A young man incarcerated as a juvenile is newly diagnosed with diabetes while in prison. His disease is well managed during incarceration, but he never learns how to manage it on his own. Upon release, seeing a physician becomes a low priority as he's faced with the more immediate problems of finding food, employment, and housing.
It's a typical case for physicians working in the Transitions Clinic Network (TCN), a national consortium of community health centers that coordinates with correctional agencies to connect recently released prisoners with health care. Many of these patients are diagnosed with chronic illnesses and started on medications while incarcerated but struggle to manage their symptoms after release, said Emily Wang, MD, TCN cofounder and associate professor at the Yale School of Medicine in New Haven, Conn.
“When released, these patients have issues unique to having been incarcerated and face huge barriers to managing their disease on top of the standard barriers all patients face,” she said. “They often have an entirely different understanding of how to manage their disease compared with patients in the general community.”
When caring for patients who have been released, internists must consider the economic and social obstacles that can impact the plan of care. Added to those impediments is the difficulty of coordinating with jails and prisons and obtaining patients' medical records.
According to a study published in the June 2017 Health Affairs, coauthored by Dr. Wang, about 80% of people released from prison have chronic medical, psychiatric, or substance abuse disorders, but care coordination is rare to nonexistent between prison and community health care settings. Many prisoners are never referred to a community physician or clinic or given their medical records upon release. Although the Affordable Care Act (ACA) allowed many former prisoners to become insured under Medicaid after 2014, insurance is only one among many barriers.
“The people we see have often lost their trust in the system after getting the short end of the stick many times,” said Sam Tri, MD, a primary care physician working in a homeless clinic in Albuquerque, N.M., where about half of the patients are newly released from prison. “Just trying to build that trust back up and convincing them that we're on their side is a lot of what we do.”
Challenges after release
Although the ACA made Medicaid an option for many formerly uninsured prisoners upon release, only 31 states opted for Medicaid expansion, and even in those states, there are few formal systems to assist prisoners with enrollment and connect them with clinicians.
“In some states, including Delaware, prisoners are given no coverage under Medicaid and told to coordinate their own care,” said LeRoi Hicks, MD, MPH, FACP, chair of medicine for Christiana Care Health System in Newark, Del., the largest provider for prisons in the state. “On top of that, they often receive very limited supplies of their medications.”
A patient who has been taking warfarin for deep venous thrombosis in prison, for example, may suddenly find himself or herself on the street with no insurance, one week's worth of medication, and no experience with the health system, said Dr. Hicks. Several studies have shown that these patients are at high risk of potentially preventable hospitalizations and deaths.
For example, a 2013 study led by Dr. Wang found that one in 12 Medicare beneficiaries incarcerated between 2002 and 2010 was hospitalized for an acute condition within 90 days of release. The study, published in JAMA Internal Medicine, found that compared with a matched control group, those who have been imprisoned have a substantially higher risk of hospitalization and death, especially within 90 days of release.
Transitions between jails, prisons, and community health care settings represent a high-risk period for these patients, the authors noted. Potential solutions include providing sufficient discharge medications, arranging appointments, and ensuring reinstatement of insurance before release.
Some large correctional systems, such as in New York City, have the resources to assist with transitions. On Riker's Island, home to nine of the city's 12 jails, prisoners are given a complete exam by a staff physician within 24 hours of incarceration, said Alison Jordan, LCSW, senior director of reentry and continuity services for Correctional Health Services in New York City. In contrast to prisons, where people have been convicted and are serving long-term sentences, jails house pretrial prisoners for an average of several days to weeks, giving physicians limited time in which to make diagnoses and initiate treatment.
With that in mind, the medical staff focuses its efforts on the transitional plan of care, she said. Discharge planning begins soon after the intake exam. Ms. Jordan's team provides a range of services to ease the transition after release, including assisting with Medicaid enrollment; ensuring adequate discharge medications; transporting and accompanying patients to appointments; and linking patients to community primary care, substance abuse, and mental health treatment offices.
Even with such resources, “it's very difficult to achieve full continuity for this population,” said Rachael Bedard, MD, a geriatrician and palliative care specialist with NYC Correctional Health Services. “Patients often leave without stable housing and move around frequently. Many end up in an ED due to a lapse in insurance coverage after release.”
In California's statewide prison system, people are released with a 30-day supply of medication along with a “patient summary” of their care, said ACP Member Jenny Espinoza-Marcus, MD, chief of the Educational Partnerships Program for the California Correctional Health Care Services Medical Services Division. Still, many patients find it difficult to get coverage and find a doctor in the first month after release.
“It's a very high-risk time,” she said. “There are so many things coming back into play that were there before they entered prison, like housing, food, and substance abuse issues, that it's hard for them to become engaged in finding care.”
Overdose is a very real risk in the weeks following release, noted John May, MD, FACP, chief medical officer for Armor Correctional Health Services in Miami and a former consultant on correctional health care to the U.S. Department of Justice. People with substance abuse issues often have difficulty when they move into the community from the controlled setting of the prison, where they had limited access to drugs and alcohol.
“Internists should recognize that former prisoners who have been addicts have lost their tolerance,” he said. “A leading cause of death for people leaving prisons is drug overdose as they return to their old habits.”
The post-release period can be especially problematic for patients with mental health disorders, which are much more common in prisons than in the outside community. About one in seven people in prison and one in four people in jail meet the threshold for serious psychological distress, according to a 2017 report by the U.S. Department of Justice titled “Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011-12.”
Major depressive disorder was the most commonly reported condition, followed by bipolar disorder and post-traumatic stress disorder (PTSD). Often, these diagnoses are accompanied by substance abuse.
For example, in Albuquerque, Dr. Tri and a therapist worked closely with a patient with PTSD who had been incarcerated for a decade and who was addicted to heroin while in prison. Although they succeeded in treating his addiction for a time, the man didn't qualify for federal housing assistance and couldn't get a job. Despite the clinic's best efforts, he resumed living on the streets and eventually returned to prison for drug trafficking.
“Every day can be a different set of needs for these patients, and connecting with their physician isn't near the top of the list,” he said. “It's very hard to get people to come back for follow-up appointments when they're constantly figuring out where they're going to eat and sleep, and just surviving.”
On the other hand, the clinic has had some success stories. Another man who had been homeless and grappling with alcohol addiction was recently moved into subsidized housing. The difference, said Dr. Tri, was that the man dropped by the clinic often so it was easier to connect him with services.
One of the biggest issues at first appointments is figuring out patients' prior diagnoses and medications, he said. Patients often don't know their exact diagnoses or medications and lack any formal medical records.
To assist with care, Dr. Wang recommends that physicians establish relationships with prison or jail administrators. According to her study in Health Affairs, patients referred to TCN by correctional systems had fewer hospital visits in the first year after release than patients referred to TCN by community partners. However, only one-third of study participants were referred to TCN by correctional facilities, even though clinic physicians forged ties with prison administrators, parole officers, and probation agencies, illustrating the challenges of connecting former prisoners to care.
Problems include the lack of any state or federal requirements for prisons to engage in discharge planning and the complexity of navigating prison policies, the authors noted. The dearth of electronic health records also impedes clinicians' ability to access and share medical information.
It's important to have mechanisms in place to engage patients and build trust once they arrive, said Dr. Wang. To do that, TCN employs community health workers who have histories of incarceration to meet with new patients and assist them with finding housing, food, and employment and with navigating probation and other legal issues. Having been in the prison system, the community health worker can also help educate the medical staff about post-incarceration challenges.
“Part of what was important to us was to address the chronic mistrust between people who have been incarcerated and the health care system,” she said. “We wanted to create a program that people would use.”