Faculty Bibliography

OBJECTIVES: To better understand jail mental health services entry, we analyzed diagnosis timing relative to solitary confinement, nature of diagnosis, age, and race/ethnicity. METHODS: We analyzed 2011 to 2013 medical records on 45,189 New York City jail first-time admissions. RESULTS: Of this cohort, 21.2% were aged 21 years or younger, 46.0% were Hispanic, 40.6% were non-Hispanic Black, 8.8% were non-Hispanic White, and 3.9% experienced solitary confinement. Overall, 14.8% received a mental health diagnosis, which was associated with longer average jail stays (120 vs 48 days), higher rates of solitary confinement (13.1% vs 3.9%), and injury (25.4% vs 7.1%). Individuals aged 21 years or younger were less likely than older individuals to receive a mental health diagnosis (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.93; P < .05) and more likely to experience solitary confinement (OR = 4.99; 95% CI = 4.43, 5.61; P < .05). Blacks and Hispanics were less likely than Whites to enter the mental health service (OR = 0.57; 95% CI = 0.52, 0.63; and OR = 0.49; 95% CI = 0.44, 0.53; respectively; P < .05), but more likely to experience solitary confinement (OR = 2.52; 95% CI = 1.88, 3.83; and OR = 1.65; 95% CI = 1.23, 2.22; respectively; P < .05). CONCLUSIONS: More consideration is needed of race/ethnicity and age in understanding and addressing the punishment and treatment balance in jails.

Use of electronic health records (EHRs) is an important innovation for patients in jails and prisons. Efforts to incentivize health information technology, including the Medicaid EHR Incentive Program, are generally aimed at community providers; however, recent regulation changes allow participation of jail health providers. In the New York City jail system, the Department of Health and Mental Hygiene oversees care delivery and was able to participate in and earn incentives through the Medicaid EHR Incentive Program. Despite the challenges of this program and other health information innovations, participation by correctional health services can generate financial assistance and useful frameworks to guide these efforts. Policymakers will need to consider the specific challenges of implementing these programs in correctional settings.

Dual loyalty is an omnipresent feature of correctional health. As part of a human rights quality improvement committee, and utilizing the unique advantage of a fully integrated electronic health record system, we undertook an assessment of dual loyalty in the New York City jail system. The evaluation revealed significant concerns about the extent to which the mental health service is involved in assessments that are part of the punishment process of the security apparatus. As a result, dual loyalty training was developed and delivered to all types of health staff in the jail system via anonymous survey. Six clinical scenarios were presented in this training and staff members were asked to indicate whether they had encountered similar circumstances and how they would respond. Staff responses to the survey raised concerns about the frequency with which they are pressured or asked to put aside their primary goal of patient care for the interests of the security mission. The online training and follow-up small group sessions have revealed widespread support for more training on dual loyalty.

Because we previously identified high rates of past TBI among adolescents arriving in the New York City (NYC) jail system we engaged adolescents in nine TBI focus groups to characterize better the level of understanding regarding the relationship between TBI and violence. During these groups, the following themes emerged: 1) physical and psychological impacts of violence; 2) roots of violence; 3) the use of violence as capital in the face of a marginalized social status; and 4) the inevitability of violence, particularly in a jail setting. Although these focus groups were initiated as a means to engage adolescents around the clinical problem of TBI, their observations are strongly centered in the larger context of violence. These results suggest that intervening in the problem of TBI among our patients will require broad-based changes in the environmental and interpersonal realities, both in the jail setting, and the communities where these adolescents reside.

OBJECTIVES: We sought to assess 6-month outcomes for HIV-infected people released from New York City jails with a transitional care plan. METHODS: Jail detainees in New York City living with HIV who accepted a transitional care plan during incarceration were asked to participate in a multi-site evaluation aimed at improving linkages to community-based care. The evaluation included a 6-month follow-up; HIV surveillance data were used to assess outcomes for those considered lost to follow-up. RESULTS: Participants (n=434) completed baseline surveys during incarceration in a jail in New York City. Of those seen at 6 months (n=243), a greater number were taking antiretroviral medications (92.6% vs 55.6%), had improved antiretroviral therapy adherence (93.2% vs 80.7%), and reported significant reductions in emergency department visits (0.20 vs 0.60 visits), unstable housing (4.15% vs 22.4%), and food insecurity (1.67% vs 20.7%) compared with baseline. CONCLUSIONS: Transitional care coordination services facilitate continuity of care and improved health outcomes for HIV-positive people released from jail.

Substance abuse represents one of the most common diagnoses in jail settings and features prominently in the path into criminal justice involvement. In addition, substance abuse plays a major role in mortality, morbidity, and recidivism after release from jail. In 2008, a substance abuse treatment program was begun within the New York City jail system, the nation's second largest. This program, A Road Not Taken (ARNT), works collaboratively with courts, security officials within the jail, and community programs to identify inmates who have substance abuse concerns and provide in-jail programming and coordination of treatment after jail. An evaluation of ARNT participants revealed that they experienced a lower rate in incarceration after their program participation than they did before participation.

OBJECTIVES: We evaluated Beyond the Bridge, a novel mental health program in the New York City jail system designed to provide residentially based cognitive behavioral therapy in jail mental observation units. METHODS: We used propensity score matching and a dose-response analysis. Outcome measures included reduction in violent incidents and fights, reduction in uses of force by corrections officers, reduction in time spent on suicide watch and incidents of self-injurious behavior, and increased length of community survival. RESULTS: There were significant reductions in all outcomes when we compared program participants (n = 218) with an earlier cohort of patients residing on the mental observation unit before programming began (n = 413). However, when we compared program participants with a cohort of other patients residing on the units at the same time but who chose not to participate (n = 267), only time spent on suicide watch unit (rate ratio [RR] = 0.72; 95% confidence interval [CI] = 0.59, 0.89) and recidivism (RR = 0.70; 95% CI = 0.59,0.83) were significantly reduced. CONCLUSIONS: This evaluation and the model we piloted may provide useful information for other settings contemplating similar interventions.

The electronic health record (EHR) is a commonplace innovation designed to promote efficiency, quality, and continuity of health services. In the New York City jail system, we implemented an EHR across 12 jails between 2008 and 2011. During the same time, our work increasingly focused on the importance of human rights as an essential element to the provision of medical and mental health care for our patients. Consequently, we made major modifications to the EHR to allow for better surveillance of vulnerable populations and enable reporting and analysis of patterns of abuse, neglect, and other patient concerns related to human rights. These modifications have improved our ability to find and care for patients injured in jail and those with mental health exacerbations. More work is needed, however, to optimize the potential of the EHR as a tool to promote human rights among patients in jail.