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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
Methods- Chronic conditions
Medical Conditions
%
Hepatitis C
Asthma/COPD
Hypertension
HIV/AIDS
Musculoskeletal
Diabetes mellitus
GI (except Hep C)
Seizure disorder
Cardiovasc. (except HTN)
Other
25.5
19.5
17.5
9.5
7.5
7
6.5
5
3.5
6.5
• 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
Descriptive Results
Public Health ModelCurrent 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
•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.
100
# Persons
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.
• 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
79
80
63
46
60
40
p=0.03, paired t-test
36
19 14
20
3
2
0
None
1-2
3-9
10 or m ore
# ER Visits
Baseline
6-Months
Distribution of Medical or Mental Health
Hospital Admissions in the 6-months
Prior to and Follow ing Incarceration
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 releasemedian 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%
80
General Health
Fair/poor
55
34
Good
24
33
VG/excellent
21
33
Pain (mod/severe)
40
20
Emotional problem
(mod/severe)
66
43
Mental Health
Problems
Doctor Visits
Increase1
Increase
ER Use
Increase
Decrease
Hospitalization
Decrease
Decrease
60
30
40
p=0.25, paired t-test
11
20
7
5
1
3
0
None
1-2
3-9
1Statistically
significant at p < 0.01
Physical based on 92 cases; Mental Health based on 57
cases
10 or more
# Hospital Admissions
Limitations
• Self reported
Change in medical facility use prior to and
following incarceration
Physician
visits
Intake 6 months
%
%
Physical
Problems
93
(n=131)
Self-reported health
– 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
Post-Release
Outcomes
111
120
100
(n=131)
• 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)
Distribution of Medical or Mental Health
Em ergency Room Visits in the 6-m onths
Prior to and Follow ing Incarceration
# Persons
Abstract
None/
none
Decreased
use
28
52
Emergency
room
55
Hospital
92
41
28
Increased
Same
use
14
8
0
37
27
11
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)
– 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
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.