Health Care Continuity in Jail, Prison and Community

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Slide 1: Health Care Continuity in Jail, Prison and Community Thomas.Lincoln@bhs.org Hampden County Correctional Center Baystate Brightwood Health Center Springfield, MA 2006

Slide 2: Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Condition Estimated # of Total # in US Pop’n Releases as % releases w/ Cond’n w/ Cond’n 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

Slide 3: 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

Slide 4: Percentage of inmates reporting any physical, mental, alcohol and/or drug problem(s) and the percentage out of these inmates wanting help 100 Percentage of inmates 80 60 reporting problem 40 wanting help 20 0 Male Female Gender HCCC 1999 intake data in Conklin TJ et al. AJPH,

Slide 5: Chronic Medical Illness: Comorbidity 60% 50% 40% Psych 30% ETOH cage>2 >5 drinks 20% 10% 0% Psych ETOH cage>2 >5 drinks HCCC 2001

Slide 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.

Slide 7: The Triad Corrections Public Health Public Safety Community Health

Slide 8: 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

Slide 9: 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

Slide 10: 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

Slide 11: 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).

Slide 12: 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.

Slide 13: Community Integrated Correctional Health Care The Hampden County Community Health Model

Slide 14: 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)

Slide 15: Drug-Related Arrests of Persons Residing in Specific Neighborhoods EForPk 40,000 16 Acres Median Family Income 35,000 Lib Pine Pt E Spf BosRd ForPk 30,000 Ind UppH McK 25,000 20,000 Bay Bri 6Cor 15,000 Met OldH S.End Mem 10,000 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) Springfield Community Partnership and Prevention Alliance, 1995

Slide 16: 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.

Slide 17: Public Health Model for Corrections • Education • Prevention • Early detection • Reservoir of Illness • Treatment • Proactive v. Reactive • Continuity of care • Sentinel function • Data • Public Health Department • Community-integrated model

Slide 18: Challenges/Opportunities Numbers

Slide 19: Bureau of Justice Statistics: Adult correctional populations 1980-2002

Slide 20: 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

Slide 21: Annual Releases of Adults Sentenced to Corrections: Massachusetts, 1989-2000 25,000 20,000 15,000 10,000 5,000 0 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.

Slide 22: 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

Slide 23: Models of Case Management release A B C D E

Slide 24: Challenges • Mindset • Costs • After release

Slide 25: HIV voluntary counseling and testing program: summary • 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 Varghese et al, HCCC, 2001

Slide 26: Barriers to Continuing Care In the Community after Release 1 month after release A Big Somewhat of Not a Not Problem a Problem Problem Applicable Not being able to pay for care 29 (23%) 18 (15%) 68 (55%) 9 (7%) or meds Not being able to get an 25 (20%) 20 (16%) 73 (59%) 6 (5%) appointment Not liking the care you get 11 (9%) 15 (12%) 88 (71%) 10 (8%) from providers Not having transportation 51 (41%) 21 (17%) 48 (39%) 4 (3%) Conflicts with work or other 18 (15%) 23 (19%) 78 (63%) 5 (4%) activities Chronic Illness Cohort, HCCC, 2001

Slide 27: Facilitators to Continuing Care In the Community after Release 1 month after release Very Somewhat Not Not Helpful Helpful Helpful Applicable Post-Release Medical 43 (35%) 5 (4%) 4 (3%) 72 (58%) Appointment Set Up in Advance 83% Dually-Based Providers 57 (46%) 29 (23%) 19 (15%) 19 (15%) 54% Health care in Jail 53 (43%) 55 (44%) 14 (11%) 2 (2%) 43% Health education in Jail 58 (47%) 43 (35%) 20 (16%) 3 (2%) 48% Drug/Alcohol Treatment in Jail 50 (40%) 30 (24%) 14 (11%) 30 (24%) 53% Chronic Illness Cohort, HCCC, 2001

Slide 28: 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

Slide 29: Relationship of scheduling appointment and primary care follow-up, stratified by level of trust 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) • 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

Slide 30: Non-medical health needs 1. Food 2. Basic safety 3. Housing 4. Transportation 5. Income 6. Family role

Slide 31: Non-medical health needs 1. Food Other priorities: 2. Basic safety 2. Cigarettes 3. Housing 4. Transportation 5. Income 6. Family role

Slide 32: Invisible Punishments: “Collateral Sanctions” • Employment • Public assistance • Housing • Driver’s license • Voting • Education • Parental rights • Expunging criminal record

Slide 33: 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

Slide 34: Geography: sites for reentry • Rhode Island • Oregon: DOC facility • Virginia: jails • Hampden County: jail, day-reporting, community corrections • Hawaii

Slide 35: Three Groups Benefit • Public • Individual patient – Reduction of disease – Unpopular to – Reduction of post- mention discharge medical costs • Less morbidity • Lower incidence • Jail – Enhanced public safety – Better environment • Decreased recidivism – Cost-effectiveness • Increased healthy behaviors

Slide 36: 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

Slide 37: Community health care after release At 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 34 Admitted to hospital 24 10 * median visits 2 3 Chronic illness cohort, HCCC 2001

Slide 38: Self-reported health Intake 6 months (n=131) % % General Health Fair/poor 55 34 Good 24 33 VG/excellent 21 33 Pain (mod/severe) 40 20 Emotional problem 66 43 (mod/severe) Chronic illness cohort, HCCC 2001

Slide 39: In Jail Services and Post-Release Health Care Use (Physical)- instrumental variable multivariate analysis Following Release In jail service 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 Chronic illness cohort, HCCC 2001

Slide 40: Percent of Smokers Involuntarily Ceasing Smoking While Incarcerated Who Remained Cigarette Abstinent, by Length of Time Post-Release Chronic illness cohort, HCCC 2001

Slide 41: Hepatitis Program • Education, from admission, peer ed, groups. • Hep B vaccinate all. (? Target those •Education with known negative serology, age •Prevention above vaccine below 45. ( 18y- VFC) •Early detection • Voluntary counseling and testing, •Treatment includes HIV and hepatitis serology profile (A?, B, C) •Continuity of • ALT on admission care • Link to community health centers •Data • Collaboration with Dept of Public Health • Vaccination and PPD info wallet card and/or electronic health record

Slide 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.

Slide 43: 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 1999

Slide 44: Hepatitis B Seroprevalence- All Detainees by Age 50 40 1.9 Prevalence 30 4.8 40 20 37 0 27.9 10 4.2 16.7 7.3 7.9 0 <20 20-29 30-39 40-49 50+ Age anti-Bs only HCCC 1999

Slide 45: 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

Slide 46: Medical Care Utilization and Coverage 200 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

Slide 47: 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

Slide 48: 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

Slide 49: Community Integrated Correctional Health Program •Health needs in their community Community •Community standard of care Health Centers : •CBO interactions •3% patients at HCCC

Black and White History in Prisons and Society – Social Stratification

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Slide 1: Black/White history • Jim Crow: Late 1800s to 1960s – System of formal Black-White segregation • After ‘Reconstruction’ in the South – Supreme Court: Plessy v. Ferguson (1896) • Plessy: ‘of seven-eighths Caucasian, and one- eighth African blood’ • Denied a seat on a first class coach in Louisiana • Court upheld ‘separate-but-equal’

Slide 2: Civil Rights era • Civil Rights era – Supreme Court: Brown v. Board of Ed (1954) • Court overturned Plessy • Rejected ‘separated-but-equal’ • School districts can’t segregate – Social movement mobilization – Challenge to segregation, 1950s-1960s

Slide 3: Civil Rights Act (1964) • Bans employer discrimination based on: – race – sex – religion – national origin • Allows current inequalities to persist – Past discrimination affects qualifications

Slide 4: 1884-1914: 3,600 lynchings Murder of James Allen and John Littlefield, Marion, Indiana, 1930

Slide 5: Executions for rape, 1930-1967 50 Not Black Black 405

Slide 6: Men in Prison, 2004 9,000 8,000 White Latino Black 7,000 Per 100,000 Men 6,000 5,000 4,000 3,000 2,000 1,000 0 18-19 20-24 25-29 30-34 35-39 40-44 45-54 55+ Source: BJS, “Prisoners in 2004.”

Slide 7: The Rich Get Richer and the Poor Get Prison

Slide 8: U.S. v. the world: Incarceration USA 724 Russia 564 South Africa 344 Israel 109 Mexico 191 England 145 Australia 120 China 118 Canada 116 Germany 97 France 88 Sweden 81 Japan 60 India 31 Rates per 100,000 population: US 2004, others most recent. Source: sentencingproject.org.

Slide 9: People in prison and jail 2,250,000 2,000,000 1,750,000 1,500,000 1,250,000 1,000,000 750,000 500,000 250,000 0 1986 1988 1996 1998 1980 1982 1984 1994 1990 1992 2000 2002 2004 Source: Bureau of Justice Statistics Correctional Surveys. Update: prison clock

Slide 10: People without freedom 8,000,000 7,000,000 Probation 6,000,000 Parole 5,000,000 Jail 4,000,000 Prison 3,000,000 2,000,000 1,000,000 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Source: Bureau of Justice Statistics Correctional Surveys.

Slide 11: Chance of ever going to prison, men 35 Black Latino White 35 30 30 25 25 Percent 20 20 15 15 10 10 5 5 0 0 1977 1980 1974 1983 1986 1989 1992 1995 1998 2001 Source: Bureau of Justice Statistics, “Prevalence of Imprisonment in the U.S. Population, 1974-2001.”

Slide 12: What the justice system does • Maintain a visible ‘class’ of criminals • Project an image – Threat of crime = threat from the poor • A system designed to fail – Practices that lead to crime, not prevent it • Turns the middle class against the poor – ideological function

Slide 13: And how it maintains crime • Criminalizes victimless crimes – Crimes with no unwilling victim • Arbitrary power for enforcers – Increases alienation, mistrust of the system • Prisons are painful and demeaning – Overcomes any deterrent effect

Slide 14: And how it maintains crime (2) • Failure to provide job training or jobs • Life-long stigma – No voting rights for former felons – Registration laws and police records • No legitimate means of success – No opportunity for ‘legitimate’ means Update: Today’s NYT

Slide 15: Florida’s ex-felons in 2000 57,489 26,359 Bush’s margin in Florida: 537 votes Non-voters Republican If ex-felons could vote: Democrat Gore wins by 31,003 529,666 With 613,514 disenfranchised ex-felons: Assumes 14% would have voted, 69% of them for Gore.

Slide 16: Failure to stop crime • Recent declines – Partly the result of anti-crime policies? • But still higher than 1960 rates – Same policies didn’t work for many years • Other explanations – Stabilization of the drug trade – Fewer teenagers – Economic improvement

Slide 17: California, thousands in prison 500 480 450 400 350 300 250 200 150 100 Imprisonment (left) 50 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 18: California prison, murder rate 500 Murder (right) 14 450 12 400 350 10 300 8 250 200 6 150 4 100 Imprisonment (left) 2 50 0 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 19: California prison, murder, jobs 500 Murder (right) 14 450 12 400 350 10 300 8 250 200 6 150 Unemployment (right) 4 100 Imprisonment (left) 2 50 0 0 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 Sources: Bureau of Justice Statistics; Bureau of Labor Statistics.

Slide 20: Reiman’s Pyrrhic defeat theory Pyrrhic victory: victory at such a high cost, it’s really defeat Pyrrhic defeat Failure to stop crime benefits the powerful so much it amounts to success.