|Where We Have Been and Where We Need To Go: A Correctional Health Care Expert’s View|
|By Barbara Granner|
That message was delivered by Rear Adm. Newton E. Kendig, MD, recently retired federal Bureau of Prisons medical director, assistant surgeon general and one of the nation’s foremost experts on correctional health, in his keynote address to the National Commission on Correctional Health Care’s national conference in October.
The explosion in jail and prison populations has brought not only new challenges, but also new opportunities to impact public health, according to Kendig. “We have come a long way, but we have a lot more work to do,” he told the audience. He cited improved policies, guidelines and access to care as important advances, as well as provider credentialing and facility accreditation, as offered by NCCHC.
Kendig laid out this 12-point plan for continuing improvements:
Invest in prevention. Acknowledging the challenges involved in practicing preventive care among corrections’ “eclectic” patient population, Kendig nonetheless urged facilities to focus on prevention and follow the U.S. Preventive Services Task Force guidelines regarding nutrition, exercise, tobacco-free living, immunizations, cancer screening, chronic disease screening and infectious disease diagnosis and education. He specifically suggested healthier meals and commissary choices as ways to battle the growing obesity problem behind bars.
Take action in oral health care. Kendig called upon correctional facilities to heed the Surgeon General’s 2003 “National Call to Action to Promote Oral Health” by integrating oral health care into primary care, reclaiming “prevention” as treatment, implementing a dental classification system in order to target the highest-risk patients and expanding providers of oral health care. “Oral health is essential to general health and well-being,” he reminded the audience.
Expand treatment options for the mentally ill. That mental illness behind bars presents huge challenges is news to no one in the field. Among Kendig’s recommendations: establish policies and procedures that ensure mentally ill inmates are carefully screened and not placed or maintained in restrictive housing; expand residential treatment programs for high-security mentally ill inmates that maximize out-of-cell therapeutic interventions; integrate the entire health care team (primary care providers, pharmacists, nurses, social workers, etc.) into the treatment of the chronically mentally ill; and engage other departments (religious services, education, recreation, case management, custody) in managing mentally ill inmates and mitigating associated risks, such as suicide and self-mutilation.
Treat addiction as a chronic disease. Following release from incarceration, drug use relapse leads to very high rates of overdose deaths. To combat this, Kendig said, the “treatment culture” needs to catch up to society’s increasing understanding of addiction as a chronic disease. He is a proponent of MAT, medication-assisted treatment, which he believes should be increasingly evaluated as an important addition to cognitive behavioral therapies in treating chronic addiction within the correctional setting and in preparation for release.
Adopt new approaches to pain management. Treating chronic pain can be very challenging; inmates often do not respond to pain medications and disproportionately suffer from chronic addiction to opioids. Kendig recommends that alternative nonpharmaceutical treatments be considered using a multidisciplinary approach. “Proven interventions should be more broadly implemented,” he said. “Those include cognitive behavioral therapy in a group setting, biofeedback, exercise/yoga and dry needling/acupuncture.”
Improve management of geriatric inmates and those with disabilities. Specific suggestions include improving screening, staff training, accommodations and reentry programs for those special populations, and expanding the use of appropriately screened and trained inmate companions to support geriatric inmates in their activities of daily living.
Treat and contain infectious diseases. “Corrections continues to play a pivotal national public health role in the management of infectious diseases,” Kendig stated. For example, he explained that identifying and treating patients with HIV infection is, on average, better achieved in the correctional setting than in the community. New challenges for correctional medicine include providing curative treatment of chronic hepatitis C with newly available – but expensive – antivirals, and more efficiently treating latent tuberculosis infection.
Embrace antibiotic stewardship. As in the free world, antibiotics are often overused within correctional facilities. Kendig recommended utilizing the CDC Get Smart About Antibiotics campaign, adopting evidence-based guidelines for treating upper respiratory tract infections and conducting quality management assessments to prevent antibiotic overuse.
Maximize medical informatics. “Advances in medical informatics have been dramatic during the past decade and provide both challenges and exciting opportunities for correctional medicine,” Kendig told the audience. At the forefront, he sees the standardization of electronic medical records to facilitate the transfer of medical information; the evolution of disease management software that will provide clinicians with critical information to improve patient outcomes; and the integration of utilization review information to maximize cost-effectiveness of health care delivery. “Strategically investing in medical informatics will be critical for advancing the field of correctional health care,” he said.
Prepare for new technologies and pharmaceuticals, such as biologics and immune-based therapies, organ and tissue transplantation, robotic surgery and implantable devices. According to Kendig, these changes will call for extraordinary expertise in care utilization and biomedical engineering.
Strengthen linkages with academic medicine. “Broader correctional health care collaboration with academic medicine is the key next step for advancing the field of correctional medicine,” Kendig said. He sees multiple opportunities for collaboration: expansion of student and resident rotations in U.S. jails and prisons; wider use of telehealth to connect inmates with complex chronic diseases and expert university subspecialists; and investment in research endeavors that are mutually beneficial to academic medicine, public health and correctional health care practice.
Be a leader. “It’s all about leadership,” he told the audience. “Building a better future and reinventing correctional medicine will require visionary health care leadership.”
Rear Adm. Newton E. Kendig was the medical director of the Federal Bureau of Prisons and assistant surgeon general of U.S. Public Health Services.
Barbara Granner is the Manager of Marketing and Communications for NCCHC.
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