Faculty Bibliography

Jails represent a critical component of the public health response to HCV elimination. We report on outcomes of 104 patients receiving HCV treatment from January 1, 2014 to June 30, 2016 in a large urban jail setting. Our data demonstrate that treatment in jails is feasible, but many barriers remain.

A cohort of frequently incarcerated individuals in the New York City jail system was identified through "hot spotting" analysis. This group demonstrated higher levels of substance use, mental illness, and homelessness than the general jail population, and was typically incarcerated on minor criminal charges. To understand this population better, in-depth interviews (n = 20) were conducted at three Rikers Island correctional facilities with people who had entered the jail system at least 18 times in a six-year period. Findings showed that life circumstances, chronic homelessness, mental illness, and substance use resulted in repeated institutionalization across multiple settings. Participants described an "institutional circuit" that promoted a state of permanent instability characterized by rotating involvement with custodial institutions. Exiting the institutional circuit requires the ability to navigate complex bureaucratic systems; however, without structural reorganization in social service delivery and an emphasis on permanent housing, participants in this group are unlikely to break the cycle.

The United States incarcerates more people than any other country in the world. The scale of mass incarceration ensures that almost all practicing physicians will treat formerly incarcerated patients. Yet the majority of physicians receive little training on this topic. In this paper, we will outline the need for expanded education on the interface between incarceration and health, describe initiatives taking place within the New York City jail system and nationally, and describe future directions for curriculum development. We conclude by highlighting the important role health care workers can play in transforming our criminal justice system and ending mass incarceration.

Background. High volumes of hepatitis C (HCV)-infected detainees pass through US jails. However, short lengths of stay and competing priorities upon release complicate linkage to HCV care. We investigated linkage rates for patients with HCV following release from New York City (NYC) jails and describe a care coordination program (CCP) we initiated in June 2015 to improve linkage rates. Methods. We conducted a pre- and post-intervention study to assess rates of linkage related to the CCP. We used NYC Department of Health surveillance data to assess pre-intervention linkage rates for patients with chronic HCV seen in a correctional health clinic at Bellevue Hospital Center from January 2014 to June 2015. Linkage was defined as an HCV viral load or genotype <90 days in the community after release from an index incarceration. The CCP consists of a needs assessment, HCV education, and appointment scheduling for detainees, followed by reminder calls and appointment escort by a community patient navigator after re-entry. Statistical significance was determined using x2 tests. Results. Of 52 patients in the pre-intervention group, 24 (46.2%) were released from their index jail stay. Of those released, 10 of 24 (42%) were reincarcerated within a median of 247 days (IQR 129-318). The remaining 28 individuals were not released from their index incarceration and transferred to state prison. Of the 26 enrolled in the CCP as of April 2016, 13 (50%) have been released (6 linked, 4 pending linkage, and 3 not linked), 9 (34.6%) have not yet been released, and 4 (15.4%) have been transferred to state prison. Criteria for linkage to care within <90 days in the pre-intervention and intervention groups, respectively, were met by 3 of 24 (12.5%) versus 5 of 9 thus far (55.6%) (p = 0.01) and overall by 11 of 24 (45.8%) versus 6 of 9 thus far (66.7%) (p = 0.29). Conclusion. Pre-intervention linkage rates were low among HCV-infected detainees. While this study is ongoing, linkage in <90 days was significantly higher in the intervention group though not overall. These data provide early evidence that an integrated community-based CCP with jail-based transitional care coordinators may be effective in improving timely linkage to HCV care following release from jail

PURPOSE: Correctional settings create unique challenges for patients with special needs, including transgender patients, who have an increased rate of overall discrimination, sexual abuse, healthcare disparities, and improper housing. As part of our correctional health quality improvement process, we sought to review and evaluate the adequacy of care for transgender patients in the New York City jail system. METHODS: Using correctional pharmacy records, transgender patients receiving hormonal treatment were identified. A brief in-person survey was conducted to evaluate their care in the community before incarceration, medical care in jail, and experience in the jail environment. RESULTS: Survey findings and analysis of transgender patient healthcare-related complaints revealed opportunities for improvements in the provision of care and staff understanding of this population. Utilizing these findings, we conducted lesbian, gay, bisexual, and transgender (LGBT) trainings in all 12 jail clinics for medical, nursing, and mental health staff. Three months after LGBT training, patient complaints dropped by over 50%. After the development and implementation of a newly revised transgender healthcare policy, complaints dropped to zero within 6 months. CONCLUSION: Our efforts to assess the quality of care provided to transgender patients revealed significant areas for improvement. Although we have made important gains in providing quality care through the implementation of policies and procedures rooted in community standards and the express wishes of our patients, we continue to engage this patient population to identify other issues that impact their health and well-being in the jail environment.

This article reviewed a program evaluation conducted among correctional health care staff in New York City (NYC) using a 68-question electronic survey to assess satisfaction, attitudes, and beliefs in relation to ethics and burnout of health care employees in NYC jails. Descriptive statistics were tabulated and reviewed, and further assessment of burnout and ethics was performed through group sessions with participants. This evaluation has led to changes in agency policies and procedures and an emphasis on the human rights issue of the dual loyalty challenges that the security setting places on the overall mission to care for patients.

OBJECTIVES: To examine uptake of screening for all individuals born between 1945 and 1965 (referred to by the Centers for Disease Control and Prevention as the "birth cohort") and outline preliminary HCV prevalence data in the New York City jail system. METHODS: Data were extracted from electronic health records for all individuals screened for HCV between June 13, 2013, and June 13, 2014, in New York City jails. We used the Abbott EIA 2.0 HCV antibody assay for testing. RESULTS: In the year of study, 56 590 individuals were incarcerated; 15.1% were born between 1945 and 1965, and 84.6% were born after 1965. HCV screening was completed for 64.1% of the birth cohort and for 11.1% born after 1965, with 55.1% and 43.8% of cases found in these groups, respectively. The overall seropositivity rate was 20.6%. CONCLUSIONS: Birth cohort screening in a large jail system identified many HCV cases, but HCV infection was common among younger age groups. Public Health Implications. Universal screening may be warranted pending further study including cost-effectiveness analyses. (Am J Public Health. Published online ahead of print May 19, 2016: e1-e2. doi:10.2105/AJPH.2016.303163).

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.