摘要：Objectives. We used “hot spotting” to characterize the persons most frequently admitted to the New York City jail system in 2013. Methods. We used our Correctional Health Services electronic health record to identify 800 patients admitted in 2013 who returned most since November 2008. We compared them to a randomly selected control group of 800 others admitted in 2013, by using descriptive statistics and cross-tabulations, including data through December 2014. Results. The frequently incarcerated individuals had a median of 21 incarcerations (median duration 11 days), representing 18 713 admissions and $129 million in custody and health costs versus $38 million for the controls. The frequently incarcerated were significantly older (42 vs 35 years), and more likely to have serious mental illness (19% vs 8.5%) and homelessness (51.5% vs 14.7%) in their record. Significant substance use was highly prevalent (96.9% vs 55.6%). Most top criminal charges (88.7%) for the frequently incarcerated were misdemeanors; assault charges were less common (2.8% vs 10.4%). Conclusions. Frequently incarcerated persons have chronic mental health and substance use problems, their charges are generally minor, and incarceration is costly. Tailored supportive housing is likely to be less costly and improve outcomes. The United States has the highest rate of incarceration in the world, with a nearly 5-fold increase in the prison population since 1978 1 and approximately 6.9 million people under the supervision of adult correctional systems at the end of 2013. 2 Though the causes of this growth are complex, the “war on drugs” and “deinstitutionalization” of inpatient psychiatric hospitals have been proposed as key drivers of growth in the incarcerated population over this time. The war on drugs refers to a law enforcement approach to the problem of substance abuse that historically focused on harsh penalties for drug possession and all aspects of distribution and sale. 3 Deinstitutionalization refers to the process by which long-term psychiatric hospitals were closed with the intention of diverting mental health resources to community-based care, though the corollary expansion of these services did not occur. 4 Both the war on drugs and deinstitutionalization contribute to the de facto criminalization of 2 societal problems that also lie squarely within the purview of public health: substance use disorders and mental illness. 5–7 Hot spotting, a practice in part inspired by targeted policing, refers to identifying and focusing on the highest users of health care services in a population and offering tailored, intensive case management in an effort to reduce costs and improve care. 8 Interventions tailored to this group have, on balance, demonstrated improved cost and health outcomes. 9–12 The high-user population identified in this manner has been shown to have high rates of mental illness, substance use, and homelessness. 13–15 The Bureau of Correctional Health Services of the New York City Department of Health and Mental Hygiene is responsible for the provision of medical, mental health, and discharge planning services in the New York City jail system. With an average daily population of approximately 11 000 persons and more than 60 000 admissions per year, the New York City jail system is among the largest in the world. Most admissions are relatively short, with a median length of stay of approximately 13 days, though a subset of patients stays for longer periods as they go through trial. Those sentenced to less than a year serve their time in 1 “sentenced” facility on Rikers Island and those with longer sentences are transferred to New York State prisons. All patients admitted to the New York City jail system undergo a full history and physical examination before being housed. The intake examination screens all patients for chronic medical and mental illness including substance abuse and sets the trajectory for follow-up care while incarcerated. We sought to characterize the medical and mental health conditions of the most frequently returning persons to New York City jails. The primary goal of this investigation was to inform the care we provide for this population, but the analysis also raises questions that cut across disciplines, including the nature of our patients’ relationship with the criminal justice system.
