On May 1, Juan Martinez went to his fourth follow-up appointment since being diagnosed with hepatitis C (HCV) a little over a year ago. Martinez, whose name has been changed to protect his identity, doesn’t know how long he had the virus before his diagnosis. HCV often remains asymptomatic until its late stages, and it had been many years since he had last seen a doctor. The virus was discovered during intake at Hampden County Correctional Center, a jail in western Massachusetts, where he has been an inmate since April 2013.
Martinez looked much older than his 57 years. Wearing a green jumpsuit and government-issued sneakers, he sat as one of the jail’s doctors, Thomas Lincoln, asked him if anything had changed since the last time they saw each other. “I put on weight,” Martinez said in a raspy voice. “You told me to!” They both laugh.
Lincoln looked over Martinez’s file and glanced at a flat screen monitor displaying an electronic version. “You’ll be out in August?” he asked. Martinez nodded. “That’s about time we’ll need to check your blood again.”
Martinez is one of ten million people who enter the local jail system each year in the United States. In contrast to prisons, jails are used to detain people for short-term sentences and low-level offenses, or while awaiting trial for a more serious charge. The average stay in jail is three months and 96 percent of inmates return directly back to their community. Of the more than 1,400 inmates at Hampden, where Martinez was detained, somewhere between 20 and 30 percent carry the HCV virus. Many, like Martinez, are first diagnosed in jail.
As the US incarceration rate has skyrocketed over the last forty years, many healthcare professionals have come to recognize that jails offer an opportunity to identify and treat people who might not otherwise seek or have access to healthcare. “With more than 2.2 million men and women and children behind bars, the health of prisoners and jail detainees and the health of the public is becoming blurred,” says Gabriel Eber, staff counsel at the ACLU’s National Prison Project.
Jail inmates are disproportionately male, people of color and poor. This population suffers from higher rates of many health problems, including chronic and infectious disease, injuries, mental illness and substance abuse. And people are often at their sickest when detained. Eighty percent of detained individuals with a chronic medical condition have not received treatment in the community prior to arrest. “It’s like an emergency room,” says Ben Butler of Community Oriented Correctional Health Services (COCHS), a nonprofit promoting healthcare connectivity between jails and communities, of jail intake. In effect, jails have become the front line for health problems that plague underserved communities in America.
Exacerbating the problem, once in jail, what treatment happens there stays there. Health records are hard to transfer in and out, leaving patients who have received care prior to arriving in jail with siloed histories, creating inefficient, costly and potentially inconsistent treatment. There is little protocol mandating follow-up care once someone is released—in fact, according to a recent study by The Journal of Urban Health, nationwide only 10 percent of people who qualify for assistance with arranging mental or physical health treatment when they re-enter their community actually receive it.
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For twenty-two years, Hampden County’s innovative, collaborative healthcare model has allowed them to combat these problems. The jail, which serves Springfield, Massachusetts, the fourth largest metropolitan area in New England, has made patient care literally continuous: doctors from local public clinics also work several shifts a week in the jail, following patients and meeting new ones. For example, Thomas Lincoln, the director of the program, is an employee of the nearby Brightwood Health Center. He splits his time between there and Hampden. Three other local clinics, covering zip codes in which 75 percent of inmates are from, send doctors into the jail on regular shifts in a similar arrangement—most work one or two half-days a week.
The Hampden County model was conceived of during the AIDS epidemic. When the antiretroviral drug AZT was put on the market in the late 1980s, Lincoln and his colleagues struggled to ensure continuous treatment for HIV-positive people in Springfield. A disproportionately high number of HIV-positive people were frequently in jail, and so, frustrated by being left in the dark about their incarcerated patients’ treatment and progress, the doctors came up with a straightforward solution in a system typically defined by red tape and bureaucracy: they would move part of their practice to the jail.
A key to the program’s success was—and continues to be—the support of Hampden County’s Sheriff Michael Ashe, who began his career as a social worker and is known in the field to be a leader of progressive reform. The healthcare collaboration fit well with the larger model of corrections he was building, which focused on rehabilitation in jail and partnering with community organizations to facilitate inmate’s transition back into the community. “How can you really be dealing with remedial education or job training when you’re dealing with health issues, or substance abuse issues, or mental illness?” Ashe asks. Soon Hampden’s collaborative health program was expanded to include three other community health clinics and to cover all patients, not just those with HIV.
Today, upwards of 90 percent of the HIV patients from Hampden County Jail have follow-up appointments within thirty days of being released. Fifty-five percent of those with less severe medical problems see a provider within thirty days of release, as do 61 percent of those with mental health issues. These numbers should be understood in the context of the chaotic and unpredictable nature of jail release. Half of the inmates at Hampden County Jail are released pretrial—after bail is posted, when charges are dropped, straight from a court hearing and so on—which means that release happens without warning. Many other jails have even higher rates of pretrial release.
Numbers from Hampden County suggest that the program may also be helping to lower incarceration rates. Healthy people are less likely to end up back in jail. The county’s recidivism rates are among the nation’s lowest, and the rate of recidivism within three years of release—a common benchmark of success—has dropped by over 10 percent since the jail’s health system was reformed.
Other localities are taking notice. Programs based on this model have been successfully implemented in Washington DC and Marion County, Florida.
In most communities around the country, however, a chasm between jail health centers and healthcare on the outside persists. While not all jurisdictions have a sheriff with a Masters in social work, or a clinic with doctors who are willing or able to split their time between their hospitals and jails, the Affordable Care Act provides a unique opportunity to address this problem. Prior to the ACA, some 90 percent of those released from prison or jail each year were uninsured. Their primary medical treatment facility outside of prison or jail tended to be the ER. However, with the ACA’s Medicaid expansion in full swing in twenty-six states and Washington DC, 5.3 million people who are or have been incarcerated are newly eligible for Medicaid. The opportunity for continuity in treatment is palpable, and across the country, a movement is brewing among forward-looking jail administrators and healthcare providers to bridge this gap.
The first step in expanding continuous care models like Hampden’s is to get people enrolled in health insurance. Because it is in Massachusetts, which has had a healthcare mandate since 2006, Hampden County is ahead of the curve on this front: 65 percent of inmates are covered by MassHealth, up from 35 percent in 2011. Elsewhere in the country, in states that have less progressive healthcare laws and less experience with the influx of expansion enrollment—that is, every other state—the influx of poor single adults who can be covered by the Medicaid expansion has proven to be an enrollment challenge. According to research by The Urban Institute, as of February many uninsured adults were not aware of the Affordable Care Act’s coverage provisions. Outreach and education is needed to ensure that the newly eligible know what they’re qualified for and how to apply. At Cook County jail in Chicago, jail intake now includes starting the application process for health insurance. “Who is eligible for the Affordable Care Act very much mirrors the population you have in the county jail: low income, single adults. There was a lot of synergy there,” says Dr. John Jay Shannon, interim CEO of Cook County Illinois’s Health and Hospitals System (CCHHS). Similar programs are running in San Francisco, Louisville, and Portland, among other jail systems.
Part of providing continuous care is, of course, providing quality care in the first place, and many jails do not. “Whether it’s resources, whether it’s facilities, whether it’s staff, whether it’s training, we find all too frequently that detainees suffer because systems can’t meet their needs,” says Eber of the ACLU. “The inability to meet the health needs of prisoners and detainees is a direct result of the over-reliance on incarceration in this country. If we didn’t have as many people in prisons we wouldn’t have the crisis that we have in healthcare in prisons and jails.” In recent years the ACLU has charged several facilities with failing to do provide adequate care, including a 2012 class-action lawsuit in Arizona. Enrolling inmates in Medicaid would offset some of the costs of providing better care.
The next crucial step in achieving continuous care is connecting people to a provider once they have been released. As with Hampden, the discharge process itself can be chaotic and hard to predict. Nationwide, local jails process 13 million admissions per year, which includes many people with multiple admissions. “We hear stories of people who literally are discharged at two in the morning. It’s very difficult to maintain contact with someone who is cycling in and out of the county jail,” says Steven Glass, executive director of managed care for CCHHS. On average 100,000 inmates cycle through Cook County jail every year; the daily population is 9,000. “It doesn’t mean we can’t solve it, and it doesn’t mean we’re not trying very hard,” he adds.
In an effort to address this problem, some systems are looking to health information technology to track itinerant patients. Like the medical centers in their communities, a growing number of jails have upgraded to electronic medical records. With electronic health records a patient’s comprehensive medical history can be made accessible to doctors both inside jail and out, with the click of a mouse. Upgrading to electronic records is not an easy process in any setting, but it is even more difficult to find record systems that work for the type—and volume—of data that is recorded in jails. “It’s inpatient, it’s outpatient, it’s emergency room, it’s rehab,” explains Ben Butler from COCHS, the nonprofit that works at the nexus of public health and public safety.
Electronic records are only as useful as the number of people who can receive and input data into them. To this end, health information exchanges (HIEs) are of vital importance. HIEs are electronic databases for patient records, which can be accessed by healthcare providers and patients. Under the 2009 American Recovery and Reinvestment Act, every state was awarded money to develop the ability to exchange health information across the healthcare system, both within and across state lines. Some states run their own databases, others partner with private companies to do so—some have been successful, others less so. Today every state has at least one functioning HIE, while several states—New York, Michigan, Texas and Florida—have more than ten, according to the Healthcare Information and Management Systems Society (HIMSS), a non-profit focused on health IT. More does not necessarily mean better. Delaware, for example, has only one database, but is considered among the best in the country because it encompasses so many providers, including not just hospitals but also specialists such as radiologists.
Some jail systems are now working to get onboard their local HIE. A perhaps unexpected leader in this field is Kentucky. The state’s exchange, Kentucky Health Information Exchange (KHIE), is among the most comprehensive in the country. Launched in 2010, KHIE connects many of the state’s largest providers and makes strategic partnerships with national organizations such as HIMSS. One of the state’s largest jails, Fayette County, is in the late stages of fully integrating its record system into the exchange.
Rodney Ballard, Fayette County Jail’s director, says administrators at KHIE were open to working with the jail when he approached them. “I said, well, 24,000 people come through my door every year, 865 people are on medication every day.” Mental health doctors at Fayette see around ninety inmates a day; nurses see 194. “They said, ‘hell we’ve got to get you onboard.’”
There were many technical difficulties along the way—including figuring out how to protect sensitive information collected in jail, such as drug abuse history. “In the past, we’ve not done a very good job in jails and prisons talking to healthcare providers about inmate healthcare,” says Ballard. “For one, they call them patients; we call them inmates. Something as simple as that.” Despite these barriers, they had the jail connected in a matter of months. The jail can now push its data onto the exchange, allowing all of the treatments that inmates receive and medications they start to be accessed by doctors in the community should he or she seek treatment upon release. The jail is now working on also receiving data.
Other city and county jails are in late stages of connecting their health record systems with local HIEs, notably New York City; Camden, New Jersey; Orange County, Florida and Multnomah County, Oregon, according to a recent COCHS paper.
As healthcare providers and correctional institutions increasingly recognize that public health and jail health should be treated as one, it is critical for government funding and regulation to follow. In August 2012, the Department of Health and Human Services published new regulations that made correctional institutions eligible to receive incentive payments for using electronic health records under the “meaningful use” program. These incentives were previously reserved for providers who cared for underserved communities outside of correctional walls. The implementation of meaningful use funds comes in three incremental stages as the provider upgrades their health information technology, with an end goal of the provider being capable of joining a HIE.
Funding aside, according to Ben Butler the most important element for success is having all of the key players engaged and supportive: the jail administrators, HIE administrators, the local government and so on. It is, Butler says, a matter of “opening eyes to the potential.”
