Geriatric Prisoners: Health Unbound

reprinted from Issue 21, Fall 2015 of Frontiers of Medicine (PDF)

Caring for Vulnerable Populations

Brie Williams, MD, (left) and Cyrus Ahalt, MPP, at the San Francisco County Jail. They conduct novel research and champion public policy innovations to improve health care for older prisoners, who make up a growing segment of the incarcerated population.

As a UCSF geriatrics fellow, Brie Williams, MD, MS, became intrigued by how aging affected incarcerated populations. Working on a survey of older women prisoners, she scoured the literature for previous research. "I found two articles: a dated one about older prisoners in a US jail, and one about French prisoners written in French," recalled Williams. "I thought, ‘This may be an important manuscript to write, because it doesn't look like we know much about the health needs of this growing population.'"

Williams is one of many people in the Department of Medicine who embody the public service mission of UCSF by improving health care for vulnerable patients. Their work stretches far beyond the clinic and hospital, reaching into prison cells, homeless shelters and the streets to discover better ways to help the most marginalized members of our community.

Williams' first publication described daily activities important for prisoners to be physically independent – such as the ability to stand for head count and climb onto an assigned bunk – and led to her work on a statewide needs assessment of aging prisoners for the California Department of Corrections and Rehabilitation. Since then, her research has taken her to correctional facilities in nine states and five countries. She works closely with Cyrus Ahalt, MPP, who brings public policy expertise to their team. Williams also serves as associate director of discovery for Tideswell at UCSF, an incubator for aging-related research, clinical care and training.

About 2 million Americans are currently in prisons, over 12 million cycle through jails annually, and health-related costs represent at least 10 percent of the criminal justice budget," said Williams. "There are incredible opportunities to improve the value and quality of criminal justice health care."

Health impacts incarceration, and vice versa. "Mental health problems, substance use disorders and cognitive impairment are leading contributors to incarceration," said Williams. "Many prisoners have had a lifetime of inadequate healthcare access, and some receive their first-ever health care in the criminal justice system. Nearly all prisoners are eventually released, so optimizing their care has the opportunity to transform lives and communities."

Some of her group's initiatives include:

In UC Criminal Justice and Health Consortium:

Williams and Ahalt, along with colleagues at UC Santa Cruz and UC Riverside, recently received a University Office of the President Catalyst Award from UC President Janet Napolitano to improve health of incarcerated patients. "We're engaging 100 UC-wide faculty members and trainees from diverse backgrounds including economics, medicine, nursing, sociology, psychology and Chicano studies," said Williams. "Our vision is to bring this UC community of scholars together with policymakers to make transformational change in criminal justice health care."

Community Aging Health Project:

Williams and Ahalt partnered with the San Francisco County Jail to conduct a study of older jail inmates. Based on the results, the jail now automatically screens older detainees for cognitive and functional impairments and refers them to a physician if needed. Williams' team used their study findings to create geriatrics health trainings for jail clinicians, adapting these trainings for police officers and judges.

"Most older adults spend relatively little time with health professionals, so we need to give other professionals knowledge in aging-related health," said Williams. For example, in their training, police officers don thick gloves, earplugs and eyeglasses that distort their vision, tie rope around their ankles to shorten their gait, then try to walk. Judges learn how dementia and hearing impairment may impact an older adult during court proceedings. They have trained over 500 San Francisco police officers, 50 California judges, and correctional health professionals in California, Hawaii and New York, as well as physicians and nurses at the International Committee of the Red Cross who work in 50 detention centers worldwide.

Resource for policymakers:

Their research on compassionate release – early release or parole for seriously ill prisoners who pose little threat to the community – was highlighted in a report issued by the Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation. Williams participated in a workshop on incarceration and health convened by the Institute of Medicine, and Williams and Ahalt recently advised the US Senate Special Committee on Aging, identifying priority issues and recommending topics for for legislation.

Coordinating efforts:

In partnership with the UCSF Center for Vulnerable Populations, the San Francisco Sheriff's Department, the Senior Ex-Offender Program of Bayview Hunters Point Multipurpose Senior Services, Inc., and other Bay Area stakeholders, Williams' team is facilitating a city-wide meeting to develop a comprehensive Roadmap for San Francisco to better engage criminal justice-involved older adults with needed services.

European-American Criminal Justice Innovation Program:

In collaboration with the Prison Law Office, a public interest law firm, Williams and Ahalt will bring state legislators, criminal justice leaders and policymakers to visit model European prisons and help them adapt best practices to their home institutions.

"It's incredible to see radically different approaches, which give us ideas for achieving transformational change at home," said Williams. Her experience at Bastøy prison in Norway was particularly striking. "From the warden to the officers and prisoners, everyone said the same thing: ‘Most inmates will eventually get out, and our goal is for them to be the best possible neighbors when they do.' Helping people to leave healthier than when they went in is an integral part of realizing that goal."

Visionary Prisons

Dr. Brie Williams (above, right) with Tom Eberhardt, warden of Bastøy Fengsel, a prison located on a Norwegian island. Williams and her colleagues will bring American lawmakers and criminal justice leaders to Bastøy and other European prisons this fall to inspire innovation in the American prison system.

Bastøy’s ultimate goal is rehabilitation. The former church in the background now hosts meetings and concerts, including performances of a nationally recognized blues band whose musicians are prisoners. Inmates who have completed two-thirds of their sentence can take prison leaves to help them reintegrate into society, and the band plays at blues festivals during the summer.

Above: The communal kitchen at Sandaker, an “open prison” halfway house in Oslo, Norway which houses inmates who are approaching the end of their sentences. The staff includes correctional officers and social workers. Inmates work at outside jobs, but are required to return at night. They also earn community visitation privileges and often continue relationships with staff during probation.

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