Lost in Transition: The Behavioral Health Needs of Veterans in Eight County Jails

Health Conditions and Treatment Utilization Among Older Male Veterans Incarcerated in Prisons

BACKGROUND

More than 50,000 older male veterans incarcerated in prisons are expected to return to their communities and utilize the Veterans Health Administration (VHA) and community healthcare systems. To support the continuity of healthcare and overall successful community reentry of older incarcerated veterans, an understanding of their health profiles and treatment utilization while in correctional care is needed.

OBJECTIVE

To assess the health status of older male veterans incarcerated in state prisons and explore demographic, military, and VHA-related factors associated with medical conditions, disabilities, behavioral conditions, and medical and behavioral treatment utilization.

DESIGN/PARTICIPANTS

Cross-sectional observational study of 880 male veterans aged 50 + incarcerated in state prisons using data from the 2016 Bureau of Justice Statistics Survey of Prison Inmates.

MAIN MEASURES

Veteran status, self-report health status, and treatment utilization since prison admission. Prevalence rates for conditions and treatment utilization were calculated. Logistic regression models were used to examine the association of characteristics with conditions and treatment utilization.

KEY RESULTS

Among the 880 older male veterans in state prisons, the majority reported having a current medical condition (79.3%) or disability (61.6%), almost half had history of a mental health condition (44.5%), and more than a quarter (29%) had a substance use disorder. Compared to White veterans, Black veterans were less likely to report a disability or mental health condition. Few demographic, military, and VA-related characteristics were associated with medical or behavioral conditions or treatment utilization.

CONCLUSION

Our results suggest that the VHA and community healthcare systems need to be prepared to address medical and disability conditions among the majority of older male veterans who will be leaving prison and returning to their communities. Integrated medical and behavioral healthcare delivery models may be especially important for these veterans as many did not receive behavioral health treatment while in prison.

Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model

BACKGROUND

A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research.

METHODS

A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM.

RESULTS

Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept).

CONCLUSIONS

There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.

"You can get a couple of ramen noodle packs for a BusparⓇ": A qualitative examination of medication access, policy, and procedures in southern jails

BACKGROUND

Jails in the United States are required to provide health care to the over 10 million people entering jails each year, a significant portion of whom need medications. Yet little is known about the processes by which medications are prescribed, obtained, and administered to incarcerated persons in jails.

OBJECTIVE

To describe medication access, policy, and procedures in jails.

METHODS

Semi-structured interviews were conducted with administrators and health workers from 34 jails (of 125 contacted) across 5 states in the southeastern United States. The interview guide covered all aspects of healthcare in jails from entry to release; however, the present study focused on responses relating to medications. Interviews were thematically coded using a combination of deductive and inductive coding guided by the research objective.

RESULTS

Four processes described medication use chronologically from intake to release: jail entry and health screening, pharmacy and medication protocols, protocols specific to medication dispensing and administration, and medications at release. Many jails had procedures for using medications brought from home, though some declined to use these medications. Medication decision-making in jails was primarily performed by contracted healthcare providers, and most medications were obtained from contract pharmacies. Almost all jails banned narcotics; however, other medication restrictions varied by jail. Most jails charged a copay for medications. Participants discussed various privacy practices related to medication distribution, as well as approaches to diversion prevention including "crushing and floating" medications. Finally, the pre-release medication management process included transition planning that ranged from no planning to sending additional prescriptions to the patient's pharmacy.

CONCLUSIONS

Medication access, protocols, and procedures in jails varies considerably, and there is a need for further adoption of existing standards and guidelines for the use of medications in jails, such as the Assess, Plan, Identify, and Coordinate (APIC) model of community re-entry.

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

BACKGROUND

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

METHODS

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

RESULTS

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

CONCLUSION

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.