It has been a couple of months since I started collecting medical data at a local jail in Southern California. It easily became routine: I exchange my I.D. for a clip-on visitor’s badge, take the button-less elevator and hand signal the medical floor number, and wait for the security-monitored heavy steel doors to slide open and let me in. I then commence my relentless data extraction in the physician’s office. Often, while searching the database for an inmate, I get a pop-up window saying that the inmate is “currently not active,” which usually means that they have been released. It occurred so frequently that I began to ask, “What happens to inmates with chronic disease and/or mental illnesses after they have been released?” The answer: They go back to society along with their chronic conditions. Jeremy Travis, president of John Jay College of Criminal Justice, highlights this notion in a lecture in Taiwan:
The ‘Iron Law of Imprisonment,’ meaning that, except for those individuals who die in prison, either through capital punishment or through natural causes, everyone we send to prison or jail returns home … The reality of prisoner reentry requires us to […] increase the chances that the individual will be successfully reintegrated into society upon his or her return.
As the rate of incarceration increases so does the number of inmates being released back into the community. Transition of care is a difficult issue in general, but it is even more challenging with respect to the incarcerated population. This is especially true after release, where former inmates were found to be at a higher risk for death during the first two weeks out in society from drug overdose or cardiovascular disease. Many of the inmates are newly diagnosed with a chronic illness during incarceration and are provided treatment. Most times, they receive the best health care while incarcerated, but they are ultimately unable to manage their symptoms post-release due to lack of access to healthcare. Scott Nolen, director of drug treatment programs for the Open Society Institute, tells Kaiser Health News:
There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care.
Think about inmate release as a public health issue. The lack of a care continuum not only jeopardizes the individual but also their poor communities, which already have limited health care funds. A national survey showed that individuals with recent criminal justice involvement had increased hospitalizations and emergency department utilization compared to the general population. Without follow-up, many former inmates do not seek care until they end up in the emergency room with more expensive conditions that are paid for by hospitals and taxpayers. Furthermore, many of the inmates are exposed to communicable diseases such as HIV, AIDS, tuberculosis, and hepatitis C during incarceration, which can be transmitted to the general community. If we target care to this sicker population, Dr. Emily Wang from Yale University School of Medicine tells NPR, “fewer communicable diseases are transmitted, substance use is treated,” and “moreover, it makes good business sense for the health system.”
Certain state governments have successfully instated transitional programs that help inmates manage their chronic conditions and reenter the community, such as the Transitions Care Network. One powerful element in this program is employing people with a history of incarceration who can relate to and help newly released inmates connect with the program, utilize their resources and maintain continuity of care. However, such programs are not widely available across the nation and discharge planning processes along with existing transitional care programs remain a work in progress. In the meantime, physicians and student physicians can still provide former inmates proper care in the clinical setting. ACP Internist outlines an excellent initiative, which encourages consideration of a patient’s economic and social obstacles when determining plan of care. They suggest the following steps:
1. Keep in mind the social determinants of health
2. Build trust
3. Learn how to treat addiction
4. Don’t assume patients know how to manage their diseases
5. Connect with prisons and jails
Prioritizing health care for the incarcerated needs to remain a priority. A recent article reported that the Orange County’s sheriff’s department will publish a “Who’s in Jail” online database showing when inmates were booked and released. This will unnecessarily stigmatize inmates who do not have a serious criminal history, making it more difficult for them to integrate into society. Though their diseases may be well managed while incarcerated, personal health care becomes a low priority when they are constantly figuring out what to eat, where to sleep or how to get a job. Many are poor and homeless and may not have the support or ability to maintain medication compliance.
Building trust is one of the most important components in providing effective medical care. Dr. Sam Tri, a staff physician at a homeless clinic in New Mexico, tells ACP Internist that the people they see have “often lost their trust in the system after getting the short end of the stick many times.” As providers, refrain from judging ex-convicts and, instead, be their advocate and their ally. Without trust, we may lose that patient to follow-up and they may even end up back in prison.
Overdose is another risk following release. Given the limited access to alcohol and drugs during incarceration, inmates lose tolerance. Upon leaving the correctional system, inmates who do not transition well may revert back to substance use, resulting in drug overdose. Studies have shown that recidivism decreases when inmates receive treatment after release. Still, few primary care providers know how to address and treat addiction.
Navigating the health care system is difficult in and of itself. In jail or prison, the nurses hand the inmates their daily medications and provide regular meals. Once they are released, many former inmates with chronic disease do not know how to manage their symptoms. For example, a diabetic diagnosed in prison may never have learned how to monitor blood glucose or administer an insulin injection. Explore the individual’s understanding of their disease and management, educate them and connect them to the appropriate resources and services. You can also take this opportunity to engage family members, if available, in the patient’s care.
Every correctional system has their own protocols and varies in their discharge process, thus also varying in health outcomes. A study published in Health Affairs suggests that improved coordination between correctional systems and community health care systems within transition programs can promote health equity for this population. So, to further your involvement, meet the medical directors of the correctional facilities in your area and seek partnership in order to develop the best approach to care. An important issue regarding these individuals is the lack of access to medical records during the incarceration period, which results in a struggle in figuring out diagnoses and medications. If possible, partner with correctional facilities to make this information accessible. In addition, providing inter-professional care has been a crucial problem as well since physicians may not have the time and expertise to address a patient’s needs (i.e. addiction medicine, psychiatric follow up and dental services).
Thousands of inmates are released every year and most return to poor communities. Many are plagued with mental illness, substance abuse, chronic conditions and communicable disease. In some facilities, inmates will only receive a discharge packet and few days’ supply of medication, while, in other facilities, they will be connected to transitional programs who will guide them through reentry. Regardless of these diverse services, former inmates will have to navigate a tough system. It is in the best interest of our patients and our communities from a public health standpoint to provide such patients nonjudgmental and deliberate care based on their outstanding needs.