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

The Rhode Island transitions clinic: connections to social and healthcare services after release from incarceration

BACKGROUND

After release from incarceration, individuals are rarely connected to primary care or to social services despite bearing a disproportionate burden of poor health (e.g., chronic illness) and structural determinants of health (e.g., housing instability). The Rhode Island Transitions Clinic (RITC) works to fill this gap, particularly for patients with complex needs, by linking individuals to primary care and social services. However, prior work has not formally assessed how successful the TCN is at connecting patients to social services. Our objective was to assess the relationship between RITC and connections to healthcare use and services addressing structural determinants of health.

METHODS

This retrospective cohort study utilizes data among those released from the Rhode Island Department of Corrections (RIDOC) from 2018-2020. These data were linked with state agency data (e.g., unemployment, Medicaid medical claims, housing and homelessness services). We estimated 6-month risk differences (RDs) of each outcome, using stabilized inverse probability weights to account for censoring and confounding.

RESULTS

Of 8,694 individuals, the 68 enrolled in RITC are, on average, older, more likely to be Black, and have had more incarcerations. The RITC was associated with higher likelihood of connection to housing and homelessness services (RD: 0.29; 95% CI: 0.17, 0.41), (re)instatement of Supplemental Security Income (RD: 0.17, 95% CI: 0.06, 0.28), Emergency Department (RD: 0.29; 95% CI: 0.17, 0.41), and primary care visits (RD: 0.32; 95% CI: 0.21, 0.43), and lower likelihood of receiving taxable wages (RD: -0.05; 95% CI: -0.14, 0.05) compared to not being in RITC within six-months of release.

CONCLUSIONS

RITC patients have complex healthcare and social service needs. The RITC is an innovative approach that is successful at connecting its patients to primary care and social services.

Data linkage studies of primary care utilisation after release from prison: a scoping review

BACKGROUND

Primary care plays a central role in most, if not all, health care systems including the care of vulnerable populations such as people who have been incarcerated. Studies linking incarceration records to health care data can improve understanding about health care access following release from prison. This review maps evidence from data-linkage studies about primary care use after prison release.

METHODS

The framework by Arksey and O'Malley and guidance by the Joanna Briggs Institute (JBI) were used in this review. This scoping review followed methods published in a study protocol. Searches were performed (January 2012-March 2023) in MEDLINE, EMBASE and Web of Science Core Collection using key-terms relating to two areas: (i) people who have been incarcerated and (ii) primary care. Using eligibility criteria, two authors independently screened publication titles and abstracts (step 1), and subsequently, screened full text publications (step 2). Discrepancies were resolved with a third author. Two authors independently charted data from included publications. Findings were mapped by methodology, key findings and gaps in research.

RESULTS

The database searches generated 1,050 publications which were screened by title and abstract. Following this, publications were fully screened (n = 63 reviewer 1 and n = 87 reviewer 2), leading to the inclusion of 17 publications. Among the included studies, primary care use after prison release was variable. Early contact with primary care services after prison release (e.g. first month) was positively associated with an increased health service use, but an investigation found that a large proportion of individuals did not access primary care during the first month. The quality of care was found to be largely inadequate (measured continuity of care) for moderate multimorbidity. There were lower levels of colorectal and breast cancer screening among people released from custody. The review identified studies of enhanced primary care programmes for individuals following release from prison, with studies reporting a reduction in reincarceration and criminal justice system costs.

CONCLUSIONS

This review has suggested mixed evidence regarding primary care use after prison release and has highlighted challenges and areas of suboptimal care. Further research has been discussed in relation to the scoping review findings.

Medicaid Inmate Exclusion Policy and Infectious Diseases Care for Justice-Involved Populations

The Medicaid Inmate Exclusion Policy (MIEP) prohibits using federal funds for ambulatory care services and medications (including for infectious diseases) for incarcerated persons. More than one quarter of states, including California and Massachusetts, have asked the federal government for authority to waive the MIEP. To improve health outcomes and continuation of care, those states seek to cover transitional care services provided to persons in the period before release from incarceration. The Massachusetts Sheriffs' Association, Massachusetts Department of Correction, Executive Office of Health and Human Services, and University of Massachusetts Chan Medical School have collaborated to improve infectious disease healthcare service provision before and after release from incarceration. They seek to provide stakeholders working at the intersection of criminal justice and healthcare with tools to advance Medicaid policy and improve treatment and prevention of infectious diseases for persons in jails and prisons by removing MIEP barriers through Section 1115 waivers.

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population: an international systematic review

BACKGROUND

High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison.

METHODS

Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text.

RESULTS

Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity.

CONCLUSIONS

It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.

No health without access: using a retrospective cohort to model a care continuum for people released from prison at an urban, safety net health system

BACKGROUND

Release from prison is characterized by discontinuity of healthcare services and results in poor health outcomes, including an increase in mortality. Institutions capable of addressing this gap in care seldom collaborate in comprehensive, data-driven transition of care planning. This study harnesses information from a data exchange between correctional facilities and community-based healthcare agencies in Colorado to model a care continuum after release from prison.

METHODS

We merged records from Denver Health (DH), an urban safety-net healthcare system, and the Colorado Department of Corrections (CDOC), for people released from January 1 to June 30, 2021. The study population was either (a) released to the Denver metro area (Denver and its five neighboring counties), or (b) assigned to the DH Regional Accountable Entity, or (c) assigned to the DH medical home based on Colorado Department of Healthcare Policy and Financing attribution methods. Outcomes explored were outpatient, acute care, and inpatient utilization in the first 180 days after release. We used Pearson's chi-squared tests or Fisher exact for univariate comparisons and logistic regression for multivariable analysis.

RESULTS

The care continuum describes the healthcare utilization at DH by people released from CDOC. From January 1, 2021, to June 30, 2021, 3242 people were released from CDOC and 2848 were included in the data exchange. 905 individuals of the 2848 were released to the Denver metro area or attributed to DH. In the study population of 905, 78.1% had a chronic medical or psychological condition. Within 180 days of release, 31.1% utilized any health service, 24.5% utilized at least one outpatient service, and 17.1% utilized outpatient services two or more times. 10.1% utilized outpatient services within the first 30 days of release.

CONCLUSIONS

This care continuum highlights drop offs in accessing healthcare. It can be used by governmental, correctional, community-based, and healthcare agencies to design and evaluate interventions aimed at improving the health of a population at considerable risk for poor health outcomes and death.

The Reentry Health Care Hub: Creating a California-Based Referral System to Link Chronically Ill People Leaving Prison to Primary Care

People released from prison experience high health needs and face barriers to health care in the community. During the COVID-19 pandemic, people released early from California state prisons to under-resourced communities. Historically, there has been minimal care coordination between prisons and community primary care. The Transitions Clinic Network (TCN), a community-based non-profit organization, supports a network of California primary care clinics in adopting an evidence-based model of care for returning community members. In 2020, TCN linked the California Department of Corrections and Rehabilitation (CDCR) and 21 TCN-affiliated clinics to create the Reentry Health Care Hub, supporting patient linkages to care post-release. From April 2020-August 2022, the Hub received 8420 referrals from CDCR to facilitate linkages to clinics offering medical, behavioral health, and substance use disorder services, as well as community health workers with histories of incarceration. This program description identifies care continuity components critical for reentry, including data sharing between carceral and community health systems, time and patient access for pre-release care planning, and investments in primary care resources. This collaboration is a model for other states, especially after the Medicaid Reentry Act and amid initiatives to improve care continuity for returning community members, like California's Medicaid waiver (CalAIM).

Public Health and Prisons: Priorities in the Age of Mass Incarceration

Mass incarceration is a sociostructural driver of profound health inequalities in the United States. The political and economic forces underpinning mass incarceration are deeply rooted in centuries of the enslavement of people of African descent and the genocide and displacement of Indigenous people and is inextricably connected to labor exploitation, racial discrimination, the criminalization of immigration, and behavioral health problems such as mental illness and substance use disorders. This article focuses on major public health crises and advances in state and federal prisons and discusses a range of practical strategies for health scholars, practitioners, and activists to promote the health and dignity of incarcerated people. It begins by summarizing the historical and sociostructural factors that have led to mass incarceration in the United States. It then describes the ways in which prison conditions create or worsen chronic, communicable, and behavioral health conditions, while highlighting priority areas for public health research and intervention to improve the health of incarcerated people, including decarceral solutions that can profoundly minimize-and perhaps one day help abolish-the use of prisons.