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2003 Model Practice Application (Public)

Practice Title
Syracuse Healthy Start
Submitting LHD/Agency/Organization
Onondaga County Health Department


The growing number of incarcerated pregnant women represents a high-risk population because many abuse substances, practice risky sexual behaviors, and have unstable living environments. This population experiences many barriers to obtaining adequate prenatal care. In 2001, the Onondaga County Health Department (OCHD) created comprehensive program to provide in-jail obstetrical and risk-reduction care coordination for pregnant inmates. This program is composed of routine prenatal care, diagnostic obstetric services, Public Health Team (PHT) nurse visits, screening for behavioral risks, HIV testing/counseling, and monitoring care, all received through enrollment into the Syracuse Healthy Start database. In first year of program, the obstetrician provided care to 77 percent of pregnant women incarcerated more than seven days. PHT nurses contacted 71.7 percent of the women and provided services to 47 percent. Women receiving PHT services delivered babies at an average gestational age of 38.3 weeks and 3066.7 grams. The health department concludes that providing in-jail medical and behavioral care coordination enhances the quality of care for pregnant incarcerated women.

Responsiveness and Innovation
In 2000, the prenatal care site that serves a high percentage of the high-risk population in Syracuse changed its policy so that inmate appointments were conducted at the hospital instead of an outpatient clinical site. Since inmates were now faced with increased waiting times and the need to attend appointments in shackles and bright orange jumpsuits, fewer women chose to attend their prenatal appointments. Bringing prenatal care to the inmates in the correctional facility responds to a public health need and addresses several issues. Syracuse, New York, has historically had high infant mortality rates. In 2000, the infant mortality rate (deaths/1,000 births) was 8.2 overall, with race-specific rates of 6.1 for White babies and 13.4 for African American babies. While these rates have dropped since Syracuse Healthy Start began, much work still needs to be done.

This program seeks to address needs of one segment of the high-risk population, incarcerated women. Care coordination in the jail ensures that all providers are involved and communicating, so that inmates receive more comprehensive care. Behavioral risks, such as substance abuse and smoking, are identified, and inmates are linked to services. These relationships nurture trust between provider and inmate, which may lead to a bond that could continue outside of the correctional facility. Fostering relationships with these women may help to ensure that they continue to seek care upon release.

Several administrative and personnel issues at these sites were also addressed by bringing healthcare to the inmates. The security departments in these facilities need to maintain a high level of security. Providing transportation to outside clinics creates several security issues that need to be addressed, which takes time away from the staff’s primary responsibilities. Bringing care to women in jail allows for increased safety and security for inmates and providers.

Agency Community Roles
In 1997, the Onondaga County Health Department (OCHD) was awarded a four-year, federally funded Healthy Start grant, which was renewed for another four years in 2001. As the lead agency in organizing and administering Syracuse Healthy Start, OCHD subcontracts with several community agencies, such as Center of Maternal and Child Health at SUNY Research Foundation, Family Ties Network, Inc., Catholic Charities, Salvation Army, Syracuse Behavioral Healthcare, and Syracuse Community Health Center.

The Syracuse Healthy Start grant covers partial employment of an obstetrical provider and Public Health Team nurse at the local jail and penitentiary. This program includes several interventions that work together to provide comprehensive care to incarcerated women. Syracuse Healthy Start collaborates with the correctional facilities including correctional health nurses, OCHD Public Health Team nurses, Syracuse Behavioral Healthcare (a chemical dependency treatment agency), the justice system (probation department, local judges, District Attorney’s office), Center for Community Alternatives (a local agency providing HIV care coordination), and case management agencies (Catholic Charities, Salvation Army, and Syracuse Community Health Center). Once the women are released, they are connected with a community health worker or case manager to continue to assist them in obtaining prenatal care and having a healthy baby.

The primary goal was to foster collaboration because all of these agencies were already working with the same population, but at different times and on seemingly different issues. Syracuse Healthy Start has collaborated with many agencies throughout the health and human service providers in Syracuse, and this was simply an extension of many existing relationships. This system of care coordination seeks to streamline care and ensure that fewer women fall through the cracks. This common goal, along with additional staffing, encouraged collaboration.

Costs and Expenditures
This program relies on strong community partnerships that have enabled care coordination to be added to the services already being provided to women. Many of the community agencies, such as Syracuse Behavioral Healthcare, Center for Community Alternatives, Probation, Public Health Team nurses, Catholic Charities, and Salvation Army already provide services in the jail and penitentiary. Therefore, replication of this program would require collaboration with appropriate community partners already serving the target population. To add to this system and provide more comprehensive care coordination, Syracuse Healthy Start pays for 0.2- FTE of a bilingual obstetrical provider and 0.5 FTE of a Public Health Nurse. Two new educational pieces have also been created – a card about Syracuse Healthy Start given at booking of the inmates and a follow-up brochure given to women upon release. About $1,000 has been dedicated to the printing of these materials.

The current Syracuse Healthy Start grant is funded through the Health Resources Services Administration from June 1, 2001 to May 31, 2005. OCHD will continue to apply for additional Healthy Start funding after this time period.

Outcome Process Evaluation
During the first year, evaluation centered on ensuring that the PHT nurse sees women as soon possible after booking and that women incarcerated for more than seven days are seen by the obstetrician. Many administrative relationships needed to be established and strengthened for the information to flow from the Justice Center to the Syracuse Healthy Start Registry in a timely manner.

The sample included women incarcerated from October 1, 2001 to September 30, 2002 (n=91 unduplicated, which represents 103 incarcerated women). During this time, the obstetrician provided care to 77 % of pregnant women incarcerated more than seven days. Of the women, almost 97% were offered registration into the Syracuse Healthy Start Registry which tracks prenatal care, social risks, case management services and birth outcomes. Of these women, 69.7% accepted and consented for registration. Public Health Team nurses contacted 71.7% of the incarcerated women to offer case management services. Forty-seven percent received services. Women receiving PHT services delivered babies at an average gestational age of 38.3 weeks and prenatal care at an average gestational age of 14.4 weeks.

An attempt was made to compare birth outcomes between incarcerated women who received PHT services and those who did not in order to measure the effectiveness of PHT services. However, the cohort was too small to significantly compare data. Birth outcome data was not found in the Electronic Birth Certificate database for 66.7% of the women who did not receive PHT services and were not registered in the Syracuse Healthy Start Registry. It is unclear where and if these women delivered in Onondaga county. Some of them may have moved from the county.

Lessons Learned
The health department found that the target population had low registration rates in the Syracuse Healthy Start Registry. Sixty percent of women in the sample were incarcerated for less than 48 hours, and only 34 percent were in jail for more than two business days, so it was very difficult to contact these women. In addition, incorrect contact information is often given at booking, increasing the difficulty of locating these women after release. In the absence of a national standard, a local standard has been set, requiring patients to receive a medical history, physical examination, and ultrasound within seven days of their incarceration. If this period were extended beyond seven days, the target would be reached more often.

The program has been modified to address these issues. First, the Syracuse Healthy Start Registry is given the names and phone numbers of women who are identified as being pregnant during their intake into jail.. At their intake examination, the women are asked to give oral permission for the Syracuse Healthy Start Registry staff to contact them.. At booking, pregnant women are given information about Syracuse Healthy Start. During incarceration, a Public Health Team nurse makes consistent visits for health and prenatal care educational sessions. The Public Health Team documents notes in the women’s medical record to ensure information is shared among providers. A follow-up form is being created to support continuity of care upon release.

Key Elements Replication
At a very minimum, the program would need the following elements:
  • Obstetrical care provider with access to a translator.

  • Public Health Team nurse with access to a translator.

  • Collaboration with justice center for referral to program.

  • Access to inmates.

  • Access to medical records.

  • Private place to meet that is accessible to guards.

  • Orientation to jail system and safety precautions.

  • Collaboration with appropriate agencies addressing substance abuse and HIV testing and counseling.

  • Correctional health card given to pregnant women at booking to introduce them to program.

  • Health education literature on smoking cessation, fetal growth and development, alcohol and substance use effects on mother and developing fetus, labor and delivery, and newborn care.