How Healthy is Correctional Health Care?
How Healthy is Correctional Health Care?
While not in crisis mode, correctional health care struggles to adjust to tighter budgets, mental illnesses, and elderly inmates, to name just a few problems.
By Joe De Patta
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Dr. Jacqueline Moore, president of Jacqueline Moore and Associates, also is the health administrator for the Cook County Juvenile Temporary Detention Center. She is a co-founder of Prison Health Services, founder of the correctional health care division at the Wackenhut Corporation, and the prior director of accreditation for the National Commission on Correctional Health Care. |
Joe De Patta: What was prison health care like when you first entered the field?
Jacqueline Moore: It was awful. There were stock bottles of medication that everybody could access. Medical charts weren’t used; instead, there were index cards and people would write procedures and medical treatments on these cards. There wasn’t any kind of coordinated system at all. If a facility had any health care it was only because it was under a consent decree and had to have it. It was abysmal. There were very few staff members. When I worked at the Delaware Correctional Prison I was the only nurse for 400 inmates. We didn’t worry about physical exams and chronic care.
JD: In what respects have you seen the greatest-or most beneficial-changes in correctional health care?
JM: Many of the facilities are going towards accreditation, which is a very positive thing. In my mind accreditation is the minimal standards that need to be met.
Also, facilities are getting integrated health care systems, and a lot of states are moving into privatization. Despite the pros and cons of privatization, the best thing that’s happened because of it is that correctional health care has its own budget. Correctional health care has been taken off the back burner and put in the forefront and private companies are competing and doing a good job.
JD: In your consulting practice, what areas of correctional health care are you most frequently asked to address?
JM: There are usually two. The first is staffing. I have done numerous staffing studies. “How many staff do we need?” is a very common question. The second is, “How much money do we need and how can we operate more efficiently?” We’ve done staffing studies in Wisconsin, Minnesota, Orange County, and Arizona, and we’ve done a lot of budgetary studies in North Carolina, Tennessee, and Oklahoma.
JD: In what area is correctional health care widely successful? What areas are in need of revision?
JM: Private firms are doing some things successfully, such as recruiting staff; there’s no doubt that there’s a nursing shortage.
If I’m working for a county, I have to go through human resources to get the position posted, then interview applicants, and then send in a request to hire-it may be three or four months before I see a candidate. The private sector can hire somebody within two or three weeks.
Another area that the private sector does better is purchasing. They buy in bulk; for all of their contracts they get better prices and they don’t have to put things out to bid over and over.
There are two areas in need of revision. One is mental health. We have more mental health inmates coming in but DOCs and jails are not equipped to provide the level of psychotropic medications. The psychiatrists are saying that the new psyche meds are the standard of care in the community and that’s what they want to provide.
The second area in need of help is the juvenile health care field. There are far too many juveniles in corrections who shouldn’t be there. Juveniles are primarily estranged from their parents, they don’t have advocates, and their attorneys and parole officers are overworked. I wrote an article a couple years ago where I compared juvenile healthcare to the orphanages of old. In the 1920s and 1930s we had orphanages. In the 1950s we had foster families and every child needed a home, then we had mental health facilities in the 1970s and 1980. Now we have correctional facilities. And you know what? Nothing’s changed.
JD: Why is it hard for correctional facilities to attract and keep staff?
JM: Staff retention is due to leadership. If the warden or jail administrator is good then the staff at the facility is going to be good and they are going to stay.
I was at a facility in Puerto Rico, in Ponce de Leone, and there were vacancies all over Puerto Rico, but at this facility they had a waiting list of people who wanted to work there. Why was that? The warden was also an attorney, the health administrator was also a physician. People were over-qualified for their positions. The facility wasn’t clean, it was pristine. There were a lot of programs for inmates, the environment was good, and staff wanted to stay. Environmental conditions mean a lot.
JD: For the most part, do you feel inmates are receiving adequate health care?
JM: I think they are. There are still pockets of areas, mostly in the South, that I’m not terrible happy with.
JD: What is your opinion of inmates receiving expensive organ transplants?
JM: It depends on the inmate, the age of the inmate, how long the inmate is going to be sentenced to a facility and how compliant the inmate has been with his medication regime.
JD: How do you feel about inmates being charged for health care?
JM: There is always a disincentive for inmates to use health care when they’re charged. On the other hand, in many facilities where there aren’t good work programs inmates tend to over-use health care services. As long as the co-payment programs don’t charge for mental health conditions, chronic care conditions, pregnancy, or things that need to be done, and the co-pay is reasonable; I think it can work.
JD: Are elderly inmate populations going to dramatically affect the correctional health care system?
JM: They will. Elderly inmates and elderly people in our population take more medication. They have more cardiac problems and disabilities. There will be more asthma, hypertension, and cardiac conditions and they will demand more medications.
JD: How successfully is the correctional system handing the issue of mentally ill inmates?
JM: A lot of systems are forming their own mental health services inside prisons. Indiana has recently established a mental health unit [see the Facility of the Month in this issue, page 23]. Special needs facilities are necessary because it is difficult to get inmates transferred to state mental health facilities.
Many jails have started holding mental health courts, trying to get inmates who are on misdemeanor charges out of the jail. If they are substance abusers, they try to get them into substance abuse programs. I really think that’s the appropriate thing because these are jails, not mental health hospitals.
JD: A few years ago, you published a book called “Correctional Health Care: Forms, Checklists & Guidelines.” Can you tell us about that book? What kind of feedback have you heard?
JM: The book and forms were basically a response to my work in the field. Every time I did a survey people were asking about this or that form. I compiled a number of forms that I’d seen after 25 years of being in corrections; I wrote to all the agencies, public, private, state, and county, and I took the best forms I could find. I put them on a disc, published them and put them out there and said, “You can use these forms or modify them. Don’t spend your time recreating something.” I donated the proceeds to the American Correctional Healthcare Association.
JD: Many counties and states are contracting with private firms to handle health care needs. Is that always necessary; is privatized health care that much better?
JM: Privatization is better as long as there are bureaucracies in personnel and purchasing and they can’t raise state rates. They are stuck in salary scales or line items and can’t adjust in fluctuation to shortages.
Privatization is not good if you don’t have a good regional manager. It doesn’t matter how good the people are at the head office, if the regional manager isn’t good, you won’t have a good contract. I often recommend that when an institution privatizes they should have someone there monitoring the contract.
JD: What advice can you offer those involved in correctional health care?
JM: Stay informed. Go to national conferences. Stay current in your educational requirements. Read and network. Also, never compromise your professional licensure. If someone asks you to do something that is illegal, whether it’s to administer medications from a stock supply or to make a diagnosis that you aren’t qualified to make, you need to refuse or leave the job. When a lawsuit comes, the law is coming after your license, not the warden’s.
JD: We frequently hear about health care wreaking havoc with corrections budgets. Is the financial situation only going to get worse? Is there anything that can be done to remedy the problem?
JM: The financial system will probably get a little worse as the economy does. One of the things we can do is to push some of the Medicaid laws. Delaware and Vermont allow Medicaid for some of their inmates. Unfortunately that’s not the case in all states. Let’s face it, if our inmates have insurance, we wouldn’t have a crisis in correctional health care.
JD: What are some of the emerging trends within correctional health care?
JM: Telemedicine has been a good trend. Hepatitis C treatments with Interferon. The use of psychotropic medications. Mental health hospitals are all emerging trends.
JD: What would you consider to be your greatest contributions to the field?
JM: I just published a book called Administration and Management in Correctional Health Care. In four or five years I’m going to retire so I’m downloading all of the information that I ever knew and I’m bringing in others to do the same thing. Some of the articles I’m writing, along with the books and journals, are helping to bring that knowledge to people.
JD: Where do you see the state of correctional health care in five or 10 years? What issues do you think we’ll be talking about then?
JM: I’m sure we’ll always talk about liability. As long as we have inmate health care we’ll have attorneys and liability issues. We will always have budgetary problems. I think infectious diseases will be big issues. Mental health, elderly, and juvenile corrections are going to be right up there, especially juvenile girls. The population of women and juvenile girls is growing faster than any other population.
JD: Is there anything you’d like to add or any final comments?
JM: I’ve had such a good time working in this field. I can’t think of anything else I’d rather do. It’s fun for me-even though I’ve had a lot of success at taking companies public, working in high positions, writing standards, and publishing books-it’s still a lot of fun for me to be a provider.
