Barriers to Entry and Continuity of care in Correctional Facilities

June 21, 2010 Becky L. White MD, MPH

Assistant Professor of MedicineUniversity of North Carolina at Chapel Hill, School of MedicineCo-director of HIV services, North Carolina Dept of Corrections

Correctional Health Care

• Guaranteed by the Constitution

• Not Primary Goal of Corrections

• Understaffed

• Overburdened-too many inmates

• Underfunded –(e.g. Jails)

Cycle of Incarceration and Release and Relation to Health care

Adapted from Zaller et al, Medscape 2009

Community to Jail :Barriers to Entry into Care

• Inmate-(disclosure issues, poor trust in correctional health care system)

• Staffing- Understaffed, High turn over

• Policy –HIV screening/testing policies

Jail :Barriers to Continuity of Care• Inmate-disclosure issues, poor trust in correctional health care

system, high inmate turn over, 50% released in less than 72 hours

• Staffing- Understaffed, High turn over, lack of HIV-related knowledge

• Policy – Medicare, Medicaid, ADAP, VA, Private discontinued or suspended, correctional health care system based on “sick-call” model of care

• Logistical-Geographically away from HIV care sites

• Financial-No funds for HAART (e. g. see Policy barriers)

Prison: Barriers to Entry into Care

• Inmate-disclosure issues, poor trust in correctional health care system

• Staffing- Understaffed, lack of HIV-related knowledge

• Policy – HIV testing policy

Prison : Barriers to Continuity of Care

• Inmates-adherence issues

• Staffing- lack of knowledge of HAART, high turn over

• Logistical-inmates often move from prison to prison having to re-establish relationships with nurses, providers, and individual prison system

Prison: Facilitators to Continuity of Care

• Staffing- HIV nurse case-managers, HIV specialist (Academic, Public Health, Private, Correctional Staff), HIV pharmacists

• Policies-treat per guideline recomm

• Financial-Access to HAART often better than community

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NC Department of Correction (NC DOC) Prisons

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Admission / Intake prison

Non-admission prison

Courtesy of D. Rosen

Prison and Jail :Barriers to Continuity of Care at Release

• Inmate- Health care not a priority, homeless, mental health issues, substance abuse issues, poor trust in health care system, resume old habits, return to same community

• Providers/Case-managers-lack of knowledge about substance abuse, overburdened by clients issues

• Policy – Need to re-access Medicare, Medicaid, ADAP, Private, gaps in coverage result

• Logistical-Geographically away from HIV care sites, No Transportation

• Financial-ADAP waiting lists

1111

Viral Load Increases Among Recidivists

HIV-

1 RN

A (c

opie

s/m

l)

Recidivists

100

1000

10000

100000

1000000Pre-releaseReincarceration

Stephenson (White et al, Public Health Reports)

NC BRIGHT: Study Schema

• Primary Outcome: Access to routine medical care post-release• Week 4: 64% BCM vs 54% Standard of care, p value 0.3• NO DIFFERENCE• Courtesy of David Wohl

BRIDGING CASE

MGMT (BCM)INTAKE

Randomize

Evaluations:<3m prior to release Release +14d +2m +6m +9m +12m

NCDOC Discharge Planning(SOC)

Continuity of Care after Release: 30 days

• Texas (Prison)-17% (JAMA 2009)

• NC (Prison)-50-60% in care (NC, Bright )

• Rhode Island (Prison)->90% (Project Bridge, Rhode Island)

• Mass- (Jail), 84-90% (Hampden County-Community Integrated Correctional Health Model

Prison and Jail : Facilitators to Continuity of Care at Release

• Collaboration between the community and correctional facilities

Cycle of Incarceration and Release and Relation to Health care

Adapted from Zaller et al, Medscape 2009

“ Prison Health is Public Health”

WHO 2005

Thanks• UNC CFAR Criminal Justice Working Group (Golin,

Fogel, Wohl etc)

• Anne Spaulding , Emory University

• David Rosen, UNC, Sheps Center

• Nichole Kiziah, Gilead Pharmaceuticals

• Linda Cross, NCDOC