Research activities are conducted statewide in selected facilities, dependent upon the aims of the study and the targeted population.
Additional systems issues are considered regarding access to inmate populations for research purposes.
CareLink-C: A program to provide Transitional Care
Transitional Care: Effective care management of persons living with multiple chronic condition is often complicated by several other health and social risk factors. For those individuals who become involved with the criminal justice system, health care needs are poorly managed, often with devastating human and economic consequences. The Transitional Care Model (TCM) is an evidence-based solution to these challenges. The TCM has consistently demonstrated improved quality and cost outcomes for high-risk, cognitively intact and impaired older adults when compared to standard care. CareLink-C is an adaptation of TCM for persons who have had an incarceration experience.
The CareLink-C TCM supports and compliments chronically ill persons by providing them with continuity care planning and follow-up coordinated by a “Transitional Care Nurse” who is trained in the care of criminal justice involved (CJI) people with chronic conditions. At the time of intake, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviors, level of social support, and with the inmate sets health goals; (ii) develops with the inmate an individualized plan of care consistent with evidence-based guidelines, in collaboration with the health care team; and (iii) conducts regular visits, focused on optimizing continuity of care at release and to independent living.
Following release, the Nurse conducts regular visits and/or scheduled phone contacts with the individual based on a standard protocol. Two main focuses of the Nurse visits/phone contacts are: (i) supporting the individual’s efforts to identify and manage changes in their health; and (ii) supporting the individual to manage resource needs to support health. Outcomes targeted include: (i) getting individuals to the first community follow-up appointment; (ii) identification of symptoms and development of action plan; (iii) appropriate use of available resources to sustain community living.
Target population: Incarcerated persons preparing to transition to the community at two (2) time points.
T 1 From prison/jail to supervised setting
T 2 From supervised setting to independence
Program structure: Clinical nursing student placements provide manpower for the intervention while providing an opportunity for learning and clinical practice.
Partners: Connecticut Department of Correction, Connecticut Correctional Managed Health Care, Re-entry Councils, UConn School of Nursing (possible inclusion of SOP)
Standard Protocol: The standardized protocol is conducted in both the prison/jail and in the community. Differences in setting are noted in how skills are practiced. In prison/jail, role play may be used more frequently; whereas in the community, following role play, the individual performs the behavior and returns and reports the level of success in achieving their goal.
Individual protocol: Evidence-based guides for adaptive treatment services from the TCU Mapping-Enhanced Counseling manuals designed for re-entry populations (included in National Registry of Evidence-based Programs and Practices, NREPP, 2008) are used to focus on health goals, planning, role playing, preparing for contingencies are explored for transitioning inmates. These pictorial guides are derived from cognitive-behavioral models designed for working in substance abuse treatment programs. These guides can be delivered in as few as three sessions up to nine sessions depending upon the individual’s capabilities and needs. Group Protocol: this supervised group provides individual members the opportunity to set the agenda with the aims to obtain clarification, identify resources and obtain system information as needed. Peer-to-peer problem solving is encouraged.
Jail Labyrinth Project
This video was produced by Northampton Cable TV, and directed by one of the members of the Labyrinth Connection of Western Massachusetts. This is the culmination of a yearlong grant funded project of the Hampshire Sheriff’s Office, the University of Massachusetts Amherst and Labyrinth Connection of Western Massachusetts. The purpose was not only to document the work in building an outdoor 80 foot labyrinth on the correctional facility grounds, but to also describe the walking program and curriculum.
Donna Zucker, RN, PhD, FAAN, Associate Professor, University of Massachusetts, Amherst.