Prevention in Promoting Continuity of Health Care

The Role of Prevention in Promoting Continuity of Health Care
in Prisoner Reentry Initiatives
LaKeesha N. Woods, PhD, A. Stephen Lanza, MA, William Dyson, MEd, and Derrick M. Gordon, PhD
Most incarcerated individuals will return to the community, and their successful reentry requires consideration of their health and how their health will affect
their families and communities. We propose the use of a prevention science
framework that integrates universal, selective, and indicated strategies to
facilitate the successful reentry of men released from prison. Understanding
how health risks and disparities affect the transition from prison to the
community will enhance reentry intervention efforts. To explore the application
of the prevention rubric, we evaluated a community-based prisoner reentry
initiative. The findings challenge all involved in reentry initiatives to reconceptualize prisoner reentry from a program model to a prevention model that
considers multilevel risks to and facilitators of successful reentry. (Am J Public
Health. Published online ahead of print March 14, 2013: e1–e9. doi:10.2105/
AJPH.2012.300961)
The economic and social costs of incarceration necessitate efforts to promote successful
reintegration into the community. Changes in
sentencing, release, and community supervision policies and practices have led to an
increase in prison populations, overrepresentation of people of color in correctional facilities, and a subsequent increase in the number
of individuals returning to the community
from prison (D. M. G., L. N.W., and W. D., unpublished manuscript, March 2007).1 Ninetyfive percent of the more than 2 million adults
who are incarcerated in the United States
will be released from prison,2,3 and most will
face a variety of reintegration challenges.
Those who are at highest risk for unsuccessful
return to the community are single men of
color who do not participate in educational or
vocational courses in prison, do not seek or do
not obtain employment following release,
have a history of substance abuse, and are
repeat offenders.4—6 A critical component of
this profile is insufficient resources, opportunities, and supports. When individuals are not
adequately supported in their transitions,
the impact is significant for them, their families, the community, and the criminal justice
system.
One of the unintentional consequences of
incarceration is the impact on the health and
functioning of those incarcerated and their
social networks.7—10 Because men of color are
disproportionately incarcerated, the health
and social effects of incarceration are particularly devastating in these communities.10—12
Thus, addressing prison reentry is an essential
strategy to address health disparities and increase health equity. Any intervention focusing on health for these communities must
consider the role of incarceration in the
observed differences in morbidity and
mortality. Furthermore, increasing the health
of formerly incarcerated men can positively
affect the health of the communities to which
they return.13
Recognizing the barriers faced by the
formerly incarcerated, some have called for
interventions that specifically target those
risks.10,13—16 The transition from prison to the
community presents a unique opportunity for
prevention efforts to address the needs of
formerly incarcerated individuals, including
their health-related needs. We propose applying a prevention science framework to
reentry initiatives to reduce the barriers to
reintegration and the physical, mental, and
emotional health risks that formerly incarcerated men face. We present observations
from an ongoing evaluation of a pilot reentry
program to illuminate strengths and areas
of development for recidivism prevention
initiatives. We also offer recommendations
for strengthening the ability of reentry initiatives to facilitate the successful reentry
of individuals returning to the community
from prison.
APPLYING PREVENTION SCIENCE
PRINCIPLES TO REENTRY
Central to public health approaches to
prevention science is a focus on etiology and
intervention development and implementation. Once malleable risk and protective
factors are identified, preventive interventions are planned to prevent disorders, reduce risks, and promote health, taking into
consideration the cultural and community
context in which the interventions will be
implemented.17,18 The principles of prevention therefore apply to prisoner reentry.
Formerly incarcerated individuals face
a variety of barriers to successful and permanent reentry that can be reduced when
anticipated and adequately addressed.
Consistent with an ecological prevention
framework that considers the individualto societal-level factors that influence
risk,17,19 providing multilevel supports
prior to release helps prisoners, service
providers, community supports, and
correctional staff anticipate and prepare
for the transition to the community.
Strengths-based universal, selective, and
indicated preventive interventions are
needed to help formerly incarcerated
individuals reduce their risks for unsuccessful reentry. Universal preventive interventions are directed at the entire population
of interest, selective interventions are for
a subgroup of the population that is at increased risk of difficulties, and indicated
interventions are designed for those at
greatest risk.20,21
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Conceptualizing both barriers to and facilitators of reentry from a universal, selective, and
indicated level of risk perspective is critical
to understanding formerly incarcerated individuals’ strengths and needs and to developing effective interventions to address them.
A prevention framework provides structure
not only to plan for treatment and immediate
needs but also to anticipate a broader array
of challenges, identify strengths and resources (e.g., education, informal supports) to
overcome those challenges, and help all individuals prepare for their reintegration into
the community. This framework can increase
awareness of the importance of promoting
the health of all returning to the community—
not just those with acute or chronic conditions—and takes into account all areas of
individuals’ lives that affect their health and
that will change when they return to the
community.
BARRIERS TO REENTRY
All levels of risk—universal, selective, and
indicated—can affect the health of individuals
returning to the community from prison.
These risks encompass not only needs related
to the health system but also social determinants of health that affect the formerly incarcerated. From a universal perspective, all
individuals returning to the community from
prison will need access to health care, housing,
employment, and social support. Economic
and social instability are primary barriers to
successful reentry into the community. Individuals’ criminal charge history and legal
status often limit their employment opportunities, also limiting their access to health
insurance or their means to pay for care.
Incarceration can jeopardize released individuals’ roles in their families and can impose
emotional and financial strain on family
members.22,23 Furthermore, informal supports such as community organizations may
feel mistrustful of formerly incarcerated individuals.24 The return of large numbers of
individuals to the community from prison can
negatively affect the health, stability, cohesion,
organization, and economic well-being of the
community.25—27
From a selective perspective, a subgroup
of formerly incarcerated individuals has
specific needs that place them at increased
risk of recidivism. For instance, environmental and social factors (e.g., housing) affect
individuals’ health, and formerly incarcerated individuals often return to environments that jeopardize their health.14,28
The communities to which individuals
return are often resource poor and have high
rates of violence or other environmental
hazards (D. M.G., L. N.W., and W. D., unpublished manuscript, March 2007). Many
incarcerated individuals also have less education, fewer job skills, and a more limited
work history than do individuals in the
community, which can decrease their
earning potential, financial stability,
and access to health care services.13,27 In
addition, substance abuse and dependence
significantly affect the recidivism of formerly
incarcerated individuals.27,29 Substance
abuse is a selective risk in this population,
with research indicating that more than 75%
of inmates have a history of substance
abuse.30 (However, substance abuse and
dependence are indicated risks in the general population, with a prevalence of 13%
among men.31)
From an indicated perspective, the economic and social challenges to reintegration
are exacerbated when an individual’s health
is compromised, making health a risk for
the subset of released individuals with acute
and chronic health conditions. Acute and
chronic physical and mental illnesses as well
as substance abuse can impede individuals’
ability to surmount other barriers to reentry,
thereby increasing their risk of relapse and
recidivism.16,32,33 A disproportionate number of medical problems and psychiatric
difficulties exist in prison, such that the health
of prisoners is comparable to that of individuals in the community who are 10 years
their senior.13,30,32 Infectious diseases such
as HIV/AIDS, hepatitis, and tuberculosis are
particularly common.30,33 Prisoners are significantly more likely than members of the
general population to be diagnosed with
a severe mental disorder.7,29,34 Psychiatric
and substance abuse disorders can be exacerbated by incarceration and overcrowding.
Prisoners typically receive treatment only
for disorders that are severe or were present at the time of the offense; inadequate
treatment planning often further worsens
their health.29,35
The higher prevalence of physical and
mental conditions among the prison population, coupled with the racial/ethnic disparities in health and in incarceration rates, put
men of color at even greater risk.28,36 Stigma,
mistrust of the health system, socialization,
masculinity, and shame and guilt can cause
men—particularly African Americans and
Latinos—to be unwilling to seek care.37—40
Returning to the community without
medical services and other necessary supports can contribute to the spread of infectious diseases, decompensation, and
relapse.27,30,33,41
CURRENT REENTRY PRACTICES
Best practice in preventive reentry interventions encompasses environmental and systemic strategies and policies to promote
successful reintegration and to decrease recidivism.42 Best practice also includes reentry
processes that begin prior to release from
prison, are connected to the community, and
build on individuals’ strengths while attending
to the needs that affect successful reintegration.24,26,30,43 To be effective, reentry interventions must also be culturally competent and
appropriate and consider racial/ethnic disparities and the particular needs, strengths, and
resources of diverse groups.22,23,26,44 Research and policy (e.g., the Patient Protection
and Affordable Care Act) suggest that cultural
competency is critical to effective services
generally and is particularly critical to reducing
health disparities and increasing health equity.45,46
Pre- and postrelease services that focus on
vocational skills, housing, and substance abuse
have been found effective.27,47,48 Yet comprehensive and integrated program models that
not only focus on these areas but also attend to
other key factors, such as men’s health, environment, and social support, are needed to
reduce the multiple risks for recidivism that
men face.49 A strengths-based prevention
framework that helps men maintain their
health, monitor health risks, and seek treatment
of acute conditions is necessary to target
multilevel challenges and support holistic
well-being.27,49
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THE COMMUNITY REENTRY
INITIATIVE
The Connecticut Building Bridges Community Reentry Initiative (CRI) was developed in response to the Connecticut General
Assembly’s 2004 Public Act Concerning
Prison Overcrowding.50 The act mandated
the development and implementation of
a comprehensive reentry strategy to reduce
recidivism and increase successful reentry
through a network of community services,
such as treatment, vocational counseling,
education, and supervision, thereby reducing
the $34 000 annual cost per individual
of incarceration.51 Local legislators, policy
analysts, social service providers, and community advocates began to develop pilot
programs in 2005 for men returning to
the largest urban areas in Connecticut, because these communities have the highest
proportion of incarcerated individuals in
the state.
The CRI was designed to be consistent with
best-practice literature,26,48,50,52 serving as
a bridge between prison and the community.
The program was guided by a strengths-based
case management and intervention model,53
focusing on stable employment and housing,
access to health care, community supports,
formal supports (e.g., entitlements), and substance abuse and mental health treatment
and aftercare. As shown in Figure 1, the
CRI pilot program aimed to establish a continuum of care from prison to the community
and to reduce recidivism rates. The $500 000
program was designed to serve 150 men,
with a per-individual cost of approximately
$3300.
Men who participated in the CRI were
expected to have lower recidivism and substance use rates as well as greater access to
health care, stable employment and housing,
fiscal responsibility, participation in substance
abuse treatment, and involvement in community support programs than did men who
received transitional supports through the
usual mechanisms provided through the State
of Connecticut Department of Correction
(DOC).54 (Prior to release, DOC staff complete
discharge plans with inmates and arrange
linkages to community release programs, relapse prevention programs, medical treatment,
and other community services, according to
inmates’ needs. In addition to community
supervision, the DOC funds community programs to support individuals after release, such
as halfway houses, supportive housing for
mental health and substance abuse difficulties,
and employment assistance.)
Program Features
The CRI was piloted in 2 level 2 minimumsecurity correctional facilities in Connecticut
with a combined population of 1600 inmates.
The facilities focus on educational and addiction programming; inmates with significant
physical or mental health needs are transferred
to other facilities.52 To be eligible for the CRI
and the evaluation, men had to be aged 18
years or older, within 3 to 6 months of release
from prison, and willing and able to provide
written consent to participate. Prior to release,
each client who agreed to enroll in the CRI was
assigned to a case manager, who completed
a reentry plan with the client, provided support
services, and coordinated care with other
community service providers. Clients were
expected to be centrally involved in the process
of setting goals and planning for their reintegration into the community. Prior to and after
release, case managers provided or arranged
vocational counseling, assisted with housing
and finances, facilitated access to health care,
connected men to community supports, and
coordinated substance abuse treatment, which
are all consistent with universal and selective
preventive interventions. Leveraging community and informal (natural) supports is a key
factor in providing culturally competent services.46 Case managers also coordinated
mental health and medical treatment in the
community, which is consistent with indicated
interventions. Case managers reviewed and
updated the reentry plans every 60 days.
To monitor progress, case managers completed weekly service logs for each client
(Figure 1). Clients could stay in the CRI for
up to 3 years; research suggests that individuals are at greatest risk of recidivism within
3 years of release.2
Evaluation Methods
We used a longitudinal, quasi-experimental
evaluation design to determine the effectiveness of the CRI. The staff members at 1 of the
participating correctional facilities determined
eligibility and ascertained inmates’ interest
in being part of the CRI. A demographically
matched sample of inmates from the other
facility, who would receive only the standard
prerelease services provided through the DOC,
was recruited as the comparison group. Individuals interested in participating in the
Goals
1) To establish a
continuum of care
from prison to the
community through
collaboration among
the criminal justice
system, community
supports, and social
service providers
2) To enhance the
motivation and
engagement of
participants
3) To reduce recidivism
4) To create a replicable
community-based
reentry program
model that can
influence state reentry
policies and practices
Strategies & Activities
Prerelease
Strengths and needs
assessment and summary
Reentry plan
Pre- and postrelease
Vocational counseling
Housing assistance
Financial assistance
Access to health care
Connection to community
supports
Substance abuse, mental
health, and medical
treatment
Reentry plan review and
updates
Weekly service logs
Reduced recidivism
Reduced substance use
Increased participation
in recovery support
groups
Increased access to
health care
Increased employment
rate and maintenance
of employment
Increased stable
housing
Increased management
of child support
judgments and bills
Increased community
involvement
Outcomes
FIGURE 1—Conceptual model of the Connecticut Building Bridges Community Reentry
Initiative, 2005–2007.
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intervention or in the comparison group for
the evaluation completed the consent and release of health information procedures with
a member of the evaluation team. Men were
informed about their participation rights
through informed consent forms, and participants’ information was protected from release
under subpoena through a Department of
Health and Human Services Certificate of
Confidentiality. Participants were informed
that the evaluation team would gather information to assist their case managers in treatment planning and to evaluate the program.
We explained that declining to participate
in the evaluation would not affect their services
or status with the staff.
Following consent, the enrolled men completed an assessment that identified their
strengths, needs, and goals for each target area
for the intervention: education, employment,
housing, financial resources, formal supports,
informal supports, substance abuse, mental
health, and physical health. An evaluation team
member administered the assessments through
semistructured interviews conducted during
3 distinct periods: before release (3 months
prior to release), release (within 1 week of
release), and after release (6-month intervals
after release for up to 3 years or until clients’
discharge). We adapted the comprehensive
assessment from the Criminal Justice—Drug
Abuse Treatment Research Studies Intake
Form,55 Transitional Case Management
Strengths Inventory,56 Center for Epidemiologic Studies Depression Scale,57 Texas
Christian University Drug Screen II,58 and
psychological well-being scales.59 The DOC
also provided health summaries to corroborate
men’s self-reported mental and physical health
information.
We used the assessment responses to generate a summary of each client’s strengths,
needs, and goals. Case managers used the
strengths and needs summary to develop a reentry plan in collaboration with each client
within 1 month of the prerelease intake. The
reentry plans comprised a summary of the
clients’ strengths and needs, goals and objectives, key prevention activities, and target
problem resolution dates. We conducted multivariate analyses of data from the strengths
and needs assessments, DOC health summaries, and service logs as well as content analyses
of the reentry plans to examine men’s strengths,
needs, and interventions that were consistent
with universal, selective, and indicated risk
factors.
Participants
The preliminary evaluation of the CRI was
based on data for the 173 clients who were
enrolled during the first 18 months of the
program, between 2005 and 2007. More than
two thirds (68.20%; n = 118) of the clients
were African American, 24.86% (n = 43) were
Latino, 4.05% (n = 7) were White, 0.58%
(n = 1) were Asian American, and 2.31%
(n = 4) self-identified as other. The high proportion of African American and Latino men is
reflective of the incarcerated population as
a whole. The men ranged in age from 19 to 54
years, with a mean age of 32.23 years (SD =
8.01). We used the Level of Service Inventory—
Revised risk factors60 to classify the majority
of clients (64.74%; n = 112) as at moderate
risk for reoffending. Case managers reported
spending up to 120 minutes per week with
clients, with a mean meeting time of about 35
minutes. The number of contacts per week
ranged from 1 to 5.
GOAL ATTAINMENT
All aspects of the men’s strengths and needs
had health implications, which are presented in
Table 1. Universal constructs measured were
employment, housing status, informal supports,
and access to health care. Among clients’
strengths were that most were employed and
had stable housing prior to incarceration. Most
men also reported having social and family
supports. By contrast, many men reported
barriers to reentry such as lack of medical
insurance and inadequate community supports. Many of the men also were uncertain of
their housing arrangements after release.
In reentry plans related to universal interventions, case managers used multiple strategies to facilitate housing and employment as
well as to strengthen men’s connection to
the community. They helped clients apply
for housing funds, arranged temporary housing, met with vocational counselors, and referred clients to job training. Case managers
connected clients to community supports,
such as mentors, peers who had successfully
reintegrated, family mediators to assist with
restoration of family relationships, and community members to reinforce to men their
value as citizens in their communities. To
facilitate access to health care, managers helped
clients apply for medical insurance entitlements.
Selective risks were histories of substance
abuse or dependence and treatment, returning
to unhealthy environments, inadequate educational attainment, and financial needs. The
modal age of initiation of alcohol or illicit drug
use was 16 years. The majority of men
reported regular substance use (i.e., ‡ 1—5
times/week) prior to incarceration; participation in substance abuse treatment programs
was a strength. Most men had at least a high
school equivalent education; more than one
third had participated in vocational training
during incarceration. Most men also reported
having significant debt and receiving government assistance in the past. The aspects of
reentry plans that case managers developed
related to selective interventions included
arranging placement in sober houses, enrolling
clients in zero-tolerance programs, connecting
clients with self-help groups, helping clients
enroll in adult education programs, and helping
them apply for financial aid and open checking
and savings accounts.
Indicated risks were mental illness, poor
physical health, and chronic health conditions.
Fewer than 25% of clients reported a history
of psychiatric disorders or chronic physical
health conditions. The DOC health summaries
generally were consistent with the men’s
self-reports, with few men receiving mental
health diagnoses other than substance use
disorders or diagnoses of chronic physical
health conditions. The strategies that case
managers developed with clients related to
indicated interventions included arranging
outpatient treatment, helping clients adhere to
medication regimens, and scheduling physical
exams.
We examined the postrelease service log
data for the 126 clients who had been released
from prison by the time of the evaluation to
assess preliminary intervention outcomes. Case
managers reported that most men transitioned
into halfway houses or private residences
after release and received assistance with
obtaining medical insurance. Nearly one half
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of the men with reported substance abuse
histories received substance abuse treatment
through a halfway or sober house or in outpatient or inpatient programs. More than one
third of the clients secured employment, received financial support (e.g., vouchers), and
received informal supports through community
support and mentorship programs. Figure 2
presents the percentage of clients who achieved
goals in each target area.
COMMUNITY REINTEGRATION
We reviewed service log data to examine
CRI participants’ reintegration into the community. At the end of the first 18 months of
the CRI, approximately 65% (n = 82) of the
clients who were released remained actively
involved in the CRI, and 35% (n = 44) were
discharged. Reasons for discharge included
noncompliance, loss of contact, and request for
withdrawal. Approximately 16% (n = 20) of
the men recidivated, as defined by rearrest and
reincarceration. (The total number of recidivated clients was greater than the number of
clients who were discharged from the CRI
because of recidivism. Clients with sentences of
less than 1 year continued to be served, and
some clients who were reincarcerated were
discharged for other reasons, such as a request
to withdraw.) The median time to recidivism
was 90 days, and all of the 20 clients recidivated within 235 days of release.
We examined the relationship between the
multilevel interventions and men’s successful
reentry (i.e., engagement in the CRI and low
risk of recidivism) by binary logistic regression.
Clients who obtained employment after release
were less likely to become inactive or withdraw from the program than were clients who
remained unemployed (odds ratio [OR] = 0.31;
P < .05). Employment within 30 days of release did not affect engagement. Clients who
lived with family members or in their own
residence after release were more likely to
become inactive or withdraw from the program
than were men who lived in transitional housing (OR = 3.12; P < .05). Clients who participated in community support programs
(i.e., mentorship, peer support, family, mediation, community member conversations)
were less likely to recidivate than were those
who did not receive such supports (OR = 0.28;
TABLE 1—Clients’ Strengths and Needs: Connecticut Building Bridges Community
Reentry Initiative, 2005–2007
Assessment or DOC Health Summary Item No. (%)
Universal risksa
Employed prior to incarcerationb 102 (58.96)
Housing
Lived in own residence or with family prior to incarcerationb 151 (87.28)
No permanent housing arrangements after releasec 52 (30.06)
Access to health care
Uninsured prior to incarcerationc 78 (45.09)
No HIV test in past yc 74 (42.77)
No physical, eye, or dental exam in past yc 40 (23.12)
Informal supports
Social and family supportsa 138 (79.77)
Inadequate community resourcesc 70 (40.46)
Feeling of isolationc 55 (31.79)
Selective risksd
Education
Enrollment in postsecondary education programb 151 (87.28)
Educational attainment of high school or equivalentb 114 (65.90)
Participation in vocational/technical training in prisonb 59 (34.10)
Financial stability
Debtsc 126 (72.83)
Received government assistance prior to incarcerationc 123 (71.10)
Child support arrearagesc 42 (24.28)
Substance abuse
Substance abuse treatment in lifetimea 107e (86.99)
Regular substance usec 123 (71.10)
History of drug abuse or dependencec 107 (62.00)
Tobacco usec 104 (60.00)
Diagnosis of substance abusec,61 100 (58.00)
Substance abuse treatment in prisonb 55 (44.72)
History of alcohol abuse or dependencec 66 (38.00)
History of polysubstance abuse or dependencec 42 (24.00)
Indicated risksf
Mental health
Good to excellent mental healthb 153 (88.44)
Psychiatric disorders,c total (< 25.00)
Anxiety 40 (23.12)
Paranoia 29 (16.76)
Depression 28 (16.18)
Suicidal ideation or attempts 10 (5.78)
Substance-induced delirium, hallucinations, or mood disordersc 31 (18)
Physical health
Good to excellent physical healthb 153 (88.44)
Current prescription medicationsc 27 (15.61)
Chronic health conditions,c total (< 10)
Asthma 17 (9.83)
High blood pressure 15 (8.67)
Continued
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P < .05). Increasing access to health care by
assisting clients with obtaining medical insurance did not significantly affect engagement or
recidivism. With respect to the subset of clients
who needed financial supports, assistance
with financial and child support needs did not
significantly affect engagement or recidivism.
For the subset of clients with substance abuse
histories, those who received substance abuse
treatment were less likely to become inactive or
withdraw than were those who did not receive
treatment (OR = 0.22; P = .01). Men who were
connected with treatment services outside of
those provided through halfway and sober
houses were particularly likely to remain engaged (OR = 0.07; P = .05). Participation in
substance abuse treatment was not significantly
related to recidivism. Table 2 displays the
regression results for each level of intervention.
PROGRAM STRENGTHS AND CLIENT
ENGAGEMENT
The observations from a preliminary evaluation of the CRI suggest a continued need to
target all identified risk factors of individuals
reentering the community from prison to support their physical, mental, and emotional
health. Men in the CRI reported the greatest
strengths in the areas of housing, social supports, education, and quality of health. They
reported the greatest need in the areas of
substance use, health insurance, preventive
health care, finances, and community resources. The majority of men met their goals
related to health insurance; most did not meet
their goals in their other areas of greatest need.
Case managers reported using multiple strategies to address areas such as substance use,
housing, and employment. However, they developed fewer strategies for areas more related
to prevention than to treatment or immediate
needs. Case managers reported limited plans
for health promotion (e.g., medical homes,
health education), which are critical to ensuring
men’s health and reintegration after release.
Consistent with extant reentry initiative
evaluation literature,29,47,48 assistance with
employment and substance abuse treatment
positively affected engagement in the program,
and community support was protective against
recidivism. Substance abuse treatment outside
of transitional housing was particularly effective, possibly because men who sought such
programs were more motivated than were men
participating in treatment that was part of
existing structured programs. By contrast to the
literature, living in private residences was related to decreased engagement in the program.
Men with such stability might not have recognized the importance of multiple supports,
seeing their families or themselves as sufficient
rather than taking advantage of the additional
resources and support that the CRI could
provide.40 The findings underscore the importance of employment, substance abuse
treatment, and informal supports in successful
reintegration into the community but also reveal the necessity of understanding clients’
perception of their recidivism risk. Service
providers should help educate clients about the
various risks to recidivism beyond basic needs,
which many clients recognize. Particularly
for men with substance abuse histories, it also is
important to help them understand triggers
for past behaviors that increase the risk of
relapse, consequences of use, and poor engagement in reentry services.15
HEALTH NEEDS
In part because of the type of correctional
facilities in which the CRI was piloted, men
in the program reported few acute health
conditions. Their health status affords an opportunity to further promote their health and
that of their communities. Often, addressing
health in prison is a more indicated realm, with
staff providing treatment to acute conditions;
however, focus must be more on prevention to
best serve all individuals returning to the
community from prison. To increase men’s
capacity to stay healthy, it is essential to
educate them on increased health risks attributable to incarceration, to educate them on
ways that they can self-manage health, and to
emphasize the importance of receiving regular
health care in the community. Ensuring
access to health care is a good first step, but
individuals returning to the community need to
take advantage of health care services. To
prevent relapse and reduce the risk of developing significant health concerns, it is necessary for these men to understand their risks
related to substance abuse, mental health,
and physical health and to continue any treatment or care they received in prison. It is
important to provide consultation to clients
about potential health challenges, preventive
care, and health-promoting behaviors to reduce the likelihood that they will seek care only
for urgent or chronic health issues. Helping
formerly incarcerated men become proactive
about their health is especially important in
light of racial/ethnic disparities in health
and health care30 as well as gender-related
issues regarding health, such as masculinity,
shame, and guilt.38—40
The CRI model began to fill the gap in
ensuring the health of individuals returning to
the community from prison, but more work
is needed to support men’s health and expand
the definition of continuum of care. At the
time of the preliminary evaluation, the comparison group sample was too small to use as
TABLE 1—Continued
Arthritis 11 (6.36)
Diabetes 4 (2.31)
Heart disease 2 (1.16)
Sexually transmitted infectionsc 6
g (3.47)
Note. DOC = Department of Correction. Health conditions and substance use were self-reported. The sample size was
n = 173.
a
Applies to entire population of interest.
b
Strength.
c
Need.
d
Applies to a subgroup of the population that is at increased risk of difficulties.
e
Based on 123 men with substance abuse histories.
f
Applies to those at greatest risk.
g
No clients reported being HIV positive.
FRAMING HEALTH MATTERS
e6 | Framing Health Matters | Peer Reviewed | Woods et al. American Journal of Public Health | Published online ahead of print March 14, 2013
a comparison for the CRI clients. In addition,
a selection bias may have operated: men who
were most motivated to reintegrate may have
agreed to participate in the CRI. We did not
have access to data on the individuals who did
not consent to enroll and therefore could not
test for significant differences between men
who did and did not enroll. Another limitation
of the evaluation was that self-reported information was a primary source of data. Although
the DOC health summaries augmented the
self-reported data, they did not address all of
the universal, selective, and indicated health
risks that could have been present for the
sample. Future research should continue to
examine multilevel health risks, interventions,
and outcomes for formerly incarcerated individuals.
RECOMMENDATIONS
Our evaluation showed that case managers
and providers appeared to have the capacity
to address employment, education, and housing, as suggested by the variety of planned
interventions and strategies in these areas. Case
managers reported fewer strategies for helping
men use preventive health services, which
all men need. Specific recommendations to
ensure continuity of care and support after
release to facilitate successful reentry are as
follows:
d Use the prevention science framework for
education, planning, and service delivery.
Case managers can work collaboratively
with clients to develop reentry action
FIGURE 2—Percentage of clients who met program goals (n = 126): Connecticut Building
Bridges Community Reentry Initiative, 2005–2007.
TABLE 2—Binary Logistic Regression of Client Engagement and Recidivism on Universal, Selective, and Indicated Interventions:
Connecticut Building Bridges Community Reentry Initiative, 2005–2007
Poor Engagement Recidivism
Intervention Variable OR (95% CI) B or –2 Log Likelihood (v2
) OR (95% CI) B or –2 Log Likelihood (v2
)
Universal (n = 110) 108.06* (12.24) 96.74 (7.57)
Employment 0.31* (0.11, 0.89) –1.16 1.74 (0.62, 4.94) 0.55
Private residence (independent or with family) 3.12* (1.20, 8.11) 1.14 0.60 (0.21, 1.76) -0.51
Community supports 1.15 (0.43, 3.08) 0.14 0.26* (0.08, 0.88) –1.35
Access to health care 0.47 (0.18, 1.26) -0.75 1.03 (0.36, 2.95) 0.03
Selective (n = 94) 97.76 (4.54) 70.50 (1.30)
Financial assistance 0.89 (0.32, 2.51) -0.12 1.44 (0.42, 5.00) 0.36
Child support arrangements 0.00 –20.13 2.51 (0.44, 14.23) 0.92
Indicated (n = 100) 103.50** (8.97) 97.19 (0.05)
Any substance abuse treatment 0.22**(0.07, 64) –1.52 1.13 (0.41, 3.06) 0.12
Nontransitional housing treatment 0.07* (0.01, 0.54) –2.68 1.28 (0.41, 3.98) 0.25
Note. CI = confidence interval; OR = odds ratio. Universal preventive interventions are directed at the entire population of interest, selective interventions are for a subgroup of the population that is
at increased risk of difficulties, and indicated interventions are designed for those at greatest risk.
*P < .05; **P < .01.
FRAMING HEALTH MATTERS
Published online ahead of print March 14, 2013 | American Journal of Public Health Woods et al. | Peer Reviewed | Framing Health Matters | e7
plans that identify needs at each level of
risk, plan strategies that build on their
strengths and resources to reduce these
risks, and revisit the plans to track progress.
Case managers can use the framework to
educate clients on health implications for
each level of risk and the multiple systems
in which they will be a part (e.g., workforce,
community, family) when they return to
the community.
d Build case managers’ capacity to help individuals understand the social determinants of health and identify all types of
needs that increase risk of recidivism to
ensure that areas that typically receive more
focus (e.g., employment, housing) and those
that also are important but might be considered less in planning (e.g., preventive
care, informal supports) are adequately
addressed. Increase providers’ capacity to
leverage informal supports and other resources to help men achieve their goals,
reduce risks, and increase health equity by
continuing to develop cultural competency
to serve African American, Latino, and
other overrepresented—and historically underserved—prisoner and former prisoner
populations.
d Work with individuals to recognize environmental triggers (e.g., previous neighborhoods, friends, family members) that might
threaten their engagement and success.
Determine the level of outreach required to
engage individuals and encourage consistent, active participation.
CONCLUSIONS
The impact of incarceration is not confined
to the prison walls.7,11,16,32 Changes in sentencing and release policies have substantially
increased the number of individuals—especially
African American and Latino men—in the
correctional system and the number who are
released back to the community. Threats to
successful community reintegration include
lack of adequate housing, community and
social supports, education, and employment;
physical and mental health concerns; and substance abuse. A lack of resources and opportunities often contributes to incarceration and
to difficulties after release. Rather than simply
looking at overall program effects of
interventions, allowing some nuances to be lost,
it is essential to consider individuals’ universal,
selective, and indicated risks to successful
reentry to best tailor pre- and postrelease
supports.
The prevention framework can help providers and men returning to the community
conceptualize and recognize multiple risks
and proactively develop a comprehensive
plan not only to address immediate needs
but also to put supports in place to prevent
potential difficulties. By identifying the degree
to which universal, selective, and indicated
risks are addressed in planning and by
aligning identified strengths and needs with
strategies outlined in reentry plans, case
managers can identify gaps in services and
determine how to better connect men to
needed resources. Furthermore, understanding the relationship between participation
in strategies to address risk and successful
reentry can reveal the importance of areas
(e.g., community support) that might not be
focused on when higher risks (e.g., substance
abuse) alone are considered.
To improve continuity of care after release
from prison, it is important to consider the role
of prevention in reentry planning for all individuals—not just those with highest risk—and
to examine complexities at each level of risk that
have implications for health. Service providers
should increasingly explore holistic health
needs and facilitate pre- and postrelease continuity of care. Leveraging resources through the
corrections and judicial systems is one way to
ensure that reentry preparation begins in
prison. Service providers should continue to
encourage clients’ consistent, active participation and develop strategies to critically examine
whether they are achieving their stated goals for
reentry. Moving forward, it is imperative to
understand the complexity of the key risks to
reentry and how ensuring continuity of care
and supports for individuals rejoining the community after incarceration can facilitate their
healthy and permanent return. j
About the Authors
At the time of the study, LaKeesha N. Woods was with and
Derrick M. Gordon is with The Consultation Center, Yale
University School of Medicine, New Haven, CT. A. Stephen
Lanza is with Family ReEntry, Inc, Bridgeport, CT.
William Dyson is with the Connecticut General Assembly,
Hartford.
Correspondence should be sent to LaKeesha Woods,
Community Science, 438 N Frederick Ave, Gaithersburg,
MD 20877 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the
“Reprints” link.
This article was accepted June 24, 2012.
Contributors
L. N. Woods helped oversee the evaluation and led the
writing of the article. A. S. Lanza was a key partner in the
reentry initiative and provided input on the content of
the article. W. Dyson was involved in the legislation
concerning community integration for formerly incarcerated individuals and provided input on the content of
the article. D. M. Gordon directed the evaluation and
participated in writing the article.
Acknowledgments
Funding for this project was provided in part by Connecticut’s Court Support Services Division, Judicial
Branch; Family Reentry, Bridgeport, CT; and Connecticut’s Department of Mental Health and Addiction Services. Article preparation for LaKeesha N. Woods was
supported by the National Institutes of Health, National
Institute of Drug Abuse (T32 DA019426-01). Community Science provided support for editing of the article.
Note. Any opinions, findings, conclusions, and recommendations expressed in this article are the authors’
and do not necessarily reflect the views of Connecticut’s
Court Support Services Division, Judicial Branch; Family
Reentry, Bridgeport, CT; Connecticut Department of
Mental Health and Addiction Services; or the National
Institutes of Health.
Human Participant Protection
The Yale University School of Medicine Human Investigation Committee approved the study.
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