Safety precautions needed when incarcerated patients are released from correctional facilities

Patient Referrals and Transitions of Care Recommendations

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The following general insights and recommendations are intended to help support correctional healthcare companies to improve patient safety. The following is not based on any known quality or safety concerns in facilities where OmniSure has provided support. This is a proactive initiative to reduce the risk of adverse events, avoid harm where possible, and prevent potential losses or litigation.

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Situation:

Correctional healthcare providers often cannot or do not coordinate care with community healthcare providers upon release of patients from the prison or jail setting and do not have information about the rates of post-release mortality to use in their continuous quality improvement efforts.

Why it matters:

According to the Agency for Healthcare Research and Quality (AHRQ), patients who transition from one ambulatory care facility or clinician to another are especially vulnerable to patient safety errors. Because of the high number of adverse events, the AHRQ published a toolkit to help with safe transitions in high-risk patients. Studies also show higher suicide and relapse rates to drugs and alcohol by those recently released from correctional facilities, often due to poor social support, medical co-morbidities, inadequate treatment, and economic resources. One study published by the American Public Health Association found that in the first two weeks after being released from prison, formerly incarcerated persons were 40 times more likely to die of an opioid overdose than someone in the general population.

What's needed:

A collaborative and comprehensive case planning process is often required for patients with ongoing medical and mental health needs. As per guidance provided by The National Sheriffs’ Association and The Council of State Governments Justice Center’s Checklist for Correctional Facilities on Preparing People for Reentry, OmniSure recommends correctional healthcare companies formally encourage the Departments of Corrections that partner with them to jointly set up protocols for safe transitions of care. The goal is to identify vulnerable patients at high risk of demise and to plan in advance for the transition of care from the correctional ealthcare company’s practitioners to mutually sourced community-based health services in order to meet the ongoing health and treatment needs of these patients upon release from incarceration.

The previously referenced checklist, suggests the following:

If patients need a referral for continuity of care due to any of the below conditions, confirm that they have an intake appointment with a treatment provider scheduled as soon as possible and that they can participate in it. (Note: many appointments may be virtual or conducted over the telephone, so the patient should have access to a phone or computer and be instructed on how to use these, if necessary. If they do not have access to a phone or computer, arrange to have the correctional facility provide them with a phone or connect them to resources for emergency phone use.)?

Has the person screened positive for mental health needs based on a validated screening tool, been diagnosed as having a mental illness, or received treatment or services prior to admission or while in the facility? Have they screened positive for suicide risk or been placed on suicide watch?

After an appointment is confirmed, provide them with a list of outpatient treatment providers they can use. If you have access to a local mobile crisis team, mobile opioid treatment programs, or peer mentors, obtain appropriate consent from the patient and inform the team, programs, or mentors of the individual’s release to the community. If appropriate, coordinate with the Local Health Department using consistent communication systems to ensure effective patient handoff across organizations.

Has the person screened positive for a substance use disorder (SUD) based on a validated screening tool or received treatment or services for SUD prior to admission or while in the facility?

After an appointment is confirmed, assist them in developing an informal relapse prevention plan prior to release and connect them with a treatment provider as soon as possible.

Provide a list of support group meetings, including virtual options.

If you have access to a local mobile crisis team, mobile opioid treatment programs, or peer mentors, obtain appropriate consent from the patient, and inform the team, programs, or mentors of the individual’s release to the community.

Does the person have a history of opioid use or have they been diagnosed with opioid use disorder (OUD)? Is the person receiving medication assisted treatment (MAT) and support for OUD?

After an appointment is confirmed, refer the patient to a MAT clinic for medication and supportive care.

Is the person in active withdrawal from alcohol or other substances (including benzodiazepines or opioids)?

First, have the person assessed by medical or clinical staff and consider transfer to a medical facility. Then, confirm an intake appointment is available once they are released from the medical facility.

Does the patient require any prescribed medications for any medical or behavioral health-related condition?

Work with a nurse or designated support staff to provide them with their prescriptions in hand at the point of release. Ensure medication supply sufficient to bridge to their appointment with the community provider.

If medication cannot be given at release, call the non-narcotic medication into a pharmacy ahead of time or provide the person with a paper prescription.

Give each person a list of their current medications and dosages. If they are prescribed an injectable medication, ensure the date of the last injection is included on the list.

Provide a list of pharmacies near where they will be residing, including pharmacies that accept discount prescription programs.

Does the patient have access to medical coverage (i.e., do they qualify for federal/state benefits such as Medicaid, Medicare, CHIPS, VA, SSI, or do they have their own insurance plan)?

Look to reinstate their medical insurance if it has been suspended or enroll them for medical insurance if they did not previously have it. If appropriate point them to navigators who can help get them into the insurance system either through the federal exchange at HealthCare.gov or through the state exchange if in a state with their own exchange.?

If the patient qualifies for Social Security Disability and Supplemental Security Income, notify the Social Security Administration ahead of time that the person is being released to enroll them in or restart benefits through a pre-release agreement.

If benefits cannot be activated before release and the person needs assistance paying for medications, connect the patient with the National Alliance on Mental Illness (NAMI) or another organization that maintains a list of resources that may apply.

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Challenges:

In many cases, the discharge planning, case management, or transition of care upon release and reentry is not contemplated, funded or addressed in the correctional healthcare provider's contract with the Departments of Corrections, the correctional facilities or other governing bodies.

Identifying community partners with the capacity to treat patients after release is difficult due to lack of resources.

Recommendations:

In order to advocate for patient care and protect providers against litigation, we recommend that correctional healthcare companies make formal requests of Correctional Leaders, contract managers, or site level superiors to either provide or outsource Reentry Case Management. Document those requests in the form of official request letters, meeting minutes or memorandums of understanding. If it is not feasible to provide reentry case management, document the reasoning and collaborate as a team to propose and engage in the best possible alternatives to prevent patient harm in the transition of care.

It may be helpful to curate from information linked below to educate Correctional Leaders at the contractual levels and custody staff at the site level on why correctional healthcare companies are making these requests. Maintain records of what was provided and to whom.

Refer to The Council of State Governments Justice Center’s checklist for correctional facilities on Preparing People for Reentry and formally suggest/request that prison leadership partner with the correctional healthcare provider to implement safer transitions of care by developing and, if needed, funding a collaborative and comprehensive case management program that sources and coordinates with the necessary supportive community services.

Point them toward the National Reentry Resource Center for information, examples, and tools.

Review the framework provided in the Transitions of Care Standards, established by the American Case Management Association, for sample ways to implement a process that focuses on improving the highest-risk and especially vulnerable care transitions. Apply whatever strategies are useful to the highest-risk patient transitions from the correctional-based healthcare setting to the community-based healthcare setting.

References:

1. https://www.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
2. https://newsroom.uw.edu/blog/high-risk-suicide-seen-formerly-incarcerated-people
3. https://ajph.aphapublications.org/doi/10.2105/AJPH.2018.304514
4. https://projects.csgjusticecenter.org/collaborative-comprehensive-case-plans/
5. https://csgjusticecenter.org/publications/preparing-people-for-reentry/
6. https://www.naccho.org/membership/lhd-directory
7. https://www.verywellhealth.com/what-is-a-health-insurance-exchange-1738734
8. https://www.ssa.gov/pubs/EN-05-10504.pdf
9. https://www.nami.org/your-journey/individuals-with-mental-illness/getting-help-paying-for-medications/
10. https://csgjusticecenter.org/publications/preparing-people-for-reentry/
11. https://nationalreentryresourcecenter.org/
12. https://transitionsofcare.org/