MetroDoctors Summer 2021: Criminal Justice and Health

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Summer 2021

Doctors Metro Met etrroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Criminal Justice and Health

In This Issue: • Caring for Minnesota’s Incarcerated Community • Update on TCMS Reorganization Plans • Celebrating Progress on Menthol Tobacco While Looking Forward


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CONTENTS VOLUME 23, NO. 2 SUMMER 2021

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Insights on Being Inside

By Robert R. Neal, Jr., MD

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PRESIDENT’S MESSAGE

Our Promise to You

By Sarah Traxler, MD

5 Page 6

IN THIS ISSUE

TCMS IN ACTION

By Annie Krapek, MPH, Interim CEO

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CRIMINAL JUSTICE & HEALTH

• Colleague Interview:

A Conversation with Tyler Winkelman, MD, MSc

10 • Caring for Patients on the Inside: Healthcare Delivery at the Hennepin County Jail By Rachel Sandler Silva, MD, MPH 12

• Medications for Opioid Use Disorder in the Washington County Jail

By Sean Young-Stephens

14 • Doulas and the Criminal Legal System By Raelene Baker and Erica Gerrity Page 5

16 • Parental Incarceration and Child Development: Considerations for Physicians By Rebecca Shlafer, PhD, MPH and Marvin So, MPH, MS4

20 • A Call to Expand the Patient Bill of Rights: Health Justice for Incarcerated Minnesotans By Hannah Lichtsinn, MD and Calla Brown, MD, MHR Page 5

22 • From Cell to Street: What Works? By Mark Groves, M.S.Ed, LADC

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18 • “Now What?” A Primer on Correctional Education in Minnesota and its Connection to Public Health By Jim Verhoye, PhD

Doctors Metro Met etrroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Criminal Justice and Health

24 • Community Supervision and Health By Marin G. Olson, BA 27

• Environmental Health—

Justice Beyond the Exam Room By Zeke McKinney, MD, MHI, MPH and Mike Menzel, MD Career Opportunities

28 Page 14

MetroDoctors

Incarceration Health in Medical Education: Medical Student Perspective By Noah Sanders, MS4 and Kristin Chu, MS3

The Journal of the Twin Cities Medical Society

In This Issue: • Caring for Minnesota’s Incarcerated Community • Update on TCMS Reorganization Plans • Celebrating Progress on Menthol Tobacco While Looking Forward

The intersection of justice and health is often complicated by extenuating factors of underlying disease, chronic conditions, injustice, equity, and social issues experienced by incarcerated persons. Articles begin on page 6.

Summer 2021

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Richard R. Sturgeon, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Amber Kerrigan MetroDoctors (ISSN 1526-4262) is published quarterly by the Twin Cities Medical Society, Broadway Place East, Minnesota Medical Joint Services Organization, 3433 Broadway Street NE, Suite 187, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 2355 Fairview Ave, #139, Roseville, MN 55113. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

Summer Index to Advertisers TCMS Officers

President: Sarah Traxler, MD President-Elect: Zeke McKinney, MD, MHI, MPH Secretary: Cora Walsh, MD Treasurer: Alex Feng, MD Past President: Ryan Greiner, MD At-large: Matthew A. Hunt, MD

Children’s MN.................. Outside Back Cover COPIC.................................................................... 8 Crutchfield Dermatology...................................... Inside Front Cover

TCMS Executive Staff

Annie Krapek, MPH, Interim CEO (612) 362-3715; akrapek@metrodoctors.com

Lakeview Clinic..................................................27

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

MedCraft..............................................................21 Mounds Park Academy...................................... 9

Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com

Philando Castile Community Peace Garden..................25 Physicians Wellness Collaborative.................26 St. David’s Center..............................................13 Superior Wealth Management Group........... 2

Kate Feuling Porter, MPH, Program Manager (612) 362-3724; kfeuling@metrodoctors.com

U.S. Army...............................Inside Back Cover

You. We only have one thing on our mind. GJ Lempe – Steve Powers – John Soukup (952) 885-5605 Securities Offered Through LPL Financial, member FINRA / SIPC

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MetroDoctors

The Journal of the Twin Cities Medical Society


IN THIS ISSUE...

Insights on Being Inside

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his is a very timely issue of MetroDoctors as our country is coming to grips with the serious deficiencies and inequities of our criminal justice system. Community correctional supervision (incarceration plus those on probation or parole) rose to 6.8 million Americans in 2014 (1 in 36 adults). This escalation began in the early 80s when it became a political tool (War on Drugs) with the “get tough on crime” laws. We are fortunate to have Tyler Winkelman, MD as our Colleague Interview. He provided many of the sources for the articles and other valued suggestions. You can read more about the gravity of the American incarceration problem, including the physical, mental, and situational problems of incarceration and recovery in the articles submitted. Rachel Silva, MD, Medical Director of the Hennepin County Jail, outlines the complex problems of providing healthcare delivery to over 56,000 incarcerated persons yearly. It’s a great challenge to manage chronic disease, substance abuse, mental health, and communicable disease in a population with varying lengths of stay. We are all familiar with the opioid crisis in our country. Sean Young-Stevens discusses the management of this problem in the Washington County Jail where they have begun to actively treat opioid addiction with medication to stabilize inmates for eventual release. The program requires coordination with community programs upon release and more physicians who provide Buprenorphine treatment are needed. The Biden Administration recently issued new practice guidelines that eliminates the need for credentialed practitioners to hold a separate registration to prescribe medications for OUD treatment. http://bit.ly/OUDtreatment. The first of two articles involving incarcerated females is by Raelene Baker and Erica Gerrity on the Minnesota Prison Doula Project. Four-to-six percent of incarcerated Minnesota women are pregnant at any given time. This Doula program has been quite successful in maintaining quality birth outcomes for both mother and child. The expansion outside of the Minnesota Correctional Facility-Shakopee is encouraging. The second article is by Dr. Rebecca Shlafer and Marvin So, MPH, MS4 and deals with parenteral incarceration. It amazes me that 1 in 14 US children have had an incarcerated parent. The many problems this produces are discussed in addition to the ways that physicians can help to address the needs of these children and families.

By Robert R. Neal, Jr., MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

What is being done to educate and rehabilitate those in prison is a question often asked. Jim Verhoye, PhD provides an excellent overview of the problem including its causes and the debate on how to manage the two million incarcerated people in the U.S. He also provides excellent references for those seeking more in-depth information. Unfortunately, there are serious problems with the health care provided in some Minnesota prisons and jails. Incarcerated people are not protected under the MN Health Care Bill of Rights. The Minnesota Dept. of Corrections has direct supervision over state prisons, however, not the county jails; therefore, there is no mechanism for oversight and accountability. Hannah Lichtsinn, MD and Calla Brown, MD describe how the system functions without this proper oversight. Mark Groves M.S.Ed.’s article provides valuable insight into the path a previously incarcerated person takes as he or she transitions to a productive life. The importance of mentoring and transitional programs, safe and affordable housing, a supportive community, and employment are cited. A resource list for post-incarceration mentoring opportunities is provided. The article on community supervision and health is by Marin Olson, a 2021 graduate of the U of M Medical School. Those under community supervision (probation or parole) are twice the incarcerated population in Minnesota. Ms. Olson discusses the system’s three main problems: racial, health, and social inequities. The Environmental Health Task Force article underscores the importance of “health justice,” which encompasses physical, mental, social, and environmental health. The medical student page submission is by Noah Sanders, MS4 and Kristin Chu, MS3 both TCMS Public Health Advocacy Fellows. They emphasize the value of including incarceration health topics in the medical school curriculum and the importance of respecting the personal autonomy of correctional patients we encounter in practice. We still have a lot to do in this country to improve criminal justice. It comes down to: 1) slowing down the number of people entering jails and prisons; 2) better sentencing guidelines and early release for many non-violent crimes; and 3) finding ways to lower the recidivism rate. I hope you will gain some valuable insights from these excellent articles that will help you to become a better medical provider and social advocate. Summer 2021

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President’s Message

Our Promise to You SARAH TRAXLER, MD

As most of you have now heard, the TCMS Board of Directors recently decided to branch out on our own as an independent organization. This decision was not taken lightly since separating from the MMA, a strong and historic organization serving physician interests across the state, meant giving up some influence and support. In deciding to become a separate organization, however, the TCMS gains the independence to continue, unencumbered, doing what we do best — advocate for public health initiatives that our membership is passionate about and are pertinent to the issues currently impacting our communities. Over the last year, we’ve seen our communities differentially impacted by the pandemic and we’ve watched the rollout of inequitable distribution of COVID vaccines. And while we are pleased to see Derek Chauvin held accountable by a guilty verdict, we understand that we are far from justice and that systemic racism continues to be one of the most egregious public health issues plaguing our communities. The TCMS Board of Directors and staff would like to acknowledge our repugnance at recent statements made by medical professionals who claim that racism does not exist in medicine. Comments such as African Americans have higher death rates from COVID-19 due to a nasal passage gene and that no physician is racist, are abhorrent. We know that race-based medicine is still taught and that racist beliefs and implicit bias impact everything we do as physicians — from the rapport we build to the medicines we prescribe. We know that some fields of medicine were built on racist practices (i.e. my own specialty of gynecology) and we know that ignoring this history only serves its continuance and deepens the hurt that Black and Brown bodies have suffered at the hands of science. To that end, the TCMS vows to make a commitment. As TCMS moves into its new era, the Executive Committee and TCMS staff wish to acknowledge that, over the centuries, people of color have suffered from racist policies, practices, and procedures in health care. There is no doubt in our minds that both those who practice the profession and those who have been recipients of care have suffered from systematic, structural, and pervasive racism. Going forward, we promise to address racism by practicing anti-racism in the following ways: 1. We will scrutinize all our organizational documents, those currently existing and those to be developed, for racist texts or assumptions, regardless of time period or original intention, so that we can remove or modify them. 2. We will monitor our publications before dissemination for any instances of racism in the text so that it, too, can be modified or removed. 3. We will monitor our speech for overtones of racism so that, if it occurs, it can be called out and addressed. 4. We will hold each other accountable to this commitment. These are our promises to you. If, at any time, you believe that we are not keeping them, please contact the TCMS interim CEO or a member of the executive committee so that we can address your concerns. As we move into our next phase, we look forward to engaging with our membership. We hope that you will join us as we envision a future that centers justice and represents the interests of physicians in the Twin Cities. References: • https://www.forbes.com/sites/brucelee/2021/03/07/jama-posts-podcast-on-structural-racism-here-is-the-backlash/?sh=42b877fe6a56. • https://www.statnews.com/2021/04/06/podcast-puts-jama-under-fire-for-mishandling-of-race/. • https://www.medscape.com/viewarticle/948993. • https://www.kqed.org/science/1973591/jama-and-other-medical-journals-under-fire-after-disastrous-podcast-on-racism-in-medicine. • https://science.thewire.in/health/editor-of-popular-medical-journal-draws-flak-for-denying-structural-racism/. • https://www.webmd.com/a-to-z-guides/news/20210310/fallout-from-jama-podcast-continues.

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The Journal of the Twin Cities Medical Society


TCMS IN ACTION ANNIE KRAPEK, MPH, INTERIM CEO

A New Future for TCMS As you have likely heard, in April Twin Cities Medical Society announced an exciting new organizational strategy. Over the coming months, TCMS will restructure our organization in ways that will strengthen our commitment to engaging physicians and medical students in community-driven public health initiatives and allow more flexibility than a traditional membership association model. Part of this strategy requires that TCMS must exit from our formal partnership with the Minnesota Medical Association. This is not a reflection of our current or past relationship. We are deeply grateful for the contributions of the MMA to our work over the past 11 years, and we are looking forward to collaborating with them in new ways. New mission and vision statements will be crafted and shared with you in the coming months, as well as additional details about our future membership structure. We are deeply grateful for the support and ideas you have shared with us so far and hope you will continue to help us build a healthy future for our organization and our community. Menthol Tobacco Twin Cities Medical Society was thrilled that last month the FDA announced a long-awaited first step toward banning menthol-flavored cigarettes and all flavored cigars nationwide (http://bit.ly/ FDAmenthol). The Tobacco Industry has aggressively targeted African Americans, the LGBTQ+ community, and youth with menthol tobacco advertisements, making

Advocates in Minneapolis celebrate the passage of a menthol-restricting ordinance in 2017.

MetroDoctors

menthol a key driver of tobacco-related health inequities. While this is an excellent first step, the work isn’t done yet. These changes will take time to implement at a Federal level and Minnesota can act now to save lives sooner. TCMS will continue to support local and statewide work to address menthol tobacco and ensure that local policies around menthol tobacco uphold our commitment to racial equity. Public Health Advocacy Fellowship In May, TCMS wrapped up the 3rd year of our Public Health Advocacy Fellowship. While this year’s program was hosted virtually due to COVID-19, it was rich with community and learning. When asked what they will take with them from their experience in the program, the medical student fellows shared: • “Cultivating relationships is an essential component of sustainable advocacy.” • “Be bold, be vulnerable.” • “Every step taken has an impact, not only the final result.” • “While we’re ending our year together, this is only the start to a lifetime journey of advocacy work.” See more takeaways at: http://bit.ly/ 2020TCMSFellows. We are deeply grateful for the physician mentors who make this program possible by generously sharing their time and expertise, and are honored to create space for medical students to discover and grow their advocacy skills. We cannot wait to introduce you to the 2021 cohort in the coming weeks! Shadow a Physician Speaking of mentors — for several years TCMS has offered a Shadow a Physician program for UMN medical students. This half-day experience offers students early in their education (primarily first or second year) exposure to various specialties of medicine and surgery before they begin their clinical rotations. A quote from a recent shadowing experience: “I had a

The Journal of the Twin Cities Medical Society

great experience observing dermatology with Dr. Hurliman. She taught me about a variety of conditions, shared educational resources, and guided me in examining different skin abnormalities. I left the experience with a deeper understanding of dermatology and appreciation for Dr. Hurliman’s mentorship.” We are currently looking for physician volunteers in most all specialties to host a student for this shadowing opportunity. Although the program is billed as just a half-day, if student and mentor agree, additional time can be accommodated. Interested? Please contact Nancy Bauer for more information at nbauer@metrodoctors.com. N O M IN A T IO N S F O R

CHARL ES B OLLES B OL L ES- ROGERS AWARD Candidates for this “Physician of Excellence” award are nominated by their peers for achievement or leadership in medicine, contributions to clinical care, teaching and/or research. Recipient is selected by the TCMS Foundation Board of Directors. NOMINATIONS ARE DUE BY JULY 31, 2021. Nominate a colleague at metrodoctors.com/awards

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Criminal Justice & Health

Colleague Interview: A Conversation with Tyler Winkelman, MD, MSc

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yler Winkelman, MD, MSc is an internist, pediatrician, and health services researcher at Hennepin Healthcare in Minneapolis, MN, an Assistant Professor in the Departments of Internal Medicine and Pediatrics at the University of Minnesota, and a staff physician at the Hennepin County jail. He is the co-director of the Health, Homelessness, and Criminal Justice Lab at Hennepin Healthcare Research Institute. Dr. Winkelman completed his medical school and internal medicine/pediatrics residency training at the University of Minnesota Medical School. He obtained a master’s degree in health and healthcare research at the University of Michigan through the Robert Wood Johnson Foundation Clinical Scholars Program. Dr. Winkelman studies issues at the intersection of criminal justice and health, with particular interest in Medicaid, substance use disorders, and healthcare utilization. He works closely with Hennepin County on cross-sector data projects that integrate criminal justice, health care, housing, and social service data to inform county policy and programs. These projects inform public policy across multiple departments and serve as a model for evidence-based policy across the state and country.

What is the scale and scope of the criminal justice system in the United States? On any given day, approximately two million people are in jail or prison in the United States. Because of the high turnover in jails, where people are either pre-trial or serving sentences of less than one year, there are approximately 10 million people who spend time in jail every year. In addition, there are approximately four million people on any given day who are on supervision in the community — typically probation or parole. The criminal justice system in the United States has grown exponentially in the last several decades and this growth is uniquely American. There is no other country in the world with a criminal justice system that has grown as quickly or as large. In Minnesota, we have among the lowest incarceration rates but one of the highest rates of community supervision in the United States.

What racial disparities exist in the criminal justice system? Black, Indigenous, and people of color are disproportionately impacted by the criminal justice system. Black individuals are six 6

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times more likely to be incarcerated than white individuals. These disparities are so large that one in three Black men will spend time in prison during their lifetime. Racial disparities in Minnesota are among the largest in the United States. For example, Native Americans represent just over 1% of Minnesotans but account for 22% of women in prison. Black Minnesotans represent 6.8% of Minnesotans but represent up to 46% of men in some prisons across Minnesota. These disparities not only impact the individual, but also have negative consequences for their children, their families, and their communities.

How and by whom are people in jails and prisons screened for healthcare needs? Screening and assessment protocols vary substantially from jail to jail and prison system to prison system. In general, individuals entering jail or prison should be screened for acute and chronic conditions, including physical health, mental health, and substance use conditions. Medications prescribed in the community should be continued and systems should be set up to triage particular health concerns to the appropriate provider. MetroDoctors

The Journal of the Twin Cities Medical Society


What percentage of people in jails and prisons have mental health issues?

What are some of the barriers to health after release from jail or prison?

Mental health issues are very common among people in jails and prisons, with up to 80% of individuals reporting some history of a mental illness. Serious mental illnesses, like schizophrenia, are up to 10 times more common among people in jails and prison compared with the general population.

People are at high risk of death and medical complications in the weeks following release from jail or prison. Mortality rates after release are up to 10 times higher compared to the general population. This is primarily due to risk of overdose death, but also because of complications of cardiovascular disease and other physical health conditions. Therefore, coordinated care upon release is critical to ensure continuity of care, particularly for people with opioid use disorder. However, there are a number of barriers to continuity of care after release: 1) medical records can be difficult to transfer to a primary care provider; 2) access in the community can be limited, particularly for opioid use disorder treatment; 3) medication is not always provided at release; 4) the timing of discharges can be unpredictable; and 5) Medicaid does not cover care coordination for people in jails and prisons. These are a few important barriers, though many others exist.

How are PTSD and TBI screened for and managed in jails and prisons? Post-traumatic stress disorder and traumatic brain injuries are extremely common conditions. Mental health providers at jails and prisons often prescribe medications for symptoms related to PTSD. Access to counseling approaches, like cognitive behavioral therapy, is typically very limited, though more common in prisons than in jails. Treatment for traumatic brain injuries in jails and prisons is often very limited.

What legal obligations do jails and prisons have to provide health care? Jails and prisons are one of few places in the United States where health care is constitutionally mandated. Jails and prisons must provide “services at a level reasonably commensurate with modern medical science and of a quality acceptable within prudent professional standards.”

Who dispenses meds? Including controlled substances? At the Hennepin County Jail, where I have clinic, medications are dispensed by a team of nurses who staff the jail 24 hours per day. There is a doctor on call 24 hours a day who can help triage urgent issues when there is not a doctor onsite.

How is health care in jails and prisons paid for? Federal law prohibits the use of federal healthcare programs like Medicaid and Medicare to pay for health care in jails and prisons. This means county governments are responsible for financing all health care in jails and state governments are responsible for paying for all health care in prisons. Medicaid is a critical tool for financing health care for up to 80% of people with recent incarceration. Despite the importance of Medicaid, it is either suspended or terminated when someone is incarcerated. This means that an individual’s health insurance may be turned off when they are incarcerated and would need to be re-enrolled upon release, a process that can create delays in care. Further, because Medicaid cannot be used in jails and prisons, healthcare budgets may be threatened during economic downtowns if counties and/ or states take in less revenue. MetroDoctors

The Journal of the Twin Cities Medical Society

Discuss the availability of health care after release from jail or prison. Once an individual is released from jail or prison, they are able to re-enroll in Medicaid or other public health insurance programs. However, there is typically limited assistance in re-enrolling in these health insurance programs upon release. Many individuals who access the healthcare system are stigmatized because of their criminal justice involvement. Individuals recently released may have difficulty finding primary care appointments within a timeframe needed to refill meds or address chronic health conditions. Thus, rates of emergency department and hospital use are high for people with recent criminal justice involvement. Many people with substance use disorders who are released from jail enter a treatment facility. Often care is continued while in treatment, but the transition out of the treatment center can also be complicated by poor coordination and there is a high risk of death after treatment completion. At Hennepin Healthcare we are developing a Transitions Clinic that is staffed by a multi-disciplinary team to meet the diverse health needs of people leaving jail. A primary goal of the Transitions Clinic is to help people with opioid use disorder stay engaged with treatment after release.

How has the Affordable Care Act affected health insurance for people involved in the criminal justice system? Our research team has shown that the Affordable Care Act dramatically improved health insurance for people involved in the criminal justice system who are not currently incarcerated. In addition, the ACA increased access to medications for opioid use

(Continued on page 8)

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Criminal Justice & Health Colleague Interview (Continued from page 7)

disorder for people involved in the criminal justice system who were admitted to treatment centers. However, other work our team has done has shown that the ACA did not have a substantial impact on access to mental health care for people with criminal justice involvement and other work has shown a relatively modest impact, overall, on access to substance use treatment. Overall, our research suggests that Medicaid expansion through the ACA is an important tool for expanding access to needed medical care for people with criminal justice involvement, but is not sufficient to reduce the large disparities that persist between people with and without criminal justice involvement.

Why do we often hear about substance use in the setting of criminal justice involvement? Most people in jails or prisons have a substance use disorder related to opioids, methamphetamine, cocaine, or alcohol. The overlap between substance use disorders and incarceration is high for several reasons, including the so called “war on drugs.” Because

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the approach to substance use disorders in the United States has often relied on the criminalization of substance use, rather than treatment, people with substance use disorders are at high risk of incarceration. My research team has shown that over half of people with an opioid use disorder and more than 70% of people who use heroin will spend time in the criminal justice system. This means that if we want to address the opioid crisis, we have to ensure policies in jails and prisons increase access to needed treatment. In addition to opioid use, there are a number of other types of substance use that are increasing. Methamphetamine use is increasingly common and is associated with increasing levels of mortality across the United States. Often methamphetamine use occurs alongside opioid use, which should not preclude individuals from treatment of their opioid use disorder. While there are well established and effective medications available for the treatment of opioid use disorder, there is less information available for the treatment of methamphetamine use disorder. However, recently released data have shown promising results for medications that may help people reduce their methamphetamine use.

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Criminal Justice & Health

Caring for Patients on the Inside: Healthcare Delivery at the Hennepin County Jail

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idden among the condos, businesses, and skyways in downtown Minneapolis sits the largest jail in Minnesota. Comprised of two buildings (the Public Safety Facility and City Hall), up to 36,000 people are booked per year at the Hennepin County Jail with a decrease since the COVID-19 pandemic began. The individuals detained in the jail are disproportionately Black, Indigenous, and people of color and have complex medical needs including substance use disorders, severe and persistent mental illness, and multiple chronic conditions. From the time the patient enters the jail to being released from custody, the Jail Health Services team provides a variety of medical services. When discussing health care in jails, understanding the funding structure is a key piece of why there is significant variability in the care provided in one jail compared to the next. Most of the patients who are detained and incarcerated in jails qualify for Medicaid while in the community. In 1965, when the incarceration system looked very different than it does today, the federal government addended the Social Security act and added the Medicaid Inmate Exclusion policy, which bans anyone detained in a carceral facility from receiving matched federal Medicaid funds to pay for health care. Because of the policy, the burden of the cost of health care for patients in jails lies disproportionately on counties. By Rachel Sandler Silva, MD, MPH

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While in larger counties in the metro, the budgets may be more robust, this has an even larger impact in greater Minnesota where healthcare resources are more scarce. Each jail administrator then determines the most economical way to provide health care which includes not only local public health and integrated health system, like Hennepin Healthcare, in the case of Hennepin County, but also includes private contractors that specialize in low-cost care delivery and risk management. Now that we have paid for the health care, we can better understand our care from start to finish. Upon intake to the jail, nursing staff assess each patient booked into the jail. This assessment includes medical history and review of chronic conditions, suicide risk assessment, review of substance use, assessment for acute injuries and medication reconciliation. Based upon this review, appropriate protocols are initiated for withdrawal for alcohol, benzodiazepines, and/or opioids and current

medications are resumed. If patients have acute medical needs beyond the scope of nursing practice, referrals are placed for the patients to see providers for medical, psychiatric, and addiction services. Nurses also see patients around day 14 of admission to offer tuberculosis and STI screening and immunizations. As a physician at the jail, the care I have the privilege to provide is a mix of acuity, complexity, and detective work all in one. On the medical side, we see many acute injuries related to gun violence, acute physical trauma, and police violence. Other common reasons for acute visits include skin and soft tissue infections such as abscesses related to IV drug use, acute alcohol, opioid, and benzodiazepine withdrawal, hyperglycemia, and hypertensive urgency/emergency. The visits for chronic conditions vary as well including infectious diseases like HIV and Hepatitis C to hypertension and diabetes. Mental health is a huge topic of importance in any jail. Many of the patients in the jail have severe and persistent mental illness like schizophrenia, bipolar disorder, and major depressive disorder. We also see many patients with substance-induced psychosis and substance-induced mood disorders. Currently, our therapies largely center around medication management, but many jails also have psychotherapy as well. Forensic psychiatry is a complicated field, and our jail health services psychiatry team collaborates with the courts to provide treatment and appropriate

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transfers to state mental health institutions. The court system has its own separate psychiatrist and psychologists who do evaluations to determine whether a patient is competent to stand trial. Beyond mental health more broadly, suicide within jails is of particular concern. Jails are generally not facilities that foster a culture of wellness and given the stress and high stakes issues that patients face, suicides happen within jails, including Hennepin County. Suicide risk assessments occur at various points during the jail stay and if a patient is determined to have suicidal ideation, they are placed on suicide watch which includes a change in uniform, change in diet, and moving to an area of the jail with more frequent checks by security staff. One challenge to suicide prevention at the jail is that many common practices for addressing suicide in jails can be difficult for the patient, like having to wear a Kevlar gown without undergarments. There is a delicate balance between suicide watch and alternative settings within the jail to help provide adequate supervision and support for the patient. At the Hennepin County Jail, we use EPIC as our electronic medical record, which allows us to see records beyond the current jail encounter. However, even with this resource, we still find that records can be incomplete. Reasons for incomplete medical records in the jail population include the use of aliases when seeking medical attention due to concern about being arrested in the healthcare setting because of outstanding warrants and the health records used in other carceral settings are not always electronic and may not be connected to the community-based health record. MetroDoctors

This difficulty with obtaining accurate records creates challenges for many pieces of healthcare continuity of care including ordering indicated follow-up testing and medication continuation. Medications pose another significant challenge. Every jail is a bit different in terms of whether they have a limited formulary or how medications are packaged and administered to patients. At Hennepin County Jail, we utilize the inpatient formulary of Hennepin County Medical

Jails are generally not facilities that foster a culture of wellness and given the stress and high stakes issues that patients face, suicides happen within jails, including Hennepin County. Center. Because of this we can offer a wide variety of medications. If a drug is non-formulary, we review the indication, cost, and estimated length of stay and decide whether an appropriate alternative exists. Medications are administered three times per day in the jail on both a scheduled and as needed basis. Discharge planning from a high turnover detention center with an average length of stay of nine days and median length of stay of 28 days, like the Hennepin County Jail, is complex. Unlike a hospital discharge, the jail health services team does not make this

The Journal of the Twin Cities Medical Society

determination, rather this is done by the courts. Because of this, patients can leave at all hours making comprehensive discharge planning complicated. Discharge is an area we are focusing on more as we are aiming to provide more medications for patients to continue upon release including medications for opioid use disorder, mental illness, and chronic conditions. We are also working to partner with community organizations to help patients re-enroll in Medicaid prior to release so they can use their benefits after release to continue to meet their health needs. Caring for patients at the Hennepin County Jail is an opportunity to work at the nexus of social justice, injustice, and equity for patients who often fall through the cracks of traditional healthcare delivery models. Sweeping criminal justice reforms and improved social policies have the potential to transform whether health care is even needed in jails. But as we wait for transformational change, continuing to provide high quality care is important to meet the needs of many marginalized patient populations. Rachel Sandler Silva, MD, MPH is the Medical Director at the Hennepin County Adult Detention Center, Staff Physician at Hennepin Healthcare, and Assistant Professor of Medicine at the University of Minnesota. She has an interest in medical education for health sciences trainees in community health settings, including criminal justice spaces, and has been a leader in quality improvement for jail healthcare delivery. She was a medical advisor to the National Sheriff ’s Association regarding COVID-19 response within jails nationwide. She can be reached at: rachel.silva@ hcmed.org. Summer 2021

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Criminal Justice & Health

Medications for Opioid Use Disorder in the Washington County Jail

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t the beginning of 2021, the Medications for Opioid Use Disorder (MOUD) Program was initiated at the Washington County Jail. MOUD, also known as Medication Assisted Treatment or MAT, involves the use of FDA-approved medications like buprenorphine and methadone as an effective, evidence-based method to treat Opioid Use Disorder. Benefits of MOUD in the Jail Setting

There is an extremely high-risk period for overdose and fatal overdose immediately after a person is released from a correctional setting like a jail or prison. Too often, this is how the story goes: A person who uses opioids like heroin, fentanyl, or oxycodone is incarcerated. During their time in custody, they lose their tolerance for opioids. They also are not provided with adequate support and a plan to address their opioid use. At release, they are thrust into a challenging transition with little stability and many essential needs to address (like food and housing). Understandably, they may return to opioid use. Their decreased tolerance means they are dramatically more likely to overdose and many times more likely to die from overdose, particularly in the first two weeks after being released. Providing MOUD in jails and prisons can change this story. These medications can give a person stability and a long-term plan to address their Opioid Use Disorder. Correctional MOUD programs like the one recently implemented in the Washington County Jail have been shown to save By Sean Young-Stephens

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lives by reducing the risk of fatal overdose post-release. But reduction of fatal overdoses only scratches the surface of the benefits MOUD can offer in the jail setting. For many people, these medications can be a key component in their successful longterm recovery. Providing MOUD during the critical time when a person is in jail can offer them a path to recovery and set them up with the best chance of success even long after they are released. Equity and a Societal Shift

Providing MOUD in correctional settings like jails and prisons is part of a broader shift toward providing more support for people with Substance Use Disorders. We are recognizing that Opioid Use Disorder and other Substance Use Disorders are health conditions that are in many ways similar to other chronic medical diseases. Substance Use Disorder is caused by a combination of genetic and environmental factors, and some people are more at-risk due to circumstances outside of their control. Substance Use Disorder is treatable and addressing it with shame, stigma, and criminalization is counterproductive. This societal shift toward compassion and support is a positive change, but we also need to recognize the negative context. The intersection of substance use and criminal justice is fraught with disparities, including a history of deliberately racist policies. Anti-drug laws in the United States have intentionally targeted certain racial groups, including Chinese immigrants and the Black community. Our current opioid crisis, which has more significantly affected white people in our

community, is being addressed with more compassion and evidence-based treatment compared to other examples of substance use crises that had different racial trends. We need to be careful and intentional to ensure that the current support for people with Opioid Use Disorder extends to all people with Substance Use Disorders, now and in the future. We also know that racial minorities are overrepresented in our incarcerated populations. This in itself is a problem, but it gives us an opportunity to provide targeted support to an underserved, stigmatized group of people who have often been victims of systemic inequities. Our new MOUD Program in the Washington County Jail is a major step in the right direction. We need to continue to retool our criminal justice system to become a support for people with Substance Use Disorders — instead of a barrier. Our MOUD Program in the Washington County Jail

So how does the MOUD Program in the Washington County Jail actually work?

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The Journal of the Twin Cities Medical Society


The workflow starts with a universal screening and assessment process for all individuals who enter the jail. The jail medical team assesses whether medications are a good fit for each individual and, if applicable, administers medications during their time in custody. Buprenorphine is the primary medication provided in our jail program. We also support those who are engaged in methadone treatment when they enter our jail, but we are somewhat limited because of the barriers presented by the federal regulatory system for methadone. There are many unique security and logistical aspects to providing MOUD in the jail setting. This means that a correctional MOUD program is only possible through strong multidisciplinary support and collaboration. In Washington County, our program came to fruition with support from the following key partners: • Washington County Public Health & Environment • Washington County Sheriff ’s Office

• Washington County Community Services • Washington County Community Corrections • Washington County Attorney’s Office • Hazelden Betty Ford Foundation • HealthPartners Stillwater Medical Group Building a Network of Community Partners

In addition to the services provided within the Washington County Jail, there is one final aspect that is essential to the success of our MOUD Program: a coordinated connection to community providers upon release. It is important to note that incarcerated populations do not align with jurisdictional boundaries. In Washington County, about two-thirds of people in our jail are out-of-county residents. Other jails across the Twin Cities are starting MOUD programs and some are already in place, including in Hennepin and Ramsey Counties.

As we seek to create a recovery-oriented system of care, we need your help to build our network of support across the Twin Cities. We need a network of buprenorphine waivered community providers who are interested in supporting people in our incarcerated populations. If you are an eligible practitioner, please consider obtaining your X-waiver to allow you to prescribe buprenorphine in your setting. (See recent changes to the Providers Clinical Support System at https:// pcssnow.org/ for more information.) Sean Young-Stephens is a Program Coordinator with Washington County Public Health & Environment. He has a background in emergency management and criminal justice. In his current role, Sean is coordinating the implementation of the new Medications for Opioid Use Disorder Program in the Washington County Jail and supporting the ongoing COVID-19 response. Sean is a graduate of North Dakota State University. He can be reached at sean.young-stephens@ co.washington.mn.us.

HELPING CHILDREN1/2 Page H TAKE THE NEXT LEAP FOR OVER 60 YEARS To refer a child for early intervention including mental health and pediatric therapies: (952) 548-8700 or stdavidscenter.org

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Criminal Justice & Health

Doulas and the Criminal Legal System

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t’s 3 am when her phone rings; the prison is calling to give notice that her incarcerated client is in labor and has been admitted to the hospital. She collects her things, heads out the door and makes the drive to a suburban hospital just south of the Twin Cities where her client awaits her. All the while thinking about what the day will bring, she knows she’ll need to help her client stay focused in the moment of birthing her baby and initial bonding, not what is to come two days from now. Walking into the hospital room, after showing two forms of identification, she sees her client with two correctional officers at her bedside, an unnatural sight she will never get used to. Since the facility does not allow hugs at all, this is the first thing she does when she enters the room. Today is the only time that physical touch is allowed between doula and client. The doula knows her job today is important; it’s more than providing physical, emotional, and informational support to someone giving birth. Today is about preserving the positive memories, mom and baby meeting and spending time getting to know each other before they will be separated when the baby is just two days old. Women in Prison

Incarcerated women are the fastest growing population in the U.S. criminal justice system, increasing by more than 800% in the past 30 years. Today, more than 230,000 women and girls are incarcerated in the U.S. Due to structural racism, a disproportionate number are women of color; 90% come from poverty; 85% report a history of trauma; and most are of childbearing By Raelene Baker and Erica Gerrity

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Raelene Baker

Erica Gerrity

age. In 2020, over 24,000 women and girls came under correctional control in Minnesota, of these 4-6% were pregnant. Incarcerated women are more likely to suffer from substance abuse, mental illness, chronic health conditions, infectious disease, and maternal stress, all of which decrease their chances of carrying a healthy baby to term. In many states, those who give birth behind bars are separated from their babies soon after birth, a practice with profound and long-lasting negative consequences for both parent and child. The trauma of incarceration and parent-child separation can cause developmental stagnation, behavioral development delays, and lasting neurological vulnerability in children, leaving them more susceptible to abuse. Imprisoned parents and their children see poorer lifetime health, developmental, and social outcomes — all due to a carceral system ill-equipped to support childbearing, birth, and strong parental relationships. As the number of women and children affected by these inadequacies grows, their impact extends

beyond prisons and jails into communities, contributing to higher rates of depression, child abuse and neglect, trauma, and familial dysfunction. In Minnesota a vast majority, 77%, of pregnant women are in prison because of a technical violation of a probation or supervised release and will only return to prison for a short period of time. The median sentence for pregnant women is just 4.5 months. Prison Doulas

In the early 2000s incarcerated women in Minnesota expressed their needs surrounding pregnancy, birth, postpartum, and parenting to the founders of the Minnesota Prison Doula Project (MnPDP) through a series of talking circles at the prison. Together ideas were formulated and after a period of development were implemented at Minnesota’s only state prison for women, Minnesota Correctional Facility-Shakopee, in 2010. The unique needs of women and birthing people are almost always left out of the conversation of criminal justice reform. MnPDP works

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to ensure these voices are heard and become part of the solution. The Minnesota Prison Doula Project aims to nurture healthy parent-child relationships, increase parenting confidence and skills, reduce the intergenerational trauma of incarceration, and increase access to opportunities that build health, healing, and change. Their mission is to work in compassionate solidarity with incarcerated parents to create community, opportunity, and change. What started out as a small doula program has grown to offer many different components for justice involved parents including comprehensive doula care, prenatal and parenting education groups, 1:1 parent counseling, supported parent/child visitation, lactation services, and reentry support. These services have expanded to other correctional facilities across Minnesota and even into the state of Alabama. In 2018 the founders of MnPDP launched a national non-profit organization called Ostara Initiative. This became home to the program and to others including one in Alabama called the Alabama Prison Birth Project. Ostara’s mission is to collectively transform systems by reimagining justice, advancing health, and reclaiming dignity in policies and practices for all pregnant and parenting people with the goal of ending prison birth in America.

cover pregnancy, birth, and up to one year postpartum for any justice involved parent who requests it. Please visit https://www.ostarainitiative.org/read – watch.html to learn more about strategies to reduce systematic harm, improve quality of care, and outcomes.

that incarcerated pregnant and postpartum people are able to access a doula for support if they choose. How to Connect and Partner with Prison Doulas

Incarcerated patients anywhere in Minnesota can be referred to the Minnesota Prison Doula Project through their website https://www.mnprisondoulaproject.org/ make-a-referral. If you have a client who is incarcerated, make space to provide them with opportunities to ask questions and express fears. Understand that the greatest separation of their life is looming and offer additional supports available at your medical facility. Please also offer to refer them to the Minnesota Prison Doula Project for free doula care and support. Doula services

Editor’s Note: On May 14, 2021, Governor Tim Walz signed the Minnesota Department of Corrections (DOC) Healthy Start Act into law, providing new resources to support the health and well-being of incarcerated mothers and their newborn babies. http:// bit.ly/HealthyStartAct Raelene Baker, Program Director of Minnesota Prison Doula Project.rbaker@mnprisondoulaproject.org. Rae is the director of MnPDP. She also facilitates childbirth education and attends births of those incarcerated at Minnesota’s only state prison for women. Erica Gerrity, Executive Director of Ostara Initiaitve. egerrity@ostarainitiative.org. Erica is the founder of MnPDP. She is a psychotherapist specializing in families affected by incarceration.

Notable Outcomes

The average gestational age of infants born with the support of the program is 39 weeks and 2 days; just 3% of births result in a primary cesarean and 97% of newborns are born at a healthy weight. In 2018, 92% of incarcerated women in Minnesota received the support of doula initiated breastfeeding during their hospital stay. In 2014, MnPDP worked to help pass legislation making it illegal to shackle those who are pregnant and postpartum, the bill passed unanimously and was signed into law. This law also includes a provision MetroDoctors

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Criminal Justice & Health

Parental Incarceration and Child Development: Considerations for Physicians

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pproximately five million, and beyond that of other related or one in 14, U.S. children experiences. have experienced the incarA growing body of research has ceration of a parent,1 a prevalence documented associations between comparable to childhood conditions parental incarceration and adverse such as ADHD (one in 15) and outcomes across the lifespan. Across asthma (one in 14) that are comthe literature, associations between monly encountered by physicians. parental incarceration and children’s Increasing attention to the social outcomes often depend on a number determinants of health and adverse of factors including which parent childhood experiences (ACEs) prois incarcerated, and the child’s age, vides the healthcare sector an opgender, and their relationships with Rebecca Shlafer, PhD, MPH Marvin So, MPH, MS4 portunity to better support families their parents and other caregivers. affected by the criminal legal system.2 In this In their recent review of longitudinal popstopped by police, arrested, and incarcerated article, we describe the characteristics and ulation-based studies, Poehlmann-Tynan than white people. As a result, children of needs of children with incarcerated parents, and Turney (2021) conclude that, even afcolor are disproportionately impacted by and offer considerations for physicians. ter accounting for key sociodemographic their parent’s incarceration. Indeed, African factors, parental incarceration is negatively American children are 7.5 times more likely Who is Affected by associated with outcomes across the lifeand Hispanic children 2.5 times more likely Parental Incarceration? course, including increased risk for behavior to have an incarcerated parent than white Most adults in jails and prisons are parents 3 problems, poorer mental health, and worse children. with minor children. Although a majoriacademic outcomes.6 For example, in early ty of incarcerated parents are fathers, the What are the Developmental and middle childhood, parental incarcerrate of maternal incarceration has outpaced Consequences of Parental ation is associated with increased risk for paternal incarceration in recent decades.3 Incarceration? internalizing and externalizing problems, Because mothers are more likely than fathers The medical and public health literature on more emotional difficulties, lower levels of to have served as the primary caregiver prior parental incarceration is relatively nascent school engagement, and more problems at to incarceration, maternal incarceration may and is limited by certain methodological school. In adolescence, youth with a history be particularly destabilizing to the family issues, such as the presence of multiple risk of parental incarceration have higher rates unit and child wellbeing. A parent’s incarfactors that often coexist particularly within of internalizing and externalizing behavceration is not a single, isolated event; it socioeconomically disadvantaged families. iors, and a higher likelihood of problems is often preceded and succeeded by many Factors such as poverty, housing instabiliin school. In adulthood, there is evidence other experiences that may be traumatic for ty, parental substance use, parental mental that parental incarceration is associated with children (e.g., parent arrest, court hearings) illness, and aspects of the criminal legal sysdecreased odds of completing high school and compromise child wellbeing. tem (e.g., witnessing the parent’s criminal and increased odds of felony convictions. Incarceration is not evenly distributed behavior, arrest, and/or court proceedings), Parental incarceration likely engenders in our communities and there are structurall collectively shape children’s development these effects through multiple pathways. Paal inequities at every level of the criminal and may be difficult to disentangle within rental absence from the household — along legal system. People from racial and ethresearch studies.1,4 Nonetheless, it is clear with surrounding circumstances such as nic minority groups are more likely to be that the incarceration of a parent within witnessing arrest — can constitute a traujail (typically for shorter periods of time) matic experience that alters children’s stress By Rebecca Shlafer, PhD, MPH and or prison (typically for sentences of a year response systems (e.g., hypothalamus-piMarvin So, MPH, MS4 or more)5 creates a window of risk above tuitary-adrenal axis).7 Loss of wages and 16

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challenges with employment and housing post-release can strain family economic resources and subsequent uptake of health-promoting services and supports. Such stressors can also affect the parenting and mental well-being of parents — which in turn influence their capacity to build the stable, responsive parent-child relationships that underlie healthy cognitive and behavioral development. What can Physicians do to Help? There are a number of things that physicians can do to address the needs of children and families affected by incarceration (Table). First, physicians can integrate screening for ACEs into routine pediatric care, such as well child visits.8,9 In the context of an established, trusting patient-provider relationship, physicians can use nonjudgmental language to ask about household composition and changes at each visit. In addition, physicians should encourage regular appointments and closely monitor developmental milestones, academics, and social functioning. Using a two-generation approach — one that simultaneously provides support for parents/caregivers and addresses children’s needs — is likely to promote family wellbeing. Physicians should identify and foster protective factors, including practices known to support development such as reading or singing together or open parent-child communication. In addition, promoting healthy relationships between children and non-parental adults (e.g., coaches, mentors), involvement in athletic or after school activities, and religious or civic groups can also be protective.10 Finally, physicians can support children and families by offering referrals for supports and services families may benefit from, including financial support, housing and childcare assistance, family therapy, and legal advocacy. When afforded resources and supports, children are capable of developing appropriately — and even thriving —  despite the risks posed by the incarceration of a primary caregiver. Ultimately, mass incarceration has impacted the lives of many families seen by the healthcare system, especially communities of color. Physicians and other healthcare providers are well-positioned to identify affected children and link them to supports that

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sustain healthy developmental trajectories. For additional information on parental incarceration and child development, see the following resources: • Heard-Garris N, Shlafer RJ. Developmental and behavioral implications for children of incarcerated parents. UpToDate. Updated November 9, 2020. • Martoma R. Tips to Support Children When a Parent is in Prison. American Academy of Pediatrics Healthy Children website. Updated July 1, 2020. • Coping with Incarceration. Sesame Street in Communities website.

Rebecca Shlafer, PhD, MPH is an Assistant Professor in the Department of Pediatrics at the University of Minnesota Medical School. Her research focuses on the health of children and families affected by incarceration. email: shlaf002@umn.edu, phone: (612) 625-9907. Marvin So, MPH, MS4, is a medical student at the University of Minnesota and Public Health Advocacy Fellow through the Twin Cities Medical Society. He is impassioned to foster healthy development for families impacted by mass incarceration. References available upon request.

Table. Possible developmental consequences of parental incarceration with associated clinical considerations

Domain

Possible experience*

Clinical considerations

Socioeconomic

 household income  employment post-release  housing stability

Referral for public benefits or financial supports; sliding scale payment option for services

Custodial status

Child cared for by non-incarcerated parent, grandparent, other relative, or foster care system

Attention to caregiver coping, social support, and medical/mental health status

Behavior

 externalizing symptoms (e.g., disruptive behaviors)  internalizing symptoms (e.g., depression)

Monitoring child emotional or behavioral symptoms using formal (e.g., Pediatric Symptom Checklist) and informal approaches

Cognitive/ academic

 school readiness  high school completion  grade retention  special education placement

Assessment of functioning, progress, and behavior in academic settings with referrals where indicated

Delinquency

 truancy and school discipline  justice system involvement

Assessment of behavioral issues at home or school (e.g., discipline) with referrals where indicated

Physical health

 activation of stress response  high cholesterol  asthma  migraines

Monitoring and promotion of child physical health (e.g., diet, sleep, exercise) despite stressful circumstances

Behavioral health

 depression and anxiety  suicidality  substance use  risky sexual behaviors

Monitoring child emotional or behavioral symptoms using formal (e.g., Pediatric Symptom Checklist) and informal approaches

Short-term

Long-term

* Possible experiences are based on available evidence on children with incarcerated parents and may not capture the history of all affected families. Certain characteristics, such as which parent is incarcerated and the timing or duration of parental absence, influence the degree to which children are affected. Individual circumstances and needs must always be considered.

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Criminal Justice & Health

“Now What?” A Primer on Correctional Education in Minnesota and its Connection to Public Health

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pring, 1998: “Good morning,” I said to the class. It’s a standard greeting from teachers to students. The difference this time was that I was at MN Correctional Facility – Oak Park Heights instead of on campus at Inver Hills Community College, where I’d been teaching Public Speaking and Interpersonal Communication since 1994. Over the next 20 years I would have the privilege of teaching a number of classes in five Minnesota state prisons, and a fundamental question was always present for me: “Now what?” That is to say, “Now that they’re in prison, what should people do with their time while they are incarcerated to benefit themselves and the larger community?” One of the answers I kept coming back to was, “Go to school.” When a person arrives in a Minnesota prison they go through a full array of assessments, including verifying their education history. Incarcerated persons without a high school diploma or equivalent are required by the Department of Corrections to attend Adult Basic Education classes. Those with a diploma or equivalent have other opportunities, such as career and technical education or higher education. Over the years the available options have evolved, but the basic premise remains the same: education programming is an essential part of Minnesota’s correctional system.1 This belief is not new and it’s not unique to Minnesota. In his 1931 book, The Education of Adult Prisoners: A Survey and a Program, Assistant Director of

By Jim Verhoye, PhD

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1994).6 Something is happening, but what is actually going on, and why? Two primary streams have converged in the national debate surrounding these issues — money and morality. The Economics:

the U.S. Bureau of Prisons Austin MacCormick, wrote that the public needs to accept the fact that “modern educational standards apply to the prison as well as to the free community.”2 MacCormick’s argument stemmed from his belief that the incarcerated population deserved to be educated prior to their release back into society, allowing them to return as more responsible, involved, and productive citizens. Ninety years later “criminal justice reform” and “correctional education” have gained national attention as a result of several factors — the 2010 publication of Michelle Alexander’s The New Jim Crow: Mass Incarceration in the Age of Colorblindness;3 the 2015 establishment of the Experimental Sites Initiative, a “second chance pilot project” reinstating Pell Grants in select jails and prisons;4 the 2018 federal First Step Act, a bipartisan effort to improve criminal justice outcomes;5 and, the total restoration of Pell Grant eligibility for the incarcerated in 2020 (Pell Grant access was eliminated for incarcerated students in

The exponential growth in the incarceration rate and its associated costs over the last 40 years has produced a public health crisis — mass incarceration.7 Minnesota has been no exception to this reality, with four times as many people incarcerated in 2020 compared to 1980.8 Only the COVID-19 pandemic has been able to shrink the prison population over the last 12 months, and it remains to be seen what will happen when courts begin to get back to pre-COVID activity.9 The fiscal reality of having more than two million adults incarcerated on any given day in the United States is sobering, and many community leaders have been seeking ways of reducing costs and redirecting that money into communities that have been systematically under-resourced for decades. Currently there are myriad reform efforts underway at the local, state, and national levels designed to: (1) slow down the number of people entering jails and prisons; (2) release those currently incarcerated sooner than originally planned; and, (3) find evidence-based solutions to lowering the rates of recidivism.10 That’s where correctional education comes into the economic argument. Shortly after a study conducted by the RAND Corporation was published in 2013, legislators and other policy makers began referencing its findings in a variety of contexts.11 The central conclusion from

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the research was that educating the incarcerated saves money over time. While there are nuances to the particulars of effective correctional education programming, the economic momentum was there to find ways to provide more educational opportunities to the incarcerated, such as reinstate Pell Grants and expand access to higher education. All of these efforts should reap savings in the long term, providing opportunities to shift spending in ways that will impact the social determinants of health and lead to healthier, safer communities. Do the Right Thing:

The connection between punishment and resources goes back millennia. A fundamental question is: “What do you deserve when you’ve ‘broken the social contract’?” Most people would accept that the government has a responsibility to provide food, shelter, and basic medical care. Beyond that, it is up to federal, state, and local policy makers to decide what incarcerated populations should have access to. A major factor in the moral debate is the proliferation of racism throughout our society, and the criminal justice system is no exception. In fact, a strong case can be made that the worst examples of systemic racism and inequality can be found within our jails and prisons — mass incarceration is the inevitable outcome of white supremacy and the dehumanization and devaluing of the BIPOC population. In Minnesota, for example, American Indian women make up 1.1% of the population, but 21% of the adult women incarcerated in the state’s prison in Shakopee.12 Thus, moral arguments also involve addressing these disparities and the factors that have contributed to them in Minnesota and throughout the nation. Providing correctional education to the incarcerated population is one way to try to mitigate factors that perpetuate a racist system. MetroDoctors

Conclusion:

What do you deserve if you go to prison, and, how should you spend your time? As Austin MacCormick noted 90 years ago, education can play a vital role in promoting human flourishing for the incarcerated. In Minnesota, those in our state prisons have access to educational opportunities that can improve their quality of life, reduce future victimization, lower costs, enhance public health and safety, and help restore the vitality of all our communities.13 Jim Verhoye, PhD grew up in San Diego, CA, five minutes from the ocean, and enjoyed a childhood of bodysurfing and beach bonfires. He came to the Twin Cities area after completing a BA and MA in Communication Studies at San Diego State University. He completed a PhD in Communication Studies at the University of Minnesota and has been teaching as an adjunct college instructor for the last 31 years. In 1998 he taught his first college class in a prison, which was his introduction to the field of Correctional Education. Jim worked in five Minnesota state prisons as a teacher and administrator for over 20 years and served as the president of the Minnesota chapter of the Correctional Education Association for two years during that time. He currently works for Avivo, a nonprofit in the Twin Cities, as the Director of the Avivo Institute of Career and Technical Education. Contact information: jim. verhoye@gmail.com; Twitter: @jimverhoye. (Endnotes) 1. For the most recent list of education classes and programs within the Minnesota Department of Corrections, see: https://mn.gov/doc/ assets/Education%20and%20Programming_ tcm1089-364582.pdf. 2. MacCormick, Austin. The Education of Adult Prisoners: A Survey and a Program, New York, National Society of Penal Information, 1931, p. 261. 3. Alexander, Michelle. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: [Jackson, Tenn.]: New Press; Distributed by Perseus Distribution, 2010. 4. https://www.ed.gov/news/press-releases/ us-department-education-launches-sec-

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5.

6.

7.

8.

9.

10.

11.

12.

13.

ond-chance-pell-pilot-program-incarcerated-individuals. https://www.bop.gov/inmates/fsa/overview. jsp#:~:text=On%20December%2021%2C%20 2018%2C%20President,mechanisms%20 to%20maintain%20public%20safety. https://www.vera.org/newsroom/congressvotes-to-lift-ban-on-pell-grants-for-people-inprison. With its many direct and indirect effects on the health of individuals, families, and communities, incarceration is a major social determinant of health and as such, mass incarceration is one of the major public health challenges facing the United States. See: https://www.ncbi.nlm. nih.gov/books/NBK555719/. https://www.prisonpolicy.org/profiles/MN.html; and, https://mn.gov/doc/assets/Adult%20 Prison%20Population%20Summary%201-12020_tcm1089-418232.pdf. The current prison population in Minnesota has gone down by 20% since the beginning of the COVID-19 pandemic; https://mn.gov/doc/ assets/Adult%20Prison%20Population%20 Summary%201-1-2021_tcm1089-467125. pdf; however, the intersection of mass incarceration and the COVID-19 pandemic has been profoundly tragic in Minnesota and throughout the United States. For Minnesota information, see: https://mn.gov/doc/about/ covid-19-updates/. For national information, see: https://www.prisonpolicy.org/reports/ covidspread.html. For a thorough review, see: https://www. prisonpolicy.org/factsheets/pie2020_allimages. pdf. A primary finding from this study was: Inmates who participate in correctional education programs had 43 percent lower odds of recidivating than those who did not. This translates to a reduction in the risk of recidivating of 13 percentage points. https://www.rand.org/ pubs/research_reports/RR266.html. https://coms.doc.state.mn.us/tourreport/04FacilityInmateProfile.pdf; and, http://www. culturecareconnection.org/matters/diversity/ americanindian.html. There is currently a bill in the Minnesota state legislature that would provide incentives to incarcerated individuals to participate in programming in order to earn reductions in time served in prison. Programming highlighted in the bill includes: substance abuse treatment and counseling; mental health counseling; and, education, such as high school graduation testing, Career and Technical Education training, and college courses: For the full text of the bill, see: https://www.revisor.mn.gov/bills/bill. php?b=House&f=HF2349&ssn=0&y=2021; also, for further information, see: https://mn.gov/ sentencing-guidelines/assets/08B-MRRA_Policy_FAQ_tcm30-474003.pdf.

Summer 2021

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Criminal Justice & Health

A Call to Expand the Patient Bill of Rights: Health Justice for Incarcerated Minnesotans

I

n Minnesota, patients seeking care are protected by the Health Care Bill of Rights. This protection applies to all people receiving care in clinics, hospitals, birthing or surgical centers, nursing homes, chemical dependency treatment facilities, and mental health treatment programs. It does not, however, guarantee the same protections to people who are incarcerated in Minnesota jails and prisons. During the past decades, the number of people incarcerated in Minnesota has increased, as have the health needs of this population. Based on national and local estimates, more than half of incarcerated people have serious mental illness. Increasing numbers also have substance use disorder and chronic medical illnesses. In some jails, the majority of detainees take at least one daily medication. Minnesota jails have thus become de-facto mental health and substance use disorder treatment facilities and also are responsible for managing both the acute and chronic illnesses of the people they house. Despite growing medical complexity among incarcerated people, there is no mechanism for ensuring that these patients receive adequate medical care. Given the often high medical acuity of these patients, we believe that incarcerated people should be included in the protections afforded by the Minnesota Health Care Bill of Rights. In Minnesota, the type of health care a justice-involved individual receives depends on where they are incarcerated. The MN Department of Corrections (DOC) has direct oversight over the operations at By Hannah Lichtsinn, MD and Calla Brown, MD, MHR

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Summer 2021

Hannah Lichtsinn, MD

Calla Brown, MD, MHR

Minnesota state prisons, and this extends to responsibility for health care. The DOC has nurses and advanced practice providers on staff and further contracts with a private healthcare group for physician services. The DOC, however, does not oversee the healthcare offerings at county jails. Minnesota county jails currently house over eight thousand people at any given time. These jails range in size from three to 839 beds. Length of stay can range from days to years. Five Minnesota county jails further contract directly with Immigration and Customs Enforcement (ICE) and detain people held on immigration charges. Each county runs its jail independently, with the sheriff at the helm. There are minimal health guidelines they are required to follow. While they must ensure that incarcerated people have access to health care, there are no details about how this care is to be provided. As a result, the nature and quality of care varies from county to county and jail to jail. Furthermore, because jails are regulated and operated locally, even the DOC does not have the authority to intervene

if there are concerns over the quality of care. When an incarcerated person has a concern about the quality of their health care or has experienced a medication error, the current practice is to refer them to the Minnesota Board of Medical Practice, which as an organization is not designed to oversee quality of care. There is currently no incentive or requirement for healthcare providers in MN incarceral settings to provide high quality care. In fact, the largest incentive is to provide low cost care. People who are incarcerated lose access to state funded health insurance including Medicaid. Therefore, the total cost of caring for patients in MN jails falls to the county. This includes reimbursement for nursing and provider time, as well as the cost of any medications provided. As the rates of chronic medical and mental illness as well as substance use disorder within the incarcerated population increase, so does the cost of care, increasing the cost burden for the county as a whole. To combat this, many counties have contracted with private correctional health companies that

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The Journal of the Twin Cities Medical Society


promise low costs. Unfortunately this has repeatedly led to cut corners and poorer quality care. For example, the Kandiyohi county jail contracts with a private correctional health company called MeND, which is currently under investigation for violations of medical ethics. During the fall of 2020, there was a widespread outbreak of COVID-19 at the Kandiyohi county jail with nearly three full units, housing both criminal and people detained by ICE, testing positive. According to those detained and an evaluation by ICE, the care in the facility was substandard with reports of lack of basic monitoring including pulse oximetry for COVID positive patients and known placement of COVID positive individuals in a cell with someone who was COVID negative. Further descriptions included that when reporting symptoms, instead of getting a thorough medical evaluation, they were placed into isolation units akin to solitary confinement which is generally used as a form of punishment. On their own assessment of the health care

in the facility, the ICE office of Detention Oversight identified numerous compliance violations placing detained people at risk. They found that detention officers without medical training were completing the facility’s medical, dental, and mental health screenings. They also noted that despite having phone interpreter services available, interpreters were not used during medical evaluations of individuals with limited English proficiency. They even discovered cases of individuals being given medical care or even psychotropic medications without consent. Despite these and other failures, ICE took no corrective actions and no MN government agencies have the authority to address the widespread use of substandard medical care. If we were to include incarcerated populations in the MN Health Care Bill of Rights, we would create a mechanism for oversight and accountability. This would allow for regular assessments of the quality of care provided to these patients, ensure jail health services meet community standards of care including for screening and

treatment of acute and chronic illness, and adequate health professional staffing levels to ensure safety. Our current medical-legal system allows for no accountability and this must change. Recognizing that prison abolition would be ideal for improving population health in Minnesota, we must also ensure that all patients in Minnesota, including justice involved patients, receive high quality medical care. Hannah Lichtsinn, MD, Internal Medicine and Sickle Cell, Hennepin Healthcare, Assistant Professor of Medicine, University of Minnesota. She can be reached at: shact003@umn.edu. Calla Brown, MD, MHR, Internal Medicine and Pediatrics, Community University Health Care Center, Assistant Professor of Pediatrics, University of Minnesota. She can be reached at: brow3601@umn.edu. References: • health care bill of rights: https://www.revisor. mn.gov/statutes/cite/144.651. • https://www.health.state.mn.us/facilities/ regulation/billofrights/docs/mn_pts_rights_ eng_reg.pdf.

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Summer 2021

21


Criminal Justice & Health

From Cell to Street: What Works?

P

risons run like a small city. Every minute of every day is accounted for. Individuals are sharing a space the size of a bathroom for perhaps one, three, maybe even 10 years with someone whom they have never met. Since the COVID-19 pandemic, an incarcerated person’s world has shrunk. Most often, they are isolated in their cellblock units, eating their meals delivered from the kitchen. Work, classes, counseling, recreation, and visits are cancelled or curtailed. Sometimes, if lucky, these activities are moved online or offered at reduced capacity. Life is even more challenging for incarcerated individuals than it was previously. Minnesota’s Prison System

A few facts and figures about Minnesota’s Prison System: • There are 10 correctional facilities in 11 locations housing 7,200 incarcerated persons. • 105,000 individuals are on probation living outside of a correctional facility. • Under determinant sentencing, twothirds of an individual’s sentence is spent incarcerated and 95% are released back to the community. • On average, 78% of individuals have previous violent crime convictions and four prior felony convictions. These offenses include individuals who have been convicted of crimes related to person (53%), drug (18%), property (10%), weapons (7%), and DWI (5%). While “rehabilitation” is an oft-stated goal of incarceration, many formerly incarcerated persons may struggle upon release By Mark Groves, M.S.Ed, LADC

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for a variety of factors, including how long they were incarcerated, what type of support system they have — including family, friends and social systems — and stigma. Given that research shows that 34% of sentenced individuals will be convicted of a new felony-level crime and 26% of individuals will be reincarcerated for a new felony conviction, their families, friends, and the broader community are impacted when individuals are not well supported upon release. Reentry to Society

Over the past several decades, the number of incarcerated individuals has grown significantly which has, in turn, led to a rise in the number of formerly incarcerated individuals reentering their communities. Historically, government officials have sponsored several major initiatives leading to the implementation of community-level prison reentry projects. Reentry of incarcerated persons is broadly applied to any program that attempts to reduce recidivism for sentenced individuals released from incarceration, but positive results of these programs are often elusive because of design problems, short duration, lack of administrative oversight, poor implementation, or absence of community aftercare. In 2009, the Minnesota Department of Corrections (DOC) implemented the Transition from Prison to Community (TPC) initiative. TPC helps sentenced individuals transition from prison to communities, thereby increasing public safety, reducing recidivism and new victimization, and making better use of scarce resources in correctional facilities and communities. The goals of TPC are for released individuals to remain arrest-free over the

long term and to become self-sufficient members of their communities. The DOC offers a range of transitional programming to sentenced individuals during confinement and after release. These resources and services are organized through the DOC Reentry Services Unit, in collaboration with facility services, field services, various state and county agencies, faith-based groups, community organizations and private citizens. The combined effort meets the complex needs of individuals as they transition from prison to community. Resources have been developed through identifying best practice models in preparing offenders to return to their communities. Each DOC facility maintains a transition center that hosts many different resources including community resources, job search assistance, housing information, higher education searches, and veterans’ resources. A comprehensive curriculum of pre-release classes and activities are also offered. The curriculum covers housing, employment, personal identification

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The Journal of the Twin Cities Medical Society


documents, health, transportation, family issues, living under supervision, and personal financial management. Reentry Isn’t Easy

Without access to social supports, community resources and stable housing, and employment upon release, a formerly incarcerated person’s chance of re-offending increases. A significant challenge is finding meaningful employment. Employers are reluctant to hire people with criminal records. Limited education, the stigma of incarceration, and a lack of employment history contribute to limited employment opportunities. When employment opportunities and resources are not available, individuals who are reentering their communities are more likely to reoffend. Another difficulty is finding safe, affordable housing. Too often, incarcerated persons do not have the financial resources needed to secure an apartment and strict housing policies make it even harder for formerly incarcerated individuals to be considered as viable candidates for housing. Moreover, a history of drug or felony convictions make individuals ineligible for public housing. These factors make the first month after release a vulnerable period during which the risk of experiencing homelessness, the risk of being rearrested, and the risk of recidivism is high.

develop an enhanced sense of self-worth and specific knowledge and skills to increase their chance of successful reentry. Mentoring is a process for the informal transmission of knowledge, social capital, and the psychosocial support perceived by the individual as relevant to work, career, and personal development. Mentors provide ongoing support during the reentry process to enhance success. Effective reentry practices recognize the important relationship that must be established between behavioral, physical, and relational health. However, mentoring alone is not enough. Finding and retaining a job, and safe, affordable housing is key. Reentry programs need to address the full range of formerly incarcerated individual’s needs — from housing to health care to employment — and they must be individualized based on each person’s unique situation. Dependable, supportive relationships are as critical to the wellbeing of formerly incarcerated individuals reentering society. For more information, please feel free to contact me at mark.groves@state.mn.us.

Mentoring

Mark Groves is the past president of the Minnesota Corrections Association (MCA). He worked at the Minnesota Department of Corrections as the Facilities Reentry Coordinator providing oversight to all reentry program elements in Minnesota Department of Corrections (DOC) facilities.

Research consistently demonstrates the importance of a positive social support system for incarcerated individuals reentering society. Mentors provide the positive social connection, support, and experience necessary for stabilization. The reason for incorporating mentoring into the individual’s life is very simple: adding the support of a caring adult helps ease a returning citizen’s reentry back to society. By extending a hand of friendship, mentors help incarcerated individuals feel cared about, help them tap into their networks, and link them to critical services that increase stabilization and positive engagement. Mentors provide a developmental relationship whereby a more experienced person helps a less experienced person

References: • Recidivism and Community Context_Integrating the Environmental Backcloth_tcm1089466939.pdf (mn.gov). • 2019 Minnesota Statewide Probation and Supervised Release Outcomes 2015 Cohort_ tcm1089-412421.pdf (mn.gov). • https://mn.gov/doc/assets/Transition%20 from%20Prison%20to%20Community-Aug2017_tcm1089-309018.pdf. • h t t p s : / / n i c i c . g o v / t r a n s i t i o n - f r o m - p r i s on-to-community. • Publications / Department of Corrections (mn. gov). • Petersilla, Joan (2009) When Prisoners Come Home: Parole and Prisoner Reentry, Oxford University Press, ISBN-10: 0195386124. • Maruna, S. (2001) Making Good: How Ex-Convicts Reform and Rebuild their Lives, Washington: American Psychological Association. ISBN-13: 978-1557987310. • Crow, Matthew & Smykla, John (2014) Offender Reentry: Rethinking Criminology and Criminal Justice, Jones & Bartlett Learning. ISBN 13: 9781449686024.

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Post-Incarceration Mentoring Programs Amicus Services of Volunteers of America MN/WI

Offering volunteer prison and post-release visiting, reentry support groups, a free drop-in reentry support center and more. Contact us to volunteer or for more information. 612-877-4250 www.voamnwi.org/reentrymentoring FreedomWorks Reentry and Aftercare

FreedomWorks exists primarily to help former incarcerated individuals who are returning to society from incarceration reconcile to God, family, and community. www.myfreedomworks.com Montage Reentry Solutions

Montage Reentry Solutions (MRS) is a social enterprise consultancy that provides information, advice, and resources focused on reentry. We partner with non-profits and government agencies to help integrate former incarcerated individuals and individuals with substance use disorders back into society. www.montagereentrysolutions.com Welcome Homes MN

Welcome Homes provides permanent supportive sober housing for men and women coming out of incarceration or treatment. Each of our homes enlist community volunteers to use as a circle of support model to manage, support, and mentor the residents returning to the community. www.WelcomeHomesMN.org Women Planting Seeds

Committed to changing lives and providing second chances. To assist women in developing and maintaining positive life experiences. www.womenplantingseeds.org Disclaimer of Endorsement: The resource information and content is supplied by third parties. Information contained herein does not constitute or imply its endorsement, recommendation, or favoring by Twin Cities Medical Society, its directors, or employees.

Summer 2021

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Criminal Justice & Health

Community Supervision and Health

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hen thinking about health and the criminal justice system, many of us picture clinics made of cinder blocks and patients in blaze orange. Yet, there are more than twice as many people living in our communities and serving out sentences under community supervision than are incarcerated in jails and prisons combined, totaling nearly 4.5 million or roughly one in 58 Americans.1 In contrast to people detained in correctional facilities, more of these individuals retain their health insurance and access care in their regular community clinics and hospitals. We know that in general, people under correctional control have higher levels of chronic physical and mental health conditions, and that Black, Indigenous, and people of color (BIPOC) are disproportionately subjected to the criminal justice system.2 However, we are only beginning to understand the relationship specifically between community supervision and health. With the potential to impact health, health inequities, and healthcare access for millions of patients, it is crucial for physicians to understand community supervision and common health concerns for people on community supervision. What is Community Supervision?

Community supervision is a category of sentencing that includes both probation and parole. Probation can take the place of a jail or prison stay with someone serving out a sentence in the community. This is different from parole, which is an early By Marin G. Olson, BA

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Summer 2021

contribute to one’s ability to meet requirements, health can play an important role. For example, someone who receives dialysis three times a week or who develops a leg infection from poorly controlled diabetes may be physically unable to make a probation officer meeting. Considering that BIPOC individuals are already more likely to have many chronic health conditions, community supervision has the potential to exacerbate existing health inequities. Community Supervision and Health

release from jail or prison contingent on a term of supervision. In both situations, there are often many requirements for regular meetings with probation or parole officers, frequent drug testing, and limitations on travel. Importantly, failing to abide by these requirements can lead to reincarceration. Inequity in Community Supervision

Similar to the justice system as a whole, community supervision disproportionately impacts certain racial and ethnic groups. People placed on probation are more likely to be younger, male, and identify as BIPOC.3 When probation rates were at their peak in 2007, nearly one in 12 Black men in the United States were under probation.4 There are not only inequities in who is subjected to community supervision, but the very nature of probation and parole can also lead to a disparity in who is “successful” at meeting the specified requirements and who “fails’’ and goes to jail or prison. While numerous factors

People on probation and parole have different health considerations than people incarcerated in jails or prisons. While individuals are not physically confined as in incarceration, the conditions of community supervision can be traumatizing and anxiety-provoking, especially for many who have previously been incarcerated. People on community supervision can maintain existing public health insurance enrollment, if available in their jurisdiction, and can potentially access care in the community. However, this subset of justice-involved individuals does not have the same constitutional guarantee to health care as do people under incarceration and access to care often remains limited for people on community supervision. Finally, people who do not meet strict requirements of their probation or parole are typically incarcerated, which has well-described negative health consequences.5 While there are few studies that look specifically at the health of people on probation and parole, we do know that people on community supervision have high health needs. People on probation

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The Journal of the Twin Cities Medical Society


are more likely than the general population to have a wide array of chronic physical health conditions like asthma or diabetes, disabilities, communicable diseases such as HIV or hepatitis B or C, and mental health conditions including substance use disorders.6,7 Overall, people on probation have higher mortality rates than the general population.8 In addition to having complex health profiles, people on community supervision also access the health system in different ways. When compared to the general population, people on probation have higher rates of emergency department and inpatient care and lower rates of outpatient visits.7 Improving the Care of People on Community Supervision

We have a lot to learn about how to best care for our patients on community supervision, and we can design better policies and programs with more detailed information. In the Health, Homelessness, and Criminal Justice Laboratory (HHCJ Laboratory housed in the Hennepin County Research Institute), we are linking datasets from Medicaid claims and county administrative data to understand what specific health conditions affect people on probation, as well as how these differ by race and ethnicity. This level of detail is especially important when designing justice-oriented interventions that recognize and eliminate existing health inequities. For instance, specific types of substance use disorders affect racial and ethnic groups differently. An informed public health program might target multiple substance use disorders, rather than the single most prevalent, to avoid disproportionately benefiting one group while worsening overall health disparities. Conclusion

Millions of people who receive care from MetroDoctors

physicians in the general healthcare system are also involved in the criminal justice system through community supervision. People on probation and parole have complex health needs and patterns of healthcare use that suggest limited access to care. Ideally, we would stop subjecting these individuals to the criminal justice system in the first place. Until then, the healthcare community can best meet their needs by understanding community supervision and common health conditions for patients on community supervision. Failure to adequately control chronic disease can result in poor health and interfere with the requirements of supervision. With better care and smarter policies, we can work toward ensuring that the health needs of people on probation and parole are met and do not result in reincarceration.

6.

7.

8.

public health, and widening inequality in the USA. The Lancet. 2017;389(10077):1464-1474. doi:10.1016/S0140-6736(17)30259-3. Winkelman TNA, Phelps MS, Mitchell KL, Jennings L, Shlafer RJ. Physical Health and Disability Among U.S. Adults Recently on Community Supervision. J Correct Health Care. 2020;26(2):129-137. doi:10.1177/1078345820915920. Hawks L, Wang EA, Howell B, et al. Health Status and Health Care Utilization of US Adults Under Probation: 2015–2018. Am J Public Health. Published online July 16, 2020:e1-e7. doi:10.2105/AJPH.2020.305777. Wildeman C, Goldman AW, Wang EA. Age-Standardized Mortality of Persons on Probation, in Jail, or in State Prison and the General Population, 2001-2012. Public Health Rep. 2019;134(6):660-666. doi:10.1177/0033354919879732.

Marin Olson is a graduating medical student at the University of Minnesota Medical School. She has worked with the Health, Homelessness, and Criminal Justice Laboratory throughout medical school and recently participated in the TCMS Dr. Pete Dehnel Public Health Advocacy Fellowship. She will start her residency in emergency medicine at the University of California, San Francisco this summer. Contact: olso7943@umn.edu. References: 1. Kaeble D, Alper. Probation and Parole in the United States, 2017-2018. Published online 2018. Accessed August 9, 2020. https://www. bjs.gov/content/pub/pdf/ppus1718.pdf. 2. Wilper AP, Woolhandler S, Boyd JW, et al. The Health and Health Care of US Prisoners: Results of a Nationwide Survey. Am J Public Health. 2009;99(4):666-672. doi:10.2105/ AJPH.2008.144279. 3. Phelps MS. Mass Probation and Inequality. In: Ulmer JT, Bradley MS, eds. Handbook on Punishment Decisions: Locations of Disparity. 1st ed. Routledge; 2018:43-66. doi:10.4324/9781315410371-3. 4. Phelps MS. Mass probation: Toward a more robust theory of state variation in punishment. Punishment & Society. 2017;19(1):53-73. doi:10.1177/1462474516649174. 5. Wildeman C, Wang EA. Mass incarceration,

The Journal of the Twin Cities Medical Society

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Summer 2021

25



Environmental Health— Justice Beyond the Exam Room

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hether it’s the tragic deaths of George Floyd and Daunte Wright; inequitable rates of COVID-19 infection, death, and vaccination; or the higher rate of insidious premature deaths to people of color from climate change, we, in the health community have a responsibility to understand why this is happening and to intervene on these causes. The biomedical ethics principle of “justice” extends beyond the examination room. The slow violence of climate disruption amplifies health impacts when broad social emergencies like COVID-19 and the preventable murders of Black, Indigenous, and people of color impact our communities. It is only through understanding the personal and ripple ecologies of historical and contemporary peripheral trauma that we can offer compassionate care. Minnesota BIPOC communities are inequitably experiencing the health impacts of climate change. As detailed in a recent Greenpeace report, the disproportionate impacts of oil, coal, and gas production and use are a major public health problem for BIPOC communities. They deem this issue “fossil fuel racism.” While not new information, this report underscores the need for environmental justice, as this form of systemic racism is an immense social determinant of health (SDOH). Positive impacts on any SDOH result in downstream improvements in health by all measures. Both climate change impacts and structural racism as SDOHs in society demand immediate action to prevent amplification of already existing inequities. We must promote climate and criminal justice through investments in health justice. Healthcare systems that meet individuals where they are and build trust for care and support without judgment, are a start. Some current clinical initiatives include providing health care in a church setting in Worthington, MN to immigrant families; offering

COVID vaccines in a Twin Cities mosque; or Hennepin Healthcare recognizing the importance of prayer for their patients and by providing directional markers in the clinic rooms. Whether it is acute physical or climate-related trauma, we must also provide and promote access to mental health services to treat and support individuals who are experiencing psychiatric symptoms related to violent or climate-related events. In terms of environmental justice, we must listen to our communities to hear their needs and understand their challenges in being partners in a green future. However, climate change may not be experienced as acute an issue as the physical and emotional violence attacking our BIPOC communities.

By Zeke McKinney, MD, MHI, MPH and Mike Menzel, MD

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The Journal of the Twin Cities Medical Society

Our charge, therefore, is to concurrently fight the systemic forces that overwhelm our most vulnerable communities across many dimensions. As health professionals, we must be a part of building a just, sustainable, and healthier state and nation for our most vulnerable citizens. Zeke McKinney, MD, MHI, MPH, President-Elect, TCMS; President, Central States Occupational and Environmental Medicine Association. Mike Menzel, MD, Health Professionals for a Healthy Climate. References: 1. Greenpeace et al. 2021. Fossil Fuel Racism: https://www.greenpeace.org/usa/reports/ fossil-fuel-racism/#exec-summary.

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Summer 2021

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Incarceration Health in Medical Education: Medical Student Perspective Introduction At the beginning of medical school, we stood shoulder to shoulder with our classmates, dressed in our brand new white coats and took an oath. We pledged to care for any and every patient, regardless of who they are, where they come from, or what is making them sick. Now, as we consider our next steps to becoming the physicians we promised we would be, our experiences learning from people detained in the Hennepin County Jail stand out as uniquely formative. The people detained in our nation’s correctional facilities make up a patient population that is especially vulnerable, suffers from distinct pathology and disease prevalence, faces daunting socioeconomic barriers, and yet is in no way separate from the general population. They are people we must learn to care for if we want to hold true to our oaths. Specific Health Needs Individuals who are incarcerated are at higher risk for HIV, Hepatitis C, and latent tuberculosis.1 In addition, they are at higher risk for sexually transmitted diseases like chlamydia, gonorrhea, and syphilis and are more likely to have chronic health conditions including diabetes, hypertension, substance use, and mental health problems.1,2 Even more, those who are incarcerated have a shortened life expectancy compared to the non-incarcerated population.3 To make matters worse, few correctional facilities offer prevention or treatments for these diseases. Understanding this specific epidemiology, as well as the circumstances before, during, and after an individual is incarcerated is crucial to integrating appropriate care into daily practice as a physician. Importance and Medical Education About 600,000 people are released from state and federal prisons each year.4 Therefore, the likelihood that any physician will care for an individual who has been incarcerated is high. Put another way: incarceration health is community health. When medical students are educated on the health risks and needs of those who are or have been incarcerated, we have an opportunity to face our biases early on and learn to provide informed, holistic care for a patient population we must be comfortable working with. Our self-pursued pre-clinical projects, third year elective clerkships, and fellowships allowed both of us to carve out opportunities to teach health literacy classes in the Hennepin County Jail, shadow jail Medicine and OBGYN providers, and work in the jail addiction medicine clinic. But currently, there is very little exposure to incarceration health care as a formal part of the University of Minnesota Medical School curriculum. Pre-clinical curriculum needs to include topics related to incarceration health, including the history of medicine and its impact on marginalized

By Noah Sanders, MS4 and Kristin Chu, MS3

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Noah Sanders, MS4

Kristin Chu, MS3

populations, addiction medicine, gender/sexual health, and immigrant and refugee health. Clinical opportunities need to be offered that allow all students to rotate through prison and jail clinics, learning from providers who have a keen understanding of the field. Other schools, like Georgetown University School of Medicine, have already begun to do this.5 Failure to educate medical students on incarceration health risks intensifying the forces keeping these individuals in the carceral system, further perpetuating healthcare injustices. The Ethics of Learning in Correctional Facilities As students are given more opportunities to work in incarceration health, it is important to remember that correctional facilities are inherently coercive and dehumanizing environments with a history of medical trauma.6 Any exposure to incarceration health must come in a manner that respects patient autonomy, understands the power dynamics at play, and acknowledges the incarcerated patient’s limited ability to consent to having learners present. For example, a patient who is sick, shackled, and within earshot of a guard may not feel empowered to ask a student to leave the room if they prefer to speak privately with the provider. Done carefully and correctly, the opportunity to learn from incarcerated patients will help a future generation of providers develop the knowledge and skills to address the unique health needs and myriad socioeconomic factors impacting this especially vulnerable patient population. Sources: 1. Davis DM, Bello JK, Rottnek F. Care of Incarcerated Patients. Am Fam Physician. 2018 Nov 15;98(10:577-583). PMID: 30365288. 2. Workowski KA. Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines.Clin Infect Dis. 2015;61 Suppl 8:S759-762. 3. Widra, E. (2017, June 26). Incarceration shortens life expectancy. Retrieved April 12, 2021, from https://www.prisonpolicy.org/blog/2017/06/26/life_expectancy/. 4. Office of The Assistant Secretary for Planning and Evaluation. (2019, July 02). Incarceration & Reentry. https://aspe.hhs.gov/incarceration-reentry. 5. Medical Student Educational Opportunities and Resources | The School of Medicine & Health Sciences. (n.d.). Smhs.gwu.edu. Retrieved April 18, 2021, from https://smhs.gwu.edu/academics/md-program/curriculum/clinical-public-health/criminal-justice-health-initiative/medical. 6. Johnson, C. G. (2013, July 7). Female inmates sterilized in California prisons without approval. Reveal. https://revealnews.org/article/female-inmates-sterilized-in-california-prisons-without-approval/.

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