Medical Isolation and Solitary Confinement: Balancing Health and Humanity in US Jails and Prisons During COVID-19.

In the face of the continually worsening COVID-19 pandemic, jails and prisons have become the greatest vectors of community transmission and are a point of heightened crisis and fear within the global crisis. Critical public health tools to mitigate the spread of COVID-19 are medical isolation and quarantine, but use of these tools is complicated in prisons and jails where decades of overuse of punitive solitary confinement is the norm. This has resulted in advocates denouncing the use of any form of isolation and attorneys litigating to end its use. It is essential to clarify the critical differences between punitive solitary confinement and the ethical use of medical isolation and quarantine during a pandemic. By doing so, then all those invested in stopping the spread of COVID-19 in prisons can work together to integrate medically sound, humane forms of medical isolation and quarantine that follow community standards of care rather than punitive forms of solitary confinement to manage COVID-19.

Balancing the Rights to Protection and Participation: A Call for Expanded Access to Ethically Conducted Correctional Health Research.

Incarcerated individuals, over 95% of whom are eventually released, experience high burdens of chronic disease and behavioral health and social risk factors. Understanding the health needs of this population is critical to ensuring that general medicine physicians in prisons and in the community are adequately prepared to meet those needs. However, people in prison are significantly underrepresented in health research. In response to historical exploitation of prisoners in medical experimentation, federal guidelines appropriately require additional oversight for, and limit the scope of, research in prisons. Yet, according to a 2006 Institute of Medicine report, these requirements have produced inconsistent local regulations that often limit opportunities for incarcerated individuals to participate in research, and can slow the development of innovative medical interventions to improve their health. In this article, we describe the historical context surrounding regulations on research involving individuals in prison, the harms that can arise from excessive limitations to research in such settings, and the benefits of greater access to ethically conducted research in prison. We conclude with recommended actions that can be taken by general medicine researchers, correctional leaders, and policymakers to achieve consistent access to health research for incarcerated populations.

Six-Month Emergency Department Use among Older Adults Following Jail Incarceration.

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6 months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6 months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6 months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p = 0.01), functional impairment (p = 0.02), hepatitis C infection (p = 0.01), a recent fall (p = 0.03), pain (p < 0.001), loneliness (p = 0.04), and safety concerns (p = 0.01). In this population of older adults in a county jail, geriatric conditions and distressing symptoms were common and associated with 6-month community ED use. Jail is an important setting to develop geriatric care paradigms aimed at addressing comorbid medical, functional, and behavioral health needs and symptomatology in an effort to improve care and decrease ED use in the growing population of criminal justice-involved older adults.

Differences between incarcerated and non-incarcerated patients who die in community hospitals highlight the need for palliative care services for seriously ill prisoners in correctional facilities and in community hospitals: A cross-sectional study.

BACKGROUND: Incarcerated populations worldwide are aging dramatically; in the United States, prisoner mortality rates have reached an all-time high. Little is known about the incarcerated patients who die in community hospitals. AIM: Compare incarcerated and non-incarcerated hospital decedents in California. DESIGN: Cross-sectional study. SETTING/PARTICIPANTS: All state hospital decedents ( N = 370,831) from 2009 to 2013, decedent age over time examined with additional data (2001-2013). RESULTS: Overall, 745 incarcerated and 370,086 non-incarcerated individuals died in California hospitals. Incarcerated decedents were more often male (93% vs 51%), Black (19% vs 8%) Latino (27% vs 19%), younger (55 vs 73 years), had shorter hospitalizations (13 vs 16 days), and fewer had an advance care plan (23% vs 36%, p < 0.05). Incarcerated decedents had higher rates of cancer, liver disease, HIV/AIDs, and mental health disorders. Cause of death was disproportionately missing for incarcerated decedents. The average age of incarcerated decedents rose between 2001 and 2013, while it remained stable for others. CONCLUSION: Palliative care services in correctional facilities should accommodate the needs of relatively young patients and those with mental illness. Given the simultaneous growth in the older prisoner population with the rising age of incarcerated hospital decedents, community hospital clinicians should be prepared to care for seriously ill, incarcerated patients. Significant epidemiologic differences between incarcerated and non-incarcerated decedents in this study suggest the importance of examining the differential palliative care needs of incarcerated patients in all communities.

Post-traumatic stress disorder symptoms and associated health and social vulnerabilities in older jail inmates.

OBJECTIVES: To examine post-traumatic stress disorder (PTSD) symptoms in older jail inmates, and to determine whether adverse social and health-related characteristics were associated with having PTSD symptoms. METHOD: We performed an exploratory cross-sectional study of 238 older (age ≥55 years) jail inmates from a county jail. PTSD symptoms were determined using the Primary Care PTSD (PC-PTSD) screen. Reporting three or more PTSD symptoms was defined as a positive screen. Descriptive statistics and multiple regression analyses were used to examine the prevalence of a positive PTSD screen and associations with social and health-related characteristics. RESULTS: The mean age was 59 years, 64% were Black, and 82% reported an annual income ≤$15,000. Nearly 40% of older jail inmates had a positive PTSD screen and 10% reported a prior PTSD diagnosis by a physician. Older jail inmates with a positive PTSD screen were significantly more likely than those with a negative PTSD screen to report medication insecurity in the past year, impairment in two or more activities of daily living, traumatic brain injury, pain in the past week, and poor self-rated health. CONCLUSION: Over one in three of the older jail inmates in this study had a positive PTSD screen, though only one in five of those with a positive screen reported a prior PTSD diagnosis. Screening for PTSD in jails may help identify older inmates who would benefit from additional mental health treatment and reentry planning to improve health in this population.

Challenges in Identifying Refugees in National Health Data Sets.

OBJECTIVES: To evaluate publicly available data sets to determine their utility for studying refugee health. METHODS: We searched for keywords describing refugees in data sets within the Society of General Internal Medicine Dataset Compendium and the Inter-University Consortium for Political and Social Research database. We included in our analysis US-based data sets with publicly available documentation and a self-defined, health-related focus that allowed for an examination of patient-level factors. RESULTS: Of the 68 data sets that met the study criteria, 37 (54%) registered keyword matches related to refugees, but only 2 uniquely identified refugees. CONCLUSIONS: Few health data sets identify refugee status among participants, presenting barriers to understanding refugees' health and health care needs. PUBLIC HEALTH IMPLICATIONS: Information about refugee status in national health surveys should include expanded demographic questions and focus on mental health and chronic disease.

The state of research funding from the National Institutes of Health for criminal justice health research.

BACKGROUND: Over 20 million Americans are currently or have been incarcerated. Most are from medically underserved populations; 1 in 3 African American men and 1 in 6 Latino men born in 2001 are projected to go to prison during their lifetime. The amount of funding from the National Institutes of Health (NIH) to understand and improve the health of persons involved with the criminal justice system is unknown. OBJECTIVE: To describe NIH funding for research on the health and health care needs of criminal justice-involved persons. DESIGN: Review of NIH grants (2008-2012) in the RePORT (Research Portfolio Online Reporting Tools) database. SETTING: U.S. criminal justice system. PATIENTS: Criminal justice-involved persons participating in NIH-funded clinical research. MEASUREMENTS: NIH research and training grants awarded, by number, type, research area, institute or center, and dollar amount. RESULTS: Of more than 250 000 NIH-funded grants, 180 (<0.1%) focused on criminal justice health research. The 3 most common foci were substance use or HIV (64%), mental health (11%), and juvenile health (8%). The National Institute on Drug Abuse and the National Institute of Mental Health funded 78% of all grants. In 2012, the NIH invested $40.9 million in criminal justice health research, or 1.5% of the $2.7 billion health disparities budget for that year. LIMITATION: NIH-supported research that did not explicitly include current or former prisoners but may have relevance to criminal justice health was not included. CONCLUSION: Federal funding for research focused on understanding and improving the health of criminal justice-involved persons is small, even compared with the NIH's overall investment in health disparities research. The NIH is well-positioned to transform the care of current and former prisoners by investing in this critical yet overlooked research area.

Older jail inmates and community acute care use.

OBJECTIVES: We examined older jail inmates' predetainment acute care use (emergency department or hospitalization in the 3 months before arrest) and their plans for using acute care after release. METHODS: We performed a cross-sectional study of 247 jail inmates aged 55 years or older assessing sociodemographic characteristics, health, and geriatric conditions associated with predetainment and anticipated postrelease acute care use. RESULTS: We found that 52% of older inmates reported predetainment acute care use and 47% planned to use the emergency department after release. In modified Poisson regression, homelessness was independently associated with predetainment use (relative risk = 1.42; 95% confidence interval = 1.10, 1.83) and having a primary care provider was inversely associated with planned use (relative risk = 0.69; 95% confidence interval = 0.53, 0.89). CONCLUSIONS: The Affordable Care Act has expanded Medicaid eligibility to all persons leaving jail in an effort to decrease postrelease acute care use in this high-risk population. Jail-to-community transitional care models that address the health, geriatric, and social factors prevalent in older adults leaving jail, and that focus on linkages to housing and primary care, are needed to enhance the impact of the act on acute care use for this population.

Stress and Anxiety Among Correctional Health Care Professionals in a U.S. State Prison System During COVID-19.

Since prisons were an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, the experience of correctional health care professionals (HCPs) may differ from HCPs in other settings. This cross-sectional descriptive study assessed stress, anxiety, and burnout levels in home and work environments among HCPs employed by one U.S. state prison system during the period of initial COVID-19 vaccine rollout. Participants (N = 444) were invited to voluntarily participate in an anonymous questionnaire distributed by prison administration from March 1 through May 17, 2021. Measures were adapted from a prior study of noncorrectional HCPs during the COVID-19 pandemic. Descriptive statistics (mean; standard deviation; 25th, 50th, and 75th percentiles), ranking measures that could alleviate anxiety and stress related to the pandemic, and qualitative responses were analyzed. Responses from 43% of HCPs (192) revealed that correctional HCPs experienced high levels of stress and anxiety at work and at home during the pandemic, with particularly high levels among females and registered nurses. Understanding and addressing these stressors will be of critical importance as prison systems work to avoid turnover of experienced HCPs in such specialized settings and also help inform human resource planning at state prison systems for future public health responses.

The resource team: A case study of a solitary confinement reform in Oregon.

The continued use of solitary confinement has sparked international public health and human rights criticisms and concerns. This carceral practice has been linked repeatedly to a range of serious psychological harms among incarcerated persons. Vulnerabilities to harm are especially dire for persons with preexisting serious mental illness ("SMI"), a group that is overrepresented in solitary confinement units. Although there have been numerous calls for the practice to be significantly reformed, curtailed, and ended altogether, few strategies exist to minimize its use for people with SMI and histories of violence against themselves or others. This case study describes the "Oregon Resource Team" (ORT), a pilot project adapted from a Norwegian officer-led, interdisciplinary team-based approach to reduce isolation and improve outcomes for incarcerated persons with SMI and histories of trauma, self-injury, and violence against others. We describe the ORT's innovative approach, the characteristics and experiences of incarcerated people who participated in it, its reported impact on the behavior, health, and well-being of incarcerated persons and correctional staff, and ways to optimize its effectiveness and expand its use.

Confined to ignorance: the absence of prisoner information from nationally representative health data sets.

BACKGROUND: Incarceration is associated with poor health and high costs. Given the dramatic growth in the criminal justice system's population and associated expenses, inclusion of questions related to incarceration in national health data sets could provide essential data to researchers, clinicians and policy-makers. OBJECTIVE: To evaluate a representative sample of publically available national health data sets for their ability to be used to study the health of currently or formerly incarcerated persons and to identify opportunities to improve criminal justice questions in health data sets. DESIGN & APPROACH: We reviewed the 36 data sets from the Society of General Internal Medicine Dataset Compendium related to individual health. Through content analysis using incarceration-related keywords, we identified data sets that could be used to study currently or formerly incarcerated persons, and we identified opportunities to improve the availability of relevant data. KEY RESULTS: While 12 (33%) data sets returned keyword matches, none could be used to study incarcerated persons. Three (8%) could be used to study the health of formerly incarcerated individuals, but only one data set included multiple questions such as length of incarceration and age at incarceration. Missed opportunities included: (1) data sets that included current prisoners but did not record their status (10, 28%); (2) data sets that asked questions related to incarceration but did not specifically record a subject's status as formerly incarcerated (8, 22%); and (3) longitudinal studies that dropped and/or failed to record persons who became incarcerated during the study (8, 22%). CONCLUSIONS: Few health data sets can be used to evaluate the association between incarceration and health. Three types of changes to existing national health data sets could substantially expand the available data, including: recording incarceration status for study participants who are incarcerated; recording subjects' history of incarceration when this data is already being collected; and expanding incarceration-related questions in studies that already record incarceration history.

How safe is your neighborhood? Perceived neighborhood safety and functional decline in older adults.

BACKGROUND: Neighborhood characteristics are associated with health and the perception of safety is particularly important to exercise and health among older adults. Little is known about the relationship between perception of neighborhood safety and functional decline in older adults. OBJECTIVE: To determine the relationship between perceived neighborhood safety and functional decline in older adults. DESIGN/SETTING: Longitudinal, community-based. PARTICIPANTS: 18,043 persons, 50 years or older, who participated in the 1998 and 2008 Health and Retirement Study. MAIN MEASURES: The primary outcome was 10-year functional decline (new difficulty or dependence in any Activity of Daily Living, new mobility difficulty, and/or death). The primary predictor was perceived neighborhood safety categorized into three groups: "very safe", "moderately safe", and "unsafe." We evaluated the association between perceived neighborhood safety and 10-year functional decline using a modified Poisson regression to generate unadjusted and adjusted relative risks (ARR). KEY RESULTS: At baseline 11,742 (68.0%) participants perceived their neighborhood to be very safe, 4,477 (23.3%) moderately safe, and 1,824 (8.7%) unsafe. Over 10 years, 10,338 (53.9%) participants experienced functional decline, including 6,266 (50.2%) who had perceived their neighborhood to be very safe, 2,839 (61.2%) moderately safe, and 1,233 (63.6%) unsafe, P < 0.001. For the 11,496 (63.3%) of participants who were functionally independent at baseline, perceived neighborhood safety was associated with 10-year functional decline (moderately safe ARR 1.15 95% CI 1.09-1.20; unsafe ARR 1.21 95% CI: 1.03-1.31 compared to very safe group). The relationship between perceived neighborhood safety and 10-year functional decline was not statistically significant for participants who had baseline functional impairment. CONCLUSION: Asking older adults about their perceived neighborhood safety may provide important information about their risk of future functional decline. These findings also suggest that future studies might focus on assessing whether interventions that promote physical activity while addressing safety concerns help reduce functional decline in older adults.

"Knowing is better": preferences of diverse older adults for discussing prognosis.

BACKGROUND: Prognosis is critical in individualizing care for older adults with late life disability. Evidence suggests that preferences for prognostic information may be culturally determined. Yet little is known about the preferences of diverse elders for discussing prognosis. OBJECTIVE: To determine the preferences for discussing prognosis of a diverse sample of older adults with late-life disability. DESIGN & PARTICIPANTS: We interviewed 60 older adults with mean age 78 and mean 2.5 Activities of Daily Living dependencies. Participants were recruited from San Francisco's On Lok program, the first Program of All-inclusive Care for the Elderly (PACE). Participants were interviewed in English, Spanish, and Cantonese, and responded to scenarios in which their doctors estimated they had 5 years and 1 year left to live. Open-ended questions explored the reasons for their responses. Results were analyzed qualitatively using grounded theory. KEY RESULTS: Sixty-five percent of participants wanted to discuss the prognosis if their doctor estimated they had <5 years to live and 75% if the estimate was <1 year. Three themes were prominent among patients who wanted to discuss prognosis: to prepare, to make the most of the life they had left, and to make medical or health-related decisions. Those who preferred not to discuss prognosis described emotional difficulty, the uncertainty of prognosis, or that it would not be useful. Nearly all participants said that doctors should not make assumptions based on race or ethnicity, though differences between ethnic groups emerged. CONCLUSIONS: Most patients in this diverse sample of disabled elders were interested in discussing prognosis, while a substantial minority was not. Among those participants who preferred to discuss prognosis, many said that prognostic information would be important as they made difficult medical and personal decisions in late-life. Clinicians should inquire about preferences for discussing prognosis before sharing prognostic estimates.

A stepwise guide for healthcare professionals requesting compassionate release for patients who are incarcerated.

PURPOSE: Compassionate release is a process that allows for the early release or parole of some incarcerated people of advanced age, with life-limiting illness, complex medical care needs or significant functional decline. Despite the expansion of State and Federal compassionate release programs, this mechanism for release remains underutilized. Health-care professionals are central to the process of recommending compassionate release, but few resources exist to support these efforts. The purpose of this paper is to provide a guide for health-care professionals requesting compassionate release for patients who are incarcerated. DESIGN/METHODOLOGY/APPROACH: This study is stepwise guide for health-care professionals requesting compassionate release for patients who are incarcerated. FINDINGS: This study describes the role of the health-care professional in requesting compassionate release and offers guidance to help them navigate the process of preparing a medical declaration or request for compassionate release. ORIGINALITY/VALUE: No prior publications have created a step-wise guide of this nature to aid health-care professionals through the compassionate release process.