Providing Inmate Continuity of Care Post-Release

1. Providing Inmate Continuity of Care Post-Release The Shared Experience of Massachusetts DOC, the University of Massachusetts Medical School and Lemuel Shattuck Hospital Ken Freedman, MD, MS, MBA, CMO, LSH Helene Murphy, MEd, LSW, UMCH

2. Learning Objectives • Recognize the advantages of a well designed/defined continuum of care between three state agencies. • Tests the ability of these parties to coordinate and manage a safe and clinically effective path to community discharge for inmates needing transitional hospitalization. • Articulate the planning steps necessary to implement a pre- and post-release system of care based upon a system of managed care referrals and the role of telemedicine. • Identify and understand the difficulties, issues and agenda items that can interfere with a smoothly run partnership, and the essential steps needed to engage, orient and ensure support for continuous quality improvement by medical and correctional staff. Correctional Health Care Conference

3. Trilateral Relationship (1) DOC-UMCH-LSH relationship overview • Contractual obligations among three state agencies • Specialty clinics (most med/surg areas) • Telemedicine program: Dermatology, Endocrinology, Gastroenterology, General Surgery, Hematology/Oncology, HIV/HCV Co-infection, Nephrology, Orthopedics, Rheumatology, and Urology. • Re-entry programs Correctional Health Care Conference

4. Trilateral Relationship (2) • Collaborating with LSH allows UMCH to obtain patient-centered medical care for incarcerated patients who otherwise may require distant transport and/or more costly care. • Partnering with LSH allows UMCH and by extension, the Department of Correction (DOC), to deploy telemedicine as well as other reentry initiatives that reduce unnecessary inmate trips and possibly reduces recidivism for newly released individuals that need complex medical care. • Success requires regular maintenance of relationships and mutual support of program goals, including ongoing systematic reviews at all levels of the partner organizations. Correctional Health Care Conference

5. Background (1) • Inmates have high rates of chronic conditions, substance abuse and mental illness (Wilper et al., 2009). • Despite poor status, only 15% to 25% of released individuals visit a physician outside of an Emergency Department in the first year of post-release (Mallik-Kane and Visher, 2008). • Newly released prisoners have high risk of poor health outcomes including death (Binswanger et al., 2007). • Lack of care coordination between prison and community health systems and lack of health insurance are among the factors contributing to poor outcomes for newly released inmates (Wang et al., 2012). • In Massachusetts, Medicaid (MassHealth) and DOC have partnered to improve access to insurance. 97% of all inmates leave with MassHealth insurance. Correctional Health Care Conference

6. Background (2) • MassHealth/DOC Prison Reintegration Program facilitates transition to MassHealth coverage for newly released offenders as part of the pre-release planning process (Kirby et al., 2011). • More recently, UMass Medical School Correctional Health Program is partnering with BHCH in a CMS Innovation Grant to evaluate a model for newly released inmates using Peer Navigation. • Enrolling newly released inmates in health plans and facilitating their connection to a “medical home” are critical interventions for better addressing their post-release health needs. Correctional Health Care Conference

7. Background (3) • An especially challenging population and one not adequately captured by these existing efforts is the sub-group of inmates who would benefit from extended hospitalization for medical and/or rehabilitative care prior to their release in the community and medical home placement. • Commonwealth Medicine (Division of the UMass Medical School) is funding a portion of this post-release hospitalization service by supporting a a discharge planner’s continual support from prison into an inpatient facility (LSH) and then three months post-LSH discharge. • Continuity of care from prison to hospital care to the community is assured. Correctional Health Care Conference

8. UMCH Partners with LSH • UMass Correctional Health (UMCH) and the Lemuel Shattuck Hospital (LSH) agreed to pilot the TransitionalStep Down Service. • Tests the ability of both parties to coordinate and manage a safe and clinically effective path to community discharge for inmates needing a transitional hospitalization. • UMCH is seeking NIMH funding to further evaluate access to care and impacts on recidivism rates for co-morbidly diagnosed inmates. Correctional Health Care Conference

9. Target Population • Inmates who have one or more chronic medical conditions, may have a MH and/or SA history, and may have spent much of their most recent incarcerated time within an infirmary setting. • Inmates still require a short term hospital level of care and frequently lack community and/or familial support. We conservatively estimate 35 participants based on the following assumptions: 5 dedicated beds at LSH, an average length of stay of 4 weeks, and a seven month operating period. Correctional Health Care Conference

10. Memorandum of Understanding (MOU) • LSH agrees to accept short-term admissions following an inmate's release from prison but prior to their community placement. • UMCH agrees to support a dedicated Discharge Planner to work with Service participants for six months following their DOC release date, inclusive of the participant's inpatient stay. • UMCH Discharge Planner will collaborate with LSH around care planning details; • jointly responsible to manage discharge to the most appropriate community setting once goals of the ex-inmate’s hospitalization have been met; • responsible to provide case management to participants in the community via monthly phone calls for six months after prison release and coordination with LSH for any needed follow-up care. Correctional Health Care Conference

11. Study Aims Pilot the Service care model and evaluate its overall feasibility and potential benefits. A key part of this effort is documentation of the extent to which implementation has taken place, nature of people being served, and degree to which the Service operates as expected. Specific aims include assessment of program: • Implementation: what worked and did not work from operational and organizational perspectives; • Performance: select participant-level process measures, including the alignment between participant service needs and service use, ability to transition into the community, adherence to outpatient treatment plan, and experience with the program. Correctional Health Care Conference

12. Demographic Data Date of referral:   _____/____/2013 Time of Referral:  ____:____       A         P Date Screened:   _____/____/2013 Patient Name: __________________________  yrs.   Living Arrangements: _______________________ SS# ______________ DOB: _____________    Religion: ___________ Race: ________________                  Interpreter Needed:        N         Y   € N/A               Language: _________________________________ Next of Kin:  ____________________________    Telephone # ________________________________     DMR    DMH    Referring Facility: ___________________________      CM/SW:___________________________________                                                                                         Telephone# ________________________________ Admitting Diagnosis: __________________________  Date of Admission: __________________________ Referred to LSH for: _____________________________________________________________________         New Admission to LSH                Re-Admission to LSH              Prior Admission          Patient Interviewed                       Staff Interviewed Correctional Health Care Conference

13. Clinical Data (1) Presentation: ________________________________________________________________________________ Special Needs:            Private Room                 Hematological Condition        Special Equipment               Prior Transfusion           ICU Stay              1:1              Behavioral Issues         DNR          DNI                SA                      Methadone Significant Clinical/ Behavioral Events in past 24-72 hours?: Y/ N      If yes Describe: ________________________________________________________________________ Guardian:       Y        N            N/A             Needed        In Process:   €Y   €N                  Guardian Name: _____________________________    Guardian Telephone: _____________________ Health Care Proxy:     Y      N       N/A       HCP Name: _______________________________  HCP Telephone: _________________________________ Insurance   _  Y / N__        Insurance Name: _____________________ Ins ID #: _______________ Correctional Health Care Conference

14. Clinical Data (2) Date Screened:  _______________ Screening Nurse:____________________________________ Date of Admission: ____________ Diagnosis:_____________________________________ ____ Transferred From:_________________________________________________________________ Living/Social Situation: _____________________________________________________________ Adm. V.S. :     T _____  P  _____ RR ________ BP  _________ Height: ___________   Weight: ________ Substance Abuse: ________________________________________________________________ PMH:___________________________________________________________________________ Admission Labs :                     EKGNeuroCXR Current Labs: Mental Status: ____________________________________________________________________ Restrained?     Y  N                                    1-1   Y   N                                          Competent?  Y  N History of Tobacco, Alcohol or Drugs (please be specific): _________________________________ Circumstances Leading to Admission:  _________________________________________________ Correctional Health Care Conference

15. Disposition Data Pt/Family Refused bed offer: ___/      /2013 Reason: ___________________________________________ €Pt Denied:   Date____/       /2013  _ Reason: ___________________________________________ Pt Accepted  Acceptance Date:____/____/2013  Accepted by: Dr.___________ Date bed offer:____/____/___ Admit Date: ____/___ /2013    Time: ____:_____ € A   € P     Service_____________ Unit: _____________ Admission Delay    Y  /   N        Reason for delay: _____________________________________________________ Notification of Admission:       CM Nursing NP/PA Attending Dialysis                                                    Respiratory Social Work Admitting Pharmacy Referring Facility Clinical Contact: _____________________________ Telephone: ____________________ Update: __________________________________________________________________________________ Correctional Health Care Conference

16. Consent for Treatment • Section 1: Information The Transition Step Down service is designed to assist inmates who would benefit from an extended hospitalization for medical and/or rehabilitative care prior to their release in the community and medical home placement. • Section 2: Inmate’s Statement of Approval and Consent I have read this consent form and discussed it with: ______________________________________ I have been giving the opportunity to ask questions I might have all of which have been answered to my satisfaction. I understand that I will not be required to pay any fees for this service. I understand that I may refuse to participate in this service at any time. I agree to work with UMCH D/C and LSH on a proper reentry plan to the community. I acknowledge by my signature below I agree to participate in the Transitional Step Down Service at LSH voluntarily. Date: ___________________ Inmate’s Signature:_____________________________________ ID#___________________ Signature of Staff:______________________________________ Date:____________________ Correctional Health Care Conference

17. Correctional Health Care Conference

18. Program Feasibility/ Implementation • Main data source will be key informant interviews with representatives of UMCH, LSH, and the Service Discharge Planner. • Three rounds of brief key informant interviews at program inception and again at 3 & 6 months. Tracking the number of participants that enroll in the program • Interviews conducted by phone with semi-structured interview guides will be utilized. Key domains of inquiry will focus on systems developed to support the care model and the strategies used to implement key components. • Feasibility measure: the degree of uptake and whether the care model meets the needs of the target population – i.e., are there sufficient beds set-aide, are LSH services well-matched to participant need, does LSH experience unanticipated challenges with the intake and/or discharge process, etc. • Key informant interviews will be ID and content-coded, and analyzed to identify major themes. Correctional Health Care Conference

19. Program Performance (1) • Main data source will be program information collected by the Discharge Planner as part of the 6-month patient follow up. Information will be derived directly from participants as well as participant care plans. • Develop data collection tool to ensure consistency of data across participants and time. • Data domains will include: health status, inpatient and outpatient, utilization, prescribed and potentially avoidable encounters, such as ED use, community placement, participant experience and general satisfaction with the Service. Correctional Health Care Conference

20. Program Performance (2) • Data will be gathered at intake, discharge, and thereafter on a monthly basis up to 6 months from each participant's prison release date. • Analysis of data that descriptively characterizes program performance (e.g., adherence to treatment plans, stability of community placement over time, satisfaction) and identify potential unexpected outcomes that might be important to capture in future studies. Correctional Health Care Conference

21. Outcomes & Dissemination Plan At the end of this study we hope to understand and disseminate the feasibility of the Service for two broad audiences: 1) correctional facilities community and 2) academic/research community • For the corrections’ audience – oral presentation for the annual Correctional Health conference (estimated for March 2014). • For the academic/research community – manuscript targeted at Public Health Reports, a journal that may be more receptive to a descriptive paper detailing an innovative care model (as opposed to original research). In addition to these dissemination plans, findings from the pilot study will be considered as the basis for a grant application to evaluate the cost and utility of the Service. Correctional Health Care Conference

22. References Binswanger IS, Stern MF, Deyo RA, et al. 2007. Release from Prison – a High Risk of Death for Former Inmates. New England Journal of Medicine 356(2):157-165. Kirby P, Ferguson W and Lawthers A. 2011. Post-Release MassHealth Utilization: An Evaluation of the MassHealth/DOC Prison Reintegration Pilot. Center for Health Policy and Research, Commonwealth Medicine. Mallik-Kane K, Visher CA. 2008. Health and Prisoner Reentry: How Physical, Mental and Substance Abuse Conditions Shape the Process of Reintegration. Washington DC: Urban Institute. Wang EA, Hong CS, Samuels L, Shavit S, et al. 2010. Transitions Clinic: Creating a Community-Based Model of Health Care for Recently Released California Prisoners. Public Health Report vol. 125: 171-177. Wilper AP, Woolhandler S, Boyd W, et al. 2009. The Health and Health Care of US Prisoners: Results of a Nationwide Survey. American Journal of Public Health 99(4): 666-672. Correctional Health Care Conference

23. Acknowledgements • Debra Beaudette • Patricia Cahill • Tom Groblewski, DO • Deborah Gurewich, PhD • Pat Herald • Barbara MacLaughlin • Joyce Murphy • Patti Onoratto • David Polakoff, MD., M.Sc. • Paul Romary Correctional Health Care Conference