Hospital care while incarcerated: a tale of two policies

Background

The United States incarcerates nearly two million people.¹ When medical care for those in jail or prison exceeds the capabilities of the correctional facility’s healthcare services, patients are transferred to community medical centers for emergency services, specialty care, and surgery.^2,3 Given the scale of mass incarceration in the United States and the high burden of disease among incarcerated individuals,⁴ many hospital-based clinicians will provide care for incarcerated patients during their careers even if they never set foot in a jail or prison.

Federal law mandates basic healthcare for people who are incarcerated,⁵ yet does not define how care is delivered. As a result, patients who are hospitalized while incarcerated experience exceptions to physical comfort, health privacy, and informed decision-making⁶ with little standardization of practices between medical centers. Individual institutional policies then inform the clinical management of incarcerated patients, establishing and perpetuating care norms.

Here we use two hospital polices pertaining to the care of patients who are incarcerated within the same state to demonstrate how differing medical center guidelines can drive disparate care practices, explore why divergent practices arise locally and nationally, and propose steps to develop equitable clinical standards across medical institutions.

Two policies

As part of a recent quality improvement effort, we reviewed examples of medical center policies pertaining to the care of patients who are incarcerated. Such policies provide guidelines and procedures specific to patients in custody, including measures related to privacy, communication, informed decision making, and restraint.

During our review, we encountered two institutions within the same state, both contracted to deliver hospital-based care for their state department of corrections. Both hospitals contained secure medical units for incarcerated patients, though at each facility medical treatment could occur outside of these forensic units, if required. Individuals in the state prison system triage to one of the two medical centers based on geographical proximity, not unique medical or security needs. Both medical centers also serve patients from county jails.

While we might expect two institutions that partner with the same department of corrections and share similar incarcerated patient populations to adopt similar language and rules, this was not the case. The terminology used to refer to patients varied and practices differed around privacy, shackling, external communication, and transitions of care including death (Table 1). In both policies, practice guidelines deviated from standards for non-incarcerated inpatients and correctional needs favored blanket security strategies over individualized safety practices for each patient.

Table 1:

Comparison of two polices governing hospital care for patients who are incarcerated.

Clinical-correctional care practice	Medical Center 1	Medical Center 2
Language used to describe patients	“Patient in custody” “Inmate” “Prisoner”	“Patient under guard” “Inmate” “Forensic patient”
Correctional officer (CO) presence	On inpatient units, CO remains within the patient room, with exceptions for operating room following anesthesia. On secure unit, CO may remain outside patient room when locked, but must accompany hospital staff when entering room.	In all clinical care areas, including the operating room but with the exception of the secure unit, CO remains at patient bedside.
Disclosure of Protected Health Information (PHI)	The CO is legally obligated to uphold patient confidentiality regarding any PHI shared during their duties and should not discuss medical information relating to the patient.	The medical center may disclose PHI to a correctional institution or law enforcement officer when necessary for the provision of health care to the patient, the health and safety of the patient, other incarcerated persons, employees of the correctional institution, persons responsible for transporting patients, law enforcement on the premises of the correctional institution, or the administration and maintenance of the safety, security and good order of the correctional institution.
Restraint with shackles (security restraints)	For patients on non-secure inpatient units and ambulatory care areas, security restraints will remain on patients at all times, according to agency policy, unless there is a medical reason preventing it. Use of shackles requires constant observation by the CO for the duration of the security restraint. When a security restraint is required for any duration, it will be reviewed with clinical staff to ensure it will not interfere with medical treatment. When caring for patients in security restraints, the nursing staff must monitor and assess the patient to ensure their safety and that their needs are met.	The use of security restraints are determined, provided, and maintained by law enforcement officers. The determination to be shackled to the bed during hospitalization is based on the security needs of the patient. Expect state department of correction inmates to be wearing leg irons ankle to ankle. Expect county inmates to be shackled to the bed by at least one extremity. All patients not housed on the secure unit will remain in leg irons during their stay. Hospital staff may request the removal of these devices.
Patient rights	Patients are afforded the same rights as non-incarcerated patients including the right to informed consent, right to refuse treatment, right to complete an advanced directive, right to be discharged against medical advice, and right to appeal their discharge.	Patients may experience exceptions to the same rights as non-incarcerated patients because of the need to provide for the safety and security of other patients, employees, and the facility. Incarcerated patients do not have a right to receive a copy of the medical center’s Notice of Privacy Practices. The restrictions of rights are determined and enforced by the law enforcement officer.
Communication with family	Correctional agency policy will determine if the patient is allowed to make phone calls or have visitors, and this policy will be communicated to the bedside nurse.	Family or friends are not to be given any information by phone regarding medical care. Any medical information will be given to family by the medical staff at the patient’s correctional facility. Any phone calls deemed necessary by physicians or staff to family members must be approved by a correctional representative.
Visitors	Visitors may provide a therapeutic benefit to the patient and are allowed unless restricted by correctional facility policy.	Visitors are allowed only after approval by a correctional representative.
Patient informed discharge counseling	Providers may not discuss discharge dates in front of patients until immediately prior to discharge.	Providers may not inform a patient from the state department of corrections of their discharge plan or date.
Death	Patient death while at the hospital require an autopsy in accordance with relevant agency rules.	In the case of patient death, provider will immediately notify the correctional agency with time and preliminary cause. Following declaration of death patients will be photographed and fingerprinted by correctional personnel before undergoing standard post-mortem care and transfer to the morgue. Ministerial personnel at the correctional facility will notify the family. There is no family viewing of patients on the nursing units at the medical center.

Note: representative policy statements condensed and edited for brevity.

Such polices directly affect patients. For example, requiring correctional officers at the bedside ensures all patients, regardless of risk, experience breaches of confidentiality during clinical encounters. Restriction on clinician or patient contact with family members impairs surrogate decision-making. Indiscriminate shackling impedes mobility and can lead to underlying skin breakdown.^7,8 For institutions providing care to incarcerated patients, such policies may be the only clinical guidance practitioners receive and the guidance differs across sites.

Why consistent guidance is lacking

Incarceration is a social determinant of health associated with excess mortality,⁹ with a two-year decline in life expectancy for each year served in prison.¹⁰ While the prevalence of incarceration is higher than that of more commonly taught medical conditions, students and trainees receive little dedicated training in how best to care for this unique population.¹¹ As a result, practicing clinicians demonstrate knowledge deficits around healthcare protections and exceptions afforded to incarcerated patients.¹²

Federal regulations informing inpatient care delivery contain exceptions or omissions for incarcerated patients. For example, the Centers for Medicare and Medicaid Services guide inpatient soft restraint management but do not address inpatient metal shackling. The Health Insurance Portability and Accountability Act protects against involuntary disclosures of protected health information but permits limited disclosures for incarcerated patients under specific circumstances.⁶

State laws inform other aspects of health care delivery for incarcerated patients, leading to disparate geographic practices. For example, while the management of pregnant individuals in federal custody is regulated through the First Step Act, many states lack similar protections for pregnant people in state prisons or jails.^13,14 As a result, the use of restraints during labor may differ according to whether the patient comes from a state or federal prison even if they are giving birth in the same hospital.

Other unwritten standards are promulgated by correctional influence on healthcare professionals. Physician-led organizations, such as the American Medical Association, promote patient-informed transitions of care, yet correctional concerns about safety during transportation often outweigh disclosure of discharge timing, patient counseling, or communication with families.⁶ Clinician bias towards incarcerated individuals may also affect clinical decision making and their internally derived standards of care.¹⁵

Structural and environmental differences between medical centers further drives aspects of clinical practice related to monitoring and detainment. Correctional representatives have broad discretion over security practices in community medical facilities when reasonably related to preventing escape or harm to others.⁷ For facilities with locked forensic units, patients may be infrequently shackled to the bed, though receive care in a setting more reflective of a cell than a hospital room.

Finally, the lack of consistent clinical guidance for incarcerated patients is affected by the fragmentation of the United States carceral system across state, county, and federal jurisdictions. Even within the examined polices, direction sometimes differed for patients coming from state prison versus county jail.

Guiding principles for equitable care

In the absence of consistent standards for hospital-based treatment, management guidelines for patients who are incarcerated arise from individual medical center policy and reflect the concerns of the carceral system in the healthcare setting, often at the expense of standard medical care and with little attention individual patient needs.

Given the unique properties of each medical center and practice setting, we propose a set of foundational principles for care across sites that: 1) ensures management practices for incarcerated patients deviate as little as possible from those for non-incarcerated patients, 2) explains deviations in care either through individualized patient-level risk-assessment, hospital-level structural characteristics, or state and federal policy, and 3) provides care that acknowledges and accounts for the unique medical and social needs of the incarcerated population.

Applying these principles to an issue such as shackling, the baseline standard would be that all hospitalized patients should remain unchained until a need for such restriction arises. If required based on an individual risk assessment, the least restrictive form of restraint needed to secure the patient would be used. The correctional need would then undergo frequent reevaluation given the bias shackles can precipitate in treating clinicians towards a patient population already predisposed to prejudice.¹⁶ Additional examples of these principles in practice can be found in Table 2.

Table 2:

Application of foundational principles

Foundational Principle	Current State	Application of Principle
Principle 1: Ensure management practices for incarcerated patients deviate as little as possible from those for non-incarcerated patients.	Custody officers learn protected health information about incarcerated patients due to their continual presence at the bedside or through disclosures from treating clinicians.	Custody officers make security arrangements that allow for privacy during clinical encounters. Officers learn protected health information only when allowed under Health Insurance Portability and Accountability Act exceptions. Treating clinicians relate the minimum necessary health information to satisfy the purpose of the disclosure.1
Principle 2: Explain deviations in care either through patient-level risk-assessment, hospital level characteristics, or state and federal policy.	Incarcerated patients are indefinitely restrained with metal shackles throughout the duration of hospitalization when outside of dedicated forensic medical units.	If required based on individual risk assessment, incarcerated patients are restrained using the least restrictive means necessary, with regular reassessment based on changes to patient health or behavioral status. Restraint of incarcerated pregnant individuals is governed by federal or state law.
Principle 3: Provide care that acknowledges and accounts for the unique medical and social needs of the incarcerated population.	Clinicians withhold discharge plans from incarcerated patients.	Unless individual risk assessment precludes, incarcerated patients are notified of their discharge plans and provided instructions written at a level that accounts for an increased prevalence of low health literacy.2 If required, surrogate decision makers are notified of hospital course, given the increased prevalence of cognitive impairment in older incarcerated adults.3

¹U.S. Department of Health and Human Services. Minimum Necessary Requirement. 45 CFR 164.502(b), 164.514(d). https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.html. Accessed September 25, 2023.

²Hadden KB, Puglisi L, Prince L, Aminawung JA, Shavit S, Pflaum D, Calderon J, Wang EA, Zaller N. Health Literacy Among a Formerly Incarcerated Population Using Data from the Transitions Clinic Network. J Urban Health. 2018 Aug;95(4):547-555.

³Ahalt C, Stijacic-Cenzer I, Miller BL, Rosen HJ, Barnes DE, Williams BA. Cognition and Incarceration: Cognitive Impairment and Its Associated Outcomes in Older Adults in Jail. J Am Geriatr Soc. 2018 Nov;66(11):2065-2071

Such guiding principles could be integrated into hospital accreditation, such as that currently performed on a voluntary basis for correctional facilities by the National Commission on Correctional Health Care, tied to medical center reimbursement if current exemptions to Medicaid and Medicare coverage for incarcerated individuals were lifted, or linked to federal Department of Justice grant funding. These principles provide a foundation on which to create institutional policy that ensures a consistent underpinning to care delivery for incarcerated patients in community settings, recognizes barriers that inform differences in care, strives to overcome those barriers rather than ignore or accept them, and prioritizes the medical needs of patients in custody.