key: cord-294423-3458rek8
authors: Boucher, Nathan A.; Van Houtven, Courtney H.; Dawson, Walter D.
title: Older Adults Post-Incarceration: Restructuring Long-Term Services and Supports in the Time of COVID-19
date: 2020-09-29
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.09.030
sha: 
doc_id: 294423
cord_uid: 3458rek8

Objectives To describe long-term care services and supports (LTSS) in the US, note their limitations in serving older adults post-incarceration, and offer potential solutions – with special consideration for the COVID-19 pandemic. Design Narrative review Setting and Participants: Long-term care services and supports for older adults post-incarceration Methods Literature review and policy analysis Results Skilled nursing facilities, nursing homes, assisted living, adult foster homes, and informal care from family and friends compose LTSS for older adults, but their utilization suffers from access and payment complexities, especially for older adults post-incarceration. A combination of public-private partnerships, utilization of health professional trainees, and unique approaches to informal caregiver support, including direct compensation to caregivers, could help older adults reentering our communities following prison. Conclusions and Implications Long-standing gaps in US LTSS are revealed by the coronavirus (SARS-CoV-2) pandemic. Older adults entering our communities from prison are particularly vulnerable and need unique solutions to aging care as they face stigma and access challenges not typically encountered by the general population. Our review and discussion offer guidance to systems, practitioners, and policy makers on how to improve the care of older adults post-incarceration.

The United States (US) imprisons a larger proportion of its population than any other 27 country with 1,291,000 prisoners in state prisons, 631,000 in local jails, and 226,000 in federal Prison accelerates aging such that the prison population develops chronic illness 10-15 40 years earlier than community counterparts; incarcerated persons can be considered an 'older 41 adult' by 55. 5, 6 Contributing factors -largely predating sentencing in these disenfranchised 42 populations -are substance use, inadequate preventive care, mental illness, and the additional 43 stress of being incarcerated. 7 More than 600,000 individuals are released from state and federal 44 prisons each year and over 60,000 of them will be age 50 or above. These released older adults 45 leave prison in worse health than when they arrived and in worse health than community-46 J o u r n a l P r e -p r o o f dwelling persons of the same age. Despite the growing number of older incarcerated individuals 47 and their potential impact on the health of society, little has been done to research optimal 48 approaches to care once they are released.

Firm data on the full extent of health status disparity is scarce, but one Texas study found 50 that incarcerated persons 55 years of age and older used an average of 7.3 prescription 51 medications, which is higher than for non-incarcerated Americans of the same age. 8 Inmates 52 often have their necessary medications stopped once out of the care of the prison system 53 including 25% of chronically ill state prisoners and over 36% of ill local jail inmates. 9 Regarding 54 neurocognitive disease (such as dementia), the Alzheimer's Association indicates dementia 55 prevalence in the general population will be increasing from 1.7% in 2009 to 1.9% in 2030 and 56 then 2.6% in 2050. 10 Based on this, inmates with dementia may increase to approximately 57 127,130 in 2050. 11 Furthermore, according to a recent systematic review, re-entry planning for 58 older incarcerated persons is "sparse and the outlook is grim, given that many are released to 59 urban communities characterized by health disparities and inadequate health care resources." 12 60 And yet, there is strong evidence that optimal utilization of health-related services is linked to 61 improved health outcomes, lower recidivism (re-incarceration), and improvements in housing, 62 employability, and support provided through families. 13,14

Recently released older adults, given high rates of health problems and chronic 64 conditions, may simultaneously face both a great need for access to routine and acute health care, 65 as well as an accelerated need for long-term services and supports (LTSS) for their age. 13 A lack 66 of insurance and potential discrimination may compound their difficulty in obtaining continuity 67 of care and medication upon release. 15 The challenges they face are further exacerbated by the 68 introduction of SARS-CoV-2 (or COVID-19) into prisons and the community alike -with 69 J o u r n a l P r e -p r o o f confined space and limited healthcare in the former, and little community support, stigma, and 70 high-risk due to age in the latter. We explore these emergent challenges and offer Early release is another approach to mitigate COVID-19 transmission but is controversial 99 due to real and perceived risks to communities such as recidivism or a perception of punishments the Affordable Care Act, 33 but again, processing these applications prior to release is critical for 127 older adults between age 55-65 years of age to allow a seamless transition to the community.

With the enhanced access that insurance coverage assures, the released persons should then be newly released individual will obtain LTSS. While these individuals may also be Medicare 147 eligible due to age or disability status (so-called dual eligibles), Medicare coverage of LTSS is 148 limited to just 100 days of post-acute care (e.g., following a minimum three-day hospital stay).

As such, Medicaid is the default option for ongoing LTSS. In many states, due to their Medicaid 

Better support of caregivers -who report financial, emotional and physical strain related 217 to their caregiving role 58,59 --can lead to improved home care for older adults, an increasing 218 concern for our aging population. Better care at home for older adults can avoid unnecessary or There is an interrelation of correctional-system health, public health, and long-term care 286 services and supports for older adults. 76 Yet, there is a major knowledge gap about older adults 287 who are decarcerated due to a lack of data --including on rates of informal care and LTSS 288 utilization after release. We must first fill this knowledge gap to serve this population better.

Between these LTSS components, and along the continuum from prison to community, there are 

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