Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism
Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism
The Michigan Prisoner Reentry Initiative, a statewide initiative through 18 regional sites that cover all 83 Michigan counties, helps newly released prisoners access services needed to facilitate successful reentry into the community. The Muskegon Community Health Project participates in the local implementation of the initiative by helping prisoners access health services. The Community Health Project has accomplished this through implementation of the Pathways model, a model that involves “pathways” of action steps implemented by community health workers who connect at-risk individuals to care. The health project's pathway links newly released prisoners to a medical home, helps them access needed medications and primary and specialty care, and ensures that they obtain their medical records on release from prison. The program appears to have been a contributing factor to a significant decline in recidivism rates in Muskegon. Without the program, more than 2,500 individuals (mostly men) who went through the pathway would have been returned to the community without access to medical support services. (Note that the state of Michigan reorganized and transitioned the program as of December 31, 2013; services are now delivered internally by the Michigan Department of Corrections.)
Date First Implemented
Although most communities have publicly or privately funded agencies to assist newly released prisoners in reentering the community by helping them secure training, employment, transportation, and housing, few of these programs address health care needs. In fact, most prisoners are released with no medical insurance, plan for a medical home, health records, or knowledge of available community resources. As a result, these prisoners are more likely to be in poor health and return to prison.
- Poor access to health care: Most parolees do not have medical insurance or access to stable sources of medical services. 1 In Muskegon County, those released from prison generally did not have insurance or a copy of their medical records; had only a 30-day supply of their medications; did not have a medical home; and had not been screened to determine eligibility for medical coverage through public programs.
- Path to poor health: Prisoners' illnesses often go undiagnosed and untreated by prison physicians. As a result, when released, they tend to be in poorer health than the general population. 2 Infectious diseases carried by ex-prisoners are particularly concerning. For example, compared with the general population in Los Angeles County, newly released prisoners experience a 4 times higher rate of active tuberculosis, a 9 to 10 times higher rate of hepatitis C, and a 5 times higher rate of AIDS. 1
- Contributions to high rates of recidivism: Recidivism rates of paroled or newly released prisoners remain very high; one study found that two-thirds of released prisoners were rearrested within 3 years. 3 Poor physical and mental health contribute to these high rates, as ex-prisoners seek the “security” of the life they knew in prison.
Description of the Innovative Activity
The Muskegon Community Health Project developed a pathway that uses medical navigators to help newly released or paroled prisoners obtain their medical records, find a medical home, and access needed primary care and specialty services. The health navigation program began in Muskegon County and serves two neighboring counties in Michigan. Key elements of the pathway include the following:
- Identification of soon-to-be-released prisoners: The Michigan Department of Corrections sends the health project a listing and case review of each individual to be released within 6 months.
- Prison “in-reach” sessions: Approximately twice a week, an initiative in-reach team goes into one of the three Muskegon County prisons to educate prisoners nearing release about the services they can expect when they reenter the community. The team includes four individuals: one medical navigator and three community health workers with specific expertise in housing, job training/employment, and transportation services. The team talks to the prisoners as a group to present the scope of services in each of these four areas. Over the course of the 6 months before release, the team meets with prisoners periodically to prepare them for the services they can expect after release.
- Health screening: The medical navigator meets one on one with each prisoner to conduct a personal health assessment to determine the presence of chronic diseases, infectious conditions, and other health needs. The medical navigator also assesses whether the prisoner may be eligible for certain entitlement programs and determines what medications the prisoner is or should be taking.
- Facilitating access to health services: Some of the health-oriented services arranged by the medical navigator and provided by the program during the year after release include the following:
- Access to medical record: The medical navigator arranges for a copy of the prisoner's medical record to be released with the prisoner upon reentry into the community.
- Access to medical home: The medical navigator sets up a primary care medical appointment for the prisoner, scheduled within 2 weeks of prison release. For parolees, keeping the medical appointment is a condition of parole. The medical navigator follows up with released prisoners to ensure that they attend their primary care visit and to address other health services needs.
- Arrangement for prescription drug coverage: The medical navigator prompts another community health worker who manages a pharmaceutical systems program to identify free and low-cost medication programs for which the prisoner might be eligible. This pharmaceutical health worker assists the ex-prisoner in applying for appropriate programs. The program covers the cost of medications while released prisoners wait for their applications to be approved, which generally takes 45 to 60 days, thus ensuring access to drugs until other assistance programs begin. According to information received in June 2014, the pharmacy assistance program has served an unduplicated count of more than 1,200 parolees since 2007 and provided them with prescription drugs valued at $1,111,580 (retail value). Parolees receive renewals of their prescriptions every 90 days. The health project's interim assistance program has provided more than $30,000 of prescriptions while parolees are waiting for the manufacturers' pharmacy assistance program to start.
- Link to needed medical services: The medical navigator links prisoners with chronic diseases to chronic disease management programs; some are triaged into the Stanford Chronic Disease Self-Management Program, run by health workers on staff at the health project. Medical navigators also arrange for community screenings and access to other community resources, such as AIDS clinic care, specialty care, and surgical procedures. In 2012, Mercy Health added a hepatitis C clinic for referrals.
- Assistance with copayments, initial visit: The program pays released prisoners' copayments at Federal health centers and other community clinics. The program will also pay for an initial office visit to a private physician, up to $125.
Context of the Innovation
The Muskegon County Health Project, located in Muskegon, MI, is a community health collaborative focused on ensuring that all county residents have appropriate access to care by linking residents to a medical home and addressing disparities in care. The county, which has a population of approximately 175,000 (roughly 10 percent of whom are uninsured), has three prisons, which released 392 parolees between March 2012 and April 2013. In 2005, the state of Michigan initiated the Michigan Prisoner Reentry Initiative program to provide services to individuals being paroled (approximately 430 parolees annually across 10 counties). The initiative, a community-based effort instituted statewide, helps newly released prisoners access services related to housing, employment, and transportation to facilitate their reentry into the community. The local coordinator of the initiative in Muskegon County realized that health care was missing from the array of services needed for stable reentry. The coordinator approached the health project director for help in listing the medical assets available for Muskegon parolees and newly released prisoners. The director quickly realized that the health project could enhance the initiative's effort by incorporating services for parolees into the project's mission. The health project currently covers three counties in western Michigan. (Note that the state of Michigan reorganized and transitioned the program as of December 31, 2013; services are now delivered internally by the Michigan Department of Corrections.)
The program appears to have been a contributing factor to a significant decline in recidivism. Without the program, more than 2,500 individuals (mostly men) who went through the pathway would have been returned to the community without access to medical services. The program also appears to have generated a positive return on investment.
- Undetermined changes in health status: No data on the health status of parolees and newly released prisoners are available (either before or after implementation of the initiative). However, health project staff believe that linking more than an average of 130 individuals per year to medical homes has greatly improved the health of at least some of these individuals, compared with what it would have been without this linkage.
- Contributing factor to a significant decline in recidivism: The overall recidivism rate for parolees has fallen since the program began, from 46 percent when the program began in 2007 to 21.8 percent in 2012 for 2-year parolees. The 2012 recidivism rate for 18-month parolees was 17.7 percent, and it was 9.3 percent for 1-year parolees. Although there is no way to determine what portion of this decline is due to the health project's medical services pathway, staff members believe that the program has made an important contribution to stabilizing these individuals in the community. The local department of corrections began a comprehensive evaluation of the program in August 2009 that will ultimately produce a 10-year trend analysis.
- Assumed positive return on investment: The cost for health navigation services averages $174 per parolee (updated June 2014). Consequently, the program appears to be highly cost effective, considering that each ex-prisoner who does not return to prison saves the state $31,000 a year. Additionally, information provided in June 2014 indicates that the total cost of the program since inception (roughly $436,750) is far less than the value of services, which includes $1,111,580 in pharmaceutical assistance plus other benefits (e.g., food assistance, health coverage programs, vision and dental services) to date. The average pharmaceutical assistance per parolee is $442 (updated June 2014).
Planning and Development Process
Key steps included the following:
- Joining local coalition: Health project representatives joined the 40-person coalition charged with implementing the local reentry initiative in Muskegon County. The health project highlighted for the coalition the interrelationships between health and other initiative goals (access to housing, employment, and transportation). The local coalition agreed to incorporate health-related services—overseen by the health project—into its mission.
- Securing funding: The health project received “carve-out” funding from the local initiative coalition to address health issues.
- Conducting medical needs assessment: The health project convened a small group of individuals—including representatives from hospitals, the county health department, and other agencies that address medical issues for low-income populations—to clarify the issues these organizations faced when serving newly released prisoners. Problems identified during the assessment process included:
- Lack of medical home and preventive care: Newly released prisoners had no primary care physician. As a result, no mechanism existed for ex-prisoners to receive preventive care. Rather, parolees only sought care in response to an acute episode, typically from the health department, an emergency department, or the state-operated indigent care program.
- No medical history: Newly released prisoners did not receive their medical records, which often documented years of care.
- No plan for infectious disease care: Infectious diseases—such as tuberculosis and human immunodeficiency virus (HIV)/AIDS—were not being adequately tracked or addressed. Health department staff did not know of all parolees with infectious diseases. In addition, newly released prisoners often did not know how to locate organizations, such as the local HIV/AIDS clinic, that provide infectious disease care.
- Researching strategies: After identifying problems and related issues, health project staff interviewed experts about prisoner and men's health to identify models for addressing the health needs of this population. The research revealed that prisoners may not have had appropriate care before incarceration and may not have had their health needs fully addressed while in prison. Optimal strategies involved taking advantage of the incarceration to stabilize the health of prisoners, monitoring prisoner health status, and ensuring a continuum of care, including transition of the medical record, once prisoners are released.
- Hiring and training: The health project hired and provided in-house training to one full-time and one half-time medical navigator from the community. The heath project already had community health workers on staff to provide services (e.g., applying for food stamps or Medicaid) to needy populations.
- Developing pharmaceutical assistance program: A staff member was charged with identifying and tracking pharmaceutical programs offering free and reduced-cost medications, and then filing applications with appropriate programs on behalf of released prisoners. The staff member developed an electronic system for tracking the programs and applications.
Resources Used and Skills Needed
- Staffing: Program staff include the following:
- Medical navigators: As noted, the program employs one full-time and one half-time medical navigator.
- Pharmaceutical community health workers: The program requires approximately 15-percent time from a pharmaceutical health worker. One additional full-time employee supplements the health project's overall pharmaceutical assistance program to accommodate growth in this service area.
- Other community health workers: The health project employs seven trained health workers who spend some of their time supporting the medical navigator by managing other aspects of cases, such as applying for food stamps, Medicaid, and Social Security benefits.
- Costs: As previously mentioned, the cost to serve more than 2,500 ex-prisoners since the program's inception has been $436,750, or roughly $174 per individual.
The State Department of Correction's MPRI fiduciary allocated $44,700 in State funding to the Health Project to provide health-oriented services during the 2012-13 fiscal year, which supported one full-time health navigator. A 1-year AMERICORP contract funded the pharmaceutical health worker; this individual was then employed as a regular health project staff member, with 15 percent of salary allocated to the prisoner release program.
In March 2012, the Michigan Department of Corrections changed the funding structure from cost reimbursement to a unit cost basis. The health project billed scheduled amounts for intake and health assessment, enrollment in the food assistance program and pharmaceutical assistance programs, and referrals to primary care homes and other social services. The capped unit cost paid by the state was $325 per parolee. This unit cost does not include interim drugs provided while the parolee awaits enrollment. The Department of Corrections reimbursed for the actual cost of interim medications provided by the health project's program.
The state funded the program through a single fiduciary in western Michigan. The health project supplemented this funding through Mercy Health Partner's community benefit program, principally to cover the remaining salary of the pharmaceutical health worker, administrative costs, and indirect expenses. Total contributions to the program from other sources was about $40,000 per year. However, as indicated above, the state of Michigan reorganized and transitioned the program in December 2013, and services are now delivered internally by the Michigan Department of Corrections (updated June 2014). The health project continues to serve former program participants, as well as new referrals from local parole officers, using revenues from other services targeting persons with chronic conditions; these funding sources include grants and community benefit funding support from Mercy Health Muskegon.
Getting Started with This Innovation
- Start slow: Start with a small number of clients to ensure that staff can execute the process outlined by the pathway.
- Acknowledge, address public perceptions by articulating program benefits: The public may view the prison population as one that does not deserve help. The health project's experience, however, suggests that newly released prisoners want to stabilize their lives, improve their health, and become productive members of society. To help the public understand the potential benefits, program developers should emphasize (1) the moral imperative of the program (“this is the right thing to do”); (2) the fact that the program can generate a positive return on community investment (lowering taxpayer costs via reduced recidivism); and (3) that many newly released prisoners have infectious diseases, creating a significant health risk in the community if left unaddressed. Health care and prisons represent the two largest line items in most state budgets. This type of program can help states cut their budgets by reducing recidivism and improving community health.
- Obtain funding: Other communities can call attention to Michigan & rsquo;s success to encourage their State governments to fund this type of program. Grant funding may also be solicited from foundations that partnered with the Michigan Department of Corrections. Would-be adopters should consider keeping foundations in their “comfort zone” by requesting seed money rather than ongoing funding.
- Hire the right staff: Hire people who are indigenous to the community, have strong interpersonal skills, and are truly interested in helping this population.
Sustaining This Innovation
- Triage parolees based on needs: Prioritize the arrangement of medical services to focus on individuals with the greatest need.
- Follow up with existing clients: Ensuring that ex-prisoners have access to the services they need on an ongoing basis can help reduce recidivism rates.
Contact the Innovator
Note: Innovator contact information is no longer being updated and may not be current.
Peter J. Sartorius
Community Benefits Grants & Planning Manager
Muskegon Community Health Project/Mercy Health
565 W. Western Avenue
Muskegon, MI 49440
(231) 672-3201 (Office)
(231) 672-3204 (Direct)
Fax (231) 672-8404
Web site: www.mercyhealthmuskegon.com
Vondie Woodbury Director, Community Benefit
Mercy Health Partners Executive Director, Muskegon Community Health Project
565 W. Western Avenue
Muskegon, MI 49440
(231) 672-3201 (Office)
Web site: http://www.mchp.org
Mr. Sartorius reported that the Muskegon Community Health project receives grant funding from Ottawa County Michigan Works, the fiduciary grantee from the Michigan Department of Corrections. Information on additional funders is available in the funding sources section. Ms. Woodbury has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
More information on this program can be found at http://www.mchp.org.
American Public Health Association. Public health and returning offenders in Los Angeles County. Summer 2006 Newsletter.
Confronting Confinement. Commission on safety and abuse in America's prisons. June 2006. Available at: http://archive.vera.org/sites/default/files/resources/downloads/Confronting_Confinement.pdf.
Bureau of Justice Statistics. Re-entry trends in the US. October 25, 2002. Available at:http://bjs.ojp.usdoj.gov/content/reentry/recidivism.cfm.
Care Coordinators Need to Be Rewarded for Serving High-Risk Individuals
By Mark Redding, MD
Medical Director, Community Health Access Project
The great and silent emergency of the American health care system is that individuals with the greatest risk of chronic and severe health conditions are not connected to critical preventive and treatment services. Instead, they show up frequently in local emergency rooms and require more intensive care services. The economic impact of this trend is significant—people with the greatest health risk make up 5 percent of the U.S. population—but represent 50 percent of health care costs. 1
To address cost or disparity, we must reach people with the greatest health care needs. Recent literature shows that an at-risk individual today is less likely to connect to and receive primary and preventive health care than a decade ago, despite the doubling of the health care budget during that time. 2
Critical social determinants of health including poverty, cultural isolation, transportation, and insurance issues represent real barriers to ensuring that people with the greatest needs receive health and social service interventions proven to improve outcomes.
Most health care and social service systems fund care coordination with the intent of reaching out and engaging those at greatest risk and connecting them to care. 3 However, in most instances, care coordination doesn't achieve the desired outcome. The fundamental problem is the lack of any meaningful financial incentives or contractual requirements to ensure that at-risk people are connected to and receive appropriate services. Indeed, most health and social service systems reward care coordination for low-risk individuals because the financial incentive is based on the number of people served.
Care coordinators typically would need to spend considerable time and effort on high-risk populations with chronic health care conditions who may be homeless, of a different culture or language, or without a phone, car, or transportation. This results in fewer people seen by the care coordinator and a potential financial loss under the current incentive system.
Changing the incentives to reward care coordination for high-risk individuals has great potential to reduce long-term health care costs and health disparities. An exciting example of innovative system change is the profile Michigan Pathways Project Links Ex-Prisoners to Medical Services, Contributing to a Decline in Recidivism. The program has incentives for supporting care coordinators to conduct outreach to populations that have not received health care services and to address the barriers they face such as transportation, health insurance, and cultural issues. The program is based on the Pathways model, which uses financial incentives tied to a series of benchmarks to hold care coordinators accountable and confirm that care is received.
Reforming the current incentives for care coordination to reward connecting high-risk individuals to care would significantly reduce health care disparities and improve the nation's economic health.
1 Monheit AC, Berk ML. The concentration of health care expenditures revisited. Academy for Health Services Research and Health Policy. Meeting. Abstr Acad Health Serv Res Health Policy Meet. 2000;17.
2 Cunningham PJ, Felland LE. Falling behind: Americans' access to medical care deteriorates, 2003-2007. Track Rep. 2008:19:1-5. [PubMed]
3 McDonald KM, Sundaram V, Bravata DM, et al. Care coordination. In: Shojania KG, McDonald KM, Wachter RM, et al, editors. Closing the quality gap: a critical analysis of quality improvement strategies, Vol. 7. AHRQ Publication No. 04(07)-0051-7. Rockville MD: Agency for Healthcare Research and Quality; June 2007 .
Disclosure Statement: The Pathways model was developed by Drs. Mark and Sarah Redding as an accountability and contracting tool in the year 2000 to specifically assure that those at risk are connected to care and the final outcome measured. The Pathways model is utilized as a quality assurance and accountability tool in community networks and within specific programs in eight states.