Chronically Ill and Incarcerated

Recently released inmates are at a high risk of death. A study conducted in Washington followed 30,237 people recently released from the Washington State Department of Corrections. In the first two weeks after release, 38 inmates died. A total of 253 died within one year after release from prison. The leading cause of death among former inmates in this study was drug overdose, followed by cardiovascular disease and then homicide. Why are these first weeks after release so dangerous?

Transitions Clinic Network

About 600,000 prisoners are released yearly in the U.S. About 80% of these former inmates have some type of medical, psychiatric, or substance use disorder. Yet persons returning to the community often prioritize finding housing, employment, and food over seeking medical treatment for chronic conditions. The criminal justice system currently offers little standardization assistance to inmates who need to manage their chronic illnesses after release.

Dr. Shira Shavit and colleagues writing in Health Affairs studied the efficacy of the Transitions Clinic Network (TCN) in helping recently released inmates manage chronic diseases. TCN uses referrals from correctional or community organizations to engage prisoners in medical care within a month of release. TCN uses community health workers with a history of incarceration to draw former prisoners to the program, and multidisciplinary medical teams that emphasize mental health and substance use treatment to improve health outcomes for former inmates. Community health workers address needs outside of strictly medical ones such as housing, food, employment, probation, and more.

TCN uses referrals from correctional or community organizations to engage prisoners in medical care within a month of release.

Currently, there are seventeen Transitions Clinic Network sites in eight states and Puerto Rico. Using data from 2013-2016, Dr. Shavit found patients referred to TCN sites by correctional organizations had fewer emergency department visits and hospitalizations. They also found that patients who attended a primary care appointment within a month after prison release were more likely to seek emergency or hospital care, suggesting that patients who find their way to TCN sites often have active clinical problems.

Social service needs come first

Health is often a lower priority for the Transition Clinic Network patient population as nearly four in five are unemployed and 20% experience food insecurity. State policies often impede self-care. Some states prohibit anyone convicted of drug felonies from participating in the Supplemental Nutrition Assistance Program (SNAP) or Section 8 housing vouchers. Consequently, these services meant for the most vulnerable population often do not reach the TCN’s patient population.

Before the Affordable Care Act (ACA), 80% of former inmates were uninsured. The ACA reduced the number without insurance especially through the Medicaid expansion. However, access to health insurance for inmates varies by state. Nineteen states terminate Medicaid coverage upon incarceration as of 2016, requiring former inmates to fully re-enroll after release.

But, as Dr. Shavit and colleagues point out: “simply having insurance does not address people’s mistrust of the health care system, nor can insurance overcome additional barriers to primary care engagement such as difficulties gaining housing and employment.”

TCN’s community health workers help patients navigate various social service needs and these health workers had on average more than five visits with the patient over the May 2013–February 2016 study period, often leading to primary care receipt. Despite the initial positive results from TCN, only 29.8% participants were referred from correctional organizations. A closer relationship between TCN and the correctional system, including higher referral rates, could decrease health disparities for former inmates.

Feature image: The.Comedian, Smith & Wesson Handcuffs, used under CC BY-NC 2.0