Abstract

1. A public health model for correctional health care: A demonstration and evaluation project Thomas Lincoln1,2, Thomas J. Conklin1, Robert W. Tuthill1,3, Sofia Kennedy4, Cheryl Ann Roberts4, Lisa Becchetti4, William Rhodes4, James Vivian, Theodore Hammett4 1Hampden County Correctional Center, 2Baystate Medical Center, 3University of Massachusetts-Amherst School of Public Health, 4Abt Associates, Inc. Study Components • Negative binomial regression • Principal variable of interest: level of contact with primary health services staff (doctor visits, case management, discharge planning, and having a provider appointment made in the community) • control variables:age, incarceration prior to index, time in the community prior, general health status, emotional problems, mental health diagnosis, level of interest in receiving assistance in jail, days in jail, time in the community between index release and 6-month interview, whether recidivated post release • an “Instrumental Variable” to control for selection bias Abstract • Chronic conditions project • Cross-sectional- descriptive • Prospective • Quasi-Experimental Design • No random assignment • Selected aspects of health care • Economic analysis • HIV counseling and testing • Chlamydia screening, partner services • HIV treatment Background:Medical and correctional professionals are increasingly realizing the extent to which chronic and infectious disease, mental illness, and substance abuse are concentrated in the correctional system. A cooperative program between a county jail, four community health centers, and other agencies in Hampden County, Massachusetts was developed nearly a decade ago which allows the same health providers to care for patients in jail and subsequently in the community. This public health model of correctional health care emphasizes five essential elements: thorough disease screening and detection, early and effective treatment, patient education, prevention, and continuity of care after release. To study this model, the Hampden County Correctional Center (HCCC), with Abt Associates Inc., has undertaken a three-year evaluation sponsored by the Centers for Disease Control and Prevention, the National Institute of Justice, and the Soros Foundation. Objectives: To assess whether the model creates any significant changes in health risk behavior and health care utilization, as well as clinical status and criminal activity, among individuals after release from HCCC. Methods:Baseline health and behavioral data were collected from inmates with chronic medical or serious psychiatric conditions at the jail. Follow-up interviews were conducted at one month and six months after release. Results and Conclusions: Analysis of study participants at intake (n=200), one month post-release (n=124), and six months post-release (n=131) shows significant improvement in self-reported health status (general, emotional, pain), emergency room use, and substance use (not including tobacco), but not in sexual risk behavior or recidivism in the period after as compared to prior to incarceration. A binomial regression analysis to determine how these improvements in health utilization in the community correlate with the amount of medical services in jail found that more services in jail correlate with further increased primary care follow-up in the six months after release. p=0.03, paired t-test Methods- Chronic conditions • Definition of chronic medical condition: Any condition requiring ongoing use of prescription medication and/or regular contact with a medical professional (i.e. 3 + times/year) • Questionnaires at intake, 1 and 6 months after release • Jail medical record abstraction 1 month results • 46% had appointment set up • 60% went to first appointment 6 month results • 81% on prescription medication • 34% jail or prison since release- median is 30 days • Official records: • Rearraignment 34% • Reconviction 19% • Reincarceration 13% • Tobacco quit rate of 3% among smokers • Prior Following • Alcohol use 73% 42% • Drug use 47% 21% p=0.25, paired t-test Descriptive Results • 200 released eligible • 75% completion either 1or 6 month post-release interview: • Intake: n = 200 • 1 month: n = 124 • 6 month: n = 131 • Intake/ baseline cohort: • 178 (89%) men • 66% pre-trial, 34% sentenced. • Length of stay: median = 80 days • Median age = 35 • Chronic conditions: • Medical 93, Mental 38, Both 69 • 57 % want help with a physical or emotional problem. • 39 % have history of drug injection- half in last month. • 7 % shared needles in past month- 25 contacts. • 4 % of men had sex with man in past 6 months. • 78 % ever tested for HIV. • 10 % report HIV+. • 45 % ever cut or stabbed. 20 % ever shot. • 5 % homeless at intake. 20% in past 6 months. Limitations • Self reported • Frankness in sensitive questions • Health center and hospital record validation • Not true control- selection bias. • To compensate: “instrumental variable” • Sample size • Recall bias (?expect higher #s recalled for 6 months before jail than after) • Further analysis Public Health Model- Current Structure • 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 HIV case manager (includes C&T) primarily community health center based • Nurse practitioner, primary nurse, associate nurse primarily jail based • Community corrections (probation/parole/DRC) component Conclusions • This part of the evaluation found that self-reported health status increased, and alcohol and drug use, health care utilization including emergency room and hospitalizations decreased overall following incarceration from levels prior to incarceration in this facility. • More health visits in jail correlated with increased primary care follow-up after release. • Although evaluation of this model for correctional health care with a control group design would be problematic, further study is warranted. Quasi-experimental analysis • Health Programs interventions: • Visits for nurse, nurse practitioner, doctor, case manager, mental health care, STD clinic dental, optometry, educational programs (discharge group, tobacco, HIV, general and specific health)