You applied and were accepted in an internship program of a state-level, Female Correctional Health Care Operation in the Southeastern United States and your primary responsibility is to work on the assigned projects related to the provision of inmate health care.
Case Study Associated Materials:
***Correctional Health Care Delivery: Unimpeded Access to Care
Section 2 and 4 are recommended for the main reference in working on this assignment.
Public Health Behind Bars
Sample Tool Control Policy
Inmate Sick Call Procedures-Corrections
Case Study Details: For the incarcerated population in the United States, health care is a constitutionally guaranteed right under the provisions of the eight amendments which is the prohibition against cruel and unusual punishment (see Estelle v. Gamble). This particular prison can hold in excess of 1,728 offenders and routinely houses between 1,600 and 1,700 women on any given day. This institution incarcerates all custody classes to include minimum security, medium security, close custody, death row, and pretrial detainees.
The health care operation provides the highest level of care for female offenders in the state. The health care facility is a 101 thousand square foot, 150 bed, three-story building that cost the taxpayers $50 million dollars to construct and is a hybrid of an ambulatory care center, long-term care center, and behavioral care center. The health care facility also houses an assisted living dorm.
The patient demographic includes women who have multiple co-morbidities including substance abuse, seriously persistent mental illnesses (SPMI), diabetes, cardiovascular disease, cancer, morbid obesity, HIV / AIDs, hepatitis, etc. On any given day there will also be 30 to 60 offenders who are pregnant, with 98% of those offenders having a history of substance abuse; all pregnant offenders are considered high-risk. The dental health of this patient population is exceptionally horrendous because of excessive drug abuse coupled with a sugary diet and poor oral hygiene practices. It is not uncommon for a 23-year-old to need all of her teeth extracted.
There are approximately 300 FTEs, including correctional staff, that operate the facility and provide care to the offender population. The healthcare facility is comprised of the following directorates: (a) Medical, (b) Nursing, (c) Behavioral Health, (d) Pharmacy, (e) Dental, (f) Medical Records, (g) Health Service Support, and (h) Operations and Security.
Although the health care facility has a vast amount of capability, there are limitations: (a) This facility does not have advanced cardiac life support capability (ACLS), (b) no surgical capability, (c) no ability to conduct telemetry, (d) no oral surgery beyond simple extractions, (e) no obstetrical capability beyond out-patient clinics, (f) MRI, (g) level 2 ultrasound, and the list goes on.
Those inmates with medical needs that cannot be addressed by the health services staff at the correctional facility will need appointments with external health care providers who have a business relationship with the prisons in this area. On any given month, there will be approximately 300 offenders who will go to outside medical appointments, and making certain that these appointments take place is where the challenge lies. Similar to many healthcare operations, the prison Utilization Review / Case Management Department facilitates all external appointments and forms the lynchpin between the correctional facility healthcare providers who refer offenders for specialty appointments and the outside organization providing that appointment.
Your assignment: You are the Case Coordinator. You have 300 patients that need to be scheduled for outside specialty appointments every month. You are tasked by the Administrator to develop a strategic plan for organizing the out-of-the-facility appointments without impairing internal services.
***Note: additional personal or financial resources are not available fortis case strategic plan. However, the question of the additional personnel or resources can be discussed in an Addendum. Specific justification must be presented and supported by evidence.
As the first step, develop a 500-800 word Memorandum addressing:
Provide an overview of Estelle v. Gamble and how that 1976 Supreme Court ruling pertains to the provision of inmate health care.
Examine the challenges of providing health care in a correctional environment.
What are the challenges of providing health care to a female offender population that may not exist in a male prison?
What framework would you apply to strategic planning? Why? (
Strategic planning frameworks)
Copyright 2020. Charles C Thomas Publisher, Ltd.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Chapter 4
SPECIAL HEALTH CONCERNS
OF INCARCERATED WOMEN
N
early everything written in this book about correctional health care applies to both women and men. Women tend to experience illness more
frequently than men and to be emotionally more vulnerable. They feel more
acutely the separation from family and children. They have special requirements. Yet, despite these differences, women are a largely ignored, almost
invisible minority in the correctional system. They often make do with environments, routines, policies, and programs that were designed for men. This
chapter aims to heighten awareness and sensitivity to special requirements
of the women.
WHO ARE THE INCARCERATED WOMEN?
Incarcerated women come largely from conditions of extreme poverty
and need. Often, their crimes were committed for economic reasons. Most
are persons of color. Few are well educated. A high percentage were heavy
substance abusers. A history of being sexually or physically abused is common, as is a history of unprotected sexual encounters with multiple and
high-risk partners. This history has indelibly scarred their psyche and is
often at the root of their medical and emotional problems.
Many are overweight. Few have had adequate access to good health care.
Some are pregnant and may have small children. They worry about who has
custody of their children and how they are faring. They feel the acute distress of separation, but are helpless to exercise any control whatsoever.
These factors have overwhelming relevance to their health care needs and
are described in detail in Braithwaite, Arriola, and Newkirk (2006).
87
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Correctional Health Care Delivery
Number of Incarcerated Women
As shown in Table 4-1, women constituted 6.3 percent of persons sentenced to more than one year in federal and state prisons in the United
States in 2000, rising to 7.3 percent in 2017. Their numbers climbed by 25.5
percent from 83,700 in 2000 to 105,033 in 2017 (an average increase of 1.3%
per year, compared to an annual average of only 0.4% for men). Total growth
peaked in 2010 and has declined since.
For jails, it is much the same. Women’s share in the total jail population
rose from 11.4 percent in 2000 to 15.3 percent in 2017, while their numbers
grew by 60.2 percent from 2000 to 2017 (averaging 2.8% per year), compared to a 14.8 percent increase in the number of men in the jails (averaging 0.8% per year) in that same period. The jail census peaked in 2008, but
for women has continued to rise.
Women constitute a small minority (10.0%) of the incarcerated population, but have disproportionately greater health care needs. The reasons are
myriad. Incarcerated women tend to carry all the health risks that accompany extreme poverty. In addition, they are usually of childbearing age and
many were pregnant at the time of incarceration and may also have small
Table 4-1
PERSONS IN LOCAL JAILS OR SENTENCED TO ONE YEAR OR
MORE IN STATE OR FEDERAL PRISONS, BY GENDER, 2000–2017
Prison (at year end)
Men
YEAR
Total
2000
2009
2010
2012
2014
2015
2016
2017
1,321,200
1,548,700
1,552,669
1,511,497
1,507,781
1,476,847
1,459,948
1,439,808
1,237,500
1,443,500
1,447,766
1,410,208
1,416,102
1,371,879
1,354,109
1,334,775
Women
% of Total
83,700 6.3%
105,200 6.8%
104,903 6.8%
101,289 6.7%
106,096 7.0%
104,968 7.1%
105,839 7.2%
105,033 7.3%
Total
Jail (at mid-year)*
Men
Women
% of Total
621,149
767,434
748,728
744,524
744,600
727,400
740,700
745,200
550,162
673,728
656,360
645,900
635,500
623,600
633,100
631,500
70,987 11.4%
93,706 12.2%
92,368 12.3%
98,600 13.2%
109,100 14.7%
103,800 14.3%
107,600 14.5%
113,700 15.3%
% Change
2000–2017
Avg. Annual
Total
9.0%
0.5%
Men
7.9%
0.4%
Women
25.5%
1.3%
Total
20.0%
1.08%
Men
14.8%
0.8%
Women
60.2%
2.8%
2016–2017
(1.4%)
(1.4%)
(0.8)%
(0.6)%
(0.3)%
5.7%
Sources: Guerino, Harrison, & Sabol (2011, 26); Minton and Zeng (2015, 3); Zeng (2018,
9); Carson (2018, 5); Zeng (2019, 5–6); Bronson and Carson (2019, 6).
Notes: * Jail data for 2015 and 2016 are estimated mid-year counts.
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Special Health Concerns of Incarcerated Women
89
children. As a group, women require more health care services than do men.
Serious mental illness, especially major depressive disorder, is diagnosed more
frequently in women—a disparity reflected also among the incarcerated.
The Plight of Incarcerated Women
Women are not the same as men. Yet, relevant gender differences are too
little respected or accommodated in correctional facilities in the United States.
As the National Institute of Corrections (NIC 1998) pointed out, often the
major difference between women’s prisons and male facilities is the style of
toilets. Their findings reflected a remarkable sameness:
• Policies on visitation and telephone use are mostly the same for male
and female units.
• In 80 percent of states, diets are the same for both. Differences in the
remaining 20 percent are usually accounted for by special diets for
pregnant women.
• Eighty percent of states have the same transportation system for both
genders, though some agencies require a female officer on the transport team when a woman is aboard.
• Roughly 80 percent have a single policy addressing pat searches.
Some require them to be performed by officers of the same sex when
possible.
• Only one-third have different policies regarding parenting programs.
As these findings suggest, equality came to mean that corrections should
provide the same programs and policies for women as for men. In other
words, “an inmate is an inmate, and gender makes no difference”—an absurd
denial of reality. Gender does matter. To cite an extreme case, one state even
began charging women for sanitary napkins on grounds that men were also
being charged for hygiene products (Morton, 2007, 6, 12). More commonly,
diet is the same for all. Thus, women are being exposed to menus high in
calorie count, carbohydrates, and sugars. The result, according to DeBell
(2001, 58), is that women sentenced to 18 months or longer reported gaining an average of 20 pounds during their sentences—a factor that can contribute to other health problems, including obesity, diabetes, hypertension,
bulimia, and anorexia nervosa.
Women also have a strong sense of “personal space” and a territorial
sense of personal property. They have stronger need for physical privacy
than men. Modesty is about respect, and often has cultural implications that
relate to an individual’s value and worth. Some gender-specific needs require
special and differential focus. These may revolve around a history of domes-
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90
Correctional Health Care Delivery
tic violence, early childhood physical and sexual abuse, or adult rape and
abuse. They may also be related to deep concerns about the welfare of young
children. Unfortunately, correctional facility design rarely reflects these realities or affords appropriate privacy and assured safety.
The American Correctional Association, in its public correctional policy
(ACA, 2012a) requires gender responsiveness so that “the physical, behavioral, social, and cultural differences between [men and women are] reflected in policies and practices” It further emphasizes the importance of family
ties and urges “gender-responsive conditions of confinement . . . [including]
proper nutrition, clothing, personal property, hygiene supplies, exercise, and
recreation/wellness programs.”
Women have been managed as the correctional system’s stepchildren,
often housed in out-of-the-way places, in mostly male facilities or in older
institutions known to be inadequate even before they were emptied of their
male residents to become women’s units. Correctional systems generally fail
to recognize women’s higher need for health care services. Providing only
the same per person resources as are provided in male prisons is an inadequate response. A secondary role for females may be reflective of society
itself, but is not acceptable.
During recent decades, correctional systems have seen the number of
incarcerated women grow faster than the number of males. Court-ordered
requirements for equalized distribution of resources by gender (both inside
and outside of correctional settings), enhanced role and visibility of women
staff members, and successful lawsuits have combined to increase the services provided to females. The legal basis for delivery of health care services
is identical for women and men, aside from the added necessity of maintaining gender equity. They also have a constitutional right to access to care,
to the care that is prescribed, and to a professional medical judgment.
INTAKE AND SCREENING ACTIVITIES
The obligation of correctional agencies to deliver health care services
begins at the moment of incarceration. As with men, screening at the point
of entry must identify serious medical needs requiring immediate treatment
and must protect the existing facility population and staff from introduction
of communicable disease. The intake process should include screening for
acute and chronic medical, dental, and mental health problems, suicidal
ideation, contagious disease, history of drug and alcohol use, history of traumatic brain injury, and history of being physically or sexually abused.
In addition, women need to be screened for pregnancy and for certain
sexually transmitted diseases. Inquiry regarding care for children left behind
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Special Health Concerns of Incarcerated Women
91
is also important. Depending on age and the expected duration of incarceration, women should be screened for menstrual difficulties, breast cancer,
and cervical cancer. The diagnostic process must be sensitive to gender and
cultural differences. ACA’s (2012b) public correctional policy says that persons who are incarcerated “have a legal right to adequate health care in accordance with generally recognized professional standards utilizing a comprehensive holistic approach that is sensitive to the cultural, age and gender
responsive needs.”
The National Commission on Correctional Health Care (NCCHC
2014a) states that “Correctional institutions need to provide intake examinations that include inter alia a breast exam and, depending on the female’s
age, sexual history, as well as past medical history, pelvic exam, Pap smear,
and baseline mammogram. . . . All women at risk for pregnancy should be
offered a pregnancy test within 48 hours of admission. Sexually active women
remain at risk for pregnancy until they go through menopause.”
Most women coming into jails and prisons are of childbearing age. Some
are pregnant (perhaps yet unaware) and will require prenatal services while
incarcerated. It is, therefore, important to identify pregnant women and plan
for their care. Many are “high risk pregnancies” because of drug use or other
concurrent health conditions. In juvenile facilities, adolescence poses an
additional factor contributing to high-risk status. These concerns are supported by the NCCHC (2018, P-F-05) and ACA (2003, ACI-4-4353) standards that require specific pregnancy management considerations, including
pregnancy testing, routine and high-risk prenatal care, management of
chemically addicted pregnant persons, and postpartum follow-up. Some jails
perform a pregnancy test on all women in the relevant age group who enter
their facility. Because, as Doctor Keamy (1998, 190–191) explains, there is a
period of approximately two weeks after conception before pregnancy will
be detected by a test, it makes sense to re-test, a few weeks after admission,
any woman who indicates at intake that she had intercourse during the week
or so prior to incarceration. Early detection of pregnancy enables prompt
commencement of prenatal care, and ensures that medications or immunizations and radiologic procedures contraindicated for pregnant women are
deferred and that a pregnant narcotics abuser can have early access to
methadone replacement therapy, at least for the duration of pregnancy.
COMMUNICABLE DISEASES
For additional detail on communicable diseases of both men and women,
the interested reader is referred to Chapters 4 and 5 of Faiver (2019).
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Correctional Health Care Delivery
Tuberculosis
Little is different about the care and prevention of tuberculosis (TB) for
women or men. The latest CDC recommendations regarding tuberculosis in
correctional settings can be found on the CDC website. A total of 376 cases
(4.2% of all TB cases) occurred in correctional facilities in 2014 (CDC,
2014a, Table 42).
TB screening, prevention, and treatment are widely recognized as important in correctional populations. Effective treatment, of course, requires
patient cooperation. Failure to adhere to the prescribed regimen can lead to
development of treatment-resistant forms of the disease. Several factors can
bear on the willingness of incarcerated women to cooperate. A woman is apt
to withhold cooperation unless she feels she is being treated with dignity and
respect, or if she fears that others will know she has TB when they see her
receiving treatment. Because of the stigma that many attach to this disease,
confidentiality and privacy are important.
It can also be frightening to have to endure the drastic procedures
employed in the case of active tuberculosis. Baucom et al. (2006, 198–199)
point out that some women feel embarrassment when trying to produce sputum for a TB diagnosis and that being confined in a negative-pressure isolation room can be embarrassing and stressful. “Incarceration and respiratory
isolation remove a vital source of support for women in crisis: other women.”
Because the patient feels overburdened, powerless, overwhelmed, isolated,
and intimidated, she may withdraw still further. Hence, health care providers must offer, with gentleness, sensitivity, and respect, and with utmost patience and understanding, the necessary education and reassurance throughout the treatment process. Though this approach will consume more time, it
leads to better outcomes.
Infectious disease experts (Ridzon and DeGroot, 2007, 4–5) are virtually unanimous in recommending directly observed therapy (DOT) for the
treatment and prevention of TB and they have good reasons for doing so, as
discussed in Faiver (2019, 88, 128–130). This advice should not go unheeded, but the advice of Greenspan (2001) that women often feel embarrassed,
stigmatized, and intimidated by the practice of DOT strongly suggests that
health practitioners at women’s institutions, in consultation with custody
staff, need to find feasible ways to minimize its undesirable aspects so that
effective treatment is not impaired. Education about the reasons for this
practice can help mitigate resistance.
One major objection—that the DOT process might reveal to others the
nature of the disease being treated, thus violating their privacy and confidentiality—is largely avoided in the practice commonly adopted in correctional settings with nurse-administered medications, whether at pill line in
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Special Health Concerns of Incarcerated Women
93
the housing units or at the medication window. Here, medications are administered by the nurse for every type of illness. To be avoided, to the extent
possible, are “pill lines” exclusively for AIDS patients, TB patients, hepatitis
patients, or mentally ill patients. To be truly DOT, however, the actual ingestion of the medications needs to be closely watched, and if this is done for
all patients with every medication being administered, there should be no
inadvertent compromise of confidentiality. The observation should be carried out in a supportive and professional manner, so as not to create unnecessary embarrassment. While there is room for debate about whether nurses or officers should perform the actual observation, it seems better, at least
in women’s facilities, to assign this function to the nurse while the officer
respectfully glances elsewhere.
DOT is the internationally recommended strategy promoted by the
World Health Organization (WHO, 1999, 13) since 1993 for treatment of
TB. It is a highly efficient and cost-effective way to ensure compliance with
the prescribed regimen and avoid development of drug-resistant strains,
while it also prevents diversion and overdose in correctional settings.
Sexually Transmitted Diseases (STD)
Certain sexually transmitted diseases may be acutely obvious and
require immediate care. Pelvic inflammatory disease (PID) is a common and
serious complication of diseases like chlamydia and gonorrhea. It can damage the reproductive organs and cause infertility, tubo-ovarian abscess, and
chronic pelvic pain. Symptoms range from none to severe, although the resulting internal damage can be serious. Prompt and appropriate diagnosis
and treatment of PID is essential. Keamy (1998, 202) cautions: “In many correctional settings, all but extremely mild cases of PID belong in a supervised
infirmary setting or hospital because of the high risk that follow-up will not
be timely or access rapid enough in case of clinical deterioration.”
Other STDs, such as syphilis, can run a more indolent course. Still others,
as gonorrhea or chlamydia, sometimes are present acutely and at other times
may be completely asymptomatic. The receiving facility should be prepared
to identify and initiate treatment for acute sexually transmitted diseases.
Nonacute conditions should be identified during the early days of incarceration but not necessarily at the point of entry. All women with symptomatic
episodes of vaginal discharge (symptoms include fever and pelvic or abdominal pain) and those who are immunologically compromised should be promptly evaluated. Women who have an STD should receive education and counseling on how to prevent re-infection and how to avoid spreading the disease.
Health care providers and correctional administrators can creatively utilize
the current period of incarceration to offer education on healthy lifestyles.
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Correctional Health Care Delivery
The Centers for Disease Control and Prevention (CDC, 2015a, 8–9)
states:
Multiple studies have demonstrated that persons entering correctional facilities have high rates of STDs (including HIV) and viral hepatitis, especially
those aged ≤35 years. . . . Although no comprehensive national guidelines
regarding STD care and management have been developed for correctional populations, growing evidence demonstrates the utility of expanded STD
screening and treatment services in correctional settings. . . . Universal
screening for chlamydia and gonorrhea in women ≤35 years entering juvenile and adult correctional facilities has been a long-standing recommendation.
For all STDs, the responsible physician should follow published CDC
guidelines and, in addition, institute specific screening guidelines depending
on risk factors, local prevalence, and recommendations of the state or local
health department. For example, CDC (2015a, 6) says that “routine screening for [chlamydia] on an annual basis is recommended for all sexually
active females aged
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