Access to Care

Providing health care in this environment requires an understanding and knowledge of governmental, bureaucratic, and paramilitary hierarchies. Many correctional health professionals are employed directly by correctional authorities. However, during the past 25 years, correctional health care models have evolved into several types. Contractual health care systems such as for-profit companies, academic medical centers, and public health agencies have assumed the administrative structure for health services in prisons and jails. Under this structure, recruiting, training, and retaining of health care professionals are often easier than when health care professionals are employed directly by the correctional authority. Having professional autonomy and judgment within organized health systems has helped to attract qualified professionals into correctional medicine. Ensuring that inmates have access to health care services is a fundamental responsibility for correctional medical professionals. It means that every inmate, regardless of where he or she is located in the jail or prison, must be able to inform health staff of his or her need to be seen, and when notified, health staff must act in a timely fashion, provide a professional clinical judgment, and ensure that ordered care is delivered. Any unreasonable barrier to inmate health service access must be removed.

What makes correctional medicine different from other venues of health care delivery is the long line of legal cases that have established incarcerated individuals’ rights to health care, addressing the responsibilities of custody officials in the health, mental health, and dental treatment of inmates. As a result of these and other court cases, correctional medicine has evolved.

Estelle v. Gamble established the concept of deliberate indifference as the test to determine whether government acted appropriately in the medical care of its inmates. As was clearly articulated, deliberate indifference is defined by prison doctors in their response to a prisoner’s needs or by prison guards in intentionally denying or delaying access to medical care or intentionally interfering with the treatment he or she has been prescribed.

The government must ensure that adequate medical, dental, and mental health services are provided to those whom it imprisons. To accomplish this, a responsible health authority (RHA) is established. The RHA ensures that primary, secondary, and tertiary care is provided for the well-being of the inmate population. The RHA works with custody staff to eliminate barriers that might hamper inmates from receiving these services in a timely manner. For example, one barrier might be when an officer, hostile to inmates, denies an inmate access to the sick call notification system. Training custody and health staff to recognize emerging medical or mental health needs is an important RHA role. Sometimes there are unreasonable delays in escorting inmates to see health professionals or to get to outside appointments to obtain necessary diagnostic workups. The RHA works to ensure that access-to-care procedures are flexible to accommodate the special health needs of inmates, such as chronic illness, serious communicable infections, physical disabilities, pregnancy, fragility, terminal illness, mental illness, potential for suicide, and developmental disability. Such special needs affect housing, work, and program assignments; disciplinary measures; and admissions and transfers to and from institutions. Correctional PAs and custody staff need to adequately communicate about these special needs inmates to ensure that government provides appropriate care.

What distinguishes correctional PAs from their civilian community colleagues is that they must be concerned with federal due process. The 8th Amendment to the Constitution prohibits cruel and unusual punishment, and the 14th Amendment ensures the right to due process and full protection under the law. The rights of prisoners cannot be abridged, and those with mental health problems have increased legal protections. Issues such as involuntary hospitalization, transfers from prison to mental hospitals, and involuntary medication and self-harm restrictions are closely scrutinized in mentally ill inmates. Few PAs are prepared to address these thorny legal and ethical access-to-care issues and as a result do not pursue this career track.

Many PA programs offer clinical clerkships in jails, prisons, and juvenile detention centers and can provide PA students an entrance into correctional medicine; however, in general, PAs are not exposed to the complexities of correctional health care.

More PA programs need to become vested in correctional medicine and the disenfranchised populations that are served.

Clinical Autonomy

The safety of inmates, staff, and visitors takes priority in correctional institutions. Many decisions that would seem inconsequential in the free world take on greater importance in corrections. For example, the choice to issue a pair of crutches for a patient with a non–weight-bearing injury takes on a different perspective when considering the safety precautions required in a jail or prison. As a result, correctional health clinicians face a number of pressures when assessing the health needs of their patients.

Inherent in a correctional institution is the power that security staff wields, deciding on what can or cannot be permitted in the institution. Decisions about staff utilization, inmate housing, work assignments, and disciplinary sanctions for both staff and inmates are under the purview of administrative security staff. For example, hiring a PA to work in a jail takes not only the approval of the responsible physician but also that of the jail administrator. The PA must pass a detailed security screening, which, in some jurisdictions, may take several months to complete. The PA must abide by the employment rules directed by the medical authority, but he or she must also abide by the directives of security.

Sometimes there is conflict between security and medical staff over clinical decisions and actions. However, custody staff should not interfere with the implementation of clinical decisions. Qualified health professionals should direct clinical decisions and actions regarding all health care provided to their patients. Case in point: A PA orders knee magnetic resonance imaging (MRI) of a high-security-risk inmate. Security staff is reluctant to transfer the inmate to the hospital for the MRI, particularly because he is a dangerous escape risk, and policy requires three officers to transport him. The jail administrator refuses to transport the inmate because of the threat to public safety. Most civilian health staff members are not accustomed to such denials of care. In this case, the clinical decision should be tempered with cooperation and consultation with administrative security staff. How urgent is the MRI to making a clinical decision? How long has the patient been complaining of his symptoms? Is the denial of care deliberately indifferent to the inmate’s medical need? The answers to these questions influence the course of action that the PA should take. More important, the successful correctional PA is one who knows how to negotiate with custody staff to achieve the goals necessary to provide the best possible care for his or her patient.

Clinical autonomy cannot be jeopardized; however, in a correctional institution, diagnostic and therapeutic orders are not issued in a vacuum. Rather, they require a coordinated effort among custodial, administrative, and health staff.

To facilitate the implementation of health care orders and decisions, most facilities hold meetings between security and health staff. Through joint monitoring, planning, and problem resolution, health, correctional, and administrative personnel can facilitate the health care delivery system. Included should be discussions on the barriers to effective treatment and care. For example, evidence-based medicine has shown that disease progression is controlled when the patient is involved in monitoring his or her disease. Patients with asthma should have peak flow meters, and patients with diabetes should have glucometers. However, custody policies often prevent such items in the housing units for fear of security breaches. Treating asthma in a correctional environment is problematic because many have inadequate ventilation systems or restrictive keep-on-person medication programs. Restricting opportunities for inmates with diabetes to self-test, self-prepare, and self-administer insulin presents additional barriers to improving disease control. Administrative problem solving, corrective actions, timetables for proposed changes, and updates on changes proposed during previous meetings are important strategies toward implementing effective patient care.

Quality of Care

Correctional PAs have to be knowledgeable in continuous quality improvement (CQI) monitoring. CQI identifies problems; proposes, implements, and monitors corrective action; and studies the effectiveness of corrective actions in addressing problems. This multidisciplinary (i.e., medical, nursing, mental health, substance abuse) structured process examines outcomes, high-risk or high-volume, or problem-prone aspects of care and ensures that established standards of care are met. CQI committees should assess processes that affect the effectiveness and efficiency of staffing, continuity of care, and quality of services.

Patient Satisfaction

Health care organizations are interested in the quality of care provided to their patients. They are interested in what their patients perceive to be quality. Correctional health systems are no different. Patient satisfaction surveys have been conducted by health care organizations for quite some time now; however, this is a new concept in corrections and is not widely accepted by correctional administrators. After all, correctional institutions are predicated on having individuals who do not want to be there and who are mistrusted by staff. This distrustful environment does not support surveying techniques. Yet a few correctional institutions are conducting inmate-patient satisfaction surveys. For example, the Oregon Department of Corrections has been conducting patient satisfaction surveys for more than a decade and has found a positive, constructive way to implement changes in patient care.

Staffing Issues

The recruiting, training, and retaining of health professionals to work in correctional health care is difficult because prisons and jails do not have medical care as the primary mission. Jails and prisons are foreign working environments for most health care professionals. Yet correctional institutions have a mandate to provide adequate and timely evaluation, treatment, and follow-up care consistent with community standards.

The numbers and types of health care professionals required depend on the size of the facility and the scope of onsite medical, mental health, dental, and substance-abuse treatment. There is a difference in the functions and responsibilities of jails and prisons. Jails detain individuals who have been accused of crimes and who are waiting adjudication by either a jury or judge. On average, jails hold detainees for about 1 year, although in some cases, jails hold individuals a few years past adjudication. The point is that after conviction and sentence have been rendered, the individual is transferred to a prison. Prisons are long-term holding facilities for individuals who have been convicted and sentenced for their crimes.

Compensation and benefit packages are generally not competitive and are a disincentive for many PAs. The security clearance process is sometimes lengthy and dissuades individuals from staying with the process, taking other jobs that may be offered. Opposition and pressure from family members is another barrier that a PA faces in taking a correctional health care position. The patient clientele are vastly different. Many are recalcitrant, ungrateful, argumentative, and even combative. Despite these drawbacks, correctional PAs find that being at the crossroad of medicine, public health, law, ethics, and criminal justice is challenging and rewarding.

To help attract health professionals, some institutions serve as clinical rotation sites for students. One such example is the Cook County Department of Corrections, Cermak Health Services, in Chicago. This site has been a clinical rotation site for area PA programs for more than 20 years. The level of morbidity and mortality in this patient population is high, and PA students often find themselves in challenging clinical situations. Clinical rotations in correctional institutions provide unique and challenging opportunities to exercise one’s clinical skills and consideration for future employment.

Physician assistants generally find correctional employment working for the legal authority (the sheriff or department of corrections). Some jails and prisons contract for-profit companies, academic medical institutions, or public health agencies to provide health services. Using these models, correctional institutions can attract health staff through better compensation, faculty appointments, and continuing education opportunities.

Finding and retaining qualified health professionals to work in jails, prisons, and juvenile detention and confinement facilities is an important concern. The goal is to find professionals who are willing to establish and maintain a therapeutic relationship with inmates. Medical professionals are trained to advocate quality patient care; however, providing such services in an antitherapeutic environment is difficult.

When these two dynamics collide, conflicts about authority over health services decision making and management occur. For example, health care professionals hold to a tenet that patients should have control over the health care decisions that affect their lives. However, in correctional institutions, such autonomy creates problems for custody.

An inmate who refuses to take clinically ordered behavior-modifying medications (increasing the likelihood of disruptive behavior) or refuses to submit to a human immunodeficiency virus (HIV) blood test when a staff member has come into contact with the inmate’s blood presents problems for custody. How custody responds in such situations is often not the way medical professionals would solve the problem. These frequent conflicts arising between custody and health staff require well-developed effective communication and problem-solving skills. Health professionals who do not have the skills are often co-opted and are seen as an extension of security rather than as medical professionals.

Physician assistants working in a correctional environment need to know that it is a constant balance between public safety and public health. They need to know that their environment is a paramilitary, organizational-based hierarchy and that public safety drives decision making relative to patient services. For example, administering medication to patients at a given time of day during pill call is made more complicated when the facility goes into a lockdown status (because of a breach in security, inmates are kept in their cells). The method and manner in which medication is administered may completely change to accommodate the public safety situation.

Clinical Performance Enhancement

The clinical performance enhancement process evaluates the appropriateness of a health clinician’s services. The PA’s clinical work is reviewed by another professional of at least equal training in the same general discipline, such as the review by the facility’s medical director or chief PA. The purpose of this review is to enhance clinical competency and address areas that need improvement. It is different from an annual performance review or a clinical case conference in that it is a professional practice review focused on the professional’s clinical skills.

Clinical performance enhancement reviews in a correctional environment are no different from any other institutional setting (e.g., the military or hospital). For example, treating patients with HIV must follow certain clinical guidelines regardless of setting. However, a correctional clinical performance enhancement review has an additional component in the review of one’s clinical judgment by assessing how one’s clinical competency affects public safety. The clinical PA may indeed be effective in managing the health care of uncooperative or even malingering inmates by gaining their trust and respect. However, if the clinical PA receives information from such inmates that public safety might be jeopardized, the clinical PA has a responsibility and duty to report it even to the point of damaging patient trust and confidence.

Staff and Inmate Safety

In January 2004, a 15-day hostage standoff between Arizona corrections officials and two inmates captivated the nation’s attention. The hostage standoff ended peacefully through a negotiated surrender of the inmates and the release of a female officer. This event perpetuates the public perception that jails and prisons are dangerous places. Although that is true, it is important to remember that events such as this are not an everyday occurrence. Correctional institutions work to ensure staff safety through strict policies and procedures and by ongoing training of its staff. Staff and public safety is compromised when lapses in training or procedures occur. For example, once in Sacramento, California, a deputy U.S. marshal placed his weapon under the front seat of his vehicle before entering the jail to pick up a prisoner. When he returned with the prisoner, he forgot to retrieve the weapon. It subsequently slid back where the prisoner was sitting. The prisoner, handcuffed with his hands in front, grabbed the weapon, ordered the deputy to pull over, and escaped. As this case reminds us, it is in the best interest of public safety to ensure that the health and well-being of staff are protected. When staff members forget or fail to abide by policy and procedure, harm can occur.

Risk and harm reduction create a working environment in which staff feel safe to do their work. There is no central repository for the collection of hazardous duty incidents incurred by correctional health professionals. There are no studies on inmate assaults on health staff, although anecdotally, staff members report that assaults on health staff rarely occur.

In 2001, Human Rights Watch released No Escape, a descriptive report on male prisoner-on-prisoner sexual abuse in the United States that outlined first-hand accounts of prisoner rape and sexual assault stories from 200 prisoners in 37 states. This report reviews the conditions that contribute to prisoner rape—namely, the rapid expansion of the incarcerated population during the past 20 years; the increasing government decisions to privatize its prisons and jails; and the dismantling of prisoners’ legal rights through the Prison Litigation Reform Act of 1996 (an act that made prisoner lawsuits regarding conditions of confinement and deliberate indifference more difficult). As a result of the shocking claims made in No Escape, Congress passed the Prison Rape Elimination Act of 2003 (PREA). PREA requires “the gathering of national statistics about the problem; the development of guidelines for states about how to address prisoner rape; the creation of a review panel to hold annual hearings; and the provision of grants to states to combat the problem.” PREA is the first U.S. federal law passed that deals with assault on prisoners and aims to improve correctional institutions’ safety.

Infection Control

Correctional facilities generally have an exposure control plan that describes staff actions to be taken to eliminate or minimize exposures to pathogens. In closed environments such as prisons and jails, it is important that health professionals maintain standard hygiene practices and precautions. They need to be aware of infection control matters and should receive orientation and annual updates to infection control policies and procedures. Facilities also have needlestick prevention programs that include the use of self-capping needles and functional sharps disposal containers.

Many correctional institutions have infection control committees that establish and maintain the exposure control plan; monitor communicable disease among inmates and staff; ensure prompt treatment for inmates and staff with infectious disease; ensure staff receive appropriate training and maintain procedures; ensure that personal protective equipment is available and used; and meet reporting requirements, laws, and regulations issued by local, state, and federal authorities.

Community-Acquired Methicillin-Resistant Staphylococcus aureus

A major problem occurring in many jails and prisons today is the increasing rate of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Jails and prisons are commonly overcrowded and do not have sufficient hygienic practices with soap, water, or clean laundry. These conditions foster environments in which contagions such as S. aureus and CA-MRSA can be transmitted from one person to another.

CA-MRSA infections are generally mild, self-limiting minor skin infections that appear as pustules or boils. Inmates often complain of “spider bites,” and correctional staff too often dismiss their claims. Education is necessary for both groups so that health staff can intervene and begin treatment.

Other confounding issues complicate the matter of containing CA-MRSA outbreaks in correctional institutions. This includes comorbidities of substance abuse and mental illness, distrust of authority figures, reluctance to cooperate with health care staff, and resistance to rules of hygienic practice. These issues contribute to complicating the ability to adequately respond to self-cleanliness. Before their incarceration, many inmates were either homeless or came from home environments that did not have adequate sanitation or did not stress personal hygiene. The hygienic practices of frequent hand washing with soap and water, avoidance of picking lesions, daily showers, and limitation of the number of personal items shared with other inmates should be emphasized to all inmates.

Other significant risk factors that have been found include prison occupation, gender, comorbidities, prior skin infection, and previous antibiotic use. Resistance to antibiotic therapy has added to this problem. Commonly, inmates have not sought regular and consistent health care from one primary care provider. Too often when they obtained medical services before incarceration, inmates went to emergency departments and public health community clinics. This episodic approach to their health care without consistent or organized management complicates the individual’s resistance to antibiotic therapy.

Another problem that complicates matters is that inmates, by nature, distrust authority and rules. When an outbreak occurs in a jail or prison, inmates are quick to blame jail administrators and health staff for the problem and not take responsibility for themselves. This distrust of authority creates a barrier to improving jail and prison conditions and eliminating the transmission of CA-MRSA.

Tuberculosis

Tuberculosis (TB) in correctional facilities is a continuous problem affecting the health status of communities at large. “Although the incident TB case rate for the general population has remained at fewer than 10 cases per 100,000 persons since 1993, substantially higher case rates, some as high as 10 times that of the general population, have been reported in correctional populations.”

The control of TB in correctional facilities is a multifaceted problem with no easy answers. Correctional institutions have policies on staff surveillance; however, it is difficult to maintain mandatory and periodic screening of correctional staff members. Between 2001 and 2004, the Florida Department of Corrections had one HIV-infected correctional staff member who was nonadherent with TB treatment and infected five correctional staff members over 2½ years. Four of the five cases were caused by an identical strain, indicating a probable common source.

Correctional institutions have poor ventilation and a transient population, which further complicate the control of TB. As a result, contact tracing is extremely difficult. In 2002, Kansas had a case in which a TB-infected inmate was transferred to three jails and one prison. In that process he came into contact with more than 800 individuals and was positively linked via identical-band via RFLP DNA testing to two inmates (cellmates in two different locations). In contact tracing, 318 of the 800 inmates were found—six had a negative prior tuberculin skin test (TST), and 196 inmates had no prior skin test information. Forty-one (21%) had positive skin test results.

Failure to control TB in jails and prisons is a threat to the community. From 1999 to 2000, the South Carolina Department of Corrections had a TB outbreak in which 31 prisoners and one medical student in the community’s hospital subsequently developed TB. In upstate New York, there was a multidrug-resistant (MDR) TB outbreak involving several correctional facilities and a hospital. The MDR TB outbreak resulted in at least 50 health care professionals being infected and the death of one prison guard.

Latent tuberculosis infection (LTBI) is four times higher among prison inmates than in the general population. Among jail inmates, LTBI prevalence is 17 times higher than the prevalence in the general population. It is estimated that 500,000 inmates with LTBI are released nationwide every year.

Active TB is 15 times higher among jail inmates than in the general population. Two studies estimate that one third of those with active TB have been recently incarcerated.

Pulmonary TB has been reported to be as high as 3.75 times more common among foreign-born inmates and federal prisoners than among the general population. Foreign-born inmates were 5.9 times more likely to have a positive TST result than U.S.-born inmates and accounted for 60% of recently diagnosed TB cases in the federal prison system. Many local jails house foreign-born inmates as well. Among highly trained correctional health staff, the U.S. Public Health Service officers provide care to the majority of foreign-born inmates in federal prisons and in Immigration and Customs Enforcement, actively surveying, treating, and monitoring TB-related concerns.

Screening for TB infection is a top priority for most jails and prisons. This screening includes planting tuberculin skin tests, performing a chest radiography if positive, and then referring for treatment. Yet TB outbreaks do occur in jails and prisons because many inmates do not complete their LTBI treatment, thus creating an ideal situation to disperse the contagion.

Correctional institutions usually screen all inmates entering their facilities for TB. The Cook County Department of Corrections (Chicago), the Rikers Island Department of Corrections (New York), and the Washington, DC, jails are a few settings in which all incoming detainees receive routine radiographic screening for TB. Most jails and prisons conduct tuberculin screening tests. In addition, many facilities have TB coordinators who monitor the screening and treatment of TB among inmates (e.g., Oregon prison system, Chicago and New York jails). The high prevalence of TB in jails and prisons suggests that correctional PAs are at the forefront of this public health battle through surveillance, detection, and treatment.

Human Immunodeficiency Virus

A major portion of the HIV epidemic is seen in jails. Hammett and colleagues estimate that approximately 25% of all U.S. HIV-infected persons passed through the correctional system in 1997. In 2012, the Bureau of Justice Statistics (BJS) reported that nearly one third of jail inmates had received an HIV test after admission. There are no jails that conduct mandatory HIV testing, and the testing they do is less systematic than in prisons.

Incarcerated women are 15 times more likely to be HIV infected than women in the general population. Black women, who bear a significant burden of the HIV epidemic, predominate in the nation’s jails and prisons.

Acquired immunodeficiency syndrome (AIDS) was estimated to be three times more prevalent in prison than in the community in 2001. Between 2001 and 2010, the rates for HIV/AIDS cases and AIDS-related deaths declined across all sizes of prison populations. The stigma of HIV and AIDS is certainly an issue in the community, but it is even more pronounced in jails and prisons. After information about an inmate’s HIV status is disclosed, it spreads throughout the institution, ostracizing the HIV-infected inmate even further in an already oppressive environment. Correctional PAs must take extra steps to protect the confidentiality of their patients’ HIV status.

Screening for HIV in correctional institutions remains one of the more important public health strategies protecting community health. The potential of finding more seropositive individuals among high at-risk individuals and the potential of increasing HIV/AIDS awareness make correctional institution HIV screening a valuable resource. The Centers for Disease Control and Prevention (CDC) recommends routine testing for HIV and that a patient is to be notified that the testing will be performed unless he or she decides to opt out from the screening process. Routine testing has the potential advantage to decrease any associated stigma when an inmate requests HIV testing. Routine HIV testing on admission to prison may be ideal. However, in jails, this may be more problematic for a number of reasons. The average jail detainee is released within 72 hours of booking, making it difficult to find an optimal time to implement routine HIV testing. In addition, many jails have limited resources to conduct such testing and may not be able to handle the volume of inmates at the intake center or support the costs for providing such screening services.

Another problem that jails face in implementing the routine HIV testing model is that when individuals are first arrested, they are stressed during the initial stages of incarceration. Issues such as addiction, potential suicide, and withdrawal from intoxication may cloud the individual’s judgment, and he or she may opt out of the screening without fully understanding the benefits to such a test. Also, with the open HIV testing model, the uncertainty of whether or not test results can be given to jail detainees in a reasonable time frame is an issue of concern.

There are unique barriers to the provision of health care to HIV-infected inmates in prisons and jails. Maintaining continuity of care is a major problem. A study by Bernard and colleagues found a gross difference between correctional institutions and community-based HIV (CB-HIV) clinics. They analyzed 30 CB-HIV clinics against 90 correctional health professionals (representing 33 states). Approximately 43% of correctional institutions did not have access to HIV specialists compared with 93% in community-based HIV clinics. Disruption in highly active antiviral therapy (HAART) is reported in 71% of correctional institutions compared with 33% in community-based HIV clinics. Plasma HIV viral load testing is available in 65% of correctional institutions and in 87% of the community-based HIV clinics.

Health care services for HIV-infected inmates need to improve through better medication distribution schedules, better testing of CD4, viral load and genotyping needs, improved availability of HIV specialist access, and improved HIV information through peer education. Improving the discharge planning of soon-to-be-released HIV-infected inmates, maintaining confidentiality, and gaining the trust of patients are other ways that the provision of health care to HIV-infected inmates can be improved.

Sexually Transmitted Diseases

The four most common sexually transmitted diseases (STDs) treated in a jail setting are syphilis, gonorrhea, Chlamydia, and genital herpes. The Institute of Medicine has recommended that jails increase their efforts in the provision of STD screening, diagnosis, treatment, counseling and education, and partner notification. National Commission on Correctional Health Care (NCCHC) standards require that within 14 days of admission to jails and within 7 days of admission to prison, inmates are screened for STDs. However, because of the lack of health staff and resources, many correctional institutions do not adequately manage STDs; they may use “test results to diagnose and treat infections but do not routinely assess the burden of disease in their population.”