Oversight Hearing: Evaluating Recent Changes in Healthcare in New York City Correctional Facilities
PATRICIA YANG, DrPH, SENIOR VICE PRESIDENT
NYC HEALTH + HOSPITALS
Thursday, May 26, 2016
NEW YORK CITY COUNCIL OVERSIGHT: EVALUATING RECENT CHANGES IN HEALTHCARE IN CITY CORRECTIONAL FACILITIES
COMMITTEE ON FIRE AND CRIMINAL JUSTICE SERVICES,
COMMITTEE ON HEALTH & COMMITTEE ON MENTAL HEALTH, DEVELOPMENTAL DISABILITY, ALCOHOLISM, SUBSTANCE ABUSE AND DISABILITY SERVICES
Good morning Chairpersons Cohen, Crowley, and Johnson, and members of the Health, Mental Health, and Fire & Criminal Justice Committees. I am Dr. Patsy Yang, Senior Vice President for Correctional Health Services at NYC Health + Hospitals. I am joined by Dr. Homer Venters, Chief Medical Officer of Correctional Health Services, and other senior members of our team. Thank you for the opportunity to review recent changes to Correctional Health Services, or CHS.
In the five months between the time Health + Hospitals assumed responsibility for CHS on August 9th, 2015 and the December 31st, 2015 expiration of the Corizon contract, we successfully created a new division of Correctional Health Services – a $235 million program with 1,500 employees and 24/7 operations in twelve jails citywide.
During this transition period, there were no lapses in coverage and no disruptions in patient care. To achieve this, we worked closely with representatives from the Mayor’s Office and City agencies to clarify governance structures, resolve legal liabilities, and ensure budget neutrality to Health + Hospitals. Furthermore, we reviewed the personnel and credential/licensing files of, and conducted background checks for each of more than 1,200 Corizon employees.
Simultaneously, we negotiated with each of our four union partners – Doctors Council, NYSNA, 1199 and DC37 – for the smooth transfer of nearly 300 city staff by August 9th; and for the employment by January 1st of over 1,000 Corizon staff to whom we offered jobs beyond December. At the time of both transitions, all union staff whom we selected to retain were covered by collective bargaining, with salaries, leave balances, pensions and health benefits preserved.
Improvements to CHS in FY16
Workforce and Infrastructure
Despite the complex challenges presented by the transfer to Health + Hospitals and disengagement from Corizon, we didn’t want to miss the opportunity to begin building a framework for our new service. An immediate and fundamental change has been to unify all management – from senior executive to jail site leadership – into one team within Health + Hospitals, replacing the previous model of an oversight agency and an entirely separate vendor. This set new expectations and replaced a culture of inherent distrust, with a new culture that emphasizes we are all in this together.
Moving away from a for-profit vendor to a public healthcare system has also enabled us to recruit and retain more mission-driven professionals. To that end, we’ve brought in psychiatrists, psychologists and social workers who have devoted their professional lives to working in the field of correctional health at institutions such as Sing Sing, Bridgeport Community Correctional Center, Lincoln Hills Juvenile Justice facility, and Bellevue Hospital.
We have integrated our mental health and discharge planning staffs into one professional psychiatric social work service. This service is led by a newly hired licensed clinical social worker with a psychotherapy background. These changes have already resulted in positive outcomes, from the quality of our discharge readiness services and connection with community agencies to our ability to recruit high quality staff. In addition, we’ve ensured that we now have deputy medical and nursing directors responsible for specific jails, and site medical directors performing some patient care.
We have also created and filled key leadership positions. Heading up our new department of substance abuse services will be an Addiction Medicine physician who has worked in an academic affiliate caring for homeless patients and who will help us optimize the clinical efficacy of our extensive substance use treatment programs and keep the care we provide on the cutting edge. We created a new position for Clinical Quality Improvement to singularly push us to constantly improve the quality of care we provide. We’ve overhauled our Quality Assurance and Quality Improvement structure and processes and are integrating into the robust quality assurance structure of Health + Hospitals.
We’ve recruited a Director of Clinical Education who will train the medical staff and promote a culture of continuing education; and a medical expert in geriatric and palliative care who will manage the care of elderly patients. We have a designated nursery coordinator who meets with every pregnant woman at the Rose M. Singer Center, pre-screens all pregnant women for eligibility for nursery placement, and reinforces the importance of prenatal care and breastfeeding. We have increased our educational efforts, establishing medical and mental health grand rounds that offer continuing education credits across multiple disciplines, and we are working to expand educational collaborations for trainees with academic partners.
The opportunity to create a unified approach in one of the nation’s largest correctional health services has also attracted professionals with expertise in the administration and operations of correctional health – areas previously managed by Corizon. On the administrative side, we built our own in-house system of employee review and tracking to ensure that anyone working in CHS has the requisite credentials, licenses and background clearances. We created a new department of Policy and Planning comprised of epidemiologists, data analysts and patient relations experts who coordinate incident and complaint investigations; responses to external inquiries ranging from patient to federal court requests; and data collection, analysis and reporting. Policy and Planning also guides the implementation of key initiatives involving external partners including our pre-arraignment screening in the Manhattan Detention Center, our collaboration with Health Homes throughout the city, and our efforts to ensure Medicaid coverage for CHS patients.
Our Operations department, led by a recently recruited professional with significant administrative and nursing experience in correctional settings, is rolling out new standards and systems for every aspect of the operation that supports the provision of clinical care. Everything from staff and patient scheduling, to inventory management is being overhauled to increase accountability and productivity.
Our Operations team has spearheaded critically important improvements to staff safety in the jails. Earlier this year, we conducted the first-ever safety survey of every clinical space in the jail system to create a baseline for necessary improvements. We are working with DOC and the health unions to determine how we can operationalize improvements to safety. With the assistance of the City’s Office of Labor Relations, we have convened a pioneering workplace safety committee that includes DOC, COBA and the four health unions and focuses on creating a safer work environment for all staff in the jails. Additionally, Operations has designated a CHS Safety Officer and has set up a CHS Safety Report line in the clinic areas so that staff concerns can be directly communicated for follow-up.
Safety in the jails cannot be discussed without acknowledging our essential partner, the Department of Correction. At an executive level, we coordinate on strategic directions and critical matters and meet weekly to jointly plan and problem solve. With the direct support of Commissioner Ponte, DOC and CHS staffs at our most challenging jails (AMKC, GRVC, GMDC and RMSC) meet daily to discuss the most pressing issues surrounding safety and patient production. Weekly meetings of custody and health jail leadership are also held to review and plan for the management the most challenging patients system-wide.
We also established the Joint Assessment and Review (JAR) process to foster better coordination with DOC around significant incidents that affect staff, patients and facilities. Under the JAR, each agency conducts its own investigations but then we come together to share respective findings and identify opportunities to jointly reduce the likelihood of recurrence. Collaboration with DOC in the JAR process has already resulted in policy and operational changes that should improve access to care and reduce likelihood of bad outcomes.
Continuity and Access
As with our workforce and infrastructure, we also began making improvements in service delivery even while we were managing the transition.
We worked with Health + Hospitals health plan, MetroPlus, to establish a presence at the Visit Center on Rikers Island. Each Friday since last December, people leaving jail or visiting someone at Rikers Island can stop at the MetroPlus desk for assistance in getting health insurance. In the seventeen weeks since we began this collaboration, 77 of our patients or their families got health insurance coverage, with 96 percent of these individuals choosing to enroll in MetroPlus.
Last month we launched a telehealth pilot program – the first-ever in the Health + Hospitals system. In collaboration with the Infectious Disease service at Bellevue Hospital Center, CHS now offers audio-video consultation to patients at jail locations. Telehealth sites have been established and tested in three jails; and physicians at the Bellevue telehealth sites have the ability to view the CHS electronic health record to facilitate clinical consultation.
Also last month, we launched Safe Landing, a new re-entry group for sentenced individuals with mental health needs. The groups provide an opportunity to discuss challenges people may face as they reenter the community, such as stress related to reuniting with family or friends. Led by our Psychiatric Social Work Service, Safe Landing helps patients learn how to identify triggers and develop coping mechanisms so they have the best chance at bringing out a positive change for themselves when they leave jail.
I am excited to announce the June 1st opening of our new Correctional Health Services Assistance Center. Located in part of our facility across the street from the Rikers Island Bridge, the Center is a “one-stop” location to help people leaving jail and their families get connected to services in the community. The Center will be staffed by representatives from CHS’ Reentry & Continuity Services, MetroPlus, Gotham Health, and NYC Health + Hospitals’ Health Home. Over time, we expect to expand beyond these four anchor programs to include key City and private agencies to improve the transition of our patients into the community.
Being part of the nation’s largest public health care system offers many opportunities to improve continuity of and access to care. For example, we’ve been working with Gotham Health on a number of fronts including connecting patients to Gotham providers when they are released. We’ve strengthened our relationship with the Health + Hospitals’ Health Home by exchanging information about known patients and dedicating resources to facilitate care coordination for eligible Medicaid patients who are dealing with multiple health issues. Most recently, the team at Bellevue Hospital Center is granting us direct access to its clinic scheduling system so that we can streamline the process for getting our patients appointments for world-class specialty care.
FY2017 and Beyond
All the important structural and systems improvements I’ve described were accomplished with existing resources. In the coming fiscal year, we will continue to examine existing processes and pilot new strategies particularly around patient production and staff productivity. We will keep pushing ourselves to try different ways to address long-standing problems.
Additionally, we have another transition ahead of us, namely the disengagement from Damian Family Health Center, the contracted service provider at the Vernon C. Bain Center in the Bronx. The process will be similar to that which we undertook with Corizon although on a smaller scale. It is our intention to ensure a smooth transition by the expiration of the Damian contract on October 1st, that results in no disruption in patient care.
We are very excited that FY17 brings opportunities to make more significant changes in the way we provide care. We were gratified to see that Mayor de Blasio’s Executive Budget includes a commitment to change the way we care for incarcerated persons. This five-year commitment will help us achieve our two main goals: to increase the quality of and access to care we provide our patients while reducing challenges to and demands on security; and increase continuity of care during and following incarceration.
The Program for Accelerating Clinical Effectiveness (or PACE) units are housing units for inmates with serious mental health issues. They have resulted in increased adherence to medical regimens, reduced injuries to patients and fewer uses of force. As with the first four PACE units, these newly funded treatment units will be designed to bring high level behavioral health services to specific cohorts of patients. PACE units operate at a cost of approximately $2 million, and the cost of the new units will be equal to or less than each of the current units, based on the blend of services in these settings. We are scheduled to open two PACE units each fiscal year through 2020.
Our Enhanced Pre-Arraignment Screening Unit (EPASU) opened last May and currently operates Monday through Friday from 6am to 2pm in Manhattan Central Booking. In eleven months of operation, almost 7,300 individuals were screened for acute medical and behavioral health needs. Approximately 28% of these were referred to a nurse practitioner for more in-depth assessment and 3% (or 59) of those 2,020 individuals, were sent to the hospital for emergency treatment. Notably, 338 individuals with acute medical needs were treated by our staff on-site, avoiding the need to transport patients to the hospital and conserving hospital, EMS and NYPD resources. Increased funding will allow us to cover all three shifts and weekends at Manhattan Central Booking.
Hepatitis C Treatment Expansion
Thanks to the Executive Budget, for the first time we will have dedicated resources to ensure we are able to treat patients with hepatitis C who are in most need. The prevalence rate for hepatitis C in NYC jails is estimated to be 12 percent, and this funding will allow us to treat more patients who have tested positive for the disease or who are continuing treatment initiated in the community.
We will also be able to significantly increase the number of mini-clinics we currently operate close to or within housing areas. These satellite clinics bring our services closer to where the patients are, thereby increasing access to needed services particularly in the larger jails. These units also reduce the challenges of patient movement and waiting.
Telehealth funding in the Executive Budget will allow us to greatly expand our pilot to sites, services and uses of technology to increase access to care and reduce the need for resource-intense and disruptive patient transportation. Our hope is to expand to other services within Bellevue as well as to other Health + Hospitals locations. While telehealth may not be appropriate for every patient, service or encounter, it can offer greater access to urgent, specialty and routine care among the jail clinics as well as between the jails and hospitals, and even within single facilities where patient movement may be a challenge.
Earlier this year, hundreds of CHS staff responded to an Employee Engagement Survey that we sent out. This survey was conducted so that we could “take the temperature” of our workforce immediately after the transition, which had been a tumultuous and uncertain time for 1,500 individuals, both personally and professionally. Of the hundreds of our staff who responded, 91% feel that the work they do is important and fully 93% are confident that CHS will be successful in the coming years. I was and remain inspired by this level of shared optimism, commitment and determination that what we do is so important, and that we can do things better.
Meeting the charge we were given in June of 2015 and achieving the transition without disrupting services or detrimentally affecting patient care required herculean efforts from our staff and all our partners both within and outside of Health + Hospitals. At the same time, we also managed to lay the groundwork for fundamental change in how we care for our patients. We very much look forward to building upon the changes we’ve made to date, none of which could have been possible without the leadership and unwavering support of President Raju and the team at Health + Hospitals, the Department of Correction, this Administration and this Council.
Although this concludes my formal testimony, we were asked to provide feedback on some proposed legislation. My colleagues from other affected agencies and I would be happy to give additional feedback on the bills on today’s agenda. First, I will briefly comment on the three bills that directly pertain to work that CHS currently performs.
INT 1064 (Crowley)
This bill would require DOC to report on providers delivering inmate programming, which is defined to include education, training, or counseling regarding drug dependencies. The substance abuse treatment services that CHS currently offers are among the most extensive offered by correctional health systems in the nation.
INT 1013 (Johnson)
This bill would require DOC and DHS to place inmates who have been identified as having multiple arrests and have lived in a shelter into appropriate treatment, health and mental health programs immediately after discharge. As part of its discharge planning activities, CHS already works with DHS regarding placement of undomiciled persons being released from jail.
INT 1183 (Cohen)
This bill would require NYPD staff to observe and report on symptoms of mental illness and require DOHMH to conduct pre-arraignment mental health screening. As noted earlier, we currently run and will be expanding a pre-arraignment screening program at the Manhattan Detention Center that enables us to screen patients for medical and behavioral health needs. For patients who don’t go through our pre-arraignment screening program, we have a comprehensive clinical evaluation on admission which allows us to screen, diagnose and often initiate treatment for a variety of medical and mental health issues.
We’re happy to further discuss how the services we provide could help address the concerns raised in these bills.