Reentry is on the lips of many in the public safety arena as they try to find ways to improve offender outcomes after release. But beyond the desire to improve public safety and lower recidivism rates is the need to protect public health.

As agencies opt for a holistic approach to release in the community, public health care partnerships have become an important part of the pre-release puzzle. As offenders learn more about disease prevention, the importance of taking medications and visiting their doctor regularly, not only will their health improve, but also the likelihood of spreading disease in the community will decrease.

"Corrections is not static, especially with jails. The Bureau of Justice Statistics estimates that a third of all inmates are released on an annual basis. I think we're seeing that the social capital they come back to the communities with is weak. If they are going to find jobs, find housing and do what communities want them to do, there has to be a supportive mechanism," said John Miles of McKing Consulting Corp. and Executive Director for Programs for the American Correctional Health Services Association.

The corrections and public health fields have intersected more frequently in recent years as closer attention has been paid to the healthcare that inmates need after release. In 2001, the Centers for Disease Control funded several demonstration projects across the country to promote public health and corrections collaborations and a report to Congress last year on the health status of soon-to-be-released inmates also highlighted the issue in a broader context.

Miles said that these efforts have gotten agencies to specifically look at peer education, improving access to care and reentry prerelease discharge planning for offenders and what services are needed in the community after release.

"Communities are becoming more aware of that and what would happen if they don't invest in that," said Miles. The challenge, he added, is "How do you get the leadership of those at the policy levels, the government levels and the traditional community organizations to step up to the bar?"

Miles, who has worked closely with the CDC in recent years on this issue, said that he has found success in meeting face-to-face with stakeholders to accentuate the need for collaboration among public health and corrections agencies.

Bringing the Issue to the Table

According to Miles, as corrections agencies have improved health care services for offenders on the inside, so too has the health care they receive after release improved.

A lot of this improvement on the outside, Miles said, has been driven by the necessity to treat offenders who have HIV.

"We've seen a recognition by the agencies. If systems invest the money to provide diagnosis and treatment, there is an obligation to continue it on the outside. If you don't, you have wasted the effort on the inside," said Miles.

Correctional healthcare providers know that if offenders do not have access to the medications they take while imprisoned, then they can develop resistant strains of the disease that are more complicated and difficult to treat. This can also impact members of the community if new strains are spread from offender to family member.

But the issues the offenders have go well beyond health care needs.

"We've done a number of projects [to look at this] and invariably, when you look at the needs the inmate thinks he has before release -- to find a job, get their kids back, etc. -- the major one is where they are going to live. If they don't have any family support or no real means, then they are subject to living in a shelter or they might be back on the street," said Miles.

Part of dealing with those basic needs is making sure that health care is available to these individuals.

"Health care has to be an element because if the individual is ill or requires multiple interventions, until the individual can be stabilized, then their ability to maintain a good employment record or deal with family issues [is compromised]," he said.

Miles, through his work as a consultant, has set up focus groups in various parts of the country to bring this issue to light.

He said that agencies at the corrections, public health and community levels need to be educated about the benefits of helping offenders stay healthy.

"The question is, How do you convince communities that this is worth utilizing scarce resources for? If you don't, you are increasing the likelihood of transmission of communicable diseases; there are more costs for dealing with chronic disease and then, the costs if they re-offend and the cost of re-incarceration and the judicial system.

Keeping them outside and returning them to be productive members of society is more cost-effective," Miles said.

One community group that took this issue and ran with it is the AIDS Foundation Houston. According to Miles, the group, which is the major AIDS service in the Houston area, developed a peer education program after participating in forums to highlight offender needs upon release from the Texas Department of Criminal Justice.

"They recognized that the incarcerated population was a priority because a quarter of the state's HIV-positive inmates came back to Houston, so they have begun to aggressively work with this population," said Miles.

Since beginning a peer education program for inmates, the organization has also recently expanded its outreach to women and has connected with shelters and pantries to provide those services to the inmates as well.

Many other agencies across the country are striving to make a difference for inmates with health problems as they are released into the community.

Making a Difference for Offenders

In Georgia, the Department of Corrections has offered transitional services to offenders with mental health problems or developmental disabilities through a program called TAPP (Transitional Aftercare for Probationers and Parolees).

Bill Kissell, Health Director for the Georgia DOC, said that the program connects probationers and parolees with caseworkers who set up residential services, appointments for treatment and vocational programs for offenders. They work closely with the probation/parole officer to ensure the offender's needs are met for six months after release.

"What would happen otherwise is they would often not be able to get into the mental health system and would leave with a referral to a mental health center, $25 and 30 days of medication," Kissell said. "This program allows someone who is familiar with services that are available in the community to advocate for that person."

The Georgia DOC also has other partnerships in the community that help offenders with health-related problems after release using federal Ryan White Title Two Funds.

The DOC is in the process of starting a pre-release transitional planning program for HIV-positive offenders who will re-enter the community. According to Jennifer Taussig, Public Health Coordinator for the DOC, the program is being piloted in 11 prisons and will identify inmates six months prior to release to assess them for services they will need, such as doctor's appointments, medications and housing.

"If people don't have stability [they can't succeed]. The more we can do to help them to get into the medical system, the more successful they are. They can engage [with the community] and we can address their needs holistically. It's not let's give them a medical appointment and that's it," she said.

Taussig said the needs of these offenders are real. She recently received a telephone call from an HIV-positive offender who was "maxing out" his sentence in a matter of days and had nowhere to live. After the phone call, the DOC's new caseworker was able to make him a medical appointment and find a housing program for people with HIV.

While evaluations of the success of these programs have not been conclusive, many know that it is the right thing to do.

"We think the principle is sound and it's not very good care to send them to the street without aftercare. We were hoping the recidivism rates [would be] better, but we think it's the right thing to do and case law has shown that aftercare is becoming a constitutional requirement," said Kissell.

In New York State, correctional healthcare leaders have also invested time and energy into public health collaborations.

One area that has been particularly successful for the New York State Department of Correctional Services is the creation of a TB registry that is shared across systems.

NYSDOCS Medical Director Lester Wright said that TB rates have gone down significantly in the last decade because of collaborations like this.

"TB control has been a major issue in my system. Ten or 11 years ago we had a rate of 225 per 100,000; last year we had 28 and, for cases diagnosed in the system, it was 12. That's better than the Manhattan Borough rate," he said.

HIV treatment is another area that the department has focused on with the New York State Department of Health. Wright said the DOH's AIDS Institute staff meet with DOC health care staff quarterly to discuss clinical care guidelines for HIV and other diseases. In addition, the two departments have teamed-up to conduct seroprevalence studies in the DOCS reception areas.

Wright said these collaborations are only natural.

"We sort of speak the same language and it seems to make sense," he said.

Wright said that the public health system is concerned with those who take excessive high risks- whether that results in sexually transmitted disease, teen pregnancy or contracting HIV. The willingness to take those risks correlates to those who are incarcerated.

"We have people who are at high risk, so it makes sense that we don't just work with the individual end result, but you get at the root cause. If we can find those people while they are in my system, it's a whole lot easier than finding them in the South Bronx. Why not educate them and test them? It just makes sense," said Wright.

In Delaware, corrections and public health officials have come to a similar conclusion regarding inmates with HIV.

The Delaware Center for Justice is another example of a corrections/public health collaboration that is helping to transition HIV-positive offenders into the community.

The center is contracted by the state Department of Public Health and Department of Corrections to provide needs assessments for HIV-positive offenders 30 days before release and then aftercare and case management for 30 days after release.

According to Alfred Onuonga, Director HIV/AIDS Services for the center, the services have to go beyond medical ones in order to truly help the offenders.

"We connect them to medical providers in the community, we try to secure housing,
substance abuse and mental health services. They would just come back and re-offend without this, especially in this cold weather they will commit offenses to stay warm," said Onuonga.

In addition to transitional case management, the center provides peer education inside the facilities to help improve offender outcomes after release.

After selecting inmates who are qualified to discuss the topic, they are trained by the center and Department of Public Health staff.

The discussions or seminars are conducted once a week in each correctional facility and are geared toward a broad spectrum of inmates.

"The inmates have been very receptive. The stigma and discrimination is still there; so we [also] educate those who are not infected about how to get rid of that feeling of isolating them from activities," said Onuonga. "On average we educate 4,000 a year. We have been working to make it almost a mandatory session to get this education once a year."

Onuonga said all these services combined are crucial to maintaining the health of the offenders and the community at large.

"Delaware has been very helpful to make sure the HIV offenders receive the best services, especially when they get out. If they start slipping, they will infect themselves and others in the community," he said.

More and more individuals in corrections and in the community are buying into this philosophy -- and for good reason.

Miles said that if a typical citizen has trouble negotiating health care services and health care coverage, then imagine how challenging it is for an ex-offender who has been out-of-touch with society in general.

"If you have been inside the prison and don't have any life skills and you are rebuffed by the first person you ask for help, you may never come back. Take an inmate who has been in for five years, you haven't had to deal with cell phones or ATMs; that's what a case manager can help with," Miles said.

Miles and others are encouraged that the recent national focus on reentry will also promote these types of collaborations and help ex-offenders be more successful in the end.

"That's why the emphasis on reentry is so important. Hopefully as the President mentioned [in his State of the Union speech] those dollars will flow. It's not coddling [offenders]. It's not hand holding; they need assistance in how to negotiate this process," he said.

Resources:

AIDS Foundation Houston - http://www.aidshelp.org/

Delaware Center for Justice (302) 658-7174