Best-Practice Models

Creating Effective Facilities and Programming for Geriatric Inmates

Ron Aday, PhD

Middle Tennessee State University

Rapid Growth Trends in PrisonsIn 1991, there were 33,499inmates age 50 and over.This number increased to113,358 in 2001. Today,there are Over 250,000Inmates age 50 and over inState & federal institutions.In 2010, there were 125,000 inmates 55 plus and expectedto rise to 400, 000 by 2030.

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1991 1996 2001 2012

Aging Inmates: Challenges Ahead The aging prison population represents one of the most dramatic

changes in U.S. prison system and is having far reaching effects on all components of the criminal justice system.

Aging prison population is also an international issue. Questions remain about how we should respond to the increasing

number of aging inmates:-- How do we keep an increasing number of frail inmates safe? -- How do we provide adequate mental and physical health care?--What about end-of- life care? --What new health delivery policies are needed?--What about increasing health care costs?--What about community partnerships?

Special Needs of Geriatric Offender Sterns (2008) projected from a national study that 45% of

inmates ages 50 and over and 82% of those 65+ have, on average, 3 chronic health problems

Nationwide surveys also project that 40% of geriatric offenders have been diagnosed with mental illness with older females typically have higher rates

Wilson and Barboza (2010) estimate that over 3,500 inmates possess symptoms of dementia, but is likely higher since few health care systems screen for cognitive impairments.

Older inmates generally need more medical and mental health services than younger offenders.

Moving Toward a Geriatric Justice System A police/court system that understands mental health

issues of the aged

House arrest/diversion programs/

Expansion of geriatric facilities, programming and health policies geared toward the aged

Second chance for lifers (POPS)

Utilization of compassionate release

Structured programs designed for inmate reentry

Aging and Prison Programs Aging in prison take place in a context of the living

environment which includes the physical structure as well as the patterns of activities and social relationships with others

An age-friendly physical environment is necessary for the frail elderly inmate and roughly one-half of the state correctional systems provides (a special grouping of inmates, wings or dormitories, dedicated special needs or geriatric facilities providing assisted living accommodations, nursing home like facilities

However, states have lagged behind in providing suitable programming for large groups of older inmates housed together

Conditions for Effective Programming Prison culture - policy and practices encouraging healthy aging

and favoring humanization of the prison environment Staffing adequacy - including culturally competent staff that

understands the aging process Prison structure - including state of repair, ADA standards,

sensitive to inmate mobility needs, space for geriatric programming

Community connections – availability of voluntary agencies, special events, services, programming

Inmate characteristics - interest and diversity including race, gender, crime classification, education, physical and mental health, adaptation strategies

Solutions: Programming Strategies Must recognize the diverse coping styles and skills of

individual inmates including the medically and cognitively challenged, gender differences, etc.

Understand that when removed from the general prison population, inmates may feel isolated, bored, and depressed

Recognize the positive influence that social programs and attachments can have on the psychological well-being of older inmates

Social participation is crucial for the successful management of a growing geriatric inmate population

Pros/Cons for Segregating Inmates Maintaining an optimum

environment for the frail elderly inmate presents significant challenges.

Many inmates have a low coping skills and are medically impaired

Creation of a supportive climate where offenders feel safe is only the first step in creating an effective social milieu.

Prisoner Assistance Programs Correctional officials are beginning

to train younger inmates to assume responsibilities for working with persons of advanced age.

Such tasks include pod cleaning, laundry, transport to meals, sick call, and other activities (ie., pushing wheelchairs), letter writing, and relaying critical information to staff members when concerns arise that require more formal, professional intervention.

Work can be considered a therapeutic activity in a prison setting

Participating in work activities enables older inmates the opportunity to stay in similar routines as younger inmates, regardless of age. Work encourages inmates to remain engaged and physically active. In this regard, work can be considered a “wellness” activity since older inmates have to walk to work. Some fortunate older inmates may work in a variety of cottage industries, which provides not only a legitimate community contribution, but a significant prison income as well. In some selective cases, inmates may earn up to $2 per hour for some contract prison labor.

Working as a dog trainer or in house-keeping are both suitable activities

Education/Training Programs for Older Inmates

Older offenders are greatly in need of educational activities that will assist them in preparing for the transition back to society.

Practical skills such as managing their personal finances, household responsibilities, and relationships with family may need to be strengthened or re-developed altogether in order to facilitate a smooth process

Care should be taken to educate these individuals in developing routines they can rely upon to continue engaging in and maintaining healthy lifestyle decisions (diet, exercise, etc.) both in and outside of prison.

A variety of arts and craft actives are found in best-practice models

Music therapy groups are found in Virginia and Nevada Prisons

Groups also have added value for older inmates such as “Golden Girls” Individual and psychotherapy

group counseling BE-ACTIV (Nursing Home

Model) Support groups for aging

inmates Grandparenting groups from

prison Reminiscence groups Recreational groups Life history groups

(autobiography) Sexual abuse support group Grief groups

A supportive social environment is important for healthy aging

Challenging end of Life Issues

Best Practice Model: True Grit Physical Fitness – walking, dancing, movement therapy,

wheelchair square dancing, billiards, ping pong, wheelchair basketball, softball, and bowling, low-impact aerobics, stationary bicycle, tennis volleyball, horseshoes

Diversion Therapy – Bingo, Latch-hook rug making, beading, crochet/needlepoint, painting, puzzles, checkers, chess, crossword puzzles, song-writing, poetry, reading

Music Programs –True Grit Choir, Do-wop Band, Spiritual Group, Country/Western Singers

Vet-to-Vet Program – utilizing community volunteers provides important group identity and recognition for vets

True Grit Programming (Cont.) Programming for Lifers/Re-entry Inmates

-- Counseling services/support groups

-- New Beginnings Re-entry Program

-- Planning for weekly shopping

-- Health and wellness education

-- Structured job assignments

Effective Outcomes Cost effective since the program utilizes outside volunteers

(compassionate care community minister, student interns, retired teachers, volunteer veterans, and other community groups that donate activity materials

Reduction in drug consumption for mental illness; fewer days in medical; increased life satisfaction

Creation of healthy prison community focus that encourages self-care and responsibility

National recognition for creative programming providing positive public relations

Future Challenges Prison location and availability of community partnerships

(education, church, civic groups)

Grouping special needs inmates/space issues necessary for special programming

Unwillingness or unable to commit financial and staff resources

Inmate interest and/or access to geriatric programming

Inmate diversity including race, gender, crime classification, education, physical and mental health characteristics

Aging OffendersOklahoma State Reformatory

Overview of Oklahoma DOC Total incarcerated offenders 26,380 89.9% male 10.1% female Average age 38.1 years

85% sentencing legislated March 1, 2000

Offenders over the age of 50 years: 4,223 (17%)Offenders confined to a wheelchair: 220

• Standing Proud

• P rofessionalism

• R ehabiliatation

• I ntegrity

• D iversity

• E xcellence

OKLAHOMA DEPARTMENT OF CORRECTIONS

Eighth Amendment Excessive bail shall not be required, nor excessive fines

imposed, nor cruel and unusual punishments inflicted (U.S. Constitution).

Estelle vs. Gamble We therefore conclude that deliberate indifference to serious

medical needs of prisoners constitutes the “unnecessary infliction of pain,”…proscribed by the Eighth Amendment (U.S. Supreme Court).

Medical Services Units 17 Medical Services clinics 5 clinics are staffed 24/7 3 male infirmaries 1 female infirmary Total of 43 infirmary beds

• DOC/Rural Hospital (LMH) partnership22 inpatient beds

• DOC/OUMC partnershipTertiary care hospital and specialty outpatient care

Monthly Averages Medical Sick Calls 7,226 2,802 Nursing Protocols 3,971 Mid Level Provider Visits 3,664 Physician Visits

Dental Sick Calls 1,959 3,102 Dentist Visits

Mental Health Sick Calls 1,618 2,802 Mental Health Visits

Monthly Averages 47,407 prescriptions monthly 12,723 offenders taking medication 5,746 offenders taking psychotropic medications

8,860 offenders with chronic medical illnesses

660 hospital days 137 at OU, 457 at LMH, 66 Local

127 ER visits

Staffing and Operations Expenditures Current Staffing is 90% of allowed FTE’s Staffing 24/7 facilities is most challenging

FY 2012 Medical Per Diem $7.35 2008 Per Diem $7.97

89% of Operations Expenditures are for Outside Medical Care and Pharmaceuticals

Dick Connor CC

Mr. P. Mr. P. convicted of murder at the age of 85. Sentenced to

LWOP.

Lived in general population until the age of 95, assisted by the offenders who lived on his unit and who treated him with respect. Seen regularly by medical staff, but no serious illnesses.

Died in the infirmary at the age of 101.

Costs of Care for Aging Offenders The cost of incarceration for offenders over the age of 50 is

estimated to be at least 3 times that of younger offenders (ACLU, 2011).

Centers for Medicare and Medicaid (2004) average annual medical costs per capita by age. 19-44 years $3,370 55-64 years $7,787 75-84 years $16,389 >85 years $25,691

Offenders over 504,223 over age of 50. Projected Average of 19 years left to serve.

1,934 serving 85%, Life, LWOP, or Death sentences.

Age

Age Group #

51‐55 2078

56‐60 1157

61‐65 564

66‐70 284

71‐75 102

76‐80 29

81‐85 6

86+ 3

Total 4223

Note: The two oldest offenders are 89 years of age.

Age on Admit

Mean 47

Median 50

Mode 51

Minimum 15

Maximum 83Sentence Length

Sentence Length #85% 992Life 703LWOP 222Death 17Note: The average projected years left to serve is 19; the average actual years left to serve is 37

Medical and Mental Health Acuity 1,066 with moderate to severe medical acuity

314 with serious mental illness

Medical AcuityMedical Acuity Level #

MAA 2637MAB 957MAC 109Unknown 520Total 4223

Most Recent MHLMental Health Level #

A 749B 1004C1 238C2 65D 11O 2035Unknown 121Total 4223

The Challenge of Correctional Medicine The primary purpose of prisons and jails is not to provide

health care (Puisis, Clinical Practice of Correctional Medicine, 2006).

Accommodations Medical infirmaries, medical units, modified units.

Air Conditioning Most ODOC beds are not air conditioned

Facility Design Hills, Steps, adapted schools and other state buildings

Medical Parole (compassionate release) Since 2008, 270 considered and 80 paroled, with peak of 27

paroled in 2010

Offender assistants Assistance with ADL’s, dementia patient companions

Infirmaries Dick Connor CC 8 beds, filled with custodial care patients

Mabel Basset CC 8 beds, female facility

Oklahoma State Penitentiary 17 beds, maximum security facility

Lexington CC 10 beds, extremely high acuity patients

J Unit at Joseph Harp CC Oklahoma DOC established the J unit in 2007

248 total beds

Satellite nursing and provider stations on unit

22 unit orderlies

130 offender patients attend pill line daily (most medications are keep on person and do not require pill line administration)

40 Diabetics receive insulin

187 offenders are enrolled in chronic disease clinic

50 offender patients are confined to a wheelchair

4 offenders with Dementia are housed with offender assistants

“Modified” General Population Beds MBCC Unit C-3A Satellite nursing station Approximately 100 medically compromised patients

John Lilly CC Unit 1 Approximately 100 medically compromised patients

Jess Dunn CC Unit C 20 hospital beds Approximately 20 medically compromised patients

T.W. T.W. is housed in a minimum security facility. He is not in an

infirmary. T.W. is 81 years of age. He has a colostomy (an opening in his abdomen that allows him to empty his bowels) and a suprapubic catheter (an opening in his abdomen that allows him to empty his kidneys). T.W. is seen by nurses for colostomy and catheter care, and is seen periodically by a physician. He takes 5 medications and suffers from 5 chronic medical illnesses. T.W. has not been hospitalized over the past 12 months. Should T.W. live another 4 years, he will discharge from DOC.

T.W. The minimum security facility that houses T.W. also houses

about 30 offenders who are confined to wheelchairs. A General Population unit at the facility has been adapted to accommodate approximately 100 chronically ill offenders.

DOC currently houses about 230 offenders who are confined to wheelchairs; 250 use a walker, crutch, or cane; 70 use some form of medical prosthesis; and 70 are significantly and functionally hearing impaired.

Oklahoma DOC Survey 2013 Using Medicaid Criteria for Nursing Home Admission,

ODOC found 67 offenders who should immediately qualify for NH placement. Currently these offenders would be housed in an infirmary or

other protected medical housing. In addition to these 67 offenders, 6 other offenders were found who would require infirmary care.

541 offenders would qualify for a corrections medical/disability unit.

194 offenders would require modified GP housing

Strategic Planning Medicaid provides payment for qualifying inpatient hospital

admissions for some offenders.

Medicaid should also provide payment for Nursing Home offender patients.

Oklahoma did not Expand Medicaid services under the Affordable Care Act

Can DOC access Medicaid to place those 67 offenders in a Nursing Home?

Strategy Can DOC expand medical beds to accommodate the aging

population? Legislative funding? Savings from centralized housing?

DOC is gradually expanding on site medical care and Telehealth.

DOC has expanded the roles of Mid Level providers. The demand for Primary Care is expected to increase under the Affordable Care Act. Can DOC compete for Doctors and Nurses?

Will legislation reverse the trend of longer sentences?

The Classical Hippocratic Oath I swear by Apollo the Physician…I will use those…regimens

which will benefit my patients according to the greatest of my ability and judgment, and I will do not harm or injustice to them (Attributed to Hippocrates, 5th century BC).

Questions?