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

Reaching the Unreachable: Intensive Mobile Treatment, an Innovative Model of Community Mental Health Engagement and Treatment

In this paper we introduce the Intensive Mobile Treatment (IMT) model, which arose from a 2016 New York City initiative to engage individuals who were "falling through the cracks" of the mental health, housing, and criminal justice systems. People who are referred to IMT often have extensive histories of trauma. They experience structural racism and discrimination within systems and thus can present as distrustful of treatment teams. We detail the structure of the program as we practice it at our non-profit agency and outline the psychodynamic concepts that inform our work with challenging populations. We acknowledge IMT's role in engaging in advocacy and addressing social justice in our work. We also discuss how through this model we are able to both mitigate and tolerate risk in participants with difficult-to-manage behaviors. This is typically a long-term, non-linear process. We address how this impacts the team dynamic as a whole and explain how with long-term, trusting therapeutic relationships, participants can change and grow over time. We also explain the ways in which our non-billing model plays an integral role in the treatment we are able to provide and identify several challenges and areas for program growth. In outlining our model and its methodology, we hope to empower other practitioners to adapt IMT to other settings beyond the New York City area.

Transitions of care between jail-based medications for opioid use disorder and ongoing treatment in the community: A retrospective cohort study

BACKGROUND

Offering medications for opioid use disorder (MOUD) in carceral settings significantly reduces overdose. However, it is unknown to what extent individuals in jails continue MOUD once they leave incarceration. We aimed to assess the relationship between in-jail MOUD and MOUD continuity in the month following release.

METHODS

We conducted a retrospective cohort study of linked NYC jail-based electronic health records and community Medicaid OUD treatment claims for individuals with OUD discharged from jail between 2011 and 2017. We compared receipt of MOUD within 30 days of release, among those with and without MOUD at release from jail. We tested for effect modification based on MOUD receipt prior to incarceration and assessed factors associated with treatment discontinuation.

RESULTS

Of 28,298 eligible incarcerations, 52.8 % received MOUD at release. 30 % of incarcerations with MOUD at release received community-based MOUD within 30 days, compared to 7 % of incarcerations without MOUD (Risk Ratio: 2.62 (2.44-2.82)). Most (69 %) with MOUD claims prior to incarceration who received in-jail MOUD continued treatment in the community, compared to 9 % of those without prior MOUD. Those who received methadone (vs. buprenorphine), were younger, Non-Hispanic Black and with no history of MOUD were less likely to continue MOUD following release.

CONCLUSIONS

MOUD maintenance in jail is strongly associated with MOUD continuity upon release. Still, findings highlight a gap in treatment continuity upon-reentry, especially among those who initiate MOUD in jail. In the wake of worsening overdose deaths and troubling disparities, improving MOUD continuity among this population remains an urgent priority.

Violence at Rikers Island: Does the Doctor Make It Worse? A Clinician Ethnographer's Work Amidst Carceral Structural Violence

In this article, I describe the dilemmas of working as a physician-ethnographer within the Rikers Island jail healthcare system before and at the beginning of the COVID-19 epidemic in April 2020. The Rikers Island jail system in New York City has been in the national spotlight as a space of violence, trauma, and death amidst calls to decarcerate by community members and abolition advocates. This article is a personal reflection on the labor and subjectivity of healthcare providers and their positionality to multiple axes of structural and interpersonal violence while attempting to provide care in carceral institutions. I observe how COVID-19 functioned as an additional form of structural violence for incarcerated people. Clinical ethnography remains an essential tool for understanding complex social phenomena such as violence. However, physician-ethnographers working in these spaces of structural violence can have unique and conflicting constraints: tasked with providing evidence-based medicine but also simultaneously participating in an unusual form of labor that is an amalgamation of care, social suffering, and punishment. Despite and across at-times conflicting roles and obligations, I propose that these fragmented subjectivities can foment social criticism, propel advocacy toward decarceration, and produce a critically engaged dialogue between fields of anthropology and medicine toward a goal of health justice.

Characterizing Arrests and Charges Among Individuals With Serious Mental Illnesses in Public-Sector Treatment Settings

OBJECTIVE

Individuals with serious mental illnesses are overrepresented in all facets of the legal system. State-level criminal histories of patients with serious mental illnesses were analyzed to determine the proportion who had been arrested and number of lifetime arrests and charges, associations of six variables with number of arrests, and the most common charges from individuals’ first two arrests and most recent two arrests.

METHODS

A total of 240 patients were recruited at three inpatient psychiatric facilities and gave consent to access their criminal history. Information was extracted from Record of Arrest and Prosecution (RAP) sheets for lifetime arrests in Georgia.

RESULTS

A total of 171 (71%) had been arrested. Their mean±SD lifetime arrests were 8.6±10.1, and mean lifetime charges were 12.6±14.6. In a Poisson regression, number of arrests was associated with lower educational attainment, Black or African American race, the presence of a substance use disorder, the presence of a mood disorder, and female sex. Common early charges included marijuana possession, driving under the influence of alcohol, and burglary and shoplifting. Common recent charges included probation violations, failure to appear in court, officer obstruction–related charges, and disorderly conduct.

CONCLUSIONS

Findings point to a need for policy and program development in the legal system (e.g., pertaining to charges such as willful obstruction of an officer), the mental health community (e.g., to ensure that professionals know about clients’ legal involvement and can partner in strategies to reduce arrests), and social services sectors (to address charges, such as shoplifting, often related to material disadvantage).

Caring for Incarcerated Patients: Can it Ever be Equal?

BACKGROUND

Incarcerated patients represent one of the most vulnerable populations in the United States healthcare system. Studying disparities in care they receive, however, has been difficult due to a history of abuse at the hands of medical researchers rendering this population excluded from most current medical research. Due to incarceration, these patients are frequently maintained in shackles and under constant guard when receiving healthcare. There is a paucity of literature on the influence these measures exert on healthcare workers and the care they provide. Our study aimed to measure surgical trainee's perception of health inequities and disparities in incarcerated individuals undergoing surgical care.

METHODS

An anonymous cross-sectional survey was administered at our single institution to all general surgery trainees assessing perceptions in delivering care to incarcerated patients within our hospital system. The survey consisted of 10 items, nine of which were yes or no responses, and 1 open-ended text question. Survey results were averaged, and percentages were reported.

RESULTS

Of all current general surgery residents (n = 60), 40 (66%) completed the survey. Almost all respondents (n = 39, 97.5%) have cared for a patient that was incarcerated or in police custody. Most respondents (n = 25, 62.5%) have operated on an incarcerated patient with an armed guard present in the operating room. Similarly, most respondents (n = 26, 65%) have cared for a patient intubated and sedated that was shackled to a bed. The majority of respondents (n = 30, 75%) recalled incidents where a trauma patient was actively questioned by law enforcement during the primary/secondary survey during initial trauma evaluation. At the time of hospital discharge, a quarter (n = 10, 25%) of respondents reported being unable to prescribe all of the medications that a non-imprisoned patient would receive with the same condition. In addition, 18 (45%) respondents felt they were unable to arrange outpatient follow-up with physical or occupational therapy and/or the patient's primary/consulting physician due to patient's incarcerated status. Strikingly, half of respondents (n = 19, 47.5%) believed that the incarcerated patient received substandard care, and the majority of respondents (n = 28, 72%) agreed that the holding areas for incarcerated patients in the emergency room provide substandard patient care.

CONCLUSIONS

The current status of caring for incarcerated patients within our system represents an urgent and needed area for quality improvement. Surgical trainees report difficulty caring for these patients, and they perceive these individuals receive substandard care. Though our cross-sectional study did not assess the origin of this disparity, the challenges trainees face in caring for incarcerated patients, from assessment to diagnosis and treatment, as well as in follow-up signals an area requiring further research and study.

The cumulative risk of jail incarceration

Research on incarceration has focused on prisons, but jail detention is far more common than imprisonment. Jails are local institutions that detain people before trial or incarcerate them for short sentences for low-level offenses. Research from the 1970s and 1980s viewed jails as "managing the rabble," a small and deeply disadvantaged segment of urban populations that struggled with problems of addiction, mental illness, and homelessness. The 1990s and 2000s marked a period of mass criminalization in which new styles of policing and court processing produced large numbers of criminal cases for minor crimes, concentrated in low-income communities of color. In a period of widespread criminal justice contact for minor offenses, how common is jail incarceration for minority men, particularly in poor neighborhoods? We estimate cumulative risks of jail incarceration with an administrative data file that records all jail admissions and discharges in New York City from 2008 to 2017. Although New York has a low jail incarceration rate, we find that 26.8% of Black men and 16.2% of Latino men, in contrast to only 3% of White men, in New York have been jailed by age 38 y. We also find evidence of high rates of repeated incarceration among Black men and high incarceration risks in high-poverty neighborhoods. Despite the jail's great reach in New York, we also find that the incarcerated population declined in the study period, producing a large reduction in the prevalence of jail incarceration for Black and Latino men.

The hepatitis C virus care cascade in the New York City jail system during the direct acting antiviral treatment era, 2014-2017

BACKGROUND

High patient turnover presents challenges and opportunity to provide hepatitis C virus (HCV) care in US jails (remand facilities). This study describes the HCV care cascade in the New York City (NYC) jail system during the direct-acting antiviral (DAA) treatment era.

METHODS

Patients admitted to the NYC jail system from January 2014 through December 2017 were included in this retrospective cohort analysis. We describe rates of screening, diagnosis, linkage to jail-based care, and treatment among the overall cohort, and among subgroups with long jail stays (≥120 days) or frequent stays (≥10 admissions). The study protocol was approved by a third-party institutional review board (BRANY, Lake Success, NY).

FINDINGS

Among the 121,371 patients in our analysis, HCV screening was performed in 40,219 (33%), 4665 (12%) of whom were viremic, 1813 (39%) seen by an HCV clinician in jail, and 248 (5% of viremic patients) started on treatment in jail. Having a long stay (adjusted risk ratio [aRR] 8·11, 95% confidence interval [CI] 6·98, 9·42) or frequent stays (aRR 1·51, 95% CI 1·04, 2·18) were significantly associated with being seen by an HCV clinician. Patients with long stays had a higher rate of treatment (14% of viremic patients). Sustained virologic response at 12 weeks was achieved in 147/164 (90%) of patients with available virologic data.

INTERPRETATION

Jail health systems can reach large numbers of HCV-infected individuals. The high burden of HCV argues for universal screening in jail settings. Length of stay was strongly associated with being seen by an HCV clinician in jail. Treatment is feasible among those with longer lengths of stay.

FUNDING

None.

Identifying demographic and health profiles of young adults with frequent jail incarceration in New York City during 2011-2017

PURPOSE

The purpose of this study was to investigate incarceration patterns among young adults in New York City jails from mid-2011 through 2017, with an aim that identification of frequently incarcerated young "hot spotters" may inform early interventions.

METHODS

We examined electronic health records for 3114 individuals with no known prior jail admission and admitted within 4.5 years after turning age 18 years. We used group-based trajectory analysis to identify hot spotters and compared their characteristics with those of other trajectory groups. We repeated the analysis for three older adult groups for additional comparison.

RESULTS

Five percent of the young individuals became hot spotters (mean = 7.7 incarcerations). They were more likely to be homeless (27.1% vs. 7.2%-16.4% in other trajectory groups), have substance use disorders (95.2% vs. 73.2%-89.8%), and mental health needs (65.7% vs. 28.5%-53.3%), and be incarcerated for theft-related charges (52.7% vs. 32.0%-49.6%) and misdemeanors (34.8 vs. 25.5%-29.4%). They differed in charge profile and homelessness compared with older hot spotters.

CONCLUSIONS

Some young adults are at risk of frequent incarceration. Tailored health- and behavior-related interventions may preclude cyclical incarceration and address barriers to well-being and stability.

Witnessed overdoses and naloxone use among visitors to Rikers Island jails trained in overdose rescue

With the opioid overdose mortality rates rising nationally, The New York City Department of Health and Mental Hygiene (NYC DOHMH) has worked to expand overdose rescue training (ORT) and naloxone distribution. This study sought to determine rates of overdose witnessing and naloxone use among overdose rescue-trained visitors to the NYC jails on Rikers Island. We conducted a six-month prospective study of visitors to NYC jails on Rikers Island who received ORT. We collected baseline characteristics of study participants, characteristics of overdose events, and responses to witnessed overdose events, including whether the victim was the incarcerated individual the participant was visiting on the day of training. Bivariate analyses compared baseline characteristics of participants who witnessed overdoses to those who did not, and of participants who used naloxone to those who did not. Overall, we enrolled 283 participants visiting NYC's Rikers Island jails into the study. Six months after enrollment, we reached 226 participants for follow-up by phone. 40 participants witnessed 70 overdose events, and 28 participants reported using naloxone. Of the 70 overdose events, three victims were the incarcerated individuals visited on the day of training; nine additional victims were recently released from jail and/or prison. Visitors to persons incarcerated at Rikers Island witness overdose events and are able to perform overdose rescues with naloxone. This intervention reaches a population that includes not only those recently released, but also other people who experienced overdose.

The HIV Care Cascade Among Individuals Under Community Supervision in Baltimore, Maryland

An estimated one in seven HIV-infected individuals pass through U.S. correctional facilities each year. Transitioning from correctional to community settings may increase HIV treatment interruptions and increase the risk of continued HIV transmission in the community. This study assessed access to HIV providers in the community, antiretroviral treatment, and viral suppression to inform the development of interventions to improve HIV treatment outcomes among individuals involved in community corrections. The sample included 100 individuals under community supervision (probation or parole) in Baltimore, Maryland. While a large proportion of the study sample had undetectable HIV viral loads, 39% did not, and this represents a significant HIV transmission risk. Given the large proportion of individuals involved in the criminal justice system who are under community supervision, community corrections may be an important point of intervention to engage or reengage HIV-positive individuals who are currently out of care.

Unpacking Pretrial Detention: An Examination of Patterns and Predictors of Readmissions

Pretrial detention makes up the majority of jail admissions, but little is known about this high-volume population. The current study fills this gap by examining the pretrial detention population in New York City and assesses their pretrial readmissions over a 10-year follow-up period. While the number of individuals detained pretrial has consistently decreased since 1995, the prevalence and the frequency of pretrial readmissions remain high: About 60% of the sample was readmitted at least once within 10 years and they were readmitted on average 3 times. A negative binomial model predicting readmission counts for felony and misdemeanor admissions found that males, non-Hispanic Blacks, and younger individuals were more frequently readmitted pretrial. Self-reported drug use and prior criminal records were associated with higher readmission counts. We also found that charge and discharge types predicted readmission counts. Findings suggest the importance of earlier intervention and developing targeted strategies to reduce further readmissions.

Reduction in Jail Emergency Department Visits and Closure After Implementation of On-Site Urgent Care

This descriptive study evaluates the impact of implementation of full service on-site urgent care services at the Los Angeles County Jail (LACJ) by examining the number of patients seen at the referral hospital, Los Angeles County + University of Southern California Medical Center (LAC+USC), and the number of hours that the referral hospital was closed to transfers in the periods before and after the development of the LACJ Urgent Care. The appropriate utilization of public resources is a critical priority for an overburdened county medical health care system. Implementing on-site urgent care staffed by emergency physicians led to reductions in the average number of patients transferred to LAC+USC, the average number of monthly closure hours, and the average days per month when closure to transfer occurred, and a cost savings of some $2 million, primarily in personnel costs.

Psychiatric education in the correctional setting: challenges and opportunities

As the need for mental healthcare services within correctional settings in the US increases, so does the need for a mental health workforce that is motivated to work within such systems. One potentially effective method by which to increase the number of psychiatrists working in jails, prisons, and parole clinics is to provide exposure to these environments during their training. Correctional settings can serve as unique training sites for medical students and psychiatric residents and fellows. Such training experiences can provide a host of benefits to both trainees and staff within the correctional mental health system. Alongside many potential benefits exist substantial potential barriers to coordinating correctional training experiences, including both programme directors' and residents' concerns regarding safety and enjoyment and negative perceptions of inmate and prisoner patients. The establishment of academic affiliations with correctional institutions and didactic instruction on commonly encountered clinical issues with inmate populations may be methods of diffusing these concerns. Improving residents' and fellows' training experiences offers a hope for increasing the attractiveness of a career in correctional psychiatry.

Tuberculosis in Jails and Prisons: United States, 2002-2013

OBJECTIVES

To describe cases and estimate the annual incidence of tuberculosis in correctional facilities.

METHODS

We analyzed 2002 to 2013 National Tuberculosis Surveillance System case reports to characterize individuals who were employed or incarcerated in correctional facilities at time they were diagnosed with tuberculosis. Incidence was estimated with Bureau of Justice Statistics denominators.

RESULTS

Among 299 correctional employees with tuberculosis, 171 (57%) were US-born and 82 (27%) were female. Among 5579 persons incarcerated at the time of their tuberculosis diagnosis, 2520 (45%) were US-born and 495 (9%) were female. Median estimated annual tuberculosis incidence rates were 29 cases per 100 000 local jail inmates, 8 per 100 000 state prisoners, and 25 per 100 000 federal prisoners. The foreign-born proportion of incarcerated men 18 to 64 years old increased steadily from 33% in 2002 to 56% in 2013. Between 2009 and 2013, tuberculosis screenings were reported as leading to 10% of diagnoses among correctional employees, 47% among female inmates, and 42% among male inmates.

CONCLUSIONS

Systematic screening and treatment of tuberculosis infection and disease among correctional employees and incarcerated individuals remain essential to tuberculosis prevention and control.

Associations of place characteristics with HIV and HCV risk behaviors among racial/ethnic groups of people who inject drugs in the United States

PURPOSE

Investigate whether characteristics of geographic areas are associated with condomless sex and injection-related risk behavior among racial/ethnic groups of people who inject drugs (PWID) in the United States.

METHODS

PWID were recruited from 19 metropolitan statistical areas for 2009 National HIV Behavioral Surveillance. Administrative data described ZIP codes, counties, and metropolitan statistical areas where PWID lived. Multilevel models, stratified by racial/ethnic groups, were used to assess relationships of place-based characteristics to condomless sex and injection-related risk behavior (sharing injection equipment).

RESULTS

Among black PWID, living in the South (vs. Northeast) was associated with injection-related risk behavior (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.21-4.17; P = .011), and living in counties with higher percentages of unaffordable rental housing was associated with condomless sex (AOR = 1.02, 95% CI = 1.00-1.04; P = .046). Among white PWID, living in ZIP codes with greater access to drug treatment was negatively associated with condomless sex (AOR = 0.93, 95% CI = 0.88-1.00; P = .038).

CONCLUSIONS

Policies that increase access to affordable housing and drug treatment may make environments more conducive to safe sexual behaviors among black and white PWID. Future research designed to longitudinally explore the association between residence in the south and injection-related risk behavior might identify specific place-based features that sustain patterns of injection-related risk behavior.