Managed care updates of subscriber jail release to prompt community suicide prevention: clinical trial protocol

BACKGROUND

Recent jail detention is a marker for trait and state suicide risk in community-based populations. However, healthcare providers are typically unaware that their client was in jail and few post-release suicide prevention efforts exist. This protocol paper describes an effectiveness-implementation trial evaluating community suicide prevention practices triggered by advances in informatics that alert CareSource, a large managed care organization (MCO), when a subscriber is released from jail.

METHODS

This randomized controlled trial investigates two evidence-based suicide prevention practices triggered by CareSource's jail detention/release notifications, in a partial factorial design. The first phase randomizes ~ 43,000 CareSource subscribers who pass through any Ohio jail to receive Caring Contact letters sent by CareSource or to Usual Care after jail release. The second phase (running simultaneously) involves a subset of ~ 6,000 of the 43,000 subscribers passing through jail who have been seen in one of 12 contracted behavioral health agencies in the 6 months prior to incarceration in a stepped-wedge design. Agencies will receive: (a) notifications of the client's jail detention/release, (b) instructions for re-engaging these clients, and (c) training in suicide risk assessment and the Safety Planning Intervention for use at re-engagement. We will track suicide-related and service linkage outcomes 6 months following jail release using claims data.

CONCLUSIONS

This design allows us to rigorously test two intervention main effects and their interaction. It also provides valuable information on the effects of system-level change and the scalability of interventions using big data from a MCO to flag jail release and suicide risk.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT05579600). Registered 27 June, 2023.

Treatment setting among individuals with opioid use and criminal legal involvement, housing instability, or Medicaid insurance, 2015-2021

Background

Individuals with criminal legal involvement (CLI), housing instability, or Medicaid insurance may experience barriers accessing substance use treatment in certain settings. Previous research has found individuals in these groups are less likely to receive medications for opioid use disorder (MOUD), but the role treatment setting may play in low rates of MOUD is unclear.

Methods

We conducted a cross-sectional study using nationally representative survey data from 2015 to 2021. We estimated the proportion of individuals who had CLI, housing instability, or Medicaid insurance who received substance use treatment in a variety of settings. We used multivariable logistic regressions to estimate the associations between group and the receipt of MOUD across treatment settings.

Results

Individuals with CLI, housing instability, or Medicaid insurance were more likely to receive substance use treatment in hospitals, rehabilitation, and mental health facilities compared with individuals not in these groups. However, all groups accessed substance use treatment in doctors' offices at similar rates. Treatment at a doctor's office was associated with the highest likelihood of receiving MOUD (aOR 4.73 [95% CI: 2.2.15-10.43]). Across multiple treatment settings, Individuals with CLI or housing instability were less likely to receive MOUD.

Conclusions

Individuals with CLI, housing instability, or Medicaid insurance are more likely to access substance use treatment at locations associated with lower rates of MOUD use. MOUD access across treatment settings is needed to improve engagement and retention in treatment for patients experiencing structural disadvantage or who have low incomes.

Military sexual trauma among Veterans using and not using VA justice-related programing: A national examination

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial.

The Stigma of Criminal Legal Involvement and Health: a Conceptual Framework

The USA incarcerates more people than any other nation in the world. Exposure to the criminal legal system has been associated with a myriad of health outcomes but less is understood about what drives these associations. We argue that stigma due to criminal legal involvement, what we call criminal legal stigma, likely has a larger role in the association between incarceration and negative health outcomes than has been previously appreciated. There is limited research on the impact on health of criminal legal stigma despite abundant research on its negative social consequences. In this paper, we describe a conceptual framework of the health effects of criminal legal stigma drawing on previous research of criminal legal stigma and advances in other areas of stigma research. We outline key concepts related to stigma mechanisms, how they function at structural and individual levels, and how they might cause health outcomes. Finally, we identify potential areas for future research and opportunities for clinical interventions to remediate negative effects of stigma.