A variety of healthcare issues affected corrections in 2003.  Practitioners in the field faced many challenges relating to substance abuse, HIV treatment and mental health.  The Corrections Connection reported on all of these topics over the past year; a summary of our correctional healthcare coverage is presented below.

HIV
MRSA
Substance Abuse
Mental Health
Staff
Costs
Legal Issues

HIV

The treatment of HIV in the free world is changing constantly. New studies are being undertaken and completed, new guidelines are being introduced and new combinations of drugs are being tried off-label. But correctional health care practitioners may find it difficult to keep up with this constantly changing information even though many inmates under their care are infected with HIV.

"Unfortunately, I think it's really challenging for community HIV providers to stay cutting-edge and it's additionally more difficult for those who have three feet of concrete wall, barbed wire and a trench around them and often lack of Internet access to stay current," said David A. Wohl, MD, of the AIDS Research and Treatment Unit at the University of North Carolina - Chapel Hill.  "That has been my experience in every [correctional institution] I have visited and I have visited a number of them. It's a theme you hear all the time and that is concerning."

Wohl said often the latest information that correctional health care providers receive about HIV treatment is from drug representatives selling their product - and that is not healthy, he said.

"Things move quickly now. There's major conferences every few months and it's really hard [to keep up]," Wohl said.

One topic that popped up in 2003, according to Wohl, was the use of the drug T-20, the first drug to interfere with HIV attaching and getting into the T-cell. 

"It was recently approved and there is a system of getting it to patients, but it is clumsy. People are getting it and taking it and for those who don't have very many options left, combining this with other drugs is reasonable," said Wohl.  "[But] it's not a drug used early in therapy," he added.

In addition to T-20, another hot topic in correctional HIV news this year was the 5095 Study.

"The study and an interim analysis found that Trizivir was inferior to the other arms and mid-way in the study it was discontinued," said Wohl.  "It was inferior in getting people to undetectable viral loads but also in keeping them undetectable," he added.  "The study involved more than 1,000 people and from regions all over the United States."

The results of the study were important because Trizivir is a drug that is used frequently in correctional healthcare.

Aside from Trizivir, a drug that received some attention this year was Tenofovir.  Being a potent once-a-day drug, it became an attractive treatment option for corrections in 2003, Wohl said. 

Although Tenofovir has it merits, correctional practitioners should be aware that it becomes toxic when combined with DDI, Wohl pointed out.

"One of the most important drug-drug toxicities is Tenofovir and DDI. They seem like a natural fit but Tenofovir increases the DDI level in the blood and that is one of two HIV therapies that carries a warning that taking them can lead to death or can cause fatal pancreatitis," said Wohl.

While issues regarding HIV treatment within correctional facilities were faced in 2003, corrections also dealt with concerns about treatment consistency after an HIV-positive inmate's release.

"One thing that was talked about [this year] was transmission issues, especially when people get out of prison," Wohl said.  "We have to think about preparing inmates to leave prison, not only to [keep] their own personal health secure to the best way we can, but also to protect the community they are returning to."

Wohl pointed out that corrections agencies need to start to address the fact that offenders may be unsafe when they become sexually active after they are released from prison.

"We need to do that through education and make sure they can get the HIV medications when they get out," Wohl said.  "If they stay on it, they have a low chance of passing on HIV," he added.  "We need discharge planning that really works. It's more than just a plan."

MRSA

While HIV is a well-known healthcare issue for correctional facilities, another less familiar inmate health problem cropped up on corrections this year.

Methicillin-resistant Staphylococcus aureus (MRSA) spread through communities nationwide in 2003, forcing correctional health care providers to take a much closer look at inmates' skin ailments.

MRSA infections are caused by Staphylococcus aureus bacteria, commonly referred to as staph, that have become resistant to various antibiotics.  Staph bacteria are typically carried on the skin or in the nose of healthy people.  Occasionally, these bacteria can cause infections, both minor ones, like pimples and boils, and more serious infections that require antibiotics to treat.  Through the years, however, staph bacteria have become resistant to certain antibiotics, resulting in a form of bacteria known as MRSA.

Because MRSA is commonly spread through direct physical contact with infected people or indirect contact with items like towels, sheets, clothes and sports equipment, environments where people are confined in close quarters are conducive to the spread of the bacteria. 

"We're a reflection of the community," said Martha Tadesse, a public health nurse in the communicable disease unit of the Los Angeles County Sheriff's Department Medical Services Bureau.  If people in the community have MRSA, it spreads into the jails, she said.

When inmates developed MRSA infections in L.A.County, the medical staff developed a treatment plan and educated its staff and inmate population about the bacteria, which was problematic for other correctional agencies across the country as well.

Dr. John Clark, chief medical officer for the Los Angeles County Sheriff's Department said that hygiene is the most effective weapon against MRSA.

"Wash your hands," said Clark.  "[It's] the most important thing."

Also, inmates must have access to basic necessities like water, showers and toilet paper and be encouraged to shower each day, Clark said.  "Certainly [MRSA] is something that all practitioners as well as all people in institutions where you have close contact need to be on the look-out for."

Substance Abuse

In 2003, drug courts were recognized for their promise in treating offenders with substance abuse problems prior to incarceration.

"I think that the country has kind-of moved in the direction [towards drug courts]," said Brenda Wilfing, a Behavioral Health Resource Specialist at CARF, a non-profit organization that accredits human service providers.  The point is, she said, "to direct [people] to a program that could give them some treatment instead of just putting them in jail."

In early 2003, CARF began its drug court accreditation program, which uses standards that are based on the Ten Key Components of drug courts.  The Ten Key Components were developed by the National Association of Drug Court Professionals (NADCP) with support from the national Office of Justice Programs.  These components reflect the importance of a drug court's ability to treat people promptly, provide access to a continuum of treatment services, maintain communication between the courts and program participants and monitor the achievement of program goals in order to evaluate effectiveness. 

Guided by these core principles, CARF identified standards that programs across the country have to meet in order to become accredited.

"I think [they] give them a framework to provide services in a manner that will truly achieve the outcomes that they want," Wilfing said about states using CARF's standards to set up and perfect their drug courts.  "If they follow the standards [and] they work diligently on that, it gives them a sound foundation to provide the services they want."

The drug court treatment program in Broward County, Fla. became the first in the country to earn an accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF) in 2003.

"We recognize that accreditation brings in national standards of excellence," said Kristina Gulick, Director of the Department of Community Control in Broward County.  "It gives a comfortability level to funders," she said, noting that accreditation also lets consumers know that the program is doing a good job.

Mental Health

A population that made headlines this past year was the large number of mentally ill offenders incarcerated in the nation's prisons and jails. But while many in the criminal justice system are aware they exist, the services available for them when they are released are fairly limited.

One program that works to help this group of offenders after release was the Thresholds Jail Program, which serves mentally ill offenders in Cook County, Ill.  The program targets those offenders with mental illness who have gotten caught in a cycle of crime that brings them in and out of the jail regularly.

"[We target] the people most in need and the most recidivistic for whom we can make a difference. We won't work with people who have [committed] a very serious crime because cases take too long," said John Fallon, Program Director for the Thresholds Jail Program.

Fallon said of the 12,000 inmates in the Cook County system, 1,000 of them are on psychiatric medications. But it is only the most recidivistic of those who will connect with Thresholds.

Fallon said the goal is to give the members dignity and an ability to live on their own with intensive support. He said most would never be able to hold a job, but they can live a clean, crime-free life as long as they take their medications and have someone to help them navigate the complexities of treatment and daily life.

Fallon is convinced that this approach is making a difference in Cook County as Thresholds members with long histories of hospital visits and jail stays continue to improve week after week and month after month with no relapses. 

Staff

While developing effective programs to help mentally ill offenders was a priority in 2003, so, too, was finding qualified mental health staff.

According to a National Institute of Corrections study (http://www.nicic.org/pubs/2002/018602.pdf) completed in December of 2002, Staffing medical, mental health and special population units is more difficult for corrections agencies than any other area of a prison.

The reasons given for this difficulty are many, including the specialized requirements these unit staff must meet, general shortages in the number of medical and mental health staff as well as the level of burnout that staff may feel in these positions.

Among the key findings of the study, 72 percent of responding DOCs reported that they had a need for more medical positions and, of the responding agencies, 26 DOCs reported that the mentally ill population posed the greatest staffing challenge, 12 DOCs reported the medical needs population and five DOCs cited women inmates as being the greatest challenge.

Respondents also said that budgetary constraints and growing offender populations complicated these staffing needs.

When managing these challenges, DOCs reported a variety of innovative solutions that ranged from locating medial and mental health units in proximity to each other, expecting staff in these unit to assist each other and the use of nurse practitioners with psychiatric training.

Other agencies noted the use of resident psychiatrists from a local university, having additional training for security staff around mental illness and instituting specialized training for security staff by mental health professionals in posts where the staff rotates frequently.

Overall, the study suggested a clear need among the county's correctional agencies to alter the staffing for these specific prison populations and that greater use of specialized approaches to staffing analysis could help justify additional positions.

Costs

Budget pressures in counties and cities across the country squeezed corrections agencies and jails into making cuts in their operating costs or finding ways to reduce their populations in 2003. No agency, be it large or small, was immune to this year's fiscal crisis.

"Probably the two largest cost items have to do with medications and the labor-intensive aspect of distributing staff and medications," said Clark.

L.A. County, he pointed out, spends about $1 million a month on pharmaceuticals. Mental health medications comprise 51 percent while HIV is 21 percent.

"The key to managing the issues related to pharmaceuticals is having an active committee to create the formulary," Clark said.  "That's an area that requires medical leadership getting the appropriate group together and making sure they meet on a monthly basis."

With budgets being cut across the country during the past year, many states and counties, including L.A. County, felt the effects and tried to find better ways to manage costs.

"Over the last several years we have worked aggressively with the California Board of Corrections to implement an alternative method for delivering medications -- a keep-on-person program where inmates give themselves medication," said Clark.  "In the past, every dose of medication that an individual receives had to be observed by custody," he added.  "Now we have about 1,000 inmates enrolled in the self-medication program."

In Georgia, correctional health care officials were able to utilize some streamlining techniques to reduce the cost per inmate for physical health care by a significant amount.

"What happened was, we came up with a budget for fiscal year 2003, but there was only X number of dollars available and it became clear that we, like a lot of states, are having budgetary issues. And, we were not going to be budgeted for the amount that our staff had come up with. Our leadership said these are the dollars and we tried to figure out how it was going to happen," said Bill Kissell, Director of Health Services for the Georgia Department of Corrections.

Kissell said the effort to solve the budgetary gap was a joint one between the DOC, the Medical College of Georgia, which provides physical health care services, and the department's mental health provider.

The total cost of health care for inmates in 2003 was $143,680,480 or $9.13 per inmate per day, which was a 4.9 percent reduction from the inmate health care costs in fiscal year 2002. Physical health care costs declined by five percent and mental health care costs declined by four percent.

"Most of our success in 2003 was due to the field professionals; they are the ones doing the hard work . This year a lot of it was focused on helping them do their jobs easier with computerization and modifying forms to make them more user-friendly and making the administrative part of their jobs easier," Kissell said.

Legal Issues

Correctional health care practitioners not only need to keep abreast of medication and treatment changes, but also other issues specific to corrections that could even lead to litigation if agencies are not aware of them.

William Rold, an attorney in New York City who provides representation to inmates in correctional health cases and also consults for correctional agencies, said that what often trips up correctional departments is not access to care, but rather providing the kind of diagnosis that a person would receive outside prison walls.

Rold said that because correctional facilities are not set-up primarily for medical services, doctors and nurses find it difficult to do their jobs to the level they would like.

"The ability to exercise your judgment can be affected by the atmosphere. I sometimes refer to it as being akin to making a ship in a bottle. Some do it well, but it is hard to do," said Rold.

"One of the major legal issues that has emerged in correctional healthcare is the idea of correctional facilities doing discharge planning," Rold said.  "For years, hospitals and nursing homes have known they just can't dump their patients; that is now starting to affect corrections," he added.  "For those [inmates] on complex regimens for HIV and hepatitis now, there needs to be liaisons with the community to continue those."

As we head into 2004, correctional healthcare providers will continue to face issues associated with HIV treatment, mental health, substance abuse and the like.  Undoubtedly, new concerns will also emerge for healthcare practitioners working in the field.  As developments and problems unfold, The Corrections Connection Network News will bring you information about the many facets of correctional healthcare.