Prison Health Care Governance: Guaranteeing Clinical Independence.

Clinical independence is an essential component of good health care and health care professionalism, particularly in correctional settings (jails, prisons, and other places of detention), where the relationship between patients and caregivers is not based on free choice and where the punitive correctional setting can challenge optimal medical care. Independence for the delivery of health care services is defined by international standards as a critical element for quality health care in correctional settings, yet many correctional facilities do not meet these standards because of a lack of awareness, persisting legal regulations, contradictory terms of employment for health professionals, or current health care governance structures. We present recommendations for the implementation of independent health care in correctional settings.

How health care reform can transform the health of criminal justice-involved individuals.

Provisions of the Affordable Care Act offer new opportunities to apply a public health and medical perspective to the complex relationship between involvement in the criminal justice system and the existence of fundamental health disparities. Incarceration can cause harm to individual and community health, but prisons and jails also hold enormous potential to play an active and beneficial role in the health care system and, ultimately, to improving health. Traditionally, incarcerated populations have been incorrectly viewed as isolated and self-contained communities with only peripheral importance to the public health at large. This misconception has resulted in missed opportunities to positively affect the health of both the individuals and the imprisoned community as a whole and potentially to mitigate risk behaviors that may contribute to incarceration. Both community and correctional health care professionals can capitalize on these opportunities by working together to advocate for the health of the criminal justice-involved population and their communities. We present a set of recommendations for the improvement of both correctional health care, such as improving systems of external oversight and quality management, and access to community-based care, including establishing strategies for postrelease care and medical record transfers.

Paying the price: the pressing need for quality, cost, and outcomes data to improve correctional health care for older prisoners.

Despite a recent decline in the U.S. prison population, the older prisoner population is growing rapidly. U.S. prisons are constitutionally required to provide health care to prisoners. As the population ages, healthcare costs rise, states are forced to cut spending, and many correctional agencies struggle to meet this legal standard of care. Failure to meet the healthcare needs of older prisoners, who now account for nearly 10% of the prison population, can cause avoidable suffering in a medically vulnerable population and violation of the constitutional mandate for timely access to an appropriate level of care while incarcerated. Older prisoners who cannot access adequate health care in prison also affect community healthcare systems because more than 95% of prisoners are eventually released, many to urban communities where healthcare disparities are common and acute healthcare resources are overused. A lack of uniform quality and cost data has significantly hampered innovations in policy and practice to improve value in correctional health care (achieving desired health outcomes at sustainable costs). With their unique knowledge of complex chronic disease management, experts in geriatrics are positioned to help address the aging crisis in correctional health care. This article delineates the basic health, cost, and outcomes data that geriatricians and gerontologists need to respond to this crisis, identifies gaps in the available data, and anticipates barriers to data collection that, if addressed, could enable clinicians and policy-makers to evaluate and improve the value of geriatric prison health care.

Aging in correctional custody: setting a policy agenda for older prisoner health care.

An exponential rise in the number of older prisoners is creating new and costly challenges for the criminal justice system, state economies, and communities to which older former prisoners return. We convened a meeting of 29 national experts in correctional health care, academic medicine, nursing, and civil rights to identify knowledge gaps and to propose a policy agenda to improve the care of older prisoners. The group identified 9 priority areas to be addressed: definition of the older prisoner, correctional staff training, definition of functional impairment in prison, recognition and assessment of dementia, recognition of the special needs of older women prisoners, geriatric housing units, issues for older adults upon release, medical early release, and prison-based palliative medicine programs.

Independent review of clinical health services for prisoners.

PURPOSE: The purpose of this paper is to describe the parameters for the development of performance measurement of the quality of medical care behind bars, drawing from widely-published free-world clinical guidelines and aspects of care that are unique to the criminal justice arena. DESIGN/METHODOLOGY/APPROACH: One way to help assure that prisoners receive timely and appropriate health care is through independent review of health care services, to identify strengths of programs and opportunities for improvement. This is a quality of medical care assessment. When done in a systematic way, this has the potential to reduce risk of harm and enhance the personal health of the prisoner and improve the public health. Independent external review provides the best opportunity to identify and remedy opportunities for improvement. "External" can mean wholly independent or "corporate," that is, review by agency staff that has no vested interest in the findings at the individual facility. Recently, the methodology for assessment of the quality of medical care in the community has blossomed, yet there is little guidance on how to adapt this methodology to the prison setting. FINDINGS: This paper introduces a prison-oriented method for assessing clinical performance. To the extent possible, the author cites references to the scientific basis for the recommendations. Where there is no science, the author relies as much as possible on consensus, and in a few cases resorts to "wisdom and experience," as unreliable as this might be. This is a conceptual paper with a viewpoint. ORIGINALITY/VALUE: The paper provides guidance on reducing risk of harm and promoting improved health and health care for prisoners.

Balancing punishment and compassion for seriously ill prisoners.

Compassionate release is a program that allows some eligible, seriously ill prisoners to die outside of prison before sentence completion. It became a matter of federal statute in 1984 and has been adopted by most U.S. prison jurisdictions. Incarceration is justified on 4 principles: retribution, rehabilitation, deterrence, and incapacitation. Compassionate release derives from the theory that changes in health status may affect these principles and thus alter justification for incarceration and sentence completion. The medical profession is intricately involved in this process because eligibility for consideration for compassionate release is generally based on medical evidence. Many policy experts are calling for broader use of compassionate release because of many factors, such as an aging prison population, overcrowding, the increasing deaths in custody, and the soaring medical costs of the criminal justice system. Even so, the medical eligibility criteria of many compassionate-release guidelines--which often assume a definitive prognosis--are clinically flawed, and procedural barriers may further limit their rational application. We propose changes to address these flaws.

Patient safety: moving the bar in prison health care standards.

Improvements in community health care quality through error reduction have been slow to transfer to correctional settings. We convened a panel of correctional experts, which recommended 60 patient safety standards focusing on such issues as creating safety cultures at organizational, supervisory, and staff levels through changes to policy and training and by ensuring staff competency, reducing medication errors, encouraging the seamless transfer of information between and within practice settings, and developing mechanisms to detect errors or near misses and to shift the emphasis from blaming staff to fixing systems. To our knowledge, this is the first published set of standards focusing on patient safety in prisons, adapted from the emerging literature on quality improvement in the community.

Tuberculosis control: lessons for outbreak preparedness in correctional facilities.

Correctional facilities typically house large numbers of persons in close and crowded conditions for long periods. Clusters of communicable diseases ranging from simple viral upper respiratory infections to more serious threats, such as tuberculosis (TB), infections with methicillin-resistant Staphylococcus aureus, and influenza, often emerge in these surroundings. The recent H1N1 influenza pandemic highlights the importance of outbreak prevention and containment preparedness, particularly in congregate settings. In this commentary, the authors propose that the TB control model can provide valuable lessons for infection control practitioners to prepare for, identify, investigate, and control outbreaks of communicable diseases to prevent transmission in correctional facilities and to the surrounding community.

Parole revocation among prison inmates with psychiatric and substance use disorders.

OBJECTIVE: This retrospective cohort study examined the association between co-occurring serious mental illness and substance use disorders and parole revocation among inmates from the Texas Department of Criminal Justice, the nation's largest state prison system. METHODS: The study population included all 8,149 inmates who were released under parole supervision between September 1, 2006, and November 31, 2006. An electronic database was used to identify inmates whose parole was revoked within 12 months of their release. The independent risk of parole revocation attributable to psychiatric disorders, substance use disorders, and other covariates was assessed with logistic regression analysis. RESULTS: Parolees with a dual diagnosis of a major psychiatric disorder (major depressive disorder, bipolar disorder, schizophrenia, or other psychotic disorder) and a substance use disorder had a substantially increased risk of having their parole revoked because of either a technical violation (adjusted odds ratio [OR]=1.7, 95% confidence interval [CI]=1.4-2.4) or commission of a new criminal offense (OR=2.8, 95% CI=1.7-4.5) in the 12 months after their release. However, parolees with a diagnosis of either a major psychiatric disorder alone or a substance use disorder alone demonstrated no such increased risk. CONCLUSIONS: These findings highlight the need for future investigations of specific social, behavioral, and other factors that underlie higher rates of parole revocation among individuals with co-occurring serious mental illness and substance use disorders.

Caregiving behind bars: correctional officer reports of disability in geriatric prisoners.

Despite increasing numbers of geriatric prisoners, little is known about geriatric disability or health care in prison. Although correctional officers often act as a liaison between prisoners and the healthcare system, the role of officers in recognizing geriatric disability has not been characterized. The goals of this study were to assess officers' assessment of disability in their assigned geriatric prisoners and to contrast their views with reports from the California Department of Corrections and Rehabilitation (CDCR). Questionnaires were given to 71 officers assigned to 618 randomly selected geriatric prisoners in 11 prisons. Information about 41 additional prisoners identified by correctional officers as "high risk" was also analyzed. Prisoner disability and health were determined through correctional officer questionnaires (activity of daily living (ADL) impairment, geriatric syndromes, level of care), chart review (medical diagnoses), and CDCR data (demographics, disability designation). Overall, 211 (34.1%) geriatric prisoners were unknown to their officer. Of the 407 known prisoners, officers reported that 5.0% had ADL impairment and 3.1% were unsafe. Discordance between officer and CDCR reports of disability was common, with officers reporting higher disability rates. The 41 high-risk prisoners were more likely to have ADL impairment (22.0% vs 5.2%, P<.01) and geriatric syndromes such as falls and incontinence than the random sample. Overall, nearly one-third of geriatric prisoners were unknown to their assigned officer. Officers identified more disability than the CDCR, and prisoners they identified as high risk had nursing home-level functional impairments. Significant improvement in disability assessment is needed for officers and the CDCR.

Mental health performance measurement in corrections.

Correctional facilities have become, by default, one of the largest providers of mental health care for patients with serious mental illness. In its 2002 Report to Congress, the National Commission on Correctional Health Care has reported that most facilities do not provide quality mental health care, nor do they conform to nationally accepted guidelines for mental health screening and treatment. This article describes the product of a consensus panel of correctional health care experts, charged to develop performance measures, based on nationally accepted standards, for selected elements of psychiatric treatment behind bars, aimed to improve the quality of care. Performance measures were developed for medication adherence, suicide prevention, mental health treatment planning, and sleep medication usage.