M E E T I N G
S U M M A R Y

The Public Health
Dimensions of Prisoner
Reentry: Addressing the
Health Needs and Risks of
Returning Prisoners and
their Families

National Reentry Roundtable Meeting
The Urban Institute
Los Angeles, California
December 11-12, 2002

With support from The California Endowment, The Robert Wood
Johnson Foundation, and Centers for Disease Control

research for safer communities

URBAN INSTITUTE

Justice Policy Center

R e e nt r y

Ro u nd ta b le

Public Health Dimensions of Prisoner Reentry:
Addressing the Health Needs and Risks of
Returning Prisoners and their Families
National Roundtable

Reentry Roundtable Meeting
The Urban Institute
Los Angeles, California
December 11-12, 2002

Contents
SECTION 1. WELCOME AND MEETING OVERVIEW ............................................................................... 1
Jeremy Travis, Urban Institute ......................................................................................................... 1
SECTION 2. PAPER PRESENTATIONS & DISCUSSION.......................................................................... 2
HEALTH PROFILE OF THE PRISON POPULATION............................................................................. 2
Lois Davis, RAND ............................................................................................................................ 2
PRISON HEALTH CARE SERVICES...................................................................................................... 5
B. Jaye Anno, Consultants in Correctional Health Care .................................................................. 5
COMMUNITY HEALTH CARE SERVICES ............................................................................................. 7
Nicholas Freudenberg, Hunter College............................................................................................ 7
ROLE OF FAMILIES AND SOCIAL NETWORKS IN IMPROVING HEALTH OUTCOMES ................... 9
Nancy Wolff, Rutgers University ...................................................................................................... 9
LINKAGES BETWEEN PRISON AND COMMUNITY HEALTH SERVICES......................................... 12
Ted Hammett, Abt Associates ....................................................................................................... 12
BARRIERS TO HEALTH SERVICES FROM A RACE AND GENDER PERSPECTIVE ...................... 15
Ray Patterson, Howard University and Bob Greifinger, The Bromeen Group............................... 15
REVIEW OF EVALUATION LITERATURE ON HEALTH OUTCOMES................................................ 17
Embry Howell, Urban Institute and Robert Greifinger, The Bromeen Group................................. 17
SECTION 3. NEXT STEPS FOR RESEARCH AND POLICY ................................................................... 19
RESEARCH AND POLICY QUESTIONS.............................................................................................. 19
Nicholas Freudenberg, Hunter College.......................................................................................... 19
CONCLUDING REMARKS......................................................................................................................... 21
APPENDICES............................................................................................................................................. 40

Acknowledgements

The Urban Institute would like to thank the many individuals and organizations that contributed to the
Reentry Roundtable on public health. We would especially like to thank our funders, whose support
made this project possible: The California Endowment, the Robert Wood Johnson Foundation, and the
Center for Disease Control. The views expressed herein should not be attributed to the Urban Institute,
its funders, or its trustees.

SECTION 1.

Welcome and Meeting Overview
Jeremy Travis, Urban Institute
One of the most profound challenges facing American society is the reintegration of more than
600,000 individuals who leave state and federal prisons and return home each year. The fourfold
increase in incarceration rates over the past 25 years has had far-reaching consequences. One
and a half million children have a parent in prison. Four million citizens have lost their right to
vote. Prisoners leave correctional facilities with little preparation for life on the outside,
insufficient assistance with reintegration, and a high likelihood of return to prison for new
crimes or parole violations. The damaging cycle of removal and return of large numbers of
young adults, mostly men, creates specific health needs and risks for returning prisoners, their
families, and the community at large.
This is the fourth in a series of Reentry Roundtables initiated by the Urban Institute’s Justice
Policy Center as part of a policy research initiative to advance our understanding of the process,
risks, and challenges of prisoner reentry. In October 2000, the Urban Institute invited academics,
practitioners, service providers, and community leaders to the first Reentry Roundtable in
Washington, D.C., which examined sentencing and public safety issues from health, substance
abuse, labor market, racial, community, family, and gender perspectives. That dynamic
discussion led to the organization of the second Reentry Roundtable in March 2001 in New York
City, which explored the impact of state policies on returning prisoners, families, and
communities and developed a research agenda on prisoner reentry. In March 2002, a third
Reentry Roundtable focused on the role of society’s civil institutions in facilitating the
reintegration process for former prisoners. The Urban Institute hopes to convene Reentry
Roundtable meetings twice a year, with the aim of promoting a national discussion on a variety
of issues relating to sentencing and prisoner reintegration. Future topics will include
employment, housing, and the impact of reentry on adolescent development.
The aim of this roundtable was to generate national discussion about the health needs and health
risks of returning prisoners and their families, and offer policymakers a critical opportunity to
improve outcomes. While the focus was on prison reentry, many participants noted that those
returning from jails also pose health problems to their communities and the health care system.
The two-day session provided an opportunity for meeting participants to explore the places
where corrections, reentry, and health perspectives intersect. The national roundtable was
followed by a one-day session focused on health and prisoner reentry in California.
The format of the roundtable discussion is as follows. The two-day meeting is divided into seven
topics. For each topic, we commission background papers written by some of the nation’s
leading researchers. For each of these issues, the author of the commissioned paper starts the
discussion on that particular topic with a brief review of the paper, followed by a highly
interactive exchange of perspectives by roundtable participants. (A full list of participants can be
found in Appendix A.)

SECTION 2.

Paper Presentations & Discussion
HEALTH PROFILE OF THE PRISON POPULATION

Lois Davis, RAND
Abstract:
Prisoners and the soon-to-be-released inmates are disproportionately inflicted with illness and
tend to be sicker, on average, than the U.S. general population. The changing characteristics of
the reentry population and their demographics have a direct impact on the prevalence of
disease. Chronic medical conditions, infectious diseases, mental illness, and substance abuse are
common within state prison and soon-to-be-released populations. Comorbidity of these
conditions is also common among the prisoner population. In this context, ethical dilemmas to
improved screening and treatment exist. The challenges to improve the health profile of the
prison population and protect the health of the families and communities that are linked to this
population are numerous.
The characteristics of the reentry population are changing rapidly. The size of the
release population is growing and concentrated in five states: California, Florida,
Illinois, New York, and Texas. The length of time served by prisoners has also
increased. Today, there are more “churners” (individuals who have multiple periods
of incarceration) and more unconditional releases than in the past. Fewer prisoners
are participating in educational, vocational, and prerelease programs. From a public
health perspective, these factors have negative implications for successful reentry
and addressing health care needs.
Demographic trends also have implications for successful reentry and addressing
health care needs. Releasees from state prisons tend to be older, introducing
complex health issues associated with age. The growing number of female
prisoners brings another set of reentry ramifications. There has been an increase of
people who are infected with HIV in need of specific treatment.
While the ethnic composition of state prison parolees has been stable over the past
10 years, important disparities remain in the amount of time served, black prisoners
having longer stays. The reentry challenges for some communities (poor,
communities of color) are greater than the challenges faced by others.
The prevalence of infectious disease is on the average 4 to 10 times greater among
prisoners than the rest of the U.S. population. Chronic disease, such as asthma, is
higher. Mental illness is anywhere from 1.5 to 5 times greater. And the prevalence
of substance abuse and dependence is higher.

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Reentry Roundtable December 2002

Table 1. National Estimates of Selected Chronic and Communicable Diseases and Mental Illness Among
A
Inmates and U.S. Population
Condition

Chronic DiseasesB
Hypertension
Asthma
Diabetes
Communicable DiseasesC
AIDS
HIV Infection
Hepatitis C
TB infection
TB disease
Mental IllnessD
Post Traumatic Stress
Disorder
Major Depression
Schizophrenia /
Psychosis

Estimated Prevalence
among Prisoners

Estimated Number of
Inmates

Prevalence among U.S.
Population

18.3%
8.5%
4.8%

283,105
140,738
73,947

24.5%
7.8%
7.0%

0.5%
2.3 – 2.98%
17.0 – 18.6%
7.4%
0.04%

9,200
35,000 – 47,000
303,000 – 332,000
131,000
1,400

0.09%
0.3%
1.8%
N/A
0.01%

6.2 – 11.7%

62,388 – 118,071

7.2%

13.1 – 18.6%
2.3 – 3.9%

132,619 – 188,259
22,994 – 39,262

18.1%
0.8%

National Commission on Correctional Health Care. 2002. “Prevalence of Communicable Disease, Chronic Disease and
Mental Illness Among the Inmate Population” in The Health Status of Soon-to-be-Released Prisoners, A Report to Congress,
Volume 1.
B Estimates of chronic diseases among the inmate population are for 1995 and include prisons and jails.
C Estimates of communicable infections and diseases are for the prison population in 1997.
D Estimates of mental illnesses among the inmate population are for state prisoners in 1995.
A

Co-morbid conditions are also an issue for the prison population. Although data are
sparse, it is believed that co-morbidity is on the rise. Treatment plans upon release
for prisoners who are dually and triply diagnosed are limited.
There is a clear need for better data management and tracking systems. State
prisons do not collect data on a regular basis to allow for estimates of disease
prevalence. As a result, it is impossible to assess the true profile of prisoner health.
The tracking systems in place are also inadequate.
Improved screening raises a host of ethical and treatment issues. If a condition is
identified, there is an ethical duty on behalf of the prison to provide treatment and
to transition the care to community providers upon the inmate’s release. This is
especially true for prisoners with infectious diseases, mental illness, and chronic
medical conditions. With limited resources, it is unclear who would pay for
increased and improved services.
The bottom line is, resources are limited. The challenge is to address the economics
of an improved system. Repackaging the issue to appeal to the public health
community is crucial.

Comments:
The term “ex-offender” is pejorative and should be abandoned. A preferable term would be
“former prisoners” or “individuals with a previous conviction.” Similarly, “prisoners” should
be used instead of “inmates” or “criminals.” Most do not have criminal minds; they are men
and women in and leaving prison.
Understanding the type of health care that is available in the communities from which
prisoners come is extremely important. It may be that the health profile of the prisoner
population is a reflection of the inadequate health care that is administered in poor
communities of color. Prevalence of disease is generally higher in prison than it is in poor
communities. However, in many cases, a prisoner’s health status improves when he/she is
incarcerated. For many, the correctional system is their only guarantee of care. Further
research in this area is needed.
It is also important to keep the jail population in mind. From a criminal justice point of view,
the policy for one system normally affects the policy of the other. And, from a sociological
point of view, jails have a larger impact on low-income communities of color because more
people move through jails than through prisons.
One of the most provocative discussion points is whether there is an ethical duty to diagnose
and treat prisoners. In most cases, the correctional system recognizes the prevalence of
mental illness, drug and alcohol abuse, and Hepatitis C, but does very little about it unless
there is a legal threat or humanitarian influence. Recognizing that each prisoner is tied to a
family and community, it is important to think carefully about the impact of these decisions
both in and outside prison walls.
The way in which screening is presented and offered can make a significant difference in the
willingness of a prisoner to undergo testing. When screening is properly packaged, voluntary
testing rates have been as high as 80 percent. Understanding why prisoners choose not to
undergo testing is central to thinking in this area. Many opt not to undergo testing for fear of
being tagged “mentally ill” or “sick,” placing the individual in a vulnerable place within the
prison culture.

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Reentry Roundtable December 2002

PRISON HEALTH CARE SERVICES

B. Jaye Anno, Consultants in Correctional Health Care
Abstract:
Prior to 1970, little attention was paid to the conditions of confinement for our nation’s
prisoners, including access to adequate health care. Many correctional officials considered
health care a privilege that could be given or withheld, depending on a prisoner’s behavior.
Today, almost all but the smallest prisons and jails have an adequate health care delivery system
in place. While substantial improvements have been made in correctional care over the past 30
years, much remains to be done. Improved quality and effective discharge planning are central
to moving forward.
What is the range of services offered in correctional facilities?
Ambulatory health services are offered on site. Regional systems and community providers
are often used for diagnostic services, hospitalizations, and specialized care. Most prisons use
resources in the community.
Who provides health services?
Licensed practitioners provide the services. In the past, unlicensed doctors and inmate nurses
were the norm. Today, doctors are board certified or board eligible.
What is the quality of those services?
Unfortunately, it is unknown. It is safe to say that correctional health care services are 20
years behind the state of practice. The National Commission on Correctional Health Care,
however, is beginning to offer training for quality control and improved services.
How do inmates access services? Are there routine screenings?
Upon arrival, a general medical history of the prisoner is taken. In some cases, a TB test will
be administered. A comprehensive exam is normally performed as a follow-up. Each system
has the authority to decide what tests are needed. Some try to follow the guidelines set forth
by national health organizations. Periodic exams also occur. In terms of access, most systems
use the written request method, where the prisoner submits his/her name, number, and
complaint. Walk-in and sign-up appointments are also available at some facilities.
Are there underserved populations?
Prisoners who are mentally retarded, mentally ill, are substance abusers, or have hepatitis
generally do not receive adequate services. The terminally ill is another population that does
not receive much attention. With the aging inmate population, many are dying behind bars.
In some cases, hospice programs have been initiated, but it has been difficult to make
accommodations that abide by the hospice philosophy in a confined environment.

Where does the funding for health services come from?
Funding is by and large provided by the state government. Medicaid and Medicare are not
available to inmates and are not a way for institutions to finance their programs. Most
prisoners do not have insurance, and for those who do, it is often revoked once they are
imprisoned.
Is there sufficient funding?
On the average, a system will spend 10 percent of its budget on health care. The average
dollars spent for prisoner health care is $2,700 per person per year, compared to $4,000 per
person per year outside of prison.
Is there a way to improve the system and better utilize the dollars allocated to health care?
Many prisoners enter the system several times in a lifetime. Currently, there is not a system
to access previous records of care provided. As a result, tests and exams are often repeated. A
system that links the medical attention provided in prison and with the care given in the
community may facilitate better utilization of current dollars. Improved discharge planning
would link the released individual to the appropriate services in his/her community.
Comments:
The variation of care that exists across jurisdictions makes it difficult to compare one
state system with another.
The state of Oregon has developed a rationing system to ensure that correctional services
are comparable to what is available to the general public. Oregon provides services to its
prisoners that are equal to those accessed by the insured poor, making correctional health
care reflective of Oregon’s statewide trends. This process has also enabled Oregon to
make important budgetary decisions related to correctional care.
The state of Texas has developed a unique system. The medical branches of the
University of Texas and Texas Tech run the correctional health care system. A committee
made up of two physicians appointed by the governor, university representatives, and
correctional facilities administrators provides oversight. To date, approximately 3.1
million medical exams and/or appointments have been solicited and nearly every case has
been attended to within 48 hours. Upon arrival, an intake for communicable diseases and
baseline data is performed. The Texas correctional facilities provide approximately
100,000 hospitalizations, 338,000 dental visits, 13,000 specialized medical consultations,
and 6,000 radiology reports per year. All facilities are accredited by different agencies,
and outside monitoring is employed to ensure proper care is given.
The fragile nature of health services in correctional settings brings an added dimension to
the discussion. Good physicians do not stay long, and service provision can change
radically depending on the health service administrator in place. High turnover coupled
with frequent prisoner reform acts has an impact on what can be done. When designing a
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Reentry Roundtable December 2002

correctional health care system, these factors must be taken into account. Furthermore,
funding correctional health care is a low priority for many decision makers. The political
environment in which budgetary discussions take place is a reality.
When speaking with state legislatures, it is important to reframe the issue so that the
discussion is not about coddling prisoners, but rather about intervening in a population
where there is high prevalence of disease. By treating this population, benefits are
accrued for the individual and community.
While prisoners are the only group of Americans with a constitutional right to health
care, there are actually very few medical services that are legally mandated. The menu of
services is left to the discretion of state decision makers. In many cases, a service is
provided to avoid potential lawsuits.

COMMUNITY HEALTH CARE SERVICES

Nicholas Freudenberg, Hunter College
Abstract:
Inmates enter the nation’s jails and prisons with a disproportionate burden of illness, receive
limited or inadequate treatment while behind bars, then return to communities that face
significant challenges in providing the health care and the public health services that can
promote health and prevent disease. This presentation examined the health care environment in
low-income, mostly urban communities in order to better understand the specific issues that
returning inmates face and inform the development of strategies to reduce these problems. While
these problems are familiar to observers of the American health care scene, a review of the
causes and consequences of limited access to quality health care provides a context for the
development of comprehensive strategies for the reintegration of returning inmates.
Criminal justice and correctional policies in the United States have created
disproportionate incarceration rates in communities that face other serious social
problems, including inadequate education, high unemployment, and limited health
care. In low-income communities, the obstacles in finding affordable, high-quality
health care are considerable.
The health service issues that prisoners experience upon release into low-income
neighborhoods are:
• Lack of health insurance—the groups at highest risk of incarceration are
also the highest at risk of not being insured;
• Managed care barriers to service—co-payments and deductibles may deter
low-income individuals from receiving care;

•
•
•
•
•

Maldistribution of health care services—health care providers go to
communities that can pay for their services;
Poor coordination of health care with mental health and substance abuse
services;
Racial and socioeconomic status (SES) disparities in access to and quality
of care;
Limited coordination between health care and public health systems; and
Diminishing role of the public sector in health care and erosion of safety
net programs.

The health profile of returning prisoners places specific demands on community
health services, which can be summarized as infectious disease treatment and
prevention, mental health services, substance abuse treatment, chronic disease
management, coordination of care for multiple problems, and access to providers
with the motivation and skills to treat the returning population.
The public health benefits of improved care for returning inmates are reduced
transmission of infectious disease, reduced substance use, improved management
of mental illness and other chronic conditions, reduced use of emergency rooms
and hospitalization, less family disruption, improved social cohesion in the
community; improved public safety, and lower costs.
Promising strategies to reduce barriers to care have been identified. Pre- and postrelease case management programs have been increasingly used within the criminal
justice system, especially for drug-using and HIV-infected prisoners. Partnerships
between correctional and community health providers have also proved to be a
model well suited for smaller cities with a limited number of service providers.
Communities have assets; the key is to bring the assets together to work for the
community. Categorical programs on HIV, substance abuse, or mental health have
also proved to be effective despite the problems associated with coordination.
Finally, health education on issues such as asthma, HIV prevention, and health care
utilization can reduce barriers to improved health and access to care.
To encourage dialogue and focus efforts to improve health care for returning
inmates, several policy and funding recommendations can be made. The first
recommendation is to make Medicaid available to eligible prisoners at the time of
release. Current federal regulations enable but do not require states to provide care.
Many prisoners leave the prison system and need to be reinstated in the Medicaid
program. It takes approximately six weeks to process a reinstatement, which is a
long time for someone in need of medication.
Funding community health and mental health centers that serve returning prisoners
in geographic areas provides another opportunity to enable successful reentry.
Another recommendation is to establish managed care “special needs” programs for
returning inmates that provide comprehensive and coordinated medical, mental
health, and substance abuse services.

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Reentry Roundtable December 2002

A final policy recommendation is to create a state or local agency that would
manage and monitor the multiple issues individuals face when reentering.
Comments:
The coercion issue involved with reentry is important to keep in mind. For those
who resist the multiple requirements placed upon them and decide not to comply
with established treatment plans, how is their health outcome compromised?
There is a tremendous waste of resources on prisoners who come into the system
on multiple accounts. If Medicaid were to follow the prisoner through their stay,
would this result in better records, better care, and reduced costs? Researchers have
estimated that state governments would save up to 50 percent on their correctional
health care budgets if Medicaid could follow individuals into prison.
The California Endowment is trying to improve the capacity of community health
clinics to serve community needs. How can the Endowment, as a funder, prepare
community clinics to be attuned to the specific needs of the reentry population?
Community clinics will be moved to address the reentry population when an
identifiable caseload is experienced. It is difficult for community clinics to tackle
the needs of a specific community without the funding to do so.
California has digitized its transitional case management system for HIV and
mental health patients. There is a tremendous amount of prerelease and discharge
planning involved. The CDC partners with the public health department and
community based groups to streamline information. Social workers gather prisoner
information and save it into the database. When an inmate leaves the system,
his/her medical information is transferred to the community providers. The early
returns have been very good. California is working to develop a system where if a
person returns to prison, their previous records are readily available and duplicate
services are avoided.

ROLE OF FAMILIES AND SOCIAL NETWORKS IN IMPROVING HEALTH
OUTCOMES

Nancy Wolff, Rutgers University
Abstract:
After years of incarceration, prisoners often draw upon their social networks to assist them with
reintegration. Research conclusively shows that the health, well–being, and service utilization
behavior of individuals with impaired health improve through the emotional and material

support provided by their social networks. People with poorer social networks, however, are
expected to have worse health and justice outcomes.
This paper focused on the social capital of prisoners and the impact of criminal behavior and
incarceration on its formation and mobilization. It argues that the incarceration experience has
the potential to alter the characteristics, potential, and mobilization of social capital in ways that
reduce its ability to produce improved health and justice outcomes for former prisoners. To
offset this depreciation effect, the authors recommend a set of investment strategies that could
potentially have a positive impact on the prisoner’s social capital and prospects for successful
reentry. Success is likely if investment occurs continuously over the prison sentence. Sturdy
“social” bridges between prisoners and the community take more than a day to build, but if
built, may lead to a road worth traveling.
Support from family and friends improves health outcomes, treatment compliance,
quality of life, and community tenure.
Social networks vary from prisoner to prisoner. Size, composition, quality, and efficacy
(ability to work efficiently and effectively) are factors that make each social network
unique. Research has found that social networks for disadvantaged populations are
smaller and less effective.
The formation and mobilization of social capital is influenced by four factors: the
willingness of the prisoner’s social relations to provide assistance, the ability of the
prisoner to motivate help from his/her social relations, the resources and endowments of
the social relations, and the social context of these relationships.
At the point of incarceration, each individual enters with a stock of social capital. With
time and isolation, that social base and connection are weakened. In prison, a prisoner’s
identity often changes. Slowly, the prisoner’s social capital becomes more prison-based,
rather than community-based. Time behind bars can also alter individual mobilization
capabilities.
Before investing in prisoner social capital, it is important to understand the normative
assumptions that underpin research on social capital. The first assumption is that all
individuals come from a middle-class upbringing. The second issue is the emphasis that
is placed on the ability to maintain connections. The last is the assumption that everyone
has the ability to maintain healthy family connections. These assumptions are not
generally characteristic of prisoners or their families. Challenging these assumptions and
replacing them with more flexible notions of family and family involvement is necessary.

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Reentry Roundtable December 2002

At the prerelease stage, interventions are recommended that assess the social capital of
the prisoner, diversify the prisoner’s social capital by expanding the number and type of
social connections, and strengthen the connections through interpersonal skill building
and social opportunities.
The most difficult work begins at release. This is the moment when social capital, if
it exists, pays initial dividends. In many cases, the first steps off a bus back into the
city can also be the first steps toward homelessness. Outreach and engagement
services have most likely not been arranged. For this reason, a post-release
investment strategy is recommended that involves community-based professional
services and peer support.
While social capital has the potential to promote prosocial outcomes, the typical prison
experience that focuses on punishment and social isolation can be expected to change the
stock of social capital in ways that weaken its potential and mobilization over time. But
the prison experience could, with appropriate and continuous investments, have a positive
impact on the prisoner’s social capital and prospects for successful reentry.
Comments:
Social networks and social capital are not resources the prison system typically relies
upon when assisting with reentry. However, real-world interactions are heavily dependent
on social networks. The correctional system should look to assisting prisoners in
developing networks rather than simply directing them to an agency. A holistic approach
is needed where networks are used to support connections with services. Social capital is
an invaluable asset in keeping and maintaining contacts with medical and mental health
services.
Giving prisoners the opportunity to define their assets is an extremely important exercise.
It gives the power back to the individual. If the individual is able to identify his/her
strengths and define specific ways he/she can contribute while incarcerated, the prisoner
can receive the proper training and preparation. When the prisoner is released, he/she can
be connected with successful ex-prisoners on the outside and community resources for
continued assistance.
The most stigmatizing label one can have is the label of an “ex-con.” The potential of
successful ex-prisoners assisting those who are coming out is tremendous; however,
many former prisoners hide their “ex con” status.
In New York, an inclusive model is used to capitalize on social and institutional assets
available at release. A social network of high-powered former prisoners with advanced
degrees has been formed to provide mutual support and guidance. The network also
reaches out to other released prisoners. However, this is just one case. More networks of
this type are needed. It is important to keep in mind that many incarcerated individuals
are highly ingenious. Skills that were once used for ill purpose are transferable to positive
endeavors.

According to research conducted in New York, approximately 30 percent of all families
in these communities have someone they care about coming out of jail. They are not
homogenous families; they range in class, ethnicity, and location. Most of these families
provide emotional support, which makes it extremely difficult to determine to what
extent a family can play a role in a prisoner’s life. As a prisoner, there are a lot of
assumptions about your family, namely that it is dysfunctional.
Understanding the environment to which prisoners are returning is another important
piece. La Bodega de la Familia, a community-based program in New York, assists
families and offenders in the reentry process. Prior to the prisoner’s return, a family
assessment is performed. Once the prisoner is released, the organization works with the
family to develop an action plan in the presence of a parole officer. Ultimately, it is about
building relationships and networks of support. This is especially important when health
issues are involved. The program is voluntary. The intent is to be perceived as a public
health model, and not as a punishment program.
Reentry affects men and women in different ways. The National Network for Women in
Prison is a small, grassroots organization with a leadership-training program for
incarcerated and formerly incarcerated women. The organization has successfully pulled
together a cadre of people who can assist other women and others who have great
capacity to lead.
When planning reentry, there are collateral consequences to consider—limitations on
welfare, Section 8 housing, educational grants, etc. These are the invisible punishments
that occur long after release.

LINKAGES BETWEEN PRISON AND COMMUNITY HEALTH SERVICES

Ted Hammett, Abt Associates
Abstract:
Correctional inmates are disproportionately burdened with many types of health problems. The
vast majority of inmates return to the community, making periods of incarceration the ideal
venue for a variety of preventive, diagnostic, and treatment interventions. These services will
benefit not only the inmates themselves, but also the larger community. It is also possible,
although largely unproven to date, that timely and efficient health interventions for correctional
inmates and releasees may result in downstream savings in other publicly funded programs and
services. Inmates and releasees often have extensive needs and face major obstacles; however,
no single agency or entity has the clear responsibility to help releasees achieve stability in their
lives following release and connect to community health care systems and other support services.
This paper discusses salient characteristics of current discharge planning and community
linkage programs, with attention to the barriers to and facilitators of successful linkage and
continuity of care. Programs with documented success and/or promising strategies for linking
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Reentry Roundtable December 2002

releasees to community health services are presented. Continuing gaps in the research on
discharge planning and community linkages are also discussed.
Based on a study of discharge planning for HIV-infected inmates in 10 states and
extensive literature on transitional services for prisoners with medical and mental health
problems, several recommendations for organizing and staffing effective continuity of
care programs are made:
•

Dedicate funding for discharge planning and post-release follow-up.

•

Assign dedicated staff to provide prerelease discharge planning services and
designate a discharge planning coordinator at each facility and statewide.

•

Arrange for state public health department collaboration and oversight of
continuity of care.

•

Establish collaborations with CBOs and outside agencies to meet with inmates
prior to release. Assign case managers to work with released inmates. When
possible, the same provider should work with the client before and after release.

•

Involve parole officers in supporting reintegration and continuity of care, yet
recognize there are different roles that may make the involvement of parole
agencies problematic. The distinction between the criminal justice function and
correctional function needs to be clear.

•

Institutionalize discharge planning through formal agreements among agencies
and with CBOs, designated agency liaisons, and broad community networks to
allow for comprehensive referrals.

Established discharge planning programs also identify the following operational issues as
important:
•

A dual system with literal continuity of care from facility to community-based
providers is the ideal model, but is probably feasible only in systems covering
relatively small geographic areas.

•

Outside discharge planning, providers need to work with correctional medical and
security staff to identify and access eligible clients.

•

Correctional discharge planning providers need to develop relationships with
community providers in order to place inmates in post-release care.

•

Discharge planning is most effective when the provider has multiple personal
contacts with the client (face-to-face or by correspondence or telemedicine)
before release.

•

Effective discharge planning programs set up specific appointments for the client
after release, instead of making general referrals to services, and give the client
clear instructions about how and when to keep the appointment.

•

Continuity of medical care is more likely to occur if clients receive medication at
release, a copy of their prison or jail medical summary, a post-release medical
appointment, and assistance completing applications for medical benefits.

•

The transition may be made smoother by connecting clients to community case
management, mental health care, substance abuse treatment, housing, cash
benefits, and assistance with other basic needs.

•

Client success can hinge on meeting immediate needs after release, such as
transportation, emergency shelter, cash, food, and clothing.

There are several research gaps that make it difficult to “sell” the importance of discharge
planning and continuity of care. The first is the almost complete absence of rigorous
evaluations of such programs. The second related gap is the almost complete absence of
cost and cost-benefit studies of discharge planning and continuity of care programs.
Comments:
From the correctional facilities perspective, its commitment to service ends at the gate.
Prison systems often state that they do not have the time, resources, or capacity to make
connections with community resources and facilitate transitions. As a result, there is a
large gulf between the services in prison and in the community.
From a prisoner’s perspective, there are very specific cultural interpretations of
transitional services. Historically, support programs have been disease specific. The
perception of many releasees is that transition support and continued case management is
essentially another arm of the correctional facility. For that reason, many do not want to
be controlled or “cased” any more. A program’s success will depend on the ability to
relate to the releasee population.
In Northern California, Centerforce attempted to change prisoner perceptions about
transitional services by holding a community resource fair where providers were invited
to present their work to the prisoners. The prisoners, in turn, were able to establish faceto-face contact with the providers. The relationship that is formed between a provider and
the releasee within the first five minutes often dictates whether a releasee will continue
with the plan of treatment.
An innovative pilot program for discharge planning and case management for HIV/AIDS
and mental health patients has proved to be successful in California. The program makes
appointments for prisoners 90 days prior to their release date. Appointments are then
reconfirmed 30 days before release. Arrangements are also made to ensure that prisoners
have a 30-day supply of medications upon release.

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Reentry Roundtable December 2002

The categorical funding issue is important to keep in mind. Often, great services are
being provided, but a fragmented model of care is perpetuated. There is a need to begin to
think about a primary care model where a wide array of illness can be treated
simultaneously and in a coordinated fashion. It is also important to think about creative
ways that categorical funding can be used to address other issues as well.
Over the past 40 years, a booming prison system has been created. This system has
become a conduit of an enormous amount of resources. With the continuous increase in
the incarcerated population, there is a need to begin to envision a societal structure that is
less dependent on correctional systems. Funding streams need to be disentangled from
prisons. Citizens should not have to be criminalized to access services provided to a
broader audience.

BARRIERS TO HEALTH SERVICES FROM A RACE AND GENDER PERSPECTIVE

Ray Patterson, Howard University, and Bob Greifinger, The Bromeen Group
Abstract:
Prisoner 722515 is a 26-year-old Hispanic male with a 10-year sentence related to gang
activity. He has refused to provide a urine sample for medical testing out of fear that
correctional staff will touch his penis. His limited English proficiency prohibits him from
understanding that the sample will not require staff involvement. He will be released in two
weeks.
Prisoner 896273 is a 42-year-old woman with a family history of metastatic breast cancer. She
detected a lump in her breast, but the correctional facility did not administer the mammography
for several months. She was released two years later with breast cancer.
These vignettes clearly illustrate the cultural dimensions of medical care in a prison setting.
Race, ethnicity, language, and gender directly influence a prisoner’s ability to access medical
services. And these same factors will follow the prisoner back into the community upon release.
This paper describes several formidable barriers to the design and implementation of successful
primary, secondary, and tertiary prevention programs behind bars. Some deal with the
experience and culture of the individual inmate, while others illustrate the culture and biases of
correctional health care. Sensitivity to race, culture and gender is believed to improve health
outcomes for the inmates themselves and for the communities to which most return.
Through litigation and nationally accepted standards, correctional health care has
advanced in the domain of personal health care services. Inmates have the right to access
care ordered by their physicians.

Inmates come primarily from poor communities and are disproportionately minority,
from diverse cultures and beliefs. In the world outside of prison, there is some evidence
that sensitivity to race, culture, and gender improves outcomes of health care. It is
intuitively obvious that the successful community reintegration of former inmates will
stem, in part, from prerelease programs tailored to individuals’ culture and beliefs.
It is important to understand the difference in mission, purpose, and philosophy of a
correctional system compared to a health care or public health entity.
Comments:
Barriers to health from a racial, cultural, and gender perspective
Disparities to health care are clearly exemplified in the African-American reality. African
Americans make up approximately 13 percent of the total population, yet represent 45
percent of the prison population. Many of the imprisoned African Americans are
substance abusers, but care for substance abuse is the least provided service.
External efforts to address the race and gender dimensions of health care provision create
an opportunity for correctional systems to explore the issue. The Department of Health
and Human Services identified the need to eliminate racial disparities as a goal. This
commitment has had a tremendous influence on funding patterns. At a minimum, this
creates an opportunity for the correctional system to address racial disparities when
accessing health care.
The public health field is sympathetic to the race and gender barriers to health care. It is
important to package the issue in such a way that the field will be more inclined to join
the discussion.
The growing interest in men’s health services provides another opportunity for
correctional health care and transitional health care funding.
When looking at issues of cultural competence, it is essential to identify programs that
have successfully tackled this issue.
Strategies to overcome disparities
While many of the community-based approaches to health care are directly applicable to
the prison environment, there are also many that are not. Group therapy, for example,
tends not be an effective technique for prisoners. It involves leaving one’s cell and
exposing oneself to the scrutiny of follow inmates. If, however, issues of confidentiality
are addressed and the prisoner is assured that the information discussed during the
session will not be relayed to a parole office, group therapy can work.
Front door screening and evaluation has been identified as an effective strategy to
increase access and improve care.

16

Reentry Roundtable December 2002

Peer education has proved to be effective when dealing with the racial, cultural, and
gender dimensions of access.
Training and conversations that go beyond the “isms” are also effective ways to raise
consciousness and address disparities.
Emory University is involved in a multisite initiative to provide cultural competency
training to community-based programs that serve the Latino and African-American
populations.

REVIEW OF EVALUATION LITERATURE ON HEALTH OUTCOMES

Embry Howell, Urban Institute, and Robert Greifinger, The Bromeen Group
Abstract:
Earlier this year, the National Commission on Correctional Health Care released a Report to
Congress on the Health Status of Soon-to-be Released Inmates. The document provides a
comprehensive overview of the health care issues surrounding the return of a large number of
former prisoners to local communities. To serve these returning inmates’ needs in a
comprehensive, cost-effective way, it is important to catalogue what is already known about
providing the services they may need. It is also important to understand how the overall societal
costs of care can be lowered through effective service provision.
This paper provides a review of the literature on the cost-effectiveness of health services for
returning prisoners. The limited literature on the cost-effectiveness of health services, coupled
with the scarce amount of information on services for returning prisoners, has forced the
researcher to concentrate on the review of studies of other marginalized groups that are similar
demographically (primarily poor men, substance abusers, the homeless, and low-income
veterans). These groups experience many similar health conditions, as well as low levels of
health care and poor access to care.
Research focused on five health conditions that are disproportionately prevalent in
returning prisoners: HIV/AIDS, sexually transmitted diseases, tuberculosis, serious
mental illness, and substance abuse. The similar communities were identified to be the
homeless population, substance abusers, seriously mentally ill, and poor veterans.
HIV/AIDS education and prevention programs were shown to be cost saving. Treatment,
on the other hand, for HIV/AIDS is not cost saving, but it is cost-effective compared to
treatment of other serious illnesses.
Screening for sexually transmitted diseases (STDs) and TB is effective, and proper drug
therapy can cure the illnesses. Screening and treating the incarcerated population is cost

saving. The cost-effectiveness of screening and treatment in the community, however,
depends on the compliance issues involved.
Community-based mental health services that include intensive case management
(sometimes called assertive community treatment or ACT) are costly but do improve the
overall wellness of those who receive such services.
Substance abuse disorders are highly prevalent in prison populations, with estimates
ranging from 29 to 80 percent. Methadone maintenance is a cost-effective but not a costsaving treatment for substance abuse. Residential care is an effective but more costly
option. Outpatient care is judged to be more cost-effective. When the justice system
monitors abusers, clients are more likely to return to jail.
In summary, health care for the five conditions studied can be cost-effective when judged
against other prevention and treatment, and some treatments are cost saving. Many of the
benefits accrue to society as a whole, not just the population served. Currently, the
service system for returning prisoners is underdeveloped and under funded. Developing a
consensus for action is difficult because benefits and costs accrue to different sectors.
Comments:
When conducting a cost-benefit analysis of health treatment and services, the societal
benefits are often left out of the discussion. The impact is difficult to quantify, and for
that reason, the analysis relies on those factors that can be easily measured (number of
hospitalizations, etc.). The societal benefits and associated savings do not show up on the
governmental budget.
Demonstration projects are effective at showing the savings that can occur in specific
locations. The challenge is to bring these projects to scale.
Community-based organizations can also contribute to the quality, availability, and costeffectiveness of reentry health services.
Before looking at other alternatives, there is quite a lot that can be done to better manage
the dollars that are currently being spent on services.

18

Reentry Roundtable December 2002

Section 3.

Next Steps for Research and Policy
RESEARCH AND POLICY QUESTIONS

Nicholas Freudenberg, Hunter College
At the end of the meeting, Nicholas Freudenberg provided the group with a list of research and
policy questions that had emerged during the two-day discussion. Dr. Freudenberg started by
highlighting aspects that will yield quality research in this area. According to Dr. Freudenberg, a
good research agenda will:
Focus the limited research dollars and resources strategically;
Target the problems and issues that are most likely to be solved and most likely to have
an impact on health;
Gain the support of key stakeholders, such as practitioners, communities, and inmates;
and
Attract resources from current funding streams.
Having set the stage, Dr. Freudenberg presented a list of questions that emerged from the
discussion and were identified as priority areas for future inquiry:
What has been the impact on former prisoners of contact with the public health care
system, both before and after incarceration?
How do health services for prisoners and released individuals lead to improved public
health?
What have been successful health interventions at the individual, institutional, and
system levels?
How can we bring these successful efforts to scale?
What are the cost benefits and cost-effectiveness of various approaches?
How do we incorporate formerly incarcerated prisoners into the program development
side of transition planning?
How do we reduce the stigma of former prisoners?
How do we engage the community and community-based service providers in reentry
issues?

How do we create a message and agenda that is appealing to multiple audiences?
What are public opinions that will best support this policy agenda?
What policy changes will support healthy reentry?
What are the connections between criminal justice and health outcomes? What are the
crosscutting issues?
Policy Recommendations:
The growing interest in prisoner reentry has created a strategic moment to influence policy.
Local and federal initiatives have engaged new constituencies in the discussion and heightened
overall interest in this area. To effectively communicate information about the health dimensions
of prisoner reentry to a broader audience, meeting participants discussed the importance of
repackaging the issue as a public health concern. Including personal vignettes and case studies in
the discussion will bring a human face to the issue and move individuals and institutions to act.
Empowering formerly incarcerated individuals to speak out about incarceration and reentry was
another strategy advocated by meeting participants.
While numerous policy recommendations surfaced during the two-day discussion, several ideas
surfaced time and time again:

20

•

Revisit correctional systems’ mission statements and include effective reentry as a core
component.

•

Allow eligibility for comprehensive benefits (e.g., Medicaid) to follow a prisoner in and
out of prison.

•

Eliminate the duplication of services by developing database management systems that
are easily accessible to the necessary parties.

•

Prioritize intersystem cooperation to blend funding sources and engage individuals and
communities in the reentry process.

•

Invest in reentry health as a strategy to promote community health and well-being.

•

Encourage the use of social networks in the reentry process.

•

Involve former prisoners in the reentry process.

•

Create an agency that deals with the reentry population and their specific needs.

Reentry Roundtable December 2002

Concluding Remarks
With 1,600 individuals walking out of prison gates every day, the health needs and risks of
returning prisoners are central to the reintegration process. The meeting of the Reentry
Roundtable explored this exciting new terrain—the public health dimensions of prisoner reentry.
Discussion began with careful review of the correctional health care system and the prisoner
health profile. Research revealed that the incarcerated population is disproportionately afflicted
by mental, chronic, and infectious diseases. While progress has been made to improve
correctional health care, resulting in improved health status for many prisoners, inadequacies
prevail. Discussion then moved outside the gates to assess the community health services
available to prisoners once released. Research found a very limited capacity on behalf of the
service providers to deal with the specific needs of the returning population. The challenge today
is to increase the organizational capacity of community health care providers to service this
unique and growing population. Once a clear portrait had been painted of health care in and
outside prison walls, meeting participants focused their attention on identifying the linkages
between prison and community health care and the prospects for successful reentry. Several
exciting projects are currently under way to ensure smoother transitions and safeguard public
wellness. The roundtable concluded with a series of research questions and policy
recommendations.
Grappling with the public health dimensions of prisoner reentry is a complicated task. Rather
than providing answers, the Reentry Roundtable has assisted in fleshing out the complexities of
the issue. New ideas have been generated, alliances formed, and agendas defined. Most
important, the Reentry Roundtable has launched a nationwide discussion on health and reentry.
The challenge that lies ahead is the application of these learnings to improve the lives of the
incarcerated and formerly incarcerated populations of America and their families.