Denise De Shields MD Executive Medical Director Texas

Denise De. Shields, MD Executive Medical Director Texas Tech University HSC CMHC CORRECTIONAL MANAGED HEALTH CARE 1

Patient Advocacy: Prison Healthcare and the Offender Patient 2

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). 3

Countries with the largest number of prisoners per 100, 000 of the national population, as of 2013 USA St. Kitts and Nevis Seychelles Virgin Islands (U. S. ) Rwanda Cuba Russia Anguila (U. K. ) Georgia Virgin Islands (U. K. ) Belarus El Salvador Bermuda (U. K. ) Azerbaijan Belize Grenada Antigua and Barbuda Panama St. Vincent and the Grenadines Cayman Islands (U. K. ) 716 649 641 539 527 510 490 487 473 460 438 425 417 407 402 395 392 389 382 4

International Rates of Incarceration, 716 U. S. Rwanda Russia Brazil Spain Australia China Canada Austria France Germany Denmark Sweden India 492 475 274 147 130 121 118 98 98 79 73 67 Imprisonment Rate Per 100, 000 People 30 0 200 400 600 800 5

U. S. State and Federal Prison Population , 1925 -2012: 1800000 Number 1600000 of People 1400000 1200000 1000000 800000 600000 400000 200000 1925 1928 1932 1936 1940 1944 1948 1952 1956 1960 1964 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012 0 6

State & Federal Prison Population by Offense State (2011) Federal (2012) 36. 9% 15. 3% Weapons 1. 4% 0. 7% 5. 9% 9. 6% Other 12. 1% Immigration 10. 6% 18. 3% 50. 6% 16. 8% 53. 0% 5. 9% Drug Public Order Violent Property Other Drug Public Order 7

State Expenditures on Corrections, 1985 -2012 60 53. 3 Billions of Dollars 50 51. 4 42. 3 40 36. 4 30 26. 1 20 16. 9 10 6. 7 0 1985 1990 1995 2000 2005 2010 2012 8

People in State and Federal Prisons, by Race and Ethnicity, 2012 8. 4% White: 500, 604 33. 1% 22. 0% Black: 551, 154 Hispanic: 332, 202 36. 5% Other: 127, 521 9

United States Prison Statistics In 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 Mississippi Oklahoma Texas (893/100, 000) (717/100, 000) (684/100, 000) (601/100, 000) § In 2012 the states with the lowest incarceration rates: Maine Minnesota Rhode Island (145/100, 000) (184/100, 000) (190/100, 000) 10

11

12

Lifetime Likelihood of Imprisonment All 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 13

14

U. S. Offender Population Has Grown Every Year Between 1978 -2009 § The national imprisonment rate for males is 14 x that of females. 15

16

Number of People Serving Life Sentences, 1984 -2012 159, 520 180, 000 160, 000 127, 677 140, 000 132, 000 142, 727 120, 000 100, 000 69, 845 80, 000 60, 000 34, 000 40, 000 20, 000 0 1984 1992 2003 2005 2008 2012 17

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. 18

Total population under the supervision of adult correctional systems and annual percentage change, 2000 -2012. Population (in millions) 8 Annual percent change Population- 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 Note: Annual percent change '01 '02 '03 '04 '05 '06 '07 '08 '09 '10 '11 '12 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 19 National Prisoner Statistics Program, 2000 -2012.

20

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. 21

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. 22

TDCJ Employees Over 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) 23

24

Offender Population Trends in Texas 25

Census/Capacity Texas currently operates the largest prison system in the United States. Capacity: 162, 057 Community Supervision Population as of August 31, 2013 Total Adults On Direct, Indirect, and Pretrial Supervision 401, 093 Operational Capacity: 155, 575 232, 899 Current Census: 168, 194 151, 273 Felony Misdemeanor Total 26

Census/Capacity – Cont’d Offender Population as of November 30, 2013 160, 000 140, 000 Prison 136, 654 120, 000 100, 000 State Jail 11, 024 80, 000 60, 000 Substance Abuse 3, 595 40, 000 20, 000 0 Total Offender Population 151, 273 27

Census Capacity 162, 057 Operating Capacity 155, 575 Population 151, 080 Percent of Capacity 93. 34% 28

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, 713 offenders received and 72, 071 offenders released. 29

Texas Department of Criminal Justice Offender Profile FY 2014 1 st Quarter – November 2013 Average Age of Offenders - 11/30/13 Death Row Offenders - 12/17/13 (last update) Average Age Prison Offenders Average Age State Jail Confinees 38 Total (includes bench warrants) 35 Percent Black 40. 7% Average Age SAFP Offenders 34 Percent White 29. 1% Percent Hispanic 28. 7% Age 55 and over total Age 55 and over female 15, 420 749 Births in Custody - FY 13 Total Offenders Who Gave Birth 275 Female 9 Gang Affiliation - 11/30/13 185 Confirmed Gang Members 8, 812 Suspected of Gang Association 1, 968 30

Texas Department of Criminal Justice Offender Profile FY 2014 1 st Quarter – November 2013 Medical Condition - 11/30/13 AIDS 786 HIV 1 1, 455 On Dialysis 228 Requiring Hospice Care 19 In Wheelchairs 2 434 Hepatitis B 3 716 Hepatitis C 3 17, 416 Outpatient Mental Health Caseload 4 23, 297 Inpatient Mental Health Average Daily Census 1, 911 Mentally Ill (Prior MHMR contacts) 54, 397 Prior MHMR Contacts - Primary Diagnoses 18, 506 Developmentally Disabled – Avg. Daily Census 5 698 1 Does not include offenders with AIDS. 2 Numbers include offenders in ADS program and offenders temporarily using wheelchairs. 3 Estimated numbers using the Hepatitis Surveillance Database as of 8/31/2013. 4 Includes dual diagnosed Developmentally Disabled Program Offenders 5 Developmentally Disabled was formally referred to as Mentally Retarded. 31

Texas Department of Criminal Justice Offender Profile FY 2014 1 st Quarter – November 2013 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 - Black 52, 884 35. 0% Total - White 47, 648 31. 5% Total - Hispanic 49, 971 33. 0% 770 0. 5% 32 *Total includes prison, State Jails and SAFPs. Race - 11/30/13 Total - Other

Texas Department of Criminal Justice Offender Profile FY 2014 1 st Quarter – November 2013 Sentences and Time-Served - FY 13 Average Sentence - Prison Receives Average Sentence - Prison On-Hand 7. 7 19. 3 Average Sentence - Prison Releases Percent Served - Prison Releases Years Served - Prison Releases 7. 9 58. 0% 4. 3 Percent served is case based and cannot be calculated using aggregate totals. Youthful Offenders - 11/30/13 Fourteen year-olds Fifteen year-olds Sixteen year-olds Seventeen year-olds Total Offenders Under Eighteen Prison Offenders Only Under Eighteen 33 0 0 5 67 72 58

Recidivism 49. 1% For prison offenders released in 1992 22. 6% For prison offenders released in 2009 34

Fiscal Year 2013 Total TDCJ Budget $3. 071 billion Cost of Incarceration: $18, 314. 64 offender/year $50. 04 offender/day 35

Fiscal Year 2013 TDCJ Health Care Budget $429 million Cost of Health Care $9. 26 offender/day 36

Fiscal Year 2012 Health 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 37

Fiscal Year 2012 Health 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. 38

Fiscal Year 2012 Health Care Costs Affected By HIV Approx 1. 6% of offenders are HIV (+) 48. 24% of the pharmacy budget was spent on antiretroviral medication. 39

Fiscal Year 2012 Health 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. 40

41

Prison Healthcare in Texas 42

Ruiz vs. Estelle (June 1972) TDCJ inmate and prison reform activist David Ruiz leaving court in 1978 (with briefcase) Photo By Alan Pogue 43

§ 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 Full Footnote: “PRISON SYSTEM. ” The Handbook of Texas Online. http: //www. tsha. utexas. edu/handbook/online/articles/view/PP/jjp 3. html, accessed Tue Sep 7 15: 01: 51 US/Central 2004 44

§ 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) 45

Constitutional Right to Health Care “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) 46

Constitutional Right to Health Care – Cont’d 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. 47

Constitutional Right to Health Care – Cont’d The “intentional denial to a prisoner of needed medical treatment is cruel and unusual punishment and violates the Eighth (8 th) Amendment to the United States. ”. Ramsey v. Ciccone, . 310 F. Supp. 600 (W. D. Mo. , 1970) 48

Constitutional Right to Health Care – Cont’d The courts have found a right to medical treatment for prisoners in the due process clause of the Fourteenth (14 th) 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. 2 d 1072 (6 th Cir. 1972). 49

Estelle vs. Gamble “We therefore conclude that deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the English (8 th) Amendment. U. S. Supreme Court in Estelle vs. Gamble, 429 U. S. 98, 97 S. Ct. 285 (1976) 50

Deliberate Indifference § 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. 51

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 F 2 d 857, 860 n. , 5 (6 th 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. 2 d 625, 626 (9 th Cir. 1970). 52

53

54

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. 55

What is Correctional Managed Health Care? 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 56

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 57

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. 58

Classification of Levels of Care Level I Medically Mandatory: Care that is essential to life Level III Medically Acceptable: Care for non-fatal 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. 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 caseby-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. 59

Our Mission Manage the health care partnership and the overall delivery system in a constitutional manner that: § Insures Access to Care Access § Maintains Quality of Care § Manages the Cost of Care Quality Cost Correctional Health Care’s Balancing Act 60

Roles and Responsibilities CMHCC § Clinical Policy Oversight § Resource Allocation § Legislative/Legal Coordination § Contract Coordination § Liaison Activities § Dispute Resolution § Quality of Care Monitoring Oversight University 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 61

CMHCC Organizational Relationships 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 TDCJ Health Services Division Governor Legislature Correctional Managed Health Care Committee CMHCC Executive Director UTMB Correctional Managed Care TTUHSC Correctional Health Care 62

Geographical Areas of Responsibility Dalhart Pampa Amarillo Tulia TTUHSC Sector Plainview Lubbock Childress Brownfield Wichita Falls Jacksbor o Breckenridge Lamesa Bonham Snyder Colorado City Winnsboro Dallas Abilene Venus El Paso New Boston Bridgeport Gatesville Brownwood Marlin Fort Stockton Bartlett Burnet Austi n UTMB Sector Diboll Midway Jasper Lovelady Livingston Woodville Huntsville Cleveland Dayton Navasota Housto n Lockhart Sugarland Kyle San Antonio Richmond Rosharon Hondo Cuero Kenedy Dilley Overton Palestine Henderson Teague Rusk Angleton Brazoria Beeville Cotulla San Diego Raymondville Edinburg 63

Offender Population – Cont’d Provider Census UTMB 119, 290 TTUHSC 30, 805 PRIVATE 985 TOTAL: 151, 080 64

Texas Department of Criminal Justice Health Services Division 65

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. 66

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 67

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 68

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 69

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. 70

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. 71

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. 2. 3. 4. 5. Treatment Issues, Medication Issues, Access to Care Issues, Mental Health Issues, and 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. 72

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) 73

Disease Surveillance § § § HIV Tuberculosis Syphilis and other STDs Hepatitis Staph Infections Isolation Outbreaks - Norovirus - Chicken Pox - Scabies - Mumps Health Diseases 74

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 75

Joint Committees § System Leadership Council § Policy and Procedure Committee § Infection Control Committee § Pharmacy and Therapeutics Committee § Morbidity and Mortality Committee § Peer Review 76

Health Services Philosophy Values 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. 77

Health Services Philosophy Values 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. 78

79

80

81

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 $100 M budget 82

TTUHSC 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 . 83

TTUHSC CMHC Mental Health Program § Services include psychology, psychiatry services and psychopharmaceuticals. § 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. 84

Special Psychiatric Programs Montford 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 85

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 86

NO WEAPONS BEYOND THIS POINT NO HOSTAGE WILL PASS THROUGH THIS GATE 87

CMHC Workforce Racial Demographics Workforce Ethnicity - Females Workforce Ethnicity - Males Mexican American: 1 Mexican American: 0 160 500 White: 334 White: 118 140 400 120 Hispanic: 16 Hispanic: 97 100 300 480 146 Black: 41 200 100 80 Black: 8 60 Asian: 5 40 Asian: 3 20 0 American Indian/Native American: 3 0 American Indian/Native American: 0 88

TTUHSC CMHC Workforce Longevity Years of Service 350 Number of Employees 300 250 200 150 100 50 0 -10 0 -50 10 20 30 40 50 Number of Years Employed 89

90

Proud CORREC To Be A TIONAL NURSE Treatm It Has ent Behin d Bars it’s P ros & Cons! 91

The Correctional Nurse We start our shift with the slamming of a gate; we enter a place where most would hate We don’t call our patient’s sweetie or Hun, for this is prison, safety is 1 st. 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 reply We 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 best We 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 tattoos and piercings along the way. WE are the family with experience high in wealth; we are nurses of Correctional Health Happy Nurses Week 2012 Jaye Escobar, RN Nurse Manager -John Middleton Unit 92

93

94

CMHC Challenges Offender Patients Dying in Prison Public Sentim ent Public Safety Aging Prison Population High Provider Turn Over & Vacancy Rates Scarce Clinical Resources MRIS Patient Privacy Workfor ce Diversity Funding Remote Location Offender Manipulation y Training & Re-entr I) Programs (TCOOM Diversionary Programs Patient Liaison Grievance System Ruiz vs. Estelle Hos pice Education & Correctional Rehabilitation Priso Advo ner c Agen acy cies Estelle vs. Gamble 95

Offender Population Age 55 and Older 1. 2 18, 000 15, 661 1 0. 8 9, 373 10, 131 10, 761 11, 565 12, 342 13, 355 14, 198 14, 000 12, 000 10, 000 0. 6 8, 000 0. 4 6, 000 4, 000 0. 2 0 16, 000 2, 000 Aug . 20 Aug 06 . 20 Aug 07 . 20 Aug 08 . 20 Aug 09 . 20 Aug 10 . 20 Aug 11 . 20 Aug 12 0. 20 13 96

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 97

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 98

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. 99

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 100

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 101

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. 102

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). 103

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 followup re ensure engagement in services. 104

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. 105

106

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) 107

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. ” 108

109

110

Questions? T T U H S C C M H C 111