Last week the Center for Disease Control reported that in fall 2005 about 91 percent of HIV-positive male inmates in Georgia were living with the virus before imprisonment. According to the CDC publication, Morbidity and Mortality Weekly Report, about 1.9 percent of the state's 44,900 male inmates tested positive upon entering prison.

While this study hopes to shed new light on HIV transmission among inmates, which some medical professionals say contradicts society's belief of its commonality in prisons, an unanswered question still remains regarding the health care of these offenders, and those who suffer from other diseases, when they leave prison.

Dr. Thomas Conklin, director of health services at Massachusetts' Hampden County Correctional Center, thinks he holds the answer with a public health model he created about ten years ago.
 
“The current system [of inmate health care] is old school, in which a physician visits the prison for about three hours a week. Here are all these patients coming in and out to be seen, but not much was being done for them. They were just reservoirs of illness,” he says.

Dissatisfied with the type of care his inmate patients were receiving, Conklin re-examined what he called the “bedlam” of Hampden's health facility along with its inmate health records.  In talking with patients, he discovered about 93 percent of them came from four communities in and around Hampden County.
 
“We know about 20 percent of our population has chronic diseases like HIV, STDs, TB, diabetes, hypertension, and all forms of hepatitis,” Conklin explains. “Most had no treatment before they came here. When I asked them what they did about their conditions, they said they went to emergency rooms. This is the worst way to take care of these patients, because it's expensive and the care is inconsistent. These people belong in a neighborhood health center.”

Community health centers had trouble tracking these patients, though, because of the large gaps in their medical history that would occur when they went to prison. In some cases, ex-offenders never returned to their clinic upon release. If they did return, the time between visits was so long, the clinic would have to conduct new assessments on their condition, which increased care costs.
 
Conklin spoke to a local physician who cared for the prison's HIV inmates about having the four area health centers participate in an inmate care program. The doctor agreed, and Conklin's innovative idea of linking corrections to public health and connecting inmates to their communities became a reality.

With support from Hampden County Sheriff Michael Ashe, the four community health centers, and the Massachusetts Department of Health, the 1,800 inmate medium-security facility rolled out a corrections health care model that now cares for a population that exists largely outside traditional primary care.

Community health centers now regularly visit the Hampden facility, which has helped Conklin's establish a two-step approach to inmate care.
His staff includes a supervising MD who visits the facility at least a day and half each week, a fulltime nurse practitioner, and a staff of nurses.

“Five nurses serve as a triage unit that visits inmates everyday to treat and care for minor issues. This frees up the clinic for those referred by the nurses because of more serve diagnoses.  Every patient is assessed constantly. We make a date for our patients to come back and see their doctors regularly, which makes this a much more personal approach,” he adds.

An additional benefit to this approach is the medical knowledge corrections officers gain from watching the nurses. As a result, they can better gauge when to send an inmate to the infirmary.
 
In Massachusetts, those sentenced to terms of three years or less are sent to facilities like Hampden. An inmate's average stay can last from 60 days to three years, causing Conklin to see a tremendous flow of patients both entering and leaving the facility at any given time. In effort to maintain consistent care for all patients, he implemented a five-step process for his medical staff.
 
“The first step is early assessment and detection. Many facilities take care of obvious or severe problems, but do not pay much attention to the rest.  Some guys don't know they have diseases. Doing an early and full patient assessment means a lot more lab work, but it pays off in the end because the sooner you can identify a disease, the sooner it can be treated,” he says.
 
Next, discovered illnesses are treated. Then, education, prevention, and post-release care follow. Full-time RNs provide weekly classes on specific diseases. Diabetic inmates, for example, gather to discuss the disease and how to care for it. Other classes teach how to avoid disseminating and contracting communicable diseases.
 
“When patients see the same doctor, nurse or practitioner, a lot of education occurs,” Conklin says. “Our nurses and case managers continually drive home the importance of keeping up with their medications. Our patients stay compliant because of this consistency and because we're able to help them understand their disease.”

This consistency also creates a certain trust that forms between doctor and patient, which tends to make inmates more forthcoming with their condition and medical history. This helps Conklin earlier diagnose their diseases and better treat their conditions.
 
Conklin says his prevention approach includes a broad immunization program that includes computerized records of inmates' immunizations, and testing for different diseases.
 
“The most important step is the last, which is continuity of care. They've had a good assessment. They've been educated, and their ready to go back into the community. Well, shame on us if we let them go into the community and do nothing afterward. It's like throwing money away if we do all this work and do nothing once they're released,” he adds.

His program empowers offenders to take care of themselves, and encourages them to see their health professionals at the local clinics once they leave his facility. He says about 80 percent of the ex-offenders he refers to health clinics make their appointments because they get see the same health practitioner that cared for them in prison.
 
“This approach saves the community a lot of money.  In prison, we can diagnose diseases early enough so they don't get so sick that it requires more expensive treatments. The relationship between inmate and doctor carries to the outside, so we're keeping people out of emergency rooms unless absolutely necessary.”

Conklin's successful approach to inmate care, along with a lack of a consistent health care program in corrections facilities nationwide, inspired the Robert Wood Johnson foundation to create Community Oriented Correctional Health Services (COCHS) this past January. The foundation's initial $7.5 million grant allows COCHS to provide technical assistance and consulting services to jails and community health centers across the country that are seeking to replicate Conklin's model.

“It is my hope that those in correctional health and public health can work together on a program that is truly effective and successful in providing health care to inmates and ex-offenders,” Conklin says.

Next week, the Corrections.com Ezine will cover the Washington, DC facility that is taking steps to incorporate Conklin's public health model with the COCHS's support.