Crisis in Correctional Healthcare

At crisis proportions—over 44 percent of incoming state inmates and 38 percent of incoming federal inmates require medical care, with 12 percent undergoing surgery within the first year of admission—indicators show that a new correctional heath care model is necessary and long overdue. 

Coupled with the above statistics, prisons face a rapidly aging inmate population, with increasingly acute and long term healthcare needs, along with significant numbers of inmates who are prone to mental illness, substance abuse, and chronic disease, largely as a result of their often poor health habits.  Using data from the United States Bureau of Justice Statistics (BJS), Human Rights Watch calculates that:

  • the number of sentenced federal and state prisoners who are age 65 or older grew an astonishing 94 times faster than the total sentenced prisoner population between 2007 and 2010.  The older prison population increased by 63 percent, while the total prison population grew by 0.7 percent during the same period.  
  • people with mental illness are represented in disproportionately large numbers in the criminal justice system—by rates of two to four times the normal population.  
  • in one northwest US women's prison, the warden reported that HIV testing has revealed that between 25 percent and 30 percent of the inmates have tested positive for the virus.  

Jail and prison officials are hard-pressed to provide appropriate housing and medical care.

The 8th Amendment's prohibition against "cruel and unusual punishment" applies to healthcare within prisons and jails. Courts have established that inmate healthcare must be equivalent to the standards of healthcare available within the "community." A landmark 1976 federal court ruling called Estelle v. Gamble (and several since then) guarantees that:

  • Inmates have the right to access to health care 
  • Inmates have the right to professional medical judgment
  • Inmates have the right to care that is ordered

Planning for Efficiency

Like the private sector, government agencies also are being required to do more with less. This affects the staffing that is allocated for correctional healthcare and it is imperative that the design and staff positions are closely coordinated to ensure effective workflow and to allow observation of inmate-patient with minimal staff. This is not only an issue of staff to inmate-patient ratios, but involves training and new skill sets, particularly for custody staff, who often have an adversarial relationship with inmates, and have little knowledge regarding health care. Ultimately, it is a matter of creating healing environments while maintaining safety and security, not just simply 'efficiency' in the conventional sense— that is the real challenge. 

Essential Collaboration of Healthcare and Security Staff 

One of the overriding concerns in these unique correctional healthcare settings is to ensure a safe, secure, and efficient workflow. There is a complex set of relationships which must be recognized by management to maintain safety and security.  The following illustrates how the interaction between inmate-patient and healthcare provider is complicated by the security function of the custody staff.  An ongoing effort to coordinate inmate healthcare is imperative. (Cross training of custody and health care staff is required to create truly interdisciplinary treatment teams.)

Some states, such as California, implement  case management and interdisciplinary treatment teams (IDTT)  where custody staff play a key role in monitoring and assessing inmate-patients' conditions and progress, as often they spend as much or more time with the inmate-patients than the clinicians.  The IDTT process is one that allows the inmate-patient to takes an active role in planning his or her treatment with clinician and custody staff. It is also important to include other inmate programs, such as education and vocational training, for continuity of care after release, in order to prepare the inmate for life outside and to reduce recidivism.  

Complex Building Codes

Healthcare combined with incarceration creates a complex set of building codes for prisons and jails. The codes focus on safety within a secure environment where the occupants cannot freely exit the building.  The common International Building Code defines a healthcare treatment room (in a prison or jail) so there is no real exception for the use of closers and self-latching hardware.  The code requires the use of expensive fire- and smoke- protected glazing and wall assemblies with nursing stations that are glass enclosed.  These are among many issues that need to be negotiated, where possible, with the authority having jurisdiction. (Note: California is revamping code to eliminate ambiguities and overlays.)

Specialized Equipment Challenges

Medical equipment (fixed or mobile) is essential to provide adequate inmate healthcare.  The very nature of the need for a secure environment, and the fact that most medical equipment utilized for diagnostic and treatment is designed for the private sector and not prisons or jails, where it may be used as a weapon, poses extreme challenges in selecting appropriate equipment.  It is essential that the planning for the clinic fit-out and the inpatient medical equipment includes a collaborative approach among the medical, custody and facilities planning teams to ensure the safety of both the staff and the inmates during use, storage and management of these items.

Multi-faceted Standards and Regulations  

Like private sector healthcare environments, prison and jail healthcare environments should endeavor to meet regulatory guidelines for safe and appropriate care to prevent undue injury to the inmate-patient.  And, many facilities strive to comply with correctional and community healthcare delivery standards for the design and subsequent operations of their care environments.  Industry and governmental standards are numerous. The following is a sample list of applicable regulations:

  • American Correctional Association
  • National Commission on Correctional Health Care
  • Prison Rape Elimination Act
  • Americans with Disability Act
  • Joint Commission
  • State Fire Marshal
  • International Building Codes

Solutions are needed to address the healthcare and aging crisis in corrections to avoid the real risk of litigation, while helping to ensure that healthy inmates can successfully re-enter society when their sentence is served.  In a challenging environment with tight budgets and rapidly changing demographics, HDR understands the stresses faced by agencies in providing adequate care in a secure environment.