Availability is not access: a pilot program to increase medical treatment for women former inmates

1. Availability is not access: a pilot program to increase medical treatment for women former inmates Diane Morse, MD; Precious Bedell, MA; Jennifer Silverstein, BS; Emily Wang, MD; Shira Shavit, MD; Geoffrey Williams, MD, PhD University of Rochester, Yale University, University of San Francisco Funding: Center for Medicare and Medicaid Services - E Wang PI, NIDA1K23DA031612-01A1 - DS Morse PI, UR DCFAR: NIHP30AI078498

2. W.I.S.H. Women’s Initiative Supporting Health

3. Rationale for projects addressing healthcare • Released prisoners have over 12x increased mortality in the first 2 weeks compared to general population • Top conditions • Drug overdose • Cardiovascular disease • Homicide • Suicide • Binswanger et al. N Engl J Med 2007

4. diseases with increased prevalence relates to risk behaviors • Asthma • HTN • Hepatitis C • HIV/AIDS • Diabetes mellitus • Cardiovascular disease • Cirrhosis • Kidney disease • Mental health disorders • Rich et al., NEJM 2011 from BOJ statistics

5. Why Women? • More than one million women behind bars or under control of criminal justice system • Fastest growing segment of incarcerated population - increasing at nearly 2x rate of men since 1985 • From 2003 to 2007, arrests of women for drug violations increased 29%, compared to 15% for men • Women Prison Association Institute on Women & Criminal Justice, 2009; American Civil Liberties Union, 2007

6. Women of color disproportionately represented in prison

7. Nearly 2/3 of women in prison are mothers • Approximately 65,600 women in federal and state custody reported being mothers of 147,400 minor children • 77% of incarcerated mothers reported providing most daily care for their child(ren) before incarceration • American Civil Liberties Union, 2007

8. women’s initiative supporting health Transitions clinic • WISH-TC • Primary care transitions clinic for women recently released from incarceration • Part of university medical center • One of 11 site national consortium providing medical care after incarceration • Community health workers, who also have been incarcerated, guide patients through complex healthcare systems and social services • Wang, et al. Am J Pub Health 2012

9. Community stakeholders • Legal • Probation, Parole, Drug Treatment Court, public defenders, jail • Re-entry • Multi-disciplinary state-funded county consortium • Half-way houses, YWCA • Substance abuse treatment centers • Domestic violence shelter • AIDS provider and DCFAR

10. self-determination theoretical model • Autonomy Support • Elicit & acknowledge patient viewpoint • Explore patient values • Provide rationale for advice • Provide options for change • Acknowledge option of no change • Support patient initiation for change • Minimize pressure and control • Perceived competence • Autonomous self-regulation Increased Health Care Utilization

11. Participants to date

12. Women’s Initiative Supporting Health Transitions Clinic Precious Bedell, MA Project Health Counselor

13. Journal Entry Dec 20. I really didn’t think I would be cleared to go into the facility. Part of me hoped that I wouldn’t. I have seen enough of jails and prisons to never want to go back. As I walked up the path, I remembered my last visit here. I had to serve weekends, four of them. Something about them changed me. My daughter came to pick me up on the last Sunday. I vowed never to return. The experience from the deputy sheriff, who stripped searched me coming in, was cruel and degrading. I knew there had to be another way. My confidence waned a bit, as I walked up the cemented pathway. I kept going. I believed in what I was going in there for. Until I got this job, which I feel is designed for me, I knew first hand the barriers, housing, employment, of feeling that you’re never good enough. The legal second class citizenship that are part of the continuing and perpetual racial caste system, which legalizes the old Jim Crow Laws, loom like a dark cloud. I kept going. I thought about other women inside, other former prisoners who were successful. When they shared their stories, they all said that someone supported them unconditionally and walked the journey with them. I kept walking into the facility.

14. Re-Entry barriers for Women • Family Reunification • Healthcare (mental health and substance abuse treatment) • Employment • Education • Trauma history • Didlick-Davis, 2009

15. Program Implementation • Recruitment Process • Monroe County Correctional Facility • Transitional Housing, Bethany House, Jennifer House, and Penny Cook Supportive Housing • Home Intakes • Referrals from service providers • Empowerment Group (Gender-Responsive)

16. Intake Process • Self Determination Theory Practices • Patient is in the Driver’s Seat • Role of CHW using SDT • Provides Client-Centered Practices • Cultural Humility

17. Successes and Challenges • Predictors of who will stick and stay • Patients in Supportive Living • Patients who go home • Follow up with patients • Supportive Advocacy (Walk the Journey)

18. questions

19. QUESTIONS • What kind of atmosphere does the WISH-TC provide for patients? • What are the challenges for patients to keep appointments? • How do we keep track of our patients? • What barriers are the most difficult for patients to address or overcome? • How do CHW’s provide their own self-care and self-awareness?