5

Guidance for Depopulating Correctional Facilities

Correctional facilities have been the sites of COVID-19 outbreaks across the country. Many of America’s correctional facilities are overcrowded, and their physical designs and conditions prevent appropriate distancing and ventilation, making them high-risk environments for virus transmission. Incarcerated people once infected are three times more likely to die from COVID-19 than the general population (Saloner et al., 2020). Furthermore, outbreaks in correctional facilities are not isolated from the communities in which they are located. Researchers have found high rates of infection among correctional staff and associations between community rates of infection and incarceration rates (Reinhart and Chen, 2020; see Chapter 2). Mitigating and ultimately ending the pandemic will require public health efforts on many fronts, among which will be mitigating the spread of the virus in correctional facilities.

This chapter provides guidance for policy makers and other decision makers at the federal, state, and local levels for depopulating correctional facilities. The chapter summarizes the committee’s findings in the previous chapters and highlights its conclusions and recommendations. The committee recognizes that some actions are immediately feasible (indeed, many are already under way in some jurisdictions), while others will take longer to implement. We offer recommendations that address immediate demands for preventing and controlling COVID-19 transmission in correctional facilities, as well as recommendations that foster preparedness for the next pandemic or emergency. Our assessment is based on the best available information and scientific evidence at this time, and we conclude with recommendations for critical data collection and research to build on this evidence base.

The preceding chapters have provided background in three ways: (1) laying out evidence on pre-pandemic conditions in prisons, jails, and U.S. Immigration and Customs Enforcement (ICE) detention centers, as well as the characteristics of incarcerated persons and their families and communities that have contributed to the spread of the novel coronavirus; (2) summarizing scholarship on COVID-19 and correctional facilities and assembling and analyzing data on COVID-19 infection in incarcerated people and staff and decarceration trends; and (3) describing prior scholarship on recidivism and evidence-based reentry supports, detailing the challenges and opportunities for responding effectively to the pandemic in the current context.

MITIGATING THE SPREAD OF THE VIRUS

The public health response to the COVID-19 pandemic in correctional facilities has been aimed at suppressing transmission of the virus to limit complications from the disease; to save as many lives as possible; and to preserve limited health care resources, including ventilators and personal protective equipment. The U.S. Centers for Disease Control and Prevention (CDC) issued guidance for correctional and detention settings twice during the pandemic (see Box 5-1 for the most recent guidance). Correctional administrators around the country have had to adapt these guidelines for the specific needs and challenges in their facilities.

Much of the CDC advice focuses on creating space between individuals; intensifying cleaning practices; and identifying, containing, and treating those infected within the operations of correctional facilities. CDC guidance encourages correctional officials to coordinate with law enforcement and court officials to identify ways to limit overcrowding (CDC, 2020), but it does not provide specifics about how best to reduce the population. Our review of the evidence indicates that relieving population pressures in jails, prisons, and detention centers greatly facilitates adherence to CDC guidelines, controlling COVID-19 outbreaks, and reducing health risks, particularly for medically vulnerable people (AMEND, 2020; Williams et al., 2020). Smaller populations make it easier for correctional officials to place individuals in single cells, have sufficient resources for testing, and safely quarantine individuals after exposure to an infected person.

The following sections summarize what the committee was able to learn during this brief study about efforts to mitigate the spread of the virus in correctional facilities, notably through its collective experience and the two webinars held in August 2020 (see Chapter 1). While some correctional, health, and legal authorities have responded creatively and vigorously to the pandemic, correctional facilities continue to experience large cluster outbreaks. Many correctional administrators still confront

pressing needs to reduce the numbers of confined people, especially those at high risk for infection and complications.

Attention to COVID-19 Prevention and Control among Incarcerated Individuals

Following CDC and other official guidance and through informal sharing of lessons between correctional leaders, facilities have adopted a range of approaches to prevent and mitigate SARS-CoV-2 transmission. These include population management (quarantines, medical isolation, cohorting, and single celling), surveillance, screening and testing for SARS-CoV-2 infection, contact tracing, and expanded communication efforts to keep incarcerated individuals and their families informed (e.g., see Box 5-2 for strategies undertaken by the Pennsylvania Department of Corrections).

Quarantines, Medical Isolation, Cohorting, and Single Celling

Quarantine, medical isolation, cohorting, and single celling are related protocols for separating COVID-19 cases from susceptible persons within

a facility. Quarantines involve separating individuals who are exposed to or expected to have an infectious disease from others in the facility until their disease status is known. In the case of COVID-19 in correctional facilities, the CDC recommends that individuals be quarantined for 14 days in individual cells (CDC, 2020).

Medical isolation is the practice of separating individuals with confirmed COVID-19 cases from the uninfected population until they are no longer contagious (Williams, 2020). Medical isolation is distinct from solitary confinement¹ (CDC, 2020). Given the negative impacts of solitary confinement (NRC, 2014), steps need to be taken to ensure the maintenance of contact with other people, including family, in cases of medical isolation. Although many facilities have suspended in-person visits to minimize viral transmission, some have implemented free virtual visiting programs and phone calls to encourage social contact. When the protocols of solitary

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¹ The CDC guidance refers to this as “punitive isolation” (CDC, 2020).

confinement are used for quarantines or medical isolation, individuals may mask or disguise coronavirus symptoms for fear of being sent to solitary confinement, which could lead to more extensive outbreaks (Cloud et al., 2020; Williams, 2020).

People with confirmed COVID-19 cases can be grouped together and isolated to prevent transmission to other people and parts of the prison or jail. This practice is known as cohorting (CDC, 2020). Cohorting individuals with confirmed COVID-19 allows correctional facilities to separate people with COVID-19 from the general population without isolating them entirely. Some correctional facilities have adopted other small groupings or cohorts in order to reduce person-to-person contacts and movement within facilities.² Assigning people to cohorts has thus served

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² For example, in the Pennsylvania Department of Corrections, the size of cohorts has ranged from 2 to 50 individuals depending on the prevalence of COVID-19 in a facility (see demobilization chart at https://www.cor.pa.gov/Documents/PA-DOC-COVID-DemobilizationPlan.pdf).

multiple purposes during the pandemic. Cohorts often share housing units and bathroom facilities and, depending on the level of virus transmission within a facility, meals, programming, and work assignments. Furthermore, correctional staff can be assigned to a single cohort, reducing the mixing of correctional staff with many different incarcerated people.

In some state prison systems, disused facilities or housing units were reopened in order to quarantine and/or medically isolate incarcerated people. In others, reducing the incarcerated population through prison releases and jail suspensions enabled the reconfiguration of units within facilities to support quarantines and isolation (CLA, 2020).

Surveillance and Screening and Testing for COVID-19

In response to COVID-19, correctional facilities have developed screening and testing procedures for staff and incarcerated individuals that have evolved throughout the pandemic. Facilities have used a range of diagnostic tests³ and have implemented mass,⁴ targeted, and prevalence⁵ testing strategies (CLA, 2020; Hagan et al., 2020).

Testing incarcerated individuals for COVID-19 proved to be a challenge for many facilities. Testing supplies were often limited and slow to arrive at correctional facilities, or sometimes rendered useless for controlling COVID-19 by the length of time required for laboratories to return

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³ Coronavirus tests fall into two primary categories: molecular or antigen (Food and Drug Administration, 2020). Molecular tests are used to diagnose an active coronavirus infection, and results for most molecular tests can take up to 1 week. Antigen tests can also be used to diagnose an active coronavirus infection, but they are more likely to produce false negatives than molecular tests. Antigen test results can be available within 1 hour. Rapid tests can be either molecular or antigen tests. These tests can be analyzed in a clinic or doctor’s office, potentially providing a result within minutes.

⁴ Mass testing usually refers to the practice of testing an entire population or group for coronavirus infection, whether or not they display symptoms. The goal of mass testing is to find asymptomatic or presymptomatic individuals with active infections (Raffle, Pollock, and Harding-Edgar, 2020). These individuals can then be isolated and their contacts can be traced to identify other potential cases. False negative and false positive test results are a concern in all coronavirus testing, and mass testing produces both false negatives and false positives in greater numbers (Raffle, Pollock, and Harding-Edgar, 2020), which carries the potential for missed cases and unnecessary isolation (Manrai and Mandl, 2020).

⁵ Prevalence testing entails testing a random sample of a population to determine the prevalence of an illness at a given point in time. Prevalence testing can provide corrections officials with useful information about viral spread in their facilities but does not identify all active COVID-19 infections. Targeted testing programs reserve tests only for those with either convincing symptoms, likely exposure to COVID-19, or risk factors for severe illness. Some have argued that incarcerated individuals and correctional staff should be priority targets for testing, given that they live and work in crowded conditions (Huerto, Goold, and Newton, 2020).

results (CLA, 2020). Accordingly, some correctional systems adopted alternative testing and surveillance approaches. The Ohio Department of Corrections (DOC), for example, supplements their surveillance by testing wastewater for the presence of the SARS-CoV-2 virus as an early warning system. In partnership with the U.S. Environmental Protection Agency and the Ohio State University, the Ohio DOC conducts regular wastewater tests of facilities (Chambers-Smith, 2020). The regular tests can identify likely outbreaks before they happen, giving correctional officials 5–7 days to prepare supplies, implement restrictive protocols, and marshal resources to the affected facility. The Ohio DOC also developed a contact tracing plan based on an incarcerated person’s movement through and within the system (Chambers-Smith, 2020); the Ohio DOC used surveys and facility-based cameras to identify people who were exposed to the infected person. Incarcerated individuals were tested on entry to a facility, when transfered between facilities, and after interaction with people in external facilities (e.g., after receiving health care services outside of their home facility) (Chambers-Smith, 2020). This testing plan allowed the Ohio DOC to identify more cases than had been revealed by mass testing or contact tracing.

Communication with Incarcerated Individuals and Their Families

Correctional leaders in some systems have used frequent communication with incarcerated individuals and correctional staff to encourage compliance with COVID-19 protective measures. The Correctional Leaders Association recommends “overcommunication” between corrections leaders and incarcerated individuals, with regular explanations of operational changes as they happen (CLA, 2020). Clearly communicating that changes to programming, movement, or visitation are occurring for the safety of incarcerated individuals, rather than punishment, is important for encouraging cooperation (CLA, 2020). One correctional official described to the committee their provision of opportunities for comfort and entertainment including setting up coffee and tea stations and providing board games and puzzles in quarantine units. Other facilities provided free access to cable television and tablets to use for education or entertainment (CLA, 2020), and free video visit programs to replace in-person visitation.

Some correctional leaders have also endeavored to communicate with the families and loved ones of incarcerated individuals about the status of COVID-19 infection within corrections and any adjustments to operations within correctional facilities. Several departments of corrections have shared information about COVID-19 within facilities with the public. The Pennsylvania DOC, for example, maintains a dashboard on its website with key coronavirus metrics for each correctional facility. The

website also includes information on facilities’ prevention and mitigation plans. Other state departments of corrections also maintain similar webpages.

Attention to Prevention among Correctional Facilities Staff

The most recent CDC guidance details protections for correctional staff (CDC, 2020), and public health experts emphasize the central importance of the occupational health of correctional staff to mitigating COVID-19 in correctional facilities (Sears et al., 2020). Like other first-line responders, correctional facility staff are essential workers and must report to work even during emergency lockdowns. They may either bring COVID-19 into the facility or acquire it at work and transmit it to their families and communities. Some correctional systems have worked to include staff in mitigation plans and make the development of these plans transparent (CLA, 2020), but balancing the safety and protection of staff while maintaining safe management of a facility is challenging. Many correctional facilities lack telework options and capability, face preexisting staff shortages that are compounded by absenteeism during the pandemic, and have limited employer-provided child care options and resources to cover new or existing staff without available paid leave.

Nonetheless, correctional administrators across the country have developed collaborations to implement practices for preventing and mitigating COVID-19 among facility staff. The committee is aware of many of these practices, including hiring community supervision officers and previous employees to address current staff shortages, streamlining onboarding processes, and providing incentives to work in high-risk areas; supporting telework where appropriate; allowing the use of administrative leave and providing paid sick leave for 14 days; promoting staff wellness by providing masks, hand hygiene stations, and resources for health and stress management; holding virtual town halls to address staff concerns; conducting on-site testing; and arranging alternative housing in hotels for staff members who self-report being exposed to COVID-19 and want to protect their families (CLA, 2020).

GUIDING PRINCIPLES OF EQUITY AND TRANSPARENCY

The COVID-19 pandemic in the correctional system follows the contours of racial and economic inequality, confronts decisions between the financial cost of mitigation and public health, and requires high-quality data for informed decision making. The committee thus adopted the following principles to consider in developing strategies for depopulating correctional facilities.

• Maximization of net benefits—Under this principle, decarceration plans will aim strategically to reduce mortality and morbidity caused by the transmission of COVID-19 among incarcerated and detained people, correctional staff, and the local communities in which they are located. In addition, planning will reflect consideration of improvements of conditions of confinement and services for those who must remain incarcerated, as well as potential public safety and fiscal costs.
• Equal regard and fairness with view to mitigation of health and racial inequities—The principle of equal regard recognizes the equal worth and value of all people, protecting them from discrimination, when determining fair approaches to limiting the use of custody and releasing individuals from correctional facilities. This principle requires that decarceration strategies be implemented in ways that do not raise risks to the health and well-being of already vulnerable individuals, families, and communities, and it also acknowledges how institutions and structures continue to increase the risk of incarcerated people for poor health outcomes, especially for Black and low-income people. Reducing COVID-19 transmission will require new partnerships across systems (housing, health care, social service, and correctional systems) and the removal of institutional and legal barriers that prevent incarcerated people from accessing food, health care, housing, and income supports following release. Achieving health equity means ensuring the fair and just opportunity to be as healthy as possible for all members of society, including those previously incarcerated. While health and safety priorities will have to be considered, the principle of fairness requires impartiality and the engagement and participation of affected groups in establishing criteria for decarceration.
• Transparency to support evidence-based decision making—A key issue for this principle is the use of health evidence to inform decisions about diversion and release. Health evidence typically has little role in criminal justice decision making, but public health emergencies necessitate a broad conception of public safety, one that encompasses the threats to life and health posed by virulent disease. The principle of transparency demands data on COVID-19 infection and complications from facilities and disclosure of the criteria and priorities that will determine people’s chances of future detention and/or release, as well as how decarceration strategies are to be implemented and whether certain populations will benefit more than others. Decisions in decarceration planning can be affirmed if they are supported by regular review of available data

• and information and informed by feedback from collaborators and stakeholders, including public health professionals and currently incarcerated individuals.

TAKING ACTION: THE COMMITTEE’S CONCLUSIONS AND RECOMMENDATIONS

Throughout this report, the committee has argued that incarcerated people and their families and correctional staff are particularly vulnerable to infection and severe illness from COVID-19. Standard prevention and infection control strategies within correctional facilities are important but can be difficult to implement, especially if facilities are overcrowded or unable to implement CDC guidance to maximize physical distancing and other mitigation strategies. Our first eight recommendations are based on one of our two key conclusions.

Decarceration is a process, not a one-time action, and will vary by state and jurisdiction, adjusting as needed for the state of viral transmission within a correctional facility and the surrounding community and the complement of housing, health care, and income supports necessary and available at the time. Safe and equitable decarceration will require a mix of policy and practice decisions among federal, state, and local officials and will require actions to reduce the number of people detained and to release incarcerated individuals from correctional facilities. It will require policies and actions to ensure adequate health care and social supports for released individuals and their families.

While the committee presents actions that may be taken in the short term to address immediate concerns, the committee also offers recommendations for preparedness for future outbreaks and pandemics, which are of key concern to decision makers and correctional leaders. Because forecasting the time frame in which the current crisis may end is highly speculative, the committee suggests actions and planning in the short term that can help with preparedness for future COVID-19 outbreaks and the next pandemic or emergency. Monitoring the progress of decarceration efforts, including regular assessments of the state of the pandemic and needs of those released

as well as those still incarcerated, will help jurisdictions make adjustments as necessary and build foundations for emergency planning during and post pandemic.

Diversion: Immediate Considerations

The committee urges all public officials with the legal authority to exercise their discretion to divert individuals from incarceration. During public health crises, there are few compelling public safety reasons to hold many people in custody. While there may often be risks of criminal behavior in the future, for many individuals, especially those held in pretrial detention, evidence suggests these risks are relatively low (see Chapter 3). The risks of crime and of viral transmission in correctional facilities both threaten community safety, and both need to be weighed in decisions to decarcerate.

As noted in Chapter 3, some jurisdictions have taken steps to decarcerate their correctional facilities through diversion. Decreases in incarcerated populations that have occurred since the onset of the pandemic are predominantly the result of declines in new entrants due to decreased arrests and fewer bookings because of lockdowns and the closure of state and local courts. As stay-at-home restrictions have been lifted and as courts have begun to resume normal operations, the number of new entrants into jails has begun to increase despite the continued public health risk. When incarceration seriously threatens a person’s health (see, e.g., Skarupski et al., 2018), incarceration for noncriminal behavior or minor charges is to be avoided. Misdemeanors, technical violations of probation and parole, and nonpayment of bail are all cases appropriate for diversion in a public health emergency. The use of discretion for diversion in this way may be especially relevant to jail incarceration and in many cases could be implemented immediately without formal changes in policy or new commitments of resources.

Release: Immediate and Medium-Term Actions

While efforts to divert individuals from incarceration will stem the flow of people into jails and, ultimately, prisons, additional mechanisms will be needed to reduce the public health risks confronted by individuals already incarcerated. The committee acknowledges that release efforts often require greater political will and more time to implement than diversion efforts. However, consideration of health equity prompts a deeper look at incarcerated individuals, especially those in prisons, who tend to be at greater risk for COVID-19 due to their age, the presence of chronic health conditions, and the length of potential exposure given their typically longer sentences. While the total prison population across the country has declined by roughly 5 percent since the onset of the pandemic (Franco-Paredes et al., 2020; see also Chapter 3), the existing legal mechanisms for release are slow (due to requirements to consider individual circumstances on a case-by-case basis) and not well suited in a public health crises, though a number of actors hold the authority to act, including correctional officials, parole boards, and governors, among others (see Chapter 3).

Moreover, the necessary extent of depopulation will vary by facility.⁶ The need and timing for various decarceration strategies will require consideration of factors such as overcrowding, the physical design and conditions of facilities, population turnover, and case positivity rates (or reproduction ratio) among the incarcerated population and surrounding community.

Past research on recidivism indicates that correctional authorities have opportunities to decarcerate in a manner that minimizes risk to public safety if given the flexibility to do so, as there are alternatives to incarceration and community supports that can reduce the risks of further criminal behavior. While prison release policies often focus on

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⁶ As noted in Chapter 3, total declines in system-wide populations by themselves may contribute little to mitigating the spread of the virus. For example, if the state of Pennsylvania incarcerated 100,000 people in January 2020 and released 20,000 in March 2020, the incarcerated population in Pennsylvania would have declined by 20 percent. However, if the state achieved that population decline by closing two facilities that housed 10,000 individuals each and did nothing to affect the population size of the remaining facilities in its system, the remaining incarcerated individuals would remain at the same risk as they were prior to the 20 percent reduction, if nothing else changed.

those convicted of nonviolent offenses, consideration of decarceration for individuals serving violent convictions is also warranted. Generally speaking, older incarcerated persons serving long prison sentences tend to be serving time for a serious violent conviction and these individuals are often those that are at high-risk for COVID-related complications and mortality due to advanced age and comorbid health conditions. Prescott, Pyle, and Starr (2020) find those convicted of violent crimes consistently have lower recidivism rates relative to individuals convicted of nonviolent crimes. Interestingly, the authors find that individuals convicted of violent offenses have lower overall recidivism rates for all age groups, though the recidivism rates are particularly lower for incarcerated people 55 and over (see Chapter 3).

Compassionate release—intended to reduce sentences and release incarcerated people for compelling reasons, usually related to medical and family circumstances—would in theory be appropriate during the pandemic. However, the committee’s review of state policies revealed substantial barriers to using compassionate release policies to shorten sentences when incarcerated people are facing significant risks to health, including death, hampering the ability of jurisdictions to undertake large-scale releases. When considering petitions for compassionate release, decision makers, such as judges and parole boards, should emphasize health criteria and age as well as the evolving environment of health risks during the pandemic, embracing evidence-based principles by adopting medical eligibility criteria that reflect current medical knowledge about how people commonly experience serious illness and die (Prost and Williams, 2020; Williams et al., 2011). Release

decisions relying substantially on the petitioner’s original crime will tend to overlook the medical criteria that should gain greater weight in a public health emergency.

In terms of procedure, states could consider revising compassionate release policies in ways that accord with changes in the federal approach to compassionate release resulting from enactment of the First Step Act. Previously courts could consider only compassionate release petitions brought by the director of the Federal Bureau of Prisons (BOP). Petitioners could file their compassionate release petitions and wait while their requests underwent multiple levels of BOP review, any one of which could result in a denial. Under the First Step Act, if petitioners receive no response to their petition within 30 days, they have the right to bring their own petition to the federal court. This shift not only speeds up the process but also allows for advocates to represent petitioners’ interests.

Reentry and Safe Return into Communities: Immediate and Medium-Term Actions

Engaging community systems to support successful reentry will be an important complement to any release efforts made in response to the COVID-19 pandemic. Research indicates that when a person leaves a correctional facility, the most urgent needs for material well-being include housing, health care, and income supports (Western, 2018). Steps taken through reentry planning and the provision of these supports, especially during the first few weeks following release, can help mitigate viral transmission, personal health, public health, and recidivism risks.

The committee recognizes that many of its recommendations for ensuring safe return to communities will have financial and budgetary implications for federal, state, and local governments, and especially correctional, housing, and health care systems. For this reason, the committee urges these actors to fully utilize existing funds and programs, ensure eligibility and enrollment of released people into existing social safety net programs, and prioritize this population in consideration for COVID-19 relief funds.

The quick release of incarcerated people, particularly those with chronic health conditions or mental illnesses, will require clear plans for continuation of medical care and information about how to protect themselves and their families from COVID-19. Prior to release, people need to receive adequate information and education on the release process, along with clear recommendations and connections to assistance programs and services that meet their specific needs (Beaudry et al., 2020). They and family advocates need to have the opportunity to meet with discharge planners or other social service providers to review discharge plans and community referrals, ask questions, and seek additional guidance as needed. Such information needs to be communicated at appropriate reading levels.

Housing, health care, and income supports, including provision for such basic needs as food, a telephone, and government identification, are important components of a discharge plan. Table 5-1 lists strategies that can be considered during discharge planning to ensure that supports and services are in place prior to reentry.

Obtaining these supports during the COVID-19 pandemic will vary by community. Community organizations may be closed or working remotely, which limits their ability to provide basic needs. In this context, telephone access is a priority, as it is critical to connecting with health care (Mann et al., 2020) and other social services (Western, 2006; Western et al., 2015). Incarcerated people being released need to therefore be given phones, preferably with video capacity, through a prepaid cell phone service or expedited referral to the Federal Communications Commission’s lifeline service. Likewise, as food systems are interrupted during the pandemic (Raifman, Bor, and Venkataramani, 2020), it will be important to facilitate the ability of those being released to obtain Supplemental Nutrition Assistance Program (SNAP) benefits prior to release, and states can expand their use of disaster SNAP benefits (Benfer and Wiley, 2020).

Given the high rates of COVID-19 among nonsheltered individuals (Baggett et al., 2020; Mosites et al., 2020), being released to homelessness during the COVID-19 pandemic is not in the interests of public health (Howell et al., 2020). Since many shelter systems are closed during community COVID-19 outbreaks, housing and medical discharge plans may need to be coordinated among housing, health care, and correctional systems to facilitate smooth and safe discharge plans, especially for the most medically vulnerable. As with past outbreaks of infectious disease in correctional facilities, multiagency collaboration is an integral part of managing release during the time of COVID-19 (Beaudry et al., 2020; CDSS, 2020) and critical to ensure racial equity. Families of Black, Hispanic, and Native American individuals tend to face more impediments and threats to safety than

TABLE 5-1 Strategies for Ensuring the Availability of a Bundle of Supports and Services for Reentry

NOTES: DEA, Drug Enforcement Agency; SAMHSA, Substance Abuse and Mental Health Services Administration; SNAP, Supplemental Nutrition Assistance Program; SSDI, Supplemental Security Disability Insurance; SSI, Supplemental Security Income.

SOURCE: Adapted from Howell et al. (2020).

White families offering housing to previously incarcerated family members (Simes, 2018a; Western, Braga, and Kohl, 2017). They are more likely to live in publicly subsidized housing, to face severe housing cost burdens, to live in overcrowded housing, and to fear eviction (National Low Income Housing Coalition, 2019). These factors all pose barriers to hosting a reentering individual and may magnify inequities if prisons and jails make decisions about whom to release based on the availability of housing and social networks.

The economic downturn brought on by the COVID-19 pandemic poses particular challenges for individuals who may be decarcerated during this period and require special considerations for social support systems related to employment, income support, and food security. Income support typically relies on the major federal antipoverty and social insurance programs, such as SNAP, Supplemental Security Income, and Social Security Disability Insurance, as well as unemployment insurance.

Access to community health care services can be challenging during COVID-19. In communities with high rates of transmission, some community health care systems are not taking new patients, and many are only conducting telemedicine visits. Especially in the midst of community outbreaks and particularly in rural areas where there is limited community outpatient and inpatient capacity, correctional facilities will need to ensure that all people reenter the community with guidance on how to access primary care and with at least a 90-day supply of their medications, which is a standard refill supply in the community (CMS, 2020).⁷ People just released from correctional systems often do not know how to make health care appointments, obtain their medications, or get a referral to access specialist care. Correctional facilities can also facilitate “warm handoffs” to community health care systems, including substance use and mental health providers (Freudenberg et al., 2005; Richie, Freudenberg, and Page, 2001), where possible, using video technologies.

Community health care systems need to screen new patients for recent release from a correctional system and provide, where possible, in-person appointments for those newly released given their propensity for poor health outcomes. When in-person visits are not possible, using telemedicine (as opposed to telephone visits) can improve patient engagement in primary care following release so additional efforts need to be made so that patients

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⁷ Primary care providers can play a key role in ensuring a health-promoting transition by checking to see whether patients have obtained their medications and know how to use them and have a telephone for future telemedicine visits and can attend to any urgent issues, including risk for postrelease relapse (Binswanger et al., 2013).

have phones with video capabilities and are not required to register for the health system patient portal prior to the visit.⁸

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⁸ Compared with telephone communication, video communication is associated with greater patient understanding, which is particularly important for newly released people given the essential role of trusting relationships and clear communication in primary and successful chronic disease management (Lion et al., 2015; Nouri et al., 2020).

Supporting Families and Communities

In implementing decarceration strategies, it is important to design reentry in a way that does not increase risk to families and communities. Many of the families and communities associated with incarcerated individuals are vulnerable to health risks, food and housing insecurities, and other forms of socioeconomic disadvantage because of the many existing institutional and structural barriers. Those challenges and needs have been exacerbated in the wake of COVID-19.

To reduce risk of COVID-19 to families and communities, testing prior to discharge with timely return of results would reduce the risk of exposing others to the virus. Given the false negatives and real-world implementation difficulties encountered with COVID-19 testing, a synergistic strategy would be to also provide individuals returning to congregate or crowded settings a place in the community to complete a 14-day quarantine in a safer environment, such as a subsidized hotel room. Providing 14 days of quarantine upon release could protect families and home communities. Individuals with a COVID-19 diagnosis, symptoms consistent with COVID-19, or exposure to a person with a confirmed or suspected COVID-19 diagnosis will need to be provided with appropriate accommodations for isolation. This strategy has been used for homeless individuals exposed to other infected individuals and to household members living in crowded housing (CDSS, 2020)⁹; implementation of this strategy would encompass people returning to shelters, halfway houses, and family homes.

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⁹ Many jurisdictions, concerned about the possibility of COVID-19 transmission in shelters, have created opportunities for those at high risk for COVID-19 infection (those who are older or have underlying health risks) to move to noncongregate shelters, such as unoccupied hotel rooms, trailers, or dorm rooms (CDSS, 2020). Relatedly, many have offered short-term stays in noncongregate shelters for those who have been exposed to or infected with COVID-19 but do not meet criteria for hospitalization (or for long-term noncongregate shelter) (CDSS, 2020). These projects were funded by a combination of funding, including Federal Emergency Management Agency (FEMA) disaster management funding, state and local funding, and funding from the Federal Emergency Services Grant program. While FEMA has provided up to 75 percent of funding for those who meet program entry criteria, the localities (or states) have needed to commit the money up front and apply for FEMA reimbursement (CDSS, 2020). Programs nationwide have found that the key to success includes providing appropriate staffing to support individuals staying in hotels. Program recipients have been provided a single-

Families of incarcerated people living in subsidized housing may face regulations that prevent adding nonleaseholders or people with certain convictions. Reentry plans need to consider family needs and may include provisions for assistance such as SNAP enrollment, public housing, and eviction protection (see the above discussion of supports for individuals).

Helping families prepare for and overcome reentry challenges can promote the health and well-being of individuals being released and their families and decrease the likelihood of recidivism. Communication to families is critical and needs to include information about the scheduled release date, time, and coordination with other agencies; any exposure to COVID-19 infections; and available support services. Providing support to families may involve partnering with community-based organizations that offer housing resources, employment and educational opportunities, child care services, case management, and such activities as relationship and parenting classes and reentry support groups.

Many individuals are mandated to community supervision or transitional housing (halfway houses) upon release and directed to report to parole or probation officers. Existing requirements often place formerly incarcerated individuals and their parole and probations officers in situations that could increase the likelihood of infection. Public officials can examine their parole and probation policies and procedures and take quick action where needed to reduce the impact of community supervision on the spread of COVID-19, as examples in Chapter 3 demonstrate. The usual conditions of supervision, such as requirements to apply for or obtain work, can be particularly onerous under pandemic conditions, when housing is highly insecure, public transportation is challenging, and unem-

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occupancy room, three meals a day, and supportive services. In California, there is also an effort to transition those in a Project Roomkey noncongregate shelter to permanent housing.

ployment is high. A coalition of community supervision executives have offered suggestions for minimizing health risks associated with probation and parole: revocation for technical violations should be greatly limited or eliminated, probation and parole should be applied only to those who absolutely need community supervision, terms of probation and parole should be reduced, office visits should be replaced wherever possible with noncontact means of collecting supervision reports, discontinuation of reporting altogether should be considered for low-risk individuals, and probation and parole staff should receive accurate and understandable training on health practices under COVID-19 (EXiT, 2020).

Improving Access to Health Insurance upon Release

Access to health insurance or assistance with navigating health care benefits is important for successful reentry during COVID-19. As discussed in Chapter 4, there are many barriers to Medicaid eligibility for incarcerated and formerly incarcerated individuals. Discharge planning should include a process for expediting enrollment or reenrollment in Medicaid or Medicare for eligible individuals upon release, especially since many government offices are closed so that people cannot obtain the necessary documents for Medicaid and Medicare applications, such as a proper form of government identification, in a timely way. For people with Department of Veterans Affairs (VA) health benefits, correctional facilities can also facilitate “warm handoffs” to VA resources. Additionally, activating Medicaid in the 30 days prior to release would not only create a path for paying for COVID-19 testing prior to release but also facilitate connections to a primary care provider, substance use and mental health treatment, and outpatient medications.

Allowing Medicaid payment for an incarcerated individual during the 30-day period prior to that individual’s release would provide a mechanism for COVID-19 testing and related services and ensure a smoother transition into primary care. There is evidence that tailoring health care practices to this population’s needs by hiring peers or community health workers with past histories of incarceration can improve patient engagement in health care (Cunningham et al., 2018; Wang et al., 2008;) and reduce preventable hospitalization, also reducing future contact with the criminal justice system (Wang et al., 2019). Community health systems could be incentivized to tailor primary care practices through Medicaid financing or financing of federally qualified health centers by the Health Resources and Services Administration, creating smoother transitions for people being released from corrections during COVID-19 and also for the opioid epidemic and other public health emergencies.

Activating Medicaid coverage in the 30 days prior to a person’s release would have the added effect of bringing oversight to correctional health care. It is well known that the quality of health care across correctional institutions varies greatly because of “a lack of uniform standards, the disconnect between correctional health care and that provided within the

community, and the variations in correctional health care providers and availability of treatments” (NRC, 2014, p. 213). While voluntary accreditation exists, there is no mandatory oversight of correctional health care as exists in the community setting that would permit identification of better- and worse-performing facilities or improvements in care delivery. Any preparedness strategy for the next COVID-19 outbreak or public health emergency will require improved integration of correctional facilities in the larger public health and health care system and especially during the transition back to the community.

PREPAREDNESS FOR FUTURE COVID-19 OUTBREAKS AND PANDEMICS

While the committee recognizes the need for urgent actions to incorporate decarceration as a tool to mitigate and prevent COVID-19 transmission in correctional facilities and the community, past literature of pandemic management in correctional facilities suggests that preparedness planning is critical to management of future COVID-19 outbreaks and other public health emergencies.

Evidence from the pandemic response in the past few months indicates that current efforts have been insufficient to reduce correctional populations in some facilities to a density that will enable those who remain incarcerated to practice adequate physical distancing or enable the release of those who are vulnerable to severe illness from COVID-19 or death. State and federal governments can take steps to improve the preparedness of correctional systems for future waves of the COVID-19 pandemic and subsequent pandemics or public health emergencies. As prison conditions and populations and the laws governing them are likely to change, existing state and federal public health agencies could provide an ongoing review of incarceration and release policies from a public health perspective and help ensure that the criminal justice system is prepared to respond appropriately to public health crises. These efforts could include the establishment of a planning and review group comprising public health experts, health care providers, and community representatives, including formerly incarcerated individuals, in collaboration with correctional officials and lawmakers, to review release policies from a public health perspective that weighs medical criteria and public health considerations with criminal justice system considerations. Such groups have been historically enacted to support governments and institutions by bringing together the appropriate balance of expertise to provide in-depth examination of particular issues and/or serve as an authoritative body between elected officials and the community to assist with public decision making.

In the context of an emergency, a group convened by federal, state, or local government could also be empowered to implement decarceration strategies in accordance with public health preparedness plans. In their deliberations, the group would need to consider both the needs of incarcerated people and those of staff, who also face elevated risks of harm during a pandemic. Such a group could also serve to provide real-time review of health care delivery and prevention efforts in correctional facilities as the science evolved. The success of any such group would depend on the exposure to a wide variety of perspectives and on an accurate understanding of prevailing carceral conditions. Channels will therefore need to be created to provide incarcerated people with access to the group, and group members will need to be granted the authority to visit and tour all parts of any carceral facility whose practices are being considered.

DATA NEEDS AND RESEARCH RECOMMENDATIONS

Currently, the prison systems of all 50 states, Puerto Rico,¹⁰ and the BOP, are providing some data relevant to COVID-19 prevention efforts and cases in their facilities in public-facing websites. Almost all prison systems report case rates and hospitalization and mortality data; however, far fewer systems report testing rates (including type of tests, repeated testing of individuals), which confounds reporting of case rates among incarcerated people and staff, as well as data on hospitalization and mortality. Across systems, these data are updated at different intervals, and there are few reports on how data are collected or defined or how data parameters may have changed over time. The lack of data standardization across correctional systems further complicates assessments of COVID-19 incidence and outcomes and comparisons with local communities. Only three states, as of this writing, provide any information on race or ethnicity, which is essential to identify and address possible disparities in COVID-19 testing, cases, and deaths.

Far less is known about COVID-19 outcomes in the 3,200 jail systems across the county. A majority of jails are not reporting any COVID-19

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¹⁰ Data from other U.S. territories are currently lacking.

case rates, hospitalizations, or deaths, and systematic data about detention centers of ICE or juvenile facilities are unavailable. Also important to understanding COVID-19 in jails and calculating basic epidemiologic characteristics of COVID-19 outbreaks are the daily populations of jails with respect to new intakes and releases, which change significantly, especially in large urban jails.

It is critical that correctional systems standardize their data. If there are gaps in reporting, systems need to also explain why and when data reporting has changed. It is not surprising that since March 2020, as the pandemic and knowledge about it has evolved, systems have changed their data reporting. However, much reporting has changed in significant ways with little transparency and explanation for the changes. If facilities are no longer reporting data or the variables being reported have changed, a narrative explanation of these changes needs to be provided. Systems also need to include definitions of all data provided and report the data both at the aggregate state level and by facility. In addition to these organizing principles, Box 5-3 lists each data point that all systems need to routinely report.

Although it may be difficult to eliminate the risk of transmission of COVID-19 from correctional facilities, the mitigation strategies recommended by the CDC, in combination with decarceration strategies described in this report, can improve the safety and health of residents and staff of these facilities and their families and communities. The limited evidence with which to judge the effectiveness of different strategies in relation to public health and public safety considerations makes decisions about these strategies challenging for jurisdictions.

Improvements in data collection, analyses and modeling of these data, and assembly of lessons learned will help meet these decision-making challenges. As indicated by the literature of the past few months reviewed for this report, researchers are using opportunities to conduct research in real time during the pandemic and provide scientific guidance as it becomes available. The committee encourages researchers to continue on this course; research

on the efficacy of correctional facility-specific surveillance, prevention, and mitigation strategies is urgently needed. This research needs to include understanding if there are unique structural risk factors of correctional systems that place staff and incarcerated people at heightened risk for COVID-19 or whether there are unique health conditions that place incarcerated individuals at increased risk for serious illness from COVID-19. Research on the role of correctional facilities in contributing to virus transmission in communities will also advance understanding of opportunities to improve public health more generally. In addition, research on the effectiveness of mitigation strategies will help in preparing for the next outbreak in this pandemic or the next pandemic or public health emergency. Research in these areas needs to consider the relative effects of diversion strategies as compared with releases from jails and prisons. Such research also needs to take into consideration the circumstances in which people are released, as well as in the housing conditions, health systems, and communities to which they are released. In addition, this research needs to examine disparities and any differential effects by subgroups and whether mitigation strategies, including decarceration, augment racial disparities in corrections or COVID-19 outcomes in the communities in which they are located.

CONCLUSION

In the perspective of this report, public safety encompasses good public health. Institutions for incarceration have hosted numerous outbreaks of infection and in this sense have posed a threat to public safety. Good health

and safety in the pandemic era will require reducing incarceration and supporting the communities whose incarceration rates are highest. Decarceration requires urgent and sustained engagement from correctional and health officials at federal, state, and local levels, as well as from those with oversight for community health systems and social services. The actions the nation takes now to prevent and mitigate COVID-19 will need to be measured and evaluated, as they represent an opportunity for learning to guide improvements to correctional health (and, by extension, to public health in vulnerable communities) and to the equitable and just use of incarceration.

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