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“I was certain you couldn’t be released
<br />fromprisonwithallthosemedicalprob-
<br />lems and not have a follow-up appoint-
<br />ment,”he says.“That was incorrect.”
<br />He learned that prison health care is
<br />soseparatedfromthehealthcaresystem
<br />outside that there was no easy way to
<br />bridge the two. Another former UCSF
<br />resident had come to the same conclu-
<br />sion. Shira Shavit, now a clinical profes-
<br />sor of family and community medicine
<br />at the university’s medical school, did
<br />part of her residency at nearby Alameda
<br />County Jail in the early 2000s and later
<br />recruited physicians to work at San
<br />Quentin Prison. She succeeded—but
<br />the young doctors she enlisted soon be-
<br />came demoralized.
<br />“They started feeling,‘What am I do-
<br />ing?’”Shavit recalls.“‘I’m caring for
<br />these patients, they’re getting healthy,
<br />andthenthey’rereleasedanddon’thave
<br />any access to services. Then they come
<br />back [to prison] on a parole violation
<br />and they’re sicker than when they left.’”
<br />Several studies have found that in-
<br />mates coming out of prison are signifi-
<br />cantly more likely to die—and not only
<br />from drug overdoses. A 2007 study in
<br />the New England Journal of Medicine
<br />tracked 30,327 people who were re-
<br />leased from prison in Washington State
<br />in the period 1999–2003 and compared
<br />them to other Washington residents
<br />matched by age, sex, and race.
<br />2 During
<br />the first two weeks after release, the for-
<br />mer inmates were morethan 12 times as
<br />likely to die of any cause and 129 times
<br />more likely to die of an overdose. Over
<br />two to three years the former inmates
<br />were 3.5 times more likely to die than
<br />theotherresidents.Atotalof443former
<br />inmates died, nearly a quarter of them
<br />from an overdose. Heart disease, homi-
<br />cide, suicide, cancer, and auto accidents
<br />were the other leading causes of death.
<br />Shavit and her colleagues saw the
<br />need to build better linkages between
<br />prisons and the community. In 2006
<br />they started a pilot program in a com-
<br />munity health center run by the San
<br />Francisco Department of Public Health.
<br />They called it the Transitions Clinic,
<br />and its aim was to connect former in-
<br />mates with chronic health conditions
<br />to health, social, and support services
<br />within two weeks of their release.
<br />Shavit and colleagues began the proc-
<br />ess by conducting focus groups to get
<br />input from people who’d been incarcer-
<br />ated.Onepieceofadvicestoodout:They
<br />would need to overcome the natural dis-
<br />trust of the health care system felt by
<br />people who had long been outside of it
<br />and often felt ignored or disparaged by
<br />its practitioners.
<br />Thebestwaytodothat,theyweretold,
<br />was to hire people who had been incar-
<br />cerated themselves and put them at
<br />the center of the program. Community
<br />health workers like Green now fill that
<br />role, connecting and building rela-
<br />tionships with potential patients and
<br />serving as supporters, advocates, and
<br />mentors.
<br />The focus groups had another sugges-
<br />tion, too: People with a history of incar-
<br />ceration didn’t want to be segregated
<br />from other patients and served in a sep-
<br />arate program. Instead, they wanted to
<br />feel like part of the community and to
<br />“sit in the waiting room with kids and
<br />familiesandtherestof thecommunity,”
<br />Shavit says.
<br />Since its start thirteen years ago in
<br />San Francisco, the Transitions Clinic
<br />has grown: Now the Transitions Clinic
<br />Network, it contains thirty-four affiliat-
<br />ed clinics in twelve states and Puerto
<br />Ricothatfollowthesamemodel,includ-
<br />ing the FIT Program in North Carolina.
<br />Ashkin started FIT with support from
<br />the North Carolina Division of Public
<br />Health. The first site, in Durham,
<br />opened in 2016. A grant from the Duke
<br />Endowment and a contract with the
<br />North Carolina Department of Public
<br />Safety, which administers the state’s
<br />fifty-five prisons, enabled the program
<br />to expand to Orange County, where
<br />Green works, and to the counties that
<br />include Charlotte and Raleigh, the
<br />state’s largest cities. Ashkin hopes to
<br />start a program in Greensboro this year
<br />and to provide greater access to mental
<br />health services in all FIT sites.
<br />Maintaining and growing the pro-
<br />gram is challenging because of the
<br />state’s decision not to expandMedicaid.
<br />The grants and contracts Ashkin has ob-
<br />tained help pay the salaries of commu-
<br />nityhealthworkerslikeGreenandcover
<br />the copays that patients would other-
<br />wise have to shell out at safety-net com-
<br />munity clinics. The clinics lose money
<br />foreveryuninsuredclientAshkinbrings
<br />them.
<br />“They’re hoping to get more insured
<br />patients to offset the cost of treating the
<br />uninsured, and I keep bringing them
<br />more uninsured patients,”he says.“If
<br />we don’t expand Medicaid, it will be-
<br />come harder and harder [to raise] pri-
<br />vate funds for this.”
<br />Today the FIT Program serves about
<br />85 inmates, Ashkin says, a number he
<br />hopes to increase to 350 by year’s end.
<br />Butthat’sa small fraction of theroughly
<br />25,000 North Carolina inmates who
<br />come out of prison each year.
<br />The failure to provide health and so-
<br />cialsupportstosomanyformerinmates
<br />fuelsrecidivismandviolence,saysDorel
<br />Clayton, another former inmate who
<br />was hired last year as FIT’s Durham
<br />County community health worker. Be-
<br />fore that, he worked as a supervisor
<br />for Bull City United. As described in a
<br />Health Affairs Blog post published con-
<br />currently with this article, Bull City
<br />United works to interrupt violence and
<br />retaliation in Durham’s high-crime
<br />neighborhoods.3 At FIT, Clayton contin-
<br />ues to collaborate with the staff of Bull
<br />City United because he sees the links
<br />between health, substance abuse, and
<br />community violence.
<br />Peoplewholackaccesstothecareand
<br />medications they need to treat their ad-
<br />diction or mental illness are more likely
<br />to self-medicate, Clayton says, by “get-
<br />ting the drug from street pharmacies,
<br />and that ties into a whole bunch of
<br />stuff.”
<br />Another factor is trauma.“Someone
<br />who is dealing with bipolar disorder or
<br />posttraumatic stress disorder—it might
<br />be a result of having seen gun violence
<br />andpeoplekilledrightinfrontofthem,”
<br />Clayton says.“So their mind-set is to
<br />continue to hurt one another. We try
<br />to educate, but the lack of resources,
<br />theinabilitytogethealthcareandinsur-
<br />ance definitely contributes to violence.”
<br />Ashkin learned that
<br />prison health care is so
<br />separated from the
<br />health care system
<br />outside that there was
<br />noeasywaytobridge
<br />the two.
<br />1618 Health Affairs October 2019 38:10
<br />Leading To Health
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