Ask the Expert: How Can I Best Provide Care to My Incarcerated Patient With Pulmonary Hypertension?

From a strictly legal standpoint, once incarcerated, your patient is no longer your patient, but that of the health system legally obligated to provide health care to that person. For physicians who have worked in an occupational medicine setting or who have experience in other types of institutional care (eg, the military or Department of Veterans Affairs), this variation on the patient-doctor relationship is not a new concept. To support care for the incarcerated patient with pulmonary hypertension (PH), the best approach is for the treating physician to adopt a clinical strategy of cooperation and coordination with the correctional facility's health care team.

An important starting point when dealing with incarcerated patients is to understand that the therapeutic environment will likely be radically different from others you have encountered in your career. Providing care to them requires a tactical understanding of how care is delivered in detention settings: understandably, incarcerated patients have fewer freedoms than the average citizen, including significant restrictions to activity, formulary, facilities, diet, access to specialists, etc. These factors can have a material effect on the care you—as a clinician with an ongoing relationship with the patient—are able to provide. While nearly all correctional settings will provide regular access to primary care services, most will also provide specialty-level care when determined necessary by the correctional health staff.

Most correctional health care team members are highly dedicated professionals who are eager to work with community specialty providers. Establishing communication with the health care team is an essential first step for providing continuity of care for the patient. Build a strong working relationship with these professionals; they are essential to alleviating any barriers between the specialty care you are accustomed to providing and any limitations in the correctional setting. Familiarize yourself with the mission of the correctional institution, the structure of its health care team, and the professional certifications and standards of correctional health care.

One approach to consider is to establish early communication with the health system administration at the facility. It's important to introduce yourself, and indicate that you have a history of taking care of one or more patients who are now incarcerated. If you are a physician in the local area or work with a local community health system, you and your practice may already be known to the correctional health administrator or clinicians. During early conversations, you will want to identify the responsible correctional health care physician—who may or may not be onsite in the facility—and make clinician-to-clinician introductions. While some of this can be done in writing, personal phone calls and accessibility on your part will go a long way toward establishing trust and developing a coordinated treatment effort.

Coordinate with the responsible health authority at the correctional facility to establish regular follow-ups at your practice setting; or, if the patient's level of custody makes this impractical, work with the institution physician or other qualified health care professionals to serve as your proxy, allowing you to direct care in those circumstances where direct contact is impossible. If telemedicine capabilities exist, consider using those.

Areas of potential clinical challenge include vascular access, medical equipment, and medication choices. With respect to vascular access, it will be important to educate the patient and clinical staff regarding care of any indwelling catheters to reduce the risk of early and late complications. Infection, occlusion, or other adverse events can occur in correctional settings just as they can in hospital and community settings. If durable medical devices are required, bear in mind that there may be restrictions on the use of such devices within the correctional setting. An important concern for PH patients is that oxygen may be available in correctional institutions.

Just as in a community setting, there may be limits and oversight of your prescription preferences. However, what might be unlike your experiences in the community, the responsible physician for the correctional facility—either within that facility, or in some cases, a regional or national responsible physician—has authority to request or even approve nearly any reasonable and needed medication. Again, building an early and positive rapport with these clinicians will support seamless and high-quality care for your patient.

Specific needs related to environment of care, medical equipment, and storage/mixing of drugs must be considered. Additionally, in-house capabilities to provide any kind of intensive treatment are very limited. The cost and feasibility of maintaining custody of patients as well as other nonmedical costs associated with transportation and outside medical housing must be factored into care decisions, so your input regarding which specialized treatments for chronic PH can safely and cost effectively be provided within the facility will be valuable.

For patients who are clinically at risk, be sure to alert facility health staff about how to identify signs and symptoms of clinical urgency quickly and train them to stabilize onsite treatment as well as provide guidance on when to transport quickly to a higher-level health care facility.

If you or your health system determines that the number of incarcerated patients is sufficient to benefit from a long-term practice in corrections, consider establishing services with more than one facility or to a network of facilities such as a state prison system. Given the challenges in diagnosing and the complexity of care required of PH patients, your involvement with incarcerated patients will be welcomed by correctional health care professionals for the benefit of their patients.