Hospitalization Through the Lens of Incarceration

Background

The Unites States (US) has the highest rate of imprisonment worldwide.¹ Such mass incarceration results in half of American families having a member who has been in jail or prison.² While some health care can be provided within carceral facilities, incarcerated patients are transferred to nearby medical centers when their medical needs exceed the capabilities of their correctional facility.

Clinicians practicing outside dedicated carceral settings encounter these patients despite limited training specific to the population.^3,4 Institutional guidance frequently defers to correctional, rather than medical, needs.⁵ Knowledge deficits, combined with implicit bias, structural racism, and an absence of standardized guidelines, result in heterogeneity of practice patterns, which negatively impact the health of incarcerated individuals.⁶

Through a case presentation, we demonstrate how incarceration can affect every aspect of a patient’s hospital presentation and care and provide insight into how individuals and institutions can create interventions that improve health equity for this marginalized population.

Clinical Case

Mr. A is a 58-year-old Black man with type 2 diabetes mellitus, chronic hepatitis C, and opioid use disorder. He is in the emergency room awaiting admission to the hospital from prison following a stab wound to his leg. He is shackled to the bed with a correctional officer at the bedside who requests to know long he will be staying in the hospital. The clinician called to admit the patient feels unprepared to address the complexities of this case.

“Mr. A is a 58-year-old Black man…”

The Demographics of Incarceration

The majority of America’s two million incarcerated individuals are confined in state prisons and county jails, with a minority in the federal prison system.⁷ Jails are short-term facilities administered by city or county agencies, typically holding those “awaiting trial,” or serving sentences less than a year. Prisons are longer-term state or federal detention facilities. Patients may arrive to an acute care center from jail, prison, or in custody directly from the community.

Racial Disparities

Mass incarceration disproportionately impacts Black, American or Alaska Native, and LatinX populations. Black individuals are over five times more likely to be incarcerated, and Hispanic individuals over three times, relative to White counterparts.⁸

In addition to racial and ethnic disparities, incarcerated individuals come from lower socioeconomic backgrounds and have lower education levels, and higher rates of illiteracy.⁹ Clinicians should take this into account when counseling patients or providing patient-facing medical materials.

An Aging Prison Population

The prison population is growing older and an increasing number of those imprisoned exhibit signs of “accelerated aging,” including cognitive decline, incontinence, susceptibility to falls, and other geriatric conditions presenting at a younger age compared to those outside the correctional system.¹⁰ Researchers now use a cutoff of age 55 to define geriatric in correctional populations as opposed to 65 in the community.^10,11

When managing patients in the hospital, clinicians may provide treatment based on chronologic age, eschewing practices normally provided to older community dwelling adults. Upon discharge, patients return to facilities historically tailored for younger populations with decreased access to memory care services, or physical or occupational therapy.

“…with type 2 diabetes mellitus, chronic hepatitis C, and opioid use disorder.”

The Prevalence of Disease and Health Effects of Incarceration

Incarceration has profound negative health consequences, with a reduction in life expectancy of two years for each year in prison.¹¹ Incarcerated patients demonstrate a higher prevalence of hypertension, asthma, cervical cancer, arthritis, and hepatitis¹² and nearly half of incarcerated individuals live with one or more chronic medical conditions.¹³ Medication formulations in jails and prisons for these chronic medical diseases vary, and often only the most low cost medication is offered. Acute on chronic medical needs may be previously undiagnosed or unaddressed in this population.

Psychiatric illness and substance use disorders are widespread.¹⁴ Opioid overdose is the leading cause of death following release from prison.¹⁵ Medication for opioid use disorder (MOUD) in correctional facilities has demonstrated reduced mortality and recidivism.¹⁶ Offering and initiating MOUD during hospitalization is best practice for all hospitalists, though unfortunately not a universally adapted practice.^17,18 Access to MOUD varies widely by correctional facility¹⁶ despite the Department of Justice stating withholding MOUD based on incarceration status violates the Americans with Disabilities Act (ADA).^19,20 Initiating patients on MOUD requires close coordination with receiving carceral facilities. If a facility refuses to provide MOUD, hospitalists should still initiate the appropriate medication for the patient’s medical needs and report potential ADA violations as appropriate.¹⁹ Not following the standard of care violates the core principals of medical ethics.¹⁹

“He is in the emergency room awaiting admission to the hospital from prison following a stab wound to his leg.”

Acute Care

Patients who are incarcerated experience rates of emergency department (ED) visits five times greater that of non-incarcerated counterparts for assault, self-harm, and opioid overdose.²¹ Common inpatient admission diagnoses include traumatic injury, skin and soft tissue infection, foreign body ingestion, cardiac disease, respiratory illness, sickle cell crisis, and altered mental status.²¹

A range of specialties, from medical to surgical to obstetric, may be involved in the care of incarcerated patients requiring clinicians to have a working knowledge of common presenting illnesses, relevant hospital policy, and state or federal laws. For example, federal regulation and most states enforce prohibitions on the restraint of incarcerated pregnant individuals in the peripartum period, which can result in legal action if not followed.^22,23 Non-profit organizations such as the Legal Action Center, the American Civil Liberties Union, or the Jail & Prison Opioid Project share information about federal laws for incarcerated patients on their websites.¹⁹ Poor follow-up after hospitalization among incarcerated patients contributes to poor health outcomes following inpatient management.²⁴ While facilities are constitutionally obligated to offer medical care,⁹ interpretation of this varies between facilities. For example, carceral facilities are often not able to provide physical rehabilitation services but will be obligated to make accommodations for devices such as walkers and wheelchairs. Required follow-up plans should be directly communicated to the patient, as much as possible, and medical personnel at the receiving carceral facility.

“He is shackled to the bed with a correctional officer at his bedside who requests to know long he will be staying in the hospital.”

Incarceration Specific Care Practices

The interface of medical and correctional needs force clinicians toward conscious and unconscious deviations in usual care. Examples include patients experiencing exceptions to freedom of movement, health privacy, surrogate decision-making, and transitions of care.

Outside dedicated forensic units, incarcerated patients are commonly shackled with metal cuffs and chains. In contrast to soft restraints, these shackles are not regulated through familiar oversight mechanisms, such as the Joint Commission. Shackling can result in direct damage to skin, nerves, and small bones of the hands.²³ Psychologically, shackling can amplify feelings of dehumanization and signal a stigmatized status, which may exacerbate practitioners’ underlying biases.²³ Clinicians may be concerned for their own safety and make wrong assumptions about a patient’s behavior while hospitalized or other stigmatizing value judgements due to the patient’s incarcerated status. It is our obligation to assess our own biases before the patient encounter to reset expectations that are in line with the standard of medical care we aim to provide. Clinicians may ask to have shackles removed, either during examination or for longer durations depending on clinical needs and hospital policy.²³

Health Insurance Portability and Accountability Act privacy protections apply to incarcerated individuals, though with notable exceptions. Disclosures of protected health information (PHI) may be made to custody officers if the information is necessary for the provision of health care, health and safety of others, or maintenance of safety, security, and order of the correctional institution.²⁵ As custody officers are tasked with controlling a patient’s movement, they may need to know certain elements of patient care particularly during transport, but relevant PHI should always be kept to the minimum necessary to achieve the purpose of the disclosure.

Table 1 reviews additional common deviations in medical care that may arise from a patient’s incarcerated status.

“The medical provider called to admit the patient feels unprepared to address the complexities of this case.”

Table 1.

Common Deviations in Inpatient Care Due to Incarcerated Status

Inpatient scenario	Current practice	Recommended practice
Health privacy	• Custody officers acquire protected health information about incarcerated patients due to continual correctional presence at the bedside, operating room, or via disclosures from treating clinicians	• Custody officers ensure security arrangements but need to allow for privacy during clinical encounters and can step away from bedside to be out of earshot while maintaining eye sight of the patient • Officers acquire protected health information from clinicians only when allowed by Health Insurance Portability and Accountability Act exceptions.15 • Treating clinicians relate only the minimum necessary health information to satisfy the purpose of the disclosure
Shackled restraint	• Incarcerated patients are placed in metal shackles throughout the duration of hospitalization when outside of dedicated hospital medical forensic units and during transport within acute care facilities	• Incarcerated patients are restrained using the least restrictive means necessary with the shackling of pregnant individuals governed by federal or state law.16 • Shackled restraint undergoes regular monitoring and reassessment based on changes to patient health or behavioral status.16
Decision-making	• Clinicians may believe, or correctional authorities may assert, that incarcerated individuals may not make their own medical decisions • Incapacitated incarcerated patients have medical decisions made by correctional authorities rather than family or other designated surrogates	• A patient’s right to autonomous medical decision making is unaffected by incarcerated status.15 • If an incarcerated patient is unable to make their own decisions, a decision maker should be identified following the state’s usual surrogate decision-making hierarchy.15 • Correctional authorities such as the warden should not act as medical decision makers as they may exhibit correctional conflicts of interest
Discharge planning	• Transportation between carceral facilities and medical centers is a potentially vulnerable time in security measures, so clinicians are instructed to withhold discharge plans from incarcerated patients to mitigate the risk of coordinated attempts at escape	• Clarify in advance with custody officers and hospital policy what information is permitted by the facility to be disclosed by the clinician to the patient • Provide permissible patient facing discharge materials at an appropriate level that accounts for an increased prevalence of low health literacy • Provide a warm handoff with medical staff at the receiving carceral facility, to ensure hospital course relayed and necessary follow-up appointments known • If a warm handoff is not possible, assume that follow-up will be minimal or delayed and complete as much care as possible in the inpatient setting to avoid mismanagement of medical conditions • Patients should be discharged with medications, particularly on weekends when it can be challenging for smaller facilities to fill less common medications. This is particularly important for MOUD given variations in availability in carceral facilities

Opportunities for Change

Healthcare Professionals

The value of caring for overlooked and marginalized patients is embedded in the oaths we take as caregivers and the standards of medical societies of which we are members. Yet clinicians may find themselves at a crossroad when confronted with the challenge of “dual loyalty,” where they feel beholden to two interests—medical and carceral—which may be frequently at odds with each other.²⁶ Instances necessitate not only clinical acumen but a deep-seated commitment to preserving the dignity and humanity of every patient, regardless of incarcerated status.

Hospitalization affords a rare opportunity for incarcerated patients to receive well-coordinated sub-specialty care, or undergo a procedure that would be difficult to coordinate in a carceral facility. While treating the admitting diagnosis, patients can be screened for communicable disease, initiated on treatment for mental health and addiction disorders, and provided evidence-based treatments for comorbidities. The hospital becomes an access point for holistic care before patients return to a sequestered and often unhealthy carceral environment.

Institutional Change

Responsibility for change cannot fall exclusively on caring clinicians; institutions have a crucial role in addressing healthcare disparities that arise from mass incarceration. Clearly articulated hospital policies can serve as roadmaps to navigate the challenge of dual loyalty and relieve individual clinicians of this burden. These policies should promote the core principal that care of incarcerated and non-incarcerated patients should differ as little as possible and any deviations should be proactively justified by either medical or correctional stakeholders. In addition, policies must recognize challenges that may arise when working with law enforcement personnel during hospitalization. These policies can create ethical approaches to care, pathways for communication with correctional representatives in advance of medical events, and mechanisms to provide feedback if necessary medical care is being hindered.⁵

Improving care for incarcerated patients aligns with many health systems’ strategic goal of providing comprehensive care for their community as 95% of incarcerated individuals eventually return to the community.¹³

Recent expansion of Medicaid in some states has allowed limited eligibility for Medicaid coverage for incarcerated individuals preceding release. Provision of health insurance is associated with increased use of primary care and a reduction in all-cause mortality.²⁷

Medical Societies

Some medical associations have issued policy statements regarding the care of incarcerated patients.^28,29 The effects of incarceration span specialties and each has an opportunity to champion care. For example, the American Society of Addiction Medicine may make specific recommendations for those affected by the opioid crisis in carceral facilities, while the College of Chest Physicians could advise on communicable pulmonary diseases, such as COVID-19, that disproportionately impact prisons. Given the prevalence of trauma-related injuries, the American College of Surgeons could propose standards for shackling in the perioperative setting. Such measures would ensure that no one specialty is solely responsible for improving the care of incarcerated individuals, but rather the opportunity lies with all.

Training and Education

Traditionally, undergraduate and graduate medical education has placed little focus on the care of incarcerated patients despite the prevalence of incarceration in the US relative to more commonly taught conditions.³⁰ The Accreditation Council for Graduate Medical Education (ACGME) has recently approved an accredited fellowship in Carceral Medicine, ensuring a subset of knowledgeable providers and champions.

Conclusion

Incarceration harms individuals and their communities,¹³ and so represents an opportunity for clinicians practicing within medical centers to extend their impact beyond the limited engagement of a hospitalization.

When we view the case of Mr. A through a lens of incarceration, we can see how his presentation and care directly relate to his incarcerated status. Such cases offer medical professionals an opening to provide compassionate care tailored to the unique needs of the patient and to take steps towards stemming health inequities arising from the carceral system. Improving inpatient medical management for this population will take not only clinician awareness, but integration into undergraduate and graduate medical education, engagement across medical specialties, and standardization of institutional policy. Many small changes can result in a large difference in care for the millions detained in our jails and prisons.

Declarations:

Conflict of Interest:

JB reports funding from National Institute on Drug Abuse (NIDA) grant K23DA055695. The authors report no other financial disclosures, funding sources, or conflicts of interest relating to the creation of this work.