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Freeze! You're Under Examination

Making sure people get health care when they leave prison saves taxpayer money and protects public health. It may even help them stay out of prison.

It's about 15 months into his four-year-long sentence at Rhode Island's minimum-security prison, and on an unseasonably brisk spring morning, Joseph has a visitor. A guard escorts the inmate, who sports a shaved head and large-framed glasses perched on a prominent nose, to a conference room just beyond a metal detector and a front door that clangs every time the deadbolt is deactivated.

Joseph, who looks small in his oversized prison-issued khakis, doesn't normally get visitors. For most of his 50 years, he's been in and out of prison while battling HIV, other sexually transmitted diseases, schizophrenia and cocaine addiction. His family is either dead or keeps him at a distance, and he doesn't have many friends on the outside. When he's out, he's the tattered, scattered homeless character the kids throw rocks at.

Joseph brightens. His visitor is Don Laliberte, a social worker with Project Bridge, a federally funded program that helps HIV-positive inmates connect with medical care in and out of the prison. On the inside, Joseph is legally guaranteed health care. But every time he's released, the Vietnam War veteran becomes one of Laliberte's most challenging clients. "It takes a lot of work to get him to medical care because he's hard to find," Laliberte confides after the visit. "He should be in a therapeutic setting. Sometimes I don't know what else to do for him."


Without a biweekly Haldol shot, the voices in Joseph's head return; because there's no space for him at psychiatric group homes in Providence, he usually winds up sleeping in alleys, after getting high on crack. Laliberte is the only reason Joseph receives any medical care at all once he's paroled. Every few months, the social worker goes to the gas station where Joseph sometimes collects trash in exchange for candy bars, picks him up and takes him to the local health clinic.

At the prison, Joseph's health can be up and down, too. On the day of this visit, he isn't in great shape. He tells the social worker that his head is pounding and that his left eye hurts. The night before, Joseph adds, he peed his bed. Joseph, who spoke to Miller-McCune under the condition his last name would not be used, alternates between rubbing his temples and his eye to give relief to his aches and pains. "I was hoping to see you," he says, pausing his self-ministrations to look at Laliberte. "I just got a parole date."

Until recently, efforts like Project Bridge have been anomalies; there's been little public sympathy for people coming out of prisons or jails, even if they're sick. But given the growing number of people returning to society after incarceration, correctional and community health providers are increasingly turning their attention to managing ex-offender health.

"In the past, we had to get tough on crime and that meant not coddling offenders," says Capt. Ron McCuan, a public health analyst with the National Institute of Corrections. "The missing component of the discussion is the part about where a patient comes from and where they are released to, and it's always the community at large. We want these individuals to become productive citizens; we want them not to be homeless and to be employed, and that requires that they have good health."

The sheer number of ex-offenders has made them hard to ignore. About 1 in 100 Americans is incarcerated, and approximately 95 percent of the people in prisons or jails will return home. That's roughly 13 million releases each year — and when they get back home, these men and women aren't exactly paragons of health.

The National Commission on Correctional Health Care reports that soon-to-be-released inmates have higher rates of infectious disease than the general public; ex-cons make up about 15 percent of people infected with HIV, about 30 percent of those with Hepatitis C and nearly 40 percent of those with tuberculosis. A recent study published in the Archives of Internal Medicine found that young ex-offenders appear more likely to have hypertension and be at greater risk for heart problems. And a four-year study of 30,000 parolees from Washington state published in the New England Journal of Medicine found that in the first two weeks after release, former inmates are nearly 13 percent more likely to die than members of the general public, mostly due to drug overdoses and heart disease.

There's a moral dimension to providing ex-inmates with health care, of course, but there's also a public health imperative. In February, the Journal of the American Medical Association published the results of a four-year study of 2,000 HIV-positive Texas inmates and found that only 5 percent of parolees filled their prescription soon enough to avoid interrupting their treatment regime. The lack of medical continuity had dire consequences. "If people are not getting their meds when they get out of prison, there's a greater risk of medical complications for the patient, that the virus will spread and that drug-resistant strains will develop," says Josiah Rich, the Project Bridge doctor and one of the authors of the study.

A 2008 Urban Institute report on parolees from Texas and Ohio illustrates the financial implications of allowing ill ex-offenders to slip through the cracks: More than 80 percent of the 1,100 study participants reported a chronic illness, and more than 60 percent had no health insurance for nearly a year after release. As a result, one-third of these ex-offenders eventually sought medical care in emergency rooms, and 20 percent were hospitalized at one point during their first year out — creating costs that are passed on to taxpayers.

"The strongest argument at the moment (for post-incarceration health care) is not a humanitarian one, it's an economic one," says Dr. Robert Greifinger, a distinguished research fellow at John Jay College of Criminal Justice and the editor of the 2007 book Public Health Behind Bars. "If we're going to drive change in the costs of criminal justice and health care systems, one very substantial area to look at is by providing through care for inmates."

Every Monday morning, there's a standing-room-only meeting for the doctors, nurses and social workers at the Miriam Hospital's Immunology Center, the clinic where all Project Bridge patients are seen once they're paroled. On a Monday in late March, Dr. Susan Cu-Uvin, the director of the clinic, emerged from the meeting with a lot on her mind. One patient the group had discussed that morning had missed an appointment because her daughter had been stabbed to death over the weekend. Another patient was experiencing such terrible leg pain that he wasn't able to catch the bus to his appointment and he couldn't afford a cab.

"Many medical problems are easy to solve," says Cu-Uvin, a stethoscope slung around her neck. "We have good mechanisms for treating HIV, but what we can't solve are the social issues. We could say that their lives are not our problem, that we're only here to solve their medical problems, but if their personal lives are chaotic, then their medical care is impossible."

From the outset, in fact, Project Bridge social workers and doctors didn't expect their clients — many challenged by mental illness and addiction — to be proactive and show up at the community clinic doorstep once they got out of prison. Instead, the program connects with clients before they're released, operating on the idea that a trusted doctor or social worker could connect a medically vulnerable patient to treatment.

"I knew that the thing we needed to do is to have continuity of person," says Leah Holmes, the program's director and designer. "I said, 'I want that person to go into the prison, meet the inmate there, start to get an idea of what they're like and develop a plan with them.' When they come out, we have to implement the plan, and we also go with them to their medical appointments as a support."

The Rhode Island prison, the Adult Correctional Institutions, routinely screens inmates for infectious diseases, and when someone tests positive for HIV, Laliberte meets and connects them with either Tim Flanigan or Rich, Brown University medical professors and doctors who practice in both the prison and the Miriam Hospital. (The Miriam Hospital and Brown University are expanding services to parolees and jail inmates who have Hepatitis C and other chronic illnesses.)

Before an offender is paroled, Laliberte helps the client craft a discharge plan that includes health and medical goals. At his release, the inmate is given a month's worth of HIV medications and an appointment with Flanigan or Rich at the Miriam Hospital clinic, which Laliberte will attend with the ex-offender.

"We go to their appointments as a means of building relationships," Holmes, the program director, explains. "We used to have focus groups, and the one thing our clients would say over and over again was, 'I only came to care about my health care when someone else cared about it.' It was a critical piece."

Evaluations of Project Bridge show that this model of co-located doctors and intensive case management, which lasts 18 months, can lead to stabilized health, a high rate of medical care engagement and, in some cases, decreased recidivism for its clients.

Still, addiction is a frequent and complicating factor for Project Bridge patients. In another wing of the hospital that same morning, Laliberte, the social worker, split his time between securing HIV medications for an inmate who'd just been released to a substance-abuse program and sitting in on a psychiatric appointment with a client who was resisting treatment for heroin use. "The thing about people is that we fall back into patterns we've struggled with, and we don't change behavior very easily," Laliberte says.

Laliberte's perspective on drug use reveals a key tenet in the Project Bridge philosophy, which operates under a harm-reduction model — that is, drug and alcohol abstinence is encouraged, but not required. That relapsed addicts have the wherewithal to manage HIV care initially surprised even the Project Bridge doctors. "We started out thinking that Project Bridge will really work when you're clean," Flanigan says. "But our data has shown that Project Bridge still works even when you're using. That's really interesting to me. So we celebrate recovery, but we realize that an attempt is made and sometimes it fails, and that's life. We still want to be able to provide medical care for them."

In a study of the program's first three years, 82 percent of the patients — the majority of whom did not have health insurance — continued to receive medical care two years after release and six months after they complete Project Bridge. But only two of those patients remained completely drug free. In a second evaluation of Project Bridge covering the 2003-to-2005 period, 96 percent maintained their medical care one year after release, even though half did not have health insurance and 50 percent said they needed help with addiction.

Project Bridge isn't cheap — it costs $5,000 to $8,000 per client — but it clearly helps patients stay healthy. According to studies of the program, 18 months after release, the strength of HIV-positive patient immune systems and the intensity of their infections show no change from when the patient was released from prison, where they have close medical supervision. "This is an example of no news being good news," Holmes notes.

Whether medical interventions like Project Bridge can influence recidivism, however, remains unclear. A study by Flanigan that led to the development of Project Bridge found that female patients who received intense case management had a recidivism rate of half that of two control groups. "That was very encouraging," Flanigan says of the findings. "But that isn't always true across the board."

Research on female offenders released from New York City jails found that women with Medicaid were significantly less likely to be re-arrested than those without health insurance, although the authors note that their study doesn't prove causation. "It is possible that women who were able to obtain Medicaid differed from those who did not in some other way we did not measure," says Dr. Nick Freudenberg, a distinguished professor of urban public health at Hunter College. "The result is promising, but further study is required."

About 30 percent of Project Bridge patients are eventually reincarcerated, compared to recidivism rates that range from about 50 to 65 percent across the country. For those who are addicts, recidivism rates are higher. "There is a direct correlation between addiction treatment and incarceration," Rich insists. "Let me use my HIV patients as an example: The patients who have addiction problems and who get treatment, I see them at the Miriam Hospital. Those who don't follow up with their addiction, I see them back in prison."

A concerted national effort to increase the connection between jails and community health care has been taking shape since 2006, when the Robert Wood Johnson Foundation received an unsolicited letter from Paul Sheehan, a then-deputy sheriff in Hampden County, Mass.

"The letter described a unique public health model that we should take a look at — bringing community health centers into the jail — and they wanted to see if we would replicate what they were doing," recalls Nancy Barrand, a special adviser for program development with the foundation. "It was not even a proposal. It was more of a challenge."

The letter detailed a correctional health program in Hampden County that's often cited as a national model. The program operates a federal health clinic in the jail and then links ex-offenders to clinics in their neighborhood when they're released. As with Project Bridge, once released they see the same doctors and case managers who've been seeing them in jail. Because jail sentences tend to be shorter than prison terms, the program has been lauded for the speed with which it identifies and treats offenders and connects them to care in their neighborhoods.

Like Project Bridge, the AIDS epidemic drove the development of the Hampden County model. As the story goes, in the early '90s, a doctor at one of the neighborhood clinics began to notice that some of his patients weren't coming back for their medications, and he went in search of them. He ended up finding them at the local jail. "The doctor says, 'Hey, that's my patient,' and the sheriff said, 'Well, that's my inmate.' So a deal was struck so that these patients could get their HIV meds," Barrand recounts. "That led to more services coming to the jail, until they established a clinic within the jail and used it as a point of connection back to the community upon re-entry."

The co-located model seems to work well in small jurisdictions — states like Rhode Island and counties like Hampden — and it may also be successful in cities. The Robert Wood Johnson Foundation is funding Community Oriented Correctional Health Services, an organization based in Oakland, Calif., that encourages jails and community health providers to collaborate based on the Hampden County approach. COCHS, for example, has helped jail and health officials in Ocala, Fla., and Washington, D.C., develop programs, and New York City is developing a system similar to Hampden County's at Rikers Island, which holds about 14,000 inmates a day.

"On the community health center side, some are reluctant to jump into this because there's a lot of stigma in terms of providers going into jails," the foundation's Barrand acknowledges. "But we didn't have to do any convincing on the corrections side. There's an overwhelming demand."

In larger states, however, a model that has the same physicians treating offenders in prison and out seems less feasible, Project Bridge administrators acknowledge. "If this were New York state, you wouldn't be able to work in Schenectady and New York City," Flanigan says. "So how can that connection be made? Can a phone call help?"

"Distance makes a difference, but it is not an insurmountable barrier," says Holmes, who suggests directing case management resources toward the ZIP codes to which most inmates return to upon release. "Where are your prisoners coming from? Have someone from that area go in and visit them before they go out so they're not sent to someone they don't know."

Despite real logistics problems, across the country, states are paying closer attention to post-incarceration physical and mental health with a focus on parolees. In Kansas, Ohio and Washington state, for example, case managers work with offenders to create comprehensive plans that take physical or mental health into consideration before the inmates are released.

San Francisco's Transitions Clinic, in partnership with the University of California, San Francisco, and the city's Department of Public Health, serves California parolees with chronic illnesses who return to the city. The model has since inspired clinics for parolees in Santa Clara and Sonoma.

Specialized medical programs are not the only way to give former inmates better health care, public health experts say. One straightforward policy fix involves Medicaid coverage. Now, most states terminate Medicaid coverage when beneficiaries are sent to prison. But many experts say suspending coverage, rather than terminating it outright, would automatically improve ex-inmate health at low cost. "Termination requires people to re-enroll when they're released," explains Hunter College's Freudenberg. "It's a hard process, and many people didn't make it through."

The National Conference of State Legislatures and the Morehouse School of Medicine report that reconnecting prisoners to Medicaid upon re-entry and streamlining the eligibility process are key to reducing recidivism. An analysis by the state of Virginia also notes that there is no practical difference between suspending and terminating Medicaid benefits. But only seven states have made a move in this direction.

New York passed legislation to suspend, rather than terminate, Medicaid for inmates just last year. "It was a five-year process to change the law," says Freudenberg, an advocate for the legislation. "There was a consensus that Medicaid termination was not good policy, it didn't protect public health and it didn't save money to different levels of government. But there were amazing arguments against it.

"One was that the New York state Medicaid computer only had a category for 'terminate' or 'not terminate,' and to add a 'suspend' category would mean redesigning the whole computer system. There were also big political obstacles."

For years, compact and energetic Herb Ramey had been the poster boy for Project Bridge. He'd faced some serious challenges in his 50 years, including childhood sexual and physical abuse, and later, heroin addiction. When he first joined the program a decade ago, Ramey was known for churning in and out of prison every few months on possession charges and parole violations.

When he was released from prison in 2004, though, something inexplicably clicked. Ramey completed a two-year residential drug treatment program, started volunteering at the courthouse as a peer drug counselor, and eventually the courts gave him a full-time job. "To me, it was all right," he tells me in the prison visiting room. "I was wearing a suit and tie every day after going in there all those years in handcuffs. It blew me away. I never thought I'd get to that level. For two years, I was able to hold on."

When budget cuts forced the courts to trim services late last year, Ramey got laid off and he picked up a heroin pipe for the first time in four years. "I got depressed a little bit," he admits. "I was happy with myself when I was working."

At the end of January, he was arrested for selling a amall amount of heroin to an undercover police officer, and because of his criminal record, Ramey could serve up to five years. So on a brisk spring morning — the same morning, in fact, that Joseph surprised his Project Bridge contact, Don Laliberte, with his upcoming parole date — Ramey is stewing in his prison cell. His younger brother had died of an overdose over the weekend; he's angry with himself for slipping back into drug use. His self-loathing is palpable. "My whole situation changed in a day," he says. "I was doing a lot of things, and it was the highlight of my life. All I had to do was stay clean and things happened. But I didn't know how to hold onto it."

In addition to being angry with himself, Ramey says, he's sorry to be a disappointment to Project Bridge. "People from Bridge walk you through it," he says. "They sit in with you at the doctor and they kept up on my numbers, and now my viral load is undetectable and my CD4 count is high. I also have Hep C. I worry that my liver is going, but Bridge helps me with that. They provided me with a lot of wonderful things.

"And when I mess up, they never turned their back on me. But I let them down so many times already."

Laliberte is tracking Ramey's case. When it eventually goes to trial, Laliberte will try to go the courthouse. The social worker is also monitoring Joseph's parole date, and when the inmate is eventually released to the streets, Laliberte will deliver his client to as many doctor appointments as he can.

At his office less than a mile from the prison, Laliberte scours the list of new admittances to the prison every morning and hopes he won't see the name of a client.

"We just had another person who was out for five years in on a new charge," Laliberte says with studied equanimity. "Heartbreaking is too strong a word, but it's very upsetting. But you pull yourself together, and you try to support them. The ability to be there for someone is a great satisfaction for me. And it's satisfying to know that if they're getting better health care, there's a chance that the other things in their life will be a little more stable.

"There's a pragmatic aspect to all of this, too. If they're getting better health care and they're on their meds, they're probably also infecting fewer people."

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