The prevalence of substance use disorders among people in Norwegian, Danish and Swedish prisons: A multi-national cohort study, 2010-19

AIMS

We estimated the prevalence of substance use disorders (SUDs) in the Norwegian, Danish and Swedish prison populations and compared the prevalence of SUDs in the national prison populations with country-specific general population prevalence rates.

DESIGN

A multi-national cohort study using data from the National Prison Registries linked to the National Patient Registries in Norway, Denmark and Sweden.

SETTING AND PARTICIPANTS

We used data from the PriSUD-Nordic study, including national prison populations aged 19 years and older in Norway (2010-19), Denmark (2010-18) and Sweden (2010-13). A total of 119 507 Individuals (108 971 men and 10 536 women) contributing to 191 549 incarcerations were included in the study (Norway: 45432 men; 5429 women, Denmark: 42 162 men; 3370 women, Sweden: 21 377 men; 1737 women).

MEASUREMENT

We calculated a study prevalence and prevalence at entry to prison for all types of SUDs before imprisonment each consecutive year of observation in each prison population. We also extracted country-specific 1-year prevalence rates from the Global Burden of Diseases database to calculate comparative national prevalence ratios.

FINDINGS

The study prevalence of any SUD was approximately 40% [Norway: 44.0%, 95% confidence interval (CI) = 43.6-44.5%; Denmark: 39.9%, CI = 39.5-40.4%; Sweden: 39.1%, CI = 38.4-39.7%] in all three countries. Women had a significantly higher study prevalence of any SUD compared with men (Norway: 55.8 versus 42.6%, P < 0.001; Denmark 43.1 versus 39.7%, P = 0.004; Sweden: 51.7 versus 38.0%, P < 0.001). Prevalence estimates were higher for SUDs among people in prison than in the general population. We observed an increasing proportion of people with SUDs entering prison in Norway (P = 0.003), while the proportion was more stable in Denmark and Sweden.

CONCLUSIONS

Substance use disorders (SUDs) appear to be highly prevalent among the Scandinavian prison populations compared with the general population, especially among women. In Norway, there was a relative increase in SUDs from 2010 to 2019.

The Dangers of Short-Term Confinement: Indicators of Safety Risks Among Individuals in Jail

Guided by the premise that an individual's safety may be more at risk when their routines, personal attributes, or lack of guardianship influence their opportunity for exposure to violence, we examined the factors that influenced victimization risks and safety perceptions among a representative sample of respondents incarcerated at a large Midwestern jail. Results showed that vulnerable individuals such as those who were victimized prior to their incarceration, and those who antagonized others such as those who perpetrated assault, were threatened more often, were more at risk of assault victimization, and perceived more dangerous conditions. Conversely, females and individuals with greater self-control were less likely to have experienced victimization and generally felt safer in jail. Our results illustrate the importance of identifying and protecting individuals who might experience greater safety risks during jail incarceration and should be interpreted alongside research and policy aimed at improving safety and welfare within correctional institutions.

Introduction to Special Section: CSA Victimization in Incarcerated Populations

Research suggests that individuals involved in the criminal justice system have higher rates of childhood trauma, including experiences of child sexual abuse (CSA). Studies also suggest that childhood victimization has an impact on the success of mental health treatment for offenders which may contribute to recidivism rates. Accordingly, policymakers and correctional staff can be better informed in choosing appropriate assessments and intervention approaches when they understand the ways in which prior experiences of CSA impact individuals in correctional settings. This special section highlights four novel studies that advance the research examining CSA in incarcerated populations.

Therapeutic Outcomes of Treatment With Long-Acting Injectable Antipsychotics in Forensic Populations With Schizophrenia-Spectrum Diagnoses

The advantages of long-acting injectable antipsychotics (LAIs) in schizophrenia are well studied. However, forensic involvement is common in schizophrenia, and incarcerated individuals are often excluded from clinical trials. Nonadherence and oral medication diversion in forensic populations with schizophrenia, and the relationship between antipsychotic nonadherence and crime support LAI utilization in this subset of patients. Yet, federal regulations limit data generation in forensic populations. This review characterizes data on therapeutic outcomes of LAIs in correctional populations with schizophrenia-spectrum diagnoses. A search for primary literature was conducted in PubMed. Favorable effects of LAIs were observed on adherence, psychiatric symptomatology, patient satisfaction, health care costs, and frequency of criminal charges. Data were primarily retrospective and included small samples and individuals with historical versus current forensic involvement. Although limited, available literature and insights into the correctional system suggest advantages to LAI use in forensic populations. Barriers to conducting research in correctional settings must be addressed to facilitate further data generation.

"Dying with a Smile, Just Knowing that Somebody's Listened to Me": End-Of-Life Care and Medical Assistance in Dying in Canadian Prisons

Medical assistance in dying (MAiD) has been legal in Canada since 2016 and some incarcerated patients who are at the end of their lives are eligible for the procedure. Interviews with nine incarcerated men at a federal penitentiary in Canada provide insight into some of the ways that people who are navigating aging and end-of-life in prison think about MAiD. Interview themes are organized around: experience with death and dying; possibilities and barriers related to applications for release from prison at end-of-life; experiences of peer-caregiving in a prison palliative care program; support for MAiD and the expansion of eligibility criteria; what a good death looks like. Themes are contextualized alongside federal guidelines related to end-of-life care (EOLC) and MAiD for prisoners, highlighting that sound policy requires both generalizable principles and attention to nuance. MAiD rests on patient voluntariness, and thus autonomy over EOLC decisions is paramount for prisoners.

Implementing Preexposure Prophylaxis for HIV Prevention in a Statewide Correctional System in the United States

HIV disproportionately affects populations experiencing incarceration. Preexposure prophylaxis (PrEP) is an effective approach to preventing HIV acquisition among populations at increased risk of acquiring HIV. Yet few, if any, efforts have been made to offer PrEP in correctional settings. Beginning in November 2019, the Rhode Island Department of Corrections (RIDOC) implemented a systemwide PrEP initiation program with linkage to PrEP care in the community upon reentry. Incarcerated individuals identified as being potentially at increased risk of HIV acquisition during standard clinical screenings and medical care were referred to a PrEP care provider for potential PrEP initiation. Of the 309 people who met with a PrEP care provider, 35% (n = 109; 88 men, 21 women) agreed to initiate PrEP while incarcerated. Clinical testing and evaluation were completed for 82% (n = 89; 69 men, 20 women) of those who agreed to initiate PrEP. Of those, 54% (n = 48; 29 men, 19 women) completed the necessary clinical evaluation to initiate PrEP, were determined to be appropriate candidates for PrEP use, and had the medication delivered to a RIDOC facility for initiation. Only 8 people (4 men, 4 women) were successfully linked to a PrEP care provider in the community after release. The RIDOC experience demonstrates notable levels of PrEP interest and moderate levels of PrEP uptake among this population. However, PrEP engagement in care after release and persistence in taking PrEP when in the community were relatively poor, indicating a need to better understand approaches to overcoming barriers to PrEP care in this unique setting.

Communicative Practices Clinicians Use to Correct Patient Misconceptions in Primary Care Visits

To investigate how clinicians correct patient misconceptions, we analyzed 23 video recordings of primary care visits. Analysis focused on operationalizing, identifying, and characterizing clinician corrections, integrating two inductive approaches: microanalysis of clinical interaction and conversation analysis. According to our definition, patient misconception-clinician correction episodes met three essential criteria: (1) the clinician refuted something the patient had said, (2) which the patient had presented without uncertainty, and (3) which contained a proposition that was factually incorrect. We identified 59 such episodes; the patient misconceptions most commonly related to medication issues; fewer than half had foreseeable implications for patients' future actions. We identified seven clinician correction practices: Three direct practices (displaying surprise, marking disagreement, contradicting the patient) and four indirect practices (presenting the correct proposition, providing explanations, invoking an outside authority, demonstrating with evidence). We found an almost equal distribution of these direct and indirect practices.

Factors related to the severity of research misconduct administrative actions: An analysis of office of research integrity case summaries from 1993 to 2023

We extracted, coded, and analyzed data from 343 Office of Research Integrity (ORI) case summaries published in the Federal Register and other venues from May 1993 to July 2023 to test hypotheses concerning the relationship between the severity of ORI administrative actions and various demographic and institutional factors. We found that factors indicative of the severity of the respondent's misconduct or a pattern of misbehavior were associated with the severity of ORI administrative actions. Being required by ORI to retract or correct publications and aggravating factors, such as interfering with an investigation, were both positively associated with receiving a funding debarment and with receiving an administrative action longer than three years. Admitting one's guilt and being found to have committed plagiarism (only) were negatively associated with receiving a funding debarment but were neither positively nor negatively associated with receiving an administrative action longer than three years. Other factors, such as the respondent's race/ethnicity, gender, academic position, administrative position, or their institution's NIH funding level or extramural vs. intramural or foreign vs. US status, were neither positively nor negatively associated with the severity of administrative actions. Overall, our findings suggest that ORI has acted fairly when imposing administrative actions on respondents and has followed DHHS guidelines.

Estimates of Hepatitis C Seroprevalence and Viremia in State Prison Populations in the United States

BACKGROUND

Prior studies demonstrate that eliminating hepatitis C virus (HCV) in the United States (US) heavily depends on treating incarcerated persons. Knowing the scope of the carceral HCV epidemic by state will help guide national elimination efforts.

METHODS

Between 2019 and 2023, all state prison systems received surveys requesting data on hepatitis C antibody and viremic prevalence. We supplemented survey information with publicly available HCV data to corroborate responses and fill in data gaps.

RESULTS

Weighting HCV prevalence by state prison population size, we estimate that 15.2% of the US prison population is HCV seropositive and 8.7% is viremic; 54.9% of seropositive persons have detectable RNA. Applying prevalence estimates to the total prison population at year-end 2021, 91 090 persons with HCV infection resided in a state prison.

CONCLUSIONS

With updated and more complete HCV data from all 50 states, HCV prevalence in state prisons is nearly 9-fold higher than the US general population. The heterogeneity in HCV prevalence by state prison system may reflect variable exposure before arrest and/or differences in treatment availability during incarceration. Elimination of HCV in the country depends on addressing the carceral epidemic, and one of the first steps is understanding the size of the problem.

Retrospective review of rates of sexually transmitted and blood-borne infection (STBBI) testing in provincial corrections facilities in Newfoundland and Labrador

Background

Sexually transmitted and blood borne infection (STBBI) testing is recommended for people who are incarcerated (PWAI). We sought to determine the rate of STBBI testing during admissions to provincial correctional institutions in Newfoundland and Labrador (NL).

Methods

This retrospective cohort study collected the identification of all admissions records in provincial correctional facilities in NL between July 1, 2020 and June 31, 2021 using the Provincial Corrections Offender Maintenance System database. Admissions to provincial detention centers were excluded. Records were linked with STBBI results, when available, within the electronic medical record (Meditech) using demographics. Testing rates, STBBI positivity rates, and univariate analysis of predictors for STBBI testing were completed.

Results

Of the 1,824 admissions identified, 1,716 were available for linkage to laboratory results. Admissions to detention centers (n = 105) were excluded. Any STBBI test result was available for 72 (4.5%) of admissions. No admission had complete testing for all STBBI. Facility testing rates ranged from 1.9 to 11.2% and 37.5% of STBBI tests had any positive results. Sixteen out of the 21 (76.2%) hepatitis C virus (HCV) antibody positives received HCV RNA testing, and 11/16 (88.8%) were HCV RNA positive. Institution (p = 0.001) and sex (p = 0.004) were found to be significant predictors of STBBI testing, while age was not significant (p = 0.496).

Conclusions

STBBI testing rates were low in provincial correctional facilities in NL, and STBBI prevalence, especially for HCV, was high among those tested. Strategies to increase the rate of testing could contribute to STBBI control in corrections facilities.

Criminal Sexual Behavior of Individuals With Autism Spectrum Disorder and Recommendations for Correctional Professionals

Continued uncertainty on overrepresentation of autism spectrum disorder (ASD) in the criminal justice system (CJS), although important, has shifted focus away from other questions of CJS treatment of neurodiverse individuals and left little guidance on best practice for people with ASD. For ASD individuals involved in sex offenses, there remains even less guidance. Because aspects of ASD symptomatology can highly influence sexual behaviors in ways that differ from neurotypical sex offending, it is imperative that clinicians and correctional professionals know more about this potential influence of ASD on sex offending behaviors. This knowledge should then inform efforts to enact more effective and equitable policies when interacting with the ASD population. This article reviews the connection between ASD symptoms and sexual behaviors as well as the lack of ASD-oriented sex education that could result in sex offending charges. A review of literature examining sex offending risk and its relation to ASD follows. Recommendations for more equitable treatment are discussed for different aspects of the correctional system, including forensic assessment, treatment efforts, and correctional staff interactions.

Recommendations for the Use of Telepsychology in Psychology-Law Practice and Research: A Statement by American Psychology-Law Society (APA Division 41)

In response to the COVID-19 pandemic and subsequent impact on psychological work, Division 41 of the American Psychological Association convened a taskforce to provide guidance to its membership regarding the use of technology for practice and research at the intersection of psychology and law. Drawing from existing research in psychology-law and beyond, as well as the first-hand experience of taskforce members, this document outlines foundational guidance to apply technology to forensic and correctional work while acknowledging these settings provide unique challenges to ethical practice. The recommendations provide support for psychologists involved in assessment, treatment, training, and research. However, these recommendations may not exhaustively apply to all areas of psycholegal practice or all forms of technology. Further, these recommendations are intended to be consulted in conjunction with other professional practice guidelines, emerging research, and policy changes that impact the integration of technologies into this work.

Betting Against the Odds: The Mysterious Case of the Clinical Override in Risk Assessment of Adult Convicted Offenders

Various tools were designed to guide practitioners in the risk assessment of offenders, including the Level of Service and Case Management Inventory (LS/CMI). This instrument is based on risk assessment principles prioritizing the actuarial approach to clinical judgment. However, the tool's architects allowed subjective judgment from the practitioners-referred to as clinical override-to modify an offender's risk category under certain circumstances. Few studies, however, have examined these circumstances. Therefore, the current study used decision tree analyses among a quasi-population of Quebec offenders (n = 15,744) to identify whether there are offenders more likely to be subjected to this discretion based on their characteristics. The results suggest that, although the override is rare, it occurred under few specific combinations of circumstances. More precisely, these findings propose that the utilization of the clinical override stems from a perceived discrepancy between risk prediction and management.

Integrated Safety and Health Promotion among Correctional Workers and People Incarcerated: A Scoping Review

Improving safety and health for correctional workers and people who are incarcerated are widespread yet separate initiatives. Correctional workers and people who are incarcerated experience similar challenges involved with poor workplaces and living conditions, including mental health crises, violence, stress, and chronic health issues, and the available resources lack integration with respect to safety and health promotion. This scoping review sought to contribute to an integrated approach for correctional system safety and health resources and identify studies of correctional resources that address health promotion among correctional workers and people who are incarcerated. Guided by PRISMA, a search of gray literature, also termed peer-reviewed literature, published between 2013-2023 (n = 2545) was completed, and 16 articles were identified. Resources primarily targeted individual and interpersonal levels. At every level of intervention, resources improved the environment for both workers and those incarcerated, with trends of less conflict, more positive behaviors, and improved relations, access to care, and feelings of safety. The corrections environment is impacted by changes from both workers and people who are incarcerated and should be examined using a holistic approach. Future health and safety resources should target the larger correctional environment by utilizing practices, policies, and procedures to improve safety and health for incarcerated people and workers.

Drug Addiction and Incarceration: A Call for Research and Transparency Among Prison-Based Substance Abuse Treatment Programs

As drug-related offense and illicit drug overdose rates continue to grow in the United States, criminologists have begun to pay more attention to factors influencing illicit drug use as well as effective methods of promoting drug abstinence in treatment programs across the nation. Although much scholarly attention is given to community-based substance abuse treatment programs, a considerably smaller focus of research is devoted to substance abuse treatment programs that are prison-based. Moreover, some of the most effective methods of treating inmates who are addicted to an illicit drug (such as Cognitive Behavioral Therapy, Therapeutic Community, etc.), although praised for their initiative and theoretical effectiveness, are often demonstrated via individualized empirical study that the expected advantages of such programmatic forms of treatment fail to emerge. The present study explores what scholars have discovered regarding the effectiveness of prison-based substance abuse treatment programs, how such findings appear to contradict one another, and why state prison systems should be more transparent regarding their in-house drug treatment programs in their publicly accessible reports that are formulated into cumulative reports on each states' Bureau of Corrections websites.

Prevalence of Psychiatric Disorders by Demographics in Jail Populations

Many individuals incarcerated in jails suffer from psychiatric disorders and require mental health treatment. However, there has yet to be a study which comprehensively described the prevalence of mental illness diagnoses by demographic variables or compared results to the general population. Data for this study were the Survey of Inmates in Local Jails, 2002. Binary logistic regression was run to compare the prevalence of diagnoses to demographic variables of the jail population. Results were compared to studies in the general population. Males were less likely than females to report five of the seven disorder categories, and employed individuals were less likely to report all seven disorders. The results were consistent with research on the general population. It is important to understand the population of individuals with mental illness in jail so we can better serve them and catch psychiatric disorders early while they are more easily treatable.

Aboriginal and Torres Strait Islander perspectives on forensic risk assessment

Risk assessment instruments are used to estimate risk of recidivism and aid in decision-making and treatment planning. However, many of these instruments, including the Level of Service/Risk, Need, Responsivity (LS/RNR), are validated on predominantly Western populations, and research has questioned whether the factors included in the LS/RNR adequately capture the experiences and needs of non-Western communities, including Aboriginal and Torres Strait Islanders. The current study aimed to canvas the opinions of Aboriginal and Torres Strait Islander community justice workers as to the suitability of the LS/RNR for use with this population. A general qualitative methodology was adopted to gain in-depth information through the facilitation of a focus group, and data were analysed thematically. Whilst participants agreed that the LS/RNR risk factors are relevant to Aboriginal and Torres Strait Islander offenders, they reported that the instrument did not adequately capture relevant culturally specific considerations and made suggestions to improve the LS/RNR.

Evaluation of Correctional Facility COVID-19 Outbreaks With Layered Mitigation Strategies Including Vaccination: Colorado, 2020-2021

In 2020-2021, a Colorado corrections facility experienced four COVID-19 outbreaks. Case counts, attack rates (ARs) in people who are detained or incarcerated (PDI), and mitigation measures used in each outbreak were compared to evaluate effects of combined strategies. Serial PCR testing, isolation/quarantine, and masking were implemented in outbreak 1. Daily staff antigen testing began in outbreak 2. Facility-wide COVID-19 vaccination started in outbreak 3 and coverage increased by the end of outbreak 4 (PDI: <1% to 59%, staff: 27% to 40%). Despite detection of variants of concern, outbreaks 3 and 4 had 97% lower PDI ARs (both 1%) than outbreak 2 (29%). Daily staff testing and increasing vaccination coverage, with other outbreak mitigation strategies, are important to reduce COVID-19 transmission in congregate settings.

Anxiety Among Correctional/Detention Health Professionals and Associated Risk Factors During the Coronavirus Disease 2019 Pandemic

Correctional health professionals are vulnerable to the negative mental health outcomes associated with the coronavirus disease 2019 (COVID-19) pandemic. A cross-sectional survey was conducted to assess anxiety symptoms in health professionals who work in correctional/detention facilities and identify associated risk factors. Data were collected from 192 health professionals from March 23 to June 30, 2021. The prevalence and degree of anxiety symptoms were assessed by the Generalized Anxiety Disorder (GAD) scale. Chi square, Mann-Whitney U, and Pearson's correlation were used to assess the associations among anxiety scores and demographic data, COVID-19 exposures, medical and psychological history, and isolation practices. Of the sample, 27.1% had at least moderate levels of anxiety (GAD-7 score >10), which is highly suggestive of a diagnosis for GAD. Main factors associated with higher levels of anxiety included female gender, younger age, type of facility, less access to personal protective equipment, and a history of chronic medical problems. The psychological burden of COVID-19 on correctional/detention health professionals is significant, and behavioral health interventions should be considered for this unique population.

Therapeutic Interventions for Mental Wellness in Correctional Facilities: A Systematic Review

The article includes a systematic review of therapeutic interventions being used to improve mental health of males and females incarcerated in U.S. jails and prisons. Using pertinent keywords, we searched the following databases: SocINDEX, CINAHL Complete, Medline Complete, PsychINFO, Psychology and Behavioral Sciences Collection, and Criminal Justice Abstracts with Full Text for studies published between 2010 and 2021. The initial search yielded 9,622 articles. After screening, 28 articles met the inclusion criteria and were reviewed. Review indicated use of a diverse range of interventions to address mental health outcomes including, but not limited to, PTSD, depression, and anxiety. A few studies did not focus on specific mental health outcomes, but rather on behavioral outcomes such as distress, affect, mood, time spent in the hospital, number of acts of self-injury, competency restoration, and wellbeing of the participants. The review includes implications for future research and practice.

Characterizing Arrest and Incarceration in a Prospective Cohort of Transgender Women

This study characterized arrest, incarceration, and risk factors for incident incarceration among transgender women (TW) in the northeastern and southern United States. During semiannual study visits over 24 months in a multicenter cohort study, TW completed HIV testing and self-administered surveys. In total, 1571 TW completed baseline survey; 1,312 HIV-negative TW enrolled in the cohort and contributed 2134.3 person-years to the analysis. At baseline, 37% had been arrested and 21% had been incarcerated. Incident incarceration was 23.4 per 1,000 person-years (95% confidence interval [CI]: 16.9-29.9). Sex work was significantly associated with baseline and incident incarceration (p < .01). A history of incarceration at enrollment was the strongest predictor of incident incarceration (adjusted odds ratio [aOR] 6.99; 95% CI: 3.43-14.24). Living in the South (aOR 2.69, 95% CI: 1.22-5.93), income below the federal poverty level (aOR 2.65 95% CI: 3.43-14.24), and having a recent partner who had been incarcerated (aOR 2.62, 95% CI: 1.20-5.69) also increased the odds of incident incarceration in multivariable modeling. Structural interventions to reduce poverty and decriminalize sex work have the potential to reduce incarceration rates among TW.

Believing and sharing misinformation, fact-checks, and accurate information on social media: The role of anxiety during COVID-19

The COVID-19 pandemic went hand in hand with what some have called a "(mis)infodemic" about the virus on social media. Drawing on partisan motivated reasoning and partisan selective sharing, this study examines the influence of political viewpoints, anxiety, and the interactions of the two on believing and willingness to share false, corrective, and accurate claims about COVID-19 on social media. A large-scale 2 (emotion: anxiety vs relaxation) × 2 (slant of news outlet: MSNBC vs Fox News) experimental design with 719 US participants shows that anxiety is a driving factor in belief in and willingness to share claims of any type. Especially for Republicans, a state of heightened anxiety leads them to believe and share more claims. Our findings expand research on partisan motivated reasoning and selective sharing in online settings, and enhance the understanding of how anxiety shapes individuals' processing of risk-related claims in issue contexts with high uncertainty.

Amending the literature through version control

The ideal of self-correction in science is not well served by the current culture and system surrounding amendments to published literature. Here we describe our view of how amendments could and should work by drawing on the idea of an author-led version control system. We report a survey (n = 132) that highlights academics' dissatisfaction with the status quo and their support for such an alternative approach. Authors would include a link in their published manuscripts to an updatable website (e.g. a GitHub repository) that could be disseminated in the event of any amendment. Such a system is already in place for computer code and requires nothing but buy-in from the scientific community-a community that is already evolving towards open science frameworks. This would remove a number of frictions that discourage amendments leading to an improved scientific literature and a healthier academic climate.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

Introduction

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

Methods

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants’ release. Data were thematically analyzed.

Results

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of ‘take-home’ OAT medications were common barriers.

Conclusions

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.