Prison Health Care System Research Articles

Enhancing Data Quality through Electronic Health Records in Prison Settings: Towards a Learning Health System

Abstract Utilizing electronic health records (EHRs) in prison settings offers a unique opportunity to establish a learning health system (LHS) aimed at enhancing healthcare quality for incarcerated individuals. Despite the challenges inherent in prison healthcare, leveraging EHRs can facilitate data-driven decision-making and foster continuous improvement initiatives. This study describes the results of an intervention aimed at improving EHR data quality in prisons and explores the potential to enhance the development of a robust LHS. We assessed EHR data quality in 2015 (38 prisons) and 2022 (35 prisons) in the Netherlands over six months. Data were extracted, de-identified, and analyzed across demographic, medication use, (history of) diagnosis, and healthcare usage categories. We measured indicator scores and evaluated variation between prisons in data quality. This project was commissioned by the Custodial Institutions Agency. In 2015, age and gender were recorded for 93% of prisoners, increasing to 100% in 2022. Diagnostic coding use rose from an average of 82% in 2015 to 98% in 2022, with reduced variation between prisons. Consultation frequency per inmate ranged from 3 to 13, reflecting challenges in constructing a uniform denominator due to institutional differences. Mental health problems accounted for 17.7% of recorded disease episodes in 2022. In addition, consultations were most often related to oral health (4.4%), drug abuse (3.2%), sleep (1.8%), fear of diseases (1.6%), and respiratory infections (1.5%). Our findings indicate improvements in EHR data quality in Dutch prisons between 2015 to 2022. Integrating EHR data reuse into prison healthcare systems is pivotal for realizing the vision of an LHS in correctional facilities. This study underscores the potential of advancing EHR recording habits and the reuse of EHR data to enhance healthcare quality in prison settings.

Care Transitions for Incarcerated Pregnant People: A Needs Assessment.

Incarcerated pregnant people face significant barriers when seeking health care services in prisons and jails, but little is known about their transitions from state prison health care systems to outside hospitals. This project analyzed current policies and procedures for care transitions for incarcerated people and presents policy recommendations to address issues of concern. We conducted in-depth interviews with stakeholders at a state prison, academic hospital, and private hospital to identify the barriers and facilitators to care transitions. Themes emerging from these interviews were operational, including medical records, communication, and education; and structural, including implicit biases and care of marginalized groups. These findings are likely applicable to similar facilities throughout the United States. A multipronged, interdisciplinary approach is needed to address challenges of care transitions.

The contingent effect of incarceration on state health outcomes

IntroductionThis study examines how growth in the population of former prisoners affects rates of communicable diseases such as tuberculosis, syphilis, chlamydia, and HIV. MethodsWe estimate state-level fixed effects count models showing how the former prisoner population affected communicable disease in U.S. states from 1987 to 2010, a period of dramatic growth in incarceration. ResultsWe find contingent effects, based on how specific diseases are recognized, tested, and treated in prisons. The rate of former prisoners increases diseases that are poorly addressed in the prison health care system (e.g., chlamydia), but decreases diseases that are routinely tested and treated (e.g., tuberculosis). For HIV, the relationship has shifted in response to specific treatment mandates and protocols. Data on prison healthcare spending tracks these contingencies. DiscussionImproving the health of prisoners can improve the health of the communities to which they return. We consider these results in light of the relative quality of detection and treatment available to underserved populations within and outside prisons.

Extraction without reserve: The case of Arizona's penal care regime

Prison healthcare reform and litigation have emerged as critical sites of social and political struggle in early twenty-first century punishment. In the case of Arizona, privatization of its prison healthcare system maintained commitments to cheap and mean punishment in the wake of economic crisis, which led to an ongoing class-action lawsuit over prisoners’ rights violations. By conducting a case study of Arizona's prison healthcare crisis, this article mobilizes important interventions in the theoretical accounts of late mass incarceration and the penal state. Not only did Arizona's brand of penal austerity anticipate the scaling back of social services across the state, but effectively subjected prisoners to a perpetual deferment of care. Drawing upon this sociopolitical context, I elaborate a theory of penal extraction whereby care capacity is not only removed from the prison, but the prisoner's life becomes like an exhaustible resource.

Older Adults' perspectives on death and dying in prison

PurposeIncarcerated people often have extensive health needs compared to their community-dwelling peers. This is especially the case among older adults, who represent a sizeable and growing portion of the U.S. prison population with a concomitant health burden. While research has expanded in recent years regarding health-related experiences among older adults in prisons, research surrounding their perceptions of death and dying in these settings remains limited. MethodsWe gathered qualitative data from 193 interviews with older men incarcerated across three U.S. prisons. ResultsExperiences related to dying and death were normative among the sample and both secondary and primary accounts of dying and death were described. Descriptions of death were most often framed with reference to health conditions versus violence. Further, respondents' perceptions of death and dying were also linked to fears in three areas: dying while imprisoned, dying due to distrust of the prison health care system, and what happens to their personal effects and persons after death in prison. ConclusionsFindings reinforce the importance of addressing carceral medical neglect, the potential role of hospice, and the need for correctional policy and practice to be attentive to disenfranchised grief.

Commentary on the harm reduction reference group of justice health and forensic mental health network and corrective services NSW, Australia.

This commentary aims to reveal how a steering committee has effectively responded to advancing accessibility to harm reduction resources, hepatitis C virus (HCV) policy and health strategies within adult prison settings in New South Wales (NSW). By reviewing the audit approach taken by the of the Justice Health and Forensic Mental Health Network and Corrective Services New South Wales Harm Reduction Reference Group (JHFMHN/CSNSW HRRG), this commentary emphasizes the committee's success in identifying contemporary harm reduction issues that affect people in custodial settings. This commentary is a compilation of data gathered through the 2018 JHFMHN/CSNSW HRRG audit and corresponding program materials. Conclusions regarding the effectiveness of the working group's audit were drawn by critically appraising the JHFMHN/CSNSW HRRG's Final Audit Report (JHFMHN and CSNSW, 2018) with reference to current harm reduction literature. The HRRG has provided leadership, professional representation and strategic advice on the development, implementation, monitoring and evaluation of best practice harm reduction strategies in prison settings. The HRRG developed and maintained networks and information exchange between the state-wide HCV health network, corrections services and the NSW harm reduction sector at large. Public health partnerships and advocacy that involve all key players, such as the HRRG, will continue to be crucial to remove barriers to enhancing HCV harm reduction measures especially in NSW prison settings. Strategies such as primary prevention and treatment can mitigate the spread of HCV in the custodial system. This audit of access to harm reduction resources was conducted on behalf of the diverse group of professionals, scholars and stakeholders comprising the HRRG. This audit and other advocacy efforts of this committee can facilitate future access to quality healthcare and the necessary policies required to support a healthier prison population at large. Collaborating with health authorities, researchers and social service workers can enable prison health-care systems to be guided by wider health workforce programs and public health standards. This collaboration can reduce the professional isolation of custodial health-care staff and promote a balanced approach to harm reduction policies by ensuring an equitable focus on both health and security imperatives.

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

BackgroundThis 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.ResultsIn 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.ConclusionsThe 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.

Behind the Wall of Indifference: Prisoner Voices about the Realities of Prison Health Care

While most Americans never see or become ensnared in the nation’s vast correctional system, there are unprecedented costs—economic, social, and ethical—that are being paid, one way or another, by everyone in this country. It is no secret that prison inmates face health threats behind bars that equal anything they face in the streets. Violent assault, rape, or the outbreak of highly infectious diseases are much more common in correctional facilities than in the general population. Prison conditions can easily fan the spread of disease through overcrowding, poor ventilation, and late or inadequate medical care. Effectively protected from public scrutiny, the prison health care system has almost zero accountability, thus escaping outside attention to serious failures of care. If you want to know about the practice of health care in prison settings, ask someone who has been “in” the system. Prisoners have a story to tell and this article gives voice to the experiences of those who have been directly impacted by the provision of health care in the prison system.

The Impact of Covid-19 on Inmate Trust in Health Care and Willingness to Seek Treatment - A Qualitative Investigation

Background and Objective: 
 The coronavirus has disproportionately impacted vulnerable members of society. With the U.S. as the global leader in incarceration and the difficulties prison systems face implementing many of the mitigation strategies employed by the general population, the incarcerated population is in a uniquely vulnerable position particularly within an already strained prison healthcare system. Given the nature of prisons as total institutions, negative experiences with the virus coupled with a lack of autonomy could lead to a loss of trust in the healthcare system which has the potential to impact health-seeking behaviors. In this study, we aim to examine the effect of Covid-19 on Indiana inmates’ trust in healthcare. 
 
 Project Methods: 
 Data from 380 surveys distributed across Indiana’s prison system will be collected and analyzed. These results will be used to develop an interview protocol to conduct at least 25 in-depth interviews which will then be coded using NVivo to identify any emerging themes regarding their experiences with Covid-19. Prior to this, in-depth literature reviews were done on health care in prison populations and trust in healthcare. 
 
 Results: 
 The surveys and interview protocol will be developed in the ensuing months and thus no data has yet been collected. The literature review revealed that the quality and accessibility of care in prisons is lacking, an issue exacerbated by the pandemic. Because of the disproportionate number of preexisting issues, inmates worried about the ability of prison administrators to properly protect inmates from contracting the virus. Additionally, it was found that trust likely does have an effect on health, and that many commonalities of inmates are poor predictors for trust. 
 
 Potential Impact: 
 This study aims to identify potential loss of trust in healthcare systems to inform community reentry programs in developing strategies that prioritize inmate health needs and perceptions.

Continuum of hepatitis C care cascade in prison and following release in the direct-acting antivirals era

BackgroundPeople with criminal justice involvement contribute remarkably to the rising hepatitis C virus (HCV) burden; however, the continuum of care is a major barrier to prison-based programs. We aimed to evaluate a comprehensive HCV care model in an Iranian provincial prison.MethodsBetween 2017–2018, in the Karaj Central Prison, newly admitted male inmates received HCV antibody testing and venipuncture for RNA testing (antibody-positive only). Participants with positive RNA underwent direct-acting antiviral (DAA) therapy (Sofosbuvir/Daclatasvir). Sustained virological response was evaluated at 12 weeks post-treatment (SVR12).ResultsOverall, from 3485 participants, 182 (5.2%) and 117 (3.4%) tested positive for HCV antibody and RNA, respectively. Among 116 patients who were eligible for treatment, 24% (n = 28) were released before treatment and 72% (n = 83) initiated DAA therapy, of whom 81% (n = 67/83) completed treatment in prison, and the rest were released. Of total released patients, 68% (n = 30/44) were linked to care in community, and 70% (n = 21/30) completed treatment, including 60% (n = 12/20) and 90% (n = 9/10) among those who were released before and during treatment, respectively. The overall HCV treatment uptake and completion were 89% (n = 103/116) and 85% (n = 88/103), respectively. From people who completed treatment, 43% (n = 38/88) attended for response assessment and all were cured (SVR12 = 100%).ConclusionsIntegrated HCV care models are highly effective and can be significantly strengthened by post-release interventions. The close collaboration of community and prison healthcare systems is crucial to promote high levels of treatment adherence. Future studies should investigate the predictors of engagement with HCV care following release.

Service Provision Study on the Implementation of Nurse-Led Clinic in the Irish Judicial System.

The exponential growth of the nurse-led clinic in the Republic of Ireland has proven to be effective in patients' care in the Irish community (National Council for Professional Development of Nursing and Midwifery, 2005). This initiative has been replicated in the penal environment and assumed to add value to the prison health care system. To date, this concept has never been explored. The main goal of this study was to examine this concept in this setting. It was hoped that the outcome of this inquiry will provide a better insight into the service, which can be used in the development of an evidence-based policy in the future.

Let My People Go

The COVID-19 pandemic has opened our eyes to the myriad vulnerabilities in the prison health care system. We need only record the number of pandemic-related deaths of federal inmates to grasp that the prison health care system is profoundly ill-equipped to handle the needs of inmates during a public health crisis. Currently, prisoner infection rates outpace those of the general, unincarcerated population by more than 150%, and prisoners are dying four times as often as prison staff who test positive. Results are far worse for elderly inmates. While COVID-19 afflicts people of all health profiles, its grip on the elderly is the most arresting. Though some effort has been exerted, federal prison officials fail to adequately protect the rights of the imprisoned elderly. It cannot be ignored that prison officials owe basic duties of care to the incarcerated, chief among them, the responsibility to provide adequate health care. However, prisons, by their very nature, are unable to care for an old and ailing population. This glaring deficiency is rendered indisputable by the novel coronavirus pandemic. For this reason, vulnerable inmates, especially the elderly, should be released to home confinement forthwith. Anything less is profoundly inhumane and represents a colossal miscarriage of justice.

Prisoners' experience and perceptions of health care in Australian prisons: a qualitative study.

Patient-centred care is a key approach used in Australia for the delivery of quality health care, and understanding experiences and perceptions is a key part to this. This paper aims to explore prisoners' experiences and perceptions of health-care service provision in New South Wales, Australia. In February and March 2017, 24 focus groups, consisting of 128 participants, were undertaken using semi-structured interviews that explored experiences of health care in prison. A conceptualisation of the prisoners' health-care experience around the core category of access to health care emerged from the data. Enablers or barriers to this access were driven by three categories: a prison construct - how the prisoners "see" the prison system influencing access to health care; a health-care system construct - how the prisoners "see" the prison health-care system and the pathways to navigate it; and personal factors. Communication was the category with the greatest number of relational connections. This study takes a pragmatic approach to the analysis of data, the findings forming the basis for a future quantitative study. The findings identify communication as a key issue for access to health care. This study provides first-hand accounts of enablers and barriers to accessing health-care services in the prison environment. To the best of the authors' knowledge, this study is the first of its kind to identify access to health care as a core category and is of value to health workers and researchers that work with the prison population.

A Quality Improvement Project for Care Transitions of Incarcerated Women [03C

INTRODUCTION: Currently incarcerated pregnant women face significant barriers when they seek health care services within prisons and jails, but little is known about transitions from state prison health care systems to outside hospitals. METHODS: With the goal of developing a policy to improve these transitions, we conducted in-depth interviews with key stakeholders at a state prison, university hospital, and local private hospital to identify the barriers and facilitators to care transitions for incarcerated pregnant women. RESULTS: Key themes emerging from the interviews were operational, including transfer of medical records, communication between systems, and education of providers, and structural, including care of marginalized populations and implicit biases. CONCLUSION: Policy changes to improve transitions of care may include the addition of a dedicated pregnancy care coordinator and a standardization of a clinician-to-clinician sign-out process. This work has the potential to motivate changes to the policies that govern care of incarcerated pregnant women, and stimulate the delivery of more effective and efficient health care to this population.

Intensified tuberculosis and HIV surveillance in a prison in Northeast India: Implementation research.

Structural and individual level factors in prisons create challenges towards detection and management of HIV/tuberculosis. WHO and India’s HIV/tuberculosis control programs recommend intensified case finding in prisons. Low HIV and tuberculosis detection rates suggest poor implementation of existing surveillance strategies within the prison healthcare system in Mizoram’s capital city of Aizawl. We explored the operational feasibility of implementing the intensified case finding strategy in Aizawl central prison. We implemented the intensified screening through entry screening of new inmates, mass screening of resident inmates and exit screening at release. We set up digital chest radiography, sputum smear microscopy and HIV testing facilities within the prison and referral to external facility for Cartridge Based Nucleic Acid Amplification Test (CBNAAT). We screened 738 inmates (Male: 626; Female: 112). Of 53% inmates having presumptive tuberculosis symptoms, 37% underwent sputum microscopy. We detected 14 new tuberculosis cases; overall tuberculosis positivity 1.9%. We tested 65% of 657 inmates for HIV, of which 41 new cases were detected; overall HIV positivity 16.5%. Three male inmates had HIV-tuberculosis co-infection. It is feasible to implement intensified case detection for tuberculosis/HIV in the prison with inter-departmental coordination, albeit with certain challenges.

Management of Hepatitis C in Delaware Prisons: : Approaching Microenvironmental Eradication.

The management of chronic hepatitis C virus (HCV) infection has been transformed due to the arrival of HCV-specific Direct-Acting Antivirals (DAAs), which are safer, more effective, and better tolerated than the interferon-based therapies that preceded them. Compared with community healthcare systems, many prison healthcare systems have been slower to adopt the routine use of HCV DAAs despite the fact that HCV infection disproportionately affects individuals in correctional institutions. In 2015, the Delaware Department of Correction (DDOC) launched a treatment program that prioritized treatment for patients who were at greatest risk of disease complications. To date, 327/345 (95%) of eligible current HCV patients have initiated DAA therapy. A total of 196/199 (98.4%) patients who have initiated treatment and who have post-treatment data available have achieved sustained virologic response, defined as undetectable HCV viral load 12 weeks after treatment. Applying a concept of microenvironmental eradication, it can reasonably be concluded that that DDOC is approaching this benchmark with regard to chronic HCV infection and will soon enter a “maintenance phase,” during which it will be feasible to treat new cases of HCV in real time. Correctional systems with significant numbers of untreated hepatitis C patients may want to consider implementing HCV treatment programs that focus on cost-effectiveness and prioritize treatment for patients who are at greatest risk of disease complications.

Improving health in prisons – from evidence to policy to implementation – experiences from the UK

PurposeThe purpose of this paper is to understand the components of a high-quality prison healthcare system and the impact, ten-years on, of the transfer of accountability in England, from a justice ministry to a health ministry.Design/methodology/approachA rapid evidence review was undertaken, which included a review of 82 papers and qualitative interviews with key informants. The concepts and themes identified were summarised and analysed through a framework analysis, designed to improve population outcomes and address health inequalities. The use of a rapid evidence assessment, rather than a systematic review methodology, the use of abstracts (rather than full-text articles) to extract the data, and limiting the search strategy to articles published in the English language only might mean that some relevant research papers and themes were not identified. The need for the evidence to be produced within a limited time frame and with limited resources determined these pragmatic approaches.FindingsThe review found that English prison healthcare has undergone “transformation” during this period, leading to increased quality of care through organisational engagement, professionalisation of the healthcare workforce, transparency, use of evidence-based guidance and responsiveness of services. The review also highlighted that there is still room for improvement, for example, relating to the prison regime and the lack of focus on early/preventive interventions, as well as specific challenges from limited resources.Research limitations/implicationsTime and resource constraints meant a rapid evidence review of papers in the English language was undertaken, rather than a systematic review. This might mean relevant papers have been missed. The review also only covered a small number of countries, which may limit the transferability of findings. The lack of quantitative data necessitated the use of qualitative data gathered from key informants. However, this enabled a good understanding of current practice.Practical implicationsThe review findings support the World Health Organisation position on the value of integrated prison and public health systems in improving quality of healthcare. It also recommends future policy needs to take account of the “whole prison approach” recognising that healthcare in prisons cannot operate in isolation from the prison regime or the community.Originality/valueThis is unique research which has great value in supporting prison reform in England. It will also be of interest internationally due to the paucity of data in the published peer-reviewed literature on the impact of commissioning models on healthcare or health outcomes.

Palliative and end-of-life care in prisons: a content analysis of the literature.

The growing numbers of terminally ill and dying in prison has high economic and moral costs as global correctional systems and the society at large. However, to date little is known about the extent to which palliative and end-of-life care is infused within global prison health care systems. The purpose of this paper is to fill a gap in the literature by reviewing and critically appraising the methods and major findings of the international peer-reviewed literature on palliative and end-of-life care in prison, identify the common elements of promising palliative and end-of-life services in prison, and what factors facilitate or create barrier to implementation. A content analysis was conducted of the existing peer-reviewed literature on palliative and end-of-life care in prison. English-language articles were located through a comprehensive search of peer-reviewed journals, such as Academic Search Premier Literature databases using differing combinations of key word search terms, "prison," "palliative care," and "end-of-life care." A total of 49 studies published between 1991 and 2013 met criteria for sample inclusion. Deductive and inductive analysis techniques were used to generate frequency counts and common themes related to the methods and major findings. The majority (n=39) of studies were published between 2001-2013 in the USA (n=40) and the UK (n=7). Most were about US prison hospice programs (n=16) or barriers to providing palliative and end of life care in prisons (n=10). The results of the inductive analysis identified common elements of promising practices, which included the use of peer volunteers, multi-disciplinary teams, staff training, and partnerships with community hospices. Obstacles identified for infusing palliative and end-of-life care in prison included ethical dilemmas based on custody vs care, mistrust between staff and prisoners, safety concerns, concern over prisoners' potential misuse of pain medication, and institutional, staff, and public apathy toward terminally ill prisoners and their human rights to health in the form of compassionate and palliative care, including the use of compassionate release laws. Implications for future research that foster human rights and public awareness of the economic and moral costs of housing the sick and dying in prisons. More research is needed to document human rights violations as well as best practices and evidence-based practices in palliative and end-of-life care in prisons. Future studies should incorporate data from the terminally ill in prison, peer supports, and family members. Future studies also should employ more rigorous research designs to evaluate human rights violations, staff and public attitudes, laws and policies, and best practices. Quantitative studies that use experimental designs, longitudinal data, and multiple informants are needed. Qualitative data would allow for thick descriptions of key stakeholders experiences, especially of the facilitators and barriers for implementing policy reform efforts and palliative care in prisons. Practical implications - This review provides a foundation on which to build on about what is known thus far about the human right to health, especially parole policy reform and infusing palliative and end-of-life care for the terminally ill and dying in prisons. This information can be used to develop or improve a new generation research, practice, policy, and advocacy efforts for that target terminally ill and dying in prison and their families and communities. There are significant social implications to this review. From a human rights perspective, the right to freedom from torture and cruel and unusual punishment is a fundamental human right along with prisoners' rights for an appropriate level of health care. These rights should be guaranteed regardless of the nature of their crime or whether they are in a prison placement. The information provided in this review can be used to educate and possible transform individual's and society's views toward the terminally ill and dying who are involved in the criminal justice system. This paper extends the extant literature by using both quantitative and qualitative analysis methods to organize, summarize, and critically analyze the international literature on palliative care and end of life care in prison. This review is designed to increase awareness among the international community of the pain and suffering of the terminally ill in prison and the facilitators and barriers to providing them compassionate care while in custody.

The Grief Experience of Prison Inmate Hospice Volunteer Caregivers

Correctional institutions are obligated to provide end-of-life care to a population with complex medical needs. Prison hospices are increasingly being formed to address this demand. Few empirical studies have examined the impact of caring for dying inmates on the hospice inmate volunteers, who, in several prison health care systems, provide direct care. In this study, experiences of the inmate hospice volunteers with death were investigated to illuminate their grief processes. Understanding the bereavement needs of hospice volunteers and how prison hospice volunteers navigate grief and remain committed to providing excellent hospice care can inform the grief processes and practices of hospice care professionals.

Prison health care inequality

Federal inmates in the Canadian correctional system receive substantially varied health care that does not measure up to that of other Canadians, according to experts in the prison health care system. Correctional Service Canada (CSC) is responsible for providing an estimated 15 055 federal