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Health Care Continuity in Jail, Prison and Community


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Health Care Continuity in Jail, Prison and Community
Hampden County Correctional Center Baystate Brightwood Health Center Springfield, MA 2006

Published in: Health & Medicine
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Health Care Continuity in Jail, Prison and Community

  1. 1. Health Care Continuity in Jail, Prison and Community [email_address] Hampden County Correctional Center Baystate Brightwood Health Center Springfield, MA 2006
  2. 2. Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Hammett TM, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999
  3. 3. Background <ul><li>Health Needs </li></ul><ul><ul><li>Infectious Diseases </li></ul></ul><ul><ul><li>Chronic Medical Disease </li></ul></ul><ul><ul><li>Mental Health Disease </li></ul></ul><ul><ul><li>Substance Addiction and Abuse </li></ul></ul><ul><li>“ 33d state,” “But They All Come Back” (J Travis 2005) </li></ul><ul><ul><li>Most return to core urban areas </li></ul></ul><ul><ul><li>~ 650,000 releases from US prisons/yr </li></ul></ul><ul><ul><li>~ 9 million releases from US jails/yr </li></ul></ul>
  4. 4. HCCC 1999 intake data in Conklin TJ et al. AJPH, 2000
  5. 5. Chronic Medical Illness: Comorbidity HCCC 2001
  6. 6. Viewed from whatever angle, whether social, economic, administrative, or moral, it is seen that adequate provision for health supervision of the inmates of penal institutions is an obligation which the state cannot overlook without serious consequences to both the inmates and the community at large.” National Society for Penal Information: Rector FL, editor. Health and Medical Service in American Prisons and Reformatories . New York: J. J. Little & Ives; 1929.
  7. 7. The Triad Corrections Public Health Community Health Public Safety
  8. 8. Model transitional programs: Searching for Common Ground Project <ul><li>NCCHC, Dr. Lambert King, JEHT Foundation </li></ul><ul><li>2 prison systems, 1 jail </li></ul><ul><ul><li>Aftercare Planning Policy of North Carolina DOC </li></ul></ul><ul><ul><li>Accountability Model of Oregon DOC </li></ul></ul><ul><ul><li>Hampden County, MA Public Health Model </li></ul></ul>
  9. 9. North Carolina DOC Aftercare Planning Program <ul><li>6 mo prior to release, inmate and social worker (along with institutional treatment team) complete an aftercare plan to coordinate the inmate’s mental health, medical care, and other social service needs post-release </li></ul><ul><li>Social worker completes form with referrals to relevant service agencies in the community </li></ul><ul><li>Host of community-based partners </li></ul><ul><li>Each person receives a copy of the aftercare planning form, medical record copy, packet includes information on other agencies, social security card, driver’s license, and records of programs completed </li></ul>
  10. 10. Oregon DOC Accountability Model <ul><li>Six Components </li></ul><ul><ul><li>Criminal Risk Factor Assessment and Case Planning </li></ul></ul><ul><ul><li>Staff-Inmate Interactions </li></ul></ul><ul><ul><li>Work and Programs </li></ul></ul><ul><ul><li>Children and Families </li></ul></ul><ul><ul><li>Reentry </li></ul></ul><ul><ul><li>Community Supervision and Programs </li></ul></ul>
  11. 11. Oregon DOC Accountability Model: Reentry program features <ul><li>Reentry Facilities : 7 prisons strategically located to encourage reach-in by the community. Transfer to facility closest to home 6 mo before release. </li></ul><ul><li>Criminal Risk Factors Identified and Mitigated through an enhanced assessment process leading to an automated corrections plan tracked through incarceration and supervision in the community. </li></ul><ul><li>Family Orientation through partnering with county community corrections agencies, Parole, and citizen Rehabilitation of Errants group (to Multnomah County-- receives ~ 1/3 of all releases). </li></ul>
  12. 12. Oregon DOC Accountability Model: Reentry program features (2) <ul><li>Information Network For Oregon (INFO): a resource directory used by a variety of other agencies providing info on resources and services available in each city and county in Oregon. Produced by inmates at Powder River Correctional Facility. </li></ul><ul><li>Oregon Trail/Offender Debit Card : built on the Oregon Trail Card for food stamps and other public assistance, inmates leaving receive “ Offender Debit Cards ” instead of checks for any monies in their trust accounts. </li></ul><ul><li>Smart Start: In partnership with Dept of Human Services, sexual health and family planning information delivered in last months before release. “Smart Start” packets on release: bag of over-the-counter birth control and personal hygiene items. </li></ul>
  13. 13. Community Integrated Correctional Health Care The Hampden County Community Health Model
  14. 14. Hampden Co. Community Integrated Model <ul><li>4 jail health teams integrated with 4 community (neighborhood) health centers </li></ul><ul><li>Patients assigned to health team by zip code or prior association with community health center </li></ul><ul><li>Dually based team members in 4 health centers and jail </li></ul><ul><ul><li>Physician(s) and case manager in both community health center and jail </li></ul></ul><ul><ul><li>Nurse practitioner, primary nurse primarily jail based </li></ul></ul><ul><li>Community corrections (probation/parole/DRC) </li></ul>
  15. 15. EForPk 16 Acres Lib Pine Pt E Spf BosRd ForPk Ind UppH Met OldH McK Mem Bay Bri 6Cor S.End Springfield Community Partnership and Prevention Alliance, 1995
  16. 16. Outcomes <ul><li>HIV patient show rate : 84-90% </li></ul><ul><li>Cost effectiveness : $9-10/inmate-day, 10% of $44 million budget. ACA avg cost prisons 10%. Mass 12%. </li></ul><ul><li>Community opinion , family opinion, patient’s opinion. </li></ul><ul><li>Promotes county-wide cooperation and coordination. </li></ul><ul><li>Evaluation and research . </li></ul><ul><li>Absolute decrease in emergency room visits and hospitalizations after vs. before jail. </li></ul><ul><li>Multivariate analysis shows increase primary care follow-up with increase health care. </li></ul><ul><li>Scheduling appointments increases follow-up. </li></ul>
  17. 17. Public Health Model for Corrections <ul><li>Education </li></ul><ul><li>Prevention </li></ul><ul><li>Early detection </li></ul><ul><li>Treatment </li></ul><ul><li>Continuity of care </li></ul><ul><li>Data </li></ul><ul><li>Reservoir of Illness </li></ul><ul><li>Proactive v. Reactive </li></ul><ul><li>Sentinel function </li></ul><ul><li>Public Health Department </li></ul><ul><li>Community-integrated model </li></ul>
  18. 18. Challenges/Opportunities Numbers
  19. 19. Bureau of Justice Statistics: Adult correctional populations 1980-2002
  20. 20. Corrections Statistics- USA <ul><li>2 million+ incarcerated. “33 rd state”. World ~ 8 million. </li></ul><ul><li>Including probation and parole, 6.7 million persons involved with corrections- over 3% of all U.S. Adults </li></ul><ul><li>13% of African-American men cannot vote </li></ul><ul><li>“ Invisible population” </li></ul><ul><li>25% of some neighborhoods </li></ul><ul><li>Incarceration rate has more than tripled since 1980 </li></ul>
  21. 21. Annual Releases of Adults Sentenced to Corrections: Massachusetts, 1989-2000 Mass DOC; Community Resources for Justice, Inc.
  22. 22. Challenges to Continuity & Responses <ul><li>Time (jails). </li></ul><ul><ul><li>Community-based program. </li></ul></ul><ul><ul><li>In various locales sheriff’s dept agreed to only release participants in care program intervention between 8am-5pm Mon-Fri. </li></ul></ul><ul><li>Distance (prisons). </li></ul><ul><ul><li>Technology- telemedicine, EMR. </li></ul></ul><ul><ul><li>Transfer policy. </li></ul></ul><ul><ul><li>Use of jails for transitional programs </li></ul></ul>
  23. 23. Models of Case Management release A B C E D
  24. 24. Challenges <ul><li>Mindset </li></ul><ul><li>Costs </li></ul><ul><li>After release </li></ul>
  25. 25. <ul><li>Costs $6071 per new HIV infection identified </li></ul><ul><li>Should 0.46 cases and would save societal dollars </li></ul><ul><li>Savings (for the most part) do not accrue to corrections </li></ul><ul><li>Collaborations </li></ul>HIV voluntary counseling and testing program: summary Varghese et al, HCCC, 2001
  26. 26. Barriers to Continuing Care In the Community after Release Chronic Illness Cohort, HCCC, 2001 1 month after release A Big Problem Somewhat of a Problem Not a Problem Not Applicable Not being able to pay for care or meds 29 ( 23%) 18 (15%) 68 (55%) 9 (7%) Not being able to get an appointment 25 ( 20%) 20 (16%) 73 (59%) 6 (5%) Not liking the care you get from providers 11 (9%) 15 (12%) 88 (71%) 10 (8%) Not having transportation 51 ( 41%) 21 (17%) 48 (39%) 4 (3%) Conflicts with work or other activities 18 (15%) 23 (19%) 78 (63%) 5 (4%)
  27. 27. Facilitators to Continuing Care In the Community after Release Chronic Illness Cohort, HCCC, 2001 1 month after release Very Helpful Somewhat Helpful Not Helpful Not Applicable Post-Release Medical Appointment Set Up in Advance 43 (35%) 83% 5 (4%) 4 (3%) 72 (58%) Dually-Based Providers 57 (46%) 54% 29 (23%) 19 (15%) 19 (15%) Health care in Jail 53 (43%) 43% 55 (44%) 14 (11%) 2 (2%) Health education in Jail 58 (47%) 48% 43 (35%) 20 (16%) 3 (2%) Drug/Alcohol Treatment in Jail 50 (40%) 53% 30 (24%) 14 (11%) 30 (24%)
  28. 28. Operational Elements for Promoting Continuity of Care <ul><li>Discharge planning starts early </li></ul><ul><li>Case Management </li></ul><ul><li>Personally connect with health worker before reentry </li></ul><ul><li>Dually based health care workers </li></ul><ul><li>Schedule post-release appointments </li></ul><ul><li>Summary health record </li></ul><ul><li>Medical benefits </li></ul><ul><li>Medication </li></ul><ul><li>Holistic: mental health, addiction, family </li></ul>
  29. 29. Relationship of scheduling appointment and primary care follow-up, stratified by level of trust <ul><li>Correlation of appointment scheduled with going to doctor is most evident in group with higher trust of health care in jail </li></ul><ul><li>Trust in health care in community showed less modifying effect </li></ul>Trust of jail care n Risk Ratio (95%CI) Low 28 1.2 (0.6-2.6) Med 26 1.3 (0.7-2.6) High 47 1.9 (1.1-3.2) All 101 1.5 (1.1-2.2)
  30. 30. Non-medical health needs <ul><li>Food </li></ul><ul><li>Basic safety </li></ul><ul><li>Housing </li></ul><ul><li>Transportation </li></ul><ul><li>Income </li></ul><ul><li>Family role </li></ul>
  31. 31. Non-medical health needs <ul><li>Food </li></ul><ul><li>Basic safety </li></ul><ul><li>Housing </li></ul><ul><li>Transportation </li></ul><ul><li>Income </li></ul><ul><li>Family role </li></ul><ul><li>Other priorities: </li></ul><ul><li>Cigarettes </li></ul>
  32. 32. Invisible Punishments: “Collateral Sanctions” <ul><li>Employment </li></ul><ul><li>Public assistance </li></ul><ul><li>Housing </li></ul><ul><li>Driver’s license </li></ul><ul><li>Voting </li></ul><ul><li>Education </li></ul><ul><li>Parental rights </li></ul><ul><li>Expunging criminal record </li></ul>
  33. 33. Contextual and Organizational Elements for Promoting Continuity of Care <ul><li>Geography </li></ul><ul><li>“ Bureaucratic simplicity” </li></ul><ul><li>Pre-existing collaborative relationships </li></ul><ul><li>Presence of a “champion” </li></ul><ul><li>Precipitating events </li></ul><ul><li>Public health worker in corrections </li></ul><ul><li>Information system </li></ul>
  34. 34. Geography: sites for reentry <ul><li>Rhode Island </li></ul><ul><li>Oregon: DOC facility </li></ul><ul><li>Virginia: jails </li></ul><ul><li>Hampden County: jail, day-reporting, community corrections </li></ul><ul><li>Hawaii </li></ul>
  35. 35. Three Groups Benefit <ul><li>Public </li></ul><ul><ul><li>Reduction of disease </li></ul></ul><ul><ul><li>Reduction of post-discharge medical costs </li></ul></ul><ul><ul><ul><li>Less morbidity </li></ul></ul></ul><ul><ul><ul><li>Lower incidence </li></ul></ul></ul><ul><ul><li>Enhanced public safety </li></ul></ul><ul><ul><ul><li>Decreased recidivism </li></ul></ul></ul><ul><ul><ul><li>Increased healthy behaviors </li></ul></ul></ul><ul><li>Individual patient </li></ul><ul><ul><li>Unpopular to mention </li></ul></ul><ul><li>Jail </li></ul><ul><ul><li>Better environment </li></ul></ul><ul><ul><li>Cost-effectiveness </li></ul></ul>
  36. 36. Some Key Points <ul><li>Almost everyone returns. Temporarily displaced. </li></ul><ul><li>Triad of corrections, community and public health- collaboration needed for mission, expertise, expenses. Structure to maintain collaboration. </li></ul><ul><li>Jails and prisons differences </li></ul><ul><li>Geographic plan </li></ul><ul><li>Dually-based health care workers, personal connection </li></ul><ul><li>Schedule appointments </li></ul>
  37. 37. Community health care after release <ul><li>At 1 month: </li></ul><ul><li>46% had appointment set up </li></ul><ul><li>60% went to first appointment. </li></ul><ul><li>Comparing 6 months before and after incarceration: </li></ul><ul><li>Intake (%) 6m (%) </li></ul><ul><li>Went to regular doctor 64* 56* </li></ul><ul><li>Went to ER 46 34 </li></ul><ul><li>Admitted to hospital 24 10 </li></ul><ul><ul><li>* median visits 2 3 </li></ul></ul>Chronic illness cohort, HCCC 2001
  38. 38. Chronic illness cohort, HCCC 2001 Self-reported health (n=131) Intake % 6 months % General Health Fair/poor 55 34 Good 24 33 VG/excellent 21 33 Pain (mod/severe) 40 20 Emotional problem (mod/severe) 66 43
  39. 39. In Jail Services and Post-Release Health Care Use (Physical)- instrumental variable multivariate analysis Chronic illness cohort, HCCC 2001 In jail service Following Release Doctor ER Hospital Doctor Visits ↑ 0.02 ↓ NS ↓ NS Case Management ↑ 0.02 ↓ NS ↓ NS Discharge Planning ↑ NS ↓ NS ↓ NS Appointment Made ↑ 0.01 ↓ NS ↔ NS
  40. 40. Percent of Smokers Involuntarily Ceasing Smoking While Incarcerated Who Remained Cigarette Abstinent, by Length of Time Post-Release Chronic illness cohort, HCCC 2001
  41. 41. Hepatitis Program <ul><li>Education, from admission, peer ed, groups. </li></ul><ul><li>Hep B vaccinate all. (? Target those with known negative serology, age above vaccine below 45. ( 18y- VFC) </li></ul><ul><li>Voluntary counseling and testing, includes HIV and hepatitis serology profile (A?, B, C) </li></ul><ul><li>ALT on admission </li></ul><ul><li>Link to community health centers </li></ul><ul><li>Collaboration with Dept of Public Health </li></ul><ul><li>Vaccination and PPD info wallet card and/or electronic health record </li></ul><ul><li>Education </li></ul><ul><li>Prevention </li></ul><ul><li>Early detection </li></ul><ul><li>Treatment </li></ul><ul><li>Continuity of care </li></ul><ul><li>Data </li></ul>
  42. 42. The health care system realizes net savings even when there is no incidence in prison, or there is no cost of chronic liver disease, or when only one dose of vaccine is administered. Thus, while prisons might not have economic incentives to implement hepatitis B vaccination programs, the health care system would benefit from allocating resources to them.
  43. 43. Multivariate model for predicting Hepatitis C <ul><li>% criteria % HCV detected % HCV+ Variables included </li></ul><ul><li>10.2 36.5 74.5 Shared needle </li></ul><ul><li>25.5 75.0 61.0 S. needle or  ALT </li></ul><ul><li>29.2 81.3 57.7 S. needle,  ALT or HxHep </li></ul><ul><li>35.6 90.1 52.7 S.needle/  ALT/HxHep/HBc </li></ul><ul><li>19.4 57.3 68.7  ALT alone </li></ul><ul><li>Definitions: </li></ul><ul><li>Shared needles: Have you ever shared needles? </li></ul><ul><li> ALT: above ULN. </li></ul><ul><li>HxHep: Has a medical professional ever told you that you had hepatitis? </li></ul>HCCC 1999
  44. 44. HCCC 1999
  45. 45. Vaccination needs of Hep C pts <ul><li>Of inmates who tested positive for hepatitis C, 65% were negative for hepatitis A antibodies. </li></ul><ul><li>Likewise 39% of those positive for hepatitis C were negative for all hepatitis B serology. </li></ul>HCCC 1999
  46. 46. Medical Care Utilization and Coverage 200 patients with chronic health conditions <ul><li>Hospitalized , past 6 months (24%) </li></ul><ul><li>ER Use , past 6 months (56%) </li></ul><ul><li>Medicaid coverage , past 6 months (68%) </li></ul><ul><li>No Coverage , (14%) </li></ul><ul><li>Sought care, but cost too much (19%) </li></ul>HCCC 2001
  47. 47. Economic Analysis in Public Health <ul><li>Can aid in resource allocation process </li></ul><ul><ul><li>determine program costs and benefits </li></ul></ul><ul><ul><li>determine cost-effectiveness of programs compared to alternatives </li></ul></ul><ul><li>Can indicate important areas for research </li></ul><ul><li>Is increasingly required </li></ul><ul><ul><li>for program evaluation </li></ul></ul><ul><ul><li>prior to program implementation </li></ul></ul>
  48. 48. Economic Analysis in Correctional Health <ul><li>Inmates often have comparatively high rates of health conditions </li></ul><ul><li>They are accessible </li></ul><ul><li>They can provide a link to non-incarcerated persons </li></ul><ul><li>Correctional health care programs often face severe budget constraints </li></ul><ul><li>Economic and cost-effectiveness analysis can quantify the cost and benefit (“production”) of correctional programs </li></ul>
  49. 49. Community Integrated Correctional Health Program <ul><li>Health needs in their community </li></ul><ul><li>Community standard of care </li></ul><ul><li>CBO interactions </li></ul><ul><li>3% patients at HCCC </li></ul>Community Health Centers :