Access to primary care in adults in a provincial correctional facility in Ontario

"Just clearly the right thing to do": perspectives of correctional services leaders on moving governance of health-care in custody

PURPOSE

Governance models are a defining characteristic of health-care systems, yet little research is available about the governance of health-care delivered in correctional facilities. This study aims to explore the perspectives of correctional services leaders in British Columbia, Canada, on the motivations for transferring responsibility for health-care services in provincial correctional facilities to the Ministry of Health, as well as key lessons learned.

DESIGN/METHODOLOGY/APPROACH

Eight correctional services leaders participated in one-on-one interviews between September 2019 and February 2020. The authors used inductive thematic analysis to explore key themes. To triangulate early effects of the transfer identified by participants the authors used complaints data from Prisoners' Legal Services to examine changes over time.

FINDINGS

The authors identified four major themes related to the rationale for this transfer: 1) quality and equivalence of care, 2) integration and throughcare, 3) values and expertise and 4) funding and resources. Facilitators included changes in the external environment, having the right people in the right places, a strong sense of alignment and shared goals and a changing culture in corrections. Participants also highlighted challenges, including ongoing human resourcing issues, having to navigate and define shared responsibilities and adapting a large bureaucracy to the environment in corrections. Consistent with outcomes described by participants, data showed that a lower proportion of complaints received after the transfer were related to health-care.

ORIGINALITY/VALUE

The perspectives of correctional leaders on the transfer of governance for health-care services in custody to the community health-care system provide novel insights into the processes and potential of this change.

Respect for bioethical principles and human rights in prisons: a systematic review on the state of the art

BACKGROUND

Respect for human rights and bioethical principles in prisons is a crucial aspect of society and is proportional to the well-being of the general population. To date, these ethical principles have been lacking in prisons and prisoners are victims of abuse with strong repercussions on their physical and mental health.

METHODS

A systematic review was performed, through a MESH of the following words (bioethics) AND (prison), (ethics) AND (prison), (bioethics) AND (jail), (ethics) AND (jail), (bioethics) AND (penitentiary), (ethics) AND (penitentiary), (prison) AND (human rights). Inclusion and exclusion criteria were defined and after PRISMA, 17 articles were included in the systematic review.

RESULTS

Of the 17 articles, most were prevalence studies (n.5) or surveys (n.4), followed by cross-sectional studies (n.3), qualitative studies (n.1), retrospective (n.1) and an explanatory sequential mixed-methods study design (n.1). In most cases, the studies associated bioethics with prisoners' access to treatment for various pathologies such as vaccinations, tuberculosis, hepatitis, HIV, it was also found that bioethics in prisons was related to the mental health of prisoners, disability, ageing, the condition of women, the risk of suicide or with the request for end-of-life by prisoners. The results showed shortcomings in the system of maintaining bioethical principles and respect for human rights.

CONCLUSIONS

Prisoners, in fact, find it difficult to access care, and have an increased risk of suicide and disability. Furthermore, they are often used as improper organ donors and have constrained autonomy that also compromises their willingness to have end-of-life treatments. In conclusion, prison staff (doctors, nurses, warders, managers) must undergo continuous refresher courses to ensure compliance with ethical principles and human rights in prisons.

Make or break: Succeeding in transition from incarceration

Several factors impact successful reintegration after incarceration. We sought to better understand these factors such as pre-release preparedness or access to financial resources in provincial correctional facilities in Ontario, Canada with an underlying focus on the role of personal identification (PID) among people at risk of homelessness. We conducted a qualitative study with one-on-one telephone interviews. Eligibility criteria included having been released from a provincial correctional facility in the preceding 2 years, being over the age of 18, speaking English and having telephone access. Participants were recruited between February 2021 and July 2021. All interviews were audio recorded and transcribed. Data was analyzed using a thematic analysis framework along with strategies from grounded theory research. We interviewed 12 individuals and identified six key themes including 1) Degree of Preparedness Pre-Release 2) Managing Priorities Post-Release 3) Impact of Support Post-Release 4) Obstacles with Accessing Services 5) Influence of Personal Identification 6) Emotions and Uncertainty. We found that people with mental health and addiction challenges are uniquely at risk post-release. Solutions must include comprehensive and proactive case management that bridges the pre-release and post-release periods, simplified processes for obtaining PID, better connections to health and social services, and improved pre-release planning for community support.

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 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.

Exploring Foot Care Conditions for People Experiencing Homelessness: A Community Participatory Approach

Introduction:

People experiencing homelessness are faced with complex challenges and are at high risk of illness due to inequities and disparities in access to health care services.

Objective:

To explore the health and foot care problems related to people experiencing homelessness in British Columbia.

Methods:

A community participatory research approach was used with a sample of 65 people experiencing homelessness. Data were collected using a survey questionnaire and face-to-face semistructured interviews.

Results:

Thematic findings shows risk of foot injuries, lack of foot care resources, and absence of family support. Barriers to equitable access to services for most participants experiencing homelessness were lack of housing (76.92%), inability to work (72.31%), and inability to afford the cost of living on their own (63.08%).

Conclusions:

There is a pressing need for early screening and detection by health care professionals and enhanced foot care services to reduce foot problems and improve foot care wellness of homeless people. Addressing foot-related care are necessary steps in promoting health, preventing illness, and improving access to health services among people experiencing homelessness.

Rates of opioid agonist treatment prescribing in provincial prisons in Ontario, Canada, 2015-2018: a repeated cross-sectional analysis

OBJECTIVE

To describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.

DESIGN

We used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.

SETTING

Provincial prisons and general population in Ontario, Canada between 2015 and 2018.

PARTICIPANTS

Adults incarcerated in provincial prisons and people ages 15 years and older in Ontario.

MAIN OUTCOMES AND MEASURES

Opioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.

RESULTS

In prison, 6.9%-8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.

CONCLUSIONS

The increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

Healthcare in a pure gatekeeping system: utilization of primary, mental and emergency care in the prison population over time

BACKGROUND

This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events.

RESULTS

In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care.

CONCLUSIONS

The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.

Putting the Patient First: A Scoping Review of Patient Desires in Canada

Patient-centred care is a key priority for governments, providers and stakeholders, yet little is known about the care preferences of patient groups. We completed a scoping review that yielded 193 articles for analysis. Five health states were used to account for the diversity of possible preferences based on health needs. Five broad themes were identified and expressed differently across the health states, including personalized care, navigation, choice, holistic care and care continuity. Patients' perspectives must be considered to meet the diverse needs of targeted patient groups, which can inform health system planning, quality improvement initiatives and targeting of investments.

"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.

Thirty-day readmission after medical-surgical hospitalization for people who experience imprisonment in Ontario, Canada: A retrospective cohort study

We aimed to compare 30-day readmission after medical-surgical hospitalization for people who experience imprisonment and matched people in the general population in Ontario, Canada. We used linked population-based correctional and health administrative data. Of people released from Ontario prisons in 2010, we identified those with at least one medical or surgical hospitalization between 2005 and 2015 while they were in prison or within 6 months after release. For those with multiple eligible hospitalizations, we randomly selected one hospitalization. We stratified people by whether they were in prison or recently released from prison at the time of hospital discharge. We matched each person with a person in the general population based on age, sex, hospitalization case mix group, and hospital discharge year. Our primary outcome was 30-day hospital readmission. We included 262 hospitalizations for people in prison and 1,268 hospitalizations for people recently released from prison. Readmission rates were 7.7% (95%CI 4.4-10.9) for people in prison and 6.9% (95%CI 5.5-8.3) for people recently released from prison. Compared with matched people in the general population, the unadjusted HR was 0.72 (95%CI 0.41-1.27) for people in prison and 0.78 (95%CI 0.60-1.02) for people recently released from prison. Adjusted for baseline morbidity and social status, hospitalization characteristics, and post-discharge health care use, the HR for 30-day readmission was 0.74 (95%CI 0.40-1.37) for people in prison and 0.48 (95%CI 0.36-0.63) for people recently released from prison. In conclusion, people recently released from prison had relatively low rates of readmission. Research is needed to elucidate reasons for lower readmission to ensure care quality and access.

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.

Medical nutrition therapy in Canadian federal correctional facilities

Background

Under- and over nutrition as well as nutrition risk factors such as communicable and non-communicable diseases are a common and major cause of morbidity and mortality in correctional facilities. Consequently, medical nutrition therapy (MNT), a spectrum of nutrition services aimed at optimizing individual well-being, is being recognized as integral to the health of people who experience incarceration. However, there is a paucity of research that explores the delivery of MNT in correctional facilities.

Methods

A scoping review combined with secondary analysis of qualitative data (field notes, in-depth stakeholder interviews) from a 2-year ethnographic study about food insecurity and incarceration was undertaken to gain insights about the delivery of corrections-based MNT in Canada. Thematic analysis of all documents was done using an interpretive framework.

Results

An understanding about MNT was developed within three themes: 1) specialized service provision in a unique environment; 2) challenges with the provision of MNT; and 3) consideration of corrections-based MNT alternatives. An incarcerated individual’s nutritional health was conceptualized as culminating from various factors that included dietary intake and health status, enabling environments, access to quality health services, and clinical nutrition services. Nutrition care practices, which range from health promotion to rehabilitation, are challenged by issues of access, visibility, adequacy, and environmental barriers. Their success is dependent on demand (e.g., ability of recipient to act) and factors that enable quality health and food services. Advancing corrections-based MNT will require policies that provide supportive food and health environments and creating sustainable services by integrating alternatives such as peer approaches and telehealth.

Conclusions

Professional associations, government, researchers and other stakeholders can help to strengthen corrections-based MNT by fostering shifts in thinking about the role of health practitioners in these contexts, preparing future health professionals with the specialized skills needed to work in these environments, generating evidence that can best inform practice, and cultivating collaborations aimed at crime prevention, successful societal reintegration, and the reduction of recidivism.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3926-3) contains supplementary material, which is available to authorized users.

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.

Factors that support successful transition to the community among women leaving prison in British Columbia: a prospective cohort study using participatory action research

BACKGROUND

In Canada, the number of women sentenced to prison has almost doubled since 1995. In British Columbia, the rate of reincarceration is 70% within 2 years. Our aim was to identify factors associated with recidivism among women in British Columbia.

METHODS

We prospectively followed women after discharge from provincial corrections centres in British Columbia. We defined recidivism as participation in criminal activity disclosed by participants during the year following release. To identify predictive factors, we carried out a repeated-measures analysis using a logistic mixed-effect model.

RESULTS

Four hundred women completed a baseline interview, of whom 207 completed additional interviews during the subsequent year, contributing 395 interviews in total. Factors significantly associated in univariate analysis with recidivism included not having a family doctor or dentist, depression, not having children, less than high school education, index charge of drug offense or theft under $5000, poor general health, hepatitis C treatment, poor nutritional or spiritual health, and use of cannabis or cocaine. In multivariate analysis, good nutritional health (odds ratio [OR] 0.52 [95% confidence interval (CI) 0.35-0.76]), good spiritual health (OR 0.61 [95% CI 0.44-0.83]), high school education (OR 0.44 [95% CI 0.22-0.87]) and incarceration for a drug offence versus other crimes (OR 0.30 [95% CI 0.12-0.79]) were protective against recidivism.

INTERPRETATION

Our findings emphasize the relevance of health-related strategies as drivers of recidivism among women released from prison. Health assessment on admission followed by treatment for trauma and associated psychiatric disorders and for chronic medical and dental problems deserve consideration as priority approaches to reduce rates of reincarceration.