Dissertations and Theses

Date of Degree

6-1-2017

Document Type

Dissertation

Degree Name

Doctor of Public Health (DPH)

Department

Community Health and Social Sciences

Advisor(s)

Juan Battle

Christian Grov

Committee Members

Juan Battle

Christian Grov

Jeff Mellow

Mary Clare Lennon

Subject Categories

Public Health | Social and Behavioral Sciences

Keywords

Incarcerated populations, health care access, recidivism and reinarceration, HIV, chronic health conditions, diabetes

Abstract

People in correctional settings often have poorer health than the general US population. For example, it is estimated that 27.9% of persons in jail have hypertension, 8.1% have diabetes, and 1.6% have HIV, compared to 25.6%, 6.5%, and 0.5%, respectively, in the general population. Jail and other correctional settings are also increasingly recognized as viable places to engage poor and underserved communities into the healthcare system by offering transitional care coordination services to connect people to healthcare and other services to meet priorities after incarceration. At the same time, recidivism is an issue—over 50% of persons in New York City (NYC) jails recidivate within 1 year.

NYC Reentry and Continuity Services (RCS) is a unit of Health + Hospitals Correctional Health Services that provides transitional care coordination to people with chronic health conditions to connect them to healthcare and other needed services in the community after incarceration. Little is known about the impact of RCS services on the longer-term health of people who pass through NYC jails. And while not a stated priority, it is not known whether RCS services have any impact on reincarceration.

This retrospective case-control study addressed these gaps in research using electronic medical records, Department of Correction data, and RCS program data for roughly 3,700 people discharged from NYC jails into the community during a 6-month timeframe. An analysis sample was constructed that included people with HIV, hypertension and/or diabetes and people who received RCS services were compared with persons who did not to investigate whether RCS services impacted reincarceration or health for people who returned to jail. The sample included incarceration data from 2008 and prior health measures for one year. The sample also included incarceration and health data for one year after incarceration.

The goal of Aim 1 (Chapter 2) was to investigate whether receiving RCS Transitional Health Care Coordination (THCC) services impact reincarceration among people with chronic health conditions and findings showed that having a confirmed connection to healthcare in the community after incarceration was associated with reduced reincarceration but receiving a greater number of services was associated with increased reincarceration. Specifically, being connected to healthcare in the community after incarceration is associated with 0.21 lower odds of reincarcerating within 90 days and 0.53 lower odds of reincarcerating within 1 year. However, receiving a greater number of services including an intake assessment, discharge plan, and a referral to and a jail-based meeting with a community partner was associated with 2.14 greater odds of reincarcerating within 90 days and 1.79 greater odds of reincarcerating within 1 year.

The goal of Aim 2 (Chapter 3) was to investigate the role that THCC services played in biological indicators of HIV disease (CD4 and viral load) among people who are moving in and out of jail. Analyses showed that receiving THCC services had no measurable impact on HIV disease progression at the biological level with the exception of the analyses of CD4 as a continuous variable which is seldom done in research. Similar to Aim 1 analyses, having a confirmed connection to healthcare in the community after incarceration was associated with a positive outcome, in this case, higher average CD4 at the subsequent incarceration by a factor of 1.08, but receiving services without a connection to healthcare—in this case, an intake assessment and discharge plan—was associated with lower CD4 by a factor of 0.71.

The goal of Aim 3 (Chapter 4) was to investigate the role that THCC services played in clinical indicators of diabetes and hypertension among people diagnosed with these conditions who were released and returned to New York City jails within 1 year. Findings showed that receiving core THCC services including an intake assessment and discharge plan was not associated with improved glycemic control, A1C value, hypertension status, or systolic blood pressure, but that it was associated with higher diastolic blood pressure. Specifically, people who received services including an intake assessment and discharge plan during the index incarceration were more likely to have higher diastolic blood pressure by a factor of 3.38 (p < 0.05) at the subsequent incarceration.

It is encouraging that having a confirmed connection to healthcare in the community after incarceration is associated with decreased odds of reincarceration and higher CD4 count, although these findings do not provide knowledge about causal relationships. The higher subsequent diastolic blood pressure among THCC participants could be a statistical artifact, since it was the only blood pressure-related clinical outcome with statistical significance, or it could be a true finding showing that THCC clients return to jail with higher diastolic blood pressure than when they left jail previously. If this is the case, this finding supports the hypotheses that THCC serves some of the sickest people in the NYC jail system and that providing services to people who are not subsequently connected to healthcare in the community after incarceration does not contribute to improved health. It is unknown what would occur to such people if these services didn’t exist, which is a limitation of the study. Taken as a whole, however, the findings suggest that connecting people with chronic health conditions to healthcare after incarceration may be beneficial in curbing recidivism and improving health.

Available for download on Thursday, November 29, 2018

Share

COinS