Providing Inmate Continuity of Care Post-Release

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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

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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.

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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

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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.

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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.

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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.

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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 planners 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.

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UMCH Partners with LSH

• UMass Correctional Health (UMCH) and the Lemuel
  Shattuck Hospital (LSH) agreed to pilot the
  Transitional Step 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.

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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.

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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-inmates 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.

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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.

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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  ____________________________    Tele
  phone ________________________________
•     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
•                                                   
                      

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Clinical Data (1)

• Presentation ____________________________________
  ____________________________________________
•  
•  
• Special Needs            Private Room
                  Hematological Condition
         Special Equipment
•               Prior Transfusion           ICU
  Stay              11              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
  _______________

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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                     EKG          
                      Neuro                         
                       CXR
• 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 
  _________________________________________________

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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 __________________________________________
  ________________________________________

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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 Inmates 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 ___________________
•  
• Inmates Signature_______________________________
  ______ ID___________________
•  
• Signature of Staff_______________________________
  _______ Date____________________ 
•  

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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.

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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.

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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.

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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.

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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.

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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