The Challenges of Health Care In Community Corrections: Working Toward Solutions

Offenders often suffer from health problems at rates significantly higher than the general population. For example, research on prison populations demonstrates that inmates have such infectious diseases as HlV, AIDS, tuberculosis and hepatitis C at rates anywhere from five to 10 times the general population,

Many offenders are also poor and arrive at programs with mental illnesses and/or substance abuse disorders, both of which serve to exacerbate medical conditions.2 This lack of resources often means that offenders do not seek services for primary ; care. If they do seek services for primary care, they often access hospital emergency rooms rather than primary care physicians in the community. This results in inconsistent, sporadic care and a drain on system resources.

While primary health care is not the immediate mission of community corrections agencies,3 addressing the health care needs of offenders represents a tremendous public health opportunity as these individuals will be leaving programs and returning to . their communities. As Theodore Hammet, Cheryl Roberts and Sofia Kennedy4 point out, "correctional facilities are part of our communities, not separate from them." Consequently, solutions to these problems require collaboration with other systems and public providers. This article describes the attempts of one community corrections agency to build such collaborations in order to expand its capacity to meet the special needs of its clients. The discussion also includes initial outcomes from the project.

Talfcert House and Its Glients

Talbert House is a large, nonprofit social services agency located in Hamilton County, Ohio. The mission of the agency is to improve social behavior and enhance personal recovery and growth. The agency operates more than 25 programs, serving approximately 18,000 clients face to face and approximately 50,000 clients via hotline services annually. Fifteen of the Talbert House programs are residential correctional programs. These programs serve male and female adults and adolescents.

Recent data from the University of Cincinnati Health Policy and Health Services survey of Talbert House clients confirm that these individuals often lack resources to access medical care. For example, less than 30 percent of the adult correctional clients reported having insurance, yet more than 90 percent of the general population in Hamilton County reported having insurance. Similarly, 16.5 percent of Talbert House clients reported using emergency rooms as a source for primary care, while less than 2 percent of the Hamilton County sample reported such use of emergency rooms. Related findings also revealed that 55.1 percent of Talbert House clients visited an emergency room at least once last year. Furthermore, almost a quarter of Talbert House clients reported going without medical care or without needed prescriptions in order to pay for food, clothing or housing. Finally, less than 10 percent of Talbert House clients reported use of Medicaid.

The Primary Gare Services Project

In 2002, Talbert House sought a grant from the Health Foundation of Greater Cincinnati to expand its primary health care services at seven of its residential sites. The decision to pursue such funding was based on information from site staff about the programs' reliance on emergency rooms for primary care for their clients. Talbert House chose the Health Foundation of Greater Cincinnati as a potential funder for this project due to its focus on strengthening primary care providers for the poor. Talbert House was awarded the grant, and the project started in July 2002.

By August, Talbert House began to set up the seven individual clinic sites necessary to implement the project. This involved purchasing a variety of equipment and supplies, renovating the layout of some of the sites and determining how clients would access each clinic. The agency then began working on the infrastructure to properly document services, perform billing of eligible services and financial monitoring, and obtain access to medication. In addition, the agency began to implement shared service arrangements with a variety of community providers and recruit staff.

It should be noted that a key component of this project was the hiring of advance practice registered nurses to work with the three doctors associated with the project - a primary care physician, adult psychiatrist and child psychiatrist. The agency decided to hire nurse practitioners, rather than more doctors, because the agency could hire two nurse practitioners for the cost of one doctor. Thus, a larger number of clients could be seen. Nurse practitioners are cost-effective because they are capable of handling routine, noncomplex illnesses and have a certain level of prescriptive authority under the Ohio Board of Nursing Formulary. While they do not have the ability to prescribe certain medications, most notably antipsychotic drugs, they can maintain clients on these medications once a physician has ordered them for the client. Use of nurse practitioners also allows programs to allocate their limited physician/psychiatrist time to more complex client issues.

ProjectGoals and Performance

The process of hiring nurse practitioners ultimately took a few months longer than anticipated, but by April 2003, all positions were filled and services were being provided at all seven sites. The major elements of the project included quick assessment and diagnosis of clients on-site, quick and efficient treatment for routine illnesses on-site and continuity of care via collaboration with community providers. In addition to these goals, there were four specific outcomes against which the success of this project was measured, including to:

* Provide on-site access to primary care at seven residential sites to at least 2,000 clients annually;

* Decrease the use of emergency rooms for nonemergency primary care by 30 percent;

* Reduce the costs of providing off-site medical care by 30 percent; and

* Decrease the amount of behavioral treatment missed due to being off-site for nonemergency medical care by 20 percent.

To determine how well the project met these goals, staff collected data six months prior to implementation to establish a baseline. Staff then continued to collect data throughout implementation of the project. Data at six months post-implementation showed that the project had served 508 clients with a total of 2,032 patient visits. The project was also able to reduce the number of off-site visits for nonemergency medical care by 18 percent. Specifically, there were 133 fewer off-site visits during the first six months. In addition, the project was able to reduce the transportation costs associated with these off-site visits by 40.8 percent for a total cost-savings of more than $4,000. Further, the number of behavioral treatment hours missed was reduced by 19.9 percent.

To assess continued progress, the agency reviewed the outcome data again at 12 months post-implementation. These data revealed that the agency continued to show improvement on each of its outcome measures. For example, the project had served 1,400 clients with a total of 3,156 patient visits. In addition, the number of off-site visits had been reduced by 32 percent. This was above the target and represented 235 fewer off-site visits for nonemergency care. The costs of providing transportation also had been reduced by 72 percent. This exceeded the target and produced an additional cost savings of more than $8,000. Finally, the amount of treatment missed by clients was reduced by 47 percent, again exceeding the target. This reduction represented a savings of almost 400 hours of behavioral health treatment.

Lessons Learned

As the nurse practitioners began identifying more client needs, agency staff were continually challenged to find solutions within existing resources. For example, staff discovered that resources did not exist for out-of-county halfway house clients who needed psychiatric medications. Several key staff then worked with the Ohio Department of Mental Health to implement a system where clients could sign a residency form to allow them access to services in Hamilton County.

Early on in the project, staff were also challenged with finding resources for all of the prescriptions generated by the nurse practitioners, as many of the clients were indigent. Solutions for this involved applying for licenses to distribute dangerous drugs for each of the sites, where applicable, so that they could house medication samples and access indigent care resources. Even this solution was limited since nurse practitioners can only monitor samples for up to three days. Given that the nurse practitioners were not full-time employees at each site, some sites were not able to use this option. The agency also taught site staff how to access indigent care programs via the Internet. Again, this solution was limited due to the time that it takes between application and approval for the medications. For example, it often takes six to eight weeks for approval.

The agency faced an additional challenge early on with its adolescent girls program. In this program, the nurse practitioner identified a high rate of sexually transmitted diseases as well as a need for increased gynecological services. To address this need, the agency has been working with the local health department to provide free culture media for the girls as well as free medication for STDs. This will allow the agency to diagnose and treat the girls more quickly as it will eliminate the need to send them off-site for tests, wait for results and wait to start them on medications. Finally, the agency also applied for a waiver from the Clinical Laboratory Improvement Amendments program so that certain medical tests could be performed on-site to yield quicker diagnoses. These tests included glucometers, pregnancy tests, strep throat tests and urine dip sticks.

Sustainability of the !Project

The grant for this project is nearing completion and efforts are under way to ensure its sustainability. One solution Talbert House is working on is to collaborate with the local federally qualified health center. This center allows communities to expand services for the poor by permitting them to recover costs for Medicaid and Medicare patients. The local health center is comprised of five neighborhood clinics. These clinics are in neighborhoods that many Talbert House clients are likely to reside in upon release. If the collaboration is successful, Talbert House programs will contract to have community physicians from the health center on site. The Talbert House nurse practitioners can then work under the supervision of these physicians, allowing the nurse practitioners to bill at the health center rates.

The Medicaid reimbursements combined with the budgeted allocations from each program will still not be enough to cover the entire cost of the project, however, because Talbert House has a number of clients who are not eligible for Medicaid. This means that the agency still needs to be able to fill a small gap in funding, approximately 20 percent of the overall budget for the project. Consequently, the agency is pursuing the possibility of a bridge grant from the Health Foundation of Greater Cincinnati. This short-term grant will cover the difference between the actual cost of services and reimbursement to the federally qualified health center during the first transition year while the agency continues to explore other options for longterm sustainability.

A Glear Benefit to Clients

A shared services model such as the one described in this article provides better integration of behavioral health and primary health care services for an underserved population. Similarly, the expansion of medical services on-site means that agency staff can provide valuable feedback to medical staff about the client's compliance with medication and response to treatment. Perhaps most important, however, is that clients with few resources have increased opportunities to receive essential services for both basic and complex health care needs.

While Talbert House did not collect data on improved health of its clients, the ability to quickly diagnose and treat most routine illnesses is an asset to Talbert House clients and represents a clear improvement over previous practices. Clients no longer have to wait in emergency rooms for primary care services, often missing correctional treatment groups aimed at reducing recidivism and relapse (the immediate mission of community corrections agencies). Clients also get the added bonus of being connected to a community physician while they are still in a correctional facility. This means that they have an established relationship with a community provider whom they can access for services upon release. This project clearly represents one creative approach to solving a complex problem during tight fiscal times. It also highlights a common theme in community corrections - while innovation in a nonprofit setting can often be a challenge, it is rarely the exception.