: Is there a cost associated with participating in the Cooperative Purchasing Agreement?
A: No, there is no cost involved with a membership with MMCAP (Minnesota Multistate Contracting Alliance for Pharmacy).

Q: Do we need to have a medical vendor in our jail to participate in the program?
A: No, there is no requirement that a jail have a contract with a medical vendor for participation in the program.

Q: Is the toolkit going to be available and where?
A: Yes, the Medication Toolkit has been posted to www.colorado.gov/pacific/cdhs/medication-consistency.

Q: How will pilot sites be selected? Are there applications?
A: Once the contract is approved with the State HIEs (CORHIO and QHN), the jails will be selected and contracts will be established. There is no application process.

Q: Are performance measures tied to this work?
A: Yes, there are performance measures included in this project and a report will include the outcomes by June 30, 2019.

Q: Are all medications included in the formulary?
A: No, the formulary and Medication Consistency project focuses on psychotropic medications.

Q: What is the purpose of participating in the Colorado Cooperative Purchasing?
A: Participation is free. Jails will have access to medications at reduced costs, in a more timely fashion, and will have the opportunity to buy in bulk.

Q: Is our jail health information safeguarded by sharing with the HIE?
A: Yes, the HIEs have these safeguards in place and will train appropriate staff on accessibility to data sharing platforms and review existing security technologies. Also, the HIEs follow laws, regulations, and guidance on HIPAA compliant data exchange. HIEs must comply with HIPAA privacy rules according to federal law.

Q: Are there privacy laws that require each inmate's consent?
A: Yes, there are laws in place that govern the disclosure of PHI (Personal Health Information). Patient consent will be in place prior to any data exchange.

Q: Will this pilot program include data exchange with DOC (Department of Corrections)?
A: The Medication Consistency Pilot program (based on Senate Bill 17-019), does not currently include funding for data exchange with DOC. However, there are other statewide initiatives that are happening concurrently that include DOC.

Background

Introduction to Medication Consistency, Senate Bill 17-019 [Print]

In 2017, the Colorado General Assembly passed Senate Bill (SB) 17-019 to improve access to effective medications for people who transfer in and out of criminal justice and mental health facilities, including institutes, jails and prisons. By having continuous access to the same set of effective medications, individuals are more likely to maintain mental wellness and be successful transitioning between the criminal or juvenile justice system and mental health service providers.

The legislation, sponsored by Senator Beth Martinez Humenik and Representative Jonathan Singer, was requested by the Legislative Oversight Committee on the Treatment of Persons with Mental Illness in the Criminal and Juvenile Justice System. This toolkit fulfills part of SB 17-019 requirements.

The bill declared the following:

• Lack of medication consistency for individuals with behavioral or mental health disorders who are involved in the criminal and juvenile justice systems creates additional, often serious, problems for these individuals.
• A broad spectrum of effective medications, including psychotropic medications, should be available to these individuals regardless of setting or service provider.
• The state can help ensure medication consistency and decrease overall state costs through a medication formulary and cooperative purchasing.
• The Medication Consistency Work Group of the Behavioral Health Transformation Council identified mental health medications that are essential and preferred for a formulary that could be used across all systems.
• Increasing information sharing and the use of a formulary and cooperative purchasing will result in long-term benefits for the state and for individuals.

In addition, SB 17-019 requires:

• The use of a medication formulary that lists required medications to be used across systems including CMHCs, MSOs, Crisis System providers, DOC and other human service providers,
• Education and marketing of the medication formulary and cooperative medication purchasing opportunities to facilities and providers,
• Electronic sharing of patient-specific information, and,
• The Colorado Department of Human Services, Office of Behavioral Health (OBH) in consultation with the Department of Corrections, to promulgate rules that require providers under each Department's to use the medication formulary.
  • OBH rules were adopted by the State Board of Human Services on June 1, 2018.
  • Because OBH does not regulate jails, these adopted rules are specific to facilities designated by OBH to provide mental health services, but can be used for guidance on how Department of Correction providers utilize the medication formulary.
  • The adopted rules further define the medication formulary and establish that designated facilities must ensure their providers have access to the medication formulary.
  • All Code of Colorado Regulations (CCR) can be accessed on the Colorado Secretary of State site. The Medication Consistency Rules for OBH Designated Facilities are listed below:

(2 CCR 502-1)

21.100 Definitions

"Medication formulary" means the Required Formulary Psychotropic Medications: 2018, which is hereby incorporated by reference. No later editions or amendments are incorporated. The medication formulary is available at no cost from the Colorado Department of Human Services at https://www.colorado.gov/pacific/cdhs/behavioral-health-laws-rules.

The medication formulary is a list of minimum medications, established pursuant to 27-70-103, C.R.S., that may be used by service providers to increase the likelihood that a broad spectrum of effective medications are available to individuals to treat behavioral health disorders, regardless of the setting or service provider. The medication formulary may not contain a complete list of medications, and providers may prescribe and/or carry any additional medications they deem necessary.

21.120.36 Medication Consistency in Designated Facilities*

A. Designated facilities shall ensure all clinical staff are aware of and have access to the medication formulary.

B. Designated facilities shall ensure their providers have access to the medications on the medication formulary when prescribing medications to treat behavioral health disorders

*jails are NOT considered designated facilities

Background and Consultation with Providers

SB 17-019 requires OBH to develop the medication formulary in collaboration with "departments, agencies and providers" (§ 27-70-103 (1)(a)) In November and December 2017, OBH worked with the Departments of Corrections, Public Safety and the Colorado Jail Association (CJA) to administer two surveys to their members - one for jail administrators and one for health providers in criminal justice systems. (Access the survey HERE.)The survey gathered information to help implement the legislation and to determine the best ways to support local jurisdictions as they work to improve coordination and outcome for people with mental health conditions involved in the criminal justice system.

In an effort to support the implementation of the Medication Consistency Pilot project, we analyzed the results of the surveys to determine our approach. The health services administrator (HSA) survey contained 48 questions. Thirty-three counties responded. Respondents reflected jail sizes statewide (small rural, medium-size and large county jails).

Table 1: Number of Health Services Administrators Responding

County Designation*	Frontier	Rural	Urban
Number of Counties Responding	8/23 (35%)	13/24 (54%)	12/17 (70%)

 

 

*Source: Colorado County Designations, 2016 Colorado Rural Health Center

Survey Findings (read the official summary of the findings HERE)

Mental Health Screening

• All reporting counties conduct some type of mental health screening, although there is a wide discrepancy in how the screenings are administered and which screening tools are completed.
• Screening is completed in most counties by the jail intake staff upon booking, individuals whose screenings results in concerns or positive results are referred to medical or mental health providers.
• Standard mental health screening instruments (e.g., PHQ9, PC-PTSD, GAD-7) are used to conduct the screenings in 19 percent of reporting counties. Other counties use internally created instruments or non-standardized screenings that may not be nationally validated for use.

Pharmaceutical Services

• Most of the reporting counties (63 percent) purchase medications from a local pharmacy either as the main or emergency pharmacy.
• Diamond Drugs Incorporated provides pharmacy services for 24 counties, primarily as a subcontractor to various comprehensive healthcare providers as either a contract pharmacy or in-house pharmacy. Diamond Drugs is the nation's largest correctional pharmacy services provider and currently serves the Department of Corrections (DOC) in Colorado. They provide "same day" delivery of medications, a complete product line and reports/documentation for each inmate for medication administration. The Minnesota Multistate Contracting Alliance for Pharmacy (MMCAP) (see Colorado Cooperative Purchasing Chapter Three for more information) offers contract pricing from Diamond Drugs to Colorado MMCAP members.

Medications

• Most counties are familiar with the use of formularies. More than half the reporting counties (62 percent) have a medication formulary. Most of the counties always have access to the medications that are used most frequently.
• Lack of a single formulary leads jails to discontinue use of physician-prescribed psychotropic medications. Nineteen counties report they are usually able to continue the psychotropic medication inmates took prior to booking. Eight counties report sometimes able to continue the medication.
• Some jails cannot provide medications prescribed during the inmate's care. Thirteen counties said they are able to provide psychotropic medications that an inmate is prescribed after booking. An additional 13 counties are usually able to do so.
• There were many reasons psychotropic medications might not be provided, whether prescribed before or after booking. Reasons included:
  • a concern the medication might be diverted or misused,
  • the medication is not on the formulary,
  • medication is too expensive,
  • medication cannot be found in the local area,
  • medication is deemed not necessary and/or an inmate is non-compliant
• Some medications present barriers for the jails.
  • Many facilities do not allow Medications prone to abuse/diversion in correctional facilities, such as some antidepressants, benzodiazepines and narcotics.
  • Medication administration methods (e.g., injection, under the tongue, patch) sometimes limit the medications that can be given. Survey respondents noted that their facilities only allow medications that can be crushed and/or orally administered, while others stated that injections required bringing medical staff on site.
  • Staffing of medical providers in jail can create a barrier if staff is not sufficient to meet the demand of the medication needs, etc.
  • The timing or frequency in which a medication is given is not an issue for most of the responding counties (23 out of 29). However, some counties report limited medical resources.

Re-entry Planning

• Several counties use the Jail Based Behavioral Health Services program to provide resources for re-entry planning.
  • Most counties responded reentry planning for community mental health care was mostly done or sometimes done. A few counties mentioned that the planning was completed when health service providers were made aware of the impending discharge.
  • Community mental health care follow-up, by referral and providing seven- or thirty day medication supply/prescription, is done by 62 percent of the responding counties. The remaining 11 counties do not arrange follow up for community mental health care.
• Telehealth is used for psychiatry or mental health services in eight of 29 counties.