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Chapter 9
Health Care
Objectives
• Appreciate the legal basis for standards of
medical care within prisons
• Identify the similarities and differences
between community and correctional
medicine and be familiar with unique end of
life issues present in correctional
environments
• Explain the process of intake screening and
the importance and exceptions of
confidentiality
The Right to Health Care
• Estelle v. Gamble – “any attempt to withhold
or delay medical care constitutes cruel and
unusual punishment”
• Standard of competence is deliberate
indifference
• Standards of care in the community and
correctional environment change constantly
Initial Screening
• Upon arrival:
– Overall health status?
– Communicable disease risk factors?
– Obvious signs of mental illness?
– Medications?
– Physical examination for pre-existing conditions?
– Alcohol/drug abuse?
– Reasons to necessitate separate housing?
Initial Screening (cont.)
• Mental status and cooperation may reflect
stress, frustration, disappointment
• May feel insecure and/or be concerned for
his/her safety
• Plans for follow-up care should be made if
chronic conditions are present
• Initial screening interview may set the stage
for inmate’s cooperation with medical
personnel
Clinics and Sick Call
• Inmate should understand procedure for sick
call
• Some institutions have instituted nominal
inmate co-pay to prevent abuse
• Should have continuity and teamwork so that
the same staff care for the same inmates
• Some conditions can be improved through
patient education films, question and answer
sessions, and counseling
Confidentiality
• Medical record should be treated with same
confidentiality as in the community
• Can disclose medical information in limited
circumstances:
– Provision of healthcare to individual
– Health and safety of inmate
– Health and safety of staff
– Health and safety of those transporting inmate
Medical Emergencies
• Heart disease, stroke, peripheral vascular
emergencies are common
• Main function of staff in emergencies is:
– Rapidly respond to scene
– Stabilize the patient
– Transport inmate to appropriate facility
• Staff should be trained in CPR, advanced
cardiac life support, and advanced trauma life
support
Medical Emergencies (cont.)
• Transportation should be done on stretcher or
backboard
• Security should be a high priority to prevent
escape
• Incident report should be written as soon as
possible, including times, medication, and
procedures administered
Medication
• Prescription medication is commonplace
among inmates
• Cost is a major expense for correctional
facilities
• Good recordkeeping is essential
• Team approach with frequent monitoring is
best for pain medication
• Correctional personnel can be helpful with
observation of inmate activities
Medication (cont.)
• Alcohol and drug abuse are major issues prior to
incarceration and may continue to be problems
within the facility
• Need a comprehensive treatment approach
• Correctional staff can assist in preventing the
manufacture of “homemade” alcohol inside
institution
• Random urine monitoring program can also help
manage substance abuse within the institution
Infection Control
• Confinement lends itself to the spread of
infectious organisms
• Prior needle use predisposes inmates to
infectious diseases
• Incidence of HIV in prison populations is high
• All personnel should have access to disposable
gloves and CPR masks
Infection Control (cont.)
• Each institution should have a routine testing
policy for TB, hepatitis B, hepatitis C, and HIV
• Treatment of HIV is expensive, time
consuming, and complex
• Medical and correctional staff should have
yearly TB tests and should consider HIV tests
as well
Unique Medical Situation
• Use of Force
– May be necessary to subdue or restrain an inmate
who is a danger or threat
– Medical staff should be present if possible and
perform careful examination afterward
• Fights or Riots
– Need to have a plan to deal with disturbances and
practice plan at regular intervals
– Prior use of radio frequencies and transportation
of injured persons will be difficult under actual
circumstances
Unique Medical Situations (cont.)
• Hostage Situations
– Medical staff should prepare for their role in
emergency management, triage, and transport
• Hunger Strikes
– Inmate should be in locked cell with water turned
off
– Frequent exams, including drawing blood
electrolytes
– Add IV fluids if strike persists
Eldercare
• Aging inmate population is taking a toll on
correctional institutions
• More offenders are aging and dying in penal
institutions
• Older inmates require more medical attention,
need special diets, and eventually will need
geriatric services
End-of-Life Considerations
• In-custody deaths might be due to natural or
unnatural causes
• Death by unnatural causes should always
require an autopsy
• Site of death should be treated as a potential
crime scene
• Living wills should be properly drawn and
notarized as part of the inmate’s record
End-of-Life Considerations (cont.)
• Hospice care exists in some facilities using
trained inmates as volunteers
• Multiple professional staff are often involved
• Frank discussions should be held with families
of the terminally ill, including arrangements
for the body
• Some facilities allow for compassionate
release of those with terminal illness
Healthcare Professional as Correctional
Officer
• Communication among all professionals is
essential to ensure a safe and effective
workplace
• Avoid tension among staff members by
holding training sessions together
• All health care staff should be familiar with
the principles of security and custody
Conclusion
• Changes in sentencing laws have resulted in
an increase of prison populations
• Need for well-trained health care
professionals is great within the prison system
• Access to health care within a correctional
facility is a constitutional guarantee
Chapter 10
Mental Health
Objectives
• Outline issues inherent in the provision of
mental health care in the correctional setting
• Determine if inmate participation in mental
health care and treatment should be required
• Explore the right to privacy with regard to
mental health records
Introduction
• Inattention to mental health needs of inmates can
lead to management problems, negative publicity,
and litigation
• Deinstitutionalization of mental hospitals has greatly
decreased numbers of mentally ill in institutions
• However, those who do not properly manage their
medication may commit crimes when their behavior
deteriorates
• Data suggests that there are more mentally ill people
in prisons than in mental institutions
Guidelines and Standards
• Incarcerated individuals have rights of access
to and provision of health care
• Crucial issue is to avoid deliberate indifference
toward the mental health needs of the
incarcerated population
• Need adequate health facilities, a well-defined
program structure, understandable written
policy, and quality assurance program
Access to Care
• Ruiz v. Estelle established 6 issues for
minimally adequate standards:
– System to insure mental health screening
– Provision of treatment while inmates are in
segregation or special housing
– Training of mental health staff
– Accurate and confidential medical record system
– Suicide prevention program
– Monitoring for appropriate use of psychotropic
medication
Screening
• Initial screening should be done on an
individual basis by a provider trained in
detecting mental disorders and interviewing
techniques
• Providers must persist in obtaining necessary
information to adequately screen inmates
• Goal of screening is to identify quickly
emergency situations and inmates who might
require more extensive interventions
Treatment and Followup Care
• Variety of treatment settings:
– Outpatient
– Inpatient
– Transitional/Intermediate
• Some facilities use state mental health system
• Goal of transitional care is usually to stabilize
the inmate in a sheltered environment
Treatment and Followup Care (cont.)
• Goal of treatment is eventual integration into
the regular prison population and preparation
for release
• Discharge planning and followup care are
crucial
• Assessing dangerousness to self and others
must be reviewed before discharge
Crisis Intervention
• Short-term interventions to deal with acute
mental distress
• All staff should be familiar with suicide
prevention
• Suicide prevention program includes training
on signs and symptoms of potentially suicidal
inmates, availability of a safe environment for
housing, constant observation
Issues Arising from Confinement
• Stress of being incarcerated can add
symptoms of mental illness that may not have
existed at the initial screening
• Stressors include:
– Involvement in legal system
– Separation from existing community support
– Peer-generated problems
– Loss of control and decision making
• Ongoing assessment is crucial
Legal Requirements
• Hospitalization is voluntary unless an inmate is
a danger to himself or others
• Civil commitment for inmates is the same as
for nonprisoners
• Inmate must give informed consent to any
type of psychiatric treatment except
emergency treatment or treatment allowed
after involuntary commitment
Privacy
• Same expectation of confidentiality as in a
community health care setting
• Information should only be shared on a needto-know basis even among health care
professionals
• Internal policy should define members of the
health care team
• Inmates have the right to access their health
record unless doing so would be detrimental
Dual Roles of Staff
• Clinical staff may feel caught between their
roles as caretakers and as correctional workers
• Patients need to be advised that information
cannot be kept confidential if it affects the
security of the institution, potential harm to
inmate or others, or concerns serious damage
to property
Special Treatment Procedures
• Use of seclusion or restraint requires close
attention in correctional environment
• Review system is needed to ensure that
special procedures are only used as necessary
and that inmate’s psychological needs are
addressed
• Must be assessed to ensure that circulation
has not been compromised and that toileting,
meals, and repositioning are accomplished as
necessary
Medications
• Medication prescription is a high risk area in
correctional environment
• Should be kept to a minimum
• Sleep medication should be limited to acute
situations
• Medication compliance should be followed
closely
• Guard against polypharmacy
• Close attention to side effects
Mental Illness
• Antisocial personality disorder is diagnosed
based on historical information
• Criteria include pattern of disregard for
others, criminal behavior, lying, impulsive,
irresponsible, and aggressive behavior
• Malingering is a behavior that involves an
individual falsely claiming and consciously
faking symptoms of an illness
Integration of Mental Health and Medical
Care
• Success for care delivery of mental health is
related to adequacy of general medical
services available in a prison
• Significant number of psychiatric patients
have concurrent mental illnesses
Conclusion
• Few clinicians and other providers are trained
during their professional education to work in
correctional environments
• Provision of adequate care constantly
competes with maintaining adequate security
• Correctional environment may be one of the
last public strongholds for adequate care of
seriously mentally ill
Chapter 11
Religious Programming
Objectives
• Explore the role of prison chaplains and
understand the challenges of providing
religious programs in the correctional
environment
• Explain the major programs coordinated by
prison chaplains and the available resources
for religious programming
• Describe the general legal framework within
which prison religious programs operate
Historical Background
• Religion has played a role in American
corrections since the inception of
penitentiaries
• Earliest prison facilities were influenced by the
Quaker belief that time away from society
would change the hearts of offenders
• Forced solitude caused emotional distress and
mental illness for many early prisoners
Religious Accommodation and Freedom
Legislation
• First Amendment of Constitution – freedom of
religion
• Prison administrators can regulate religious practices
in order to protect the security of the institution
• Religious Freedom Restoration Act of 1993 –
governments were prevented from interfering with
individuals’ religious observances unless the
interference was the least restrictive means of
furthering a compelling government interest
Religious Accommodation and Freedom
Legislation (cont.)
• Religious Land Use and Institutionalized
Persons Act of 2000 – prohibited the
government from restricting prisoners’
religious worship opportunities unless the
government can demonstrate that the
restriction furthers a compelling government
interest
• Many corrections officials oppose these
legislative initiatives for fear of lawsuits
requesting religious accommodations
Religious Accommodation and Freedom
Legislation (cont.)
• In some states, inmate grievances have
increased
• All who work in a correctional environment
should understand the impact of these laws
• Cutter v. Wilkinson – inmates of small and
unfamiliar religious groups won their appeal
for the opportunity to meet for religious
worship
Professional Standards
• Professional standards require a balance
between provision of religious programs and
restriction of religious practices
• Staff accommodate religious practices as long
as the accommodation will not interfere with
safety, security, and orderly operation of the
institution
• All religious programs must be voluntary
Professional Standards (cont.)
• Religion should not be used as a tool for
manipulation, nor should inmates be
rewarded for participation
• Chaplains are responsible for working with
inmates of all faith groups
• Rely on expertise of community religious
leaders to complement the care and services
they can provide
Role of Chaplains
• Chaplain may serve as spiritual guide,
preacher, teacher, dietitian, counselor, and
advocate
• Religious impact in institution depends on the
unique pastoral manner in which the chaplain
helps inmates
• Gravest problem among religious service
providers is that they lose sight of their role as
correctional workers
Role of Chaplains (cont.)
• Complexity of the multi-faith correctional
environment requires a high level of
professionalism to ensure that inmates of all
faiths have the opportunity to benefit from
religious programs
• Integration of ministry and management is
essential because of added dimension and
challenges of ministry with an incarcerated
congregation
Religious Pluralism
• Chaplaincy corps should reflect accurately the
beliefs of the inmate population
• Religious issues outside of the chaplain’s
expertise should be referred to qualified
leaders in the community
• Contract chaplains can be used as spiritual
leaders for inmates whose beliefs differ from
those of the full-time chaplain
Congregate Services
• Meeting of several people to worship, study, or pray
should be provided unless specific security or safety
issues are presented
• Inmates who become involved in religious programs
often have improved attitudes and can draw upon a
support group when they leave prison
• Congregate services should be led by a person with
proper credentials and should broadly appeal to all
within a particular religion
Congregate Services (cont.)
• At a minimum, all inmates should have
– Access to spiritual leaders
– Regular opportunities for worship on a weekly
basis
– Special holy days
– Access to religious study materials
– A religious diet accommodation
Religious Needs
• Religious Programming
– Study groups and religious education classes fill
inmate’s time that might otherwise be idle
– Development of individual talents should be one
objective of the religious program
• Religious Diets and Holy Days
– Inmates of many faiths may request special diets
mandated by their religion
– Requests can generally be accommodated with
sufficient advanced notice to staff
Religious Needs (cont.)
• Religious Literature, Apparel, and Objects
– Inmates should have access to religious literature
and should be allowed to wear religious clothing
as long as it is consistent with the security of the
institution
• Religious Counseling
– Inmates may receive religious counseling from the
chaplain, community volunteer, or religious leader
from the community
Religious Needs (cont.)
• Special Rites
– Special rites are formal religious ceremonies such
as baptism, confession, or individual communion
– Should be performed by the appropriate religious
leader with proper credentials
Religious Volunteers
• Corps of specially selected, trained, and
supervised volunteers can greatly enhance the
effectiveness of a chaplain
• Faith groups represented in the inmate
population will provide pastors interested in
working with inmates
• Volunteers need to understand they are not
recruiting converts
Religious Volunteers (cont.)
• Chaplain should establish and maintain a good
relationship with religious leaders from the
community
• Volunteer should be given a manual with
institutional policies
Unique Requests for Recognition or
Accommodation
• Religious request review board should
consider:
– Whether requested accommodation is a basic
tenet of religion’s members
– Whether the inmate meets the religion’s
requirements for this practice
– Whether the inmate shows good faith in the
discussion of a solution and accommodation
Unique Requests for Recognition or
Accommodation (cont.)
• Generally, it is best to rely on the classic
definition of a religion when dealing with
special requests for accommodations
• Of particular concern are religious
“organizations” that put some inmates in a
hierarchy position over others or espouse
racial hatred
Conclusion
• Religious programs in correctional institutions
should be tailored to the mission and
resources of the institution
• The chaplain should look to the community
for contract chaplains, volunteers,
consultation, and support of the inmates’
individual faith development
Chapter 12
Intake, Discharge, Mail, and
Documentation
Objectives
• Explain the critical nature of receiving and
discharging offenders from jail or prison
• Identify some of the complexities associated
with receiving and discharge operations at
prisons and jails
• Differentiate between the various types of
records maintained on arrestees and inmates
Intake
• Staff who work intake and booking should be
mature, well-trained personnel skilled in
interpersonal communication
• If not handled property, the admissions
process can create undue humiliation and
stress that can lead to disciplinary problems
Intake (cont.)
• Goals of intake
– Prevent contraband from entering institution
– Gather the necessary information about the
offender
– Orient the offender to the policies and procedures
of the institution
– Assess the offender’s physical and mental health
– Perform an accurate inventory of the offender’s
personal property
– Perform personal cleanliness and minimize the risk
of infestation or infection
Intake (cont.)
• Search
– Complete search should be conducted in a private
area by a member of the same sex
– Prisoner should not be touched
– Body cavity searches should be conducted by
medical personnel in a private area
• Gathering information
– Staff should not ask questions related directly to
the inmates’ criminal charges
Intake (cont.)
• Orientation
– All prisoners should be oriented to the basic rules
and regulations of the institution
• Inventory
– Intake begins with a complete inventory of the
offender’s personal property
– Jewelry should be described by color
– Clothing should be described thoroughly
– Money counted in front of inmate
– Prisoner should sign a property slip indicating
agreement with inventory
Intake (cont.)
• Health and Psychological Screening
– Basic questions about health condition, history, and
medications helps to assess the individual’s
immediate health needs
– First 48 hours is when most suicides occur, giving
great importance to initial psychological screening
– Most health screening forms include observations
and questions
– All screening forms should give specific directions
on what to do with critical yes and no answers
Intake (cont.)
• Showering and Dress
– Changing from personal clothes to prison clothing
reduces the possibility of theft, gambling,
bartering, and strong-arming
– During this process, intake and booking staff can
search visually for rashes, cuts, abrasions, scars,
tattoos, etc.
Release
• It is of utmost importance that the releasing
officer verify the identity of the subject being
released
• Reasons for release
– Personal recognizance
– Bail
– Bond
– Court order
– Time served
– Release to other law enforcement
– Release documentation
Mail
• First amendment gives inmates the right to
send and receive mail
• Prisons and jails can place restrictions as long
as they further a substantial government
interest
• Mail censorship must relate to security, order,
rehabilitation, etc.
Mail (cont.)
• Legal Correspondence
– Official correspondence should be inspected in
front of the inmate
– Inmates have right to confidentiality with
attorneys and public officials
• Social Correspondence
– Institutions often open personal correspondence
to search for contraband and remove money
orders
Documentation
• Each institution should maintain accurate, up-to-date
records on all inmates
• Courts are often not willing to interfere with prison
operations unless there are clear constitutional
violations
• Documentation provides administrators with data
that can be used in making policy decisions,
forecasting trends, performing staffing analyses,
evaluating climate of the institution, projecting
future budget needs
Documentation (cont.)
• Mandatory records are:
– Admission and release records
– Medical records
– Disciplinary records
– Grievance records
– Visitation records
– Criminal justice records
– Personal property records
– Inspection records
– Logs that reflect all activities within the institution
Conclusion
• Information-gathering phase provides
institution with personal history of offender
• Prior to discharge, a wanted persons check
should be performed to verify that the person
being released is not wanted by another
agency
• Inmates can send and receive mail, but
institutions can place reasonable restrictions
on that right