Health Care Continuity in Jail, Prison and Community

Thomas.Lincoln@bhs.orgHampden County Correctional CenterBaystate Brightwood Health Center

Springfield, MA 2006

Percent of Total Burden of Infectious Disease Found Among People Passing Through

Correctional Facilities, 1996Condition Estimated # of

releases w/ Cond’n Total # in US Pop’n

w/ Cond’n Releases as %

of US Pop’n w/ Cond’n

AIDS

39,000 229,000 17%

HIV+ 98,000-145,000 750,000 13-19%

HepBsAg+ 155,000 1-1.25 million 12-16%

Hep C+ 1.3-1.4 million 4.5 million 29-32%

TB disease 12,000 34,000 35%

Hammett TM, Abt Associates, Nat’l HIV Prevention Conf. Aug 1999

Background• Health Needs

– Infectious Diseases– Chronic Medical Disease– Mental Health Disease– Substance Addiction and Abuse

• “33d state,” “But They All Come Back” (J Travis 2005)

– Most return to core urban areas– ~ 650,000 releases from US prisons/yr – ~ 9 million releases from US jails/yr

Percentage of inmates reporting any physical, mental, alcohol and/or drug problem(s) and the

percentage out of these inmates wanting help

0

20

40

60

80

100

Male Female

Gender

Per

cen

tag

e o

f in

ma

tes

reporting problem

wanting help

HCCC 1999 intake data in Conklin TJ et al. AJPH, 2000

Chronic Medical Illness: Comorbidity

0%

10%

20%

30%

40%

50%

60%

Psych ETOH cage>2 >5 drinks

PsychETOH cage>2>5 drinks

HCCC 2001

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.

The Triad

Corrections Public Health

Community Health

Public Safety

Model transitional programs: Searching for Common Ground Project

• NCCHC, Dr. Lambert King, JEHT Foundation

• 2 prison systems, 1 jail– Aftercare Planning Policy of North Carolina DOC– Accountability Model of Oregon DOC– Hampden County, MA Public Health Model

North Carolina DOC Aftercare Planning Program

• 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

• Social worker completes form with referrals to relevant service agencies in the community

• Host of community-based partners• 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

Oregon DOC Accountability Model

• Six Components 1. Criminal Risk Factor Assessment and Case

Planning

2. Staff-Inmate Interactions

3. Work and Programs

4. Children and Families

5. Reentry

6. Community Supervision and Programs

Oregon DOC Accountability Model: Reentry program features

• Reentry Facilities: 7 prisons strategically located to encourage reach-in by the community. Transfer to facility closest to home 6 mo before release.

• 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.

• 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).

Oregon DOC Accountability Model: Reentry program features (2)

• 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.

• 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.

• 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.

Community Integrated Correctional Health Care

The Hampden CountyCommunity Health Model

Hampden Co. Community Integrated Model

• 4 jail health teams integrated with 4 community (neighborhood) health centers

• Patients assigned to health team by zip code or prior association with community health center

• Dually based team members in 4 health centers and jail

– Physician(s) and case manager in both community health center and jail

– Nurse practitioner, primary nurse primarily jail based

• Community corrections (probation/parole/DRC)

Drug-Related Arrests of Persons Residing in Specific Neighborhoods

10,000

15,000

20,000

25,000

30,000

35,000

40,000

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Annual Rates of Arrest (per 1,000)

Med

ian

Fam

ily I

ncom

e

EForPk16 Acres

LibPine PtE Spf

BosRd ForPk

Ind UppH

MetOldH

McK

Mem

BayBri6Cor

S.End

Springfield Community Partnership and Prevention Alliance, 1995

Outcomes

• HIV patient show rate: 84-90%

• Cost effectiveness: $9-10/inmate-day, 10% of $44 million budget. ACA avg cost prisons 10%. Mass 12%.

• Community opinion, family opinion, patient’s opinion.

• Promotes county-wide cooperation and coordination.

• Evaluation and research.

• Absolute decrease in emergency room visits and hospitalizations after vs. before jail.

• Multivariate analysis shows increase primary care follow-up with increase health care.

• Scheduling appointments increases follow-up.

Public Health Model for Corrections

• Education

• Prevention

• Early detection

• Treatment

• Continuity of care

• Data

• Reservoir of Illness

• Proactive v. Reactive

• Sentinel function

• Public Health Department

• Community-integrated model

Challenges/Opportunities

Numbers

Bureau of Justice Statistics: Adult correctional populations 1980-2002

Corrections Statistics- USA

• 2 million+ incarcerated. “33rd state”. World ~ 8 million.

• Including probation and parole, 6.7 million persons involved with corrections- over 3% of all U.S. Adults

• 13% of African-American men cannot vote• “Invisible population”• 25% of some neighborhoods• Incarceration rate has more than tripled since 1980

Annual Releases of Adults Sentenced to Corrections: Massachusetts, 1989-2000

0

5,000

10,000

15,000

20,000

25,000

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Hampden All County HOC State/DOC TOTAL

Mass DOC; Community Resources for Justice, Inc.

Challenges to Continuity & Responses

• Time (jails).– Community-based program.– In various locales sheriff’s dept agreed to

only release participants in care program intervention between 8am-5pm Mon-Fri.

• Distance (prisons).– Technology- telemedicine, EMR.– Transfer policy.– Use of jails for transitional programs

Models of Case Management

releaserelease

AA

BB

CC

EE

DD

Challenges

• Mindset

• Costs

• After release

• Costs $6071 per new HIV infection identified

• Should 0.46 cases and would save societal dollars

• Savings (for the most part) do not accrue to corrections

• Collaborations

HIV voluntary counseling and testing program: summary

Varghese et al, HCCC, 2001

Barriers to Continuing Care In the Community after Release

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%)

Chronic Illness Cohort, HCCC, 2001

Facilitators to Continuing Care In the Community after Release

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%)

Chronic Illness Cohort, HCCC, 2001

Operational Elements for Promoting Continuity of Care

• Discharge planning starts early• Case Management• Personally connect with health worker before

reentry• Dually based health care workers• Schedule post-release appointments• Summary health record• Medical benefits• Medication• Holistic: mental health, addiction, family

Relationship of scheduling appointment and primary care follow-up, stratified by level of trust

• Correlation of appointment scheduled with going to doctor is most evident in group with higher trust of health care in jail

• Trust in health care in community showed less modifying effect

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)

Non-medical health needs

1. Food

2. Basic safety

3. Housing

4. Transportation

5. Income

6. Family role

Non-medical health needs

2. Food

3. Basic safety

4. Housing

5. Transportation

6. Income

7. Family role

Other priorities:

1. Cigarettes

Invisible Punishments:“Collateral Sanctions”

• Employment• Public assistance• Housing• Driver’s license• Voting• Education• Parental rights• Expunging criminal record

Contextual and Organizational Elements for Promoting Continuity of Care

• Geography

• “Bureaucratic simplicity”

• Pre-existing collaborative relationships

• Presence of a “champion”

• Precipitating events

• Public health worker in corrections

• Information system

Geography: sites for reentry

• Rhode Island

• Oregon: DOC facility

• Virginia: jails

• Hampden County: jail, day-reporting, community corrections

• Hawaii

Three Groups Benefit

• Public– Reduction of disease

– Reduction of post-discharge medical costs

• Less morbidity

• Lower incidence

– Enhanced public safety

• Decreased recidivism

• Increased healthy behaviors

• Individual patient– Unpopular to

mention

• Jail– Better environment

– Cost-effectiveness

Some Key Points• Almost everyone returns. Temporarily displaced.• Triad of corrections, community and public

health- collaboration needed for mission, expertise, expenses. Structure to maintain collaboration.

• Jails and prisons differences• Geographic plan• Dually-based health care workers, personal

connection• Schedule appointments

Community health care after releaseAt 1 month:• 46% had appointment set up• 60% went to first appointment.

Comparing 6 months before and after incarceration:

Intake (%) 6m (%)Went to regular doctor 64* 56*Went to ER 46 34Admitted to hospital 24 10

* median visits 2 3

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

Chronic illness cohort, HCCC 2001

In Jail Services and Post-Release Health Care Use (Physical)- instrumental

variable multivariate analysis

In jail serviceFollowing Release

Doctor ER Hospital

Doctor Visits ↑ ↑ 0.020.02 ↓ NS ↓ NS

Case Management ↑ ↑ 0.020.02 ↓ NS ↓ NS

Discharge Planning ↑ NS ↓ NS ↓ NS

Appointment MadeAppointment Made ↑↑ 0.010.01 ↓ NS ↔ NS

Chronic illness cohort, HCCC 2001

Percent of Smokers Involuntarily Ceasing Smoking While Incarcerated Who Remained Cigarette Abstinent,

by Length of Time Post-Release

Chronic illness cohort, HCCC 2001

Hepatitis Program• Education, from admission, peer ed,

groups.• Hep B vaccinate all. (? Target those

with known negative serology, age above vaccine below 45. ( 18y- VFC)

• Voluntary counseling and testing, includes HIV and hepatitis serology profile (A?, B, C)

• ALT on admission• Link to community health centers• Collaboration with Dept of Public

Health• Vaccination and PPD info wallet card

and/or electronic health record

•Education•Prevention•Early detection•Treatment•Continuity of care•Data

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.

Multivariate model for predicting Hepatitis C

% criteria % HCV detected % HCV+ Variables included

10.2 36.5 74.5 Shared needle

25.5 75.0 61.0 S. needle or ALT

29.2 81.3 57.7 S. needle, ALT or HxHep

35.6 90.1 52.7 S.needle/ALT/HxHep/HBc

19.4 57.3 68.7 ALT alone

Definitions:Shared needles: Have you ever shared needles?ALT: above ULN.HxHep: Has a medical professional ever told you that you had

hepatitis? HCCC 1999HCCC 1999

Hepatitis B Seroprevalence- All Detainees by Age

7.3 7.9

27.937

16.7

40

4.2

4.8

1.9

0

0

10

20

30

40

50

<20 20-29 30-39 40-49 50+Age

Pre

vale

nce

anti-Bs only HCCC 1999

Vaccination needs of Hep C pts

• Of inmates who tested positive for hepatitis C, 65% were negative for hepatitis A antibodies.

• Likewise 39% of those positive for hepatitis C were negative for all hepatitis B serology.

HCCC 1999

Medical Care Utilization and Coverage200 patients with chronic health conditions

• Hospitalized, past 6 months (24%)

• ER Use, past 6 months (56%)

• Medicaid coverage, past 6 months (68%)

• No Coverage, (14%)

• Sought care, but cost too much (19%)

HCCC 2001

Economic Analysis in Public Health

• Can aid in resource allocation process– determine program costs and benefits

– determine cost-effectiveness of programs compared to alternatives

• Can indicate important areas for research• Is increasingly required

– for program evaluation

– prior to program implementation

Economic Analysis in Correctional Health

• Inmates often have comparatively high rates of health conditions

• They are accessible• They can provide a link to non-incarcerated persons• Correctional health care programs often face severe

budget constraints• Economic and cost-effectiveness analysis can

quantify the cost and benefit (“production”) of correctional programs

Community Integrated Correctional Health Program

•Health needs in their communityHealth needs in their community•Community standard of careCommunity standard of care•CBO interactionsCBO interactions•3% patients at HCCC3% patients at HCCC

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