For Health Equity, We Must End Mass Incarceration.

This Viewpoint discusses the health harms to individuals and communities because of mass incarceration in the US and proposes interventions to ensure health equity for all individuals.

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.

Formerly Incarcerated Community Health Workers Engaging Individuals Returning From Incarceration Into Primary Care: Results From the Transition Clinic Network.

Over half a million individuals return from United States prisons and millions more from jails every year, many of whom with complex health and social needs. Community health workers (CHWs) perform diverse roles to improve health outcomes in disadvantaged communities, but no studies have assessed their role as integrated members of a primary care team serving individuals returning from incarceration. Using data from participants who received primary care through the Transitions Clinic Network, a model of care that integrates CHWs with a lived experienced of incarceration into primary care teams, we characterized how CHWs address participant health and social needs during interactions outside of clinic visits for 6 months after participants established primary care. Among the 751 participants, 79% had one or more CHW interactions outside of the clinic documented. Participants with more comorbid conditions, longer stays during their most recent incarceration, and released with a prescription had more interactions with CHWs compared to those with fewer comorbidities, shorter stays, and no prescription at release. Median number of interactions was 4 (interquartile range, IQR 2-8) and 56% were in person. The most common issues addressed (34%) were social determinants of health, with the most common being housing (35%). CHWs working in interdisciplinary primary care teams caring for people with histories of incarceration perform a variety of functions for clients outside of scheduled primary care visits. To improve health outcomes among disadvantaged populations, CHWs should be able to work across multiple systems, with supervision and support for CHW activities both in the primary care clinic and within the community.

Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals.

Perceived discrimination based on criminal record is associated with social determinants of health such as housing and employment. However, there is limited data on discrimination based on criminal record within health care settings. We examined how perceived discrimination based on criminal record within health care settings, among individuals with a history of incarceration, was associated with self-reported general health status. We used data from individuals recruited from 11 sites within the Transitions Clinic Network (TCN) who were released from prison within the prior 6 months, had a chronic health condition and/or were age 50 or older, and had complete information on demographics, medical history, self-reported general health status, and self-reported perceived discrimination (n = 743).Study participants were mostly of minority racial and ethnic background (76%), and had a high prevalence of self-reported chronic health conditions with half reporting mental health conditions and substance use disorders (52% and 50%, respectively), and 85% reporting one or more chronic medical conditions. Over a quarter (27%, n = 203) reported perceived discrimination by health care providers due to criminal record with a higher proportion of individuals with fair or poor health reporting discrimination compared to those in good or excellent health (33% vs. 23%; p = .002). After adjusting for age and reported chronic conditions, participants reporting discrimination due to criminal record had 43% increased odds of reporting fair/poor health (AOR 1.43, 95% CI 1.01-2.03). Race and ethnicity did not modify this relationship.Participants reporting discrimination due to criminal record had increased odds of reporting fair/poor health. The association between perceived discrimination by health care providers due to criminal record and health should be explored in future longitudinal studies among individuals at high risk of incarceration.Clinical Trial Registration: NCT01863290.

Health Literacy Among a Formerly Incarcerated Population Using Data from the Transitions Clinic Network.

Health literacy is increasingly understood to be a mediator of chronic disease self-management and health care utilization. However, there has been very little research examining health literacy among incarcerated persons. This study aimed to describe the health literacy and relevant patient characteristics in a recently incarcerated primary care patient population in 12 communities in 6 states and Puerto Rico. Baseline data were collected from 751 individuals through the national Transitions Clinic Network (TCN), a model which utilizes a community health worker (CHW) with a previous history of incarceration to engage previously incarcerated people with chronic medical diseases in medical care upon release. Participants in this study completed study measures during or shortly after their first medical visit in the TCN. Data included demographics, health-related survey responses, and a measure of health literacy, The Newest Vital Sign (NVS). Bivariate and linear regression models were fit to explore associations among health literacy and the time from release to first clinic appointment, number of emergency room visits before first clinic appointment and confidence in adhering to medication. Our study found that almost 60% of the sample had inadequate health literacy. Inadequate health literacy was associated with decreased confidence in taking medications following release and an increased likelihood of visiting the emergency department prior to primary care. Early engagement may improve health risks for this population of individuals that is at high risk of death, acute care utilization, and hospitalization following release.

Transitions Clinic Network: Challenges And Lessons In Primary Care For People Released From Prison.

Low-income and minority communities are disproportionately affected by incarceration, which exacerbates health disparities. Through enhanced primary care, the Transitions Clinic Network (TCN) seeks to improve the health of people with chronic conditions who return to their communities from prison. Using TCN data, we assessed the impact of early engagement in primary care and referral from correctional systems to TCN on the use of acute care (emergency department visits and hospitalizations) and recidivism. Of 751 patients, 29.8 percent were referred by correctional partners, and 52.7 percent were engaged in TCN care within one month after release. In the twelve months after release, patients referred by correctional partners had fewer acute care visits, compared to those referred by community-based partners, while early engagement was associated with more acute care visits. Neither referral by correctional partners nor early engagement was significantly associated with recidivism. Our findings suggest that health equity for this vulnerable population could be achieved through improved coordination between correctional and community health care systems.

Transitions clinic: creating a community-based model of health care for recently released California prisoners.

Most California prisoners experience discontinuity of health care upon return to the community. In January 2006, physicians working with community organizations and representatives of the San Francisco Department of Public Health's safety-net health system opened the Transitions Clinic (TC) to provide transitional and primary care as well as case management for prisoners returning to San Francisco. This article provides a complete description of TC, including an illustrative case, and reports information about the recently released individuals who participated in the program. From January 2006 to October 2007, TC saw 185 patients with chronic medical conditions. TC patients are socially and economically disenfranchised; 86% belong to ethnic minority groups and 38% are homeless. Eighty-nine percent of patients did not have a primary care provider prior to their incarceration. Preliminary findings demonstrate that a community-based model of care tailored to this disenfranchised population successfully engages them in seeking health care.