Osborne Testifies at Assembly Committees on Health and Corrections

16 November 2017

Testimony for the Osborne Association, by the Osborne Center for Justice Across Generations for the Assembly Health and Corrections Committees at the joint public hearing on healthcare in correctional facilities. 

Presented by: Elizabeth Gaynes, Osborne President and CEO on October 30, 2017

Thank you for the opportunity to speak with you today. My name is Elizabeth Gaynes, CEO of the Osborne Association. In addition to a wide range of diversion and reentry programs at sites in the Bronx, Brooklyn, Newburgh, and soon Harlem, we offer services at 27 New York State prisons and 7 New York City jails. Osborne programs most relevant to this hearing are our HIV/HCV services in the Green Haven hub as part of the AIDS Institute Criminal Justice Initiative, and our Elder Reentry Initiative at Fishkill, Sing Sing, Queensboro and Rikers Island.

Osborne’s policy advocacy, which is pursued largely through the Osborne Center for Justice Across Generations, has focused much of its energy on the fastest growing population in New York and nationally: older adults. Next month we will be issuing our updated white paper, The High Cost of Low Risk, originally issued in 2014 and highlighting the growing crisis of aging in prison. Earlier this month, a new report entitled Prison Health Care:  Costs and Quality, was issued by the Pew Charitable Trust, subtitled “how and why states strive for high-performing systems.” This timely report, which I am sure will be of interest to these Committees, also highlights the significance of the graying of prison systems across the country.

While I will focus much of my testimony today on the multi-faceted policy challenges related to aging, including medical parole, I want to briefly mention several other concerns regarding healthcare in prison that I am sure colleagues will discuss, including the need to expand the availability of medication for all genotypes of Hepatitis C, with and without HIV co-infection – which to the credit of DOCCS is being utilized far ahead of many other states but needs further expansion; the need to incorporate Medication Assisted Treatment into correctional healthcare (including Suboxone/buprenorphrine and Vivitrol/Naltrexone); and the need to better coordinate mental and physical health concerns between DOCCS and OMH, a relationship which is especially problematic “on the ground” in the facilities, particularly with respect to psychiatric treatment and medication and the emergence of dementia and cognitive impairments within the population, causing problems along the continuum of effective health care in prison.

I think it is exactly right that these two Assembly committees should be working together, in some sense demonstrating the irony of the fact that what we now call the “social determinants of health” are identical to what we used to call “root causes of crime.” This confirms that the prison healthcare system needs to embrace the entire range of physical and mental health concerns from present-and post-traumatic stress to substance misuse to mental illness to chronic and communicable diseases. As the Pew report demonstrates, New Yorkers are spending nearly $400,000,000 annually on this care, at a time when Washington is threatening to destroy multiple avenues for paying for healthcare. Clearly, we need to focus resources where they will make the most difference, and the reality is that improved health care leads to improved justice outcomes.

Basic facts on older adults in New York prisons:

Those aging in prison (often defined as those over age 50 or 55, due to the accelerated aging that can result from long-term incarceration) are the fastest growing demographic in corrections. While there is increasing press coverage of the crisis, there is no coordinated community approach. The facts are striking:

  • Today, there are over 10,000 aging incarcerated individuals in New York state prisons, comprising close to 20% of the state’s total prison population;[1]
  • While the number of people in prison under the age of 30 has been in almost constant decline since the mid 1990s, the number of people in prison aged 50 and older has been on a consistent and troubling rise. [2]
  • Each year, some 1,500 men and women age 60 or over leave state prison and return to New York City.
  • Despite the unprecedented increase of older people in prison and returning home, there is only one known reentry program in N.Y. that specifically focuses on this age cohort (Osborne’s Elder Reentry Initiative).
  • Programs serving elders in the community, such as senior centers, geriatric clinics, and nursing homes, are currently ill-equipped to recognize or meet the complex needs that result from a combination of aging and the trauma of long-term incarceration.
  • The significant uphill challenges of reentry for anyone coming home after incarceration (discrimination, barriers to housing and employment, reintegrating into family, mental health and health issues, for example) are far exacerbated for the older population.
  • Formerly incarcerated older people are at very low risk of recidivism, but are at very high risk of falling through the cracks in our social safety net.[3] 


Much of the work to date has come through the leadership and expertise of those directly affected who are the experts in what is needed, and who should continue to have an important role in any future policy discussions. My own understanding of the significance of the issue came at me point blank when my children’s father – released from prison 8 years ago at 67 after 25 years – began exhibiting signs of dementia from traumatic brain injury and we were faced with trying to find long term care.  Numerous barriers – including the fact that Medicare is not available for people on parole and most Longtermers aren’t eligible for Medicare anyway – accompany efforts to access appropriate nursing and long term care for people after prison. In our case, we were able to access the best available options  (which aren’t all that great) because after 45 years in the field I know everyone who runs anything. But that’s not how it turns out for most people, and even so, my daughter is in a daily struggle to manage his care.

The older population that we are seeing on Rikers Island, and that I believe will be increasing in upstate jails, is different from the older population in prison and presents a distinct set of challenges, and demands a different service and community response. Older people in jail have often cycled in and out of jail for decades due to addiction, mental health, homelessness, and being the victims of violence. Or, a tragedy or trauma left them vulnerable and grieving and led them (back) to jail. And at this point, it is likely that opioids are compounding their contact with the justice system.

Osborne’s program for older adults:

The Elder Reentry Initiative serves those in both city and state correctional facilities. As far as we can tell, it is one of only two programs in the country that provides a full continuum of care, beginning during confinement and continuing through release and reentry. Through a grant from Robert Wood Johnson Foundation to the Brookdale Center on Healthy Aging at Hunter College, the director of our program and I had the opportunity to visit a program in the UK that focuses on older adults. We visited three of Her Majesty’s prisons and post-release residences, and hope to incorporate some of what we observed into our work and into DOCCS programming. Of course the fact that Britain has a National Health Service that provides continuous medical care before, during, and after incarceration makes a difference that is not immediately replicable but it is possible that New York’s Medicaid expansion (and related efforts on everything from electronic health records to health homes) will improve continuity of care upon release. As a policy matter, we would like to see recent incarceration “count” as one of the two chronic conditions required to qualify for health home inclusion.

Many of the recommendations for improving the experiences and outcomes for older adults during and after prison came from the Aging Reentry Task Force which met in NYC from 2013-2014, and demonstrates what focused, inclusive, inter-disciplinary attention to this issue can accomplish. That Task Force, co-chaired by the NYC Department for the Aging, Osborne, Columbia Center on Justice, Fordham, and RAPP, included the leadership of those formerly incarcerated and brought together the fields of aging, criminal justice, corrections, and health, and produced important recommendations and models, and identified the need for specialized geriatric assessments for incarcerated people, and specialized reentry services for older adults leaving prison and jail. The model that grew out of that Task Force was adopted by Osborne to develop our current Elder Reentry Initiative, which was piloted through foundation funding and is now receiving some City and Federal funding. As Assemblymember Weprin knows (and has supported), we have sought State funding to enable us to support the new Senior Living Dorm at Ulster or expand to serve more individuals. To date, ERI has a strong track record in terms of securing parole release (our parole release rate is close to 60%, triple the average and very low parole release rate of 20%, including for older people who consistently score very low on the risk assessment tool used to assess public safety risk) and post-release success. For the last two years, we have been seeking state funding in order to continue.

It is important to note that both city and state corrections departments have welcomed our program and other efforts to make jails and prisons more age-friendly. One of our board members, Dr. Rachael Bedard, was hired to be DOC’s first full time geriatrician. The state prison system is establishing a Senior Living Dorm for older men. But the better longterm solution is to create a welcoming environment for returning elders, that enables them to be economically self-sufficient when they are able, and to receive appropriate support and long term care when they are no longer able. A huge barrier to this remains the high rate of parole denials for older people. A recent parole denial of an older man in our Elder Reentry Program - who has incurable cancer and has been incarcerated for 42 years for a crime he committed as a teenager (after having witnessed the murder of his parent at 5, sexually molested at 8, and sentenced to 18-life, which was less than the maximum because the judge thought him redeemable)- reminds us of the urgency to advocate for parole reform and of the costly implications, on human and economic terms, of punitive parole denials of older people.

Recommended policy and practice changes:

Our policy recommendations fall generally into two categories:   Improve the health of and conditions for the rapidly expanding number of people aging in prison, and expand and increase the mechanisms for releasing aging men and women who pose little risk and can be assets to our communities.

A. Improve responses to aging within correctional facilities:

  • Define and universalize the age at which an incarcerated person is considered ‘aging’ and encourage correctional systems to recognize this population as a unique sub-group with specialized needs[i]
  • Develop and integrate models and best practices for geriatric care into the National Commission on Correctional Health Care standards[ii]
  • Design and implement geriatric assessments and care plans within correctional settings that evaluate the needs of older adults starting at age 50, and just prior to their release to connect them with appropriate community-based service providers. Osborne has developed a specialized prison-based geriatric assessment which could be broadly implemented by correctional staff.  Geriatric assessments should be re-administered at regular intervals consistent with the community standard.
  • Offer advanced care planning and health care proxies for those over age 50.
  • Amend the disciplinary process to consider administering dementia screenings for anyone over age 50 who receives a “ticket” (disciplinary charge) if they have no infraction history within the prior 10 years.
  • Allow older incarcerated people to “retire”- to be allowed to stop working at age 65 while permitting program participation upon request, and continuing income based on prior work and earnings history  - similar to a pension.


Program Enhancements:

  • Introduce support groups for older adults and geriatric counseling for stress and trauma[iii]
  • Maximize age-appropriate exercise opportunities and age-friendly, illness informed diets to prevent earlier onset of aging, disease, disability and terminal illness.
  • Test and measure interventions that decrease medical costs while maintaining healthcare quality, incorporating existing gerontological models[iv]


Age-friendly environments:

  • Modify structural conditions within correctional institutions through age-appropriate retrofitting[v] and conduct additional research into architectural modifications that may produce positive outcomes for aging individuals, e.g. minimizing risk of falls[vi]
  • Identify activities of daily living that are prison-specific in order to recognize functional impairment among the incarcerated population[vii]
  • Research the relative benefits of segregating versus integrating incarcerated older people from the general prison population to help develop effective and appropriate correctional housing  models[viii]
  • Train correctional staff in geriatric care techniques and empower them with the knowledge to respond to the physical, mental, emotional, and gender-specific needs of the aging population[ix]


B: Expand and implement release mechanisms for older people.

  • Increase utilization of compassionate release and medical parole policies by broadening eligibility criteria and streamlining the process for approval, including the availability of “fast-tracking” medical parole should the individual’s condition significantly or suddenly decline.
  • Train medical providers in the application process for medical parole and compassionate release.
  • Provide enhanced Medicaid rates to nursing homes for formerly incarcerated elders and guarantee that in-prison medical units are equivalent to hospital stays for the purposes of Medicaid reimbursement.  
  • Improve discharge planning and reentry preparation for older adults by expanding or replicating Osborne’s Elder Reentry Initiative across the system.
  • Improve DOCCS’ ability to connect people with community health services prior to release by granting medical and transitional planning staff full access to the Internet, and digitize medical records so that transferring incarcerated individuals does not impede health care.
  • Require OMH to provide discharge plans, including housing or residential care, for individuals on their caseloads BEFORE they appear before the parole board, so that parole does not continue to deny release to mentally ill individuals because they don’t have a viable discharge plan.
  • Provide the Parole Board with information about cognitive impairments and medical information to inform their interactions at parole hearings and their decisions regarding release.
  • Ensure continuity of care through specialized transitional planning and follow up for the aging population, including connection to geriatricians, health insurance and care coordinators.[x]

Despite my general skepticism about algorithmic risk scores, the fact is that age is the best predictor of risk of recidivism, and individuals who have aged in prison are, by virtually every measure, safe bets. I don’t believe there is a senior corrections official who isn’t both appreciative of the lifers for their work and positive influence, and baffled by why they are still in prison at all. We should not have to depend on the Governor’s generosity in granting clemency to do what is right: the law should provide presumptive parole for individuals with low risk scores who are over 60 and have served at least a decade behind bars.

References:

1 New York State’s Aging Prison Population. DiNapoli (2017). http://osc.state.ny.us/reports/aging-inmates.pdf

2 Ibid.

3 Aging in prison: A human rights problem we must fix. Cool, Kerness, Henry, Ross (2017). https://www.afsc.org/sites/afsc.civicactions.net/files/documents/Aging%20in%20prison%20report%202017.pdf

3Aging adult in prison have the lowest recidivism rate and pose almost no threat to public safety. (Snyder, C., van Wormer, K., Chada, J., & Jaggers, J. (2009). Older adult inmates: The challenges for social work.

Social Work, 54, 117–124.)

[i] Policy Research Associates, 2012; Maschi, T., Viola, D. & Sun, F., 2012.

[ii] Id.

[iii] Id.

[iv] Id.

[v] Policy Research Associates. (August 2012). Responding to the Needs of an Aging Prison Population. Available at http://gainscenter.samhsa.gov/cms-assets/documents/66624-251634.aging-in-correctional-custodyfinal.pdf

[vi] Williams, B. et al. (2012). Addressing the Aging Crisis in U.S. Criminal Justice Health Care. American Geriatrics Society, 60.6, 1150-1156.

[vii] Williams, B., Lindquist, K., Sudore, R. et al. (2006). Being old and doing time: Functional impairment and adverse experiences of geriatric female prisoners. Journal of the American Geriatrics Society, 54, 702–707.

[viii] Thivierge-Rikard, V., & Thompson, M. S. (2007). The association between aging inmate housing management

models and non-geriatric health services in state correctional institutions. Journal of Aging and Social Policy, 19, 39–56.

[ix] Id. 

[x] See Williams & Abraldes, 2007; Aday, 2003; and Crawley & Sparks, 2006.