David L. Rosen

To examine whether the socio‐medical needs and imprisonment risk among transitional care clients with serious mental illness (SMI) differ from other transitional care clients. A retrospective cohort study was conducted of adults who entered the Formerly Incarcerated Transition (FIT) Program from 2018 to 2023 following a period of incarceration. At program entry, FIT clients were screened for socio‐medical needs and diagnoses, including those reflecting SMI. Imprisonment outcomes were assessed using administrative records. Cumulative imprisonment risk and relative risk of imprisonment were estimated comparing clients by SMI status. Among 759 clients, 78.1% were men, 53.6% were aged 31–50 years, 59.8% reported Black race, and 32.9% had SMI. Clients with SMI were significantly more likely to be female, aged ≤40 years, White race, recently without food, to have healthcare coverage, to be unhoused, and to be in need of housing assistance, disability benefits, or legal assistance. Cumulative imprisonment risk at 360 and 720 days for clients with SMI (0.14 and 0.21) was higher than for those without (0.08 and 0.11), p < 0.001. In a multivariable proportional hazards model, SMI was associated with increased risk of imprisonment (1.75, 95% CI: 1.18, 2.60). Released persons with SMI have a particularly heavy burden of socio‐medical needs and high imprisonment rates in North Carolina (NC). Similar programs in other states should consider assessing outcomes among their clients with SMI. In NC, efforts are underway to facilitate greater care continuity upon re‐entry for people with SMI, including direct linkage to co‐located primary and psychiatric care.

Objectives: Injection drug use is a leading and growing risk factor for infective endocarditis (IE), as evidenced by a marked national increase in hospitalizations for drug use–associated infective endocarditis (DUA-IE). The typical treatment approach for persons with DUA-IE is a 6-week inpatient course of intravenous antimicrobials. This approach is resource-intensive, requiring substantial hospital resources and lengthy stays. Alternative methods of antibiotic delivery for DUA-IE treatment have been proposed and piloted, but their acceptance among people who inject drugs is unknown. Methods: Persons hospitalized with DUA-IE (N = 16) completed semi-structured interviews to identify facilitators and barriers to 3 proposed IE treatment options: (A) hospitalization for the entirety of antibiotic treatment, the current standard of care; (B) home-based outpatient parenteral antimicrobial therapy via indwelling catheter; or (C) weekly outpatient visits for long-acting antibiotic infusion. Interviews were transcribed and thematically coded to identify participant perspectives and preferences among these strategies. Results: Option A was ranked the most preferred treatment regimen (8 participants, 50%), followed by options C (5 participants, 31%) and B (3 participants, 19%). Participants felt option A provided the most effective treatment for their endocarditis, despite dissatisfaction with the hospitalization length. Options B and C appealed to participants given the convenience of outpatient care; however, inadequate transportation and housing instability were prominently cited as barriers. Conclusions: These diverse patient perspectives should inform trials to evaluate the effectiveness of alternative antibiotic delivery strategies, as well as interventions to improve patient-centered decision-making for DUA-IE treatment.

We aimed to compare rates and characteristics of suicide mortality in formerly incarcerated people with those of the general population in North Carolina. We conducted a retrospective cohort study of 266,400 people released from North Carolina state prisons between January 1, 2000, and March 1, 2020. Using direct and indirect standardization by age, sex, and calendar year, we calculated standardized suicide mortality rates and standardized mortality ratios comparing formerly incarcerated people with the North Carolina general population. We evaluated effect modification by race/ethnicity, sex, age, and firearm involvement. Formerly incarcerated people had approximately twice the overall suicide mortality of the general population for 3 years after release, with the highest rate of suicide mortality being observed in the 2-week period after release. In contrast to patterns in the general population, formerly incarcerated people had higher rates of non–firearm-involved suicide mortality than firearm-involved suicide mortality. Formerly incarcerated female, White and Hispanic/Latino, and emerging adult people had a greater elevation of suicide mortality than their general-population peers compared with other groups. These findings suggest a need for long-term support for formerly incarcerated people as they return to community living and a need to identify opportunities for interventions that reduce the harms of incarceration for especially vulnerable groups. This article is part of a Special Collection on Mental Health.

Background: Jails annually incarcerate millions of people with health problems, yet jail healthcare services have not been well described. Objective: To describe jail healthcare staffing. Design: Phone-administered survey conducted October 2020 to May 2021. Setting: County jails in North Carolina, South Carolina, Georgia, and Alabama. Participants: Jail personnel “most knowledgeable” about jail healthcare. Main Measures: Weekly on-site healthcare coverage rate (hours per 100 incarcerated person-weeks [IPWs]) by personnel type; telemedicine rates and detention officers’ healthcare duties. Key Results: Survey response rate was 73% (254/346). Among surveyed jails, 71% had on-site non-psychiatric providers (e.g., physicians, physician assistants) (median of 3.3 h per 100 IPWs); 90% had on-site nursing (median of 57.0 h per 100 IPWs) including 50% with on-site registered nurses (median of 25 h per 100 IPWs) and 70% with on-site licensed practical nurses (median of 52 h per 100 IPWs); 9% had on-site psychiatric providers (median of 1.6 h per 100 PWs). Telemedicine was used for primary care in 13% of jails (median 2.1 h per 100 IPW); for mental healthcare in 55% (median 2.1 h per 100 IPW); and for other specialties in 5% (median 1.0 h per 100 IPW). In 81% of jails, officers conducted medical intake and in 58% assessed urgency of medical requests (i.e., “sick call”). The number of officers’ healthcare responsibilities increased inversely with weekly nursing coverage. Conclusions: Nearly 30% of surveyed jails routinely lacked on-site healthcare providers and in most other jails providers’ on-site presence was modest. Jails relied heavily on LPNs and officers for care, resulting in missed opportunities for care and potentially endangering incarcerated persons.

Most incarcerations for people living with HIV (PLWH) occur in jails, yet studies of HIV care during jail incarceration are limited. As part of a larger study to explore the ethical considerations in extending public health HIV surveillance to jail settings, we conducted semi-structured interviews with twenty-three PLWH with more than 300 distinct jail incarcerations post HIV diagnosis in 21 unique North Carolina jails. Interviews included questions about HIV disclosure in jail, the type of HIV care received in jail, and overall experiences with HIV care in jail. We report on participants’ experiences and perspectives in four domains: access to HIV care in jail; impact of jail incarceration on continuity of HIV care; privacy and stigma; and satisfaction with HIV care in jail. Although most participants received HIV medications and saw providers while in jail, almost half reported that their greatest challenge in regard to HIV care was obtaining their HIV medications in the face of limited jail resources or policies that made access to medications difficult. Findings from this study suggest that jail leadership should review internal policies regarding HIV medications to ensure that PLWH can receive them quickly upon entry into jail. Findings also suggest that more external resources are needed, for example from state and local health departments, so that jails can provide timely HIV medications for PLWH incarcerated in their facilities.

Background: Incarceration can disrupt retention in HIV care and viral suppression, yet it can also present an opportunity to re-engage people living with HIV (PLWH) in care. Data-to-Care (D2C) is a promising new public health strategy that uses HIV surveillance data to improve continuity of care for PLWH. The goal of this study was to examine perspectives on and experiences with D2C among PLWH who had recently been incarcerated in jail. Setting: Community and prison settings in North Carolina. Materials and Methods: Semi-structured, qualitative interviews with 24 PLWH about (1) knowledge of and experiences with D2C and (2) attitudes about implementing D2C in the jail setting. Results: Participants who had been contacted for D2C described their interactions with state public health workers favorably, although almost half were not aware that the state performs HIV surveillance and D2C. While most participants indicated they would welcome assistance from the state for reengaging in care, they also framed retention in care as an individual responsibility. Most participants supported the idea of jail-based D2C. A vocal minority expressed adamant opposition, citing concerns about the violation of privacy and the threat of violence in the jail setting. Conclusion: Findings from this study suggest that D2C interventions in jails could be beneficial to reengaging PLWH in care, and acceptable to PLWH if done in a way that is sensitive to the needs and concerns of incarcerated individuals. If implemented, jail-based D2C programs must be designed with care to preserve privacy, confidentiality, and the autonomy of incarcerated individuals.

Law enforcement officers frequently encounter people with health conditions. We sought to estimate the rates, diagnoses, and characteristics of emergency department (ED) visits among patients transported directly by law enforcement. We analyzed statewide North Carolina Emergency Department data for adults, aged 18+ years, from 2009 to 2016. We estimated transport rates using census data; categorized primary ED diagnoses into 13 major and 8 substituent categories; compared county transport rates by rurality; and examined patient characteristics. There were 136,240 patients transported by law enforcement; annual rates increased from 186.9 (per 100,000 adult residents) in 2009 to 279.2 in 2016. Among visits, 67.7% were among men, the median age was 37 years, and 20.4% resulted in a hospital admission. Most common primary diagnoses were Mental Health Diagnoses (43.1%)—including Schizophrenia and other Psychotic Disorders (7.6%), Mood Disorders (9.7%), and Alcohol and Substance Use (10.7%)—followed by Injury and Poisoning (12.4%) and Circulatory conditions (4.1%). Involuntary commitments constituted 22% of all visits. The median transport rate in rural counties, 291.1, was 2 times that of large metro counties, 145.1. The visit rate increased by nearly 50% during the study period, with the highest rates in rural counties. Many transports were for Mental Illness and involuntary commitments. The relatively common occurrence of law enforcement transports suggests the need for greater research to understand factors influencing law enforcement transport decisions, the impact of these transports on patient health and safety, and the repercussions on patient care of a growing officer presence in EDs.