Health outcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan.

OBJECTIVES: We sought to assess 6-month outcomes for HIV-infected people released from New York City jails with a transitional care plan. METHODS: Jail detainees in New York City living with HIV who accepted a transitional care plan during incarceration were asked to participate in a multi-site evaluation aimed at improving linkages to community-based care. The evaluation included a 6-month follow-up; HIV surveillance data were used to assess outcomes for those considered lost to follow-up. RESULTS: Participants (n=434) completed baseline surveys during incarceration in a jail in New York City. Of those seen at 6 months (n=243), a greater number were taking antiretroviral medications (92.6% vs 55.6%), had improved antiretroviral therapy adherence (93.2% vs 80.7%), and reported significant reductions in emergency department visits (0.20 vs 0.60 visits), unstable housing (4.15% vs 22.4%), and food insecurity (1.67% vs 20.7%) compared with baseline. CONCLUSIONS: Transitional care coordination services facilitate continuity of care and improved health outcomes for HIV-positive people released from jail.

Meaningful Use of an Electronic Health Record in the New York City Jail System.

Use of electronic health records (EHRs) is an important innovation for patients in jails and prisons. Efforts to incentivize health information technology, including the Medicaid EHR Incentive Program, are generally aimed at community providers; however, recent regulation changes allow participation of jail health providers. In the New York City jail system, the Department of Health and Mental Hygiene oversees care delivery and was able to participate in and earn incentives through the Medicaid EHR Incentive Program. Despite the challenges of this program and other health information innovations, participation by correctional health services can generate financial assistance and useful frameworks to guide these efforts. Policymakers will need to consider the specific challenges of implementing these programs in correctional settings.

The Rikers Island Hot Spotters: Defining the Needs of the Most Frequently Incarcerated.

OBJECTIVES: We used "hot spotting" to characterize the persons most frequently admitted to the New York City jail system in 2013. METHODS: We used our Correctional Health Services electronic health record to identify 800 patients admitted in 2013 who returned most since November 2008. We compared them to a randomly selected control group of 800 others admitted in 2013, by using descriptive statistics and cross-tabulations, including data through December 2014. RESULTS: The frequently incarcerated individuals had a median of 21 incarcerations (median duration 11 days), representing 18 713 admissions and $129 million in custody and health costs versus $38 million for the controls. The frequently incarcerated were significantly older (42 vs 35 years), and more likely to have serious mental illness (19% vs 8.5%) and homelessness (51.5% vs 14.7%) in their record. Significant substance use was highly prevalent (96.9% vs 55.6%). Most top criminal charges (88.7%) for the frequently incarcerated were misdemeanors; assault charges were less common (2.8% vs 10.4%). CONCLUSIONS: Frequently incarcerated persons have chronic mental health and substance use problems, their charges are generally minor, and incarceration is costly. Tailored supportive housing is likely to be less costly and improve outcomes.

Disparities in Mental Health Referral and Diagnosis in the New York City Jail Mental Health Service.

OBJECTIVES: To better understand jail mental health services entry, we analyzed diagnosis timing relative to solitary confinement, nature of diagnosis, age, and race/ethnicity. METHODS: We analyzed 2011 to 2013 medical records on 45,189 New York City jail first-time admissions. RESULTS: Of this cohort, 21.2% were aged 21 years or younger, 46.0% were Hispanic, 40.6% were non-Hispanic Black, 8.8% were non-Hispanic White, and 3.9% experienced solitary confinement. Overall, 14.8% received a mental health diagnosis, which was associated with longer average jail stays (120 vs 48 days), higher rates of solitary confinement (13.1% vs 3.9%), and injury (25.4% vs 7.1%). Individuals aged 21 years or younger were less likely than older individuals to receive a mental health diagnosis (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.93; P < .05) and more likely to experience solitary confinement (OR = 4.99; 95% CI = 4.43, 5.61; P < .05). Blacks and Hispanics were less likely than Whites to enter the mental health service (OR = 0.57; 95% CI = 0.52, 0.63; and OR = 0.49; 95% CI = 0.44, 0.53; respectively; P < .05), but more likely to experience solitary confinement (OR = 2.52; 95% CI = 1.88, 3.83; and OR = 1.65; 95% CI = 1.23, 2.22; respectively; P < .05). CONCLUSIONS: More consideration is needed of race/ethnicity and age in understanding and addressing the punishment and treatment balance in jails.

Beyond the bridge: evaluating a novel mental health program in the New York City jail system.

OBJECTIVES: We evaluated Beyond the Bridge, a novel mental health program in the New York City jail system designed to provide residentially based cognitive behavioral therapy in jail mental observation units. METHODS: We used propensity score matching and a dose-response analysis. Outcome measures included reduction in violent incidents and fights, reduction in uses of force by corrections officers, reduction in time spent on suicide watch and incidents of self-injurious behavior, and increased length of community survival. RESULTS: There were significant reductions in all outcomes when we compared program participants (n = 218) with an earlier cohort of patients residing on the mental observation unit before programming began (n = 413). However, when we compared program participants with a cohort of other patients residing on the units at the same time but who chose not to participate (n = 267), only time spent on suicide watch unit (rate ratio [RR] = 0.72; 95% confidence interval [CI] = 0.59, 0.89) and recidivism (RR = 0.70; 95% CI = 0.59,0.83) were significantly reduced. CONCLUSIONS: This evaluation and the model we piloted may provide useful information for other settings contemplating similar interventions.

Solitary confinement and risk of self-harm among jail inmates.

OBJECTIVES: We sought to better understand acts of self-harm among inmates in correctional institutions. METHODS: We analyzed data from medical records on 244 699 incarcerations in the New York City jail system from January 1, 2010, through January 31, 2013. RESULTS: In 1303 (0.05%) of these incarcerations, 2182 acts of self-harm were committed, (103 potentially fatal and 7 fatal). Although only 7.3% of admissions included any solitary confinement, 53.3% of acts of self-harm and 45.0% of acts of potentially fatal self-harm occurred within this group. After we controlled for gender, age, race/ethnicity, serious mental illness, and length of stay, we found self-harm to be associated significantly with being in solitary confinement at least once, serious mental illness, being aged 18 years or younger, and being Latino or White, regardless of gender. CONCLUSIONS: These self-harm predictors are consistent with our clinical impressions as jail health service managers. Because of this concern, the New York City jail system has modified its practices to direct inmates with mental illness who violate jail rules to more clinical settings and eliminate solitary confinement for those with serious mental illness.

Female sex workers incarcerated in New York City jails: prevalence of sexually transmitted infections and associated risk behaviors.

OBJECTIVES: Sexually transmitted infections (STIs) are an important cause of morbidity among incarcerated women and female sex workers (FSW). Little is known about FSW incarcerated in New York City (NYC) jails. We reviewed jail health records to identify the STI and HIV prevalence among newly incarcerated FSW in NYC jails. We also examined the relationship of demographics and self-reported clinical and risk behaviour history with FSW status and compared FSW with non-FSW incarcerated women to identify FSW predictors and, guide NYC jail programme planning and policy. METHODS: We retrospectively reviewed routinely collected jail health record data to identify the prevalence of chlamydia (Ct), gonorrhoea (Ng) and HIV infection among women newly incarcerated in NYC jails in 2009-2010 (study period) and studied the relationship of STIs, demographics and self-reported clinical and risk behaviour history with FSW status. RESULTS: During the study period, 10 828 women were newly incarcerated in NYC jails. Of these, 10 115 (93%) women were tested for Ct and Ng; positivity was 6.2% (95% CI 5.7% to 6.7%) and 1.7% (95% CI 1.4% to 1.9%), respectively. Nine percent had HIV infection. Seven hundred (6.5%) were defined as FSW. FSW were more likely to have Ct (adjusted OR (AOR): 1.55; 95% CI 1.17 to 2.05; p<0.0001) but not Ng or HIV. FSW were more likely to report age 20-24 years, reside in boroughs other than Manhattan, ≥6 prior incarcerations, ≥2 incarcerations during the study period, condom use with current sex partners, multiple sex partners and current drug use. CONCLUSIONS: Women incarcerated in NYC jails had high rates of Ct, Ng, and HIV infection. FSW were at higher risk for Ct than non-FSW incarcerated women. These findings are being used to design targeted interventions to identify FSW, provide clinical and preventive services in jail and coordinate care with community partners.

Deaths in New York City jails, 2001-2009.

Approximately 90,000 inmates are admitted annually to the New York City jail system, many of whom require a high level of medical or mental health services. According to our analysis of deaths in custody from 2001 to 2009, crude death rates have dropped significantly despite the increasing age of the population. Falling HIV-related mortality appears to contribute to this change. Other observations include low rates of suicide across all 9 years and increasing age of the population in recent years.

Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island.

New York City (NYC) jails are the epicenter of an epidemic that overwhelmingly affects Black and Hispanic men and offer a significant opportunity for public health intervention. The NYC Department of Health and Mental Hygiene instituted population based approaches to identify the HIV-infected, initiate discharge planning at jail admission, and facilitate post-release linkages to primary care. Using a caring and supportive 'warm transitions' approach, transitional care services are integral to continuity of care. Since 2010, over three-quarters of known HIV-infected inmates admitted to jails received discharge plans; 74 % of those released were linked to primary care. The EnhanceLink initiative's new Health Liaison, a lynchpin role, facilitated 250 court-led placements in medical alternatives to incarceration. Transitional care coordination programs are critical to facilitate continuity of care for people with chronic health conditions including the HIV-infected returning home from jail and for the public health of the communities to which they return.

Preventing Another Fifty Years of Mass Incarceration: How Bioethics Can Help.

In the article "Fifty Years of U.S. Mass Incarceration and What It Means for Bioethics," Sean Valles provides an important reminder of the consequences of mass incarceration in the United States and identifies potential roles for bioethicists in addressing this system. My limited view-that of a physician who conducts court-ordered investigations and monitoring of health services behind bars-is that the ongoing failure of most academic and professional organizations to be more effective in this much-ignored area stems from the lack of leaders and staff who have been directly impacted by mass incarceration. As conditions behind bars worsen, and a new war on drugs recoils the spring of mass incarceration, there is a pressing need to train, recruit, and promote people who know the realities of the criminal (and immigration) justice system and its impact on health and well-being. This step can bring a more powerful engagement of bioethics regarding housing, employment, and health care and policing, as well as the numerous and harmful elements of jails, prisons, and detention settings. I provide examples of partners I learn from in this arena, as well as some discrete and technical areas for possible investigation.

Injury surveillance in New York City jails.

To characterize injuries occurring in jails, we analyzed injury report forms from the New York City jail system. We abstracted data from 4695 injury report forms representing 3863 patients. Of the injuries reported, 66% were classified as intentional. The 2 leading causes of injuries were inmate-on-inmate aggression (40%) and slips and falls (27%). Injuries place a considerable burden on jail health care systems, and there is a need for more studies on this problem and development of injury prevention programs.

Understanding US Immigration Detention: Reaffirming Rights and Addressing Social-Structural Determinants of Health.

A crisis of mass immigration detention exists in the United States, which is home to the world's largest immigration detention system. The immigration detention system is legally classified as civil, rather than criminal, and therefore non-punitive. Yet it mimics the criminal incarceration system and holds detained individuals in punitive, prison-like conditions. Within immigration detention centers, there are increasing reports and recognition of civil and human rights abuses, including preventable in-custody deaths. In this paper, we propose understanding the health impacts of detention as an accumulation of mental and physical trauma that take place during the entirety of a detained immigrant's experience, from migration to potential deportation and removal. Further, we explore the social-structural determinants of health as they relate to immigration detention, contextualize these determinants within a human rights framework, and draw parallels to the larger context of US mass incarceration. Realizing the right to health requires addressing these social-structural determinants of health. For the care of immigrant patients to be effective, clinicians and public health professionals must incorporate an awareness of the health risks of the immigration detention system into trauma- and human rights-informed models of care during and after detention.

HIV screening and care for immigration detainees.

The detention of immigrants in the United States is a rapidly expanding endeavor with serious health consequences for the detainees. This detainee population represents non-criminal immigrants who are detained because of a visa violation or other immigration issue but who are not charged with any crime and do not enter the criminal justice system. HIV-positive detainees are especially vulnerable to lapses in proper medical care, and press reports have highlighted deaths and adverse medical outcomes among HIV-positive detainees. We have examined reports on detainee health issues published by numerous groups and conducted our own analysis of the health plan used to govern much of the specialty care for detainees who are HIV positive. We conclude that the system of immigration detention in the US fails to adequately screen detainees for HIV and delivers a substandard level of medical care to those with HIV. We provide several specific recommendations for improving screening and medical care among this highly vulnerable population.

Violence and mortality in the Northern Rakhine State of Myanmar, 2017: results of a quantitative survey of surviving community leaders in Bangladesh.

BACKGROUND: In August, 2017, Myanmar security forces initiated a widespread response against the Rohingya ethnic minority in Northern Rakhine State, displacing thousands of people to Bangladesh. This attack was purportedly in response to attacks committed by the Arakan Rohingya Salvation Army, a non-state insurgent group, on Myanmar police, Border Guard Police, and military posts, killing 12 security personnel on Aug 25, 2017. This study aimed to capture the experiences of the population from all Rohingya hamlets in the Northern Rakhine State who have been displaced to Bangladesh. METHODS: A quantitative survey was done among Rohingya leaders displaced to refugee camps in Bangladesh. Community leaders from 590 Rohingya hamlets and eight urban wards provided hamlet-level data on the extent, nature, and perpetrators of the violence in Northern Rakhine State in August, 2017, and the resulting morbidity and mortality. RESULTS: From May 28 to July 25, 2018, 462 (77%) of 604 hamlet leaders reported that the primary reason they and their community members fled was because of violence in their hamlet or in a neighbouring hamlet. 568 (94%) respondents reported that they had experienced destruction in their hamlets, including burning or destruction of fields or farms, homes, and mosques; 531 (89%) of 599 respondents reported violence in their hamlets before flight and 373 (64%) of 586 reported violence against civilians in flight. The main perpetrators of violence included but were not limited to Border Guard Police, Myanmar military, and Rakhine extremists. Of the 531 respondents who reported violence in their hamlets, 408 (77%) reported that military forces used helicopters, 372 (70%) reported military vehicles, and 113 (21%) reported tanks in these assaults on civilian communities. We estimate that 7803 Rohingya died from violent and non-violent causes associated with the August, 2017, attacks and subsequent displacement. INTERPRETATION: In 2017, the Rohingya ethnic minority population of Northern Rakhine State were the targets of a campaign of widespread and systematic violence, including violence by state forces. FUNDING: An anonymous grant to Physicians for Human Rights.