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.
When an inmate is released from the Davis County Jail, the officer gives them an instruction sheet, that informs them that if they have current prescription medications, they may go over to the Harmon’s Pharmacy, across the street and pick up a free 1 weeks supply of medications and we have authorized a 30 day refill on any of those meds that they may purchase at their own expense. The only problem for them is they must go during business hours. So if they are released at night they will have to come back in the morning. We have not found any significant costs associated with this program here either. It is working well for us. The only real difference with Davis County Jail’s program with that of Ada County Jail is: when the inmate goes to the Harmon’s Pharmacy to pick up their free meds or the 30 day refill, Harmons does not call the jail to find out what current meds the inmate was on. Instead, Harmons calls our main contract pharmacy to get current med orders and our nurses do not have to spend time on the phone or looking up meds for released inmates. We do not have to do anything when an inmate is released from the jail because we do not have any meds to release with them and we do not accept personal meds either so deputies do not need to ever call the nurse when an inmate is released. We no longer have blister cards at all in the jail. We have gone to daily delivery of pre-packaged meds from our contracted pharmacy, so we have do not have meds in the jail to set up or return or destroy or send out with the inmate.
Fine plan, James. The most important thing about this program that you did not mention (but that we discussed at the Essentials conference), is how little money it costs since so few discharged inmates take advantage of the program!
Our approach to discharge medication is: if they brought medication and we approve them they take any remaining; if they did not bring or stayed longer a 72 hour (+/- holidays) for all ‘medically necessary medications.
The medications are obtained through one pharmacy (our support pharmacy) and they must purchase them – the pharmacy does not fill until the patient arrives. Those who have refills are sent to their own pharmacy. We do not (routinely) include controlled medication – the patient must see their community provider for that. Special arrangements can be made for unique cases on an individual basis. The sign off for bubble packs is a great idea. We also have individuals sign the control medication sheet if released to them (personal meds).
At utah county jail we do not provide them with medications when they are discharged. Typically we just give them back their property which has the medications they came into jail on and they can start taking those. We do not have the responsibility to care for their needs once they leave the jail.
I would disagree a little bit with the statement that we have no responsibility after the inmates leave the jail. There is some degree of medico-legal risk here. Let’s say for example, that an inmate has heart disease and is discharged from the jail with none of his heart meds. Let’s say that he has a big MI two days after his release. He can and probably will blame the bad outcome on the abrupt discontinuation of his meds. How big this risk is, I don’t know. But it is not zero; there is risk here. It seems to me simple enough to either give the inmates their meds at discharge (if you just going to destroy them anyway) or else give them a one month prescription that they can fill at their own expense. Even paying for discharge meds, as I talked about in may article and as they do in Davis County, is not expensive. If nothing else, it helps me to sleep better at night knowing that I have that risk covered.
I work at Jackson County Detention Center in Kansas City MO…Inmates are never given meds paid for by the county when discharged
I understand why the county would do that–the county paid for the meds so they belong to the county; not the inmate. The problem is that if you have no mechanism for medication continuity after discharge, you run the risk that a former inmate will have a bad event and blame it on not getting their medication. I would recommend that you at least set up a program whereby inmates can get a one month prescription for the meds they were taking in jail that they can fill at their own expense. Very, very few (in fact, hardly anyone) will actually use the program, but from a medico-legal perspective, it is probably good to have. Also, what do you do with the county-purchased medications that you do not give to the inmates? If you just destroy them, why not give them to the inmates at discharge?
I understand the pro’s and con’s of having a discharge medication program but wish there was a more definitive understanding of the medico-legal risks involved with both….our providers are concerned about what happens if the inmates get the medications filled and a negative consequence happens such as an interaction with another medication that they may have never told us about or if they have a severe hypoglycemic event because they take a medication at the wrong time of day….I would want to venture a guess that the inmate would be held responsible for that but with all the lawsuits that take place surrounding corrections and health care, our providers are nervous to be responsible in any way for an inmate that has been released from custody. Are there is any legal cases sited about this topic? That would probably help sway our providers into feeling more comfortable about writing a prescription for inmates being released into the community. Thanks!
In California prisons–we provide a 30 day supply of all essential medications free for patients paroling. We also dispense more if needed to complete certain treatment like Hep C or latent TB. We also provide controlled substance to the patients (at the prescriber’s discretion and some feel comfortable only writing for 2 weeks supply instead), and emphasize to patients that they have to establish care ASAP to continue treatment outside. Patients also get a medication list with Sig, so they can show their outside prescriber what meds they are on
Thanks Dave! It appears that California DOC has a good system. Unfortunately, it is a bit harder in jails because jails often do not know when a particular patient will be released. Family can post bond at two in the morning and out the patient goes. Or the courts can reduce or eliminate a bond unexpectedly. Jails have to have some method of dealing with these surprise releases.
Continuity of care is difficult in jail. Some straight forward steps can make an impact. Screening should include questions about PCP & pharmacy – with a release to PCP for any chronic care issues. The release is an issue. A letter to the PCP with the release should indicate a willingness to care for the patient until release – and explicit statement that the patient will be redirected to the PCP on release.
Releases do cause some difficulty with planning; yet cooperation from corrections – usually requiring top down buy-in from administration can improve things. Individuals who are going to prison are not a problem (about 20-30%). People who are sentenced (another 25-35%) can be coordinated fairly well particularly if corrections keeps medical informed and the plan is started 30 days before release. When there is a ‘Pre-Trial’ agency (assumes monitoring for people who have not been adjudicated but have bail that is out of reach – usually low risk offenders) can also help with coordinated release. The individuals who bail (usually in the first 48-72 hours (about 10-25%) are also usually not a problem for medical.
Yes the % does vary with facility / season / etc. – an approach that tries to look at groups with similar features can be helpful.
We did chose to identify one pharmacy (the contract pharmacy providers local back up source) to provide all discharge medications and they wisely chose not to prepare the medication until they saw the ‘whites of the individual eyes. For the most part, discharge medication was limited to: completion of a course of care (antibiotics), 72 hours +/- holiday for chronic medications occasionally a bit longer for new meds (HTN, DM, etc.), with coordination would prescribe up to 14 days for mental health meds.
Exceptions to all of the above could and did occur when necessary
Many of the people we dealt with were returning to the community in a short time and could reconnect to their previous health provider. A real problem would occur with people who had been convicted of an additional crime while in prison (located in our county) as after spending years in prison they would have to do a county sentence – with no PCP on release.
Hope some pf these ideas are helpful
Excellent observations, Al.