Over 10 million individuals were incarcerated in the United States at some point in 2014. Incarcerated individuals are disproportionately poor, black, and homeless, and suffer from higher rates of mental illness, substance use disorders, and chronic disease than the general public. Most were uninsured prior to 2014. However, in states that have expanded Medicaid under the Affordable Care Act (ACA), nearly all individuals are presumed to be eligible for Medicaid following release from prison or jail.
Connecting to health care after release is critical. Former prisoners have mortality rates 12 times higher than the general public in the first two weeks after release from prison. While some states enroll prisoners in Medicaid prior to release, few ensure that former prisoners in their communities receive needed care after release.
In other words, for incarcerated individuals with health care needs, there is rarely an adequate discharge plan. Developing discharge plans for reentering individuals who are Medicaid eligible can improve important health outcomes, save money, and reduce re-incarceration. An unusual combination of national programs—the Veteran’s Justice Programs and the Medicare Readmissions Reduction Program—can inform future work to improve the health and wellbeing of a highly vulnerable population.
Developing Discharge Plans for Medicaid Eligible Inmates
Why should Medicaid programs target soon-to-be-released inmates with a comprehensive discharge plan? First, released inmates have a markedly elevated risk of death, driven by factors including overdose, cardiovascular disease, liver disease, HIV-related conditions, and suicide. Some of these factors may be preventable through access to comprehensive medical care that includes mental health care, physical health care, and substance use disorder treatment.
However, it can be challenging for individuals recently released from prison or jail to access needed health care services if they have no prior relationship with a health provider and little experience independently navigating the health care system. Discharge plans that include a broad range of services (e.g. patient education, timely follow-up, medication reconciliation, and transition coaching) would improve health outcomes and could potentially reduce high mortality rates among justice-involved individuals following release.
Second, former inmates have high rates of emergency department (ED) utilization and hospitalization after release. ED use peaks in the first two weeks after release and both ED visits and hospitalizations are commonly for conditions that could be treated in an ambulatory care setting. Without targeted care coordination, recently incarcerated individuals will continue to face challenges connecting to primary care and behavioral health services and will instead utilize expensive acute-care services.
Finally, by facilitating an appropriate discharge plan, Medicaid programs could play an important role in mitigating mass incarceration in the United States. Prior research suggests that Medicaid enrollment upon release from jail can reduce rates of recidivism for those with serious mental illness. Furthermore, utilization of community mental health and substance abuse treatment have also been associated with reduced levels of recidivism.
Learning from the Veteran’s Justice Programs
The civilian health system’s inattention to prisoners upon their release contrasts with the comprehensive support provided by the Veterans Health Administration (VHA). Although veterans are incarcerated at lower rates than the civilian population, veterans accounted for approximately 8 percent of those in prison or jail in 2011/2012. To meet the needs of justice-involved veterans, VHA launched two Veterans’ Justice Programs (VJP): Heath Care for Reentry Veterans (HCRV) in 2007 and Veterans Justice Outreach (VJO) in 2009.
HCRV primarily serves veterans incarcerated in state or federal prisons, whereas VJO serves veterans in county jails or treatment courts. Both programs work to connect veterans with health care, housing, and a variety of other benefits, so that resources are available immediately upon release from prison or jail. By linking veterans to robust mental health, substance abuse, and clinical services, VHA aims to “improve social and clinical outcomes… and end Veterans’ cyclical contact with the criminal justice system.”
VHA has shown it is possible to engage returning prisoners with medical needs. Over 90 percent of veterans with a mental health disorder enter mental health services following release from prison, and over 50 percent enter substance abuse treatment. Research to determine whether these efforts reduce rates of recidivism is ongoing. Nonetheless, the VA’s Justice Programs provide evidence that developing relationships between health care and justice institutions and providing health care transitions for justice-involved patients is feasible when incentives are appropriately aligned.
Can the Readmissions Reduction Program Guide Plans for Prisoner Release?
Creating a successful reentry plan for justice-involved patients is similar to the work health systems and hospitals already undertake to ensure vulnerable patients successfully ‘re-enter’ society after hospitalization and avert readmissions. State Medicaid programs and Medicaid managed care plans could leverage existing readmissions reduction infrastructure to replicate VHA’s work and improve care for justice-involved individuals in their community (Table 1).
Similar to readmission case managers, Veteran’s Justice Program specialists provide each patient with an individualized reentry plan that includes scheduling information for appointments and logistical tips on accessing services upon release after they are notified that a veteran’s release date is approaching. Correctional facilities could similarly communicate release dates with state Medicaid programs or directly with managed care plans who can then provide further care coordination. Although federal Medicaid dollars cannot pay for services while an individual is incarcerated, upfront care coordination can reduce ED use and may provide overall cost savings for states who fund such initiatives.
While VHA’s Justice Programs provide a model framework for Medicaid programs and health plans to retool readmissions reduction programs and meet the needs of justice-involved individuals, they have not been without implementation challenges. Cross-sector relationships were built over years to foster open communication and information transfer between VHA and state and county departments of corrections.
To facilitate identification of veterans who may be eligible for VHA services, VHA has operationalized the Veterans Re-Entry Search Service, which allows prisons and jails to upload their census and crosscheck it with military records. Some states are using similar processes to enroll reentering prisoners in Medicaid. These processes could be extended to individual Medicaid managed care plans so that they are made aware of patients who are in need of care management prior to release.
Providing Effective Care for a Vulnerable Population
While the VA’s integrated structure differs dramatically from traditional fee-for-service payment models, most Medicaid enrollees now participate in Medicaid managed care plans or, increasingly, in Medicaid Accountable Care Organizations. Similar to the VA, incentives in these payment models are aligned to improve quality while containing costs and improving the patient experience. Medicaid plans can improve quality and decrease cost by developing discharge plans for reentering prisoners.
Ultimately, improved prison and jail discharge coordination will ensure that individuals who have recently gained health insurance are able to access comprehensive physical and mental health services within a medical home and reduce their reliance on emergency departments and hospital care. These efforts could also reduce re-incarceration rates through improved access to timely care. Transitions back to the community, whether from hospitals or from prison, benefit from anticipatory planning and individual-centered attention that addresses complexity and recognizes risk. The framework of VHA’s Veterans Justice Programs is highly instructive for Medicaid programs interested in a similarly effective approach for their vulnerable beneficiaries.
Table 1. Comparison of VHA’s Heath Care for Reentry Veterans (HCRV) Program with Standard Interventions to Reduce Hospital Readmissions
|
|
|
|---|---|
| Pre-Discharge Intervention | |
| Patient education | Regional HCRV specialists provide education regarding available resources. A tailored guidebook is provided to each veteran. |
| Discharge planning | VHA eligibility is processed and an individualized reentry plan is created after a comprehensive needs assessment. |
| Medication reconciliation | Prisoners may be given a 30-day supply upon release in some states. HCRV specialists encourage veterans to bring prison medical records to VA appointments. |
| Appointment scheduled before discharge | In states that have reliable prison discharge dates, HCRV specialists schedule appointments for veterans at a VA medical center prior to release from prison. |
| Post-Discharge Intervention | |
| Timely follow-up | HCRV specialists follow clients up to four months after release. Specialists facilitate medical or mental health appointments for those deemed most fragile. |
| Timely communication with primary care physician | VA physicians are able to view HCRV documentation in the VA’s electronic medical record. HCRV assists with communication between prison health care providers and facilities (i.e. nursing home, residential housing) if applicable. |
| Follow-up telephone call | HCRV specialists follow up with those deemed most fragile. |
| Patient hotline | A specialist is available by phone or email up to four months after release. |
| Intervention Bridging the Transition | |
| Transition coach | HCRV specialist provides education and assistance for reentering prisoners. |
| Patient-centered discharge instructions | Prior to release, prisoners are either connected to housing, employment, and health care or provided with contact information for these resources. |
| Provider continuity | HCRV specialists provide continuity throughout the reentry process and facilitate connections to VA beginning in prison and upon release. |
Readmissions reduction interventions adapted from: Hansen, et al.
Authors’ Note
We wish to thank Sean Clark, JD, and Jessica Blue-Howells, LCSW, for their constructive input regarding the structure and function of VHA’s Justice Programs. The opinions expressed here are those of the authors and do not necessarily reflect the opinions or policies of the Veterans Health Administration.
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