Improving Carceral Care

In January 2016, the provision of health care in the New York City jails became the responsibility of the city’s Correctional Health Service (CHS), a new direct service division of its Health + Hospitals (H+H) system, leveraging the resources of the country’s largest municipal health care system. Prior to 2016, carceral health care had been provided through contractual arrangements between the city Health Department and private vendors. CHS was launched as an integral element of the city’s efforts to reform the criminal legal system, and work began to not only improve the quality of and access to health care for persons in custody, but to fundamentally recast the approach to health care from an episodic transaction to a public health frame in which the whole condition of the person is considered for preventive and curative intervention, with consideration of the individual’s physical, psychological and social context. 

One of CHS’ earliest efforts to change the way health care is delivered was to establish and then expand the number of therapeutic units within the jails. These are referred to in shorthand as JTxHU, shorthand for Jail Therapeutic Housing Units. CHS and the Department of Correction (DOC) jointly designate housing units within the jails to accommodate patients with particular mental health, medical and/or substance use needs. An individual’s clinical needs are the primary consideration in determining whether they will be housed in a JTxHU, which allows for strengthened care coordination for, and more effective treatment of, high-need patients. Benefits include more robust patient engagement with clinical staff embedded in the units, enhanced relationships with trained teams of CHS and DOC staff, improved access to treatment and better spatial layouts. The most familiar of these units is the Program to Accelerate Clinical Effectiveness (PACE) for patients with serious mental illnesses. 

JTxHUs comprise a suite of different types and levels of care: mental observation units for patients with serious mental illnesses who don’t require such a high level of care; special medical units that address medical or physical needs, including two infirmaries, a communicable disease unit, a nursery for new mothers and their infants, and cohorts of patients with certain medical conditions such as diabetes; and a new housing unit to accommodate patients with both substance use and mental health needs who would benefit from living in a therapeutic community that fosters peer-support opportunities. Examples of therapeutic efficacy include an increase in medication adherence, improved clinical stability and a reduction in re-hospitalization. 

Despite the establishment of the JTxHUs, CHS identified a gap in the continuum of care it was offering its patients who needed specialty or subspecialty care only available in an acute-care facility. CHS found that many patients who needed critical, sometimes life-saving outpatient treatment available only in a fully equipped hospital, such as chemotherapy, were declining care because of the arduous, often exhausting hours-long round-trip journey between jail and hospital. While some people incarcerated at Rikers are admitted to hospitals, these patients, however weak or fatigued, were not acutely clinically ill enough to warrant admission to a hospital bed. 

To address this issue, CHS proposed outposting to certain H+H hospitals the therapeutic housing model that had been successfully used within the jails. These Outposted Therapeutic Housing Units (OTxHUs) bridge the gap between the care provided in the jails and inpatient hospitalization. CHS identified available and appropriate locations within three H+H facilities — Bellevue, Woodhull and North Central Bronx hospitals —  and received approval to proceed in 2019 and capital funding for requisite renovation in 2020.

The OTxHU is a unique concept. The units will be secured by DOC officers and will meet the minimum standards and other regulations that apply to jails. However, different from a regular jail unit or even a JTxHU, they will be located in community-based health care facilities, unhindered by the physical plants and relative remove of Rikers Island. Patients will live within the four walls of each hospital but won’t be receiving inpatient levels of care; CHS will continue to be the primary provider of care on the units, but in closer coordination with hospital specialists. 

As in the JTxHU, an individual’s medical, mental health and substance use needs will be the primary consideration for housing placement. Like the health units, the outposted units will incorporate features that will provide a more therapeutic milieu ranging from steadily assigned, embedded staff to smaller cohorts of patients in intentionally designed physical spaces. Unlike the jail units, the outposted units will be at most an elevator ride away from specialists and equipment, and the demand for escorting and transporting patients between Rikers and the hospitals for specialty care appointments will be lessened. 

Currently, efforts have been focused on opening the Bellevue units, with construction completion — barring significant unforeseen field conditions — projected for late spring 2025. The Bellevue site will contain 104 beds. Subject to final design, in total the outposted project across the three H+H facilities will bring 363 beds online. Although the OTxHU project was developed independent of the plans for the borough-based jails, as we look to larger reforms, it has taken on an even greater significance. 

Recently, conversations have been sparked as to whether creating even more outposted therapeutic beds can offer a pathway for further reducing the number of people held on Rikers Island. However, the idea to outpost more such units in hospitals is not supported by the clinical needs of persons currently or projected to be in custody. Nor should the idea be considered without scrutiny of all costs and benefits of creating more housing units in hospital facilities for people in custody who do not require that close access to hospital-based outpatient specialty care. Any further expansion of the OTxHU footprint must carefully consider the broad range of issues including but not limited to the availability of appropriate hospital space to convert to this use; the loss and conversion of hospital assets from community care; the operational and resource implications for DOC, CHS and hospitals; and so on.

A critical semantic distinction must be made between the “therapeutic” effect the OTxHUs will offer in improved access to certain necessary medical treatments and the “therapeutic” principles of purposefully designed and operated jails. Examples of these principles were identified in the early scoping sessions for the borough-based jails and included steadily assigned security officers working with health staff to focus on and support habilitation and rehabilitation; smaller, more stable housing communities; and spatial layouts that are visually and acoustically less harsh. Elements such as these define a more therapeutic milieu — physical, operational and cultural factors that can have a positive effect or help mitigate negative impacts of incarceration — that would benefit any person held in custody. 

At the same time, the inherent risk of focusing on building better jails ought not distract from the core issue of detention itself. People are not jailed because of their clinical needs, and it is essential to decouple the clinical from the criminal. Care must be taken to neither medicalize nonclinical behaviors nor criminalize clinical conditions. Doing either can have short- and long-term detrimental implications for the individual patient, the systems of care and custody, and society.

Within the public health frame, CHS has embraced the opportunity not only to attend to the medical needs of the individual while in custody but to work to help patients leave jail and not return, and support efforts to avoid unnecessary days in detention. From its earliest days as part of H+H, CHS expanded its efforts to provide, with patient consent, relevant clinical information that could support a court’s decision for an alternative to detention. CHS also enhanced its discharge planning efforts to identify and facilitate arrangements, beginning on the first day of an individual’s admission to the jail system, that an individual might need upon release. In addition to such arrangements as health insurance or stable housing, another essential prescription for healthy, independent living is health care that is geographically, temporally, linguistically and culturally accessible. Again looking to leverage its relationship with the H+H system, CHS proposed in 2018 the establishment of Point of Reentry and Transition (PORT) practices at Bellevue and Kings County hospitals. Opened the following year, these practices include staff who had themselves experienced incarceration and reentry, to help people newly released from incarceration navigate many of the logistics of getting care in the community such as registration and appointments. Health care providers from CHS work alongside providers from the hospitals both to strengthen the continuity of patient-provider relationships and to improve integration and transition from carceral to community-based care. The PORT practices have become incorporated into the hospitals’ operations and provide a template for approachable, available community-based care.

In an often-cited metaphor, rescue efforts are frequently focused on pulling people out from rushing waters downstream from a washed-out bridge, rather than looking upstream to repair the bridge. CHS, with the continuing support of the city, remains committed to being a leader in caring for people while they are in custody and working to help reduce or altogether avoid unnecessary detention. 

Regardless of how robust and high-quality the medical care or how humane the custody management is, the realities of incarceration, with its restrictions on individual freedom and self-agency, remain. Individuals incarcerated in jail settings are at risk of negative health outcomes. 

Given the myriad of factors — where we are born, how we live, what we learn, how we use our time — that in sum help determine the extent to which a life lived can be healthful and productive, for better ways to care for people, we must look upstream to vital communities, and a vital city.