July 13, 1998 98-R-0835
FROM: Lawrence K. Furbish, Assistant Director
RE: Department of Correction Health Services for Inmates
You asked for a description of how health services are provided to inmates now that the Department of Correction (DOC) has contracted with the University of Connecticut Health Center (UCHC) for those services. You also wanted background on the consent judgements that had been entered settling court lawsuits regarding health care for inmates.
Health and mental health services for inmates are provided by mostly the same staff and in much the same way that they were provided when DOC was responsible for inmate's health care. Under the agreement between DOC and UCHC, most of the DOC employees who worked to provided health care were transferred to the Health Center and have continued to do their jobs. This has also included those medical providers who were not state employees but operated under service contracts.
Several DOC medical employees remained in the department to monitor the Health Center's provision of care and compliance with the consent decrees.
Health care used to be provided to inmates without cost, but pursuant to PA 95-235, which required the DOC commissioner to adopt regulations assessing inmates for some of the costs of their incarceration, DOC charges a $3 copayment for each medical visit. This only applies to inmates who can afford the fee, and no inmate is denied medical care because he does not have the copay fee. PA 97-245 also mandated that when an inmate requiring hospitalization is insured the insurance carrier must either pay the hospital directly or pay the inmate who must then reimburse the hospital.
UCHC employs full-time physicians, nurses and other health personnel and also contracts out for a variety of medical personnel, including specialists. Ambulatory services are provided in all correctional facilities. Some have infirmaries that allow for lengthier stays by inmates. Offenders in need of hospital services are taken to the John Dempsey Hospital at UCHC. A utilization review process is used to assure that appropriate services are provided and inappropriate ones are not.
A number of consent decrees directly affect the provision of health care to inmates. Smith v. Meachum primarily addresses the treatment and housing of inmates infected with the human immunodeficiency virus (HIV). Doe v. Meachum addresses medical and mental health care services for HIV-infected inmates. West v. Manson concerns a variety of issues, including health care services at the state's prison for women (formerly Niantic, now York).
MEMORANDUM OF UNDERSTANDING
The shift of inmate health services from DOC to the UCHC has taken place in two phases. The first was a 1995 Memorandum of Understanding (MOU) between the two agencies concerning inpatient services. Before this, inmates requiring hospitalization had been placed in the community hospital located closest to the sending facility (prison or jail). Under the MOU, the Health Center undertook to accept all inmates requiring inpatient hospital care and treat them in a designated ward of the John Dempsey Hospital in Farmington. DOC agreed to provide the security personnel and the UCHC the treatment space and medical personnel.
In 1997 a second MOU was signed concerning all other health services. Under this agreement the UCHC agreed to take over responsibility for providing all health and mental health services to inmates. Approximately 650 state employee positions were transferred from DOC to the UCHC. DOC had provided the bulk of its health services through medical personnel who were state employees it hired directly, although it also had personal service contracts with approximately 50 private providers who were not state employees. According to Dr. Brett Rayford, head of Health Services for DOC, the health care union (1199) supported the plan and the transfer.
Rayford states that the UCHC inherited the DOC staff and proceeded with basically the same health delivery system as had existed before the transfer (some differences are noted below). Dr. Rayford and four other employees remained with DOC to monitor the contract and assure that the UCHC was providing the agreed upon services, both under the MOU and those required by the medical-care related consent decrees DOC is subject to. According to Rayford, DOC hopes that the UCHC would not only continue to provide all of the medical and mental health services that had been available for inmates under DOC, but, because of its significantly more sophisticated medical resources and technology, it would be able to provide a better and more intensive degree of care. A national commission on inmate health care standards has developed voluntary certification guidelines for correctional facilities and systems. Rayford hopes that the Health Center affiliation will allow Connecticut's inmate health care system to meet these standards.
The second MOU, which subsumed the first, has a two-year term and runs until June 30, 1999 when it can be renewed by agreement of the two parties. The cost of providing the medical care is approximately $48 million. DOC pays UCHC on a quarterly basis using a capitated rate. This means that the Health Center must provide the required services within the allocated budget, although in case of an unexpected emergency causing cost overruns, a deficiency budget appropriation can be requested. This was the same procedure that DOC followed when it operated the health care services itself.
Dr. Steven Strongwater, a vice president and professor at the UCHC is, among his other duties, ultimately in charge of UCHC's provision of inmate health care. Ken Parker has daily operational responsibilities for UCHC's inmate health care.
ORGANIZATION OF CURRENT SERVICES
Health Center staff provide comprehensive health and mental health care in ambulatory settings and in inpatient environments. Seven units manage the health care responsibilities: (1) clinical services, consisting of community health, utilization management, and physician services; (2) dental services; (3) forensic services, involving the monitoring and coordination of acute mental health needs and transfers; (4) mental health services; (5) nursing services; (6) pharmacy services; and (7) quality assurance, consisting of infectious disease monitoring, HIV counseling and testing services, and infection control.
Ambulatory health care is provided in all DOC correctional facilities. While staffing varies from facility to facility, it is primarily a "nurse-driven" system using registered nurses, licensed practical nurses, and in some cases advanced practice registered nurses (APRNs).
Nurses provide first aid services, dispense nonprescription medication, and act on the prescriptive orders of physicians, APRNs, and others with the legal ability to prescribe drugs. Generally, nurses provide health coverage in correctional facilities for about 12-16 hours per day. Some correctional facilities have infirmaries where overnight and lengthier stays are accommodated. Infirmaries have 24-hour nursing coverage.
LABORATORY AND PHARMACY SERVICES
DOC used to contract out for its laboratory services, but the UHCH has its own lab and now provides these services directly. DOC used to have its own in-house pharmacy with 12 pharmacists on staff. UCHC has chosen to absorb the 12 pharmacy employees and subcontract with a company called Pharmacy America (previously known as Capstone) for all pharmacy services.
DOC established and UCHC has continued a utilization review unit that regulates the access of inmates to health care services. Inmates are constitutionally entitled to health care, but this does not automatically mean that they receive any and all services they want. Rayford characterizes the guideline as a lower middle class community standard.
As an example of care that would not be provided, Rayford cited an inmate who wished to have a hernia operated on when (1) the hernia was not causing the inmate medical problems and (2) he was close to his release date.
CONSENT JUDGMENTS CONCERNING THE HEALTH CARE OF INMATES
Victoria Smith v. Larry Meachum
This August, 1989, consent judgment (Civil Action No. H-87-221, U.S. District Court, Connecticut) concerned present and future inmates who test positive for HIV and are confined on Hospital III at the Connecticut Correctional Institution at Somers (CCI-Somers). The action was originally filed in March, 1987, and challenged certain policies and practices of the defendant correction officials pertaining to the treatment and housing of inmates with HIV infection at CCI-Somers.
The consent judgment requires the DOC to adopt and implement a written comprehensive policy and procedure concerning the housing and treatment of inmates with HIV infection. Inmates cannot be segregated from the general population solely due to being HIV positive. Inmates may be segregated when required by their individual security or medical needs, as determined on a case-by-case basis. Inmates requiring inpatient care may be placed on Hospital III or any other medical facility when deemed appropriate by a physician. They must be returned to the general population or other appropriate housing when a physician determines medical care is no longer necessary.
In regard to medical care, DOC must provide adequate medical care to HIV-infected patients on Hospital III in conformity with community standards, and adequate physician staff must be maintained consistent with the needs of the patients as determined by the medical director.
The consent judgment also addresses the issues of a chronic care ward, visitation, laundry and cleaning services, ventilation, nutrition, religious services, counseling, continuing education, medical records review, reporting requirements, mental health, quality assurance, pre-release planning, and monitoring.
David Doe v. Larry Meachum
This consent judgment was entered into on November 3, 1990 (No. 88-562, U.S. District Court, Connecticut). The lawsuit was originally filed in 1988 and challenged certain DOC policies and practices concerning HIV education, counseling prior and subsequent to testing for HIV information, medical and mental health care provided to inmates infected with HIV, and confidentiality protections for inmates with HIV.
The consent judgment required DOC to establish infectious disease specialist services in or for each DOC complex to which particular inmates with HIV infection had to be referred for health care services. These specialist services must be provided by physicians who either are infectious disease specialists; infectious disease fellows; or board-certified in internal medicine, family practice, or preventive medicine with at least two years of experience in in- and outpatient management of persons with HIV.
The current judgment required the DOC commissioner to designate for each DOC facility the medical staff person responsible for ensuring compliance with the judgment's terms and to act as a liaison with the DOC director of health services.
The consent judgment requires a written comprehensive policy and procedure manual addressing health care treatment standards for inmates infected with HIV. It also specifies that within 12 hours of admission to a DOC facility from any place other than another DOC facility, each inmate must receive a health screening examination. The screening must be done in private by a correctional medical attendant, licensed nurse, nurse clinician, physician assistant, or physician. One aspect of the screening must be to determine whether the inmate has or may have HIV infection.
This lengthy and detailed judgment also addresses access to medical care for acute illnesses; drug therapies; health care records of HIV-infected inmates; prescription and administration of medications for HIV-infected inmates; emergency kits; diet for HIV-infected inmates; mental health care for such inmates; dental care; additional criteria for the care of HIV-infected women such as an annual PAP smear; discharge planning; housing of HIV-infected inmates (chronic care ward at CCI-Niantic for female HIV-infected inmates); staff education; quality assurance; and consent judgment monitoring.
Valerie West v. John Manson
This consent judgment (Civil Action H-83-366, U.S. District Court, Connecticut) was entered into on October 13, 1988. It resolves disputes and issues between the plaintiffs (present and future inmates at CCI-Niantic) and the defendants (officials of DOC and the Connecticut Department of Children and Families).
Medical Care. This consent judgment addresses a variety of issues. In terms of medical care, it requires the CCI-Niantic (CCIN) medical department to implement a computerized data base incorporating basic medical information on each inmate at CCIN. A routine history and general physical examination must be performed on each inmate by a physician, nurse clinician, physician assistant or, subject to approval by the mediation panel, a trained nurse within 48 hours for sentenced inmates and within 96 hours for pretrial detainees. If neither the initial screening exam nor a full physical examination suggests a potential medical condition requiring special housing, immediate placement in appropriate housing is acceptable. No one can be placed in general population housing until the physical examination is completed.
The judgment specifies that all inmates in CCIN must have an annual physical exam, including a breast exam, pelvic examination with a PAP test, rectal exam with blood check, and a basic review of health status, in addition to other tests the physician feels are appropriate. Vaccines must be available based on general federal Centers for Disease Control (CDC) recommendations.
Under the judgment, the medical department at CCIN had to implement the following within three months: (1) exams performed by CCIN doctors, nurses, medical personnel and outside consultants must be conducted in appropriate examining facilities; (2) on-site x-ray services must be provided for inmates (routine blood studies can be drawn on-site, but the actual laboratory performing the studies can be located outside CCIN); (3) a medical unit of at least 20 beds must be established at CCIN with full-time licensed nursing coverage and 24 hour on-call physician back-up; (4) other than simple over-the-counter medicine, medications can be administered only by medically-trained personnel; (5) no prescription medication can be administered without a physician's order; if a physician is not present in the medical unit, an RN may relay information to the physician by telephone concerning the inmate's condition; and (6) an inmate cannot be barred from receiving medication solely by reason of the inmate being unavailable to request or obtain the medication by a certain time.
HIV-Related Issues. The consent judgment specifies that HIV testing be made available to high-risk inmates upon admission to CCIN. Those who are positive must be offered appropriate counseling. An AIDS education program must be established for all inmates and staff. When an HIV-positive inmate develops a fever or other signs of infection, and the CCIN physician deems it appropriate, the inmate must be transferred to an outside hospital with facilities to treat AIDS-related disorders.
Pregnant Inmates. The judgment required the CCIN medical staff to implement a program for pregnant inmates within three months. This includes: (1) testing for pregnancy upon arrival to CCIN of inmates capable of child-bearing; (2) assigning pregnant inmates to bottom bunks; (3) nurse or physician approval before a pregnant woman or woman in post-partum period is placed in leg irons or other restraints; (4) assessment of the dietary needs of each pregnant inmate by the attending obstetrician; (5) availability of prenatal vitamins to pregnant inmates, as deemed appropriate by the attending obstetrician; (6) regular prenatal classes, regardless of the inmate's security status; (7) providing a pregnancy test as soon as reasonably possible to an inmate believing she is or may be pregnant; (8) the same rights to terminate a pregnancy that nonincarcerated women have; and (9) efforts to place pregnant inmates in their third trimester in rooms closest to the staff office in each housing unit unless the inmate requests otherwise.
Drug and Alcohol Treatment. The consent judgment includes a number of provisions on drug and alcohol treatment of inmates. CCIN admissions staff are directed to obtain a drug and alcohol history for each inmate. The staff must promptly refer to the medical unit the name of each inmate exhibiting signs of dependency or withdrawal and/or who requests treatment for withdrawal.
All inmates exhibiting signs of drug or alcohol dependency must be examined by a physician associate or appropriately trained nurse within 12 hours of admission to CCIN and by a physician as soon as appropriate but no later than 24 hours. This examination must include a physical exam. Each inmate with signs of drug or alcohol dependency must be interviewed by a qualified substance abuse professional. Inmates addicted to alcohol and in the withdrawal stage must also have medical withdrawal symptoms evaluated by a physician, physician associate, or nurse practitioner periodically, but at least once a day.
Detoxification of an inmate as determined by a physician must be done in the medical unit designated for inpatient services at CCIN. If beds are filled and places for detoxification unavailable, CCIN must increase the number of beds to meet inpatient demands.
The consent judgment outlines specific detoxification regimens for both nonpregnant and pregnant inmates, as well as general detoxification regimens. Before any detoxification regimen can begin, an inmate must give her informed consent. Before initiation of methadone treatment, an inmate must sign a consent form approved by the mediation panel.
CCIN's addiction services counselors must encourage inmates who have requested treatment services to be involved in community treatment programs upon discharge and make the appropriate referrals. Such treatment programs can include halfway houses, methadone maintenance, methadone-to-abstinence programs, outpatient drug-free programs, or residential inpatient programs. All inmates requiring detoxification or having a history of substance abuse, even if not in treatment at CCIN, must be encouraged to attend one or more counseling sessions regarding realistic plans for treatment after their discharge from CCIN.
In regard to staffing, a state licensed physician must be designated to direct the detoxification and treatment services. The physician must have experience or training in the diagnosis and treatment of substance dependent persons. A state licensed physician, similarly trained, must be on call and available to come to CCIN during all those hours when the physician is not physically present at CCIN. At lease one licensed nurse, with training in substance abuse care, must be on duty at all times in the medical unit. CCIN must also employ four addiction services counselors. The judgment also specifies various treatment methodologies for those with substance abuse problems.
Valerie West v. John Manson—Mental Health Services
An earlier consent judgment in this lawsuit (Civil No. H 83-366, April 22, 1987) addressed mental health services at CCIN. Basically, the delivery of mental health services must be interdisciplinary, based on an assessment of individual need, and delivered in concert with the security needs of individuals and the overall operation of the institution. The use of medication may be a necessary treatment method to stabilize an individual.
The consent judgment specifies that psychotropic medication must not be given, except in an emergency, to a CCIN inmate in the absence of documentation in the inmate's mental health record of: (1) a full mental health and medical history, (2) a recent physical exam, (3) a recent mental status evaluation, (4) a diagnosis, or a provisional diagnosis, (5) a treatment plan approved by a psychiatrist, (6) a record of the type of medication and dosage as prescribed by a psychiatrist, and (7) a record of all other medications being taken by the inmate.