Caring for Patients on the Inside: Healthcare Delivery at the Hennepin County Jail

Hidden among the condos, businesses, and skyways in downtown Minneapolis sits the largest jail in Minnesota. Comprised of two buildings (the Public Safety Facility and City Hall), up to 36,000 people are booked per year at the Hennepin County Jail with a decrease since the COVID-19 pandemic began. The individuals detained in the jail are disproportionately Black, Indigenous, and people of color and have complex medical needs including substance use disorders, severe and persistent mental illness, and multiple chronic conditions. From the time the patient enters the jail to being released from custody, the Jail Health Services team provides a variety of medical services. When discussing health care in jails, understanding the funding structure is a key piece of why there is significant variability in the care provided in one jail compared to the next. Most of the patients who are detained and incarcerated in jails qualify for Medicaid while in the community. In 1965, when the incarceration system looked very different than it does today, the federal government addended the Social Security act and added the Medicaid Inmate Exclusion policy, which bans anyone detained in a carceral facility from receiving matched federal Medicaid funds to pay for health care. Because of the policy, the burden of the cost of health care for patients in jails lies disproportionately on counties. While in larger counties in the metro, the budgets may be more robust, this has an even larger impact in greater Minnesota where healthcare resources are more scarce. Each jail administrator then determines the most economical way to provide health care which includes not only local public health and integrated health system, like Hennepin Healthcare, in the case of Hennepin County, but also includes private contractors that specialize in low-cost care delivery and risk management. Now that we have paid for the health care, we can better understand our care from start to finish. Upon intake to the jail, nursing staff assess each patient booked into the jail. This assessment includes medical history and review of chronic conditions, suicide risk assessment, review of substance use, assessment for acute injuries and medication reconciliation. Based upon this review, appropriate protocols are initiated for withdrawal for alcohol, benzodiazepines, and/or opioids and current medications are resumed. If patients have acute medical needs beyond the scope of nursing practice, referrals are placed for the patients to see providers for medical, psychiatric, and addiction services. Nurses also see patients around day 14 of admission to offer tuberculosis and STI screening and immunizations. As a physician at the jail, the care I have the privilege to provide is a mix of acuity, complexity, and detective work all in one. On the medical side, we see many acute injuries related to gun violence, acute physical trauma, and police violence. Other common reasons for acute visits include skin and soft tissue infections such as abscesses related to IV drug use, acute alcohol, opioid, and benzodiazepine withdrawal, hyperglycemia, and hypertensive urgency/emergency. The visits for chronic conditions vary as well including infectious diseases like HIV and Hepatitis C to hypertension and diabetes. Mental health is a huge topic of importance in any jail. Many of the patients in the jail have severe and persistent mental illness like schizophrenia, bipolar disorder, and major depressive disorder. We also see many patients with substance-induced psychosis and substance-induced mood disorders. Currently, our therapies largely center around medication management, but many jails also have psychotherapy as well. Forensic psychiatry is a complicated field, and our jail health services psychiatry team collaborates with the courts to provide treatment and appropriate

transfers to state mental health institutions. The court system has its own separate psychiatrist and psychologists who do evaluations to determine whether a patient is competent to stand trial. Beyond mental health more broadly, suicide within jails is of particular concern. Jails are generally not facilities that foster a culture of wellness and given the stress and high stakes issues that patients face, suicides happen within jails, including Hennepin County. Suicide risk assessments occur at various points during the jail stay and if a patient is determined to have suicidal ideation, they are placed on suicide watch which includes a change in uniform, change in diet, and moving to an area of the jail with more frequent checks by security staff. One challenge to suicide prevention at the jail is that many common practices for addressing suicide in jails can be difficult for the patient, like having to wear a Kevlar gown without undergarments. There is a delicate balance between suicide watch and alternative settings within the jail to help provide adequate supervision and support for the patient. At the Hennepin County Jail, we use EPIC as our electronic medical record, which allows us to see records beyond the current jail encounter. However, even with this resource, we still find that records can be incomplete. Reasons for incomplete medical records in the jail population include the use of aliases when seeking medical attention due to concern about being arrested in the healthcare setting because of outstanding warrants and the health records used in other carceral settings are not always electronic and may not be connected to the community-based health record. This difficulty with obtaining accurate records creates challenges for many pieces of healthcare continuity of care including ordering indicated follow-up testing and medication continuation. Medications pose another significant challenge. Every jail is a bit different in terms of whether they have a limited formulary or how medications are packaged and administered to patients. At Hennepin County Jail, we utilize the inpatient formulary of Hennepin County Medical

Jails are generally not facilities that foster a culture of wellness and given the stress and high stakes issues that patients face, suicides happen within jails, including Hennepin County.

Center. Because of this we can offer a wide variety of medications. If a drug is non-formulary, we review the indication, cost, and estimated length of stay and decide whether an appropriate alternative exists. Medications are administered three times per day in the jail on both a scheduled and as needed basis. Discharge planning from a high turnover detention center with an average length of stay of nine days and median length of stay of 28 days, like the Hennepin County Jail, is complex. Unlike a hospital discharge, the jail health services team does not make this determination, rather this is done by the courts. Because of this, patients can leave at all hours making comprehensive discharge planning complicated. Discharge is an area we are focusing on more as we are aiming to provide more medications for patients to continue upon release including medications for opioid use disorder, mental illness, and chronic conditions. We are also working to partner with community organizations to help patients re-enroll in Medicaid prior to release so they can use their benefits after release to continue to meet their health needs. Caring for patients at the Hennepin County Jail is an opportunity to work at the nexus of social justice, injustice, and equity for patients who often fall through the cracks of traditional healthcare delivery models. Sweeping criminal justice reforms and improved social policies have the potential to transform whether health care is even needed in jails. But as we wait for transformational change, continuing to provide high quality care is important to meet the needs of many marginalized patient populations.

Rachel Sandler Silva, MD, MPH is the Medical Director at the Hennepin County Adult Detention Center, Staff Physician at Hennepin Healthcare, and Assistant Professor of Medicine at the University of Minnesota. She has an interest in medical education for health sciences trainees in community health settings, including criminal justice spaces, and has been a leader in quality improvement for jail healthcare delivery. She was a medical advisor to the National Sheriff’s Association regarding COVID-19 response within jails nationwide.