By Leah Holmes, M.S.W.

Abstract
Introduction
Project Bridge
Where Two Worlds Meet
Barriers and Strategies
Conclusions
References

Populations in correctional facilities have a higher incidence of HIV infection than is found among the general United States population.1 For chronic offenders incarceration and release to the community becomes a revolving door. Their health care needs are addressed while incarcerated; however, they are quickly lost to medical follow-up after their prison release. Several regions, among them Connecticut, Rhode Island, New York and Washington, DC, have pioneered discharge-planning programs for inmates approaching their release date. Because of the success of these programs, public health providers and AIDS service agencies are creating programs that place community case managers within correctional facilities. While the term "case manager" continues to be undefined in terms of scope of services rendered and training required, social workers will be employed as frontline workers and/or supervisors in the emerging projects. Implementing a program designed to place social workers within correctional settings presents project administrators with unanticipated barriers that are endemic to institutional settings. An understanding of the different missions of social work and correctional care is an important element in reducing areas of friction. Flexibility and problem solving skills are necessary ingredients in turning challenges into opportunities, skills that are part of every social worker's professional development.

In 1997, it was estimated by the Bureau of Justice Statistics that there were 1.8 million people in the custody of the criminal justice system in the United States. Of those it was further estimated that 56,000 had an AIDS diagnosis. In 1997, it was estimated that there were between 151,000 and 197,000 HIV-infected individuals incarcerated.11 The incidence of HIV within correctional settings is approximately five times that of the general population.1-6 A high percentage of the HIV-infected inmate population are substance users serving relatively short sentences. The rising number of HIV-infected inmates is occurring in conjunction with increased awareness of the importance of medical adherence for the successful treatment of HIV disease. These two factors are combined with recognition that ex-offenders have difficulty accessing health care.7-9 Together, this creates an increased urgency to provide continuity of medical care for HIV positive inmates as they return to the community.

In October 1996, Project Bridge of The Miriam Hospital in Providence, Rhode Island, received funding from Special Projects of National Significance (SPNS), a division of the Health Resources and Services Administration (HRSA), to provide services aimed at increasing continuity of medical care for ex-offenders. The design of the project provides case management services to the specific underserved population of people who are HIV positive and incarcerated at the point of program enrollment. While the program has the cooperation of the state correctional facility, there are on-going challenges in working within a host setting. These challenges arise from the fundamental differences in mission between corrections and social work.

Case management for a person with HIV disease illustrates some of the difficulties involved in creating a consistent definition for case management. Because HIV is a relatively recent phenomenon, the literature of social case management for people with HIV is sparse. The articles that exist speak to the unique aspects of providing case management services to this population. As with other case management models, there are core functions of an HIV case manager (Indigle, et. al., 1993). However, based on the multiple challenges faced by persons affected by HIV, the case manager must be able to rely on skills and a knowledge base that encompasses sensitivity to the psychosocial issues of drug use, chronic illness, poverty and discrimination (Piette, et. al., 1992). In many HIV service agencies, more weight is placed on the experience of "case managers" with populations affected by HIV than with academic or theoretical training in social case management. In other words, while certain core tasks remain constant for HIV social case managers, much of their work and their knowledge base centers on the client population they are serving. Therefore, HIV case managers currently apply generalist skills within an area of specialization that reflects their client base.

Project Bridge   TOP

Project Bridge is an intensive case management program in a Brown University affiliated hospital outpatient clinic which serves people infected and affected by HIV. The mission of Project Bridge is to improve the retention of HIV positive ex-offenders in outpatient medical care through social stabilization.

The program is an outgrowth of an on-going collaboration between the hospital and the State Department of Corrections. Physicians provide HIV specialty care within the state prisons. The goal is to improve continuity of care for inmates returning to the community through a process of discharge planning prior to prison release with intensive community follow-up for a period of eighteen months after prison release. To date 96 clients are enrolled. Of that number, 65 (68%) were without housing at the point of prison release. All have a history of substance abuse.

The program design consists of two-person teams assigned to each client. The teams are comprised of a professional level social worker and a paraprofessional assistant. Their roles are interdependent and complimentary. The social worker provides client enrollment, overall treatment planning, clinical decision-making, coordination of services, and advocacy. The social worker also acts as the medical liaison. She/he attends medical rounds and accompanies the client to each medical examination. The assistant provides a supportive role by accompanying clients who are applying for social services, teaching basic life skills (such as using the bus system), and locating clients who are temporarily unavailable. Weekly team meetings assure timely case assignments and provide for overall sharing of information.

Potential clients are identified by prison health services staff. These physicians and nurses are aware of patients who are nearing their release dates. Prisoners give their permission for the referral to Project Bridge. The nurse calls a Project Bridge case manager to relay the name of a prisoner who has been informed about the program and has expressed an interest in becoming a client. A case manager is assigned to the client. The case manager contacts the person for an interview 30-90 days before the scheduled release date.

While in theory every HIV positive offender is eligible for the program, the program is not appropriate for a few. The level of involvement - weekly encounters, home/community based services, regularly scheduled medical care - may be more intense than some potential clients can tolerate. Those few are more appropriate candidates for traditional office based services. The Project Bridge case managers give these few referrals to other community resources.

The majority of offenders nearing release are anxious for assistance in obtaining basic survival needs. Generally there are two or three interviews in prison before the client is released to the community. Program enrollment is for eighteen months. If enrolled clients are reincarcerated during their time in the program, they will be visited while in prison. This serves the purposes of assessing their continuing medical care and creating a revised treatment plan for them upon their next release. Therefore, the case managers, sometime accompanied by the assistants, are frequently at the prison. While there, they have the official status of a visitor. This affects their movement within the facility and the nature of their interactions with their clients.

Project Bridge case managers are outsiders at the prison and, as such, are viewed less as an asset than as a liability by the correctional officers. Anyone who is not an employee of the Department of Corrections is a security threat, which is a fact of prison management not a reflection on the integrity of the non-employee. Correctional officers are responsible for the safety of visitors within their facility. When you enter a prison for the first time, you enter a foreign country. Each prison has its own character, and its own rules. There is a wide range of management philosophies and traditions within the individual state prisons and city or county jails.

The most frequent complaint of community-based staff who spend part of their time working within a correctional setting is that they feel unwelcome. It is a truly alien setting with rules that seem rigid and sometimes arbitrary. There are challenges unique to the setting; however, some of the perceived barriers may stem from a lack of understanding of the corrections mission. The training of correctional staff and that of professional social workers have little in common in terms of values or mission. Social work is founded on the principle of client self-determination. Corrections is founded in the need to maintain security. Social work strives to increase client autonomy. Corrections strives to enforce obedience to authority. Social work organizational structure is fairly flat and based on cooperation. Correctional structure is hierarchical and based on compliance. Social workers give responses and offer suggestions; correctional officers follow and enforce orders. Social work grew out of the social reform movement of the nineteenth century; corrections grew from a quasi-military, social control model.

Consider the correctional environment. Officers face a daily barrage of negativity from inmates, colleagues and the institution. There is a high potential for personal danger - such jobs are ranked as one of the most dangerous of all occupations. The job of correctional officer does not hold high status in the general community. While their pay may compare positively with industrial workers in some areas of the country, advancement opportunities are slow and stress level is high. Salary, benefits and job security may correlate with longevity on the job, but that is not an accurate measure of job satisfaction. They have very little autonomy in their work. Low levels of autonomy coupled with high levels of responsibility equate with high levels of stress. Approximately 70% of the people currently incarcerated are serving sentences for non-violent crimes, that leaves thirty percent who are known to be violent. There is no assurance that the majority of inmates serving sentences for non-violent crimes are without histories of physical assault.

Project Bridge clients lead lives of casual brutality. While these inmates may not consider personally committing murder or rape, they are accustomed to seeing interpersonal conflict result in physical assault. The atmosphere in many prisons is charged with an undercurrent of hostility. The more poorly run the prison, the greater the potential for violence. That is the reason for discipline and routine. Routine provides greater physical and emotional safety. Routine may be boring, but it is also reassuring. Structuring the inmates' time decreases anxiety and relieves boredom. Maintaining safety is a delicate balance between the correctional officers and the inmates.12 Prisons and jails are oppressive institutions and everyone within them shares somewhat in the experience of oppression.

Enter the social worker. He/she may be quite ignorant of the conditions within the facility and the manner in which those conditions are maintained. While social workers generally do not consider themselves a threat, the presence of any outsider poses the possibility for a security breach. Disruptions in routine are opportunities for savvy inmates to escape or harm others. Correctional officers are charged with the responsibility of keeping the inmates safe from one another and keeping the community at large safe from the inmates. The prime directive of any correctional facility is to maintain a safe and secure environment.

The social worker may feel insulted when asked to leave personal items, such as beepers, cell telephones or jewelry in their car. They may not want to stand, back against a wall, when inmates walk past. Such requests seem excessive to the outsider. However, it is rare to find a social worker that has experienced or witnessed someone being grabbed by the neck from behind. Correctional officers, trained to expect such behavior, guard against it.

In addition, for inmates and correctional officers alike, the advent of someone from the outside may be a novelty in an otherwise boring routine. Either the inmate or officer may test the social worker's patience or trustworthiness.

While the correctional facility has never deliberately impeded Project Bridge's work, it does impinge upon it. However, given the aforementioned differences, it is not strange to find feelings of mutual misunderstanding between the two worlds. As social workers are entering correctional facilities, it is incumbent on them (the guest professionals) to make accommodations to the host setting.

The three primary barriers within a correctional facility are: (1) access to the inmates that provides sufficient time to accomplish the Assessment and Treatment Plan, (2) maintaining confidentiality, and (3) assuring the reliability of the release date.

To overcome barriers of access it is necessary to develop familiarity with the correctional facility in which you are working. To the uninitiated, visiting a prisoner for a legitimate, professional reason would seem a straightforward proposition. The social worker makes an appointment with the inmate, goes to the facility and interviews the inmate there. In order to move within the prison as a visitor a person is required to be in the company of a prison employee. At Project Bridge staff contact the medical service employee. Taking the time and having the willingness to assist Project Bridge social workers are not, strictly speaking, parts of anyone's job description. Fortunately, Project Bridge staff have identified two or three correctional employees who are willing to make the time to escort them in to each of the facilities to which they need access.

However, there are times when access is not possible. Several times each day inmates must return to their quarters to be counted. When "count" is in progress, there is no movement of personnel or visitors within the non-administrative sections of the facilities. There are also times known as "lock-down" when movement is not permitted. Inmates need to go to meals at strictly defined hours or they will not be fed until the next meal. Access to the inmates has to occur between these events and/or other events that can occur without notice. If the social worker arrives during a period when the inmates are eating or being counted, he/she will have to wait or return later. It is often tempting to feel that the officers are disrespectful, but it is equally true that the social worker is disrespecting the prison routine. Project Bridge staff travel to the prison without any guarantee that they will be able to meet the client with whom they have an appointment.

One of the primary access challenges is familiarizing staff with the rules, both formal and informal, of the institution. Project Bridge staff received one day of training provided by the prison. At that training, the attendees are told the formal expectations of them in the performance of their duties within the prison walls. However, there are a number of informal expectations that can directly affect the social workers' success at accessing clients. As previously mentioned, a social worker might be subjected to either officers' or inmates' testing their limits. For example, if an officer impedes a social worker's visit there may be a temptation to speak to the captain about being delayed. However, doing so might be spending social capital prematurely. It is necessary to differentiate between blatant abuse of power and mild testing of limits. It is better to accept non-threatening delays or mild teasing with good grace rather than to risk being labeled as a snitch - thereby earning the enmity of more than the officer involved the original incident. Learning these informal expectations comes with experience and observation of others. Adapting to the correctional setting requires a great deal of flexibility.

Confidentiality is one of the most difficult barriers encountered when working in correctional settings. Since the mission of the correctional officers is to assure safety while inside the prison, there is always someone within sight and earshot of any meeting with an inmate. There simply is no privacy within a correctional facility. Completing intake forms and treatment plans is difficult to accomplish. Many questions that the case managers would like to ask have to wait until after the client has been released from prison in the service of maintaining confidentiality. Project Bridge staff understand that respecting security measures and prison protocol are more important than completing an Intake form. As such, confidentiality, the highest priority, is always in danger of being breached. Working within these parameters, while possible, requires flexibility and an ability to tolerate frustration.

The final barrier, realistic release dates, can be dealt with by understanding the prison discharge process. Prisoners are released on any day of the year, including holidays. When their sentence has been served and their paperwork processed, legally and literally they can not be detained another day. Project Bridge clients were being released on holidays and on weekends. Additionally, release dates are subject to change based on the behavior of inmates. It is possible for a release date to move up based on the accumulation of "good time," which is a reduction in time served based on causing no problems during incarceration. It is equally possible to have a release delayed because the client created a disturbance causing him/her to be "booked" - given additional time to serve - as a punishment. Legal as well as illegal aliens who have committed a felony can be placed on hold for deportation by the Department of Immigration and Naturalization Service. The variability of release dates frequently precludes the case manager's ability to make community-based appointments within the desired 24-hour timeframe. The variability of release dates also affects the ability to schedule an initial clinic visit following prison release.

After Project Bridge receives a referral for an inmate the approximate release date is determined. The initial appointment is set for sometime during the three to one month period before the release date. The reason for doing so is to decrease the association in the inmate's mind of the case manager with the facility. In addition, Project Bridge staff do not try to engage inmates who have less than a month before release, because it does not allow sufficient time to identify needs, make referrals, obtain appointments and verify locator information. Since it is never certain how long it will take to gain admittance to the inmate's facility, allowing less than a month to accomplish the various tasks could be futile.

Working with corrections can be an enlightening experience despite the innate frustrations for professionals who are accustomed to more autonomy "outside the walls." Social services staff can, and will, learn much concerning the mission of correctional staff and the potential dangers they face daily.

Project Bridge staff learned a new language consisting of number of "bids" (number of sentences served), "rap sheet" (charges), "booking"(arrests), and "PD" (public defender). Familiar words, such as "count", have taken on new meanings. Staff have also come to understand the process of institutionalization in a deeper way. It is poignant to hear an ex-offender refer to prison in terms that are generally used to describe one's home. One person expressed this as "The porch light is always on." As dreadful as it may seem to most of us, for some of the inmates there is a certain safety that occurs behind the walls. As outsiders, staff have gained a new respect for the expression "three hots and a cot." Three meals a day and a bed to sleep on are, after all, more than they are guaranteed in the outside world. Within our prison system, the inmates receive a level of health care that is not available to them elsewhere. It is ironic that inmates are the only segment of society for whom health care is a right. 66% of Project Bridge clients leaving prison have no health insurance. 68%of Project Bridge clients are functionally homeless at the point of prison release. Once they are returned to the community, it is a challenge to secure for them the simple shelter and health care that is given to them inside of the prison walls.

Social workers can use their knowledge of social institutions to enhance access to offenders and ex-offenders. In accepting the challenge implicit in collaborating with institutions whose mission is significantly different from our own, it is important to be prepared to provide training and supervision to the social workers who will be "in the field" to reduce their sense of discomfort in negotiating an alien system. Respecting differences is important in gaining acceptance. Since social work is frequently done in host settings - hospitals, nursing homes, schools, to name a few - this is simply a matter of asking staff to transfer their already existing skills into a new arena. In so doing, we can build stronger alliances between systems and improve continuity of care for people who are incarcerated as they move between corrections and the community.

Despite the barriers Project Bridge is grateful to the prison employees for their willingness to make themselves available and to the correctional officers for ensuring safety. We strive to maintain the relationships and to build new ones by treating the staff at the correctional facilities with the same respect that we give to our clients. Our roles and goals may be different, but they can be complementary.

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