making the case for community based transitional care from prison to the community emily wang, md...

Making the Case for Community Based Transitional Care

From Prison to the Community

Emily Wang, MDTransitions Clinic

Southeast Health Center

San Francisco Department of Public Health

Outline• Brief overview of post-release care

• Description of Transitions Clinic

• Preliminary Data from Transitions Clinic

• Future Plans

• Wrap up

Prisoners return to the community

• 11 million people are released from prison and jail each year in the US

• 1500 parolees are released to SF county/yr from 33 California prisons

• One third return to Bayview-Hunters Point

Burden of Disease in Returning Parolees

• 30-40% have a chronic physical or mental health condition including diabetes, hypertension, asthma, depression

HEALTH PROBLEMS OF PRISONERS AND FORMER PRISONERS

Communicable Diseases

25% of all HIV-infected people, 30% of people with hepatitis C virus infection, and 40% of those with tuberculosis served time

Hammett TM, Harmon MP, Rhodes W. Am J Public Health 2002; 92: 1789-1794.

HEALTH PROBLEMS OF PRISONERS AND FORMER PRISONERS

Chronic Diseases

Disease State Prison NHANES-III

Asthma 8.5 7.8

Diabetes 4.8 7.0

Hypertension 18.3 24.5

*rates per 100 patients

(NCCHC report in April, 2002: Health Status of Soon to be Released Inmates)

HEALTH PROBLEMS OF PRISONERS AND FORMER PRISONERS

Mental Illness

•16% of state prisoners report a mental condition or an over night stay in a psychiatric hospital

•Rates of depression, dysthymia, schizophrenia, bipolar disorder, anxiety are all higher in prison populations compared to the general population

HEALTH PROBLEMS OF PRISONERS AND FORMER PRISONERS

Substance Abuse

• While 13% of newly sentenced state prisoners in 1985 were convicted of drug offenses, by 1990 this had increased to 32%

• 65-80% of prisoners are involved in some aspect of substance use and abuse

• But only 10-25% have ever been treated for substance abuse

Where do parolees access care upon release?

• Recently released parolees are more likely to use the emergency department for health care

– Less than 10% received meds and a follow up appointment upon release

– 80-90% of returning prisoners do not have any form of medical insurance

– In California, transitional care is only provided to patients with HIV or severe psychiatric disorders

Increase risk of death upon release

• Risk of death was 12 times higher in prisoners compared to age matched controls in the first 2 weeks after release

• Leading causes of death were overdose, cardiovascular disease, homicide, suicide, and cancer

Creating a model for care

• Southeast Health Center

• Roundtable meeting

• Opened in January 2006 as a half day/wk clinic

• Staffed by 2 volunteer physicians and Southeast Health Center staff

What is Transitions Clinic?

• Community based intervention that provides transitional care and serves as a primary care medical home for parolees with chronic medical conditions

• First clinic of its kind in the nation and a model for delivery of care to this population

Parolee Specific Care at Transitions Clinic

• Targeted care for newly released prisoners with chronic medical conditions in the first 2 weeks after release

– Physicians with experience caring for patients with a history of incarceration

– Culturally-competent community health worker to assist with basic case management

– Partnerships with existing community organizations that serve formerly incarcerated individuals

Transitions Flow Chart Parole and Community Team meeting

Transitions Clinic, Southeast Health Center

Yes

Referred back to regular PMD

No

Chronic medical condition?Age over 50 years old?Needs refill of medications?

Primary care doctor?

Transitions Clinic OR new PMD

Referrals

• On site dentist, psychiatrist, podiatrist, laboratory

• On site social worker for disability and Medi-Cal evaluation

• Community partners that provide– Employment and educational resources– Substance abuse treatment and counseling– Housing– Child support services– Legal services

Transitions Clinic: Preliminary data

• 180 signed for appointments; 100 patients seen

• 30% from Bayview-Hunters Point; 10% from Visitation Valley; 24% homeless

• 80% seen previously; 14% with previous PMD in CHN

• 53% first time show rate; 69% follow up rate

Transitions Clinic: Chronic Diseases

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Bottom Line

• Our patients are chronically ill and previously received care in the safety net system

• They are seen at Transitions Clinic soon after release and stay in primary care

How is Transitions Clinic supported?• Community Health Worker:

– San Francisco Foundation– Catholic Health Care West– California Endowment

• Other Staff– In-kind contribution– Volunteer physicians

• Evaluation– California Policy Research Center– California Endowment

Future Plans: Evaluation of Transitions Clinic

• To determine whether targeted medical services for former prisoners improve health access measures– Primary care utilization– ED and psychiatric emergency service utilization– Insurance status– Hospitalization– Return to prison or jail

• Findings to be presented to California Legislators

Difficulties encountered

• Duplication of care in prison; limited records• Fragmentation of care (substance abuse

treatment)• Medications --regimens not on formulary or not standard

of care --chronic pain medications• Transitional care: where are they going to get

care?• Funding

Summary

• Transitions Clinic is a unique model of care for parolees with medical conditions

• Preliminary data demonstrates that it serves transitional needs and as a medical home for parolees

• Upcoming evaluation will demonstrate whether– parolee specific care improves health access

measures– this model should be replicated in other community

settings– this model is cost effective

Access to Usual Source of Care by Chronic Disease Status in SF county jail

P<0.0001

0

20

40

60

80

100

UsualSource of

Care

IntermittentCare

ED/UrgentCare

No Care

% o

f re

spon

dent

s

HIV

Chronic Disease

No Chronic Disease

Characteristic Adjusted OR*

95% CI

Chronic disease status No chronic disease/HIV ref

Chronic medical dz, noHIV HIV

1.67.4

0.8, 3.23.6, 15.6

Insurance 3.0 1.6, 6.0

Factors associated with having access to a usual source of care

•Adjusted for covariates physical health functioning MOS-36, age, monthly income

•Sample weighted using 2001 rates of HIV in SFCJ, (2% of all inmates)

Access to care of SF jail population compared to general population

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

>50 years Male Black Insured Uninsured

HIV Chronic Disease No chronic disease

Access to care of San Francisco population