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. 2021 Jul 14;16(7):e0254578. doi: 10.1371/journal.pone.0254578

Physicians’ perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study

Latasha Jennings 1,*, Carolina Fernández Branson 2, Andrea M Maxwell 3, Tyler N A Winkelman 1,4, Rebecca J Shlafer 5
Editor: Nickolas D Zaller6
PMCID: PMC8279398  PMID: 34260620

Abstract

Background

In 2016, over 11 million individuals were admitted to prisons and jails in the United States. Because the majority of these individuals will return to the community, addressing their health needs requires coordination between community and correctional health care providers. However, few systems exist to facilitate this process and little is known about how physicians perceive and manage these transitions.

Objective

The goal of this study was to characterize physicians’ views on transitions both into and out of incarceration and describe how knowledge of a patient’s criminal justice involvement impacts patient care plans.

Methods

Semi-structured interviews were conducted between October 2018 and May 2019 with physicians from three community clinics in Hennepin County, Minnesota. Team members used a hybrid approach of deductive and inductive coding, in which a priori codes were defined based on the interview guide while also allowing for data-driven codes to emerge.

Results

Four themes emerged related to physicians’ perceptions on continuity of care for patients with criminal justice involvement. Physicians identified disruptions in patient-physician relationships, barriers to accessing prescription medications, disruptions in insurance coverage, and problems with sharing medical records, as factors contributing to discontinuity of care for patients entering and exiting incarceration. These factors impacted patients differently depending on the direction of the transition.

Conclusions

Our findings identified four disruptions to continuity of care that physicians viewed as key barriers to successful transitions into and out of incarceration. These disruptions are unlikely to be effectively addressed at the provider level and will require system-level changes, which Medicaid and managed care organizations could play a leading role in developing.

Introduction

In 2016, over 600,000 individuals were admitted to a state or federal prison in the United States (US) [1], and 10.6 million people were admitted to a US jail [2]. Nearly all of these individuals will return to the community following their incarceration [2, 3]. Previous research has shown that people in prison and jail have a high burden of chronic physical health conditions, infectious diseases, disability, mental illness, and substance use [4–9], which require ongoing health care during incarceration and upon release. People in prison or jail have higher odds of hypertension, asthma, arthritis, cervical cancer, and hepatitis compared to the general population [4]. In addition, it is estimated that 32% of individuals in prison and 40% of individuals in jail have at least one disability related to hearing, vision, cognition, mobility, self-care, or independent living [5]. Further, over half of all individuals in prison or jail have a mental health problem or meet criteria for drug dependence or abuse [6, 8]. In Hennepin County, MN, where this study was conducted, 52% of the jail population reported having a mental health problem, and 20% reported using or abusing opioids [10]. Addressing the health needs of individuals cycling in and out of prisons and jails requires coordination between community and correctional health care providers. However, this coordination is often inconsistent or nonexistent and complicated by barriers like sharing medical records between correctional and community health providers [11–13].

While some specialized programs have been developed to meet the needs of individuals leaving prison or jail, most people do not interact with these programs because they serve limited geographical areas [14–18]. The majority of individuals leaving prison or jail establish care with a community-based physician not affiliated with a re-entry program. Yet, little is known about community-based providers’ understanding of transitions related to incarceration or providers’ experiences with navigating care transitions for individuals who were recently incarcerated. Such information could identify opportunities to improve continuity of care for patients transitioning between the community and prison or jail.

The goal of this qualitative study was to address this gap in the literature by describing physicians’ views on, and experiences with, patient transitions into and out of incarceration and how these transitions impact care plans for patients.

Methods

Semi-structured interviews were conducted with physicians from three safety-net clinics in Hennepin County, Minnesota between October 2018 and May 2019. Hennepin County is Minnesota’s largest county with a population of 1.3 million people and contains the city of Minneapolis and several large, suburban cities. These clinics were selected because they serve a high number of patients who have histories of justice system involvement. Further, each clinic serves as a medical training institution that may be ideal sites for implementation of future physician training curriculum. This study was approved by the Institutional Review Boards at Hennepin Healthcare Research Institute and the University of Minnesota. Written informed consent was obtained from all participants.

Interview questions were developed by research team members LJ, TW, and RS, and were initially generated based on known gaps in physician training and education related to working with patients with justice system involvement. Given this gap, interview questions were created to assess physicians’ knowledge of the US criminal justice system and how it impacts their patients. These questions were reviewed and refined using an iterative process by both the research team and external stakeholders with backgrounds in public health and criminal justice. The interview questions were further refined after conducting two pilot interviews. The final interview guide covered five main topics: 1) knowledge of the criminal justice system; 2) medical education and training related to the criminal justice system and working with patients involved in the criminal justice system; 3) if and how physicians screen patients for criminal justice system involvement; 4) the physical, mental, and substance-related health needs of patients with criminal justice system involvement; and 5) recommendations on how the health care system should meet the needs of patients with histories of criminal justice involvement.

After receiving approval from the medical director at each institution from which we recruited, we extended invitations to physicians by email to participate in the study. We used purposive sampling to recruit physicians within the specialties of internal medicine, psychiatry, family medicine, and emergency medicine. In recruitment materials, participants were told that the purpose of the study was to better understand physicians’ knowledge and perceptions of the criminal justice system and its impact on patients to inform development of training curricula and programs that better meet the needs of providers and patients.

A total of 47 physicians were directly contacted by LJ. Of those 47 physicians, 27 (57%) responded to our inquiry, and nearly all of those who responded to our inquiry agreed to participate in a one-time interview (n = 23, 85%). Participants identified as predominantly White (n = 19, 83%), non-Hispanic (n = 21, 91%) and male (n = 16, 70%), with an average age of 48 years (range = 36–75).

All interviews were facilitated by LJ, a female project coordinator with a Master’s degree in Public Health and graduate-level experience and training in conducting qualitative research. A student notetaker was also present during interviews. Interviews lasted between 36 and 90 minutes, and no repeat interviews were conducted. Interviews were conducted in private offices at participants’ workplaces. One interview was conducted at a public coffee shop at the participant’s request. Following each interview, LJ compiled field notes to record observations. Field notes were used to record information regarding interview setting and length along with notes on interviewee responses and body language. These notes were used to support transcription of interview audio recordings. Data collection concluded upon agreement amongst the research team that no new findings were emerging and data saturation had been reached. Interviews were audio recorded and transcribed verbatim using a web-based transcription service. All transcripts were reviewed for accuracy by members of the study team. Transcripts were not returned to participants for comment or correction.

A thematic analysis approach was utilized to identify patterns within the data [19]. For this thematic analysis, both deductive and inductive coding was used [19, 20]. Codes are words or short phrases that are used to summarize key features of the data [19]. Deductive coding was conducted by applying a priori codes that were defined based on the interview guide. For example, “knowledge of the criminal justice system” was one a priori code used to organize data related to physicians’ ability to define criminal justice terminology (i.e., prison, jail, probation parole). Inductive coding was conducted by allowing data-driven codes that were not predefined to emerge [19, 20]. “Continuity of care,” the focus of this manuscript, was one such inductive code. The codes were organized into a codebook from which we identified patterns, or themes, that were present across the data [21].

Three transcripts were independently coded by LJ, RS, and CFB and a preliminary codebook containing both deductive and inductive codes was developed [21]. This preliminary codebook was independently applied to one transcript by LJ, RS, and CFB, and the team met to discuss codebook revisions. An iterative process was used to further refine the codebook, in which a subset of transcripts were independently coded by two of the coders and compared until the researchers were confident that a consensus on the meaning of all codes had been reached. The codebook was independently applied by LJ, RS, and CFB to the remaining transcripts. The codebook was ultimately refined to 18 codes (12 deductive and 6 inductive). From these codes, multiple themes were identified, and just one code, “continuity of care,” is the focus of this paper. LJ, RS, and CFB identified, “continuity of care,” as warranting further sub-analysis given the complexity of the data contained within this code. This sub-analysis revealed distinct patterns related to continuity of care, which was not one of the guiding questions of this research project. Those themes are described herein. NVivo (version 12) was used for all coding and analyses. Participants did not provide feedback on the findings.

Results

Four themes emerged from our interviews with physicians related to care transitions and factors that physicians perceived as contributing to discontinuity of care for patients entering and exiting incarceration: (1) disruptions in patient-physician relationships, (2) barriers to accessing prescription medications, (3) disruptions in insurance coverage, and (4) problems with sharing medical records. Physicians discussed how these factors impacted patients differently depending on whether the patient was transitioning from the community to prison or jail, or transitioning from prison or jail back to the community. In some instances, physicians’ knowledge of a patient’s past or upcoming incarceration played a significant role in informing the physician’s care plan for the patient.

Disruptions in patient-physician relationships

Physicians noted changes in medical providers as an issue impacting patients entering and leaving incarceration. In most cases, physicians in the correctional setting were not the same physicians patients saw in the community setting. Changes in medical providers introduced barriers to care coordination due to limited communication between the two settings. Participants emphasized the need for transitional care planning for patients upon their release to improve communication between correctional and community health care providers. For example, one physician remarked:

“For patients who are currently incarcerated and are going to be changing their living situation, I would love it if we could do a transitional care visit with their primary care provider.” (Participant 21)

There were rare exceptions in which a community-based provider also provided correctional health care. Two physicians shared how their roles in both correctional and community settings provided unique opportunities to maintain the patient-provider relationship. As expressed by one of these physicians:

“There would be people that…I’d seen ‘em in the jail. And then they would just come over [to community clinic], and I’d keep ‘em … So we had continuity of care.” (Participant 8)

Physicians with roles in both correctional and community settings were able to continue their care plans for patients during transitions between correctional and community settings, while physicians without access to correctional settings experienced gaps in patients’ treatment plans. This resulted in negative health impacts for patients, especially those experiencing chronic physical and mental health conditions that require long-term care.

Barriers to accessing prescription medications

Physicians reflected on patients’ challenges to continue their prescription medications around periods of incarceration. Physicians expressed that their patients often experienced barriers to accessing medications for common physical chronic conditions, as well as unique barriers related to medications for opioid use disorder treatment.

Physicians shared instances in which medications that had been prescribed to their patients in the community were confiscated or otherwise discontinued when the patient became incarcerated. For instance, one physician said:

“I’ve had a number of patients tell me that their medications were taken away when they were arrested or brought into custody …” (Participant 19)

Physicians prescribing medications for opioid use disorder treatment, like buprenorphine and methadone, were particularly attuned to their patients’ criminal justice system involvement due to patients being unable to continue such medications during their incarceration. In some instances, physicians made intentional changes to their care plans if a patient believed they may be incarcerated in the near future. One physician shared their approach to slowly tapering a patient off their medication for opioid use disorder in an instance where the patient was facing upcoming incarceration. While not the physician’s ideal approach, the option to continue this patient’s medication while incarcerated was not available:

“They know that incarceration’s a real option or is impending for them. In which case, then it’s trying to taper them off even though it’s not the appropriate medical care for them, but because they’re not going to be able to get it while they’re incarcerated regardless. Then, in order to make that transition easier for the patient, then either I or they will … request to be tapered down to a much lower [dose] or off of their medication.” (Participant 6)

For patients returning to the community from a period of incarceration, physicians expressed that patients often faced barriers to getting their medications after release. Patients were generally released from prison or jail with either no medications or a limited supply. In addition, patients often experienced financial barriers to refilling their medications once they returned to the community. One physician with experience working in a correctional health care setting shared how they prescribed affordable medications to reduce the financial burden upon release:

“I learned that it is really important to, when you’re treating people with medications for chronic illnesses in prison, it’s your responsibility to make sure you treat them with the best medication at the lowest price. Because if you get them stable in prison, you want them to be able to continue their medical care outside of prison.” (Participant 22)

Disruptions to insurance coverage

Physicians were also attuned to disruptions related to insurance coverage for patients who had been incarcerated. Notably, patients on public health insurance experienced suspension or termination of their health insurance when they were admitted to prison or jail, and physicians expressed frustration with this practice and acknowledged the barriers this creates for patients, especially upon their release.

One physician shared their experience with a patient foregoing needed health care because they lacked health insurance following a recent incarceration:

“The fact that MA [Minnesota’s Medicaid program] gets turned off and people are getting out of custody without …having insurance … they … come back and they’re like, ‘Yeah, I’ve been off my meds six months because I just didn’t get around to getting insurance back.’” (Participant 3)

Thus, physicians were tasked with adapting care plans to treat complex medical problems with as little financial burden on uninsured patients as possible. As shared by another physician:

“That was a big issue for a number of people that I saw coming out of jail is that they didn’t have …health insurance, and they came out with some pretty …significant health care needs …that we were trying to manage …without health insurance.” (Participant 11)

Physicians perceived that having continuous access to health insurance would reduce financial barriers to accessing health care and result in improved health outcomes for patients.

Problems with sharing medical records

Community-based physicians also had limited access to correctional health care records, which presented challenges for physicians trying to review the care that patients received while incarcerated. As stated by one physician:

“Trying to find out what kind of evaluation and treatment and sort of what happened when they were incarcerated. [It] can be really hard to get those medical records.” (Participant 11)

Physicians expressed delays in receiving medical records from correctional facilities, and if medical records were received, they often lacked adequate information on what care was delivered during incarceration. For example, one physician stated:

“I have gotten records from [the] prison health care system previously, but not easily …definitely not promptly. It’s always me asking and then receiving [the records] sometime later. It’s not always clear from those records what happened while the patient was there.” (Participant 23)

Thus, physicians were tasked with creating patient care plans with incomplete information on what care was received during a patient’s incarceration.

Discussion

Physicians identified multiple ways in which incarceration disrupts continuity of care for patients transitioning between the community and prison or jail. Barriers to maintaining continuity of care included disruptions in patient-physician relationships during periods of incarceration, barriers to medication access (especially those for opioid use disorder), lapses in health insurance coverage, and difficulties obtaining medical records from correctional facilities. Thus, physicians were tasked with developing care plans for patients with histories of incarceration without complete information on the health care services patients did or did not receive during their incarceration. Further, physicians recognized that patients leaving prison or jail without health insurance might have difficulty affording medical visits and medications to address their complex health needs. Given these system failures identified by physicians, physicians implemented ad hoc solutions, for example, adapting care plans to reduce the financial burden of health care costs on uninsured patients.

The barriers to continuity of care identified by providers, including disruptions to patient-provider relationships, medication access and health insurance coverage, align well with findings from previous research that explored experiences of individuals recently released from incarceration, as well as physicians who work in jail or prison settings [22–25]. Such disruptions to care may contribute to poor health outcomes and an increased risk of recidivism. Previous research has found that maintaining a continuous relationship with a primary care provider is associated with a lower likelihood of return to prison or jail [26], suggesting that this relationship plays an important role in addressing health-related factors that contribute to recidivism. The current study adds the perspectives of community-based physicians to this existing body of literature, highlighting the barriers physicians face to providing care to patients recently released from prison or jail and their approaches to mitigating these barriers. In particular, this study finds, in lieu of functioning systems to support these transitions, physicians took it upon themselves to troubleshoot issues with little to no support for such complex transfers of care.

Physicians in our study were also concerned that many correctional facilities did not provide standard of care, particularly for patients with opioid use disorder. While access to medications for opioid use disorder has expanded, there are still many jails and prisons that do not provide this treatment to patients [27], and obtaining information on the particular policy a certain prison or jail has regarding treatment for opioid use disorder can be difficult. Further, physicians shared the difficulties their patients faced accessing community-based health care without health insurance, which suggests that linkage to health insurance is needed during transitions to the community as well.

Strengths and limitations

Although this study is the first of its kind to identify perspectives of community-based physicians about the barriers to treating patients with a history of criminal justice involvement, it does have several limitations. First, only physicians from three clinics in one geographic region and from a limited number of subspecialties were included in the study, which may limit generalizability to other health care settings and medical subspecialties. Second, sampling bias may have been introduced due to physicians with a strong interest in the study topic potentially being more likely to respond to interview invitations. Third, this study lacks the inclusion of patient voices and perspectives. Thus, we do not know if patients’ perspectives on barriers to continuity of care align with those of the physicians interviewed, which would have important implications for implementing patient-centered care and should guide the development of any physician training. Finally, this study focused on transitions between the community and incarceration. However, individuals involved with the criminal justice system also make transitions within the criminal system, including transfers between jails and prisons for example, that may also impact their health. Despite these limitations, this study contributes vitally needed data to fully assess, and thus eventually mitigate, barriers to care in this specialized patient population.

Implications

Physicians’ ad hoc approaches to addressing care transitions for patients entering or leaving jail or prison, suggests that there is a lack of systems level coordination to support these transitions. Findings from this study indicate that there is a need to develop a system of care that ensures proper transitions of care between correctional facilities and community health care providers. Currently, specialized transition programs exist to facilitate transfer of care to community providers [14–18]. However, these specialized programs serve limited geographical areas and are not accessible to all individuals transitioning between prison or jail and the community.

In order to improve health outcomes and reduce recidivism, systems-level solutions are required to link care between community settings and prisons and jails. Physicians’ reports of their difficulties communicating with correctional health care providers and obtaining medical records from correctional facilities suggests that increased communication channels between the two settings are needed. This could include being more transparent about what services are offered in the correctional setting so that community providers know what patients have access to during their incarceration and more readily sharing medical records when consent is obtained from patients [28]. Because patients may not yet have an established relationship with a community provider at the time of release, they should also be provided access to free copies of their medical records from correctional health care providers to help reduce barriers to establishing care in the community.

Given the barriers patients face gaining access to health insurance coverage upon release from prison or jail, correctional health care agencies should consider partnering with health agencies to build systems to support patients upon release. This could include ensuring that patients leaving prison or jail are enrolled in health insurance coverage that will cover their medical expenses when they return to the community. This could be done through partnerships with community-based organizations that provide health insurance navigation services. Enrollment in health insurance, combined with improved medical record sharing, would allow patients to quickly establish care with a new provider in the community and receive medications they may need in a timely manner.

Medicaid and managed care organizations that administer Medicaid could play a key role in developing these system-level supports. Access to Medicaid for low-income adults was expanded under the Affordable Care Act, with most individuals released from prisons likely to be eligible for such coverage [29]. Medicaid expansion provides an opportunity to link individuals who are incarcerated to health insurance coverage prior to release and coordinate care during their transition back to the community. The barriers identified by physicians in this study suggest that coordination of care for this population through a Medicaid managed care organization would alleviate barriers to medication access, lapses in health insurance coverage, and difficulties obtaining medical records from correctional facilities. Such system-level support may lead to improved health outcomes, including a reduced risk of death, as well as reduced likelihood of recidivism for individuals with a history of incarceration.

The findings from this study highlight several important areas where further research is needed. Future research should implement and test system-level supports, such as those described herein, for patient transitions between incarceration and the community to examine their impact on health and well-being for individuals with a history of incarceration. Further, because this study was conducted in one urban, Midwest county, future research should explore rural physicians’ perceptions of the impact of incarceration on continuity of care for patients. Finally, additional research is also needed to better understand the impact of transitions within the criminal justice system, such as transitions from jail to prison, and how this impacts continuity of care and overall health.

Supporting information

S1 File. This is the S1 interview guide.

(DOCX)

Click here for additional data file. (19.3KB, docx)
S2 File. This is the S2 interview transcripts.

(ZIP)

Click here for additional data file. (771KB, zip)

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

TW receives funding through a career development award from Hennepin Healthcare (https://www.hennepinhealthcare.org). LJ, TW, and RS receive financial support from the University of Minnesota Grand Challenges Research Initiative (https://strategic-planning.umn.edu/gcr-phase-2-awards). AM is funded by NIH T32 GM008244 (https://projectreporter.nih.gov/project_info_details.cfm?aid=9852690&icde=51017452). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Decision Letter 0

Nickolas D Zaller

5 Mar 2021

PONE-D-21-03231

Physicians' perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study

PLOS ONE

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Reviewers' comments:

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1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: I Don't Know

**********

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Reviewer #1: No

Reviewer #2: Yes

**********

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this manuscript. Authors are correct that there is great need to better understand physician engagement with people recently released from jails and prison. Overall, the paper is well written and takes an exploratory approach to understanding the topic area. Listed below are several areas to address to strengthen the paper:

• In the methods section, authors discuss collecting field notes – what was observed and documented in these notes? Were they analyzed and integrated into the findings presented in the paper? Additional information is needed about them.

• The analysis section needs additional detail. What specific qualitative analysis was utilized? For example, it sounds like some kind of thematic approach was used but not specifically stated. It’s important to explicitly state the approach and cite the appropriate sources. Themes don’t just emerge from the data. There is a systematic process that should be followed. Authors do a nice job describing the development of the codebook but then suggest the themes emerged from the refined codebook. People do that—make decisions about the themes and what is salient and what is not. Authors may benefit from reviewing Braun & Clark who outline, step by step, the process for conducting a thematic analysis.

• Authors write “While the majority of physicians did not provide care in correctional settings…” (p.7, line 170). No descriptions were provided about this anywhere else in the text. If authors suggest a “majority” of physicians, it’s important to describe these characteristics with the specific percentage who did work in corrections settings.

• The findings could highlight more depth in meaning. For example, on page. 7, authors identify two physicians who saw people in the community and during incarceration and the quote suggests there was continuity of care in these cases. We know generally why continuity of care is important but for this study, it would be great to detail how continuity of care is beneficial. What do physicians suggest is missing or happens to people when care is disrupted?

• Part of the stated goal of the project on page 4 says the project explores how physicians develop care plans when their patients have been recently incarcerated. The article doesn’t leave readers with much information about this. Participants discussed how physicians might alter care plans when a person is going to enter a longer period of incarceration for opioid use but there is no substantial discussion around care planning after a person exits jail or prison. This is something important to add.

• P. 14, lines 336-337: How does physicians’ use of ad hoc approaches equate to the need for more medical education? The idea that this study would inform the need for specialized training or additional training in medical school was mentioned in the introduction and I don’t think the findings from this study inform training needs in any capacity. Either additional data needs to be presented or this implication should be removed.

Reviewer #2: General comments

● Obtaining physicians’ perspectives on care of the chosen population is innovative and the topic is important

● The paper could be more concise, though was generally well-written.

● Though the research design seemed appropriate for the aims, the Methods section needs more detail and organization.

Introduction

● Clear and effectively introduces subject

● Could more completely specify characteristics of patient population served by the physicians, eg add more of a profile of incarcerated individuals in the particular geographic area

Methods

● This section is lacking adequate detail and references, and the methods are even harder to follow because it is not the order in which the research occurred.

● If applicable, the authors could identify a theoretical model and cite and then how this informed the questions that were used in the interviews. If there is not theoretical model, it would be helpful to understand more about how the authors devised the questions.

● If the journal space allows, the authors could list interview questions in a table

● The authors could elaborate on how the 47 physicians were recruited

● The authors need to cite which qualitative analytic approach was used, describe it, and cite it. There very well may be more than one cite needed in the methods section to cover all the methods used if one does not cover it all

● With this in mind, the authors could elaborate on and cite the type of approach that uses a codebook and how the four themes were arrived at

○ In particular, the authors could elaborate on and cite inductive vs. deductive coding

Results

● Appreciate presenting demographics of the participants.

● The themes are relevant, though again the methods do not adequately explain how they were chosen

● The quotes are sometimes redundant and could be edited or removed; suggest removing quotes which express a concept more than once and shorten the quotes that are used

● It is unclear how many physicians endorsed each theme/experience. Often a table is used to present the numbers of quotes in each category or theme. Eg, do the themes differ in importance? Could be more meaningful if some themes appeared to be supported more than others

● It is also common to label each quote with a pseudonym or number to enhance validity by making it clear that the quotes were from multiple individuals.

Discussion

● Consider adding subheadings to provide more detailed organization, as the journal allows. Or at least follow the order and topics in the results in order to help the readers’ orientation to the data and subsequent conclusions.

● How do the data presented in this study uniquely support changes being advocated for?

● Could more directly address how the physician perspectives in this study affect care

● Again, a quantification table could help by the authors being able to describe the percent who had a particular point of view.

Limitations

● Appreciate the authors framing limitations first with the strengths. Could call this instead “Strengths and limitations.”

● This section was very well done.

Conclusions

● Consider whether this section could instead be called “Implications” as the comments are apt but seem more consistent with this labeling.

● There appears to be a pattern of physicians going above and beyond to compensate for systematic gaps in care; this would be an interesting topic to address in this section to lead into the conclusions/implications

● Does it make sense to suggest that Medicaid/managed care organizations would be able to close the gaps in care?

○ Elaborating on lack of training in medical education might be more in line with objectives and physician perspectives or in the discussion

**********

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Reviewer #1: Yes: Kelli E. Canada

Reviewer #2: No

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PLoS One. 2021 Jul 14;16(7):e0254578. doi: 10.1371/journal.pone.0254578.r002

Author response to Decision Letter 0

31 Mar 2021

Reviewer #1:

1. In the methods section, authors discuss collecting field notes – what was observed and documented in these notes? Were they analyzed and integrated into the findings presented in the paper? Additional information is needed about them.

We have added additional information on what was documented in the field notes and how they were used to support data analysis to Page 6, lines 146-148:

Field notes were used to record information regarding interview setting and length along with notes on interviewee responses and body language. These notes were used to support transcription of interview audio recordings.

2. The analysis section needs additional detail. What specific qualitative analysis was utilized? For example, it sounds like some kind of thematic approach was used but not specifically stated. It’s important to explicitly state the approach and cite the appropriate sources. Themes don’t just emerge from the data. There is a systematic process that should be followed. Authors do a nice job describing the development of the codebook but then suggest the themes emerged from the refined codebook. People do that—make decisions about the themes and what is salient and what is not. Authors may benefit from reviewing Braun & Clark who outline, step by step, the process for conducting a thematic analysis.

We have added citations regarding our hybrid inductive and deductive coding approach to Page 6, lines 154-157. We have added a citation regarding which approach uses a codebook to Page 6, line 158. Further, we added additional information on how themes were identified to Page 6, lines 164-167:

LJ, RS, and CFB identified one code, ‘continuity of care,’ as warranting further sub-analysis given the complexity of the data contained within this code. This sub-analysis revealed distinct patterns related to continuity of care, which are the themes described herein.

3. Authors write “While the majority of physicians did not provide care in correctional settings…” (p.7, line 170). No descriptions were provided about this anywhere else in the text. If authors suggest a “majority” of physicians, it’s important to describe these characteristics with the specific percentage who did work in corrections settings.

Our goal was to highlight the two physicians who did work in both community and correctional settings. We have reworded this section on Page 8, line 213 to remove language related to a “majority” of physicians in order to focus on the two physicians that worked in both community and correctional settings and who shared how this impacted continuity of care for their patients.

4. The findings could highlight more depth in meaning. For example, on page. 7, authors identify two physicians who saw people in the community and during incarceration and the quote suggests there was continuity of care in these cases. We know generally why continuity of care is important but for this study, it would be great to detail how continuity of care is beneficial. What do physicians suggest is missing or happens to people when care is disrupted?

Thanks for this thoughtful feedback. We have added additional depth in meaning to:

Page 8, lines 222-226: Physicians with roles in both correctional and community settings were able to continue their care plans for patients during transitions between correctional and community settings, while physicians without access to correctional settings experienced gaps in patients’ treatment plans. This resulted in negative health impacts for patients, especially those experiencing chronic physical and mental health conditions that require long-term care.

Page 11, lines 313-314: Physicians perceived that having continuous access to health insurance would reduce financial barriers to accessing health care and result in improved health outcomes for patients.

5. Part of the stated goal of the project on page 4 says the project explores how physicians develop care plans when their patients have been recently incarcerated. The article doesn’t leave readers with much information about this. Participants discussed how physicians might alter care plans when a person is going to enter a longer period of incarceration for opioid use but there is no substantial discussion around care planning after a person exits jail or prison. This is something important to add.

Thank you for this feedback. In revisiting the language that we used on page 4, we believe that it is more accurate to say that our goal is to highlight the “impact” of incarceration on care plans. We have edited Page 4, lines 81-83 to:

The goal of this qualitative study was to address this gap in the literature by describing physicians’ views on, and experiences with, patient transitions into and out of incarceration and how these transitions impact care plans for patients.

6. P. 14, lines 336-337: How does physicians’ use of ad hoc approaches equate to the need for more medical education? The idea that this study would inform the need for specialized training or additional training in medical school was mentioned in the introduction and I don’t think the findings from this study inform training needs in any capacity. Either additional data needs to be presented or this implication should be removed.

Thank you for this feedback. We have removed this implication from Page 14, line 405.

Reviewer #2:

General comments

1. Obtaining physicians’ perspectives on care of the chosen population is innovative and the topic is important

2. The paper could be more concise, though was generally well-written.

3. Though the research design seemed appropriate for the aims, the Methods section needs more detail and organization.

Thank you! We have addressed your general comments in more detail below.

Introduction

4. Clear and effectively introduces subject

Thank you!

5. Could more completely specify characteristics of patient population served by the physicians, eg add more of a profile of incarcerated individuals in the particular geographic area

We have added health statistics available for the jail population in Hennepin County, MN, where this study was conducted. Page 3, lines 64-66:

In Hennepin County, MN, where this study was conducted, 52% of the jail population reported having a mental health problem, and 20% reported using or abusing opioids.(10)

Methods

6. This section is lacking adequate detail and references, and the methods are even harder to follow because it is not the order in which the research occurred.

We have added citations regarding our hybrid inductive and deductive coding approach to Page 6, lines 154-157. Further, we added additional information on how themes were identified to Page 6, lines 164-167:

LJ, RS, and CFB identified one code, ‘continuity of care,’ as warranting further sub-analysis given the complexity of the data contained within this code. This sub-analysis revealed distinct patterns related to continuity of care, which are the themes described herein.

We have also moved the statement regarding IRB approval to the end of the paragraph 1 on Page 4, lines 92-94 to better match the order in which this occurred relative to the other procedures described in the Methods. Similarly, we have moved information regarding interview facilitation to Page 5, lines 131-133 to better match the order in which the research occurred.

7. If applicable, the authors could identify a theoretical model and cite and then how this informed the questions that were used in the interviews. If there is not theoretical model, it would be helpful to understand more about how the authors devised the questions.

We did not use a theoretical model to develop our interview questions. We have added a sentence on how interview questions were developed to Page 4, lines 98-100:

Given this gap, interview questions were created to assess physicians’ knowledge of the US criminal justice system and how it impacts their patients.

8. If the journal space allows, the authors could list interview questions in a table

Thank you for this suggestion! The interview questions will be provided as supplementary information with our resubmission.

9. The authors could elaborate on how the 47 physicians were recruited

This is addressed in our methods section Page 5, lines 117-127:

After receiving approval from the medical director at each institution from which we recruited, we extended invitations to physicians by email to participate in the study. We used purposive sampling to recruit physicians within the specialties of internal medicine, psychiatry, family medicine, and emergency medicine. In recruitment materials, participants were told that the purpose of the study was to better understand physicians’ knowledge and perceptions of the criminal justice system and its impact on patients to inform development of training curricula and programs that better meet the needs of providers and patients.

A total of 47 physicians were directly contacted by LJ. Of those 47 physicians, 27 (57%) responded to our inquiry, and nearly all of those who responded to our inquiry agreed to participate in a one-time interview (n = 23, 85%).

10. The authors need to cite which qualitative analytic approach was used, describe it, and cite it. There very well may be more than one cite needed in the methods section to cover all the methods used if one does not cover it all

With this in mind, the authors could elaborate on and cite the type of approach that uses a codebook and how the four themes were arrived at

a. In particular, the authors could elaborate on and cite inductive vs. deductive coding

We have added citations regarding our hybrid inductive and deductive coding approach to Page 6, lines 154-157. We have added a citation regarding which approach uses a codebook to Page 6, line 158. Further, we added additional information on how themes were identified to Page 6, lines 164-167:

LJ, RS, and CFB identified one code, ‘continuity of care,’ as warranting further sub-analysis given the complexity of the data contained within this code. This sub-analysis revealed distinct patterns related to continuity of care, which are the themes described herein.

Results

11. Appreciate presenting demographics of the participants.

Thank you!

12. The themes are relevant, though again the methods do not adequately explain how they were chosen

We added additional information on how themes were identified to Page 6, lines 164-167:

LJ, RS, and CFB identified one code, ‘continuity of care,’ as warranting further sub-analysis given the complexity of the data contained within this code. This sub-analysis revealed distinct patterns related to continuity of care, which are the themes described herein.

13. The quotes are sometimes redundant and could be edited or removed; suggest removing quotes which express a concept more than once and shorten the quotes that are used

We have edited quotes to reduce redundancy and removed one quote that did not express a unique concept. These edits were made to quotes on Page 7, lines 206-208; Page 8, lines 218-220; Page 9, lines 246-247; and Page 9 lines 250-251.

14. It is unclear how many physicians endorsed each theme/experience. Often a table is used to present the numbers of quotes in each category or theme. Eg, do the themes differ in importance? Could be more meaningful if some themes appeared to be supported more than others

Thank you for this feedback. However, we have chosen not to add a table to present the numbers of quotes in each theme given that the goal of qualitative research is to understand experiences and perspectives in a non-numerical approach. This decision is informed by Johnny Saldana’s 2011 book, Fundamentals of Qualitative Research and Lario Viljoen’s 2018 article entitled, Beyond the Numbers: Why Qualitative Data Should Not Be Used to Make Quantifying Claims--Understanding the Real Value of Qualitative Research.

15. It is also common to label each quote with a pseudonym or number to enhance validity by making it clear that the quotes were from multiple individuals.

We have added Participant numbers to each quote on Page 7, line 208; Page 8, lines 219-220; Page 9, line 247; Page 9, line 263; Page 10, line 289; Page 10, line 304; Page 11, line 311; Page 11, line 323; Page 11, line 332.

Discussion

16. Consider adding subheadings to provide more detailed organization, as the journal allows. Or at least follow the order and topics in the results in order to help the readers’ orientation to the data and subsequent conclusions.

We have reordered the Discussion to follow topics in the results on Page 13, lines 367-384.

17. How do the data presented in this study uniquely support changes being advocated for?

To date, physician perspectives on how criminal justice involvement impacts patients have not been characterized. This study adds to existing literature assessing patients’ perspectives and demonstrates an alignment in viewpoints between both patients and their physicians in the barriers to continuity of care due to transitions in and out of incarceration.

18. Could more directly address how the physician perspectives in this study affect care

We agree! We currently have another manuscript in-progress which focuses on how physician perspectives on criminal justice involvement impact patient-provider care interactions.

19. Again, a quantification table could help by the authors being able to describe the percent who had a particular point of view.

Thank you for this feedback. As stated above, we have chosen not to add a table to present the numbers of quotes in each theme given that the goal of qualitative research is to understand experiences and perspectives in a non-numerical approach.

Limitations

20. Appreciate the authors framing limitations first with the strengths. Could call this instead “Strengths and limitations.”

We agree and have renamed this section “Strengths and Limitations” on Page 14, line 406.

21. This section was very well done.

Thank you!

Conclusions

22. Consider whether this section could instead be called “Implications” as the comments are apt but seem more consistent with this labeling.

We agree with your feedback and have renamed this section “Implications” on Page 15, line 521.

23. There appears to be a pattern of physicians going above and beyond to compensate for systematic gaps in care; this would be an interesting topic to address in this section to lead into the conclusions/implications

We agree and have added a sentence to address this topic in this section to Page 15, lines 522-523:

Physicians’ ad hoc approaches to addressing care transitions for patients entering or leaving jail or prison, suggests that there is a lack of systems level coordination to support these transitions.

24. Does it make sense to suggest that Medicaid/managed care organizations would be able to close the gaps in care?

a. Elaborating on lack of training in medical education might be more in line with objectives and physician perspectives or in the discussion

Thank you for this thoughtful feedback. We too grappled with this question and felt that our themes (i.e., disruptions in patient-physician relationships, barriers to accessing prescription medications, disruptions to insurance coverage, and problems with sharing medical records) were indications of systems level problems that were outside the control of an individual physician. Medicaid and managed care organizations have the ability to provide systems level care coordination for patients with a history of incarceration that would eliminate the barriers to continuity of care identified by physicians in this study. While training on criminal justice involvement in medical education is important, education alone would not solve the barriers identified by physicians in our study.

Decision Letter 1

Nickolas D Zaller

19 Apr 2021

PONE-D-21-03231R1

Physicians' perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study

PLOS ONE

Dear Dr. Jennings,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 31, 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Nickolas D. Zaller

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors did a nice job addressing the feedback. I have no other concerns to address and think the paper is ready for publication.

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Diane Morse

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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PLoS One. 2021 Jul 14;16(7):e0254578. doi: 10.1371/journal.pone.0254578.r004

Author response to Decision Letter 1

30 May 2021

Reviewer #2:

METHODS

1. For validity, at what point did Continuity of Care emerge as a theme? Was it one of your guiding questions that drove this process or did it emerge in the interviews?

Continuity of Care emerged during the interviews and was not one of the guiding questions of this research project. Language has been added to Page 7, Lines 157-159 to clarify this point:

This sub-analysis revealed distinct patterns related to continuity of care, which was not one of the guiding questions of this research project.

Further, language has been added to Page 6, Lines 143-144 to indicate that Continuity of

Care was an inductive code that emerged during the interviews:

“Continuity of care,” the focus of this manuscript, was one such inductive code.

2. It would be helpful to clarify that among the many themes found in the interviews, you chose Continuity of Care as the theme of focus for this paper, in Methods section, and then that you subdivided this as you already described.

Thank you for this feedback. We have added additional clarification to Page 7, Lines 154-156:

From these codes, multiple themes were identified, and just one code, “continuity of care,” is the focus of this paper.

3. The added information on recruitment is clear and informative.

Thank you!

4. To help in understanding your analysis methods, in addition to citing the references, suggest summarizing the method in 2-3 sentences.

Additional language has been added to throughout the Methods section on Page 6, Lines 136-148 to summarize the analysis methods. The added language is underlined below:

A thematic analysis approach was utilized to identify patterns within the data.(19) For this thematic analysis, both deductive and inductive coding was used. (19, 20) Codes are words or short phrases that are used to summarize key features of the data. (19) Deductive coding was conducted by applying a priori codes that were defined based on the interview guide. For example, “knowledge of the criminal justice system” was one a priori code used to organize data related to physicians’ ability to define criminal justice terminology (i.e., prison, jail, probation parole). Inductive coding was conducted by allowing data-driven codes that were not predefined to emerge.(19,20) “Continuity of care,” the focus of this manuscript, was one such inductive code. The codes were organized into a codebook from which we identified patterns, or themes, that were present across the data.(21)

Three transcripts were independently coded by LJ, RS, and CFB and a preliminary codebook containing both deductive and inductive codes was developed.(21)

RESULTS

1. We note that the authors chose not to list the numbers of a particular subtheme which were found in the data. While the qualitative approach is not based upon numbers, it can be helpful in the interpretation of the data. We leave this to the editors to consider in importance.

Thank you. Our response that was included in our first letter is included below for the editors’ consideration:

Thank you for this feedback. However, we have chosen not to add a table to present the numbers of quotes in each theme given that the goal of qualitative research is to understand experiences and perspectives in a non-numerical approach. This decision is informed by Johnny Saldana’s 2011 book, Fundamentals of Qualitative Research and Lario Viljoen’s 2018 article entitled, Beyond the Numbers: Why Qualitative Data Should Not Be Used to Make Quantifying Claims--Understanding the Real Value of Qualitative Research.

DISCUSSION

1. Improved organization.

Thank you!

2. Generally, the authors seem to be drawing more definitive conclusions than the data warrant, though the data are compelling. The discussion should: summarize the results, contextualize results in light of prior data, indicate where future work is needed, and carefully describe implications that are rooted in the data. In that light, consider moving some portions of discussion (the last two paragraphs-- “in order to improve health outcomes and reduce recidivism…” and “Medicaid and managed care organizations…”) to the implications section.

Thank you for this feedback. We have moved these two paragraphs to the Implications section where it is better suited. Further, we removed language from the original Implications section that is now redundant and no longer necessary due to this reorganization. These changes can be found on Pages 15-16, Lines 351-383.

3. And consider less definitive statements of “should;” these statements can be moved to the implications section as well.

We have moved these statements to the Implications section and edited the language to include statements that are less definitive than “should.” These changes can be found on Page 15, Lines 355:

This could include being more transparent about what services are offered…

Page 15, Lines 363-371:

Given the barriers patients face gaining access to health insurance coverage upon release from prison or jail, correctional health care agencies should consider partnering with health agencies to build systems to support patients upon release. This could include ensuring that patients leaving prison or jail are enrolled in health insurance coverage that will cover their medical expenses when they return to the community. This could be done through partnerships with community-based organizations that provide health insurance navigation services. Enrollment in health insurance, combined with improved medical record sharing, would allow patients to quickly establish care with a new provider in the community and receive medications they may need in a timely manner.

Page 15, Line 373:

Medicaid and managed care organizations that administer Medicaid could play a key role in…

4. This is particularly important for policy change recommendations which could perhaps be described as worthy of examination and to then study outcomes.

We have added this as a potential focus of future research to Page 16, Lines 386-388:

Future research should implement and test system-level supports, such as those described herein, for patient transitions between incarceration and the community to examine their impact on health and well-being for individuals with a history of incarceration.

LIMITATIONS

1. The authors rightly and importantly point out that rural physicians are inadequately described in this area. It could be stated as a limitation in this study and/or point in the direction for future research.

We have added this another focus of future research to Page 16, Lines 388-390:

Further, because this study was conducted in one urban, Midwest county, future research should explore rural physicians’ perceptions of the impact of incarceration on continuity of care for patients.

Decision Letter 2

Nickolas D Zaller

30 Jun 2021

Physicians' perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study

PONE-D-21-03231R2

Dear Dr. Jennings,

We are pleased inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Nickolas D. Zaller

Academic Editor

PLOS ONE

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: This paper has been re-reviewed and the concerns have been addressed. The authors have addressed this reviewer's concerns.

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Reviewer #2: No

Acceptance letter

Nickolas D Zaller

5 Jul 2021

PONE-D-21-03231R2

Physicians’ perspectives on continuity of care for patients involved in the criminal justice system: A qualitative study

Dear Dr. Jennings:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Nickolas D. Zaller

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. This is the S1 interview guide.

    (DOCX)

    Click here for additional data file. (19.3KB, docx)
    S2 File. This is the S2 interview transcripts.

    (ZIP)

    Click here for additional data file. (771KB, zip)
    Attachment

    Submitted filename: PLOS ONE - Physicians Perspectives_ Re-Review.docx

    Click here for additional data file. (14KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files.

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