Promising Practices and Fashions for Older Adults Transitioning from Incarceration Again to the Group

Introduction

When older adults depart jail or jail, they typically face explicit challenges to profitable reentry into their communities. They could be leaving with persistent well being circumstances in addition to bodily and psychological disabilities that inhibit actions of day by day residing. On account of structural racism within the felony authorized system and the criminalization of poverty, older adults leaving carceral settings usually tend to be low-income individuals of coloration. They’re susceptible to not assembly their primary wants on account of discrimination and gaps in public advantages and social companies programs. Nonetheless, alternatives exist for advocates, states, and federal policymakers to attach older adults leaving jail and jail to applications that assist them thrive. This coverage paper identifies promising practices and fashions in housing, well being care and financial safety to raised help older adults transitioning from carceral settings to the group.

Connecting to Housing

Steady housing is important for older adults re-entering the group. But previously incarcerated older adults face excessive dangers of homelessness on account of numerous components, together with lack of earnings and housing discrimination in opposition to individuals with felony information. The 2023 California Statewide Research of Individuals Experiencing Homelessness, for example, discovered {that a} important quantity (33%) of older adults within the research recognized their felony information as a barrier to securing everlasting housing.^[1] Worse but, homelessness additionally will increase the chance of reincarceration because of the rising criminalization of acts associated to homelessness, reminiscent of loitering or sleeping outdoors.^[2] An extra problem is that these unhoused older adults, who typically have advanced medical circumstances or bodily and cognitive disabilities, want a spread of helps to search out and preserve housing.

Some states and native communities are, nevertheless, growing methods of delivering these helps and growing entry to housing for previously incarcerated individuals. Two promising fashions for supporting this inhabitants embrace: (1) Everlasting supportive housing with a “Housing First” strategy; and (2) Medicaid 1115 waivers that present housing-related companies.

Present Everlasting Supportive Housing with a “Housing First” Strategy

An essential intervention that may meet the housing wants of previously incarcerated older adults is everlasting supportive housing (PSH). PSH supplies rental help and voluntary supportive companies with out deadlines, and PSH often targets households with disabilities susceptible to or experiencing persistent homelessness. PSH helps, which goal to advertise housing retention and unbiased residing, could embrace wraparound companies reminiscent of case administration and behavioral well being remedy.^[3] PSH applications will also be tailor-made for particular subpopulations, reminiscent of older adults and folks with prior involvement within the felony authorized system.

Importantly, PSH applications are inclined to undertake a “Housing First” strategy. Housing First is a confirmed mannequin of addressing homelessness that expedites entry – with minimal preconditions – to everlasting housing with voluntary helps. Housing First applications have low-barrier admissions insurance policies and, in contrast to different forms of housing, typically don’t display individuals out due to felony information (with restricted exceptions).^[4] When these applications do display for felony historical past, they nonetheless search to attenuate the impression of felony information. For instance, earlier than denying anybody primarily based on a felony conviction, Housing First applications could encourage candidates to supply mitigating info, reminiscent of medical information or letters of help from third events, to be able to conduct holistic and individualized assessments of candidates’ felony histories and current circumstances.^[5] Such practices scale back overbroad, discriminatory housing denials primarily based on felony information.

Analysis has demonstrated that PSH with a Housing First strategy is efficient in retaining individuals housed and might break the cycle between incarceration and homelessness. One current instance is the Denver Supportive Housing Social Affect Bond Initiative, a research which supplied supportive housing to individuals experiencing persistent homelessness who additionally had a historical past of involvement with the felony authorized system. Outcomes confirmed that 77% of individuals remained stably housed after three years, and individuals had a mean of 40% fewer re-arrests than individuals who acquired companies in the neighborhood however didn’t obtain supportive housing.^[6] In an analogous research of a program known as Returning Residence Ohio (RHO), researchers evaluated a program providing PSH to individuals re-entering the group with sure medical wants and susceptible to homelessness. In comparison with the management group, individuals have been 40% much less more likely to be re-arrested and 61% much less more likely to return to jail inside a yr. As well as, over a interval of almost 4 years, roughly 79% of individuals maintained their housing.^[7]

Given PSH’s effectiveness and the excessive charges of homelessness amongst previously incarcerated older adults, communities ought to take into account prioritizing this group for placement in PSH. Most PSH placements happen by way of a group’s HUD-funded coordinated entry system run by teams known as Continuums of Care (CoCs). CoCs exist in each state, and every CoC operates a coordinated entry system that prioritizes eligible households for referral to homeless interventions like supportive housing, with higher-need households given larger precedence for referrals. (One barrier for the reentry inhabitants, nevertheless, is that folks should meet HUD’s definition of “homeless” to qualify for CoC help; individuals leaving establishments, reminiscent of prisons, are solely eligible in the event that they meet slim standards.)^[8]

Coordinated entry assessments concentrate on a family’s vulnerability to continued homelessness, and CoCs can incorporate a person’s historical past of incarceration into these evaluations. For instance, numerous CoCs use evaluation instruments that ask about individuals’s contacts with the felony authorized system and the frequency or size of time a person has been incarcerated.^[9] Such assessments acknowledge that folks’s felony authorized involvement creates obstacles to housing and signifies a higher want for help. Some CoCs additionally take into account older age of their prioritization standards for comparable causes.^[10] By prioritizing previously incarcerated older adults for referrals to PSH, communities can goal restricted PSH assets to individuals with among the biggest housing challenges and meet this inhabitants’s wants.

Leverage Medicaid Part 1115 Waivers to Present Housing Helps

New flexibilities within the Medicaid program supply alternatives for states to deal with enrollees’ health-related social wants, together with housing by way of Part 1115 Demonstration waivers.^[11] Via these waivers, states have began to make use of Medicaid funding to cowl housing helps reminiscent of housing search help and eviction prevention companies. Part 1115 waivers additionally permit states to supply sure Medicaid recipients with momentary rental help for as much as six months, which may function a essential bridge whereas individuals hook up with long-term helps.^[12] States with accredited waivers have focused these housing companies to subpopulations that usually embrace previously incarcerated older adults, reminiscent of individuals with felony authorized system involvement or individuals susceptible to or experiencing homelessness.

Oregon, for instance, is leveraging a Medicaid 1115 waiver to supply complete housing helps for previously incarcerated older adults. Underneath Oregon’s 1115 waiver, some Medicaid enrollees – together with individuals 65 and older – who’re transitioning from carceral settings or susceptible to or experiencing homelessness can qualify for numerous Medicaid-funded housing advantages. These advantages embrace rental and utility help for as much as six months. Different accessible housing helps embrace house modifications crucial for well being and security, in addition to tenancy sustaining companies that assist people with points like speaking with landlords, understanding leases, and referring individuals to authorized support.^[13] Oregon’s Medicaid-funded housing helps due to this fact goal to supply a broad vary of help find and retaining housing.

As states proceed to implement these waivers, cross-sector collaboration will likely be key for profitable outcomes. To help such collaborations, the U.S. Division of Well being and Human Providers (HHS) and Housing and City Improvement (HUD) just lately launched the Housing and Providers Partnership Accelerator program. The Accelerator program supplies technical help for taking part states with accredited 1115 waivers masking housing-related companies. A central focus of this system is to foster partnerships between the housing, well being, and growing older and incapacity sectors to raised align programs and advance methods for lowering homelessness for older adults and folks with disabilities.^[14] HHS and HUD ought to encourage states to incorporate entities offering reentry companies, reminiscent of state departments of corrections (DOCs), in these interdisciplinary efforts as properly. Doing so might lead to extra coordination throughout companies to stop homelessness for older adults leaving incarceration.

Connecting to Well being Care

Leverage Medicaid 1115 Demonstrations to Connect with Residence and Group-Based mostly Providers

States may also use 1115 waivers to supply well being care and helps to people reentering the group after incarceration. Individuals leaving incarceration, together with older adults, exhibit disproportionately excessive charges of persistent well being circumstances, in addition to disproportionately excessive charges of incapacity, psychological well being problems, and substance use.^[15] Additionally they are inclined to have little to no earnings and few assets, and due to this fact depend on applications like Medicaid to satisfy their well being care wants. Sadly, on account of Medicaid legislation’s prohibition on federal reimbursement for medical companies in jails and prisons, individuals leaving incarceration typically expertise gaps of their care that result in poor well being outcomes, together with exacerbated well being circumstances, repeated hospitalizations, frequent use of emergency rooms, and excessive overdose and suicide charges.

Recognizing that medical companies are important to enhance well being outcomes for people leaving incarceration, almost half of states have acquired or are presently in search of Part 1115^[16] demonstration authority to waive Medicaid’s federal “inmate exclusion” and permit entry to Medicaid companies beginning thirty to ninety days previous to launch from incarceration.^[17]

The Facilities for Medicare and Medicaid Providers (CMS) inspired states to use for 1115 demonstrations to ship pre-release Medicaid eligibility and reentry companies in steerage to states from April 2023.^[18] CMS is requiring all states to incorporate a minimal set of advantages of their demonstrations: case administration to evaluate wants and help with entry to pre- and post-release companies, Treatment-Assisted Therapies for substance use problems, and a 30-day provide of prescription treatment. Nonetheless, as a result of 1115 demonstrations give states flexibility in whom to serve and what companies to incorporate, there’s important variation amongst present reentry demonstrations within the goal populations eligible to entry pre-release companies and within the forms of companies supplied.

Though individuals leaving incarceration have excessive charges of incapacity, states’ demonstration functions largely omit the house and community-based companies (HCBS) which can be key for individuals who want help with actions of day by day residing. Excluding HCBS within the pre-release part can simply translate into their exclusion from reentry planning altogether. For instance, the implementation information for California’s Justice Concerned CalAIM initiative didn’t embrace any HCBS in pre-release screening, assessments, reentry planning and post-release service coordination, till incapacity and growing older advocates raised this with the state.^[19]

Regardless of heavy funding in pre-release helps, older adults and folks with disabilities are susceptible to unmet care wants that may result in housing instability, poor well being outcomes, and institutionalization if entry to crucial HCBS isn’t built-in into these demonstrations. In mild of disproportionately excessive incapacity charges amongst people leaving incarceration, states ought to embrace pre-release actions that anticipate a necessity for HCBS, and display and join people with Medicaid HCBS at reentry by:

• Requiring screening for HCBS in pre-release wants assessments.
• Together with HCBS navigation companies within the 1115 demonstration for people who want help with actions of day by day residing or different helps.
• Together with software help and repair certification help as a reimbursable service supplied by in-reach case administration.
• Together with coordination of HCBS at reentry as a coated reimbursable service.
• Together with HCBS coordination as a part of housing navigation and help by way of the reentry planning course of.

Advocates ought to present enter to their state Medicaid companies throughout all phases of the reentry demonstration waiver course of on these suggestions, from software by way of implementation. It’s essential for HCBS advocates to be on the desk in order that older adults and folks with disabilities aren’t left behind as states undertake this transformative alternative.

Foster Connections to Medicare Enrollment Counseling

As mentioned above, because of the low incomes and financial savings of individuals leaving incarceration, Medicaid is a typical well being care possibility. Nonetheless, it isn’t the one possibility. Adults age 65 and older and folks with disabilities could also be eligible for Medicare.

Medicare protection is useful for a variety of totally different causes. For some older adults re-entering with larger incomes or financial savings, Medicare could also be their solely well being protection possibility. For different people who’re additionally eligible for Medicaid, enrolling in each Medicaid and Medicare can lead to extra expansive supplier networks and broader service protection.

Enrolling in Medicare at re-entry could be complicated. Sadly, many older adults leaving incarceration nor individuals within the reentry sector have no idea Medicare is an possibility, and, in the event that they do, they in all probability have questions like:

• How do I do know if I’m eligible?
• How do I keep away from late enrollment penalties?
• Is there assist accessible for Medicare premiums and different prices?
• My Social Safety examine is being lowered by past-due Medicare premiums. Is there something I can do?

There’s a community of free, unbiased Medicare counselors who’re a part of the State Well being Insurance coverage Help Program (SHIP community) accessible in each state. For instance, a SHIP counselor can:

Because the incarcerated inhabitants grows older, there is a chance to attach the re-entry sector with SHIP counselors. As an example, many states are presently within the means of hiring a big cohort of re-entry navigators as a part of Medicaid re-entry demonstrations. These navigators might establish people seemingly eligible for Medicare, advise them of their protection choices, and refer them to their native SHIP. Navigators may also reap the benefits of outreach assets developed by CMS and translated into eight languages (Arabic, Chinese language, Haitian Creole, Korean, Russian, Spanish, Ukrainian, and Vietnamese) to assist people hook up with Medicare, Medicaid, and different well being protection upon re-entry.

Connecting to Financial Safety

Supplemental Safety Earnings (SSI) and Social Safety are foundational advantages that assist older adults and people with disabilities to safe housing and pay for different primary wants. To make sure that the SSI program higher helps previously incarcerated older adults, the SSI 12-month suspension restrict must be eliminated, and the Social Safety Administration (SSA) ought to share finest practices for the pre-release course of.^[20]

Enable SSI To Resume Upon Launch for People Who Beforehand Certified

For people who have been receiving public advantages previous to incarceration, with the ability to re-connect to those advantages is essential for a profitable transition to the group. For older adults who aren’t but eligible for age-based advantages and solely qualify for disability-based advantages, the re-connection guidelines differ between SSI incapacity and SSDI, with the SSI rule making it tough for people to rapidly resume their prior profit.

A person who acquired SSDI or one other Social Safety profit previous to incarceration can reinstate their profit upon launch with no important limitations. In distinction, a person who acquired SSI previous to incarceration can solely reinstate their SSI profit after their launch whether it is inside 12 months of when their SSI profit was suspended. In follow, the differing guidelines imply that people who beforehand acquired SSDI are in a position to simply re-connect to advantages, whereas people who beforehand acquired SSI on the idea of incapacity are negatively impacted by the 12-month suspension restrict and should have to file a brand new incapacity software.

A more practical and equitable course of would permit SSA to reinstate the SSI profit no matter how lengthy the individual has been incarcerated, as is the case with SSDI. This alteration would make the SSI rule in line with the SSDI rule and likewise be extra in line with our understanding of incapacity. There isn’t any indication that being incarcerated for a couple of yr improves incapacity and, if something, is extra more likely to worsen a disabling situation.

Share Finest Practices for SSA’s Pre-Launch Course of

People who weren’t receiving SSI or Social Safety earlier than incarceration can use SSA’s pre-release course of to submit an software as much as a number of months earlier than their anticipated launch, with SSA figuring out the person’s potential eligibility and cost quantity primarily based on their anticipated circumstances.

People with little to no earnings and assets can qualify for SSI if they’re age 65 or older or in the event that they meet SSA’s definition of incapacity. The incapacity willpower course of is notoriously tough and might take a number of years for people whose functions are denied and who should enchantment the denial. Previously incarcerated people with disabilities who’re homeless or housing-insecure expertise obstacles with even primary parts of the appliance course of, reminiscent of having a secure handle or cellphone quantity, making it tough to efficiently full an software. Bettering the effectiveness of SSA’s pre-release course of would assist people with disabilities to submit full and complete incapacity functions to SSA, and enhance the probability of people who qualify really receiving the incapacity profit upon launch.

People age 65 or older have a a lot less complicated SSI software expertise, as they don’t have to undergo the incapacity willpower course of. Guaranteeing an efficient SSA pre-release course of ought to permit nearly all of those previously incarcerated older adults to obtain SSI advantages upon launch.

The main points of SSA pre-release agreements can differ, each from state to state and even inside the identical state as a neighborhood jail could have their very own pre-release settlement. SSA ought to overview how the method works now, collect finest practices from present SSA pre-release agreements and different related reentry efforts, and share this info with federal, state, native, and group companions curious about and engaged on this work. The work of gathering and sharing finest practices can assist establish areas the place candidates or software companions lack enough info, or the place gaps exist in operations or coverage. This info can assist SSA to enhance its outreach, in addition to its pre-release processes and coordination. Higher coordination may also assist maximize the impression of pre-release work in different profit applications like Medicare and SNAP, serving to previously incarcerated people to entry the entire advantages they qualify for extra rapidly, at a time once they want them probably the most.

Conclusion

Whether or not within the context of well being care, housing, or financial safety, reentry and growing older advocates and state and federal policymakers have alternatives to help older adults leaving jail and jail by connecting them to and enhancing the essential companies and applications that permit them to age with dignity of their communities.

Endnotes

1. Benioff Homelessness and Housing Initiative, “Towards Dignity: Understanding Older Grownup Homelessness” (Might 2024). ↑

2. See, e.g., The Attraction, “Cities Rush to Criminalize Homelessness After Supreme Courtroom Ruling” (August 2024). ↑

3. HUD Alternate, Everlasting Supportive Housing (PSH); HUD, Discover CPD-16-11, Discover on Prioritizing Individuals Experiencing Continual Homelessness and different Weak Homeless Individuals in Everlasting Supportive Housing (July 2016). ↑

4. HUD doesn’t require homeless help tasks funded by the Continuum of Care program to disqualify households primarily based on felony historical past, and the company strongly discourages tasks from excluding individuals on the idea of felony information. Nonetheless, tasks could also be topic to different federal, state, or native legal guidelines that require them to display out individuals with sure information, reminiscent of individuals on intercourse offender registries who could also be prohibited from residing in sure areas. HUD Alternate, Truthful Housing and Equal Entry – Prison Historical past. ↑

5. HUD, “Implementing Housing First Practices for Individuals Concerned with the Prison Justice System.” ↑

6. City Institute, “Housing First Breaks the Homelessness-Jail Cycle” (July 2021). ↑

7. HUD, “Decreasing Offender Recidivism and Reconnecting Alternative Youth” (2016). ↑

8. People who find themselves leaving establishments the place they’ve stayed for extra 90 days don’t meet HUD’s definition of “homeless” and aren’t eligible for CoC-funded homeless help, together with many PSH applications. Solely individuals who have been homeless earlier than getting into an establishment the place they stayed for 90 days or much less qualify as “homeless.” 24 CFR § 91.5; 24 CFR § 578.3. Different forms of homeless help, reminiscent of Medicaid-funded housing helps, could have broader eligibility standards. ↑

9. HUD, “Methods for Prioritizing Individuals with Prison Data in Coordinated Entry Programs.” ↑

10. See, e.g., Cobb Homeless Alliance, “What’s Coordinated Entry?”; Lee County Continuum of Care Written Requirements & Coordinated Entry Insurance policies and Procedures (July 2023). ↑

11. States may also use different Medicaid authorities, reminiscent of state plan authorities, to cowl health-related social wants. See CMS, Protection of Well being-Associated Social wants (HRSN) Providers in Medicaid and the Youngsters’s Well being Insurance coverage Program (CHIP) (November 2023). ↑

12. Middle on Funds and Coverage Priorities, “States Can Use Medicaid to Assist Handle Well being-Associated Social Wants” (February 2024). ↑

13. Oregon Well being Authority, Ceaselessly Requested Questions (FAQ): OHP 1115 Medicaid Waiver for 2022-2027. ↑

14. Housing and Providers Useful resource Middle, Housing and Providers Partnership Accelerator Program Overview. ↑

15. Well being Affairs, Vol 41, No. 10, “The Hyperlinks Between Incapacity, Incarceration, and Social Exclusion,” (Oct, 2022). ↑

16. §1905(a)(30)(A) of the Social Safety Act. ↑

17. As of August 2024, CMS accredited eleven such demonstrations, with 13 functions pending approval. Hinton, Elizabeth, Pillai, Akash, and Diana, Amaya, KFF, “Part 1115 Waiver Watch: Medicaid Pre-release Providers for Individuals Who’re Incarcerated,” (Aug. 19, 2024). ↑

18. CMS, SMD #23-003 “Alternatives to Check Transition-Associated Methods to Help Group Reentry and Enhance Care Transitions for People Who’re Incarcerated,” (April 17, 2023). ↑

19. California Division of Well being Care Providers, Coverage and Operational Information for Planning and Implementing the CalAIM Justice-Concerned Reentry Initiative (October 20, 2023) (closing model that features reference to house and community-based companies has not been made public by the point of this publication.). ↑

20. The Social Safety Advisory Board has additionally made a variety of suggestions to enhance reentry for SSI claimants in its report on Supplemental Safety Earnings and Incarceration (2024). ↑