Hearing on Opiate Addiction and Usage, Legislative Committee of the Cook County Board, April 29, 2015

The Legislative Committee held hearings on Opiate Addiction and Usage on April 29, 2015 at 2:25 pm.    A complete video of the testimony by various experts may be viewed below.

http://cook-county.granicus.com/MediaPlayer.php?view_id=3&clip_id=1134

Commissioners Gorman and Suffredin called the hearings to try to understand opiate addiction to be able to address cost and treatment issues for the Criminal Justice System and HHS in Cook County.

Commissioners Butler, Boykin, Sims, and Garcia were also present, although nearly everyone had left by the end of the meeting almost 2 hours later. 

The hearings called many experts in Cook County and beyond to help explain the patterns and origins of opiate addiction.  Drug poisoning has overtaken motor vehicle accidents for deaths in Illinois and around the nation.

Usage is well distributed all over suburban Cook County, according to Dr. Mason, a specialist in treatment for non-Chicago Cook County area hospitals.

Opiate addicts typically start using and abusing OTC (over the counter) opioids like Vicodin, Tylenol 3, Oxycontin.  When they can no longer justify a medical excuse for obtaining OTC “legal” opioids, they switch to heroin.

Dr. Timothy Condon works with TASC as the Chief Science Officer, and is at the National Institute of Drug Abuse:  Drug abuse is a disease which is treatable.  It is a brain disease.  Death rates from opiates in the Northeast and Midwest are six times higher than in 2006-2007.  Nationally abuse is concentrated in non-Hispanic Whites and Black users.  We now have tools to deal with opiate addiction, which we did not in the past.  It doesn’t matter what is in the syringe, whether it is heroin or an opiate prescription drug, the user is still an addict, and has to be treated.

Narcan or Naloxone is a powerful “new” drug that can revive people who ordinarily would have died from an opiate overdose, but Narcan does not treat the addiction.

The drug of choice for treating opiate addiction is Naltrexone.  Unlike the imperfect Methadone “treatment” that likewise created dependency, Naltrexone is an addiction agonist so it blocks the euphoria that the opiate creates in the brain.  Vivitrol is the time-release version of Naltrexone.

Dr. Eka Jones is with the Sheriff’s office inside the Women’s Justice program for mental health and drug treatment within Cook County Jail.  More than 50% of her enrollees cited heroin as their drug of choice.  Drug treatment has to be tailored to meet individual needs.

Dr. Minella, the Head of Cermak Mental Health Clinic at the Cook County Jail, has been there since 1991.  Everyone gets screened for physical and mental issues during Cook County jail intake, and about 80% have substance histories.  12% actively use heroin of the intake population at the jail.  Of the 500 people in the Detox unit every month, about 80% are heroin users, committing crimes to get heroin.  The inmates are very vulnerable when in detox and the issue is that they don’t stay long enough to get off the substance.  25% leave within 2 days, and 50% leave within 12 days.  6 weeks is considered the proper amount of time to get someone off of opiate addiction.

Judge Charles Byrne from 26^th Street courthouse has the Drug Treatment Court.  Addicts have to be dealt with differently from young people who are caught for the first time.  80% of addicts are heroin “frequent fliers” where they have been in and out of jail and the penitentiary between 5 and fifteen times.  You have to try to get them clean.  Every $1 spent in treatment saves $2 later.  They are typically using $200 to $300 in heroin each day.  They need to be supervised in a sober environment.  If they complete the treatment program, 85% of them stay out of the criminal justice system for at least one year.  74% non-recitivism after three years.  They need jobs as well so they can be able to make money.  Everyone who graduates from the program gets their case dismissed.  Many groups now, including the CTA, have a felon-hiring program.  The drug treatment program gets funded from Judge Evans’ budget.

Dr. Aix, a Stroger Emergency Room doctor and head of Toxicology at Stroger, says we are in the middle of an opioid epidemic.  It began to take off in 2000 when there was over-prescription of opioid OTC drugs.  The opiate prescription drugs lure teens into experimentation.

At Stroger ER there are 5000 patients admitted for drug overdoses in a year, with 20% of them repeat overdosers.

There needs to be an increase in Detox and addiction facilities. 

There are two pilot programs being tested by the State of Illinois in Winnebago County and Madison County.  Both use Vivitrol for long term easing off of opiates, and both use community treatment and outreach to maintain the link to support once the person has left jail.  They use Medicaid to treat people in jail.

Another speaker, Joel Johnson, at HRDI, Human Resources Development Institute, said it was very hard to get Medicaid to pay for Vivitrol treatment, even though it has proven successful.

Chief Scofield, Fire Chief in Orland Park, testified that Orland Park went from 3 to 70 overdoses in the last ten years.  The families are embarrassed and hide their kids and the addiction from the public.

Chief Roberts, head of the Cook County Forest Preserve police, lost his son to a heroin overdose in 2009.  There were 7000 deaths in the nation in 2007, 43,000 in 2014.  He is happy to see the Cook County Board doing something proactive.

Dr. Dan Lustig of the Haymarket Center said that heroin addicts need 6 or 7 treatments of Vivitrol before “freedom from opiates” can take hold.

Sally Thorin, Executive Director of Gateway Foundations, says there are three key parts of treatment.  Proper diagnosis, therapeutic mindfulness, and Vivitrol treatment.

Respectfully submitted by Amy Little

Health & Hospitals Systems Board Meeting April 25, 2014

Commmittee Reports:  Board member Lewis Collens reported that TB patients formerly treated by the city are now cared for at CCHHS clinics, with a chargeback from CCHHS to the city to pay for their care. He also reported that though immunization of CCHHS employees is mandatory, only 61% of Stroger employees, 58% of Provident employees, and 84% of Cermak clinic employees were immunized.  Chairman David Carvalho commented, "That employees can expose their patients to preventable, communicable diseases in appalling."

The board approved a recommendation that the Cook County Board exercise an option to purchase a currently-leased property at 2424 S. Pulaski which houseds CCHHS' Dr. Jorge Prieto Health Center.

Chairman Carvalho reported the the CEO search is moving ahead: candidates are to be reviewed in May, with interviews to begin in June.

Interim CEO Dr. Jay Shannon reported:

• the Stroger cafeteria has been updated;
• the 2015 budget is in development with some planned capital equipment additions;
• there are now more than 95,000 CountyCare patients;
• CCHHS has received an extension to October 2015 to comply with the ICD (International Classification of Diseases) 10 disease coding, a complex coding system increasing the ICD9 codes from 14,000 to iDC 10, 70,000 codes, providing greater specificity for improvemeng diagnoses and for assessing the true cost of care, particularly in anesthesia and orthopedics.

The meeting adjourned to closed session at 9:45.

Submitted by Linda Christianson

CCHHS Quality Assurance and Patient Safety Committee December 11, 2013 Meeting

Attending: Chairman Collens, Commissioner Munoz, Commissioner Hammond (not a member of the Committee) and Commissioner Lerner (by phone).

Only 50% of hospital staff have received the flu shot.  Legal counsel is ascertaining whether this is a matter which must be addressed by collective bargaining or whether CCHHS can unilaterally make vaccination a condition of employment. Management attributes the low level of vaccination to "cultural barriers," its euphemism for African-Americans’ suspicion of medicine as practiced by whites in general and the government in particular.

Cermak Health Services (serving the Cook County Jail and the Juvenile Temporary Detention Center) gave a comprehensive account of its activities, including an 80% staff vaccination rate. Interim Chief Medical Officer Dr. Concetta Mennella noted in her report that "correctional medicine" once meant controlling communicable diseases but now means treating mental illness and substance abuse.

The Quality Assurance Department has finally created a report form which will show the System’s progress on each identified measurement. The report form likely was created without consideration of the STAR report, which was never mentioned.

The Committee adopted the FY 2014 Quality Assurance Plan after Dr. Das explained that it focuses on four High-Risk High-Volume priority areas: discharge transitions, procedural safety, medication safety and handling malignant pathology. The overall goal, of course, is to prevent "adverse events," and particularly "sentinel events," which are adverse events with catastrophic outcomes.

The plan also provides a smoother system of reporting, from internal committees to the Hospitals’ Executive Staff to the Hospital Board Committees to the full Hospital Board. Each internal committee will track three key indicators, and a combined quarterly report will show up or down arrows reflecting progress or lack thereof in each. Every department has responsibility for improving its own key indicators, and therefore for assessing the performance of physicians and contractors as well as front-line staff.

Overall, the three areas to be tracked are time to treatment, core measures (which vary by department) and patient satisfaction. CCHHS is above the median in patient satisfaction for safety-net hospitals. But now that patients have the option to go elsewhere, their satisfaction is paramount, so the System’s goal for the next year is a 10% increase in that measure, to 71%. Das reported that CCHHS was "near the median" for all hospitals, though that median is 75% and the System is now apparently at 61%.

The ultimate goal, achieved by the top 10% of the nation’s hospitals, is 100% satisfaction plus 100% in each core measure.

Collens suggested that the System communicate to the patients its new commitment to improved quality, as just knowing about the effort might improve their satisfaction.

Das stressed that improved data collection would help CCHHS identify opportunities for improvement. She said the System is implementing "six-sigma" to achieve consistent performance.

Flu: Dr. Shannon reported a minimal flu season thus far in the county and the state. Vaccine has been widely available to CCHHS patients and staff since the first week in October, but only 3000 employees (slightly more than half the workforce) has been vaccinated. To encourage vaccination, CCHHS has set up standing orders for vaccines, and offers them on-site 24/7 free to staff members. Still, the rate of vaccination has slipped since the historical high in 2009, the year of the H1N1 flu.  90% of pharmacy and CORE staff have been vaccinated. The Committee then discussed whether the Board could require vaccination.

Cermak Health Services: Dr. Mennella noted that prisoners were the only Americans Constitutionally entitled to medical care, under a 1976 Supreme Court case, so Cermak provides Constitutionally-required care; but she stressed the goal of improving the health of the most marginalized in society and of their communities. The 100-acre Cermak campus includes 17 buildings providing different levels and types of care, including the newly-opened 979-bed intermediate-care Residential Treatment Facility, which will be used largely for treatment of drug and alcohol problems and the mentally ill.

Menella provided statistics explaining Cermak’s size:

• It does 100,000 intake screenings a year; every detainee is screened, so Cermak is able to capture the 20% who are mentally ill.
• It sees 2,000 of the County’s 10,000 detainees every day.
• It provides 5 million doses each year, using a robotic pharmacy to reduce errors.
• It has produced 5% of CountyCare enrollees, and expects 9 out of 10 of its patients to have health insurance coverage under Obamacare, versus only 1 in 10 now.
• It cares for the 300-plus daily population at the Juvenile Temporary Detention Center (JTDC) with nationally-accredited services.
• Between 1985 and 2012 the jail population doubled because mental hospitals closed and the length of stay increased: 2 extra days adds 600 patients/month to the census.
• 57 days is the average length of a jail stay; 12 days is the median. Every month there are 250 detainees who have been there more than a year.
• Cermak manages chronic diseases including Hepatitis C and liver cancer.
• It handles 550 opiate and alcohol withdrawal cases at a time and is authorized to dispense methadone to those who have already had it prescribed.
• It offers more than the ten hours/month of programming required by the Department of Justice for mentally ill patients.
• It treats most patients on-site, with only 20 people transferred to Stroger each day, mostly for orthopedics (to treat incarceration-induced trauma). Detainees at Cermak are treated without shackles unless the Sheriff insists; at Stroger they are shackled.
• All detox at Cermak will be consolidated in the new Residential Treatment Facility, which has been open since June but is still awaiting necessary equipment. It should be fully operational by June 2014. 86% of its patients will be there for mental health issues.
• 80% of its staff has been vaccinated for flu, and while prisoners often opt out, "they bare their arms when they see others getting sick." Vaccination isn’t mandatory because detainees have the same right to decline treatment as anyone else.

Cermak’s key issue is staffing: because the patients can’t call their doctors or participate much in their own care, intensive nursing is required and Cermak plans to add nurses in 2014. It used to get young providers through the National Health Service Corps but is now trying to recruit those who need student-loan relief. Lerner urged Mennella to provide detainees with navigators to negotiate mental-health as well as medical reimbursement issues.

Other goals for 2014: hire an orthopedist to reduce the need for transfers to Stroger; implement an Electronic Medication Administrative Record-keeping system. (Cermak already has EMR.)

Services are the collective responsibility of the Sheriff, the Department of Facilities Management and Cermak Health Services. Cermak is monitored by the Department of Justice under a consent decree; it’s considered "partially compliant" at 50%, and has no units which are noncompliant. In response to a question, no one could say how the residental treatment unit building was financed, though it costs $90 million.

There was no report from Provident.

From Stroger Hospital, Dr. Ochoa reported that the medical staff had approved the Quality Assurance Plan. It also changed the name and composition of its internal quality group; the new Hospital Quality and Patient Safety Committee will convene in February.

Submitted by Kelly Kleiman

Nov. 8, 2011 Meetings on the Budget: Sheriff, Clerk of the Court, & State's Attorney

Sheriff Tom Dart

Sheriff Dart stated that his budget of $401 million is down from both 2011 ($412 million) and 2010, despite $54 million increase in salaries to be paid as approved by County Board.  The savings is due in part to the following:  inmates helping out at Animal Control; reduction in overtime from $22 million in 2010 to $11 million; payments from the Illinois Dept. of Corrections for housing some of their inmates; reducing the cost of food by having inmates prepare lunch (and may be able to have inmates prepare breakfast, both of which are “cold meals”); and reduction in jail population.  He praised the judiciary for increasing the number of those on electronic monitoring from 300 to 1100 currently.  He noted that while the total admissions has decreased (75,000 in 2007 vs. 65,000 in 2011), the average length of stay has increased from 47 to 54 days.  The inference was that it is taking longer to bring these people to trial. The Sheriff also stated that he thinks that they are getting close to putting the Duran court case and oversight behind them after 30 years.

His biggest concern is in the number of inmates with mental illnesses (regularly runs between 1200 to 2500 out of the 9,200 in custody), and this population produces the most costs to the County. With the closing of more state-run mental health facilities, he expects that population to grow even more.  Comm. Steele raised his concern about the proposed changes at Cermak  (which is responsible for treating the inmates) that the Health & Hospitals System is making with regard to changing out the mental health specialists who are currently not licensed with higher-level licensed specialists, but who are not known by the inmates.  Comm. Steele asked the Sheriff to talk to the Health & Hospitals System about the negative effect wholesale and quick changes may have.

Sheriff Dart said that his department could and should be handling more of the closings of foreclosed home sales since they can do them well and at lower costs than others who are doing them.  If his department handled all such closings, it would amount to $13 million in revenues for the County, but in 2011 he is bringing in only $118,000 for 448 out of the 9,500 he expected to do.  He has no explanation yet as to why his department isn’t being used.  On the plus side, in only 7 weeks of stepped up enforcement, his department has issued $1 million in citations for unpaid cigarette taxes.  He expects significantly more in 2012.

While Sheriff Dart stated that his department is 100% in compliance in taking the required furlough days, upon questioning, it turns out that about 5500 of his employees have been deemed “essential” and thereby exempt from taking the days.  In addition to the fact that much of his area (the patrol officers and jail) operate 24/7, the Sheriff stated that if these employees had to take furlough days, that would result in other employees covering through overtime, thereby increasing those costs.  Comm. Tobolski said that rather than some of these “essential” employees being allowed to take personal days, maybe these days should be furlough days. 

Comm. Silvestri stated that he had reached out to all the townships to see if they would help fund the graffiti unit which is being eliminated in this budget.

Clerk of the Court Dorothy Brown

Clerk Brown explained some of the achievements of the past year, including having motorists paying tickets online for $10 million; and piloting a program with 4 municipalities to have e-tickets issued and sent directly to her area with the expectation that all 128 municipalities will be participating this year.  She expects all judges to have computers on the bench in 2012, which will eliminate the need for her employees to bring paper files into court. 

At the time the proposed budget was published, her request was not in alignment with the President’s recommendation. However, Clerk Brown stated that she is working on coming into compliance and will submit proposed amendments by the deadline of Nov. 16.  In order to meet the recommendation, either layoffs or some furlough days will be necessary.

She noted that she did a study comparing her area to those in the 6 largest counties in the U.S.  While Cook is the 2^nd largest in # of cases filed, Cook is the 3^rd largest in # of employees.  Looking at 2010 numbers, her budget is at the bottom.  Comm. Tobolski stated that court filings are down 28% over the past 10 years, but the number of employees under the Clerk of the Court is down only 12%.  Clerk Brown pointed to her county comparison study in response.

Comm. Fritchey expressed concern over Clerk Brown’s proposal to seek State authorization to charge a 50 cent or $1 fee for every filing in a case, over and above the $303 to initiate a case.  Comm. Fritchey also asked about the Clerk’s Inspector General’s office with 20 FTEs, vs. the County Inspector General who has 18.  Clerk Brown stated that some of those employees are actually filling an auditing role, as opposed to handling complaints.  She is going to clarify the roles.  Comm. Fritchey also asked about the Controller’s office under the Clerk of the Court which has 65 FTEs vs. the County Controller only having 38.  Clerk Brown stated that her area handles lots of over-the-counter transactions and has to disburse funds to 950 agencies, necessitating lots of oversight and controls. 

State’s Attorney Anita Alvarez

While the State’s Attorney’s office has submitted a budget request in line with the President’s recommendation, it was clear that Ms. Alvarez was seeking additional money from the Board to reduce the number of layoffs that are necessary under the proposed budget (113, 93 of whom are administrative, including a number of those in the Victims’ Assistance department who have received a lot of attention in the public hearings).  She has done a comparison with other large counties and says her attorneys carry a much larger caseload.  Her proposed cuts in attorneys are more on the civil, rather than criminal side, to which she has given a priority out of public safety concerns.  However, she said the cuts on the civil side will necessitate having to go outside for some of the civil actions which will mean that the County will be paying a minimum of $185/hr vs. the $45/hr cost to handle inside.

It was clear that a number of the Commissioners will be trying to find more money for this office through the amendment process.  Comm. Tobolski stated that he is looking to cut more from the Health & Hospitals budget to provide more for the State’s Attorney.

-- reported by Priscilla Mims

CC Board Finance Comm. Budget Review - CCHHS - Oct. 29, 2009

The proposed budget for the Health and Hospitals Systems (HHS) was previously presented to the Commissioners in September so this meeting was an opportunity to again question CEO, Mr. Foley and the Independent Board President Mr. Batts about the proposed budget. The CCHHS Board is also in the midst of holding public hearings concerning their proposed Strategic Plan for the System so there were questions also about the plan. The President’s proposed budget for HHS is $968.5m. When asked if they would be able to cut their budget if the sales tax was decreased Mr. Foley stated that his management team is working with the CCHHS Board to identify opportunities for budget cuts with or without a tax decrease and how this will impact delivery of services is what they are working on in their Strategic Plan.

Several of the Commissioners raised questions about the layoffs which had just occurred in the system. Comm. Sims was concerned with how this would affect the morale of employees and whether it would result in lawsuits. Comm. Daley stated that if the layoffs were done in compliance with labor contracts, they could be done. Comm. Collins requested information on the amounts spent on registry nurses, on outsourcing, on overtime and administrative costs including contractual studies. She was not able to find this information in the budget books and thought the layoffs could have been done in a better way. Comm. Beavers and Comm. Sims both wanted information on the new Executive Team that is running the hospital - were they from Cook County. Comm. Beavers said the word was that the new CEO was bringing in his own people and he referred to it as "pinstripe patronage" and said this was not a fair way to run the system. Mr. Foley and the HR Director provided information on the new Executive Team - some are from Cook County and some are from outside but with experience relevant to public hospitals.

Comm. Suffredin had questions about reconciling the proposed budget with what had been previously approved and some coding errors were noted in some line items which will be corrected. He also requested that the HHS Board send any employee communications to the Commissioners as well, so they know what is going on. He stated that there have been many rumors circulating and it is helpful to have the facts to deal with the rumors that get going.

Comm. Gainer was concerned with the number of employees that are out on disability and how this impacts reliance on the use of the nurses’ registry and how it impacts overtime. She also wanted to know how the transfer to the Independent Board was progressing. Mr Foley reported that HR is in the middle of their transfer to become separate from HR at the county, and that the purchasing function has mostly been switched from the county to the Health and Hospitals System. It was also clarified that the sunset date for the CCHHS Independent Board as of now is February 28, 2011.

Comm. Schneider raised the issue of the H1N1 vaccinations and there was a lengthy discussion of that issue with Dr. Martin, Chief of Public Health. Comm. Claypool was concerned with how the Strategic Plan is integrated into the budget and how the plan will be carried out. Mr. Foley gave a figure of about $30m for implementation of the Strategic Plan but he said that was hard to say since the plan is still being devised.

Comm. Butler wanted to make clear that the budget for 2010 reflects a decreased subsidy paid by taxpayers to the HHS of $74m. In 2009 the amount of subsidy to support the HHS was $382m and in 2010 it is estimated to be $308m due to anticipated increased revenue generated by HHS.

Comm. Gainer asked about the progress on bringing Cermak Hospital up to the standards necessary for the County to comply with a consent decree dealing with issues there. The person in charge of Cermak Hospital stated that staffing there is now adequate but there continue to be IT problems that result from structural wiring problems. Comm. Daley stated that the Commissioners should ask the Sheriff about the money for dealing with the IT problems and Capital Planning about the plans for dealing with the problems.

Comm. Daley ended the session stating that the budget request for HHS should not be a surprise to anyone since it had been presented in September and was essentially the same budget as they reviewed then.