Country (center) with our Innovation Operations Program Manager Bill Nice and Clinical Manager Michelle Adyniec.

On an August afternoon, Vincent — known to his friends as “Country” — unlocked the door to his new apartment and stepped inside. He set his luggage down in the living room to take in the tan sofa, scarlet armchairs, and matching table lamps. “I love it. All this furniture, I love it,” he said. It was the first home he could call his own in years, and his move-in date landed on his birthday. To celebrate, his care team brought birthday and welcome home cards, so Country got his reading glasses from his pocket and sat down. With a grin, he tilted his fedora to the side, crossed his legs, and leaned back on his new sofa.

Just six months before, Country sat in his cell at the Camden County Correctional Facility, not knowing whether he would be sent to prison for the remainder of his sentence for a probation violation. He was deeply depressed and needed his psychiatric medications. For nearly two decades, the 59-year old Camden resident had been struggling with homelessness and mental health and substance use disorders, in addition to his asthma and diabetes. The jail stay was yet another stop in a long series of arrests, hospitalizations, and discharges.

Like Country, people who are locked up over and over carry their health needs with them, whether they’re in or out of jail. But our society rarely takes into account our shared responsibility for their healthcare. Many end up cycling through hospitals and emergency rooms, with no one taking the time to assess all their needs and understand them as whole people. That’s why the Camden Coalition has been developing partnerships across the traditionally siloed sectors of criminal justice, healthcare, and social services to see what works to reduce their high rates of hospital use and arrests, and help them become as healthy as they can be.

Lowering the walls between jails and hospitals

To discover and address the root causes of recurrent hospitalization and incarceration among many Camden residents, the Camden Coalition launched Camden RESET last December. A pilot program created in collaboration with the Camden County Re-Entry Committee and funded by the Laura and John Arnold Foundation, RESET helps participants gain the skills and medical, social, and legal supports they need to avoid arrests and preventable hospital admissions, and to improve their wellbeing. The program brings our nationally-recognized core intervention to Camden County jail inmates. Instead of approaching potential participants at the hospital bedside, the RESET intervention begins in jail.

The pilot program grew from findings from our Camden ARISE project, which brought together data from regional hospitals and the Camden County Police Department to better understand individuals caught in a cycle of arrest and hospital use. A Camden Coalition paper published this year by Harvard revealed that one-third of the people arrested in Camden had been to area emergency rooms at least five times from 2010 to 2014. The study found that these patients face underlying problems that neither the healthcare nor criminal justice sectors are designed to address: housing instability, chronic medical conditions, substance use disorders, and mental health challenges. These unaddressed social factors in fact appear to drive a cycle of repeated arrests and hospitalizations.

When our care team first met Country at the Camden County jail in February, he was struggling with all of these issues. Program Manager for Innovation Operations Bill Nice approached him to offer services to help him deal with his chronic health and social challenges. It turned out that Country had already heard about the Camden Coalition a few years back when he served as assistant mayor of Camden’s Tent City encampment. “When I met Bill, I could feel the genuineness when he interviewed me to see if I wanted to accept their help,” Country recalled during a recent visit to our office on Cooper Street. “I knew it was my turn. I went back to my cell and I told everybody, ‘I finally got my break. Now I got somebody on my side to listen to me.’”

Country was clear about the barriers that would prevent his success if he was released, said Bill. “He knew he needed to stay stable on the mental health medications that have worked well for him, and that he needed housing. He said, ‘I really want to do this. I’m older now. I don’t want to be out on the street. I feel I have other ways I can contribute to those experiencing similar issues if I’m stable.’”

Navigating past barriers

The probation violation that landed Country in jail stemmed from the barriers he faced being homeless. “His homelessness and the things that arise from that — a lack of connection to mental health medication and social support — hurt his ability to fulfill his probation obligations,” Bill said. “Country’s probation officer also really understood the challenges he was facing,” he noted. “He knew this was a larger systemic issue that they didn’t have an answer for, and it’s really playing a factor in why he’s not being compliant. He understood the value of collaborating with us and was willing to be a vocal proponent for him.”

Still, Country faced the strong likelihood of being sent to prison for the remainder of his sentence. Our care team worked closely with Country’s public defender to ask the judge and prosecutor for additional time before a prison transfer so that Country could apply for a Housing First voucher. They also requested that the court consider removing the probation violation from his record if his housing was approved. The court agreed to the proposal.

Soon after, the care team helped Country access his mental health medications. With the countdown for sentencing put on hold, the focus was now on meeting the overwhelming documentation requirements for applying to Housing First. Because Country lacked a photo ID to apply for housing and other services, the care team worked with the Camden County jail to create a jail re-entry ID for him. To provide evidence of his long history of homelessness, the team researched his medical records, interviewed him and his probation officer, and compiled news articles of interviews he gave to reporters while living in Tent City. Letters of support from the Coalition and his probation officer and public defender were also included.

“We were showing that other parties in the system were acknowledging that they see housing as a key component for Country’s success,” said Bill. “If we can connect him to Housing First, he would not be sent to prison. He would thrive.”

The advocacy paid off. Three weeks after his application was submitted, he received a voucher from the New Jersey Department of Community Affairs for permanent affordable housing. Country became the first Camden Coalition program participant to be approved for Housing First while actively incarcerated. He was released on probation.

Fortunately for Camden residents like Country who are returning from jail, their clinical health data from Camden County jail is now shared with the Camden Coalition Health Information Exchange. This makes it possible for Camden healthcare and social service providers to access critical health information from inside the jail — and to provide better, more efficient care for returning citizens so they can lead healthier lives. Upon his release, the team linked Country to the right services to help him rebuild his life. That included connecting him to a primary care provider who was able to get a fuller picture of Country’s medical history, and to mental health and addiction treatment services at Rutgers University Behavioral Health Care. Interim housing and transportation for probation and medical appointments were also arranged for him by the team.

While the judge kept Country’s probationary status, she recognized his hard work and progress in improving his health, and moved to dismiss his probation violation.

“I’m trying to be a voice”

Six weeks since moving in, Country says he can already feel the effects of his new home on his health and wellness. He has a place to meditate in peace, enjoys fixing his own meals and eating healthier, and says that his blood pressure remains stable. “I haven’t used my asthma pump not once, and I cut down on my smoking,” he said. “Fresh air, it makes a difference too, as opposed to sleeping on the side of the highway with all the fumes.” He is also better able to manage his chronic pain. “I’m able to get in the shower now, instead of self-medicating to get to where I had to get to. The hot water helps, and I got some ointment to rub on my back, shoulder, and knees. If I was outside, I couldn’t put that on because I would catch cold.”

These days, Country continues to work on his goals with the support of our care team. One of those goals is pursuing his passion for community advocacy — an interest he’s had since his days as assistant mayor of Tent City. In September, he and two other Camden Coalition program participants rallied in Trenton with residents from across New Jersey to support a bill expanding access to driver’s licenses to more residents. A few weeks later, he was invited to share his story about his mental health struggles and journey toward recovery and wellness with the Camden Coalition’s Community Advisory Council.

“I’m trying to be a voice for those people who are going through what I’ve been through, and those people who have been through it and still don’t see any hope. But there’s always hope,” he said at the meeting.

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