CORRECTIONAL MANAGED HEALTH CARE COMMITTEE March 20, 2018 10:00 A.M

CORRECTIONAL MANAGED HEALTH CARE

COMMITTEE

AGENDA

March 20, 2018

10:00 a.m.

Frontiers of Flight Museum Conference Room 6911 Lemmon Ave. Dallas, Texas 75209

CORRECTIONAL MANAGED HEALTH CARE COMMITTEE March 20, 2018 10:00 a.m.

Frontiers of Flight Museum Conference Room 6911 Lemmon Ave. Dallas, Texas 75209

I. Call to Order

II. Recognitions and Introductions

Retirement of Pam Myers, RDH, Dental Hygiene Program Manager – University of Texas Medical Branch-Correctional Managed Care, effective March 31, 2018

III. Consent Items (TAB A) (pgs. 1 - 98)

1. Approval of Excused Absences

2. Approval of CMHCC Meeting Minutes, December 5, 2017

3. TDCJ Health Services Monitoring Reports - Operational Review Summary Data - Grievance and Patient Liaison Statistics - Preventive Medicine Statistics - Utilization Review Monitoring - Capital Assets Monitoring - Accreditation Activity Summary - Active Biomedical Research Project Listing - Administrative Segregation Mental Health Monitoring

4. University Medical Directors Reports - Texas Tech University Health Sciences Center - The University of Texas Medical Branch

5. Summary of CMHCC Joint Committee / Work Group Activities

IV. Update on Financial Reports (TAB B) (pgs. 99 - 111)

V. Summary of Critical Correctional Health Care Personnel Vacancies (TAB C) (pgs. 113 - 121)

1. Texas Department of Criminal Justice

______EACH ITEM ABOVE INCLUDES DISCUSSION AND ACTION AS NECESSARY

CMHCC Agenda (Continued) March 20, 2018 Page 2

2. Texas Tech University Health Sciences Center

3. The University of Texas Medical Branch

VI. Medical Directors Updates (TAB D) (pgs. 123 - 130)

1. Texas Department of Criminal Justice - Health Services Division Fiscal Year 2018 First Quarter Report

2. Texas Tech University Health Sciences Center

3. The University of Texas Medical Branch

VII. Correctional Managed Health Care Update (TAB E) (pgs. 131 - 163)

Texas Correctional Managed Health Care Program- Lannette Linthicum, MD, CCHP-A, FACP

TTUHSC-CMC- Denise L. DeShields, MD, Executive Medical Director

UTMB-CMC- Owen J. Murray, DO, MBA, Vice-President Offender Care Services

VIII. Public Comments

IX. Adjourn

______EACH ITEM ABOVE INCLUDES DISCUSSION AND ACTION AS NECESSARY

Page 1 of 163

Consent Item

Approval of CMHCC Meeting Minutes December 5, 2017 Page 2 of 163

[This page left blank intentionally for pagination purposes.] CORRECTIONAL MANAGED HEALTH CARE COMMITTEE

December 5, 2017

Chairperson: Margarita de la Garza-Grahm, M.D.

CMHCC Members Present: Lannette Linthicum, M.D., CCHP-A, FACP, Cynthia Jumper, M.D., Ben Raimer, M.D., F. Parker Hudson III, M.D., John Mills, D.O., Tamela Griffin

CMHCC Members Absent: Elizabeth Anne Linder, Ed.D., Harold Berenzweig, M.D., Mary Annette Gary, Ph.D.

Partner Agency Staff Present: Oscar Mendoza, Beckie Berner, Toni Moore, Ron Steffa, Eidi Millington, M.D., Alice Castleberry, PsyD, Chris Black-Edwards, RN, Lorie Davis, Myra Walker, RN, Teresa Winegar, Texas Department of Criminal Justice; Olugbenga Ojo, M.D., Marjorie Kovacevich, Ryan Micks, Owen Murray, D.O., Joseph Penn, M.D., Anthony Williams, Monte Smith M.D., Stephanie Zepeda, PharmD, Kelly Coates, David Connaughton, Billy Horton, D.D.S., Jessica Khan, M.D., University of Texas Medical Branch (UTMB); Barbara Beadles, M.D., Will Rodriguez, Brian Tucker, D.D.S., Lindsey Tubbs, Texas Tech University Health Sciences Center (TTUHSC)

Others Present:

Location: UTMB Conroe Operations Offices, 200 River Pointe Dr., Suite 200, Conroe, Texas 77304

Agenda Topic / Presenter Presentation Discussion Action I. Call to Order Dr. Margarita de la Garza-Grahm called the Correctional - Dr. Margarita de la Garza-Grahm Managed Health Care Committee (CMHCC) meeting to order at 10:02 a.m. then noted that a quorum was present, and the meeting would be conducted in accordance with Chapter 551 of the Texas Government Code, the Open Meetings Act.

Dr. de la Garza-Grahm acknowledged that all wishing to offer public comment must be registered and would be allowed a three minute time limit to express comments. There was no public comment.

Dr. de la Garza-Grahm thanked and welcomed everyone for being in attendance. She then moved onto recognitions and introductions.

II. Recognitions and Dr. de la Garza-Grahm reported that there were several

Introductions recognitions and introductions. She introduced and welcomed Page 3 of 163 two new CMHCC members, Dr. F. Parker Hudson and Dr. John Mills. Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and Dr. Hudson received a Bachelor’s of Science degree in Dr. de la Garza-Grahm asked Dr. Hudson if he Introductions genetics and cellular biology from the University of Georgia. wanted to tell the committee more about (Cont.) He attended medical school at the University of Pennsylvania himself. - Dr. Margarita de la Garza-Grahm School of Medicine where he also completed his medical residency in internal medicine and pediatrics. Additionally, he Dr. Hudson stated that Dr. de la Garza-Grahm received a Masters of Public Health degree in epidemiology summed up his professional background. Dr. and specialized in adult infectious diseases at the University Hudson thanked the committee and said that it is of North Carolina Gillings School of Global Public Health. a privilege and honor to be here to serve the state Dr. Hudson has been honored as an assistant professor of as a relatively new arrival. Internal Medicine and Infectious Diseases at the Dell Medical School at the University of Texas in Austin. He practices and teaches at Dell Seton Medical Center and within Community Care in Austin.

Dr. Mills received a Bachelor’s of Science degree with honors Dr. de la Garza-Graham welcomed Dr. Mills. in medical technology, a Masters of Science degree in Dr. de la Garza-Grahm also thanked Dr. Mills anatomy, and a Doctor of Osteopathic Medicine degree from for his service and asked Dr. Mills if he wanted Michigan State University. Dr. Mills also received a Masters to speak. of Public Health degree from the University of Michigan. He completed his residency at the United States Air Force School Dr. Mills stated that it was an honor to be here. of Aerospace Medicine, Brooks Air Force base in San Antonio, Texas. Dr. Mills is a member and past president of the American Osteopathic Board of Preventive Medicine and a lifetime member of the United States Army Society of Flight Surgeons and the Vietnam Helicopter Pilots Association. Among his many professional honors and awards, Dr. Mills was designated as the “founding father” of Correctional Medicine by the American Osteopathic College of Occupational and Preventive Medicine in 2010 and a Distinguished Fellow in 2013. Currently, he is an associate professor and medical director of Correctional Programs at the University of North Texas Health Science Center in Fort Worth. He also served with the United States Army from 1967-1970 and 1987-1989 where he was decorated with 27 air medals, including the Distinguished Flying Cross and the Meritorious Service medal. Page 4 of 163

Dr. de la Garza-Graham next called on Dr. Cynthia Jumper on behalf of Dr. Denise DeShields to recognize the retirement of Dr. Brian Tucker, Dental Director at TTUHSC on December 31, 2017. Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and Dr. Jumper informed the committee that Dr. DeShields was Introductions unable to attend the meeting. Dr. DeShields wrote a heartfelt (Cont.) commentary that Dr. Jumper read to the committee.

- Dr. Cynthia Jumper on Dr. DeShields wrote that today we celebrate the illustrious 27 behalf of Dr. Denise year career of Dr. Brian Tucker, Texas Tech CMHC Dental DeShields Director. Dr. Tucker completed his undergraduate studies at West Texas State where he obtained a Bachelor’s of Science in Biology and a Bachelor’s of Science in Nursing. He began his career as an operation room technician and then became an operation room nurse. He subsequently attended the Baylor College of Dentistry and came to Texas Tech and CMHC after 11 years in private practice on March 26, 1990. He was not only instrumental in opening the Clements Unit in Amarillo but all Texas Tech units as he traveled tirelessly across the vast expanses of West Texas. Over the past 27 years, Dr. Tucker’s management of the Texas Tech Dental Program has been flawless as evidence by the dental access to care 1, 2, and 3 with nearly perfect scores.

He also established an elaborate metric based productivity and reporting system, and improved the quality of dental care that has been provided to the offenders in West Texas. He was a positive force on the Joint Dental Working Group, leading the group to establish their charter, as well as being a champion for the electronic health record and the implementation of digital dental radiology. Dr. Tucker has constantly and passionately championed for quality, timely, and accessible dental care throughout his tenure. However, Dr. Tucker was more than a dentist.

He is a constant advocate for positive change and for quality improvement, a crusader for always doing what is right in all disciplines and not only dental. He has always been an active, prepared, and informed participant in regional and statewide Pharmacy and Therapeutics, Infection Control, Policy and Procedure, System Leadership, and Peer Review Committees. He is not only a talented educator, providing several presentations at National Commission on Correctional Health Care (NCCHC),

Page 5 of 163 Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and but a lifelong student as he is currently completing a Masters Introductions of Science in Health Administration. (Cont.) Dr. Tucker has embraced the concept of institutional - Dr. Cynthia Jumper on succession in his final months, and he has orchestrated a behalf of Dr. Denise smooth transition on dental leadership to his Regional Dental DeShields Directors, one of whom, Dr. Cecil Wood, will succeed him.

Dr. Tucker embarks on a new adventure, and he is looking forward to an active retirement with his wife Becky and spending more time with his grandchildren. He will now spend more time traveling the highways and byways in his converted van, boating, fishing, mentoring children and grandchildren, and telling fish tales. We can all rest assure that the fish tales told by Dr. Tucker will be accurate, precise, well researched, and delivered with unparalleled passion. Congratulations Dr. Tucker on your retirement and an exceptional career.

Dr. Cynthia Jumper then called on Dr. Lannette Linthicum to recognize the retirement of Dr. Brian Tucker.

- Dr. Lannette Linthicum Dr. Linthicum announced that Dr. Tucker has been such an integral part of the correctional managed health care team and does not know what they will do without him.

Dr. Linthicum informed the committee that Dr. Hirsch, TDCJ Dental Director, was unable to attend. Dr. Hirsch prepared a statement for Dr. Tucker’s retirement, and Dr. Linthicum read the statement to the committee.

- Dr. Lannette Linthicum Dr. Hirsch wrote that “I would be forever remorseful if I were on behalf of Dr. Manuel given the opportunity to say a few words about Dr. Tucker Hirsch and did not take the advantage. Although prior commitments prevent me from being present, I wanted to express the admiration that I have for a leader in the dental profession. A leader that I will always associate with the statement, “Don’t Page 6 of 163 worry about who gets the credit? Let’s get it done.” If I had to use a single word to describe Dr. Tucker, it would be integrity. Integrity is defined in the dictionary as the quality of being honest and having strong moral principles. In the 10 years that

Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and I have worked with Dr. Tucker, I have had the opportunity to Introductions learn to appreciate his genuine honesty. (Cont.) - Dr. Lannette Linthicum Dr. Tucker’s father was a professional educator and this is the on behalf of Dr. Manuel approach Dr. Tucker takes on many issues that are discussed. Hirsch He never gives the quick answers that is expected. Rather, he gives us directions to pursue the answers with book titles, websites, and journals. He follows up until you have formulated your own conclusions and answers. My feeling was did Dr. Tucker not have the answers supported with a strong moral conviction? His goal was to help you solidify your own conclusions. His thirst for knowledge is contagious.

He encourages continuing education by sharing his knowledge of upcoming events, and his detailed notetaking at the conventions kept me engaged as I knew that he would call later to discuss the details. The fact that he is receiving an MBA at the same time he is retiring says a lot about his lifetime commitment to learning and development. Endurance has to be associated with Dr. Tucker as a marathon runner and a triathlon participant. Retirement will not interfere with his determination as he prepares to run the Oklahoma City Marathon again in the Spring with his son. His monumental efforts can motivate the couch potato in all of us.

Dr. Tucker’s compassion for his family, his wife Becky, sons, his little dog Lillie, and the grandchildren who are his marathon cheering section saying “Go fast Papa!” makes you want to find more time to spend with your own family.

Dr. Tucker has touched so many lives in so many positive ways and it has truly been an honor to consider him as a friend.”

- Dr. Lannette Linthicum Dr. Linthicum announced and presented a certificate of appreciation to Dr. Tucker on behalf of TDCJ Health Services Page 7 of 163 Division in recognition of 27 years of dedicated service to the TDCJ offender health care program. Dr. Linthicum also presented a plaque to Dr. Tucker on behalf of TDCJ that recognized his outstanding service, commitment, and support to the health care program of TDCJ. Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and Dr. Linthicum then called on Dr. Tucker to give his parting Introductions words to the committee. (Cont.) Dr. Tucker thanked the committee for the opportunity to end - Dr. Brian Tucker things well and say goodbye. He appreciated the effort and the time people have made to say wonderful things in recognition of his retirement.

Dr. Tucker stated that he loved getting to know so many people that are brilliantly talented and dedicated to a mission. A mission to take care of people that are created in God’s image, and to find ways to do what they can with limited resources to do a very difficult job. He went on to say that he has been inspired by the leadership of many of the people in the committee, and the dedication is admirable and will always be remembered.

Dr. Tucker also stated that he has enjoyed learning from the new challenges that came up every day, and he found the new challenges very rewarding. Developing ways to make the program better has brought him a lot of satisfaction, and the building of the dental program in West Texas was his contribution to further Texas Tech CMC. Like a handoff in a relay race as people did good work before him, he took the handoff for a while. Dr. Tucker stated that he is now ready to hand it off, and he feels confident that he is handing it off to people who are able and willing to carry on an honorable task.

Dr. Linthicum next called on Dr. Billy Horton, UTMB CMC Dental Director, and Dr. Owen Murray to recognize the retirement of Dr. Brian Tucker.

- Dr. Billy Horton Dr. Horton announced to the committee that he has had the pleasure to work with Dr. Tucker for approximately 9 to 10 years, and he had known Dr. Tucker before they began working together. The dental department in CMC is the best in the state because of what Dr. Tucker has done in the Page 8 of 163 leadership that he has provided. Dr. Horton shared with the committee that he has enjoyed working with Dr. Tucker, listening to stories about his family and grandchildren, and he will be missed. Dr. Horton praised Dr. Tucker for being a good man and dentist and that people Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and can learn from him. Dr. Horton thanked Dr. Tucker and Introductions wished him the best. (Cont.) - Dr. Owen Murray Dr. Owen Murray said that everyone has hit all of the highlights of Dr. Tucker’s career.

Dr. Murray recalls being new to the Pharmacy and Therapeutics Committee meeting, and Dr. Tucker eloquently spoke about a drug and its interactions. Dr. Tucker was not speaking about a dental drug. Dr. Murray remembered leaving the meeting asking if Dr. Tucker was the Texas Tech Medical Director, but he found out that Dr. Tucker was the Texas Tech Dental Director.

Dr. Murray agreed with Dr. Horton that the dental program at TDCJ has a lot to do with the energy and efforts of Dr. Tucker. From a technology perspective, Dr. Tucker has always pushed the dental program at TDCJ to the electronic health record. Dr. Murray told the committee that Dr. Tucker had envisioned the electronic health record before it was ever embraced, and that you do need advocates for technology whether if it is for digital radiology or electronic health records. Dr. Murray thanked Dr. Tucker for pushing the committee in the right direction to go back to the Legislature to ask for those funds that happened with Dr. Tucker’s continued advocacy.

Dr. Murray said that the people who are being left in charge can be very thankful for the program that Dr. Tucker has left, and the investments that Dr. Tucker has helped to promote the Legislature to make in the program, as well as all the time and energy that Dr. Tucker has spent.

Dr. Murray thanked Dr. Tucker and wished him the best.

- Dr. Margarita de la Dr. de la Garza-Grahm next called on Dr. Jumper to introduce Garza-Grahm the new Texas Tech staff member. Page 9 of 163

- Dr. Cynthia Jumper on Dr. Jumper introduced Ms. Lindsey Tubbs who will be the behalf of Dr. DeShields new Chief Financial Officer for Texas Tech Correctional Health Care effective January 2018. Ms. Tubbs started the position last month. She has been currently working with Mr.

Agenda Topic / Presenter Presentation Discussion Action

II. Recognitions and Jerry Hoover to get integrated for a smooth transition. Mr. Introductions Hoover will be the consulting CFO for Texas Tech until his (Cont.) retirement in March 2018. Mr. Hoover has been Texas Tech - Dr. Cynthia Jumper on CFO for approximately 20 years. behalf of Dr. DeShields Dr. Jumper stated that Ms. Tubbs has worked in the private sector in healthcare and in the academic sector, and she was the senior managing administrator for internal medicine at Texas Tech. Dr. Jumper has worked with Ms. Tubbs closely as she performed all of the financial duties in operating the business office. Ms. Tubbs has a lot of years of experience in budgeting within a bureaucracy.

Ms. Tubbs has a good background. She received a degree from Texas Tech, as well as an MBA from Texas Tech in healthcare. She is very prepared for this position as she has already been in Amarillo and Lubbock. Dr. Jumper welcomed Ms. Tubbs and said that Texas Tech is looking forward to working with her.

- Dr. Margarita de la Dr. de la Garza-Grahm next called on Dr. Linthicum to Garza-Grahm introduce Dr. Alice Castleberry.

- Dr. Lannette Linthicum Dr. Linthicum introduced Dr. Alice Castleberry, the new TDCJ Director of the Office of Mental Health Monitoring and Liaison. Dr. Linthicum informed the committee that Dr. Castleberry is a PsyD, and asked Dr. Castleberry to tell the committee more about her background.

- Dr. Alice Castleberry Dr. Castleberry informed the committee that she has been licensed since 2004 and has worked in Texas at various inpatient and outpatient settings. She has also worked in the state hospital system primarily focused on both forensic and clinical areas. She is looking forward to learning more about

the correctional setting and thanked the committee. Page 10 of 163

- Dr. Margarita de la Dr. de la Garza-Graham moved onto agenda item III approval Garza-Grahm of consent items. Agenda Topic / Presenter Presentation Discussion Action

III. Approval of Consent Items Dr. de la Garza-Grahm stated that the following five consent items would be voted on as a single action: - Dr. Margarita de la Garza-Grahm - Approval of Excused The first consent item was the approval of excused absences- Absences hearing none; she moved onto the second consent item.

- Approval of CMHCC The second consent item was the approval of the CMHCC Meeting Minutes – meeting minutes from the September 20, 2017 meeting. Dr. September 20, 2017 de la Garza-Grahm asked if there were any corrections, deletions or comments-hearing none; Dr. de la Garza-Grahm moved onto the third consent item.

- Approval of TDCJ The third consent item was the approval of TDCJ Health Health Services Services Monitoring Report and there was no comments or Monitoring Report discussion of these reports.

- University Medical The fourth consent item was the approval of the University Directors Reports Medical Directors Report. There were no comments or - TTUHSC discussion of these reports. - UTMB

- Summaries of CMHCC The fifth consent item was the approval of the summaries of Joint Committee/ Work CMHCC Joint Committee/Work Groups Activities. There Groups Activities was no comments or discussion of these reports.

Dr. de la Garza-Grahm then called for a motion to approve the Dr. Raimer made a motion consent items. to approve all consent items, and Dr. Jumper seconded the motion which prevailed by unanimous vote.

IV. Update on Financial Dr. de la Garza-Grahm next called on Mr. Ron Steffa to Reports present the financial report. Page 11 of 163 - Ron Steffa Mr. Steffa reported on statistics for the Fourth Quarter of Fiscal Year (FY) 2017, as submitted to the Legislative Budget Board (LBB). The report was submitted in accordance with the General Appropriations Act, Article V, Rider 47.

Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial Unit and psychiatric care expenses represent the majority of Reports (Cont.) health care cost at $351 million or 52 percent of total - Ron Steffa expenses; hospital and clinical care accounted for $250 million or 37 percent; and pharmacy services were at $68.8 million or 10 percent of the total expenses. The average daily census within the incarceration setting had a slight decrease compared to the Fourth Quarter of FY 2016 by 0.3%.

The offender population age 55 and over had a 5.4% increase with an average daily census of 16,825 through the Fourth Quarter of FY 2016 compared to 17,727 through the Fourth Quarter of FY 2017.

Mr. Steffa reported on the unit and psychiatric care revenues of $360 million and $351 million of expenditures giving a surplus of $9.3 million in the strategy.

The unit and psychiatric care expenses represent the majority of total health care costs at $351 million or 52%, hospital and clinical care at $250 million or 37%, and pharmacy services at $68.8 million or 10% of total expenditures.

Mr. Steffa reported on hospital and clinical care revenues of $213 million and expenditures of $250 million leaving a shortfall of $37.5 million in the strategy.

Managed health care pharmacy revenues of $63 million and expenditures of $68.8 million leaving a shortfall of $5.6 million in the strategy.

Mr. Steffa next reported on the details for the combined Dr. Linthicum asked Mr. Steffa if the amount summary for both universities. For the year in totality, there totaling $265 thousand was the health care was a shortfall of $33.7 million for FY 2017. FY 2017 spend services cost fee. forward to cover the shortfall in FY 2016 were received, and

the LBB approved to move FY 2017 monies to cover FY 2016 Mr. Steffa responded yes. The annual health Page 12 of 163 monies in the amount of $48 million. Excess health care fees care fee charged to the offenders required to be were collected above the required amount totaling $265 collected is $2 million which is a part of the thousand. The requested supplemental of $80 million was appropriations. Any amount above that is applied leaving a net difference to date of $1.5 million. The appropriated to us to offset health care costs. UTMB final FY 2017 Hospital Cost Reconciliation report will Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial be ready to report between January and February 2018 Dr. Linthicum asked Mr. Steffa does the other Reports (Cont.) timeframe to show the final results for the end of the year. $2 million go back to general revenue. - Ron Steffa Mr. Steffa responded no. The amount of $2 million is included in the appropriations. Mr. Steffa next reported on the TDCJ CMHC annual trending data FY 2011-FY 2017 giving 7 years of information by the strategies as they are found in the General Appropriations Act.

The unit and psychiatric care between FY 2016 and FY 2017 on the unit side was a 7% increase and a 3.8% increase for psychiatric.

The hospital and clinical care annual trending showed the Dr. Linthicum asked Mr. Steffa if he could changes over the years for West Texas Regional Medical explain to the two new CMHCC members that Facility (RMF), Hospital Galveston, and Community West Texas RMF is not in fact a hospital but a Hospitals. Comparing FY 2016 and FY 2017 showed a part of the Montford Unit. decrease in overall costs for community hospitals at approximately 3.4%, Hospital Galveston increased slightly to 4.3%, and West Texas RMF decreased slightly at 3.5%. Mr. Steffa responded yes. The West Texas RMF Overall, there was a cost increase in hospital and clinical care technically is not a hospital; however, the West of 1.5%. Texas RMF has a higher level of acuity of services that they provide. It historically has been funded in the hospital strategy. We are appropriated through the General Appropriations Act. Monies for correctional managed care is in the three strategies: unit and psychiatric care, hospital and clinical care, and pharmacy services. West Texas RMF is a unit based facility that is funded in the hospital strategy.

Dr. Linthicum clarified that West Texas RMF is a part of the Montford Unit. Page 13 of 163 Mr. Steffa agreed with Dr. Linthicum adding that West Texas RMF is unique in that perspective.

Dr. Mills asked Mr. Steffa if a better breakdown could be given to explain the $72.7 million for Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial community hospitals to show which units the Reports (Cont.) patients came from with patient demographics. - Ron Steffa Dr. Linthicum responded yes. There are quarterly meetings with each university. UTMB does daily hospital reports that details how many patients are offsite every day. UTMB has provider network of approximately 148 hospitals that they cover. Texas Tech provider network covers approximately 49 hospitals. Dr. Linthicum further added that a list of hospitals that are utilized can be provided as well as snapshots of how many patients are seen offsite at community hospitals.

Dr. Mills stated that his concern is about if anything can be done to make sure that the inmates who are at risk for being hospitalized move closer to university facilities.

Dr. Linthicum stated there is a utilization review management system in place. Dr. Ojo, Chief Medical Officer at Hospital Galveston, and his staff work closely with the provider network to move patients in, preferentially to the prison hospital in Galveston when it is necessary.

Dr. Linthicum stated that there is a similar utilization review management system in West Texas with Dr. DeShields and her staff where patients are moved to access the university medical center in Lubbock. Dr. Linthicum added that attention is paid closely to this issue.

Dr. Linthicum further added that the financial Page 14 of 163 compensation for these hospitals were outlined in statute. Dr. Linthicum asked Mr. Steffa to explain about Rider 47.

Mr. Steffa responded yes. Rider 47 is in the General Appropriations Act that specifies for Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial community hospitals that payments shall be at Reports (Cont.) 100% of their Medicare rate unless an exception - Ron Steffa has been requested and approved by the Legislative Budget Board (LBB). There are some hospitals that have requested a rate above 100% when that went into effect.

Mr. Steffa stated that the universities that contracted with the hospitals had negotiated rates. When Rider 47 came into place, those rates went to 100% of Medicare for those hospitals that were not accepting this. The universities then looked for alternate hospitals. The hospitals said no and that they would not accept 100% of Medicare. They looked for an alternative hospital to see if one was available that would accept 100% of Medicare. If so, we would go with that hospital. In some cases, the distance of the hospital would cause additional travel. However, it was deemed that it would be necessary to contract for those services at those hospitals. A request was made to the LBB for them to approve over the 100% of the Medicare rate. The hospitals are reimbursed at the Medicare rate or at their approved percent of Medicare.

Mr. Steffa explained that this is done on the reimbursement side. The utilization review management system looks at the volume and determines where the patients go as well as utilizing Hospital Galveston that UTMB has.

Dr. Raimer stated that one of the things that

UTMB has tried to do over the years is to take Page 15 of 163 patients with certain chronic diseases who require immediate hospitalizations, whether someone is on chemotherapy, have chronic liver disease, or have congested heart failure. First, we try to group these patients into clusters at units that have expertise in taking care of their Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial diseases at a higher level. Secondly, we try to Reports (Cont.) move them close to a hospital if they need to be hospitalized.

Dr. Raimer informed the committee that one practice that both medical directors, Dr. DeShields and Dr. Murray, have done is relegate to the individual units and the regional medical centers more training and expertise in their staff. Some are performing paracentesis on patients with liver failure to keep these patients out of the hospital.

Dr. Raimer stated that we have been trying to continue this practice. It is a good opportunity to look at some of the areas that were suggested and with Dr. Mills experience in Corrections to see if there are other opportunities for improvement. Many improvements are being done as much as possible at the local units to keep patients from being transferred offsite because of the security issues. We have worked really well with TDCJ when the offenders are offsite in a non-secure facility, and the security requirements of a correctional officer increases quickly. We try to send as many patients as we can to the regional medical facilities or to Hospital Galveston where it is secure.

Dr. Linthicum stated that a medical hub system was created for offenders. Every unit has a medical mission, and we know the level of care that each unit can provide. We create centers of clinical excellence on various units. The

regional medical facilities are the centers for Page 16 of 163 providing a multitude of services. In addition to that, we have created medical hubs where offenders are actually diverted for evaluation. The offenders are physically triaged and assessed, and a decision is made whether or not to send them to an emergency room. Through Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial that process, approximately 70-75% of Reports (Cont.) offenders are actually returned to their units of - Ron Steffa assignment and never go offsite.

Mr. Steffa continued the report on the hospital and clinical care costs. Between FY 2016 and FY 2017, there was a decrease in volume in community hospitals of approximately 4% overall.

Mr. Steffa reported on the annual trending data for pharmacy. Between FY 2016 and FY 2017, there was an increase of approximately 6.9% for pharmaceuticals and a 3.1% increase for pharmaceuticals operations.

Mr. Steffa next reported on the annual trending data for the Dr. Linthicum stated that we have a lot of average daily population that served. The average daily specialized populations and centers of clinical population has decreased between FY 2011 to FY 2016 to excellence where offenders are cohorted in order approximately 6,500 offenders or 4.2% in the population to deliver services more effectively and to being served. Mr. Steffa noted that for next year the East access tertiary care more efficiently. Texas Treatment Facility would be added to the UTMB contract that was health care provided through the contract with a private vendor. There will be an increase in the population because of this additional facility being on the Correctional Managed Health Care.

Mr. Steffa reported on the cost per day charts that showed Dr. Murray stated that trending down is good as pharmaceuticals cost per patient per day increase of 7.6% it relates to the population decrease seen in FY between FY 2016 and FY 2017. Overall, cost per day 2016. However, one of the points of discussion increased to 5.1% of $12.55 in FY 2017. today have been the growth of offenders aged 55 and older.

Mr. Steffa responded that a decrease has not been seen specifically in the age group 55 and older. As that age group continues to grow, it is

suspected at some point to plateau and level off. Page 17 of 163 However, it has been growing for a while.

Dr. Linthicum added that the facilities closed did not have many geriatric offenders. The reason why the population decreased is because four units were closed this past Legislative Session. Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial Dr. Raimer asked Dr. Linthicum what area of Reports (Cont.) cancer care has seen a fairly dramatic rise in cost.

Dr. Linthicum responded the standard of care has changed as it relates to cancer medications and treatments. There were four transplants at one time this year and stem cell transplants continue to rise.

Dr. Murray responded that age is driving more patients to having a diagnosis of cancer. The treatment has changed. More and more the standard of care is moving towards stem cell transplants and other forms of therapy that historically have not been covered in the benefit plan. The total number of stem cell transplants through the last fiscal year is approximately 6, and this number keeps rising.

Dr. Linthicum added that almost every month an offender has been sent to MD Anderson for a stem cell transplant.

Dr. Murray stated that looking at the trend in pharmaceuticals, cancer is becoming a chronic disease given some of the newer drugs. Some of the newer drugs have great promises and great results, but they also have great costs being chronic medications. The trend in spending in terms of pharmaceutical cost and hospital care, given that there is not going to be a change in the age demographics is still an issue that we all Page 18 of 163 have to continue to address. More detailed information will need to be given about the growth of some of the disease states, and the related costs. Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial Dr. Raimer suggested that at some point when Reports (Cont.) dealing with an increasing number of transplants, it would be good to go to the entity providing the transplants to ask for a discount on the prices.

Dr. Linthicum stated that MD Anderson is used exclusively for transplants but unsure about Texas Tech. Texas Tech probably uses UMC for transplants, but they have a smaller number.

Dr. Jumper stated that Texas Tech used to perform transplants at UMC and had a good cost break. Texas Tech closed their stem cell unit because of two competing transplant programs in Lubbock. The numbers were small. The larger stem cell transplant programs in Lubbock has stayed in the private sector, and Texas Tech has approached this private vendor several times. The staff says yes but the medical directors says no. They are not willing to do stem cell transplants on TDCJ offenders; therefore the offenders are being transferred to the UTMB sector.

Dr. Jumper also stated that they will try to go back to the private sector in Lubbock to see if they will take TDCJ patients again.

Dr. Murray stated that UTMB does not always get Texas Tech high acuity patients because the cost of care is less expensive there. UTMB was going to shift from MD Anderson to a West Page 19 of 163 Texas provider but it did not materialize. UTMB always shop around for the next best deal and it would be helpful to get better rates from MD Anderson. Agenda Topic / Presenter Presentation Discussion Action

IV. Update on Financial Dr. Raimer stated that we tend to lump all Reports (Cont.) cancers into the older people aged 55 and older. A number of patients this year have been ages less than 50 who had leukemia and some of these cancers are shifted to the younger people.

Dr. Linthicum agreed with Dr. Raimer, and she added that there has been a number of younger V. Summaries of Critical Dr. de la Garza-Grahm then called on Dr. Linthicum to begin leukemia and lymphoma patients. Correctional Health Care the presentation of the TDCJ’s Critical Correctional Health Personnel Vacancies Care Personnel Vacancies.

- Dr. Lannette Linthicum Dr. Linthicum informed the committee that she would introduce key health care staff throughout the presentation to Dr. Hudson and Dr. Mills.

Dr. Linthicum first introduced Chris Black-Edwards RN, Ms. Black-Edwards gave the report on vacant BSN TDCJ Chief Nursing Officer to update the committee on positions in her department. She updated the vacancies in her department. committee on which positions had been interviewed and are in the clearance process awaiting a background check. Dr. Linthicum stated that the Hilltop Unit was shut down during the hiring freeze, and Texas Tech stepped in to assist with the correspondences. Dr. Linthicum also stated that the Patient Liaison Program answers all patient health care complaints whether it comes from third-parties, patient advocacy groups, inmate families, lawyers, and legislators. These are the positions that interview the offenders and review the medical records in order to respond to the

complaints. Page 20 of 163

Dr. Linthicum reported on the Investigator II position in the Ms. Black-Edwards responded that the positon Patient Liaison Program at the Stiles unit and asked Ms. is closed. The applications are being reviewed Black-Edwards what was the status of this positon. and interviews will be scheduled. Agenda Topic / Presenter Presentation Discussion Action

V. Summaries of Critical Dr. Linthicum reported on the Nurse II position in the Office Ms. Black-Edwards stated that interviews were Correctional Health Care of Health Services Monitoring. conducted last week, and a candidate would be Personnel Vacancies (Cont.) presented to Dr. Linthicum after the meeting. Dr. Linthicum reported that there is an Investigator III Ms. Black-Edwards stated that an interview is - Dr. Lannette Linthicum position vacant in the Office of Professional Standards at the pending and will be scheduled soon. Huntsville location.

Dr. Linthicum reported that the Deputy Division Director in Health Services is a physician position that is currently posted.

Dr. Linthicum reported that there are two vacant Health Ms. Winegar stated that there are two applicants Specialist V positions in the Office of Mental Health and interviews are in the process of being Monitoring and Liaison and asked Ms. Teresa Winegar, scheduled. Manager III about the status of these positions.

Dr. Linthicum reported that the Program Supervisor V position will support the correctional managed health care committee. That position has been hired and is here with us today, Ms. Renee Warren.

The Director II position in the Office of Public Health is a Registered Nurse position. This positon is currently on hold. However; Ms. Black-Edwards is currently serving in this capacity.

- Dr. Cynthia Jumper on Dr. Jumper reported that Texas Tech had one critical vacancy behalf of Dr. DeShields which was the Medical Director at the Smith Unit. The position was filled, and the new hire started October 1.

- Dr. Owen Murray Dr. Murray reported that he will first discuss the filled positions for the new CMHCC members.

Dr. Murray introduced Dr. Monte Smith, UTMB CMC Medical Director for Inpatient Operations, Dr. Joseph Penn, UTMB CMC Mental Health Director, Ms. Marjorie Kovacevich, UTMB CMC Associate Vice President of

Inpatient Services, Dr. Olugbenga Ojo, UTMB CMC Chief Page 21 of 163 Medical Director at Hospital Galveston, Dr. Stephanie Zepeda, UTMB CMC Associate Vice President for Pharmacy Services, Kelly Coates, UTMB CMC Associate Vice President for Clinical Support Services, Mr. David Agenda Topic / Presenter Presentation Discussion Action

V. Summaries of Critical Connaughton, UTMB CMC Chief Financial Officer, Mr. Correctional Health Care Ryan Micks UTMB CMC Director of Legislative Affairs, Dr. Personnel Vacancies (Cont.) Billy Horton, UTMB CMC Dental Director, Dr. Jessica Khan, - Dr. Owen Murray UTMB CMC Infectious Disease Physician, and Mr. Anthony Williams, UTMB CMC Associate Vice President of Outpatient Services.

Dr. Murray reported that UTMB vacancies remain unchanged, and the senior leadership staff positions remain stable.

VI. Medical Director’s Updates Dr. de la Garza-Grahm then called on Dr. Linthicum to present the TDCJ Medical Director’s Report. - TDCJ – Health Services Division FY Dr. Linthicum began by explaining that the TDCJ Medical 2017 Fourth Quarter Director’s report focuses on the Fourth Quarter FY 2017 Report (June, July and August 2017). During this quarter, -Dr. Lannette Linthicum Operational Review Audits (ORAs) were conducted at the following 9 facilities: Formby, Hobby, Kegans Intermediate Sanction Facility (ISF), Marlin, Montford (PSYCH/RMF), Pack, Polunsky, Wallace, and Wheeler. Dr. Linthicum referenced the 6 items found to be most frequently below the 80 percent compliance, and corrective actions have been requested on all of these items.

- Capital Assets Dr. Linthicum reported that the Fixed Assets Contract Monitoring Monitoring officer audited the same 9 facilities listed above for ORA’s during the Fourth Quarter of FY 2017 and all 9 facilities were within the required compliance range. The Capital Assets Monitoring Program continues to do very well.

- Dental Quality Review Dr. Linthicum reported that the Dental Quality Review Audits Dr. de la Garza-Graham asked Dr. Linthicum to Audit conducted by Dr. Hirsch were done at 11 facilities. Item 20 explain the meaning of the 80 percent threshold was the item found to be the most frequently below the 80 level to the new CHMCC members. percent threshold. Item 20 requires that if panoramic Dr. Linthicum responded the 80 percent radiographs were taken during in-processing (intake) that they threshold was arbitrarily set by the Correctional

be currently available at the facility. Corrective actions were Page 22 of 163 requested. Dr. Linthicum explained that there are 24 intake Managed Health Care Committee at the units and on a yearly basis there are approximately 70,000 inception of the program. The goal threshold is intakes a year. of course 100 percent compliance level. However, UTMB, Texas Tech, and TDCJ Agenda Topic / Presenter Presentation Discussion Action

VI. Medical Director’s Updates agreed that 80 percent compliance level would (Cont.) be acceptable or satisfactory. Corrective actions are requested if the threshold falls below the 80 percent compliance range.

- Grievances and Patient Dr. Linthicum introduced Ms. Myra Walker, BSN, RN, TDCJ Liaison Correspondence Chief of the Office of Professional Standards Patient Liaison Program. Dr. Linthicum then reported that the Office of Professional Standards operates the Family Hotline, the Patient Liaison Program (PLP), Step II Medical Grievance Program, and Sick Call Request Verification Audit process. During the Fourth Quarter, the PLP and the Step II Medical Grievance received 4,389 correspondences. The PLP received 3,094 correspondences and Step II Grievance received 1,295. There were 248 Action Requests generated. The percentage of sustained Step II Medical grievances from UTMB was seven percent and eight percent for TTUHSC.

- Quality Improvement There were 18 Sick Call Request Verification Audits (QI) Access to Care conducted on 17 facilities. A total of 153 indicators were Audit reviewed and 9 of the indicators fell below 80 percent compliance. Corrective actions were requested.

- Office of Public Health Dr. Linthicum continued by explaining that the Office of Public Health conducts surveillance for infectious and communicable diseases within TDCJ as well as reporting to the Department of State Health Services (DSHS). During the Fourth Quarter, there were 16,600 intake HIV tests performed. Of those tested, 197 offenders were newly identified as having HIV infection. During the same time period, there were 9,193 pre-release tests performed with none found to be HIV positive. For this quarter, 13 new AIDS cases were identified.

There were 624 cases of Hepatitis C identified for the Fourth Quarter FY 2017. Page 23 of 163 124 cases of suspected Syphilis were reported. 66 cases required treatment or retreatment. Agenda Topic / Presenter Presentation Discussion Action

VI. Medical Director’s Updates 216 Methicillin-Resistant Staphylococcus Aureus (MRSA) (Cont.) cases were reported for the Fourth Quarter FY 2017. - Office of Public Health Dr. Linthicum reported that there was an average of 20 Tuberculosis (TB) cases under active management for the Fourth Quarter FY 2017.

Dr. Linthicum next reported that the Office of Public Health employs a Sexual Assault Nurse Examiner (SANE) Coordinator which collaborates with the Safe Prisons Program and is trained and certified by the Texas Attorney General’s Office. This person provides in-service training to facility staff in the performance of medical examinations, evidence collection and documentation and use of the sexual assault kits.

This position also audits the documentation and services provided by medical unit personnel for each sexual assault reported. During the Fourth Quarter FY 2017, there were 182 chart reviews of alleged sexual assaults. There were 38 deficiencies found this quarter and corrective actions have been requested. 50 blood-borne exposure baseline labs were drawn on exposed offenders. To date, no offenders have tested positive for HIV in baseline labs routinely obtained after the report of sexual assault.

Dr. Linthicum reported that during the Fourth Quarter FY 2017, 6 units received a 5 day training which included the Wall Talk Training and the Somebody Cares Training in the Peer Education Program. In the month of July 2017, one unit received a three day training which included the Wall Talk Training. As of the close of the Fourth Quarter of FY 2017, 99 of the 105 facilities housing Correctional Institutions Division (CID) offenders had active peer education programs. During this quarter, 47 offenders were trained to become peer educators, and 20,456 offenders attended the classes

presented by peer educators. Page 24 of 163

- Mortality and Morbidity Dr. Linthicum reported that the Morbidity and Mortality committee is a joint committee consisting of the three partners: UTMB, Texas Tech and TDCJ. Dr. Ojo and Dr. Agenda Topic / Presenter Presentation Discussion Action

VI. Medical Director’s Updates Millington are the co-chairs. 113 deaths were reviewed during (Cont.) the months of June, July, and August of 2017. Of those 113 deaths, 6 were referred to peer review committees. 4 cases were referred to provider peer review and 2 cases were referred to nursing and provider peer review.

- Office of Mental Health Dr. Linthicum next provided a summary of the activities Monitoring & Liaison performed by the Office of Mental Health Monitoring & Liaison (OMHM&L) during the Fourth Quarter of FY 2017. Administrative Segregation (Ad Seg) audits were conducted on 16 facilities. 2,138 offenders were observed, 2,701 were interviewed, and one offender was referred to the university providers for further evaluation. Access to Care (ATC) for mental health ATC four and five were met at 100 percent at 15 of the 16 facilities.

The OMHM&L also monitors all instances of compelled psychoactive medication to offenders to ensure that we have followed appropriate procedures for documentation purposes. Compelled psychoactive medications are only done at the outpatient psychiatric units. For the Fourth Quarter FY 2017, 53 instances of compelled psychoactive medication administration occurred. There were 11 instances at Montford, 32 at Skyview, 9 at Jester IV, and one at the Bill Clements unit. All units were 100 percent compliant.

The Intake Mental Health Evaluation audit conducted by Dr. Linthicum informed the committee that the OMHM&L is designed to provide reasonable assurance that corrections mental health population is offenders coming in at intake are identified as having a constantly being talked about and that prisons potential mental health need and receive a Mental Health are said to have become the de facto mental Evaluation within 14 days of identification. Audits were health hospitals. TDCJ has 2,000 inpatient conducted at 28 intake facilities and 26 facilities identified psychiatric beds; 605 male offenders are incoming offenders in need of Mental Health Evaluations. 20 of the 26 facilities met or exceeded the 80 percent cohorted on one unit that have developmental compliance for completing Mental Health Evaluations within disabilities, 100 female offenders in the 14 days of identified need. developmental disability program at the Crain unit, and approximately 24,000 offenders are on Page 25 of 163 the outpatient mental health caseload. The mental health patients keep coming into the Texas criminal justice system. This is an area of diminishing resources and bed capacity. Agenda Topic / Presenter Presentation Discussion Action

VI. Medical Director’s Updates The last TDCJ inpatient psychiatric facility built (Cont.) was the Montford unit in 1995. In terms of going forward with the Legislative Action Plan, another inpatient psychiatric facility will have to be considered. - Office of the Health Dr. Linthicum reported that the Office of Health Services Services Liaison Liaison (HSL) conducted 164 hospital and 43 infirmary discharge audits. UTMB had 45 deficiencies identified and 6 from TTUHSC identified for the hospital discharge audits. UTMB had 7 deficiencies identified and TTUHSC had 1 for the infirmary discharge audits.

- Accreditation Dr. Linthicum reported that the ACA Summer Congress of Corrections was held in St. Louis, Missouri on August 18-22, 2017. During this conference, the following facilities were represented: Byrd, Clements, Daniel, Formby/Wheeler, Jester Complex, Ramsey, Roach, Skyview/Hodge, Smith, and Wynne. TDCJ has the Golden Eagle Award which means that all aspects of the agency are fully accredited.

- Biomedical Research Dr. Linthicum reported on the summary of active and pending Projects biomedical research projects as reported by the TDCJ Executive Services. The CID has 28 active and 6 pending biomedical research projects. The Health Services Division has 8 active and 4 pending biomedical research projects.

- Texas Tech University Dr. de la Garza-Grahm thanked Dr. Linthicum then called on Health Sciences Dr. Jumper to present the report for TTUHSC. Center

- Dr. Cynthia Jumper on Dr. Jumper reported that there were no updates on the behalf of Dr. Denise percentage end. DeShields

- University of Texas Dr. de la Garza-Grahm thanked Dr. Jumper and then called on

Medical Branch Dr. Murray to present the report for UTMB. Page 26 of 163

- Dr. Owen Murray Dr. Murray reported that there were no further updates. Agenda Topic / Presenter Presentation Discussion Action

VII. Disease Management Dr. Zepeda reported on the Hepatitis C Policy and Program. Guideline and Policy Presentation Hepatitis C The Hepatitis C Workgroup is a multidisciplinary team with Chronic (Revision) representatives from UTMB, Texas Tech, and TDCJ. The - Dr. Stephanie Zepeda Hepatitis C disease management guideline was approved by the Joint Pharmacy & Therapeutics Committee in November.

The rationale for policy changes is due to the FDA approval of the new oral direct acting antivirals (DAAs). National guidelines no longer recommend dual therapy with peginterferon plus ribavirin (PEG/RBV), PEG/RBV plus boceprevir or telaprevir, or PEG as part of an oral regimen with DAAs. The new therapies have a higher cure rate of approximately 95% for the healthier patients, shorter duration of treatment at 12 weeks instead of 6 to 12 months, and are better tolerated. However, the new therapies are more expensive.

Chronic hepatitis C is a significant burden in the United States Dr. Linthicum stated that this is a diagnosed (U.S.). There is an increase in prevalence with an increase in prevalence. A TDCJ seroprevalence study was age, and a substantially higher burden in the prison and jail conducted with the University of Texas Health population. The prevalence rates is 1-1.5% for the U.S. Sciences Center at Houston, and the Texas population and 12.3% for the TDCJ population. The genotype Department of Health in 2001 that demonstrated distribution mirrors the U.S. general population with the 30% of the incoming offenders to TDCJ are majority of patients having genotype 1. infected with Hepatitis C. The 12.3% is the actual diagnosed prevalence rate. Chronic hepatitis C also has a significant economic burden. The American Association for the Study of Liver Diseases (AASLD) conducted a study that reported medical costs to double over the next 20 years, and the death rates to triple. The rationale for treatment is starting to be seen in the TDCJ population. In FY 2017, 12.8% of the TDCJ drug budget cost was approximately $6.9 million. This percent will continue to rise as the infrastructure for treating these complex patients continues to grow. Dr. Zepeda reported that treating hepatitis C protects the

public. Patients in state prisons are expected to return to the Page 27 of 163 community and over 67,000 offenders were released from TDCJ in FY 2016. Achieving a cure has been shown to prevent disease progression, development of hepatocellular carcinoma (HCC), deaths, and leads to long-term cost savings. Agenda Topic / Presenter Presentation Discussion Action

VII. Disease Management Dr. Zepeda next reported on the trend of TDCJ population Guideline and Policy with end stage liver disease. These are patients with ascites Presentation Hepatitis C and hepatic encephalopathy. Hepatitis is the third leading Chronic (Revision) (Cont.) cause of death in state prisons, and the majority of TDCJ - Dr. Stephanie Zepeda patients have chronic hepatitis C.

Dr. Zepeda reported on the trend of TDCJ liver cancer deaths. The trend continues to rise but there was a downtick in 2016.

Dr. Zepeda next reported on the policy changes. Dr. Zepeda Dr. Linthicum asked Dr. Zepeda what will be clarified how patients would be treated once therapy was done about the alert code for patients being finished and considered clinically cured. Patients that are discharged out of the of hepatitis C chronic care asymptomatic would be discharged from the hepatitis C program. chronic care clinic. Patients with end stage liver disease, such Dr. Jessica Khan responded that there is a new as cirrhosis or abnormal liver function tests, will be kept in the alert code that says hepatitis B or C result. hepatitis C chronic care clinic. These patients will also continue to be followed by the UTMB virology team.

Dr. Zepeda reported that Epclusa is now used for all genotypes. However, Mavyret for chronic kidney disease stages 4 and 5, and Vosevi for patients who are treatment experienced are other agents that may be used. Both of these agents are significantly expensive and their use will be limited.

Dr. Zepeda next reported on the cost of these drugs compared Dr. Linthicum stated that an inquiry was to the UTMB and Texas Tech sectors. UTMB incremental received from Senate Finance regarding why cost treating 400 patients for hepatitis C is approximately $8.7 Mavyret was not being used in TDCJ. It was million. This cost is a projection based on the assumption that explained that it was more expensive than the these patients will receive 12 weeks of Epculsa therapy. other agents. Dr. Linthicum also stated that UTMB uses 340B pricing versus Texas Tech, and asked Dr. Zepeda to clarify the pricing for the two new CMHCC members.

Dr. Zepeda responded that UTMB qualifies for the federal 340B discount program through its Page 28 of 163 eligibility as a disproportionate share hospital. This is one of the benefits of the relationship that Correctional Managed Health Care has with Agenda Topic / Presenter Presentation Discussion Action

VII. Disease Management UTMB. Sub-ceiling 340B pricing is actively Guideline and Policy negotiated, and the Epculsa price is lower than Presentation Hepatitis C the 340B price. The Epculsa price is a sub- Chronic (Revision) (Cont.) ceiling contracted price that was negotiated by UTMB Pharmacy Services office.

Dr. Linthicum stated that the 340B Epculsa price is outstanding compared to what other Department of Corrections are paying.

Dr. Jumper stated that these costs are not incurred at Texas Tech because they do not treat them. 340B savings are maximized by UTMB, and Texas Tech does not incur these costs. - Dr. Stephanie Zepeda Dr. Zepeda next reported on the patient management strategy. 18,399 patients have been identified with chronic hepatitis C. 4,554 patients meet priority criteria including F3-F4 fibrosis, co-infection with HIV, and, or extra-hepatic manifestations. The sickest patients are treated first and then other patients will be treated according to acuity.

Dr. Zepeda continued to report on the patient management strategy. Patients will continue to be treated in the UTMB sector to maximize 340B savings. Patient caseload will be managed directly by the UTMB virology team through Dr. Khan. Patients receiving treatment are moved to centers of excellence where the nursing staff, and the primary care providers have been trained on how to manage these patients. The centers of excellence ensure that these patients are closely monitored, adherent to therapy in order to avoid resistance, and prevent therapy disruptions. The centers of excellence for male offenders are at Stiles, Jester III, and Dominguez unit. The centers of excellence for female offenders are at Young and Woodman unit.

Dr. Zepeda next reported on the outcomes of the current Page 29 of 163 hepatitis C program. In March 2017, the preferred DAA therapy changed with Epclusa replacing Harvoni. In September 2015, Correctional Managed Health Care began Agenda Topic / Presenter Presentation Discussion Action

VII. Disease Management the use of these new DAA oral regimens. 282 patients have Guideline and Policy been started on therapy. Presentation Hepatitis C Chronic (Revision) (Cont.) 105 patients are midcourse or awaiting outcome assessment - Dr. Stephanie Zepeda 12 weeks after completing therapy. Through the Fourth Quarter of FY 2017, 177 patients are on therapy long enough to achieve cure. 18 patients are deceased, released, or discontinued treatment. 1 patient refused the final viral load at the end of treatment. 24 patients failed treatment. 134 patients approximately 84.8%, achieved cure.

- Dr. Margarita de la Garza-Grahm Dr. de la Garza-Grahm then called for a motion to approve the Dr. Jumper made a motion revisions of the Hepatitis C Policy and Program. to approve the revisions of the Hepatitis C Policy and Program, and Dr. Raimer seconded the motion which prevailed by unanimous vote. VIII. Public Comments Dr. de la Garza-Grahm noted that in accordance with the Dr. Raimer announced that UTMB continues to - Dr. Margarita de la Garza-Grahm CMHCC policy, during each meeting the public is given the work with the Legislative Delegation and others opportunity to express comments- hearing none; she then from Texas regarding the 340B pricing. There is acknowledged Dr. Raimer to make an announcement to the committee. a move by large pharma to remove the 340B program entirely which would cost UTMB approximately $119 million a year. This would be a huge increase to the Correctional Managed Health Care budget. The Governor’s Office has been notified about this and UTMB has received help.

Dr. de la Garza-Grahm next acknowledged Dr. Jumper to Dr. Jumper introduced Mr. Will Rodriguez, make an announcement to the committee. Texas Tech Senior Managing Director, and Dr. Barbara Beadles, Texas Tech Mental Health Director to the two new CMHCC members. IX. Adjourn Dr. de la Garza-Grahm then called for a motion to adjourn the Dr. Linthicum made a

meeting. motion to adjourn the Page 30 of 163 meeting, and Dr. Jumper seconded the motion which prevailed by unanimous vote. Agenda Topic / Presenter Presentation Discussion Action

Dr. de la Garza-Grahm thanked everyone for their attendance and adjourned the meeting. Dr. de la Garza-Grahm announced that the next CMHCC meeting is scheduled for March 20, 2018 in Dallas Texas.

The meeting was adjourned at 11:33 a.m.

______Margarita de la Garza-Grahm, M.D., Chairperson Date Correctional Managed Health Care Committee Page 31 of 163 Page 32 of 163

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Consent Item

TDCJ Health Services Monitoring Reports Page 34 of 163

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TEXAS DEPARTMENT OF CRIMINAL JUSTICE

HEALTH SERVICES DIVISION

QUARTERLY MONITORING REPORT

FIRST QUARTER FISCAL YEAR 2018 (SEPTEMBER, OCTOBER AND NOVEMBER 2017) Page 36 of 163

[This page left blank intentionally for pagination purposes.] Page 37 of 163

Rate of Compliance with Standards by Operational Categories First Quarter, Fiscal Year 2018 September - November 2017 Operations/ General Coordinator of Administration Medical/Nursing Infectious Disease Dental Mental Health Fiscal Unit Items 80% or Items 80% or Items 80% or Items 80% or Items 80% or Items 80% or Greater Greater Greater Greater Greater Greater n Compliance n Compliance n Compliance n Compliance n Compliance n Compliance Beto 33 33 100% 12 10 83% 30 24 80% 11 10 91% 14 13 93% 6 6 100% Cleveland 32 32 100% 13 13 100% 26 24 92% 11 11 100% 1 1 100% 4 4 100% Coffield 33 32 97% 13 12 92% 29 20 69% 9 9 100% 16 12 75% 6 5 83% Daniel 33 33 100% 13 12 92% 21 21 100% 10 10 100% 14 11 79% 4 4 100% Dominguez 33 33 100% 15 15 100% 40 35 88% 11 11 100% 15 15 100% 4 4 100% Ney 30 29 97% 13 13 100% 16 15 94% 11 11 100% 2 2 100% 4 4 100% San Saba 33 33 100% 13 12 92% 23 21 91% 10 9 90% 14 13 93% 5 5 100% Smith 41 41 100% 19 17 89% 25 16 64% 18 17 94% 27 26 96% 8 8 100% Torres 31 31 100% 13 13 100% 2523 21 91% 11 11 100% 2 2 100% 124 4 100% n = number of applicable items audited. Page 38 of 163

Compliance Rate By Operational Categories for BETO FACILITY October 02, 2017

HSR-110 Page 39 of 163

Compliance Rate By Operational Categories for CLEVELAND FACILITY November 01, 2017

HSR-110 Page 40 of 163

Compliance Rate By Operational Categories for COFFIELD FACILITY October 18, 2017

HSR-110 Page 41 of 163

Compliance Rate By Operational Categories for DANIEL FACILITY September 13, 2017

HSR-110 Page 42 of 163

Compliance Rate By Operational Categories for DOMINGUEZ FACILITY November 07, 2017

HSR-110 Page 43 of 163

Compliance Rate By Operational Categories for NEY FACILITY November 07, 2017

HSR-110 Page 44 of 163

Compliance Rate By Operational Categories for SAN SABA FACILITY September 18, 2017

HSR-110 Page 45 of 163

Compliance Rate By Operational Categories for SMITH FACILITY September 12, 2017

HSR-110 Page 46 of 163

Compliance Rate By Operational Categories for TORRES FACILITY November 07, 2017

HSR-110 Page 47 of 163

Dental Quality of Care Audit Urgent Care Report For the Three Months Ended November 30, 2017

Urgent Care Definition: Individuals, who in the dentist’s professional judgment, require treatment for an acute oral or maxillofacial condition which may be accompanied by pain, infection, trauma, swelling or bleeding and is likely to worsen without immediate intervention. Individuals with this designation will receive definitive treatment within 14 days after a diagnosis is established by a dentist. Policy CMHC E 36.1

Offenders receiving Charts Assessed by Offenders identified as Facility Urgent Care Score * TDCJ as Urgent treatment but not within timeframe ** needing definitive care*** Baten ISF 10 100% 0 0

Connally 10 90% 1 0

Dalhart 10 100% 0 0

Ellis 10 90% 1 0

Garza 10 100% 0 0

Jordan 10 100% 0 0

McConnell 10 80% 2 0

Roach 10 100% 0 0

Stevenson 10 100% 0 0

Tulia 10 100% 0 0

* Urgent Care score is determined: # of offenders that had symptoms and received definitive treatment with 14 days = 100% Total # of offenders in audit. ** A Corrective Action is required by TDCJ Health Services if the Urgent Care score is below 80% *** A Corrective Action is required by TDCJ Health Services giving the date and description of definitive care. PATIENT LIAISON AND STEP II GRIEVANCE STATISTICS QUALITY OF CARE/PERSONNEL REFERRALS AND ACTION REQUESTS STEP II GRIEVANCE PROGRAM (GRV) Total numberof Action Total number of Action Total number of Total number of Total number of Percent of Action Requests Referred to Requests Referred to Texas GRIEVANCE GRIEVANCE Action Requests Requests from University of Texas Tech University Health Fiscal Correspondence Correspondence (Quality of Care, Total # of Medical Branch- Sciences Center- Year Received Each Closed Each Personnel, and GRIEVANCE Correctional Managed Correctional Managed 2018 Month Month Process Issues) Correspondence Health Care Health Care

Percent of Percent of Total Action Total Action Requests Requests Referred QOC* Referred QOC* September 440 422 19 4.50% 13 4.03% 4 0 0.47% 2 October 570 495 31 6.26% 17 4.65% 6 7 1.62% 1 November 520 412 21 5.10% 13 4.13% 4 2 0.97% 2 Totals: 1,530 1,329 71 5.34% 43 4.29% 14 9 1.05% 5

PATIENT LIAISON PROGRAM (PLP) Total numberof Total numberof Percent of Action Total number of Action Total number of Action Patient Liaison Patient Liaison Total number of Requests from Requests Referred to Requests Referred to Texas Program Program Action Requests Total number of University of Texas Tech University Health Fiscal Correspondence Correspondence (Quality of Care, Patient Liaison Medical Branch- Sciences Center- Year Received Each Closed Each Personnel, and Program Correctional Managed Correctional Managed 2018 Month Month Process Issues) Correspondence Health Care Health Care

Percent of Percent of Total Action Total Action Requests Requests Referred QOC* Referred QOC* September 916 829 18 2.17% 16 2.17% 2 0 0.00% 0 October 1,082 1,041 35 3.36% 17 2.59% 10 4 0.77% 4 November 857 829 17 2.05% 3 1.57% 10 0 0.48% 4 Totals: 2,855 2,699 70 2.59% 36 2.15% 22 4 0.44% 8 GRAND TOTAL= 4,385 4,028 141 3.50% Page 48 of 163 *QOC= Quality of Care

Quarterly Report for 1st Quarter of FY2018 Page 49 of 163

Texas Department of Criminal Justice Office of Public Health Monthly Activity Report

September 2017 Reports

Reportable Condition 2017 2016 2017 2016 This Same Year to Year to Month Month Date Date* Chlamydia 1 3 11 39 Gonorrhea 1 3 8 16 Syphilis 37 64 332 677 Hepatitis A 0 0 0 1 Hepatitis B, acute 4 1 27 13 Hepatitis C, total and (acute£) 171 137 1840 2101 Human immunodeficiency virus (HIV) +, known at intake 211 173 1,811 1,709 HIV screens, intake 5,101 4,747 46,598 45,490 HIV +, intake 40 23 535 364 HIV screens, offender- and provider-requested 788 762 6,954 7,326 HIV +, offender- and provider-requested 0 0 10 2 HIV screens, pre-release 3,415 3,891 27,968 32,661 HIV +, pre-release 0 0 0 1 Acquired immune deficiency syndrome (AIDS) 3 3 33 11 Methicillin-resistant Staph Aureus (MRSA) 84 58 528 467 Methicillin-sensitive Staph Aureus (MSSA) 43 37 332 254 Occupational exposures of TDCJ staff 20 30 130 131 Occupational exposures of medical staff 1 2 35 32 HIV chemoprophylaxis initiation 7 12 38 42 Tuberculosis skin test (ie, PPD) +, intake 94 176 1330 1541 Tuberculosis skin test +, annual 43 52 541 556 Tuberculosis, known (ie, on tuberculosis 0 1 3 15 medications) at intake Tuberculosis, diagnosed at intake and attributed to 1 0 1 1 county of origin (identified before 42 days of incarceration) Tuberculosis, diagnosed during incarceration 4 1 12 17 (identified after 42 days of incarceration) Tuberculosis cases under management 18 19 Peer education programs ¶ 0 0 99 100 Peer education educators∞ 54 160 6,163 5,385 Peer education participants 8,083 5,348 61,992 60,619 Alleged assaults and chart reviews 78 71 530 587 Bloodborne exposure labs drawn on offenders 26 23 166 200 New Sero-conversions d/t sexual assault ± 0 0 0 0

Texas Department of Criminal Justice Office of Public Health Monthly Activity Report

October 2017 Reports

Reportable Condition 2017 2016 2017 2016 This Same Year to Year to Month Month Date Date* Chlamydia 3 1 14 40 Gonorrhea 0 0 8 16 Syphilis 69 73 401 750 Hepatitis A 0 0 0 0 Hepatitis B, acute 2 4 29 17 Hepatitis C, total and (acute£) 203 53 2043 2154 Human immunodeficiency virus (HIV) +, known at intake 279 167 2,090 1,876 HIV screens, intake 6,826 5,676 53,424 51,166 HIV +, intake 25 46 560 410 HIV screens, offender- and provider-requested 715 686 7,669 8,012 HIV +, offender- and provider-requested 0 2 10 4 HIV screens, pre-release 3,002 3,945 30,970 36,606 HIV +, pre-release 0 0 0 1 Acquired immune deficiency syndrome (AIDS) 4 4 37 15 Methicillin-resistant Staph Aureus (MRSA) 84 76 612 543 Methicillin-sensitive Staph Aureus (MSSA) 36 32 368 286 Occupational exposures of TDCJ staff 21 10 151 141 Occupational exposures of medical staff 2 3 37 35 HIV chemoprophylaxis initiation 7 3 45 45 Tuberculosis skin test (ie, PPD) +, intake 181 216 1511 1757 Tuberculosis skin test +, annual 46 40 587 596 Tuberculosis, known (ie, on tuberculosis 1 1 4 16 medications) at intake Tuberculosis, diagnosed at intake and attributed to 0 0 1 1 county of origin (identified before 42 days of incarceration) Tuberculosis, diagnosed during incarceration 3 2 15 19 (identified after 42 days of incarceration) Tuberculosis cases under management 17 21 Peer education programs ¶ 0 0 99 100 Peer education educators∞ 24 16 6,187 5,401 Peer education participants 8,153 7,473 70,148 68,092 Alleged assaults and chart reviews 74 68 604 655 Bloodborne exposure labs drawn on offenders 30 26 196 226 New Sero-conversions d/t sexual assault ± 0 0 0 0

Texas Department of Criminal Justice Office of Public Health Monthly Activity Report

November 2017 Reports

Reportable Condition 2017 2016 2017 2016 This Same Year to Year to Month Month Date Date* Chlamydia 3 8 17 48 Gonorrhea 0 0 8 16 Syphilis 43 72 444 822 Hepatitis A 0 0 0 0 Hepatitis B, acute 1 0 30 17 Hepatitis C, total and (acute£) 157 203 2200 2357 Human immunodeficiency virus (HIV) +, known at intake 226 182 2,316 2,058 HIV screens, intake 5,878 5,023 59,302 56,189 HIV +, intake 39 36 599 446 HIV screens, offender- and provider-requested 670 622 8,339 8,634 HIV +, offender- and provider-requested 0 0 10 4 HIV screens, pre-release 3,109 2,826 34,079 39,432 HIV +, pre-release 0 0 0 1 Acquired immune deficiency syndrome (AIDS) 5 8 42 23 Methicillin-resistant Staph Aureus (MRSA) 81 53 693 596 Methicillin-sensitive Staph Aureus (MSSA) 35 24 403 310 Occupational exposures of TDCJ staff 13 16 167 157 Occupational exposures of medical staff 3 3 40 38 HIV chemoprophylaxis initiation 3 2 48 47 Tuberculosis skin test (ie, PPD) +, intake 149 148 1660 1689 Tuberculosis skin test +, annual 30 40 617 1905 Tuberculosis, known (ie, on tuberculosis 2 0 6 15 medications) at intake Tuberculosis, diagnosed at intake and attributed to 1 0 2 1 county of origin (identified before 42 days of incarceration) Tuberculosis, diagnosed during incarceration 0 2 15 21 (identified after 42 days of incarceration) Tuberculosis cases under management 19 18 Peer education programs ¶ 0 0 99 99 Peer education educators∞ 26 24 6,213 5,432 Peer education participants 5,764 8,153 71,796 70,148 Alleged assaults and chart reviews 68 57 672 712 Bloodborne exposure labs drawn on offenders 16 13 212 239 New Sero-conversions d/t sexual assault ± 0 0 0 0

 Year-to-date totals are for the calendar year. Year-to-date data may not equal sum of monthly data because of late reporting. £ Hepatitis C cases in parentheses are acute cases; these are also included in the total number reported. Only acute cases are reportable to the Department of State Health Services ¶ New programs are indicted in the column marked “This Month”; total programs are indicated in the column marked “Year to Date.” ∞ New peer educators are indicted in the column marked “This Month”; total peer educators are indicated in the column marked “Year to Date.” ± New sero-conversions. * New reporting beginning August 1, 2011 Health Services Liaison Utilization Review Hospital and Infirmary Discharge Audit During the First Quarter of Fiscal Year 2018, ten percent of the UTMB and TTUHSC hospital and infirmary discharges were audited. A total of 172 hospital discharge and 58 infirmary discharge audits were conducted. This chart is a summary of the audits showing the number of cases with deficiencies and their percentage. Freeworld Hospital Discharges in Texas Tech Sector Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 5 2 40.00% 0 N/A 0 N/A 0 N/A 1 20.00% October 7 2 28.57% 0 N/A 0 N/A 0 N/A 1 14.29% November 5 2 40.00% 0 N/A 0 N/A 0 N/A 5 100.00% Total/Average 17 6 35.29% 0 N/A 0 N/A 0 N/A 7 41.18% Freeworld Hospital Discharges in UTMB Sector Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 26 1 3.85% 0 N/A 0 N/A 0 N/A 4 15.38% October 25 0 N/A 0 N/A 0 N/A 0 N/A 1 4.00% November 24 3 12.50% 0 N/A 4 16.67% 0 N/A 14 58.33% Total/Average 75 4 5.33% 0 N/A 4 5.33% 0 N/A 19 25.33% UTMB Hospital Galveston Discharges Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 22 0 N/A 3 13.64% 6 27.27% 3 13.64% 0 N/A October 22 0 N/A 0 N/A 1 4.55% 0 N/A 0 N/A November 36 0 N/A 1 2.78% 4 11.11% 1 2.78% 0 N/A Total/Average 80 0 N/A 4 5.00% 11 13.75% 4 5.00% 0 N/A GRAND TOTAL: Combined Hospital Discharges (Texas Tech Sector, UTMB Sector and Hospital Galveston) Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 53 3 5.66% 3 5.66% 6 11.32% 0 N/A 5 9.43% October 54 2 3.70% 0 N/A 1 1.85% 0 N/A 0 N/A November 65 5 7.69% 1 1.54% 0 N/A 1 1.54% 0 N/A Total/Average 172 15 8.72% 4 2.33% 15 8.72% 4 2.33% 26 15.12% Texas Tech Infirmary Discharges Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 6 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A October 10 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A November 15 5 33.33% 0 N/A 1 6.67% 0 N/A 1 6.67% Total/Average 31 5 16.13% 0 N/A 1 3.23% 0 N/A 1 3.23% UTMB Infirmary Discharges Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 5 1 20.00% 0 N/A 0 N/A 0 N/A 0 N/A October 13 5 38.46% 0 N/A 2 15.38% 0 N/A 0 N/A November 9 0 N/A 0 N/A 0 N/A 0 N/A 0 N/A Total/Average 27 6 22.22% 0 N/A 2 7.41% 0 N/A 0 N/A Page 52 of 163 GRAND TOTAL: Combined Infirmary Discharges (Texas Tech and UTMB) Charts Vital Signs Not Recorded 1 Appropriate Receiving Facility2 No Chain-In Done 3 Unscheduled Care within 7 Days 4 Lacked Documentation 5 Month Audited (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiencies) (Cases with Deficiences) September 11 1 9.09% 0 N/A 0 N/A 0 N/A 0 N/A October 23 5 21.74% 0 N/A 2 8.70% 0 N/A 0 N/A November 24 5 20.83% 0 N/A 1 4.17% 0 N/A 1 4.17% Total/Average 58 11 18.97% 0 N/A 3 5.17% 0 N/A 1 1.72% Footnotes: 1. Vital signs were not recorded on the day the offender left the discharge facility. 2. Receiving facility did not have medical services available sufficient to meet the offender's current needs. 3. Chart not reviewed by a health care member and referred (if applicable) to an appropriate medical provider as required by policy. 4. The offender required unscheduled medical care related to the admitting diagnosis within the first seven days after discharge. 5. Discharge information was not available in the offender's electronic medical record within 24 hours of arriving at the unit. Page 53 of 163

FIXED ASSETS CONTRACT MONITORING AUDIT BY UNIT FIRST QUARTER, FISCAL YEAR 2018

Total Total Total Numbered Property Number Number Number On Inventory of of New September 2017 Report Deletions of Transfers Equipment Daniel 3 0 0 0 San Saba 23 0 4 4 Smith 16 0 0 0 Total 42 0 4 4

Total Total Total Numbered Property Number Number Number On Inventory of of New October 2017 Report Deletions of Transfers Equipment Beto 43 0 2 0 Coffield 60 7 0 3 Total 103 7 2 3

Total Total Total Numbered Property Number Number Number On Inventory of of New November 2017 Report Deletions of Transfers Equipment Cleveland 13 0 0 0 Dominguez 41 0 0 0 Ney 16 0 0 0 Torres 22 0 0 0 Total 92 0 0 0 Page 54 of 163

CAPITAL ASSETS AUDIT FIRST QUARTER, FISCAL YEAR 2018

Audit Tools September October November Total Total number of units audited 3 2 4 9 Total numbered property 42 103 92 237 Total number out of compliance 0 0 0 0 Total % out of compliance 0.00% 0.00% 0.00% 0.00% Page 55 of 163

AMERICAN CORRECTIONAL ASSOCIATION ACCREDITATION STATUS REPORT First Quarter FY-2018 University of Texas Medical Branch

Unit Audit Date % Compliance Mandatory Non-Mandatory Beto September 11-13, 2017 100.00% 98.30% Torres/Ney September 18-20, 2017 100.00% 98.80% Lopez/Segovia October 16-18, 2017 100.00% 98.80% Luther October 23-25, 2017 100.00% 99.00% Holliday October 25-27, 2017 100.00% 99.00%

Texas Tech University Health Science Center

Unit Audit Date % Compliance Mandatory Non-Mandatory Jordan/Baten September 25-27, 2017 100.00% 98.55%

The ACA 2018 Winter Conference will be held in Orlando Florida on January 4-9, 2018. During this conference, the following Facilities will be represented: Polunsky, Briscoe/Cotulla, Cole/Moore, Gist, LeBlanc, Goodman, Woodman, Stiles, Beto, Torres/Ney, Jordan/Baten, Lopez/Segovia, Luther, and Holliday. Page 56 of 163

Executive Services Active Monthly Academic Research Projects Correctional Institutions Division

FY-2018 First Quarter Report: September, October, November

______

Project Number: 202-RL02 Researcher: IRB Number: IRB Expiration Date: Research Began: Kymn Kochanek 12.06.05 7/10/2018 5/1/2002 Ti tle of Research: Data Collection Began: National Longitudinal Survey of Youth 1997 10/12/2015 (Bureau of Labor Statistics) Data Collection End: Proponent: NORC - National Organization for Research at the University of Chicago Project Status: Progress Report Due: Projected Completion: Data Collection-Round 17 03/06/2018 07/01/2018 ______

Project Number: 221-RL02 Researcher: IRB Number: IRB Expiration Date: Research Began: Kymn Kochanek 12.05.11 7/10/2018 6/6/2002 Title of Research: Data Collection Began: National Longitudinal Survey of Youth 1979 (for Bureau of Labor 10/1/2014 Statistics) Data Collection End: Proponent: NORC at the University of Chicago Project Status: Progress Report Due: Projected Completion: Data Collection-Round 26 03/06/2018 07/01/2018 ______

Project Number: 434-RL04 Researcher: IRB Number: IRB Expiration Date: Research Began: Marilyn Armour 2003-11-0076 1/6/2014 3/10/2004 Title of Research: Data Collection Began: Victim Offender Mediated Dialogue: Study of the Impact of a Victim- 8/31/2004 Oriented Intervention in Crimes of Severe Violence Data Collection End: Proponent: 5/31/2012 University of Texas- Austin Project Status: Progress Report Due: Projected Completion: Pending Manuscript 1/4/2018 1/4/2018 Page 57 of 163

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Project Number: 547-RL07 Researcher: IRB Number: IRB Expiration Date: Research Began: Robert Morgan 501024 12/31/2012 6/11/2008 Title of Research: Data Collection Began: Re-Entry: Dynamic Risk Assessment 6/11/2008 Data Collection End: Proponent: 8/30/2012 Texas Tech University Project Status: Progress Report Due: Projected Completion: Pending Manuscript 2/20/2018 7/1/2018 ______

Project Number: 587-AR09 Researcher: IRB Number: IRB Expiration Date: Research Began: Marcus Boccaccini 2009-04-032 7/20/2016 9/6/2009 Title of Research: Data Collection Began: Item and Factor Level Examination of the Static-99, MnSOST-R, and 7/15/2010 PCL-R to Predict Recidivism Data Collection End: Proponent: 02/28/2016 Sam Houston State University Project Status: Progress Report Due: Projected Completion: Pending Manuscript 12/06/2017 12/31/2018 ______

Project Number: 605-AR10 Researcher: IRB Number: IRB Expiration Date: Research Began: Patrick Flynn SUM 13-0401506CR 6/24/2016 10/3/2011 Title of Research: Data Collection Began: Reducing the Spread of HIV by Released Prisoners 10/3/2011 Data Collection End: Proponent: 06/30/2016 Texas Christian University Project Status: Progress Report Due: Projected Completion: Data Analysis 2/20/2018 6/30/2018 ______Project Number: 612-AR10 Researcher: IRB Number: IRB Expiration Date: Research Began: Jeffrey Bouffard 210-08-008 10/4/2011 12/27/2010 Title of Research: Data Collection Began: A Test of Rational Choice Theory among Actual Offenders 1/24/2011 Data Collection End: Proponent: 5/19/2011 Sam Houston State University Project Status: Progress Report Due: Projected Completion: Pending Manuscript 12/04/2017 12/31/2018 Page 58 of 163

______Project Number: 629-AR11 Researcher: IRB Number: IRB Expiration Date: Research Began: Jurg Gerber 2011-03-071 5/6/2012 10/25/2011 Title of Research: Data Collection Began: Perception of Family and Community Support among 10/25/2011 Released Felons in the State of Texas Data Collection End: Proponent: 4/2/2012 Sam Houston State University Project Status: Progress Report Due: Projected Completion: Data Analysis 6/14/2018 12/1/2018 ______Project Number: 661-AR12 Researcher: IRB Number: IRB Expiration Date: Research Began: Byron Johnson 656915 8/4/2018 1/7/2013 Title of Research: Data Collection Began: Assessing the Long-Term Effectiveness of Seminaries in Maximum 1/7/2013 Security Prisons: An In-Depth Study of the Louisiana State Penitentiary and Darrington Prison Data Collection End: Proponent: Baylor University Project Status: Progress Report Due: Projected Completion: Data Collection 12/6/2017 1/6/2020 ______

Project Number: 664-AR12 Researcher: IRB Number: IRB Expiration Date: Research Began: Scott Walters 2011-125 4/7/2016 1/1/2013 Title of Research: Data Collection Began: In-Person vs. Computer Interventions for Increasing Probation 1/1/2013 Compliance Data Collection End: Proponent: 8/31/2015 University of North Texas Project Status: Progress Report Due: Projected Completion: Pending Manuscript 03/30/2018 03/30/2018 Page 59 of 163

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Project Number: 666-AR12 Researcher: IRB Number: IRB Expiration Date: Research Began: Jesus Amadeo N/A 12/28/2012 Title of Research: Data Collection Began: Enhanced Transitional Jobs Demonstration 12/28/2012 Data Collection End: Proponent: MDRC Project Status: Progress Report Due: Projected Completion: Project is external to TDCJ to provide data only. 12/31/2017 MOU dated 12/21/12. Project will run through 2017 ______

Project Number: 686-AR13 Researcher: IRB Number: IRB Expiration Date: Research Began: Jeffrey Bouffard 10-12362 10/12/2014 10/14/2013 Title of Research: Data Collection Began: Criminal Decision Making Among Adult Felony Inmates 4/11/2014 Data Collection End: Proponent: 6/12/2014 Sam Houston State University Project Status: Progress Report Due: Projected Completion: Data Analysis 9/8/2017 6/30/2018 ______Project Number: 692-AR14 Researcher: IRB Number: IRB Expiration Date: Research Began: Jacqueline Hogan N/A 1/22/2014 Title of Research: Data Collection Began: U.S. Department of Education 4/28/2014 Data Collection End: Proponent: 5/30/2014 United States Department of Education Project Status: Progress Report Due: Projected Completion: Project Review by Exec Srvcs 02/01/2018 Page 60 of 163

______Project Number: 695-AR14 Researcher: IRB Number: IRB Expiration Date: Research Began: Dan Bloom FWA 0003522 06/06/2017 6/23/2015 Title of Research: Data Collection Began: Multi-site Demonstration Field Experiment: 6/23/2015 What Works in Reentry Research Data Collection End: Proponent: 8/1/2016 MDRC Project Status: Progress Report Due: Projected Completion: Data Analysis 12/06/2017 12/31/2018 ______Project Number: 697-AR14 Researcher: IRB Number: IRB Expiration Date: Research Began: Jodi Walton 798475-1 9/22/2016 12/15/2014 Title of Research: Data Collection Began: Enhanced Transitional Jobs Demonstration (ETJD) - 12/15/2014 MDRC - Jail Research Project Data Collection End: Proponent: 7/31/2016 MDRC Project Status: Progress Report Due: Projected Completion: Project Review by Exec Srvcs ______Project Number: 715-AR14 Researcher: IRB Number: IRB Expiration Date: Research Began: Shannon Carey HSRRC 121177 6/4/2017 1/9/2015 Title of Research: Data Collection Began: Cross-Site Evaluation of the 1/9/2015 Second Chance Act Reentry Courts Program Data Collection End: Proponent: 12/12/2016 NPC Research Project Status: Progress Report Due: Projected Completion: Project Review by Exec Srvcs Page 61 of 163

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Project Number: 716-AR14 Researcher: IRB Number: IRB Expiration Date: Research Began: Janet Mullings 2014-09-19302 8/8/2016 7/20/2015 Title of Research: Data Collection Began: Understanding Prison Adjustment and Programming 8/11/2015 Needs of Female Offenders Survey Data Collection End: Proponent: 05/30/2016 Sam Houston State University Project Status: Progress Report Due: Projected Completion: Pending Manuscript 05/15/2018 5/31/2019

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Project Number: 723-AR15 Researcher: IRB Number: IRB Expiration Date: Research Began: David Pyrooz 00001971 1/13/2018 8/5/2015 Title of Research: Data Collection Began: Gangs on the Street, Gangs in Prison: Their Nature, 8/5/2015 Interrelationship, Control, and Re-entry Data Collection End: Proponent: Sam Houston State University Project Status: Progress Report Due: Projected Completion: Data Collection 12/31/2017 12/31/2017 ______Project Number: 725-AR15 Researcher: IRB Number: IRB Expiration Date: Research Began: Vikram Maheshri Exempt 2/1/2020 6/9/2015 Title of Research: Data Collection Began: Local Impacts of Incarceration 7/6/2015 Data Collection End: Proponent: University of Houston Project Status: Progress Report Due: Projected Completion: Data Collection 3/6/2018 2/1/2020 Page 62 of 163

______Project Number: 733-AR15 Researcher: IRB Number: IRB Expiration Date: Research Began: Pamela Carey 2016-186 3/2/2017 3/8/2016 Title of Research: Data Collection Began: Post-Secondary Correctional Education Program Usefulness of Ex- 3/8/2016 Offenders' Participation: Utilization-Focused Evaluative Case Study Data Collection End: Proponent: 9/1/2016 Capella University Project Status: Progress Report Due: Projected Completion: Project Review by Exec Srvcs 02/01/2018 ______Project Number: 736-AR15 Researcher: IRB Number: IRB Expiration Date: Research Began: Timothy Smith 13623 3/23/2018 3/24/2016 Title of Research: Data Collection Began: Survey of Prison Inmates 5/17/2016 Data Collection End: Proponent: 10/14/2016 Bureau of Justice Statistics, RTI International Project Status: Progress Report Due: Projected Completion: Data Analysis 6/1/2018 6/29/2018 ______Project Number: 737-AR15 Researcher: IRB Number: IRB Expiration Date: Research Began: William Evans FWA00002462 10/18/2017 8/23/2016 Title of Research: Data Collection Began: Evaluation of the Red & Black Books Financial Literacy Tool 7/29/2016 Data Collection End: Proponent: University of Notre Dame Project Status: Progress Report Due: Projected Completion: Data Collection 12/31/2017 12/31/2017 Page 63 of 163

______Project Number: 747-AR16 Researcher: IRB Number: IRB Expiration Date: Research Began: Angela Thomas N/A 12/6/2016 Title of Research: Data Collection Began: A Quantitative Analysis of Relationships between Male Inmates Participating 12/5/2016 In Academic/Social Courses during Incarceration and Recidivism Data Collection End: Proponent: 4/5/2017 Grand Canyon University Project Status: Progress Report Due: Projected Completion: Project Review by Exec Srvcs ______Project Number: 751-AR16 Researcher: IRB Number: IRB Expiration Date: Research Began: Francis Cassidy 16-08-004 8/24/2017 11/10/2016 Title of Research: Data Collection Began: Evidence-Based Learning 11/10/2016 Data Collection End: Proponent: 8/14/2017 University of the Incarnate Word Project Status: Progress Report Due: Projected Completion: Data Analysis 2/28/2018 02/28/2018 ______Project Number: 761-AR16 Researcher: IRB Number: IRB Expiration Date: Research Began: William Kelly IRB00008463 1/12/2018 7/14/2017 Title of Research: Data Collection Began: Travis County State Jail Probation Study 7/14/2017 Data Collection End: Proponent: Texas Criminal Justice Coalition Project Status: Progress Report Due: Projected Completion: Data Collection 2/1/2018 7/14/2018 01/02/2018 received revision to include Woodman State Jail, sent for division review. ______Project Number: 764-AR17 Researcher: IRB Number: IRB Expiration Date: Research Began: John Hepburn 00002035 6/15/2018 4/26/2017 Title of Research: Data Collection Began: Measuring the Effects of Correctional Officer Stress on the Well-Being 5/1/2017 of the Officer and the Prison Workplace and Developing a Practical Index of Officer Stress for Use by Correctional Agencies Data Collection End: Proponent: Arizona State University Project Status: Progress Report Due: Projected Completion: Data Collection 1/19/2018 6/30/2018 Page 64 of 163

Executive Services Pending Monthly Academic Research Projects Incomplete ApplicationCorrectional Institutions Division A FY-2018 Fourth Quarterly Report: September, October, November

______Project 754-AR16 Application Received: Researcher: IRB Number: 9/20/2016 Mark Trahan Application Completed: Title of Research: 9/20/2016 A Randomized Control Trial of Fathering Programs on Re-Integration of Prisoners into Families Division Review Requested:

Proponent: Reviewer: Texas State University IRB Project Status: Detail: Review by Executive Services

______Project 767-AR17 Application Received: Researcher: IRB Number: 3/21/2017 Whiteley Kathryn 2015-061 Application Completed: Title of Research: Self-Identities of Women Incarcerated for Acts of Violence Division Review Requested:

Proponent: Reviewer: Messiah College Pending Project Status: Detail: 10/5/17: project approved. Pending review of research agreement and Pending Letter of approval letter Approval/Research Agreement.

______Page 65 of 163

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Project 771-AR17 Application Received: Researcher: IRB Number: 4/19/2017 Jazmine Wells 2017-04-0014 Application Completed: Title of Research: Writing as a Means to Perform Motherhood Behind Bars Division Review Requested:

Proponent: Reviewer: University of Texas- Austin Pending Project Status: Detail: 11/3/17: to OGC for review/approval of revisions Pending OGC Review

______Project 775-AR17 Application Received: Researcher: IRB Number: 6/19/2017 Matthew May IRB2017-0239D Application Completed: Title of Research: Student Experience in Prison College Classes Division Review Requested:

Proponent: Reviewer: Texas A & M University Project Status: Detail: Pending RPD review ______Project 778-AR17 Application Received: Researcher: IRB Number: 9/6/2017 Lisa Muftic 2017-04-34613(EXEMPT) Completed Title of Research: Predicting County Victim Impact Statement Form Completion Rates Peer Panel Schedule: Based on Victim Assistance Coordinator Practices

Proponent: Panel Sam Houston State University Pending Project Status: Detail: Review by Executive Services

______Page 66 of 163

Executive Services Active Monthly Medical Research Projects I Health Services Division

ApplicationFY-2018 Fourth Quarterly Report: September, October, November

______

Project Number: 615-RM10 Researcher: IRB Number: IRB Expiration Date: Research Began: John Petersen 11-069 9/28/2017 9/12/2013 Title of Research: Data Collection Began: Serum Markers of Hepatocellular Cancer 1/1/2014 Data Collection End: Proponent: University of Texas Medical Branch at Galveston Project Status: Progress Report Due: Projected Completion: Data Collection 12/6/2017 1/1/2020 ______

Project Number: 705-RM14 Researcher: IRB Number: IRB Expiration Date: Research Began: Mostafa Borahay 13-0428 3/15/2018 3/9/2015 Title of Research: Data Collection Began: Clinical Outcomes and Cost Analysis of 4/1/2015 Robotic Gynecologic Surgery Data Collection End: Proponent: UTMB Project Status: Progress Report Due: Projected Completion: Data Collection 02/1/2018 12/31/2018

**1/2017: New PI Dr. Gokhan Kilic. ** ______Page 67 of 163

______

Project Number: 707-RM14 Researcher: IRB Number: IRB Expiration Date: Research Began: Mostafa Borahay 10-229 11/09/2017 3/9/2015 Title of Research: Study of Mediators and Potential Therapeutics in Uterine Fibroids, Data Collection Began: Endometriosis and Adenomyosis 4/1/2015 Data Collection End: Proponent: UTMB Project Status: Progress Report Due: Projected Completion: Data Collection 1/31/2018 12/31/2018

**1/2017: New PI Dr. Gokhan Kilic. **

______Project Number: 709-RM14 Researcher: IRB Number: IRB Expiration Date: Research Began: Celia Chao 14-0018 2/8/2018 5/28/2015 Title of Research: Data Collection Began: A Pilot Study to Correlate Cancer 5/28/2015 Diagnosis with Urine Thiosulfate Data Collection End: Proponent: UTMB Project Status: Progress Report Due: Projected Completion: OGC review/approval 02/01/2018 9/30/2018

______Project Number: 724-RM15 Researcher: IRB Number: IRB Expiration Date: Research Began: Zbigniew Gugala 14-0351 8/18/2018 6/29/2015 Title of Research: Data Collection Began: The Efficacy of the Air Barrier System in the Prevention of Surgical 9/21/2015 Site Infection: A Multi-Center, Randomized, Controlled Trial Data Collection End: Proponent: UTMB Project Status: Progress Report Due: Projected Completion: Data Collection 12/21/2017

______Page 68 of 163

______Project Number: 729-RM15 Researcher: IRB Number: IRB Expiration Date: Research Began: Jacques Baillargeon 14-0283 3/27/2018 10/1/2015 Title of Research: Data Collection Began: The Health and Healthcare Needs of Older Prisoners 10/1/2015 Data Collection End: Proponent: UTMB Project Status: Progress Report Due: Projected Completion: Data Collection 02/01/2018 12/31/2019

______Project Number: 750-RM16 Researcher: IRB Number: IRB Expiration Date: Research Began: Ilyse Kornblau 16-0167 5/23/2018 12/6/2016 Title of Research: Data Collection Began: Incidence of Endophthalmitis following Intravitreal Injection 12/06/2017 Comparing 30 vs. 32 Gauge Needles Data Collection End: Proponent: UTMB-Galveston Project Status: Progress Report Due: Projected Completion: Data Collection 3/06/2018 07/01/2018 ______Project Number: 752-RM16 Researcher: IRB Number: IRB Expiration Date: Research Began: Lara Reichert 16-0216 6/6/2018 12/21/2016 Title of Research: Data Collection Began: Practice Patterns, Patient Characteristics, and Complications of 12/21/2017 Tracheotomy at UTMB Data Collection End: Proponent: UTMB-Galveston Project Status: Progress Report Due: Projected Completion: Data Collection 5/17/2018 08/1/2018

______Page 69 of 163

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Project Number: 765-RM17 Researcher: IRB Number: IRB Expiration Date: Research Began: Laurie Stelter 19297 12/1/2018 9/27/2017 Title of Research: Data Collection Began: Impact of an Occupation-based Program for Incarcerated Women w/ 10/01/2017 Intellectual and Developmental Disabilities Data Collection End: Proponent: Projected Completion: Texas Women University 12/19/2017 09/27/2018 Project Status: Progress Report Due: Data Collection Page 70 of 163

Executive Services Pending Monthly Medical Research Projects I Health Services Division FY -2018 First Quarter Report: September, October, November

Project 689-RM13 Application Received: Researcher: IRB Number: 11/7/2013 Troy Quast 2013-12371 Application Completed: 12/12/2013 Title of Research: Impact of the Annual Health Care Services Fee Division Review Requested: 9/11/2014 Proponent: Reviewer: Sam Houston State University Pending Review Status: Detail: Awaiting response from requestor as to whether they wish to continue with project ______Project 763-RM17 Application Received: Researcher: IRB Number: 1/11/2017 Jacinta Assava Application Completed: Title of Research: Diabetes Foot Assessment Training Module for Correctional Nurses Division Review Requested:

Proponent: Reviewer: UTMB-Galveston Project Status: Detail: Awaiting response from requestor as to whether they wish to continue with project ______Page 71 of 163

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Project 776-RM17 Application Received: Researcher: IRB Number: 8/3/2017 Douglas Tyler 17-0160 Application Completed: Title of Research: Retrospective Data Analysis of the TDCJ's Surgical Patients Division Review Requested:

Proponent: Reviewer: University of Texas-Medical Branch Pending Project Status: Detail: Sent to Mr. Mendoza for review ______

Project 779-RM17 Application Received: Researcher: IRB Number: 10/13/2017 Amy Jo Harzke Application Completed Title of Research: Using Implementation Science to Improve Health Care Outcomes Division Review Requested: For Prison Populations Proponent: Reviewer: University of Texas-Medical Branch Pending Project Status: Detail: Awaiting OIG Clearance

______Page 72 of 163

4th Quarter FY 2017 TDCJ Office of Mental Health Monitoring & Liaison Mental Health Segregation Audit Summary

Mental Requests 911 ATC ATC ATC Date Unit Observed Interviewed Health Referrals Fwd Tool 4 5 6 6/2/2017 Pack 17 17 0 0 100 100 100 100 6/7-6/8/2017 Estelle 218 200 0 6 100 100 100 100 6/21/2017 Hughes 87 82 0 4 100 100 100 100 6/21/2017 Murray 86 75 0 4 100 100 100 100 6/22/2017 Mt. View 23 23 0 3 100 100 100 100 6/26/2017 Michael 84 78 0 1 100 100 100 100 7/18/2017 Lychner 15 15 0 0 100 100 100 100 7/18/2017 Gist 16 16 0 1 100 100 100 100 7/19/2017 Stiles 95 889 0 8 100 100 100 100 7/26/2017 Coffield 576 505 1 3 100 100 100 100 8/8-10/2017 Ferguson 246 221 0 8 100 100 100 100 8/15-16/2017 Eastham 337 284 0 3 100 100 100 100 8/17/2017 Kegans 3 3 0 0 100 100 100 100 8/22-23/2017 Robertson 296 254 0 8 100 100 100 100 8/23/2017 Travis 14 14 0 0 100 100 100 93 8/23/2017 Formby 25 25 0 0 100 100 100 100

Total 2,138 2,701 1 49 Page 73 of 163

INTAKE MENTAL HEALTH EVALUATION (MHE) AUDIT Conducted in 4th Quarter of 2017 Period Audited—June, July and August Charts MHE’s completed Charts Charts MHE Audit FACILITY Requiring within 14 days (at Excluded Reviewed Score MHE (1) Intake Unit) (2) Bartlett State Jail 7 6 6 1 100% Baten ISF 18 18 5 0 28% Bradshaw State Jail 8 7 4 1 57% Byrd Unit 18 8 10 8 100% Dominguez State Jail 20 20 19 0 95% East TX Treatment Facility 20 20 19 0 95% Formby State Jail 8 7 4 1 57% Garza Transfer Facility 20 17 17 3 100% Gist State Jail 3 3 3 0 100% Glossbrenner SAFPF 3 3 3 0 100% Gurney Transfer Facility 20 16 5 4 31% Halbert SAFPF 7 7 6 0 86% Holliday Transfer Facility 20 20 20 0 100% Hutchins State Jail 15 15 15 0 100% Jester I SAFPF 15 15 15 0 100% Johnston SAFPF 5 5 4 0 80% Kegans ISF 17 17 8 0 47% Kyle SAFPF N/A N/A N/A N/A N/A Lindsey State Jail 5 5 5 0 100% Lychner State Jail 20 20 16 0 80% Middleton Transfer Facility 20 20 19 0 95% Plane State Jail 20 19 16 1 84% Roach ISF 20 20 19 0 95% Sanchez State Jail 2 2 1 0 50% Sayle SAFPF 5 5 5 0 100% Travis State Jail 14 14 14 0 100% West Texas-Unit Closed Woodman State Jail 20 20 20 0 100% GRAND TOTAL 350 329 278 19

1. Offenders entering TDCJ who are identified during the Intake Mental Health Screening/Appraisal process as having a history of treatment for mental illness, currently receiving mental health treatment, history of self-injurious behavior or current symptoms/complaints of symptoms of mental illness will have a Mental Health Evaluation (MHE) completed by a Qualified Mental Health Professional (QMHP) within 14 days of identification. 2. If the offender was transferred from the intake unit within 14 days of identification, the chart is excluded from the sample of charts requiring an MHE.

A Corrective Action Plan is required of all units scoring below 80%. Page 74 of 163

COMPELLED PSYCHOACTIVE MEDICATION AUDIT

4th Quarter 2017 Audits Conducted in June, July and August

Audit Compelled Medication Cases Documented in UNIT Month Medical Record1

Reviewed Applicable Compliant Score Corrective Action Clements June 0 0 N/A N/A None Jester IV June 3 3 3 100 None Montford June 4 4 4 100 None Skyview June 13 13 13 100 None

Reviewed Applicable Compliant Score Corrective Action Clements July 0 0 N/A N/A None Jester IV July 6 6 6 100 None Montford July 2 2 2 100 None Skyview July 12 12 12 100 None

Reviewed Applicable Compliant Score Corrective Action Clements August 1 1 1 100 None Jester IV August 0 0 N/A N/A None Montford August 5 5 5 100 None Skyview August 7 7 7 100 None

1. Documentation supports that psychoactive medication was compelled because the patient refused to voluntarily comply and failure to take the medication would have resulted in: 1.Emergency - imminent likelihood of serious harm to the patient and/or to others, or 2. Non-emergency – likelihood of continued suffering from severe and abnormal mental, emotional and physical distress or deterioration of the patient’s ability to function independently. Page 75 of 163

Consent Item

University Medical Director’s Report Texas Tech University Health Sciences Center Page 76 of 163

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Correctional Health Care

MEDICAL DIRECTOR’S REPORT

1ST QUARTER FY 2018 Page 78 of 163

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Medical Director's Report:

SEPTEMBER OCTOBER NOVEMBER Qtly Average

Average Population 29,547.81 29,616.21 29,704.76 29,622.93

Rate Per Rate Per Rate Per Rate Per Number Offender Number Offender Number Offender Number Offender Medical encounters

Physicians 2,579 0.087 2,873 0.097 2,175 0.073 2,542 0.086 Mid-Level Practitioners 6,949 0.235 8,108 0.274 7,371 0.248 7,476 0.252 Nursing 105,836 3.582 134,539 4.543 133,162 4.483 124,512 4.203

Sub-total 115,364 3.904 145,520 4.914 142,708 4.804 134,531 4.541 Dental encounters Dentists 2,912 0.099 3,866 0.131 3,294 0.111 3,357 0.113 Dental Hygienists 767 0.026 758 0.026 909 0.031 811 0.027 Sub-total 3,679 0.125 4,624 0.156 4,203 0.141 4,169 0.141 Mental health encounters

Outpatient Mental Health Visits 2,886 0.098 3,026 0.102 2,321 0.078 2,744 0.093

Crisis Mgt. Daily Census 331 0.011 273 0.009 249 0.008 284 0.010 Sub-total 3,217 0.109 3,299 0.111 2,570 0.087 3,029 0.102

Total encounters 122,260 4.138 153,443 5.181 149,481 5.032 141,728 4.784

Encounters as Rate Per Offender Per Month Encounters by Type

4.500 4.203 Outpatient 4.000 Mental Health Visits Dental 7.8% 3.500 Hygienists 0.6% 3.000 Crisis Mgt. Dentists Daily Census 2.500 2.4% 0.2%

2.000 Physicians 1.8% 1.500

1.000 Mid-Level Practitioners 4.7% 0.500 0.252 0.113 0.093 Nursing 0.086 0.027 0.010 0.000 87.9% Physicians Mid-Level Practitioners Nursing Dentists Dental Hygienists Outpatient Mental Health Visits Crisis Mgt. Daily Census Page 80 of 163

Medical Director's Report (Page 2):

SEPTEMBER OCTOBER NOVEMBER Qtly Average Medical Inpatient Facilities Average Daily Census 121.00 116.00 116.00 117.67 Number of Admissions 208.00 219.00 197.00 208.00 Average Length of Stay 10.00 11.00 10.00 10.33 Number of Clinic Visits 663.00 792.00 758.00 737.67

Mental Health Inpatient Facilities Average Daily Census 459.00 473.00 469.00 467.00 PAMIO/MROP Census 404.00 396.00 403.00 401.00

Specialty Referrals Completed 1,347.00 1,391.00 1,370.00 1,369.33

Telemedicine Consults 1,180 1,597 1,587 1,454.67

Average This Quarter Percent Health Care Staffing Filled Vacant Total Vacant Physicians 16.77 3.37 20.04 16.30% Mid-Level Practitioners 37.00 3.50 40.50 8.64% Registered Nurses 126.82 27.53 154.36 17.84% Licensed Vocational Nurses 265.92 54.08 320.00 16.90% Dentists 17.77 1.97 19.74 9.96% Psychiatrists 6.77 2.00 8.77 22.81%

Average Length of Stay Staffing Vacancy Rates

11.20 25.00% 22.81% 11.00 11.00 20.00% 17.84% 10.80 16.90% 16.30%

10.60 15.00%

10.40 9.96% 10.00% 8.64% 10.20

10.00 10.00 10.00 5.00%

9.80 0.00%

9.60 Physicians Mid-Level Practitioners

9.40 Registered Nurses Licensed Vocational Nurses SEPTEMBER OCTOBER NOVEMBER Dentists Psychiatrists Page 81 of 163

Consent Item

University Medical Director’s Report The University of Texas Medical Branch Page 82 of 163

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Correctional Health Care MEDICAL DIRECTOR'S REPORT

FIRST QUARTER FY 2018 Page 84 of 163

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Medical Director's Report:

September October November Qtly Average Average Population 120,088 118,815 119,128 119,344

Rate Per Rate Per Rate Per Rate Per Number Offender Number Offender Number Offender Number Offender Medical encounters Physicians 10,604 0.088 11,518 0.097 10,118 0.085 10,747 0.090 Mid-Level Practitioners 38,317 0.319 44,485 0.374 40,042 0.336 40,948 0.343 Nursing 648,727 5.402 693,666 5.838 663,525 5.570 668,639 5.603

Sub-total 697,648 5.809 749,669 6.310 713,685 5.991 720,334 6.036 Dental encounters Dentists 11,140 0.093 12,601 0.106 11,142 0.094 11,628 0.097 Dental Hygienists 1,844 0.015 2,417 0.020 1,927 0.016 2,063 0.017 Sub-total 12,984 0.108 15,697 0.132 13,069 0.110 13,690 0.115 Mental health encounters Outpatient mental health visits 13,892 0.116 15,680 0.132 14,219 0.119 14,597 0.122 Crisis Mgt. Daily Census 78 0.001 78 0.001 78 0.001 78 0.001 Sub-total 13,970 0.116 15,758 0.133 14,297 0.120 14,675 0.123

Total encounters 724,602 6.034 781,124 6.574 741,051 6.221 748,699 6.273

Encounters as Rate Per Offender Per Encounters by Type Month

6.000 5.603

5.000 Dental Hygienists 4.000 0.3% Outpatient mental health Dentists visits 1.9% 3.000 1.6%

2.000 Crisis Mgt. Daily Census 0.0% 1.000 Physicians 0.343 1.4% 0.090 0.097 0.017 0.122 0.001 0.000 1 Nursing Mid-Level Practitioners Physicians Mid-Level Practitioners 89.3% 5.5%

Nursing Dentists

Dental Hygienists Outpatient mental health visits

Crisis Mgt. Daily Census Page 86 of 163

Medical Director's Report (Page 2):

September October November Qtly Average Medical Inpatient Facilities Average Daily Census 87.07 87.94 87.93 87.65 Number of Admissions 313.00 336.00 331.00 326.67 Average Length of Stay 7.68 7.23 6.98 7.30 Number of Clinic Visits 5,766.00 7,670.00 6,382.00 6,606.00 Mental Health Inpatient Facilities Average Daily Census 1,055.73 979.36 958.17 997.75 PAMIO/MROP Census 728.56 728.97 733.36 730.30

Telemedicine Consults 12,470 13,831 11,695 12,665.33

Average This Quarter Percent Health Care Staffing Filled Vacant Total Vacant Physicians 53.00 12.00 65.00 18.46% Mid-Level Practitioners 129.00 12.00 141.00 8.51% 300.00 25.00 325.00 7.69% Registered Nurses Licensed 602.00 52.00 654.00 7.95% Vocational Nurses Dentists 72.00 3.00 75.00 4.00% Psychiatrists 17.00 5.00 22.00 22.73%

Average Length of Stay Staffing Vacancy Rates 7.80 7.68 25.00% 22.73% 7.60 20.00% 18.46% 7.40 7.23 15.00% 7.20 10.00% 6.98 8.51% 7.95% 7.00 7.69%

5.00% 4.00% 6.80

6.60 0.00% Physicians Mid-Level Practitioners Registered Nurses September October November 1 Licensed Vocational Nurses Dentists Psychiatrists Page 87 of 163

Medical Director's Report (Page 3):

CMC Update Page 88 of 163

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Consent Item

Summary of CMHCC Joint Committee/ Work Group Activities Page 90 of 163

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Correctional Managed Health Care Joint Committee/Work Group Activity Summary for March 20, 2018, CMHCC Meeting

The CMHCC, through its overall management strategy, utilizes a number of standing and ad hoc joint committees and work groups to examine, review and monitor specific functional areas. The key characteristic of these committees and work groups is that they are comprised of representatives of each of the partner agencies. They provide opportunities for coordination of functional activities across the state. Many of these committees and work groups are designed to insure communication and coordination of various aspects of the statewide health care delivery system. These committees work to develop policies and procedures, review specific evaluation and/or monitoring data, and amend practices in order to increase the effectiveness and efficiency of the program.

Many of these committees or work groups are considered to be medical review committees allowed under Chapter 161, Subchapter D of the Texas Health and Safety code and their proceedings are considered to be confidential and not subject to disclosure under the law.

This summary is intended to provide the CMHCC with a high level overview of the ongoing work activities of these workgroups.

Workgroup activity covered in this report includes:

 System Leadership Council  Joint Policy and Procedure Committee  Joint Pharmacy and Therapeutics Committee  Joint Infection Control Committee  Joint Dental Work Group  Joint Mortality and Morbidity Committee  Joint Nursing Work Group

System Leadership Council

Chair: Dr. Owen Murray

Purpose: This group’s membership consists of discipline directors in medical, nursing, mental health, dental and allied health care staff appointed by the Joint Medical Directors. This group is charged with implementation of the CMHCC Quality Improvement/ Quality Management (QI/QM) Plan. The purpose of this plan is to provide a streamlined, integrated, clinically driven state-of-the-art Quality Improvement Program, which adds value to the quality of health care services, provided to TDCJ offenders. The plan demonstrates that quality will be consistently/ continuously applied and/or measured, and will meet or exceed regulatory requirements. The CMHCC strongly endorses and has administrative oversight for implementation of the plan. The agents of the CMHCC and the TDCJ Health Services Division will demonstrate support and participation for the plan. The committee meets on a quarterly basis. Page 92 of 163

Meeting Date: February 8, 2018

Key Activities:

I. Call to Order

II. Approval of Minutes

III. Reports from Champions/Discipline Directors A. Access to Care-Dental Services B. Access to Care-Mental Health Services C. Access to Care-Nursing Services D. Access to Care-Medical Staff E. Sick Call Request Verification Audit (SCRVA)

IV. FY 2018 SLC Indicators A. Dental: Total Open Reminders with Delay > 60 Days B. Mental Health: Heat Restrictions C. Nursing: Intra-System Transfer Screening D. Support Services: Inpatient/Outpatient Physical Therapy E. Clinical Administration: Missed Appointments (No Shows) F. Joint Medical/Pharmacy: Hepatitis C

V. Standing Issues A. New SLC Indicators B. New FLC Indicators C. CMHCC Updates D. CMHC Pharmacy Report E. Hospital Galveston Report

VI. Miscellaneous/Open for Discussion Participants A. ATC Accuracy Evaluation B. Nurse Protocol Audits C. Nursing QA Site Visit Audits

VII. Adjournment

Joint Policy and Procedure Committee

Co-Chair: Robert Dalecki, MBA

Co-Chair: Chris Black-Edwards, RN, BSN

Purpose: This group’s membership consists of clinicians, nurses, health care administrators and dentists appointed by the Joint Medical Directors. This group is charged with the annual review of all 131 CMHC policies and procedures. The committee meets on a Page 93 of 163

quarterly basis and one fourth of the manual is reviewed at each of its quarterly meetings. Meeting Date: January 11, 2018

Sub Committee Updates:  Chronic Care Renewal of Medications G-51.10 – Chair, Benjamin Leeah, MD. Members: Mike Jones, RN, Monte Smith, MD, Justin Robinson, RN, Eidi Millington, MD, Myra Walker, RN, Renee Lenz, PharmD.  Formation of subcommittees with recent legislative changes – Monte Smith, MD

Committee Updates:  None

Committee Referrals:  Joint Mental Health Working Group – Shana Khawaja, PhD

The Following Policies Were Reviewed and Acted on by the Joint Policy and Procedure Committee: A-01.1 A-02.1 A-02.2 A-03.1 A-04.1 A-04.2 A-08.9* A-08.10* C-18.1 C-19.1 D-27.1 D-27.2* D-27.3 E-31.1 E-31.3 E-32.1* E-34.1 E-34.2 E-34.3 E-36.1 E36.2 F-46.1 G-51.1 G-51.2 G-51.3* G-51.4 G-51.5 G-52.2 H-60.1* H-60.4 I-66.1 I-68.1 I-68.2 I-68.3 * Indicates Attachment(s) included in the policy.

The Following Policies Were Submitted for Changes or for Discussion: POLICY # POLICY NAME SUBMITTED BY A-01.1 Access to Care Paula Reed E-31.3 Obtaining Community Hospital Offender Information Cecilia Horton E-34.5 Chemicals Agents and the Use of Force Shana Khawaja Contraindication List E-36.1 Dental Treatment Level of Care Manual Hirsch E-36.2 Inprocessing Offender-Dental Examination, Manual Hirsch Classification, Education and Treatment E-42.2 Missed Clinic Appointments Ben Leeah G-51.1 Offenders with Special Needs Cecilia Horton G-51.3 Admission Health Appraisals for Offenders with Cecilia Horton Physical Disabilities G-51.5 Certified American Sign Language (ALS) Interpreter Dale Dorman Services H-60.4 Utilization of the Electronic Health Record Dale Dorman I-66.3 Psychiatric Inpatient Seclusion Shana Khawaja

Adjournment

 Next Meeting Date: April 12, 2018 Page 94 of 163

Joint Pharmacy and Therapeutics Committee

Chair: Dr. Joseph Penn

Purpose: This group’s membership consists of physicians, nurses, clinicians, dentists and pharmacists appointed by the Joint Medical Directors. This group is charged with developing and maintaining the statewide drug formulary, drug use policies and disease management guidelines. This group also establishes policy regarding the evaluation, selection, procurement, distribution, control, use, and other matters related to medications within the health care system. This group further serves to support educational efforts directed toward the health care staff on matters related to medications and medication use. Disease management guidelines are reviewed annually and updated as needed by the CMHCC Joint Pharmacy and Therapeutics Committee. All changes to consensus guidelines published by the Centers of Disease Control and Prevention and the National Institutes of Health or other nationally recognized authorities are considered. In addition, CMHCC Joint Pharmacy and Therapeutics Committee reviews adverse drug reaction reports, drug recalls, non-formulary deferral reports and reports of medication errors. Clinical pharmacists present reviews of drug classes to the committee for education and consideration of new updates to the formulary. Clinical pharmacists also periodically conduct medication usage evaluations. Finally, this group reviews and evaluates all pharmacy and therapeutic policies and procedures annually. This group meets on a bi- monthly basis.

Meeting Date: January 11, 2018

Key Activities:

I. Approval of the Minutes from November 9, 2017 Meeting

II. Reports from Subcommittees A. COPD – Dr. Fisher B. DMG Triage – Dr. Sandmann C. Immunizations – Dr. Gonzalez D. Opioid Overdose – Dr. Agrawal E. Psychiatry – Dr. Finocchio

III. Monthly Reports A. Adverse Drug Reaction Reports (none) B. Pharmacy Clinical Activity Report C. Drug Recalls (November – December 2017) D. Non-Formulary Deferral Reports 1. Texas Tech Sector (September – November 2017) 2. UTMB Sector (November – December 2017) E. Utilization Reports (FY18 through November) 1. HIV Utilization 2. Hepatitis C Utilization 3. Hepatitis B Utilization 4. Psychotropic Utilization Page 95 of 163

F. Quarterly Medication Error Reports – 1st Quarter FY18 1. UTMB Sector 2. Texas Tech Sector 3. Medication Dispensing Error Report G. Special Reports 1. Top 50 Medications by Cost and Volume – 1st Quarter FY18 2. Top 10 Non-Formulary Medications by Cost and Volume – 1st Quarter FY18 H. Policy Review Schedule

IV. Old Business – Polies 50-10 to 75-30 tabled at November 2017 meeting due to time constraints (see Policy and Procedure Revisions)

V. New Business A. Action Requests 1. Annual Review of Hepatitis C and HIV Education a. HIV and Hepatitis Annual Update for Employees b. HIV Annual Update for Offenders c. Hepatitis C Annual Update for Offenders 2. Hepatitis C Patient Education Sheet 3. Formulary Addition of Benztropine 1 mg/mL, 2 mL injection B. FDA Medication Safety Advisories C. Manufacturer Shortages and Discontinuations D. Policy and Procedure Revisions 1. Automatic Stop Orders for Drugs (10-10) 2. Critical Medications Dispensed upon Hospital Galveston Discharge (10-50) 3. Controlled Substance Record Keeping (20-15) 4. Sigma Spectrum Infusion Pump with Master Drug Library (30-15) 5. Self-Administration of Medication (50-10) 6. Drug Therapy Management by a Pharmacist (55-10) 7. Therapeutic Interchange (55-15) 8. Clozapine Protocol (55-20) 9. Disease Management Guidelines (55-25) 10. Emergency Drugs (60-05) 11. Requisition of Drugs by EMS (60-10) 12. Credential Requirements for Administration of Medication (65-05) 13. Therapeutic Optometrists (65-10) 14. Representatives of Pharmaceutical Supplies and Related (70-05) 15. Drug Samples (70-10) 16. Adverse Medication Reaction Reports (75-05) 17. Medication Errors (75-10) 18. Pharmacy Medication Area Audits and Inspections (75-15) 19. Record Retention (75-20) 20. Medication Safety (75-30)

VI. Miscellaneous

VII. Adjournment Page 96 of 163

Joint Infection Control Committee

Co-Chair: Kirk Abbott, RN, BSN Co-Chair: Chris Black-Edwards, RN, BSN

Purpose: This group’s membership consists of physicians, nurses, clinicians, dentists and pharmacist appointed by the Joint Medical Directors. This group is charged with developing and promulgating policies and procedures for infection control, prevention and treatment. This group is charged with the annual review of all Correctional Managed Health Care Infection Control Policies and meets on a quarterly basis.

Meeting Date: February 8, 2018

Key Activities:

I. Review of previous minutes

II. New Business B-14.5 HUB Kits

III. Committee Updates None

IV. Committee Referrals None

V. The Following Policies Were Reviewed and Acted on by the Joint Infection Control Committee: B-14.01 B-14.02 B-14.05* B-14.06 *Indicates Attachment(s) included in the Policy

The Following Policies Have Been Submitted with Changes or for Discussion: POLICY # POLICY NAME SUBMITTED BY B-14.03 Employee TB Testing Kirk Abbott B-14.04* Prevention of Hepatitis B Virus (HBV) Infection Dr. Coglianese in the TDCJ Facilities B-14.07* Immunizations Dr. Coglianese B-14.10 Tuberculosis Dr. Coglianese B-14.11* Human Immunodeficiency Virus (HIV) Dr. Coglianese

VI. Adjourn

Next Meeting: April 12, 2018

Joint Dental Work Group Page 97 of 163

Chair: Dr. Billy Horton

Purpose: This group’s membership includes the TDCJ Director for the Office of Dental Quality and Contract Compliance, the UTMB CMC Dental Director, and the TTUHSC CMC Dental Director. This group is charged with the development of dental treatment and management guidelines; as well as the development of dental initiatives. It reviews changes to the Dental Scope of Practice Act and makes recommendations for policy changes as needed. Finally, this group also reviews and makes recommendations to the CMHCC Joint Policy and Procedure Committee on all dental policies and procedures.

Meeting Date: January 24, 2018

I. Call to Order A. Minutes Confirmation- Review/Approval of Minutes from July 12, 2017 meeting

II. Dental Policy Review A. F-46.1 Dental Health Education and Promotion B. G-51.10-D Chronic Care Dental Program C. H-60.1 Dental Health Record –Organization and Maintenance D. B-15.1 Dental X-Ray Operating and Safety Procedures E. B-15.1B Chemical and Hazardous Material Control F. B-14.1 Infection Control in Dental Clinics and Laboratories

III. Dental Services Manual- Proposed Addition of CMHC Policy E-37.1 (Dr. M. Hirsch)

IV. Paste Template Revision Committee (Dr. C. Wood)

V. Adjournment

Next Meeting: TBD

Joint Mortality and Morbidity Committee

Co -Chair: Dr. Eidi Millington Co-Chair: Dr. Olugbenga Ojo

Purpose: This group’s membership consists of physicians and nurses appointed by the Joint Medical Directors. The group is charged with reviewing the clinical health records of each offender death. The committee makes a determination as to whether or not a referral to a peer review committee is indicated. This group meets on a monthly basis. For the Three Months Ended November 2017: There were 106 deaths reviewed by the Mortality and Morbidity Committee during the months of September, October and November 2017. Of those 106 deaths, 4 were referred to peer review committees.

Joint Nursing Work Group Page 98 of 163

Chair: Chris Black-Edwards, RN, BSN

Purpose: This group’s membership includes the TDCJ Director of Nursing Administration, the UTMB CMC Chief Nursing Officer, the TTUHSC CMC Director of Nursing Services, and the UTMB CMC Director of Nursing Inpatient Services. This group is charged with the development of nursing management guidelines and programs. It reviews changes to the Nursing Scope of Practice Act for RNs and LVNs and makes recommendations for policy/practice changes as needed. Finally, this group also reviews and makes recommendations to the CMHCC Joint Policy and Procedure Committee on all nursing policies and procedures. Meeting Date: January 11, 2018

I. Call to Order II. Approval of Minutes from the October 11, 2017 meeting

III. Old Business 1. ORA Separating Nursing/Medical – Chris Black-Edwards, RN IV. New Business 1. Sexual Assault Documentation – Chris Black-Edwards, RN 2. Note Wizard Templates – Mike Jones, RN V. Other VI. Next Meeting: April 11, 2018 at 10:00am in Conroe, TX. VII. Adjournment Page 99 of 163

Financial Report on Correctional Managed Health Care

Quarterly Report FY2018 First Quarter

September 2017 –November 2017 Page 100 of 163

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First Quarter Financial Report on Correctional Managed Health Care

Overview

 Report submitted in accordance with the FY2018-19 General Appropriations Act, Article V, Rider 46, 85th Legislature, Regular Session 2017

 FY2018 TDCJ Appropriations allocated to Correctional Managed Health Care:  $302.2M Unit and Psychiatric Care, Strategy C.1.8  $189.5M Hospital and Clinical Care, Strategy C.1.9  $60.7M Pharmacy Care, Strategy C.1.10

Method of Finance Summary FY2018 SB 1, Article V, TDCJ Appropriations Strategy C.1.8. Unit and Psychiatric Care $ 302,184,774 Strategy C.1.9. Hospital and Clinic Care $ 189,537,341 Strategy C.1.10. Pharmacy Care $ 60,733,962 TOTAL $ 552,456,077

Allocation to Universities University of Texas Medical Branch Unit and Psychiatric Care $ 241,250,820 Hospital and Clinic Care $ 158,319,640 Pharmacy Care $ 48,565,181 Subtotal UTMB $ 448,135,641 Texas Tech University Health Sciences Center Unit and Psychiatric Care $ 59,933,954 Hospital and Clinic Care $ 31,217,701 Pharmacy Care $ 12,168,781 Subtotal TTUHSC $ 103,320,436 TOTAL TO UNIVERSITY PROVIDERS $ 551,456,077 Allocation to Capital Budget Infirmary Unit Capacity Expansion, Jester and Telford $ 1,000,000 TOTAL ALLOCATED $ 552,456,077 Page 102 of 163

Population

 Overall offender service population has increased 1.8% from FY2017  Average daily census 146,282 through 1st quarter of FY2017 compared to 148,967 through 1st quarter of FY2018

 Offenders aged 55 or older population increased 6.9% from FY2017  Average daily census 17,316 through 1st quarter of FY2017 compared to 18,512 through 1st quarter of FY2018  While comprising about 12.4% of the overall service population, offenders age 55 and over account for 44.2% of the hospitalization costs received to date.

 Mental health caseloads:  FY2018 average number of psychiatric inpatients through 1st quarter: 1,866  FY2018 average number of psychiatric outpatients through 1st quarter: 24,996

CMHC Service Population

20,000

158,000 19,000 Offenders Age 55+

18,000 155,000

17,000 152,000

16,000 149,000 Total Population Population Total Offenders Age 55+ 15,000 146,000 14,000 Total Population 143,000 13,000

12,000 140,000 Page 103 of 163

Health Care Costs

 Total expenses through 1st quarter, FY2018: $171.5M

 Unit and Psychiatric Care expenses represent the majority of total health care costs  $90M, 52.4% of total expenses

 Hospital and Clinical Care - $63.4M, 37% of total

 Pharmacy Services - $18.1M, 10.6% of total  HIV related drugs: 40.3% of total drug costs  Psychiatric drugs: 5.5% of total drug costs  Hepatitis C drug therapies: 15.8% of total drug costs

 Cost per offender per day, FY2018 through 1st quarter: $12.65  1% increase compared to FY2017 cost per day of $12.55

Comparison of Total Health Care Costs

4-Year FYTD 18 FY 14 FY 15 FY 16 FY17 Average 1st Qtr Population UTMB 118,705 117,779 116,828 116,574 117,472 119,343 TTUHSC 31,314 30,790 30,004 29,807 30,479 29,623 Total 150,019 148,569 146,832 146,381 147,950 148,966

Expenses UTMB $456,286,749 $474,922,507 $523,473,857 $554,779,025 $502,365,535 $141,641,876 TTUHSC $102,834,980 $107,975,637 $118,262,289 $115,982,376 $111,263,821 $29,840,434 Total $559,121,729 $582,898,144 $641,736,146 $670,761,401 $613,629,355 $171,482,310

Cost/Day UTMB $10.53 $11.05 $12.24 $13.04 $11.71 $13.04 TTUHSC $9.00 $9.61 $10.77 $10.66 $9.99 $11.07 Total $10.21 $10.75 $11.94 $12.55 $11.36 $12.65

Note: UTMB total expenses do not include the final Hospital Cost Reconciliations. Page 104 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018

Method of Finance TTUHSC UTMB Total C.1.8. Unit & Psychiatric Care TDCJ Appropriation $ 14,942,438 $ 59,648,835 $ 74,591,273 State Reimbursement Benefits $ 2,285,665 $ 13,062,864 $ 15,348,529 Other Misc Revenue $ 326 $ 19,444 $ 19,770 C.1.8. Total Method of Finance $ 17,228,429 $ 72,731,143 $ 89,959,572 C.1.9. Hospital & Clinical Care TDCJ Appropriation $ 7,783,043 $ 39,471,472 $ 47,254,515 State Reimbursement Benefits $ 493,344 $ - $ 493,344 Other Misc Revenue $ - $ - $ - C.1.9. Total Method of Finance $ 8,276,387 $ 39,471,472 $ 47,747,859 C.1.10. Managed Health Care - Pharmacy TDCJ Appropriation $ 3,033,860 $ 12,108,031 $ 15,141,891 State Reimbursement Benefits $ 20,652 $ 550,002 $ 570,654 Other Misc Revenue $ - $ - $ - C.1.10. Total Method of Finance $ 3,054,512 $ 12,658,033 $ 15,712,545 TOTAL METHOD OF FINANCE $ 28,559,328 $ 124,860,648 $ 153,419,976

Method of Finance Summary TTUHSC UTMB Total TDCJ Appropriation $ 25,759,341 $ 111,228,338 $ 136,987,679 State Reimbursement Benefits $ 2,799,661 $ 13,612,866 $ 16,412,527 Other Misc Revenue $ 326 $ 19,444 $ 19,770 TOTAL METHOD OF FINANCE $ 28,559,328 $ 124,860,648 $ 153,419,976

Expenditures TTUHSC UTMB Total C.1.8. Unit & Psychiatric Care $ 17,267,677 $ 72,684,431 $ 89,952,108 C.1.9. Hospital & Clinical Care $ 9,509,529 $ 53,932,044 $ 63,441,573 C.1.10. Managed Health Care - Pharmacy $ 3,063,228 $ 15,025,401 $ 18,088,629 TOTAL EXPENDITURES $ 29,840,434 $ 141,641,876 $ 171,482,310

DIFFERENCE $ (1,281,106) $ (16,781,228) $ (18,062,334)

Based on data submitted by UTMB and TTUHSC Page 105 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018

C.1.8. UNIT & PSYCHIATRIC CARE

TTUHSC UTMB Total Method of Finance: TDCJ Appropriation $ 14,942,438 $ 59,648,835 $ 74,591,273 State Reimbursement Benefits $ 2,285,665 $ 13,062,864 $ 15,348,529 Other Misc Revenue $ 326 $ 19,444 $ 19,770 TOTAL METHOD OF FINANCE $ 17,228,429 $ 72,731,143 $ 89,959,572

Expenditures: Unit Care Salaries $ 5,773,707 $ 43,746,083 $ 49,519,790 Benefits $ 1,802,011 $ 12,389,280 $ 14,191,291 Other Operating Expenses $ 593,602 $ 5,546,017 $ 6,139,619 Professional Services $ 547,489 $ - $ 547,489 Contracted Units/Services $ 3,792,126 $ - $ 3,792,126 Travel $ 42,891 $ 302,080 $ 344,971 Capitalized Equipment $ 23,917 $ 198,772 $ 222,689 Subtotal, Unit Care $ 12,575,743 $ 62,182,232 $ 74,757,975

Psychiatric Care Salaries $ 3,174,463 $ 6,931,789 $ 10,106,252 Benefits $ 856,159 $ 1,718,184 $ 2,574,343 Other Operating Expenses $ 41,660 $ 61,349 $ 103,009 Professional Services $ 200,241 $ - $ 200,241 Contracted Units/Services $ - $ - $ - Travel $ 8,494 $ 32,779 $ 41,273 Subtotal, Psychiatric Care $ 4,281,017 $ 8,744,101 $ 13,025,118

Indirect Expenditures (Shared Services) $ 410,917 $ 1,758,098 $ 2,169,015

TOTAL EXPENDITURES $ 17,267,677 $ 72,684,431 $ 89,952,108

DIFFERENCE $ (39,248) $ 46,712 $ 7,463

Based on data submitted by UTMB and TTUHSC Page 106 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018

C.1.9. HOSPITAL & CLINICAL CARE

TTUHSC UTMB Total Method of Finance TDCJ Appropriation $ 7,783,043 $ 39,471,472 $ 47,254,515 State Reimbursement Benefits $ 493,344 $ - $ 493,344 Other Misc Revenue $ - $ - $ - TOTAL METHOD OF FINANCE $ 8,276,387 $ 39,471,472 $ 47,747,859

Expenditures: Hospital and Clinical Care University Professional Services $ 400,000 $ 5,292,860 $ 5,692,860 Freeworld Provider Services $ 3,630,077 $ 4,142,553 $ 7,772,630 TTUHSC Western Regional Medical Facility & UTMB Hospital Galveston Hospital Services $ 3,373,919 $ 33,721,638 $ 37,095,557 Estimated IBNR $ 1,891,499 $ 9,470,480 $ 11,361,979 Subtotal, Hospital & Clinical Care $ 9,295,495 $ 52,627,531 $ 61,923,026

Indirect Expenditures (Shared Services) $ 214,034 $ 1,304,513 $ 1,518,547

TOTAL EXPENDITURES $ 9,509,529 $ 53,932,044 $ 63,441,573

DIFFERENCE $ (1,233,142) $ (14,460,572) $ (15,693,714)

Based on data submitted by UTMB and TTUHSC Page 107 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018

C.1.10. MANAGED HEALTH CARE - PHARMACY

TTUHSC UTMB Total Method of Finance TDCJ Appropriation $ 3,033,860 $ 12,108,031 $ 15,141,891 State Reimbursement Benefits $ 20,652 $ 550,002 $ 570,654 Other Misc Revenue $ - $ - $ - TOTAL METHOD OF FINANCE $ 3,054,512 $ 12,658,033 $ 15,712,545

Expenditures: Managed Health Care - Pharmacy Salaries $ 519,435 $ 1,831,852 $ 2,351,287 Benefits $ 23,200 $ 592,634 $ 615,834 Other Operating Expenses $ 84,911 $ 349,903 $ 434,814 Pharmaceutical Purchases $ 2,349,322 $ 11,882,062 $ 14,231,384 Travel $ 2,929 $ 5,514 $ 8,443 Capitalized Equipment $ - $ - $ - Subtotal, Managed Health Care - Pharmacy Expenditures $ 2,979,797 $ 14,661,965 $ 17,641,762

Indirect Expenditures (Shared Services) $ 83,431 $ 363,436 $ 446,867

TOTAL EXPENDITURES $ 3,063,228 $ 15,025,401 $ 18,088,629

DIFFERENCE $ (8,716) $ (2,367,368) $ (2,376,084)

Based on data submitted by UTMB and TTUHSC Page 108 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018

Key Population Indicators

September October November 1st Quarter FY2018 YTD

Average Service Population UTMB Service Population 120,088 118,815 119,128 119,344 119,343 TTUHSC Service Population 29,548 29,616 29,705 29,623 29,623 Average Service Population 149,636 148,431 148,833 148,967 148,966

Population Age 55 and Over UTMB Population 15,273 15,456 15,581 15,437 15,437 TTUHSC Population 3,053 3,091 3,082 3,075 3,075 Population Age 55 and Over 18,326 18,547 18,663 18,512 18,512

HIV Population 2,015 2,026 2,023 2,021 2,021

Medical Inpatient Average Daily Census UTMB-Hospital Galveston 83 89 90 87 87 UTMB Freeworld Hospitals 39 35 35 36 36 TTUHSC Freeworld Hospitals 9 10 7 9 9 Medical Inpatient Average Daily Census 131 134 132 132 132

Medical Outpatient Visits UTMB Specialty Clinics and ER Visits 6,881 8,722 7,391 7,665 7,665 TTUHSC Freeworld Outpatient and ER Visits 1,326 1,370 1,268 1,321 1,321 Medical Outpatient Visits 8,207 10,092 8,659 8,986 8,986

Mental Health Inpatient Average Census UTMB Psychiatric Inpatient 1,056 979 958 998 998 TTUHSC Psychiatric Inpatient 863 869 872 868 868 Mental Health Inpatient Average Census 1,919 1,848 1,830 1,866 1,866

Mental Health Outpatient Caseload, Month End UTMB Psychiatric Outpatient 19,492 20,041 19,597 19,710 19,710 TTUHSC Psychiatric Outpatient 5,260 5,298 5,301 5,286 5,286 Mental Health Outpatient Caseload, Month End 24,752 25,339 24,898 24,996 24,996

Amounts may differ from previous report due to updates received from the university provider.

Based on data submitted by UTMB and TTUHSC Page 109 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018 Texas Tech University Health Sciences Center Annual Total STRATEGY 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Projection TTUHSC 1/11/2018 REVENUE: TDCJ Appropriation $ 25,759,341 $ - $ - $ - $ 25,759,341 $ 103,320,436 State Reimbursement Benefits $ 2,799,661 $ - $ - $ - $ 2,799,661 $ 11,198,644 Other Misc Revenue $ 326 $ - $ - $ - $ 326 $ 1,304 TOTAL REVENUES $ 28,559,328 $ - $ - $ - $ 28,559,328 $ 114,520,384

C.1.8. UNIT & PSYCHIATRIC CARE EXPENDITURES: Unit Care Expenditures Salaries $ 5,773,707 $ - $ - $ - $ 5,773,707 $ 23,594,828 Benefits $ 1,802,011 $ - $ - $ - $ 1,802,011 $ 7,358,044 Other Operating Expenses $ 593,602 $ - $ - $ - $ 593,602 $ 2,574,408 Professional Services $ 547,489 $ - $ - $ - $ 547,489 $ 2,339,956 Contracted Units/Services $ 3,792,126 $ - $ - $ - $ 3,792,126 $ 14,090,987 Travel $ 42,891 $ - $ - $ - $ 42,891 $ 221,564 Capitalized Equipment $ 23,917 $ - $ - $ - $ 23,917 $ 95,000 Subtotal, Unit Care Expenditures $ 12,575,743 $ - $ - $ - $ 12,575,743 $ 50,274,787 Psychiatric Care Expenditures Salaries $ 3,174,463 $ - $ - $ - $ 3,174,463 $ 12,697,852 Benefits $ 856,159 $ - $ - $ - $ 856,159 $ 3,424,636 Other Operating Expenses $ 41,660 $ - $ - $ - $ 41,660 $ 191,640 Professional Services $ 200,241 $ - $ - $ - $ 200,241 $ 800,964 Travel $ 8,494 $ - $ - $ - $ 8,494 $ 33,976 Subtotal, Psychiatric Care Expenditures $ 4,281,017 $ - $ - $ - $ 4,281,017 $ 17,149,068 Total Expenditures, Unit & Psychiatric Care $ 16,856,760 $ - $ - $ - $ 16,856,760 $ 67,423,855

C.1.9. HOSPITAL & CLINICAL CARE EXPENDITURES: University Professional Services $ 400,000 $ - $ - $ - $ 400,000 $ 1,300,000 Freeworld Provider Services $ 3,630,077 $ - $ - $ - $ 3,630,077 $ 22,385,000 TTUHSC Western Regional Medical Facility & UTMB Hospital Galveston Hospital Services $ 3,373,919 $ - $ - $ - $ 3,373,919 $ 13,520,676 Estimated IBNR $ 1,891,499 $ - $ - $ - $ 1,891,499 $ - Total Expenditures, Hospital & Clinical Care $ 9,295,495 $ - $ - $ - $ 9,295,495 $ 37,205,676

C.1.10. MANAGED HEALTH CARE PHARMACY EXPENDITURES: Salaries $ 519,435 $ - $ - $ - $ 519,435 $ 2,077,740 Benefits $ 23,200 $ - $ - $ - $ 23,200 $ 92,800 Other Operating Expenses $ 84,911 $ - $ - $ - $ 84,911 $ 339,644 Pharmaceutical Purchases $ 2,349,322 $ - $ - $ - $ 2,349,322 $ 9,536,280 Travel $ 2,929 $ - $ - $ - $ 2,929 $ 11,716 Capitalized Equipment $ - $ - $ - $ - $ - $ - Total Expenditures, Managed Health Care Pharmacy $ 2,979,797 $ - $ - $ - $ 2,979,797 $ 12,058,180

Indirect Expenditures (Shared Services) $ 708,382 $ - $ - $ - $ 708,382 $ 2,841,312

TOTAL EXPENDITURES $ 29,840,434 $ - $ - $ - $ 29,840,434 $ 119,529,023

DIFFERENCE $ (1,281,106) $ - $ - $ - $ (1,281,106) $ (5,008,639)

Based on data submitted by UTMB and TTUHSC Page 110 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018 University of Texas Medical Branch Annual Total STRATEGY 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Projection UTMB 1/25/2018 REVENUE: TDCJ Appropriation $ 111,228,338 $ - $ - $ - $ 111,228,338 $ 448,135,641 State Reimbursement Benefits $ 13,612,866 $ - $ - $ - $ 13,612,866 $ 58,029,004 Other Misc Revenue $ 19,444 $ - $ - $ - $ 19,444 $ 77,992 TOTAL REVENUES $ 124,860,648 $ - $ - $ - $ 124,860,648 $ 506,242,637

C.1.8. UNIT & PSYCHIATRIC CARE EXPENDITURES: Unit Care Expenditures Salaries $ 43,746,083 $ - $ - $ - $ 43,746,083 $ 175,913,525 Benefits $ 12,389,280 $ - $ - $ - $ 12,389,280 $ 53,503,271 Other Operating Expenses $ 5,546,017 $ - $ - $ - $ 5,546,017 $ 22,375,001 Professional Services $ - $ - $ - $ - $ - $ - Contracted Units/Services $ - $ - $ - $ - $ - $ - Travel $ 302,080 $ - $ - $ - $ 302,080 $ 1,211,999 Capitalized Equipment $ 198,772 $ - $ - $ - $ 198,772 $ 1,316,490 Subtotal, Unit Care Expenditures $ 62,182,232 $ - $ - $ - $ 62,182,232 $ 254,320,286 Psychiatric Care Expenditures Salaries $ 6,931,789 $ - $ - $ - $ 6,931,789 $ 28,172,522 Benefits $ 1,718,184 $ - $ - $ - $ 1,718,184 $ 6,983,136 Other Operating Expenses $ 61,349 $ - $ - $ - $ 61,349 $ 245,399 Professional Services $ - $ - $ - $ - $ - $ - Travel $ 32,779 $ - $ - $ - $ 32,779 $ 131,115 Subtotal, Psychiatric Care Expenditures $ 8,744,101 $ - $ - $ - $ 8,744,101 $ 35,532,172 Total Expenditures, Unit & Psychiatric Care $ 70,926,333 $ - $ - $ - $ 70,926,333 $ 289,852,458

C.1.9. HOSPITAL & CLINICAL CARE EXPENDITURES: University Professional Services $ 5,292,860 $ - $ - $ - $ 5,292,860 $ 22,236,166 Freeworld Provider Services $ 4,142,553 $ - $ - $ - $ 4,142,553 $ 50,262,483 TTUHSC Western Regional Medical Facility & UTMB Hospital Galveston Hospital Services $ 33,721,638 $ - $ - $ - $ 33,721,638 $ 137,257,120 Estimated IBNR $ 9,470,480 $ - $ - $ - $ 9,470,480 $ - Total Expenditures, Hospital & Clinical Care $ 52,627,531 $ - $ - $ - $ 52,627,531 $ 209,755,769

C.1.10. MANAGED HEALTH CARE PHARMACY EXPENDITURES: Salaries $ 1,831,852 $ - $ - $ - $ 1,831,852 $ 7,347,605 Benefits $ 592,634 $ - $ - $ - $ 592,634 $ 2,177,661 Other Operating Expenses $ 349,903 $ - $ - $ - $ 349,903 $ 700,941 Pharmaceutical Purchases $ 11,882,062 $ - $ - $ - $ 11,882,062 $ 49,846,145 Travel $ 5,514 $ - $ - $ - $ 5,514 $ 22,118 Capitalized Equipment $ - $ - $ - $ - $ - $ - Total Expenditures, Managed Health Care Pharmacy $ 14,661,965 $ - $ - $ - $ 14,661,965 $ 60,094,470

Indirect Expenditures (Shared Services) $ 3,426,047 $ - $ - $ - $ 3,426,047 $ 14,325,350

TOTAL EXPENDITURES $ 141,641,876 $ - $ - $ - $ 141,641,876 $ 574,028,047

DIFFERENCE $ (16,781,228) $ - $ - $ - $ (16,781,228) $ (67,785,410)

Based on data submitted by UTMB and TTUHSC Page 111 of 163 TEXAS DEPARTMENT OF CRIMINAL JUSTICE Financial Report on Offender Health Care, pursuant to Agency Rider 46 First Quarter, FY2018 Combined Total

Combined Annual STRATEGY 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Total Projection

REVENUE: TDCJ Appropriation $ 136,987,679 $ - $ - $ - $ 136,987,679 $ 551,456,077 State Reimbursement Benefits $ 16,412,527 $ - $ - $ - $ 16,412,527 $ 69,227,648 Other Misc Revenue $ 19,770 $ - $ - $ - $ 19,770 $ 79,296 TOTAL REVENUES $ 153,419,976 $ - $ - $ - $ 153,419,976 $ 620,763,021

C.1.8. UNIT & PSYCHIATRIC CARE EXPENDITURES: Unit Care Expenditures Salaries $ 49,519,790 $ - $ - $ - $ 49,519,790 $ 199,508,353 Benefits $ 14,191,291 $ - $ - $ - $ 14,191,291 $ 60,861,315 Other Operating Expenses $ 6,139,619 $ - $ - $ - $ 6,139,619 $ 24,949,409 Professional Services $ 547,489 $ - $ - $ - $ 547,489 $ 2,339,956 Contracted Units/Services $ 3,792,126 $ - $ - $ - $ 3,792,126 $ 14,090,987 Travel $ 344,971 $ - $ - $ - $ 344,971 $ 1,433,563 Capitalized Equipment $ 222,689 $ - $ - $ - $ 222,689 $ 1,411,490 Subtotal, Unit Care Expenditures $ 74,757,975 $ - $ - $ - $ 74,757,975 $ 304,595,073 Psychiatric Care Expenditures Salaries $ 10,106,252 $ - $ - $ - $ 10,106,252 $ 40,870,374 Benefits $ 2,574,343 $ - $ - $ - $ 2,574,343 $ 10,407,772 Other Operating Expenses $ 103,009 $ - $ - $ - $ 103,009 $ 437,039 Professional Services $ 200,241 $ - $ - $ - $ 200,241 $ 800,964 Travel $ 41,273 $ - $ - $ - $ 41,273 $ 165,091 Subtotal, Psychiatric Care Expenditures $ 13,025,118 $ - $ - $ - $ 13,025,118 $ 52,681,240 Total Expenditures, Unit & Psychiatric Care $ 87,783,093 $ - $ - $ - $ 87,783,093 $ 357,276,313

C.1.9. HOSPITAL & CLINICAL CARE EXPENDITURES: University Professional Services $ 5,692,860 $ - $ - $ - $ 5,692,860 $ 23,536,166 Freeworld Provider Services $ 7,772,630 $ - $ - $ - $ 7,772,630 $ 72,647,483 TTUHSC Western Regional Medical Facility & UTMB Hospital Galveston Hospital Services $ 37,095,557 $ - $ - $ - $ 37,095,557 $ 150,777,796 Estimated IBNR $ 11,361,979 $ - $ - $ - $ 11,361,979 $ - Total Expenditures, Hospital & Clinical Care $ 61,923,026 $ - $ - $ - $ 61,923,026 $ 246,961,445

C.1.10. MANAGED HEALTH CARE PHARMACY EXPENDITURES: Salaries $ 2,351,287 $ - $ - $ - $ 2,351,287 $ 9,425,345 Benefits $ 615,834 $ - $ - $ - $ 615,834 $ 2,270,461 Other Operating Expenses $ 434,814 $ - $ - $ - $ 434,814 $ 1,040,585 Pharmaceutical Purchases $ 14,231,384 $ - $ - $ - $ 14,231,384 $ 59,382,425 Travel $ 8,443 $ - $ - $ - $ 8,443 $ 33,834 Capitalized Equipment $ - $ - $ - $ - $ - $ - Total Expenditures, Managed Health Care Pharmacy $ 17,641,762 $ - $ - $ - $ 17,641,762 $ 72,152,650

Indirect Expenditures (Shared Services) $ 4,134,429 $ - $ - $ - $ 4,134,429 $ 17,166,662

TOTAL EXPENDITURES $ 171,482,310 $ - $ - $ - $ 171,482,310 $ 693,557,070

DIFFERENCE $ (18,062,334) $ - $ - $ - $ (18,062,334) $ (72,794,049)

Based on data submitted by UTMB and TTUHSC Page 112 of 163

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Summary of Critical Correctional Health Care Personnel Vacancies Prepared for the Correctional Managed Health Care Committee As of February 2018

Title of Position CMHCC Vacant Actions Taken to Fill Position Partner Since Agency (mm/yyyy) Deputy Division Director-Health Contract 04/01/2017 This position is currently posted. Services Director II-Office of Public Health TDCJ 06/15/2015 This position is on hold. Health Specialist V-Office of Mental TDCJ 01/31/2016 The position posting has closed and the Health Monitoring and Liaison applications are being reviewed. Investigator II-Patient Liaison TDCJ 04/15/2017 The interviews for this position are Program scheduled for 02/27/2018. (Hilltop Unit) Investigator II-Patient Liaison TDCJ 10/15/2017 The position will be reposted due to the lack Program of applicants. (Stiles Unit) Investigator III-Step Two Medical TDCJ 2/15/2018 The position is currently posted. It will close Grievance (Huntsville) on 03/02/2018. Licensed Vocational Nurse III-Step TDCJ 02/01/2018 The position is currently posted. It will close Two Medical Grievance (Huntsville) on 02/22/2018. Nurse II-Office of Health Services TDCJ 10/31/2017 The position closed on 02/12/2018 and the Monitoring applications are being reviewed. Southern Regional Dental Dir. TTUHSC 01/2018 Candidate selected. Allred Unit Medical Director TTUHSC 10/2017 Candidate selected. Daniel Unit Physician I-II (15) UTMB 03/01/2015 Local and National Advertising, TAFP‡ , CMC NCCHC† Conferences, ACA Conference * and Agency Contacts. Mid-Level Practitioners UTMB 12/10/2017 Local and National Advertising, Career (PA and FNP) (7) CMC Fairs, TAPA# and TNP║ Conferences, Intern Programs. Psychiatrists (6) UTMB 04/08/2014 Local and National Advertising, NCCHC† , CMC TSPPΔ, Agency Contacts.

* ACA: American Correctional Association † DO: Doctor of Osteopathic Medicine Advertising ‡ NCCHC: National Commission on Correctional Health Care # TAFP: Texas Academy of Family Physicians ║ TAPA: Texas Academy of Physician Assistants ΔTNP: Texas Nurse Practitioners ◊ TSPP: Texas Society of Psychiatric Physicians Page 114 of 163

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University Vacancy Rate Report by Quarter FY 2014 – FY 2018

Texas Tech University Health Sciences Center Page 116 of 163

[This page left blank intentionally for pagination purposes.] TTUHSC Vacancy Rates (%) by Quarter FY 2014 – FY 2018

45 40 35 30 25 20 15 10 5 0

Physician PA/NP RN LVN Dentist Psychiatrist Page 117 of 163

Correctional Managed Health Care Page 118 of 163

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University Vacancy Rate Report by Quarter FY 2014 – FY 2018

University of Texas Medical Branch Page 120 of 163

[This page left blank intentionally for pagination purposes.] UTMB Vacancy Rates (%) by Quarter FY 2014 – FY 2018

30 25 20 15 10 5 0

Physician PA/NP RN LVN Dentist Psychiatrist Page 121 of 163

Correctional Managed Health Care Page 122 of 163

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TEXAS DEPARTMENT OF CRIMINAL JUSTICE

HEALTH SERVICES DIVISION MEDICAL DIRECTOR’S REPORT First Quarter FY 2018

Lannette Linthicum, MD, CCHP-A, FACP Page 124 of 163

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TDCJ Medical Director’s Report

Office of Health Services Monitoring (OHSM)

OPERATIONAL REVIEW AUDIT (ORA)

During the First Quarter Fiscal Year (FY) 2018 (September, October and November 2017), Operational Review Audits (ORAs) were conducted at the following 9 facilities: Beto, Cleveland, Coffield, Daniel, Dominguez State Jail, Ney State Jail, San Saba, Smith and Torres.

 To be considered compliant, a facility must score 80% or better on an Operational Review Question. For any question below 80%, a corrective action plan is required from the facility to ensure future compliance. The following is a summary of the 7 items found to be most frequently out of compliance in the Operational Review Audits conducted in the First Quarter of FY 2018:

1. Item 3.060 requires dental records for offenders received by the facility via intra-system transfer bereviewed by facility dental staff for priority one conditions within 7 days of arrival. The following 5 facilities were not in compliance with this requirement:  Beto (58%) – Corrective action plan pending  Dominguez (79%) – Corrective action plan pending  San Saba (58%) – Corrective action plan received and accepted  Smith (73%) - Corrective action plan received and accepted  Torres (79%) - Corrective action plan pending

2. Item 6.351 requires Hepatitis C Virus infected patients that do not have documented contraindication for antiviral therapy with Aspartateaminotransferase (AST) Platelet Ratio Index (APRI) score greater than 0.70 or with abnormal liver function (Prothrombin Time, Total Bilirubin, or Albumin) be referred to the designated physician, clinic, or appropriately treated according to Correctional Managed Health Care (CMHC) Hepatitis C Evaluation, and Treatment Pathway. The following 4 facilities were not in compliance with this requirement:  Dominguez (78%) – Corrective action plan pending  Ney (67%) – Corrective action plan pending  Smith (40 %) – Corrective action plan received and accepted  Torres (33%) – Corrective action plan pending

3. Items 4.070 requires facility’s self-reported Access to Care Audit data that is reported to TDCJ Health Services on a monthly basis be accurate and consistent with current methodology. The following 4 facilities were not in compliance with this requirement:  Beto (0%) – Corrective action plan pending  Daniel (46%) – Corrective action plan received and accepted  San Saba (75%) – Corrective action plan received and accepted  Smith (25%) - Corrective action plan received and accepted

4. Item 5.251 requires documentation that three Hemoccult cards were offered to offenders 50 years of age or greater within the required time frame of their annual date of incarceration. The following 3 facilities were not in compliance with this requirement:  Beto (48%) – Corrective action plan pending  Coffield (50%) – Corrective action plan pending  Smith (73%) – Corrective action plan received and accepted Page 126 of 163

OPERATIONAL REVIEW AUDIT (ORA) (CONTINUED)

5. Item 6.020 requires offenders with a positive tuberculin skin test be evaluated for active disease or the need for chemoprophylaxis by a physician or mid-level practitioner before initiation of medication. The following 3 facilities were not in compliance with this requirement:  Coffield (56%) – Corrective action plan pending  San Saba (0%) – Corrective action plan received and accepted  Smith (71%) – Corrective action plan received and accepted

6. Item 6.040 require offenders receiving anti-tuberculosis medication at the facility have a Tuberculosis Patient Monitoring Record (HSM-19) completed. The following 3 facilities were not in compliance with this requirement:  Cleveland (75%) – Corrective action plan pending  Coffield (17%) – Corrective action plan pending  Smith (70%) – Corrective action plan received and accepted

7. Item 6.205 requires newly diagnosed HIV positive offenders be referred to dental for oral/periodontal evaluation within 30 days of initial chronic care clinic. The following 3 facilities were not in compliance with this requirement:  Coffield (0%) – Corrective action plan pending  San Saba (0%) – Corrective action plan received and accepted  Torres (0%) – Corrective action plan pending

 During the previous quarter, ORAs for 9 facilities had pending corrective action plans: Formby, Garza East, Garza West, Hobby, Kegans Intermediate Sanction Facility (ISF), Marlin, Polunsky, Wallace and Wheeler. During the First Quarter FY 2018, all were closed.

CAPITAL ASSETS CONTRACT MONITORING

The Fixed Assets Contract Monitoring officer audited the same 9 facilities listed above for operational review audits during the First Quarter of FY 2018. These audits are conducted to monitor compliance with the Health Services Policy and State Property Accounting (SPA) policy regarding inventory procedures. All 9 facilities were within the required compliance range.

DENTAL QUALITY REVIEW AUDIT

During the First quarter of FY 2018 (September, October, and November 2017), Dental Quality Review audits were conducted at the following 10 facilities: Baten ISF, Connally, Dalhart, Ellis, Garza West/East, Jordan, McConnell, Roach, Stevenson, and Tulia. The following is a summary of the items found to be most frequently below 80 percent:

 Item 2 assesses if charts of incoming (chain-in) intra-system offenders transfers are reviewed by the facility dental department within seven (7) days of arrival. 2 of the 10 facilities were out of compliance: Tulia (69%), McConnell (71%).

 Item 21 assesses if the radiographs utilized in the formulation of the Comprehensive Treatment Plan (CTP) were of diagnostic quality necessary for assessment and treatment planning. 2 of the 10 facilities were not in compliance: Dalhart (64%), Tulia (48%). Page 127 of 163

GRIEVANCES AND PATIENT LIAISON CORRESPONDENCE

During the 1st Quarter of FY 2018, the Patient Liaison Program (PLP) and the Step II Grievance Program received 4,385 correspondences: The PLP received 2,855 and Step II Grievance received 1,530. There were 141 Action Requests generated by the Patient Liaison and the Step II Grievance Programs.

The University of Texas Medical Branch (UTMB) and Texas Tech University Health Sciences Center (TTUHSC) overall combined percentage of sustained offender medical grievances closed in the First Quarter FY2018 for the Step II medical grievances was 3.5%. Performance measure expectation is six percent or less (Article IX, Correctional Managed Health Care contract). The percentage of sustained Step II medical grievances from UTMB was 4.29% and 1.05% for TTUHSC for the First Quarter of FY2018.

Action Requests are generated to address Quality of Care issues, i.e., clinical decisions, complaints about medical personnel and staff practice issues. Action Requests are also generated to address access to care, policy and documentation issues.

QUALITY IMPROVEMENT (QI) ACCESS TO CARE AUDIT

During the First quarter of FY 2018, (September, October, and November 2017), the PLP nurses and investigators performed 16 Sick Call Request Verification Audits (SCRVAs) on 15 facilities. At some units, Expansion Cell Block areas were counted as a separate audit. This audit was formerly known as Access to Care (ATC) audits.

The SCRVA examines and verifies the facility methodology for reporting Access to Care. A random sample of Sick Call Requests was also audited by the Office of Professional Standards (OPS) staff. A total of 123 indicators were reviewed at the 15 facilities and 37 of the indicators fell below the 80 percent compliance threshold representing 30 percent. The discipline composite score (medical/nursing, dental, and mental health) is an overall assessment of compliance with the sick call process of the 15 facilities audited. There were 4 units with one or more discipline composite scores below 80. Corrective action has been requested from these facilities. At each unit, OPS staff continued educating the medical staff.

The frequency of the SCRVAs was changed in the Fourth Quarter of FY 2011. Units with an average composite score of 80 or above in each discipline will be audited one time per fiscal year. Those with average composite scores less than 80 in a discipline(s) or less than a two year history of scores will have that discipline(s) audited quarterly.

OFFICE OF PUBLIC HEALTH

The Public Health Program monitors cases of infectious diseases in newly incarcerated offenders as well as new cases that occur within the TDCJ offender population. The data is reported by the facilities for 11 infectious conditions including Syphilis, Hepatitis C Virus (HCV), Human Immunodeficiency Virus (HIV), and Tuberculosis (TB) as well as the data for occupational exposures to bloodborne pathogens.

 The reporting mechanism for HIV tests was changed effective February 1, 2010. HIV tests are now to be classified as belonging to one of four categories: intake, provider requested, offender requested, or pre- release. HIV testing became mandatory at intake in July 2007. However, offenders who are already known to be HIV positive are not required to be retested at intake. Instead, they are offered laboratory testing to assess the severity of their infections. HIV testing became mandatory for pre-release in September 2005 (HB 43). Pre-release testing generally occurs during the last six months of incarceration. Two categories of offenders do not require pre-release testing: those already known to be HIV positive and those whose intake test were drawn within six months of an offender’s release date. During the First Quarter FY 2018, there were 17,805 intake HIV tests performed. Of those tested, 104 offenders were newly identified as having HIV infection. During the same time period, there were 9,526 pre-release tests performed with 0 found to be HIV positive. For this quarter, 12 new AIDS cases were identified. Page 128 of 163

OFFICE OF PUBLIC HEALTH (CONTINUED)

 There were 481 cases of Hepatitis C identified for the First Quarter FY 2018. This number may not represent an actual new diagnosis, but rather the first time it was identified in TDCJ.

 152 cases of suspected Syphilis were reported in the First Quarter FY 2018. 89 required treatment or retreatment. Syphilis can take months to identify, these figures represent an overestimation of actual number of cases. Some of the suspected cases will later be reclassified as resolved prior infections.

 249 Methicillin-Resistant Staphylococcus Aureus (MRSA) cases were reported for the First Quarter FY 2018. For the same time period, 114 Methicillin-Sensitive Staphylococcus Aureus (MSSA) cases were reported. These cases are based on culture reports and may include offenders who have previously been diagnosed with MRSA or MSSA. Numbers for both organisms have fluctuated over the last few years with no trends or concerning patterns identified.

 There was an average of 18 TB cases (pulmonary and extra-pulmonary) under management for the First Quarter FY 2018. This number includes those diagnosed prior to entering TDCJ and still receiving treatment, and those who were diagnosed in TDCJ. Although TB numbers often fluctuate significantly from year to year, there has been a slight increase in the numbers of offenders under management for TB over the last few years.

 In FY 2006, the Office of Public Health began reporting the activities of the Sexual Assault Nurse Examiner (SANE) Coordinator. This position collaborates with the Safe Prisons Program and is trained and certified as a SANE. This position audits the documentation and services provided by medical personnel for each sexual assault reported. There have been 220 chart reviews of alleged sexual assaults performed for the First Quarter FY 2018. There were 70 deficiencies found this quarter and corrective action requested. Blood-borne exposure baseline labs were drawn on 72 exposed offenders. To date, 0 offenders have tested positive for HIV in follow-up labs routinely obtained after the report of sexual assault.

 During the First Quarter FY 2018, 3 units received a 3 day training which included the Wall Talk Training and the Somebody Cares Training. 3 units received a 2 day training which included the Somebody Cares Training. As of the close of the quarter, 99 of the 105 facilities housing Correctional Institutions Division (CID) offenders had active peer education programs. During this quarter, 104 offenders trained to become peer educators and 22,379 offenders attended the classes presented by peer educators.

MORBIDITY AND MORTALITY

There were 106 deaths reviewed by the Morbidity and Mortality Review Committee during the months of September, October and November 2017. Of those 106 deaths, 4 were referred to peer review committees.

A referral to a peer review committee does not necessarily indicate that substandard care was provided. It is a request for the Correctional Managed Health Care providers to review the case through their respective quality assurance processes. Referrals may also be made to address systemic issues to improve the delivery of health care.

Peer Review Committee Number of Cases Referred Provider Peer Review 2 Nursing Peer Review 2 Nursing and Provider Peer Review 0 Total 4 Page 129 of 163

OFFICE OF MENTAL HEALTH SERVICES MONITORING & LIAISON

The following is a summary of findings by the Office of Mental Health Monitoring & Liaison (OMHM&L) during the First Quarter of FY 2018:

 The OMHM&L monitors all Segregation facilities within the TDCJ CID and State Jails once every six months. During the First Quarter of FY 2018, 17 Segregation facilities were audited including: Allred (12 Building and ECB), Bradshaw, Clemens, Clements, Cole, Connally, Darrington, Dominguez, East Texas, Hutchins, Lewis, Lopez, McConnell, Powledge, Polunsky, Ramsey, and Sanchez. The OMHM&L auditors observed 2,332 offenders, interviewed 1,976 offenders, and referred 2 offenders for further evaluation by university providers.

 In addition to monitoring the mental health status of segregated offenders, the OMHM&L auditors also assess access to care (ATC) for mental health and availability of the 911 tool to be used in case of emergency. The auditors check for timely triage (ATC 4), appropriate description of chief complaint (ATC 5), and timely provider visits after referral (ATC 6). For ATC, 4 16 of 17 units were 100% compliant. For ATC 5, 16 of 17 units were 100% compliant. For ATC 6, 16 of 17 units were 100% compliant. Cole had NSP on ATC 4, ATC 5, and ATC 6. East Texas Transfer Facility was 89% compliant on ATC 4 and 95% compliant on ATC 5. Hutchins was N/A on ATC 6. For the 911 tool availability, 17 of 17 units were 100% compliant.

 The OMHM&L monitors all instances of administration of compelled psychoactive medication to offenders to ensure that all instances are appropriately documented. During the First Quarter FY 2018, a total of 94 instances of compelled psychoactive medication administration occurred. There were 17 instances at the Montford unit, 60 instances at the Skyview unit, 12 instances at the Jester IV unit and 5 instances at the Clements unit. During each month of the quarter, Jester IV, Montford, and Skyview were 100% compliant with required criteria for implementation and documentation of compelled psychoactive medication. Clements Unit was 100% compliant in September, 100% compliant in October, and N/A in November.

 The Intake Mental Health Evaluation audit conducted by the OMHM&L is designed to provide reasonable assurance that those offenders identified as having a potential mental health need upon intake receive a Mental Health Evaluation within 14 days of identification. Of the 25 intake facilities, 24 facilities identified incoming offenders in need of Mental Health Evaluations. At the Kyle unit there were no offenders identified as applicable to the audit. 21 of the 25 facilities met or exceeded 80% percent compliance for completing Mental Health Evaluations within 14 days of identified need: Baten, Bradshaw, Byrd, Dominguez, Formby, Garza, Gist, Glossbrenner, Halbert, Holliday, Hutchins, Jester 1, Johnston, Lindsey, Lychner, Middleton, Plane, Sanchez, Sayle, Travis and Woodman. 3 of the 25 facilities earned compliance scores of 79% or lower: East Texas Transfer Facility (60%), Gurney (20%) and Kegans (22%). Corrective action plans were requested from these 3 facilities.

OFFICE OF THE HEALTH SERVICES LIAISON

 The Office of the Health Services Liaison (HSL) conducts a random audit of 10 percent of electronic health records (EHRs) of offenders discharged from hospitals and infirmaries in the TTUHSC and the UTMB sectors. In the First Quarter of FY 2018, HSL conducted 172 hospital and 58 infirmary discharge audits.

 Each audit determines if vital signs were recorded on the day the offender left the hospital/infirmary; if the receiving facility had medical services sufficient to meet the offender’s current needs; if the medical record was reviewed by a nursing staff member and referred (if applicable) to an appropriate provider as required by policy; if the offender required unscheduled medical care related to the admitting diagnosis within the first seven days after discharge and if discharge information was available in the offender’s EHR within 24 hours of the offender arriving at the unit. Page 130 of 163

OFFICE OF THE HEALTH SERVICES LIAISON (CONTINUED)

• Of the 172 hospital discharge audits conducted, 155 were from the UTMB Sector and 17 were from the TTUHSC sector. There were 46 deficiencies identified for UTMB and 13 identified for TTUHSC. Of the infirmary discharge audits conducted, 27 were from the UTMB sector and 31 were from the TTUHSC sector. There were 8 deficiencies identified from UTMB and 7 for TTUHSC. ACCREDITATION The ACA 2018 Winter Conference will be held in Orlando Florida on January 4-9, 2018. During this conference, the following Facilities will be represented: Polunsky, Briscoe, Cotulla, Cole, Moore, Gist, LeBlanc, Goodman, Woodman, Stiles, Beto, Torres/Ney, Jordan/Baten, Lopez/Segovia, Luther, and Holliday. BIOMEDICAL RESEARCH PROJECTS The following is a summary of current and pending research projects as reported by the Texas Department of Criminal Justice (TDCJ) Executive Services: • Correctional Institutions Division Active Monthly Research Projects - 27 • Correctional Institutions Division Pending Monthly Research Projects - 5 • Health Services Division Active Monthly Medical Research Projects - 9 • Health Services Division Pending Medical Research Projects - 4 An Overview of the Texas Correctional Managed Health Care Program

Presented by: Lannette Linthicum, MD, CCHP‐A, FACP Director, Health Services Division Texas Department of Criminal Justice (TDCJ)

March 20, 2018 Correctional Managed Health Care Committee Dallas, Texas Page 131of163 Consensus for Change

 “A managed care health system should be established for inmates of TDCJ”

 “The system should be governed by a board comprised of officials from TDCJ, UTMB and TTUHSC” Texas Performance Review, “Against the Grain,” January 1993.  “The state is developing and implementing a comprehensive managed health care plan with the hope that spiraling inmate health costs can be more effectively controlled.” State Audit Report, “TDCJ Health Services

Review,” September 1993. Page 132of163 What is Correctional Managed Health Care?

A Strategic Partnership between: . The Texas Department of Criminal Justice . The University of Texas Medical Branch at Galveston . Texas Tech University Health Sciences Center Focused upon a shared Mission: . To develop a statewide health care network that provides TDCJ offenders with timely access to a constitutional level of health care while also controlling costs

Managed by a statutorily established body: Page 133of16 . The Correctional Managed Health Care Committee Statutory Authority & History

CMHC authorizing legislation originally passed in 1993 (SB 378)

Now codified as Subchapter E, Chapter 501, Texas Government Code: . Establishes ten ‐person committee that includes at least six physicians. Six of the ten members are appointed by the Governor, the remaining four members are appointed by partner agencies and the state Medicaid Director . Charges the committee with establishing a statewide network to provide health care services to TDCJ offenders

. Maximize the use of state medical schools to the extent Page 134of163 possible CMHCC Organizational Relationships

GOVERNOR LEGISLATURE

Correctional Managed Health Care Committee

TDCJ Health Services Division & UTMB Correctional TTUHSC Correctional Business & Finance Division Managed Care Managed Care Page 135of163 Roles and Responsibilities

CMHCC University Providers TDCJ

 Onsite Services  Resource Allocation  Clinical Policy Oversight  Offsite Services  Legislative/Legal  Liaison Activities . Specialty Clinics Coordination  Dispute Resolution . Hospitalization  Contract Coordination  Quality of Care Monitoring   Monitoring Oversight Pharmacy Services  Mental Health Services . Access to Care  Utilization Management . Operational Reviews  Provider Network . Grievances Management . Financial  Quality of Care Monitoring  Preventive Medicine  TDCJ Employee Health  Health Services Liaison Services  Professional Standards  Administrative Functions Page 136of163 Geographical Areas of

Dalhart Responsibility Pampa Amarillo Tulia Plainview

Lubbock Childress Brownfield Wichita Falls Jacksboro Bonham New Boston Lamesa Bridgeport Breckenridge Snyder Dallas Winnsboro Abilene Overton Colorado City Venus Palestine Teague Henderson El Paso Gatesville Brownwood Rusk Marlin Diboll Jasper Fort Stockton Midway Lovelady Livingston Bartlett Huntsville Woodville Burnet Cleveland Austin Liberty Navasota Dayton Beaumont Kyle Houston Atascosita Lockhart Sugarland San Antonio Richmond Hondo Rosharon Texas City Capacity 30,518 Angleton Capacity 124,926 Cuero Galveston Brazoria Offenders Dilley Kenedy Offenders Beeville

Cotulla San Diego Page 137of163

Raymondville Edinburg Redefining Traditional Roles

Partnership between the state government and academic health science centers . Seeks to leverage the expertise of each partner to the maximum benefit. . Moves the health science center from serving primarily as advisor/tertiary provider to role with primary responsibility for delivery systems, from point of service forward. . Allows TDCJ to focus on core correctional processes (security, detention, etc.). Page 138of163 Page 139of163

1 HISTORY

Established by the Texas Legislature in 1993 • Ruiz v. Estelle, Estelle v. Gamble • Primary Mission: improve access to quality health care for TDCJ offenders while containing cost by – maximizing the use of the state’s medical schools – securing efficiencies through improved intergovernmental collaboration – utilizing managed healthcare tools Page 140of163 TTUHSC KEY PERSONNEL

Associate Dean Health Services Management Cynthia Jumper, MD

Executive Medical Director Denise DeShields, MD

Senior Managing Director Clinical Leadership Will Rodriguez

Finance Medical North Lindsey Tubbs Ben Leeah, MD

Operations Medical South Gary Tonniges Sheri Talley, MD

Human Resources Mental Health Ella O’Neal Barbara Beadles, MD Dental Cecil Wood, DDS

Nursing Page 141of163 Mike Jones, RN UM Brenda Whitney, RN TODAY: OUR SECTOR

21 Facilities in 17 geographical sites • Approx. 30,000 offenders • State prison, jail and Intermediate Sanction Facilities • (3) 17 bed infirmaries (Abilene, Amarillo and Wichita Falls) • 98-bed medical/surgical unit in Lubbock • 1000+ inpatient psychiatric beds

FY18 budget $103M

960 employees Page 142of163 • 37% of workforce has 10+ years of service CONTRACT NETWORK

Total: 223 Hospital and Page 143of163 Professional Services Contracts OUR SERVICES

Levels of Care Provided • Medically Mandatory • Medically Necessary Annual Encounters FY17 - Approx. 1.8M • Medical - 24,074 encounters CMHC • Dental - 50,324 encounters Triple Aim • Mental Health - 86,533 encounters • Nursing Full Service – 194,619 encounters Cost of Care • Nursing Limited Service – 1,435,146 encounters Encounters via Telehealth Technology – 10,860 Page 144of163 SPECIAL MEDICAL PROGRAMS

Montford Regional Medical Facility (RMF) 2 Surgical Suites Onsite Dialysis 128 Beds • 50 Ward beds • 44 Long Term Care beds • 4 Step Down SCU beds • 30 Holding beds CT, Ultrasound, and MRI Diagnostics

Physical, Occupational and Respiratory Therapy Page 145of163 SPECIAL PSYCHIATRIC PROGRAMS

Montford Inpatient Psychiatric Unit 550 beds co-located with RMF Inpatient Psychiatry, Psychology, and Social Work Program For Aggressive Mentally Ill Offenders (PAMIO) 208 bed capacity Structured services for aggressive and assaultive behavior Chronically Mentally Ill (CMI) 260 bed capacity

14 Crisis Management beds Page 146of163 Designed to decompress inpatient beds across the state CHALLENGES

Aging Offender Population Mental Health Needs • Limited Infirmary and Long Term Care beds • 39.6% of offenders meet criteria for a • Offenders are physiologically 10-15 years older mental health diagnosis Rising Cost of Pharmaceuticals • Offenders aged 55+ Healthcare Professional Shortage – 11% of TDCJ population (18,000+) – 43% of our hospitalization costs Rural locations – 80% are not eligible for release Aging Workforce Page 147of163 COSTVINGS SA INITIATIVES

Pharmacy Efficient Clinical Care • Managed Care Formulary • Preventative Care • Drug Reclamation Program • Chronic Care Management • Collaborative Patient Reassignment • Evidence Based Medicine Limited Use of Agency Staff and Utilization of RMF Facility Professional Recruiters • New contracts, investments in the facility Utilization of Telemedicine • Projected offsite care cost avoidance of $1M • Reduces offender transport Expanded Hours of Operation • Enhances provider availability • Reduces ER and offsite care utilization Page 148of163 Open Forum Page 149of163 Page 150 of 163 February 21, 2018

Overview of UTMB Correctional Managed Care Services

Owen Murray, DO, MBA Vice President, Offender Health Services University of Texas Medical Branch Page 151of163 Correctional Managed Care UTMB CMC Patient Care

• CMC provides healthcare for 114,000 patients within the Texas Department of Criminal Justice. We operate 81 ambulatory clinics over the eastern half of the state of Texas and provide:

• Dental Services • Mental health inpatient • Dialysis services • Primary care • Pharmacy operations • Hospital Care • Radiology and Lab services • Infectious disease services • Specialty Care • Infirmary level care • Telehealth services • Mental health services • Urgent Care Page 152of163

Working Together to Work Wonders 2 UTMB CMC Patient Demographics

• 30% of CMC patients have at least one chronic condition • 8,000 patients with asthma • 8,000 patients with diabetes • 2,500 patients with heart disease • 14,500 patient with hepatitis C • 2,000 patients who are HIV+ • 34,000 patients with hypertension • 290 dialysis patient • 488 infirmary beds • 1,000 mental health inpatients • 18,500 patients on mental health caseload • Rapidly growing 55+ population – 17,000 patients Page 153of163

Working Together to Work Wonders 3 CMC Innovative Clinical and Support Programs

• CMC dialysis centers • CMC manages the largest dialysis program in the state of Texas • In-house nephrologist, dialysis nurses • Adheres to state and federal regulations

• Internal pharmacy and medication distribution system • 340B pricing • Process and deliver 325,000 prescriptions per month

• Telehealth • CMC provides Telehealth services to all UTMB CMC facilities. • Provides solutions to provider and nursing shortages in hard to fill geographic regions. • Centralized provider group for: • Primary care, sick call, urgent care, tele-nephrology, mental health, infectious disease, wound care, and clinical pharmacology Page 154of163 • Over 120,000 Telehealth encounters in FY17 (largest non-military program in the US)

Working Together to Work Wonders 4 CMC Innovative Clinical and Support Programs (cont.)

• Utilization Management • 24-7 UR case managers • Manage all urgent/emergent offsite movement • Provide concurrent offsite patient management • Maintain cost based contracts with local freeworld hospitals • Manage 488 infirmary beds across the state with bed management software • Track high risk patient population (e.g. cancer) for continuity

• Clinical Continuity • All providers utilize CMC specific disease management guidelines for common conditions and emergencies. • CMC meets or exceeds national clinical endpoint benchmarks

• Electronic medical record • All CMC facilities are linked using an intrasystem EMR

• The EMR is linked to the pharmacy system and high use offsite hospitals Page 155of163

Working Together to Work Wonders 5 CMC Innovative Clinical and Support Programs (cont.)

• Quality/Performance improvement • Provider and nursing peer review • Lean six sigma trained central and facility staff • CMC dashboard • On demand clinical outcomes (asthma, diabetes, CAD, HTN) • Facility linked reports for access to care, encounters, pharmacy utilization, Telehealth utilization • Provides central and facility leadership access to current goal status • Corrective action planning and monitoring for clinical dashboard

• Access to care • Patient access to clinical services is critical in correctional medicine and is measured monthly.

• CMC consistently maintains access to care at or above 98% Page 156of163

Working Together to Work Wonders 6 CMC FacilityBased Telehealth

Encounters 100000 120000 140000 20000 40000 60000 80000 0 y8 y9 y0 y1 y2 y3 y4 y5 y6 fy17 fy16 fy15 fy14 fy13 fy12 fy11 fy10 fy09 fy08 Mental health care Primary Pharmacy Wound care Infectious disease Working TogetherWondersWork to since FY08 CMC T increase in the useof There hasbeena2fold elehealth services elehealth

7 Page 157 of 163 of 157 Page UTMB CMC Clinical Dashboard Results

Diabetes Diabetes DM LDL Diabetes HTN BP CAD LDL Asthma BP <140/90 HgA1c <8% <100 Nephropath BP140/90 <100 Correct y Screening Meds CMC 60% 59% 72% 88% 58% 69% 88% 7/17 HEDIS* 60.4% 45.5% 33.9% 79% 56.5% 40.5% 73% Page 158of163

*Healthcare Effectiveness Data and Information Set

Working Together to Work Wonders 8 Hospital Galveston Page 159of163

9 Overview • Opened in 1983 • Only maximum security hospital on the campus of a major academic medical center • One of a kind setting granting nurses, students, fellows, residents and faculty a very diverse pathology • Tertiary acute inpatient and outpatient facility • Accredited by Joint Commission for Accreditation of Health Care Organizations Page 160of163

Working Together to Work Wonders 10 Outpatient Specialty Clinics

An average of 300 visits per day for specialty and ancillary services

• Adult Burn • Heart Station • Plastic Surgery • Allergy • Hematology • Phlebotomy • Audiology • Infectious Diseases • Pulmonology • Cardiology • Inpatient Dialysis • Radiation Therapy • Chemotherapy and • Nephrology • Radiology Infusion Therapy • Nerve Conduction • Rheumatology • Dermatology Studies • Sleep Studies • DOT Physicals • Neurology • Speech Pathology • Echocardiography • Neurosurgery • Thoracic Surgery • Electroencephalogram • Oncology • Transplant • Endocrinology • Ophthalmology • Urology • Gastroenterology • Oral Surgery • Urodynamic Testing • Gender Identity • Orthopedic Surgery • Vascular Studies • General Surgery • Otolaryngology • Vascular Surgery • Gynecology Urology • Pain Page 161of163

Working Together to Work Wonders 11 Telemedicine Clinics

− Innovative means of healthcare delivery − Average 5,000 patients a year • Dermatology • Oncology • Gastroenterology • Pain Medicine • Hematology • Pulmonary • Neurosurgery • Radiation Therapy • Neurology • Urology Page 162of163

Working Together to Work Wonders 12 Inpatient Units

• 136 inpatient beds which include Medical/Surgical ICU, telemetry, medical/surgical and oncology

Statistics FY14 FY15 FY16

Average Daily Census (ADC) 76.7 88.6 101.3

Case Mix Index (Weighted Acuity) 1.49 1.55 1.65

Avg. Length of Stay (Raw Data) 7.15 8.65 9.02

Avg. Length of Stay (Adjusted CMI) 4.79 5.58 5.48

Discharges 3,917 3,740 4,109 Page 163of

Working Together to Work Wonders 13