BACKGROUND

Each year, 1.5 million people are entangled in the US criminal-legal system, a higher proportion of the population than anywhere else on earth.1 People with a history of incarceration face higher rates of chronic disease, serious mental illness, and substance use disorder. Incarceration itself reduces life expectancy.2, 3 A history of incarceration also affects individuals’ abilities to meet many health-related social needs, such as housing and employment.

Individuals transitioning from a correctional facility back to the community face an especially high risk for death.4 Implementation of programs and resources to support individuals returning from incarceration may improve health, reduce risk of death, and even reduce rates of reincarceration.5, 6 Healthcare organizations have the opportunity to play a pivotal role to improve health and social outcomes for individuals transitioning back to the community. To identify strengths and opportunities for improved transitional support within health systems in the greater Boston area, we conducted a qualitative analysis of interviews with community stakeholder organizations.

METHODS

We conducted interviews with a purposive sample of national experts in efforts related to reentry and healthcare. These interviews were used to refine the interview guide for local stakeholder interviews. We then identified key stakeholders of local reentry efforts from pre-existing professional networks in the categories of government, community-based organizations, and academic medical centers. This project was approved by the Partners Healthcare Institutional Review Board (No. 2018P000292).

Interviews were conducted using an interview guide but were intentionally open-ended. Interviews were recorded and transcribed by two reviewers (JF and LE). These co-authors coded each interview in NVivo (QSR International, Burlington, MA, USA), then reconciled their respective coding schemes. There were iterative meetings between all co-authors to build consensus regarding the coding tree and themes until consensus was reached. Major and minor themes are displayed in Table 2.

RESULTS

A total of 7 national stakeholders and 10 local stakeholders were interviewed prior to reaching thematic saturation. Aggregated stakeholder details are displayed in Table 1. Major and minor themes are identified in Table 2. A total of 7 major themes were divided into 3 larger categories: existing strengths, challenges for transitional care, and challenges faced by patients. Respondents noted that facilitated referral to the medical system can allow patients upon release to receive necessary treatment such as buprenorphine-naloxone initiation and to receive social services such as public transit passes, donated clothing, and case management. Limitations to achieving facilitated referrals included difficulty in transferring medical information between settings. Another frequently noted barrier to robust care was clinician hesitancy to inquire about a history of incarceration in community-based settings and structural challenges associated with navigating the healthcare system, such as difficulty scheduling follow-up appointments soon after release. Respondents also identified patient-specific barriers to navigate the healthcare system including lack of insurance, reduced health literacy, stigmatization, and economic disadvantage.

Table 1 Content Experts Interviewed
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Table 2 Themes Identified in Interviews
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DISCUSSION

Our interviews with reentry stakeholders in Greater Boston and nationally identified health system barriers to safe community reentry. Strengthening existing medical-correctional partnerships to increase referral and information transfer can allow healthcare systems to better serve patients transitioning back to the community; provider training is another key component. Developing a targeted spectrum of services for returning patients, including pathways for substance use treatment, primary care, and social work, is necessary to meet the group’s complex array of needs. Continuity of care through positions such as recovery coaches or caseworkers can also provide key support during the transition period.

A major limitation to this work is that it focused on considerations at the system and organizational level. The study did not target individuals experiencing incarceration. The perspectives of this marginalized population should be central to any efforts to enhance the transition from incarceration back to the community, and additional work is needed to explore the perspectives of this group.

This analysis identified opportunities to enhance healthcare for patients returning from incarceration through increasing information exchange between community and correctional facilities and through increasing the availability of support services in the medical setting. Expansion of targeted resources for this vulnerable population, as well as ongoing provider training, will help advance health equity.