The health care challenges faced by the community over the last year were reflected and even magnified in the corrections setting in 2005. Prisons and jails increasingly house a population that has a concentrated prevalence of illnesses and diseases ranging from hepatitis C to HIV to mental illnesses. MRSA, for example, was a problem in many institutions this year and infection control measures received new attention as a result.

These issues required corrections agencies to be innovative in their approach to preventative medicine and rapid in their response to emergency health care needs.

In addition, corrections agencies also faced a shortage of nurses familiar with corrections medicine – made worse by the nursing shortage also being felt in the outside community.

With these difficulties apparent, legal cases involving corrections medical care were disposed of this year. The courts focused anew on medical inadequacies behind bars and the California Department of Rehabilitation and Corrections was a major recipient of guidance from the federal courts. That system's medical care is now in receivership.

Additionally, the Commission on Safety and Abuse in America's Prisons, which was created earlier in 2005, focused a portion of its hearings on health care behind bars. That commission will release its recommendations in 2006.

Corrections agencies also looked hard at health care efficiencies and ways to cut costs. One department, the Colorado DOC, initiated a quality improvement program that has saved the agency considerable money. The idea behind the program is by improving quality of care and performance measures, the cost of providing care will go down – and it has.
 
Yet with all of these issues, the correctional health care field strove to improve standards and educate those working in the field about the importance of providing quality health care services to inmates.

Read on for a summary of the correctional health care stories of 2005 covered by corrections.com.

Outbreaks, Disease and Response
Mental Health
Legal Challenges

Outbreaks, Disease and Response

Early in the year several correctional facilities experienced outbreaks of infections among inmates that resisted common treatments. Chief among them was MRSA which is a type of  Staphylococcus aureus bacteria.

The L.A. County jails saw about 200 inmates becoming infected each month from the bacteria early in the year. The infections were particularly problematic for corrections agencies because they are caused by inmates passing the disease to fellow prisoners.

L.A. County officials said, however, that about 25% of those inmates infected were coming in infected from the community. The infections, commonly called staph, usually provoke a mild skin reaction. But in severe cases, they can cause serious blood and bone infections. The ailments led to more than 50 inmates requiring treatment in L.A. facilities and, four sheriff's deputies have reported contracting the infection.

Staph infection was found to be the cause of two inmate deaths in Allegheny County (Pa.) earlier this year. The investigation showed the inmates died of a bacterial infection, not after inhaling cleaning product vapors, as had been originally thought. The deaths were from a secondary bacterial infection caused by drug-resistant staph infection according to the county's coroner.
Viral cultures also revealed the women had the flu. Officials originally thought the women inhaled vapors from improperly mixed cleaning products. The women had been cleaning the jail, where bleach, disinfectant and ammonia are typically used, before becoming sick.

In Dallas County, Texas, a jail cell block of 24 prisoners was under quarantine in February following a flu outbreak there. The county health department's epidemiological unit was notified of about five cases of flu among inmates and of the decision to quarantine the prisoners by the University of Texas Medical Branch, which is under contract to handle the jail's medical care. Flu shots were made available to jail staff to prevent the spread of the flu.

And, in Nevada, corrections officials there began extensive testing of inmates for TB after eight staffers at Nevada State Prison, located in Carson City, tested positive during routine, once-a-year examinations. Testing was started on about 11,400 prison inmates in the complex.

A grand jury report released this year around the death so of two inmates at the San Joaquin County (Calif.) Jail in 2003 prompted changes that could help prevent similar tragedies. The San Joaquin County grand jury's latest investigation into booking procedures at the county jail in French Camp was a follow-up to a report last year on the deaths of the inmates.

One of the deaths was liked to suffocation after being pepper-sprayed during a cell extraction. The other death was related to inadequate care given him when he was booked into the facility. The San Joaquin County Sheriff's Office has created a Critical Emergency Response Team (CERT) to safely extract problem inmates from cells at the jail, and such incidents are now videotaped. The grand jury noted that the sheriff's office has also instituted policies to make sure restraints at the jail are in good condition, and that it has replaced some leather restraints with sturdier plastic ones.

Corrections agencies also created new programs to improve inmate health and success after release. The Georgia Department of Corrections' Pre-Release Planning Program (PRPP), which is geared towards HIV-positive offenders, helps offenders get their feet on the ground release from prison. The DOC a little over a year ago hired a new pre-release coordinator to begin working with HIV-positive offenders who are within six months of release to prepare them for their transition back into the community.  The coordinator works with inmates from 11 DOC institutions in the central region of the state to connect them with some of the services they will need when they are released from incarceration. Because all Georgia inmates are tested for HIV upon intake, the coordinator gets a list of all those who test positive in the targeted facilities and meets with them to tell them about the pre-release program.

The program has also helped the DOC develop new relationships with community services for offenders such as AID Atlanta and The Living Room, which are both non-profits providing services, housing and education to people with HIV.
Correctional health care providers have also taken a long hard look at hepatitis C prevention in light of the numbers of infected offenders incarcerated in their facilities. With prevalence rates of hepatitis C in prisons running between 12 and 35 percent, most correctional agencies have placed importance on identifying which inmates have the disease. But what has not yet become standard practice is the treatment provided to offenders who test positive. Yet some agencies, such as the Pennsylvania DOC, have tried hard to follow recently issued national guidelines.

The National Institutes of Health and the Centers for Disease Control issued guidelines and recommendations for the testing and treatment of those with hepatitis C that have been slowly implemented in corrections.  Pennsylvania's corrections system began an aggressive program in 2000 that screened everyone who came in the door, initially with the idea of treating everyone and conducting no liver biopsies. That program was revised in 2003 to better target those offenders who would progress to liver disease and need treatment more quickly. With this information they began using biopsies in combination with viral load levels and genotype to determine treatment need.
Those agencies that are able to meet the community standards of health care stand a better chance of avoiding litigation, but those who do not may find themselves and their staff named in inmate filed lawsuits.

Mental Health

A growing problem for corrections agencies has been how to adequately care for the large number of offenders who need mental health services, including those with major mental illness.

One federal effort that may help is the funding of the Mentally Ill Offender and Crime Reduction Act. In November an appropriations bill to fund the act was sent to President Bush's desk. In relation to other programs, the $5 million appropriation is small, but it shows that there is support for new collaborations between mental health agencies and corrections to work with this population.
In Kansas, the DOC estimates that 20 percent of the inmate population has significant mental health needs and at least half of those inmates are severely or persistently mentally ill. So officials there have already begun to create alliances between the corrections department and mental health agencies. This collaboration allows the two agencies to share information about the mentally ill population once they are incarcerated and prepare them for a smooth transition to the community and community-based treatment after release.

Other agencies, such as the New York City Department of Correction and the city's health department have also teamed up to assist these offenders in transitioning to the community. Officials there were spurred by a legal case in which the court ruled that the city had a responsibility to provide discharge planning for inmates with mental health issues.

Mental health practitioners are also trying to keep abreast of the latest research around offenders with mental illness. Several researchers have recently presented information about self-injurious behavior to corrections health care practitioners – most recently at the National Conference on Correctional health Care in the fall.
Experts on SIB say it is a phenomenon not uncommon to inmates, especially those with borderline personality disorder. Some agencies, such as the Washington State Juvenile rehabilitation administration have tried a new approach to the corrections field – dialectical behavior therapy that has had promising results in the general population.

Dialectical Behavior Therapy [DBT] is a treatment and therapy developed by Marsha Linehan from the University of Washington that is typically used for those diagnosed with borderline personality disorder. Related to psychotherapy, the treatment is related to cognitive behavior therapy currently used in many correctional settings. DBT works with individuals to accept who they are and simultaneously works with them to change in ways that are empowering.
The handful of corrections agencies trying DBT, which also includes the Connecticut Department of Corrections, hope to have results and statistics specific to corrections populations by later next year.

Legal

In April, a prison health care monitor determined that prison medical staff at an Alabama prison for women was substandard and led to the deaths of two of three female inmates last year. The report was required by a court settlement of a lawsuit over crowded conditions and medical care at Alabama's only prison for women. The report stated that the prison system's private contractor lacked follow-up, made mistakes in prescribing drugs and gave substandard care to 19 of 22 prisoners whose charts were reviewed. Women with HIV, staph infections, diabetes and other conditions were consistently denied treatment,  the report also said.

In Mississippi, the American Civil Liberties Union filed suit against the department's inmate health care provider for inmates at the Mississippi State Penitentiary at Parchman, alleging prisoners have been misdiagnosed and received inadequate treatment.

The federal lawsuit one of the nation's largest for-profit medical providers for prisoners, was filed on behalf of 1,000 inmates. The lawsuit alleges that contractor employees routinely ignore inmates' health complaints. However, state and company officials both said the care inmates at the facility receive is standard care.
Later in the year, a federal court judge in California put an end to years of legal wrangling about the provision of correctional health care in California. In a written decision, U.S District Court Judge Thelton Henderson concluded that a Receivership was needed to take control of the delivery of medical services to all prisoners in the state.

The judge concluded that the correction medical system was “broken beyond repair” and that “The harm already done in this case to California's prison inmate population could not be more grave…”

The court was conducting a nationwide search this past fall for a receiver to take over the troubled health care system and, in the interim, the court appointed a national corrections expert who has served as a master in another prison-related lawsuit in California, to oversee correctional healthcare operations.

Corrections officials said they recognized the massive nature of improvements that are required to bring medical care to the level required by the Constitution. The class action case that instigated an investigation into health care services within the California Department of Corrections and Rehabilitation, Plata v. Davis, was filed in 2001 on behalf of all prisoners incarcerated in the state's prisons. Ten class representative inmates provided the specific facts of the case.

They claimed they received substandard health care and experienced serious injury from the state's and prison system's deliberate indifference to their serious medical needs when they ignored their requests for care, failed to report medical needs upon transfer and delayed care that ultimately led to some inmate deaths.
According to the Prison Law Office in California, which represents the inmates in the class-action case, the problems with health care in California's prisons have been long standing. In previous testimony in the Plata case, Undersecretary of Corrections Kevin Carruth said that medical care is not a “core competency” of the department and is “not the business of the CDC, and it never will be the business of the Department of Corrections to provide medical care.” But under new leadership, prison health care will no longer follow that credo.

Correction health care experts across the country expect that when the receivership is over and a new system is in place, the provision of correctional healthcare in California will set the new standard for the country.