1. How Unmet Health Needs Affect Reentry of Returning Prisoners and Success in Reintegrating Back into Communities
Lois Davis, Ph.D.
November 9, 2010

2. Presenter Disclosure Lois Davis, Ph.D.
The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
No relationships to disclose

3. Background CA prison population grew threefold in past 20 years
At release, ex-prisoners bring with them host of health and social needs
Acute and chronic physical conditions
Social, behavioral, and mental health issues
In the past year, California has:
Severely reduced funding for rehabilitative services in-prison
Implemented new policies to reduce size of correctional population
Also, ex-prisoners are returning to communities with severely strained safety nets—raising serious public health challenges

4. Background CA prison population grew threefold in past 20 years
At release, ex-prisoners bring with them host of health and social needs
Acute and chronic physical conditions
Social, behavioral, and mental health issues
In the past year, California has:
Severely reduced funding for rehabilitative services in-prison
Implemented new policies to reduce size of correctional population
Also, ex-prisoners are returning to communities with severely strained safety nets—raising serious public health challenges
RAND studying public health implications of prisoner reentry

5. Today’s Agenda
What have we learned about healthcare needs and variation in gaps in potential access to services?
What challenges do the formerly incarcerated face in meeting their healthcare needs (realized access)?
What is potential impact of California’s changes in parole policy on referral to services?

6. CA Inmates Have High Levels of Healthcare and MH/SA Treatment Needs
Healthcare needs are high
Physical acute and chronic health conditions (e.g., cardiac, asthma, hypertension, tuberculosis): 40%
Physical disability: 33%
Mental health and substance abuse treatment needs are even higher
Drug or alcohol dependence: 58%; 55%
Recent mental health problem: 56%
Previously diagnosed with a mental health condition: 27%
Co-occurring mental health and substance abuse/dependence problems: 48%
Based on analysis of the BJS survey

7. Differences Exist in Treatment for Healthcare Versus Mental Health and Substance Abuse
Most prisoners with medical problems reported receiving treatment while in California prisons
But California inmates with drug abuse or dependence problems reported being half as likely to receive treatment in prison than counterparts nationally: 22% vs. 40%
Rates are a little better for MH treatment in prison
About half reported receiving it: ~ same as national average

8. Differences Exist in Treatment for Healthcare Versus Mental Health and Substance Abuse
Most prisoners with medical problems reported receiving treatment while in California prisons
But California inmates with drug abuse or dependence problems reported being half as likely to receive treatment in prison than counterparts nationally: 22% vs. 40%
Rates are a little better for MH treatment in prison
About half reported receiving it: ~ same as national average
Findings are from 2004 survey—situation has become significantly worse since then

9. Project Measured Potential Access to Healthcare Services in 4 California Counties
Assumed most parolees would have to rely on counties’ safety net providers
Mapped distribution of safety net facilities (hospitals and clinics) relative to parolee concentration in 4 counties
Developed potential access measure that accounts for:
Capacity of a facility (measured by FTEs)
Underlying demand for services (% of households below FPL)
Travel distance (10-minute drive time)

10. Across Four Counties, We See Great Variability in Parolee Access to Hospitals
Total L.A.
Lowest
Mid-Low
Mid-High
Highest
Total Alameda
Lowest
Mid-Low
Mid-High
Highest
Total San Diego
Lowest
Mid-Low
Mid-High
Highest
Total Kern
Lowest
Mid-
Low
Mid-High
Highest 10 20 30 40 50 60 70 80 90
100
Distribution of Parolees Across Hospital Accessibility Quartiles (%) 10

11. In L.A. County, African-American Parolees Have Lower Hospital Access Than Latinos/Whites
Total L.A.
Lowest
Mid-Low
Mid-High
Highest
White
Lowest
Mid-Low
Mid-High
Highest
Latino
Lowest
Mid-Low
Mid-High
Highest
African
American
Lowest
Mid-Low
Mid-High
Highest 10 20 30 40 50 60 70 80 90
100
Distribution of Parolees Across Hospital Accessibility Quartiles (%) 11

12. Summary of Analysis of Potential Access
Capacity of safety net varies by facility type
For example, in L.A., Alameda, and San Diego counties, more parolees lived in areas with relatively low levels of accessibility to hospitals
In all counties, community clinics appear to play role in filling in geographic gaps in safety net
Accessibility also varied by geographic area (within and across counties) and by race/ethnicity
Suggests variation in capacity of safety net at local level to meet the needs of the reentry population 12

13. Today’s Agenda
What have we learned about healthcare needs and variation in gaps in potential access to services?
What challenges do the formerly incarcerated face in meeting their healthcare needs (realized access)?
What is potential impact of California’s changes in parole policy on referral to services?

14. Formerly Incarcerated Face Key Challenges in Accessing Services
8 in 10 men and 9 in 10 women had chronic health problems requiring treatment or management
Most had no health insurance 8–10 months after release, but were heavy consumers of services
Reentry outcomes varied by health status
Those with physical health, MH/SA problems were more likely to:
Need housing assistance
Report poorer employment outcomes
Depend on family for assistance

15. What Did Preliminary Interviews with Providers Reveal?
Low levels of health insurance and lack of finances limit treatment options
HIPAA requirements make it difficult to share information
Individuals reluctant to report mental health problems due to stigma
Will wait to crisis develops to ask for help
Parolees reluctant to ask parolee officer for help in accessing services
Concerned will be labeled a troublemaker

16. We Also Identified Other Barriers to Access
Financial Barriers
Limited options for receiving care to county safety net providers because of lack of insurance or finances
Perceived lower quality of care
Administrative Barriers
Bureaucratic and procedural obstacles to receiving care
Long wait times
Perceived indifference of staff or lack of empathy
Ineffectual treatment from medical or administrative staff

17. Today’s Agenda
What have we learned about healthcare needs and variation in gaps in potential access to services?
What challenges do the formerly incarcerated face in meeting their healthcare needs (realized access)?
What is potential impact of California’s changes in parole policy on referral to services?

18. California Parole Policy Has Created a New Category Called Non-Revocable Parole
On January 25, 2010 California began placing individuals on Non-Revocable Parole (NRP)
Low-to-moderate risk offenders are eligible for NRP status
Validated prison gang members, sex offenders, and serious and violent offenders not eligible
Those on NRP no longer supervised by parole and cannot be returned to prison for technical violations
How NRP eligibility is defined will mean women and individuals incarcerated for drug-related offenses will be disproportionately represented

19. California Parole Policy Has Created a New Category Called Non-Revocable Parole
On January 25, 2010 California began placing individuals on Non-Revocable Parole (NRP)
Low-to-moderate risk offenders are eligible for NRP status
Validated prison gang members, sex offenders, and serious and violent offenders not eligible
Those on NRP no longer supervised by parole and cannot be returned to prison for technical violations
How NRP eligibility is defined will mean women and individuals incarcerated for drug-related offenses will be disproportionately represented
Statewide cuts to corrections included $250 million
for rehabilitative programs

20. NRP Population Will No Longer Be Eligible for Corrections-funded Community Treatment
Providers in general don’t know how to readily identify or reach reentry population
Identifying those on NRP will become even more difficult
Traditional mechanisms to refer ex-prisoners to services (e.g., parole officers and PACT meetings) no longer available to NRP
NRP will rely solely on counties’ severely strained safety nets
NRP group could become a “hidden population”

21. New NRP Policy Has Implications for Referrals and Access to Services
County mental health and alcohol and drug treatment programs expect increase in demand for services
Comes when county agencies have experienced significant cuts in base funding
Initial impact may be more on hospital ERs and county jail treatment services
But NRP could also represent an opportunity
Enable county safety net and community providers to improve coordination in providing services

22. New NRP Policy Has Implications for Referrals and Access to Services
County mental health and alcohol and drug treatment programs expect increase in demand for services
Comes when county agencies have experienced significant cuts in base funding
Initial impact may be more on hospital ERs and county jail treatment services
But NRP could also represent an opportunity
Enable county safety net and community providers to improve coordination in providing services
Need to take account for these changes in our analyses

23. Next Steps Conducting focus groups with parolees
Meeting healthcare needs
How health affects ability to address other basic needs
Barriers to accessing care
Conducting interviews with service providers
Facilitators and barriers and strategies to overcome barriers
Conducting focus group with family members/caregivers
How incarceration of a parent or family member impacts children in particular
Assessing policy/institutional barriers

24. Project Team Lois M. Davis, Ph.D. Kathryn Pitkin Derose, Ph.D., M.P.H.
Malcolm Williams, Ph.D.
Rev. Eugene Williams, III (Regional Congregations and Neighborhood Organization)
Contact Information:

25. Understanding the Public Health Implications of Prisoner Reentry in California