Transcript Transitions Clinic - Urban Strategies Council

Making the Case for Community
Based Transitional Care
From Prison to the Community
Emily Wang, MD
Transitions 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
Chronic medical condition?
Age over 50 years old?
Needs refill of medications?
Transitions Clinic,
Southeast Health Center
Primary care doctor?
Yes
No
Referred back to regular PMD
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
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Number of patients
Transitions Clinic: Chronic
Diseases
20
18
16
14
12
10
8
6
4
2
0
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
100
% of respondents
80
HIV
60
Chronic Disease
No Chronic Disease
40
20
0
Usual
Source of
Care
P<0.0001
Intermittent
Care
ED/Urgent
Care
No Care
Factors associated with having access to a
usual source of care
Characteristic
Chronic disease status
No chronic disease/HIV
Adjusted
OR*
ref
Chronic medical dz, noHIV 1.6
HIV
7.4
Insurance
95% CI
3.0
0.8, 3.2
3.6, 15.6
1.6, 6.0
•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
1.6
1.4
1.2
1
0.8
Access to
care of San
Francisco
population
0.6
0.4
0.2
0
>50 years
Male
HIV
Black
Chronic Disease
Insured
No chronic disease
Uninsured