Denise DeShields, MD Executive Medical Director Texas Tech University HSC 1.

1

CMHCCORRECTIONAL MANAGED HEALTH CARE

Denise DeShields, MDExecutive Medical DirectorTexas Tech University HSC

2

Patient Advocacy:Prison Healthcare and the Offender Patient

3

Vital Statistics

• No country incarcerates a higher percentage of it’s population than the United States.

• The U.S. incarceration rate is 716/100,000 population (according to the International Center for Prison Studies).

4

382389392395402407407417425438

460473487490

510527539

641649

716USASt. Kitts and NevisSeychellesVirgin Islands (U.S.)RwandaCubaRussiaAnguila (U.K.)GeorgiaVirgin Islands (U.K.)BelarusEl SalvadorBermuda (U.K.)AzerbaijanBelizeGrenadaAntigua and BarbudaPanamaSt. Vincent and the GrenadinesCayman Islands (U.K.)

Countries with the largest number of prisoners per 100,000 of the national population, as of 2013

5

India

Sweden

Denmark

Germany

France

Austria

Canada

China

Australia

Spain

Brazil

Russia

Rwanda

U.S.

0 100 200 300 400 500 600 700 800

30677379

9898

118121130

147274

475492

716

Imprisonment Rate Per 100,000 People

International Rates of Incarceration, 2012/2013

6

1925

1928

1932

1936

1940

1944

1948

1952

1956

1960

1964

1968

1972

1976

1980

1984

1988

1992

1996

2000

2004

2008

2012

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

U.S. State and Federal Prison Population , 1925-2012N

um

be

r

of

P

eo

pl

e

2012: 1,570,400

7

State & Federal Prison Population by Offense

53.0%16.8%

18.3%

10.6%

1.4%

Violent Drug Property Public Order

Other

State (2011)

50.6%

5.9%

12.1%

Immi-gration

15.3%

Weapons

9.6%Other

0.7%

5.9%

Drug Property Public Order Other

Violent

36.9%

Federal (2012)

8

1985 1990 1995 2000 2005 2010 20120

2

4

6

8

10

12B

illi

on

s o

f D

oll

ar

sState Expenditures on Corrections, 1985-2012

9

33.1%

36.5%

22.0%

8.4%

White: 500,604

Black: 551,154

Hispanic: 332,202

Other: 127,521

People in State and Federal Prisons, by Race and Ethnic-ity, 2012

10

United States Prison StatisticsIn 2012 there were 6,937,600 offenders under the supervision of the adult correctional system (i.e. parole, probation, or under the custody of state, federal prisons and local jails). Of that, 1,571,013 were incarcerated (22%).

In 2012 the states with the highest incarceration rates:

Louisiana (893/100,000)

Mississippi (717/100,000)

Oklahoma (684/100,000)

Texas (601/100,000)

In 2012 the states with the lowest incarceration rates:

Maine (145/100,000)

Minnesota (184/100,000)

Rhode Island(190/100,000)

11

12

13

Lifetime Likelihood of ImprisonmentAll Men: 1 in 9 White Men: 1 in 17 Black Men: 1 in 3 Latino Men: 1 in 6

All Women: 1 in 56 White Women: 1 in 111 Black Women: 1 in 18 Latina Women: 1 in 45

14

15

U.S. Offender Population Has Grown Every Year Between 1978-2009

The national imprisonment rate for males is 14x that of females.

16

171984 1992 2003 2005 2008 2012

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

34,000

69,845

127,677132,000

142,727

159,520

Number of People Serving Life Sentences, 1984-2012

18

Correctional Populations in the United States, 2012

In 2012 about 1 in every 35 adults in the United States or 2.9% of adult residents, was on probation or parole or incarcerated in prison or jail.

The decrease during 2012 was the fourth consecutive year of decline in the U.S. correctional population.

Although the correctional population declined by 0.7% during 2012, this was the slowest rate of decline observed since 2009.

More than half (56%) of the decrease in the U.S. correctional population during 2012 was attributed to a drop in California’s correctional population, a decline driven by the state’s Public Safety Realignment Act of 2011.

19

Total population under the supervision of adult correctional systems and annual percentage change, 2000-2012.

Note: See Methodology for information on the methods used to calculate annual change in the correctional population.

Sources: Bureau of Justice Statistics, Annual Probation Survey, Annual Parole Survey, Annual Survey of Jails, Census of Jails, and National Prisoner Statistics Program, 2000-2012.

Population (in millions)       Annual percent change

8                          2.5%

7                          2.0%

6                          1.5%

5                          1.0%

4                          0.5%

3                          0.0%

2                          -0.5%

1                          -1.0%

0                          -1.5%

  '00 '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12  

Annual percent change Population-

20

21

Texas Department of Criminal Justice

The mission of the Texas Department of Criminal Justice is to provide public safety, promote positive change in offender behavior, reintegrate offenders into society, and assist victims of crime.

22

TDCJ History• 1848 Texas Legislature passed an act establishing a State Penitentiary.

• The prison system began as a single institution in Huntsville. Over time, more prisons were built primarily in the historic cotton/slavery belt of Texas (Stephen F. Austin’s Colony).

• In 1921 George W. Dixon of The Prison Journal published a report on the Texas Prison System facilities stating that it was one of the most "brutal" in the world. He reported that “convicts” were subject to whippings, beatings, and isolation.

• Before 1972, there were 18 prisons, 16 for males, 2 for females with 25,000 offenders.

• In the 1980’s Texas embarked on a massive prison construction project. There are now 109 TDCJ Units, that incarcerate over 150,000 offenders.

• In 1989, The Texas Department of Criminal Justice was created absorbing the functions of The Texas Department of Corrections, The Texas Board of Pardons and Paroles, and the Texas Adult Probation Commissions.

23

TDCJ EmployeesOver 37,000 employees

Over 32,000 work in a confinement facility

Over 23,000 of those are Correctional Officers

Additionally, there are 3,900 contracted health care staff serving 114 facilities (109 TDCJ facilities, 5 private facilities)

24

25

Offender Population Trends in Texas

26

Census/CapacityTexas currently operates the largest prison system in the United States.

Capacity:

162,057

Operational Capacity:

155,575

Current Census:

151,273

Felony Misdemeanor Total

232,899

168,194

401,093

Community Supervision Population as of August 31, 2013

Total Adults On Direct, Indirect, and Pretrial Supervision

27

Census/Capacity – Cont’d

Series10

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

Offender Population as ofNovember 30, 2013

Prison 136,654

State Jail 11,024

Substance Abuse 3,595

Total Offender Population 151,273

28

Census Capacity

Capacity 162,057

Operating Capacity 155,575

Population 151,080

Percent of Capacity 93.34%

29

TDCJ FACTS

TDCJ manages offenders in 109 state and 5 privately operated facilities.

56% of offenders have a violent offense of record

Nearly 27,000 sex offenders

Average IQ score is 90.7

12,174 female offenders

Average Educational Achievement score 8.2

15,420 offenders are 55 years of age or older

275 offenders on death row

In fiscal Year 2013, 71,713 offenders received and 72,071 offenders released.

30

Average Age of Offenders - 11/30/13 Death Row Offenders - 12/17/13 (last update)

Average Age Prison Offenders 38 Total (includes bench warrants) 275Average Age State Jail Confinees 35 Percent Black 40.7%

Average Age SAFP Offenders 34 Percent White 29.1%

Age 55 and over total 15,420 Percent Hispanic 28.7%

Age 55 and over female 749 Female 9

Births in Custody - FY 13 Gang Affiliation - 11/30/13Total Offenders Who Gave Birth 185 Confirmed Gang Members 8,812

Suspected of Gang Association 1,968

Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

31

Medical Condition - 11/30/13AIDS 786HIV 1 1,455On Dialysis 228Requiring Hospice Care 19In Wheelchairs 2 434Hepatitis B 3 716Hepatitis C 3 17,416Outpatient Mental Health Caseload4 23,297Inpatient Mental Health Average Daily Census 1,911Mentally Ill (Prior MHMR contacts) 54,397Prior MHMR Contacts - Primary Diagnoses 18,506Developmentally Disabled – Avg. Daily Census 5 6981Does not include offenders with AIDS.2Numbers include offenders in ADS program and offenders temporarily using wheelchairs. 3Estimated numbers using the Hepatitis Surveillance Database as of 8/31/2013. 4Includes dual diagnosed Developmentally Disabled Program Offenders

5Developmentally Disabled was formally referred to as Mentally Retarded.

Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

32

Offense of Record - 11/30/13 Number Percent

Total* - Violent 84,089 55.6%

Total* - Property 23,810 15.7%

Total* - Drug 24,346 16.1%

Total* - Other 19,028 12.6%

*Total includes prison, State Jails and SAFPs.

Race - 11/30/13    

Total - Black 52,884 35.0%

Total - White 47,648 31.5%

Total - Hispanic 49,971 33.0%

Total - Other 770 0.5%

Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

33

Sentences and Time-Served - FY 13

Average Sentence - Prison Receives 7.7

Average Sentence - Prison On-Hand 19.3

Average Sentence - Prison Releases 7.9

Percent Served - Prison Releases 58.0%

Years Served - Prison Releases 4.3

Percent served is case based and cannot be calculated using aggregate totals.

Youthful Offenders - 11/30/13

Fourteen year-olds 0

Fifteen year-olds 0

Sixteen year-olds 5

Seventeen year-olds 67

Total Offenders Under Eighteen 72

Prison Offenders Only Under Eighteen 58

Texas Department of Criminal Justice Offender ProfileFY 2014 1st Quarter – November 2013

34

Recidivism

49.1% For prison offenders released in 1992

22.6% For prison offenders released in 2009

35

Fiscal Year 2013

Total TDCJ Budget $3.071 billion

Cost of Incarceration:

$18,314.64 offender/year

$50.04 offender/day

36

Fiscal Year 2013

TDCJ Health Care Budget

$429 million

Cost of Health Care

$9.26 offender/day

37

Fiscal Year 2012Health Care Costs Affected By Age

Offenders 55 years-old and older comprise 9.6% of the population but account for 39.1% of hospital costs in TDCJ

38

Fiscal Year 2012Health Care Costs Affected By Dialysis Average number of offenders requiring dialysis

at any given time in 2012 was 213 (0.14% of the offender population).

Dialysis accounts for 1.11% of the annual budget

This approx 8 fold increase in costs does not include hospitalizations and clinic services not directly related to dialysis that are also more frequent in this population.

39

Fiscal Year 2012Health Care Costs Affected By HIV

Approx 1.6% of offenders are HIV (+)

48.24% of the pharmacy budget was spent on antiretroviral medication.

40

Fiscal Year 2012Health Care Costs Affected By Mental Health

The second largest categorical pharmacy cost in 2012 was psychiatric medications.

6.31% of pharmacy budget is spent on psychoactive medication.

41

42

Prison Healthcare in Texas

43

Ruiz vs. Estelle(June 1972)

TDCJ inmate and prison reform activist David Ruiz leaving court in 1978 (with briefcase)Photo By Alan Pogue

44

Full Footnote: “PRISON SYSTEM.” The Handbook of Texas Online.http://www.tsha.utexas.edu/handbook/online/articles/view/PP/jjp3.html, accessed Tue Sep 7 15:01:51 US/Central 2004

Overcrowding – particularly the placement of two and even three inmates in cells designed for a single inmate

Inadequate security – claimed to be the result of too few guards, sometimes resulting in the handing over of supervision of whole sections of prisons to inmates (known as “building tenders”) who assisted guards

Inadequate healthcare – an insufficient number of professional medical personnel for the number of prisoners, the use of non-professional personnel to deliver professional medical care, and limited therapy for psychiatric patients

Unsafe working conditions – exposure of prisoners to unsafe conditions and lax enforcement of safety procedures

Severe and arbitrary disciplinary procedures

45

December 1992 – Judge Justice signed Final Judgment in Ruiz. With regard to health care and psychiatric services, the Final Judgment imposed a series of additional reporting requirements in the short term, and in the long term imposed the following mandates:

1) maintain NCCHC accreditation of all unit and regional health care

facilities;

2) Ensure that no prisoner is assigned to do work that is medically

contraindicated;

3) Ensure full access to health care for all prisoners;

4) Ensure that nonmedical staff cannot countermand medical orders; and

5) Maintain medical, dental, rehabilitation and psychiatric staffing and

facilities that enable timely delivery of health care to all prisoners,

consistent with contemporary professional standards for correctional

health care, vigorously recruit the required staff, and stay

competitive in the recruitment of staff.

TDCJ was not liberated from this Federal requirement until 2003!

(1972-2003)

46

“having custody of the prisoner’s body and control of the prisoner’s access to medical treatment, the prison authorities have a duty to provide needed medical attention”.

Ramsey v. Ciccone,. 310 F.Supp. 600 (W.D.Mo., 1970)

Constitutional Right to Health Care

47

As early as 1970, the US Supreme Court first recognized the need for health care for those in prison. Since then through a series of decisions including Estelle v. Gamble (1976), access to adequate medical care has been held to be a constitutional right for inmates in correctional facilities.

Constitutional Right to Health Care – Cont’d

48

The “intentional denial to a prisoner of needed medical treatment is cruel and unusual punishment and violates the Eighth (8th) Amendment to the United States.”.

Ramsey v. Ciccone,. 310 F.Supp. 600 (W.D.Mo., 1970)

Constitutional Right to Health Care – Cont’d

49

The courts have found a right to medical treatment for prisoners in the due process clause of the Fourteenth (14th) Amendment and held that “Under totality of the circumstances, adequate medical treatment must be administered when and where there is reason to believe it is needed.”Mills v. Oliver, 367 F.Supp. 77,79 (E.D.Va., 1973)

Fitzke v. Shappell, 468 F.2d 1072 (6th Cir. 1972).

Constitutional Right to Health Care – Cont’d

50

“We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the English (8th) Amendment.

U.S. Supreme Court in Estelle vs. Gamble, 429 U.S. 98, 97 S.Ct. 285 (1976)

Estelle vs. Gamble

51

Right to Access Care: Access to care must be provided for any condition be it medical, dental, or psychological, if the denial of care might result in pain, suffering, deterioration or degeneration.

Right to a Professional Judgment: A prisoner must receive appropriate attention required for the condition.

Right to Care that is Ordered: A constitutional violation is present when needed prescribed care is denied or delayed to an inmate.

Deliberate Indifference

52

Professional Judgment

Federal courts are reluctant to “second guess” the adequacy of treatment rendered except in egregious cases: “The medical attention rendered is so woefully

inadequate as to amount to no treatment at all.”

Westlake v. Lucas, 537 F2d 857, 860 n., 5 (6th Cir. 1976)

“Treatment so cursory as to amount to no treatment at all, may in the case of serious medical problems violate the Fourteenth Amendment.”

Tolbert v. Eyman, 437 F.2d 625, 626 (9th Cir. 1970).

53

54

55

Correctional Managed Health Care

Correctional managed health care (CMHC) was established by the Texas Legislature in 1993. Key provisions of the legislation included statutory requirements as follows: Establish the Managed Health Care Advisory Committee to TDCJ; Develop a managed health care plan for TDCJ inmates; Establish a managed care network of physicians and hospitals to serve

TDCJ inmates: Integrate, to the extent possible, Texas public medical schools into the

established managed care network; Initiate a competitive bidding process for contracts with other medical care

providers for services the public medical schools cannot provide; and Develop a managed health care plan that reduced the cost for state inmate

medical services.

56

A Strategic Partnership between:

The Texas Department of Criminal Justice

The University of Texas Medical Branch at Galveston

Texas Tech University Health Science Center

Focused upon a shared Mission:

To develop a statewide health care network that provides TDCJ offenders with timely access to quality health care while also controlling costs

What is Correctional Managed Health Care?

57

Main Duties of the CMHC

Establish offender Health Services Plan

Establish Policies and Procedures related to the provision of health care within TDCJ

Provide a forum to resolve any disputes between TDCJ and the university providers

58

Health Care and Medical Necessity

Health Care: Health related actions taken, both preventive and medically necessary, to provide for the physical and mental well-being of the offender populations.

Medically Necessary: Services, equipment or supplies furnished by a health care provider which are determined to be:

- Appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition; and

- Provide for diagnosis or direct care and treatment of the medical condition; and

- Within standards of good medical practice within the organized medical community; and

- Not primarily for the convenience of the TDCJ Offender Patient, the physician or another provider, or the TDCJ Offender Patient’s legal counsel; and

- The most appropriate provision or level of service which can safely be provided.

59

Classification of Levels of CareLevel I Medically Mandatory: Care that is essential to life and health and without which rapid deterioration is expected. The recommended treatment intervention is expected to make a significant difference or is very cost effective. Examples include: appendectomy, repair of deep wounds, burn treatment, heart attacks, treatment of severe head injury, and prenatal care. Examples of mental health services in this classification include: schizophrenia, other psychotic disorders, delirium, bipolar disorder, suicide risk, or any psychiatric condition requiring hospitalization.

Care at Level I is authorized and provided to all inmates.

Level II Medically Necessary: Care that is not immediately life threatening, but without which the patient could not be maintained without significant risk of serious deterioration or where there is a significant reduction in the possibility or repair later without treatment. Examples include: diabetes, asthma, hypertension, heart disease, treatable cancers, immunizations, and comfort care such as end stage care of terminal illness. Examples of mental health include: dementia, major depression, anxiety disorders, adjustment disorder, and severe personality disorder.

Care and treatment of conditions at Level II is provided to all inmates but evolving community standard and practice guidelines controls the extent of service.

Level III Medically Acceptable: Care for non-fatal conditions where treatment may improve the quality of life but will not in general affect the length of life. Examples include treatment of non-cancerous skin lesions, cataract removal, hip replacement, and routine hernia repair. Examples of mental health include: mental retardation, dysthymic disorder, and moderate personality disorder.

Level III conditions are considered on a case-by-case basis by a review process.

Level IV Limited Medical Value: These are treatments that may be valuable to certain individuals but are significantly less cost effective or produce no long-term gain. This category includes treatment of minor conditions where treatment merely speeds recovery or offers minimal reduction in symptoms or is for the convenience of the individual. Examples include tattoo removal, nasal reconstruction, cosmetic or plastic surgery and treatment of diseases that resolve on their own such as the common cold. Examples of mental health include: pedophilia, sleep disorder, and conduct disorder.

Treatment of Level IV conditions is not generally authorized; however, a review process may consider exceptional individual cases.

60

Our Mission

Manage the health care partnership and the overall delivery system in a constitutional manner that:

Insures Access to Care

Maintains Quality of Care

Manages the Cost of Care

Access

CostQuality

Correctional Health Care’s Balancing Act

61

CMHCC

Clinical PolicyOversight

Resource Allocation Legislative/Legal

Coordination Contract Coordination Liaison Activities Dispute Resolution Quality of Care

Monitoring Oversight

Roles and ResponsibilitiesUniversity Providers

Onsite Services Offsite Services

-Specialty Clinics -Hospitalization

Pharmacy Services Mental Health Services Utilization

Management Provider Network

Management Quality of Care

Monitoring TDCJ Employee

Health Services

TDCJ Health Services

Monitoring-Access to Care-Quality of Care

-Operational Reviews

-Grievances Public Health/Infection Control Health Services Liaison Professional Standards Administrative Functions

62

CMHCC Organizational Relationships

Governor Legislature

Correctional Managed Health Care Committee

CMHCCExecutive Director

UTMB Correctional Managed Care

TDCJ Health Services Division

TTUHSC Correctional Health Care

Committee includes five Members appointed as follows:

Two Physicians appointed by the Governor

A representative from TDCJ appointed by TDCJ Executive Director

A Physician from the University of Texas Medical Branch appointed by the President of the University.

A Physician from the Texas Tech Health Sciences Center appointed by the President of Health Sciences Center

63

Wichita Falls

Amarillo

Huntsville

Houston

Dalhart

Pampa

Childress

Bonham New Boston

Plainview

LubbockBrownfie

ld

Lamesa

Snyder

Colorado CityAbilene

El Paso

Fort Stockton

Raymondville

San Diego

Beeville

KenedyDilley

Hondo

San Antonio

LockhartKyle

Austin

Burnet

GatesvilleBrownwoo

d

Marlin

Bartlett

Navasota

Sugarland

RichmondRosharo

n Angleton

Brazoria

Cleveland

Livingston

Cuero

Midway

Lovelady

Diboll

Woodville

Jasper

Teague

Palestine

Rusk

Dallas

Venus

BridgeportBreckenridge

Jacksboro

Henderson

Overton

Winnsboro

Dayton

Cotulla

Tulia

Edinburg

TTUHSC Sector

UTMB Sector

Geographical Areas of Responsibility

64

Offender Population – Cont’d

Provider Census

UTMB 119,290

TTUHSC 30,805

PRIVATE 985

TOTAL: 151,080

65

Texas Department of Criminal Justice

Health Services Division

66

Health Services Mission

It is the mission of the Health Services Division to work with the Correctional Managed Health Care Committee and its contracting entities to ensure that quality health care is provided to incarcerated offenders in the custody of the Texas Department of Criminal Justice as well as monitor the delivery of all health care services.

67

Health Services Division

The TDCJ Health Services Division is divided into six clinical departments:

Health Services Liaison Office Health Services Monitoring Office of Mental Health Monitoring and Liaison Office of Professional Standards Office of Public Health Office of Special Monitoring

68

Health Services Liaison

Provide TDCJ Bureau of Classification and the Transportation Department with technical expertise regarding offenders with special medical and mental health needs.

Coordinate intra-system unit offender assignments

Inter-system transfers from counties admitting offenders to TDCJ

Assist TCOOMMI (Texas Correctional Office on Offenders with Medical or Mental Impairments) in coordinating continuity of medical/psychiatric care for offenders prior to their release from TDCJ

Monitor discharges from hospitals and infirmaries

69

Office of Health Services Monitoring

Perform Operational Review Audits to ensure compliance

- Accreditation Standards

- System Policies and Procedures

- Applicable State and Federal Law

Oversee Quality Improvement/Quality Monitoring Program

Perform Onsite Quality Assessments

70

Office of Mental Health Monitoring and Liaison

Provide the Agency with technical expertise regarding mental health to ensure access to quality mental health care.

Conduct operational reviews of mental health services.

Conduct mental health services quality of care audits.

Liaison with Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI) to improve continuity of mental health care.

71

The Office of Professional Standards

Patient Liaison Program

- Investigates and responds to medical concerns/complaints from third parties (Offender families, advocates, lawyers,

governmental officials, etc.)

- Operate a family hotline

- Public Awareness Corrections Today (PACT) Conference

Step Two Offender Medical Grievances

- Conducts an appellate process for medically-related grievances not resolved to the offender’s satisfaction at the Step One Level.

72

Offender Medical Grievance Program

The top five complaints registered with the Step II Offender Medical Grievance program were as follows:

1. Treatment Issues,

2. Staff Related Complaints,

3. Medication Issues, Access to Care Issues, and

4. Concerns about the legislatively mandated Annual Health Care Service Fee.

The top five complaints, not in order of priority, registered with the Patient Liaison Program in fiscal year 2013 were:

1. Treatment Issues,

2. Medication Issues,

3. Access to Care Issues,

4. Mental Health Issues, and

5. Medical Classification Issues.

In fiscal year 2013, Step II and Patient Liaison combined offender Medical Grievance Program investigated and responded to a total of 7,132 offender medical grievances.

73

Office of Public Health

Disease surveillance and reporting

Coordinate Infection Control Policy and provide consultation

TDCJ Employee Health

Peer Education related to Health Care

Safe Prisons Program (PREA)

74

Disease Surveillance

HIV Tuberculosis Syphilis and other STDs Hepatitis Staph Infections Isolation Outbreaks

- Norovirus

- Chicken Pox

- Scabies

- Mumps

Health Diseases

75

S.A.N.E.

Sexual Assault Nurse Examiner

Component of Safe Prisons Program

Purpose– Raise awareness and sensitivity to sexual assault– Train medical staff in proper chain of custody

collection and handling of physical examination evidence

– Audit quality of sexual assault examinations

76

Joint Committees

System Leadership Council

Policy and Procedure Committee

Infection Control Committee

Pharmacy and Therapeutics Committee

Morbidity and Mortality Committee

Peer Review

77

Health Services PhilosophyValues Toward Offenders

Believe all offenders are entitled to receive quality health care that is timely, appropriate, and consistent with policies and procedures.

Believe offenders are to be treated as patients and are to be provided access to treatment regardless of past behavior, race, color, gender, national origin, religious preference, or handicap.

Believe offenders should be provided educational opportunities to learn about wellness, self care, and disease prevention.

78

Health Services PhilosophyValues Toward Offenders (Cont’d)

Believe offenders should be housed in a safe and healthy environment.

Believe offenders should be given opportunities to achieve improved levels of mental and physical health.

Believe offenders are entitled to know about the condition of their health and that such information should be treated confidentially.

79

80

81

82

TTUHSC Correctional Managed Health Care

Mission: Provision of quality, comprehensive, cost efficient health care to 31,000 TDCJ offenders in West Texas.

TTUHSC Services: - 25 TDCJ facilities in 18 West Texas locations west of I-35

- (3) 17 bed infirmaries, Montford RMF

- Inpatient, outpatient, hospitalization, ER and Telemedicine Services via onsite and offsite

providers, Montford (WRMF) and contractual agreement with community hospitals.

- TTUHSC manages over 352 health care provider contracts for services to TDCJ offenders

- TTUHSC CMHC has 932 employees and over $100M budget

83

TTUHSC Telemedicine

Telemedicine is available at 15 TDCJ units. With shared access, telemedicine is

available to 92% of our offenders.

Telemedicine has been available in CMHC for nearly two decades. We conduct approximately 10,000 telehealth visits per year.

Advantages: - Instant access to offender patients

- enhance public safety

- convenience

-rural locations have enhanced access to specialty care

- reduces provider travel thereby increasing access to care

- feasible venue to conduct extender supervision in remote locations.

84

TTUHSC CMHC Mental Health Program

Services include psychology, psychiatry services and psycho- pharmaceuticals.

Services are provided on site at 23 TTUHSC affiliated TDCJ facilities in West Texas:

Inpatient providers at Montford cover outpatient mental health via 40 telepsych clinics per month.

TTUHSC Manages current mental health inpatient census of 970 offender patients, 550 at the Montford Psychiatric Hospital in Lubbock and 420 at the PAMIO (Program for Aggressive Mentally Ill Offenders) In Amarillo.

These 970 inpatient beds comprise nearly 50% of total TDCJ inpatient caseload.

85

Special Psychiatric ProgramsMontford In-patient Psych

Co-located with RMF, established in 1995

550 bed forensic inpatient unit Provides specialty social work psychology, and psychiatry

services in addition to inpatient services. Globally CMHC psych services manages over 6,300

mental health outpatient encounters/yr, 100 crisis management admissions/month and 825 telepsych eval/month

PAMIO: Program for Aggressive Mentally Ill Offenders - Clements Facility (Amarillo) PAMIO

(established in 1990). 208 bed capacity Innovative behavioral program offering structured Mental

Health Services to a unique sub set of offender patients whose mental illness is compounded by aggressive and assaultive behavior.

CMI Program: Clements Amarillo 234 beds, established in June 2013 Program for the chronically mentally ill Program designed to decompress inpatient beds across the state that were occupied by chronically

mentally ill offenders

86

Special Medical Programs

Montford Regional Medical Facility (RMF) – Lubbock, TX (est. 1995)

The most complex TDCJ medical unit in the State of Texas

50 ward beds, 4 step down ICU beds (with ventilator capacity), 44 LTC beds, 30 holding beds, onsite dialysis capacity for 48 patients.

(2) surgical suites

CT, ultrasound and MRI diagnostic capability

Physical, occupational and respiratory therapy

87

NO HOSTAGE WILL PASS THROUGH THIS GATENO WEAPONS BEYOND THIS POINT

88

0

100

200

300

400

500

Workforce Ethnicity - Females

Mexican Amer-ican: 0

White: 334

Hispanic: 97

Black: 41

Asian: 5

American Indian/Na-tive Ameri-can: 3

480

0

20

40

60

80

100

120

140

160

Workforce Ethnicity - Males

Mexican American: 1

White: 118

Hispanic: 16

Black: 8

Asian: 3

American Indian/Na-tive Ameri-can: 0

146

CMHC Workforce Racial Demographics

89

0 5 10 15 20 25 30 35 400

50

100

150

200

250

300 Years of Service

N u m b e r o f Y e a r s E m p l o y e d

Nu

mb

er

of

Em

plo

ye

es

TTUHSC CMHC Workforce Longevity

90

91

Proud To Be A CORRECTIONAL NURSE

Treatment Behind BarsIt Has it’s Pros & Cons!

92

The Correctional Nurse

We start our shift with the slamming of a gate; we enter a place where most would hateWe don’t call our patient’s sweetie or Hun, for this is prison, safety is 1st.We put up a wall that can’t be let down, for our private lives are hidden in this locked up little

town.Our patients have been convicted of murder and rape, yet we treat their medical needs, no

matter their case.The world of nursing doesn’t understand why we do what we do, but this is our choice, just as

your job suits you. We can’t have our children stop by and say “Hi”, or check our text messages for a replyWe must cut up our fruit and unwrap our candy, trust me things are not handy.We have met gangsters, some family and even freaks; we assess cuts, wounds piercings, and

leaks (haha)We get threatened and cussed out, even when doing our bestWe must visit some patients, while wearing a protective vest, but we are nurses and a Great

job we do.  I am so very proud of each one of you.You are amongst the few that can actually say, “You looked eye to eye with a killer and were

not afraid”We’ve grown used to inmates in cuffs and the smell of pepper spray; we’ve seen a thousand of

tattoosand piercings along the way.

WE are the family with experience high in wealth; we are nurses of Correctional Health   Happy Nurses Week 2012Jaye Escobar, RN

Nurse Manager -John Middleton Unit 

93

94

CMHC Challenges Offender Patients

Offender Manipulation

Scarce Clinical Resources

High Provider Turn Over & Vacancy

RatesRemote Location

Funding

Estelle vs. GambleRuiz vs. Estelle

Patient Liaison

Grievance System

Prisoner Advocacy Agencies

Education &

Correctional

Rehabilitation

HospiceTraining & Re-entry

Programs (TCOOMI)

Diversionary Programs

MRIS

Aging Prison

Population

Public Safety Workforce Diversity

Public SentimentPatient Privacy

Dying in Prison

96

0

2

4

6

8

10

12

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

9,37310,131

10,76111,565

12,34213,355

14,19815,661

Offender Population Age 55 and Older

97

TREATMENT PROGRAMS

The Rehabilitation Programs Division manages activities related to offender programs and is responsible for ensuring that all programs operate with consistent quality. The Windham School District was established by the Texas Legislature as an entity separate and distinct from the Texas Department of Criminal Justice and provides academic, as well as career and technology education, to eligible offenders incarcerated within the TDCJ.

The Texas Department of Criminal Justice and the Windham School District offer the following programs as well as many other volunteer led initiatives:

•Baby and Mother Bonding Initiative •COURAGE Program for Youthful Offenders•In-Prison Driving While Intoxicated Recovery Program•In-Prison Therapeutic Community•"Innerchange" Faith-Based Pre-Release Program•Post-Secondary Education Program (Academic & Vocational)•Pre-Release Substance Abuse Program•Pre-Release Therapeutic Community •Serious and Violent Offender Reentry Initiative•Sex Offender Education Program•Sex Offender Treatment Program •Substance Abuse Felony Punishment•Administrative Segregation Pre-Release Program•State Jail Substance Abuse Program

•Academic•CHANGES/Pre-Release •Cognitive Intervention •English as a Second Language•Literacy•Parenting•Perspectives and Solutions•Special Education•Vocational •Voyager Faith Based Pre-Release

98

DIVERSION PROGRAMS

The Texas Legislature has strengthened community supervision and parole by reducing caseloads, increasing availability of substance abuse treatment options, and providing sufficient funding to implement a progressive sanctions model.

Diversion programs available through local CSCDs and the TDCJ Parole Division include:

•Adult Education Programs•Batterers Intervention and Prevention Programs •Cognitive Programs•Court Residential Treatments Centers•Programs for the Mentally Impaired •Sex Offender Surveillance and treatment •Substance Abuse Treatment Facilities•Victim Services Programs•Vocational/Employment and Life Skills Training

•Community Opportunity Programs in Education•District Reentry Centers•Electronic Monitoring•Halfway Houses•Intermediate Sanction Facilities•Sex Offender Program•Special Needs Offender Program•Substance Abuse Counseling Program•Therapeutic Community Substance Abuse Aftercare

99

TCOOMMI Overview

• Mission Statement: To provide a formal structure of criminal justice, health and human service and other affected organizations to communicate and coordinate on policy, legislative, and programmatic issues affecting offenders with special needs (i.e., special needs include offenders with serious mental illnesses, intellectual disabilities, terminal or serious medical conditions, physical disabilities and those who are elderly).– One of three states with a statutorily mandated coordinating body for

offender with special needs.– The only state with continuity of care legislation.– One of a few state with targeted funds for juveniles and adult offenders

with special needs.– One of a few states with specialized juvenile and adult probation/parole

caseloads.– The most proactive state in regulatory, statutory, procedural and

programmatic practices for offenders with special needs.

100

TCOOMMI Overview – Cont’d

• Continuity of Care (Mental Health and Medical): A program designed to provide a responsive system for individuals discharging from TDCJ, local referrals from parole, jail, family and other related agencies. Components include, but are not limited to:– Liaison with community resources, community supervision

and parole offices, provide technical assistance to medical service providers caring for offenders and work with the Wrongfully Convicted Program.

– Screening and linkage to appropriate services, including medically appropriate residential plans.

– Federal entitlement application services– Jail screening– Court intervention

101

TCOOMMI Overview – Cont’d

• Adult Intensive Case Management: Clients must have a high criminogenic risk and high clinical need. Risk is determined by the criminal justice partners Risk Assessment. Services includes, but are not limited to:– Case Management– Rehabilitation/Psychological Services– Substance Abuse Treatment– Psychiatric Services/Medication Monitoring– Linkage to Hospice and Medical Services

102

TCOOMMI Overview – Cont’d

• Adult Transitional Case Management: A program that provides transitional mental health services to offenders with severe and persistent mental illness who have been served in Adult Intensive Case Management caseload, and require ongoing services to reduce risk of recidivism, reduce or stabilize symptoms while linking the offender to natural and/or alternative supports. Additionally, this program may be provided to offenders with a severe and persistent mental illness who present with very little risk of harm and a level of functioning that requires less intensive levels of care to maintain community tenure.

103

TCOOMMI Overview – Cont’d

 • Juvenile Case Management/Special Needs Diversionary

Program: A program that provides community-based mental health treatment and specialized supervision to juveniles (i.e., age 10-18) who have received deferred prosecution, juvenile court-ordered probation or who have been released under court ordered conditions of release and are being supervised in the community, and who have a serious emotional disturbance. The Special Needs Diversionary Program is administered in a collaborative model by the Texas Juvenile Justice Department (TJJD) and the Texas Correctional Office on Offenders with Medical and Mental Impairments (TCOOMMI).

104

TCOOMMI Overview – Cont’d

• HIV/AIDS Continuity of Care: A program designed to provide a responsive system for individuals with HIV/AIDS discharging from TDCJ with discharge planning (i.e., linkage to appropriate services), and post-discharge follow-up re ensure engagement in services.

105

TCOOMMI Overview – Cont’d

• Medically Recommended Intensive Supervision (MRIS): To provide early release from incarceration for offenders who suffer from mental illness or intellectual disabilities, or who are elderly, physically handicapped, terminally ill, or require long-term care, and who pose minimal public safety risk. This program provides immediate linkage to appropriate services, including medically appropriate residential plans.

106

107

Winston Churchill on Prisons

“The mood and temper of the public in regard to the treatment of crime

and criminals is one of the most unfailing tests of the civilisation of any

country. A calm and dispassionate recognition of the rights of the accused

against the state and even of convicted criminals against the state, a constant

heart-searching by all charged with the duty of punishment, a desire and

eagerness to rehabilitate in the world of industry of all those who have paid

their dues in the hard coinage of punishment, tireless efforts towards the

discovery of curative and regenerating processes and an unfaltering faith that

there is a treasure, if only you can find it in the heart of every person – these

are the symbols which in the treatment of crime and criminals mark and

measure the stored up strength of a nation, and are the sign and proof of the

living virtue in it.”

The Magistrate’s Blog (2005-2012)

108

U.S. Attorney General Eric Holder

“We need to ensure that incarceration is used to punish, deter and rehabilitate – not merely to convict, warehouse and forget,” Holder said in remarks to the American Bar Association in San Francisco. “Although incarceration has a role to play in our justice system, widespread incarceration at the federal, state and local levels is both ineffective and unsustainable. … It imposes a significant economic burden – totaling $80 billion in 2010 alone – and it comes with human and moral costs that are impossible to calculate.”

109

110

111

Questions?

TTUHSC

CMHC