Healthcare Provider Uses HIE Data to Help Inmates Transition from Jail

A jail-to-community transition program improves medication consistency and continuity of care, based upon the goal of reducing recidivism.

People who go to jail frequently lack access to healthcare, mental health services, and appropriate medications before, during and after they are incarcerated. Without proper treatment, many of these individuals return to substance and/or alcohol use, causing mental health issues to go untreated. This can perpetuate a cycle of recidivism that further deepens their legal, financial, and personal woes.

In an effort to help inmates make a transition towards healthier, more functional lives, Health Care Partners Foundation and other healthcare providers serving county jails utilize data from CORHIO’s PatientCare 360® to make informed decisions on their care. A growing number of detention centers use Health Information Exchanges (HIE) to access health information on inmates as part of a medication consistency pilot program supported by the states.

Health Care Partners Foundation, a Colorado nonprofit organization, began using CORHIO data as part of this program under the Colorado Department of Human Services’ Office of Behavioral Health. The program is designed to improve records access and strengthen medication consistency and continuity of care through utilization of HIE systems.

The importance of finding medication data
Rita Torres, Chief Executive Officer of Health Care Partners Foundation, says capturing the medications and health history data is critical in establishing continuity of care after inmates are released.

“Many providers might end up seeing an individual to determine medication consistency since the patient might not come back to the practitioner to determine if those medications are working,” Torres explains. 

The Foundation works with a national pharmacy through an electronic system to obtain current prescription information that otherwise might not track certain painkillers or anti-depressants which could be helpful (or problematic). The program emphasizes a formulary for affordable, non-narcotic medications. Upon discharge and transition, the Foundation also has an addiction specialist who can provide continuity for medication-assisted treatment.  

Fitting into the big picture
Dena Strick, Regional Supervisor for Health Care Partners Foundation, notes that the medication consistency pilot program is only one piece of the Foundation’s overall focus.

Committed to the health and well-being of vulnerable populations in Colorado and New Mexico, the Foundation employs 10 people and a network of volunteers between three states. To connect individuals with healthcare professionals, the Foundation uses advanced telehealth tools to create a seamless transition to healthcare services after discharge – with the goal of reducing recidivism by establishing continuity of care through its providers. CORHIO is key to integrating medical and medication history within the Foundation electronic tools to ensure individuals do not fall through the cracks and can transition successfully with a plan for continuity of care.

Strick says the advent of HIE provided by CORHIO’s PatientCare 360 product has been instrumental to the Foundation’s work.

“Many people in jail have serious health problems,” Strick says. “We’ve seen people with Stage 5 liver cancer, renal failure, and many other critical issues. CORHIO has given us a better picture of what we’re dealing with. It has shortened the time to get critical medical and medication records to our provider to effect a more rapid treatment plan.”

Torres says she thinks every jail in Colorado should be connected to CORHIO’s data.

“We strongly believe in continuity of care, which is only done with as much medical history you can get to ensure providers have the information they need for a good treatment plan for incarceration and upon discharge,” she says.

The Foundation’s tech-savvy approach and commitment to continuity of care seems to be paying off as a reduction of recidivism shows.  In counties with their jail-to-community program, the recidivism rate averaged 20% as compared to a rate of 68% in counties without this program.

“CORHIO has helped us truly save lives because we have quicker access to records,” Strick says. “It allows us to be prompt and effective in delivering and managing continuity of care. If not for the information from CORHIO, we’d be starting again at square one.”

Case history for jail-to-community program participant (July 2019 – present)
▪ Patient is a 57-year-old male with history of multiple incarcerations and frequent recidivism.
▪ HIE information is accessed to gain a clear picture of his health history.
▪ Patient mental health history includes diagnosed depression, anxiety, and anger issues.
▪ Patient substance history includes heavy alcohol use and multiple DUIs.
▪ Patient expressed desire to stop drinking but had difficulty maintaining his sobriety, with frequent relapses of binge episodes -- leading to difficulty keeping a job.
▪ Providers and care coordinator assessed needs and determined well-being for provider and community resources prior to discharge.
▪ Patient has been active in the program for over a year, with great success maintaining sobriety and employment and recidivating back into jail.
▪ Care Coordinator maintains weekly outreach with patient.
▪ Patient is now stable, maintains medications; consistently keeps appointments.

Case summary provided by Health Care Partners Foundation