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Public Health Collaborations In a Corrections Setting: New York City's Model

Posted on: Wednesday, 27 October 2004, 02:00 CDT

More than 100,000 of the sickest and most clisadvantaged New Yorkers enter New York City's correctional system each year. According to the demographics and health indicators, the inmate population presents a significantly higher prevalence of communicable diseases, chronic conditions and mental illnesses than the general population. Many of these individuals are often homeless, unemployed or substance abusers with limited access to health care prior to incarceration. This certainly presents an enormous challenge to those responsible for providing health care to inmates. In order to address these needs, the New York City Department of Correction and the Department of Health and Mental Hygiene have collaborated to implement various health-related programs addressing the needs of inmates.

A reorganization of health care for inmates in New York City has created a unique opportunity for the DOC and the Department of Health and Mental Hygiene to collaborate in the implementation of public health initiatives. The city charter mandates that the health commissioner is responsible for the delivery of health care services to inmates in the custody of the DOC. Since 1994, the health department had met its charter responsibility through an agreement with Health and Hospital Corp., which is responsible for operating all of the municipal hospitals in New York City. Health and Hospital Corp. was then authorized to provide jail-based services either directly or through contracting with a health care vendor. Health Commissioner Dr. Thomas Frieden ended this arrangement in July 2003. As a result, the health department currently assumes direct responsibility of jail-based correctional health services. This new arrangement of responsibilities enhances the city's ability to implement citywide public health initiatives inside jails, leading to a safer community upon inmate release.

An Interagency Effort

The health and correctional commissioners share a common belief that joint efforts on behalf of inmates and their families during their incarceration will have longterm, sustainable impacts on the overall health status of the entire city. By treating the inmates, counseling them on their health status and related issues, and by focusing on discharge planning and aftercare follow-up, a new continuum of services has begun to emerge. This integrated approach begins with admission to a detention facility and follows the inmate during incarceration and through reentry to the community.

The two agencies are presented with many challenges in working with the inmate population such as a large census, rapid drop-off rate, frequent transfers and stringent oversight requirements. At an average daily census of approximately 14,000, the DOC also has an exceptionally rapid drop-off rate, with 28 percent of those admitted being released within three days, 52 percent within seven days and 67 percent within 14 days. This makes identifying, assessing, and caring for physical and mental health conditions an enormous undertaking as tens of thousands of inmates are discharged after they receive a health exam, yet before their diagnostic test results are known. The average length of stay for both detainees and city- sentenced inmates is less than two months. In order to establish permanent health care connections, it is necessary to look beyond facility walls because male inmates, in particular, are frequently transferred between the 10 DOC facilities. In such a fluid environment, establishing linkages and making connections is a difficult task.

By identifying common goals for both agencies and the city, the DOC and the health department sustain a mutually beneficial, collaborative relationship. The earliest example of this successful collaboration occurred in March 2003 when Frieden spearheaded the enactment of stringent laws limiting the use of tobacco products in public places, including the city jails. In collaboration with the health department, the DOC completely phased out smoking for both staff and inmates over a period of seven weeks. This served as a precursor to the new paradigm in July 2003, where Frieden implemented citywide public health initiatives in the New York City jails.

Managing HIV

In an effort to continue successfully promoting health initiatives in the jails, both the DOC and the health department have turned to addressing HIV within New York City jails. Since an estimated 25 percent of people living with HIV in New York City have never been tested and are unaware of their status, the health department and the DOC have developed the NYC Jail Rapid HIV Testing Program, which began March 3, 2004. Using a relatively new testing method, the health department can now learn someone's HIV status within 20 to 40 minutes, as opposed to approximately three days using the traditional test. Given the rapid turnover of the DOC population, many inmates who receive the traditional HIV tests were discharged before their results were returned.

The new Rapid HIV Testing Program allows the health department to conduct pre-test counseling, administer the test and get a result within the hour. Positive tests are treated as preliminary and are confirmed by the conventional HIV testing method. Negative tests are conclusive and post-test counseling is afforded to all inmates, positive or negative, including a referral to mental health services where necessary. Those who test preliminarily positive for HIV are referred to the MedSpan program for health education, risk reduction and discharge planning services, including appointments in the community. A hallmark of the MedSpan program is medication information and health management. In addition, referrals are made to Project Bridge, which links HIV-positive inmates with community- based organizations that provide transitional case management services.

Education, counseling and treatment can begin prior to the receipt of the confirmatory result. Beginning in 1997, the MedSpan program, operated by the health department, has sought to provide continuous medical care to inmates receiving protease inhibitors to treat HIV/AIDS while incarcerated. MedSpan staff individually meet with and advise patients on treatment options, counsel them of the facts about their health status and reinforce positive behaviors. The program also includes a discharge planning component to ensure continued treatment upon release from jail with follow-up in the community, including up to five days of medication and/or prescriptions.

The public health presence brought to Rikers Island by the DOC/ health department collaboration has also worked to combat the spread of the two most common sexually transmitted infections from males to females. Male inmates under the age of 35 will receive the urine- based DNA amplification test for both chlamydia and gonorrhea at intake. All males with either of the infections will promptly receive the appropriate medication as well as steps and guidelines on partner notification. Connections will also be made with the health department's Bureau of Sexually Transmitted Disease Control to ensure the availability of post-release follow-up.

Discharge Planning

Mental health care in the city's jails is an equally compelling example of collaborative efforts in discharge planning. Approximately 2,000 to 2,500 inmates in DOC custody are being treated or followed by mental health staff. Management, treatment and the provision of discharge planning services to this population has required significant collaboration between the two agencies.

DOC provides specialized housing for many of these inmates, and escorts them to and from the clinics so that the health department can provide treatment and develop a comprehensive discharge plan. The end result is that inmates who are provided mental health services also receive medications, prescriptions, access to entitlement programs such as the Medication Grant Program and Medicaid, and appointments with community-based providers to continue the treatment started in jail.

While the delivery of health-related discharge planning services is the responsibility of the health department, DOC Commissioner Martin F. Horn is responsible for the care of all inmates in his custody. Accordingly, he has made discharge planning and aftercare placement the major focus of his administration's programmatic efforts on behalf of DOC inmates, their families and the community. This has entailed the creation of a multiagency, multidiscipline task force of city and community stakeholders revolving around the issue of re-entry into the community. These services will also be needed in conjunction with the health care provided by the health department for effective discharge planning.

Visitor Outreach Program

Another public health collaboration that has recently been initiated has promising potential. DOC studies reveal that 71 percent of inmates come from and return to 13 areas of the greatest need in the city, all of which are in the South Bronx, central/east Harlem and central Brooklyn. From the point of initial health intake history and physica\l on the first day, many opportunities are available during incarceration to effect a positive health change for these inmates. It is also evident that the family and friends who visit the inmates at Rikers Island come from the same highrisk neighborhoods in which the health department was already attempting to make inroads. Through outreach and education, using the Rikers Island Visitors Center, the health department has begun efforts to engage and refer residents of those at-risk neighborhoods in one central place. In fiscal year 2004, approximately 500,000 visits took place on Rikers Island or in borough facilities, so the potential reward is obvious.

In collaboration with the DOC, the health department developed the visitor outreach program to empower visitors by providing health education and information, and to begin a process of facilitated enrollment into health insurance programs. The DOC provides the health department with space in the Central Visit Control Building, where all visitors must register and then wait for a bus to depart for the facility where the inmate they have come to see is housed.

The health department has assigned two staff members to interact with inmate visitors in the Visit House. Pre-screening services, information and referral for facilitated enrollment for health insurance services, health provider information and linkages to community resources are also provided. In addition, health surveys are administered to establish areas of interest with incentive items given to encourage participation. The health department also has a community linkage program to facilitate re-entrant access to community health care. These community offices, located in the identified areas of greatest need, are available to re-entrants and their families. Provider networks are established to facilitate connections to health care providers and health insurance enrollment services in these high-risk communities.

Office of Correctional Public Health

Clearly, New York City is unique among large jail systems due to its size and the collaborative relationship between the DOC and the health department. With an average annual discharge of 60,000 inmates, the DOC has the opportunity to serve as an integral point of intervention in meeting New York City public health needs. This is particularly evident in the creation of the Office of Correctional Public Health (OCPH). Recognizing the enormous implications for community health that programs originating on Rikers Island can offer, the health department has created OCPH specifically to focus on these issues.

OCPH will enhance the public health focus in current clinical services, help establish linkages with the broader public health community both inside and outside of the health department and contribute greatly to improving the health of both inmates and the larger community. This office works closely with others in the health department and with the DOC to coordinate, integrate and streamline public health activities in New York City jails to facilitate the enhancement of public health activities in clinical programs by initiating disease surveillance systems, conducting epidemiological and quality improvement projects and recommending public health-related policy changes. OCPH was also established to facilitate incorporation and coordination of city, state and federal public health program priorities into current clinical and preventive services provided to New York City jail inmates.

Plans are already in place to expand and enhance the breadth and scope of the public health initiatives operated by the health department within DOC facilities. By working collaboratively, the New York City DOC and Department of Health and Mental Hygiene are establishing a national model for the focus on inmates as a starting point for a public health approach. By working with the highest risk populations, the potential for success multiplies.

Roger K. Parris is deputy commissioner of strategic planning and programs for the New York City Department of Correction.

Copyright American Correctional Association, Incorporated Oct 2004

Source: Corrections Today

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