Bridging Correctional Health Care and Community Health: An Opportunity to Improve Health and Control Costs

The number of Americans ever incarcerated climbed recently to an all-time high and shows no signs of abating. According to the Bureau of Justice Statistics, in 2001, 5.6 million adults in the U.S. had served time in a state or federal prison. If the current trend continues, 6.6 % of people born in the year 2001 will be incarcerated in their lifetime.

The prison system carries a heavy burden of communicable disease. It is estimated that 25 % of all people infected with HIV, 33 % of people with Hepatitis C, and 40 % of those with active Tuberculosis spend time in a correctional facility each year.

Inmates who are homeless or unemployed in the six months prior to incarceration are at significantly higher risk of having a medical problem at intake. Concurrently, the unemployed and the homeless are far less likely to have a source of medical care. The setup is a dangerous one: a population with a high rate of communicable disease and poor access to care shuffling between the community and the corrections system.

There are approximately 650,000 people released from state and federal prisons each year. 7 million inmates are released from jails. Two-thirds of those released from prison will be re-arrested within three years of release. Access to health care is one of many challenges for inmates re-entering community. A large proportion of the re-entrant population falls outside of the heath care safety net before and after incarceration. Upon intake to prison, those who accessed care via Medicaid are dropped automatically from Supplemental Security Income (SSI). It can take six to twelve months post-release to regain eligibility, if they do at all. Many of those who are in need of care do not carry a diagnosis qualifying them for Medicare coverage, further limiting immediate options for access to care.

According to an Urban Institute study, inmates rely on family, friends, and emergency departments after release to continue receiving crucial medications. In a New England Journal of Medicine study of inmates released from the Washington state prison system, the all cause mortality rate of inmates during the first two weeks after release was 12.7 times higher than that of other state residents.

The cost of corrections has outpaced the growth of state budgets. Likewise, the proportion of corrections health care costs as a portion of the corrections budget has been trending upward. In a report by the Council of State Governments, the corrections community has identified factors contributing to this trend, including privatization of jails and prisons, an aging inmate population, prescription costs, chronic health care costs, mental health care costs, and infectious disease. The current strategies to address these problems focus on reduction of costs inside of the facility. They do not, however, address inmate health or community health as part of a strategy to reduce overall corrections health care costs. Nor do they address the costs to the state’s safety net health care system which, as mentioned above, many inmates will use heavily upon release.

An example of this bridging approach can be found in Hampden County, Massachusetts, which is gaining national attention. In this program, people released from prison are directed to community health centers (CHCs) in neighborhoods where high concentrations of former inmates reside. The same CHC providers initiate care inside the correctional facility and act as a bridge to the external centers. This program has shown promise for community health and cost control, with similar programs in the District of Columbia and Florida recently funded by a grant from the Robert Wood Johnson Foundation.

A project funded by a grant from the Health Foundation of Greater Cincinnati in Hamilton County, Ohio garnered equally encouraging results. In this model, Talbert House, a social services provider, identified access to medical care as a significant problem for recently-released clients. They established infrastructure in seven clinics staffed by physicians and nurse practitioners to meet goals of providing primary care on site, decrease emergency department visits, reduce off-site medical costs, and decrease the no-show rate for behavioral health visits. After only six months, emergency visits were reduced by 18 % and transportation costs for off-site visits were reduced by 40 %. After 12 months, off-site visits had been reduced by 32 %, transportation costs were reduced by 72 %, and the no-show rate for behavioral health visits was reduced by an impressive 47 %.

The American Academy of Family Physicians has been instrumental—along with the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association—in pioneering the concept of a Patient-Centered Medical Home (PCMH). This comprehensive model for health care delivery offers continuity, coordination of care, access, and quality, resulting in improved heath outcomes and lower costs. This model has magnified potential in un-served and underserved populations where health care disparities are greatest. People released from prison generally fall into these two categories.

Often, providers who serve the incarcerated population are isolated from local established provider networks. In the absence of much overlap of physicians practicing in both settings, pre- and post-release providers should commit to dialogue focused on developing community-specific strategies for providing continuity of care, particularly to those with serious communicable disease.

Goals of bridging pre- and post-release care should include: portable, complete medical records; coordinated discharge planning; accurate demographic information on providers and clinics; medication coordination; transportation; and, most importantly, communication between physicians transferring care.

Inmates identify obtaining health insurance as one of their most crucial needs post-release. When reintegrating a population with such a large burden of disease at a time of markedly increased risk for mortality, it is of utmost importance to maintain contact with the health care system. Those with access to case management via parole generally are better equipped to navigate a complex health care system. There are many barriers to post-release insurance coverage for this population, though, including a difficult re-qualification process for government-sponsored insurance and limited employment opportunities. One study that concentrated on recently released inmates in the Cincinnati area found that 90 days post-release, only 33% of releasees had federal, state, or employer-provided coverage.

Goals of improving access post-release should include securing access to critical health care services for releasees through a sustainable PCMH and allocating and coordinating resources to help providers develop strategies to keep former inmates in contact with the health system, keeping them and their communities healthier.

The recently released population requires intensive coordination of care. The PCMH would serve as central hub, networking the often unlinked providers accessed by the re-entrant population, such as social workers, public health workers, treatment counselors and probation and parole officers. Implicit in this role is secure portability of the medical record from the releasing institution to the physician leading the releasee’s PCMH. The importance of knowing the history of diagnoses and interventions in such a complicated population is paramount and could save significant cost and time for the justice, corrections and health care systems, let alone lives saved.

According to the Bureau of Justice Statistics, 31 % of state inmates reported a “physical impairment or mental condition,” and 25 % reported more than one condition or reported a condition that limited their ability to work. In addition to a significant burden of communicable disease and other conditions, there is a markedly greater incidence in this population of mental illness and substance abuse, both of which contribute greatly to recidivism and thus increased corrections costs to the public. Advantages of delivering coordinated care to a recently released population in the setting of a PCMH include fostering of provider networks in the community, better control of communicable disease for public health, and potentially reduced recidivism, positive effects which ripple outward to the community.

The PCMH aims to provide up-to-date, evidence-based treatment for the formerly incarcerated population. This is important especially for patients with diseases like HIV, for which treatment is rapidly evolving. As the body of evidence directing care for this population is lacking, a key strategy for promoting quality will involve networking with local academic secondary and tertiary care centers, as well as national organizations, to promote practice-based research in this under-studied and difficult to serve, population.

North Carolina adopted for part of its Medicaid program a community-oriented model of care that aligns closely with the PCMH. This program, known as Community Care of North Carolina, produced significant savings for the state. Over two years (2000-2002), it saved an estimated $5.5 million on asthma and diabetes care alone while reducing hospital admissions. Further, in 2004, the program saved the state an estimated $230 to $260 million compared to historical fee-for-service. For this savings, the state spent $10.2 million to operate the program.

Providing health care services for inmates while they are incarcerated is costly. This investment is a significant portion of most state budgets. However, that investment yields low return if only administered to inmates while they are in prison or jail. Diseases like HIV, Hepatitis C, and TB—in addition to other chronic conditions like diabetes, hypertension, mental illness and substance abuse—require long term follow up. The cost of losing these individuals to follow-up once released is magnified as their diseases progress without treatment.

These breaks in treatment for mental health and substance abuse, in particular, can contribute recidivism. The costs for these breaks in care are magnified as they become emergency department visits, avoidable hospitalizations, and disease exposure to the community. If these people are re-incarcerated, their lack of care on the outside requires a higher level of care inside, driving up medical costs.

If states adapt the model of the PCMH to service of this population, and support access and continuity on release, the correctional health center will act as a first point of contact for what become sustained, healing relationships. It is an opportunity to diagnose and treat illness early, before it becomes more costly, and to avoid exposing others to infections diseases. By exclusively providing care within the walls of the institution, we miss an opportunity to improve the health of our communities and control costs to the government, and taxpayers, overall.