A case management program launched by a private nonprofit organization has found that providing better healthcare access to inmates at the local jail has resulted in many benefits.

  • The local detention center began to see a decrease in its daily census, which suggests a reduction in its recidivism rate.
  • ED utilization dropped by 20% to 40%.
  • Former inmates began to improve their health and find jobs.

A case management program in South Carolina focuses on filling the health access gap for low-income, uninsured people with multiple chronic conditions. A few years ago, case managers in the small city began to notice a trend involving the local jail population.

“We used to have a number of patients who would show up at our office and say, ‘I was just released from the detention center and they gave me five days’ worth of medication and referrals to mental health, but when I went to mental health, they can’t see me,’” recalls Carey Rothschild, director of AccessHealth Spartanburg.

The person would want to renew a prescription, but could not. “This happened often enough that we looked into finding alternatives to keep this from happening,” Rothschild says.

The result was an initiative that specifically targets people in the detention center with the goal of providing them with free access to medical and behavioral health services once they leave jail. The program has been successful in expanding healthcare access and in improving enrollees’ health. There’s another positive benefit: It’s helped reduce the recidivism rate.

The Spartanburg County Detention Center’s average daily population dropped from 815 in fiscal year 2012 to 769 in fiscal year 2016, says Neal Urch, director of jail operations when the AccessHealth program was introduced, and who retired Dec. 31, 2016.

The lowered daily population resulted in a $1.4 million savings over two years for the detention center, which was able to use that savings to fund an education and jobs program that helps inmates find jobs when they’re back in the community, Urch says.

AccessHealth enrolls about 3,000 people in its program, and a small portion are from the detention center. The program’s overall outcomes include a 20% to 40% — depending on the health condition — reduction in ED utilization, Rothschild says.

As one of the states that did not expand its Medicaid coverage under the Affordable Care Act (ACA), access to free or affordable healthcare in South Carolina has been limited for many adults with marginal incomes. Rothschild estimates that 13,000 people in a county with about 300,000 people need the help AccessHealth Spartanburg provides.

“We connect low-income, uninsured adults primarily to a medical home, healthcare, behavioral healthcare, and a host of other resources including food stamps, transportation, and housing,” Rothschild says.

The nonprofit, private organization also has teamed up with Spartanburg Regional Health System (SRHS) to expand its services to the detention center population.

“We would see a lot of people when they left the detention center,” says Schenell Hawkins, LBSW, discharge planner with case management services at SRHS.

“They’d come to the emergency room with COPD, diabetes, and hypertension, seeking help,” she says. “Once we got those people in the ER, we didn’t have any alternative [for helping them in the community] before AccessHealth.”

Now, the health system has a case manager in the ER who can work with the detention center population and others who need to find access to care in the community.

The ER case manager helps patients connect with AccessHealth, medication programs, and other organizations that can provide community-based care, Hawkins says.

“The health system has benefited from the case management program and AccessHealth, seeing a reduction in charity care expenses in recent years and an increase in the number of people connected to medical homes or behavioral health specialty care,” Rothschild says. “Some of those outcomes have been hugely important.”

Anecdotally, the health system’s ER staff has noticed a decrease in the number of inpatient admissions coming from the detention center population, Hawkins says.

In the collaboration between AccessHealth and SRHS, the health system’s computer system sends out an email notification when there’s an ER visit or inpatient admission by a patient from the detention center. The AccessHealth team contacts the patient to see if he or she needs new medication or another service that might have prevented the hospital visit, Rothschild says.

“Many people in our program have never had a medical home, so there’s an education process where we explain what it means to be a patient,” she says. “If you’re not feeling well, call your doctor first.”

The program’s long-term effect on healthcare utilization by a detention center population still is being evaluated, but there is potential for it to be big, Rothschild, Hawkins, and Urch say. (For more information, see the case study in this issue.)

For example, they pulled data on 20 people who had been in the detention center and were diagnosed with mental health problems. These patients were frequent fliers in hospital EDs as well as in the jail. The healthcare and detention costs to the community for just these 20 people amounted to about $2 million, Urch says.

“If someone is off their medication and then taken to the detention center where they’re put back on their medication, then they are released and get off their medication again,” Rothschild says. “It’s a vicious cycle.”

Here’s one case study example. “We had a lady, who — between March 2012 and October 2014 — had been in jail 16 times on 34 different charges, including disorderly conduct, shoplifting, trespassing, and other minor offenses,” Urch says. “She had a lot of issues even when she was inside the jail. The last time she was arrested, she spit on the magistrate who was there for her bond.”

After the woman was diagnosed with a mental illness and put on a medication regimen supported by case management services, she began to recover, he says.

“Since October 2014, she has not been back in jail and has been going to mental health services and has a job cleaning rooms for a hotel,” Urch adds.

The following is a brief look at how the program works:

Identify inmates who need the service. The hospital’s intake process includes questions to identify people who could use the AccessHealth services. Also, the detention center contacts AccessHealth about particular inmates who could use the organization’s help.

“There are about a couple of inmates a week who are connected to AccessHealth,” Rothschild says.

A nurse case manager, social worker, or community health worker regularly visits the detention center to screen people for enrollment in AccessHealth’s program.

“The detention center has created a survey assessment for detainees to identify who does not have insurance,” Rothschild says.

Case managers then make appointments with the detainees before they are released from the detention center.

Also, AccessHealth’s partnerships with other community organizations help connect people released from prison to its services, she adds.

A big piece in the assessment process involves psychosocial issues and the social determinants of health, Rothschild says.

“We look at their medical conditions, housing, level of education, and their assets, including being part of a church or religious community and having a support system,” she explains. “If you are unable to take care of yourself, do you have someone you can call? We help people navigate that, making connections to community partners and sending people to ministries for food, housing.”

Meet with inmates and build trust. “We need to increase their confidence in the healthcare system,” Hawkins says. “We want them to know they can have someone out there they can depend on.”

Many people in the community have accessed medical care solely through the ED, Rothschild says.

“They don’t have a lot of confidence in the hospital system and criminal justice system,” she notes. “There is a lot of distrust, so it’s important to have individuals like our community health workers who are creating an ongoing relationship with people.”

Trust-building includes reinforcing providers’ messages. For instance, AccessHealth’s clients often return from a doctor’s appointment, telling their case managers that the doctor told them something they don’t believe. The case management team can reinforce confidence in the doctor by confirming the information, Rothschild says.

Simplify visits and enrollment. AccessHealth provides enrollment opportunities at several different locations in the county, including the detention center, nonprofit organizations that help the homeless and indigent, and the library.

“We go to people’s homes sometimes,” Rothschild says. “When you have someone living in a tent, as we have, then we’re generally meeting them at the library.”

Remove barriers to medical care. The organization has a contract with a county transportation service that it pays to take clients to and from medical appointments and behavioral health appointments, Rothschild says.

“We have several different services we tap into to assist these patients and make sure they get to their appointments, whether it be our SRHS Foundation or charity programs,” Hawkins says.

“We do try to make sure they get started with that transportation system, and then AccessHealth keeps an eye on it, and they continue to set up their appointments,” she adds.

AccessHealth also has partnerships with homeless shelters in the community and with the local housing authority to help people apply for housing or to connect them with shelters, as needed.

The program’s chief effort is to make people’s lives better through better health, Rothschild notes.

“It’s really about making lives better,” she says. “All of the community partners are working to look at interventions and get people back to work and able to take care of their own health.”