Coordinating and Improving Care for Young People who are Incarcerated

Youth in juvenile detention centers typically have more unmet health care needs than their peers. Data shows that incarcerated youth are more likely to be diagnosed with dental problems and sexually transmitted infections (STIs), while as many as 70% of these young people struggle with mental health disorders.

Incarcerated youth often lack access to primary health care, largely because they lose their Medicaid coverage as part of their incarceration. Research unsurprisingly shows that this lack of access leads to worse health outcomes, including fewer preventive care visits and an increased use of emergency services. It even increases the risk of reincarceration by age 23. One of the best ways to address these risks is increasing access to primary care.

That’s where Partners For Kids at Nationwide Children’s Hospital steps in. Partners For Kids is one of the nation’s oldest and largest pediatric accountable care organizations and has improved pediatric health outcomes for more than 41,000 children through care coordination. Care coordinators help patients with complex medical needs navigate the health care system and connect with community resources.

In August 2021, Partners For Kids created a care coordination team specifically to improve access to care and resources for incarcerated youth in Franklin County.

Nationwide Children’s operates Franklin County’s Juvenile Intervention Center health clinic and can often help the youth in the detention center get the health care they need but could not access before their incarceration.

During each patient’s initial physical exam at the Juvenile Intervention Center, clinic staff screen for needs where care coordination could make a difference. These patients are referred to Partners For Kids’ justice-involved youth care coordination team. With the permission of parents and guardians, the team can begin working with the young person.

“We are fully integrated into the clinic,” says Hannah Schroeder, LISW-S, supervisor of Care Coordination for Children in Custody at Partners For Kids. “We have a designated space so we can meet with these kids and involve them in the care coordination process.”

Detained youth are most commonly referred to care coordination for needs like an annual wellness exam, dental care and behavioral health services. According to Schroeder, care coordinators have helped patients with issues like getting much-needed glasses or coordinating with a local school district so they can complete their GED while incarcerated.

Once released, care coordinators continue to help patients and their families achieve their health goals by connecting them to health care and community-based resources like food pantries, housing resources and reconnecting the patient to Medicaid.

After enrollment, the patient can stay in care coordination until they turn 22. While Partners For Kids typically coordinates care for children under Medicaid managed care plans, justice-involved youth don’t need Medicaid or any other kind of insurance coverage to be eligible.

Schroeder says the team was initially concerned that families involved in the justice system might be reluctant to want more case management in their lives. Instead, in the last two years, the justice-involved youth care coordination team has converted even more referrals into enrollments than the rest of the Partners For Kids care coordination program.

“There is an eagerness about participating in our program,” says Schroeder. “Families are excited about getting the support they need for their kids.”

Over the past two years, the care coordination team has focused on building up the program and creating a collaborative relationship with the Juvenile Intervention Center health clinic and corrections staff. This year, Schroeder says the team will continue to strengthen the program, in particular by focusing on keeping patients and families engaged in care coordination after release.

“We can serve these kids until they turn 22, and we can serve them regardless of their insurance coverage,” she says. “We want to explore our engagement strategies so we can maintain those relationships even after the patient is released.”