Communication Over Incarceration: Improving Care Coordination Between Correctional and Community Mental Health Services

Incarcerated people tend to have high rates of mental disorders and substance use disorders (1), and U.S. correctional facilities manage >8 million admissions annually (2). As a result, incarceration and release back into the community can serve as key transition points in mental health care for millions of people. Alongside this churn of people into and out of U.S. correctional facilities, care coordination between correctional and community mental health services remains a challenge. Legal, technological, and other factors often impede information sharing between correctional and community mental health professionals (MHPs), disrupting continuity of care and threatening the well-being of incarcerated and formerly incarcerated people. This Open Forum examines barriers to information sharing, a critical component of care coordination, between correctional and community mental health services and offers suggestions to improve continuity of care in these contexts. The following case examples are composites and are not representative of actual patient-clinician encounters.

Case 1: The Community Perspective

Dr. Y, a community psychiatrist, learns from a patient’s family that the patient was recently arrested, and the family does not know where he is being held. Dr. Y searches her clinic’s electronic health record (EHR), including outside records, for updates about the patient but sees none. Because the patient is taking clozapine, an antipsychotic with strict prescribing requirements, Dr. Y attempts to contact jail health staff about the patient’s care. She finds a website for the county jails, but the website does not list contact information for jail health services. She calls the main jail telephone number, which leads her to various options that do not include health staff. After several calls, she is eventually transferred to a jail health voicemail and leaves a message asking for a callback. She never receives one.

Case 2: The Correctional Perspective

Dr. Z, a jail psychologist, is evaluating an incarcerated patient with symptoms of psychosis. The patient’s statements are difficult to understand, but the patient alludes to receiving psychiatric medications from a nearby clinic. Dr. Z calls the clinic to obtain additional information; however, the clinic’s front desk staff seem hesitant about speaking to someone from a jail and the legal implications of doing so. Dr. Z reiterates that he is a health professional seeking to coordinate care for treatment purposes, but the clinic staff insist on receiving a release of information (ROI) form signed by the patient before disclosing any information. Dr. Z returns to the patient to complete the paperwork, but the patient is in distress and does not cooperate. Dr. Z is unable to obtain the clinic’s information about the patient and must make treatment decisions with limited information.

Barriers to Information Sharing

Many of the barriers to information exchange between correctional and community mental health settings mirror broader problems in U.S. health care. For example, HIPAA established important rules for protecting patient privacy; however, because of fears about violating the law’s complex requirements, health staff often will not disclose patient information before receiving signed ROI forms, even though the law does not generally require patient authorization to disclose protected health information to another health professional for treatment purposes (3), as in Dr. Z’s situation. Addressing substance use can be a key part of mental health care, in that substance use disorders and mental disorders are often closely intertwined; nonetheless, Title 42 of the Code of Federal Regulations (CFR) Part 2, which adds confidentiality requirements related to substance use disorder services, can also deter MHPs from exchanging necessary patient information in various health care settings (4). Despite greater use of EHRs in U.S. health care, many EHRs still cannot “talk with one another,” and this lack of interoperability frequently prevents access to patient information across care providers (5). Yet the correctional-community interface has unique characteristics that further impede sharing of mental health information.

Security

For security reasons, such as preventing escapes or decreasing the risk of assaults within their facilities, many correctional facilities strictly control the flow of information about incarcerated people (6). As seen with Dr. Y, the community psychiatrist, limited public access to basic information, such as contact information for correctional health services, can obstruct MHPs from coordinating care for people entering or leaving correctional settings. Because of security concerns, among other reasons, correctional facilities may not readily share medical records, whether through EHRs or other means, with community clinicians (7). A 2018 survey found just two (5%) of 44 responding correctional systems could send requested medical records via electronic record systems, and at least 10 (23%) of these 44 correctional systems required outside health professionals to pay fees for patient records (7). Even if patients pursue their own correctional health records, regulations, such as 45 CFR 164.524, may include specific provisions that allow correctional facilities to deny these requests for security-related reasons.

Privacy

Privacy concerns are heightened in regard to incarceration and the exchange of mental health information. Correctional facilities might also strictly control access to incarceration-related records because these records can contain sensitive information related to an individual’s legal status and mental health; in fact, some correctional systems even require a subpoena before sharing medical records (7). Because of the stigma surrounding incarceration, incarcerated patients may not want correctional MHPs to contact community clinicians for privacy reasons. Some correctional MHPs might hesitate to obtain collateral information, for example, from attorneys or families, because of concerns about unintentionally influencing patients’ legal circumstances. Similarly, as encountered by Dr. Z, the jail psychologist, community health staff may avoid disclosing patient information to correctional MHPs because of concerns about the legal implications of sharing this information.

Limited Professional Exposure to Correctional Environments

Lack of familiarity with correctional environments might also deter community clinicians from communicating and coordinating care with correctional MHPs. MHPs often train and work in various health care settings, such as emergency departments, hospitals, and clinics; however, many MHPs have never worked behind bars and lack knowledge about mental health services inside correctional facilities (8). As a result, they may be less willing to reach out to correctional systems to coordinate care for patients who have been incarcerated. Even if community MHPs do reach out, they may be less effective because of limited familiarity with correctional environments (e.g., not knowing the differences between jails and prisons).

Breaking Down These Barriers

Given overlapping federal and state privacy regulations, including carve-outs regarding mental disorders, substance use disorders, and incarceration, collaborative efforts among the U.S. Department of Health and Human Services (HHS), state regulators, and correctional health organizations (e.g., National Commission on Correctional Health Care) are needed to study the effects of these regulatory frameworks on care coordination between correctional and community mental health services (3). Concurrently, development of clinical decision support tools, such as privacy algorithms for MHPs to determine when they can and cannot share information, can facilitate care coordination in these situations. For example, the HHS website includes searchable Frequently Asked Questions about HIPAA for health professionals, which could offer additional guidance regarding coordination of correctional and community mental health services (9).

Greater integration into correctional facilities of EHRs that can exchange information with community-based EHRs is essential. Through legislation such as the Health Information Technology for Economic and Clinical Health Act of 2009, U.S. policy makers have incentivized EHR adoption in both community and correctional settings (4, 10). Recent studies have described growing EHR uptake by correctional systems, including in Arizona, California, Florida, Massachusetts, New Jersey, New York, and Oregon (4, 10, 11). By installing EHRs that have interoperability with community EHRs, correctional systems can facilitate more rapid exchange of clinically relevant mental health information across multiple systems, including community clinics, hospitals, and pharmacies (4). However, interoperable EHRs are not panaceas, because Internet connectivity issues (11), costs (10), legal concerns (11), and mental health–specific consent considerations (4), among other factors, must be considered.

Increased patient access to mental health records may support information exchange surrounding incarceration. Under the 21st Century Cures Act of 2016, U.S. health providers must now provide patients with more immediate access to their medical records (i.e., “open notes”) (12), which might help patients recall aspects of their mental health care and participate in shared decision making with correctional and community MHPs (12, 13). Federal rules under this law still include exceptions, such as reducing risk of harm to the patient and others, as well as provisions under 45 CFR 164.524, whereby correctional facilities can restrict patient access to mental health records for security and other reasons (14).

Additional strategies are also needed. For example, correctional facilities might integrate completion of ROI forms for current outpatient MHPs into the screening and intake process. Doing so might also carry drawbacks, such as additional workloads for correctional health staff and the possibility of patients providing signatures when unable to provide genuine consent (e.g., while intoxicated or feeling coerced to do so amid arrest). By expanding correctional training opportunities for MHPs, medical schools, residency programs, and other training institutions can increase MHPs’ familiarity with incarceration and coordinating these transitions in care (8). Correctional facilities can develop more secure communication channels, whether through EHRs or public-facing contact information (e.g., centralized telephone or e-mail options), for coordinating care with community mental health services. In addition, U.S. policy makers could reverse restrictions on Medicaid eligibility for incarcerated people, which would expand access to community mental health services and facilitate care coordination upon release from incarceration (15).

Even if policy makers, correctional facilities, and community mental health systems do not advance clinically indicated sharing of mental health information, litigation through courts may eventually force them to do so (6, 16). Recent litigation, for example, in the U.S. Court of Appeals for the Second Circuit, has highlighted how inadequate psychiatric discharge planning from correctional settings may constitute a violation of constitutional rights (16). Given the public mental health implications of inadequate care coordination between correctional and community mental health services, litigation will likely continue to arise—and may be essential for addressing these persistent issues.