One of the “systems” problems that all jails have to deal with is what to do with medications when a patient is released from jail. Prisons deal with this issue as well but tend to have fewer headaches than jails, mainly because they know exactly when inmates are leaving the facility and can plan ahead. In jails, often we don’t know exactly when a patient will leave. We and the inmate might think that he will be with us for months when, lo and behold, someone posts bond at 2:00 in the morning. What happens to the inmate’s medications then? Jails have to have a system in place to deal with this. The Ada County Jail in Boise, Idaho recently started a remarkable new program to help deal with this problem that I would like to present. First, however, let’s discuss the overall dimensions of the problem.
Continuity of Care
The overall goal of discharge medication planning, of course, is one of continuity of care. If an inmate is taking medications for HIV infection, say, or hypertension or schizophrenia, we do not want their medications to abruptly stop when they leave the jail. Under the best of circumstances, it will take time for the patient to get their medications refilled on the outside. That gap in treatment is not good medical care and in some circumstances can be devastating. We can’t hold former inmates’ hands after they leave the jail, but we do need to develop policies to ensure, as well as possible, that discharged inmates have a supply of medication adequate to last until they can reasonably contact an outside provider for refills.
The simplest way to do this is simply to hand the patients whatever meds they have remaining on the med cart as they are being discharged. However, there are four problems with this simple approach. Two are easy to deal with and two are a little trickier.
Problems with Jail Discharge Medications
The first problem is that medications in most jails are bubble-packaged. These bubble-packed cards are not child proof containers. The worst case scenario is that the former inmate takes the meds home and a child gets into the meds—and we get blamed. I actually have never heard of a case of this happening, so it is more of a theoretical consideration than a practical one. The solution, however, is simple. As the inmates are handed the bubble packaged medications, they must read and sign a statement acknowledging that the medications are not in a child-proof container and it is their responsibility to keep them out of the reach of children. Since we will be giving other instructions as well, this is a simple little sentence to add to the instructions.
The second problem with handing inmates medications as they leave is that sometimes, they are discharged suddenly and without our knowledge and so inevitably leave the facility medication-less. I already mentioned the inmate who is bonded out at 2:00 in the morning. It is unlikely he will be handed his medications as he leaves. What is he to do? The solution here is pretty simple, as well. You set up a specific time and place where recently discharged inmates can return to get their medications. One possibility is 8:00 – 10:00 AM at the front desk of the jail. The instructions on how to do this are in the inmate handbook and these instructions are also handed to every inmate leaving the facility by the discharging deputy. The recently discharged inmate needs to report in person within, say, two weeks at the appropriate time and appropriate place. He needs to bring a valid photo ID confirming this identity. Medicationss will not be released to anyone else. If no one has picked up the meds by two weeks, the meds are destroyed.
A third problem is what to do with controlled substances. This is a thornier issue that I have discussed previously (found here) and will not rehash now. But the discussion, including the comments section, is well worth re-reading!
The final problem is the tricky one. If you hand the inmates their remaining medications, different inmates will receive different supplies depending on when the meds were last refilled. Compare, for example, two inmates named “Jeff” and “Ernest” taking blood pressure medications. The jail in which they reside refills medications once a month. Jeff is discharged one day after the jail received a month’s supply of medications from the pharmacy and so will leave with nearly a full month’s supply in hand. But Ernest is discharged exactly one day before the new card of medications arrives. He receives only one day’s worth of medication when he leaves. That may not be an adequate supply to last until he can get an outside refill.
Two ways to ensure adequate discharge supplies of medications
So the question is, how do we ensure that all inmates receive an adequate supply of medications until they can get a refill? Two solutions stand out in my mind. The first is to give each and every discharged inmate a one-month prescription for the medications they were taking in jail. They must fill this prescription at their own expense, though the meds shouldn’t be too pricey. Almost all of the meds I prescribe are in the “$5.00 for a month’s supply” category.
The way this process works in practical terms is this: when the inmate is discharged, he is given an instruction sheet that he can present to any pharmacy. The instruction sheet tells the pharmacist to call either the jail pharmacy or the jail medical department (numbers provided) to get the prescriptions. When called, we verify the medications and dosages that the patient was taking in jail (minus the controlled substances). We authorize a one month supply of these medications with no refills. Unfortunately, such prescriptions are rarely filled. However, from a medico-legal perspective as a mechanism promoting continuity of care, this program is “bullet-proof” (according to one correctional attorney I talked to).
The second solution begins by deciding exactly how many meds-in-hand is an adequate supply. If we give a discharged inmate enough medications for one day, plus the one month own-expense prescription, is that enough? How about a one week supply? Two weeks?
In my view, jails do not need to discharge inmates with as many medications as does a prison. The reason is that jail inmates usually have an active outside provider—the person who prescribed their meds before they came to jail. Prison inmates, who have been incarcerated for a long time, usually do not have an active outside provider and must seek one out. It makes sense to send out a prison inmate with, say, a month’s worth of medications. However, a one week supply seems to me to be plenty for most jail inmates, especially when coupled with an active prescription. Most inmates receive far more than this.
But what do you do for those few inmates who, because of when they are discharged, get less than a one week supply? You could just shrug and say that by arranging for a month’s own-expense prescription, continuity of care is covered. However, very few former inmates actually fill an “own-expense” prescription, so in actual practice, most of the patients discharged with few meds probably run out.
Ada County Jail Discharge Medication Program
The Healthcare Administrator at the Ada County Jail in Boise, Kate Pape, wanted to do better that that, so for the last six months or so, the Ada County Jail has been trying something new. It works like this:
Inmates who have less than a week’s worth of medications available at discharge receive a prescription for seven days of their medications paid for by the county. They have to go to one particular pharmacy, which is within easy walking distance from the jail. And they have to have the prescription filled within 48 hours of being discharged from the jail. But if they fulfill these two terms, the prescription is free to them; the county covers the cost.
Of course, the big question here is how much money will the county spend on this program? I have to admit that I was leery or this program when Kate first presented it because I feared it would be too expensive. However, that has not turned out to be the case.
First, not every inmate gets this paid-by-the-county prescription; only those who have less than one weeks’ supply of meds remaining at discharge. That is a small minority. Second, of those who are offered such a prescription, many have no need for it because they already have a supply of medications at home. Finally, not everyone who is given a prescription like this makes the effort to fill it.
In the end, the cost of this program at the Ada County Jail has been minimal. In fact, the total cost of this program in the first six months of operation at Ada County has been less than $100.00.
In my mind, the benefits of this program far outweigh the small costs of administering it.