Disclosures

I have nothing to disclose. Care of the Patient with History of Incarceration

Shira Shavit, MD Executive Director, Transitions Clinic Network Associate Clinical Professor Dept. Family and Community Medicine University of ,

Caring for a Patient with a History Incarceration: Case Mr. Jones a 67 year old man with Objectives type 2 DM, HTN, hyperlipidemia, HCV, chronic low back pain, major • Review demographics of mass incarceration depression and a history of heroin addiction. • Describe health status of returning Released from 1 week ago • Review health impacts of incarceration after 23 years of incarceration. Staying in halfway house for another • Review approach to healthcare for recently 3 weeks. From Los Angeles, but lost contact with all family members released prisoners during incarceration. Was not released with any medications. Takes 7 different pills, but unsure of the names/dosages except for the morphine “30’s” he gets for his low back pain.

1 Case Case Did I mention… What is the likelihood of a primary care provider encountering a patient like Mr. Jones in their clinical practice? Mr. Jones arrived 45 minutes late to his appointment because he got lost A. Unlikely, since most prisoners like on the way to the clinic. Mr. Jones will never be released back to the community And…. B. Unlikely, since most returning He had to get off the bus once it got prisoners do not have health crowded, because he started having insurance and cannot access care. a panic attack. C. Unlikely, since most clinics have a 15 minute late policy And… D. Unlikely, (I hope) because thinking about seeing a patient You only have a 15 minute like this is stressing me out. appointment scheduled for him and 3 patients are waiting.

Jail vs. Prison Incarceration in the U.S.

• ~ 2.2 million people in and jails Jail Innocent until proven guilty Awaiting trial • More than one in every 100 adults is now incarcerated Short(er) terms • 1 in 37 adults have been incarcerated

Prison After trial and sentencing • 1 in 36 under some form of correctional supervision Parole violation

1: The Pew Charitable Trusts. “One in 100: Behind Bars in America 2008.” 2: Bureau of Justice Statistics: Prevalence of imprisonment in the U.S. Population 2014

2 CANADA

1852 (SQ) (FOL) Incarceration In The US 1880

1974-2001: number incarcerated for the first time tripled

Bureau of Justice Statistics. “Prevelance of Imprisonment in the U.S. Population, 1974-2001. ”

3 1852 San Quentin State Prison (SQ) Prisons in California 1852 San Quentin State Prison (SQ) Prisons in California 1880 Folsom State Prison (FOL) 1880 Folsom State Prison (FOL) 1933 California Correctional Institution -- Women (Closed) (CCI) 1933 California Correctional Institution -- Women (Closed) (CCI) World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men ’’’s Colony (CMC) 1955 - California Medical Facility (CMF)

1954 - California Correctional Institution – Men (CCI)

1852 San Quentin State Prison (SQ) Prisons in California 1852 San Quentin State Prison (SQ) Prisons in California 1880 Folsom State Prison (FOL) 1880 Folsom State Prison (FOL) 1933 California Correctional Institution -- Women (Closed) (CCI) 1933 California Correctional Institution -- Women (Closed) (CCI) World War II World War II 1941 - California institution for Men (CIM) 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men ’’’s Colony (CMC) 1954 East - California Men ’’’s Colony (CMC) Vietnam War 1955 - California Medical Facility (CMF) Vietnam War 1955 - California Medical Facility (CMF) 1954 - California Correctional Institution – Men (CCI) 1954 - California Correctional Institution – Men (CCI) 1961-1965 1961 West- California Men ’’’s Colony (CMC) 1961-1965 1961 West- California Men ’’’s Colony (CMC) 1962 – California Rehabilitation Center (CRC) 1962 – California Rehabilitation Center (CRC) 1963 - California Correctional Center (CCC) 1963 - California Correctional Center (CCC) 1965 – Sierra Conservation Center (SCC) Reagan and 1965 – Sierra Conservation Center (SCC) the War on 1984-1997 1984 – California State Prison Solano (SOL) Drugs 1986 – California State Prison, Sacramento (SAC) 1987 – (ASP) 1987 – (MCSP) 1987 – R.J. Donovan Correctional Facility at Rock Mountain (RJD) 1987 - Northern California Women ’’’s Facility (NCWF) 1988 – California State Prison, Corcoran (COR) 1988 - Chuckawalla (CVSP) 1989 – (PBSP) 1990 – Central California Women ’’’s Facility (CCWF) 1990 – Waco State Prison (WSP) 1992 – (CAL) 1993 – California State Prison, los Angeles County (LAC) 1993 – (NKSP) 1993 – Centinela State Prison (CEN) 1994 – (ISP) 1994 – Pleasant Valley State Prison (PVSP) 1995- Valley State Prison for Women (VSPW) 1992 – Calipatria State Prison (CAL) 1995 – High Desert State Prison (HDSP) 1996 – Salinas Valley State Prison (SVSP) 1997 – California Substance Abuse Treatment Facility (SATF)

4 1852 San Quentin State Prison (SQ) Prisons in California 1880 Folsom State Prison (FOL) Incarceration in the U.S. 1933 California Correctional Institution -- Women (Closed) (CCI) World War II 1941 - California institution for Men (CIM) 1941-1955 1946 - Correctional Training Facility (CTF) 1952 - California Institution for Women (CIW) 1953 - Deuel Vocational Institution (DVI) 1954 East - California Men ’’’s Colony (CMC) Lifetime chance of incarceration Vietnam War 1955 - California Medical Facility (CMF) 1954 - California Correctional Institution – Men (CCI) 1961-1965 1961 West- California Men ’’’s Colony (CMC) 1962 – California Rehabilitation Center (CRC) 1963 - California Correctional Center (CCC) Reagan and 1965 – Sierra Conservation Center (SCC) • Black males 1 in 3 the War on 1984-1997 1984 – California State Prison Solano (SOL) Drugs 1986 – California State Prison, Sacramento (SAC) 1987 – Avenal State Prison (ASP) • Latino males 1 in 6 1987 – Mule Creek State Prison (MCSP) 1987 – R.J. Donovan Correctional Facility at Rock Mountain (RJD) 1987 - Northern California Women ’’’s Facility (NCWF) 1988 – California State Prison, Corcoran (COR) • 1988 - Chuckawalla Valley State Prison (CVSP) White males 1 in 17 1989 – Pelican Bay State Prison (PBSP) 1990 – Central California Women ’’’s Facility (CCWF) 1990 – Waco State Prison (WSP) 1992 – Calipatria State Prison (CAL) 1993 – California State Prison, los Angeles County (LAC) 1993 – North kern State Prison (NKSP) 1993 – Centinela State Prison (CEN) 1994 – Ironwood State prison (ISP) 1994 – Pleasant Valley State Prison (PVSP) 1995- Valley State Prison for Women (VSPW) 1992 – Calipatria State Prison (CAL) 1995 – High Desert State Prison (HDSP) 1996 – Salinas Valley State Prison (SVSP) 1997 – California Substance Abuse Treatment Bush Facility (SATF) Bureau of Justice Statistics: Prevalence of imprisonment in the U.S. Population 2003. 2001 - 2005 2005 – Delano State Prison (DEL) Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

Prison Industry: US Expenditures Case Mr. Jones was incarcerated in state prison. Which of the following statement about the prevalence of behavioral health conditions in people 1987: $10.6 billion with a history of incarceration is true? A. More than 80% of state prisoners meet the criteria of 2007: $44 billion having either a mental or substance use issue. States in the U.S. are B. 82% of jail inmates meet the criteria for having either a spending more and mental or substance use issue more on inmates who C. 72% of federal inmates meet the are less and less a criteria for having either a mental or substance use issue. threat to public safety D. All of the above.

Pew Center Public Safety Performance Project 2007

5 Patient demographic is changing. Prison environments can exacerbate poor health.

Healthcare is constitutionally guaranteed in prison. Access is limited by institutional policies. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

6 Self management of chronic conditions is difficult. Almost everyone goes home. Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

Case Case What is the most likely cause of death for Mr. Jones in the first 2 weeks post- Mr. Jones a 67 year old man with release? type 2 DM, HTN, hyperlipidemia, HCV, chronic low back pain, major depression and a history of heroin addiction. A. Exposure to the elements if he becomes homeless. • Recently released from prison B. Complications of his diabetes • Marginally housed and at risk for C. Drug overdose homelessness D. Violence related to his past • No social support crime • No medications • Low health literacy • Currently experiencing PTSD sx

7 Health-related Reentry Challenges

• No discharge planning and short supply of medications

• No health insurance/lapse in Medicaid and Medicare B

• Additional barriers to meeting basic needs (social determinants of health)

Image Courtesy of Ray Chavez and CA Prison Health Care Receivership

Collateral Consequences of Incarceration Health Risks Following Release  Employment: Unable to apply for certain jobs, conviction barriers to employment

 Public Assistance: Prohibited from collecting food stamps, WIC, Pell Chronic medical grants, federal student aid conditions, HIV and 1 Incarceration substance use  Housing: Prohibited from section 8 housing, restrictions on

distance from schools/parks 2 Hospitalization

 Voter disenfranchisement: 1 of 13 African Americans (7.7 %) is 3 disenfranchised, compared to 1.8 percent of non-African Death Americansⁱ.

http://www.abacollateralconsequences.org/map/ Community

i. Subramanian et al, Relief in Sight? States Rethink the Collateral Consequences of Criminal 1 S Springer, et. al. CID 2004, MJ Milloy, et.al. JID 2011. 2 EA Wang, et. al. JAMA Internal Medicine, July 2013. 3 IA Binwanger, NEJM 2007; D Rosen, Conviction, 2009-2014. Vera Institute of Justice, DECEMBER 2014 AJPH 2008.

8 Barriers to Care Engagement Correctional System Release from Prison—A High Risk of Death for Former Prisoners  12 times increased risk of death in first 2 weeks after release  The leading causes of death: Barriers 1. Drug overdose 2. Cardiovascular disease 3. Homicide Community & 4. Suicide Individual Healthcare system 5. Cancer

I. Binswanger, et al NEJM 2007; 356:157-65

Discrimination Shifting the Paradigm

• Already experienced discrimination in the healthcare setting based on socioeconomic status, racial and ethnic backgrounds, and lower 1-4 levels of education

• Resulting in psychological distress and reduced healthcare 5 engagment

• Less likely to have routine physical within the past year, delays in Image Courtesy of Ray Chavez and CA Prison Health Care Receivership care, poor adherence to recommended care, and decreased use of 6-10 preventive services

• 42% of recently prisoners experienced discrimination based on CJ 11 history

1.Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health 2003;93(2):200-8. 2.Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol 2006;35(4):888-901. 3.Shavers VL, Fagan P, Jones D, Klein WM, Boyington J, Moten C, et al. The state of research on racial/ethnic discrimination in the receipt of health care. Am J Public 3.Health 2012;102(5):953-66. 4.Grollman EA. Multiple forms of perceived discrimination and health among adolescents and young adults. J Health Soc Behav 2012;53(2):199-214 5. Turney K, Lee H, Comfort M. Discrimination and Psychological Distress Among Recently Released Male Prisoners. Am J Mens Health 2013. 6. Van Houtven CH, Voils CI, Oddone EZ, Weinfurt KP, Friedman JY, Schulman KA, et al. Perceived discrimination and reported delay of pharmacy prescriptions and medical tests. J Gen Intern Med 2005;20(7):578-83. 7. Casagrande SS, Gary TL, LaVeist TA, Gaskin DJ, Cooper LA. Perceived discrimination and adherence to medical care in a racially integrated community. J Gen Intern Med 2007;22(3):389- 36 8. Hausmann LR, Jeong K, Bost JE, Ibrahim SA. Perceived discrimination in health care and use of preventive health services. J Gen Intern Med 2008;23(10):1679-84. 9. Benjamins MR. Race/Ethnic Discrimination and Preventive Service Utilization in a Sample of Whites, Blacks, Mexicans, and Puerto Ricans. Med Care 2012. 10. Blanchard J, Lurie N. R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care. J Fam Pract 2004;53(9):721-30. 11. Frank, J, Discrimination based on criminal record and healthcare utilization among men recently released from prison: a descriptive study. Health Justice. 2014 Mar 25;2:6

9 Patient Centered Care for Returning Prisoners

 Culturally competent primary care teams.

 Patient centered services; i.e. access to primary care within 2 weeks of release (starting in prison), behavioral health integration, re-entry support.

 Partnerships with existing community organizations that serve formerly incarcerated individuals to address social determinants of health.

 Multidisciplinary team including certified community health worker (CHW) with past history of incarceration to assist with patient engagement, navigation, care management, and chronic disease self-management support. Transitions Clinic Network

What can a provider do during a Incarceration History clinic visit? • Duration of incarceration • Past Medical History • Location • Mental health History • Number of times incarcerated Diagnoses, symptoms, medications, hospitalizations • Date released • Social history • Solitary confinement Social determinants of health: housing, food • High risk behaviors (tattoos, sexual activity, security, family support/reunification, education, IVDU) substance use, relapse prevention, harm • Trauma reduction, health literacy • Incarceration History • Community supervision Crime--- To ask or not ask?

10 Summary Contact Information

• Prison populations in US have increased dramatically leading to mass incarceration. Transitions Clinic Network

• Prisoners have higher burdens of mental illness, Shira Shavit, MD infectious diseases, substance use disorders and other chronic diseases Executive Director [email protected] • Risks of release include mortality, hospitalization, discontinuity of medical care, including medications www.transitionsclinic.org • Community providers can play an important role Follow Us on twitter: @_Transitions

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