Providing Inmate Continuity of Care Post-Release The Shared Experience of Massachusetts DOC, the University of Massachusetts Medical School and Lemuel

Providing Inmate Continuity of Care Post-Release

The Shared Experience of Massachusetts DOC,

the University of Massachusetts Medical School and Lemuel Shattuck Hospital

Ken Freedman, MD, MS, MBA, CMO, LSHHelene Murphy, MEd, LSW, UMCH

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• Recognize the advantages of a well designed/defined continuum of care between three state agencies.

• Tests the ability of these parties to coordinate and manage a safe and clinically effective path to community discharge for inmates needing transitional hospitalization.

• Articulate the planning steps necessary to implement a pre- and post-release system of care based upon a system of managed care referrals and the role of telemedicine.

• Identify and understand the difficulties, issues and agenda items that can interfere with a smoothly run partnership, and the essential steps needed to engage, orient and ensure support for continuous quality improvement by medical and correctional staff.

Learning Objectives

March 21, 2013Correctional Health Care

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DOC-UMCH-LSH relationship overview

• Contractual obligations among three state agencies

• Specialty clinics (most med/surg areas)

• Telemedicine program: Dermatology, Endocrinology, Gastroenterology, General Surgery, Hematology/Oncology, HIV/HCV Co-infection, Nephrology, Orthopedics, Rheumatology, and Urology.

• Re-entry programs

Trilateral Relationship (1)


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• Collaborating with LSH allows UMCH to obtain patient-centered medical care for incarcerated patients who otherwise may require distant transport and/or more costly care.

• Partnering with LSH allows UMCH and by extension, the Department of Correction (DOC), to deploy telemedicine as well as other reentry initiatives that reduce unnecessary inmate trips and possibly reduces recidivism for newly released individuals that need complex medical care.

• Success requires regular maintenance of relationships and mutual support of program goals, including ongoing systematic reviews at all levels of the partner organizations.

Trilateral Relationship (2)


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• Inmates have high rates of chronic conditions, substance abuse and mental illness (Wilper et al., 2009).

• Despite poor status, only 15% to 25% of released individuals visit a physician outside of an Emergency Department in the first year of post-release (Mallik-Kane and Visher, 2008).

• Newly released prisoners have high risk of poor health outcomes including death (Binswanger et al., 2007).

• Lack of care coordination between prison and community health systems and lack of health insurance are among the factors contributing to poor outcomes for newly released inmates (Wang et al., 2012).

• In Massachusetts, Medicaid (MassHealth) and DOC have partnered to improve access to insurance. 97% of all inmates leave with MassHealth insurance.

Background (1)


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• MassHealth/DOC Prison Reintegration Program facilitates transition to MassHealth coverage for newly released offenders as part of the pre-release planning process (Kirby et al., 2011).

• More recently, UMass Medical School Correctional Health Program is partnering with BHCH in a CMS Innovation Grant to evaluate a model for newly released inmates using Peer Navigation.

• Enrolling newly released inmates in health plans and facilitating their connection to a “medical home” are critical interventions for better addressing their post-release health needs.

Background (2)


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• An especially challenging population and one not adequately captured by these existing efforts is the sub-group of inmates who would benefit from extended hospitalization for medical and/or rehabilitative care prior to their release in the community and medical home placement.

• Commonwealth Medicine (Division of the UMass Medical School) is funding a portion of this post-release hospitalization service by supporting a a discharge planner’s continual support from prison into an inpatient facility (LSH) and then three months post-LSH discharge.

• Continuity of care from prison to hospital care to the community is assured.

Background (3)


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• UMass Correctional Health (UMCH) and the Lemuel Shattuck Hospital (LSH) agreed to pilot the Transitional Step Down Service.

• Tests the ability of both parties to coordinate and manage a safe and clinically effective path to community discharge for inmates needing a transitional hospitalization.

• UMCH is seeking NIMH funding to further evaluate access to care and impacts on recidivism rates for co-morbidly diagnosed inmates.

UMCH Partners with LSH


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• Inmates who have one or more chronic medical conditions, may have a MH and/or SA history, and may have spent much of their most recent incarcerated time within an infirmary setting.

• Inmates still require a short term hospital level of care and frequently lack community and/or familial support.

We conservatively estimate 35 participants based on the following assumptions: 5 dedicated beds at LSH, an average length of stay of 4 weeks, and a seven month operating period.

Target Population


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• LSH agrees to accept short-term admissions following an inmate's release from prison but prior to their community placement.

• UMCH agrees to support a dedicated Discharge Planner to work with Service participants for six months following their DOC release date, inclusive of the participant's inpatient stay.

• UMCH Discharge Planner will collaborate with LSH around care planning details; jointly responsible to manage discharge to the most appropriate community

setting once goals of the ex-inmate’s hospitalization have been met; responsible to provide case management to participants in the community via

monthly phone calls for six months after prison release and coordination with LSH for any needed follow-up care.

Memorandum of Understanding (MOU)


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Pilot the Service care model and evaluate its overall feasibility and potential benefits.

A key part of this effort is documentation of the extent to which implementation has taken place, nature of people being served, and degree to which the Service operates as expected.

Specific aims include assessment of program:

Implementation: what worked and did not work from operational and organizational perspectives;

Performance: select participant-level process measures, including the alignment between participant service needs and service use, ability to transition into the community, adherence to outpatient treatment plan, and experience with the program.

Study Aims


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Date of referral: _____/____/2013 Time of Referral: ____:____ A P Date Screened: _____/____/2013

Patient Name: __________________________ yrs. Living Arrangements: _______________________

SS# ______________ DOB: _____________ Religion: ___________ Race: ________________

Interpreter Needed: N Y € N/A Language: _________________________________

Next of Kin: ____________________________ Telephone # ________________________________

DMR DMH

Referring Facility: ___________________________ CM/SW:___________________________________

Telephone# ________________________________

Admitting Diagnosis: __________________________ Date of Admission: __________________________

Referred to LSH for: _____________________________________________________________________

New Admission to LSH Re-Admission to LSH Prior Admission

Patient Interviewed Staff Interviewed

Demographic Data


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Presentation: ________________________________________________________________________________

Special Needs: Private Room Hematological Condition Special Equipment

Prior Transfusion ICU Stay 1:1 Behavioral Issues

DNR DNI SA Methadone

Significant Clinical/ Behavioral Events in past 24-72 hours?: Y/ N If yes

Describe: ________________________________________________________________________

Guardian: Y N N/A Needed In Process: €Y €N

Guardian Name: _____________________________ Guardian Telephone: _____________________

Health Care Proxy: Y N N/A

HCP Name: _______________________________ HCP Telephone: _________________________________

Insurance _ Y / N__ Insurance Name: _____________________ Ins ID #: _______________

Clinical Data (1)


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Date Screened: _______________ Screening Nurse:____________________________________

Date of Admission: ____________ Diagnosis:_____________________________________ ____

Transferred From:_________________________________________________________________

Living/Social Situation: _____________________________________________________________

Adm. V.S. : T _____ P _____ RR ________ BP _________

Height: ___________ Weight: ________

Substance Abuse: ________________________________________________________________

PMH:___________________________________________________________________________

Admission Labs : EKG Neuro CXR

Current Labs:

Mental Status: ____________________________________________________________________

Restrained? Y N 1-1 Y N Competent? Y N

History of Tobacco, Alcohol or Drugs (please be specific): _________________________________

Circumstances Leading to Admission: _________________________________________________

Clinical Data (2)


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Pt/Family Refused bed offer: ___/ /2013 Reason: ___________________________________________

€Pt Denied: Date____/ /2013 _ Reason: ___________________________________________

Pt Accepted Acceptance Date:____/____/2013 Accepted by: Dr.___________ Date bed offer:____/____/___

Admit Date: ____/___ /2013 Time: ____:_____ € A € P Service_____________ Unit: _____________

Admission Delay Y / N Reason for delay: _____________________________________________________

Notification of Admission: CM Nursing NP/PA Attending Dialysis

Respiratory Social Work Admitting Pharmacy

Referring Facility Clinical Contact: _____________________________ Telephone: ____________________

Update: __________________________________________________________________________________

Disposition Data


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• Section 1: Information

The Transition Step Down service is designed to assist inmates who would benefit from an

extended hospitalization for medical and/or rehabilitative care prior to their release in the

community and medical home placement.

• Section 2: Inmate’s Statement of Approval and Consent

I have read this consent form and discussed it with: ______________________________________

I have been giving the opportunity to ask questions I might have all of which have been answered to my satisfaction.

I understand that I will not be required to pay any fees for this service.

I understand that I may refuse to participate in this service at any time.

I agree to work with UMCH D/C and LSH on a proper reentry plan to the community.

I acknowledge by my signature below I agree to participate in the Transitional Step Down Service at LSH voluntarily.

Date: ___________________ Inmate’s Signature:_____________________________________ ID#___________________ Signature of Staff:______________________________________ Date:____________________

Consent for Treatment


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Correctional Health Care Conference 17

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• Main data source will be key informant interviews with representatives of UMCH, LSH, and the Service Discharge Planner.

• Three rounds of brief key informant interviews at program inception and again at 3 & 6 months. Tracking the number of participants that enroll in the program

• Interviews conducted by phone with semi-structured interview guides will be utilized. Key domains of inquiry will focus on systems developed to support the care model and the strategies used to implement key components.

• Feasibility measure: the degree of uptake and whether the care model meets the needs of the target population – i.e., are there sufficient beds set-aide, are LSH services well-matched to participant need, does LSH experience unanticipated challenges with the intake and/or discharge process, etc.

• Key informant interviews will be ID and content-coded, and analyzed to

identify major themes.

Program Feasibility/ Implementation


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• Main data source will be program information collected by the Discharge Planner as part of the 6-month patient follow up. Information will be derived directly from participants as well as participant care plans.

• Develop data collection tool to ensure consistency of data across participants and time.

• Data domains will include: health status, inpatient and outpatient, utilization, prescribed and potentially avoidable encounters, such as ED use, community placement, participant experience and general satisfaction with the Service.

Program Performance (1)


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• Data will be gathered at intake, discharge, and thereafter on a monthly basis up to 6 months from each participant's prison release date.

• Analysis of data that descriptively characterizes program performance (e.g., adherence to treatment plans, stability of community placement over time, satisfaction) and identify potential unexpected outcomes that might be important to capture in future studies.

Program Performance (2)


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At the end of this study we hope to understand and disseminate the feasibility of the Service for two broad audiences: 1) correctional facilities community and 2) academic/research community

For the corrections’ audience – oral presentation for the annual Correctional Health conference (estimated for March 2014).

For the academic/research community – manuscript targeted at Public Health Reports, a journal that may be more receptive to a descriptive paper detailing an innovative care model (as opposed to original research).

In addition to these dissemination plans, findings from the pilot study will be considered as the basis for a grant application to evaluate the cost and utility of the Service.

Outcomes & Dissemination Plan


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Binswanger IS, Stern MF, Deyo RA, et al. 2007. Release from Prison – a High Risk of Death for Former Inmates. New England Journal of Medicine 356(2):157-165.

Kirby P, Ferguson W and Lawthers A. 2011. Post-Release MassHealth Utilization: An Evaluation of the MassHealth/DOC Prison Reintegration Pilot. Center for Health Policy and Research, Commonwealth Medicine.

Mallik-Kane K, Visher CA. 2008. Health and Prisoner Reentry: How Physical, Mental and Substance Abuse Conditions Shape the Process of Reintegration. Washington DC: Urban Institute.

Wang EA, Hong CS, Samuels L, Shavit S, et al. 2010. Transitions Clinic: Creating a Community-Based Model of Health Care for Recently Released California Prisoners. Public Health Report vol. 125: 171-177.

Wilper AP, Woolhandler S, Boyd W, et al. 2009. The Health and Health Care of US Prisoners: Results of a Nationwide Survey. American Journal of Public Health 99(4): 666-672.

References


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• Debra Beaudette

• Patricia Cahill

• Tom Groblewski, DO

• Deborah Gurewich, PhD

• Pat Herald

• Barbara MacLaughlin

• Joyce Murphy

• Patti Onoratto

• David Polakoff, MD., M.Sc.

• Paul Romary

Acknowledgements


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Documents

Providing Inmate Continuity of Care Post-Release The Shared Experience of Massachusetts DOC, the University of Massachusetts Medical School and Lemuel