They’re Out of Prison. Can They Stay Out of the Hospital?

SAN FRANCISCO — The night Ronald Sanders turned his life around, he had been smoking crack for two days in a tiny, airless room. His infant son, Isaiah, was breathing in the fumes. “His chest was beating really hard,” Sanders recalled. “So I pray: ‘If my son makes it through the night, that’s it.'”

Sanders quit using drugs and stopped cycling in and out of prison more than two decades ago. He is now a community health worker who helps people getting out of prison deal with a host of medical, psychiatric and substance abuse disorders.

As the country tries to shrink its aging prison population, the inmates being released after years locked away often have mental illnesses and addictions that can land them back in prison if untreated. Sanders and other former prisoners are central players in an approach to helping these men and women that is expanding in California and North Carolina, among other states. By year’s end, Los Angeles County plans to have hired 220 such workers to help released inmates navigate life outside.

“We’ve always known incarceration is bad for health,” said Leah G. Pope, director of the substance use and mental health program at the Vera Institute of Justice, a research and advocacy group. “But in an age of increasing attention to justice reform and health care reform, the two are increasingly connected.”

Sanders works for the Transitions Clinic Network, which has doubled in size over the past five years and now works out of 25 health centers in eleven states and Puerto Rico. It has treated some 5,000 patients since it got its start here in 2006 at a city-run clinic for low-income residents in Bayview-Hunters Point, a neighborhood heavily affected by incarceration.

At the time, the bulk of inmates left prison without health insurance. The expansion of Medicaid in 32 states under the Affordable Care Act has been what many in the field consider a criminal justice milestone, making low-income men and women who are single and childless potentially eligible for free health care for the first time.

Sanders, 54, who was incarcerated during his 20s for drug dealing and parole violations, now counsels formerly incarcerated patients whose experiences echo his own. He urges them to manage chronic diseases and quells their occasional panic attack. Offenders incarcerated as teens emerge in middle age as if from a time machine, unfamiliar with transit swipe cards, smartphones, even email.

Among his regulars is Darryl, 58, who did time in prison for drug dealing, vehicle theft and possession of a firearm. Darryl, who asked that his last name not be used to protect his privacy, has hypertension, near-crippling depression and memory loss from a traumatic brain injury. Sanders said Darryl was suicidal when they first met: He connected Darryl with a therapist, helped him get into treatment for drug addiction and eventually found him housing in a single-room-occupancy hotel in the Tenderloin, the same neighborhood where Sanders once lived on the streets.

When Darryl is out of touch, Sanders goes to his door. “I don’t want to see you dead because you haven’t checked your damn blood pressure!” Sanders chides him.

The community workers serve as mentors. “You’re building that rapport with someone who has walked the same walk and been successful,” said Nicole Sullivan, the re-entry director for the North Carolina Department of Public Safety. It is spending $600,000 to expand the Transitions model, which started as a grant-funded pilot in Chapel Hill, across the state.

Prisons and jails are constitutionally mandated to provide health care, but that responsibility ends upon release. For those getting out, the first two weeks are particularly perilous. A study in Washington state published in The New England Journal of Medicine in 2007 found that former inmates are 12 times likelier to die than other state residents in the two weeks following their release, especially of lethal overdoses, a risk factor confirmed by later studies.

Access to health care can be a roll of the dice: Medical discharge plans vary from nonexistent to prisons with dedicated planners who coordinate health insurance and medical appointments before release. Most of the 32 Medicaid expansion states suspend, rather than terminate, coverage for inmates who previously had it and send them out with an insurance card when they leave. Ohio and Indiana, among others, have programs to enroll inmates in Medicaid prior to release.

Preventive care is often lacking in the disadvantaged neighborhoods that are home ground for many inmates, the vast majority of whom are black and Hispanic.

“There’s mistrust combined with a lack of knowledge about navigating the health system,” said Joseph Calderon, a Transitions worker. “In our communities, people are taught how to take care of their cars but not how to take care of their health.”

Many ex-offenders ignore chronic conditions and wind up in costly emergency rooms or hospitalized for preventable conditions.

There is no definitive evidence yet that the Transitions program helps ex-inmates stay out of prison. Preliminary data from a study in New Haven, Connecticut, suggests that people who received care through the Transitions Network spent less time incarcerated than those in a control group in the year following their release.

There is some evidence that the program helps people stay out of emergency rooms and hospitals: A study in the American Journal of Public Health of 200 chronically ill former inmates in San Francisco, half assigned to a Transitions clinic and half to a primary care program, found that the Transitions patients’ use of emergency rooms was 50 percent lower.

“People coming home have many health needs,” said Dr. Shira Shavit, the network’s executive director and a clinical professor of family and community medicine at the University of California, San Francisco. “They need food, a place to stay and a job, and many face discrimination in housing and employment. They may have lost connections with family. So it is important to address the big picture.” At the clinic, she saw a new patient who had just been released after 16 years and eight months in prison. “Any tattoos?” she asked him. “Drug use? Sexual acts in prison?”

Knowing a patient’s history can yield important clues “about past substance abuse, trauma, poverty, violence, lack of access to clean needles for tattooing or drug use or PTSD from solitary confinement, all of which are clinically relevant,” she said.

This particular patient had kidney disease and had a heart attack in prison; since his release, he had been dealing with insomnia and nightmares. By far the worst thing, he told Shavit, has been loneliness. “In prison, you had shared experiences,” he said.

Because the program is based at a health center, Shavit was able to connect him to a psychiatrist on site. Substance-use disorders are also typically treated there. The Transitions team usually works with patients for about six months.

Community workers like Sanders can make a big difference, former inmates say.

“If it weren’t for Ron, I’d be dead or in prison,” Darryl said. “He may not be a religious guy. But he does all the things the Scripture say do.”

Last month, Sanders rushed to meet a distraught, mentally ill former inmate in the Tenderloin whose service dog, a terrier named Jack, had been struck by a car and killed. He found her weeping on the street, mascara streaked across her face. He coaxed her once again to try Suboxone, a medication that reduces cravings for opioids. He took her to get two new dogs spayed. And he filled out 44 pages of housing forms on her behalf and later gave her good news: He had found her a place in a nice building with lots of dogs.

An eternity ago, Sanders was the one needing guidance. He was homeless and sleeping in doorways. He was lucky enough to meet a social worker, who saw a spark in him and took him under her wing.

These days, he walks past wire-gridded doors and over shards of broken glass, trying to connect with patients who have lost their way. He gives them his card and says, “Hey man! When are you going to come see me?”

“They get tired,” he said. “These streets can tear you up worse than prison.”