Barriers to Entry and Continuity of care in Correctional Facilities

1. Barriers to Entry and Continuity of care in Correctional Facilities June 21, 2010 Becky L. White MD, MPH Assistant Professor of Medicine University of North Carolina at Chapel Hill, School of Medicine Co-director of HIV services, North Carolina Dept of Corrections

2. Correctional Health Care • Guaranteed by the Constitution • Not Primary Goal of Corrections • Understaffed • Overburdened-too many inmates • Underfunded –(e.g. Jails)

3. Cycle of Incarceration and Release and Relation to Health care Adapted from Zaller et al, Medscape 2009

4. 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

5. 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)

6. 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

7. 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

8. 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

9. NC Department of Correction (NC DOC) Prisons Admission / Intake prison Non-admission prison Courtesy of D. Rosen

10. 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

11. Viral Load Increases Among Recidivists 1000000 Pre-release Reincarceration 100000 10000 1000 100 Recidivists HIV-1 RNA (copies/ml) Stephenson (White et al, Public Health Reports) 11

12. NC BRIGHT: Study Schema BRIDGING CASE MGMT (BCM) I N T A K E Randomize NCDOC Discharge Planning (SOC) Evaluations:<3m prior to release Release +14d +2m +6m +9m +12m 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

13. 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

14. Prison and Jail : Facilitators to Continuity of Care at Release • Collaboration between the community and correctional facilities

15. Cycle of Incarceration and Release and Relation to Health care Adapted from Zaller et al, Medscape 2009

16. “ Prison Health is Public Health” WHO 2005

17. 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