Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

1. Background

GDC delivers constitutionally-required healthcare services to a population of approximately 42,000 offenders1 in state custody who are housed in approximately 60 state correctional facilities. This includes 34 state prisons and 26 alternate sentencing locations (e.g., Residential Substance Abuse Treatment Centers (RSATs), Probation Detention Centers (PDCs), Transitional Centers (TCs), and Integrated Treatment Facilities (ITFs)).

The exact composition of GDC’s offender population fluctuates monthly as offenders enter and leave state custody but has stayed relatively stable on an annual basis. June 2019 data shows that approximately 23% of offenders have a mental health condition, with approximately 15% of all offenders on psychotropic medications.2 Approximately 2% of offenders are being treated for HIV, and approximately 0.1% are on Hepatitis C treatment and 0.1% are on chemotherapy at any given time.

Healthcare delivery under the current supplier

GDC’s current healthcare delivery model is managed by a state university (“the current supplier”) with an associated medical center. This delivery model was developed and implemented more than 20 years ago. Since implementation, the management of the delivery of care has remained largely unchanged while healthcare reform, innovation, and new value- based care models have driven significant evolution in the healthcare ecosystem. The current supplier currently utilizes a paper-based health records system.

Mental health services, dental services, and pharmacy services are contracted separately; however, the physical health supplier provides approximately 40 mental health nurses, so all nurses are aligned under one Director of Nursing. The current supplier interacts closely with other contracted providers in order to provide comprehensive care to GDC’s offender population.

At present, GDC’s current supplier delivers healthcare services in the following settings (not exhaustive):

On-site care within GDC facilities • Sick call clinics3 available across all state correctional facilities. • 14 regional infirmaries providing 24-hour, 7-days-a-week with nursing staff to provide sub-acute healthcare services. The total combined capacity is 195 beds used for care, similar to observation-level care in a hospital setting. • The Helms facility provides dialysis as well as prenatal care for offenders. Labor and deliveries occur at Atlanta Medical Center. • Secure inpatient care, specialty ambulatory care, and additional services (e.g., dialysis, radiology, physical therapy) at Augusta State Medical Prison. Augusta State Medical

1 Historically, the average daily population (ADP) of offenders was approximately 42,000. In 2020, GDC’s ADP has decreased to approximately 40,000. Future ADP growth rates are expected to be lower than ADP growth rates in the past. 2 Includes some offenders who receive psychotropic medications for seizure disorder 3 Sick call clinics are on-site care locations within GDC facilities for offenders to visit if they are ill Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

Prison also has 2 operating rooms to provide ambulatory surgery and outpatient procedures. • Ambulatory surgery at a modular surgery unit located at Georgia State Prison with 2 operating rooms; dedicated 15-bed recovery ward in Georgia State Prison. • 22 bed inpatient acute bed forensic unit4 at Atlanta Medical Center. • Long-term care and accommodated living units at three facilities (Augusta State Medical Prison, Autry, and Johnson State Prisons).

Out-of-prison care • Outside of prison healthcare is provided at community, tertiary, and quaternary hospitals across the state based on negotiated contracts between the current supplier, hospitals, and physicians. • Specialized services, such as radiology and chemotherapy, are provided off-site by providers contracted through the current supplier. Please refer to Attachment S for a list of subcontracted service suppliers supporting specialized services today. • Contracting for long-term care facilities is currently negotiated on a case-by-case basis.

2. Overview of current on-site physical healthcare services GDC’s role is to ensure all offenders have adequate access to constitutionally required healthcare services. This begins with intake and routine care. GDC’s Standard Operating Procedures (SOPs) for on-site healthcare services can be referenced in Attachment M.

Intake at prison facilities

The current supplier is responsible for physical healthcare services at intake – as soon as the offender arrives on-site at a GDC facility and enters GDC’s custody. This begins during the intake processes at the Georgia Diagnostic and Classification Prison (GDCP – Male) and Lee Arrendale State Prison (Female) facilities and continues throughout the term of an offender’s detention.

At intake, all offenders undergo a physical health screening to assess their current state of health and healthcare needs. Offenders over the age of 45 receive additional screening for chronic disease in the first week following intake.

Routine care

Routine care includes but is not limited to: preventive and primary care, sick call, pill call, chronic care, urgent/emergent care, and care in infirmaries. Additional primary care visits and screening tests are scheduled periodically throughout an offender’s term of incarceration based on his or her age, health status, and individual needs.

• Primary and preventive care:

o Female offenders are provided diagnostic and health maintenance needs. Services (non-exhaustive) include annual exams (e.g., pelvic exam, STD

4 Discrete area of hospital dedicated to provide care for those in state custody Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

screening, health screening) and prenatal care. Prenatal care is provided at Helms Facility.

o Male offenders are provided diagnostic and health maintenance needs.

• Sick call: The sick call process allows offenders to request to be seen by a provider as acute symptoms or injuries arise. Sick call is conducted at all GDC facilities.

• Pill call: End-to-end pharmacy services are contracted to a pharmacy supplier. Medications are administered by physical healthcare nursing staff during pill calls. In some cases, self-administered medications (SAMs) are dispensed to qualifying offenders. Today, the pill call process for nursing-administered medications uses a paper-based medication administration record (MAR) and varies across facilities, based upon security needs and infrastructure.

• Chronic care: All offenders are screened, identified and monitored for chronic illnesses in order to initiate appropriate therapeutic regimens to promote health and prevent underappreciated disease states. All patients with chronic conditions are recorded in the Chronic Illness Clinic (CIC) Tracking logs.

• Urgent / emergent care: GDC’s medical units at all 34 state prisons treat urgent and emergent needs (e.g., chest pain, abdominal pain and constipation, bone fractures, lacerations) that do not require admission to a community hospital.

• Infirmaries: The 14 infirmaries provide 24-hour clinical care, daily physician rounds, IV medications, and private patient rooms. Care at infirmaries includes illness, injury, or diagnostic work-up requiring observation and/or medical management that does not require admission to a community hospital. The infirmaries provide observation-level care on-site for patients with less severe illness that do not require hospitalization, as well as patients immediately post-discharge from community hospitals who need additional recovery prior to safely return to general population housing.

Specialty care

Primary care physicians may refer offenders for specialty care consultations (i.e., specialty treatments or specialty provider visits). Specialty care consults are currently provided at the Augusta State Medical Prison clinic or by community providers. Outpatient surgeries/procedures may be performed in Augusta State Medical Prison’s two operating rooms, at a subcontracted mobile surgery unit at Georgia State Prison, or other community-based hospitals or provider locations. With the new supplier GDC is interested in maximizing its in-prison operating capacity to deliver high-quality services at predictable and sustainable costs.

Telemedicine

GDC provides telemedicine equipment and the basic peripherals (e.g., stethoscope, otoscope) in all 34 state prison facilities. GDC’s current supplier is responsible for managing the provider network to support the provision of telemedicine. For the past three years, the utilization of telemedicine has been about 3,550 visits per annum. Telemedicine is provided via a desktop Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information computer “portal” in a room that offenders can access under a nurse’s supervision and a correctional officer.

Acute, specialized medical care at Augusta State Medical Prison

Augusta State Medical Prison operates the central healthcare facility for male offenders in Georgia. Augusta State Medical Prison receives patients with acute, complex non-emergency healthcare needs from across the state prison system, including visits for specialty consultations, outpatient surgeries/procedures, inpatient stays, and residential dialysis. In addition to the outpatient visits or inpatient stays of offenders from other prison facilities, Augusta State Medical Prison provides for the ongoing healthcare needs of offenders housed in Augusta State Medical Prison’s own facility on a long-term basis.

Augusta State Medical Prison has 214 beds designated for physical health, all of which are highly utilized, including:

• 95 beds for medical/surgical acute patients

• 20 beds for accommodative living

• 23 beds for respiratory patients, with in-facility capabilities for pulmonary function testing

• 11 stations for dialysis patients, which run three shifts per day, six days a week for GDC’s 66 male dialysis patients. GDC is in the process of expanding its capacity to 21 stations, which will reduce the number of shifts. Anticipated completion in FY 21.

Augusta State Medical Prison’s facility and its capabilities also include:

• Two operating rooms for non-emergent, outpatient surgeries/procedures, including pre- op and post-op beds

• CLIA lab

• Augusta State Medical Prison hosts rooms for multispecialty clinics with network providers, who offer the following specialties:

- Comprehensive Cardiology Clinic, including treadmill and nuclear stress tests - Cardiothoracic Surgery - Dermatology - Endocrinology - Gastroenterology - General Surgery - Hematology - Infectious Diseases (includes 340B5) - Nephrology

5 The current supplier operates a 340B program for HIV and Hepatitis C patients. The current supplier is a 340B-eligible entity and rents space onsite at Augusta State Medical Prison to operate a 340B-eligible clinic to treat patients with HIV and Hepatitis C. Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

- Neurology - Neurosurgery - Oncology - Ophthalmology - Optometry - Orthopedic Surgery - Otolaryngology - Pain Management - Plastic Surgery - Podiatry - Pulmonology - Radiology - Rheumatology - Urology - Vascular Surgery Scheduling for outpatient appointments at Augusta State Medical Prison is performed offsite through a central scheduling team (operated by GDC’s current supplier).

Dialysis

GDC has a chronic dialysis population of approximately 66 offenders. Today, Augusta State Medical Prison has 11 dialysis stations, Pulaski State Prison (female) has 4 dialysis stations, and Helms Facility has 6 dialysis stations. Please refer to Attachment S for details on existing dialysis subcontractors.

Imaging

Imaging services, including X-ray, ultrasound, MRI, and CT, are currently performed in the community or in-facility through a mobile imaging unit with a mobile tech provided by the current supplier. Images are read by outsourced community radiologists. The X-ray equipment currently located at Augusta State Medical Prison is analog.

Women’s Health

Health services provided to female offenders focus on health maintenance, gynecological services, mammography, prenatal care, and contraceptive needs prior to release. Prenatal care is provided at Helms Facility. Female offenders are housed at Pulaski State Prison, Lee Arrendale State Prison, Whitworth Parole Detention Center, Emmanuel Women’s Facility, all of which are female-only facilities.

Security protocols for transfer across facilities and/or to off-site physical healthcare services

Current GDC Security SOPs require a minimum of two correctional officers to escort an offender to a regional prison infirmary, to Augusta State Medical Prison, or to a community provider. If care requirements are emergent and unable to be addressed on-site in prison facilities, correctional officers accompany the offender to a community hospital or emergency department and remain with the offender for the duration of his or her hospital admission. Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

3. Overview of current off-site physical healthcare services

Provider network development

GDC’s current supplier negotiates pricing and contracts with community providers.

Management of care in community settings

Between 2016-2019, GDC’s number of community hospital admissions has increased from 1,755 to 2,443, with total hospital days near 11,200. Outpatient consultations have trended up as well, with approximately 58,000 ordered during this period. There were approximately 5,600 community emergency department visits in 2019.

Management of community-based care involves utilization management, consultations pre- authorization, and scheduling. Utilization management team employees have nursing and case management backgrounds and concurrently review inpatient stays and coordinate discharges with GDC’s case managers. GDC employs a team of nurses who manage hospital discharges back to the state facilities and ensure appropriate placement and continuity of care for offenders.

Medicaid enrollment

GDC currently partners with the Georgia Department of Community Health (DCH) to fund two employees to enroll eligible offenders in Medicaid when an inpatient admission occurs and to provide support to physicians submitting claims directly to Medicaid after rendering inpatient and emergency department care that led to inpatient admission.

GDC is responsible for sending all eligible offender applications to the Richmond County Division of Family and Children Services (DFCS) office for application processing.

Upon eligibility, the current supplier works with the TPA to ensure claims are accurately billed to Medicaid. (Please refer to Attachment T for GDC’s current Medicaid Offender Policy).

4. Overview of current claims management

GDC’s current supplier subcontracts elements of third-party claims administration (referenced in Attachment S). The Third Party Administrator (TPA) interacts with GDC’s Utilization Management team, contracted providers, state Medicaid, and GDC’s offender database (SCRIBE) in order to support comprehensive claims payment and data processing. The TPA services include a customer support/service center to support claims status inquiries, staffing a GDC dedicated management team (e.g., Contract Service Agreement, Business Manager, Claims Processors), and technology (i.e., providing customer access to claims data, history, reports, and a TPA portal for secure communication). The TPA must meet banking requirements and is held to performance guarantees (as referenced in Attachment S).

Additionally: • The current supplier is responsible for the payment of all facility and provider claims.

• GDC and the Georgia Department of Community Health (DCH) have a partnership to enroll eligible hospitalized offenders in Medicaid. Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information

• The current supplier works with the TPA to ensure claims are accurately billed to Georgia Medicaid.

5. Facility overview

GDC’s state correctional facilities provide a range of healthcare services within the prison facilities (e.g., sick call, pill call, infirmaries, specialty consults, outpatient surgeries/procedures, inpatient stays, etc.). Each facility has a scope of healthcare services tailored to its mission, population, and overall size. In-facility physical health services are performed for male and female offenders at separate facilities. GDC has four dedicated facilities for female offenders, including the provision of prenatal care to approximately 50 female offenders per year. Augusta State Medical Prison provides acute, specialized care (as defined above). Augusta State Medical Prison and Georgia State Prison house and treat only male offenders. Helms is the only co-ed healthcare facility housing pregnant females, dialysis patients, and other offenders requiring ongoing access to specialty care in the metropolitan Atlanta area.

The medical equipment available at GDC’s facilities vary but generally range from basic care to specialty care. Today, GDC purchases and owns medical equipment, and GDC’s current supplier manages and operates equipment. A non-exhaustive inventory of existing government furnished equipment (GFE) by GDC facility is included as Attachment Q. An inventory of existing GFE within GDC’s infirmaries, including purchase date and cost details, is included as Attachment R. The equipment is available for use by the supplier under the terms described in Mandatory Requirements Section 4.3. When GDC’s existing GFE reaches End of Life (EOL), the supplier will be responsible for replacing equipment.

6. Overview of current IT infrastructure and operations

Core systems, processes, and network environment The current medical supplier maintains paper-based health records. Currently, all notes and orders are hand-written and partial information entered into SCRIBE. In the future, GDC is seeking a supplier that will provide an Electronic Health Record (EHR) as part of the proposed solution.

All GDC’s 34 state prisons have broadband Wide Area Network (WAN) access, and all have wired Local Area Network (LAN) infrastructure. Across facilities, LAN design and architecture are relatively uniform, but the availability of effective bandwidth capacity varies based on local application portfolio and usage patterns. Ten of GDC’s facilities have some degree of wireless access (Wi-Fi) in various locations throughout the facility. In engaging with a new physical healthcare supplier, GDC would be responsible for providing LAN and WAN capacity to connect all remote sites to a U.S. data center: Suppliers should assume that LAN capacity will exist for the agreed-upon solution proposed or that special requirements would be negotiated. In contrast, wireless access cannot be assumed to be available with either Cellular or Wi- Fi/Bluetooth capabilities due to available infrastructure, construction materials, wireless containment systems and the general lack of wireless service in specific geographic locations. While some Wi-Fi does exist in GDC’s facilities, the overall use and capacity do not represent full coverage across facilities. An individual site survey with the selected vendor will be required as part of the implementation. GDC maintains and plans to retain full control of its network and Georgia Department of Corrections GDC0000946: Attachment K – Current Model for Physical Healthcare Services Information reserves the right to request modification for delivery of services as needed. Operations are expected to operate 24/7 365 days a year. A high-level network diagram is included in Attachment V.

GDC through the Georgia Technology Authority (GTA) maintains a contract with AT&T to manage its TCP/IP Addressing Schema, including: (a) Furnishing specific addresses for network devices that require them at each remote site

(b) Furnishing remote site subnet numbers and subnet masks

GTA manages the State’s network and computer hardware through Georgia Enterprise Technology Services (GETS) through which AT&T is responsible for network services and security.

Security GDC’s IT environment and IT solutions comply with standards regarding IT Accessibility and 508 Compliance, including providing effective, interactive control and use with nonvisual means. GDC’s IT environment also complies with physical and technological security requirements of high-trust environments to meet the standards defined by Health Insurance Portability and Accountability Act (HIPAA) and NIST 800, including provision of an HL7 interface, adherence to FHIR protocols, and encryption of data transferred in motion and at rest. All security policies are provided by the Georgia Office of Information Technology (OIT) which will reflect the State standard security policies necessary.

GDC completes background investigations of supplier participants with network access, and identity management is controlled by GDC Active Directory for user logon to the Agency network, including tables and attributes. GDC’s data is stored within a United States-based Tier 3 or greater secure data center.

Data, Backup, and Storage Given regulatory considerations, GDC uses a cloud storage solution that is hosted in a U.S. data center, and GDC maintains the rights and usages of all intellectual property concerning data.

7. GDC Policies and Standard Operating Procedures GDC has specific requirements related to staffing within the correctional setting. Detailed requirements can be found in Section L of the Minimum Basic Requirements.