Acknowledgements: The authors wish to acknowledge the support of the Medical College of Georgia Telemedicine Center, Max Stackware, MD, Director and the MCG Department of Psychiatry and Health behavior. Author inquiries should be directed to Dr. Durrell at the MCG Department of Psychiatry and Health behavior, 706-721-3141
Abstract
Within a state prison hospital, the provision of mental health services presents many challenges to those responsible for the delivery of care. An overview of current mental health services offered at Augusta State Medical Prison (AMP) in Georgia reveals that even a well-staffed prison mental health program can be overwhelmed when dealing with crises that arise simultaneous with the continuing demand for routine mental health care. Service provision through the Georgia Statewide Telemedicine Program is suggested as a means for supporting the day-to-day activities of on-site mental health professionals. Telepsychiatric services used outside the prison system suggest that support o this type would be of benefit to patients and staff.
Introduction
Augusta State Medical Prison (AMP) is the prison/hospital for the Georgia Department of Corrections (DOC). The DOC provides prison medical and mental health coverage by contracting with qualified providers. Presently, medical and mental health consultation services for AMP are provided by the Medical College of Georgia in Augusta, Georgia.
The mental health section of AMP consists of mental health outpatients residing in the general population dorms; patients in a 100-bed supportive living unit; patients on the 5 bed crisis stabilization in the hospital proper unit; a 3 bed hospital unit for medically disabled mental health patients; and other mental health patients in various medical wards throughout the prison hospital. Presently about 150 mental health patients are followed by mental health professionals.
The mental health staff consists of one full time equivalent psychiatrist (one psychiatrist covering four days a week and two others each covering 1/2 day per week). The remainder of the full time mental health staff is made up of one psychologist, one Mental Health Director (Masters degree level), seven counselors (Masters degree level), two registered nurses with mental health experience, one special education teacher, one Activities Director and one secretary. A psychiatry resident from the MCG Department of psychiatry Residency Program travels to the prison two 1/2 days per week to provide supervised psychiatric services. Occasionally, psychology interns enrolled in a graduate program at Augusta State University spend a few months working under supervision as counselors.
Psychiatrists offer a full range of services including evaluation of new patients, psychiatric consultation services to medical wards in the hospital, ongoing psychiatric care to chronically mentally ill inmates, operation of the Crisis Stabilization Unit for psychiatrically unstable inmates from other prisons, emergency psychiatric care for AMP inmates, supervision of nurses and counselors, and overall direction of clinical activities. The psychiatrist also chairs the Continuous Quality Improvement committee and provides in service education to the nurses, psychologists and counselors. The psychologist is responsible for providing psychological testing services, treatment plan supervision for the MH counselors, sexual abuse counseling and supervision of special management problems. The Mental Health Director acts as the department manager and is the liaison between mental health professional services and the DOC. Mental health counselors provide the bulk of face-to-face contact with patient/inmates and typically know the needs of inmates better than other staff members. They are best at advocating and linking with other mental health professionals as they work closely with correctional officers assigned to the mental health units. Ongoing educational workshops are conducted by the counselors and include classes on current events, Anger Management, Depression Management, Humor, Substance Abuse, Dual Diagnosis, Sexual Disorders, and Post Traumatic Stress Disorder (PTSD). Registered Nurses keep track of the medical/psychiatric needs of all assigned mental health patients. They insure that the patients are seen by mental health staff members and that prescribed medications are monitored. The special education teacher handles special education needs of those patients who are intellectually challenged or who have specific learning disabilities. The activities director coordinates inmate recreation and the secretary covers clerical needs of the entire team.
Background
Psychiatric and psychological coverage of the MH/MR inmate populations a responsibility that consumes significant time and resources. Resources required to care for the inmates with Axis I disorders are similar to those needed for patients outside prison. Mentally retarded inmates may need more protection in a prison setting, as other inmates may pose a threat to them. The Axis II inmate presents a difficult set of problems that can be very time and resource demanding and a source of stress for staff. For example, inmates diagnosed with Antisocial or Borderline Personality Disorders, are apt to 'act out' in ways that present significant danger to self and/or others. Behaviors may occur repeatedly and result in considerable fatigue for professionals working in the program. Most crises involve Axis II inmates who are acting out by cutting themselves, swallowing objects, or trying to hang themselves. Although many of these actions may be manipulative in nature, prudent and appropriate care dictates that each episode is treated potentially life-threatening and that an appropriate response must be taken. Proper responses make significant time demands on counselors, nurses and psychiatrists. It is important to note that crises evaluation and intervention activities take place in the midst of providing routine MH/MR care concurrent with also transient and medical inpatient consultation.
Demands of time and personnel resources are great and constant. Mental health needs are not constrained by time. Crises happen, and hen they do, services are needed immediately. Routine care must continue and the needs of the mental health patient should be met in as effective a manner as possible, recognizing that the routine is always interrupted by the emergent. Keeping it all working smoothly is a great challenge requiring the services and dedication of the entire MH/MR team.
Everyone on the mental health team is already working very hard. Meeting the challenges requires working 'smarter.' Advanced telecommunications technology offers opportunities for working smarter within the Georgia correctional system. The Georgia Statewide Telemedicine Program (GSTP), which is already in place in Georgia, provides a means of delivering routine mental health services through video conferencing and information technologies. Valuable resources (time, personnel, and money) are freed, allowing for more efficient resolution of crisis situations.
The Georgia Statewide Telemedicine Program (GSTP)
Georgia has man areas with limited access to healthcare services, including correctional facilities, as many are located in rural or isolated areas of the state. In 1998, there were still counties with no practicing physicians, and fewer than 5-0 percent f counties had a practicing pediatrician. In an attempt t address this problem, the Georgia Statewide Academic and Medical System GSAMS was developed. One of the goals of GSAMS is providing access to health care services for all citizens of Georgia. GSAMS represents one of the most comprehensive distance education and health care networks in operation.
The telemedicine portion of GSAMS is known as the Georgia Statewide telemedicine Program. The GTSP is managed by the Medical College of Georgia Telemedicine Center in Augusta, Georgia. Rural hospitals, medical centers, clinics, tertiary care centers, and seven correctional facilities across the state are linked through a T-1 fiber optic communication network that operates as a 'hub and spoke' fashion. As of December 31, 1997, over 2000 telemedicine encounters have been completed and evaluated since the GSTP began operation in late 1991. (1) Other states have used telemedicine to provide care to inmate populations suggesting that providing correctional health care via telemedicine is becoming commonplace. Specifically, Texas and Ohio routinely use telemedicine in their state prisons.
Faculty members at ASMP are often unable to participate in meetings, or conferences in the Department of Psychiatry at MCG because of the extra time commitment required for travel between facilities (approximately 10 miles). A crisis could arise at any moment that would require immediate attention. This potential creates a burden that also makes it difficult for the psychiatrist to stray far from ASMP grounds. Telemedicine technology facilitates the prison psychiatrist's 'virtual' attendance at important conferences and meetings on the MCG campus and allows the prison psychiatrist to lead seminars for the psychiatrics trainees at MCG.
As the correctional facility charged with caring for the state's incarcerated population who suffers from mental disorders, ASMP receives many transfers from other state prisons. Inmates are referred when non-psychiatric staff suspect that an inmate is suffering from mental illness based on their history and/or behavior. Often, this is the case. However, many inmates may exhibit concerning behaviors but do not have Axis I disorders. Inmates may view the medical environment at ASMP as less restrictive and may malinger in hopes of a transfer. Inmate transfers entail several disadvantages including costs for transportation vehicles, transportation personnel, and security personnel. The personnel involved in the transfer may accumulate overtime hours at great expense to the system. There is also an increased security risk any time an inmate is to be transferred from one location to another. Assessment of these individuals by a trained mental health professional is necessary to determine whether they have a mental disorder requiring the resources and facilities available at ASMP. A telemedicine connection between the prison referring the inmate and the psychiatrist at ASMP allows for pre-transfer assessment of the inmate. Reassurance from the mental health professional to the referring facility that an inmate is not a danger to self or others, combined with education
on managing behavior, helps to avoid unnecessary time and expense associated with transferring the inmate. Not surprisingly, many of these transfers occur during evening hours and weekends when the psychiatrist is not on site. In this instance, a telemedicine connection between the referring facility and the on-call psychiatrist at MCG could prevent many inappropriate transfers.
Obstacles To Implementing Prison Mental Health Services Through Telemedicine
Although the infrastructure for telemedicine services is in place in Georgia, the possibility of using it to provide mental health services to inmates has not yet been fully explored. Since 1993, 28 consultations between ASMP and MCG have taken place. All but one have been infectious disease cases.
Special issues exist with this population that have made establishing a mental health telemedicine system somewhat problematic. One administrative issue has to do with the contracting out for mental health services by the state system. MCG has the contract to provide mental health services to ASMP, but the remainder of the prisons in the state are served by a different mental health provider. Using telemedicine to evaluate inmates prior to transfer from prisons other than ASMP may cause turf issues and reevaluation of existing contracts may be necessary. The incarcerated population also presents some interesting procedural challenges to telemedicine. Some inmates' aggressive behavior may preclude them from being safely escorted to the telemedicine room in their facility. Issues of security must be considered any time inmates leave their cellblock to report to the telemedicine room.
Telemedical Mental Health Services Outside the Prison System
The telemedicine system in Georgia is designed to distribute health care services to isolated populations and allows patients to be seen within their own community rather than travel a great distance for appropriate care. Often, the time and expenses required to travel to the nearest care provider serve as barriers and many patients simply go without treatment. This is particularly true for mental health care in Georgia where 120 of 159 counties have no psychiatrist. (2) To date, the Medical College of Georgia has provided 236 telepyschiatric consults to other sites within the GSTP. (3) The number of monthly telepsychiatry consult requests at MCG has increased steadily since June 1997 and is expected to reach over 50 per month by early 1998. Services have been comprehensive and include diagnostic assessment, pharmacological management, ongoing supportive and insight oriented therapy, hospital pre-discharge planning, supervision of psychiatric residents and a multi-specialty pediatric neuropsychiatric clinic.
Cost Analysis of Telemedicine in the Prison Setting
The success of telepsychiatry in Georgia certainly demonstrates that telemedicine is a viable and accepted way to deliver a range of mental health care services but the question of whether it is economically feasible for the DOC remains unanswered. The findings in Texas after completion of phase I of the UTMB project estimate the cost of providing high volume telemedicine care is between $40 and $70 per consult, including equipment, personnel and operating costs. The average cost of transporting a prisoner for medical care in Texas is over $180. Ninety-five percent of those consultations prevented the transport of a prisoner and saved the state a significant amount of money per consult. (4) Elsewhere, a cost/benefit analysis of a telemedicine delivery system for HIV-positive inmates between the Virginia Department of Corrections and Medical College of Virginia showed an overall net savings of $14,486 for 165 consults. (5) Although neither Texas nor Virginia included psychiatric consults in their analysis, these findings suggest that telemedicine is a cost-effective way to provide services to the incarcerated population.
Between March 1995 and August 1996, 122 specialty telemedicine encounters were completed over the GSTP that involved DOC inmates. The largest percentage of encounters was in the area of dermatology, although consultations were completed by a number of medical specialists. Of the 122 encounters, only 30 inmates were subsequently transported outside of the prison, indicating that only 75% of the inmates did not have to travel outside of the prison. The average cost of transporting an inmate to a medical consultation outside of the prison is $324 per day. By using telemedicine rather than transporting inmates to outside medical specialists, the DOC saved 'at least $29,000 in transportation costs' over a period of 17 months. (6) Since most telepsychiatric consults to not require the use of medical peripherals, it can be postulated that the savings for telepsychiatry would be even greater.
Discussion
One option is being explored which might offer some useful insights into the feasibility and usefulness of telepsychiatry in the Georgia prison system. Currently, psychiatry residents from MCG spend at least an hour per day commuting to ASMP from MCG for a twice-weekly resident clinic. Residents at MCG connected to the prison via the GSTP could continue to see their regular inmate caseload through telemedicine. The time saved by not having to travel between facilities could be used by the clinician either to increase their caseload or to provide more in depth services to their current patients.
Certain types of inmates would not be appropriate for this interaction, such as those in lock down as they are not able to travel to the telemedicine site within the prison. Nonetheless, a clinic of this sort might be used to identify the limits of telepsychiatry in the inmate population. More detailed analysis of related data would serve as baseline to guide future developments, such as roll-about or 'desktop' applications.
Conclusion
Utilization of the GSTP is proposed as a means for improving mental health services available for improving mental health services available to Georgia's incarcerated population. Potential advantages include decreased isolation for the prison psychiatrist by allowing more interaction with an academic Department of Psychiatry, improved efficiency of the resident clinic, decreased inappropriate mental health transfers to the medical prison thus preventing unnecessary expansion of the mental health case loads, as well as cost savings for the DOC. The telepsychiatry experience at MCG suggest that telemedicine may also have some unique benefits in dealing with Axis II disorders. Cost analyses from other states suggest telemedicine might also have a positive economic impact on the prison system. The prison setting presents challenges to providing telemedical services. A full understanding of these challenges and the potential for overcoming them will best be learned from experience.
References
1 Adams, L.N., Grigsby, R.K. The Georgia State Telemedicine Program: Initiation, Design, and Plans. Telemedicine Journal 1995; (1) 227-235
2 Randolph, L. Physician Data By County. American Medical Association, 1993
3 Medical College of Georgia Telemedicine Center. Telemedicine Consultation Statistics. Augusta, GA: Mimeograph, January 31, 1998
4 Brecht, R.M. et al, The University of Texas Medical Branch - Texas Department of Criminal Justice Telemedicine Project: Findings from the First Year of Operation. Telemedicine Journal 1996; 2(1) 25-25
5 McCue, M.J. et al, The Case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia. Telemedicine Journal 1997;3(1) 11-17
6 'Atlanta, GA...Department of Corrections Telemedicine Update.' Telemedicine Today, 1996; 4(5) 10.
This article is an edited version reprinted from the Journal of the Mental Health in Corrections Consortium, Volume 44, No. 1
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