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
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 postrelease 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 postrelease (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 planner’s 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;


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jointly responsible to manage discharge to the most appropriate community
setting once goals of the ex-inmate’s 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.
SS# ______________ DOB: _____________
Living Arrangements: _______________________
Religion: ___________ Race: ________________
Interpreter Needed:
Language: _________________________________
N
Y €N/A
Next of Kin: ____________________________
DMR DMH
Telephone # ________________________________
Referring Facility: ___________________________
CM/SW:___________________________________
Telephone# ________________________________
Admitting Diagnosis: __________________________
Date of Admission: __________________________
Referred to LSH for: _____________________________________________________________________
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New Admission to LSH
Re-Admission to LSH
Patient Interviewed
Staff Interviewed
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Prior Admission
Clinical Data (1)
Presentation: ________________________________________________________________________________
Special Needs:
Private Room
Prior Transfusion
DNR
DNI
Hematological Condition
Special Equipment
ICU Stay
1:1
Behavioral Issues
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: _______________________________
Insurance _ Y / N__
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HCP Telephone: _________________________________
Insurance Name: _____________________
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Ins ID #: _______________
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: ___/
€Pt Denied: Date____/
/2013 _
/2013
Reason: ___________________________________________
Reason: ___________________________________________
Pt Accepted Acceptance Date:____/____/2013
Accepted by: Dr.___________ Date bed offer:____/____/___
Admit Date: ____/___ /2013 Time: ____:_____ €A €P Service_____________ Unit: _____________
Admission Delay Y / N
Notification of Admission:
Reason for delay: _____________________________________________________
CM
Nursing
Respiratory Social Work Admitting
NP/PA
Pharmacy
Attending
Dialysis
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: Inmate’s 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: ___________________
Inmate’s 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 CommunityBased 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
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