Shining a Spotlight on Inadequate Response to COVID-19 in Prisons and Jails

In this recurring section, Healthcare Innovation editors take an in-depth look into the numerous ways the COVID-19 pandemic is impacting the healthcare ecosystem. In this issue, we specifically look at the impact of the virus spreading in prisons and jails, as well as how digital technology is helping employers get folks back to work safely.

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Researchers and advocates who track healthcare in prisons forewarned that COVID-19 was going to bring disaster to incarcerated people, prison staff and surrounding communities. The well-documented inadequate response has proven them correct. Will anything change going forward?

With 148,938 COVID-19 cases and 1,228 COVID-related deaths among people incarcerated in U.S. prisons, the COVID Prison Project (CPP) was established to increase transparency about coronavirus in incarceration settings as well as to track national and state policies and procedures. Advocates point out that in jails and prisons, inmates have little freedom of movement, often lack access to adequate hygiene and healthcare facilities, and may be unable to isolate if infected.

The CPP’s co-founder, Lauren Brinkley-Rubinstein, Ph.D., assistant professor of social medicine at UNC-Chapel Hill, researches how incarceration can impact health outcomes. She joined a recent panel discussion of how COVID-19 has spread through jails and prisons, how that is affecting not only inmates but also surrounding communities, what corrections officials are—and are not—doing to address COVID-19, and what should be done to improve health outcomes for and control the spread of COVID-19 among this population.

“We knew this was going to hit hard in jails and prisons,” she said. “By the summer it was clear there had been major outbreaks. Nine of the largest outbreaks in the country were in prisons and jails. We have seen some increases in testing, but it has never been adequate. There has been some one-time testing in prisons to appease advocates, but we still haven’t seen any long-term testing plans by a majority of places.”

“Prisons started giving us more data than they ever had before,” Brinkley-Rubinstein said. “We now have a pretty good understanding of incidents in 53 prison systems and 70 jails that are giving us the number of cases, deaths, and people tested. Our group is doing preliminary analysis of policies to make the link between correctional health and public health.” Only three states so far are providing any demographic data on COVID in prison, and she said her team of researchers knows much less about what is happening in jails, she noted. “Even the biggest jails aren’t giving us much data at all.”

‘Like having a cruise ship in every county’

Joining Brinkley-Rubinstein in speaking at the forum co-hosted by the Duke Initiative for Science & Society was Joseph Neff, a staff writer for The Marshall Project, an online news site covering the legal system and immigration. He expressed concern about jails as nexuses of community spread. Most people in jail are only there for a few weeks or months, he noted. “It’s like having a cruise ship in every county with people cycling in and out and lots of community spread. I am frustrated that this is an untold story happening all over the country. There is one county jail in Georgia that had 100 cases this week, 30 involving staff.” These outbreaks are popping up and are often unreported in the media, he said.

Neff added that prisons have been slow to test both incarcerated people and staff members. Part of the reason wardens may not want to test staff is that they are so understaffed already. “When prisons did mass testing, they found mass infection. Prison wardens have been slow to test because they don’t want to know what is going on in their facilities,” he said. It makes sense when you consider the crisis of short staffing in prisons. “In North Carolina state prisons are 25 to 30 percent understaffed. In Mississippi, only 50 percent of positions are filled. I believe they don’t want to know how infected the staff is because they don’t want to scare any more employees away. That is a managerial challenge to them.”

One way to deal with the situation would be to send more incarcerated people home early, Neff noted. Many are on work release and are trusted to go out into the community every day but return to the prison to sleep at night. “There is a real resistance to letting people out,” Neff said. He cited the following numbers for the first three months of pandemic — March, April, and May — concerning prisoners who applied for compassionate relief because they are old and/or sick and don’t have much time left on their sentences. In those three months, 10,940 applied. Of those, wardens approved 156, less than 1.5 percent. The rest were denied or ignored. Of the 156 approved, 84 were submitted to the federal Bureau of Prisons, which denied 73 of the 84. So it approved 11 of 11,000 who applied, Neff said.

‘Atrocious conditions’

Maria Morris, J.D.; senior staff attorney for the National Prison Project at the ACLU, also spoke at the event. She said that one of the things that tends to happen when a natural disaster or any other kind of disaster arises is that prisons and jails are forgotten about. “We began sounding the alarm early on to think through how prisons and jails dealt with the illness, because there are so many factors about the way they function that made it almost a certainty that what has happened would happen,” Morris said. “We knew that once in, COVID-19 would tear through prisons doing terrible harm. As the months wore on, we have been litigating with some, but not great, success for the most part. Appellate courts have not been very receptive to these cases.”

“What we have seen have been atrocious conditions,” Morris added. “Separate from COVID, prisons have problems of being crowded and not having very good medical care, and high populations of people that have the vulnerabilities that are likely to result in serious cases of COVID and death — high levels of diabetes, hypertension and lung diseases. In addition, they don’t tend to be the cleanest of places,” she explained, adding that even in places where there is a policy of wearing masks, staff and incarcerated people are not wearing masks consistently, and they tend to have poor quality masks. “What is being reported is the number of positive tests. They are not doing a good job of quarantining or isolating patients and when they are isolated, it is in solitary confinement, which carries its own risks.”

She gave one example from North Carolina in June. Its low-security facility in Butner prison had a significant outbreak and several people died. On June 1, they decided to do a round of mass testing. “Unfortunately, they didn’t do anything with the test results until June 10. The case numbers were jumping by 200 per day and had reached 600 in that facility out of 1,100 total inmates. They divided them up into housing units by whether they had tested positive or negative 10 days earlier, even though they were all in close contact that whole time. People were placed in negative units, even though they now had symptoms. So the testing didn’t have the impact it could have if they had acted upon it in a timely way.”

Brinkley-Rubinstein added that lag times in lab results and an inability to do contact tracing and quarantining — issues that haven’t been mastered in the community at large— are so much worse in these settings. In response to an audience question, she said that how vaccines will be distributed in prisons and jails is another issue that will need to be addressed from an ethical framework and with the input of incarcerated people.

By midsummer, it becoming clear that very few judges had an appetite for a broad release of people from prisons and even jails, Morris said. “There was some movement with jails trying to bring populations down somewhat by limiting people they were bringing in. As the attention started waning, you would see jail populations ticking back up. The focus has been more on trying to improve conditions. But they needed to address the risk and they weren’t doing that. We are still pushing forward with litigation to keep the pressure up. We are trying to keep scrutiny from the public and courts on prisons and jails.”

In Wisconsin, Using Technology to Get Healthcare Workers Back Safely

A digital app allows users to complete a short survey to assess their symptoms, exposure, and risk of infection

By Rajiv Leventhal

Nearly half of all workers who were surveyed earlier this year said they are concerned about being exposed to COVID-19 at work, according to a Gallup poll. Meanwhile, in June, a Kaiser Family Foundation analysis found that one in four workers is at high risk for serious complications from COVID-19 if infected.

These statistics are undoubtedly top-of-mind for individuals and their employers across all U.S. sectors as businesses continue to grapple over the best approach to get back to work safely. In healthcare, of course, the consequences of not being proactive and protective enough are severe. This is why leaders at ThedaCare, a seven-hospital health system serving a community of more than 600,000 residents across northeast and central Wisconsin, recently opted to introduce a solution called “Return to Work,” from healthcare technology company b.well, to its team members in an effort to safeguard front-line workers and ensure they check in daily on any COVID-19 symptoms or exposure.

The digital solution, accessed through a smartphone or PC, is designed to transition workers safely back to shared work spaces with new functionality that manages risk and complies with government regulations, according to b.well officials. Users complete a short survey to assess their symptoms, exposure, and risk of infection, and then receive personalized recommendations based on their responses.

Mark Cockley, M.D., chief clinical officer of ThedaCare, says the impetus behind implementing the solution was that while the health system’s hospitals already had processes in place to prevent employees from being exposed, gaps still exist when they’re at home, when their kids are going to school, and when they’re getting together with their families.

“We want to monitor them on a daily basis so that when they have come to work, they have taken a moment to see if they have symptoms or if they have been around someone who has exposed them. You could bring a disease into the hospital or clinic and expose people who are at risk. So it’s about having a process every morning or evening before going to work to say, ‘I am safe to go in,’” he says.

The solution has been deployed to thousands of employees, and the data gets recorded to the b.well platform, allowing health professionals at ThedaCare to monitor it and see how active and engaged users are. If an employee marked down that he or she did display symptoms or was exposed to someone who tested positive, for example, next steps might include accessing a virtual care visit, in-person appointment scheduling, benefits information, mental health resources, and COVID-19 updates and information, including regulatory requirements for their state and directions to the nearest COVID-19 testing centers.

Cockley further speaks to the importance of daily monitoring, as sometimes the symptoms are subtle, meaning someone might not have any today but could tomorrow, additionally noting there has been an uptick in local community spread over the last few weeks. Indeed, some Wisconsin hospitals are resorting to wait-listing patients, or sending them to other facilities, according to the Milwaukee Journal Sentinel. “Maybe the exposure [to the virus] was five days ago, but only now you are developing symptoms. It’s important to get it in your routine every day,” he contends.

The Return to Work solution is one part of the b.well Connected Health platform being leveraged by ThedaCare, which has rebranded the health management tool under the name “Ripple.” Leaders at ThedaCare say the name for the app illustrates the power of change and the role the platform can have in the health system’s communities. Through this digital experience, individuals—both ThedaCare employees and members of the community—will have the ability to coordinate health information across providers, pharmacies, and healthcare systems. Everyone who downloads Ripple and registers will be able to access their provider and insurance information, manage their medication, and receive alerts and reminders on future care needs, immunizations, and preventative care, officials attest.

Cockley notes that many people on their phones use digital apps and often have separate ones for different medical needs: one for pharmacy, one for insurance, and one for providers, for example. The b.well Connected Health platform, he says, ties those different apps together. “So you can have that one go-to app that goes across your healthcare system and your healthcare experience,” he says.

Ultimately, says Cockley, progress in this area will be measured in a few different ways. For one, he offers, “How many people and employees will get signed up? And how much of the community can ThedaCare provide good information for so that they continue to be engaged? How often are those accounts getting used and what percentage of those accounts get used on a regular basis?”

Cockley and this team will also be looking at how they’re helping people, starting with employees, with their regular health maintenance. The app can be used to remind them to get their blood pressure checked, or to schedule their colonoscopy or flu shot, for instance. “How can we help them lead a healthier life? We are working those elements into this to help determine how effective we are,” he says.

Another area in which progress will be evaluated is patient satisfaction, Cockley states. “Are they getting the information they need, and are they happy with it?” Of course, the cost of care will play a big role in determining success as well. We’re taking care of 7,000 employees and a few hundred thousand people in the community. Are people spending money wisely and getting value for their healthcare dollar? If not, how can we get there? This [platform] allows you to touch people in their healthcare journey more frequently, giving them the information they need when they need it, at their fingertips.” 

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