Coordination of Care for Incarcerated Female Surgical Breast Cancer Patients

Background: Breast cancer patients who are incarcerated often have their treatment for cancer deterred due to being in the penal system. When an individual is incarcerated, he or she is “entitled” to standardized quality medical care. When care begins, oftentimes the patient is at an advanced stage and faces barriers in care.¹ Both medical providers (surgeon, medical oncologist, radiation oncologist, and/or plastic surgeon) and medical facilities that are willing to accept these patients must be secured.

The breast fellow surgeon for Medical City Arlington was approached by representatives of a women’s penal institution to care for their breast cancer patient population. Medical City Arlington has an existing breast navigation program with pathways currently in place. Navigation is well-established and has been integrated for all breast cancer patients admitted at the facility. Initially a discussion was held with the breast fellow surgeon at Medical City Arlington and the breast navigator to discuss incarcerated female breast cancer patients receiving the same standard of care as a nonincarcerated patient. It was noted that the current standard of care, while well-established, would not be inclusive and would need modification for the incarcerated female breast cancer patients.

Objectives: “The care of incarcerated cancer patients can be uniquely challenging” without communication between the prison healthcare team, the patient, and the medical specialist outside of the penal system.² Creating a breast cancer treatment plan for the incarcerated female breast cancer patients, while maintaining security for the facility and those caring for the patient, is the goal.

Methods: Medical City Arlington leadership consisted of the following departments: registration, quality, risk management, and surgical services. Meetings and communication with the key stakeholders and the breast navigator occurred to discuss a plan of care for the incarcerated breast cancer patients. The breast navigator was tasked with taking the lead in the process of implementing a coordination of care for the incarcerated female breast cancer patients and communicating the results.

The discussion of possible opportunities and barriers included:

1. Implementation of the current navigation pathways
2. Admission and discharge processes
3. Security concerns and implementation
4. Notification to all caring for the patient of patient rights
5. Education of all hospital employees
6. Consents and clinical trials
7. Guards and the guards’ role during all procedures, especially surgery
8. The area in which a patient would be admitted

Results: During the process of implementation for incarcerated breast cancer patients, it was noted that a policy was in place for forensic patients. Forensic is the terminology for the incarcerated patient. The policy was initiated January 1, 2015.³ With the support of Medical City Arlington’s leadership team, a process was implemented specifically for incarcerated patients with breast cancer.

The process is as follows:

1. Surgery is scheduled through Scheduling
2. Communication of date and procedure to Perioperative Director/Manager
3. Perioperative leadership to communicate to Risk/Oncology Navigator date and time of surgery
4. Risk to communicate with Security Lead at least 48 hours before date of surgery
5. NO names or procedure information to be communicated
6. Security will have a person ready at ED door, with wheelchair and blanket for privacy of securement devices, to escort patient to preoperative area
7. Patient to come to the ED entrance with guards; guards to stop at security office and preferably be greeted at door
8. Security will escort guards and patient to preadmission area
9. All consents and written information/x-rays should come with patient
10. Patient pre-op as usual, day of procedure
11. Guards do not help with any physical care
12. Only guards can work with the shackles
13. Guards must be with patient at all times
14. Guards must go to surgery with the patient. They are to be in scrubs or bunny suit; if in scrubs, a jacket should be provided to conceal weapons that must be on the guards at all times per their security policies
15. Patient will remain in shackles at all times until intubated as determined by the guards
16. Patient to have no phone, silverware, or visitors
17. Patient is a no publication/confidential patient
18. Staff are not to discuss nor ask questions about incarceration
19. Hospital rule: Security over Privacy

Coordination of Care: *Surgery scheduled with notification to navigator and perioperative director/manager. *Patient preadmission to occur on the day of surgical procedure. *Upon arrival patient and guard(s) enter the facility and meet with hospital security. *Patient escorted to day surgery. *Patient name de-identified on visual boards and changed to “Forensic.” *Navigator and staff are to enter patient room and announce their role to patient and to the guard(s) present. *Education by staff and navigator initiated with all handouts approved by guards. *Plan of care reviewed, except anticipated discharge time and or date are not discussed with patient.

During 2018, a total of 12 breast cancer surgical patients were navigated using the current standard of care at Medical City Arlington. Prior to 2018, there were no known breast cancer patients surgically cared for at Medical City Arlington.

The breast navigator initiated education to the surgical services staff with the support of surgical services leadership during monthly staff meetings for the morning and evening employees.

Conclusion: Although the number of breast cancer patients navigated through Medical City Arlington was small, the process established a coordination of care for other incarcerated patients with cancer to be treated through the hospital system with dignity while maintaining a safe work environment for all involved.

References

1. The Center for Prisoner Health and Human Rights. www.prisoner health.org/news-and-events/news/health-of-justice-involved-populations.
2. Garbutt T. Prisoner or patient? Challenges of cancer care in the incarcerated population. www.oncologynurseadvisor.com/home/cancer-types/general-oncology/prisoner-or-patient-challenges-of-cancer-care-in-the-incarcerated-population. 2018.
3. Medical City Arlington Policy and Procedure.