A Public Health Model OF Care For Corrections
With one in 32 adults under some form of corectional supervision, the United States has the highest incarceration rate in the world, Incarcerated individuals experience disproportionately higher rates of infectious and chronic diseases, substance abuse, mental illness and trauma than the general population. Inmates are also overwhelmingly poorer, less educated and more likely to be persons of color than the general population. Since the majority of inmates are eventually released back to their communities, interventions to address their physical and mental health problems present opportunities to improve both the public’s health and safety. Consequently, the Hampden County Correctional Center (HCCC) in Massachusetts developed the Public Health Model of Care for Corrections.
The public health model offers a framework for providing a spectrum of health and mental health services to inmates, linking them to the community from which they came and will return. This successful and innovative system builds collaborations among community health, correctional health and public health with reduced costs realized by contracting with nonprofit community providers. Five elements form the basis for all services and programs in the Health Services Department at HCCC: early assessment and detection, prompt and effective treatment at a community standard of care, comprehensive health education, prevention measures, and continuity of care in the community upon release.
The public health model of correctional health care values wellness, treatment of disease, prevention of illness and access to care during and after incarceration. The model takes a comprehensive approach to the physical and mental health care needs of inmates and their communities. It delivers high-quality health care based on community standards and establishes close linkages with providers in the communities to which inmates return. These linkages ensure continuity of care and ongoing management of medical and mental health problems. Providers are dually based at the correctional facility and in the community. This integration allows for substantial collaboration and communication between corrections and health care professionals.
The public health model also benefits inmates, whose health problems have often gone unaddressed in the community. For many, it is the first time they have received adequate health care from a caring group of providers. The commitment to continue their care is evident in the high rates of inmates who keep their medical appointments after release.
Taking advantage of the period of incarceration to diagnose and treat infected citizens is consistent with established public health mandates to control communicable diseases and promote effective prevention measures. The program model not only treats acute health needs, but also evaluates the long-term needs of the inmate population. A correctional jurisdiction that adopts the major components of the public health model can reap the benefits of improved inmate, staff and community health and safety.
Creating the Model
The process by which HCCC pursued and developed its collaborations with local community health centers has its history in the HIV/AIDS epidemic. In the early 1990s, Brightwood Health Center, a large community health center located in Springfield, Mass., which served a diverse, urban population within a predominately Latino neighborhood, employed a physician and nurse to provide weekly care to HIV-positive inmates at the jail. It quickly became evident that the practice of bringing community providers on- site had many advantages, including practicing a community standard of care, as well as linking inmates with opportunities for follow- up care after release.
In 1992, the original HCCC facility in Springfield, built more than 100 years ago, was replaced with a modern facility at the current Ludlow location. At that time, the sheriff charged the medical department with developing a community-based system of health care that was in accordance with the overall jail philosophy that correctional facilities are an integral and important part of the extended community.
Each of Springfield’s community health centers estimated that 3 percent to 5 percent of their patient population was incarcerated on any given day. The average time spent at HCCC for pretrial inmates was 12 to 14 weeks, so these patients returned quickly to the community. On average, HCCC admits and releases more than 5,000 inmates per year. Although generally in jail for only a few days, weeks or months, the period of incarceration often turned out to be beneficial for inmates. While incarcerated, inmates received comprehensive health care treatment and learned to cooperate in the treatment. Gradually, inmates saw the value of ongoing health care delivered by providers interested in their welfare. This set of events helped inmates to become more active partners in their own health care. Patient compliance and adherence to treatment were greatly enchanced.
At the same time, staff at Brightwood Health Center realized that the model of care they were delivering to people with HlV would be equally beneficial for all inmates, especially those with chronic diseases.
The concept of health care teams based on residential geography and community service areas was thus born in collaborative discussions between HCCC and the health centers. After much discussion and negotiation, it was agreed that the existing HIV model (in which health center staff work both in the jail and the community) should be expanded. At that point, three health centers agreed to collaborate. Later, a fourth health center came on board.
Expansion: A True Team Effort
The comprehensive spectrum of health care and social support programs available from the health centers ensures that inmates receive high-quality care while reducing barriers to good health (e.g., homelessness, substance abuse relapse and lack of health insurance). Health care providers and social service professionals work together as part of a team from each health center; a case manager’s expertise in the social service needs of inmates strongly complements the health care delivered by physicians and nursing staff.
Health center providers approached HCCC with a request to provide confidential HIV care to inmates at the jail. Changes were made that allowed county jails to be reimbursed by the state for all HIV/AIDS- related medications, including pegylated interferon and ribavirin for AIDS patients with hepatitis C. This was a crucial decision supporting the public health model and allowed for the proper management of all HlV/AIDS patients within the jail.
Discussion soon moved beyond the needs of HIV patients and focused on delivering care to inmates with chronic conditions using the same community model. The demographic profile of HCCC inmates underscored the need for such expansion. More than 80 percent of the residential zip codes of inmates came from neighborhoods serviced by a community health center. The match was obvious and the expansion of the model – by assigning inmates to health center providers based on zip codes was under way.
Engaging the other three health centers in the model involved numerous meetings, discussions and planning decisions. One of the centers was in the formative stages of its development and needed time to incorporate the jail work into its overall operations. Eventually, it took two years to incorporate all four centers into a plan to provide care at the jail and for inmates upon their release.
As the model was refined, the issue of continuity of care became critical. The need for a “bridge” between the jail and the community resulted in the creation and development of dually based case manager positions for inmates with chronic diseases, allowing the jail and health centers to more fully monitor ongoing treatment plans and inmates’ progress and support inmates upon their release.
The case management component of the model demonstrates its value in increased rates of treatment adherence, improved show rates for post-incarceration clinic appointments, and reduced use of local emergency rooms for primary health care.
The State Department of Public Health played a key role in providing financial support for development of the public health model of care. The public health department’s AIDS Bureau funded HIV services for inmates throughout the state at both county and state correctional facilities, including dedicated staff positions to conduct HIV testing, counseling and prevention services in correctional sites.
As HCCC and Brightwood Health Center further defined the collaborative public health model, they engaged the Department of Public Health in discussions about HIV care and potential expansion of its role in the model. The department looked favorably upon the public health model and explored replication to other correctional facilities. With the success of linkages in HIV care, HCCC and the public health department identified additional areas in which to collaborate.
Given the prevalence of sexually transmitted infections among inmates, the public health department established HCCC as a site to pilot test urine chlamydia screeni\ng and a partner notification process.
When the department established a statewide hepatitis C screening, education and case management program, HCCC was awarded the first contract in western Massachusetts under the new initiative. The department’s Bureau of Substance Abuse Services and the State Department of Mental Health in part supported the Substance Abuse Treatment Unit and mental health services at HCCC.
The linkage with state agencies proved to be critical in the initial development and expansion of the model as well as ongoing service delivery. Relationships with state agencies provide for innovative programs, targeted services to high-risk populations and cost-effective delivery of health care to inmates. State fundingaugments the resources of the health services department and contributes to improved public health in the region.
The following benefits of implementing a public health model of correctional health care have been experienced at HCCC. The following data, some of which is unpublished, is derived from studies conducted at HCCC.
Improved Inmate Health
Through the public health model, the individual inmate’s serious and often unmet health care needs are addressed and ongoing treatment is maintained via discharge planning and continuity of care in the community. Providers working at community health centers are often from the local community that is served, and they represent the culture of the neighborhood. It has been proved that when staff demonstrate cultural and linguistic competence, communication and trust, the relationship between inmates and their caregivers are all enhanced.
Research also shows that more than 88 percent of HIV-positive inmates referred for ongoing care after release from HCCC keep their initial medical appointments at their designated community health center. This fact alone shows the value and impact of the system on adherence of HlV and other mandatory medications.
Improved Public Health
Each year, the HCCC program introduces comprehensive health care to thousands of high-risk people who previously went untreated. Most of the inmates are uninsured, poor and undereducated about health issues.
Public health improvement is evident by immediate disease detection, treatment and continuity of care after release. For infectious diseases, adequate treatment and education to prevent future transmission provide tangible public health benefits to the inmates’ families, sexual partners and communities, and early detection and treatment of infectious diseases prevent costly complications.
On any given day, there are between 80 and 100 HIV cases, and approximately 20 individuals being treated for latent tuberculosis at HCCC. Annually, more than 1,400 cases of sexually transmitted diseases are treated. The community benefits from the provision of curative treatment for communicable disease, prevention of secondary infections and surveillance of reportable conditions. Given the number of infectious diseases detected in jails, these facilities may be the first to identify emerging trends in communicable disease patterns such as the surge in tuberculosis in the late 1980s and early 1990s.
In addition, immunization against hepatitis A and B provided to atrisk inmates improves community immunity and interrupts disease transmission. Mental health care and substance abuse treatment begun in jail and continued in the community improve overall public health, individual employability, and family and social functioning.
Community health center workers continue linkages via outreach and follow-up once an inmate has returned to the community to support disease management, recovery from addiction and prevent disease transmission.
Cost Savings
There has been significant downstream savings in community health care costs from the early and effective detection and treatment of disease. Substantial savings are realized by using community-based, nonprofit providers for health care, pharmacy, dental care, optometry, health education and mental health services. These services are provided at a substantially lower cost than if HCCC used its own staff under state payroll or contracted with for- profit medical providers.
Community cost-savings are seen by enrolling eligible inmates into Medicaid, which helps to ensure that patients, upon release, will use community health care services instead of more costly emergency rooms for primary care treatment.
improved Public Safety
Health care enhances public safety. When a person is healthy and receiving proper and adequate care, he or she is more likely to exhibit appropriate behaviors, thereby reducing crime in the community. In addition, providing good mental health and substance abuse treatment to inmates during incarceration increases the likelihood of recovery from drug addiction and, hence, improves public safety. Also, continued support for recovery from drug addiction can reduce future criminal activity as part of acquiring illegal drugs.
Better Use of the Health Care System
With almost half of the male inmates and nearly twothirds of the female inmates at HCCC reporting use of local emergency rooms for their health needs in the previous year, the financial and public health drain on resources is significant. Inmates also report frequently waiting for symptoms to become severe before seeking care. This leads to more costly treatment. A major benefit of the public health model is the dramatic decrease in the use of the emergency room as the primary care provider. Once inmates are released back to their community, they use the community health center to which they were assigned based on their residential zip code.
Recidivism
Researchers at HCCC have documented recidivism rates that are lower than national averages. In a three-year study of inmates released from HCCC in 1998, 36.5 percent were reincarcerated in a Massachusetts correctional facility between 1998 and 2001. A national study involving prisons in 15 different states and examining a similar three-year period, showed a reincarceration rate of 51.8 percent. Although many factors affect recidivism rates, researchers believe the lower rate at HCCC reflects favorably upon the intensive care model.
Replicating the Program
While there are many challenges to changing a health care delivery system that has used the same practices and providers for many years, the HCCC administrative staff believe that – with sufficient support – the Public Health Model of Care for Corrections can be replicated in a variety of settings. Some facilities may choose to replicate the model as a whole, while others will adopt it incrementally or select only specific components. Additionally, the model may need to be modified to address the specific needs of a population or correctional system.
The benefits of adopting a public model of correctional health care are many, including:
* Improved inmate and community health;
* Improved public safety;
* Improved correctional staff safety;
* Improved use of the health care system;
* Cost savings for communities; and
* High-quality health care at a cost no greater than the national average.
With the Public Health Model of Care for Corrections, HCCC hopes to encourage new partnerships among correctional administrators, their state health departments and the nonprofit providers in their surrounding communities. Further collaborations aimed at addressing the many needs of the incarcerated population will help to build healthier and safer communities across the nation.
… providing good mental health and substance abuse treatment to inmates during incarceration increases the likelihood of recovery from drug addiction and, hence, improves public safety.
Dr. Thomas J. Conklin is director of health services for the Hampden County Correctional Center in Ludlow, Mass.
Copyright American Correctional Association, Incorporated Oct 2004