Development of a health-related social need screener for adults soon to be, and recently released, from incarceration

Abstract

Background

A history of incarceration is associated with poor overall health and increased health care utilization and costs. The challenges facing people recently released from prison vary by age, gender, and reason for incarceration. Better identification and management of the needs facing this population is critical for both state departments of correction, tasked with ensuring effective re-entry into the community, and for the health care system, tasked with caring for a population with potentially high and costly utilization. A justice systems-focused screening tool tailored to the social needs specific to the soon-to-be released and recently released adult incarcerated population could better assist transition planning and risk assessment.

Methods

We identified social needs for a justice systems-focused screening tool through interviews and focus groups with adults incarcerated in Indiana state prisons, individuals with lived experience of past incarceration, and individuals who work professionally with the justice system. Through content and face validation, we reduced candidate needs to a relevant set and adapted language from existing screening items to be appropriate for the population.

Results

The finalized tool included 25 needs in the following domains: Material resources, Access to health services, Economic resources and opportunities, Competencies, and Relationship management. Needs reflecting material resources, including their availability, accessibility, and ability to be secured, were among the most frequently identified. Health services, particularly mental health and substance use services, were identified in every interview and focus group as particularly important during a person’s transition home. Individuals identified employment as a need, but also noted the importance of programs and social supports when individuals returning home did not have access to their own financial resources. Competencies included skills and abilities important to successful reentry, such as coping skills, digital literacy, health literacy, financial literacy, general literacy, knowledge of parole conditions, and job readiness.

Conclusions

Individuals recently released from incarceration faced an expansive and varied set of social needs. Many needs mirrored the social needs prioritized in the health care system for all patients, but several factors were unique to those with a history of incarceration. Information about the social needs could support connection to services, identification of trends, and allocation of resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40352-025-00364-2.

Background

Incarceration, or the long-term confinement of individuals convicted and sentenced for a crime [1], is the most intensive form of involvement with the US criminal justice system. Since its peak in 2009, the percentage of the US population currently incarcerated has slightly decreased, but the total number of individuals living in incarceration remains close to 2 million [2]. While significant disparities exist, approximately 1 in 20 Americans has a history of incarceration [3, 4]. Incarceration rates are again on the rise [5], but recent trends in the US have been towards attempting to reduce the size of the incarcerated population [6]. Annually, over 7 million people are released from jails and 600,000 people are released from prisons into the community, often under conditions of parole, probation, and community supervision [7]. Recent estimates indicate that 2.1% of US adults are either currently incarcerated or under some form of community supervision [2].

A history of incarceration is associated with a wide range of adverse outcomes, including poor overall health [8, 9], barriers to employment and health care [10], and increased health care utilization and costs [11]. Some of these negative outcomes are explainable due to the deleterious psychological effects of incarceration along with increased exposure to infectious disease [12–15]. In addition to these ill effects are the challenges of unmet social needs, which after release further increase the risk for adverse health outcomes [13, 16, 17]. Overall, recently released individuals face numerous and varied social needs that can adversely impact their health and well-being [18]. For example, barriers to employment limit access to health insurance coverage and financial resources to pay for care that, in turn, limit access to care [19]. Challenges in securing stable, affordable, and safe housing [20] may threaten personal safety [21] and increase the likelihood of homelessness, which increases risks to health and well-being [22, 23]. Also, lack of available transportation can be a barrier to accessing care [24]. Also, individuals who have experienced incarceration are not homogenous; age, reasons for incarceration, and gender intersect and interact to exacerbate and further complicate needs. For example, older incarcerated adults may face increased burdens of chronic conditions and social isolation [14] and recently incarcerated females may face higher family-related needs [25].

The social needs facing individuals soon to be released from prison incarceration and those recently released affect the operations of organizations within both the criminal justice and health care systems. State Departments of Correction are responsible for ensuring reentry and employ case managers, reentry coordinators, or transitional health liaisons to assist in the process by identifying individuals’ needs, organizing resources, and coordinating appropriate services. Effective reentry services are comprehensive in scope giving attention to an array of health, social, and educational needs [26, 27]. Tools are available that focus on level of supervision needs and potential recidivism [28, 29], but these tools are not specifically focused on the drivers of health and US health care utilization. Unaddressed social needs are a barrier to successful reentry [15] and a poor health outcomes [8, 9]. For the health care system, people returning home from incarceration may experience potentially high and costly utilization due to increased health-related social needs [30] and attentiveness to all patients’ social needs are increasingly required by US policy [31]. A social needs screening tool at the intersection of the justice system and the health system perspectives may help to focus the limited time and resources available to those tasked with supporting reentry in identifying and managing individual’s most pressing needs. Thus, we sought to develop a justice systems-focused screening tool tailored to the health-related social needs specific to the soon-to-be released and recently released adult prison incarcerated population. A tailored screening tool could better assist transition planning and risk assessment for a large and at-risk population in the US. This screening tool builds on existing health-related social needs screening literature and incorporates needs identified by those with lived experience of incarceration and Department of Correction professionals specializing in reentry transitions.

Methods

We developed a justice systems-focused social needs screening tool by combining a modified nominal process with content and face validation [32]. The nominal process included an expert panel of individuals with lived and professional experience to identify potentially relevant social needs for screening (i.e., domains). The content validity and face validity processes assessed the suitability of identified domains and ensured clarity and appropriate wording of screening tool items. We defined a “need” as a “requirement to achieve an end” [33], in this case, to manage health and well-being. We emphasized social needs, as opposed to medical needs, to encompass broader societal issues and conditions that influence health [34]. We draw heavily on qualitative methods because needs are inherently an expression of values and preferences [34–36]. Our team included health services researchers with expertise in social needs screening, health equity, and the delivery of peer-led health education services with people currently or recently incarcerated. This project was approved by the Indiana University Institutional Review Board and the Indiana Department of Health Research Committee. All recruited individuals provided written informed consent. Due to the restrictions on providing incentives in correctional settings, individual participants that were currently incarcerated were offered a food and beverage incentive and expert panel participants were compensated for their time with a gift card.

Identifying relevant social needs: expert panel formation

We recruited an expert panel of 21 individuals with in-depth knowledge of the needs and challenges experienced during transition from incarceration. Experts were either previously incarcerated, work professionally with people incarcerated, and/or have research expertise in correctional health. These experts were purposively recruited through professional networks and with the assistance of the Indiana Department of Correction. These experts represented the Midwest and Southwest regions of the United States and had titles such as Correctional Coordinator, Director of Reentry, Transitional Health care Parole Liaison, Recovery Support Systems Coordinator, Reentry Specialists, professor, and directors. Among expert panel members, 12 reported a history of previous incarceration.

Additionally, we recruited 28 individuals currently incarcerated in Indiana and set to be released. These individuals resided in four different facilities, including short-term and long-term facilities, facilities specific to women and to men, and a facility providing Indiana Sex Offender Management and Monitoring (INSOMM) programming. Facilities were both privately and publicly owned. Individuals had to be over the age of 18 and able to speak English. Most participants had a pending release date within 180 days of the time of the interview. The Indiana Department of Correction randomly sampled registry records to identify potential participants from each facility. All interactions with currently incarcerated individuals occurred in-person at the respective facilities. Throughout the recruitment period, we monitored participants’ self-reported demographics to ensure diverse representation by gender, race, and ethnicity (Table 1).

Table 1.

Demographics of justice systems-focused social need screening tool expert panel participants (focus group and currently incarcerated participants combined)

Characteristics	n = 49	%
Race
Asian	1	2%
Black / African American	14	29%
Multiple / other	9	18%
White	25	51%
Ethnicity
Hispanic/Latinx	4	8%
Gender
Female	18	37%
Male	30	61%
Non-binary	1	2%

Identifying relevant social needs: qualitative data collection

Data collection with the expert panel and participants currently incarcerated followed similar procedures yet occurred separately. For the expert panel, the study team (consisting of authors JRV, AJ, & JW) conducted three 90-minute focus groups (n = 5, n = 7, n = 9) via videoconference and in-person. These focus groups began by informing panel members of the study’s objective to develop a justice systems-focused social needs screening tool to be used by the Indiana Department of Correction and providing a common definition of social needs. For all study participants, we defined social needs as anything that affects health and well-being but occurs “outside of the doctor’s office or pharmacy”. We also provided examples of social needs. The focus groups followed a nominal group approach where each expert panelist, in turn, was asked to suggest a social need that they believed was important to individuals incarcerated and soon to be released [32]. The process continued until all ideas were exhausted. We repeated the process to identify additional needs relevant to recently released individuals (e.g., within the last 30–90 days). Panelists often provided explanations and commentary on their choices (See Supplemental File 1). A research team member (BM) documented all suggestions, and focus groups were recorded.

For individuals currently incarcerated, the study team (consisting of authors AJ, BM, & JW) conducted on-site interviews at Indiana Department of Correction locations. Interviewing occurred in pairs, with one team member acting as interviewer and the other serving as notetaker. As in panel sessions, incarcerated participants were informed of the study objective and definition of social needs. The interview script mirrored the focus-group’s nominal approach by asking each interviewee to identify social needs important for successful reentry, until no further suggestions came to mind (See Supplemental File 1). The incarcerated participants were allowed to provide explanations and commentary on identified social needs. Interviews were audio recorded and lasted between 15 and 45 min.

Following the collection of all suggestions, three team members (AJ, BM, & JRV) used a series of group discussions to consolidate synonymous terms, apply labels to the groups, and identify appropriate definitions from the literature for each social need. Choices were made by consensus. As a check on the comprehensiveness of the resulting list, we compared the identified social needs with those previously reported in the literature. We also presented our list of social needs to Indiana Department of Correction staff as a member-check during a group meeting. The total number of identified social needs was 27.

Identifying relevant social needs: content validation

To further prioritize and refine our list, we conducted a follow-up survey that asked the expert panel members to rate and rank all the suggested social needs [37, 38]. Each member rated the importance (not at all important, low importance, neutral, very important, extremely important) of each social need to successful reentry. We also asked members to report their top five most important social needs pre- and post-release, as well as the five social needs for which individuals currently receive the least support. For each social need, we provided definitions. Seventeen panel members completed the survey. Because follow-up visits were not possible at the facilities included, the incarcerated interviewees completed the ranking survey (with the listing of social needs identified from focus groups) during their qualitative interviews.

To identify the most important needs, we calculated the content validity index (CVI), defined as the proportion of informants rating the item as very or extremely important for each of the social needs [39]. We used a general 0.75 threshold to identify those social needs that were highly supported as important [39]. We compared these highly rated social needs against the top five ranking lists and qualitative results to ensure consistency.

Candidate item identification

To identify candidate screening items for each social need, we initially drew on existing health-related social needs screening tools. We began by using items from the Centers for Medicare & Medicaid Services’ Accountable Health Communities Health-Related Social Needs Screening tool [40] due to its policy-relevance and broad coverage of social need domains (e.g., food insecurity, employment, job readiness, personal safety, and social support). For social needs not included in that screening tool, we used the Social Interventions Research & Evaluation Network’s (SIREN) Social Needs Screening Tool Comparison Table [41] and Google Scholar and PubMed searches for suitable candidates. We prioritized brief instruments focused on adults. In instances where no items were available, we developed our own drawing on the language used by the key informants. Selection of candidate tools and items was made by consensus among the research team.

Face validation

Because we drew items from instruments not specifically designed for individuals living in incarceration or recently released, we undertook a face validation step to ensure appropriate item wording and respondent comprehension [42]. Eight expert panel members participated in additional moderated online sessions to review the identified candidate items (See Supplemental File 1). We selected expert panel members who were representative of those who would use or respond to the screening tool. These follow-up interviewees rated each of the suggested items on clarity (not clear, item needs some revision, clear but minor revision needed, or very clear) and suitability (not suitable to the population, item needs some revision, suitable but needs minor revision, or very suitable to the population) [42, 43]. Interviewees rating items less than very clear or very suitable were invited to offer reasons for selections and suggest improvements. Given the number of potential items to review, we presented a random sample of half of the social need domains to each participant (i.e., the participants had access to all the items measuring the domain). Sessions were recorded with consent.

For each item, we calculated the proportion of respondents rating clarity as very clear and appropriateness as very suitable. Items not rated 100% in clarity and appropriateness were reviewed by the team for modifications. We used interviewees’ suggestions and additional literature searches to identify alternative wording to modify the items.

Qualitative data analysis

All focus groups and individual interview recordings were transcribed for analyses. Given the specific purpose of our research (to develop the screening tool), we employed a template analysis approach, which applies a set of a priori developed codes [44]. Our template included the following codes: each of the identified social needs, reasons for inclusion (e.g., the participant’s motivation or suggested importance for inclusion in the screening tool), consideration for key populations (e.g., women, etc.), and observations on implementation and usage. We tested the template by independently applying the codes to three transcripts and by reviewing through a joint reading session. Two team members then independently read and coded the remaining transcripts using the template. As a check of consistency of viewpoints among our different participants, we also noted whether the coded text originated from the focus groups or from the interviews with currently incarcerated individuals. To facilitate discussion and presentation, we grouped the individual social needs into larger need categories as follows: Material resources, Access to health services, Economic resources and opportunities, Competencies, and Relationship management.

Results

Of the 27 social needs suggested through focus groups and interviews, 25 were retained (i.e., had a CVI ≥ 0.75 or where nearly highly as rated and emphasized in qualitative interviews) for inclusion in the proposed screening tool (Table 2 and Supplementary File 2). Descriptive quotes illustrating the motivation for inclusion, or importance of the social need are presented in Table 3.

Table 2.

Social needs relevant to the soon-to-be-released and recently released populations identified and rated by key informants

Need	Definition	CVI1	Kept
Material Resources
Clothing	Accessible and functional garments [66].	0.78	*
Documentation & Identity Management	Identity documents (IDs) are tools that permit the bearers to prove or confirm their identity with a high degree of certainty [67].	0.93	*
Food Access	Household lacks access to adequate food because of limited money or other resources [68].	0.87	*
Housing - Availability	Stable, reliable and consistent housing, free of disruptions or related problems, from frequent moves or difficulty paying rent to being evicted or being homeless [69].	0.95	*
Housing - Safe	Decent, safe, sanitary, and in good repair [70].	0.98	*
Personal Care Products	Hygiene products are usually available over the counter and normally used for hygienic purposes to prevent infection and transmission of diseases, provide hygiene, and enhance care in the hospital ward and operating room [71].	0.82	*
Technology Access	The physical availability of Internet-connected devices and then the factors that support or constrain availability [72].	0.78	*
Transportation	Access to modes of transportation and burdens by distance / travel time; The mode of transportation does not matter (only if there is a barrier associated with it) [73].	0.93	*
Health Services
Health Services & Needs	Phenomena that require medical care services [74].	0.96	*
Mental Health Services & Needs	Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices. [75].	0.93	*
Substance Use Services & Needs	The use of selected substances, including alcohol, tobacco products, drugs, inhalants, and other substances that can be consumed, inhaled, injected, or otherwise absorbed into the body with possible dependence and other detrimental effects [76].	0.89	*
Economic Resources & Opportunity
Employment Options	Inclusion in the workforce [77].	0.95	*
Financial Obligations/Hardship	The perceived ability of one’s income to fulfil financial obligations; state of being wherein a person cannot fully meet current and ongoing financial obligations, cannot feel secure in their financial future, and is unable to make choices that allow them to enjoy life. Opposite of “well-being” [78].	0.98	*
Public Assistance Programs	Public assistance refers to assistance programs that provide either cash assistance or in-kind benefits to individuals and families from any governmental entity [79].	0.87	*
Social Support (Instrumental)	The degree to which releasees have family members who can assist them with housing, substance abuse problems, employment, transportation and general financial assistance [80].	0.93	*
Competencies
Coping and Awareness Skills	Managing Stress, managing feelings, self-management, and self-monitoring [81].	0.89	*
Digital Literacy	The ability to access, manage, understand, integrate, communicate, evaluate and create information safely and appropriately through digital technologies [82].	0.73	*
Financial Literacy	The understanding that includes how to earn, manage, and invest money [83].	0.87	*
Health Literacy	The degree to which individuals have the capacity to obtain, process, and understand basic health-related decisions [84].	0.69	*
Job Readiness	Characteristics that make an individual more or less competitive in the labor market. These characteristics generally include personal and family challenges, education and hard-skill deficits, soft-skill deficits or related attitudinal issues, and other needs that may impair an individual’s ability to attain and retain employment [85].	0.84	*
Literacy	A continuum of learning and proficiency in reading, writing and using numbers throughout life [82].	0.80	*
Parole Conditions	Binding rules set at release by parole agencies, are noted to structure post-release experiences in ways that may take precedence over other social objective [86].	0.87	*
Relationship Management
Gang Membership	Participation in a group with a historical, current or predicted engagement in crime/social harms to achieve goals [87].	0.24
Interpersonal Connections & Skills	Develops and maintains effective relationships with others; relates well to people from varied backgrounds and in different situations; shows understanding, courtesy, tact, empathy, concern, and politeness [88].	0.30
Parenting	Natural and social resources required for individuals to meet their individual goals for parenting and life [89].	0.84	*
Personal Safety	Behavior that threatens, attempts or causes physical harm. Inclusive of: physical violence, psychological violence, betrayal, neglect, trauma, bullying, child abuse, intimate partner abuse, and elder abuse.  Limited to violence that is personally experienced (i.e. “at you”). Does not include witnessing violence [90].	0.82	*
Social Support (Emotional)	The extent to which individuals report having emotional attachments to family members and family members who can be relied on for advice [80].	0.91	*

¹CVI = Content validity index

Table 3.

Social needs of adults soon-to-be-released from incarceration and recently released

Domain	Social Need	Quote
Material Resources	Clothing	“As far as clothing, I would say, I would say that that’s very important because you gotta be able to have something to wear when you need to go to an interview and all that stuff. So I find that very important to if anything go to a clothing bank like the Salvation Army or something like that.”
	Documentation & Identity Management	“Maybe they have access to a vehicle on the outside, but the driver’s license needs to be reinstated. So, working with the BMV to see how that can be made possible, what kind of hoops they’re gonna have to go through, the financial commitment to get that reinstated because if that vehicle is available and they have a driver’s license, now there’s a pathway to employment.”
	Food Access	“I’m thinking more they may know how to find food but thinking about like the food deserts and healthy food and not just stuff that they would have bought on commissary. Do they know how to access healthy food for themselves and their family if there isn’t a grocery store around or how would they get to that grocery store, things like that? So access to food would be a good one.”
	Housing - Availability	“They [landlords] always say like, are you a felon? You can’t get a house and then a lot of people is like trying to get housing in other people’s names and then that might be a problem or it might be an issue with like, yes, like um when I came home I, to be honest, being real and being honest, like uh my first place I had to put it in somebody else’s name because they like, oh you’re a felon and bam, bam, bam, bam, bam, bam…”
	Housing - Safe	“Where they can and can’t access [housing], that’s something that I learned really quickly. When I was working with this population, people is like, ‘I can’t live on the east side’. Ok. Well, can you tell me why? ‘No, but I can tell you who will find me and I can’t live on the east side, right?’ That’s especially for people who have been engaged in sex work. People who have been engaged in any kind of survival based like criminal behavior will tell you like, ‘I can’t live in XYZ.’  And like I trust that. And so I feel like we should all trust that.”
	Personal Care Products	“Grooming, a barber shop or like a, you know, a grant or something like that. Some money to do a haircut and shave, possibly a feet work or something like that because, you know, they don’t even sell toenail clippers in DOC.”
	Technology Access	“Besides everything else trying to deal with when you first get out, having to have that phone, having that phone number that the PO wants you to have so that they can contact you.”
	Transportation	“Transportation. Um even sometimes from the facility they’re leaving, they may not even have transportation to check into community corrections sometimes. And then we work with the community corrections locally here in Lafia and the majority of folks there do not have transportation to get to doctor’s appointments, to get to work, to find a job, to get to the, I mean anywhere.”
Health Services	Health Services & Needs	“How would I get insurance for my medication, you know?”
	Mental Health Services & Needs	“I had a brother who took his life five days post incarceration, and he had multiple suicide attempts before he left. So, echoing what was already shared about having stable housing lined up and access to a phone to reach out and get connected for continuity of care is important. But then also being aware of what crisis services are available for the area you’re going to in case you do run into issues.”
	Substance Use Services & Needs	“Staying sober is gonna be my problem because I been an alcoholic for 30 years and I like beer. I mean, I don’t do it to get drunk anymore. It’s just a daily thing.”
Economic Resources & Opportunity	Employment Options	“Particularly folks who are gonna exit on the Sex and Violent Offender Registry. I think it intensifies the level of navigation they need. It intensifies the level of support that they need. And for those individuals, everything they’re trying to do is going to get harder. Housing, employment, family relations is all gonna be exponentially harder.”
	Financial Obligations/Hardship	“Utilities is a big one and a lot of people do have past utility bills that prevent them from getting into housing.”
	Public Assistance Programs	“Social services? Like I really didn’t know where to go to sign up for food stamps and stuff.”
	Social Support (Instrumental)	“Whenever I get out my grandpa will be taking me back and forth or I can ride with his friend that works out there too.”
Competencies	Coping and Awareness Skills	“But, and then I’ve done told my family what I expect from them, like when I get out, you know what I mean? I don’t wanna be around anybody that does anything. Like if I’m going to go to family functions, you guys are drinking beer or whatever, I’m going to leave just because I don’t want to get pulled into that.”
	Digital Literacy	“We always hear from guys who have been down 10 years, ‘I don’t even know what a cell phone looks like.’ ‘I went to the grocery store, and they only had these U scans.’ I had one guy tell me he stood there for 20 minutes and stared at it because he didn’t know what to do and he didn’t wanna look like an idiot.”
	Financial Literacy	“How to understand to balance the checkbook. What debts that they had before they got locked up, how can they get that taken care of. Really how to run a household. I’ve been gone a long time, so I have not had the privilege of actually running my own household.”
	Health Literacy	“Just the breakdown of what insurance look like, what it looks like, like what is covered, what is not copay and then the resources and options for organizations or things that can help you with copay, especially if you’re fresh out and you have, you don’t have employment. Another thing is, finding a GP for each county.”
	Job Readiness	“A lot of times when folks get out, they really don’t have any resume, they need to learn how to use their transferable skills. You know, if they work with Grandpa in a barn for 10 years and they’re good at mechanical things, they need to be able to document that… A lot of times they get out and they don’t remember dates, they don’t remember who they worked for. So we can kind of while they’re in facility work through the. Did you work there in the spring? … Are they still, do you still have contacts there that we could reach out to, to find out your work history with them? So, starting from scratch in facility to where they have like a bare bones resume.”
	Parole Conditions	“I think it’d be cool if you could have some type of connection to the probation or parole officer that the individual may be connected to, they are phenomenal. They should be a phenomenal resource when transitioning out. So if we could get that relationship or that introduction started sooner rather than later, we might have a better wraparound kind of transition.”
Relationship Management
	Interpersonal Connections & Skills	“We can lose our communication skills when we get out because we have prison communication skills. But then there’s like professional communication skills and people are not gonna be able to understand what you mean when you say certain slang words and that all that. So that is very important.”
	Parenting	“When they get out, you know, is there access to daycare? Someone to watch their kids? We have the women who have had the babies while they’ve been incarcerated. Are they getting the help that they need when they get out so that they can work and provide for their children?”
	Personal Safety	“Gender specific question to the women. Do they feel like they have to be a victim to stay wherever they’re living or are they like, are they suffering abuse just to have a place to stay?”
	Social Support (Emotional)	“They (people with sex offenses) didn’t have the proper support system throughout the time that they were here, or the support system they had, because as long as they were down, it’s now gone. They’ve got to now develop a new support system, and not one that makes you feel ashamed for the fact that you are trying to reach out.”

Note: Literacy and gang membership were identified through member checks with current professionals and not discussed during interviews or focus groups

Material resources

Needs reflecting material resources, including their availability, accessibility, and ability to be secured, were among the most frequently identified and highly rated. These needs encompassed available and safe housing, transportation, food access, and clothing. Interview and focus group participants drew a clear distinction between housing in terms of availability and safety. Individuals recently released from incarceration experienced reduced housing options and numerous barriers. As one person with a history of incarceration stated, “They [landlords] always say like, ‘Are you a felon?’ You can’t get a house and then a lot of people is like trying to get housing in other people’s names and then that might be a problem or it might be an issue with like, yes, like um when I came home I, to be honest, being real and being honest, like uh my first place I had to put it in somebody else’s name because they like, ‘Oh you’re a felon and bam, bam, bam, bam, bam, bam…’” Notably, the nature of the conviction could further reduce housing availability. For example, one individual working in the criminal justice system remarked, “Sex offender population - that’s a unique kind of situation. I can’t just live anywhere that I want to, so the offense that the person has had makes a huge difference in how we would be approaching any type of resource that we would offer to them….” In addition to housing availability, safe housing was described as a different concept. As one criminal justice professional recounted, “Where they can and can’t access [housing], that’s something that I learned really quickly. When I was working with this population, people is like, ‘I can’t live on the east side.’ Ok. Well, can you tell me why? ‘No, but I can tell you who will find me and I can’t live on the east side, right?’ That’s especially for people who have been engaged in sex work. People who have been engaged in any kind of survival based like criminal behavior will tell you like, ‘I can’t live in XYZ.’ And like I trust that. And so I feel like we should all trust that.”

Additionally, challenges of accessing documents that allow a person to prove their identity create barriers to attaining employment, food, housing, and other needs. One professional elaborated, “maybe they have access to a vehicle on the outside, but the driver’s license needs to be reinstated. So, working with the [Bureau of Motor Vehicles] to see how that can be made possible, what kind of hoops they’re gonna have to go through, the financial commitment to get that reinstated because if that vehicle is available and they have a driver’s license, now there’s a pathway to employment.”

Health services

Identified needs in this section related to one’s ability to access health services. Mental health and substance use services were identified in every interview and focus group as particularly important during a person’s transition home. One focus group member shared the following: “I had a brother who took his life five days post incarceration, and he had multiple suicide attempts before he left. So, echoing what was already shared about having stable housing lined up and access to a phone to reach out and get connected for continuity of care is important. But then also being aware of what crisis services are available for the area you’re going to in case you do run into issues.” Along with mental health services, the necessity of substance use services was further emphasized by one interviewee living in incarceration: “Staying sober is gonna be my problem because I been an alcoholic for 30 years and I like beer. I mean, I don’t do it to get drunk anymore. It’s just a daily thing.”

Economic resources & opportunities

Participants described the importance of financial resources. Within this set, interviewees and focus group members identified employment as the primary need, but they also noted the importance of programs and social supports when they did not have access to their own financial resources. They detailed how a history of incarceration affects employment opportunities, noting some individuals may be further constrained by the nature of their offense. One professional described it best, stating, “Particularly folks who are gonna exit on the Sex and Violent Offender Registry. I think it intensifies the level of navigation they need. It intensifies the level of support that they need. And for those individuals, everything they’re trying to do is going to get harder. Housing, employment, family relations is all gonna be exponentially harder.” Public assistance programs like Supplemental Nutrition Assistance Programs (SNAP or food stamps) or local programs were underscored as important financial resources.

Furthermore, participants noted that “instrumental” social support, or the way family or friends might provide resources, plays a role in success. Participants described how someone recently released may rely on their social support system for getting to work, finding housing, or knowing how to do something, such as using technology or applying for assistance. Whether it was, “She (her mom) bought me a little mini house and put it in the backyard” or “Whenever I get out my grandpa will be taking me back and forth or I can ride with his friend that works out there too”, having people to help provide resources was important to economic stability.

Competencies

Several skills and abilities emerged as important to successful reentry, including coping skills, digital literacy, health literacy, financial literacy, general literacy, knowledge of parole conditions, and job readiness. Digital literacy and health literacy fell below the 0.75 CVI threshold, but were emphasized in the qualitative data were related to other competencies and therefore retained. One professional highlighted the importance of coping skills as a person’s environment drastically changes during reentry: “You know, if you have an officer that comes over and kicks your bed every day, then you get home and you have a 5-year-old and he comes in, he’s jumping on the bed, kicking the bed and dad jumps up and goes, ‘What the * f* are you doing?’ That’s not the appropriate response, but that’s a response he’s been able to give for the last so many years.” The duration of incarceration may also have an impact on the skills and knowledge individuals have. Another professional shared: “We always hear from guys who have been down 10 years, ‘I don’t even know what a cell phone looks like.’ ‘I went to the grocery store, and they only had these U scans.’ I had one guy tell me he stood there for 20 minutes and stared at it because he didn’t know what to do and he didn’t wanna look like an idiot.”

Relationship management

Some needs referred to a person’s relationships with others such as parenting, emotional social support, interpersonal connections and skills, personal safety, and gang membership. The way a person can parent changes during incarceration and, as one professional shared, will change again at release: “When they get out, you know, is there access to daycare? Someone to watch their kids? We have the women who have had the babies while they’ve been incarcerated. Are they getting the help that they need when they get out so that they can work and provide for their children?” One incarcerated individual expanded on the struggles experienced by those without a support system, especially depending on conviction: “They (people with sex offenses) didn’t have the proper support system throughout the time that they were here, or the support system they had, because as long as they were down, it’s now gone. They’ve got to now develop a new support system, and not one that makes you feel ashamed for the fact that you are trying to reach out.”

Discussion

This study utilized an iterative, qualitative process to understand the social needs of individuals who are nearing release or were recently released from incarceration. The primary outcome is the development of a screening tool specifically oriented to measure the unique needs of individuals in this population.

A main finding of the study is the expansive and varied nature of the social needs identified as important by those with expertise in the reentry process. The list generated by our participants mirrored the social needs established in justice-related literature and the social needs prioritized in both health systems screening tools and quality reporting requirements [45]. Frequently mentioned social needs were housing instability, financial strain, and transportation barriers. Beyond this list, several factors unique to those with a history of incarceration were identified. Specifically, concerns with coping and awareness skills and digital literacy have origins in the very act of being separated from society for a prolonged period.

Another key finding is that, for people leaving incarceration, social needs are often interconnected and occur simultaneously [46]. It can be difficult to prioritize any one need at a time, as several needs are likely to influence one another through a complex web of socioeconomic factors. For example, specific barriers to housing availability for individuals with histories of justice involvement may cause ripple effects into personal safety, interpersonal relationships, substance use, and risks for experiencing violence or recidivism. Transportation challenges may determine whether an individual can successfully secure employment, which can influence insurance coverage, access to health care, food security, and the ability to meet other financial, family, and legal obligations, especially during probation and parole periods.

Screening for social needs is the first, and necessary, activity in improving outcomes [47]. Screening results enable organizations to link patients to social service organizations, which can ultimately help meet individual’s needs [48–50]. A justice systems-focused social needs screening tool is a potentially timely resource. Hundreds of thousands of individuals are released from federal and state prisons annually [51] and in recent years the rate of release has increased [52]. Social needs of individuals exiting the US criminal justice system can pose operational challenges for health care systems, particularly emergency department services [11, 53]. Some states are considering ways of improving Medicaid enrollment to avoid gaps in coverage upon release [54, 55]. Social needs screening also aligns with efforts to improve Medicaid enrollment processes (or re-enrollment) for individuals soon to be released from incarceration. Many state Medicaid agencies screen for social needs [56], so more specific screening could fit within existing protocols. Additionally, Medicaid Managed Care Organizations have more flexibility to offer services for social needs [57], which could connect recently released individuals to resources if those needs are systematically identified. Aggregated screening data may support organizational decision-making and policy-setting [48]. For correctional agencies and health care payers, such population-level data could help identify and organize the resources, staffing, and community partnerships necessary to support health and wellbeing. Correctional agencies could optimize social needs screening and referral processes to promote successful reentry. Conversely, as social needs negatively affect health care utilization [58], costs [59], and act as a barrier to primary care [60], state Medicaid agencies and Medicaid Managed Care Organizations may be the most incentivized to support such screening activities and linkages to social services.

Our findings from both professional experts and people experiencing incarceration are consistent with prior research suggesting that the criminal justice system could explore supporting social needs screening activities as an avenue for lowering recidivism [61]. For some identified needs, such as various types of literacy and intra- or interpersonal skills, education and training are possible intervention strategies. Other needs, however, are much more difficult to address: housing, employment, access to mental health services, and access to substance use services require larger societal and policy changes. Moreover, some of these social needs, like employment and transportation barriers, can limit access to health services. While critical to this population (and others), many social needs are more difficult for any single agency or organization to address.

Transitional health programs are one model to address the social needs of individuals as they prepare for release [62]. For example, Indiana Department of Correction’s Transitional Health Care Services, part of the Medical Division, includes staffing and services tailored to support individuals during reentry. Transitional health facilitators work within facilities to create personalized physical and behavioral health release plans for individuals preparing for their release. They also partner with state-based agencies and health care systems to ensure insurance coverage and provide a continuum of care upon release.

The screener developed in this study can support the work of the Transitional Health care teams by proactively identifying health-related social needs. End users (people incarcerated and DOC staff) may individually benefit from use of the tool. Several interviewees remarked that the screening assessment items (e.g., clothing, parole conditions, public assistance programs, social supports, etc.) could serve as a planning checklist for individuals preparing for release. The tool can also help staff to optimize limited time in case management meetings by identifying the most urgent needs and efficiently ruling out needs for which an individual does not want or need assistance. Furthermore, executive Department of Correction leadership can use aggregated screening data to inform organizational decision-making, staffing, and resource allocation.

Nonetheless, given the diverse social needs and the complexities of criminal justice systems, implementing a screening process presents feasibility challenges. The tool is designed to collect data at two points in time: six months before release and 30–90 days post-release. With 51 and 54 questionnaire items (pre- and post-release respectively) needed to measure the included social needs, the capacity of appropriate staff (e.g., case managers, reentry coordinators, transitional health facilitators), time required, and data collection infrastructure are of concern for the screener’s administration. Future research should explore the operationalization of procedures and infrastructure for the screener’s use in correctional and transitional health settings and the acceptability of the screening process among individuals in reentry.

Strengths and limitations

We followed a content and face validation approach to ensure the screening tool addressed topics important to the population and used appropriate language. Our methods are strengthened by the participation of individuals currently incarcerated, formerly incarcerated individuals, and professionals and researchers currently active in correctional settings. Their insights helped to identify the most significant social needs to assess during the reentry transition period. Several limitations are also worth noting. At the time of publication, this justice systems-focused social needs screening tool has yet to be tested for construct validity or reliability. While we drew on existing screening instruments, composite screening tools do not typically retain the psychometric properties of the source instruments [63]. The next step is to evaluate the sensitivity and specificity of our tool. Additionally, our currently incarcerated key informants were all from a single state, which might limit the generalizability of our findings. We attempted to mitigate this limitation by including those with lived experience and expertise from other states. Additionally, our sample was drawn from prison incarcerated populations, which might limit generalizability to those incarcerated in jails. While individuals in jails typically have a shorter duration of incarceration, individuals still are at higher risk for negative health outcomes [64] and face barriers when returning home [65]. Lastly, this study does not account for needs that may have existed prior to incarceration. Future work could consider pre-incarceration factors in order to better contextualize post-release assessments.

Conclusion

Social needs are increasingly of interest in the health care sector due to their impact on health outcomes, and individuals with a history of incarceration may face different or more intense difficulties. This study identified an expansive list of social needs and developed a screening tool to assess them. Information about the social needs of individuals as they are released can support connection to services, identification of trends, and allocation of resources.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

JRV and CAH conceived the study design. AJ led key informant recruitment. JW, AJ, BM and JRV conducted interviews and focus groups. JRV and BM led the qualitative analyses. BM, AJ, CAH and JRV led the quantitative analysis and selection of the source instruments. BM and JRV drafted the initial manuscript. BM, AJ, JW, and CAH provide critical revisions and interpretations. All authors approved the final manuscript.

Funding

This work was supported by the Indiana Department of Correction [#75501].

Data availability

The resulting screening tool and all references to source instruments are included in this publication and its supplementary material files. The datasets generated as part of qualitative interviews are not publicly available in order to maintain participant confidentiality.

Declarations

Ethics approval and consent to participate

This project was approved by the Indiana University Institutional Review Board. All recruited individuals provided written informed consent.

Competing interests

Joshua Vest is a founder and equity holder in Uppstroms, LLC, a health technology company.