Readers of this chapter will learn how to:
Describe unique aspects of providing care in correctional health settings.
Define deliberate indifference and responsible health authority (RHA).
Discuss clinical situations in correctional health settings that may require negotiation among medical, custody, and security staff.
Explain challenges associated with managing communicable and chronic diseases in correctional health settings.
Discuss conflicts that can occur when balancing inmates’ health care needs with the goals and constraints associated with incarceration.
Inmates have a higher prevalence of health problems than the general population, both acute and chronic. For instance, the overall rate of confirmed AIDS cases among the nation’s prison population is five times the rate of the general population. This stems in part from the communities inmates come from. More than 60% of incarcerated individuals are African American or Latino. Typically they are from an underserved urban community. By screening and treating inmates for various diseases, we take the important first step of preventing their spread into the larger community. But I believe it is also possible to make progress on eliminating disparities through corrections-based interventions. Vice Admiral Richard H. Carmona, MD, MPH, FACS, CCHP, U.S. Surgeon General, U.S. Department of Health and Human Services National Conference on Correctional Health Care, Austin, Texas, October 6, 2003
Working in a correctional environment
Why would a physician assistant (PA) want to work in a jail or prison? That is certainly an important question, but it’s the wrong one. The question should be, “Why would a PA not want to work in a jail or prison?” As former Surgeon General Richard Carmona observed, correctional medicine addresses public health issues that impact our communities; therefore it should not be quickly dismissed. Furthermore, correctional medicine provides an enormous opportunity to make progress on eliminating health disparities.
Correctional institutions are a microcosm of society and, as such, require correctional medicine practitioners to be specialists in public health, primary care, infectious disease, chronic disease, and mental health. Correctional populations are marginalized because of racial disparities, low socioeconomic status, substance abuse, and mental health disorders.
The importance and complexity of correctional medicine and the marked health status and outcome disparities experienced by incarcerated populations are well documented. For every 38 Americans, there is one person incarcerated. The total number of people involved in the criminal justice system in the United States is estimated at 2.1 million. Notably, although the adult population in the United States has increased, there has been a decline in custody confinements, which has contributed to a decline in the total number of incarcerated individuals for the past decade. Nevertheless, these statistics do not reduce the need for qualified and committed health professionals to serve in correctional settings.
The opportunity to practice in correctional institutions enables PAs to help rebuild lives and make a difference. Correctional health often attracts individual professionals who see their role as important to the overall health of the community. Some of our society’s sickest individuals live in correctional facilities, and PAs working in correctional medicine need special skills and attitudes. In fact, correctional medicine is one of the cornerstones of public health in this country. PAs wanting to work in the eye of the public health storm in this country or those who want to address health disparities should consider correctional medicine as a career. The role and relationship between PAs and their patients are unique. Issues of race, poverty, addiction, mental illness, and economically depressed communities create enormous problems for the physician–PA health care team but present opportunities for professional satisfaction for correctional PAs.
This chapter covers issues commonly found in correctional medicine, such as access, staffing, environmental, safety, quality of care, and ethical issues. The chapter also addresses an array of clinical duties that correctional PAs perform, including conducting health screenings and evaluations; evaluating and managing chronic disease patients in clinics or infirmaries; conducting daily sick calls; making cell checks in segregated housing; reviewing laboratory and other diagnostic test results; developing, monitoring, and modifying individual treatment plans; and engaging in discharge planning activities.
Providing health care in correctional institutions
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, correctional health care models have evolved into several types. Some jails and prisons contract for-profit companies, academic medical institutions, or public health agencies to provide health services. Contractual health care systems such as these have assumed the administrative structure for health services in prisons and jails. It is often easier to recruit, train, and retain health care professionals under this structure than to employ health care professionals directly by the correctional authority.
PAs generally find correctional employment by working for the legal authority (the sheriff or department of corrections). Using these models, correctional institutions can attract health staff through better compensation, faculty appointments, and continuing education opportunities.
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 professional clinical judgment, and ensure that ordered care is delivered. Any unreasonable barrier to inmate health services 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 the incarcerated individual’s 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 demonstrated by prison doctors in their lack of response to the prisoner’s needs or by prison guards in intentionally denying or delaying access to medical care or interfering with the treatment once prescribed. Regardless of how it is evidenced, deliberate indifference to a prisoner’s serious illness or injury constitutes a cause for action.
The government must ensure that adequate medical, mental health, and dental services are provided to the imprisoned. To accomplish this, a responsible health authority (RHA) must be 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 where 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 processes are flexible to accommodate inmates’ special health needs, such as chronic illness, serious communicable infections, physical disabilities, pregnancy, fragility, terminal illness, mental illness, potential for suicide, or developmental disability. Such special needs affect housing, work, and program assignments; disciplinary measures; and admissions/transfers to and from institutions. Correctional PAs and custody staff need to adequately communicate these special needs regarding inmates to ensure access to 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 with 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.
The safety of inmates, staff, and visitors takes priority in a correctional institution. Many decisions that would seem inconsequential in the free world take on great importance in corrections. For example, the choice to issue a pair of crutches for a patient with a nonweight-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 in deciding 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 or medical administrator 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. Custody staff should not, however, 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: the PA orders a knee magnetic resonance imaging (MRI) test for 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 importantly, 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, the health, correctional, and administrative personnel can facilitate the health care delivery system. Included should be discussions about the barriers to effective treatment and care. For example, evidence-based medicine has shown that disease progression is best controlled when the patient is involved in monitoring his or her disease. Patients with asthma should have peak flow meters, and diabetic patients should have glucometers. Custody policies, however, often prevent such items in the housing units for fear of security breaches. Treating asthma in a correctional environment is problematic because many facilities 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 an additional barrier to improving disease control. Administrative problem-solving, corrective actions, timetables for proposed changes, and updates on changes proposed during previous meetings are important strategies for 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, as well as high-risk, 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 the quality of services.
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. Nevertheless, a few correctional institutions have started conducting inmate-patient satisfaction surveys.
Staffing in correctional medicine
It is difficult to recruit, train, and retain health professionals to work in correctional health care because prisons and jails do not have medical care as their primary mission. Jails and prisons are foreign working environments for most health care professionals. Nevertheless, correctional institutions have a mandate to provide adequate and timely evaluations, 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 on-site medical, dental, mental health, and substance-abuse services. There is a difference in the functions and responsibilities of jails and prisons. Jails detain individuals who have been accused of a crime and who are waiting adjudication by either a jury or judge. On average, jails will hold detainees for about a year, although in some cases jails will hold individuals a few years past adjudication. The point is that once a 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; they may instead take another job that has been offered. Opposition and pressure from family members is another barrier that a PA may face in taking a correctional health care position. The patient clientele are vastly different from the norm. Many are recalcitrant, ungrateful, argumentative, and even combative. In spite of these drawbacks, correctional PAs find that being at the crossroad of medicine, public health, law, ethics, and criminal justice is challenging and rewarding.
Finding and retaining qualified health professionals to work in jails, prisons, and juvenile detention and confinement facilities are important concerns. To help attract health professionals, some institutions serve as clinical rotation sites for students. Clinical rotations in correctional institutions provide unique and challenging opportunities for students to exercise clinical skills and be considered for future employment. The goal in hiring health professionals is to find professionals who are willing to establish and maintain a therapeutic relationship with inmates. Medical professionals are trained to advocate for 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 may occur. For example, health care professionals hold to a tenet that patients should have control over the health care decisions that affect their lives. In correctional institutions, however, such autonomy may create 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. The frequent conflicts that may arise between custody and health staff require well-developed, effective communication and problem-solving skills. Health professionals who do not have those skills are often co-opted and seen as an extension of security rather than as medical professionals.
PAs working in a correctional environment need to know that there 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 (where, 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 a 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, treatment for HIV must follow certain clinical guidelines regardless of setting. Nevertheless, 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 devaluing 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 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 staff. Staff and public safety are 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 in doing 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 reviewed the conditions that contributed to prisoner rape, including the rapid expansion of the incarcerated population during the prior 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 assaults on prisoners and aims to improve correctional institutions’ safety.
Communicable disease in correctional institutions
Correctional facilities generally have an exposure control plan that describes the 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. Well-publicized outbreaks of the novel coronavirus SARS-CoV-2 in jail and prison settings demonstrate the need for infection control measures in these settings and highlight the challenges associated with developing effective protocols. In fact, at the time of this writing, measures to control of the spread of coronavirus disease 2019 (COVID-19) in correctional settings are still evolving.
Community-acquired methicillin-resistant staphylococcus aureus
A major problem occurring in many jails and prisons today is the increasing rate of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Jails and prisons 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. They include 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 can complicate the ability to adequately ensure 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, male 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 many 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 (TB) in correctional facilities has been a continuous problem affecting the health status of communities at large. Over the last several years, the incidence of TB has been declining; in 2017 the incidence in the general population was 2.8 cases per 100,000 persons. The proportion of TB cases in the U.S. attributable to non-U.S. born persons, however, has increased. Although a similar trend has been observed in correctional facilities, the incidence of TB among incarcerated individuals is substantially higher overall than in the general population.
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 two and a half years. Four of the five cases were caused by an identical TB strain, indicating a probable common source.
Correctional institutions may have poor ventilation and a transient population, which further complicates 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. During the process he came into contact with more than 800 individuals and was positively linked, via identical-band restriction fragment length polymorphism (RFLP), to two inmates with active TB (cellmates in two different locations). In contact tracing, 318 of the 800 inmates were identified and 256 were tested. Among 196 who had no previously documented tuberculin skin test (TST), 41 (21%) had a positive TST during the investigation screening.
Latent tuberculosis infection (LTBI), a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB, is higher among prison inmates than in the general population. Inmates with latent TB should be assessed and treated and receive appropriate education prerelease. It is estimated that 500,000 inmates with LTBI are released nationwide every year.
Screening for TB infection is a top priority for most jails and prisons and involves administering tuberculin skin tests, performing a chest radiograph if positive, and referring positive cases for treatment. Nevertheless, TB outbreaks do occur in jails and prisons because many inmates do not complete their LTBI treatment.
In addition to screening tests, many facilities have TB coordinators who monitor the screening and treatment of TB among inmates. Among highly trained correctional health staff, the U.S. Public Health Service officers provide care to the majority of foreign-born inmates in the custody of federal prisons and in Immigration and Customs Enforcement (ICE) by actively surveying, treating, and monitoring TB-related concerns.
The high prevalence of TB in jails and prisons suggests that correctional PAs are at the forefront of this public health battle, which requires surveillance, detection, and treatment.
Corrections populations have high rates of hepatitis C. Estimates indicate that 12% to 39% of all Americans with hepatitis C have spent some time incarcerated. This clear and present public health threat requires consistent policies and programming. With the emergence of new treatments for hepatitis C that result in greater than 90% cure rates, the screening, monitoring, and treating of incarcerated individuals is imperative for public health. Correctional PAs are poised to address the full spectrum of hepatitis C cases, including ones that involve coinfection with hepatitis B or HIV and ones found to have more than one hepatitis C genotype. One treatment consideration is to administer vaccines to prevent other infections, including hepatitis A and B.
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. Screening for HIV in correctional institutions remains one of the more important public health strategies protecting community health.
There are no jails that conduct mandatory HIV testing, and the testing they do is less systematic than in prisons. Routine testing has the potential advantage of decreasing any associated stigma when an inmate requests HIV testing. In jails, however, 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 overwhelmed during the initial stages of incarceration. Issues such as addiction, potential suicide, and withdrawal from intoxication may cloud the individual’s judgment and they may “opt out” of the screening without fully understanding the benefits to such a test. Also, with routine HIV testing in jails, uncertainty about whether test results can be given to detainees in a reasonable timeframe is an issue of concern.
The rates for HIV, acquired immune deficiency syndrome (AIDS) cases, and AIDS-related deaths are at the lowest levels in decades across all prisoner populations. Correctional PAs must take extra steps to protect the confidentiality of their patient’s HIV status. The stigma of HIV and AIDS is certainly an issue in the community, but it is even more pronounced in jails and prisons. Once information about an inmate’s HIV status is disclosed, it spreads throughout the institution, possibly ostracizing the HIV-infected inmate even further in an already oppressive environment.
There are unique barriers to the provision of health care to HIV-infected inmates in prisons and jails. Maintaining continuity of care is challenging. Disruption in highly active antiretroviral therapy (HAART) is reported in 71% of correctional institutions, compared with 33% in community-based HIV clinics.
Disruption is concerning because health care services for HIV-infected inmates require consistent medication distribution schedules. Other HIV management considerations include CD4, viral load, and genotype testing; improved availability of HIV specialist access; and HIV information provided 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.
Other sexually transmitted diseases
The four most common sexually transmitted diseases (STDs) treated in a jail setting are syphilis, gonorrhea, chlamydia, and genital herpes. In 1997 the Institute of Medicine recommended that jails increase their efforts in the provision of STD screening, diagnosis, treatment, counseling, education, and partner notification. The 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. Because of a lack of health staff and resources, however, 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.”
Treating STDs in jails remains elusive and compounds a public health problem that could be remedied. Economic modeling has found that routine screening for STDs in prisons and jails is cost-effective. Aggressive screening, diagnostic, and treatment practices for STDs provide an opportunity to improve the public’s health. Correctional PAs should work with their local public health department to ensure that contact tracing, partner testing, and counseling are accomplished.
The positive test rate for syphilis is high among persons entering correctional facilities. The most high-prevention-value female cases (i.e., cases associated with a high likelihood of transmission if left untreated) have been found in jail settings. All people with a positive syphilis test should be tested for HIV because these diseases are epidemiologically linked. Patients who have latent syphilis should be evaluated for neurosyphilis. Careful evaluation and follow-up care for neonates born to syphilis-infected mothers is also recommended because the mother can transmit syphilis to her newborn.
Gonorrhea and chlamydia
Because of risky sexual behavior and lack of access to routine screening before incarceration, jail inmates are at a high risk for STDs such as chlamydia and gonorrhea . Urine testing has simplified screening techniques for chlamydial and gonococcal infections; however, because medical staff and space are often limited and there are large numbers of detainees to process, screening is not effectively accomplished. Policies that direct screening when the inmates complain of symptoms are ineffective because high rates of infected individuals do not report symptoms. For those who are tested, gonococcal and chlamydial infection rates are high.
The prevalence of chlamydia among juveniles is high, mainly because of high-risk sexual behavior. Public health departments can also provide an important service of follow-up care to adults and youth who are discharged from correctional institutions while still under treatment for chlamydia.
Rapid and accurate diagnostic testing for genital herpes simplex virus (HSV) is unavailable in most correctional facilities. Although symptomatic treatments exist, education about prudent sex practices is paramount for inmates with genital herpes.
Chronic disease in correctional institutions
This section discusses the common correctional setting barriers to treating chronic diseases such as asthma, diabetes, and hypertension. Correctional PAs can play an important role in working with custody staff while advocating for patients’ needs and encouraging self-management of chronic conditions among inmates.
Data from the Centers for Disease Control and Prevention (CDC) show that a large disparity exists between minority populations and whites with asthma. Of the approximately 25 million U.S. adults with asthma in 2017, individuals belonging to minority groups were significantly more likely to have the respiratory condition. Because correctional institutions have high percentages of minorities, they will have a disproportionate burden of asthma. The CDC recommends targeted public health interventions to address these disparities.
Many factors hinder asthma care in correctional institutions. Smoking restriction policies exist in a majority of correctional settings. Nevertheless, some correctional institutions (except juvenile detention and confinement facilities) still permit cigarette smoking by inmates.
Other factors include environmental problems, such as inadequate ventilation systems, poor temperature control, poor maintenance of air filters, and old physical structures with mold. As a result, exacerbation of asthma is high among inmates in these environments. Asthmatic inmates may be exposed to chemical means of restraint and other methods of control, such as mace, pepper spray, or use of a Taser or stun gun. These may exacerbate their asthmatic condition.
Many jails and prisons do not permit inmates to keep their inhalers, making it difficult for them to get timely access to their inhalers or, in some cases, timely access to urgent care. Many correctional institutions do not have adequate medication management systems that ensure medication continuity for asthmatic patients. Because of the nature of jails, where inmates bond out or are released within hours of their arrest, asthmatic care is episodic.
Correctional PAs can improve the quality of life of their asthmatic patients through steps that ensure appropriate categorization of the patient’s disease control and status as soon as they are admitted into the jail or prison. This care includes monitoring the patient’s use of beta-agonist inhaler canisters during the month, offering and ensuring that their patients receive flu vaccinations, and obtaining and documenting peak flow meter readings in assessing acute respiratory attacks.
One area in which correctional PAs can make a difference is tobacco control. Tobacco use before incarceration is a huge problem in this population. It is estimated that 80% of inmates used tobacco before their incarceration. Too often, inmates resume their tobacco addictions soon after release, which, unfortunately, can lead to other addictive behaviors. Correctional PAs have an excellent opportunity to break the cycle by providing health education and guidance related to tobacco use and other addictions and by referring inmates to appropriate counseling and addiction services.
The National Commission on Correctional Health Care (NCCHC) estimates a prevalence of 4.8% of inmates with diabetes. Inmates with insulin-treated diabetes should be identified within 2 hours of intake into jail; however, too often, they languish in police lockups (without any medical services) and are then transferred to the jail. As a result, many do not receive health services for several hours. Rapid identification and treatment of inmates with diabetes does not universally occur.
Because inmates do not have easy access to medical staff or services, diabetic care is particularly difficult, especially for insulin-dependent diabetic individuals. Institutional schedules such as mealtimes, pill lines, court appearances, schooling, or offender programming often interfere with consistent and routine diabetic care. Correctional PAs should work with their patients with diabetes and with custody staff to develop flexible treatment strategies that allow the inmate to work within the institutional schedule while maintaining diabetes control. This is especially true for patients with uncontrolled type 1 diabetes, who need extensive health care resources and institutional flexibility to manage their diabetes. Glucose control should be the priority. Facilities that cannot accommodate these patients’ needs may not be the right place to house them. Inmates with uncontrolled type 1 diabetes should be housed in facilities with 24-hour nursing care.
The role of diet and exercise in maintaining glycemic control is well documented. Nevertheless, not all inmates with diabetes have access to daily exercise or low-fat, low-carbohydrate diets. In fact, medical nutrition is one of the most difficult factors to control in correctional institutions. Special diets may be ordered, but the lack of communication or follow-through in the kitchen often results in failure to ensure that the right diet gets to the right patient. Supplemental food items in institutional commissaries have limited heart-healthy snacks or alternatives to high-calorie, high-carbohydrate choices.
Correctional PAs can play an important role in the management of diabetes. Working with custody administration and staff, PAs can ensure that their diabetic patients have appropriate opportunities for exercise and adequate diets and alternatives. Correctional PAs can take an active role in training staff, encouraging patient self-management, and stressing the need to control carbohydrate consumption and participate in daily exercise.
Inmates’ active involvement in diabetes management using self-monitoring equipment has been shown to be effective in the correctional setting. Self-preparation of insulin remains under direct staff supervision because of security concerns.
Correctional PAs can advocate for opportunities for their inmate patients with diabetes to have a better understanding of how to control their disease through self-management and regulation. Correctional PAs can make a difference by providing annual and routine training sessions to all correctional staff on diabetes emergency care. In addition, by monitoring the status of soon-to-be-released patients with diabetes, correctional PAs can ensure that appropriate information and support is given so that follow-up care in the community occurs.
Hypertension is the number one chronic condition reported by inmates, at nearly 25% singularly or in combination with other conditions, according to the Bureau of Justice Statistics 2011 inmate survey. Among the challenges for managing inmates with hypertension is the lack of coordinated educational opportunities for self-management of their disease, and the promotion of lifestyle changes that are a cornerstone to improving outcomes. Correctional PAs can improve chronic hypertension care by ensuring that the patient’s level of control and conditional status is properly categorized and that the patient is encouraged to gain self-management of his or her disease. Monitoring patient adherence through medication distribution systems and assessment of disease control are important strategies correctional PAs can use in managing their patients with hypertension.
Managing mental health in correctional institutions
When prisons were first developed in the United States, rehabilitation and social control dominated the debate as to what the main focus of imprisonment should be. Little attention was given to mental health; however, since the 1980s, correctional institutions have evolved into repositories of mentally ill offenders. An increased number of inmates have a serious persistent mental illness (SPMI). People with SPMI deviate from social norms and acceptable behavior, and as a result they come to the attention of the criminal justice system.
Mental health screening
The prevalence of mental illness among inmates is difficult to accurately report. Data collection includes the self-reports of offenders and various assessments performed upon incarceration. The mental health care capacities in U.S. jails are inadequate. In a study of correctional facilities, it was found that 41.6% did not use a screening instrument to assess mental illness in newly arriving inmates. Rather, screening was usually performed by visual observation and inmate verbal report. In general, inmates entering correctional settings who self-report mental health complaints or screen positive for mental illness through use of a screening instrument are referred to mental health staff for an in-depth and thorough mental health assessment.
Inmate suicides were the leading cause of death in 1983 (56% of all deaths), but because of improved standards and training, suicide rates have steadily declined. In 2002 the jail suicide rate was 47 per 100,000 inmates, compared with 129 per 100,000 inmates in 1983. Prisons have steadily maintained their suicide rate of 16 per 100,000 since 1990 (from a high of 34 per 100,000 in 1980). In comparison, jails have a suicide rate three to four times that of the national average, which in 2013 was 12.6 suicides per 100,000.
Suicide prevention efforts begin with well-trained staff who aggressively conduct intake screening and provide an ongoing assessment of all inmates entering the correctional facility. Five points in time are especially important in monitoring individuals for suicidal ideation during their confinement: during initial admission into the facility, after adjudication when the inmate is returned to the facility from court, after receiving bad news or suffering any type of humiliation or rejection, during confinement in isolation or segregation, and after a prolonged stay in the facility.
Correctional PAs should take an active role in the screening and assessment process to identify inmate suicide risk. Being alert to behavioral cues that an inmate might be contemplating suicide is ultimately the strongest preventive measure that correctional staff can demonstrate. Correctional PAs can help prevent inmate suicides by establishing trust with inmates, gathering pertinent information, and taking action through effective communication.
In the realm of correctional health, PAs may find themselves at the forefront of evaluation, treatment, counseling, and medical management of individuals diagnosed with gender dysphoria. Gender dysphoria is defined in the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 as “a strong and persistent cross-gender identification. It is manifested by a stated desire to be the opposite sex and persistent discomfort with his or her biologically assigned sex.” Working with psychological services, PAs seeing transgender inmates are faced with ever changing clinical practice guidelines and further ethical responsibilities as case laws are decided and as more inmates identify themselves as transgender. This is an area of correctional medicine that requires culturally competent PAs for effective management.
The relationship between drugs and crime is well established, with about half of state inmates and a third of federal prisoners reporting that they committed their current offense while under the influence of alcohol or drugs. Studies consistently report between 72% and 78% of inmates with mental illness have a comorbid drug or alcohol abuse problem. Nevertheless, despite the well-established relationship between mental illness, drugs, and crime, few jails and prisons use a formal validated screening instrument for drug abuse among their entering inmates. Correctional PAs should promote the use of accurate and timely screening instruments for substance abuse.
Special issues in corrections
In recent years, although the rates for incarcerated individuals have decreased, the number of female inmates has risen. Drug offenses for female offenders are now outpacing those for males. The health needs of incarcerated women include concurrent medical conditions and higher rates of sexually transmitted infections. Women offenders must also be evaluated and treated for substance-related issues, mental illness, and sexual and physical abuse. Incarcerated women may not have up-to-date preventative health screenings and upon intake require appropriate breast and pelvic examinations and screening or diagnostic Pap smears and mammograms. Pregnant inmates may have complicated and high-risk pregnancies. Correctional PAs managing pregnant inmates will coordinate the medical and mental health issues, which include contraception education upon release planning.
One issue that challenges all corrections health professionals is how to differentiate between legitimate pain sufferers and those manifesting drug-seeking behavior. Nearly 70% of the incarcerated population has been charged with serious drug offenses and has some sort of drug-seeking behavior. Distinguishing a true chronic pain sufferer from an individual who is manipulating and seeking drugs is something that a correctional PA learns to do quickly.
The history is an important way to distinguish pain sufferers from manipulators. A true chronic pain sufferer is usually someone who has narrowed his or her selection of medications to actually find some, but not total, relief. The drug-seeking individual, on the other hand, is more likely to have a polypharmacy approach, often mixing classes of drugs “without finding any relief.”
Associated pain with movement is another way to distinguish legitimate chronic pain sufferers from those exhibiting drug-seeking behavior. A legitimate chronic pain sufferer generally reports being pain free at rest, whereas the individual who expresses multifocal pain at rest may need more careful evaluation for drug-related manipulation issues.
Nonmalignant pain management in correctional institutions is complex. Because incarcerated populations have documented histories of trauma, mental illness, and substance abuse disorders, clinicians may find it difficult to assess what and how much to prescribe to this population. A multidisciplinary team can address the biological, psychological, behavioral, social, and medicolegal aspects associated with chronic pain.
Correctional PAs involved in chronic pain management can find supplemental information by reviewing the NCCHC’s Position Statement on Chronic Pain Management.
End of life
Several factors contribute to the incarcerated population death rate. Data on prisoner deaths remain sketchy; however, limited studies have indicated that, compared with the same age groups of civilians (such as ages 55–65 and ages 65 and older), prisoners have significantly higher mortality rates because of malignant neoplasms, chronic liver disease, pneumonia, septicemia, HIV, and AIDS.
How are terminally ill inmates managed? In general, there are two options for managing terminally ill inmates in prison. The first is to compassionately release the dying inmate to a community setting. A compassionate or early medical release program permits terminally ill patients to return to the community and be housed in a home care setting, a hospice, or a long-term care skilled nursing facility. In this way a terminally ill prisoner can return home to be near his or her family in the last stages of death. Nevertheless, there are many barriers to the liberal use of compassionate release programming. A prisoner’s criminal record, public safety concerns, statutory limitations, and public activism against release have prohibited the compassionate release of some prisoners. The lack of community resources for accepting transferees from prisons or the lack of outside family support may in fact disqualify a prisoner from an early release. In addition, the approval process may be inordinately long. Approvals for early release may require an independent medical board, a judge, a prosecutor, and even public input before a decision is made to allow an individual to be released early and die outside the prison setting. It is not uncommon for prisons to release an inmate hours before he or she dies.
The second option is to create a correctional hospice program. There are a number of barriers to developing a hospice program; they include: lack of funding, a staff untrained in hospice care, and a prison culture that fosters suspicion and insensitivity. Approximately 85% of hospice patients receive Medicare coverage for services, but prisoners are not Medicare or Medicaid eligible, so any hospice-type service that is provided in correctional institutions is absorbed within the department budget or through pro bono activity by community hospice agencies. Most departments of corrections do not have formal hospice programs. Nearly 70% of terminally ill inmates are kept in infirmaries, about 10% are compassionately released, and about 20% are cared for in a hospice program. Thus hospice training and experience among correctional health workers is limited. Finally, the prison culture hampers the implementation of hospice care. Many consider correctional institutions as places for harsh punishment, providing as few services as possible and assuming an attitude that demonizes inmates. This includes hospice care. Some staff members believe that palliative or hospice care amounts to “coddling prisoners” and therefore does not provide an appropriate tone for a prison. Another barrier to overcome is that inmates may have a dim view of death and dying behind the “walls” and would rather be transferred to an outside hospital or have a compassionate release so that they can be with family and friends during their last stages of life. State rules governing such releases are often not supportive of compassionate releases. Consequently, with an increase in the elderly inmate population and terminal illness, there will be more need for hospice services.
The correctional PA is often involved in hospice and end-of-life care issues. Providing clinical support for a dying inmate is one aspect of that involvement, but the correctional PA can also be involved in providing support to staff and inmate volunteer workers who are involved in hospice care. Training of staff and providing psychological support are some of the ways that correctional PAs can be involved in hospice care.
One area of death that correctional PAs should not be involved in is executions. The mandate from professional organizations is clear on this point. The American Academy of Physician Assistants (AAPA) policy prohibits PAs from participating in executions. The NCCHC standard and position statement for health care professionals prohibits the involvement of health staff in any aspect of the execution process. The ethical conundrum of establishing a therapeutic relationship with a patient, only to participate in his or her termination of life, is one that few PAs face; nonetheless, many correctional PAs have had to face this and many other ethical dilemmas on a daily basis.
Managing ethical conflicts in correctional institutions
Correctional health care is the nexus among criminal justice, public health, law, and ethics. Although the challenging ethical issues of the correctional health care field are similar to the community at large, the nature of prisons and jails limits autonomy and choice. Correctional medicine ethics is much more complex because there are no clear-cut guidelines for ethical conduct of correctional health professionals.
The competing priorities between correctional interests and health interests continuously provide flashpoints of conflict and tension. For example, one cornerstone of medical ethics is patient freedom of choice. In a prison or jail setting, a patient’s choice of provider is limited. Their ability to choose or change health providers is limited and in many cases not an option. Likewise, if a PA is having difficulty communicating with a troublesome patient, there is little opportunity to change to a different health care professional. As a result, both patient and PA are stuck with each other and must resolve their issues.
Issues such as informed consent and refusal of treatment are complex in correctional settings. Inmates have the right to be informed of the risks and benefits of proposed procedures and therapies and may refuse. Still, can an inmate refuse treatment for a health condition that poses a risk to others? Correctional health staff are obligated to ensure the safety and public health of institutions. Medical isolation is usually the first step to containing an infectious inmate who refuses treatment. If the inmate remains recalcitrant, correctional health clinicians will obtain a court order to enact appropriate care. Nevertheless, system disincentives, such as payment of a fee for health services or programming and conflicts between sick call and court visits, might be causes for inmate refusals and should be analyzed. Other possible alternatives should also be investigated.
One ethical conundrum is that when inmates are protesting their condition of confinement, refusal, such as hunger strikes or refusal to abide by custody rules, may be their only alternative. The dilemma that correctional health clinicians find themselves in is protecting the patient’s health and life while honoring his or her efforts to effectuate system change. In these situations, correctional PAs need to educate and communicate with their patients and custody officials to alleviate conflict and improve clinical outcomes.
One ethical tenet is that patients are to be treated equally. Health care professionals are taught that they must remain neutral in their perspective about the patients they encounter and treat them accordingly. That ethical principle is put to the test every day in correctional medicine. How would you feel about treating a child molester with diabetes? Would a rapist with chlamydia be treated any differently? This can be a major deterrent for many PAs who are new to correctional health care, and it can put their professional objectivity to the test every day. Regardless of their criminality, inmates should receive health care that is at the level of community care standards.
The ethical principle of acting only for the benefit of the patient is beneficence. Correctional clinicians are challenged with regard to what constitutes beneficence for the patient or obligations to the state. For example, contraband in a correctional institution is a serious problem because it jeopardizes the safety and security of everyone. Body cavity searches are one method that correctional administrators use to ensure that contraband is not entering the facility. This presents a conflict for the correctional clinicians who should conduct their actions with beneficence and resist efforts to have body cavity searches conducted on their patients. Of course, if there is sufficient medical indication to conduct a body cavity search, then it should be performed.
Another issue that challenges the principle of beneficence is competency for execution. Establishing a therapeutic relationship is contingent on a goal to restore the individual to full function and thus improve his or her quality of life. It is antithetical to cases where the goal is to restore an individual’s competency to carry out an execution sentence. The NCCHC position statement advises correctional clinicians that restoring an inmate to competency for the purposes of execution should be done by an independent expert and not by any health care professional regularly in the employ of, or under contract to provide health care with, the correctional institution or system holding the inmate. This requirement does not diminish the responsibility of correctional health care personnel to treat mental illness in death row inmates.
In an environment where there are “no secrets,” it is difficult to protect the confidentiality of inmates’ health problems. Maintaining confidentiality and privacy of patient information is difficult under circumstances where control is not maintained by health staff. The use of per diem workers, visiting clinicians, or other temporary health care providers also complicates how confidentiality is maintained.
The principle of confidentiality assures the patient that disclosure of specific information given to the provider during a course of treatment will remain confidential. Because this can be complicated in a jail or prison, correctional PAs have to work harder to gain patient trust in a therapeutic relationship. When an inmate tells the clinician that he broke his jaw “while slipping in the shower” or by “tripping and hitting my bunk bed,” the clinician needs to understand that pressing for more information could jeopardize the patient-clinician relationship. On the other hand, if an inmate tells the clinician, in the course of a clinical encounter, that his new tattoo was obtained in the cell block, the clinician has the responsibility of informing custody that there is a potential that contraband material (ink, needles) is present in the prison. Discerning the difference between patient-specific confidential information and information that must be shared with custody staff is a fine line that many correctional PAs must negotiate.
Correctional PAs serve to educate inmates about appropriate management of their acute and chronic health conditions, disease prevention, and healthy lifestyles in anticipation of release. The planning for self-management and continuity of care begins at intake and continues through the time of release.
Through the Patient Protection and Affordable Care Act (PPACA), the majority of states have adopted Medicaid expansion, thereby increasing access to health insurance for people with low incomes. Consequently, upon leaving jail or prison, many individuals now have access to health insurance via Medicaid. Moreover, new care delivery strategies are being used to provide continuity and comprehensive care after someone is released from a correctional facility. These strategies include: 1) data exchange between correctional facilities and Medicaid agencies to prompt planning for an individual’s release into the community, 2) jail or prison “in-reach” to help inmates establish with a primary care provider before release, 3) addressing housing issues and other social determinants of health within days after release, 4) use of peer support specialists to help individuals navigate the health care system, and 5) the engaging of health care providers who have expertise in working with individuals who have been incarcerated. Although the outcomes are not yet known, these new approaches aim to address the significant medical, behavioral health, and substance abuse issues experienced by those who have been incarcerated. Therefore, they have the potential to reduce recidivism and related costs.
Unlike their noncorrectional colleagues, PAs who work in jails and prisons have unique challenges to their professional ethics and personal beliefs. Some are well suited for this work environment, whereas others do not fare well. This chapter has described the areas that are unique in correctional medicine, which are often not discussed in PA educational programs.
Why would a PA want to work in a jail or prison? After all, working conditions in U.S. prisons and jails are what you would expect in developing countries’ health care systems, where patients often present to the clinic late in the course of their disease; they have self-medicated or used traditional treatments; the health facilities are so “poor” that they may delay diagnosis; referrals (if needed) are not easily arranged; there are problems with shortages of trained staff; there is poor infection control and lack of follow-up care; and the patient may be unable (e.g., because of financial hardship) to fully adhere to treatment.
Beyond the similarity between U.S. correctional institutions and developing countries, why would you want to provide health care to patients who are seeking to “game the system” or who have had little contact with health care services? The answer lies in the PA’s role. Practicing correctional medicine creates an opportunity for PAs to advocate for individual and community health, two cornerstones of the profession.
As patient advocates, correctional PAs have the opportunity to make a difference in the lives of disadvantaged and disenfranchised populations who need specialists in public health, primary care, infectious disease, and chronic disease. PAs may see inmates in clinical, emergency, and consultation settings for their acute and chronic conditions. Increasingly, PAs may evaluate, treat, and consult on inmates in community settings for specialty services or upon their release. Jails and prisons are challenged when caring for inmates with physical deformities, congenital issues, and sensory or cognitive deficits. Rising costs for care further challenge correctional administrators to review requests for compassionate release, transferring those costs to society.
Correctional PAs can advocate for improved conditions of confinement and improved health services, making improvements in clinical care and patient outcomes.
An average day in the life of a correctional PA is complete with clinical and administrative responsibilities ( Case 49.1 ). Seeing patients in a variety of settings, such as segregation cells, sick call clinics, and inpatient settings while performing a number of administrative tasks is a dynamic that creates opportunities for correctional PAs to advocate for patient needs.
As advocates for public health, PAs working in corrections address issues that directly prevent the spread of disease into our communities and have an impact on eliminating health care disparity to disenfranchised populations.