Why the Justice System’s Hidden 'Silver Tsunami' Needs an Urgent Healthcare Response

As the U.S. healthcare system braces for the silver tsunami, there is a hidden demographic that demands special consideration: the growing population of aging adults within the prison system. By 2030, it is estimated that one-third of incarcerated individuals in the U.S. will be 55 or older. Upon release, elderly incarcerated individuals face myriad challenges to accessing the healthcare they need. In addition, compassionate release laws in some states enable frail older adults to be released on medical parole, adding to the complexity of care navigation for severe illness. 

Geriatricians and primary care physicians are at the frontlines of this crisis and must consider these patients’ specific challenges. How can correctional and healthcare systems evolve to better serve this wave of justice-involved older adults as they transition into the mainstream health system? 

Facing barriers beyond bars 

Accelerated aging is a recognized phenomenon within prison populations. People re-entering society after extended incarceration can suffer from age-related decline often associated with people a decade older or more. Individuals as young as 50 can emerge from incarceration with poor mobility, multiple chronic conditions, and cognitive decline. Yet, there is no existing blueprint to identify and link these patients to appropriate supportive services, and they risk falling into a gap between traditional primary care and geriatric medicine. 

Beyond existing outside the framework of traditional care models, Nicole Mushero, MD, PhD, a geriatrician at Boston Medical Center (BMC) and advocate for compassionate release, believes that justice-involved individuals face a more fundamental barrier to accessing care: trust. 

“I think much of our population at BMC has issues with trust because of systemic injustices and history of healthcare being used against them,” Dr. Mushero explains. “And nowhere is that truer or more deeply felt then people coming from prison who are more likely to be Black and are more likely to be from communities that have been historically harmed by healthcare institutions.” 

“We encounter roadblock after roadblock getting these patients the services they need to exist in the world.”

Nicole Mushero, MD, PhD, geriatrician, Boston Medical Center

Furthermore, a 2021 study published in Heath and Justice, which evaluated medical mistrust among incarcerated individuals, found that older individuals (ages 33 to 42 and 43 to 66) had the highest levels of mistrust of the medical system. These findings underline the necessity of increased outreach and partnership to build trust and improve connections to healthcare providers, especially as justice-involved older adults enter the pre-release period.  

Stigma from the medical community remains the most significant challenge that justice-involved older adults face. The perception of dangerousness and subsequent bias against formerly incarcerated individuals causes logistical problems that can not only stymie access to care but worsen health outcomes among frail adults who require the most intensive services. 

“These patients struggle getting placement at nursing facilities, getting dialysis beds, and getting nursing to visit them at home,” said Dr. Mushero. “I had one patient who could not secure transportation to dialysis because the company did not feel comfortable transporting him in the van. We encounter roadblock after roadblock getting these patients the services they need to exist in the world.” 

Rethinking care models 

At BMC, Dr. Mushero has created an interdisciplinary working group to help find solutions that address the complex health issues that confront people coming out of prisons and jails in Greater Boston. 

One idea in development is the “transitions clinic model”—a multidisciplinary clinic of physicians, nurses, social workers, and community health workers with a history of incarceration. The clinic would serve as a medical home for justice-involved individuals, helping patients navigate specialty services to address their complex needs. Community health workers would provide an additional layer of individualized case management, connecting patients to resources and specialty organizations outside of the hospital to better address social determinants of health.   

Similar models instituted at other hospitals have proven effective in helping individuals connect early to primary care services and reduce rates of emergency department utilization. While the transitions clinic model would serve patients at all stages of life, Dr. Mushero believes the greatest benefit would be for older adult patients who require the most support and advocacy.  

Early education on justice-involved patients 

Dr. Mushero is also working to educate the next generation of physicians on how to work alongside patients who are currently or were formerly incarcerated. She has created an educational pathway, an elective for internal medicine residents, so they can learn about the issues of accelerated aging and get involved performing medical parole evaluations for incarcerated people who are very sick or have terminal illness for their compassionate release. 

Her push to start this education in early stages of a physician’s career is inspired by one patient who she was assigned to care for during her own residency. The patient was entering the clinic after being incarcerated for several decades. 

“They were 70, and it really opened my eyes to the idea that there are older people in prison coming out into the community with serious health issues. That really inspired the work I have done since,” Dr. Mushero says. “It inspired both my own work clinically and my interest in teaching residents and medical students about ways to advocate for this population.”