Chapter 9

Health Care

Objectives• Appreciate the legal basis for standards of

medical care within prisons• Identify the similarities and differences

between community and correctional medicine and be familiar with unique end of life issues present in correctional environments

• Explain the process of intake screening and the importance and exceptions of confidentiality

The Right to Health Care

• Estelle v. Gamble – “any attempt to withhold or delay medical care constitutes cruel and unusual punishment”

• Standard of competence is deliberate indifference

• Standards of care in the community and correctional environment change constantly

Initial Screening

• Upon arrival:– Overall health status?– Communicable disease risk factors?– Obvious signs of mental illness?– Medications?– Physical examination for pre-existing conditions?– Alcohol/drug abuse?– Reasons to necessitate separate housing?

Initial Screening (cont.)

• Mental status and cooperation may reflect stress, frustration, disappointment

• May feel insecure and/or be concerned for his/her safety

• Plans for follow-up care should be made if chronic conditions are present

• Initial screening interview may set the stage for inmate’s cooperation with medical personnel

Clinics and Sick Call

• Inmate should understand procedure for sick call

• Some institutions have instituted nominal inmate co-pay to prevent abuse

• Should have continuity and teamwork so that the same staff care for the same inmates

• Some conditions can be improved through patient education films, question and answer sessions, and counseling

Confidentiality

• Medical record should be treated with same confidentiality as in the community

• Can disclose medical information in limited circumstances:– Provision of healthcare to individual– Health and safety of inmate– Health and safety of staff– Health and safety of those transporting inmate

Medical Emergencies

• Heart disease, stroke, peripheral vascular emergencies are common

• Main function of staff in emergencies is:– Rapidly respond to scene– Stabilize the patient– Transport inmate to appropriate facility

• Staff should be trained in CPR, advanced cardiac life support, and advanced trauma life support

Medical Emergencies (cont.)

• Transportation should be done on stretcher or backboard

• Security should be a high priority to prevent escape

• Incident report should be written as soon as possible, including times, medication, and procedures administered

Medication

• Prescription medication is commonplace among inmates

• Cost is a major expense for correctional facilities

• Good recordkeeping is essential• Team approach with frequent monitoring is

best for pain medication• Correctional personnel can be helpful with

observation of inmate activities

Medication (cont.)

• Alcohol and drug abuse are major issues prior to incarceration and may continue to be problems within the facility

• Need a comprehensive treatment approach• Correctional staff can assist in preventing the

manufacture of “homemade” alcohol inside institution

• Random urine monitoring program can also help manage substance abuse within the institution

Infection Control

• Confinement lends itself to the spread of infectious organisms

• Prior needle use predisposes inmates to infectious diseases

• Incidence of HIV in prison populations is high• All personnel should have access to disposable

gloves and CPR masks

Infection Control (cont.)

• Each institution should have a routine testing policy for TB, hepatitis B, hepatitis C, and HIV

• Treatment of HIV is expensive, time consuming, and complex

• Medical and correctional staff should have yearly TB tests and should consider HIV tests as well

Unique Medical Situation

• Use of Force– May be necessary to subdue or restrain an inmate

who is a danger or threat– Medical staff should be present if possible and

perform careful examination afterward• Fights or Riots– Need to have a plan to deal with disturbances and

practice plan at regular intervals– Prior use of radio frequencies and transportation

of injured persons will be difficult under actual circumstances

Unique Medical Situations (cont.)

• Hostage Situations– Medical staff should prepare for their role in

emergency management, triage, and transport

• Hunger Strikes– Inmate should be in locked cell with water turned

off– Frequent exams, including drawing blood

electrolytes– Add IV fluids if strike persists

Eldercare

• Aging inmate population is taking a toll on correctional institutions

• More offenders are aging and dying in penal institutions

• Older inmates require more medical attention, need special diets, and eventually will need geriatric services

End-of-Life Considerations

• In-custody deaths might be due to natural or unnatural causes

• Death by unnatural causes should always require an autopsy

• Site of death should be treated as a potential crime scene

• Living wills should be properly drawn and notarized as part of the inmate’s record

End-of-Life Considerations (cont.)

• Hospice care exists in some facilities using trained inmates as volunteers

• Multiple professional staff are often involved• Frank discussions should be held with families

of the terminally ill, including arrangements for the body

• Some facilities allow for compassionate release of those with terminal illness

Healthcare Professional as Correctional Officer

• Communication among all professionals is essential to ensure a safe and effective workplace

• Avoid tension among staff members by holding training sessions together

• All health care staff should be familiar with the principles of security and custody

Conclusion

• Changes in sentencing laws have resulted in an increase of prison populations

• Need for well-trained health care professionals is great within the prison system

• Access to health care within a correctional facility is a constitutional guarantee

Chapter 10

Mental Health

Objectives

• Outline issues inherent in the provision of mental health care in the correctional setting

• Determine if inmate participation in mental health care and treatment should be required

• Explore the right to privacy with regard to mental health records

Introduction

• Inattention to mental health needs of inmates can lead to management problems, negative publicity, and litigation

• Deinstitutionalization of mental hospitals has greatly decreased numbers of mentally ill in institutions

• However, those who do not properly manage their medication may commit crimes when their behavior deteriorates

• Data suggests that there are more mentally ill people in prisons than in mental institutions

Guidelines and Standards

• Incarcerated individuals have rights of access to and provision of health care

• Crucial issue is to avoid deliberate indifference toward the mental health needs of the incarcerated population

• Need adequate health facilities, a well-defined program structure, understandable written policy, and quality assurance program

Access to Care

• Ruiz v. Estelle established 6 issues for minimally adequate standards:– System to insure mental health screening– Provision of treatment while inmates are in

segregation or special housing– Training of mental health staff– Accurate and confidential medical record system– Suicide prevention program– Monitoring for appropriate use of psychotropic

medication

Screening

• Initial screening should be done on an individual basis by a provider trained in detecting mental disorders and interviewing techniques

• Providers must persist in obtaining necessary information to adequately screen inmates

• Goal of screening is to identify quickly emergency situations and inmates who might require more extensive interventions

Treatment and Followup Care

• Variety of treatment settings:– Outpatient– Inpatient– Transitional/Intermediate

• Some facilities use state mental health system• Goal of transitional care is usually to stabilize

the inmate in a sheltered environment

Treatment and Followup Care (cont.)

• Goal of treatment is eventual integration into the regular prison population and preparation for release

• Discharge planning and followup care are crucial

• Assessing dangerousness to self and others must be reviewed before discharge

Crisis Intervention

• Short-term interventions to deal with acute mental distress

• All staff should be familiar with suicide prevention

• Suicide prevention program includes training on signs and symptoms of potentially suicidal inmates, availability of a safe environment for housing, constant observation

Issues Arising from Confinement

• Stress of being incarcerated can add symptoms of mental illness that may not have existed at the initial screening

• Stressors include:– Involvement in legal system– Separation from existing community support– Peer-generated problems– Loss of control and decision making

• Ongoing assessment is crucial

Legal Requirements

• Hospitalization is voluntary unless an inmate is a danger to himself or others

• Civil commitment for inmates is the same as for nonprisoners

• Inmate must give informed consent to any type of psychiatric treatment except emergency treatment or treatment allowed after involuntary commitment

Privacy

• Same expectation of confidentiality as in a community health care setting

• Information should only be shared on a need-to-know basis even among health care professionals

• Internal policy should define members of the health care team

• Inmates have the right to access their health record unless doing so would be detrimental

Dual Roles of Staff

• Clinical staff may feel caught between their roles as caretakers and as correctional workers

• Patients need to be advised that information cannot be kept confidential if it affects the security of the institution, potential harm to inmate or others, or concerns serious damage to property

Special Treatment Procedures

• Use of seclusion or restraint requires close attention in correctional environment

• Review system is needed to ensure that special procedures are only used as necessary and that inmate’s psychological needs are addressed

• Must be assessed to ensure that circulation has not been compromised and that toileting, meals, and repositioning are accomplished as necessary

Medications

• Medication prescription is a high risk area in correctional environment

• Should be kept to a minimum• Sleep medication should be limited to acute

situations• Medication compliance should be followed

closely• Guard against polypharmacy• Close attention to side effects

Mental Illness

• Antisocial personality disorder is diagnosed based on historical information

• Criteria include pattern of disregard for others, criminal behavior, lying, impulsive, irresponsible, and aggressive behavior

• Malingering is a behavior that involves an individual falsely claiming and consciously faking symptoms of an illness

Integration of Mental Health and Medical Care

• Success for care delivery of mental health is related to adequacy of general medical services available in a prison

• Significant number of psychiatric patients have concurrent mental illnesses

Conclusion

• Few clinicians and other providers are trained during their professional education to work in correctional environments

• Provision of adequate care constantly competes with maintaining adequate security

• Correctional environment may be one of the last public strongholds for adequate care of seriously mentally ill

Chapter 11

Religious Programming

Objectives

• Explore the role of prison chaplains and understand the challenges of providing religious programs in the correctional environment

• Explain the major programs coordinated by prison chaplains and the available resources for religious programming

• Describe the general legal framework within which prison religious programs operate

Historical Background

• Religion has played a role in American corrections since the inception of penitentiaries

• Earliest prison facilities were influenced by the Quaker belief that time away from society would change the hearts of offenders

• Forced solitude caused emotional distress and mental illness for many early prisoners

Religious Accommodation and Freedom Legislation

• First Amendment of Constitution – freedom of religion

• Prison administrators can regulate religious practices in order to protect the security of the institution

• Religious Freedom Restoration Act of 1993 – governments were prevented from interfering with individuals’ religious observances unless the interference was the least restrictive means of furthering a compelling government interest

Religious Accommodation and Freedom Legislation (cont.)

• Religious Land Use and Institutionalized Persons Act of 2000 – prohibited the government from restricting prisoners’ religious worship opportunities unless the government can demonstrate that the restriction furthers a compelling government interest

• Many corrections officials oppose these legislative initiatives for fear of lawsuits requesting religious accommodations

Religious Accommodation and Freedom Legislation (cont.)

• In some states, inmate grievances have increased

• All who work in a correctional environment should understand the impact of these laws

• Cutter v. Wilkinson – inmates of small and unfamiliar religious groups won their appeal for the opportunity to meet for religious worship

Professional Standards

• Professional standards require a balance between provision of religious programs and restriction of religious practices

• Staff accommodate religious practices as long as the accommodation will not interfere with safety, security, and orderly operation of the institution

• All religious programs must be voluntary

Professional Standards (cont.)

• Religion should not be used as a tool for manipulation, nor should inmates be rewarded for participation

• Chaplains are responsible for working with inmates of all faith groups

• Rely on expertise of community religious leaders to complement the care and services they can provide

Role of Chaplains

• Chaplain may serve as spiritual guide, preacher, teacher, dietitian, counselor, and advocate

• Religious impact in institution depends on the unique pastoral manner in which the chaplain helps inmates

• Gravest problem among religious service providers is that they lose sight of their role as correctional workers

Role of Chaplains (cont.)

• Complexity of the multi-faith correctional environment requires a high level of professionalism to ensure that inmates of all faiths have the opportunity to benefit from religious programs

• Integration of ministry and management is essential because of added dimension and challenges of ministry with an incarcerated congregation

Religious Pluralism

• Chaplaincy corps should reflect accurately the beliefs of the inmate population

• Religious issues outside of the chaplain’s expertise should be referred to qualified leaders in the community

• Contract chaplains can be used as spiritual leaders for inmates whose beliefs differ from those of the full-time chaplain

Congregate Services

• Meeting of several people to worship, study, or pray should be provided unless specific security or safety issues are presented

• Inmates who become involved in religious programs often have improved attitudes and can draw upon a support group when they leave prison

• Congregate services should be led by a person with proper credentials and should broadly appeal to all within a particular religion

Congregate Services (cont.)

• At a minimum, all inmates should have– Access to spiritual leaders– Regular opportunities for worship on a weekly

basis– Special holy days– Access to religious study materials– A religious diet accommodation

Religious Needs

• Religious Programming– Study groups and religious education classes fill

inmate’s time that might otherwise be idle– Development of individual talents should be one

objective of the religious program• Religious Diets and Holy Days– Inmates of many faiths may request special diets

mandated by their religion– Requests can generally be accommodated with

sufficient advanced notice to staff

Religious Needs (cont.)

• Religious Literature, Apparel, and Objects– Inmates should have access to religious literature

and should be allowed to wear religious clothing as long as it is consistent with the security of the institution

• Religious Counseling– Inmates may receive religious counseling from the

chaplain, community volunteer, or religious leader from the community

Religious Needs (cont.)

• Special Rites– Special rites are formal religious ceremonies such

as baptism, confession, or individual communion– Should be performed by the appropriate religious

leader with proper credentials

Religious Volunteers

• Corps of specially selected, trained, and supervised volunteers can greatly enhance the effectiveness of a chaplain

• Faith groups represented in the inmate population will provide pastors interested in working with inmates

• Volunteers need to understand they are not recruiting converts

Religious Volunteers (cont.)

• Chaplain should establish and maintain a good relationship with religious leaders from the community

• Volunteer should be given a manual with institutional policies

Unique Requests for Recognition or Accommodation

• Religious request review board should consider:– Whether requested accommodation is a basic

tenet of religion’s members– Whether the inmate meets the religion’s

requirements for this practice– Whether the inmate shows good faith in the

discussion of a solution and accommodation

Unique Requests for Recognition or Accommodation (cont.)

• Generally, it is best to rely on the classic definition of a religion when dealing with special requests for accommodations

• Of particular concern are religious “organizations” that put some inmates in a hierarchy position over others or espouse racial hatred

Conclusion

• Religious programs in correctional institutions should be tailored to the mission and resources of the institution

• The chaplain should look to the community for contract chaplains, volunteers, consultation, and support of the inmates’ individual faith development

Chapter 12

Intake, Discharge, Mail, and Documentation

Objectives

• Explain the critical nature of receiving and discharging offenders from jail or prison

• Identify some of the complexities associated with receiving and discharge operations at prisons and jails

• Differentiate between the various types of records maintained on arrestees and inmates

Intake

• Staff who work intake and booking should be mature, well-trained personnel skilled in interpersonal communication

• If not handled property, the admissions process can create undue humiliation and stress that can lead to disciplinary problems

Intake (cont.)• Goals of intake– Prevent contraband from entering institution– Gather the necessary information about the

offender– Orient the offender to the policies and procedures

of the institution– Assess the offender’s physical and mental health– Perform an accurate inventory of the offender’s

personal property– Perform personal cleanliness and minimize the risk

of infestation or infection

Intake (cont.)

• Search– Complete search should be conducted in a private

area by a member of the same sex– Prisoner should not be touched– Body cavity searches should be conducted by

medical personnel in a private area

• Gathering information– Staff should not ask questions related directly to

the inmates’ criminal charges

Intake (cont.)

• Orientation– All prisoners should be oriented to the basic rules

and regulations of the institution• Inventory– Intake begins with a complete inventory of the

offender’s personal property– Jewelry should be described by color– Clothing should be described thoroughly– Money counted in front of inmate– Prisoner should sign a property slip indicating

agreement with inventory

Intake (cont.)• Health and Psychological Screening– Basic questions about health condition, history,

and medications helps to assess the individual’s immediate health needs

– First 48 hours is when most suicides occur, giving great importance to initial psychological screening

– Most health screening forms include observations and questions

– All screening forms should give specific directions on what to do with critical yes and no answers

Intake (cont.)

• Showering and Dress– Changing from personal clothes to prison clothing

reduces the possibility of theft, gambling, bartering, and strong-arming

– During this process, intake and booking staff can search visually for rashes, cuts, abrasions, scars, tattoos, etc.

Release• It is of utmost importance that the releasing

officer verify the identity of the subject being released

• Reasons for release– Personal recognizance– Bail– Bond– Court order– Time served– Release to other law enforcement– Release documentation

Mail

• First amendment gives inmates the right to send and receive mail

• Prisons and jails can place restrictions as long as they further a substantial government interest

• Mail censorship must relate to security, order, rehabilitation, etc.

Mail (cont.)

• Legal Correspondence– Official correspondence should be inspected in

front of the inmate– Inmates have right to confidentiality with

attorneys and public officials

• Social Correspondence– Institutions often open personal correspondence

to search for contraband and remove money orders

Documentation

• Each institution should maintain accurate, up-to-date records on all inmates

• Courts are often not willing to interfere with prison operations unless there are clear constitutional violations

• Documentation provides administrators with data that can be used in making policy decisions, forecasting trends, performing staffing analyses, evaluating climate of the institution, projecting future budget needs

Documentation (cont.)• Mandatory records are:– Admission and release records– Medical records– Disciplinary records– Grievance records– Visitation records– Criminal justice records– Personal property records– Inspection records– Logs that reflect all activities within the institution

Conclusion

• Information-gathering phase provides institution with personal history of offender

• Prior to discharge, a wanted persons check should be performed to verify that the person being released is not wanted by another agency

• Inmates can send and receive mail, but institutions can place reasonable restrictions on that right