Low-intensity case management increases contact with primary care in recently released prisoners: a single-blinded, multisite, randomised controlled trial

Health status and health-care utilization among men recently released from a superjail: a matched prospective cohort study

PURPOSE

Continuity of care and access to primary care have been identified as important contributors to improved health outcomes and reduced reincarceration among people who are justice-involved. While the disproportionate burden of health concerns among incarcerated populations is well documented, less is known about their health service utilization, limiting the potential for effective improvements to current policy and practice. This study aims to examine health status and health care utilization among men recently released from a superjail in a large metropolitan area to better understand patterns of use, risk factors and facilitators.

DESIGN/METHODOLOGY/APPROACH

Participants included adult men (n = 106) matched to a general population group (n = 530) in Ontario, Canada, linked to medical records (88.5% linkage) to examine baseline health status and health utilization three-months post-release. The authors compared differences between the groups in baseline health conditions and estimated the risk of emergency department, primary care, inpatient hospitalization and specialist ambulatory care visits.

FINDINGS

Superjail participants had a significantly higher prevalence of respiratory conditions, mental illness, substance use and injuries. Substance use was a significant risk factor for all types of visits and emergency department visits were over three times higher among superjail participants.

ORIGINALITY/VALUE

This empirical case is illustrative of an emerging phenomenon in some regions of the world where emergency departments serve as de facto "walk-in clinics" for those with criminal justice involvement. Strategic approaches to health services are required to meet the complex social and health needs and disparities in access to care experienced by men released from custody.

The impact of supported accommodation on health and criminal justice outcomes of people released from prison: a systematic literature review

BACKGROUND

Supported accommodation intends to address challenges arising following release from prison; however, impact of services, and of specific service components, is unclear. We describe key characteristics of supported accommodation, including program components and outcomes/impact; and distil best-evidence components.

METHODS

We conducted a systematic review, searching relevant databases in November 2022. Data were synthesised via effect direction plots according to the Synthesis Without Meta-analysis guidelines. We assessed study quality using the McGill Mixed Methods Appraisal Tool, and certainty in evidence using the GRADE framework.

RESULTS

Twenty-eight studies were included; predominantly cross-sectional. Program components which address life skills, vocational training, AOD use, and mental health appear to positively impact criminal justice outcomes. Criminal justice outcomes were the most commonly reported, and while we identified a reduction in parole revocations and reincarceration, outcomes were otherwise mixed. Variable design, often lacking rigour, and inconsistent outcome reporting limited assessment of these outcomes, and subsequently certainty in findings was low.

CONCLUSION

Post-release supported accommodation may reduce parole revocations and reincarceration. Despite limitations in the literature, the findings presented herein represent current best evidence. Future studies should clearly define program components and measure their impact; use analyses which reflect the high risk of adverse outcomes, such as time-to-event analyses; and consider outcomes which reflect the range of challenges faced by people leaving prison.

REGISTRATION

PROSPERO registration CRD42020189821.

Is use of opioid agonist treatment associated with broader primary healthcare use among men with recent injecting drug use histories following release from prison? A prospective cohort study

BACKGROUND

A precipitous decline in health status among people recently released from prison is common. In Victoria, Australia, opioid agonist treatment (OAT) in the community involves frequent contact with primary care, potentially facilitating broader use of primary healthcare services. Among a cohort of men who injected drugs regularly pre-imprisonment, we estimated differences in rates of primary healthcare use and medication dispensation between people who did and did not receive OAT post-release.

METHODS

Data came from the Prison and Transition Health Cohort Study. Three-month post-release follow-up interviews were linked with primary care and medication dispensation records. Generalised linear models were fit with one exposure (OAT: none/partial/complete) for 13 outcomes relating to primary healthcare use, pathology testing, and medication dispensation, adjusted for other covariates. Coefficients were reported as adjusted incidence rate ratios (AIRR).

RESULTS

Analyses included 255 participants. Compared to no OAT use, both partial and complete OAT use were associated with increased rates of standard (AIRR: 3.02, 95%CI: 1.88-4.86; AIRR: 3.66, 95%CI: 2.57-5.23), extended (AIRR: 2.56, 95%CI: 1.41-4.67; AIRR: 2.55, 95%CI: 1.60-4.07) and mental health-related (AIRR: 2.71, 95%CI: 1.42-5.20; AIRR: 2.27, 95%CI: 1.33-3.87) general practitioner (GP) consultations, total medication (AIRR: 1.88, 95%CI: 1.19-2.98; AIRR: 2.40, 95%CI: 1.71-3.37), benzodiazepine (AIRR: 4.99, 95%CI: 2.81-8.85; AIRR: 8.30, 95%CI: 5.28-13.04) and gabapentinoid (AIRR: 6.78, 95%CI: 3.34-13.77; AIRR: 4.34, 95%CI: 2.37-7.94) dispensations, respectively. Partial OAT use was also associated with increased after-hours GP consultations (AIRR: 4.61, 95%CI: 2.24-9.48) and complete OAT use? with increased pathology utilisation (e.g. haematological, chemical, microbiological or immunological tissue/sample testing; AIRR: 2.30, 95%CI: 1.52-3.48).

CONCLUSION

We observed higher rates of primary healthcare use and medication dispensation among people who reported partial and complete OAT use post-release. Findings suggest that access to OAT post-release may have a collateral benefit in supporting broader health service utilisation, underscoring the importance of retention in OAT after release from prison.

Asthma-related mortality after release from prison: a retrospective data linkage study

BACKGROUND

People who experience incarceration are at increased risk of asthma and have a higher prevalence of risk factors associated with asthma-related mortality. However, there has been little research on the relationship between asthma and mortality in people released from prison.

OBJECTIVES

This study examined the association between asthma and all-cause and cause-specific mortality, and estimated the increased risk of asthma-related mortality among adults released from prison compared to the age- and sex-matched general population.

DESIGN

We used data from a nested case-control sample (N = 1658) within a retrospective cohort study of all adults released from prisons in Queensland, Australia, from 1994 to 2007 (N = 42015). Deaths were identified using linkage to national mortality records. Nested study cases were sampled from deaths, with a matched control from the cohort. We examined medical and case management records to identify risk factors potentially associated with mortality. Asthma-related mortality in the cohort was compared to that of the matched general population of Queensland.

RESULTS

People released from prison were more likely than their age and sex matched general population counterparts to have an asthma-related death (HR = 3.32 95%CI:2.14-5.16). Those who had been identified as having asthma in prison had increased odds of mortality from all-cause (OR = 1.86 95%CI:1.40-2.47), drug-related (OR = 2.5 95%CI:1.40-4.46), cardiovascular-related (OR = 3.2 95%CI:1.57-6.51), and respiratory-related (OR = 3.30 95%CI:1.63-6.70).

CONCLUSION

Among people exposed to incarceration, those with asthma are at elevated risk of death after release from custody. Improved management of respiratory disease in this population may contribute to reducing their high rate of preventable mortality.

The health of detainees and the role of primary care: Position paper of the European Forum for Primary Care

This position paper aims to increase awareness among primary care practitioners and policymakers about the specific and complex health needs of people who experience incarceration. We focus on the importance of primary care and of continuity of care between prison and community. We highlight what is known from the literature on the health of people who experience incarceration, on the organisation of prison health care, and on the role of primary care both during and after detention. We present three case descriptions of detainees' encounters with the organisation of prison health care in three European countries. Finally, we describe the position that the European Forum for Primary Care takes. Prisoners and ex-prisoners have a worse physical and mental health compared with a cross-section of the population. However, access to good quality treatment and care is often worse than in the outside situation. In particular, well-organised primary care in the prison context could benefit prisoners and, indirectly, society at large. Moreover, continuity of care between the community and the prison situation needs improvement.

Cost savings of a primary care program for individuals recently released from prison: a propensity-matched study

Background

Criminal justice system costs in the United States have exponentially increased over the last decades, and providing health care to individuals released from incarceration is costly. To better understand how to manage costs to state budgets for those who have been incarcerated, we aimed to assess state-level costs of an enhanced primary care program, Transitions Clinic Network (TCN), for chronically-ill and older individuals recently released from prison.

Methods

We linked administrative data from Connecticut Department of Correction, Medicaid, and Department of Mental Health and Addiction Services to identify a propensity matched comparison group and estimate costs of a primary care program serving chronically-ill and older individuals released from incarceration between 2013 and 2016. We matched 94 people released from incarceration who received care at a TCN program to 94 people released from incarceration who did not receive care at TCN program on numerous characteristics. People eligible for TCN program participation were released from incarceration within the prior 6 months and had a chronic health condition or were over the age of 50. We estimated 1) costs associated with the TCN program and 2) costs accrued by Medicaid and the criminal justice system. We evaluated associations between program participation and Medicaid and criminal justice system costs over a 12-month period using bivariate analyses with nonparametric bootstrapping method.

Results

The 12-month TCN program operating cost was estimated at $54,394 ($146 per participant per month). Average monthly Medicaid costs per participant were not statistically different between the TCN ($1737 ± $3449) and comparison ($1356 ± $2530) groups. Average monthly criminal justice system costs per participant were significantly lower among TCN group ($733 ± $1130) compared with the matched group ($1276 ± $1738, p < 0.05). We estimate every dollar invested in the TCN program yielded a 12-month return of $2.55 to the state.

Conclusions

Medicaid investments in an enhanced primary care program for individuals returning from incarceration are cost neutral and positively impact state budgets by reducing criminal justice system costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07985-5.

Implementing a Culture of Health Among Probationers

Justice-involved individuals struggle with a multitude of health issues, and addressing the needs of these individuals requires the efforts of multiple agencies working across traditionally siloed systems. This study provides evidence on the implementation of a one-stop health services delivery model, Culture of Health, piloted in an urban probation office. This model uses a change team approach to focus the efforts of multiple agencies toward improving the alignment, collaboration, and synergy of health and other social service delivery to this underserved population. This article reports on the development and application issues involved in instituting such a novel design. The study demonstrates that the health culture within probation, buy-in from probation officers, and dwindling support from change team members all posed noteworthy issues for program implementation.

Contact with Mental Health Services After Acute Care for Self-Harm Among Adults Released from Prison: A Prospective Data Linkage Study

OBJECTIVE

To determine the care pathway and rate and predictors of mental health care contact within seven days of discharge from acute care following self-harm.

METHOD

In a representative cohort of adults released from prisons in Queensland, Australia, we probabilistically linked person-level, statewide ambulance, emergency department, and hospital records, both prospectively and retrospectively, and community mental health service and Medicare records prospectively, to baseline survey data. We fit multivariate modified log-linked Poisson regression models to examine the association between sociodemographic, health, and criminal justice factors and mental health care contact after self-harm.

RESULTS

Of 217 discharges from acute care following self-harm, 55% (n = 119) received mental health care within seven days of discharge. Mental health care contact was associated with substance use disorder (adjusted relative risk (ARR) = 0.48; 95% CI: 0.27-0.85), dual diagnosis (ARR = 0.58; 95% CI: 0.41-0.82), physical health-related functioning (ARR = 0.98; 95% CI: 0.97-0.99), being female (ARR = 1.39; 95% CI: 1.02-1.90), being identified as at risk of self-harm by correctional authorities (ARR = 1.50; 95% CI: 1.07-2.09), and prior engagement with state-funded mental health care (ARR = 1.55; 95% CI: 1.08-2.22).

CONCLUSION

Our findings highlight the need to improve the integration of community mental health care for people who present to acute care following self-harm with a recent history of incarceration, particularly for men and those with substance use disorder or dual diagnosis.

Age-specific incidence of injury-related hospital contact after release from prison: a prospective data-linkage study

BACKGROUND

In population studies, the risk of injury declines after early adulthood. It is unclear if a similar age difference in the risk of injury exists among people released from prison.

METHODS

Prerelease survey data collected between 1 August 2008 and 31 July 2010, from a representative cohort of sentenced adults (≥18 years) in Queensland, Australia, were linked prospectively and retrospectively to person-level emergency department, inpatient hospital and correctional records. To ascertain predictors of injury-related hospital contact, we fit a multivariate Andersen-Gill model and tested the interactions between age group (<25 years, ≥25 years) and each variable.

RESULTS

In 1307 adults released from prison, there were 3804 person-years of follow-up. The crude injury rate was 385 (95% CI 364 to 407) per 1000 person-years and did not differ according to age group. Factors associated with increased injury-related hospital contact included a history of mental illness, preincarceration injury, a history of incarceration, release from a short prison sentence (<90 days), being reincarcerated during follow-up and identifying as Indigenous. The effect of mental illness, risky alcohol use, prior incarceration and intellectual disability differed across age group and predicted increased risk of injury among people aged ≥25 years compared with their counterparts without these characteristics.

CONCLUSIONS

Unlike in the general population where the risk of injury declines with age, older adults released from prison are at similar risk compared with their younger peers. Adults released from prison with mental illness, a history of injury-related hospital contact and who identify as Indigenous are particularly indicated groups for injury prevention.

"When you first walk out the gates…where do [you] go?": Barriers and opportunities to achieving continuity of health care at the time of release from a provincial jail in Ontario

We aimed to explore continuity of health care and health barriers, facilitators, and opportunities for people at the time of release from a provincial correctional facility in Ontario, Canada. We conducted focus groups in community-based organizations in a city in Ontario, Canada: a men’s homeless shelter, a mental health service organization, and a social service agency with programs for people with substance use disorders. We included adults who spoke English well enough to participate in the discussion and who had been released from the provincial correctional facility in the previous year. We conducted three focus groups with 18 total participants. Participants had complex health needs on release, including ongoing physical and psychological impacts of time in custody. They identified lack of access to high quality health care; lack of housing, employment, social services, and social supports; and discrimination on the basis of incarceration history as barriers to health on release. Access to health care, housing, social services, and social supports all facilitated health on release. To address health needs on release, participants suggested providing health information in jail, improving discharge planning, and developing accessible clinics in the community. This pilot study identified opportunities to support health at the time of release from jail, including delivery of programs in jail, linkage with and development of programs in the community, and efforts to support structural changes to prevent and address discrimination. These data will inform ongoing work to support health and continuity of care on release from a provincial correctional facility.

Attachment to primary care and team-based primary care: Retrospective cohort study of people who experienced imprisonment in Ontario

OBJECTIVE

To examine attachment to primary care and team-based primary care in the community for people who experienced imprisonment in Ontario, and to compare these attachment data with data for the general population.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

All persons released from provincial prison in Ontario to the community in 2010 who were linked with provincial health administrative data, and an age- and sex-matched general population group.

MAIN OUTCOME MEASURES

Primary care attachment and team-based primary care attachment in the 2 years before admission to provincial prison (baseline) and in the 2 years after release in 2010 (follow-up) for the prison release group, and for the corresponding periods for the general population group.

RESULTS

People in the prison release group (n = 48 861) were less likely to be attached to primary care compared with the age- and sex-matched general population group (n = 195 444), at 58.9% versus 84.1% at baseline (P < .001) and 63.0% versus 84.4% during follow-up (P < .001), respectively. The difference in attachment to team-based primary care was small in magnitude but statistically significant, at 14.4% versus 16.1% at baseline (P < .001) and 19.9% versus 21.6% during follow-up (P < .001), respectively.

CONCLUSION

People who experience imprisonment have lower primary care attachment compared with the general population. Efforts should be made to understand barriers and to facilitate access to high-quality primary care for this population, including through initiatives to link people while in prison with primary care in the community.

Staying Quit After Release (SQuARe) trial protocol: a randomised controlled trial of a multicomponent intervention to maintain smoking abstinence after release from smoke-free prisons in Victoria, Australia

INTRODUCTION

Smoke-free policies have been introduced in prisons internationally. However, high rates of relapse to smoking after release from prison indicate that these policies typically result in short-term smoking cessation only. These high rates of relapse, combined with a lack of investment in relapse prevention, highlight a missed opportunity to improve the health of a population who smoke tobacco at two to six times the rate of the general population. This paper describes the rationale and design of a randomised controlled trial, testing the effectiveness of a caseworker-delivered intervention promoting smoking cessation among former smokers released from smoke-free prisons in Victoria, Australia.

METHODS AND ANALYSIS

The multicomponent, brief intervention consists of behavioural counselling, provision of nicotine spray and referral to Quitline and primary care to promote use of government-subsidised smoking cessation pharmacotherapy. The intervention is embedded in routine service delivery and is administered at three time points: one prerelease and two postrelease from prison. Control group participants will receive usual care. Smoking abstinence will be assessed at 1 and 3 months postrelease, and confirmed with carbon monoxide breath testing. Linkage of participant records to survey and routinely collected administrative data will provide further information on postrelease use of health services and prescribed medication.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Corrections Victoria Research Committee, the Victorian Department of Justice Human Research Ethics Committee, the Department of Human Services External Request Evaluation Committee and the University of Melbourne Human Research Ethics Committee. Results will be submitted to major international health-focused journals. In case of success, findings will assist policymakers to implement urgently needed interventions promoting the maintenance of prison-initiated smoking abstinence after release, to reduce the health disparities experienced by this marginalised population.

TRIAL REGISTRATION NUMBER

ACTRN12618000072213; Pre-results.

Propensity-matched study of enhanced primary care on contact with the criminal justice system among individuals recently released from prison to New Haven

BACKGROUND

Health systems can be integral to addressing population health, including persons with incarceration exposure. Few studies have comprehensively integrated state-wide data to assess how the primary care system can impact criminal justice outcomes. We examined whether enhanced primary care can decrease future contact with the criminal justice system among individuals just released from prison.

METHODS

We linked administrative data (2013-2016) of Connecticut Department of Correction, Department of Mental Health and Addiction Services, Department of Social Service, Court Support Services Division, and Department of Public Health to conduct a quasi-experimental study using propensity score matching of 94 participants who received enhanced primary care in Transitions Clinic to 94 controls not exposed to the programme. The propensity score included 23 variables, which encompassed participants' medical and incarceration history and service utilisation. The main outcomes were reincarceration rates and days incarcerated in the first year from the index date, which was either enrolment in the Transitions Clinic programme or release from prison in the control group.

RESULTS

The odds of reincarceration, including arrests and new convictions, were similar for the two groups, but Transitions Clinic participants had lower odds of returning to prison for a parole or probation technical violation (adjusted OR: 0.38; 95% CI 0.16 to 0.93) compared with the control group. Further, Transitions Clinic participants had fewer incarceration days (incidence rate ratio: 0.55; 95% CI 0.35 to 0.84) compared with the control group.

CONCLUSIONS

Enhanced primary care for individuals just released from prison can reduce reincarceration for technical violations and shorten time spent within correctional facilities. This study shows how community health systems may play a role in current strategies to reduce prison populations.

Modifiable risk factors for external cause mortality after release from prison: a nested case-control study

AIM

People released from prison are at higher risk of mortality from potentially preventable causes than their peers in the general population. Because most studies of this phenomenon are reliant on registry data, there is little health and behavioural information available on those at risk, hampering the development of targeted, evidence-based preventive responses. Our aim was to identify modifiable risk and protective factors for external cause and cause-specific mortality after release from prison.

METHODS

We undertook a nested case-control study using data from a larger retrospective cohort study of mortality after release from prison in Queensland, Australia between 1994 and 2007. Cases were 286 individuals who had died from external causes (drug overdose, suicide, transport accidents, or violence) matched with 286 controls on sex, Indigenous status, and release date. We extracted data from detention, case-management, and prison medical records.

RESULTS

Factors associated with increased risk of external cause mortality included use of heroin and other opioids in the community [odds ratio (OR) = 2.20, 95% CI 1.41-3.43, p &lt; 0.001], a prescription for antidepressants during the current prison sentence (OR = 1.94, 95% CI 1.02-3.67, p = 0.042), a history of problematic alcohol use in the community (OR = 1.54, 95% CI 1.05-2.26, p = 0.028), and having ever served two or more custodial sentences (OR = 1.51, 95% CI 1.01-2.25, p = 0.045). Being married (OR = 0.45, 95% CI 0.29-0.70, p &lt; 0.001) was protective. Fewer predictors were associated with cause-specific mortality.

CONCLUSIONS

We identified several behavioural, psychosocial, and clinical markers associated with mortality from preventable causes in people released from prison. Emerging evidence points to interventions that could be targeted at those at increased risk of external cause mortality. These include treatment and harm reduction programmes (for substance use), improving transitional support programmes and continuity of care (for mental health), diversion and drug reform (for repeat incarceration) and nurturing stable relationships during incarceration. The period of imprisonment and shortly after release provides a unique opportunity to improve the long-term health of ex-prisoners and overcome the disadvantage associated with imprisonment.

Primary care utilization in people who experience imprisonment in Ontario, Canada: a retrospective cohort study

Background

Access to primary care is an important determinant of health, and data are sparse on primary care utilization for people who experience imprisonment. We aimed to describe primary care utilization for persons released from prison, and to compare utilization with the general population.

Methods

We linked correctional data for all persons released from provincial prison in Ontario, Canada in 2010 with health administrative data. We matched each person by age and sex with four general population controls. We compared primary care utilization rates using generalized estimating equations. We adjusted rate ratios for aggregated diagnosis groups, to explore this association independent of comorbidity. We examined the proportion of people using primary care using chi squared tests and time to first primary care visit post-release using the Kaplan-Meier method.

Results

Compared to the general population controls, the prison release group had significantly increased relative rates of primary care utilization: at 6.1 (95% CI 5.9-6.2) in prison, 3.7 (95% CI 3.6-3.8) in the week post-release and between 2.4 and 2.6 in the two years after prison release. All rate ratios remained significantly increased after adjusting for comorbidity. In the month after release, however, 66.3% of women and 75.5% of men did not access primary care.

Conclusions

Primary care utilization is high in prison and post-release for people who experience imprisonment in Ontario, Canada. Increased use is only partly explained by comorbidity. The majority of people do not access primary care in the month after prison release. Future research should identify reasons for increased use and interventions to improve care access for persons who are not accessing care post-release.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3660-2) contains supplementary material, which is available to authorized users.

Access to Primary Care for Persons Recently Released From Prison

We aimed to determine if a history of recent imprisonment affects access to primary care. Using patient roles, we telephoned to request an initial appointment with all family physicians (n = 339) who were accepting new patients in British Columbia, Canada. We sequentially assigned patient scenarios: male or female recently released from prison; male or female control. Controls were 1.98 (95% CI, 1.59-2.46) times as likely to be offered an appointment compared with persons recently released from prison, with an absolute risk difference of 41.8% (95% CI, 31.0-52.5). Our study suggests discrimination is a barrier to primary care for people released from prison, even with universal health insurance. We need to improve access to primary care during the high-risk period following prison release.

Cost-utility analysis of low-intensity case management to increase contact with health services among ex-prisoners in Australia

OBJECTIVES

The economic burden of incarceration is substantial in Australia. People released from prison are at high risk of poor health and this is an important predictor of recidivism. The 'Passports Study' was a randomised controlled trial of an intervention designed to increase health service utilisation after release from prison. The aim of this study is to conduct a cost-utility analysis of this transitional programme.

SETTING

Australia DESIGN: A hybrid simulation model was developed to estimate the changes to total economic costs and effectiveness expressed as quality-adjusted life-years (QALYs) from the adoption of the 'Passports' intervention compared with the control group. Model parameters were informed by linked data from Queensland Corrective Services, Medicare, Pharmaceutical Benefits Scheme, Queensland Hospital Admission Patient Data Collection, Emergency Department Information System and National Death Index. Health-related quality of life was measured using the Short-Form 8 Health Survey (SF-8). The primary outcomes were the costs and estimated QALYs associated with the intervention group and the control group. Probabilistic sensitivity analysis was conducted to test parameter uncertainties.

RESULTS

Compared with the control group where no attempt was made to encourage health service utilisation, an average participant in the intervention group incurred an extra cost of AUD 1790 and experienced slightly reduced QALYs, which indicated that the intervention was dominated in the baseline analysis. Probabilistic sensitivity analysis revealed that the transitional programme had a low probability of being cost-effective with the outcome measures selected.

CONCLUSION

The findings of this study do not provide economic evidence to support the widespread adoption of the Passports intervention. Due to the reductionist nature of the cost-utility approach, it may be that important health-related benefits have been omitted. Another research approach using a wider range of health-related measures might generate different conclusions.

The health care utilization of people in prison and after prison release: A population-based cohort study in Ontario, Canada

BACKGROUND

Many people experience imprisonment each year, and this population bears a disproportionate burden of morbidity and mortality. States have an obligation to provide equitable health care in prison and to attend to care on release. Our objective was to describe health care utilization in prison and post-release for persons released from provincial prison in Ontario, Canada in 2010, and to compare health care utilization with the general population.

METHODS

We conducted a population-based retrospective cohort study. We included all persons released from provincial prison to the community in 2010, and age- and sex-matched general population controls. We linked identities for persons released from prison to administrative health data. We matched each person by age and sex with four general population controls. We examined ambulatory care and emergency department utilization and medical-surgical and psychiatric hospitalization, both in prison and in the three months after release to the community. We compared rates with those of the general population.

RESULTS

The rates of all types of health care utilization were significantly higher in prison and on release for people released from prison (N = 48,861) compared to general population controls (N = 195,444). Comparing those released from prison to general population controls in prison and in the 3 months after release, respectively, utilization rates were 5.3 (95% CI 5.2, 5.4) and 2.4 (95% CI 2.4, 2.5) for ambulatory care, 3.5 (95% CI 3.3, 3.7) and 5.0 (95% CI 4.9, 5.3) for emergency department utilization, 2.3 (95% CI 2.0, 2.7) and 3.2 (95% CI 2.9, 3.5) for medical-surgical hospitalization, and 21.5 (95% CI 16.7, 27.7) and 17.5 (14.4, 21.2) for psychiatric hospitalization. Comparing the time in prison to the week after release, ambulatory care use decreased from 16.0 (95% CI 15.9,16.1) to 10.7 (95% CI 10.5, 10.9) visits/person-year, emergency department use increased from 0.7 (95% CI 0.6, 0.7) to 2.6 (95% CI 2.5, 2.7) visits/person-year, and hospitalization increased from 5.4 (95% CI 4.8, 5.9) to 12.3 (95% CI 10.1, 14.6) admissions/100 person-years for medical-surgical reasons and from 8.6 (95% CI 7.9, 9.3) to 17.3 (95% CI 14.6, 20.0) admissions/100 person-years for psychiatric reasons.

CONCLUSIONS

Across care types, health care utilization in prison and on release is elevated for people who experience imprisonment in Ontario, Canada. This may reflect high morbidity and suboptimal access to quality health care. Future research should identify reasons for increased use and interventions to improve care.

Incidence and risk factors for mortality after release from prison in Australia: a prospective cohort study

AIMS

To estimate the incidence and identify risk factors for mortality in adults released from prisons in the state of Queensland, Australia.

DESIGN

Prospective cohort study, linking baseline survey data with a national death register.

SETTING

Selected prisons within Queensland, Australia.

PARTICIPANTS

Adults (n = 1320) recruited in Queensland prisons within 6 weeks of expected release, between August 2008 and July 2010, followed for up to 4.7 years in the community.

MEASUREMENTS

Participants completed a comprehensive baseline survey covering psychosocial circumstances, physical and mental health, substance use and health risk behaviours. Clinical data were abstracted from prison medical records and obtained through probabilistic linkage with state-based, community health records. Dates of prison release and reincarceration were obtained from correctional records. Deaths were identified through probabilistic linkage with the National Death Index. Adjusted hazard ratios (AHR) were calculated using proportional hazards regression models. Standardized mortality ratios (SMR) were calculated using the population of Queensland as the reference. General population data were obtained from the Australian Bureau of Statistics.

FINDINGS

The rate of mortality in the cohort was higher than in the age- and sex-matched general population of Queensland for all causes [SMR = 4.0, 95% confidence interval (CI) = 2.9-5.4] and drug-related causes (SMR = 32, 95% CI = 19-55). In a multivariable model, adjusting for age, sex and Indigenous status, factors associated with increased mortality risk included expecting to have average or better funds available on release (AHR = 2.9, 99% CI = 1.2-7.1), poor mental health (AHR = 2.6, 99% CI = 1.1-6.1) and self-reported life-time history of overdose (AHR = 2.5, 99% CI = 1.04-6.2).

CONCLUSIONS

People released from prison in Queensland, Australia are at increased risk of death, due particularly to drug-related causes. Those at greatest risk of death are characterized by poor physical and mental health and a history of risky substance use.

Social Environment and Hospitalisation after Release from Prison: A Prospective Cohort Study

This study examined the association between remoteness and area disadvantage, and the rate of subsequent hospitalisation, in a cohort of adults released from prisons in Queensland. A baseline survey of 1267 adult prisoners within 6 weeks of expected release was prospectively linked with hospital, mortality and reincarceration records. Postcodes were used to assign remoteness and area disadvantage categories. Multivariate Andersen-Gill regression models were fitted to test for associations between remoteness, area disadvantage and hospitalisation after release from prison. Over a total of 3090.9 person-years of follow-up, the highest crude incidence rates were observed in areas characterised by remoteness and area disadvantage (crude incidence rate (IR) = 649; 95%CI: 526-791), followed by remoteness only (IR = 420; 95%CI: 349-501), severe area disadvantage only (IR = 403; 95%CI: 351-461), and neither of these factors (IR = 361; 95%CI: 336-388). Unadjusted analyses indicated that remoteness (hazard ratio (HR) = 1.32; 95%CI: 1.04-1.69; p = 0.024) was associated with increased risk of hospitalisation; however, this attenuated to the null after adjustment for covariate factors. The incidence of hospitalisation for those who live in remote or socio-economically disadvantaged areas is increased compared to their counterparts in more urban and less socio-economically disadvantaged areas. Experiencing both these factors together may compound the hospitalisation in the community.

Substance use disorders in prisoners: an updated systematic review and meta-regression analysis in recently incarcerated men and women

AIMS

The aims were to (1) estimate the prevalence of alcohol and drug use disorders in prisoners on reception to prison and (2) estimate and test sources of between study heterogeneity.

METHODS

Studies reporting the 12-month prevalence of alcohol and drug use disorders in prisoners on reception to prison from 1 January 1966 to 11 August 2015 were identified from seven bibliographic indexes. Primary studies involving clinical interviews or validated instruments leading to DSM or ICD diagnoses were included; self-report surveys and investigations that assessed individuals more than 3 months after arrival to prison were not. Random-effects meta-analysis and subgroup and meta-regression analyses were conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

In total, 24 studies with a total of 18 388 prisoners across 10 countries were identified. The random-effects pooled prevalence estimate of alcohol use disorder was 24% [95% confidence interval (CI) = 21-27], with very high heterogeneity (I²  = 94%). These ranged from 16 to 51% in male and 10-30% in female prisoners. For drug use disorders, there was evidence of heterogeneity by sex, and the pooled prevalence estimate in male prisoners was 30% (95% CI = 22-38; I²  = 98%; 13 studies; range 10-61%) and, in female prisoners, was 51% (95% CI = 43-58; I²  = 95%; 10 studies; range 30-69%). On meta-regression, sources of heterogeneity included higher prevalence of drug use disorders in women, increasing rates of drug use disorders in recent decades, and participation rate.

CONCLUSIONS

Substance use disorders are highly prevalent in prisoners. Approximately a quarter of newly incarcerated prisoners of both sexes had an alcohol use disorder, and the prevalence of a drug use disorder was at least as high in men, and higher in women.

Intellectual disability and patient activation after release from prison: a prospective cohort study

BACKGROUND

Intellectual disability and patient activation may be important drivers of inequities in health service access and health outcomes for people with intellectual disability transitioning from prison to the community. We assessed the association between intellectual disability and patient activation after prison release and examined whether this association varied, depending on whether intellectual disability was identified prior to prison release.

METHODS

Overall, 936 prisoners were screened for intellectual disability by using the Hayes Ability Screening Index and completed the Patient Activation Measure (PAM) within 6 weeks of prison release and again at 1, 3 and 6 months post-release. We estimated the association between intellectual disability status and PAM scores by using a multilevel linear model, adjusting for sociodemographic, behavioural, health and criminogenic factors. We used propensity score matching to estimate the impact of being identified with intellectual disability prior to release from prison on the change in mean PAM score after prison release.

RESULTS

Compared with those who screened negative for intellectual disability, ex-prisoners who screened positive, both with and without prior identification of intellectual disability, had significantly decreased mean PAM scores [(B = -4.3; 95% CI: -6.3, -2.4) and (B = -4.5; 95% CI: -6.8, -2.3), respectively] over 6 months of follow-up. Among those who reported being identified with intellectual disability prior to release from prison, a significant increase in PAM score at the 6-month follow-up interview (B = 5.89; 95% CI: 2.35, 9.42; P = 0.001) was attributable to being identified with intellectual disability prior to release.

CONCLUSIONS

Ex-prisoners screening positive for possible intellectual disability have decreased patient activation for at least 6 months after release from prison. However, individuals whose possible intellectual disability is unidentified appear to be particularly vulnerable. Incarceration is a pivotal opportunity for the identification of intellectual disability and for initiating transitional linkages to health and intellectual disability-specific community services for this marginalised population.

Case management helps prevent criminal justice recidivism for people with serious mental illness

Purpose

The purpose of this paper is to discuss how case management can decrease recidivism for people with serious mental illness (SMI) because people with SMI are at high risk for incarceration and recidivism.

Design/methodology/approach

Examples of successful case management models for formerly incarcerated individuals with SMI found through a secondary analysis of qualitative data and an analysis of the literature are presented.

Findings

Currently, no international, national, or statewide guidelines exist to ensure that formerly incarcerated individuals with SMI receive case management upon community reentry despite evidence that such services can prevent further criminal justice involvement. Recommendations include establishment of and evaluation of best practices for case management. In addition, the authors recommend additional funding for case management with the goal of greatly increasing the number of individuals with SMI leaving the criminal justice system in their ability to access adequate case management.

Originality/value

Providing effective case management tailored to the needs of formerly incarcerated people with SMI improves their quality of life and reduces their involvement in the criminal justice system with clear positive outcomes for public safety and public health.

High rates of general practice attendance by former prisoners: a prospective cohort study

OBJECTIVES

To determine the rates at which people recently released from prison attend general practitioners, and to describe service users and their encounters.

DESIGN, PARTICIPANTS AND SETTING

Prospective cohort study of 1190 prisoners in Queensland, interviewed up to 6 weeks before expected release from custody (August 2008 - July 2010); their responses were linked prospectively with Medicare and Pharmaceutical Benefits Scheme data for the 2 years after their release. General practice attendance was compared with that of members of the general Queensland population of the same sex and in the same age groups.

MAIN OUTCOME MEASURES

Rates of general practice attendance by former prisoners during the 2 years following their release from prison.

RESULTS

In the 2 years following release from custody, former prisoners attended general practice services twice as frequently (standardised rate ratio, 2.04; 95% CI, 2.00-2.07) as other Queenslanders; 87% of participants visited a GP at least once during this time. 42% of encounters resulted in a filled prescription, and 12% in diagnostic testing. Factors associated with higher rates of general practice attendance included history of risky opiate use (incidence rate ratio [IRR], 2.09; 95% CI, 1.65-2.65), having ever been diagnosed with a mental disorder (IRR, 1.32; 95% CI, 1.14-1.53), and receiving medication while in prison (IRR, 1.82; 95% CI, 1.58-2.10).

CONCLUSIONS

Former prisoners visited general practice services with greater frequency than the general Queensland population. This is consistent with their complex health needs, and suggests that increasing access to primary care to improve the health of former prisoners may be insufficient, and should be accompanied by improving the quality, continuity, and cultural appropriateness of care.

Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia

Incarcerated people living with HIV and opioid dependence face enormous challenges to accessing evidence-based treatment during incarceration and after release into the community, placing them at risk of poor HIV treatment outcomes, relapse to opioid use and accompanying HIV transmission risk behaviors. Here we describe in detail the design and implementation of Project Harapan, a prospective clinical trial conducted among people living with HIV and opioid dependence who transitioned from prison to the community in Malaysia from 2010 to 2014. This trial involved 2 interventions: within-prison initiation of methadone maintenance therapy and an evidence-based behavioral intervention adapted to the Malaysian context (the Holistic Health Recovery Program for Malaysia, HHRP-M). Individuals were recruited and received the interventions while incarcerated and were followed for 12months after release to assess post-release HIV transmission risk behaviors and a range of other health-related outcomes. Project Harapan was designed as a fully randomized 2×2 factorial trial where individuals would be allocated in equal proportions to methadone maintenance therapy and HHRP-M, methadone maintenance therapy alone, HHRP-M alone, or control. Partway through study implementation, allocation to methadone maintenance therapy was changed from randomization to participant choice; randomization to HHRP-M continued throughout. We describe the justification for this study; the development and implementation of these interventions; changes to the protocol; and screening, enrollment, treatment receipt, and retention of study participants. Logistical, ethical, and analytic issues associated with the implementation of this study are discussed.

Self-harm following release from prison: A prospective data linkage study

OBJECTIVE

Prisoners are at increased risk of both self-harm and suicide compared with the general population, and the risk of suicide after release from prison is three times greater than for those still incarcerated. However, surprisingly little is known about the incidence of self-harm following release from prison. We aimed to determine the incidence of, identify risk factors for and characterise emergency department presentations resulting from self-harm in adults after release from prison.

METHOD

Cohort study of 1325 adults interviewed prior to release from prison, linked prospectively with State correctional and emergency department records. Data from all emergency department presentations resulting from self-harm were secondarily coded to characterise these presentations. We used negative binomial regression to identify independent predictors of such presentations.

RESULTS

During 3192 person-years of follow-up (median 2.6 years per participant), there were 3755 emergency department presentations. In all, 83 (6.4%) participants presented due to self-harm, accounting for 165 (4.4%) presentations. The crude incidence rates of self-harm for males and females were 49.2 (95% confidence interval: [41.2, 58.7]) and 60.5 (95% confidence interval: [44.9, 81.6]) per 1000 person-years, respectively. Presenting due to self-harm was associated with being Indigenous (incidence rate ratio: 2.01; 95% confidence interval: [1.11, 3.62]), having a lifetime history of a mental disorder (incidence rate ratio: 2.13; 95% confidence interval: [1.19, 3.82]), having previously been hospitalised for psychiatric treatment (incidence rate ratio: 2.68; 95% confidence interval: [1.40, 5.14]) and having previously presented due to self-harm (incidence rate ratio: 3.91; 95% confidence interval: [1.85, 8.30]).

CONCLUSION

Following release from prison, one in 15 ex-prisoners presented to an emergency department due to self-harm, within an average of 2.6 years of release. Demographic and mental health variables help to identify at-risk groups, and such presentations could provide opportunities for suicide prevention in this population. Transition from prison to the community is challenging, particularly for those with a history of mental disorder; mental health support during and after release may reduce the risk of adverse outcomes, including self-harm.

Critical time Intervention for Severely mentally ill Prisoners (CrISP): a randomised controlled trial

Background

The transition from prison to community is difficult for prisoners with mental illness. Critical time intervention (CTI) is designed to provide intensive support to meet health, social care and resettlement needs through close working between client and key worker pre, and up to 6 weeks post, release.

Objectives

To establish whether or not CTI is effective in (1) improving engagement of discharged male prisoners who have mental illness with community mental health teams (CMHTs) and (2) providing practical support with housing, finance and re-establishing social networks.

Trial design

A multicentre, parallel-group randomised controlled trial, with follow-up at 6 weeks and at 6 and 12 months. A subset of prisoners and case managers participated in a complementary qualitative study.

Setting

Eight English prisons.

Participants

One hundred and fifty adult male prisoners, convicted or remanded, cared for by mental health in-reach teams and diagnosed with severe mental illness, with a discharge date within 6 months of the point of recruitment.

Intervention

Participants were randomised to either the intervention or the control (treatment as usual). The intervention group was assigned a case manager who assessed mental and physical health before and following release, made appropriate links to health, housing and financial services and supported the re-establishment of family/peer contact.

Outcome

The primary outcome measure was engagement with a CMHT 6 weeks post discharge. Secondary outcomes included contact with mental health services at 6 and 12 months. A health economic evaluation was undertaken using service contact at the follow-up time points. We were unable to assess the intervention’s effect on reoffending and longer-term health-care use because of study delays.

Results

One hundred and fifty prisoners were recruited: 72 were randomised to the intervention and 78 were randomised to the control. Engagement with teams at 6 weeks was 53% for the intervention group compared with 27% for the control group [95% confidence interval (CI) 0.13% to 0.78%;p = 0.012]. At 6 months’ follow-up, intervention participants showed continued increase in engagement with teams compared with control participants (95% CI 0.12% to 0.89%;p = 0.029); there were no significant differences at 12 months. Increased engagement resulted in higher levels of service use and costs for the intervention than for the control. Qualitative data showed the intervention group reporting better continuity of care and improved access to services.

Conclusion

The intervention significantly improved contact with services at 6 weeks, although at a higher cost than the control. This is important as, in the days and weeks following release, recently released individuals are at a particularly high risk of suicide and drug overdose. Further research is required to establish how teams can better maintain contact with clients when the intervention ends.

Future work

Further studies are indicated for groups with different needs, for example women, young prisoners and those in police custody, and at other transition points, for example following arrest and short-term custody, and at points of transition between different mental health services.

Trial registration

Current Controlled Trials ISRCTN98067793.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 5, No. 8. See the NIHR Journals Library website for further project information.