Removing Barriers to Care

By Lester Wright, MD, MPH

Posted on April 15, 2009 – Although treatment of hepatitis C requires months of medication and significant provider time, the disease itself tends to progress slowly, usually over decades, so treatment is never an “emergency.” Since most correctional systems have neither responsibility nor ability to pay for care after an inmate is released, and since most people who are released from prison do not immediately have health insurance, most treatment protocols for hepatitis C in correctional systems defer treatment if the inmate is likely to be released before that treatment could be completed.

Treatment of hepatitis C is indicated only at certain phases of the disease. Ideally, treatment should be available at those times, whether or not the infected inmate is likely to be released in the near future. Although care in the community is often influenced by insurance status, both in the community and in corrections, it should be determined by medical need.

In the New York State Department of Correctional Services (DOCS) system we have approximately 8000 inmates who test positive for hepatitis C infection or approximately 13% of 61,000 inmates spread among 70 state prisons. We have had primary care guidelines for hepatitis C for ten years with revisions as indicated.

Treatment requires approval by the Chief Medical Officer who reviews whether the guideline is met or there are extenuating circumstances. Through the end of September 2008, over 2500 inmates have been treated. All guidelines prior to the 2005 revision required an expected length of stay long enough to complete care; however, the problem with this criteria is that length of stay is often unclear. For example, parole boards are often unpredictable. Thus an inmate-patient may have hepatitis C treatment deferred since it seemed likely that he or she would be released in the near future only to have parole denied, resulting in a length of stay long enough to complete treatment if it could have been predicted accurately.

Although inmates with chronic illnesses requiring medication are released with a two week medication supply (30 days for HIV), treatment of hepatitis C requires not only oral, but also injectable medication. Sending released patients out of prison with syringes and injectable medication may set them up for problems with their parole officers. Additional barriers to continuity include regular monitoring of potentially serious side effects and the fact that partial treatment may select out resistant organisms and may not benefit the patient. But treatment at the right time can produce considerable benefit for the individual as well as society at large.

We decided to develop a system to connect patients with a “medical home” in the community, thus allowing hepatitis C treatment to be initiated without regard for length of stay in prison. It would not have been possible to develop such a system without partners. In New York State, our partnership began with the Department of Health and its AIDS Institute, the Division of Parole (DOP) and the New York City Health and Hospitals Corporation (a large public hospital system with units throughout the City.) Since over half of inmates are released to New York City, this allowed us to initiate the program. During the first year of the program, the AIDS Institute was able to convince designated AIDS treatment centers throughout the state to participate even if the patient was not HIV infected. Since that time, additional hospitals and practices have also become partners, meaning that within a year the program could expand to include inmates released into any part of the state. Unfortunately, since some parts of the state are very rural with few health care providers, the nearest participating provider may still be a long drive from where a released inmate lives.

When treatment is approved, DOCS identifies inmates who may need to become part of the continuity program. Prior to release, DOCS identifies inmates who do indeed need to become part of the program. The program is explained to the inmate and consents are signed. Facility-based parole officers work with DOCS to determine where the patient will be living, and the inmate selects the most convenient provider from our list of participating partners. DOCS contacts the selected provider and coordinates arrangements, medical record sharing and appointments. The inmate is released with a two week supply of Ribavirin, the oral medication. A two week supply of pegylated interferon, the injectable medication, is shipped to the provider selected. The in-facility parole officer communicates with DOP Central Office who contacts the street parole officer. Assistance is given with paperwork to apply for Medicaid coverage if eligibility is a possibility.

After release, DOP staff helps arrange supportive services, e.g. mental health care, housing, substance abuse treatment, and helps support treatment adherence. The AIDS Institute collects data used to evaluate the program. Recognizing that some may not be Medicaid eligible, another set of partners has become part of the program. In those cases, manufacturers of the treatment drugs have agreed to provide medication through their access programs. As of the end of September 2008, 109 inmates have been enrolled in the program and have thus been able to initiate treatment of hepatitis C without regard for their length of stay in prison.

We have learned that wide-scale collaboration such as this is not only possible, but essential. It is important that each partner recognize how they can benefit. The network of providers will always be “fluid” as some leave the area or retire and others begin service. Thus, keeping the network functional takes continuing work. It is important to have ONE contact at each partner to simplify communication. Collecting data for evaluation from many partners also requires continuing work. We continue to encourage additional providers to participate, particularly in more remote areas of the state.

Using this continuity program as a model, New York is working to make continuity of care available to all inmates with chronic disease who are being released. The New York Academy of Medicine has signed on as partner in that process.

Dr. Wright is Chief Medical Officer of the New York State Department of Correctional Services. He presented this topic at 2008 annual SCP conference. Readers may contact Dr. Wright at lnwright@docs.state.ny.us.