Friday, August 30, 2013

Better Linkages to Healthcare Needed for Ex-Offenders

For the past few decades, the direction and focus of corrections policy has been impacted by scholarly research, evidence-based practices, and a focus on improved outcomes in public safety and reduced recidivism.

On the correctional healthcare front, better linkages to community care for ex-offenders to improve continuity of care and personal and public health outcomes have grown considerably.  Costs associated with providing constitutionally mandated healthcare for an increasingly aging inmate population with prevalence rates of chronic diseases often 3 or 4 times the rate seen in the general public reach as high as $10 billion a year.

The national economic slump and sluggish recovery caused state and local governments to adapt to cuts in funding and resources. As a result, elected officials, voters and of course corrections professionals also had to adapt by setting their priorities, identifying efficiencies, improving outcomes and reducing duplication and redundancy of services.  This trend in reductions in correctional budgets has offered a unique opportunity to rethink how we “do” corrections and correctional healthcare.  This has opened a door of opportunity to re-imagine how to better serve inmate populations living with HIV/AIDS.

More than 2.5 million individuals are correctional inmates in the United States.  1 out of 100 adults are behind bars in our country. Over 700,000 prisoners return to the community every year.

Each year, an estimated 1 in 7 persons living with HIV pass through a correctional facility. A reported 20,093 inmates with HIV/AIDS were in custody in state or federal prison at year end 2010. These figures do not include numbers from local/county jail facilities.

On any given day, one-third of America’s inmates are in jails, but nine million individuals pass through jails in any given year. A jail is a facility in which the inmate is held for a shorter period of time, serving a sentence that is usually less than 1 year, or awaiting transfer to other facilities after conviction.  Inmates remain in jails for much shorter stays than in prisons, which results in significantly greater turnover in jail populations.

The costs, both in terms of human suffering and quality of life as well as in impact on strained public resources, is immense:

  • Future treatment for the 40,000 people infected with HIV in the United States every year will cost $12.1 billion annually.
  • The drug mix that an HIV patient must take can cost between $15,000 to $30,000 a year. The average price is about $20,000.
  • Discontinuation of antiretroviral therapy (ART) that is often associated with poor linkages to care for formerly incarcerated individuals returning home to their communities may result in viral rebound, immune decompensation, and clinical progression, resulting in higher costs of care and treatment

These circumstances pose important opportunities and challenges for arranging for HIV testing in jails and linking inmates living with HIV/AIDS with services both while they are incarcerated and after release.

Assisting more individuals in these high-risk jail populations represents an important public health opportunity; learning their HIV status, assuring that they are linked to any needed care, and tracking and reporting outcomes are key factors to success.

Recent demonstration projects funded by the Centers for Disease Control and Prevention (CDC) establish the feasibility of rapid HIV testing in jail settings and its acceptability to inmates and jail administrators.  Models for linking HIV-positive jail inmates to HIV care while incarcerated and upon release to the community have been cropping up all over the country, and important issues for crafting the models have become apparent:

  • Linkage procedures vary across different jail systems and jurisdictions;
  • Coordination among project partners (e.g., jails, community medical providers) is essential to any success;
  • Secure and innovative technology and mechanisms for linkage need to be in place;
  • Scopes of services need to be well defined;
  • Understanding inmate characteristics, eligibility for public services and holistic needs (not just medical diagnoses, lab results, CD4 count, but also criminogenic needs profile based on validated needs assessment tools);
  • Secure, HIPAA-compliant and appropriate information sharing needs have to be well-defined; and 
  • Administration and implementation issues need to be addressed

A critically important benefit of focusing on not only linkages to care for HIV/AIDS treatment and services, but the holistic needs of offenders and ex-offender is improved public safety and fewer individuals returning to incarceration.  Closely following evidence-based practices and providing coordinated linkages to appropriate levels and types of care and services has a proven impact on reducing recidivism. The extent to which these principles are followed and treatment integrity is practiced correlates highly with client outcomes as measured by recidivism.

The National Council on Crime and Delinquency in 2006 stated, “Offenders returning to their communities bring with them a host of problems including physical and mental health and substance abuse issues, literacy, few job skills, and minimal work history. These deficits contribute directly to continuing patterns of crime, and unless they are addressed in a comprehensive and consistent fashion-both in the institutions and in the community-parolees will continue to fail.”

Underscoring the nexus of public health, public safety and taxpayer value benefits of improved linkages to care is a vital component of “selling” this approach to elected officials, voters and critical decision makers.

States across the country like Texas, North Carolina, Ohio and California are taking the lead in addressing the decades-long problems they have struggled with in corrections.  Applying evidence-based approaches, connecting offenders with appropriate levels of service and supervision, and being able to monitor, measure and report on outcomes in a timely fashion using secure, cutting edge technology is the future of Corrections.

Linkage programs need to be tailored to fit the characteristics, culture and policies/practices of particular jails and jurisdictions including their inmate populations. Linkage models vary. Linkage to care may take place within the jail, from jail to prison or, upon release, from jail to the community. Successful strategies for linking HIV-infected inmates to outside services may include:

  • Face-to-Face discharge planning (Correctional Healthcare Physicians, Nurses, or dedicated Discharge Case Planners);
  • Making every effort to obtain accurate information on release dates;
  • Making appointments for releasees with community-based service providers; and
  • Meeting releasees at the gate (“warm hand-off”) and transporting them to their initial critical   service appointments.

Some considerations for what types and levels of services should linkage models offer:

  • Should programs focus on just the diagnosis and the initial linkage to post-release care and treatment (i.e., making the linkage and getting people to their first appointments)?
  • Should programs have the broader goal of making and maintaining the linkage to care and treatment for an extended period after release?
  • Should programs be ambitious and comprehensive, addressing a wider range of needs such as housing, employment and family stability?
  • Should programs provide full-scale case management or just focus on referrals?


David Manson
David Manson is Product Manager for Ramsell Correctional Application (RCA) at Ramsell Corporation ( RCA is a web based system that solves the problem of coordination of care and benefits for ex-offenders who are in need of any of a number of different paths of assistance to successful reentry into society from state and city/county correctional facilities with the available programs and resources within a community.

David presented at the ADAP Advocacy Association's 2012 and 2013 Annual Conferences in Washington, DC. This year's presentation is available online.

Friday, August 23, 2013

Is it time to Reauthorize the Ryan White CARE Act?

On September 30th, some HIV/AIDS advocates have pontificated that the world will end with respect to supports and services afforded to people living with HIV/AIDS...but that simply isn't true. That is the date when the current Ryan White CARE Act -- which was reauthorized by Congress in 2009 as the "Ryan White HIV/AIDS Treatment Extension Act" -- is set to expire. Maybe federal lawmakers anticipated four years ago that the partisan gridlock would only worsen by today, but interestingly enough the law doesn't include language that is fairly common in reauthorizing legislation: a sunset provision.

What does that mean? In legislative terms, it means that the current law is likely (as in, very likely) to continue under the current law's framework and structure -- including appropriation levels. Putting the hysteria aside, it is nonetheless important for Ryan White stakeholders remain engaged to ensure that the "payor of last resort" safety net that the law provides remains intact, and robust funding accompanies it. Fortunately, coalitions such as the Ryan White Work Group, ADAP Coalition and the National ADAP Working Group (all of which the ADAP Advocacy Association is a member organization), are working to monitor this situation and propose meaningful advocacy strategies.

Of particular interest to most Ryan White stakeholders is the fate of the current law's "Hold Harmless" provision, which was added during a previous reauthorization. The Hold Harmless provision initially continued the previous 95% rate for the first two fiscal years, but increased to 100% of fiscal year 2010 funding for each of the fiscal years 2011 and 2012. For fiscal year 2013, the amount will be 92.5% of the previous fiscal year’s grant. This hold harmless continues to apply to both Part A and Part B grants.[1]

On July 16th, Rep. Frank Pallone (D-NJ) introduced H.R.2699. The legislation would "extend the hold harmless provisions of the Ryan White HIV/AIDS Program pending reauthorization of the overall program." The legislation has no co-sponsors and it also reportedly doesn't have the support of the majority staff on the House Committee on Energy & Commerce, Subcommittee on Health. In other words, Rep. Pallone's legislation probably isn't going anywhere in the Congress.

According to Bill McColl of AIDS United and Co-Chair of the Ryan White Work Group, "We are aware that hold harmless will be a major issue for many people in the HIV community and will be trying to develop points of agreement as the Congress works on a continuing resolution or appropriations bill in FY 2014."

Meanwhile, ADAPs have already experienced a major systemic shock between the changes in the funding formula, and the pending cuts from Sequestration. Data from the Health Resources & Services Administration (HRSA) demonstrates the changes between this year's number with last year's totals.

(Editor's Note: The totals are calculated from the actual reduction from last year per locality after subtracting accounting adjustments and carryovers from prior years). The numbers paint a picture that should keep Ryan White stakeholders on the edge of their seats.

PART A FUNDING: (Avg. Cut  7.12%)
The Part A spreadsheet encompasses all Part A areas in the country. This section of funding had experienced a few changes, including:
1) There was a new TGA in the Part A funding stream (i.e., Columbus, Ohio) , As a result, the EMA/TGA pie had to be divided up with one more additional locality.
2) Sequester had played a varying effect per locality as reflected by the percentages.
3) Shifting trends in epidemiology and formulas towards the South; therefore the cuts were somewhat cushioned and less drastic.

PART B FUNDING: (Avg. Cut  5.61%) 
The Part B Basic Earmark spreadsheet is the bulk (90-95%) of the Federal Grant to the States for ADAPs.
1) The Part B Grant for Medical Services has not been broken out yet as that will take some time to separate and compile that data as the Part B grants are multi-layered.
2) Again, Sequester had played a big factor in the reduction but the Southern States were saved the brunt of the Sequester because of a new formula change.

Eddie Hamilton, who heads up the ADAP Educational Initiative, summarized it best: "The grassroots do need to be afraid of sequester 2.0 coming up as it looks like Congress won’t be able to change that anytime soon."

In light of the current political climate on Capitol Hill, practically everyone with an interest in protecting HIV/AIDS supports and services is taking nothing to chance. Considering that the Ryan White law -- and especially the AIDS Drug Assistance Program (ADAP) -- has long enjoyed bipartisan support, education efforts to remind lawmakers of its importance are ongoing, including a new web video released by the AIDS Healthcare Foundation.

[Photo: AHF Ryan White Video]

One thing is for certain, prematurely opening up a popular law that doesn't require reauthorization could prove disastrous in the hyper-partisan, hyper-political environment that has consumed the current Congress.  Any suggestion to the contrary simply ignores the political realities that exist today. A more cautious approach might be pursuing a legislative technical fix.

The reality of the situation is best summarized by Bill Arnold, President & CEO of the Community Access National Network (CANN): "The issue boils down to congressional staff has no appetite to enter the debate over a full reauthorization until they have data after Affordable Care Act implementation, and can assess the impacts nationally, as well as locally."

Arnold suggests that the data won’t be available until well after “opening day” on January 1, 2014, and it will likely take all of that same year to clean and sort through the data. "That argues for a serious attempt to reauthorize in 2015, especially since it will also be past congressional election," Arnold said.

The bottom line is Ryan White stakeholders must remain vigilant in their efforts to maintain the nation's oldest and only law solely dedicated to providing life-sustaining supports and services to people living with HIV/AIDS in the United States. No one could disagree that the need exists. How the "community" achieves that objective is open to interpretation.

Stay tuned.

[1] Department of Public Health, Los Angeles County, California, "SECTION-BY-SECTION DESCRIPTION OF RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT OF 2009,” December 2009.