1. A health needs assessment for individuals leaving Boston-area jails
Transitions Home
A health needs assessment for individuals leaving Boston-area jails

2. About the project
Thanks to the generous support of the Massachusetts General Hospital Department of Medicine Community Council
Team:
Matthew Tobey MD MPH
Lisa Simon DMD, HMS Class of 2020
Josephine Fisher, HMS Class of 2020
Leo Eisenstein, HMS Class of 2019

3. Community Transitions after Incarceration
Hazards of incarceration
Disproportionate burden of chronic illness, SUDs, poor oral health, serious mental illness
129-fold risk of death from overdose just after release (NEJM 2007)
Suffolk County
6,000 detained per year in short-term jails
20 released per day
Gaps in post-release health access due to limited workforce and uncertain release dates

4. Ongoing Work Crimson Care Collaborative at Nashua Street Jail
Four years observing the discharge planning process
Albert Schweitzer Community Fellowship → patient navigator pilot
Other grant-funded projects (MMS, SAMHSA, Gold Foundation)
Understanding the reentry landscape
What are best practices nationally?
What is happening in Boston?

5. Methods Conversations with best-practice programs
Rikers Island
Montefiore Hospital
NYC Dept of Health & Mental Hygiene
Los Angeles Dept of Health
Transitions Clinic Network
Semi-structured interviews with local stakeholders
Department of Corrections
Probation officers
Physicians
City officials
A job training program
Community-based organizations
An important next step: interviews with individuals affected by incarceration

6. Academic Medical Centers - Successes
Pre-release care coordination for SUDs (BMC) 01
Transitions clinics 02
Substance use-related clinics and programs 03
Academic Medical Centers - Successes

7. AMCs - Challenges 01 02 03 04 05 06 Provider knowledge gaps Stigma
Communication barriers 01
Appointment scheduling 02
Provider knowledge gaps 03
Stigma 04
Patient health literacy 05
Insurance barriers 06
AMCs - Challenges

8. AMCs - Opportunities Targeted clinical and community programs
Engagement with pre- and post-release navigation
Inreach programs
Increased access to dental care
Trainee, provider and staff education
Establish employment programs
AMCs - Opportunities

9. Next steps Convene stakeholders Publish report Qualitative analysis
AJPH / RWJF supplemental issue: “Mass Incarceration as a Social- Structural Driver of Health Inequalities” (Due April 2019)
Align next steps with ongoing funded work

10. Thank you to the DOM CC for its support!
Visit our website: me/about-project
Contact us:
Thank you to the DOM CC for its support!