Jennifer Colamonico: Welcome to HMAS vital viewpoints on health care concise conversations with experts that identify practical solutions to make healthcare and human services work better. I'm your host, Jennifer Colamonico, and I'm thrilled to be your guide as we explore new ideas for solving challenges that confound our uniquely American systems. Charged with delivering health and health care in a world that has far too much information and far too little wisdom, we'll aim to keep it simple, frank conversations about what it really takes to reimagine these systems of health and healthcare. Our HMA experts know how things work and don't work, and they have viewpoints on both the problems and solutions that are born from that experience. Vital viewpoints on healthcare is not just another podcast, it's your window into the minds of those steering us toward a healthier future. Subscribe now and together we will explore the hard-earned wisdom that could change the way you think about your professional challenges. With more than two decades of clinical expertise and system transformation experience, Linda Fallen wider is an accomplished consultant and practitioner. An advanced practice registered nurse and board-certified family nurse practitioner, Linda has worked directly with patients and population systems to mitigate risk, improve care delivery and quality. She's helped to operationalize processes to support high quality and coordinated care across the health system, including the carceral setting as a point in the care continuity of healthcare services. And we're going to talk more about that today. Linda has direct experience in the correctional healthcare delivery system, from leadership to the direct delivery of care. She was the chief operations officer for healthcare services provided to patients at Cook County Jail in Chicago and the Juvenile Temporary Detention center. While she was there, she oversaw the delivery and operations for an array of clinical and ancillary services for approximately 9000 persons in those settings. Cook County Jail is actually considered the largest single site municipality jail in the United States. On a typical day, greater than 35% of the population is receiving active treatment for mental health conditions and about 20 or 30 people go to close observation for active drug or alcohol use. So Linda, I'm really glad to have you here on the podcast today because I think the work that you do is interesting and I think a lot of people don't really understand this part of the healthcare system. So to start, I'd love to know just how you got into this work.

Linda Follenweider: Hi, great, thank you for having me to talk today about this as well. I actually had worked as a registered nurse for a long time in inpatient settings and gone back to school to become a nurse practitioner and one of my early jobs was to provide physicals as part of the Illinois Department of Corrections for people as they entered the prison system. And while I was, I was also working at a federally qualified health center. And it really struck me as a clinician, how connected the clinical needs for people were and how the people that I saw when they were entering prison, when they left, didn't have the type of. There was no continuing of the care or building onto the care that was provided. Like I would see in other aspects of care, like when a person leaves the hospital or leaves an emergency room, we connect that care when people return to the community. So that throughout my career, it was a population that, prior to that, had not been visible to me. But I began to see in every aspect of my career. So I worked in level one trauma emergency room outside Chicago, and I would see people there. I would see them in primary care, inpatient care, and began to connect some dots around the fact that the care that was provided in carceral settings frequently wasn't carried through to people as they reached the community. But it was an interesting transition in my professional growth.

Jennifer Colamonico: So were you seeing the same people coming back through, or just sort of seeing people having been released and not having continuity of care there?

Linda Follenweider: I think what happened for me as a clinician, I started to ask questions as I did assessments on people, which is a normal part of care, where we. We do risk assessments, we ask questions about history of the present illness, or was there ever time when you were stable in your chronic illness, like diabetes or asthma? And sometimes the answer I started to get was, when I was incarcerated, I had regular care, and I received medications for this for the first time. Or sometimes people were reluctant to talk about it. It might take a second or third question, but it became clear that there was this time where there was care being delivered and medications that was very disconnected from the care that people were receiving in the community that I didn't really have access to. Like, if you had been seen in another healthcare setting, I could request records. You can request records for people that are incarcerated settings, but people don't know to do it. And what would become sad to me is that if I. I frequently was working in areas for urgent care or, like emergency room, I would see people that decompensated in the community because they didn't have access to continuing the medications that kept them healthy and stable while they were in the carceral setting. So that began just an awareness of it. And then it became a question that I asked people I would ask about, and the more I asked, the more visible it became to be.

Jennifer Colamonico: Now, that's not a standard question, is it? On an intake?

Linda Follenweider: I've never seen it as a question on an intake. I do think with the way that things are changing with the 1115 waiver and justice involved services, it's tapping. It will become part of a screening process because there is going to be services that are. Are going to be provided. But historically, people that are incarcerated, single male, had a household, weren't eligible for services, which is another reason why. And by services, I mean services provided by an insurance plan like Medicaid, which is another reason why they would end up having to seek episodic care in an emergency room or another place. They didn't have regular provision of care. They didn't have regular access to care. And all of those things impact the ability of a person to stay stable in the community.

Jennifer Colamonico: So just so I'm clear on what you just said, that in some cases, Medicaid, they would be ineligible for Medicaid because of having been incarcerated.

Linda Follenweider: Not in relationship to their incarceration, but in relationship to. Prior to Medicaid expansion, single male, had a household, was not eligible category for Medicaid coverage. And there's still ten states in the United States that don't have Medicaid expansion where that's not. This particular population is not typically covered for ambulatory or health services.

Jennifer Colamonico: I see what you're saying. Right. So they'd come out and then they just wouldn't have insurance. So they'd end up in clinics or in emergency rooms with probably unmanaged care because if they didn't have their medications and so forth.

Linda Follenweider: Correct. So, you know, you mentioned about there's a. And certainly there's been a lot of attention on the fact that carceral settings have become the de facto provider of mental health services in the country. So, you know, as an example, if you have a person that is being treated and receives medication and services, is well controlled with their mental health condition when they're released, what would make sense for the community is to have a continuation of that care, because these are, to me, they're my patients. So for me, the patients, the persons that are incarcerated, they would, if they were leaving my care in the hospital, I would make sure that they had access to prescriptions of the community. If they were leaving my care from the emergency room when I was there, I would make sure they had access to their I medications in the community. In carceral settings, there's historically been a disconnect and although there's some effort to provide medications, it's frequently not the level of involvement that's required to help people. So people then decompensate in the community, and then they end up in an emergency room, or they end up being picked up again for on charges, or become a public nuisance, or have another really poor outcome where it could be, to me, as a clinician, as a nurse practitioner who's worked for a long time with people, to me, what would make much more sense is to connect them into service to treat their medical conditions. We know 97% of people that are incarcerated are going to be released in the community. I don't think a lot of people think about it that.

Jennifer Colamonico: No, they don't.

Linda Follenweider: People think that TVs or movies that they watch. You think of people in carceral settings as being something different, but the reality is 97%, these are your neighbors. This is people in your community. And the care provided in a jail or in a prison is just another point in the continuum of care that people receive during their life. It's just another place where people receive healthcare services. And people that are in carceral settings frequently bear a higher burden of chronic illness and of behavioral health and mental health conditions. So it just makes sense that when we identify that, that we put an effort into keeping those people healthy as they return into the community, or to connect them into services to be healthy in the community, because it makes our community healthier, and it creates a more, actually even a more affordable healthcare system, because treating people by giving them medications and keeping them in the community and outpatient services is much more affordable to the health system than treating people for an acute event, after an acute event, because they were unable to access appropriate care when they return to the community.

Jennifer Colamonico: Right. And they end up in the emergency rooms. And we all know that that's highly expensive and inefficient, not in their best interest, and very expensive. You mentioned 97% end up back in the community. Can you talk a little bit about kind of jails versus prisons? Right? Like, break it down a little bit. Right. You've assumed there's some people who are. Maybe they're released in a couple days, some people released in a couple months. I'm trying to think from a continuity of care perspective. You know, a couple days, depending on your condition, obviously, even a couple days without meds can be disruptive, but, you know, a couple of months, presumably you're now a patient on the inside. So maybe talk a little bit about break down that 97%, in terms of you know, where they go and how quickly they're released.

Linda Follenweider: So just to me, the easiest way to understand. In general, we think about jails as being where people are held in custody prior to adjudication or prior to a decision being made about what their charge is. And a prison is a place where people are typically housed after sentencing. The reality is that jails do hold people that are sentenced, but in prison, as far as connecting people in the community, the opportunity is a little bit easier because there's a release date. So you know when a person is going to be released, and typically those sentences are longer than a year. So again, you're talking earlier. If a person is receiving adequate health care while they're in a prison setting, they would be well controlled and able to just connect them into service community makes a lot of sense. Jails are a little bit more complicated because in a jail, you're in custody based on your charges and you're released based on your charges. So unlike other healthcare settings or places where health care are provided, you don't go in because you're seeking health care like you go into a hospital because you're sick, you're seeking health care. And a lot of people that are in jails do not have great access in the community. So frequently they may have conditions that have been under treated or not treated when they were in the community, including chronic illnesses, or they may be diagnosed with the condition when they're in because they haven't had good access to healthcare. In a jail, many people are released in the first 24, 72 hours. Some people, if you're acutely ill, you could be released to an emergency room or a hospital because you can't hold people beyond their charges. That would violate their civil rights. So people are released from jails and various levels of control or stabilization of their medical conditions. Also, frequently in this country, there's a lag in people getting their healthcare assessment and the medications when they enter a jail or facility, that it's not an immediate process like when you walk into an emergency room. In some places it is, in other places it isn't. There's a lot of variability. But once for the jail, because you don't know when people are going to be released, it's a lot harder to coordinate that care. So having a system that's ready and responsive to that makes a big difference.

Jennifer Colamonico: So they all get a medical assessment when they come into a jail.

Linda Follenweider: Jails and prisons, there's assessments done when people first come in to make sure you know if they're not too sick. If they're too sick, they would go out for medical clearance before they came in. But once they're accepted into the facility, they're put on a schedule to receive a screening. And that can happen in the first two weeks. If we look at what the, some of the standards are there in some places like Cook county, we did it immediately. When people came in, they were seen by a physical health provider and a mental health provider because we wanted to identify things early. But there's huge variability in the way that healthcare is provided in chances throughout the country.

Jennifer Colamonico: But I think that's interesting. So your point is, you know, you can not have any regular access to health care. And, you know, when you, you go in for whatever reason, like that is a point of service, right. That's a screening point. And you may not have been getting those screenings. So you're identifying potentially, you know, perhaps some sort of mental illness or something, you know, or chronic disease, all of which could be compounding that. So, I mean, from a healthcare ecosystem perspective, you know, you think really big picture. I mean, this is a, this is a really important intake point for a lot of people who aren't otherwise in the system, which creates an opportunity, right?

Linda Follenweider: It really, really does. If you look at, you know, care coordination and mitigating risk, and when I talk mitigating risk to the patient for patient outcome, mitigating risk to system for cost and resources being used for things that should have been handled at an ambulatory setting. So inappropriate use, there's just a lot of opportunity. It's to really help people, help families, help communities as well. I know just as an example, at Cook County, when we looked at, I'll use dental services because dental services are also provided. 70% of our population was naive to dental services as an adult when they.

Jennifer Colamonico: So that means they've never had dental services as.

Linda Follenweider: Not as an adult. Yes. So beyond what was provided in, typically provided as part of school children programs or dental access. So there's a lot of different opportunities around healthcare for people and not a lot of access by virtue of default. People too, that are incarcerated frequently have a lot of health related social needs as well. And there's a lot of poverty. And the fact the bond system, the way it's set up in the country, for some people, even a $100 bond is too much for them to get out. And that determines whether you stay in jail overnight or don't stay in jail. So a lot of the effects of poverty can also be seen among people that are incarcerated or in carceral settings. So when you look at those type of supports as well, it's important. Things like housing, things like transportation to visits make a huge difference in their outcomes for health as well.

Jennifer Colamonico: These are all things that, of course, within federally qualified health centers, within Medicaid, the systems that are set up to serve lower income, not that they all serve lower income and FQHCS, but the systems that we've created to serve lower income folks, we've seen a lot of awareness and engagement around those health-related social needs. To me, what's so interesting about this is that when these folks come out, you made the point that now a greater percentage of them might be eligible for Medicaid. So they might end up on a Medicaid managed care plan, depending on the state, or certainly within an FQHC, which oftentimes is more kind of taking a whole person care approach. So point is, these folks are landing on, somebody else is going to end up having risk for this patient. If we want to talk in healthcare terms now, somebody's going to have risk for this patient. And that disruption of care, it simply kind of costs them more money. Right. There's kind of an economic argument here for this continuity of care, wouldn't you say? I mean, if you're talking, there's the human-interest side, which obviously is into itself a reason, but there's also a financial incentive. Isn't there a reason to have better continuity of care?

Linda Follenweider: Absolutely. I mean, I think when I look at healthcare, and I think I've worked in across settings, so, including federally qualified health centers to provide care. And I've worked in complex care management for health plans for populations. Actually, the populations I looked at were worked, in particular were Medicare and at-risk people. But you identify people that are vulnerable to health systems. Certainly people who are leaving carceral settings would be among them. We've already talked about that they bear a high, higher burden of disease than the regular population. They have higher health needs and those for health plans and for communities and for states, they don't have appropriate access to care at the appropriate level of service, which means they receive ambulatory services in outpatient settings, and they're only in inpatient settings. When they reach an inpatient level of service, it's a risk that they have a system in place that helps to facilitate that coordination of care. The other part of it, the other downstream risk of that is if we allow people that decompensate, it creates a bigger risk for the patient, for a poor outcome, for their health, but also the services that they utilize are limited. Those resources are limited within a facility. And it's much better to prevent someone from ending up in the emergency room through pennies on the dollar in care, then, you know, it's healthier for, as you mentioned earlier, hospitals are, and emergency rooms are not benign. They can be create bad outcomes for people as well as just because they're in the inappropriate setting for them. So the more we can get people to be treated at the right level of service, at the right time, timely access to care, and get the right type of care, the more efficient and affordable the health system becomes, the more resources are available for everyone in the community that needs those hospital and emergency room resources.

Jennifer Colamonico: And what you just said, nobody would disagree with. Right. If we were in a room full of executives, everybody would be nodding their heads. But you obviously have stigma, right? You have like a, you know, double, triple whammy of stigma, right? You know, it's not only poverty and now it might be mental illness and now it, you know, incarceration. Right? So you, so, because if you just look on paper, everything you said makes perfect sense, right? We want to prevent them from ending up in the emergency room unnecessarily. This is what we're trying to do everywhere. So. But it's harder here. Do you think it's stigma? Do you think it's sort of just silos, that the carceral healthcare system is just so disconnected from the rest of healthcare? What do you think the biggest obstacle is?

Linda Follenweider: I do believe that all those things that you discussed exist. But I also think back to when I first started, I think that that hasn't changed. I think these are people that have very low visibility to healthcare sitting settings, to communities. I think when people begin to look, they'll see. And I think for health plans, because they weren't responsible for the care, they were off the radar for this. And as their people are on the radar, we haven't put in place the appropriate screening questions to identify that early. I think health plans, probably better than anyone else, are really great at gathering data and mitigating risk and identifying people as far as creating access for them at the appropriate level of care. I think that I've worked with different settings where there's a lot of really good people, good conditions, trying to do the right thing for people. I think the biggest shift that has to happen is people have to recognize that this is just another point in the continuum of care. And just like you ask, have you been hospitalized in the last year? Have you been to an emergency room for this condition in the last year. Can you tell me where you received healthcare in the last year? We should look for that. People may have received healthcare in a carceral setting. I would ask, has this condition ever been under control? Have you ever felt good? And could you tell me about what medications you were on that helped you with this? That one question would help me so much to help that person to reestablish health in the community so that they can get a job, so that they can, can work. When you're trying to bring into control a condition that's difficult, a chronic condition that's difficult to control, all the other things in life are impossible to coordinate as well. A job. You know, frequently people exiting carceral settings are in jobs where if you miss a day, you're at jeopardy of losing your job. So I think sometimes we focus on those type of things. Why aren't they work? Why don't people work? Why don't they do this? And we know creating that stability in their health and being confident that they can receive treatment for that has a big impact in moving people in the right direction. So for me, the biggest thing is bias. All those things are true, but not actually to essentially have a total carve out for carceral settings. Not actually looking at that as something that had a huge impact on that person's health, including maybe trauma informed care, other types of surrogate markers, rather, if I could use my population health language and a language we use things like, we use high school diploma as a surrogate marker for poverty. Right. They're two separate things. But we should. What we should say is that use carceral setting as a surrogate marker for people that have experienced trauma, that probably have a higher burden of chronic diseases, and we should have a more intensive screening. We have great science on transition to care that people, when they leave a hospital, that they don't return to the hospital, or they don't have poor outcomes, particularly people with chronic illness, if they're seen within the first 72 hours or connect in the first 72 hours for healthcare. Done. Great, great science, great work on that transition in care. It's not reentry, it's transition into the community. If I could get the word reentry out of the vocabulary, I would do it. This is a transition into the community, people that we've identified that have real health needs, and we should treat it just like we treat that transition. We should say someone, we need to connect them and we need to connect them early, and we should expect a better outcome because we do that. That's where I think the problem is and the visibility. Even when people end up in the emergency room, we don't ask them, are you exiting a carceral setting? We know that in the first two weeks that people are released from jail, that they're at high risk for a lot of different conditions, including overdose. So having an intervention is going to have a huge impact for people during that time of entering the community. Again, that transition, just another transition in healthcare.

Jennifer Colamonico: Part of me wonders if we're getting closer. So everything you just described so well, I feel like we're kind of like building those systems in a way that we haven't before. Right. We're having those conversations about trauma informed care. We're having conversations about transitions in all of these other settings. It's like the focus is getting closer and closer and closer. Right. And it's not quite there yet. But are you hopeful? Do you feel like we're closer and it's more possible today? Because this is like, these are words that people understand now, right. This is kind of a reality that's part of health care planning that I certainly wasn't 1020 years ago when I first came into healthcare.

Linda Follenweider: Yeah, I would say I feel like my life's work has really been looking, really working with a lot of different people at points when they're vulnerable to healthcare systems. And I do believe that with the 1115 Waiver expansion demonstration project for justice involved that currently live in several states where we're really looking at healthcare delivery and enrolling people in Medicaid. Cook County Jail was one of the early enrollers for Medicaid. We did that when people entered the jail and we found that 90% of people were eligible for Medicaid that came through. This is a huge volume of opportunity to identify and then treat people the way the program is set up. It's to connect them early while they're still incarcerated, identify their needs, create a care plan, and then connect them into the community. And to me, this is, again, this is care so much more affordable. As you said earlier, it's the right thing to do for people. If we start, it's the right thing to do. But if we're not just going to do it because the right thing to do, it's affordable and it creates efficiency and it is. Setting it up certainly is expensive, but once it's in place, it's going to help people to receive care better. I think part of the other, if people realize how expensive it is to provide disjointed ineffective, episodic, acute care to people, which is what happens frequently to a lot of different people, a lot of different populations, but particularly poor people in this country. They would recognize that the costs were being paid. The cost is being paid. Regardless, we need to open our eyes so that we can solve the problem and help people well.

Jennifer Colamonico: And to say nothing of the costs of just ending up back in the criminal justice system unnecessarily. You made a really good point about kind of getting stability around health and employment. And, you know, stability is, we know those connections, and it's certainly not any different. Might be harder, but it's not any different for these populations. So let me ask you one final question, and I think maybe you might have said it, but I just really want to crystallize. If you had a magic wand, you may be tempted to have several magic wands, given the complexity of the issues as you describe them. But pick one. If you had a magic wand and you could change something that would really have a ripple effect to improve the situation, what would that be?

Linda Follenweider: I think I would love to have a magic wand to begin with, but I do believe I've spent my life in healthcare and in this career. As I said to me, these are my patients. I've worked in jails and prisons across the country to try to help them with improving the quality of care and the provision of care and access to care. So I think my wish for people in carceral settings would be the same as my wish for any of my patients is that they have the opportunity to have access to high quality, good care in a timely manner at the appropriate point, to make an impact in their lives, so that they can function at their highest level of ability to function, so that they have every opportunity to pursue their life without having to worry about where their healthcare is coming from or how their healthcare is received or. Or making a decision about rent or shoes for their kids rather than going for an appointment or having access to care. So that would be my. Because I do think. I do believe also that many people in healthcare just want to take care of our patients and provide those type of things for our patients.

Jennifer Colamonico: And so the application of that, while that's sort of what we want for everyone, but that appropriate time, right. In this case, the appropriate time is a really clear transition point that we just haven't quite figured out yet. But that brings a specificity to that goal, right? The appropriate time being that transition.

Linda Follenweider: I think that there's a few. I mean, there's the point when people enter carceral facilities as well is to really tighten up those screenings early and those assessments early, so that people are started on appropriate care, identified early. And I again, that is addressed in the 1115 waiver language and then carrying that out, that assessment and that plan of care, carrying it out for when people transition back into the community. So I think those are having that system. To me, if you went into an emergency room right now, you would be assessed, they would start your plan of care. They might not do everything there, but you would have a plan. And when you're released, you transition back into the community. When you re entertain community from the emergency room, you have clear idea and connections and appointments and names of people and a coverage typically for most people to be able to receive those services, there's a huge impact on your life to go to a hospital, to go to emergency room. There's a huge impact in your life to go into a carceral setting as well. So these disruptions, we know, impact people's outcomes. Those transitions are really difficult points for people, and it's where we lose people and it's where people have bad outcomes that are totally preventable. It's a high-risk time and there's interventions that would really help people. And what I would really like to see is us use that good science, good experience, the things we've learned about the importance of transitions and hot handoffs or warm handoffs to apply as well to people who are in carceral settings or leaving carceral settings.

Jennifer Colamonico: Yeah, it's possible if we commit ourselves to it, because it is the right thing to do.

Linda Follenweider: Right. We have a lot of really translatable, good programs. We just need to apply those well.

Jennifer Colamonico: Linda, thank you so much for making time for this conversation. I think it's important that more people understand this world that. That you live in and the work that you're doing with states to get closer to this reality. So thank you for all that you do, and thank you for being with us.

Linda Follenweider: Oh, thank you for having me.

Jennifer Colamonico: This episode of Vital Viewpoints on Healthcare is brought to you by HMA Grant prospector is your organization looking for behavioral health grant funding? HMA's grant prospector is your ultimate solution to streamline your grant search time and maximize your grant seeking success. Get started today and unlock your organization's potential. For more information on the grant prospector, visit HMAIS dot healthmanagement.com. thank you for tuning in to another enlightening episode of HMA's vital viewpoints. On healthcare. We hope today's discussion has sparked new insights and perspectives. To learn more about our esteemed guests, please be sure to visit healthmanagement.com podcast. Until next time, stay informed, stay curious, and keep searching for the wisdom that will help to transform our healthcare landscape. This podcast was produced by myself, Jennifer Colamonico, along with Tiffany McKenzie, in collaboration with our guests. The content is the property of Health Management Associates.