Data-sharing relationships, even the use of simple tools such as spreadsheets, can be key to finding and addressing the needs of patients who are repeatedly cycling through systems and accruing significant costs.
Person-centered and trauma-informed approaches to patient engagement are useful in correctional settings and as part of reentry programs. When providers build authentic healing relationships, program participants are able to build trust, hope, and self-competence.
Investing time and resources in building the capacity of partner organizations helps to build the ecosystems of care that are required to serve people with complex health and social needs.
Many contemporary care redesign initiatives aim to change health care delivery to better serve patients who face complex medical, behavioral, and social challenges. Often, these patients require a combination of services across multiple sectors to adequately address their needs. Service delivery fragmentation, including lack of care coordination and data silos, leads to service redundancies and inefficiencies, driving up costs and perpetuating poor outcomes.
Much like the subset of individuals we see in health care who are experiencing high hospital use, people also repeatedly cycle in and out of correctional facilities. When these individuals are released back into the community, many rely extensively on hospitals, rather than on outpatient primary or specialty care, for their health care needs. Underlying the patterns of health-care and justice-system cycling are interrelated health and social needs, including chronic medical conditions, mental illness, addiction, poverty, housing instability, psychological and physical trauma, and more, all complicated by systemic, intergenerational racism.
People who are incarcerated carry their health needs with them. Take the case of Vincent (known to friends as “Country”), who was struggling with long-standing, poorly managed asthma, diabetes, mental health diagnoses, and a substance use disorder — in addition to a lack of stable housing — when he was most recently incarcerated in Camden, New Jersey. Country’s inability to manage his health conditions contributed to a missed meeting with his parole officer, which resulted in his third jail incarceration in a year. Despite many emergency department visits, inpatient stays, and health assessments in the jail, Country’s underlying needs were not being addressed.
For people like Country who experience extensive hospital and criminal justice system cycling, each institutional touch point represents an opportunity to intervene. However, a number of barriers make it challenging to respond to the multifaceted needs of correctional populations. Federal law requires correctional facilities to provide health services, but the quality and quantity of services vary across states and types of correctional facilities.
Furthermore, both copays for medical visits and the environment of the correctional facility can discourage people from seeking care. In a 2009 study of incarcerated individuals with medical needs, two-thirds of those in jails and one-fifth of those in state prison did not receive a medical examination during their incarceration. That same study also showed that fewer than one-half of the people in jail who had been taking a psychiatric medication prior to incarceration were continuing to take that medication while incarcerated. In addition, once individuals are released, their rates of health care access beyond the hospital are low. Even though many individuals are enrolled in Medicaid prior to incarceration, their Medicaid benefits will either be suspended or terminated altogether (depending on their state of residence) when they enter jail or prison. Often, these newly uninsured individuals then turn to the emergency department as a primary source of health care.
In Camden, New Jersey, the Camden Coalition of Healthcare Providers (Camden Coalition) works alongside community partners to connect service delivery and data silos in order to improve outcomes for the region’s most vulnerable residents. Suspecting that there was an overlap in the populations served by the health care and criminal justice systems, we enacted a data-sharing relationship with the Camden County Police Department in 2015 to combine arrest data with all-payer claims data from the regional hospitals with which we had long-standing data-sharing relationships.
By combining these data sets, we identified a subset of people who had extensive contact with both hospitals and the police. We found that 67% of Camden residents who had been arrested by the police at any time between 2010 and 2015 also had at least one emergency department visit or inpatient admission during that same period and that a small subset had extreme patterns of dual-system contact. Specifically, 5% of individuals in the combined data set accounted for 25% of all arrests and had ≥10 emergency department visits over the 5-year period. Those individuals had a very high prevalence of mental health and substance use diagnoses in the hospital, and many were experiencing homelessness during at least one of their hospital visits or arrests.
In light of these findings, we asked ourselves, “How can we work with the criminal justice system to improve outcomes for individuals experiencing extreme patterns of dual-system cycling?”
Because it is person-centered, trauma-informed, and strengths-based, we suspected that our signature complex care intervention, the Camden Core Model, would be a good fit for addressing the complex needs of individuals who cycle repeatedly through the health care and criminal justice systems. For over a decade, we have received funding from multiple philanthropic foundations, payers, and government agencies to deliver wraparound care management to individuals with extreme patterns of hospital utilization in Camden and the surrounding area. Working with patients at the hospital bedside and in the community, our care teams empower patients to make positive, self-directed changes toward improved health and well-being.
We wanted to build on what we’ve learned through the Camden Core Model to understand whether and how we could be effective in improving the health and well-being of this population while reducing their reliance on hospitals for health care and their involvement in the criminal justice system.
We began the pilot against the backdrop of criminal justice reform in the state of New Jersey. On January 1, 2017, New Jersey passed a bail reform law that replaced cash bail with a system in which a risk-assessment tool is used to determine pretrial release eligibility for people arrested for misdemeanors or low-level felonies. In the first year of bail reform, New Jersey saw a 20% reduction in its pretrial jail population.
Camden County launched a bail reform pilot program in 2016. The county had been working to reduce its jail population since 2009, when the average daily population of 1,686 exceeded the facility’s limit by nearly 400 individuals. Now, the jail population is down to just over 800, a change partly facilitated by the state’s bail reform law, leaving more resources for reentry initiatives. In 2017, the Camden County Department of Corrections spearheaded the Camden County Reentry Committee, a cross-sector group that facilitates communication and collaboration among reentry initiatives. At the time, several reentry initiatives existed in the county, including those run by the county and two large-scale programs operated by the Volunteers of America Delaware Valley.
A Camden Coalition team met with the warden, lieutenant, and population manager of the Camden County Correctional Facility (CCCF) in 2016 to discuss the potential for a reentry program focused on the most medically and socially complex people in the facility. We learned of the jail leadership’s commitment to identifying ways to better address the needs of this group and their frustration with past efforts to prevent these individuals from returning to jail. The Camden Coalition’s reputation as a trusted community partner appealed to jail leadership, who supported our proposal to launch a small reentry pilot and granted permission for our care team to engage individuals while they are incarcerated.
The Camden Coalition brought a unique perspective to the table when we joined the Camden County Reentry Committee in 2017; specifically, we offered expertise based on our work with patients who have complex health and social needs, and we were the only reentry program in the county to work with the pretrial population.
The Camden Coalition’s approach to care redesign is to start small, to learn and adapt, and to scale if and when the data suggest that we are making an impact. With funding from Arnold Ventures, we planned to engage a small group of individuals incarcerated in the CCCF in our jail-based reentry pilot, Camden RESET (Re-Entering Society with Effective Tools). To enroll participants, we combined data from the Camden Coalition Health Information Exchange (HIE) with data from the CCCF to identify individuals in the jail who, in the past year, had at least three stays in the CCCF and either a minimum of four emergency department visits or two inpatient admissions.
Identifying Camden RESET Participants
Several times per week, the population manager at the CCCF sent spreadsheets listing bookings, releases, charges, and aliases to the Camden Coalition analysts. Using the jail’s common booking identification number, our analysts reformatted and imported the data from each spreadsheet into our own database and created one record per period of incarceration. The analysts then identified the individuals who had three or more jail stays within the previous year and created a spreadsheet listing the demographic characteristics and jail histories of those individuals. The Camden RESET care team then used personal identifying information from that spreadsheet to find potential participants in the Camden Coalition HIE, basing eligibility on past hospital use and Camden residency.
The care team included a registered nurse, a community health worker, and a program manager with a social work background. Through our Camden Core Model, we found that talking with individuals in the hospital provides a continuity of care that leads to higher engagement rates than is the case if enrollment occurs after discharge. For this reason, the registered nurse and program manager engaged eligible individuals together at the CCCF and invited these individuals to enroll in Camden RESET.
Our patient-centered care planning also began in the jail, with the care team helping participants to prioritize their needs and prepare for community reentry. To start building rapport with participants, the care team used the Camden Coalition’s signature COACH framework, which helps us to build authentic healing relationships that empower patients to take control of their health. As soon after release as possible, the RESET care team met participants wherever they were — for example, at a day program, a transitional housing facility, outside of the jail as they were released, or at their home.
Throughout the intervention, the care team drew on the Camden Coalition’s network of local social service providers to provide wraparound care management, accompanying participants to appointments and helping them navigate agencies and services such as housing, mental health services, and substance use treatment. The team also provided legal accompaniment — for example, going with participants to court, making statements or writing letters on their behalf, and coordinating with probation officers. The Camden Coalition’s medical-legal partnership attorney was available to provide legal consultation for Camden RESET participants and staff as needed.
The Camden RESET care team enrolled 16 participants beginning in December 2017. Fourteen of the participants were men, eight were African American, and four were Hispanic. The average age at the time of enrollment was 36 years. The team used data from the Camden Coalition HIE and local hospital electronic medical records to learn more about participants at the time of enrollment. The numbers of participants with specific characteristics are shown in Table 1.
Staff Time and Effort
The median duration of intervention was 175 days for Camden RESET participants, compared with 80 days for Camden Core Model patients. The average time spent on direct engagement or care coordination was 71 hours per individual for RESET participants (Table 2), compared with 46 hours per individual for Camden Core Model patients. The most time-intensive domains were behavioral health and social care needs, underscoring the care navigation needs of individuals being released into the community after incarceration.
There is no time limit on the intervention; our care team works with participants until they “graduate.” Participants were considered to have graduated from the program once they were stabilized in the community and were making progress toward achieving the goals that they and the care team had set earlier in the intervention (e.g., finding employment, securing stable housing, finishing a GED, improving management of a chronic illness, maintaining sobriety, reconnecting with family, etc.). As of July 23, 2019, seven participants had graduated, four had been lost to contact after return to the community, three had been lost to contact after being re-incarcerated, and two had declined further services.
The Camden RESET panel was too small for us to draw firm conclusions about the impact of the intervention on hospital utilization and criminal justice recidivism, but the utilization outcomes have been promising. For the seven participants who completed the program, the number of emergency department visits after RESET enrollment was 37% lower than the 1-year pre-enrollment period, hospitalizations were 57% lower, and CCCF jail incarcerations were 80% lower.
The RESET intervention was the Camden Coalition’s first foray into explicitly serving this population and represented the first time that we enrolled people while they were incarcerated. Along the way, we had difficulties addressing our participants’ social and behavioral health needs and faced challenges working within the criminal justice sector.
Meeting the Needs of RESET Participants
Over the course of the Camden RESET intervention, we learned that people with complex health and social needs who have extensive contact with the criminal justice system require more coordination — and require it much sooner — than the average patient enrolled in the Camden Core Model. In the words of the RESET team’s registered nurse:
“We move as quickly as possible to get things back together for them, so we can start putting all the pieces back. But it’s a really tough period. It’s really even hard for us. When we have a release that week, it’s exhausting. And for the participants, the transition of going from a completely structured place right into no structure means that all their needs, all their family stuff, everything just floods back in. All these things were on pause and then they’re back. Being in jail is really stressful, and then getting out of jail is really stressful, and there’s no break.”
The lives to which the Camden RESET participants returned after incarceration were often more chaotic than the RESET care team realized, particularly with regard to housing. At enrollment, several RESET participants indicated they would have stable housing upon their release from jail, but to those participants, reliable housing meant having somewhere to go on the day of release. However, this temporary solution was clearly not an answer to a person’s need for long-term housing stability. Of the 16 participants, seven needed to find housing immediately upon release. The RESET program manager described the importance of housing people immediately:
“When we say we need to focus on housing immediately, we’re really saying that we need to make a person safe enough where they can focus on other things and be willing to engage with us. And if they’re telling us ‘I can’t go to the shelter and I don’t have family or friends, and my only other option is the street,’ we know they will not be safe. The mental wear and tear of not having a safe place to stay slowly shifts a person’s focus away from what they’d like to accomplish to what they feel they need to do to survive.”
Interim housing options are limited in Camden, and many participants expressed that they would not feel safe in a group house. The care team placed most of these participants in a hotel, which posed challenges. In particular, going from the jail, where the entire day’s schedule was mandated, to the unstructured reality of living in a hotel often triggered emotional distress in participants with mental health needs. Often, this distress manifested as suicidality. Because participants’ safety was essential, the care team created “behavioral contracts” to provide guidelines for individuals who were struggling with the lack of structure. The contracts outlined specific expectations for participants that were designed to help keep them stable, including attending medical appointments and drug treatment programs. Continued housing support was not predicated on strict adherence to the rules — rather, contract violations were treated as opportunities for conversations about what type of support participants needed.
Substance use also significantly affected participant stabilization and the care team’s ability to engage participants after release. While some participants frequently used alcohol, opioids, and cocaine, our care team also saw a notable rise in the use of K2, also known as synthetic marijuana or spice. K2 is a legal, relatively inexpensive, dangerous drug that can cause psychosis, catatonia, and erratic behavior. While there is little research exploring the prevalence of K2 use in general, our RESET and Camden Core Model care teams have anecdotally reported increasing use of the drug among our patients, seemingly because of its low cost and because its legal or semilegal status makes it difficult to detect through standard drug testing.
Working within the Criminal Justice Sector
The challenges that we experienced were not unique to the CCCF, and, overall, collaborating with jail staff was an overwhelmingly positive experience. Leadership were responsive to the care team’s needs and requests, always helpful, and aligned with our approach to engaging people in the jail and supporting their reentry process. The most pressing issue that the team faced was not knowing when RESET participants would be released. Although this issue eventually was resolved for people who were connected to a reentry program, a gap between jail medical staff and jail administrative staff around release coordination was not fully resolved. Jail staff do not always have the opportunity to review medical paperwork upon a person’s release from the facility and therefore do not know when they should coordinate with the jail health care provider to ensure that people were discharged with appropriate medications.
In fact, a very challenging aspect of working within the CCCF was the bureaucratic hurdles to medical and behavioral health care delivery. For the Camden RESET care team, understanding and addressing the deeper and ongoing medical, behavioral, and social problems that incarcerated individuals themselves define as important is key to building trust and helping people change the course of their lives. In contrast, jail-based medical and mental health providers, who are employed by a third party rather than by the CCCF, focus on addressing what they define as being the most urgent needs and do not always prioritize the underlying needs that may be driving an individual’s cycle of emergency department use, arrest, and incarceration. Also, jail-based health care providers did not consistently ensure that people have their routine medications, including psychiatric medications, during their incarceration. This gap was partly a logistical and legal challenge: Staff would have to verify that the person had been taking medications consistently prior to entering the facility and were hesitant to start a new medication protocol in the jail.
CCCF staff were eager to improve care inside the jail and coordination of services upon a person’s release from jail. A testament to this resolve is that the CCCF jail health care provider now contributes data to the Camden Coalition HIE, which represents a significant gain for continuity of care in the region.
The Value of Engaging People in Jail
Although the environment is stressful, jail provides temporary stability, giving the care team time to learn about individual participants and their goals and to begin building the relationship that will be so crucial to maintaining a connection to participants once they return to the community. The Camden RESET team’s registered nurse expressed the value of engaging people in the jail as follows:
“The nice part about meeting people in the jail is that you know they’ll be there. And the environment is so devoid of stimulation that it’s easy to get into deeper conversations. When people are in there, it seems to me that they’re in a more contemplative state, so it’s a little easier to get down to what is important to them and learn what’s been going on in their lives.”
Beginning the relationship with participants before they leave the jail helps the team to prepare the participants for what they will need upon return to the community. At times, the care team plays the role of holding jail personnel accountable to their obligations in the reentry process. The RESET team’s community health worker expressed the importance of this role, noting that:
“When people come out of the jail, there’s often no support and no coordination between services in the jail and services outside. They are just kind of thrown out, and everything they might have been getting help with in the jail stops. A good example is when [name withheld] was released, he was supposed to have been given three days’ worth of meds — which is protocol. But that didn’t happen. Luckily, we met him right when he was released, and we asked if he had his meds and he was just like, ‘Nah, they never gave them to me.’ So, we went to the jail medical provider and were able to get his meds for him right away.”
Building Hope, Trust, and Competence
A person’s life is much more than an encounter in the hospital or in the jail. RESET participants expressed a desire for a “normal life,” but many forces work against that possibility upon release. With this in mind, RESET staff played a critical role in supporting people as they navigated complex systems after their release from jail. By developing authentic healing relationships with participants, engaging them consistently, and showing them that they can solve problems, the Camden RESET care team helped to restore participants’ hope and trust in themselves and others. This process also bolstered participants’ confidence in their own ability to manage competing responsibilities and obligations and to make choices that could lead to positive outcomes. During an interview with the Camden Coalition’s evaluation team, one RESET participant framed the value of the program as follows:
“It’s a light in a darkness . . . the team has been so helpful to me, and I feel so much better than I did the day that I got out. And I thank God the people from the Coalition found me, because I don’t know where I would be right now. Out there freezing, I know that. I was happy to get out of jail, but that happiness lasted until I realized that ‘Okay, I’m out. Now what?’ And when my aunt wouldn’t let me stay with her, I was like, ‘Oh, might as well do what I know how to do. At least if I drink, I won’t feel it.’ But I haven’t had the urge to drink, haven’t had the urge to use a drug. Having that help from the program just strengthened my resolve.”
Another RESET participant described the importance of authentic healing relationships between participants and the RESET care team:
“The team rejuvenated me. They showed that they wasn’t just doing their job, which was enough. Just doing their job was enough. But they genuinely cared. They genuinely put forth an effort and they got other people to understand my point of view. My lawyer stepped up then. The judge started listening. And now everybody’s paying attention. And this is what I needed. I needed this. So, it’s a great blessing for me.”
Building a Community-Wide Ecosystem of Care
Camden RESET never would have gotten a start, and never would have achieved the success that it did, if the Camden Coalition hadn’t prioritized community engagement and capacity-building efforts. Our program was designed not only to provide direct patient care, but also to build a community-wide ecosystem that connected organizations serving people with complex health and social needs who are reentering the community from jail. In fact, we earmarked nearly one-fifth of our RESET budget to cover the costs of strengthening the community’s capacity to address the needs of correctional populations. These activities included participating in the Camden County Reentry Group, updating our data-sharing agreement with the police department, and helping the Camden County Department of Corrections to improve their reporting system.
The Camden County Reentry Group was a forum for identifying shared challenges and amplifying the efforts of the groups around the table. As a group, we were able to advocate for a “safe release” policy to ensure that individuals who are connected to any reentry program in the county are released from CCCF during business hours and that their case worker is alerted to the release. This policy represents a significant change that goes a long way toward improving the continuity of care between the jail and the community. The group also worked to support the county’s successful application for a MacArthur Foundation Safety and Justice Challenge grant, which provides support and technical assistance to enact local criminal justice reforms.
Where to Start
Adding value to existing collaborations through content expertise, networks, and support can all be ways to build trust with organizations working on similar issues. Actively contributing to the groups, and listening carefully to the barriers that these groups are facing, can help your organization understand the value that you bring to this work. Also, rather than creating a brand-new intervention, assess your existing efforts to determine whether they are adaptable for a new population. Doing so will help your staff make the transition more smoothly and will allow you to use what you’ve learned from other work to inform the new program.