Addressing the Unique Needs of Patients Returning Home from Prison and Jail Aaron Fox, MD, MS, Assistant Professor of Medicine Albert Einstein College of Medicine/Montefiore Medical Center; Attending Physician, Comprehensive Health Care Center Beth Hribar, MPP, Program Director Institute of Advanced Medicine of the Mount Sinai Health System Martha A. Sparks, PhD, Associate Director Mental Health Services, Spencer Cox Center for Health, Institute of Advanced Medicine of the Mount Sinai Health System Collaborative Family Healthcare Association 17 th Annual Conference October 15-17, 2015 Portland, Oregon U.S.A. Session # C6b, Period 6 October 17, 2015

Faculty Disclosure The presenters of this session have NOT had any relevant financial relationships during the past 12 months.

Learning Objectives At the conclusion of this session, the participant will be able to: 1.Describe how the high rate of incarceration in the United States affects the health of returning citizens and communities of color. 2.List barriers to care and care engagement for returning citizens in traditional models of healthcare delivery and changes that can be made at the clinic level to address these barriers. 3.Describe features of culturally sensitive healthcare for individuals returning home. 4.Identify at least one benefit of having a formerly incarcerated individual as a member of the care team.

Selected References Binswagner, I.A. et. Al. (2011). "From the prison door right to the sidewalk, everything went downhill," a qualitative study of the health experiences of recently released inmates. International Journal of Law and Psychiatry, 34(4). Carson, E. A. (2014). Prisoners in Bulletin from the United States Department of Justice. Retrieved from: Cloud, D. (2014). On life support: Public health in the age of mass incarceration. Vera Institute of Justice. Retrieved from mass-incarcerationhttp:// mass-incarceration Drucker, E. (2011). A plague of prisons: The epidemiology of mass incarceration in America. The New Press: New York. Glaze, L. E., and Kaeble, D. (2014). Correctional populations in the United States, Bureau of Justice Statistics. Retrieved from:

Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

Outline 1.Background: serving the formerly incarcerated matters 2.Barriers post-incarceration 3.The Transitions Clinic model -Bronx Transitions Clinic -Coming Home Program

Prisons are overflowing

Chronic Health Conditions Overrepresented Among Inmates Chronic ConditionPrevalence in Jail/Prison Population DifferencePrevalence in General Population Diabetes8 – 11%>6.5% Hypertension28-31%>26% HIV %>>0.5% Hepatitis5 – 6%>>1.3% Any mental health condition 26%-33%>>10% Substance Use Disorders 62%>>>5% CASA Behind Bars; Wilper AJPH 2009

Incarceration history in primary care Survey Question Percent of sample (N = 118) Current, criminal proceedings18% Current, family member incarcerated18% Ever arrested25% Ever, family member arrested55% Ever incarcerated18% Ever, family member incarcerated51% Shah JHCPU 2009

Medical care post-incarceration

Reentry and mortality * 12x increased risk of death Binswanger. NEJM Deaths per 100,000 person-years By weeks after release

Barriers to medical care post-release Barrier to careIntervention Individual-level Competing Priorities (housing, employment, etc) Mistrust Relapse to substance use Mental health/Trauma Transportation Provider-level Stigma Uncaring Demeanor Systems-level Costs Health Insurance Long waiting times Van Olphen J Urban Health 2006; Binswanger Int J Law & Psychiatry 2011; Richie Crime & Deliquency 2001

Transitions Clinic Models Hong et al. 2011

Community Heath Workers

Overcoming barriers to care BarrierTransitions Clinic Intervention Competing PrioritiesOsborne Association (OA) – Case Management MistrustCommunity Health Worker Relapse to substance useOA, Buprenorphine Treatment Uncontrolled mental health*Referral TransportationMetrocards, van StigmaCultural Competence Training Uncaring DemeanorMs. Diaz CostsFQHC Health InsuranceMedicaid Enrollers Provider waiting timeOpen access session (Saturday)

Bronx Transitions Clinic

Overcoming barriers to care BarrierTransitions Clinic Intervention Competing PrioritiesCase management from Coming Home Coordinators MistrustCommunity Health Worker Relapse to substance useOA, Buprenorphine Treatment Uncontrolled mental healthIntegrated behavioral health TransportationMetrocards, van StigmaCultural Competence Training Uncaring DemeanorFormerly incarcerated staff CostsACA enrollment Health InsuranceHEAL Center Provider waiting timeOngoing challenge!

Provider Training Curriculum

Acknowledgments Richard Medina, Osborne Association, Bronx Transitions Clinic patients The Coming Home Team: Mary Johnson, Kimalee Garner, Iris Bowen, Monique Carter, Donna Hylton Victoria Sharp, MD, Former Director of the Spencer Cox Center for Health