The palliative care team at the University of New Mexico (UNM) Health System in Albuquerque is used to dealing with complex cases involving patients with terminal illnesses, but the case of a man incarcerated at a nearby jail was especially challenging. Despite being discharged with new prescriptions and instructions to control his escalating pain, the man returned five times over six weeks for symptoms related to end-stage cancer.
“Each time he would get sent back to jail with the assumption that the medications prescribed would be provided, but that never seemed to happen,” said Lisa Marr, MD, chief of palliative medicine and professor of internal medicine at UNM. “We realized that we needed to find out exactly what level of medical care prisons offered and figure out how to connect with people who could help ensure smoother transitions.”
The experience prompted Dr. Marr and her colleagues to take a tour of nearby jail medical facilities and to put together a list of resources and contacts. Soon, the palliative care service became the hospital's go-to resource whenever questions arose about caring for prisoners.
“The key was building relationships with people who worked in the prison system,” said Dr. Marr. “In the past, prisons were like a big black box and no one knew much about what went on inside or what happened when prisoners left the hospital.”
According to a 2016 report by the U.S. Department of Justice, state and federal prisoners are significantly more likely than the general population to experience serious illnesses that often require hospital-level care. For example, 44% of state and federal prisoners reported ever having had a chronic condition—such as cancer, cirrhosis of the liver, hypertension, and stroke-related issues—compared to 31% in the general population in 2011-2012, the most recent data available. Rates of diagnoses of infectious diseases—such as hepatitis B and C, sexually transmitted diseases, and tuberculosis—were 21% among prisoners compared to 5% in the general population.
Yet hospitalists are often confused or uncertain about how to handle issues surrounding care for prisoners, experts say. Better communication and coordination between hospital and prison medical staffs are critical factors in smoothing transitions of care and potentially improving patient outcomes.
“Relationships can make a huge difference in enhancing the continuity of care, keeping communication open, and exchanging information,” said John May, MD, FACP, chief medical officer for Armor Correctional Health Services in Miami who has consulted on correctional health care to the U.S. Department of Justice. “If we don't have a relationship with a provider at the hospital, there's a risk that we'll lose track of the patient and the proper information won't be relayed in either direction.”
Medical care in prison
In an ideal world, a patient's prisoner status should have no bearing on medical decisions surrounding his care in the hospital. However, these patients present some unique challenges that impact workflow as well as the bedside exam and discharge planning.
In Delaware, prisoners requiring hospital-level care are initially taken to the ED, often to a secure room separate from other patients, said LeRoi Hicks, MD, MPH, FACP, chair of medicine for Christiana Care Health System in Newark, the largest provider for prisons in the state. During the intake examination, patients remain restrained or handcuffed and must be accompanied by two security guards throughout their stay in the ED and after admission to the wards.
“There are unique challenges that providers face when delivering care to the prison population,” said Dr. Hicks. “For example, security measures, while appropriate, can make it more difficult to negotiate a patient encounter. For example, it can be hard to examine a patient and have a conversation about risks and diagnoses when they are in handcuffs and leg restraints.”
Health care facilities can vary among correctional facilities, whether they be federal or state prisons or local jails. Larger facilities tend to have more in-house medical resources (more staff, higher-level credentialing, available during more hours) compared to smaller facilities which may have few, if any medical staff and little capacity to deal with complex health care problems. Hospitalists need to know something about where their area prisons or jails fall on that spectrum in order to plan successful discharges.
In the ED, physicians might be asked to provide medical clearance for a newly arrested person to be taken to jail, noted Marc Stern, MD, MPH, FACP, assistant affiliate professor of public health at the University of Washington in Olympia and a consultant in correctional health care. Familiarity with the jail facility is key to making that decision.
“The challenge is that a lot of ED physicians don't understand what they're clearing the prisoner for,” he said. “To make an appropriate decision, the physician needs to know what level of medical care that particular jail can provide.”
Some larger correctional systems have dedicated prison hospitals or wards. Correctional Health Services in New York City, for example, manages 12 jails and prisons located primarily on Riker's Island and is affiliated with two public hospitals: Elmhurst in Queens and Bellevue in Manhattan.
“We have strong relationships with the community hospitals where we send patients who cannot be safely managed in the jails. The hospitals where we send our patients have jail wards and dedicated staff who can help with care coordination for this vulnerable population,” said Rachael Bedard, MD, a geriatrician and palliative care specialist with Correctional Health Services. “We are in daily contact with hospitalists and subspecialists who know our patients well.”
Similarly, California Correctional Health Care Services (CCHCS), which manages 35 prisons under the California Department of Corrections and Rehabilitation, maintains a collaborative relationship with physicians at the local community hospital in San Joaquin County, which includes a large guarded unit. That's helped to forge effective communication between hospital and prison medical staff, noted ACP Member Jenny Espinoza-Marcus, MD, chief of the Educational Partnerships Program in CCHCS's Medical Services Division.
In the absence of such relationships, hospitalists may not understand the critical importance of providing detailed discharge summaries and medication lists to prison staff, she said.
“A hospitalist might be used to giving instructions directly to patients or assuming they have access to previous prescriptions,” she noted, “but that's not the case with prisoners.”
All medications prescribed to prisoners while hospitalized must be approved and distributed by the prison medical staff upon their return, she explained. Additional requirements, such as special diets or splints, must be noted and specially ordered.
Prisons and jails also have their own drug formularies, noted Dr. May. Hospitalists should be aware that not all medications are immediately accessible to prison medical staff.
“Most jails and prisons have broad formularies, but some specialty medications might not be readily available, especially on a Friday or holiday,” he said. “If we have advance notice of discharge by the hospitalist, we can prepare accordingly and avoid any interruption in the patient's regimen.”
Communication about medications can be especially challenging for patients with life-threatening illness, said Dr. Marr in Albuquerque. For example, jail medical staff balked when one prisoner was discharged with a recommendation for oxycodone to treat severe cancer-related pain.
“Prisons and jails understandably have concerns about the opioid epidemic,” she said. “There is a perception that high doses of opioids are bad, but these are sometimes needed when a patient is near the end of life.”
Incarceration presents extra steps and decisions that are unnecessary with other patients, she said. Hospitalists must obtain the prison warden's permission to contact a patient's next of kin, for example, and discharging to hospice can be difficult, even when justified by medical circumstances.
It's often easier to get permission from the courts to release patients from custody into hospice when they are in jail versus prison, said Dr. May. That's mainly because most jail prisoners are short-term residents awaiting trial whereas those in prison are convicted and serving longer-term sentences.
Although many prisons have their own hospice facilities, they tend to have stricter rules about dispensing opioids for pain and allowing frequent family or support visits compared with nonprison settings, he said. “It takes close coordination between hospitalists, security personnel, and prison medical staff to ensure that a person with advanced malignancy, for example, gets adequate treatment.”
At Christiana Care, palliative care specialists coordinate with the prison warden and medical director about medication dosing and other issues before discharging to a prisoner to hospice, said ACP Member Roshni Guerry, MD, inpatient medical director of Christiana's supportive and palliative care program. The warden and medical director are especially important contacts in cases where the prisoner does not have any family members.
Dr. Marr sometimes writes formal requests for compassionate release of prisoners, as she did for the man with end-stage cancer. In that case, the request was successful and the patient was allowed to return home to die. Dr. Marr's team even helped coordinate a hospital wedding before he left.
“We try to advocate for patients to go to hospice when we feel their medical needs cannot be met adequately in jail or prison,” she said. “We can't change where things are going medically, but we can try to make the time they have left as meaningful as possible.”