By Rachel Crumpler
Ted Zarzar sees firsthand the cycling of people who have a serious mental illness — such as schizophrenia or bipolar disorder — between the community, emergency rooms and prison.
That’s because he spends half his time as a psychiatrist working in the community at UNC Health and the rest at Central Prison in Raleigh.
Since 2016, when he first started working at the prison, he’s increasingly seen the intertwining of incarceration and mental illness.
“It was not until I got to the prison where I just really saw the magnitude of it where a full quarter of the people in the prison system are receiving mental health services,” Zarzar said.
Data shows that people with mental illness are overrepresented in incarcerated, probation and parole populations nationwide.
In his role, Zarzar has seen how gaps in care often contribute to slips and crises, as he sees some of the same people bounce between the community and incarceration.
“We would see people [in the emergency room] who had just gotten out of jail or just gotten out of prison,” Zarzar said. “They didn’t have anywhere to stay and they often were not on their meds and they often did not go to whatever follow-up appointment had been scheduled for them. They sort of just got lost in the system and ended up in crisis.”
Zarzar is working to foster better reentry outcomes by providing continuity of care for this high-risk population. Since the launch of FIT Wellness in Wake County in August 2022, that’s what he’s been able to do as the program’s medical director and lead psychiatrist.
FIT Wellness, which is part of the North Carolina Formerly Incarcerated Transition Program (NC FIT), provides psychiatric and physical health care along with connections to community supports such as housing and transportation to people with a serious mental illness leaving the state prison system.
“It’s not just about giving someone psych drugs,” Zarzar said. “It’s comprehensive reentry planning.”
The program’s reach is about to grow substantially, thanks to the N.C. Department of Health and Human Services’s $5.5 million investment in the program. The department’s investment aligns with Gov. Roy Cooper’s January executive order, which provides for a whole-of-government approach to improving reentry support for formerly incarcerated people in North Carolina.
The funding will allow FIT Wellness to expand to two additional sites, serving formerly incarcerated people in three more counties: Durham, Orange and New Hanover. Zarzar said he anticipates FIT Wellness will be able to serve an estimated 600 people over the next four years, including starting to serve people leaving jail.
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Comprehensive reentry support
FIT Wellness’ targeted reentry support for people with serious mental illness is critical, Zarzar said, as research shows that people with serious mental illness are more likely to return to prison.
“People with [serious mental illness] have higher rates of trauma, higher rates of victimization and have more physical health problems to deal with,” Zarzar said. “They have more food insecurity, more housing insecurity — multiple different obstacles on top of just reentry being challenging.”
That’s why FIT Wellness takes a comprehensive approach to reentry support to help address these factors. Addressing behavioral health care needs alone is not enough to facilitate better outcomes, Zarzar said.
At FIT Wellness sites, psychiatry and primary care work side by side in one clinic location. The co-located care makes it easier for clients to access the health care they need in one visit, rather than traveling across the county for appointments.
Additionally, Zarzar said it’s important that someone with a serious mental illness also addresses their physical health care needs, which can sometimes go overlooked.
“The life expectancy of someone with schizophrenia is about 15 years less than the general population,” Zarzar said. “It’s not because of suicide or homicide — those factor in but not predominantly. It is because of things like coronary artery disease, diabetes, COPD, cancer and physical health conditions. People with severe mental illness often may be going to see a psychiatrist, but they may not be going to see a primary care doctor, and the morbidity and mortality that we see in this population is often related to their physical health needs.”
In addition to the pairing of behavioral and physical health care, another crucial part of FIT Wellness is hiring formerly incarcerated people and training them as community health workers.
Shawn Tyrone Baker spent 15 years incarcerated before becoming a FIT Wellness community health worker. In his role, Baker meets with clients upon release and remains in consistent contact with them to help address concerns such as housing, employment and transportation.
“I give them all the tools I used upon my release and getting reacclimated back into society and the community,” Baker said.
Baker said his shared lived experience with clients helps establish rapport and trust. For example, Baker said many clients who are released from prison have lost trust in medical staff. When he vouches for the quality of care at the clinic, that helps clients take the step to obtain medical care.
Lives changed
DHHS originally funded FIT Wellness as a two-year pilot program but its success has allowed for expansion.
“We are looking forward to demonstrating that people who are in FIT Wellness do better and have fewer hospitalizations, less re-incarceration and better health outcomes,” said Evan Ashkin, director of NC FIT. “We’ve not been able to find really any other model in the U.S. that actually does this for people with serious mental illness.”
The initial FIT Wellness data is positive, as 75 percent of FIT Wellness participants had no emergency department visit within three months of release, and 81 percent had no hospital visit.
Beyond the data, FIT Wellness client experiences like that of Christopher Chandler, who was released from prison on Jan. 31, demonstrate the impact of continuity of care.
In just over a month, Chandler said the program has already changed his life. He never thought he would be in a stable and secure position so quickly.
As Chandler’s release date neared, he felt anxious.
“I was truly stressing because the prison system gives you a 30-day supply of your meds and then that’s pretty much all they’re obligated to do,” Chandler said. “I was really nervous, really scared about coming out and not having, first of all, not having a place to go. And secondly, not having access to any kind of health care at all.”
But many of his worries subsided when a prison social worker told him about FIT Wellness and scheduled an initial telehealth visit with Zarzar and a FIT community health worker about seven days before his release date.
It’s exactly what he needed, Chandler said, and he thought the program sounded too good to be true — even telling his wife to Google it to check it out.
Chandler said the program has more than delivered.
Already, Chandler said he’s seen Zarzar twice and a primary care doctor twice to address his health care needs coming out of prison, including medication adjustments, HIV screening and more. He said the program has also provided him with a phone, clothes and food. They also helped him enroll in Medicaid and secure a job that he started on Monday — his first in years.
“I’m very secure in the fact that I have a clinic to go to and that I can open up and tell them what I need and that they don’t judge,” Chandler said. “They have been more than willing to go out of their way and to address anything that I needed and then some. I feel very stable.”
Chandler, 47, has been in and out of prison six times since he was about 20 years old. This time feels different, though, he said. His mindset has changed, but so has the level of reentry support he’s received.
“I’m still in shock, actually, that the program is there to help people like me,” Chandler said. “They’ve changed my life. They’ve changed my family’s life. It’s an amazing program. I hope that it grows and grows because it’s something that dudes in prison really need coming home.”
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