PROVIDING HEALTHCARE IN THE PRISON ENVIRONMENT What services belong behind bars and what services belong in the community setting? DAVID REDEMSKE, ASHE, CCHP Principal, Health Planning ACKNOWLEDGMENTS This project would not have been possible without the support of HDR leadership, the HDR Fellowship Committee and the Fellowship Committee Chairman, Michael Schneider. I am especially indebted to Jeri Brittin for her support and suggestions when I was applying for the Fellowship; to Hank Adams and Roger Stewart for being my sponsors for this Fellowship; and to Scott Foral, Erik Carlson, and Jim Atkinson for allowing me to pursue this Fellowship as a full-time project. I am grateful to all of those who I have had the pleasure to work with throughout this project. To Troy Parks for being a sounding board and copy editor for some of my early studies and drafts; to Carol O’Donnell for copy editing of the full document; and to Matthew Delaney for his amazing graphics and document assembly. Nobody has been more important to me throughout this Fellowship than Francesqca Jimenez. She has been my teacher, my advisor, and my main sounding board during this study. Without her guidance and support, this document would not be as complete and comprehensive as it is. ABSTRACT ABSTRACT BACKGROUND METHODS CONCLUSION While there are numerous built environmental A systematic literature review including key There is no “one-size-fits-all” answer to the models for prisoner health care, little has word searches of multiple relevant databases, question of where the best location is to been done to assess the models to see if a title and abstract reviews, and the full text provide care for prison inmates. However, particular location for care better serves the review of 169 pertinent sources. there are a number of questions that state inmate population’s health needs over other departments of corrections should investigate locations. “Mass incarceration” has been used RESULTS when determining where to provide their to describe the recent dramatic expansion of Due to growth of the prisoner population healthcare services. In addition, there are the criminal justice system in the United States. in the U.S., many states are struggling to two other factors states can review regarding Underserved communities with minimal access provide a constitutional level of health care inmate healthcare: (1) Can the prison to healthcare services disproportionately to their inmates. Numerous care models population be reduced so that there are bear the burden of mass incarceration. This have been created using both in-house and fewer inmates who require care, and (2) Are huge influx into the prison population of those community-based facilities. Many enter prison there community-based health system best who have received little or no medical care with untreated medical and mental health practices that can be applied to a corrections throughout the course of their lives, along conditions, and if they are not treated within setting in order to provide more efficient care with a court ruling mandating a constitutional the prison environment, they will bring those to the population? level of care for prisoners, has resulted in a conditions back to their communities. In greater demand for healthcare services for addition, though they may receive care while this population. The purpose of this literature incarcerated, many discharged inmates are review is to shed light on the challenging left untreated once they are released, due to a healthcare process, the best environments for lack of coordination between the prison health prison inmates to receive care, and to generate system and the community health system. recommendations for the future. 03 1 Abstract 03 2B.9 Medical Classifications and Care Levels 25 Background 03 2B.10 Location of Testing and Services 26 Methods 03 2B.11 Funding 27 Results 03 2B.12 ACA Effects 27 Conclusion 03 2B.13 Obtaining Informed Consent and Other Ethical Issues 28 2B.14 Alternatives to Incarceration 29 2 Introduction 08 2.0 References 30 2.1 Research Aim and Questions 08 2.2 Research Scope 09 53 Methodology 34 2.3 Research Organization 09 3.0 References 36 2A 3 Demographics 11 64 Ambulatory and General Care 38 2A.1 The Number of Prisoners Worldwide 11 4.1 Results 38 2A.2 Distribution by Inmate Age, Race and Sex 12 4.1.1 Primary Care Model 38 2A.3 Common Prisoner Backgrounds 13 4.1.2 Public health Model 40 4.1.3 Description of an Academic Partnership model 42 2A.4 Conviction Types and Duration of Sentence 13 4.1.4 Diagnostic and Treatment Services 45 2A.5 Common Medical Conditions 14 4.1.5 Telemedicine 46 2A.6 Causes of Death While Incarcerated 16 4.2 Discussion 49 2A.7 Incidence of Release for the Incarcerated 17 4.3 References 52 2A.8 Rate of Recidivism 17 2A.9 Costs to Incarcerate 17 75 Elder Care 55 2A.10 Medical Costs 18 5.1 Results 55 2A.11 Post-Release Concerns 19 5.1.1 Types of older inmates (lifers, recidivists, first offense) 55 5.1.2 Characteristics of aging Inmates 55 2B 4 The Current State of Healthcare in Prisons 20 5.1.3 Older Prisoner Use of Health services 57 2B.1 Estelle v Gamble 20 5.1.4 Providing Care in a Community Facility 58 2B.2 War on Drugs / Mandatory Minimums 21 5.1.5 Providing care in a Prison Facility 58 2B.3 Three Strikes 21 5.1.6 Collaborations with Community Health / Discharge Planning 62 2B.4 Deinstitutionalization of Inmates with Behavioral Health Issues 22 5.2 Discussion 63 2B.5 Accreditation Bodies 22 5.3 References 66 2B.6 Healthcare Delivery Methods 22 86 Palliative Care 68 2B.7 Contracting methods 24 6.1 Results 68 2B.8 Standard of Care 24 04 6.1.1 Defining the Need for Inmate Hospice and Palliative Care 68 911 Mental HealthCare 98 6.1.2 NPHA and GRACE Standards 68 9.1 Results 98 6.1.3 Meeting Community Standards of Care 69 9.1.1 Impacts of Traumatic Brain Injury 6.1.4 Eligibility Standards for a Prison Hospice Program 69 (TBI) and Trauma on Mental Health 98 6.1.5 Interdisciplinary Care Teams 70 9.1.2 Difficulties for the Mentally Ill in Prisons 100 6.1.6 Health Literacy of Inmates 70 9.1.3 Mental Health and Criminal Justice 102 6.1.7 Providing Inmate Hospice Care in a Community Facility 70 9.1.4 Alternatives to Prison—Drug Courts and Divergent Centers 104 6.1.8 Providing Inmate Hospice Care in the Prison Facility 71 9.1.5 Guidelines 104 6.1.9 Palliative Care 75 9.1.6 Recommendations 106 6.1.10 Compassionate release 75 9.2 Discussion 106 6.2 Discussion 77 9.2.1 Increased Funding for Community- 6.3 References 80 based Outpatient Treatment Programs 107 9.2.2 Increased Funding for the Construction, Staffing, and 79 Emergency/Trauma Care 82 Maintenance of Community-based Inpatient Mental Health Beds 107 7.1 Results 82 9.2.3 Increased Funding for Diversion Programs 108 7.1.1 Traumatic Brain Injury 82 9.2.4 Standardized Screening and Treatment Processes 108 7.1.2 Prison Injuries 82 9.2.5 Increased training in Mental Health Conditions for 7.1.3 Prison Drug Use 84 Corrections Officers 108 7.1.4 Use of Emergency Departments 84 9.2.6 Increased Training and Treatments on the Effects of TBI 109 7.1.5 Alternatives to the ED 85 9.2.7 Provide Trauma-Based Treatment Programs 109 7.1.6 Leveraging Telemedicine 86 9.2.8 Reduce the Use of Segregated Housing for the Mentally Ill 109 7.1.7 Location of Care 86 9.2.9 Increase the Number of Prison-based Acute Care and Intermediate Care Beds 110 7.2 Discussion 86 9.2.10 Increased Funding on Programs to Reduce Recidivism 110 7.2.1 Implications 88 9.2.11 Implications 111 7.3 References 89 9.3 References 111 810 Dental Care 91 1012 Women’s Healthcare 113 8.1 Results 91 10.1 Results 113 8.1.1 Types of Dental Conditions in Prisoners 91 10.1.1 Women’s Health Needs 114 8.1.2 Barriers to Care 92 10.1.2 Children and the Community 115 8.1.3 Range of Services 93 10.1.3 Programs for Women 116 8.2 Discussion 94 10.1.4 Women’s Primary Care 117 8.3 References 96 10.1.5 Women’s Chronic Care 119 10.1.6 Women’s Elder Care 120 05 10.1.7 Women’s Reproductive Health 123 12 14 Transportation 147 10.1.8 Women’s Mental HealthCare 127 12.1 Results 147 10.1.9 Areas for Improvement 130 12.1.1 Reasons for Transport 147 10.2 Discussion 131 12.1.2 Types of Transport 147 10.2.1 Children and Community 131 12.1.3 Process for Transport 148 10.2.2 Programs for Women 132 12.1.4 Security Concerns 149 10.2.3 Where care is Provided 133 12.1.5 Cost of Transport 149 10.2.4 Partnerships 133 12.1.6 Recommendations 150 10.2.5 Diagnostic and Treatment Services 133 12.2 Discussion 150 10.2.6 Dental Care 134 12.3 References 152 10.2.7 Access to Care and Use of Co-pays 134 10.2.8 Women’s Chronic Care 134 13 15 Conclusion 154 10.2.9 Women’s Elder Care 134 13.1 Recurring Issues in Providing Quality Healthcare 10.2.10 Functional Impairments 134 for Inmate-Patients 154 10.2.11 Community Linkages, Compassionate Release, and Hospice 135 13.1.1 Community-based Services 154 10.2.12 Women’s Reproductive Health 135 13.1.2 The Need for Nationally 10.2.13 Shackling Policies 135 Recognized Definitions and Standards 155 10.2.14 Bonding with Newborns 136 13.1.3 Continuity of Care 156 10.2.15 Pregnancy Termination 136 13.1.4 Use of Technology 156 10.2.16 Women’s Mental Healthcare 136 13.1.5 Staffing and Training 157 10.2.17 Alternatives to Incarceration 137 13.1.6 Programming and Diversion Opportunities 158 10.2.18 Corrections Officer Training 137 13.1.7 Inmate Data Collection 158 10.2.19 Implications 137 13.2 Service and Policy Changes to Reduce Prison Populations 159 10.3 References 137 13.2.1 Creating or Expanding Community-based Services