As the COVID-19 pandemic continues, telehealth is becoming increasingly ingrained within our healthcare system. This includes environments beyond the traditional office or hospital setting. With 2.3 million people currently residing in US jails or prisons, healthcare delivery to justice-involved individuals (JIIs) is an important component to consider. (Note: the term “justice-involved individual (JII)” refers to those held in both jails and prisons.)
To better understand healthcare delivery and the use of telehealth within correctional facilities, I met with both Saira Haque, PhD a telehealth expert and the Director of RTI’s Data Interoperability and Clinical Informatics program, and Nick Richardson, PhD a research analyst in RTI’s Applied Justice Research division.
Can you describe the healthcare needs of JIIs and how they differ between jails and prisons?
Dr. Richardson: Jails and prisons have the same goal; however, jails are for people who have not been sentenced or who have been sentenced to shorter stays (generally <1 year). JIIs in prison have been sentenced and typically have stays that exceed 1 year – up to life. Because of the length of stay expectations, state prisons generally have more resources than jails, such as educational opportunities, trade classes, and treatment programs.
Dr. Haque: The jail population tends to be more transient, and healthcare in jails will usually address short-term/acute needs to stabilize JIIs. In prisons, there are still immediate needs, but there are also long-term/chronic conditions that need to be managed.
What are the challenges both jails and prisons face when providing healthcare to JIIs?
Dr. Richardson: A big issue for prisons is the “graying” of JIIs. Since the mid-90s, the prison population aged 55 and older has increased by 600%. As in the general population, older JIIs tend to have more health issues. This is also worsened by the harsh prison environment, as individuals age faster in a prison setting. In addition, compared to the general population, the prison population has higher rates of HIV/AIDS, Hepatitis C, cirrhosis of the liver, and other conditions that may require lifelong treatment. About half of JIIs have some form of mental illness, about 20% have severe/persistent mental illness, and about 2/3 have an active substance use disorder. JIIs in jails have more acute problems (such as withdrawal) that require constant supervision and/or medical attention. Further, jails are often located in rural or poor areas with limited resources.
Dr. Haque: Many prisons are also in rural areas that tend to be remote. Maintaining a workforce, particularly of clinical providers, is difficult in these areas. Many providers were not trained in providing care in correctional facilities and may not be familiar with the nuances involved. Specialists may find it difficult to integrate providing care to JIIs with the rest of their practice. Thus, turnover tends to be high for clinical staff. That’s one reason telehealth is important: it can help with consistency by addressing geographical barriers and making it easier for JIIs to receive the care they need.
Dr. Richardson: Some jail/prison facilities have full-time clinical staff, but in rural counties without those resources, staff might not have the background necessary to deliver specialty services (such as conducting needs and risk assessments). Also, healthcare is costly. For JIIs, the facilities are the ones to bear the costs. The funding comes from state budgets and taxpayers. How can we provide quality healthcare without exceeding state budgets? JIIs have serious and chronic needs that are extensive.
Dr. Haque: JIIs have healthcare needs that are disproportionately severe. The social determinants of health that affect the general population, such as poverty, are common among JIIs. JIIs have higher rates of illnesses to start, and this is compounded by the fact the population is aging. There’s a shortage of behavioral health providers generally, and the shortage is worse in rural areas. A jail or prison in a rural area may be unable to find staff locally.
How has the COVID-19 pandemic affected the delivery of healthcare within jails and prisons?
Dr. Richardson: The pandemic has resulted in jails and prisons rethinking healthcare delivery. There are no CDC guidelines tailored to correctional facilities. JIIs are in close physical proximity to each other, and the facilities typically do not have good ventilation systems. In reality, security needs can often overrule healthcare needs. Virtual care is an opportunity for medical staff to easily and safely collaborate with jail/prison staff and leadership.
Dr. Haque: The criminal justice system serves a host of purposes, and healthcare is just one component. Telehealth can help provide JIIs the care they need without disrupting operations and helps reduce physical contact, both within and outside the facility.
Can you provide a brief overview of how telehealth is used in jails and prisons?
Dr. Haque: There are a few ways in which telehealth can be used:
- Provide services that JIIs might not typically have access to because of workforce shortages or difficulty with transfers
- Monitor chronic disease such as diabetes, heart disease, and behavioral health disorders
- Facilitate planning for release
JIIs frequently do not know where they will receive healthcare outside of the jail/prison facility and may have multiple needs to address prior to release. By some estimates, JIIs are 3-8x more likely to die of an overdose during the first two weeks after release compared to later. Telehealth could help establish a relationship between a JII and their new provider or connect a JII to community services.
Dr. Richardson: The risk of overdose immediately after release from incarceration is very real, as people who use drugs can lose tolerance while incarcerated and may lose access to treatment upon release. Using telehealth to support medication-assisted treatment (MAT) for opioid use disorder is extremely important and can help recently released individuals safely transition back into the community.
Part 2 is here.
I would like to thank Dr. Haque and Dr. Richardson for sharing their insights about healthcare delivery and the use of telehealth in jails and prisons. To learn more about recent changes to telehealth policies, check out Dr. Haque’s earlier Medical Care Blog post on updated telehealth guidance during the COVID-19 public health emergency.
Alexa Ortiz