Academic health centers (AHCs), particularly those that are publicly funded institutions, have as their mission the treatment of disadvantaged populations, the training of the next generation of clinicians, and the development and dissemination of knowledge to reduce the burden of disease and improve the health of individuals and populations. Yet, only a small proportion of AHCs have reached out to incarcerated populations to fulfill their mission. Incarceration rates in the United States have increased more than threefold since 1980, and the United States incarcerates more individuals than any other country.1 On any given day, 1 in 108 adults is incarcerated, with a disproportionate risk of incarceration for minorities. AHCs have an opportunity to fulfill their mission by serving this disadvantaged population through collaboration with correctional facilities and systems.2,3
Only a few states’ correctional systems have partnered with an AHC to provide care for inmates, rather than outsourcing care to private providers or providing the services themselves. These states are Texas since 1978,4 Connecticut since 1997,5 Georgia since 1997,6 New Hampshire since 2001,7 Massachusetts from 1998 to 2013,2 and New Jersey since 2005.3 These AHCs implemented health system reform while improving care and controlling costs.4,8
Most AHCs remain hesitant at best about the potential institutional benefits of a commitment to correctional health. Common among their concerns are the value and popularity of “training behind bars”; the cost, liability, and pragmatics of caring for a medically complicated population; and the viability of correctional health research and extramural research funding. From the perspective of those AHCs actively engaged in correctional health care delivery, we have addressed these concerns in our practice and found the benefits of such partnerships numerous. In this Commentary, we discuss these concerns, how existing partnerships have overcome them, and the benefits to both AHCs and correctional facilities.
The Case for Improving Public and Population Health
Disease burden is most prevalent and acute in incarcerated populations,5,9 who face multiple unique medical challenges.10 Thus, working with this population provides numerous opportunities for improvements to care delivery and training for all clinical disciplines.
Health disparities are arguably the most extreme in this population, even in comparison with disparities in inner-city populations. Those who become incarcerated typically are uninsured or eligible for Medicaid.11,12 They tend to have low use rates of community-based care, which could be due to lack of access or personal choice. Correctional systems, however, have the potential to become integrated into medical home models and to build on continuity-of-care systems.12,13
In addition, the public’s health is directly affected by the health of this population. Over 95% of inmates return to the community.14 If, during incarceration, their illnesses are recognized, their health statuses improved, their knowledge of illness self-management increased, their medications optimized, their addictions addressed, and their ability to regulate their emotions and relationships with others enhanced, the community benefits when they return.10,15–20 For example, adaptations or de novo development of harm reduction techniques used in these settings provide an excellent framework for how to improve function for these patients, both while they are incarcerated and when they return to the community.
Most prison systems, and many large jails, are single-line items on the state or county budget, creating global capitated populations that have grown given the increasing prevalence of incarceration.4,8 Yet funding streams have either not kept pace or remained flat. Moreover, long-standing federal statutory exclusions of inmates from Medicaid and Medicare benefits leave state and local governments without federal financial support. In particular, the high prevalence of serious mental illness and chronic infection as a result of injection drug use carry very high pharmaceutical costs. Yet, AHCs have done little to use these opportunities to model optimum managed health care and population health.
AHCs have much to offer correctional systems—providing expertise in evaluation, quality improvement, evidence-based practice, and implementation science—to address these and other challenges. Indeed, correctional care provides an excellent environment for academic physicians to develop population health skills. Developing structured care-transformation efforts within this fully capitated care system may inform similar community efforts already underway. Such efforts include the development of accountable care organizations and capitated public insurance systems. Similarly, AHCs benefit from working with state Medicaid departments.21
AHC leaders may worry about risk management in providing care to a high-risk population, for whom a constitutional mandate for care exists. For example, physicians who provide care to an inmate population are more likely to face lawsuits. Such litigation then diverts their limited time from patient care. Of note, however, is that the cost of litigation is ultimately absorbed by departments of corrections or the state, not the AHC. Since changing from a risk-based contract with a private, for-profit corporation to a cost-based agreement with a Rutgers University–affiliated AHC in 2008, the New Jersey Department of Corrections (the state’s prison system) has had fewer litigations and no payouts to inmates to date. We believe that medical staff decisions based on medical necessity and the absence of financial incentives to restrict care are responsible for this change. Thus, such partnerships could create savings for states. AHCs also recognize the importance of attending to patient satisfaction, service recovery, and advocating for the health needs of patients, all of which reduce the potential for litigation. In support of health care providers, AHCs bring a culture of education, peer support, and quality improvement that translates into improved health outcomes.
Health care providers have other pragmatic concerns as well. Many unfamiliar with a correctional environment express concerns about safety. In fact, the rates of assaults and violent acts by inmate patients against health care staff working within the Departments of Corrections in Connecticut, New Jersey, and Massachusetts consistently have been below those found in the community. For example, over the past 12 months, only 1 in 2,000 health care staff working in a correctional setting in these three states was assaulted. This rate of 0.5 assaults per 1,000 people falls below the national rates of 0.9 per 1,000 for health service workers, 1.5 for social service workers, and 2.5 for nursing and personal care facility workers.22 In fact, we believe that the intensive employee orientation and ongoing staff training about security and boundary issues leads to greater staff safety in correctional settings than in community settings.
Next, specialty care may require that inmates are transported to the AHC for treatment, and hospital leaders worry that being in the midst of inmate patients, who are readily identifiable because of their jumpsuits, shackles, and armed security staff, may make other patients nervous or unhappy. A common strategy to address such concern is to establish a separate, secure, dedicated clinic setting for care delivery to inmates. In addition, corrections officers are present to ensure public safety. Telemedicine consultation is also rapidly evolving as a means to care for this population without transporting them to a hospital. Finally, for procedure-based services, such as orthopedics, renal dialysis, and ophthalmology, clinics often are scheduled at the correctional facility.
The Case for Clinical Training
Training students in correctional settings can demonstrate the value of providing meaningful care to the disadvantaged and educate developing clinicians on the critical importance of primary and chronic disease care management. Supervised rotations and internships are routine in several systems; for example, in the past year, the University of Connecticut has hosted over 100 nursing, social work, psychology, pharmacy, and physician trainees in Connecticut’s jails and prisons. Adult and child psychiatry residents complete rotations, with faculty supervision, in jail and prison settings, with acute and continuity experiences, respectively. Residents who have completed these rotations in recent years (n = 58) rated the experience a 4.9 out of 5 (5 = excellent). Rutgers University, in collaboration with the New Jersey Department of Corrections, developed a forensic psychiatry fellowship and funds positions for psychiatric fellows and psychology interns. Both the University of Massachusetts Medical School and Rutgers University offer interdisciplinary training experiences for medical and nursing students in prisons. Nova Southeastern University College of Medicine developed a fellowship in correctional medicine, which has now been recognized by the American Osteopathic Association as an official specialty. The Universities of Connecticut and North Texas are implementing similar accredited programs. Further, academic detailing—integrating academic faculty into the clinical workforce in these settings—can support ongoing care improvement in correctional facilities.
Care delivery in such settings also requires a unique set of competencies seldom taught in traditional training.23 For example, serious mental illness, HIV and HCV infection (as well as coinfection), and substance abuse, all prevalent in inmate populations, provide opportunities for training in psychiatry, infectious disease, and addictions treatment.
A related concern to training students in correctional settings is faculty development. Faculty may fear that their participation in correctional health care delivery will not contribute to their professional advancement. We have seen this concern addressed in multiple ways. For example, faculty may spend all or part of their clinical time in a corrections setting; their teaching and research may or may not be directly linked (as is the case with all faculty). Opportunities for career development and promotion for faculty working in corrections settings include such initiatives as curriculum development, clinical program creation or enhancement, and applied/translational research. While the use of medical educator or clinician–faculty tracks is common, opportunities exist for academic development as scholars, educators, and clinical researchers.
The Case for Research
Our research findings have been consistent with the findings and recommendations of the 2007 Institute of Medicine report on research with prisoners—incarcerated populations have become an understudied group.24,25 For example, we know little about appropriate adaptations of care for correctional environments or about the best ways to address disease burden and care management in this population. Thus, more research is needed to answer questions such as, “How do we adapt the chronic illness care model to enhance diabetic patient self-efficacy in an environment where patients cannot monitor glucose levels, self-inject, or handle syringes?” The implications of conducting such research extend well beyond the boundaries of the prison walls. This work may provide insight into more effective engagement of disenfranchised populations in general. The need to educate, empower, and engage patients who suffer health disparities is clear.9,11–13 Correctional research may provide further understanding about how to achieve enhanced population health.
The three public AHCs featured here—the Universities of Connecticut and Massachusetts and Rutgers University—each have developed full-scale care delivery systems for inmate populations within their states. In turn, they have benefited from the development and dissemination of innovative programs addressing the complex needs of these populations. All AHCs are struggling to develop viable financial models that fit the rapidly changing clinical reimbursement and research funding climate. Working collaboratively with state and county correctional systems may provide both a stable income stream for AHCs and excellent clinical training opportunities, a learning laboratory for exploring evolving care delivery models for high-risk populations, and global risk or managed care contracting. Many AHCs currently lack the administrative and practical skills required for financial risk-based population management. However, the knowledge required to negotiate and manage a risk-based contract for population-based care is almost certainly needed for financial stability as health care evolves in the coming years. Correctional health care contracts may offer AHCs an opportunity to develop and refine these skills.
AHCs are mission-driven institutions. Partnering with correctional facilities to provide health care offers opportunities for AHCs to fulfill their core missions of clinical service, education, and research, while also enhancing their financial stability, to the benefit of all.
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