As the American population ages, the number of incarcerated and homeless older adults is increasing rapidly.1–3,19
We found that older veteran and non-veteran prisoners who were within 2 years of release had a similar burden of medical and psychiatric conditions, and an equal number of risk factors for homelessness.
Appropriate targeting of community-based medical services to the growing number of newly released older prisoners is hampered by inadequate information about their health needs.17
A survey of returning prisoners of all ages showed that one-third of those with physical or mental health conditions used emergency room care and one-fifth were hospitalized within 8–10 months after release.50
Another survey found that most older prisoners had fears about their post-incarceration health.18
Former prisoners have a 12.7-fold increased risk of death in the 2 weeks following release (even excluding seriously ill prisoners granted compassionate medical release); the most common causes of death for those over age 45 are cardiovascular disease and cancer.14
We found that nearly 80% of older pre-release prisoners in our sample reported at least one chronic medical condition (average of 2.1) and that the rates of many medical conditions exceeded those reported in the community.51
These findings highlight the importance of pre-release health care planning for older prisoners.
The prevalence of serious mental illness in older community-dwelling adults is 15%–20%.35
A current or past history of serious mental illness was reported by 13.6% of our sample, similar to rates reported among older prisoners in Texas (11.0%),36
and Utah (13.6%).35
The actual proportion of our sample burdened with significant mental illness is undoubtedly higher than 13.6% because PTSD was excluded from the “serious mental illness” category. This exclusion is the result of an operational definition created to maintain consistency and comparability with other studies and is not intended to imply that PTSD is not a serious mental illness. There is a complex relationship among mental illness, homelessness, and incarceration, and a heightened risk of both recidivism and homelessness among released prisoners with mental illness has been observed.36,52,53
Additionally, homeless adults with mental illness and an incarceration history have a higher likelihood of experiencing long-term homelessness than those without mental illness.54
These findings underscore the importance of providing linkages to community-based mental health services for older released prisoners.
Because of the association between homelessness and increased acute health care utilization and mortality,20–25
homelessness prevention strategies have received increasing attention.44
A history of incarceration is a risk factor for homelessness,41,44,55
and between 6.3% and 11.4% of prisoners of all ages use homeless shelters following release.41
At least 8.4% of our sample was at risk for homelessness (based on a prior history of homelessness) and more than a quarter expected to live alone following release. These findings suggest that expanded efforts to secure housing for pre-release older prisoners are warranted.
Although pre-release health care and homelessness prevention planning for all older prisoners is needed, well-established and coordinated programs are typically available only to veterans. In 2001, Congress mandated that the Department of Veterans Affairs collaborate with the Department of Labor and the Bureau of Prisons to assist veterans during reentry.28
This collaboration culminated in the Incarcerated Veterans Transition Program in 2003, a demonstration program providing incarcerated veterans with connections to housing, health care, training, and employment.56
The Healthcare for Reentry Veterans Program, implemented in 2007, has provided outreach and reentry services to over 12,000 veterans in 451 state and federal prisons through June of 2009.57
Our study showed that 77% of pre-release older prisoners who were veterans reported military discharges with conditions likely to make them eligible for VA services. In addition, while veterans comprise about 10% of the state prison population,26
nearly 40% of our sample of older prisoners were veterans. This highlights the importance of the VA’s outreach efforts for this segment of the incarcerated population.
Conversely, 60% of our sample of older prisoners were non-veterans, underscoring the importance of developing national transition programs for non-veterans for whom existing services are limited.58
While non-veterans on parole may receive reentry assistance via a parole officer or formal parole programs, such services are diminishing with increasing non-parole releases and parole officer caseloads.58
Although the Serious and Violent Offender Reentry Initiative, established in 2003, provided more than $100 million to local reentry program development, the programs only focused on prisoners aged 35 and younger.30,59
Although coordinated reentry programs for non-veteran older prisoners are lacking, we found that rates of poor health status and risk of homelessness were just as high among this group as among veterans. Unfortunately, most states terminate Medicaid, Medicare, and Social Security Disability Income eligibility during incarceration,8–10
and reinstituting coverage can take up to 3 months.8,9
Given the high costs of emergency department services and the high risk of homelessness, all pre-release older prisoners should receive assistance with securing housing, medical care, and reinstatement of benefits, and should be screened for eligibility for VA services.
A strength of our study was that it included a random, nationally representative sample of US prisoners. Limitations included the use of self-reported data, although the majority of studies have found relatively strong agreement between self-report and medical record validation of major medical conditions in older adults.37–40
A validation of the medical questions in the SISFCF did identify some underreporting of medical conditions compared with administrative medical data.32
Although we do not know the extent of underreporting, the fact that Census Bureau employees conducted the survey and that no financial incentive was offered for participation likely minimized any incentives to provide inaccurate information. Additionally, underreporting of medical conditions would strengthen our finding that pre-release older adults have more medical conditions than nonincarcerated older adults. Also, it is possible that some veterans in our sample failed to self-identify, while other respondents falsely identified themselves as veterans. Given that we found few differences between the two groups, this possibility is unlikely to have affected our findings. Finally, because this study was cross-sectional, we were unable to determine how many respondents actually experienced homelessness after reentry. Prospective studies are needed to assess rates of homelessness, medical decompensation, and mortality among older released prisoners.
To our knowledge, this is the first study describing the health status and homelessness risk for older pre-release prisoners. We found that such prisoners had high rates of medical conditions, serious mental illness, and risk of post-release homelessness, regardless of veteran status. While national reentry planning programs for veterans are expanding, the overwhelming similarity in poor health status and homelessness risk between older veterans and non-veterans suggests that programs of equal breadth and caliber are needed for non-veteran older prisoners.