Addressing the Needs of Elderly,

Chronically Ill, and Terminally Ill Inmates

2004 Edition

C o rrectional

Heal t h Care

DEPARTMENT OF JUSTICE

NATIONAL INSTITUTE OF CORRECTIONS

U.S. Department of Justice

National Institute of Corrections
U.S. Department of Justice

National Institute of Corrections

320 First Street, NW

Washington, DC 20534

Morris L. Thigpen

Director

Larry Solomon

Deputy Director

Susan M. Hunter

Chief, Prisons Division

Madeline Ortiz

Project Manager

National Institute of Corrections

World Wide Web Site

http://www.nicic.org
CORRECTIONAL HEALTH CARE

Addressing the Needs of Elderly,

Chronically Ill, and Terminally Ill Inmates 

B. Jaye Anno, Ph.D., C.C.H.P.–A.

Camelia Graham, M.S.P.H.

James E. Lawrence, M.A.

Ronald Shansky, M.D., M.P.H.

Judy Bisbee, B.A., Project Manager

John Blackmore, M.A., Project Director

February 2004

NIC Accession No. 018735
Criminal Justice Institute, Inc.

213 Court Street, Suite 606

Middletown, CT

http://www.cji-inc.com

This document was prepared under cooperative agreement number 16–603 from the National Institute of Corrections,

U.S. Department of Justice.

Points of view or opinions stated in this document are those of the authors and do not necessarily represent the official

position or policies of the U.S. Department of Justice.
iii

FOREWORD

As the median age of inmates in our jails and prisons

steadily increases and the incidence of chronic illness

and disabilities grows ever larger, the issue of how

best to manage services and care for older inmates

and those with chronic and terminal illnesses

becomes more prominent.

The National Institute of Corrections (NIC) recognizes that correctional practitioners and correctional

health care providers are seeking comprehensive

and useful knowledge about current, innovative,

effective, and economical practices that address the

special needs of these populations.

NIC commissioned this publication to guide prison

administrators in managing aging and infirm inmates.

This report reviews the most recent relevant literature, provides examples of promising approaches

from six states, and clarifies how the nation’s correctional agencies are meeting the operational, programmatic, and health care challenges associated

with meeting these inmates’ needs.

This report is exploratory in nature. It is not intended to provide absolute answers or a single comprehensive model that all corrections agencies might

follow. Rather, it respects the different laws and traditions that govern state and territorial corrections

and attempts to provide examples and guidance

from corrections systems that have addressed these

issues successfully. It is up to individual correctional

administrators and medical practitioners to consider

these examples and to determine what best works

for them.

As this is a work in progress, we at NIC would

appreciate and welcome the input of corrections

practitioners who are facing similar challenges.We

will endeavor to incorporate your ideas and suggestions in future work in this area.

Morris L.Thigpen

Director

National Institute of Corrections

v

ACKNOWLEDGMENTS

The Criminal Justice Institute would like to acknowledge the leadership of the National Institute of

Corrections (NIC), which provided the foundation

and support for this project.We are particularly

grateful to Susan Hunter, Chief of NIC’s Prisons

Division, for conceiving this project, and to Madeline

Ortiz, Program Manager, whose interest and input

enabled us to carry it out.

Many individuals contributed to this project.We give

special recognition and thanks to our expert consultants, Dr. B. Jaye Anno, Dr. Ronald Shansky, James

E. Lawrence, and Camelia Graham, for their guidance, expertise, involvement, and dedication to our

efforts.They are substantially responsible for conducting the research and producing the text that follows.

Special thanks to the following six Departments of

Corrections that allowed us to visit their prisons:

Michigan Department of Corrections, Minnesota

Department of Corrections, New York State

Department of Correctional Services, Ohio

Department of Rehabilitation and Correction,

Oregon Department of Corrections, and Pennsylvania Department of Corrections.Thanks also

to the individuals who facilitated the six site visits,

including Twyla Snow (Michigan Department of

Corrections), Nanette Schroeder (Minnesota Department of Corrections), Joan Smith (New York

State Department of Correctional Services), Kay

Northrup (Ohio Department of Rehabilitation and

Correction), Dr. Steve Shelton (Oregon Department

of Corrections), and Superintendent Frederick

Rosemeyer (Pennsylvania Department of

Corrections).

We would also like to acknowledge Judy Bisbee and

John Blackmore of the Criminal Justice Institute for

their diligent efforts in supporting the work of the

project team.

George and Camille Camp, Co-Principals

Criminal Justice Institute

February 2004

During the past decade, the number of elderly and

infirm inmates in state prison systems has increased

dramatically.The aging of U.S. prison populations is

due, in part, to the effect of baby boom demographics on the general population and to crime and sentencing trends of the 1980s and 1990s.As the

inmate population has increased, correctional administrators have encountered new challenges in managing the requirements of older inmates and those

with special physical and medical needs.

The most significant challenges facing corrections

systems include the following:

• Management and Housing of Inmates With

Special Needs. As the number of elderly and

seriously ill inmates increases, administrators must

weigh the advantages and disadvantages of various

means of managing them, such as the use of mainstream housing versus construction or remodeling

of special housing units or facilities. Cost implications, programming concerns, and classification

and screening methodologies are critical factors

that must be assessed.

• Special Accommodations, Facilities, and

Programs for Inmates With Special Needs.

The challenge of providing activities and services

that meet these inmates’ special needs requires a

new dimension of thinking.As the inmate population ages, administrators need to consider special

architecture, such as grab bars in cells, showers,

and toilets; elevated toilet seats, stools, or benches in showers; and improved access to toilet facilities. Institutional medical and dietary professionals

also must rethink their services to ensure that the

special needs of these inmates are addressed.

vii

EXECUTIVE SUMMARY

• Cost Containment in Providing for Inmates

With Special Needs. The most serious challenge facing correctional administrators with

regard to the elderly and infirm inmate population

is containment of health care costs.

• Epidemiological Considerations. The stress

imposed by incarceration can exacerbate the

health problems of elderly and infirm inmates.

Institutionalization increases the likelihood that

contagious disease will spread and may increase

chronic disease symptoms.

• Preparing Correctional Staff To Respond

to the Requirements of Special Needs

Inmates. Medical and correctional staff should

be trained to identify issues posed by the presence of elderly and chronically ill inmates.

• Functional Assessment of Special Needs

Inmates. The key to addressing the above challenges is selecting and using the most appropriate

and effective functional assessment instruments.

Prison classification and screening instruments

generally have not sufficiently accounted for the

special needs and issues of older and disabled

inmates. Identification of screening and classification instruments that address these concerns can

help administrators manage these populations and

determine whether additional programming, housing, and medical services are needed. Functional

assessment will assist correctional managers and

health care planners in understanding and anticipating the overall array of procedures, services,

programs, and accommodations that will be

required.
viii

A functional assessment is a screening tool that is

used to identify behaviors or physical, mental, or

emotional disabilities that may cause a patient (or

inmate) difficulty in day-to-day activities or mental

health issues in getting along with others. Functional

assessments help caregivers identify circumstances

regularly associated with a physical or emotional

difficulty. In addition, they provide information that

lays the groundwork for decisions concerning medical treatment or the most appropriate institutional

living environment.

It is important to note that three prison populations—

the elderly, chronically ill, and terminally ill—overlap

considerably.They might be considered subcategories

of a single special needs population of inmates who,

as a result of their illness or disability, require

enhanced services. For this report, the population is

divided into three categories: aging and elderly,

chronically ill, and terminally ill.The functional assessment, encompassing all three categories with respect

to policymaking and programming issues, has

become increasingly important as a tool to ensure

effective, efficient, and humane programming for

inmates as they enter the system.

In the pages that follow, consideration has been

given to the functional assessment; specific program,

housing, and treatment considerations; and correctional policy considerations for these populations.

The authors believe these areas require the most

attention and change if special needs inmates are to

receive appropriate care that meets humane and

constitutional standards.
ix

CONTENTS

FOREWORD ............................................................................................................................................................................iii

ACKNOWLEDGMENTS ..........................................................................................................................................................v

EXECUTIVE SUMMARY ......................................................................................................................................................vii

CHAPTER I. INTRODUCTION ..............................................................................................................................................1

Introduction ..........................................................................................................................................................................3

Project Goals ........................................................................................................................................................................3

Approach/Methodology ......................................................................................................................................................3

Outcome ................................................................................................................................................................................4

Summary ................................................................................................................................................................................4

CHAPTER II.WHATWE KNOW ABOUT ELDERLY, CHRONICALLY ILL,

AND TERMINALLY ILL INMATES ................................................................................................................................................5

Introduction ..........................................................................................................................................................................7

What We Know Now ........................................................................................................................................................8

Elderly Inmates............................................................................................................................................................8

Chronically Ill Inmates ............................................................................................................................................11

Terminally Ill Inmates ..............................................................................................................................................12

References............................................................................................................................................................................13

CHAPTER III. EFFECTIVE EVALUATION FOR IDENTIFYING THE SPECIAL NEEDS OF INMATES ........................15

Introduction ........................................................................................................................................................................17

Entry Into the System ......................................................................................................................................................17

Pitfalls in the Process ........................................................................................................................................................18

Corrections-Systems Versus Free-World Functional Assessments ........................................................................19

Needs Requiring Special Accommodation....................................................................................................................20

Mobility Impairment ................................................................................................................................................20

Sensory-Neural Impairment..................................................................................................................................20

Chronic Illness..........................................................................................................................................................21

Mental Illness ............................................................................................................................................................22

Terminal Illness ........................................................................................................................................................23

Women’s Health Problems....................................................................................................................................24
x

Tracking Individuals With Special Needs ......................................................................................................................24

Conclusion ..........................................................................................................................................................................24

Notes ....................................................................................................................................................................................25

References............................................................................................................................................................................25

Chapter IV. Program, Housing, and Treatment Considerations ............................................................27

Introduction ........................................................................................................................................................................29

Elderly Inmates....................................................................................................................................................................29

Treatment Needs ....................................................................................................................................................30

Housing Options......................................................................................................................................................30

Program Considerations ........................................................................................................................................33

Chronically Ill Inmates ......................................................................................................................................................34

Treatment Needs ....................................................................................................................................................34

Housing Options......................................................................................................................................................35

Program Considerations ........................................................................................................................................35

Terminally Ill Inmates ........................................................................................................................................................36

Treatment, Housing, and Program Needs ..........................................................................................................36

Early Release Options ............................................................................................................................................40

Prerelease Planning ............................................................................................................................................................42

Conclusion ..........................................................................................................................................................................43

Notes ....................................................................................................................................................................................43

References............................................................................................................................................................................43

Chapter V. Ethical and Policy Considerations for the Care of Elderly 

and Infirm Inmates ......................................................................................................................................................45

Prison Organization and Specialized Care ..................................................................................................................47

Special Needs Care in Prison ..............................................................................................................................47

Ethical Medical Practice in Prison ........................................................................................................................47

Health Care Organization and Administration............................................................................................................49

Health Care Dispersion ........................................................................................................................................49

Sick Call......................................................................................................................................................................49

Infirmaries..................................................................................................................................................................50

Hospitals ....................................................................................................................................................................50

Congregate Care Versus Mainstreaming ......................................................................................................................50

Staffing for the Care of the Elderly and Infirm............................................................................................................51

Terminal Care: Bioethical Issues......................................................................................................................................52

Compassionate Release ....................................................................................................................................................53

Health Care Policymaking for Inmates..........................................................................................................................53

Notes ....................................................................................................................................................................................54

References............................................................................................................................................................................54

C ONTENTS
xi

Chapter VI. Conclusion ..............................................................................................................................................55

Program, Housing, and Treatment Considerations ....................................................................................................57

Elderly Inmates ........................................................................................................................................................57

Chronically Ill Inmates ............................................................................................................................................57

Terminally Ill Inmates ..............................................................................................................................................57

The Functional Assessment..............................................................................................................................................58

Policy Considerations........................................................................................................................................................58

Appendixes

A.Criminal Justice Institute Survey: Managing the Needs of Aging Inmates and Inmates 

With Chronic and Terminal Illnesses..............................................................................................................59

Managing the Needs of Aging Inmates................................................................................................................61

Managing the Needs of Terminally Ill Inmates ..................................................................................................75

Managing the Needs of Chronically Ill Inmates ................................................................................................87

Staff Training ............................................................................................................................................................97

Classification and Treatment ..............................................................................................................................101

B.Managing Long-Term Inmates and Inmates With Chronic and Terminal Illnesses:

Site Visit Reports ....................................................................................................................................................107

Michigan Department of Corrections ..............................................................................................................111

Minnesota Department of Corrections ..........................................................................................................117

New York State Department of Correctional Services................................................................................121

Ohio Department of Rehabilitation and Correction ..................................................................................125

Oregon Department of Corrections ..............................................................................................................133

Pennsylvania Department of Corrections ......................................................................................................137

C. Site Visit Checklist:The Functional Assessment—Issues Considered 

and Questions Covered During the Site Visits ......................................................................................141

The Functional Assessment ................................................................................................................................143

Balancing Custody Concerns and Appropriate Care....................................................................................145

Medical, Program, and Housing Considerations ............................................................................................147

List of Exhibits

1. State and Federal Inmates Age 50 and Older (1992–2001) ..................................................................................7

2. Percentages of Inmates Age 50 and Older (1992–2001)........................................................................................8

3.Average Health Care Cost per Inmate (1991–2001) ............................................................................................11

C ONTENTS

INTRODUCTION

Chapter I

3

INTRODUCTION

In October 2000, the Criminal Justice Institute (CJI)

and the National Institute of Corrections (NIC)

established a cooperative agreement to advance

knowledge about promising approaches for the

effective management and treatment of elderly

inmates and those with chronic and terminal

illnesses.

To conduct this project, CJI assembled a multidisciplinary team of medical and correctional experts

and practitioners, including Dr. B. Jaye Anno, health

care researcher, Consultants in Correctional Care;

Dr. Ronald Shansky, correctional medical care consultant and former medical director of the Illinois

Department of Corrections; James E. Lawrence,

director of operations for the New York State

Commission of Correction; and Camelia Graham,

M.S.P.H., epidemiologist,AIDS Administration,

Maryland Department of Health and Mental

Hygiene.

PROJECT GOALS

The four major project goals were to identify the

following:

• Current practices, policies, and procedures that

relate to the management and treatment of elderly inmates, inmates with chronic diseases, and/or

inmates with terminal illnesses.

• The impact of current policies, procedures, and

practices on elderly inmates, inmates with chronic

illnesses, and/or inmates with terminal illnesses.

• Effective practices and interventions in the care

and management of elderly inmates, inmates

with chronic illnesses, and/or inmates with terminal illnesses

• Ways to assist jurisdictions in improving treatment and associated protocols.

APPROACH/

METHODOLOGY

To scan the field for current policies and practices

relating to the needs of elderly inmates and those

with chronic and terminal illnesses, the project team

relied on various surveys and assessments. Of special relevance was CJI’s 2001 survey of existing practices in departments of corrections in the United

States and its territories.The project team used

these survey results to identify six departments of

corrections that offered a range and breadth of care

and programs worthy of further examination.

To explore current practices in managing special

needs inmates, Dr.Anno, Dr. Shansky, and Mr. Lawrence visited six state departments of corrections

that had instituted programs of comprehensive care

in Michigan, Minnesota, New York, Ohio, Oregon, and

Pennsylvania.

Before the visits, the team developed a program

component checklist and needs assessment instrument (see appendix C) to document key program

elements in a consistent manner and to determine

how each jurisdiction addressed formative and operational issues in implementing its program strategies.

Chapter 1

INTRODUCTION
The team members used this information to inform

and validate their findings and suggestions and to

enrich the content of this report with examples of

practical applications.

OUTCOME

The project culminated in the production of this

monograph, which addresses issues concerning the

effective management and treatment of elderly

inmates and those with chronic and terminal illnesses.The focus of the monograph is as follows:

• Identification of management and treatment protocols that reflect effective and humane practices

and care for these populations.

• Exposition of effective management and care

practices that take into account screening techniques, treatment and intervention, classification

and case management, transition planning, discharge planning approaches, specially designed

correctional programs and services, training of

correctional staff and clinicians, and provision of

services to culturally diverse populations and

inmates of different gender.

C HAPTER I

4

• Explanation, with examples, of how comprehensive correctional programs and services are

organized and delivered for elderly and seriously

ill inmates.

• Identification of various treatment modalities and

evidence of their effectiveness in addressing the

special care needs of these populations.

• Identification of innovative practices that expand

our knowledge about effective care, management,

and treatment approaches for these populations.

SUMMARY

This report is designed to serve as a resource guide

for correctional agencies researching management

and treatment for elderly, chronically ill, and terminally ill inmate populations. It does not present a

comprehensive model that can be adopted by all

agencies, nor does it impart prescriptive, definitive

advice. Rather, it is meant to provide guidance and

information about promising approaches to help

correctional managers and planners address these

inmates’ special needs.
Chapter II

WHAT WE KNOW ABOUT

ELDERLY, CHRONICALLY ILL, AND

TERMINALLY ILL INMATES

0

20,000

40,000

60,000

80,000

100,000

120,000

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

41,586 44,302

50,478

55,281

63,004

73,543

83,667

92,362

113,358

103,132

7

WHAT WE KNOW ABOUT

ELDERLY, CHRONICALLY ILL,

AND TERMINALLY ILL INMATES

Chapter 11

INTRODUCTION

When considering dangerous, violent, and predatory

inmates, one does not usually envision an elderly

man hobbling down a prison corridor with a cane or

walker. However, in reality, some of the most dangerous and persistent criminals who were sentenced to

life in prison without parole 30 years ago are now

old, debilitated, frail, chronically ill, depressed, and

no longer considered a threat to society or the

institution.

During the past decade, the number of elderly and

infirm inmates in state prison systems has increased

dramatically. From 1992 to January 1, 2001, the number of state and federal inmates age 50 and older

increased from 41,586 to 113,358, a staggering

increase of 172.6 percent (Camp and Camp,

1992–2001) (see exhibit 1).

In 1992, inmates age 50 and older represented 5.7

percent of the prison population. By 2001, they represented 7.9 percent (Camp and Camp, 1992–2001)

(see exhibit 2).

The aging of American prison populations is due, in

part, to the same baby-boom demographics that

cause concern about the future of Social Security

and long-term elder care outside prison. In the criminal justice system, however, the demographic

changes affecting the general population have been

compounded by crime and sentencing trends.A

middle-age bulge in most large state prison populations reflects the advent of “three strikes” felony

sentencing, which calls for third-time felony

offenders to serve mandatory sentences of 25 years

to life, and the punitive sentencing measures associated with the war on drugs of the 1980s and 1990s.

Furthermore, 14 states and the Federal Bureau of

Prisons have eliminated parole, which for many years

served as a vehicle of early release for well-behaved

inmates and as a population pressure release valve in

times of overcrowding. State laws requiring truth in

sentencing, enacted as a result of the Violent Crime

Control and Law Enforcement Act of 1994, offered

prison construction grants and other incentives to

EXHIBIT 1.

State and Federal Inmates 

Age 50 and Older (1992–2001)
states that required violent criminals to serve at

least 85 percent of their sentences.

WHAT WE KNOW NOW

The specialized medical needs of older inmates,

including those with chronic illnesses and terminal

diseases, have been well documented.

In a National Institute of Corrections (NIC) report

on special needs inmates, LIS, Inc., surveyed state

correctional agencies and found that more than half

of the state departments of corrections (DOCs) had

located the delivery of medical services at one site.

Similarly, in 23 DOCs, inmates with terminal illnesses

were being cared for at a single location. Fifteen

DOCs were placing elderly inmates in a single facility. Other findings included an increased use of

telemedicine, fees for services paid by inmates, and

the use of managed care and private providers

(National Institute of Corrections Information

Center, 1997).

C HAPTER II

8

Elderly Inmates 

As the population of Americans age 65 and older

continues to increase, families, health care providers,

social services agencies, government managers, and

policymakers, including those who plan for and

manage correctional institutions, face new challenges

with respect to managing the needs of the elderly

and those with special physical and medical

requirements.

A recently published federal report estimated that,

in the year 2000,“35 million people age 65 or older

[were] in the United States, accounting for almost

13 percent of the total population. By 2030, it is projected that one in five people will be age 65 or older

[and that] the size of the older population is projected to double over the next 30 years, growing to

70 million.” (Federal Interagency Forum on AgingRelated Statistics, 2000).

Just as the number of elderly individuals is growing

in the United States, the number of geriatric inmates

is steadily increasing.This is the result of overall

demographic trends and increased frequency of

incarceration of older offenders due to sentencing

laws enacted in the past 25 years, especially statutes

requiring long-term determinate sentencing for

predicate felons and other classes of specially targeted offenders, such as substance abusers (Glaser et

al., 1990).

At this time, no consistent definition of what “elderly” means in correctional systems exists in the

United States. Some administrators recommend that

age 50 be the chronological age defining the elderly

in prison.While 50 may seem young to be classified

as elderly in the free world, several important factors seem to speed the aging process for those in

prison.These factors include the amount of stress

experienced by new inmates trying to survive the

prison experience unharmed; efforts to avoid confrontations with correctional staff and fellow

inmates; financial stress related to inmates’ legal,

family, and personal circumstances; withdrawal from

chronic substance abuse; and lack of access to

4%

6%

8%

10%

5.7%

6.0% 5.9%

6.1%

6.6%

6.8%

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

7.2%

7.0%

8.6%

7.9%

EXHIBIT 2.

Percentages of Inmates 

Age 50 and Older (1992–2001)
adequate medical care prior to incarceration.All

contribute to inmate stress, which, in turn, accelerates the aging process.

As part of a 2001 survey, the Criminal Justice Institute (CJI) asked representatives of state correctional

agencies whether they had a specific definition for

when inmates in prison are considered to be elderly.

Of the 49 respondents, 22 said that they did have a

definition of the elderly in prison; the average first

qualifying age was 55 years. Eight defined elderly as

55 years of age and older, seven defined elderly as

50 years and older, four defined elderly as 60 years

and older, one defined elderly as 62 years and older,

and two defined elderly as 65 years and older. Some

states did not have a chronological age cutoff but,

instead, defined elderly based on degree of disability.

Another based its definition on chronological age

with the explicit provision that the inmate must have

a debilitating disease or disability to be considered

elderly (Criminal Justice Institute, 2001).

In 1999, the Ohio Department of Rehabilitation and

Correction predicted that inmates age 50 and older

would represent close to 25 percent of its general

population by the year 2025 (Ohio Department of

Rehabilitation and Correction, 1999).According to

the CJI survey, as of December 31, 2000, an average

of 1,835 inmates per jurisdiction were age 50 and

older (Criminal Justice Institute, 2001).

Of the 49 systems assessed by CJI, only 15 had special housing areas designated for elderly inmates; of

those, 7 special housing areas were available only for

elderly inmates with special medical needs or for

those who were otherwise eligible for hospice care.

Only one agency reported that it had special housing for elderly inmates solely upon their request (see

appendix A).The lack of personal protection for elderly inmates, who may be frail and therefore vulnerable to the threats of assault by younger predatory

inmates, contributes to the emotional stress and

physical deterioration they routinely experience,

especially among those who may be already vulnerable owing to chronic or terminal illness and who

have few options for change in their environment.

A review of the literature confirms the increasing

numbers of elderly inmates, the link between aging

inmates and those with chronic illnesses and behavioral problems, and the role of gender with regard

to illness within the aging inmate population. For

example, Lindquist and Lindquist found: “Jail and

prison inmates experience disproportionately high

levels of chronic and acute physical health problems

... [and] . . . gender and age are the most consistent

demographic predictors of health status and medical

utilization, with females and older inmates reporting

higher morbidity and concomitantly higher numbers

of medical encounters” (Lindquist and Lindquist,

1999).With regard to higher morbidity rates among

inmates, the number of inmates dying from natural

causes increased from 946 in 1990 to 2,105 in 1999,

an increase of 123 percent.As prisoners’ length of

stay increases, these problems are likely to intensify

in that “self-reported health problems increase with

inmates’ duration of incarceration” (Lindquist and

Lindquist, 1999).“The results suggest a need for

medical care in correctional settings to adapt to

the medical needs of older inmates and women,”

Lindquist and Lindquist conclude,“in addition to

improving treatment for chronic conditions and preventive services” (Lindquist and Lindquist, 1999).

In a 1997 article, Smyer, Gragert, and LaMere reported:“Aging inmates form a distinct cultural subgroup.”

They also concluded that aging within the prison

setting differs from aging outside the prison environment and that programs and services must take

those differences (“loss of family, employment, and

sexual identity”) into account (Smyer, Gragert, and

LaMere, 1997).

Management issues associated

with elderly inmates

Management problems associated with elderly

inmates, although not unique to prisons, are intensified in the prison setting and include the following:

• Vulnerability to abuse and predation.

• Difficulty in establishing social relationships with

younger inmates.

9

WHAT WE KNOW ABOUT ELDERLY, CHRONICALLY ILL, AND TERMINALLY ILL INMATES
• Need for special physical accommodations in a

relatively inflexible physical environment.

• Need for special programs in a setting where special privileges are disdained as counterproductive

to discipline and orderliness.

Furthermore, in an environment of scarcity, elderly

inmates consume a disproportionate amount of

health services.Their greater need for peace, quiet,

and privacy—highly desirable commodities for all

inmates—puts them in conflict with the general

population.The elderly require help in coping with

the fast pace, noise, and confusion of modern life,

whether or not they are residents in a crowded correctional facility.The elderly frequently feel unsafe

and vulnerable around younger people. Fear-based

abrasive relations between young and old are becoming increasingly prevalent in prisons and in society in general (Aday, 1994a).

The few reliable longitudinal studies of elderly inmates that have measured group-specific and overall

health and functional status reveal accelerated signs

of aging and deterioration of health among state

inmates age 50 and older. Most prevalent were

increased rates of incontinence, sensory impairment,

impaired flexibility, respiratory illnesses, cardiovascular disease, and cancer.These conditions are exacerbated by lifelong histories of substance abuse,

including alcoholism and smoking, which are common to inmates.The most common chronic illnesses

reported are arthritis, hypertension, ulcer disease,

prostate problems, and myocardial infarction.These

patterns are not substantially different from those of

the overall population but are concentrated in distressed and needy subpopulations (Colsher et al.,

1992).These and other prevalent problems of

inmates older than age 55, most associated with lifelong medical and social histories of high-risk sexual

practices and other unhealthy behaviors, accelerate

their aging processes to an average of 11.5 years

older than their chronological ages after age 50

(Aday, 1994a). Ordinary cognitive impairments of age

aside, decreased sensory acuity, muscle mass loss,

intolerance of adverse environmental conditions,

C HAPTER II

10

dietary intolerance, and general vulnerability precipitate collateral emotional and mental health problems. Elderly inmates experience a reduction in

human interaction and tend to withdraw owing to a

lack of privacy and a loss of self-esteem.They are

frightened, anxious, and dependent, particularly on

prison staff. Some report the fear of dying in prison.

Many others report fearing release from prison

more than dying in one.This creates excessive stress

for elderly inmates living in large state prison populations, often producing illness and debilitation as

manifestations of decompensation (Morton and

Jacobs, 1992, pp. 6–7).

A typology of elderly inmates first established by

Delores Craig-Moreland and William McLaurine

(Neeley,Addison, and Craig-Moreland, 1997; Morton

and Jacobs, 1992) and substantiated by a variety of

experts includes three distinct groups:

• First-time offenders. Inmates who have committed their crime after the age of 50.Their

crimes are likely to be serious, considering they

have been imprisoned for a first-time offense at

an advanced age.They are likely to have problems

adjusting to prison since they are new to the environment, which will cause underlying stress and

probable stress-related health problems. Furthermore, they are “easy prey” for more experienced

predatory inmates.

• Recidivists. Habitual offenders who have been in

and out of prison for most of their lives.They

often have substance abuse issues that can lead

to chronic diseases, such as asthma, heart problems, circulatory problems, and kidney or liver

problems.

• Long-term servers. Inmates who have earned

long sentences and have “aged in place.” Inmates

who have aged in place are generally the best

adapted to prison life because they have been in

prison since their youth and have adjusted to it.

It is difficult to say what health problems this

group may be likely to develop, since their environment remains largely the same.
Nationally, about 50 percent of elderly inmates are

first-time offenders incarcerated after age 55. Prison

recidivists have long criminal histories and a sequential record of imprisonment.They are well adjusted

to incarceration. Long-term inmates have extended,

uninterrupted histories in prisons and are heavily

institutionalized. Moreover, they have few community

ties, limited coping strategies, and, consequently, feelings of diminished self-worth.

Newly incarcerated offenders have emerged recently

as a subcategory in the first-time offender classification.Their criminal conduct is often a function of

changes associated with aging. Loss of ordinary social

inhibitions, inflexibility, and paranoia often translate

into aggression; consequently, this is a violence-prone

group.Their criminal behaviors are often situational

and spontaneous, so they rarely see themselves as

criminals.Their most common offenses are aggravated assault and murder. First-time incarcerated older

inmates are frequently severely maladjusted and

especially at risk for suicide, explosiveness, and other

manifestations of mental disorder. Since their behaviors are not well tolerated by other inmates, their

victimization potential is high. Consequently, they

often appear to be withdrawn (Aday, 1994b).

Recidivists generally adjust better to prison because

multiple prison reentries over time interspersed

with community placements have given them more

realistic expectations and greater coping skills.Their

behavior problems tend to be chronic and are often

related to histories of substance abuse.They are violent or mentally disturbed less often than older firsttime offenders. Given demographic trends, recidivists

are destined to constitute a larger portion of the

elderly inmate population (Morton and Jacobs,

1992).

Cost implications of providing

services to elderly inmates 

The growing number of elderly inmates with chronic

and terminal illnesses affects correctional administrators in several ways.The annual cost of incarcerating this population has risen dramatically to an

average of $60,000 to $70,000 for each elderly

inmate compared with about $27,000 for others in

the general population (Beiser, 1991). From 1997 to

2001, health care spending in U.S. prison systems

increased 27.1 percent, from $2,747,843,808 to

$3,493,047,306. From 1992 to 2000, the average

daily cost per inmate for health care rose from

$5.62 to $7.39, an increase of 31.5 percent (Camp

and Camp, 1992–2001) (see exhibit 3).

Chronically Ill Inmates 

The Bureau of Justice Statistics (BJS) report Medical

Problems of Inmates, 1997 (Maruschak and Beck,

2001) indicates that 326,256 state (31.0 percent)

and 20,734 federal (23.4 percent) inmates reported

having a physical or mental problem that required

attention from their correctional facility.Approximately 12 percent of state inmates and 11 percent

of federal inmates reported an overall physically

impairing condition, and just more than 48 percent

of state inmates (21.0 percent male and 27.2

11

WHAT WE KNOW ABOUT ELDERLY, CHRONICALLY ILL, AND TERMINALLY ILL INMATES

$5.00

$6.00

$7.00

$8.00

$5.04

$5.62

$5.90

$6.07

$6.53 $6.59

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

$6.97

$6.86

$7.34 $7.39

EXHIBIT 3.

Average Health Care 

Cost per Inmate (1991–2000)
percent female) reported having medical problems

brought about by causes other than injury.The

greatest percentage (30.4 percent) of state inmates

reporting medical problems were those who had

been in prison for 72 months or more.

In 2000, 18.4 percent of Federal Bureau of Prisons

inmates were reported to have been under care for

serious chronic illness: “[A]t midyear 2000, the

Federal system had 5,639 (4.4%) inmates with asthma, 4,616 (3.6%) in a diabetic clinic, 3,358 (2.6%) in

a cardiac clinic, and 10,011 (7.8%) in a hypertension

clinic” (Maruschak and Beck, 2001).Approximately

17 percent of inmates housed in state facilities selfreported specific conditions, including HIV/AIDS (1.7

percent), heart disease (1.1 percent), circulatory

problems other than heart disease (2.4 percent),

respiratory problems (1.4 percent), cancer (0.2 percent), neurological problems (0.7 percent), skeletal

problems (2.6 percent), kidney/liver problems (0.9

percent), and diabetes (0.9 percent) (Maruschak and

Beck, 2001).

The authors of the BJS report HIV in Prisons and Jails,

2000 (Maruschak, 2002) indicate that 2.2 percent of

state inmates and 0.8 percent of federal inmates

were known to be infected with HIV, the virus

known to cause AIDS.Although the number of

AIDS-related deaths in state prisons has decreased

significantly, from 1,010 deaths in 1995 to 174 in

2000, the overall incidence of AIDS in state prisons

has remained much higher than that in the free

world—nearly four times the rate in U.S. communities.About 52 in every 10,000 inmates had confirmed AIDS compared with 13 in 10,000 persons in

the U.S. general population.

BJS reported that, when questioned about medical

assessments they had received since admission to

prison, 96.2 percent of respondents said they had

been tested for tuberculosis exposure, 86.7 percent

said they had had a blood test, and 85 percent said

they had had a medical examination for any reason

since their admission (Maruschak and Beck, 2001).

Only 59.7 percent were checked to see whether

C HAPTER II

12

they had a medical issue at the time of their admission, and only 82.3 percent of inmates responded

that they had been asked questions about their

health or medical history at the time of their admission (Maruschak and Beck, 2001).

In the 2001 CJI survey, when correctional agencies

were queried about how chronic medical problems

are discovered in agencies, 48 of 49 agencies (98.0

percent) responded that chronic illnesses are

detected through the reception health screening,

reception health appraisal, or sick call and 46 of the

49 responding agencies (93.9 percent) said that

chronic illnesses are discovered during annual health

appraisals.All 49 agencies (100 percent) reported

that chronic illnesses are discovered by self-referral.

Terminally Ill Inmates 

Most systems define inmates as terminally ill if they

are known to have a fatal disease and have fewer

than 6 months to live.

According to the Guiding Responsive Action in

Corrections at End-of-Life (GRACE) Project of

the Volunteers of America, largely because of the

decrease in AIDS deaths nationally since 1995 with

the introduction of protease inhibitors, the number

of deaths in U.S. prisons has declined since 1995

(GRACE Project, 2001).According to the most

recent statistics from the National Center for HIV,

STD, and TB Prevention at the Centers for Disease

Control and Prevention, deaths due to AIDS in the

United States have declined from 51,117 in 1995 to

15,245 in 2000 (Centers for Disease Control and

Prevention, 2001).

Deaths due to other causes in prison, however, have

approximately doubled (GRACE Project, 2001). Data

are limited on the causes of death in U.S. prisons.

One agency stated that causes of death other than

AIDS included overdose, execution, suicide, homicide, cancer, heart attack, liver disease, congestive

heart failure, and other (GRACE Project, 2001).The

research literature provides no clear indication as to

which of the “other” causes are most responsible
for the increased death rate or why the rate has

increased so precipitously.

Generally, the current approaches to dealing with

terminally ill inmates are release and provision of

prison-based services (GRACE Project, 2001).

“Release” usually occurs in the form of compassionate release, when a dying inmate is released before

completing his or her sentence to be allowed to

die outside prison walls.“Services” typically refers to

palliative care or “end-of-life services” provided

within the institution, which are designed to make

the last days or months of terminally ill inmates’

lives somewhat more comfortable.The most widespread service response has been the initiation of

prison-based hospice programs that provide palliative care services “including pain management,

spiritual support, and psychological counseling”

(National Institute of Corrections Information

Center, 1998).

According to the 2001 CJI survey, compassionate

release provisions were available in 43 (87.8 percent) of the 49 responding agencies.The average

annual number of requests for compassionate

release was 18, and the average number granted

was 8.The highest number of requests was 115 in

Texas, which also granted the highest number (49).

Compassionate release procedures vary from state

to state, and there is no common definition of the

criteria for the compassionate release of dying

inmates.

When asked whether hospice care was available for

terminally ill inmates, 25 (51.0 percent) of the 49

responding agencies said it was. Five agencies (20

percent) offer hospice services in a separate unit;

22 (88 percent) operate the hospice as part of their

infirmary; 4 (16 percent) operate the hospice as part

of a housing unit; and 8 (32 percent) operate a hospice as a part of an outpatient program. Only 11

agencies (44 percent) assign staff who have no other

responsibilities than to their hospice unit.

There appears to be rapid recent growth in the

number of hospice programs for terminally ill inmates.A 1998 NIC survey reported that 11 states

and the Federal Bureau of Prisons had hospice services. In 2001, the GRACE Project found 19 states

with formal end-of-life programs for terminally ill

inmates.The CJI survey found 25 agencies that operated hospice programs.

In the chapters that follow, we examine how prison

systems have responded to the need for early

assessment of special needs.We also discuss program, housing, and treatment considerations for elderly, chronically ill, and terminally ill inmates. Finally,

we discuss policy implications in managing special

needs inmates.

REFERENCES

Aday, Ronald H. 1994a.“Golden Years Behind Bars:

Special Programs and Facilities for Elderly Inmates.”

Federal Probation 58 (2): 48.

Aday, Ronald H. 1994b.“Aging in Prison:A Case

Study of New Elderly Offenders.” Journal of Offender

Therapy and Comparative Criminology 38 (1): 80.

Beiser,Vince. 1991.“Prisoners or Pensioners?” Nation

268 (18): 28–31.

Camp, George, and Camille Camp. 1992–2001. The

1992–2001 Corrections Yearbook. Middletown, CT:

Criminal Justice Institute.

Centers for Disease Control and Prevention. 2001.

HIV/AIDS Surveillance Report. Midyear Edition, vol. 13,

no. 1, June.Atlanta, GA: Division of HIV/AIDS

Prevention, National Center for HIV, STD, and TB

Prevention.

Colsher, Patricia L., Robert B.Wallace, Paul L.

Loeffelholz, and Marilyn Sales. 1992.“Health Status of

Older Male Inmates:A Comprehensive Survey.”

American Journal of Public Health 82 (6): 881–884.

Criminal Justice Institute. 2001. Managing the Needs

of Aging Inmates and Inmates With Chronic and Terminal

Illnesses. Middletown, CT: Criminal Justice Institute.

Federal Interagency Forum on Aging-Related

Statistics. 2000. Older Americans 2000: Key Indicators

of Well-Being. Washington, DC: Federal Interagency

Forum on Aging-Related Statistics,August.

13

WHAT WE KNOW ABOUT ELDERLY, CHRONICALLY ILL, AND TERMINALLY ILL INMATES
Glaser, J.B.,A.Warchol, D. D’Angelo, and H. Guterman. 1990.“Infectious Diseases of Geriatric

Inmates.” Reviews of Infectious Diseases 12 (4)

(July–August): 683–692.

GRACE Project. 2001. Incarceration of the Terminally

Ill: Current Practices in the United States. Alexandria,

VA:Volunteers of America.

LaMere, S.,T. Smyer, and M. Gragert. 1996.“The Aging

Inmate.” Journal of Psychosocial Nursing and Mental

Health Services 34 (4): 25–29.

Lindquist, Christine H., and Charles A. Lindquist.

1999.“Health Behind Bars: Utilization and Evaluation

of Medical Care Among Jail Inmates.” Journal of

Community Health 24 (4) (August): 285–303.

Maruschak, Laura M. 2002. HIV in Prisons and Jails,

2000. Bureau of Justice Statistics Bulletin.

Washington, DC: U.S. Department of Justice, Office

of Justice Programs, October, NCJ 196023.

Maruschak, Laura M., and Allen J. Beck. 2001. Medical

Problems of Inmates, 1997. Bureau of Justice Statistics

Special Report.Washington, DC: U.S. Department of

Justice, Office of Justice Programs, January, NCJ

181644.

C HAPTER II

14

Morton, Joann B., and N.C. Jacobs. 1992. An

Administrative Overview of the Older Inmate.

Washington, DC: National Institute of Corrections.

National Institute of Corrections Information

Center. 1997. Prison Medical Care: Special Needs

Populations and Cost Control. Special Issues in Corrections. Longmont, CO: U.S. Department of Justice,

National Institute of Corrections, September, NIC

accession no. 013964.

National Institute of Corrections Information

Center. 1998. Hospice and Palliative Care in Prisons.

Longmont, CO: U.S. Department of Justice, National

Institute of Corrections, September, NIC accession

no. 014785.

Neeley, Connie L., Laura Addison, and Delores CraigMoreland. 1997.“Addressing the Needs of Elderly

Offenders.” Corrections Today 59 (5): 120–123.

Ohio Department of Rehabilitation and Correction.

1999. Comprehensive Approach to Addressing the Needs

of Aging Prisoners. Columbus, OH: Ohio Department

of Rehabilitation and Correction.

Smyer,T., M.D. Gragert, and S. LaMere. 1997.“Stay

Safe! Stay Healthy! Surviving Old Age in Prison.”

Journal of Psychosocial Nursing and Mental Health

Services 35 (9): 10–17.
Chapter III

EFFECTIVE EVALUATION FOR

IDENTIFYING THE SPECIAL

NEEDS OF INMATES

17

INTRODUCTION

Correctional managers are now being asked to meet

the needs of a growing population of elderly inmates

and inmates who exhibit a variety of complex medical and mental health problems.They must properly

identify these inmates’ needs at the time they enter

the prison system.This will result in more effective

and efficient care for special needs inmates and also

will reduce court challenges and liability risks for the

prison system.

This chapter describes what prison systems across

the country have done to ensure early identification

of these needs. It characterizes the variety of needs

that require special attention, describes the impact

of these special needs on the institutions, and

explains how the corrections systems have effectively responded to special needs inmates.The chapter

concludes with a discussion of the measures prison

systems have adopted to ensure that accommodations ordered by a physician to meet a patient’s

needs continue to be provided when an inmate

transfers between institutions.

ENTRY INTO THE SYSTEM

In most prison systems, a member of the medical

staff, ordinarily a nurse, performs an intake history

or screening exam shortly after the inmate arrives at

a reception center.This health care screening

attempts to identify whether the inmate suffers

any physical disability, has current illnesses, is currently taking medications, or has allergies.The staff

member then asks a series of questions regarding

symptoms or diseases that is designed to provide

the basis for developing an appropriate treatment

plan.Typically, female inmates are also asked a separate set of questions that attempts to identify such

gender-specific problems as pregnancy, gynecological

problems, or breast problems.Additional questions

may relate to contagious diseases, hospitalization,

substance use or abuse, and mental health problems.

This initial screening is designed to identify individuals whose medical needs must be addressed immediately, usually on the same day as the screening.Thus,

an inmate arriving in a wheelchair would be referred

to a physician who would conduct an immediate

assessment to develop a plan for responding to the

inmate’s needs. In most systems, individuals who do

not appear to have a problem requiring urgent

attention are referred for a complete medical history and physical examination, usually within the first 7

to 14 days of incarceration.

In addition to taking the history and conducting a

physical exam, prison medical staff evaluate newly

arrived inmates for tuberculosis (TB).A nurse performs a TB skin test that is read between 48 and 72

hours later.This allows prison medical staff to quickly identify individuals who may have acquired a TB

infection for which prophylactic treatment is indicated. In some instances, individuals with active TB are

identified. In addition to the TB screening, most

prison systems perform a test for syphilis at intake,

and many systems also test for gonorrhea at the

time of the physical exam. Some systems also routinely perform HIV tests at intake.A few systems

Chapter III

EFFECTIVE EVALUATION FOR

IDENTIFYING THE SPECIAL

NEEDS OF INMATES
test for hepatitis as well. Complete blood counts

and blood chemistries are also performed on entry

to the corrections system in some jurisdictions.

Ideally, the clinician uses data collected from the

initial screening,TB skin test, and other blood tests,

along with the information gathered during the

history and physical exam, to identify the inmate’s

health care needs.

PITFALLS IN THE

PROCESS

The responsiveness of the health care portion of the

reception process may be undermined if any of the

following problems occur:

• The medical history and physical exam are performed and inmate planning begins before data

from the other intake tests are received and evaluated. If patient data are to be used effectively to

plan for the inmate’s needs, delaying formulation

of the long-term plan until all requisite data are in

place makes sense.There are notable exceptions,

however, such as the need to screen immediately

on admission, to evaluate those rating positive on

the screening for suicidal intentions, and to

respond to other circumstances indicating that an

inmate might present risk of harm to himself or

herself or others.

• During the medical history and physical exam

process, the data are not collected effectively or

the feedback loop is not completed.An example

would be when, in sequence, an inmate completes

a self-history inventory, then a nurse later adds

more history, and finally the physician performs a

physical exam but fails to review the data from

the inmate’s self-history or the nursing history.

• A nurse collects the medical history for the

inmate in a location where confidentiality is not

ensured, thus inhibiting candor on the part of the

patient. Inmates tend to be cautious in disclosing

information where it may be overheard by other

staff or inmates and potentially used against them.

C HAPTER III

18

Any of these problems will result in the development of an inaccurate or incomplete plan for the

inmate.When a self-history is conducted and the

inmate has checked multiple items in his or her history as positive, often a physician does not follow up

on the items.These situations can interfere with the

inmate receiving needed and effective treatment and

can create serious potential liabilities for the corrections agency.

At the completion of the history and physical exam,

the physician is responsible for developing a treatment plan that includes diagnostic and therapeutic

interventions based on the data collected. In addition, at this point the physician usually identifies the

inmate’s particular needs.Those needs may be relevant to housing assignment, needed prosthetics,

work assignments, or educational activities. Corrections systems have developed the following two

effective strategies to develop plans that address

inmates’ special needs:

• Physician lists specific needs. Many departments have the physician list particular needs

(such as “Patient with a seizure disorder needing

a low bunk” or “Patient in a wheelchair needing

a handicap-accessible housing arrangement”) for

individual inmates.This can inform the formal

classification system and enable placement staff

to prioritize placements. For this strategy to work

well, the placement staff must know what environmental and professional resources are available at

each prison in the system.

• Coding system. Other departments employ

variations of a system used in the military that

provides decisionmaking categories (such as

physical capabilities, upper extremities, lower

extremities, hearing, vision, and psychiatric considerations) for which the examining physician must

rate the inmate as “normal,” “moderate needs,” or

“severe restrictions.” Correctional counselors

then use this system to determine appropriate

inmate placement.

In one variation of the coding system described

above, the Ohio Department of Rehabilitation and
Correction (ODRC) uses a medical classification

grid with the following classifications:

• Class 1: Medically stable inmates who require

only periodic care and do not require any chronic

care clinic or infirmary monitoring.

• Class 2: Medically stable inmates who require

routine followup and chronic care.This would

include those with diabetes, hypertension, HIV disease, and other problems.

• Class 3: Inmates who require frequent, intensive,

skilled medical care who can maintain their own

activities of daily living (ADLs). Inmates in this category include individuals on dialysis, those with

severe lung disease, unstable seizure disorder

patients, paraplegics, hemiplegics, and inmates with

other health problems.

• Class 4: Inmates who require constant medical

care and who need medical assistance with ADLs.

ODRC has identified institutions that are eligible

to receive inmates from each classification. Based

on the classification scoring grid and information

provided to the counselors, determinations also

are made with regard to educational activities, job

assignments, etc.The health care capability of a

prison is factored in with these other issues to

determine the placement for each inmate. Elderly

inmates with more severe problems are sent to a

specific institution. Other elderly inmates may be

mainstreamed in the general population based on

their physical capabilities.

CORRECTIONS-SYSTEMS

VERSUS FREE-WORLD

FUNCTIONAL

ASSESSMENTS

In both the free world and corrections systems, the

medical history and the physical examination are

critical elements in determining and responding to

functional needs. One difference is that many hospitals or health care organizations employ a survey

developed by the Rand Corporation, the SF–36,

that allows patients to complete a self-assessment

questionnaire with regard to their general health

and their functional capability.1 Such self-assessment

instruments are less commonly used in prison settings.The SF–36 includes 11 questions that attempt

to determine how the patient perceives his or her

own functioning and also how that current perception differs from the patient’s past perceptions.

Another purpose of the SF–36 is to determine

whether the patient’s perception of his or her health

status corresponds with the health care provider’s

perception.This instrument is particularly helpful in

identifying patients who are perceived as overutilizing or underutilizing health services.

Owing to an understandable skepticism prevalent

throughout the corrections environment, prison

medical staff tend to rely more heavily on objectively

observed data than on data provided exclusively by

the patient.This skepticism is based on concerns

that inmates will not be forthright in responding to

questionnaires and that they may attempt to gain

preferential treatment or undermine security by

giving exaggerated or untrue responses.Although

the primary focus of corrections is security, corrections officials are also obligated by tenets of law and

humaneness to provide an environment that meets

inmates’ needs. In the free world, the focus is on

understanding the patient well enough to create

conditions that will enable the patient to be as

healthy and fulfilled as possible.

19

EFFECTIVE EVALUATION FOR IDENTIFYING THE SPECIAL NEEDS OF INMATES
Despite these differences in focus and priority

between how free-world and prison-based functional

assessments are conducted, it might be useful for a

prison system to pilot the SF–36 functional assessment survey with a group of inmates.This would

help confirm or discontinue the widely held belief in

corrections that inmates tend to overutilize health

services, especially through the sick call process.

Insight could be gained by comparing SF–36 results

and health care direct assessments with inmates’ use

patterns. If those scoring high on the SF–36 are also

high users of services and if health care staff are not

identifying a physiological basis for many of the service requests, it would be productive to bring together a multidisciplinary team consisting of medical and

mental health staff to determine the basis for this

apparent disconnect.The Health Services Division of

the Oregon Department of Corrections conducted

a study several years ago to understand utilization

patterns and compare them with professional evaluations.The study demonstrated that one-third of

inmates used services consistent with medical staff

expectations, one-third underutilized services, and

one-third overutilized services.The study also found

that the overutilizers believed they were less healthy

than the medical staff believed.2

NEEDS REQUIRING

SPECIAL

ACCOMMODATION

A number of conditions require special accommodation, including mobility impairment, sensory-neural

impairment, chronic illness, mental illness, terminal

illness, and certain types of women’s health

problems.

Mobility Impairment 

Inmates with mobility impairments pose a challenge

for correctional facilities. Such impairments include a

reduced ability to ambulate due, most commonly, to

spinal cord injury, neurological problems, severe

arthritis, or complications of chronic diseases such

C HAPTER III

20

as diabetes. Mobility-impaired individuals include not

only those who require the use of a wheelchair but

also amputees and others who need to walk with

the aid of an assistive device such as a crutch, cane,

or brace. Depending on the severity of the disability,

an inmate may require housing in a room or cell

that has been modified to accommodate that disability. Modifications might include a wider door to

allow for wheelchair access, grab bars around the

toilet and in the shower, a sink and toilet of the

appropriate height, a shower chair, and handheld

shower fixtures. Since the enactment of the Americans with Disabilities Act (ADA) in 1990, federal

guidelines have identified the appropriate types of

accommodations required in prisons.To comply with

ADA requirements, most prison systems now cluster inmates who require wheelchairs in newer or

specially modified institutions. In addition, many

inmates with mobility impairments require other

devices. Many no longer have bladder or bowel

control and therefore require catheters and other

equipment. Some prison systems assign inmate

workers to assist mobility-impaired inmates in

moving around the prison environment. Mobilityimpaired individuals also may need specially selected

work assignments or the opportunity for educational activities in a modified class environment.

Sensory-Neural Impairment 

Inmates suffering from sensory-neural impairments

also may require special housing.This category

includes inmates who cannot see, hear, or speak or

who experience significant difficulty in performing

these activities.These individuals may need to be

housed in sheltered environments. Some prison

systems have assigned inmate workers to assist

those suffering from sensory-neural impairments so

that they can function in the prison environment.

Operational ramifications 

Patients suffering from mobility or sensory-neural

impairments present widespread operational

ramifications and pose significant challenges to

institutional managers and staff. Modifications may be
required in the dining area to allow suitable access

for mobility-impaired individuals. Sensory-neuralimpaired individuals, such as those who are deaf or

hard of hearing, may require special phones or other

assistive devices. Many of these inmates will require

access to specialists (e.g., occupational therapists,

physical therapists, physiatrists, ophthalmologists,

audiologists), which must be arranged by the health

care program. Departments of corrections may also

need specially modified vans to transport individuals

with severe mobility impairments.

Several successful class action suits have been

brought on behalf of inmates who have not received

the accommodations they need to adequately adjust

to their environments.Thus, it is clearly in the interest of each correctional agency to engage planners

and clinicians in efforts to identify the types of disabilities individuals have on intake and to plan

accordingly to address their needs adequately,

whether they are to be housed in special facilities or

accommodated in the general population (Anno,

2001).3 Much of the institutional response has been

driven by regulation and lawsuits, all too often in a

makeshift fashion.

Chronic Illness 

The National Commission on Correctional Health

Care (NCCHC) report The Health Status of Soon-ToBe-Released Inmates:A Report to Congress projects

the numbers of inmates who experience such common chronic diseases as hypertension, diabetes,

seizure disorder, asthma, and HIV disease (National

Commission on Correctional Health Care, 2002).

After examining data received from correctional institutions, the authors of the NCCHC study suggest

that these diseases may, in fact, be underdiagnosed.

NCCHC has published clinical guidelines that provide educational information derived from national

consensus panels of experts and detail useful strategies for diagnosing, monitoring, and treating individuals with these diseases.4

Many prison systems now have well-organized

chronic disease programs in which patients are

referred to a chronic clinic for a specific disease.

Individuals with multiple chronic diseases have all of

their diseases treated at the clinic where they have

been referred for treatment for their most severe

disease. Prison systems without organized chronic

care clinics are likely to have more grievances and

litigation. In addition, costs for hospitalizations and

specialty services are likely to be greater owing to

the higher morbidity rates that result from inadequately treated chronic diseases.

Despite clear evidence in the literature that morbidity and mortality are reduced when desired clinical

outcomes are achieved, some prison systems with

organized chronic clinic programs do not encourage

their providers to focus each chronic disease visit on

the desired clinical outcomes. Several sources of this

evidence are cited below:

• American Diabetes Association. 2003a.“Clinical

Practice Recommendations 2003.” Diabetes Care

26 (suppl. 1) (January).5 Guidelines are issued each

January.Archives provide information for each

year. (See http://care.diabetesjournals.org/content/

vol26/suppl_1/.) 

• American Diabetes Association. 2003b.“Management of Diabetes in Correctional Institutions.”

Diabetes Care 26 (suppl. 1) (January): S129–S130.

The American Diabetes Association has been producing this supplement for about 5 years.

• Diabetes Control and Complications Trial

Research Group. 1993.“The Effect of Intensive

Treatment of Diabetes on the Development and

Progression of Long-Term Complications in

Insulin-Dependent Diabetes Mellitus.” New

England Journal of Medicine 329 (14): 977–986.

• National Institutes of Health. 1997. The Sixth

Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood

Pressure. Bethesda, MD: National Institutes of

Health, National Heart, Lung and Blood Institute.

November, NIH 98–4080.

21

EFFECTIVE EVALUATION FOR IDENTIFYING THE SPECIAL NEEDS OF INMATES
• Puisis, Michael, and John M. Robertson. 1998.

“Chronic Disease Management.” In Clinical Practice

in Correctional Medicine, ed. Michael Puisis. St.

Louis, MO: Mosby, 51–66.

In May 2002, NCCHC received a demonstration

grant from the Robert Wood Johnson Foundation to

develop a correctional health care, outcome-based

measurement system that will provide feedback to

correctional systems to measure the percentage of

inmates with hypertension, diabetes, asthma, seizure

disorder, or HIV disease who are under good, fair, or

poor control at any time. For this demonstration

project, NCCHC will be working with the states of

Michigan and Georgia and will encourage those

states to assess their patients based on standardized

and agreed-upon definitions of good, fair, and poor

control for each disease.The data from the patient

encounters will be forwarded to NCCHC. Each correctional system will receive a quarterly report indicating the percentage of inmate patients with each

disease under good, fair, or poor control at each

institution within the system.Agency managers and

clinicians at each prison system will then use the

data to identify the prisons in which the highest percentages of patients are under good control and to

identify practices that can be employed to improve

the outcomes at other prisons within the system.

NCCHC hopes ultimately to create a permanently

funded system that will make this resource available

to all prisons on a voluntary basis.

The Michigan Department of Corrections, as part

of its chronic clinic program, has developed a unique

disability clinic for individuals who have serious

mobility or sensory-neural impairments.This disability clinic employs definitions of good, fair, and poor

control for inmates with mobility or sensory-neural

impairments.This allows the primary care provider

to see these patients on a regular basis (every 3

months) and to intervene with these inmates if it

is found that their problems are not under good

control. In Michigan, if someone with a disability has

several other chronic conditions, the disability clinic

is the main clinic in which all the other diseases are

addressed.

C HAPTER III

22

Most chronic clinic programs begin with a physician

writing an order to enroll the patient in the chronic

clinic program.At the first visit, comprehensive data

related to the specific disease and its potential complications are collected.A patient with hypertension

or diabetes will have information gathered with

regard to cardiovascular risk factors, smoking, etc.

Once these data are collected on the initial visit

(and this may include blood tests and other ancillary

studies), the physician is then able to develop a plan

for each patient.To have a successful chronic clinic

program with positive patient outcomes, it is incumbent on the physicians to work very closely with

the patients, as it has been shown that shared

responsibility between patient and provider is correlated with success in achieving positive treatment

outcomes.

Most well-run chronic care clinics in corrections settings rely heavily on registered nurses. Registered

nurses perform valuable functions in patient education, medication counseling, and assurance that

appropriate tests are performed before a scheduled

chronic care clinic visit.A well-organized chronic

clinic program in which good outcomes are achieved

is almost certain to reduce such costs as emergency

room visits and hospitalizations.This is an example

where an initial investment in developing an organized chronic care program with well-trained professional staff benefits both the inmate and the agency.

Mental Illness 

Several jurisdictions have reported that roughly

15 percent of all prison inmates suffer from some

variety of mental illness (Council of State Governments, 2002). Most of these individuals have personality disorders; in addition, a significant minority of

individuals have schizophrenia or affective disorders.

The initial intake history, physical exam, and screening

evaluation are designed to detect histories of mental

illness and to identify individuals whose behavior

requires some kind of intervention. Beyond the

intake evaluation, many prison systems provide various psychological tests to further delineate mental

health and mental retardation problems. Most
systems employ formal psychological testing to

detect developmental disabilities. Many systems also

use such psychological tests as the Minnesota Multiphasic Personality Inventory (MMPI), Draw-A-Person

test, or Finish Sentence test. Individuals with an identified mental illness then receive a more comprehensive mental health evaluation.This evaluation

determines whether the inmate requires an acute

mental health inpatient bed, a chronic mental health

bed, or maintenance on an outpatient mental health

caseload.The mental health evaluation is also important in determining whether the individual is at risk

for suicide. If it is determined during the intake

process that an individual is at risk for suicide, the

inmate generally will be placed under suicide observation until the situation has been stabilized.

Individuals who are being followed in an outpatient

mental health program or in a program for the

chronically mentally ill should be provided with as

much relevant programming as possible.They may

participate in educational and some vocational activities. It is important, however, to identify and track

their problems and status so that they do not become lost to followup and, therefore, fail to benefit

from followup interventions.When these inmates

are lost to followup, the likelihood of decompensation is greatly increased.

Another category of individuals with mental health

problems that must be addressed includes those

who have personality disorders, including selfmutilators; individuals with borderline personality

disorders; and others who are aggressively mentally

ill. Inmates with these problems disrupt both the

prison population and the health care program.

Historically, psychiatrists have attempted to avoid

responsibility for responding to these types of

patients because their diagnoses do not always meet

the definition of serious mental illness. On the other

hand, if mental health professionals do not participate in providing a structured program for these

inmates, then custody officers are in essence abandoned to their own devices in attempting to

respond to them.This is unfair to the custody officers, inappropriate for the inmates, and ultimately

disruptive to the prison environment. Individuals

with these types of problems function much better

in a structured behavior management milieu in

which positive and negative consequences of behaviors are part of the program rules.These rules go

beyond the traditional custody rules.An example is

entering into a behavioral management contract

with a self-mutilator who, when he cuts himself, may

be put into restraints for a defined period of time. If

the negative behavior is avoided, on the other hand,

privileges may accrue. Such inmates need to understand the consequences of their self-destructive

behavior, and the consequences need to be meted

out in a predictable way.

Individuals thought to have mental retardation,

defined as having an IQ below 70 and significant

deficits in everyday living skills, should reside in a

dedicated environment.This type of setting will allow

them to receive the assistance of competent others

and help them function adequately and avoid the

need for confinement to ensure their safety.

Terminal Illness 

Most systems define inmates as terminally ill if they

are known to have a disease determined to be fatal

and have less than 6 months to live. In the CJI survey, the two most often mentioned program responses for terminally ill inmates were hospice

programs and programs for compassionate release,

both discussed earlier in this report.Whatever the

response, it is important that inmates with terminal

conditions be identified as soon as possible. Some

individuals with terminal illnesses are able to function quite adequately in the mainstream population

until shortly before their death. Still others may

require a more protected inpatient housing arrangement. In general, the terminally ill inmate should participate in the decision as to whether or not to

remain in general population housing; most inmates

prefer to stay in the general population to the extent that they are physically capable. Regardless of

where the inmate resides, the sooner these individuals and their problems are identified, the sooner an

appropriate plan can be made for their housing and

functioning within the prison environment.

23

EFFECTIVE EVALUATION FOR IDENTIFYING THE SPECIAL NEEDS OF INMATES
Women’s Health Problems 

It is well recognized that women, both in the free

world and in corrections, use health services far

more frequently than their male counterparts and

that they have distinct health care requirements.

Women’s institutions require more physician hours

per 100 inmates than prisons that house men.Thus,

it is incumbent on a prison system to provide adequate resources to ensure that women’s problems

are addressed in a timely, effective, and efficient

manner. During the intake process, it is important

to identify any problems related to pregnancy,

menstruation, mental and emotional problems, and

history of abuse. Because women who are incarcerated are at very high risk for both sexually

transmitted diseases and certain types of cancer, it

is important to include testing for sexually transmitted diseases, such as gonorrhea, chlamydia, and

syphilis, as part of the reception process and to conduct a pelvic examination and Pap smear to identify

cervical cancer.

TRACKING INDIVIDUALS

WITH SPECIAL NEEDS

In many prison systems, grievances and litigation

have occurred because problems identified at one

institution are not followed up at a second institution. Problems and delays may occur, for example,

when medical equipment or supplies that are needed for an inmate’s accommodation and ordered by a

physician at one institution must be reordered by

another physician when that inmate is transferred to

a new institution.

The Michigan Department of Corrections has developed a model program that attempts to reduce

these types of problems. Michigan’s system begins

during the reception process when a Special Needs

Identification Screening Form is completed in the

reception area.This form identifies individuals’ limitations with regard to a number of physical problems.

It also identifies particular appliances that individuals

may need to be adequately accommodated, along

C HAPTER III

24

with any ongoing treatments, restrictions, or special

needs (e.g., provision of a low bunk or housing in a

low gallery) that may be required.The reception

physician completes the form. In addition, the department has developed a form called the Special

Accommodation Notice.This form, prepared in

quadruplicate, identifies needs for housing, work

assignment, medical equipment and supplies, transportation, therapeutic diet, communication assistance, and any other needs that the physician may

indicate.This form goes in the unit health record

with copies going to the inmate’s master file, to the

counselor, and to the inmate.This form is universally

recognized at all Michigan correctional institutions,

and all accommodations that are checked on this

form must be adhered to unless a new, updated

form is generated that calls for changes in the

accommodations ordered. Since the implementation

of this form, problems of inmates being denied necessary accommodations after moving from one institution to another have been dramatically reduced. In

addition, at one Michigan institution, the G. Robert

Cotton Correctional Facility, this information is

maintained in a computer file, which also identifies

the inmate’s location within the prison.This automated system is now being planned for use throughout the Michigan prison system. On a printout from

the G. Robert Cotton Correctional Facility, one can

immediately identify inmates who use wheelchairs as

well as those who must have bottom bunks, must be

on the ground floor, must be in a single cell, or are

hearing impaired.

In addition, Michigan correctional physicians fill out

a Medical Detail Form to identify inmates who are

expected to need an accommodation for fewer than

6 months.The physician indicates the accommodation and the expiration date (see appendix B,

“Site Visit Report: Michigan Department of

Corrections”).

CONCLUSION

By identifying special needs early and then providing

an organized approach to meeting these special
needs, prison systems will be able to more satisfactorily handle the variety of problems that they must

address. Clearly, this will minimize grievances, decrease litigation, and create a more accepting inmate

population.With such policies and procedures in

place, it will be much easier to manage a prison with

all of its complicated human interactions.Although

the challenges are great, substantial rewards may be

derived from designing and implementing a comprehensive approach to identifying and responding to

inmates’ special needs that begins at the time they

are processed through reception.

NOTES

1. SF–36v2TM Health Survey Scoring Demonstration;

http://www.sf36.com/demos/SF-36v2.html.

2. Personal communication from B. Jaye Anno to

Steven Shelton, Medical Director, Oregon

Department of Corrections.

3. See, for example, Armstrong v. Terhune (California

Department of Corrections); Armstrong v. Davis, 124

F.3d 1019 (9th Cir. 2001).

4.Additional information regarding NCCHC clinical

guidelines may be obtained from its Web site at

www.ncchc.org.

5.The American Diabetes Association produces an

annual supplement to Diabetes Care that contains

clinical practice recommendations. Guidelines are

updated and issued each January.Archives provide

information for each year. (See http://care.

diabetesjournals.org/content/vol26/suppl_1/.)

REFERENCES

American Diabetes Association. 2003a.“Clinical

Practice Recommendations 2003.” Diabetes Care 26

(suppl. 1) (January).

American Diabetes Association. 2003b.“Management

of Diabetes in Correctional Institutions.” Diabetes

Care 26 (suppl. 1) (January): S129–S130.

Anno, B. Jaye. 2001. Correctional Health Care: Guidelines for the Management of an Adequate Delivery

System. 2001 Edition. Chicago, IL: National Commission on Correctional Health Care.

Council of State Governments. 2002. Criminal

Justice/Mental Health Consensus Project. New York,

NY: Council of State Governments, June.Available

online at http://consensusproject.org.

Diabetes Control and Complications Trial Research

Group. 1993.“The Effect of Intensive Treatment of

Diabetes on the Development and Progression of

Long-Term Complications in Insulin-Dependent

Diabetes Mellitus.” New England Journal of Medicine

329 (14): 977–986.

National Commission on Correctional Health Care.

2002. The Health Status of Soon-To-Be-Released Inmates:A Report to Congress. Chicago, IL: National

Commission on Correctional Health Care.

National Institutes of Health. 1997. The Sixth Report

of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Bethesda, MD: National Institutes of Health, National

Heart, Lung and Blood Institute, November. NIH

98–4080.

Puisis, Michael, and John M. Robertson. 1998.

“Chronic Disease Management.” In Clinical Practice in

Correctional Medicine, ed. Michael Puisis. St. Louis,

MO: Mosby, 51–66.

25

EFFECTIVE EVALUATION FOR IDENTIFYING THE SPECIAL NEEDS OF INMATES

Chapter IV

PROGRAM, HOUSING, AND

TREATMENT CONSIDERATIONS

29

INTRODUCTION

A number of individuals who are chronically ill, elderly, or terminally ill require special accommodation

in their housing and program assignments. Owing to

their physical condition, they often need specialty

care in addition to basic health services. In this chapter, treatment, programs, and accommodation for

inmates with special needs are explored in detail.

Examples are given of how these special populations

are managed in the six state prison systems that

were visited.Although the terms “elderly,” “chronically ill,” and “terminally ill” are not mutually exclusive, for practical reasons they are discussed

separately below.

ELDERLY INMATES

Strong encouragement to live healthier lifestyles,

coupled with advances in medical treatment, have

contributed to longer lives for more people. In the

general population outside prison, recent census

data indicate that people older than age 65 represent the fastest growing segment of the U.S. population.At the turn of the 20th century, only 4 percent

of the U.S. population was older than age 65; at its

close, this figure had more than tripled. Projections

for the year 2050 place the number of Americans

older than age 65 at 20 percent of the population

(Robert Wood Johnson Foundation, 1998).

A similar trend can be seen among the incarcerated.

Although they still represent a minority of prison

admissions, offenders older than age 40 represent

the fastest growing segment of the inmate population in many states.This is true for two reasons:

first, more offenders in this age group are being sentenced to prison; and, second, mandatory sentences,

longer sentences, and more restrictive release policies mean that more inmates are growing old behind

bars (Anno, 2001).

It is difficult to state with any precision how many

elderly inmates are in U.S. prisons at any given time,

partly because there is no universally accepted definition of the term “elderly.” The Federal Bureau of

Prisons defines as elderly those inmates who are

older than 50 years of age; however, different states

use ages 50, 55, 60, or even 65 as their lower limit

to define elderly inmates (see the CJI survey results

in appendix A). In the six prison systems visited for

this report, two had no definition of elderly (New

York and Pennsylvania), Ohio and Oregon defined

elderly inmates as age 50 and older, Minnesota used

age 55 as the lower limit, and Michigan used age 60

and older.

Regardless of the lower age limit used to define elderly inmates, correctional health professionals generally agree that the onset of geriatric conditions

usually occurs at a younger age among inmates than

among the general population.This difference is

largely attributable to inmates’ relatively greater

poverty and to their lifestyles, which are less healthy

than those of the general population. Most inmates

are poor and from racial, ethnic, and cultural minority groups that do not receive optimum health care

services. Most of them use or have used tobacco,

alcohol, and illicit drugs. Many have engaged in risky

Chapter 1V

PROGRAM, HOUSING, AND

TREATMENT CONSIDERATIONS
sexual practices and have had multiple sexual partners.These factors, taken together, make inmates as

a group “among the least likely to have had access to

preventive care or regular health services and

among the most susceptible to serious illness,

violence, and debilitating conditions” (Anno, 1997,

p. 291).

Treatment Needs 

It is clear that older inmates have considerably

greater health care needs than younger inmates in

the general prison population. Many suffer from

chronic illnesses, including heart disease, hypertension, diabetes, and chronic obstructive lung disease.

They also are subject to a number of conditions that

accompany the normal aging process, including loss

of vision, impaired hearing, sleep disturbances, incontinence, mental confusion, and gastrointestinal disorders. Osteoporosis (loss of bone density) is another

risk factor for older people, especially for women.

In fact, the cost of providing health care to older

inmates has been reported as three times the cost

for the typical adult inmate (Faiver, 1998).

Because of their increased risk of having one or

more chronic diseases as well as the debilitating

conditions that may accompany the aging process,

older inmates should be placed in institutions that

offer a full range of health services, including availability of health care staff and emergency care 24

hours a day, 7 days a week, and access to such specialty services as geriatrics, pulmonology, cardiology,

and nephrology.Additionally, some older inmates

may be too frail or weak to attend to their own

activities of daily living (ADLs) (e.g., eating, bathing,

toileting). Increasingly, larger departments of corrections (DOCs) are developing nursing home environments to care for their frail elderly who require

such assistance. In smaller DOCs that do not have

an extensive older population, the frail elderly typically are managed in an infirmary.

Elderly inmates also often need a number of adaptive devices that enable them to be more functional.

C HAPTER IV

30

All or almost all of the DOCs surveyed indicated

that they provide walkers and canes, hearing aids,

dentures, eyeglasses, supportive devices, warmer

clothing, and extra blankets to the older inmates

who need them. Geriatric chairs and beds were provided by more than half of the DOCs surveyed (see

appendix A).

Housing Options 

A number of older inmates are healthy and do not

require special housing.They can be placed in any

housing area that is appropriate to their custody

classification. Others may require placement in a

nursing home environment or in an infirmary, as

noted above.There is a third group of elderly

inmates, though, who are not sufficiently debilitated

to require nursing home placement but who still

need a sheltered housing area that can accommodate their special needs. Older inmates may have difficulty relating to younger, more aggressive inmates.

Additionally, they are more prone to being victimized by younger inmates.Also, according to Faiver:

The physical plants commonly found in correctional facilities were designed for young

and physically active inmates. Living units

and support service buildings frequently are

scattered over wide areas, and inmates

must walk long distances for meals, medical

services, and other activities.Architectural

barriers, such as steps, narrow doorways,

and lack of handrails or grab bars, present

additional problems which older inmates

encounter. Poor ventilation and inadequate

climate control can be extremely hard on

the elderly. . . . (Faiver, 1998, p.130)

As a consequence, some correctional systems now

provide separate living facilities for the elderly, the

handicapped, or others who may benefit from a

more sheltered environment. Examples include facilities in Minnesota, Oregon, Pennsylvania, and Ohio

(see site reports in appendix B).
The Linden Unit at Minnesota

Correctional Facility, Faribault,

Minnesota 

The Minnesota Department of Corrections (MDC)

offers special housing for older inmates.Although

elderly inmates in Minnesota (defined as anyone 55

years of age or older) may remain in the general

prison population if they choose to do so, they also

may choose to live in a dedicated housing unit at the

Minnesota Correctional Facility (MCF) at Faribault.

MCF-Faribault, a medium-security facility for adult

males, has established the Linden unit, a special

housing unit for inmates with chronic health problems who are 55 or older and for younger inmates

with disabilities (such as those who are blind, deaf,

or confined to wheelchairs).The Linden unit has 103

beds.At the time the site visit for this report was

conducted, 80 beds were filled with special needs

inmates (both elderly and disabled).The other beds

were used by inmates from the general prison population.According to the nursing staff, general population inmates are moved out if beds are needed for

special needs inmates, but they are required to keep

the beds filled.The Linden unit has licensed practical nurses who provide coverage 16 hours a day.

Nursing coverage is available 24 hours a day in the

main clinic area. Inmates housed at Linden must be

able to perform their own ADLs, including eating,

bathing, and toileting. If inmates require assistance

with their ADLs or 24-hour nursing care, they are

transferred to the Transitional Care Unit (infirmary)

at MCF-Oak Park Heights.There is no “keep on the

person” medication program in Minnesota.The nurses pass all medications individually to ensure better

compliance.

The features and accommodations of the Linden

unit, including the recreation equipment, dining area,

and telephone booths, are handicapped accessible.

There are TTY machines for the deaf, and interpreters are provided for all adversarial hearings.

Special needs inmates stay in two-person rooms

(not cells). Hospital beds with railings are available as

needed. General population inmates assigned to this

unit reside in dorms.

Inmates who are wheelchair bound or severely disabled may be assigned a personal care attendant

(helper), who helps the inmate clean the room, push

the wheelchair, and perform other activities.The

personal care attendant may not assist with ADLs

because, as noted above, inmates at Linden must be

able to perform their own ADLs.

Inmates assigned to the Linden unit usually do not

mix with general population inmates in other housing areas.They have their own dining area, weight

room, craft room, and recreation area with a pool

table. Little other programming is available. Job

assignments are limited to janitor, kitchen worker, or

personal care attendant. During the summer, a horticultural program is provided, and inmates may plant

a garden. Inmates who are 55 and older who choose

to live at Linden cannot work because the DOC

considers them to be “retired” (see appendix B,“Site

Visit Report: Minnesota Department of

Corrections”).

Unit 13 at Oregon State

Correctional Institution 

The Oregon Department of Corrections defines

anyone older than age 50 as elderly. However, it has

no special programs or housing specifically for elderly inmates. Unit, program, and work assignments are

based on the functional abilities of individual inmates

older than 50.

At Oregon State Correctional Institution (OSCI),

however, a 61-bed dorm (called Unit 13) offers a

more protected environment for elderly, disabled,

and mobility-impaired male inmates. Eighteen inmate

orderlies work in this dorm (12 as janitors and 6

who assist with ADLs, such as providing “wheelchair taxi service” as needed). Hospital-style beds 

equipped with extra padding, bedding, trapeze features, etc., are provided as needed.Toilets, sinks, and

showers are handicapped accessible.At special times,

Unit 13 inmates can use a therapeutic gym equipped

with a pool table configured at a lower height to

accommodate those in wheelchairs.An elevator

ramp is available adjacent to the stairway leading to

31

PROGRAM, H OUSING, AND TREATMENT REATMENT CONSIDERATIONS ONSIDERATIONS
the gym. Unit 13 has its own barbershop and sewing

program to reduce the amount of movement these

inmates must make. It is important to note that Unit

13 is not an inpatient unit.Although nursing care

is available at OSCI 22 hours a day, the inmates

assigned to Unit 13 do not require ongoing nursing

services. If they do, they are transferred to the nursing home at the Snake River Correctional Institution.

The Oregon system provides several other accommodations for inmates with specific disabilities.

Several units have wheelchair taxi service available;

this is a paid job for the inmates who provide the

service. Blind inmates may be assigned a “seeing eye”

cellmate. Closed-captioned television and specially

equipped phones are available for the hearing

impaired.Although only the newer units are ADA

compliant, most prisons in the system have at least

some cells that are handicapped accessible (see

appendix B,“Site Visit Report: Oregon Department

of Corrections”).

State Correctional Institution at

Laurel Highlands, Pennsylvania 

In 1996, the Pennsylvania Department of Corrections established a special prison for elderly inmates

and others who require long-term care or assisted

living. DOC’s management recognized that housing

elderly and infirm inmates at multiple sites required

duplicating services, which increased costs and lowered quality. Hence, a decision was made to convert

the Somerset State Hospital (which had been closed

as a result of the mental health system’s deinstitutionalization policy) to a special prison unit known

as State Correctional Institution (SCI) Laurel

Highlands. In an innovative development, a decision

was made not only to convert the state hospital to a

correction/geriatric/assisted living facility but also to

convert the existing staff to that purpose. Department of Welfare employees, mostly registered nurses, licensed practical nurses, and certified nurse

assistants, were screened and then offered correctional health positions with the understanding that a

new program for elderly inmates would be developed.This not only saved jobs but also created a

C HAPTER IV

32

positive work ethic and morale that continue to

contribute to the program’s success.

SCI Laurel Highlands has 437 inmates, including longterm care inmates (capacity 107) managed at the

skilled nursing/high-acuity level; the Personal Care

Program (capacity 140), which is a self-care/assisted

living program; and a general population work cadre

that assists staff in maintaining the facility. Expenses

average approximately $65,000 per inmate per year

versus $27,000 per inmate per year elsewhere in the

Pennsylvania system.

Admission to SCI Laurel Highlands is based on a

functional assessment.The referring institution completes an eight-page application.A senior nurse from

Laurel Highlands often goes to the referring institution to assist in this process.The facility is able to

accommodate adult males of all security classifications. Nursing staff are available around the clock

(see appendix B,“Site Visit Report: Pennsylvania

Department of Corrections”).

Hocking Correctional Facility, Ohio 

In Ohio, all wardens receive training on the aging

process and its impact on inmates. In five institutions, elderly inmates are housed together in distinct

units; one of these is the Hocking Correctional

Facility (HCF). HCF is a medium-custody facility

holding older adult males.As of November 5, 2001,

HCF had a population of 403.The inmates’ ages

range from 37 to 90 years; the mean age is 61 years.

More than 90 percent of the population at HCF is

older than age 50.

At HCF, a program called 50+ and Aging addresses

the physical, psychological, and social needs of older

inmates. Programs and services, including chair aerobics, adult basic education, and GED classes, are

provided.All HCF inmates have job assignments

designed to meet their needs, including positions

such as elevator operator and other sitdown jobs.

A case manager assists inmates in a variety of areas,

including applying for Social Security benefits, completing Medicaid and Medicare applications, writing

wills, securing postrelease placement, and obtaining
housing and meal services. Recreational activities

geared to older inmates are offered, such as bingo,

wiffleball, shuffleboard, horseshoes, putt-putt, board

games, and a three-level (beginner, intermediate, and

advanced) walking program.

In addition, the mental health department at HCF

has developed an Associate Aide Program to assist

inmates who suffer from memory loss and other

mental conditions. Inmates who are interested in

serving as an aide complete an application and are

then interviewed and screened.The aides are required to attend annual training that reviews the

duties they are expected to perform and those they

are prohibited from performing. In general, the aides’

responsibilities include serving as an escort to appointments, meals, commissary, etc., until locations

and routes are learned and reminding their assigned

“associates” of upcoming appointments, the importance of personal hygiene, and other concerns (see

appendix B,“Site Visit Report: Ohio Department of

Rehabilitation and Correction”).

Program Considerations 

The most important consideration in determining

program assignments for older inmates is their physical limitations. Factors such as hearing and vision

loss, reduced physical strength, and the inability to

stand for long periods of time affect the types of

work assignments that may be appropriate. Similarly,

these same factors may affect the types of recreational activities that are appropriate for the elderly.

Special accommodations may be required in educational programs as well, such as use of large print

books and other materials.

Despite their physical limitations, older inmates need

to stay physically active and mentally alert as long as

possible.They can benefit from a number of adult

education courses and self-help programs, particularly those that will help them more successfully reenter the world outside prison.As Faiver notes:

Douglass et al. pointed out the importance

of considering the plight of long-term inmates who return to a world that rejected

them and that they rejected.The older, discharged prisoner usually faces substantial

difficulties upon reentry to the community,

as highlighted by a 1988 study of elderly

homeless persons in Detroit. It showed that

the probability of homelessness for the elderly was as strongly associated with prior

prison experience as with mental hospitalization (about 30 percent). (Faiver, 1998,

p. 132)

One facility that provides significant educational programming for the elderly is the Ohio Reformatory

for Women in Marysville, Ohio. It has approximately

12 different educational and recreational programs

that deal with problems and issues relevant to elderly or special needs female inmates.These include

educational and support programs, such as “The

Aging Process,” which presents information on what

to expect and how to come to terms with the aging

process;“Topic Talk,” a guided discussion group that

encourages women to take more control of their

lives;“Helping Others Together (HOT),” which

allows inmates to assist fellow inmates who are incapable of performing ADLs;“Heart to Heart,” an educational support program for women who are

chronically ill; and “Topics of Powerful Significance,”

which addresses health issues, codependency issues,

substance abuse, and other topics.A special recreation program is suited to the limitations of special

needs inmates, and a garden club encourages the

women to get involved in outdoor horticultural

activities. Inmates also are given information to assist

them with prerelease planning on such relevant

topics as Social Security, Medicare/Medicaid, estates

and wills, advance directives, funeral planning, and

community-based services (see appendix B,“Site

Visit Report: Ohio Department of Rehabilitation and

Correction”).

33

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
CHRONICALLY ILL

INMATES

By definition, chronic illnesses are either ongoing or

recurring. Individuals with such chronic conditions as

asthma,AIDS, heart disease, diabetes, hypertension,

and hepatitis C and those with certain permanent

physical conditions (e.g., paraplegia) need to be monitored closely to maintain their health status or to

slow the progression of their disease or condition.

The first step in developing an effective program is

to identify the number of inmates in any given system with specific chronic conditions.Although this

seems obvious, the health care staff in many DOCs

still cannot state with precision how many inmates

they have at any given time with specific chronic

conditions.A 1998 survey conducted by the National Commission on Correctional Health Care

(NCCHC) and the National Institute of Justice of

the 50 state prison systems, the District of Columbia, and the Federal Bureau of Prisons found that of

the 41 systems responding, only 19 (46 percent)

were able to identify the number of inmates in their

systems with specific chronic diseases (Hornung et

al., 2002).

Identification of chronic diseases and conditions

should occur at intake, at the time of repeat health

assessments, or whenever a clinician suspects the

onset of a disease based on the patient’s clinical

symptoms. It is helpful to develop a database of

inmates with chronic conditions so they can be

tracked centrally for planning purposes and they can

receive attention and relevant programs regardless

of their unit of assignment.

Treatment Needs 

People with chronic conditions generally are among

the sickest of the prison population. Consequently,

they should be placed in facilities that have the highest level of health care services available, including

around-the-clock emergency services, nursing care,

infirmary care, and specialty care.

C HAPTER IV

34

Each DOC should have clinical protocols for specific

chronic conditions (based on national guidelines)

that provide direction to practitioners in managing

their patients’ care.A number of professional specialty societies (e.g., the American Diabetes

Association) and government agencies (e.g., the

Centers for Disease Control and Prevention, the

National Institutes of Health) offer regularly updated, evidence-based protocols for managing such diseases as asthma, diabetes, tuberculosis, HIV, and

hepatitis C. In addition, NCCHC has developed sample clinical protocols for six chronic diseases based

on national guidelines.1

Each chronic care patient should have an individualized treatment plan that specifies the types of medication prescribed; any restrictions on exercise, diet,

or work assignments; the type and frequency of laboratory and other diagnostic testing; any special

therapies needed (e.g., respiratory therapy, physical

therapy); and the frequency of followup for reevaluation of the patient’s condition and adjustment of the

treatment plan as necessary (Anno, 2001; National

Commission on Correctional Health Care, 1997).

The frequency of followup is dependent on the

extent to which the patient’s disease is controlled

under the current treatment regimen.A number of

correctional health practitioners recommend that

most chronic care patients be seen by a provider,

such as a physician, physician’s assistant, or nurse

practitioner, every 3 months.2 A provider can see

more stable patients every 6 months, with an intervening nurse visit. Less stable patients should be followed more often, as dictated by their clinical

condition.

Establishing chronic care clinics where such patients

are scheduled for routine revisits to the health unit

can help ensure they receive needed care. Some

DOCs group their patients with the same disease

together, so that, for example, diabetics are seen on

the third Tuesday of the third month, asthmatics on

Wednesdays, etc. In Minnesota, at the time of the

site visit conducted for this report, the medical

director was working on developing clinical
protocols and planned to implement chronic care

clinics at each of the prisons.The plan is that all of

the institutions for adult males will have the same

schedule for chronic care clinics to ensure that

inmates who are transferred to a different facility do

not miss their appointments (see appendix B,“Site

Visit Report: Minnesota Department of

Corrections”).

In the Oregon system, on the other hand, inmates

with the same diagnoses are not all scheduled to

be seen at the chronic care clinic on the same day.

Instead, they receive individual appointments. Staff

there found that many inmates have multiple problems and do not fit neatly into one diagnosis. In addition, the Oregon health care staff felt that such

scheduling would undermine patient confidentiality, in that other inmates could easily ascertain a

patient’s diagnosis simply by tracking who attended

which clinics on which days (see appendix B,“Site

Visit Report: Oregon Department of Corrections”).

Regardless of how chronic care clinics are organized,

several correctional health experts recommend that

flowsheets be used at each encounter to track the

patient’s progress (Puisis and Robertson, 1998;

Spencer, 1999). Flowsheets record basic data regarding laboratory test results, medications, vaccinations,

weight, blood pressure and/or glucose readings, vital

signs, etc., based on the specific disease entity being

followed.They enable the provider to see at a glance

what has been done and how well the patient is

doing on his or her current treatment regimen, and

they serve as a reminder to the provider when additional tests or exams need to be ordered.

Patient education is another important component

of chronic disease management. Counseling and selfcare instruction by providers, dietitians, or health

educators can be of great assistance to these

inmates, both within the correctional facility and

when they return to the community. Diabetics, for

example, can be instructed on how to select an

appropriate diet, monitor their glucose, and administer their own insulin.Although health care staff still

must monitor some of these activities for security

reasons, the inmates will have received valuable

information that they can use to care for themselves

throughout their entire lives.Teaching inmates to

assume some responsibility for managing their

chronic conditions also can improve their adherence

to a treatment regimen while they are incarcerated

(Anno, 2001).

Housing Options 

As noted above, owing to the serious nature of

many chronic conditions, inmates diagnosed with

such conditions should be housed in prisons with

the highest available level of health care services.

They also should have ready access to an acute care

hospital, as these are the patients most likely to have

a medical crisis.Within an institution, many chronic

care patients will have other housing needs that

should be considered. For example, frail inmates and

those with seizure disorders will require a bottom

bunk.Those suffering from heart disease, certain respiratory conditions, or difficulty in ambulating should

be housed on a lower tier to avoid the need to

climb stairs. If the facility is not smoke free, certain

chronic care patients, particularly those with respiratory ailments, require placement in nonsmoking cells

or dorms. Patients with certain spinal cord injuries

must be housed in air-conditioned areas. Mobilityimpaired inmates should be placed in a barrier-free

facility, or at least in a housing area that is handicapped accessible.As noted below, health care

providers should develop a mechanism to inform

classification staff of inmates’ special housing

considerations.

Program Considerations 

Inmates with chronic diseases often have special

requirements that should be taken into account

before work, school, and other program decisions

are made.Typically, correctional agencies have a systemwide classification board that makes initial unit

assignments and reviews transfer requests, and unit

classification committees that determine work, housing, and program assignments. For these groups to

35

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
make effective decisions, they must have some information about inmates’ medical and mental health

status.The dilemma for health professionals is how

to provide classification staff with important information about inmates’ health conditions without

violating the inmates’ right to confidentiality.The

solution is relatively simple: a form that summarizes

any medical restrictions regarding housing, work, or

program assignments without revealing the inmate’s

precise condition or diagnosis (Anno, 2001).

The form should include, for example, any restrictions in terms of facility assignment (e.g., medical

facility, barrier-free facility, extended care facility),

unit housing assignment (e.g., single cell, special

housing), bunk assignment (no restriction or lower

bunk only), or row assignment (no restriction or

ground floor only). It also should address specific

work restrictions, such as sedentary work only, limited standing, no walking more than a specified number of yards, no lifting more than a specified number

of pounds, no temperature extremes, no exposure

to environmental pollutants, etc. Such a form should

be completed for each inmate at the time of admission to the prison system (based on the initial health

assessment) and updated periodically when an inmate’s condition improves or deteriorates. One

copy should be sent to the classification committee

and another copy retained in the inmate’s health

record.3

TERMINALLY ILL INMATES

Given the fact that aging and chronic illness are both

progressive, it is inevitable that a number of inmates

with these conditions will reach a terminal stage.

While there is no consensus about how “terminal”

is defined, the concept of a prognosis of less than 6

months to live is gaining increasing acceptance.

Treating a terminally ill individual in prison is difficult

at best. Inmates are usually isolated from their

friends and family on the outside precisely when

they need them most. In addition, compassion for

the dying means that correctional health care staff,

C HAPTER IV

36

as well as other correctional staff, must make a

change in the way they relate to the terminally ill—

one that transforms them from inmates to patients

to human beings.

There are other concerns as well. Inmates seldom

trust that the correctional system is acting in their

best interests.That is why it is so important that

they be given the opportunity to participate in decisions regarding end-of-life care in a voluntary, uncoerced manner. Dying patients should be provided

with information on available treatment options,

including any remaining curative procedures, as well

as palliative care and hospice services.They also

should have the opportunity to issue advance directives such as living wills, health care proxies, and “do

not resuscitate” (DNR) orders (Dubler and

Heyman, 1998).

In the sections that follow, the special needs of this

growing subset of inmates are discussed, along with

examples of how different prison systems manage

this population.

Treatment, Housing, and

Program Needs 

Terminally ill inmates need to be placed in facilities

with the highest level of available health care services.While they are still receiving curative treatment,

such patients require medication for pain and discomfort and frequent access to specialty services;

they tend to cycle in and out of infirmaries and hospitals.As their condition worsens, they often will

require around-the-clock nursing services. Inevitably,

they reach a point where medicine can offer little

help.The primary health goal then shifts from one

of curing illness to palliative care, which entails keeping the patient comfortable and pain free, and also

helping the inmate adjust to imminent death. Because terminally ill individuals may experience

increased anger and depression and are at increased

risk of suicide, the involvement of clergy, mental

health professionals, and others who can offer supportive counseling is essential (Anno, 2001).
Although the usual prison work and school programs are seldom options for them, terminally ill

inmates need to be kept humanely and comfortably

occupied.The availability of books, music, and, above

all, companionship are important components that

can elevate a dying patient’s mental outlook.

Just as hospice services are becoming an increasingly

common option for terminally ill people in the community, the same is true for people dying in prison.

In the assessment conducted as part of this project,

half of the responding DOCs reported that they

offered hospice services (see appendix A). Four such

programs are described below. For staff contemplating the initiation of a hospice program, the Standards

of Practice for End-of-Life Care in Correctional Settings,

developed by the Guiding Responsive Action in

Corrections at End-of-Life (GRACE) Project of the

Volunteers of America, can be helpful (GRACE

Project, 2000).

Minnesota Correctional Facility,

Oak Park Heights 

Owing to its small size, MDC does not have a hospice unit. Instead, terminally ill inmates (males only)

are managed in the Transitional Care Unit (infirmary), the Mental Health Unit at MCF-Oak Park

Heights, or in community facilities under a conditional release process. Hospice care is included as

part of MDC’s contract with Correctional Medical

Services (CMS). CMS contracts with Health East

Hospice, which is a part of Saint Joseph’s Hospital

in Saint Paul.When a terminally ill inmate chooses

hospice care and will remain at MCF-Oak Park

Heights, a nurse and a social worker from Health

East Hospice staff meet with the inmate and his family to discuss their services.The hospice staff explain

the options available to the patient and, based on

the patient’s wishes, help the patient execute

advance directives, which can include DNR orders,

“do not intubate” orders, maximum pain relief, and

other options. Hospice staff also work with the facility’s nursing staff and the patient to develop a plan of

care.Thereafter, they visit the patient at least once

each week.

No specific written criteria need to be considered for

hospice care in Minnesota.“Terminal illness” is not

defined by time, level of functioning, the patient’s specific diagnosis, or the inmate’s current offense. Instead,

the only criterion is a physician’s recommendation

that the patient receive a consultation with hospice

staff.

MCF-Oak Park Heights normally allows 16 hours

of visitation each month. Special visitation arrangements are made for the hospice patient’s family over

and above the regular visits, however, including bedside visits when the individual is no longer ambulatory. Decisions regarding visits by other inmates are

made on a case-by-case basis. Religious counseling is

available if the hospice patient requests it. Memorial

services led by religious leaders are held when the

patient dies.

Palliative care is available for terminally ill inmates

and for those with other painful conditions.

Intravenous narcotics are not used; only patches,

pills, and injectable liquids are permitted.All narcotics are administered under directly observed

therapy. If a patient is in the general population

rather than the Transitional Care Unit, only oral

narcotics are permitted.

Staff indicated that administrative and custody staff

at MCF-Oak Park Heights never exhibited any concern about or resistance to the hospice or palliative

care programs.According to the warden,“Medical

staff make the medical decisions, and we figure out

how to implement them” (see appendix B,“Site Visit

Report: Minnesota Department of Corrections”).

Coxsackie Correctional Facility,

New York 

The Coxsackie facility currently operates the only

hospice program offered by the New York State

Department of Correctional Services (NYSDOCS),

although others are planned for other regional medical units (RMUs) operating in the prison system.The

hospice program is located within the Coxsackie

RMU and is managed as part of the RMU contract

by Correctional Medical Services. It is not a discrete

37

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
unit with a specific number of beds but, rather, a

series of services provided to individuals designated

as terminally ill who have chosen hospice for their

end-of-life care.As many as 12 hospice patients have

received services at one time. Last year, the program

served 28 male inmates. Hospice services have been

available at Coxsackie since 1997 through a contract

with a community hospice program, but CMS staff

themselves have provided these services only since

October 2001.

The Coxsackie hospice program uses the National

Hospice and Palliative Care Organization definition

of 6 months or less to live as its definition of terminal illness. Staff members have developed worksheets for several diseases and conditions to assist

physicians in determining who may be terminally ill.

Unlike consideration of medical parole, the type of

crime the inmate committed is not a factor in determining eligibility for hospice services.

All RMU staff undergo training in hospice philosophy

and programs.The RMU director of nursing is a certified case manager and a hospice and palliative care

nurse.A certified hospice volunteer from the community provides assistance.The program also benefits from the services of four hospice aides, who are

inmates paid to work in these positions.These aides

receive 40 hours of preservice training.Their primary role is to provide companionship for the dying

patient (e.g., reading, talking, writing letters, listening).

They do not assist in any way with patient care

activities but are permitted to touch the patient

(e.g., hold his hand, rub his back) if staff approve of

such contact.This is a compelling and compassionate

feature of this hospice program, particularly because

correctional health care staff are repeatedly warned

not to become emotionally involved with their

patients or to touch them in anything other than a

professional manner.Allowing the aides to have such

contact provides the necessary “human touch” that

is so important at the end of life.When death is

imminent, the aides hold a 24-hour vigil to ensure

that the inmate does not die alone.

C HAPTER IV

38

All inmates are required to issue advance directives

when they are admitted to the RMU.These are on

file if the inmate becomes terminally ill and elects to

receive hospice services. Inmates are not required to

issue DNR orders to receive hospice care but, if

they do not, the staff questions whether they really

understand the hospice philosophy.

Visits are available to all RMU patients on Saturdays

and Sundays.Arrangements can be made for midweek visits when necessary, and bedside visits are

permitted when the patient is in critical condition.

Terminally ill patients receive extra snacks and nutritional supplements, and staff try to fulfill special

requests if possible.

Palliative care is available to terminally ill inmates as

well as to those with other painful conditions. Both

intravenous and by-mouth medications (including

narcotics) are available for symptom control. Patientcontrolled analgesia (PCA) pumps (devices that

allow patients to control the dosing of pain medications) are seldom used, and the physicians in this

program avoid prescribing patches because of their

abuse potential.

According to the health care staff, the primary barrier to implementing the hospice program was the

resentment of line correctional officers who were

“morally opposed” to criminals receiving such services.The key to eliminating this barrier has been

to educate correctional staff that the basic rule of

treating inmates “professionally, but not compassionately,” shifts at the end of life (see appendix B,“Site

Visit Report: New York State Department of

Correctional Services”).

Oregon State Penitentiary, Salem 

A hospice program for men in the prison system is

located at the Oregon State Penitentiary (OSP).

Currently, there are no terminally ill women in the

Oregon prison system, but a room has been prepared at the Oregon Women’s Correctional Center

should the need arise, and health care staff there

have received hospice training.
At OSP, hospice patients are kept in the general

population as long as possible because that is their

“home.” When they become too ill, they are moved

to the infirmary, which has a 21-bed ward, two single

rooms, and two traditional secure cells.The hospice

patient can elect to be housed in one of the separate rooms or in the ward, depending on whether

he wants privacy or company.

The only criteria for receiving hospice care are that

two practitioners must have determined that the

inmate has less than a year to live and that the

inmate elects to receive hospice services.The

inmate’s diagnosis, level of functioning, and type of

crime are not considered. No staff are dedicated to

hospice care (in part, because few inmates require

these services), but OSP health care staff have

received training from a community hospice expert.

The program also utilizes pastoral counseling and 22

inmate volunteers, each of whom has received 44

hours of training in hospice philosophy and services.

Criteria for their selection include an absence of disciplinary reports over the past year, but there are no

restrictions on who may volunteer in terms of the

seriousness of the crime committed.The volunteers

are supervised by a nurse coordinator, who also

gives them their assignments.When death is imminent, the hospice volunteers organize a 24-hour-aday vigil.

Individuals who elect to receive hospice care are not

required to sign advance directives, including DNR

orders, but most do. Inmate law clerks in the law

library have copies of these forms for terminally ill

inmates who wish to use them.

Hospice inmates in the general prison population

follow the regular visitation rules.Those in the infirmary can have bedside visits, including visits from

other inmates that the patient has identified as “family.” If the patient is dying, children under the age of

18 may visit. On one occasion, a dying patient’s dog

was permitted to visit. Other amenities in the infirmary include special food and drinks, a television

with a VCR player, a CD player for music, and access

to the health services’ telephone where the patient

does not have to call collect.

Palliative care is available to terminally ill inmates as

well as those with other painful conditions. Patches

and pills are available to individuals in the general

prison population and PCA pumps are available to

those in the infirmary. Most of the narcotics taken in

pill form are crushed and floated in water, and all are

directly observed when taken. Staff admitted that the

patches had the potential of posing contraband

problems but said those with patches were checked

daily.

Staff indicated they were satisfied with their current

end-of-life care services but would like to do more

in the way of bereavement services after a patient

dies, especially for institutional staff and the inmate’s

prison family.They hold a memorial service in the

chapel when someone dies, but the infirmary staff

would like to take a further step and organize a

bereavement group.

Staff stated that the costs of hospice care are paid

for out of the regular health services budget.They

feel that hospice may save money because inmates

are not dying in the hospital where care and services would be more costly.

The health care staff found no real barriers to implementing the hospice program. Once they received

approval from the director of the DOC, the rest of

the correctional staff fell in line.They felt that it was

a real advantage that health services in the Oregon

DOC are a separate division and that they report to

the systemwide medical director rather than to a

warden (see appendix B,“Site Visit Report: Oregon

Department of Corrections”).

Corrections Medical Center, Ohio 

The Ohio prison system has a six-bed hospice unit

located at the state’s Corrections Medical Center.

Two separate three-bed rooms in a ward area are

considered to be hospice rooms. Eligibility criteria

for the hospice unit include a prognosis of less than

6 months to live and discontinuation of any curative

efforts. No criteria are related to level of functioning, type of crime, diagnosis, or any other factors.An

inmate’s decision to reside in the hospice unit must

39

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
be fully voluntary. On average, four patients are

residing in hospice beds at any given time.There is

no outpatient hospice program.

Owing to the small number of patients, no staff

members have been dedicated to the hospice unit.

Nursing staff are available nearby, as are other staff

from the Corrections Medical Center. Inmate volunteers are also used as part of the hospice program.

Stephen Ministries provides all inmate volunteers

with training geared to listening.After completing

this training, medical staff screen the inmate volunteers for their appropriateness for this position; the

screening includes consideration of the volunteers’

behavior while incarcerated.Those selected to serve

as volunteers are matched with the hospice patients

according to personality type.The volunteers function primarily as companions to the dying.They are

prohibited from providing any care.They may interact with the families of patients and participate in

predeath vigils.

Terminally ill inmates in Ohio may issue advance

directives, including DNR orders, but these are not

required for the inmate to receive hospice care.

Generally, family input is sought before the inmate

issues an advance directive. Staff report that family

members occasionally try to coerce the inmate to

issue a DNR order.

Once an inmate is in the hospice program, each person on the inmate’s list is permitted to visit the

inmate up to three times each week.When death

is imminent, there is no limitation on visitation.

Nonhospice patients at the Corrections Medical

Center are allowed a total of four visits each week.

If a general population inmate is terminally ill, the

number of visits permitted is based on his or her

security level, either once or twice a month. Other

inmates may visit hospice patients only if they are

volunteers or live in the same unit, although exceptions are made for blood relatives who are also

inmates.

Because staffing is minimal at the end-of-life program

at Columbus, the program operates at a low cost. It

is funded from regular revenues plus the efforts of

volunteers and donations.The program does receive

C HAPTER IV

40

some donations for appliances and special food.A

refrigerator is provided in the hospice unit, and additional food and drink are available to these patients

at all times.

Although hospice staff are generally satisfied with

the end-of-life services they are able to provide, they

would like to add a music therapist to the program.

They also would like to be able to use a massage

therapist for hospice patients but anticipate that

correctional staff would offer resistance.

The primary institutional barrier encountered when

the current hospice program originated was the correctional staff’s opposition to relaxing the rules on

visitation for a subset of the prison population. For

the hospice patients, however, these changes have

made a substantial difference. Hospice has also

allowed for much greater family involvement in caring for the dying inmate patient (see appendix B,

“Site Visit Report: Ohio Department of

Rehabilitation and Correction”).

Early Release Options 

Although 43 of the 49 DOCs surveyed in the CJI

study reported the availability of a compassionate

release program for seriously ill inmates (see appendix A), the time required to process the paperwork

as well as political considerations as to the type of

crime the inmate committed limit it as an option.

Only a few terminally ill inmates in most states are

granted compassionate release (see Dubler and

Heyman, 1998). Still, for inmates who meet a state’s

criteria for early release, the option should be

aggressively pursued. Care should be taken, however,

to ensure that the dying inmate has an adequate

release plan that considers the interest and involvement of family and friends on the outside. Responsible

release policies mandate that provisions be made for

continuing care of the terminally ill in community settings (Anno, 2001, p. 206).

The process for initiating an early release request

differs from state to state, as do the eligibility criteria.Those for four of the six states visited are

described below.
Minnesota 

If someone is gravely ill or cannot be medically managed within the MDC system, Minnesota provides

for conditional medical release. In this case, the

inmate is placed in an appropriate community health

facility to receive needed care.The basic criteria for

an inmate to be considered for conditional medical

release are that the inmate has a grave health condition that is not likely to improve, is incapable of selfcare, and does not pose a risk to public safety. If

these conditions hold, it must be determined that

the inmate’s health needs can be better met by a

community facility than in a prison.With conditional

medical release, an inmate can be placed in the community during his or her incarceration term but can

be brought back into the prison system if his or her

health improves to the point that it can be managed

within MDC facilities.

A request for conditional medical release of a specific inmate is initiated by health services personnel

and forwarded to the Hearings and Release unit. If

approved by that unit, the request is sent to central

office personnel (including the commissioner).The

process is not cumbersome and can be completed in

a week or so if necessary (see appendix B,“Site Visit

Report: Minnesota Department of Corrections”).

New York 

An inmate’s health status or medical needs can serve

as the basis for early release from NYSDOCS

through either a request for executive clemency or

medical parole.A Bureau of Executive Clemency

runs the former; the NYSDOCS deputy commissioner for health services manages the medical

parole program. Requests for medical parole for terminally ill inmates are usually initiated by the nurse

administrator at the inmate’s current facility of residence and forwarded to the deputy commissioner

for approval and processing.The legislature and

NYSDOCS commissioner have developed specific

criteria for medical parole, including the following:

• The inmate must be serving an indeterminate

sentence.

• The inmate must have a terminal health condition.

• The inmate must be “so debilitated or incapacitated as to be severely restricted in his or her ability

to self-ambulate and to care for him or herself.”

• The inmate must not be serving a sentence for

“murder in the first or second degree, manslaughter in the first degree, any sex offense . . . or

any attempt to commit any of these offenses.”4

Individuals who qualify for medical parole are usually

released to a subacute setting, although sometimes

they are released to home with hospice care.The

process generally takes about 2 months (see appendix B,“Site Visit Report: New York State Department

of Correctional Services”).

Ohio 

ODRC has a medical parole policy that establishes

procedural guidelines for the medical assessment of

inmates for whom death is imminent.This medical

parole policy delineates criteria for consideration

of inmates’ early release as if on parole. Imminent

death in Ohio is defined as a predicted life expectancy of less than 6 months.A physician initiates the

request for medical parole at the facility and forwards the request to the warden’s office.The warden then directs the heads of social services and

mental health each to generate a summary of the

inmate’s condition. Based on the accumulated data,

the warden makes a recommendation to the regional director, who determines whether to approve or

disapprove the request. If approved, the regional

director forwards his or her recommendation along

with the medical director’s statement, a placement

investigation request, and a background report to

the ODRC director.The director then asks the

Adult Parole Authority to conduct an investigation

into an appropriate community placement, identify

the terms and conditions to which the inmate will

be subject if released, and provide any additional

information that may assist the Governor in deciding

whether to grant the medical parole request.

41

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
If the request is granted, the inmate must agree to

abide by all terms and conditions, including a requirement that the inmate be medically evaluated if

requested by ODRC.A supervising parole officer

monitors the physical condition of the released

inmate in the community. If the releasee survives for

9 months, the Governor is notified. He may choose

to revoke the medical parole at this time or allow

the inmate to remain on it.The Governor ultimately

grants medical parole to about 40 percent of those

recommended for it (see appendix B,“Site Visit

Report: Ohio Department of Rehabilitation and

Correction”).

Oregon 

An inmate’s health status or medical needs can serve

as the basis for early release from the Oregon prison system through either a request for executive

clemency, which the inmate makes on his or her

own, or through early parole release (EPR).A centralized EPR committee consists of the systemwide

medical director, a medical case manager, a unit

health services representative, and the inmate’s

assigned release counselor. Medical criteria for EPR

include being elderly and incapacitated, having a serious or terminal medical condition that is incapacitating, or having a condition that prevents the inmate

from participating in prison life.The EPR committee

makes a recommendation regarding early release to

the DOC’s Executive Committee. If it agrees, the

request is forwarded to the DOC director. If the

director agrees, the matter is referred to the Board

of Parole for a final decision.The process usually

takes about 2 months. Inmates who have committed

certain serious crimes are excluded from consideration for EPR (see appendix B,“Site Visit Report:

Oregon Department of Corrections”).

PRERELEASE PLANNING

Although the number of in-prison deaths is increasing, most inmates are released to the community at

the expiration of their sentence or under some

type of supervision.As a consequence, prerelease

C HAPTER IV

42

planning is particularly important for those who are

elderly, who are chronically or terminally ill, or who

have other special health needs.At a minimum, special needs patients should be discharged with an

appointment or referral to a provider in the community to which they are returning, and they should

have a supply of medication sufficient to last until

the community provider is seen. Patients who are

too frail or too ill to be candidates for home care

will need assistance in finding placement in an appropriate community facility, such as a hospital, nursing

home, or hospice.

Additional services that should be considered as

part of an adequate prerelease planning program

include classes on how to apply for government

entitlements (e.g., Medicaid/Medicare, Social Security,

welfare benefits, food stamps) and provision of a

social worker or case manager to coordinate the

release plan with the inmate, the family, correctional

staff, parole or supervising authorities, and community health providers.With the inmate’s permission, certain information about the inmate’s health

status should be shared with all concerned to give

the inmate the best chance of succeeding on the

outside.

In Minnesota, inmates who observe the rules serve

two-thirds of their sentence in prison and one-third

in the community under supervised release (which is

similar to parole). Since most inmates in Minnesota

leave prison under supervised release, all get some

prerelease planning. Each facility has case managers

who work with the inmates to develop acceptable

release plans. In addition, a prerelease class called

“Invest” is offered to any inmate who is within 20

months of release.Two 1- or 2-hour class sessions

are offered each week for 6 weeks.Among the

topics covered are how to apply for Medicaid/

Medicare, Minnesota Care, or another medical plan

when the inmates leave the prison.An information

packet and applications are provided. Inmates with

ongoing medical conditions are given a prescription

as well as a 7-day supply of needed medications on

release. Inmates with disabilities are assisted in

obtaining adaptive devices as needed (see appendix
B,“Site Visit Report: Minnesota Department of

Corrections”).

In Oregon, all inmates receive prerelease planning

and information on applying for benefits, such as

Social Security, Medicaid/Medicare, disability, food

stamps, etc. Each person is assigned a release counselor who assists the inmate in developing an appropriate release plan. Releases can occur from any

institution, but there are also designated release centers.All inmates are supervised when released to

the community.

The Oregon prison health service system also

employs a half-time medical case manager who

assists inmates with chronic and terminal illnesses in

finding an appropriate placement in the community.

The case manager makes followup appointments

with community providers, may assist with finding

residential housing, and works with other state

agencies to obtain benefits and services for those

in need.The DOC provides subsidized housing for

releasees without other plans for up to 30 days.

Prison physicians can provide up to 30 days of medications to an inmate upon release, although narcotics are usually restricted to a 2-week supply (see

appendix B,“Site Visit Report: Oregon Department

of Corrections”).

CONCLUSION

Today’s inmates are older, sicker, and staying longer

behind bars than ever before. Managing the special

needs of elderly, chronically ill, and terminally ill

inmates behind bars is indeed challenging, but it is a

responsibility that all prison systems must face.To

meet this responsibility adequately, good communication between custody staff and health staff is paramount . Custody staff need to know what specific

limitations such individuals have so they can make

appropriate housing, work, school, and other program assignments.To ensure continuity of care,

health staff must be informed of impending transfers.

To conduct adequate prerelease planning, health staff

must know the inmate’s scheduled release date. Staff

awareness training and good communication are

especially important in programs designed to meet

the needs of inmates who are dying because components of such programs often involve relaxing certain security rules, such as those regarding extra

food or visitation policies. Health staff should take

the lead in ensuring that their correctional colleagues are not just informed but are also active participants in the development of programs for special

needs inmates.

NOTES

1.These can be obtained from NCCHC, 1300 West

Belmont, Chicago, IL 60657 (phone 773–880–1460).

2. See, e.g., Puisis and Robertson (1998) and the

references cited therein.

3.This discussion is based on a form developed by

the Texas Department of Criminal Justice entitled

“Health Summary for Classification,” described in

Anno, 2001.

4. N.Y. Exec. Law § 259–r (Consol. 2003).

REFERENCES

Anno, B. Jaye. 1997.“Health Behavior in Incarcerated

Persons.” Chapt. 14 in Handbook of Health Behavior

Research III, ed. David S. Gochman. New York, NY:

Plenum Press, pp. 289–303.

Anno, B. Jaye. 2001. Correctional Health Care: Guidelines for the Management of an Adequate Delivery

System. 2001 Edition. Chicago, IL: National Commission on Correctional Health Care.

Douglass, Richard L., Mary Lindemann, and William

Lovett. 1991. Oldtimers: Michigan’s Elderly Inmates.

Lansing, MI: Michigan Office of Services to the Aging

and the Gerontological Society of America.

Dubler, Nancy N., and Budd Heyman. 1998.“End-ofLife Care in Prisons and Jails.” Chapt. 30 in Clinical

Practice in Correctional Medicine, ed. Michael Puisis. St.

Louis, MO: Mosby, pp. 355–364.

43

PROGRAM, HOUSING, AND TREATMENT CONSIDERATIONS
Faiver, Kenneth L. 1998.“Special Issues of Aging.”

Chapt. 7 in Health Care Management Issues in

Corrections, ed. Kenneth L. Faiver. Lanham, MD:

American Correctional Association, pp. 123–132.

GRACE Project. 2000. Standards of Practice for End-ofLife Care in Correctional Settings.Alexandria,VA:

GRACE Project,Volunteers of America.

Hornung, Carlton A., B. Jaye Anno, Robert B.

Greifinger, and Soniya Gadre. 2002.“Health Care for

Soon-To-Be-Released Inmates:A Survey of State

Prison Systems.” In National Commission on Correctional Health Care, The Health Status of Soon-ToBe-Released Inmates:A Report to Congress, vol. 2.

Chicago, IL: National Commission on Correctional

Health Care, pp. 1–11.

C HAPTER IV

44

National Commission on Correctional Health Care.

1997. Standards for Health Services in Prisons. Chicago,

IL: National Commission on Correctional Health

Care.

Puisis, Michael, and John M. Robertson. 1998.

“Chronic Disease Management.” Chapt. 6 in Clinical

Practice in Correctional Medicine, ed. Michael Puisis. St.

Louis, MO: Mosby, pp. 51–66.

Robert Wood Johnson Foundation. 1998.“Eldercare:

Where Medicine, Economics, and Demographics

Collide.” Advances:The Robert Wood Johnson Foundation Quarterly Newsletter 1998 (3): 1–2.

Spencer, Steven S. 1999.“Standardizing Chronic

Illness Care Behind Bars.” Journal of Correctional

Health Care 1: 41–61.
Chapter V

ETHICAL AND POLICY

CONSIDERATIONS FOR THE CARE

OF ELDERLY AND INFIRM INMATES

47

The problems posed by special needs populations

raise wide-ranging concerns related to prison organization and specialized care, including ethical and

moral issues, organization and administration, congregate care versus mainstreaming, staffing, bioethical

issues of terminal care, compassionate release, and

policymaking.Addressing policy challenges regarding

elder and infirm care in a sociopolitical environment

is complicated by the overlay of attitudes, behaviors,

and beliefs on the part of government executives,

legislators, prison managers, and staff.These encompass legitimate concerns about controlling costs; the

concerns of corrections supervisors and officers,

often about security risks posed by those convicted

of serious crimes; and a pervasive belief that inmates

are, by nature, malingerers capable of coercing and

sometimes not-so-subtly intimidating health care

providers.

PRISON ORGANIZATION

AND SPECIALIZED CARE

The large increase of special subpopulations in prisons, such as the populations of elderly and infirm

inmates, has imposed an unprecedented need for

dramatic revision of current correctional policies

and services. Correctional administrators confronted

with this need may find the lack of information

daunting. Effective response by caregivers requires

significant autonomy to respond to the ever-changing

needs of the patient population, which poses a direct

challenge to the institutional control model. In addition, issues related to caring for special population

inmates generate tensions between care and custody

in a number of areas.

Special Needs Care in Prison 

Prison health care systems were not originally

designed to provide sophisticated and intensive care

to large numbers of chronically ill and/or elderly

inmates.These inmates require a standard of medical

care and treatment well beyond that provided to the

general inmate population.The emergence of special

needs populations can upend prison system priorities by commanding greater staff attention and resources, intruding on operational imperatives of

custody and control, and, ultimately, alienating the

workforce—in short, becoming a radically destabilizing influence.

Ethical Medical Practice

in Prison 

The legal right to care in prisons is well established

and not a matter of dispute. Inmates are constitutionally entitled to receive access to care for serious

medical needs unimpeded by prison officials.1 They

are entitled to care that is medically ordered and to

a medical judgment that is autonomous and made

according to professional standards. Prison administrators beset with rudimentary health care systems,

difficult-to-treat subpopulations, and the pervasive

belief that inmates themselves are responsible for

their own plight may find that caring for elderly and

chronically ill inmates raises subtle and complex ethical issues.

Chapter V

ETHICAL AND POLICY

CONSIDERATIONS FOR THE CARE

OF ELDERLY AND INFIRM INMATES
Although scholarship in the field of biomedical ethics

has provided a significant body of literature, little of

it concerns prisons or offenders (Wishart and

Dubler, 1983).The tension between care and custody in prisons has not, until very recently, been part

of the biomedical ethical discussion. In the tradition

of the Hippocratic oath, medical practitioners concern themselves with "doing no harm," and with

comfort, reassurance, and teaching. Health care at its

best is defined as respectful, considerate, and

collegial among its practitioners; egalitarian, albeit

within the class boundaries of one's professional

credential; and, above all, individualized. Moreover,

medical care is delivered in the context of informed

choices, selectivity, and securing of patient satisfaction. On the other hand, prisons are authoritarian

institutions, organized as hierarchies that tend to

focus on expedient, time-honored, standardized solutions to problems. Prisons, furthermore, are defined

by the imperatives of custody and control. Following

the dictates of public safety and security, corrections

officials concern themselves rather with "allowing no

harm," with neutralizing threat, containment, and, on

occasion, punishment. Prisons are alien and intimidating to the sensitivities and vulnerabilities of old

age and illness. In short, providing care in prison settings poses significant challenges to ethical and effective medical practice (Anno, 2001).

The recent dramatic increase in the number of elderly inmates amplifies and aggravates conflicts that,

until lately, have been largely submerged in prison

culture.The physician-patient relationship in prison

has become ever more formal and legal, while its

essential attributes—mutual respect, patient comfort, implicit trust, and patient autonomy—cannot

always be achieved. Similarly, informed choice—the

ability to understand health information, to measure

it against personal values and preferences, and to

communicate medical decisions anonymously—is difficult to achieve in prison, where most behaviors are

subject to surveillance and coercion. In prison, consent is not a transactional process. Rather, it begins

and ends with procedures and paperwork—and

C HAPTER V

48

paperwork is susceptible to being completed by staff

on behalf of uncooperative inmates, often noting an

"informed refusal" of care.

Although essential to an ethical physician-patient

relationship, the objective of confidentiality—

establishing the therapeutic alliance through trust—

is not an organizational imperative in prison.

Although intended for the protection of the rights

and privacy of inmates, confidentiality rules can isolate the inmate and even interfere with his or her

access to health care. Confidentiality and privacy in

prison are often miscast as anonymity, giving inmates

the opportunity to "hide out" in various niches in

the prison system so as not to be stigmatized or

penalized for weakness associated with old age or

illness. Prison administrators frequently acquiesce to

this tendency in the prison population because it

contributes to the atomization of that population, an

implicit objective of the control model of prison

management.This also has the effects, intended or

otherwise, of interfering with effective congregate

health monitoring or health education and of discouraging health care providers from taking the initiative in addressing the needs of individual patients.

It also tends to impede development of specialized

or focused treatment centers where patients can

be congregated and/or organized into cohorts for

special care.

A final issue generated by the tension between care

and custody has to do with moralism—the belief

that those convicted of serious crimes have somehow earned their suffering, as if the pain of illness

and old age in prison were a part of the inmate's

just deserts.These beliefs are widespread and

intense among some custody personnel and are

prevalent also among health care providers.

Corrections practitioners and policymakers must

address the potential for inattention, indifference,

even negativity among those in charge of custody

and care of elderly and infirm inmates to ensure that

they receive respectful and considerate care (Cohn,

1999).
HEALTH CARE

ORGANIZATION AND

ADMINISTRATION

Modern health care delivery systems in the free

world are organized so as to clearly separate the

administration of health care services from the delivery of patient care (National Commission on

Correctional Health Care, 1997, p. 3). In some state

prison systems, administration of health care has not

been centralized. In others, it has occurred only

incompletely. Even when care is centrally organized,

facility health care staff frequently report that they

cannot always rely on the central health services

authority for assistance and encouragement in

addressing and solving the health care problems and

needs encountered at the facility level, even when

problems arise from such broader issues as staffing

or access to hospital facilities.

Health Care Dispersion 

A complete and sophisticated range of services and

a multidisciplinary approach to inmate patients—

one that draws on the medical, nursing, dietary, psychological, social work, and pastoral disciplines—are

required to deal with the increasing numbers of elderly, infirm, and ill inmates.To establish these, the

same kind of centralization that governs custody

needs to be adopted for health care. Most institutional health care delivery systems were not

designed to meet complex care demands. Rather,

they are primary care systems oriented to respond

to patient demand for service.When confronted

with elderly, debilitated, or chronically ill inmates,

managers of decentralized systems are often driven

to an ever-increasing reliance on public and community hospital-based inpatient and outpatient services

at a time when community agencies show increasing

resistance to providing those services to inmates.

A more serious consequence of decentralized

authority is that usually no single entity exists that

can determine the appropriate level of care that

facilities are able to provide (i.e., determine how

much complexity or severity of illness a given facility

is competent to assess and manage). Moreover, such

tasks as personnel recruitment and administration,

purchasing, housekeeping, arranging for specialty

care, fiscal management, and organization of the daily

functions of an institution's medical department tend

to be left to the clinicians and allied health care

workers at the various facilities. Consequently, the

energies of the professionals responsible at most

institutions for the quality and availability of direct

medical care (e.g., the medical director and registered nurse “administrator”) are often diverted to

tasks that would be more efficiently accomplished at

a central office.

The lack of an integrated, statewide delivery system

with defined levels of care and centralized administrative leadership can result in wide variation in the

level of care, quality of care, and access to care.The

relative quality of health care staff, more often than

not, depends on the professional human resources

available in the community. Similarly, the range of

essential outpatient services, specialty clinics, and

special programs are largely local phenomena that

may bear little relationship to the needs of the target population.

Sick Call 

Aside from serious accidents or other medical

emergencies, access to primary care in prisons is

primarily through sick call. Sick call represents a

unique challenge to the delivery of primary care to

the elderly or chronically ill. First, sick call operates

on the assumption that the patient base is primarily

healthy and that illness is the exception—an assumption that is unfounded with the elderly and chronically ill.2 Second, inmates are often encouraged to

use sick call access for trivial reasons. Inmates often

seek out health care staff for assistance in obtaining

patent medicines, excuses from work, extra blankets,

an unscheduled shower, or even in resolving problems with shoes or a bed. Sick call becomes a way

for an inmate to secure an encounter with someone

equipped and motivated to give him or her individual help.This generates skepticism among

49

ETHICAL AND THICAL AND POLICY CONSIDERATIONS FOR THE ONSIDERATIONS FOR THE CARE OF ELDERLY AND LDERLY AND INFIRM INMATES
corrections health care providers and custodial personnel about whether inmates are requesting medical services for frivolous reasons.Third, sick call

visits are driven by patient demand and thus tend to

be episodic, discontinuous, and not under the advice

and control of treatment providers.These problems

and attitudes can have a profound impact on how

motivated medical personnel are to explore the

increasingly atypical inmate health complaints of elderly and chronically ill inmates as they age and their

health fails.

Infirmaries 

Many state prison infirmaries, originally designed for

medical supervision of convalescing or debilitated

inmates, are situated in facilities that offer only the

most basic features of primary care. Day areas and

visiting space are scarce. Inmates who have no medical or habilitative problems are sometimes housed

there for security or protective reasons.Yet, infirmaries are often pressed into service for the elderly

and the terminally and chronically ill.Thus, owing to

a lack of alternatives, elderly and chronically ill

inmates pass their days in these units, inappropriately sharing quarters with inmates who do not belong

there.

Hospitals 

Other than those few large state systems that maintain full-service correctional hospitals, correctional

managers who seek to provide effective care to the

elderly and chronically ill have to make do with having a significant portion of needed acute care provided outside prison at area hospitals. Daily trips for

emergency department referrals or planned admissions are to be expected. Prison system executives

and policymakers face the challenge of establishing

satisfactory service agreements with a hospital that

is staffed and equipped to provide effective care to

elderly and infirm inmates. Such facilities can be difficult to find in rural locales (where state prisons are

often located) because hospital resources are scarce.

Also, the managers and staff at local hospitals may be

C HAPTER V

50

unfamiliar with and/or resistant to working with

inmates with special needs, so they will require special orientation and training.To ensure that appropriate medical resources are available, careful planning

is needed, particularly when deciding where to admit

concentrations of elderly and chronically ill inmates.

CONGREGATE CARE

VERSUS MAINSTREAMING

Correctional executives face a number of policy

challenges associated with the management of elderly, terminally ill, and chronically ill inmates, specifically

those aspects of care that concern the conditions of

daily living. Of primary concern is whether to house

elderly inmates in one congregate setting or to

mainstream them with the general population at various locations throughout the prison system.

Congregate housing for the elderly and infirm may

be provided in dedicated, separately managed care

units or in freestanding facilities. In congregate settings, care levels can be stratified according to need

in subunits to which inmates are assigned according

to the results of functional assessments. Many of the

problems associated with fragmentation of health

care services for elderly and chronically ill inmates

can be avoided by locating medical staff, resources,

and patients needing special services at a central

location. Health care staff interested in gerontology

and chronic disease care can opt for assignment to

such comprehensive facilities or units and receive

advanced and continuing medical education to pursue the health care career path of their choice.

Arrangements for outpatient subspecialty care, hospital inpatient care, and rehabilitative and supportive

services are easier to make at congregate facilities

and are more cost effective owing to economies of

scale. Once initial costs for capital development,

equipment, and human resource development are

amortized, annual operating expenditures in congregate elder care settings can be stabilized and made

predictable. In a typical comprehensive care setting,

such care would cost $65,000 per inmate year in
2002.3 In contrast, attempts to replicate services for

individual elderly and infirm inmates wherever they

may be found in a multi-institutional system will likely introduce service duplication and gaps in care and,

in addition, considerable cost instability and additional expense.

Consolidation of health services for this population

succeeds in addressing the fiscal concerns of the

corrections system and in meeting the daily living

needs of elderly and chronically ill inmates. Economies of scale in health care staff deployment and

group utilization of such services as pharmacy, dialysis, and respiratory care are achieved. Better care

and more amenable and humane living conditions

can be obtained at lower cost (Flynn, 1992).

Moreover, long-term inmates and prison recidivists,

two of the three types of elderly offenders cited by

Craig-Moreland, respond well to treatment in congregate care (Neeley,Addison, and Craig-Moreland,

1997).These inmates can also be of great help in

facilitating stability in the inmate population, which,

in turn, will assist in managing the third type: the

volatile first offender.

Congregate units also afford the policy planner an

opportunity to comprehensively furnish or retrofit

facilities for safe, controlled, and amenable surroundings.At a minimum, the following habilitation issues

should be addressed:

• Visitation access.

• Dayroom settings.

• Alternative disciplinary procedures that take the

problems of aging and terminal illness into

account.

• Alternative work rules and assignments.

• Hospital access.

• Ramps and grades.

• Handrails and thresholds.

• Unobstructed sightlines.

• Physical therapy.

• Bathing facilities.

• Sound control.

• Enhanced lighting.

• Laundry services.

Some corrections executives and criminal justice

practitioners nevertheless favor dispersal of elderly

and infirm inmates among several institutions and

their integration with other inmates.They contend

that separate facilities should be established only if

the number of elderly and infirm inmates warrants

it. Many prison officials believe that they can successfully address habilitation concerns with wheelchair

ramps, special cells, "old man" dormitories, and

relaxed work rules.Those who advocate mainstreaming contend that it ensures equal access to

existing prison programs.Also, the presence of older

inmates in the general population is said to have a

stabilizing effect. Furthermore, federal requirements

for mainstreaming the elderly are easier to meet

when they are housed in the general prison population, especially given that the alternative may be segregation in unsuitable settings that are not program

rich.

Despite these claims, a hint of hostility is sometimes

evident in the arguments of the more outspoken

advocates of the geriatric mainstreaming school of

thought. Prisons should not, of course, be dungeons.

But, they say, adjustments to accommodate life-term,

serious criminals must be justified as absolutely necessary before being implemented (Pelosi, 1997). Such

attitudes are less prevalent today, as more corrections managers recognize that humane and secure

care for special needs populations is more effectively

and efficiently provided in congregate environments.

STAFFING FOR THE CARE

OF THE ELDERLY AND

INFIRM

Another argument in favor of a dedicated congregate care setting is the enriched staffing patterns

51

ETHICAL AND POLICY CONSIDERATIONS FOR THE CARE OF ELDERLY AND INFIRM INMATES
typically required for an ill and/or debilitated patient

cohort.A skilled and committed nursing staff is the

mainstay of a successful elderly and chronic care

program.The most successful congregate care programs, some profiled in this report (e.g.,“Site Visit

Report: Pennsylvania Department of Corrections,”

appendix B), provide overall nursing staff-to-patient

ratios approaching 1:6. Nursing care concentrated in

skilled nursing and assisted living settings have typical

professional/patient staff ratios of 1:3.When all ancillary staff are taken into account, multidisciplinary

staff ratios in full-service congregate care units are

often found to be close to 1:1.4 Of course, not only

the number of staff but also their quality and skills

are of critical importance.

A potential barrier to appropriate special needs care

for an elderly and chronically ill inmate is the lack of

a carefully selected and adequately trained security

staff. Not everyone who works in a correctional setting may have the aptitude, interest, or essential skills

needed to manage elderly inmates. Careful recruitment of staff, followed by extensive and sustained

inservice training appropriate to these issues, is

essential. In matters of staff selection, a premium

should be placed on attributes of sensitivity and

adaptability to the unique requirements of elderly

inmates. Flexibility and the capacity to work with

inmates and supervisors to maintain a disciplinary

system that keeps order but also accounts for the

cognitive and emotional problems of the elderly and

chronically ill are particularly vital. Exceptional interpersonal communication skills and the ability to be

selective and adaptable in matters of enforcement

are important.To that end, interdisciplinary training

involving administrative personnel, line security staff,

and health care staff should emphasize increased

knowledge of the aging process, living with chronic

illness, the social and emotional needs of the elderly,

dynamics of death and dying, signs of depression, and

skills for making referrals to expert care (Aday,

1994).

C HAPTER V

52

TERMINAL CARE:

BIOETHICAL ISSUES

Although they are a direct consequence of being

elderly or having a chronic or life-threatening disease, the biomedical and ethical issues associated

with death and dying in prison are significantly different from the consideration of care for the elderly

and chronically ill inmate and require separate discussion.The demographics of inmate aging and crime

and sentencing trends inevitably will lead to dramatic

increases in death from chronic and terminal illness

in prison. In 2000, more than 3,200 state prison

inmates died nationwide, approximately 78.3 percent

of them from natural causes (Camp and Camp,

2001).

Despite the constitutional right to care, which is

beyond dispute in modern correctional practice, the

usual circumstances of dying in prison are very different from those in the free world.This is due, in

part, to inmates’ lack of freedom and to their inability to choose from among health care and other

end-of-life options. For these reasons, say medical

ethicists Nancy Dubler and Budd Heyman, what may

be called a “good death”—one that involves reconciliation with the inevitable outcome and time with

family and friends, supported by professionals in an

appropriate setting—is rarely available to inmates.

The dilemma is that planning and implementing a

good death may run afoul of prison routines and priorities (Dubler and Heyman, 1998).

Ethical treatment of dying inmates requires making a

host of policy choices, most of which depart from

the usual prison norms. Important features of endof-life options include—

• Continuing palliative care, which enables staff to

assess and ameliorate patient discomfort and

includes aggressive pain control.

• Enhanced opportunities for family visitation

without regard to the frequency or number of

visitors.
• Opportunities for reestablishing or maintaining

family relationships, including telephone, mail, and

family outreach, such as planned family-oriented

events.

• Professional, pastoral, mental health, and social

services that include assistance with finances, family problems, insurance, personal property, and

other issues.

• Professional assistance with end-of-life arrangements, including advance directives; health care

proxy appointments; orders not to resuscitate;

and wills, trusts, and funeral arrangements.

As with care for the elderly and chronically ill in

general, humane and compassionate end-of-life care

is best provided in a multicare-level congregate setting that is equipped to provide terminal care along

with skilled care, assisted living, and chronic care.

COMPASSIONATE

RELEASE

Compassionate release programs for state inmates

came into vogue during the height of the AIDS pandemic of the late 1980s and were initiated in some

jurisdictions as late as 1990.The procedures for

compassionate release are often so convoluted—and

involve so many levels of review and consent—that

they make release of any but the most profoundly ill

inmates virtually impossible. Often, compassionate

release is in name only, as in cases where inmates

are released only days before death and are simply

transferred from prison to a community hospital so

that it can be said that, at least, the patient did not

die in prison.A few jurisdictions, such as California,

actively employ compassionate release. In that state,

as many as 35 percent of compassionate release

applications are approved each year (Dubler and

Heyman, 1998). Most jurisdictions, however, release

proportionately far fewer inmates.Although compassionate release procedures exist in every state, many

states release few prisoners or none at all. Because

they are so narrowly employed, compassionate

release programs are not viable end-of-life policy

alternatives for the vast majority of those who might

qualify.

HEALTH CARE

POLICYMAKING FOR

INMATES

A host of questions are unanswered concerning

correctional policies related to elderly and infirm

inmates. Do prison systems have the capacity to

medically manage and care for large numbers of elderly, chronically ill, and terminally ill inmates? Do

they have the current resources to address the

wide-ranging operational implications? Should elderly, chronically ill, and debilitated inmates be mainstreamed into the general population or placed in

separate, specialized units? How will correctional

agencies redefine their policies to better address

elderly, chronically ill, and terminally ill inmates as

their numbers continue to increase? 

Sometimes, it is difficult to see a problem at all.As

economist Aaron Wildavsky points out,“[a] difficulty

is a problem only if something can be done about it”

(Kingdon, 1997). Policy problems, by definition, must

be judged to be problems appropriate for governmental action, a judgment that is heavily influenced

by values and ideology. Policy analyst John Kingdon

notes that, depending on one's viewpoint, the presence of poor people might be a problem; poverty,

however, might just as easily be seen as a natural

condition. It is from this framework that the challenge of geriatric prison health care policy emerges.

Until now, prison health care policy has not been

developed as a series of deliberate choices from

among identified alternatives, or even from intentional steps in one direction but, rather, has more

often been formulated on the basis of a series of

defaults that stem from a lack of prospective

planning.

Prison systems are “command” or “machine”

bureaucracies dedicated to the safety of the public

53

ETHICAL AND POLICY CONSIDERATIONS FOR THE CARE OF ELDERLY AND INFIRM INMATES
and the prison staff.As long as the work remains

predictable and the environment remains stable, they

function without undue stress or serious incident.

This, and the isolation of prisons from the community at large, reinforces inflexible prison management

practices. Over the short term, innovation is often

discouraged as too risky. For that reason, a disciplined, objective approach is needed, one that (as

articulated by policy analyst Stephen Toulmin and

later elaborated by William Dunn) seeks to determine what prisoner old age and infirmity actually

are; what is right, both for these inmates and for the

rest of the correctional system; and what to do

about their growing presence and insistent need

(Dunn, 1994).This can be a daunting task, given the

limitations discussed thus far. Still, as evidenced by

some of the model programs presented in this

work, progress is possible. In the most successful of

these programs, policy formulation was a preeminent value:A problem was recognized, a solution

was at hand, the policy change was compelling, and

the potential constraints were not prohibitive. Care

in these custody settings improved substantially,

making these systems safer, stable, and more

humane.

NOTES

1.The landmark case establishing a constitutional

right to prison medical care is Estelle v. Gamble, 429

U.S. 97(1976), which held that deliberate indifference

to a prisoner's medical needs violated the eighth

amendment's prohibition against cruel and unusual

punishment.

2.This is also a basic assumption in the military,

which also uses sick call, and thus is often cited by

prison executives as validating its use in prison.

However, chronically or otherwise seriously ill military personnel are usually discharged, whereas the

prison system cannot employ that remedy.

3. Personal communication from Fredric Rosemeyer,

Superintendent, SCI Laurel Highlands, Somerset, PA,

to James E. Lawrence, November 8, 2001.

4. Ibid.

C HAPTER V

54

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System, 2001 edition. Chicago, IL: National Commission on Correctional Health Care.

Camp, George, and Camille Camp. 2001. The Corrections Yearbook, 2001. Middletown, CT: Criminal

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Cohn, F. 1999.“The Ethics of End-of-Life Care for

Prison Inmates.” Journal of Law, Medicine and Ethics

27: 252–260.

Dubler, Nancy N., and Budd Heyman. 1998.“End-ofLife Care in Prisons and Jails.” Chapt. 30 in Clinical

Practice in Correctional Medicine, ed. Michael Puisis. St.

Louis, MO: Mosby, pp. 355–364.

Dunn,William N. 1994. Public Policy Analysis. 2d ed.

Upper Saddle River, NJ: Prentice Hall.

Flynn, Edith. 1992.“Graying of America's Prison

Population.” The Prison Journal 72 (1/2): 77–98.

Kingdon, John W. 1997. Alternatives,Agendas, and

Public Policies. 2d ed. Boston, MA: Longman.

National Commission on Correctional Health Care.

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IL: National Commission on Correctional Health

Care.

Neeley, Connie L., Laura Addison, and Delores CraigMoreland. 1997.“Addressing the Needs of Elderly

Offenders.” Corrections Today 59 (5): 120–123.

Pelosi,A. 1997.“Age of Innocence.” New Republic 216

(18): 15–18.

Welch, Michael. 1989.“Social Junk, Social Dynamite

and the Rabble: Persons With AIDS in Jail.” American

Journal of Criminal Justice 14 (1) (Fall): 135–147.

Wishart, Margaret D., and N. Dubler. 1983. Health

Care in Prisons, Jails and Detention Centers: Some Legal

and Ethical Considerations. Bronx, NY: Montefiore

Medical Center.
Chapter VI

CONCLUSION

57

To be consistent with basic tenets of humaneness

and to comply with constitutional standards, prison

systems must provide special accommodations that

meet the medical and security needs of elderly

inmates and inmates with chronic and terminal

illnesses.

PROGRAM, HOUSING,

AND TREATMENT

CONSIDERATIONS

Most individuals who are elderly, chronically ill, or

terminally ill require special accommodation in their

housing and program assignments because of their

physical conditions.

Elderly Inmates 

Many older inmates suffer from chronic illnesses,

including heart disease, hypertension, diabetes, and

chronic obstructive lung disease.They also are subject to conditions that accompany the normal aging

process, including loss of vision, impaired hearing,

sleep disturbances, incontinence, mental confusion,

and gastrointestinal disorders.A number of older

inmates are healthy and do not require special housing.They can be placed in any housing area that is

appropriate to their custody classification. Others

may require placement in a nursing home environment or an infirmary.When determining appropriate

work assignments, program assignments, and recreational activities for older inmates, it is important to

consider such physical limitations as hearing and

vision loss, reduced physical strength, and the inability to stand for long periods of time.

Chronically Ill Inmates 

By definition, chronic illnesses are either ongoing or

recurring. Individuals with such chronic diseases as

asthma,AIDS, heart disease, diabetes, hypertension,

and hepatitis C, and those with certain permanent

physical conditions (e.g., paraplegia), need to be

monitored closely to maintain their health status or

slow the progression of their disease or condition. It

is important to identify the number of inmates in a

system with specific chronic conditions.Although

this may seem obvious, health care staff in many correctional agencies do not know at any given time

precisely how many inmates they have with specific

chronic conditions.

People with chronic conditions generally are among

the sickest of the prison population and should be

placed in facilities that have the highest level of

health services available. Such services include

around-the-clock emergency services and nursing

care, infirmary care, and specialty care.

Terminally Ill Inmates 

Terminally ill inmates also need to be placed in facilities with the highest level of available health services.These inmates require palliative care and frequent

access to specialty services.They tend to cycle in

and out of infirmaries and hospitals.As their conditions worsen, they often will require around-theclock nursing services. Inevitably, they reach a point

Chapter VI

CONCLUSION
where medicine can offer little more.The primary

health goal then shifts from curing illness to keeping

the patient comfortable and pain free and helping

the inmate adjust to imminent death. Hospice

services are becoming increasingly common for

terminally ill people in prisons as well as in the

community.Terminally ill inmates need to be kept

humanely and comfortably occupied.The availability

of books, music, and, above all, companionship can

elevate the dying patient's mental outlook.

THE FUNCTIONAL

ASSESSMENT

The correctional managers who are now being

asked to meet the needs of a growing population of

elderly inmates and inmates who exhibit a variety of

complex medical problems must properly identify

these inmates' needs immediately upon their entry

into the prison system. Early identification will result

in more effective and efficient care for special needs

inmates and will reduce court challenges and liability

risks for the prison system.

Medical staff in most prison systems perform an

intake history or screening exam shortly after the

inmate arrives at a reception center.The purpose of

this initial screening is to identify the individuals

whose medical needs must be addressed immediately, usually on the same day as the screening.

Pitfalls in the intake screening process may result in

the development of an inaccurate or incomplete

plan for the inmate.These problems can interfere

with the inmate's receiving necessary and effective

treatment and create serious potential liabilities for

the corrections agency. Several strategies exist for

corrections systems to plan for, identify, and address

inmate special needs.Two effective strategies are

highlighted in this report.The medical history and

physical examination are critical elements in determining and responding to functional needs both

inside and outside correctional settings. In the free

world, however, many hospitals and health care

organizations also employ an effective functional

C HAPTER VI

58

assessment tool (the SF–36) that attempts to determine both how the patient perceives his or her own

functioning and how that current perception differs

from past perceptions.This tool also may be used to

determine whether the patient's perception of his

or her health status corresponds with the health

care provider's perception. Unfortunately, many

correctional agencies have not yet incorporated

this type of assessment into their intake medical

protocols.

POLICY

CONSIDERATIONS

Prison health care systems are not designed to provide sophisticated and intensive care to large numbers of chronically ill people. Providing for elderly

and chronic care inmates requires a standard of

medical care and treatment well beyond that provided to the general inmate population. Many issues

associated with managing special needs inmates

affect policy. Issues to be considered include staffing

for the care of elderly and infirm inmates, compassionate release, health organization and administration, and congregate care versus mainstreaming.

Regardless of the accommodations and services that

are made available to prisoners within institutions,

correctional practitioners have to be mindful that

most inmates are released to the community or

under some type of supervision at the expiration of

their sentence. As a consequence, prerelease planning is particularly important for those who are elderly, chronically ill, or terminally ill or who have

other special health needs.

Today's inmates are older, sicker, and staying in

prison longer than ever before. Managing the special

needs of elderly, chronically ill, and terminally ill

inmates poses many challenges but is a responsibility

that all prison systems must face. It requires highly

effective intake assessments; appropriate housing,

programming, and treatment; and creative and

thoughtful policies.
Appendix A

CRIMINAL JUSTICE

INSTITUTE SURVEY:

Managing the Needs of Aging Inmates and 

Inmates With Chronic and Terminal Illnesses

April 2001

61

MANAGING THE NEEDS OF

AGING INMATES

Appendix A

63

CRIMINAL JUSTICE INSTITUTE SURVEY

No. Inmates Age 50+ 

Agency Definition of Elderly Age Elderly As of 12/31/00

Alabama 2,006

Alaska1 ✓ 50 456

Arizona 2,399

Arkansas2 860

California 12,215

Canada3 ✓ 50 1,544

Colorado4 ✓ 65 1,406

Connecticut 813

Delaware 277

District of Columbia ✓ 65 425

Federal5 13,872

Florida ✓ 50 5,873

Guam 16

Idaho ✓ 50 220

Illinois 2,392

Indiana6 1,619

Iowa 477

Kansas7 727

Kentucky 1,541

Louisiana 3,091

Maryland ✓ 60 1,253

Massachusetts8 ✓ 60 1,219

Michigan9,10 ✓ 60 4,380

Minnesota ✓ 55 374

Mississippi11 1,170

Missouri 2,054

Montana ✓ 55 276

Nebraska 294

New Hampshire ✓ 55 281

New Jersey 1,854

New Mexico ✓ 50 52

New York 5,111

New York City 674

North Carolina ✓ 50

North Dakota ✓ 62 65

Ohio ✓ 50

Oklahoma 946

Oregon ✓ 55 1,076

Pennsylvania 3,613

Philadelphia 249

Rhode Island 209

Does Your Agency Have a Definition for When an Inmate Is Considered “Elderly”?

(continued on next page)
APPENDIX A

64

No. Inmates Age 50+ 

Agency Definition of Elderly Age Elderly As of 12/31/00

South Carolina12 ✓ 55 1,433

South Dakota13 60 202

Tennessee ✓ 55 708

Texas ✓ 55

Utah 465

Virginia ✓ 55 2,474

Washington 1,378

West Virginia ✓ 50 372

Total/Average 22 55 1,835

% of Total 44.9

1. Definition of elderly is 50 years of age and suffering from one or more chronic illnesses and/or physical/mental disabilities.

2. Depends on degree of debility; Arkansas prisons have housed 70-year-olds who were not considered elderly and 40-year-olds 

who were.

3. Canada does not use the term “elderly” but rather “older offenders.” 

4. Over 65 years of age and are unable to care for themselves.

5. 13,872 represents the number of inmates age 51 or older.

6. As of 1/2/01.

7. NCCHC uses age 55 in its definition of elderly, so Kansas DOC uses this age breakdown for accreditation.This definition is also 

used in medical planning discussions.

8. Varies by purpose; however, usually 60 years.

9. Definition of elderly:An inmate who has reached 60 years of age and does not have a debilitative chronic illness or disability.

10. As of 2/1/01.

11. No state statute.

12. In jurisdiction; 1,399 in institutions.

13. This is the age SD DOC would consider to be elderly, but there is no definition per se.

Does Your Agency Have a Definition for When an Inmate Is Considered “Elderly”?

(continued)
65

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency “Yes”

Alabama

Alaska

Arizona ✓

Arkansas

California

Canada

Colorado ✓

Connecticut

Delaware

District of Columbia

Federal1

Florida No answer

Guam

Idaho

Illinois

Indiana

Iowa

Kansas No answer

Kentucky ✓

Louisiana ✓

Maryland

Massachusetts

Michigan ✓

Minnesota

Mississippi ✓

Missouri

Montana ✓

Does Your Agency Provide Supervised Recreational Programs Specifically

Designed for Older and Elderly Inmates?

Agency “Yes”

Nebraska

New Hampshire ✓

New Jersey 

New Mexico

New York

New York City

North Carolina ✓

North Dakota No answer

Ohio ✓

Oklahoma

Oregon

Pennsylvania ✓

Philadelphia ✓

Rhode Island

South Carolina

South Dakota ✓

Tennessee

Texas

Utah

Virginia ✓

Washington

West Virginia ✓

Total 15

% of Total 30.61

1. Games such as Bingo are available but are not specifically 

designed for the elderly population.
APPENDIX A

66

Do You Designate Special Housing Areas for Elderly Inmates Within Your Prisons?

Special Housing

Agency Areas Designated Discrete Subpopulation? At What Age?

Alabama

Alaska

Arizona1

Arkansas ✓

California2

Canada

Colorado3

Connecticut

Delaware

District of Columbia ✓

Federal

Florida

Guam

Idaho4 ✓

Illinois

Indiana

Iowa

Kansas

Kentucky No answer

Louisiana5 ✓ ✓

Maryland6

Massachusetts

Michigan ✓

Minnesota7

Mississippi8 ✓ ✓ 50 

Missouri ✓

Montana

Nebraska

New Hampshire ✓

New Jersey 

New Mexico ✓ ✓ 55 

New York9 ✓

New York City

North Carolina

North Dakota

Ohio10 ✓ ✓

Oklahoma

Oregon

Pennsylvania11 ✓

Philadelphia

Rhode Island12

South Carolina

South Dakota13
67

CRIMINAL JUSTICE INSTITUTE SURVEY

Do You Designate Special Housing Areas for Elderly Inmates Within Your Prisons?

(continued)

Special Housing

Agency Areas Designated Discrete Subpopulation? At What Age?

Tennessee ✓ 55

Texas14 ✓ ✓

Utah

Virginia ✓

Washington

West Virginia ✓ ✓ 50

Total 15 7

% of Total 30.61 14.29

1. Not by operations policy.

2. Housing is based on medical needs and security, not age.

3. Only if hospice care is needed.

4. When medically necessary.

5. Based on physical condition.

6. Although special housing units are not specifically designated, elderly inmates are usually assigned to specific areas of specific 

institutions.

7. Only if they have chronic medical needs.

8. When medically necessary.

9. Based on disability/care needs.

10. Based on inmate’s request or physical condition.

11. As needed.

12. Housing depends on function.

13. Not exclusively for elderly inmates.

14. Depends on mobility and general health.
APPENDIX A

68

Do You Designate Facilities for Elderly Inmates Within Your Prisons?

Special Facilities No. of Special 

Agency Designated? Age Eligible for Referral Facilities in System

Alabama1 ✓ 1

Alaska

Arizona2

Arkansas ✓ Any 3

California

Canada

Colorado

Connecticut

Delaware

District of Columbia

Federal

Florida ✓ 50 1

Guam

Idaho

Illinois

Indiana

Iowa

Kansas No answer

Kentucky

Louisiana3 ✓ 1

Maryland

Massachusetts

Michigan ✓ 1

Minnesota4

Mississippi5 ✓ 50 3

Missouri

Montana6 ✓ 1

Nebraska

New Hampshire ✓ 55 1

New Jersey 

New Mexico ✓ 55 1

New York

New York City

North Carolina 1

North Dakota

Ohio7 ✓ 1

Oklahoma

Oregon

Pennsylvania8 ✓ 3

Philadelphia

Rhode Island

South Carolina

South Dakota
69

CRIMINAL JUSTICE INSTITUTE SURVEY

Special Facilities No. of Special 

Agency Designated? Age Eligible for Referral Facilities in System

Tennessee ✓ 55 1

Texas ✓ 60 8

Utah

Virginia ✓ Any 1

Washington

West Virginia

Total/Average 14 2

% of Total 29

1. Age is variable.

2. Only according to medical need.

3. Based on physical condition.

4. MN DOC has one unit designated for elderly inmates with chronic medical needs.

5. When medically necessary.

6. Based on handicap.

7. Based on inmate’s physical condition.

8. As medically needed.Three special facilities as of July 2001.

Do You Designate Facilities for Elderly Inmates Within Your Prisons? (continued)
APPENDIX A

70

Are Older Inmates in Your Agency Scheduled for Annual

Comprehensive Health Appraisals? 

Agency “Yes” At What Age?

Alabama ✓ 50

Alaska ✓ 50

Arizona ✓ 50

Arkansas1 ✓ 64

California

Canada

Colorado ✓ 50

Connecticut

Delaware ✓ 50

District of Columbia ✓

Federal ✓ 50

Florida ✓

Guam

Idaho ✓ 50

Illinois

Indiana2 ✓

Iowa ✓ 50

Kansas No answer

Kentucky ✓

Louisiana ✓ 45

Maryland

Massachusetts ✓ 50

Michigan3 ✓

Minnesota ✓ 50

Mississippi ✓ 50

Missouri ✓ 50

Montana ✓ 40

Nebraska ✓ 50

New Hampshire4 ✓

New Jersey5

New Mexico ✓ 50

New York ✓ 50

New York City ✓ 40

North Carolina ✓ 50

North Dakota ✓

Ohio ✓ 50

Oklahoma ✓ 40

Oregon ✓ 55

Pennsylvania ✓ 50

Philadelphia6 ✓

Rhode Island ✓ 40

South Carolina

South Dakota7
71

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency “Yes” At What Age?

Tennessee ✓ 65

Texas

Utah ✓

Virginia

Washington ✓ 40

West Virginia ✓ 50

Total/Average 37 49

% of Total 76

1. Unless other chronic illnesses are present.

2. All inmates receive annual health appraisals.

3. All inmates receive annual health exams.

4. In accordance with ACA Standards.

5. Every 2 years for age 50 and older.

6. All inmates have an annual physical exam.

7. All inmates age 40 and older receive a health appraisal every 2 years.

Are Older Inmates in Your Agency Scheduled for Annual

Comprehensive Health Appraisals? (continued)
APPENDIX A

72

What Assistive Devices Are Provided for Geriatric Inmates?

Geriatric Geriatric Walkers/ Hearing Supportive Warmer Extra 

Agency Chairs Beds Canes Aids Dentures Eyeglasses Devices Clothing Blankets

Alabama ✓ ✓ ✓✓✓ ✓ ✓ ✓

Alaska ✓ ✓✓✓ ✓ ✓ ✓✓

Arizona ✓✓✓ ✓ ✓ ✓✓

Arkansas ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

California ✓✓✓ ✓ ✓ ✓✓

Canada ✓ ✓✓✓ ✓ ✓ ✓✓

Colorado ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Connecticut ✓ ✓✓✓ ✓ ✓ ✓✓

Delaware ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

District of Columbia ✓✓✓ ✓ ✓ ✓✓

Federal ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Florida ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Guam ✓ ✓

Idaho ✓ ✓✓✓ ✓ ✓ ✓✓

Illinois ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Indiana ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Iowa ✓ ✓✓✓ ✓ ✓ ✓✓

Kentucky ✓✓ ✓ ✓ ✓ ✓

Louisiana ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Maryland ✓✓ ✓ ✓

Massachusetts ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Michigan ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Minnesota ✓✓✓ ✓ ✓ ✓✓

Mississippi ✓ ✓ ✓✓✓ ✓ ✓ ✓

Missouri ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Montana ✓✓✓ ✓ ✓ ✓✓

Nebraska ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

New Hampshire ✓✓✓ ✓✓✓

New Jersey ✓ ✓✓✓ ✓ ✓ ✓✓

New Mexico ✓✓✓ ✓ ✓ ✓✓

New York ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

New York City ✓✓✓ ✓ ✓ ✓

North Carolina ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

North Dakota ✓✓✓ ✓ ✓ ✓✓

Ohio ✓ ✓ ✓✓ ✓ ✓✓✓

Oklahoma ✓✓✓ ✓ ✓

Oregon ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Pennsylvania ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Philadelphia ✓ ✓✓✓ ✓ ✓ ✓

Rhode Island ✓✓✓ ✓ ✓ ✓✓

South Carolina ✓ ✓ ✓✓✓ ✓ ✓ ✓✓
73

CRIMINAL JUSTICE INSTITUTE SURVEY

What Assistive Devices Are Provided for Geriatric Inmates? (continued)

Geriatric Geriatric Walkers/ Hearing Supportive Warmer Extra 

Agency Chairs Beds Canes Aids Dentures Eyeglasses Devices Clothing Blankets

South Dakota ✓✓✓ ✓ ✓ ✓✓

Tennessee ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Texas ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Utah ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Virginia ✓ ✓ ✓✓✓ ✓ ✓ ✓✓

Washington ✓ ✓✓✓ ✓ ✓ ✓✓

West Virginia ✓✓✓ ✓ ✓

Total 31 27 48 46 45 48 45 41 42

% of Total 65 56 100 96 94 100 94 85 87

75

MANAGING THE NEEDS OF

TERMINALLY ILL INMATES

Appendix A

77

CRIMINAL JUSTICE INSTITUTE SURVEY

Is It a Part of Part of An Outpatient 

Agency Hospice Unit? Separate Unit? Infirmary? Housing Unit? Program? No. of Beds

Alabama

Alaska

Arizona

Arkansas1

California2 ✓ ✓ 15

Canada3

Colorado ✓ ✓ 1–4

Connecticut ✓✓ ✓ 3–4

Delaware

District of Columbia

Federal4 ✓ ✓✓ ✓

Florida

Guam ✓ ✓ 1

Idaho

Illinois ✓ ✓ 4

Indiana

Iowa ✓ ✓ ✓✓ ✓

Kansas5

Kentucky ✓ ✓✓ ✓ 50

Louisiana ✓ ✓ 44

Maryland ✓ ✓ 4

Massachusetts

Michigan

Minnesota ✓ ✓ 39

Mississippi6 ✓ ✓ 4–8

Missouri ✓ ✓

Montana

Nebraska ✓✓ ✓ 5

New Hampshire7 ✓ ✓

New Jersey8

New Mexico ✓ ✓ 34

New York9

New York City ✓✓ ✓ 6

North Carolina ✓ ✓

North Dakota

Ohio ✓ 6

Oklahoma10

Oregon11 ✓ ✓✓ ✓ 21

Pennsylvania ✓ ✓✓ 3

Philadelphia ✓ ✓

Rhode Island12

South Carolina13 ✓ ✓✓ ✓

South Dakota14

Does Your Agency Operate a Hospice Unit?
APPENDIX A

78

Does Your Agency Operate a Hospice Unit? (continued)

Is It a Part of Part of An Outpatient 

Agency Hospice Unit? Separate Unit? Infirmary? Housing Unit? Program? No. of Beds

Tennessee

Texas15 ✓ ✓ 24

Utah

Virginia16

Washington

West Virginia ✓ ✓

Total 25 5 22 4 8

1. Arkansas DOC operates a licensed hospital, but it has no specific designation as hospice.

2. 17 male, 8 female, table lists 15 beds.

3. Palliative care patients are sent to a hospital when needed.

4. The hospice unit is part of the inpatient area of the infirmary.The number of beds varies.

5. Kansas DOC has plans for a hospice unit underway.

6. Available beds as needed.

7. Available beds as needed.

8. NJ DOC is in the process of developing a hospice unit.

9. NY DOC has hospice services available to patients who need them.

10. A pilot program is underway.

11. Oregon DOC’s hospice is a philosophy, not a specific designation.

12. RI DOC does not have a specific hospice unit; however, special provisions can be made with outside facilities.

13. No number designated.

14. SD DOC contracts health services.Terminally ill patients can be moved to a medical facility.

15. The number of beds can expand on an as-needed basis.

16. No separate hospice unit; however, hospice care is provided in major infirmaries.
79

CRIMINAL JUSTICE INSTITUTE SURVEY

If Your Agency Does Operate a Hospice Unit, Does the Unit Have a Dedicated Staff?

Agency Dedicated Staff? What Are Their Job Classifications/Titles?

California 3 Male Unit: RN, Medical Technical Assistant, Certified Nursing Assistants

Female Unit: RN, Certified Nursing Assistant

Colorado 3 Nurses, Mental Health Staff, Chaplain

Connecticut

Federal1

Guam

Illinois

Iowa 3 Deputy Warden of Treatment, Physician, Psychologist, RN,Treatment Director,

Pharmacist, Counselor, Correctional Officer, Dietician, Chaplain,Activity Director

Kentucky 3 Physician, RNs, LPNs, Caseworker

Louisiana 3 RN, Social Workers, Nurses

Maryland

Minnesota 3 RNs, LPNs, Social Workers, and Physicians Provided Under Contract With Vendor

Mississippi

Missouri 3 RNs, LPNs, Physicians, Psychologists, Caseworker, Chaplain

Nebraska

New Hampshire

New Mexico

New York City

North Carolina

Ohio

Oregon 

Pennsylvania 3 RN, LPN, Counselor

Philadelphia 3 Nurse Managers, Physicians, Psychiatrist, Social Worker, Correctional Officer

South Carolina 3 Social Workers

Texas 3 Physician, Chaplain, Nurses, Social Workers, Psychologist

West Virginia2

Total 11

1. Chemotherapy and medical/surgical nurses who have continuing education in this area are routinely scheduled to work with 

these patients.

2. Medical services are handled on a contract basis.
APPENDIX A

80

No. of No.

Agency Provisions? Who Initiates the Request? Who Makes Final Decision? Requests Granted

Alabama ✓ Inmate’s Family Parole Board 5 1

Alaska ✓ Medical Parole Board 2 2

Arizona ✓ Staff through Deputy Warden Director 22 0

Arkansas ✓ Primary Care Physician Parole Board or Governor 7 4

California ✓ Health Care Man./Chief Medical Superior Court 6 1

Canada1 ✓ Institutional Parole Office National Parole Board 3 1

Colorado2 ✓ Team Approach Parole Board N/A

Connecticut ✓ Clinical Director Board of Parole 5 1

Delaware ✓ DOC/Warden Parole Board/Judge 5 3

District of Columbia ✓ Health Care Providers Parole Board

Federal ✓ Warden Agency Director 38 34

Florida ✓ Facility Chief Health Officer Parole Commission 31 17

Guam ✓ Inmate and Facility Physician Parole Board 0 0

Idaho ✓ Case Worker/Medical Pardons and Parole Comm. 12 2

Illinois

Indiana ✓ Commissioner Governor 0 0

Iowa

Kansas

Kentucky3 ✓ Physician Parole Board 33 15

Louisiana ✓ Warden Secretary/Parole Board 12 12

Maryland4 ✓ Physician Parole Commission 55 16

Massachusetts

Michigan

Minnesota5 ✓ Health Services Administrators Commissioner/Designee 5 5

Mississippi

Missouri ✓ Inmate, Staff, Physician Board of Prob. and Parole 66 19

Montana6 ✓ Family, Inmate, Physician Parole Board

Nebraska ✓ Inmate Facilitated by Medical Staff Parole Board 2 1

New Hampshire ✓ Div. of Med. and Psychiatric Services Commissioner 3 3

New Jersey ✓ Inmate/Rep./Admin. Parole Board/Governor 13 1

New Mexico ✓ Inmate/Case Worker/Medical Parole Board 10 8

New York ✓ No One Initiating Source Parole Agency 21 12

New York City ✓ Legal and Medical District Attorney and Judge 28 27

North Carolina7 ✓ Physician, Family, or Custody Governor 0

North Dakota ✓ Medical Staff Parole Board 1 0

Ohio ✓ Warden Governor or Parole Board 9 7

Oklahoma ✓ Physicians Governor 59 8

Oregon8 ✓ Health Services Parole Board 6 3

Pennsylvania9 ✓ Corrections Health Care Administrator Court Order

Philadelphia ✓ Physician and Admin. Diagnostic Manager Judge 12 11

Rhode Island10 ✓ Inmate’s Attending Physician Parole Board 8 4

South Carolina ✓ Attending Physician with Patient Director 2

South Dakota11 ✓ Inmate, Family, Staff, or Health Services Governor 4 3

Are There Provisions for Compassionate Release?
81

CRIMINAL JUSTICE INSTITUTE SURVEY

No. of No.

Agency Provisions? Who Initiates the Request? Who Makes Final Decision? Requests Granted

Tennessee ✓ Institutional Physician Commissioner 2 1

Texas12 ✓ Inmate, Family, Staff Board of Pardons and Parole 115 49

Utah ✓ Clinical Director Board of Pardons

Virginia13,14 ✓ Clinical Director Board of Pardons or Governor 25 7

Washington ✓ Physician DOC Secretary 24 4

West Virginia ✓ Inmate Governor 15 2

Total/Average 43 18 8

% of Total 87.76

1. From those eligible for release.

2. Team includes medical doctor, mental health worker, case manager, clinical team leader.

3. During 2000.

4. FY 2000.

5. FY 2000.

6. MSP allows medical paroles but not compassionate releases.

7. Actual number unknown.

8. Two pending.

9. Unknown.

10. Approximately.

11. One still pending.

12. 781 referrals, 666 not processed, 115 eligible.

13. If parole eligible; if not, Governor makes the decision.

14. Clemency requests to Governor. Parole requests unknown.

Are There Provisions for Compassionate Release? (continued)
APPENDIX A

82

Agency Advance Directives? DNR Orders?

Alabama1 ✓

Alaska ✓ ✓

Arizona ✓ ✓

Arkansas ✓ ✓

California2 ✓

Canada ✓ ✓

Colorado ✓ ✓

Connecticut3 ✓

Delaware ✓ ✓

District of Columbia

Federal ✓ ✓

Florida ✓ ✓

Guam ✓

Idaho ✓ ✓

Illinois ✓ ✓

Iowa ✓ ✓

Indiana ✓ ✓

Kansas ✓ ✓

Kentucky ✓ ✓

Louisiana ✓ ✓

Maryland ✓ ✓

Massachusetts4 ✓

Michigan ✓ ✓

Minnesota ✓

Mississippi ✓

Missouri ✓ ✓

Montana ✓

Nebraska ✓ ✓

New Hampshire ✓ ✓

New Jersey ✓ ✓

New Mexico ✓ ✓

New York ✓ ✓

New York City

North Carolina ✓ ✓

North Dakota ✓ ✓

Ohio ✓ ✓

Oklahoma5

Oregon ✓ ✓

Pennsylvania6 ✓

Philadelphia

Rhode Island

South Carolina ✓ ✓

South Dakota ✓ ✓

In Your Agency, Do Terminally Ill Inmates Issue Advance Directives? DNR Orders? 
83

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency Advance Directives? DNR Orders?

Tennessee ✓ ✓

Texas ✓ ✓

Utah ✓ ✓

Virginia ✓ ✓

Washington ✓

West Virginia ✓

Total 35 42

% of Total 71.43 85.71

1. Doctor discusses and patient signs.

2. Policy is being finalized for final approval.

3. Staff members issue advance directives, not the inmates.

4. Not in prison but maybe in hospital.

5. Legislation is pending.

6. Per physician.

In Your Agency, Do Terminally Ill Inmates Issue Advance Directives? DNR Orders?

(continued)
APPENDIX A

84

Agency Special Foods/Drinks Any Restrictions?

Alabama1 ✓ ✓

Alaska2 ✓ ✓

Arizona3 ✓

Arkansas4 ✓ ✓

California5 ✓ ✓

Canada ✓

Colorado6 ✓ ✓

Connecticut ✓

Delaware ✓

District of Columbia ✓

Federal ✓

Florida ✓

Guam ✓

Idaho7 ✓ ✓

Illinois ✓

Indiana8 ✓

Iowa ✓

Kansas ✓

Kentucky ✓

Louisiana ✓

Maryland ✓

Massachusetts ✓

Michigan ✓

Minnesota ✓

Mississippi ✓

Missouri ✓

Montana ✓

Nebraska9 ✓ ✓

New Hampshire ✓

New Jersey10 ✓

New Mexico ✓

New York ✓

New York City ✓

North Carolina ✓

North Dakota ✓

Ohio11 ✓ ✓

Oklahoma

Oregon ✓

Pennsylvania12

Philadelphia

Rhode Island ✓

South Carolina ✓

South Dakota ✓

Are Special Foods and Beverages Available to Terminally Ill Inmates?
85

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency Special Foods/Drinks Any Restrictions?

Tennessee ✓

Texas

Utah13 ✓ ✓

Virginia ✓

Washington ✓

West Virginia ✓

Total 45 9

1. For weight loss as ordered by site physician.

2. Restrictions are limited to the individual and his/her medical diagnosis and assessment.

3. Diets are developed on medical advisement of needs prior to determination of terminally ill status.

4. Diet trays only available at meal times, or as ordered by medical staff.

5. For inpatients in licensed health care facility, meals are available at standard meal times; if some items are held in unit refrigerator,

nursing staff may provide at a later time. Nourishment and supplements are provided for inmates to consume when they choose.

6. Special dietary needs are accommodated by the facility, and the facility may also order canteen items not available to offenders in the

infirmary. Nursing staff monitor the food from the canteen to prevent theft and overeating.

7. Food or healthy choice, extra portions, etc.

8. As part of a special diet for specific illnesses only.

9. By medical order only.

10. As medically indicated.

11. Food must be prepared by inmate dining room staff.

12. Very occasional, with exception of Jello or puddings.

13. Usually at pill line.

Are Special Foods and Beverages Available to Terminally Ill Inmates? (continued)

87

MANAGING THE NEEDS OF

CHRONICALLY ILL INMATES

Appendix A

89

CRIMINAL JUSTICE INSTITUTE SURVEY

Reception Health Reception Health Annual Health 

Agency Screening Appraisal Sick Call Appraisal Self-Referral

Alabama ✓ ✓ ✓✓ ✓

Alaska ✓ ✓ ✓✓ ✓

Arizona ✓ ✓ ✓✓ ✓

Arkansas ✓ ✓ ✓✓ ✓

California ✓ ✓ ✓✓ ✓

Canada ✓ ✓

Colorado ✓ ✓ ✓✓ ✓

Connecticut ✓ ✓ ✓✓ ✓

Delaware ✓ ✓ ✓✓ ✓

District of Columbia ✓ ✓ ✓✓ ✓

Federal ✓ ✓ ✓✓ ✓

Florida ✓ ✓ ✓✓ ✓

Guam ✓ ✓ ✓✓ ✓

Idaho ✓ ✓ ✓✓ ✓

Illinois ✓ ✓ ✓✓ ✓

Indiana ✓ ✓ ✓✓ ✓

Iowa ✓ ✓ ✓✓ ✓

Kansas ✓ ✓ ✓✓ ✓

Kentucky ✓ ✓ ✓✓ ✓

Louisiana ✓ ✓ ✓✓ ✓

Maryland ✓ ✓ ✓✓ ✓

Massachusetts ✓ ✓ ✓✓ ✓

Michigan ✓ ✓ ✓✓ ✓

Minnesota ✓ ✓ ✓✓ ✓

Mississippi ✓ ✓ ✓✓ ✓

Missouri ✓ ✓ ✓✓ ✓

Montana ✓ ✓ ✓✓ ✓

Nebraska ✓ ✓ ✓✓ ✓

New Hampshire ✓ ✓✓ ✓

New Jersey ✓ ✓ ✓✓ ✓

New Mexico ✓ ✓ ✓✓ ✓

New York ✓ ✓ ✓✓ ✓

New York City ✓ ✓✓ ✓

North Carolina ✓ ✓ ✓✓ ✓

North Dakota ✓ ✓ ✓✓ ✓

Ohio ✓ ✓ ✓✓ ✓

Oklahoma ✓ ✓ ✓✓ ✓

Oregon ✓ ✓ ✓✓ ✓

Pennsylvania ✓ ✓ ✓✓ ✓

Philadelphia ✓ ✓ ✓✓ ✓

Rhode Island ✓ ✓ ✓✓ ✓

South Carolina ✓ ✓ ✓✓ ✓

South Dakota ✓ ✓✓ ✓

How Are Chronic Illnesses Discovered in Your Agency?

(continued on next page)
APPENDIX A

90

Reception Health Reception Health Annual Health 

Agency Screening Appraisal Sick Call Appraisal Self-Referral

Tennessee ✓ ✓ ✓✓ ✓

Texas ✓ ✓ ✓✓ ✓

Utah ✓ ✓ ✓✓ ✓

Virginia ✓ ✓ ✓✓ ✓

Washington ✓ ✓ ✓✓ ✓

West Virginia ✓ ✓ ✓✓ ✓

Total 48 48 48 46 49

% of Total 98.0 98.0 98.0 93.9 100.0

How Are Chronic Illnesses Discovered in Your Agency? (continued)
91

CRIMINAL JUSTICE INSTITUTE SURVEY

Do Chronically Ill Inmates Have Access to a Congregate Activity Place Separate

From the General Population of Inmates?

Agency “Yes”

Alabama

Alaska

Arizona

Arkansas1 ✓

California

Canada

Colorado

Connecticut

Delaware

District of Columbia ✓

Federal2

Florida

Guam

Idaho3 ✓

Illinois

Indiana

Iowa ✓

Kansas

Kentucky4 ✓

Louisiana

Maryland

Massachusetts

Michigan ✓

Minnesota ✓

Mississippi5 ✓

Missouri ✓

Montana6

Nebraska

New Hampshire

New Jersey 

New Mexico

Agency “Yes”

New York

New York City ✓

North Carolina

North Dakota

Ohio7 ✓

Oklahoma

Oregon ✓

Pennsylvania

Philadelphia

Rhode Island

South Carolina

South Dakota ✓

Tennessee

Texas

Utah

Virginia ✓

Washington

West Virginia

Total 15

% of Total 30.6

1. Not segregated based on illness, but those in sheltered 

living do.

2. Yes, in the sense that sick inmates are housed in a specific 

area and they congregate in the television room/recreation 

area where other inmates would be out of bounds.

3. Some chronically ill inmates.

4. Some chronically ill inmates.

5. HIV-positive inmates have a separate living area.

6. Montana DOC has one unit where many chronically ill 

inmates reside; however, it is not designated specifically for 

chronically ill inmates.

7. Only at OCI Frasier Unit.
APPENDIX A

92

Agency “Yes” Duties

Alabama ✓ Feed, bathe, change clothes

Alaska ✓

Arizona

Arkansas ✓ Push wheelchairs, assist with transfer, advise staff of crises

California ✓

Canada1 ✓

Colorado

Connecticut

Delaware

District of Columbia

Federal ✓ Provide transportation within prison, carry food trays, etc.

Florida ✓

Guam

Idaho

Illinois ✓ Assist with activities of daily living

Indiana2 ✓

Iowa

Kansas

Kentucky ✓ Provide transport, read mail, provide other assistance

Louisiana ✓ Assist in ambulation, provide moral support to HIV/AIDS patients

Maryland

Massachusetts

Michigan 

Minnesota ✓ Assist with wheelchair and transport

Mississippi3 ✓

Missouri4 ✓

Montana5 ✓

Nebraska

New Hampshire

New Jersey ✓ Perform duties of infirmary orderlies

New Mexico ✓ Assist with activities of daily living 

New York6

New York City

North Carolina

North Dakota

Ohio7 ✓ Provide companionship 

Oklahoma ✓

Oregon

Pennsylvania ✓

Philadelphia

Rhode Island ✓

Are Inmate Volunteers Used To Assist Chronically Ill Inmates? 
93

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency “Yes” Duties

South Carolina ✓ Assist with activities of daily living and ambulation

South Dakota

Tennessee

Texas8 ✓

Utah

Virginia ✓ Push wheelchairs

Washington ✓ Push wheelchairs, act as peer counselors

West Virginia ✓

Total 26

% of Total 53.1

1. In some cases, only where a program to train caregivers exists.

2. Minimally—outpatient settings only.

3. Inmate volunteers work under the direct supervision of prison staff.

4. Only trained offenders who participate in the hospice program.

5. Inmate volunteers assist when the chronically ill inmate becomes terminally ill.

6. NY DOC is considering implementing an inmate volunteer program.

7. Only in hospice unit.

8. Only in hospice.

Are Inmate Volunteers Used To Assist Chronically Ill Inmates? (continued)
APPENDIX A

94

Agency “Yes” Duties

Alabama

Alaska

Arizona

Arkansas ✓ Recreational activities, visit in hospital

California

Canada 

Colorado

Connecticut

Delaware

District of Columbia

Federal

Florida

Guam

Idaho

Illinois

Indiana 

Iowa

Kansas

Kentucky ✓

Louisiana ✓ To provide religious/spiritual services

Maryland

Massachusetts

Michigan1 ✓

Minnesota

Mississippi 

Missouri ✓

Montana 

Nebraska

New Hampshire

New Jersey

New Mexico

New York ✓ Bereavement counseling and religious services

New York City

North Carolina ✓

North Dakota

Ohio ✓ Religious services and support

Oklahoma

Oregon

Pennsylvania

Philadelphia

Rhode Island

South Carolina

South Dakota

Are Community Volunteers Used To Assist Chronically Ill Inmates? How?
95

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency “Yes” Duties

Tennessee ✓ Spiritual services and support

Texas 

Utah

Virginia

Washington

West Virginia

Total 9

% of Total 18.4

1. Very limited use of community volunteers; however, one individual who works with a local hospice volunteers at the prison hospital.

Are Community Volunteers Used To Assist Chronically Ill Inmates? How? (continued)

STAFF TRAINING

97

Appendix A

99

CRIMINAL JUSTICE INSTITUTE SURVEY

Agency Elderly Inmates Terminally Ill Inmates Chronically Ill Inmates

Alabama

Alaska ✓ ✓✓

Arizona

Arkansas1 ✓ ✓

California ✓ ✓

Canada

Colorado ✓ ✓✓

Connecticut2 ✓

Delaware ✓

District of Columbia ✓

Federal3 ✓

Florida

Guam

Idaho

Illinois

Indiana ✓ ✓✓

Iowa ✓ ✓

Kansas

Kentucky ✓ ✓✓

Louisiana

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

New Hampshire

New Jersey 

New Mexico

New York4 ✓ ✓✓

New York City

North Carolina5

North Dakota

Ohio ✓ ✓✓

Oklahoma

Oregon ✓ ✓

Pennsylvania6

Philadelphia ✓ ✓

Rhode Island

South Carolina7

South Dakota8

Is Training Provided for Correctional Officers in Working With

the Following Populations?

(continued on next page)
APPENDIX A

100

Agency Elderly Inmates Terminally Ill Inmates Chronically Ill Inmates

Tennessee

Texas

Utah

Virginia ✓✓✓

Washington

West Virginia

Total 8 13 14

% of Total 16.33 26.53 28.57

1. Not for all officers. Medical services and mental health services have specially trained officers.

2. In the process of developing a lesson plan for working with terminally ill inmates.

3. For mental health issues only.

4. Training provided for staff in Regional Medical Units only.

5. All custody training is standard; specialized training is provided as needed.

6. Not at present; however, PA DOC is working on programming and education for staff and inmates working with these populations.

7. AIDS only.

8. No general training; however, medical staff for correctional officers working in area of infirmary receive some training.

Is Training Provided for Correctional Officers in Working With

the Following Populations? (continued)
CLASSIFICATION AND TREATMENT

101

Appendix A

103

CRIMINAL JUSTICE INSTITUTE SURVEY

Objective-Based Treatment Needs Perform Treatment Needs

Agency Classification Instrument Assessment Feature Assessments at Intake?

Alabama ✓ ✓✓

Alaska ✓ ✓✓

Arizona ✓ ✓✓

Arkansas ✓ ✓✓

California ✓ ✓✓

Canada ✓ ✓

Colorado ✓ ✓

Connecticut ✓ ✓✓

District of Columbia ✓ ✓✓

Delaware ✓ ✓✓

Federal ✓ ✓

Florida1 ✓ ✓

Guam ✓ ✓

Idaho ✓ ✓✓

Illinois ✓ ✓

Indiana ✓ ✓✓

Iowa ✓ ✓✓

Kansas ✓ ✓

Kentucky ✓ ✓

Louisiana ✓ ✓✓

Maryland ✓

Massachusetts ✓ ✓

Michigan ✓ ✓

Minnesota ✓ ✓

Mississippi

Missouri ✓ ✓✓

Montana ✓ ✓✓

Nebraska ✓ ✓

New Hampshire2 ✓ ✓

New Jersey ✓

New Mexico3 ✓ ✓

New York ✓ ✓✓

New York City ✓ ✓✓

North Carolina ✓ ✓✓

North Dakota ✓ ✓✓

Ohio ✓ ✓✓

Oklahoma ✓ ✓✓

Oregon ✓ ✓

Pennsylvania4 ✓ ✓

Philadelphia5 ✓ ✓

Rhode Island ✓ ✓✓

South Carolina ✓ ✓✓

South Dakota ✓ ✓✓

Does Your Agency Use the Following Classification and Assessment Instruments?

(continued on next page)
APPENDIX A

104

Objective-Based Treatment Needs Perform Treatment Needs

Agency Classification Instrument Assessment Feature Assessments at Intake?

Tennessee6 ✓ ✓

Texas7 ✓

Utah

Virginia ✓ ✓✓

Washington ✓ ✓✓

West Virginia ✓ ✓✓

Total 42 31 44

% of Total 86 63 90

1. Classification instrument does not include a treatment needs feature because health-related treatment is confidential.

2. The provider decision is based on a 1–5 scale indicative of ability to work. A “5” may indicate the need for infirmary placement 

assessed individually.

3. Assessment is by a physician or midlevel provider.

4. Clinical review conducted by central office coordinator of receiving facility.

5. Assessment is performed by Social Services.

6. Decision of medical director.

7. Offenders are referred by medical staff.

Does Your Agency Use the Following Classification and Assessment Instruments?

(continued)
105

CRIMINAL JUSTICE INSTITUTE SURVEY

Rehabilitation Occupational Physical Speech

Specialists Specialists Specialists Specialists

Agency C E T* C E T C E T C E T

Alabama ✓✓ ✓✓

Alaska1 ✓✓ ✓✓

Arizona2 ✓✓✓✓

Arkansas ✓

California ✓✓✓ ✓✓✓ ✓✓✓

Canada3

Colorado ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Connecticut

District of Columbia ✓✓ ✓✓ ✓✓

Delaware

Federal ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Florida4 ✓✓✓ ✓✓✓ ✓✓✓

Guam

Idaho

Illinois ✓✓ ✓ ✓✓✓ ✓✓

Indiana5 ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Iowa

Kansas ✓✓✓

Kentucky ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Louisiana ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Maryland6 ✓✓✓ ✓✓✓ ✓✓✓

Massachusetts ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Michigan ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Minnesota7 ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Mississippi ✓✓✓

Missouri ✓✓ ✓✓ ✓✓ ✓✓

Montana

Nebraska ✓✓✓ ✓

New Hampshire ✓✓✓

New Jersey ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

New Mexico ✓✓✓ ✓✓✓ ✓✓✓

New York ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

New York City ✓✓✓

North Carolina8 ✓ ✓

North Dakota

Ohio

Oklahoma ✓ ✓

Oregon

Pennsylvania9 ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Philadelphia10 ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Rhode Island11 ✓✓✓ ✓✓✓ ✓✓✓

Does Your Agency Employ or Engage the Services of Any of the

Following Health Care Specialists?

(continued on next page)
APPENDIX A

106

Rehabilitation Occupational Physical Speech

Specialists Specialists Specialists Specialists

Agency C E T* C E T C E T C E T

South Carolina ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

South Dakota ✓✓✓ ✓✓✓ ✓✓✓

Tennessee ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Texas ✓✓✓ ✓✓✓ ✓✓✓ ✓✓✓

Utah

Virginia

Washington ✓✓✓✓

West Virginia ✓ ✓

Total 25 24 18 25 22 20 36 33 27 24 22 19

% of Total 51 49 37 51 45 41 73 67 55 49 45 39

1. Alaska DOC also employs eye specialists.

2. Geriatric/elderly inmates may be afforded all of the services identified (e.g., chronically or acutely ill patients can be geriatric).

3. Occupational therapists are employed in regional mental health treatment facilities.When required, the other three specialists

are hired on contract.They will provide these services at the institution or on an outpatient basis.

4. Contract services based on medical need.

5. As ordered by attending physician.

6. Services provided on an as-needed basis to all inmates.

7. Services provided on an as-needed basis to all inmates.

8. Therapists are provided on a case-by-case basis as needed.

9. The facility may engage any medical service through a physician’s order.

10. Services are provided through specialty clinics whenever deemed medically necessary by a physician.

11. Contracted professionals come to the site to provide rehabilitation and physical therapy services.

*C = Chronically Ill; E = Elderly;T = Terminally Ill.

Does Your Agency Employ or Engage the Services of Any of the

Following Health Care Specialists? (continued)
Appendix B

MANAGING LONG-TERM INMATES

AND INMATES WITH CHRONIC

AND TERMINAL ILLNESSES: 

Site Visit Reports

109

MANAGING LONG-TERM INMATES

AND INMATES WITH CHRONIC

AND TERMINAL ILLNESSES: 

SITE VISIT REPORTS

Appendix B

To impart currency and relevancy to the findings of

this report, three of the project’s expert consultants

visited six representative departments of corrections

(DOCs) that are considered to have considerable

experience with elderly, chronically ill, and terminally

ill inmates. Each of these DOCs also has in place a

comprehensive approach for planning and delivery of

services for these inmate populations.A consistent

checklist of questions was developed for these site

visits (see appendix C). Information and examples

from the site visits are mentioned throughout this

report.This appendix provides more detailed information about the programs and policies in place at

the six sites, including responses to the checklist of

questions.

SITE VISIT REPORT:

MICHIGAN DEPARTMENT

OF CORRECTIONS

SITE EVALUATOR:

RONALD SHANSKY, M.D.

EVALUATION DATE:

NOVEMBER 7–8, 2001

The Functional Assessment

1.What is the screening tool used for inmates with special needs on entry to systems?

The Michigan Department of Corrections has an

intake history screening form that is completed by a

nurse at the time of the inmate’s arrival.This is a history of any types of problems, including medical and

mental health problems, that the inmate may provide. If the inmate has a special need, such as

impaired mobility, the inmate is immediately referred

to a physician who identifies the need and arranges

for the inmate to be placed in appropriate housing

during the reception process.Within 10 days of

entry into the system, the inmate receives a complete history and physical examination. During that

examination any specific accommodations needed

for medical problems are identified.After identifying

the special needs, the physician fills out the bottom

half of the Special Needs Identification Screening

Form, which lists particular treatments, procedures,

specialty medical care, and any restrictions (e.g., low

bunk) that the inmate may require. In addition, the

physician fills out the Special Accommodation

Notice.This form allows for four copies: one to be

kept in the medical record, one to be kept in the

inmate’s master file, one to go to the inmate’s counselor, and one to be kept by the inmate.This accommodation form is considered to be documentation

of permanent accommodation needs. If the inmate’s

needs change, the physician fills out a new form and

replaces the old form with the new form.This

Special Accommodation Notice is designed to

ensure that the special accommodations are maintained even when inmates are transferred between

institutions. Data on this form are maintained in an

electronic system.

2.What other kinds of screening mechanisms are used

at intake to determine functionality?

Additional screening tests used for inmates include

psychological tests consisting of the draw-a-person

test, the finish-sentence test, and the Minnesota

Multiphasic Inventory (MMPI).These are used to

screen for mental health problems and developmental disabilities. No other special screening mechanisms are used at intake.

3. Is a functional assessment routinely conducted on all

inmates at intake? If yes, what does the functional

assessment entail?

The functional assessment performed at intake is the

history and physical performed by the physician.At

the time inmates with specific disabilities, such as

mobility or sensory neural impairments, are identified, they are enrolled in a disability chronic clinic

and seen for their first chronic care visit within 5

days of entering the permanent facility. In addition,

the inmates are seen for their first visit, during

which time the comprehensive database on the disability is completed.

4. How does your classification program work to separate inmates based on need?

The Special Accommodation Notice is sent to the

counselor responsible for the inmate; the counselor

then makes housing and programmatic decisions

based on needs identified on the form. Some jobs

are designed for individuals with certain types of

impairments.There is no structural method to the

medical classification, such as classifying people as

class 1, 2, 3, or 4. Rather, the specific accommodations identified are used for each inmate.

5. How do you ensure that the special needs which have

been identified are recognized?

111

MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
Michigan ensures that identified needs are recognized by use of the Special Accommodation Notice.

These accommodations are, by policy, required to be

recognized and provided for at all facilities.At the G.

Robert Cotton facility, one of the facilities that houses a large number of special needs inmates, the

accommodation needs are listed on a computer

count sheet so that each day the count for the facility includes the inmates’ location, beds, and housing

needs. It is planned that other institutions within the

department will use this system.

6.What is your mechanism to ensure that the special

needs of the inmate are always maintained? (Including

upon transfer from one facility to another.)

The mechanism to ensure that the special needs of

inmates are always maintained, even upon transfer, is

use of the Special Accommodation Notice.The

health care staff receives a printout once each

month with a list of the special accommodation

needs, including any about to expire (those that are

of less than 6 months’ duration), and they also

receive a list of all inmates with permanent

accommodations.

Balancing Custody Concerns

and Appropriate Care

1. Does your departmental offender tracking system

count inmates considered to be elderly separately?

The Michigan Department of Corrections has a

statewide Committee on Geriatrics that plans for

the needs of these inmates.The committee is

appointed by the regional prison administrators.This

committee is developing recommendations regarding

programming, facility housing, and medical needs.The

Michigan Department of Corrections does not have

an offender tracking system that separately identifies

the elderly. It can, however, print out a list of inmates

by age, gender, race, county of commitment, prior

commitments, felony, most serious commitment

offense, and initial security classification assignment.

In the State of Michigan, an inmate is defined as elderly if he or she is 60 years or older and has no significant disability.This is in contrast to the Michigan

APPENDIX B

112

Department of Corrections definition of a geriatric

inmate: a special needs inmate who is 60 years or

older and has a chronic illness or disability related

to the aging process that has caused permanent

impairment in the individual’s ability to pursue

activities of daily living, such that special housing or

special programs are required.

2. Does your departmental offender tracking system distinguish between:

Inmates who entered the system younger

than age 50 and who attained that age

while incarcerated?

Inmates who were age 50 or older at entry

but were never incarcerated before?

Inmates who were age 50 or older at entry

who were previously incarcerated?

Michigan does not differentiate between inmates

who entered the system younger than 50 and

attained that age while incarcerated, inmates who

were age 50 or older at entry but were never incarcerated before, or inmates who were age 50 or

older at entry who were previously incarcerated.

3.Are elderly inmates in your department housed congregately in special housing as a discrete subpopulation?

Elderly inmates are housed in congregate housing,

but by functional need, and they may be housed with

younger inmates.

4.Are elderly inmates housed in one or more separate

facilities in your departmental system?

Most elderly inmates are housed at the Lakeland

facility, the Cotton facility, or at one of two of the

southern Michigan prisons, Parnall Correctional

Facility and Southern Michigan Correctional Facility.

In addition, younger inmates with special needs are

frequently housed in the same units.Women with

special needs are mainstreamed at each of the two

women’s facilities.

5. Does your department provide educational or other

personal development programs specifically designed for

elderly inmates that include issues and problems?
The Michigan Department of Corrections does provide some special recreation programs, particularly

at the Lakeland facility, and some educational

programs, but these are individually based. Lakeland

has a tutor to work with the inmates.

6. If yes, does the program include:

Education on the aging process?

Education on physical, psychological, and social

issues associated with aging while incarcerated?

Education on self-care and activities of daily

living basic adult education and literacy?

The state Department of Aging provides education

on the aging process.There is some individual education on physical, psychological, and social issues

associated with aging, and there is some group

counseling.There is no formal structure to provide

education on activities of daily living or basic adult

education and literacy, although individuals may

enroll for tutorials.

7. Does your department provide supervised recreational

programs specifically designed and appropriate for elderly inmates? Please describe the programs available.

The Lakeland facility provides some supervised

recreational programs specifically designed and

appropriate for elderly inmates, such as horseshoes

and playing cards.

8. Does your department survey/sample your population

of inmates age 50 or older to assess their perceptions of

their needs?

A survey of older women was conducted recently,

but the data have not been compiled yet. Males have

not yet been surveyed.

9. Does prerelease planning for elderly inmates include

information on

Social Security?

Medicare?

Estates and wills?

Advance directives (such as “do not

resuscitate”)?

Funeral preplanning?

Other community-based services for the elderly (e.g.,“meals on wheels”)?

Some individual counseling is provided for inmates

with concerns about Social Security, Medicare, and

estates and wills.There is discussion regarding

advance directives that is done each year at the

inmates’ annual exam, but compliance with this policy is not very good.

10. Does your departmental health services division provide organized health education services to inmates considered elderly? 

The departmental health services division does not

provide organized health education services to

inmates considered elderly. Most of the education

they provide is disease specific, such as education

about diabetes or hypertension.

11. Is there a peer-visiting program for elderly inmates?

There is no peer-visiting program for elderly

inmates.

12. In your department, do inmates who are debilitated,

frail, or medically fragile have access to a congregate

therapeutic living community where they can be medically supervised, specially programmed, and assisted with

the activities of daily living? If yes, is that program available to both men and women?

There is no congregate therapeutic living community

where inmates can be medically supervised, specially

programmed, or assisted with the activities of daily

living.There is a chronic care unit that is more like

skilled nursing at the Dwayne Waters Hospital, and

the Lakeland facility has a geriatric unit where

inmate aides are available to assist inmates in some

activities of daily living.The vast majority of inmates

at Lakeland are independent with regard to activities

of daily living.

13. Does your department’s health services division

promulgate and implement chronic protocols or guidelines for all of the major chronic conditions?

The department does promulgate and implement

chronic disease protocols for all the major chronic

113

MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
APPENDIX B

114

diseases, such as diabetes, hypertension, asthma,

seizure disorder, HIV, and TB prophylaxis; and they

have a special disability clinic that is unique.The disability clinic results in a thorough disability evaluation for each inmate who is enrolled in the clinic,

and these inmates are seen on a regular basis no

less frequently than every 3 months, regardless of

their condition. If an inmate has a disability, such as

mobility impairment, and has other chronic diseases,

his or her major clinic is the disability clinic and the

other diseases are addressed during that clinic

session.

14. Does your department operate prerelease centers

or halfway houses with programs designed for elderly

inmates?

The Michigan Department of Corrections does not

operate prerelease centers or halfway houses with

programs designed for elderly inmates.

15.Are inmates who are considered elderly in your

department provided:

Universal access to the entire physical plant

housing them?

Single or lower bunks?

Additional heat in cold weather?

Air conditioning in warm weather?

Inmates who are considered elderly are provided

universal access to the entire physical plant and single or lower bunks.They may get extra blankets or

clothing in cold weather.There is no air conditioning.

A list of high-risk inmates, including those on psychotropic medications, is maintained, and these

inmates’ concerns regarding heat and cold are

specifically addressed.

16.Are medical social services professionals available

to your department’s population of inmates directly or

to your health services division as case management

consultants?

No medical social services professionals are available

to this population except for those housed at

Dwayne Waters Hospital.

17. Does your department operate or have access to levels of care ordinarily identified with nursing homes?

A level of nursing home care is available at the

Dwayne Waters Hospital, at Huron Valley

Correctional Center, and at the Marquette State

Prison.

18. Does all or part of your department’s physical plant

comply with the Americans with Disabilities Act?

Of the approximately 43 state prisons, 18 are barrier free and comply with the Americans with

Disabilities Act.

Medical, Program, and Housing

Considerations: Requirements

for Elderly, Chronically Ill, and

Terminally Ill Inmates 

A. Compassionate release

1. Is there a compassionate release/medical parole program for terminally ill inmates in your system?

2.Who initiates the request for compassionate release?

3. How long does the process generally take?

4.Which agency can grant the release request?

Although there is a compassionate release/medical

parole process, it like most others is subject to

political decisions and thus relatively few inmates are

able to benefit from it.The institution would initiate

the request.The process may take a very long time.

The release is granted by the Governor’s office.

B. Hospice care

1. Do you have a hospice unit for inmates who are terminally ill?

Plans are being made for a hospice to be housed at

the Dwayne Waters Hospital.This will not be in a

specific room. Rather, a group of services will be

available to inmates deemed eligible for hospice

services.The services that would be made available

would include increased property availability,
increased visitation, increased dietary options, and

the use of standing orders by the nurses for symptom management.There are plans to utilize volunteers from the hospice of the town of Jackson.

There are currently case management care teams at

the Dwayne Waters Hospital, and it would be up to

these teams to refer inmates who may be eligible for

hospice care.

2.What are the eligibility criteria in terms of:

a.The definition of “terminal illness”?

b.The level of functioning?

c.The type of crime the inmate committed?

d.The diagnosis?

e. Other?

3. Is this a discrete unit? Part of the infirmary? Part of a

housing unit? An outpatient program? 

4. How many beds are in the hospice unit?

5. How many patients do you usually serve at one time?

6. How many patients in all did you serve last year? 

7.Are there dedicated staff for the hospice unit? If yes,

what types?

8. Do you use other inmates as volunteers in your

program?

9. If yes, describe the screening selection process, the

training program, the types of activities they perform, and

any rules/restrictions they operate under.

10. Do you use any volunteers from the community? If

yes, describe this program.

N/A (Questions 2–10)

11. Do terminally ill inmates in your system issue

advance directives? DNR orders? If yes to either, what

safeguards are in place to ensure that they have given

non-coerced informed consent?

In general, advance directives and “do not resuscitate” (DNR) orders are used only by inmates at

Dwayne Waters Hospital. It is state policy to resuscitate all other inmates.The state is interested in

putting together a committee to reevaluate this

process and possibly to create greater flexibility with

regard to the DNR policy.

12.What is the visitation policy for the terminally ill

patient’s family? Other inmates?

Now on a case-by-case basis, a warden may make

exception to structured rules with regard to family.

No other inmates are allowed to visit.

13.Are special foods and drinks available to terminally ill

patients at all times? 

Currently, no special foods and drinks are available

to terminally ill inmates, although the plans for the

hospice, which may start within the next few

months, would allow for such.

14.Are there or were there institutional barriers (e.g.,

security rules, administrative concerns) that affect your

ability to provide support for the terminally ill in your system? If yes, what are they and how are you addressing

them?

There are the usual medical needs versus securitylevel barriers that preclude some options.Terminal

inmates who are mainstreamed are currently not

allowed to have a DNR order, although this issue

may be revisited.

15. Do you have hospice programs in all of your facilities? If not, how many do you have?

There are currently no hospice programs in any of

the facilities.

16.Are terminally ill inmates in all facilities able to be

transferred to a unit with a hospice program?

No.The planned program will be voluntary.

Currently, if a terminally ill inmate is bedridden, he

or she may go to the Marquette or Huron Valley

infirmary or Dwayne Waters Hospital. In those units,

they may have a DNR order.

C. Palliative care

1. Is there a palliative care program in your facilities?

There is currently a pain management program at

the Joint Commission on Accreditation of

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
Healthcare Organizations (JCAHO)-accredited

Dwayne Waters Hospital.This program is designed

to meet JCAHO accreditation requirements.The

structured pain evaluation is currently utilized both

pre- and postmedication.What is extremely exciting

is that there are plans to allow nurses to use standing orders that offer a significant degree of flexibility

on the dosages of controlled substances to be provided to the inmates based on the inmates’ selfassessment of the level of pain.There are plans to

start this on a pilot basis at Dwayne Waters on

December 1, 2001. I strongly recommended that the

institution develop data on the number of inmates

utilizing controlled substances for pain management

at Dwayne Waters between September 1 and

December 1, and on the total number of doses provided. I also encouraged them to maintain the same

data for a 6-month period after December 1.There

is a goal, if the Dwayne Waters Hospital pilot program works, to look to expanding the pain management program statewide where possible.

2. If yes, is palliative care available to those with

advanced disease but who have not yet been defined

as terminal?

No.

3.What types of palliative care do you offer?

See answer to no. 1, above.

4.What are the eligibility criteria for receiving it?

A booklet on the pain management program, which

I’ve included with this report, includes the criteria

for inmates receiving such care.The current program requires a pain assessment and a flowsheet to

record the status of the pain, including a form for

cognitively impaired patients and a flowsheet for

them.There is also a patient’s rights statement.

Three institutional needs assessments have been

conducted looking at implementation of the pain

management program. Implementing this program at

the Dwayne Waters Hospital has resulted in some

attitude changes among nurses.

5. Does your pain management program include the use

of narcotics? If yes, did you encounter any resistance

from custody staff? If yes, how did you overcome it?

Describe what is available.

APPENDIX B

116

The pain management program does include the use

of narcotics. Custody staff have accepted it as part

of a medical program.

6. (No question no. 6 was listed on the form.)

7. Do you use an interdisciplinary team in your palliative

care program? If yes, what types of personnel are on it?

Who leads the team? What is the team’s role?

An interdisciplinary team works on the palliative

care program. It includes physicians, nurses, social

workers, physical therapists, custody staff, and

dietitian.

8. Do you develop individualized care plans for your palliative care patients?

Individualized care plans are part of the palliative

care program.

9. Can patients in the palliative care program continue to

receive curative care?

Inmates who receive the palliative care program can

also receive curative care.

D. General

1.Are your end-of-life programs available to women

inmates as well as men? Are there any differences in

terms of what is available to women?

The end-of-life programs that are available at

Dwayne Waters Hospital will be available to both

genders.

2.Are you satisfied with the end-of-life care you are able

to offer currently? If not, what more is needed?

The plan is to pilot the use of this end-of-life pain

management program and possibly move it

statewide. In addition, there are plans to develop

hospice services more on an outpatient basis but to

make special services previously listed available to

groups of inmates who meet the criteria.

3. How are your end-of-life programs funded?

There is no discrete funding for the planned hospice

programs.There are plans to use existing staff and

volunteers.

11/19/01
SITE VISIT REPORT:

MINNESOTA

DEPARTMENT OF

CORRECTIONS

SITE EVALUATOR:

B. JAYE ANNO, PH.D.

EVALUATION DATE:

NOVEMBER 2001

Preface

In November 2001, I visited two correctional facilities in Minnesota to see how they manage their elderly, chronically ill, and terminally ill inmates. I toured

the Minnesota Correctional Facility (MCF)-Faribault

on November 1 and the Minnesota Correctional

Facility (MCF)-Oak Park Heights on November 2.

My observations and findings are noted below.

Background

The Minnesota Department of Corrections (MDC)

operates nine facilities, including seven for adult

males, one for adult females (MCF-Shakopee), and

one for juveniles (MCF-Red Wing).The total population averages 6,400 adults and 100 juveniles on any

given day.The majority (51 percent) of inmates are

people of color, and the balance are Caucasian.

Minnesota has a centralized health system with all

health services (i.e., medical, dental, and mental

health) organized under a single health authority.At

the MDC central office, there is a director of health

services who reports to the deputy commissioner.

Additional staff include a director of nursing, a director of mental health services, a half-time medical

director, and a budget manager.The latter oversees

health expenditures of $31 million annually. MDC

contracts with a for-profit group, Correctional

Medical Services (CMS), for its providers (i.e., MDs,

DOs, and midlevels), specialty care, and hospitalization at the rate of $12.8 million per year.All other

health staff at the units, including nurses, lab and xray technicians, dental staff, and mental health staff

(excluding psychiatrists), are state employees.

Management of the Chronically

Ill and Inmates With Special

Health Needs

Assessment of chronic and special health needs

occurs at intake (MCF-Saint Cloud for males and

MCF-Shakopee for females).The form used is a traditional one that gathers information on the inmate’s

health history on arrival and is followed by a physical

exam consisting of a review of systems within 14

days of confinement.A brief mental health assessment is also completed within the first 24 hours of

an inmate’s arrival. More extensive followup assessments are completed if any mental illness or disability is noted.At the unit level, chronic care patients

are followed individually.There are no chronic care

clinics per se, and no clinical protocols for the management of specific diseases, although I was told that

the CMS medical director was working on developing the latter. MDC plans to implement chronic care

clinics at each of its facilities when the protocols are

in place.All of the adult male institutions will have

the same schedule for clinics to ensure that inmates

who are transferred do not miss their appointments.

MDC does not do any functional assessment on

intake. I was told that the classification committee

does not consider health needs when making unit

assignments for adult males. Rather, inmates are

assigned to a facility based on their security rating

only. If it turns out that the facility cannot meet their

medical needs, the inmate is transferred (see policies

on “Transfers for Needed Care” and “Special Needs

Transfer Process”).

Three adult male facilities provide special health

services. MCF-Faribault is a medium security facility

that has a dedicated housing unit, called Linden, for

inmates who are 55 or older with chronic health

problems or younger inmates with disabilities (e.g.,

blind, deaf, wheelchair-bound inmates). MCF-Oak

Park Heights is the only maximum-security facility in

the system. It also has the only Transitional Care

Unit (TCU or infirmary).The TCU has 38 beds, and

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
a separate Mental Health Unit (MHU) has 46 beds

(see attached policies for admission criteria to these

two units).The MCF-Lino Lakes facility has 10 beds

for mentally ill or developmentally disabled inmates

and a 30-bed unit for dually diagnosed (mentally

ill/chemically dependent) inmates.

Management of Elderly

Offenders

MDC defines anyone 55 or older as elderly.An

offender tracking system, referred to as “COMS,”

has the capacity to track the elderly separately, but

this is not done.The system includes fields for gender, race, county of commitment, number of prior

commitments, level of felony, most serious commitment, and initial classification assignment as well as

fields for certain health information. Elderly inmates

are not separated into those who were 55 or older

when incarcerated and those who attained the age

of 55 while incarcerated.

Elderly inmates in MDC may remain in the general

population.As noted previously, MCF-Faribault has

the Linden unit available for older inmates who need

extra monitoring or want to live in a more protected environment. Inmates who are 55 or older can

submit a request to live at Linden. If they do so, they

cannot work because they are considered to be

“retired.” The Linden unit has 100 beds.At the time

of my visit, 80 beds were filled with special needs

inmates (both elderly and disabled). General population inmates used the other beds. I was told the

general population inmates would be moved out if

beds were needed for special needs inmates, but

they are required to keep the beds filled.

The Linden unit has 16-hour-per-day coverage by

licensed practical nurses. Nursing coverage is available 24 hours per day in the main clinic area.

Inmates housed at Linden must be able to perform

their own activities of daily living (ADLs). If they

require assistance with their ADLs or 24-hour

nursing care, they are transferred to the TCU at

MCF-Oak Park Heights.There is no “keep on the

person” medication program here.The nurses pass

all medications individually to ensure better

compliance.

APPENDIX B

118

The Linden unit is handicapped accessible, including

the recreation equipment, dining area, and telephone

booths.There are TTY machines for the deaf, and

interpreters are provided for all hearings. Special

needs inmates stay in two-person rooms (not cells).

Hospital beds with railings are available as needed.

General population inmates assigned to this unit stay

in dorms.

Inmates who are wheelchair bound or severely disabled may be assigned a “personal care attendant”

(i.e., an inmate helper), who helps clean the room,

push the wheelchair, etc.They may not assist with

ADLs because, as noted above, inmates at Linden

must be able to perform their own ADLs.

All inmates at the Faribault facility use a common

dining room, with two units eating at the same time.

Inmates assigned to the Linden unit share the dining

room with a treatment unit.The Linden unit has its

own weight room, recreation area with a pool table,

patio, and courtyard. Job assignments include janitor,

kitchen worker, personal care attendant, and industry jobs in woodshop or ballroom assembly. Linden

inmates can become involved in crafts, attend

school, or serve as tutors to inmates in the general

population.

Release and Discharge Planning

In Minnesota, inmates who observe the rules serve

two-thirds of their sentence in prison and one-third

in the community under supervised release (which is

similar to parole). If someone is gravely ill or cannot

be medically managed within the MDC system, the

state also has a provision for conditional medical

release. In this case, the offender is placed in an

appropriate community health facility to receive

needed care.The basic criteria for an inmate to be

considered for conditional medical release are that

he or she has a grave health condition that is not

likely to improve, is incapable of self-care, does not

pose a risk to public safety, and has health needs

that can be better met by a community facility.With

conditional medical release, an offender can be

placed in the community during his or her incarceration term but can be brought back into the prison
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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES

system if the health condition improves to the point

that it can be managed within MDC facilities.

A request for conditional medical release of a specific inmate is initiated by facility health services personnel, sent through the facility chain of command,

then sent to the central office hearings and release

unit (HRU). HRU makes a recommendation to the

director of health services, assistant commissioner

for facilities, and commissioner. Usually about a

month is required to complete the process, but it

can be expedited as necessary.

Since most inmates in Minnesota leave prison under

supervised release, they all get some prerelease

planning. Each facility has case managers who are

responsible for working with the inmates to develop

acceptable release plans. In addition, prerelease classes are offered to any inmate who is within 4 to 6

months of release.The topics covered include how

to apply for Medicaid/Medicare, MinnesotaCare, or

another medical plan when inmates leave the prison.

An information packet with applications is provided.

Furthermore, inmates with ongoing medical conditions are given a prescription and a 7-day supply of

needed medications on release.Also, inmates with

disabilities are assisted in obtaining adaptive devices

as needed.

Management of the

Terminally Ill

Owing to its small size, the Minnesota Department

of Corrections does not have a hospice unit per se.

Instead, terminally ill inmates (males only) are managed in the TCU or MHU at MCF-Oak Park Heights

or in community facilities under the conditional

release process described above (both males and

females). Hospice care is included as part of MDC’s

contract with Correctional Medical Services. CMS

contracts with HealthEast Hospice, which is a part

of Saint Joseph’s Hospital in Saint Paul.When a

terminally ill inmate chooses hospice care and will

remain at MCF-Oak Park Heights, a nurse and a

social worker from HealthEast Hospice come into

the facility and discuss their services with the

patient and his family.The hospice staff explain the

options available to the patient, and based on the

patient’s wishes, help him execute advance directives, which can include “do not resuscitate” orders,

“do not intubate” orders, maximum pain relief, etc.

Hospice staff also visit with the facility’s nursing staff

and the patient and develop a plan of care.Thereafter, they visit the patient at least once per week.

The department does not define “terminal illness” in

its policy but uses HealthEast’s definition. By virtue

of obtaining hospice care, the offender has no more

than 6 months to live, generally.The patient’s specific

diagnosis is not a factor, and the type of crime the

individual committed is not considered.A physician

must recommend that a patient have a consultation

with hospice staff.

The basic visitation policy at MCF-Oak Park Heights

is 16 hours per month. Special arrangements are

made for the hospice patient’s family over and above

the regular visits, however, including bedside visits

when the individual is no longer ambulatory.

Decisions regarding visits by other inmates are made

on a case-by-case basis. Hospice patients also

receive nutritional supplements as needed. Religious

counseling is available if the hospice patient requests

it. Memorial services led by religious leaders are

held when the patient dies.

Palliative care is available to terminally ill inmates

and to those with other painful conditions. Patientcontrolled and intravenous narcotics are not used—

only patches, pills, and injectable liquids are

permitted.All narcotics are administered under

directly observed therapy. If a patient is in the general population rather than the TCU, only oral narcotics are permitted.

I was told that there was never any concern or

resistance to the hospice or palliative care programs

by administrative or custody staff at MCF-Oak Park

Heights.According to the warden,“Medical staff

make the medical decisions and we figure out how

to implement them.”

SITE VISIT REPORT:

NEW YORK STATE

DEPARTMENT OF

CORRECTIONAL SERVICES

SITE EVALUATOR:

B. JAYE ANNO, PH.D.

EVALUATION DATE:

DECEMBER 2001

Preface

On December 7, 2001, I visited the Coxsackie

Correctional Facility in Coxsackie, New York, to see

how they manage their elderly, chronically ill, and

terminally ill inmates. My observations and findings

are noted below.

Background

The New York State Department of Correctional

Services (NYSDOCS) operates 57 major institutions

housing more than 70,000 inmates. Five of these

facilities have regional medical units (RMU), including

one at the Coxsackie prison and one for females at

Bedford Hills.The Coxsackie Correctional Facility

(CCF) is a maximum-security prison housing

approximately 1,100 male inmates. In terms of health

services, it has an ambulatory clinic for the CCF residents, specialty clinics for male inmates in the

region it serves (more than 100 inmates come for

specialty care each weekday), a 20-bed infirmary for

the CCF general population, and a 60-bed inpatient

unit known as the RMU.The RMU is operated by

Correctional Medical Services (CMS), a national forprofit health provider.

Management of the Chronically

Ill and Inmates With Special

Health Needs

Assessment of chronic and special health needs

occurs at intake at a reception facility. Inmates are

assigned a medical classification level of I through IV

during the initial health appraisal, which is performed

within the first week of admission. Each institution

has a corresponding number that indicates the level

of medical acuity it can accept. Unfortunately, I did

not have time to visit a reception center, so I do not

know the extent of the health appraisal that is performed upon admission. Once at their unit of assignment, chronic care patients are followed regularly.

The New York correctional system has a series of

primary care practice guidelines for several of the

most common diseases and conditions, including

HIV, diabetes, asthma, hepatitis C, and high blood

pressure.

Management of Elderly

Offenders

NYSDOCS does have a computerized inmate tracking system. I was told, however, that elderly inmates

are not tracked separately and that there are no

special programs for elderly offenders at the

Coxsackie facility.

Release and Discharge Planning

An inmate’s health status or medical needs can serve

as the basis for early release from NYSDOCS

through either a request for executive clemency or

medical parole (see attached policies).The former is

run by a separate Bureau of Executive Clemency,

and the medical parole program is managed by the

deputy commissioner for health services. Requests

for medical parole for terminally ill inmates may be

initiated by the nurse administrator or by anyone on

behalf of the inmate, such as family or staff. Requests

are forwarded to the deputy commissioner for

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
approval and processing.The legislature and the

NYSDOCS commissioner have developed specific

criteria for medical parole, including the following.

The inmate must:

1. Be serving an indeterminate sentence;

2. Have a terminal condition;

3. Be “so debilitated or incapacitated as to be

severely restricted in his or her ability to

self-ambulate and to care for himself or

herself”; and

4. Not be serving a sentence for “murder in

the first or second degree, manslaughter in

the first degree, any sex offense. . . or any

attempt to commit any of these offenses.”

Individuals who qualify for medical parole are usually

released to a subacute setting or sometimes to

home with hospice care.The process generally takes

about 2 months.

Management of the

Terminally Ill

The Coxsackie facility currently operates the only

hospice program in the NYSDOCS system, although

others are planned for other RMUs.The hospice

program is physically located within the Coxsackie

RMU and is managed as part of the RMU contract

by Correctional Medical Services. It is not a discrete

unit with a specific number of beds but, rather, a

series of services provided to individuals who have

been identified as terminally ill and have chosen hospice for their end-of-life care.At the time of my visit,

6 hospice patients were at the RMU, but there have

been as many as 12 at one time. Last year, the program served 28 male inmates. Hospice services have

been available at Coxsackie since 1997 through a

contract with a community hospice program, but it

has only been since October of last year that the

CMS staff began providing these services themselves.

The Coxsackie hospice program uses the National

Hospice and Palliative Care Organization definition

of “6 months or less to live” as its definition of

APPENDIX B

122

terminal illness. Staff have developed worksheets for

several diseases and conditions to assist physicians in

determining who may be terminally ill. Unlike medical parole, the type of crime the inmate committed

is not a factor in determining eligibility for hospice

services.

All staff at the RMU have had training in hospice philosophy and programs. In addition, the director of

nursing for the RMU is a certified case manager and

hospice and palliative care nurse, and a certified hospice volunteer from the community assists as well.

The program also benefits from the services of four

hospice aides, who are inmates paid to work in

these positions.The aides receive 40 hours of preservice training.Their primary role is to provide

companionship for the dying patient (e.g., reading,

talking, writing letters, listening).They do not assist

in any way with patient care activities but are permitted to touch the patient (e.g., hold his hand, rub

his back) if staff have approved such contact. I found

this to be a compelling and compassionate feature of

this hospice program, particularly because correctional health staff are repeatedly warned not to

become emotionally involved with their patients or

to touch them in anything other than a professional

manner.Allowing the aides to have such contact provides the necessary “human touch” that is so important at the end of life.When death is imminent, the

aides hold a 24-hour vigil to ensure that the inmate

does not die alone.

All inmates are encouraged to issue advance directives when they are admitted to the RMU.

Therefore, these are on file if the inmate becomes

terminally ill and elects to receive hospice services.

Inmates are not required to issue “do not resuscitate” orders to receive hospice care, but if they do

not, the staff questions whether they really understand the hospice philosophy.

Visits are available to all RMU patients on Saturdays

and Sundays.Arrangements can be made for midweek visits when necessary, and bedside visits are

permitted when the patient is critical.Terminally

ill patients receive extra snacks and nutritional
supplements, and staff try to fulfill special requests if

possible.

Palliative care is available to terminally ill inmates as

well as to those with other painful conditions. Both

intravenous and peroral medications (including

narcotics) are available for symptom control.

Patient-controlled analgesia (PCA) pumps are seldom used, and I was told that the physicians are getting away from prescribing patches because of their

abuse potential.

According to the health staff I spoke with, the primary barrier to implementing the hospice program

was the resentment from line correctional officers

who were “morally opposed” to criminals receiving

such services.The key to eliminating this barrier has

been to educate staff that the basic rule of treating

inmates professionally but not compassionately shifts

at the end of life.

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES

SITE VISIT REPORT:

OHIO DEPARTMENT OF

REHABILITATION AND

CORRECTION

SITE EVALUATOR:

RONALD SHANSKY, M.D.

EVALUATION DATE:

NOVEMBER 5–6, 2001

The Functional Assessment

1.What is the screening tool used for inmates with special needs on entry to systems?

The Ohio Department of Rehabilitation and

Correction (ODRC) uses a screening by a nurse or

nurse practitioner immediately upon intake and performs a complete medical, mental health, and dental

evaluation within 14 days.This includes a history, a

physical exam, and a variety of diagnostic tests,

including tuberculosis (TB) screening. Hearing and

vision are tested during the comprehensive evaluation; a history is taken with regard to substance use

and abuse; a detailed mental health screening is

given, including suicide screening; and a comprehensive health history is taken.At the completion of the

physical exam, the physician classifies the inmate

according to medical need. Classifications include the

following:

• Class 1. Basically healthy inmates who may be sent

to any institution.

• Class 2. Individuals who are medically stable but

require routine followup care and examinations,

such as those with chronic illnesses.These individuals can also be housed in almost all institutions.

• Class 3. Inmates who require frequent intensive

skilled medical care, but who can maintain their

own activities of daily living.These would include

patients on dialysis; those with severe lung disease, HIV or AIDS, or advanced cardiovascular

disease; paraplegics; hemiplegics; unstable patients

with seizure disorder; or those undergoing

aggressive cancer treatment. Individuals in Class 3

may be housed at only one of two facilities.

• Class 4. This classification includes inmates who

require constant skilled medical care and those

who need assistance with activities of daily living.

This includes those who require convalescent

pre- and posthospitalization. In this category

would be unstable diabetics, those who require

oxygen therapy on a continued basis, advanced

cases of HIV disease, advanced cardiovascular disease, quadriplegics, severely unstable patients with

seizure disorder, and patients with advanced cancer and terminal cancer.All inmates in class 4 are

housed at the Corrections Medical Center.

2.What other kinds of screening mechanisms are used

at intake to determine functionality?

In addition to each inmate being classified in classes

1 through 4, functional need is identified and

checked off on the physical exam form. Functional

needs include wheelchair user, speech impaired,

hard-of-hearing/deaf, mobility impaired, vision

impaired, or other.The classification number is followed by a letter or a number of letters that indicate the function needs. Inmates who may have been

identified as having a vision or hearing impairment

through a routine exam are referred to the correctional medical center for more thorough evaluation.

3. Is a functional assessment routinely conducted on all

inmates at intake? If yes, what does the functional

assessment entail?

A functional assessment, per se, is not conducted on

all inmates at intake.There is, however, a history and

physical. No other specific tool is used for all

inmates.

4. How does your classification program work to separate inmates based on need?

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
As indicated previously, there is a medical classification with a functional need attached where indicated, and there is a medical classification grid that

identifies which medical needs and classifications can

be housed in different facilities. Once the physician

has completed the classification and functional needs

assessment, this information is provided to the classification staff. Ultimately, the classification staff considers the inmate’s medical needs and security status

and the number of available beds to determine

where the inmate will be housed.

5. How do you ensure that the special needs which have

been identified are recognized?

Ohio uses an intrasystem transfer and receiving

health screening form.This form is used to ensure

that medical classification and functional needs are

identified and continued on transfers between institutions.When an inmate is received at a new facility,

a physician must see that inmate face-to-face within

72 hours and determine whether all of his or her

current needs have been identified.

6.What is your mechanism to ensure that the special

needs of the inmate are always maintained? (Including

upon transfer from one facility to another.)

As indicated in question 5, the intrasystem transfer

and receiving health screening form are used to

ensure that the special needs are always maintained.

Beyond these things, a physician may order specific

restrictions on a separate form that is then sent to

Custody (for things like a cane or a slow-walking

pass, etc.).

Balancing Custody Concerns

and Appropriate Care

1. Does your departmental offender tracking system

count inmates considered to be elderly separately?

ODRC does not track inmates considered to be

elderly separately. However, their computerized

offender tracking system could generate a list of

inmates above a given age and by gender, race, county of commitment, number of prior commitments,

APPENDIX B

126

level of felony, most serious commitment offense,

and initial security classification assignment.

2. Does your departmental offender tracking system distinguish between:

Inmates who entered the system younger than

age 50 and who attained that age while

incarcerated?

Inmates who were age 50 or older at entry

but were never incarcerated before?

Inmates who were age 50 or older at entry

who were previously incarcerated?

ODRC’s offender tracking system does not distinguish between inmates who entered the system

younger than age 50 and who attained that age

while incarcerated. Such a list could, however, be

generated.The same is true for inmates who are age

50 or older at entry but were never incarcerated

before, and the same is also true for inmates who

were age 50 or older at entry who were previously

incarcerated.

3.Are elderly inmates in your department housed congregately in special housing as a discrete subpopulation?

Elderly inmates as a group are housed in part at the

Hocking Correctional Institution; a census on the

day I visited indicated approximately 403 inmates.

The average age of inmates at Hocking is currently

61 years.Additionally, four other institutions have

distinct housing units in which groups of older

inmates are housed together.

4.Are elderly inmates housed in one or more separate

facilities in your departmental system?

Inmates older than 50 years old are mainstreamed.

5. Does your department provide educational or other

personal development programs specifically designed for

elderly inmates that include issues and problems? 

Yes.

6. If yes, does the program include:

Education on the aging process?
Education on physical, psychological, and social

issues associated with aging while incarcerated?

Education on self-care and activities of daily

living basic adult education and literacy?

All wardens received training on the aging process

and its impact on inmates. In addition, at Hocking a

program called “50+ and Aging” addresses the physical, psychological, and social needs of older inmates.

Programs such as chair aerobics, adult basic education, and GED are all provided.All inmates at

Hocking have a job assignment that meets their

needs, including jobs such as elevator operator and

other sitdown jobs.A case manager is responsible

for working with the inmates and helping them handle issues such as Social Security, Medicare, wills,

outside meals, placement, etc. Placement postrelease

for some of these inmates who have no family is difficult. One of the things that the staff would like to

see is a postrelease assisted living unit that would

accept convicted felons.

7. Does your department provide supervised recreational

programs specifically designed and appropriate for elderly inmates? Please describe the programs available.

The Ohio Reformatory for Women has approximately 12 different educational or recreational programs that deal with problems and issues relevant to

elderly or special needs female inmates.This includes

a program entitled “The Aging Process”; a program

entitled “Topic Talk,” which encourages inmates to

take more control of their lives; a program entitled

“Helping Others Together”; a program entitled

“Heart to Heart,” which is an educational support

program for women who are chronically ill; and a

program entitled “Topics of Powerful Significance,”

which includes health issues, codependency issues,

substance abuse, etc.A special recreation program is

suited to the needs of special needs inmates, and a

garden club encourages inmates to get involved in

outdoor horticultural activities.The programs at

Hocking and at the Ohio Reformatory for Women

provide supervised recreational programs specifically

designed and appropriate for elderly inmates.

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES

8. Does your department survey/sample your population

of inmates age 50 or older to assess their perceptions of

their needs?

Hocking Correctional Institution conducts an annual

survey to determine the inmates’ perception of their

needs, and there is a plan to have each department

at Hocking create a separate survey to determine

whether the specific department is meeting or can

better meet the inmates’ needs.

9. Does prerelease planning for elderly inmates include

information on

Social Security?

Medicare?

Estates and wills?

Advance directives (such as “do not

resuscitate”)?

Funeral preplanning?

Other community-based services for the elderly (e.g.,“meals on wheels”)?

There is prerelease planning for inmates with regard

to Social Security, Medicare, estates and wills,

advance directives, funeral preplanning including cremation or donation of a body to science, and other

community-based services.

10. Does your departmental health services division provide organized health education services to inmates considered elderly?

The departmental health services division does not

have specific organized health care programs aimed

at the elderly.There are, however, chronic disease

health education programs.These are all one-on-one

health education.

11. Is there a peer-visiting program for elderly inmates?

There is no peer-visiting program for elderly inmates

in Ohio.There are only volunteer religious-based

programs that visit the elderly.

12. In your department, do inmates who are debilitated,

frail, or medically fragile have access to a congregate
therapeutic living community where they can be medically supervised, specially programmed, and assisted with

the activities of daily living? If yes, is that program available to both men and women?

Inmates who are debilitated or medically fragile can

live in congregate living only at the Corrections

Medical Center or at the Ohio Reformatory for

Women. Inmates at the Hocking facility must be

independent. Programs at the Corrections Medical

Center are available both to men and to women; a

few co-ed programs are also there.

13. Does your department’s health services division

promulgate and implement chronic protocols or guidelines for all of the major chronic conditions?

The Department of Health Services does have a

chronic care program.The chronic clinic program

includes a cardiovascular/hypertension clinic, a diabetes clinic, a seizure clinic, a pulmonary clinic, and a

TB infection clinic.An HIV clinic protocol also exists.

14. Does your department operate prerelease centers

or halfway houses with programs designed for elderly

inmates?

Ohio does not operate prerelease centers or

halfway houses with programs designed for elderly

inmates.

15.Are inmates who are considered elderly in your

department provided:

Universal access to the entire physical plant

housing them?

Single or lower bunks?

Additional heat in cold weather?

Air conditioning in warm weather?

Elderly inmates are provided universal access to the

entire physical plant housing them.They are provided lower bunks if that is indicated.They are provided

extra blankets in cold weather when needed.Those

inmates who are considered high-risk based on diseases or based on being on certain medications,

including psychotropics, are monitored more carefully for heat-related problems.

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128

16.Are medical social services professionals available

to your department’s population of inmates directly or

to your health services division as case management

consultants?

Counselors perform some social service-type

activities.

17. Does your department operate or have access to levels of care ordinarily identified with nursing homes?

Levels of care at the Corrections Medical Center

are similar to those that would be found in a nursing

home.There is no ability, however, to release

inmates who pose no threat into a nursing home

rather than maintain them in a prison.

18. Does all or part of your department’s physical plant

comply with the Americans with Disabilities Act?

At least 15 institutions contain an environment that

complies with the Americans with Disabilities Act.

Medical, Program, and Housing

Considerations: Requirements

for Elderly, Chronically Ill, and

Terminally Ill Inmates

A. Compassionate release

1. Is there a compassionate release/medical parole program for terminally ill inmates in your system?

2.Who initiates the request for compassionate release?

3. How long does the process generally take?

4.Which agency can grant the release request?

A policy is designed to establish procedure guidelines for the medical assessment of inmates in imminent danger of death and to establish criteria for

consideration of their release as if on parole.

Imminent death in Ohio would be a predicted life

expectancy of less than 6 months.A physician initiates the request for medical parole at the facility.

The physician forwards a statement to the warden’s

office, and the warden then directs his heads of

social services and mental health each to generate a
summary of the inmate’s condition. Based on the

accumulated data, the warden makes a recommendation to the regional director.The regional director

approves or disapproves and forwards the recommendation with the accompanying medical director’s

statement, a placement investigation request, and a

background report to the director.The director will

then require the Adult Parole Authority to conduct

an investigation into an appropriate community

placement, identify the terms and conditions to

which the inmate will be subject if released, and provide any additional information that will assist the

Governor in deciding whether to grant the release

as if on parole.The Adult Parole Authority will issue

a report of the investigation to the director with 10

days.The director will then forward the investigation

report and other information from the Adult Parole

Authority to the Governor, together with a statement indicating whether or not the director concurs

with the warden’s recommendation. If the Governor

authorizes release as if on parole, the inmate may be

released as if on parole upon written acceptance of

the terms and conditions of such release, including

the condition that the inmate agrees to be evaluated

at a facility designated by the department at any

time requested following his or her release.

Following the inmate’s release, the supervising parole

officer monitors the physical condition of the

released inmate. If the releasee survives for a period

of 9 months, the department’s medical director will

confer with the releasee’s personal physician and

with the ODRC director, and the director will notify

the Governor that the releasee has survived for 9

months.The Governor may choose to revoke the

parole or to allow the inmate to remain on parole.

I was informed that recently, approximately 40 percent of those recommendations from the Corrections Medical Center this year have been granted.

That would be about 8 requests granted out of 20

total requests.

B. Hospice care

1. Do you have a hospice unit for inmates who are terminally ill?

Ohio has a six-bed hospice at the Corrections

Medical Center.

2.What are the eligibility criteria in terms of:

a.The definition of “terminal illness”?

b.The level of functioning?

c.The type of crime the inmate committed?

d.The diagnosis?

e. Other?

Eligibility to be housed in the hospice includes a

prognosis of less than 6 months and a discontinuation of any curative efforts.There are no criteria

related to level of functioning, type of crime, diagnosis, or any other factors, although residing in the

hospice is a voluntary decision by the inmate.

3. Is this a discrete unit? Part of the infirmary? Part of a

housing unit? An outpatient program?

The hospice is on a ward.Two separate three-bed

rooms are considered to be the hospice rooms.

There is no outpatient program.

4. How many beds are in the hospice unit?

Six.

5. How many patients do you usually serve at one time?

On average about four patients are in hospice beds

at any one time.

6. How many patients in all did you serve last year?

Last year, six inmates resided in the hospice.

7.Are there dedicated staff for the hospice unit? If yes,

what types?

No staff are dedicated for the hospice. Nursing staff

are available nearby, as are other staff from the

Corrections Medical Center.

8. Do you use other inmates as volunteers in your

program?

Yes, other inmates volunteer as part of this program

and receive training.

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
9. If yes, describe the screening selection process, the

training program, the types of activities they perform, and

any rules/restrictions they operate under.

Stephen Ministries provides a training program

geared to listening for all inmate volunteers.After

completing the training process provided by Stephen

Ministries, inmate volunteers are screened by medical services for appropriateness, including their

behavior within the prison system.Those selected

are matched with the patients according to personality type.These inmate volunteers function as companions.They provide no care.They may interact

with the families of patients and on occasion have

even attended the funeral of the terminal patient

who died.They do participate in a predeath vigil.

10. Do you use any volunteers from the community?

If yes, describe this program.

Some volunteers, mostly from religious-based groups

in the community, participate.

11. Do terminally ill inmates in your system issue

advance directives? DNR orders? If yes to either, what

safeguards are in place to ensure that they have given

noncoerced informed consent?

Terminally ill inmates in Ohio do use advance directives, and there are “do not resuscitate” (DNR)

orders. DNR orders are not required in order for a

person to be in the hospice, and, in general, family

input is always sought prior to any DNR decision.

ODRC has found that occasionally the family itself

may try to coerce the patient.

12.What is the visitation policy for the terminally ill

patient’s family? Other inmates?

Once an inmate is in the hospice, visitation is three

times per week per visitor on the inmate’s list for

each inmate in the hospital.When death is imminent,

there is no limitation to visitation. Nonhospice

patients are allowed up to four total visits per week

at the Corrections Medical Center. If someone is

terminal and mainstreamed, the number of visits

allowed is based on his or her security level, either

APPENDIX B

130

once or twice a month. Other inmates may visit

hospice inmates only if they are volunteers as part

of the program or if they live in the same unit.

Exception will be made for a blood-relative inmate.

13.Are special foods and drinks available to terminally ill

patients at all times? 

A special refrigerator is in the hospice, and additional food and drink are available to inmate patients at

all times.

14.Are there or were there institutional barriers (e.g.,

security rules, administrative concerns) that affect your

ability to provide support for the terminally ill in your system? If yes, what are they and how are you addressing

them?

With regard to institutional barriers, the biggest

problem to the hospice was the mindset of the

prison regarding rules on visits, but for the hospice

patients, this really has changed.The hospice has also

allowed much greater family involvement.

15. Do you have hospice programs in all of your facilities? If not, how many do you have?

The only hospice program is at the Corrections

Medical Center.There is no hospice for females, but

they could come to an area in the Corrections

Medical Center that could be designated as a hospice.That has not occurred yet.

16.Are terminally ill inmates in all facilities able to be

transferred to a unit with a hospice program?

Terminally ill inmates from all facilities may take part

in the hospice program.

C. Palliative care

1. Is there a palliative care program in your facilities?

2. If yes, is palliative care available to those with

advanced disease but who have not yet been defined as

terminal?

No regular organized palliative care program is available at the Corrections Medical Center. Pain treatment is provided on a case-by-case basis.
3.What types of palliative care do you offer?

Inmates may be referred from the Corrections

Medical Center to the Ohio State University Pain

Management Clinic.

4.What are the eligibility criteria for receiving it?

No specific criteria would exclude an inmate from

being referred to this pain management clinic.

5. Does your pain management program include the use

of narcotics? If yes, did you encounter any resistance

from custody staff? If yes, how did you overcome it?

Describe what is available.

Pain management at the Corrections Medical Center

includes the use of Roxanol and morphine. However,

at all other institutions, only Darvon or codeine are

used. Custody staff at the Corrections Medical

Center have exhibited no resistance to the use of

narcotics.

6. (No question number 6 was listed on the form.)

7. Do you use an interdisciplinary team in your palliative

care program? If yes, what types of personnel are on it?

Who leads the team? What is the team’s role?

At the Corrections Medical Center, an interdisciplinary team, including physician, nurse, clinical social

worker, clergy, dietician, and custody staff, may develop a treatment plan for each inmate and suggest

strategies to better meet the inmate’s needs.

8. Do you develop individualized care plans for your palliative care patients?

Yes, there are individualized care plans for patients

at the Corrections Medical Center.

9. Can patients in the palliative care program continue to

receive curative care?

Patients at the Corrections Medical Center can continue to receive curative care.

D. General

1.Are your end-of-life programs available to women

inmates as well as men? Are there any differences in

terms of what is available to women?

End-of-life programs may be available to women at

the Corrections Medical Center, but they would be

housed in a separate area.

2.Are you satisfied with the end-of-life care you are able

to offer currently? If not, what more is needed?

The staff at Corrections Medical Center would like

to be able to use the services of a music therapist.

They would also like to be able to use a massage

therapist; however, they anticipate there would be

some resistance to this.

3. How are your end-of-life programs funded?

The end-of-life program is funded out of regular

revenues plus the efforts of volunteers. Staffing is

minimal, and the program is conducted on a shoestring. Donations are received for special foods and

appliances.

Additional Special Programs

The Ohio system maintains a facility called the

Robert Frazier facility, which provides a type of congregate housing for partially disabled inmates who

may need the assistance of other inmates to perform some duties.A 24-bed infirmary is provided; a

registered nurse’s note is required in the infirmary

on each shift, and a medical doctor’s note is required

each week.There are 76 residential housing unit

inmates; in those units, the medical doctor writes a

note monthly, and the nurses write a note once a

day.

The Robert Frazier facility also contains the department’s dialysis unit. It has 14 chairs, 1 of which is

used for inmates infected with hepatitis B.The current census was 52; it appears to go up in winter

and down in summer.The staffing for the dialysis

program includes two licensed practical nurses and

six registered nurses. Each inmate is seen monthly

by an Ohio State nephrology fellow through the

telemedicine program.

11/19/01

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES

SITE VISIT REPORT:

OREGON DEPARTMENT

OF CORRECTIONS

SITE EVALUATOR:

B. JAYE ANNO, PH.D

EVALUATION DATE:

DECEMBER 2001

Preface

In December 2002, I visited three correctional facilities in Oregon to see how they manage their elderly,

chronically ill, and terminally ill inmates. I toured the

Oregon Women’s Correctional Center (OWCC)

and the Oregon State Correctional Institution

(OSCI) on December 11, 2001, and the Oregon

State Penitentiary (OSP) on December 12, 2001.

My observations and findings are noted below.

Background

The Oregon Department of Corrections operates

13 facilities, including 10 for adult males, 1 for

females, and 2 that are coed. It houses 10,600

inmates on any given day.

Oregon has a centralized health care system. Medical

and dental services are under one division and mental health services under another.The directors of

both of these divisions report to the same correctional administrator, who heads up correctional programs. Both the health services director and the

mental health services director have line authority

over the institutional health staff in their divisions.

Management of the Chronically

Ill and Inmates With Special

Health Needs

Assessment of chronic and special health needs

occurs at intake. Inmates receive screening for

health problems on admission, and followup occurs

within 7 days with a more detailed health appraisal.

Traditional forms designed to comply with the standards of the National Commission on Correctional

Health Care are used. Inmates identified on admission as being at risk for mental illness are referred

for a more indepth mental assessment, which is

completed within 14 days.

The Oregon Department of Corrections has a computerized inmate tracking system that also includes

information regarding each individual’s medical

needs, mental health needs, educational level, etc.

The “health status” portion does not indicate diagnoses but, rather, any restrictions the person has in

terms of housing (e.g., handicapped accessible, lower

bunk), work, or other programming. Health staff

enter any such restrictions into the database at the

time of the initial health appraisal. Classification and

programming staff use this information to make unit

and job assignments. If someone tries to place a person in a unit where their needs cannot be met or in

a job they cannot do, the computer flags it. Designation of available services has been made for each of

the Oregon facilities, so it is easy to see at a glance

what special needs can be accommodated at any

given facility.

At the unit level, chronic care patients are followed

regularly—at least every 3 months for HIV patients

and at least every 4 months for other diagnoses and

conditions. Providers refer to “Practitioner Guidelines for Special Needs Clinics” to guide their management of specific diseases and conditions.There

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MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
also are flowsheets for specific diagnoses to record

what was done at each visit. In the Oregon system,

inmates with the same diagnoses are not all scheduled to be seen in the chronic clinic on the same

day. Staff felt this was stigmatizing. In addition, many

inmates have multiple problems that do not fit neatly

into one diagnosis.A computerized information system allows health staff to track inmates with special

needs. Lists can be compiled by diagnoses, age, disability, etc.

The Oregon system makes several other accommodations for inmates with specific disabilities. Several

units have a “wheelchair taxi service” available.This

is a paid job for inmates providing the service. Blind

inmates may be assigned a “seeing eye” cellmate.

Closed caption TV and specially equipped phones

are available for the hearing impaired.Although only

the newer units comply with the Americans with

Disabilities Act, most prisons have at least some cells

that are handicapped accessible.

Nursing home care is available at the male prison in

Snake River.At OSCI, a 61-bed dorm (called Unit

13) is available for elderly, disabled, and mobilityimpaired male inmates. Eighteen inmate orderlies

work in this dorm (12 as janitors and 6 who assist

inmates assigned there with activities of daily living

and provide “wheelchair taxi service” as needed).

Hospital-style beds (with extra padding, bedding, trapeze, etc.) are provided when needed.Toilets, sinks,

and showers are all handicapped accessible. Unit 13

inmates can use a therapeutic gym at special times,

and a pool table is available at a lower height to

accommodate those in wheelchairs.An elevator

ramp is available adjacent to the stairway leading to

the gym. Unit 13 has its own barbershop and sewing

program to reduce the amount of movement these

inmates must make. It is important to note that Unit

13 is not an inpatient unit.Although nursing care is

available at OSCI 22 hours per day, the inmates

assigned to Unit 13 do not require ongoing nursing

services. If they do, they are transferred to the nursing home at the prison in Snake River.

APPENDIX B

134

At present, the Oregon system has more difficulty

accommodating women with special needs owing to

the age and space limitations of the primary female

facility.At OWCC, women with special needs are

tracked on a computerized system by their condition.There is no infirmary, though, and there is no

space to house individuals with special needs together. Instead, the facility staff try to address special

needs creatively. For example, a doublewide bed and

oversize wheelchair were purchased for a woman

weighing 600 pounds who had difficulty ambulating.

A special toilet railing was erected in the cell of a

woman without legs.A handicapped shower was

installed.Whenever possible, health staff try to take

services to inmates with special needs to reduce the

amount of movement those who have difficulty

ambulating have to make. In addition, inmate “caregivers” are paid to assist certain women with activities of daily living.The women are expected to be

moved to a new prison at Coffee Creek in April that

will have a 16-bed infirmary, a larger clinic area, and

more housing options for females with special

needs.

Management of Elderly

Offenders

The Oregon Department of Corrections defines

anyone “over 50” as elderly. However, it does not

have any special programs or housing specifically for

elderly inmates. Unit, program, and work assignments are based on the functional abilities of those

over 50.

Release and Discharge Planning

In Oregon, all inmates receive prerelease planning

and information on applying for benefits such as

Social Security, Medicaid/Medicare, disability, food

stamps, etc. Each person is assigned a release counselor who assists the inmate in developing an appropriate release plan. Releases can occur from any

institution, but there are also designated release centers.All inmates are supervised when released to

the community.
An inmate’s health status or medical needs can serve

as the basis for early release from the prison system

through either a request for executive clemency

(which the inmate makes on his or her own) or

through “early parole release” (EPR).A centralized

EPR committee includes the systemwide medical

director, a medical case manager, a unit health services representative, and the inmate’s assigned release

counselor. Medical criteria for early release include

being elderly and incapacitated, having a serious or

terminal medical condition that is incapacitating, or

having a condition that prevents the inmate from

participating in prison life.The EPR committee

makes a recommendation regarding early release to

the Oregon Department of Corrections’ Executive

Committee. If they agree, the request is forwarded

to the director. If he agrees, it goes to the Board of

Parole for a final decision.The process usually takes

about 2 months. Inmates who have committed certain serious crimes are excluded from consideration

for EPR.

The Oregon prison health service system employs a

half-time medical case manager, who helps inmates

with chronic and terminal illnesses find an appropriate placement in the community. She also makes followup appointments with community providers, may

assist with finding residential housing, and works

with other state agencies to obtain benefits and

services for those in need.The DOC provides subsidized housing for releasees without other plans for

up to 30 days. Prison physicians can provide up to

30 days of medications to an inmate upon release,

although narcotics are usually restricted to a 2-week

supply. Fourteen case managers are provided for

those with mental illness who need assistance with

release planning.

Management of the

Terminally Ill

The hospice program for males is located at OSP.

Currently, there are no terminally ill females, but a

room has been readied at OWCC and the health

staff there have received hospice training.

At OSP, hospice patients are kept in the general

population as long as possible, since that is their

“home.” When they become too ill, they are moved

to the infirmary, which has a 21-bed ward, 2 single

rooms, and 2 hard cells.The hospice patient can

elect to be housed in one of the separate rooms or

in the ward, depending on whether he wants privacy

or company.

The only criteria for receiving hospice care are that

two practitioners have determined that an inmate

has less than 1 year to live, and that the inmate

elects to receive hospice services.The inmate’s diagnosis, level of functioning, and the type of crime he

committed are not considered. No staff are dedicated for hospice care (in part, because few inmates

require these services), but health staff at OSP have

received training from a community hospice expert.

The program also utilizes pastoral counseling and 22

inmate volunteers, who have received 44 hours of

training in hospice philosophy and services. Criteria

for their selection include an absence of disciplinary

reports over the last year, but no restrictions are in

place in terms of the seriousness of the crime committed.The volunteers are supervised by a nurse

coordinator, who also gives them their assignments.

When death is imminent, a 24-hour per day vigil is

held by the hospice volunteers.

Individuals electing hospice care are not required to

sign advance directives, including “do not resuscitate” orders, but most do. Inmate law clerks in the

law library have copies of these forms if a terminally

ill inmate wishes to use them.

Hospice inmates in the general prison population

follow the regular visitation rules.Those in the infirmary can have bedside visits, including those from

other inmates whom the patient has identified as

“family.” If the patient is dying, children under 18 may

visit. One dying patient’s dog was even permitted to

visit. Other amenities while in the infirmary include

special food and drinks, a TV with a VCR so the

patient can watch movies, a CD player for music,

and access to the health services telephone so the

patient does not have to call collect.

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Palliative care is available to terminally ill inmates as

well as those with other painful conditions. Patches

and pills are available to individuals in the general

population, and patient-controlled analgesia (PCA)

pumps are available for those in the infirmary. Most

of the narcotics in pill form are crushed and floated

in water, and all are directly observed when taken.

Staff admitted that the patches could cause some

problems with contraband but said they check on

those with patches daily.

Staff indicated they were satisfied with their current

end-of-life care but would like to do more in the

way of bereavement services after a patient dies,

especially for institutional staff and the inmate’s

prison family.They do hold a memorial service in the

chapel when someone dies, but the infirmary staff

would like to start a bereavement group.

APPENDIX B

136

Staff stated that the costs of hospice care are paid

for out of the regular health services budget.They

feel that hospice may even save money because

inmates are not dying in the hospital.

The health staff I spoke with said there were no real

barriers to implementing the hospice program. Once

they received an okay from the director of the

Oregon Department of Corrections, the rest of the

correctional staff fell in line.They felt that it was a

real advantage that health services in the Oregon

Department of Corrections is a separate division

and that they report to the systemwide medical

director rather than to a warden.
SITE VISIT REPORT:

PENNSYLVANIA

DEPARTMENT OF

CORRECTIONS

SITE EVALUATOR:

JAMES E. LAWRENCE

EVALUATION DATE:

NOVEMBER 8–9, 2001

Preface

Opened in July 1996 and located in Somerset

County in rural western Pennsylvania, State

Correctional Institution (SCI) Laurel Highlands is a

former state mental hospital that was converted

into a medium-security state correctional facility,

presently housing 582 inmates, including 111 longterm care inmates and 73 personal care or assistedliving inmates.The staff complement totals 407.This

congregate-care facility was developed to provide

for the special needs of the long-term care and

physically challenged inmates housed throughout the

Pennsylvania Department of Corrections’ 23 other

male state correctional institutions.Although

Pennsylvania’s average inmate age is 24, the average

age of inmates living at SCI Laurel Highlands is

almost twice that at 47 years. SCI Laurel Highlands

and SCI Waymart are the state’s only institutions

specifically developed and designated for the care,

custody, and control of long-term assisted living,

wheelchair-bound, and chronically ill prisoners.A

host of special needs programs are provided.These

are focused on advanced medical, nursing, and mental health care supplemented by substance abuse

treatment, adult education, life skills training, and

leisure and recreational activities, all managed

through individualized, age-appropriate treatment

plans.

Developmental History

SCI Laurel Highlands was established in 1996 with

the conversion of the Somerset State Hospital after

it was closed as part of the deinstitutionalization of

the state mental heath system. During the late 1980s

and first half of the 1990s, Pennsylvania Department

of Corrections policy analysts and executives began

noting that one ominous effect of longer sentences

due to truth-in-sentencing was a growth in the

inmate population older than age 55 of approximately 10 percent per year.This burgeoning elderly and

infirm population was hitherto managed at multiple

sites throughout the system, requiring duplicative

services, which increased costs and impaired quality.

Then-Secretary of Corrections Martin Horn recognized the need to consolidate and centralize services and was able to get this issue recognized as a

policy problem worthy of the attention of the state’s

executive and legislative leadership.

The first and present superintendent of SCI Laurel

Highlands, Fredric Rosemeyer, Ph.D., was recruited

from SCI Waynesburg to design and implement the

program. In an atypical and innovative development,

it was decided not only to convert Somerset State

Hospital to a corrections/geriatric/assisted living

program but also to convert the existing staff to

that purpose. State Department of Welfare employees at Somerset, consisting mostly of registered professional nurses, licensed practical nurses, and

certified nurse assistants, were screened and then

offered correctional health positions with the understanding that a new program for elderly inmates

would be developed.This saved 251 jobs slated for

abolition and created a positive work ethic and high

morale that continue to contribute to the program’s

success.

Program Overview

The physical plant is a multibuilding complex sited

on 53 acres in southwestern Pennsylvania.The environment is fully renovated.“A” Unit consists of

three mirror-image floors with semiprivate rooms,

large dayrooms with full outside views, an integrated

137

MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
officer/nurses’ station, chart room, pharmacy, visiting

room with children’s play area, and bath and showers with full handicap accessibility for toilet use and

bathing.A fully equipped physical therapy unit is

attached to the ambulatory services unit first floor.

A fully equipped dialysis unit has eight complete stations.The Laurel Highlands medical director is a

board-certified nephrologist.

The overall client census includes 582 inmates consisting of Long-Term Care Program inmates (capacity

111) managed at the skilled nursing/high-acuity level;

the Personal Care Program (capacity 73), which is a

self-care/assisted living program; and a general or

“cadre” population that maintains the facility and

provides workers for essential services. Of 407 total

staff members, 77 are nursing and allied nursing positions. Expenditures average approximately $65,000

per inmate year versus $27,000 for the rest of the

Pennsylvania system.The Deputy Superintendent

responsible for operations is a registered professional nurse, the former nurse-administrator of the

Somerset State Hospital.

The health services management, administration,

physical therapy, occupational therapy, dialysis, and

support services programs, as well as the medical

director and other physician services, are provided

through a contract vendor.The Pennsylvania Department of Corrections exclusively provides overall

program administration and all nursing services.The

uniformed security staff is organized for unit management.All inmate security classifications are eligible for the SCI Laurel Highlands Long-Term Care

Program if otherwise qualified. SCI Laurel Highlands’

administration is empowered to reject inappropriate

or maladjusted patients or to require their transfer

once admitted.

Medical and Nursing Staff

A full-time medical director is employed who, as a

board-certified nephrologist, also heads the renal

dialysis program.A full complement of clinical physicians and certified physician’s assistants provide

medical care, which includes the staff of an ambulatory services clinic for outpatient care of the inmate

APPENDIX B

138

service cadre.The nursing staff is enriched for highacuity care and for effective organization and administration. On weekdays, the nursing staff consists of

five registered professional nurses, six licensed practical nurses, and four certified nurse’s assistants. On

evenings, the staff includes four registered nurses, six

licensed practical nurses, and three nurse’s aides.At

night, the facility staffs three registered nurses, three

licensed practical nurses, and four nurse’s aides.

Weekend coverage is similar to that on weekday

evenings.

Functional Assessment

The institution offers multiple, coordinated levels of

care.The Long-Term Care Program provides highacuity skilled nursing for inmates who are bedridden,

depend on a respirator, or are terminal total care

patients. Moderate acuity patients needing nursing

supervision are also managed, as are those requiring

nursing assistance with activities of daily living and

those with altered mental status, including dementia.

The Personal Care Program, sited in a separate

building, provides assisted living at the health-related

facility level of care.

An eight-page referral/application is completed at

the originating institution; Laurel Highlands occasionally sends a senior registered nurse to originating

facilities to assist with the functional assessment,

which begins with the medical director’s or health

services administrator’s referral with application.

Medical autonomy is an important element in each

admissions process. Final approval for all placements

rests with the Bureau of Health Care Services in the

Pennsylvania Department of Corrections’ Central

Office.An intensive second functional and medical

assessment is completed upon reception at Laurel

Highlands.

Admission/Reception and

Continuity of Care

Patient admissions are planned and begin with a

comprehensive screening by a registered nurse

immediately upon arrival.A complete history, physical examination, and mental health evaluation follow
within 1 day.This includes a complete review of systems and a supplemental functional assessment.

A registered nurse is dedicated for chronic care

coordination in each of the two main programs, i.e.,

Long-Term Care (Unit “A” skilled) and Personal

Care (assisted living). Chronic care clinics are held

weekly; these include clinics for asthma, renal, surgery, neurology, hypertension, cardiology, and infectious disease.A weekly superintendent’s meeting is

held with all service chiefs.The medical audit committee (MAC), the primary interdisciplinary organizational and therapeutic workgroup, meets monthly.

A medical and administrative meeting provides a

quarterly review of vendor performance.A full-time

registered nurse is assigned to Quality Improvement;

activities are scheduled monthly and reported to the

MAC.A policy and procedure review meeting is held

bimonthly.The Pharmacy and Therapeutics

Committee meets quarterly.A full-time registered

nurse is assigned to manage the infection control

program; results are reported to the MAC.Apart

from organizational and administrative controls, the

continuity-of-care model is one of case management

with multidisciplinary treatment team meetings on

problem cases.

Support Services

Laboratory. A contract laboratory provides nextday courier service; a staff phlebotomist is available

twice each week; results are sent via fax. STAT laboratory services are available at nearby Somerset

Hospital.

Pharmacy. A local contractor is employed.At

Laurel Highlands, a main pharmacy and five satellite

substocks are provided.

Radiology. A full installation is on site.

Laundry. Nearby SCI Somerset handles all institutional laundry at temperatures sufficient to eliminate

biohazard.

Medical Records. The problem-oriented (SOAP)

medical record is exclusively employed.

Chronic Care. A flowsheet system is used for all

chronic care.

Nutrition. Commissary access is limited for therapeutic reasons; 137 therapeutic diets are available on

same-day notice.

Dental Care. Three fully equipped modern operatories, a panoramic x-ray, a full-time dentist, and a

hygienist/assistant are provided.An oral surgeon is

contracted. Dentures are fabricated and repaired by

a contract laboratory with 3-day service.

Hospital Services

Somerset Hospital, a community general hospital

located in the facility’s host community, provides a

full range of inpatient and emergency department

services to SCI Laurel Highlands.At present, Superintendent Rosemeyer serves as a member of the

Hospital Board.

Mental Health Services

SCI Laurel Highlands provides a full range of psychiatric and adjunct mental health services.The facility

staffs a clinical psychologist, two psychiatric social

workers (Ph.D. or master’s prepared), together with

12 hours of psychiatry (medical doctor) weekly.

Habilitation Services and

Programs

Substance Abuse Services. Group therapy, multimedia teaching aids, and drug and alcohol treatment

from Department of Corrections-certified counselors are offered.

Life Skills Program. A comprehensive program is

offered in four modules: Positive Change, Informed

Decisions and Choices,Anger Management, and

Interpersonal Communication.

Employment. Opportunities are offered in carpentry, groundskeeping (including horticulture), library,

maintenance/small engine repair, stock clerking, and

custodial jobs.The Barber Manager’s Program

139

MANAGING LONG-TERM INMATES AND INMATES WITH CHRONIC AND TERMINAL ILLNESSES
combines vocational education with an essential

inmate service.

Leisure Activities. Passive games, particularly puzzles for cerebral stimulation, are emphasized. Largeformat games, puzzles, books, and playing cards are

available for the visually impaired.The Arts and

Crafts Program is designed around bench-style

crafts, such as ceramics and painting, to accommodate physical limitations.

Religious Activities. SCI Laurel Highlands staffs a

full chaplaincy department offering congregate and

individualized worship. Religious education and

spiritual group activities are available to residents.

Education. Full Adult Basic Education and GED

programs are offered to all inmates; classrooms are

equipped to accommodate wheelchairs, and all

learning equipment is adjustable to meet physical

limitations. Programming, instruction, and tutoring

are delivered to inmates who cannot attend classes

owing to debilitation or other limitations.

Discipline. The standard Pennsylvania Department

of Corrections disciplinary system is modified at SCI

Laurel Highlands to include an informal resolution

component overlying the due process system. Senior

correctional supervisors are able to resolve even

serious infractions on the spot with mild sanctions,

APPENDIX B

140

provided that agreement exists between security

staff charging the offense, any involved victim, and

the medical staff.

Visitation. Rules and schedules are relaxed so that

families may visit virtually at will; frequency is generally unlimited, and amenities and services are excellent, including full accommodations for children.

Hospice. Complete hospice care is provided as

medically indicated.At SCI Laurel Highlands, patients

who become terminal are not ordinarily transferred

elsewhere and are managed palliatively as their conditions progress. Hospice St. John’s at SCI Waymart

operates a second hospice program.

Despite its unique history and innovative programs,

SCI Laurel Highlands remains a state correctional

facility. It is tasked first and foremost to provide safe,

humane, and secure confinement for inmates committed to its care and custody. However, SCI Laurel

Highlands represents one of the first and best

accommodations to the fact that, throughout the

United States, inmates committed for serious crimes

will be staying in prison longer and growing old

there.This facility, its staff, and its programs can

serve as an object example to corrections departments nationwide as they all eventually, but inevitably, confront the problem of safe and humane

management of elderly and infirm inmate populations.
Appendix C

SITE VISIT CHECKLIST: 

The Functional Assessment—Issues 

Considered and Questions

Covered During the Site Visits 

143

SITE VISIT CHECKLIST: THE

FUNCTIONAL ASSESSMENT—ISSUES

CONSIDERED AND QUESTIONS

COVERED DURING THE SITE VISITS

Appendix C

THE FUNCTIONAL

ASSESSMENT

Issues To Be Considered

What are current and ideal practices on conducting functional assessments of inmates upon

commitment? 

While there is a high level of agreement

among medical professionals that conducting an initial comprehensive functional

assessment is the critical initial step in

determining the kind and level of care for

these inmates, few adult institutions have

such a protocol in place, or even persons

qualified to carry one out.

What can free-world medicine teach corrections about the conduct of such assessments? Are there efficient and effective

assessment protocols available that would

work well in corrections settings?

How might the results of such assessments

be employed to prescribe the right kind

and level of care for individual inmates?

How might the results of such assessments

be employed to determine the amount and

kind of specialty care resources that are

required to efficiently and effectively

respond to the needs and requirements of

aging, chronically ill, and terminally ill

inmates?

Based on such assessments, what kinds of approaches, strategies, and programs are indicated? 

How might the results of such assessments

be employed to prescribe the right kind

and level of care for individual inmates?

What kinds of programs and strategies

might be considered? [Hospice care, compassionate leave, special medical technologies, etc.] 

What programmatic issues are likely to be

encountered? 

What is the system doing to ensure that the special

needs of inmates are recognized? 

What is the mechanism used to ensure that the special needs of the inmate are always maintained?

Specific Questions To Be

Covered

1. What is the screening tool used for inmates

with special needs on entry to systems?

2. What other kinds of screening mechanisms are

used at intake to determine functionality?

(Gather available forms.)

3. Is a functional assessment routinely conducted

on all inmates at intake? If “yes,” what does the

functional assessment entail?

4. How does your classification program work to

separate inmates based on need?
5. How do you ensure that the special needs

which have been identified are recognized?

APPENDIX C

144

6. What is your mechanism to ensure that the

special needs of the inmate are always maintained? (Including upon transfer from one facility

to another.)
BALANCING CUSTODY

CONCERNS AND

APPROPRIATE CARE:

HOW DO WE COME TO

TERMS WITH THE

SPECIAL NEEDS AND

REQUIREMENTS OF

ELDERLY, CHRONICALLY

ILL, AND TERMINALLY ILL

INMATES? 

Issues To Be Considered

What kinds of approaches, strategies, and programs

are indicated? What kinds of programs and strategies

might be considered? [Hospice care, compassionate

leave, special medical technologies (such as telemedicine), etc.]

What are the enablers and barriers to establishing

provision of appropriate care for these populations? 

What programmatic issues are likely to be encountered? [For instance, under what circumstances

should chronically ill and terminally ill inmates, as

distinguished from aging and elderly inmates, be

housed in separate facilities and/or segregated from

other inmates, and under what circumstances might

they be “mainstreamed” with the general inmate

population?]

What are the current and proposed correctional

policies relating to these populations? 

What are the political and financial costs involved?

Specific Questions To Be

Covered

1. Does your departmental offender tracking system count inmates considered to be elderly

separately? _____ Yes _____No

______By gender?

______By race?

______By county of commitment?

______By number of prior commitments?

______By level of felony?

______By most serious commitment offense?

______By initial security classification 

assignment?

2. Does your departmental offender tracking system distinguish between

Inmates who entered the system younger than

age 50 and who attained that age while incarcerated? _____ Yes _____No

Inmates who were age 50 or older at entry but

were never incarcerated before?

_____ Yes _____No

Inmates who were age 50 or older at entry who

were previously incarcerated? 

_____ Yes _____No

3. Are elderly inmates in your department housed

congregately in special housing as a discrete subpopulation? _____ Yes _____No

4. Are elderly inmates housed in one or more separate facilities in your departmental system?

_____ Yes _____No

5. Does your department provide educational or

other personal development programs specifically designed for elderly inmates that include

issues and problems? _____ Yes _____No

6. If “yes,” does the program include

______Education on the aging process?

______Education on physical, psychological, and

social issues associated with aging while

incarcerated? 

______Education on self-care and activities of

daily living, basic adult education, and

literacy?

7. Does your department provide supervised

recreational programs specifically designed and

appropriate for elderly inmates? 

_____ Yes _____No 

145

SITE VISIT CHECKLIST
Please describe the programs available:

8. Does your department survey/sample your population of inmates age 50 or older to assess

their perceptions of their needs? 

_____ Yes _____No

9. Does prerelease planning for elderly inmates

include information on

______Social Security?

______Medicare?

______Estates and wills?

______Advance directives (such as “do not

resuscitate” (DNR) orders)?

______Funeral planning?

______Other community-based services for the

elderly (e.g.,“meals on wheels”)?

10. Does your departmental health services division

provide organized health education services for

inmates considered elderly? 

_____ Yes _____No

11. Is there a peer-visiting program for elderly

inmates? _____ Yes _____No

12. In your department, do inmates who are debilitated, frail, or medically fragile have access to a

congregate therapeutic living community where

they can be medically supervised, specially programmed, and assisted with the activities of daily

living? _____ Yes _____No

If “yes,” is that program available to both men

and women?

_____Men only 

_____Women only

_____Men and women

APPENDIX C

146

13. Does your department’s health services division

promulgate and implement chronic protocols

or guidelines for all of the major chronic

conditions? _____ Yes _____No

14. Does your department operate prerelease centers or halfway houses with programs designed

for elderly inmates? _____ Yes _____No

15. Are inmates who are considered elderly in your

department provided

______Universal access to the entire physical

plant housing them?

______Single or lower bunks?

______Additional heat in cold weather?

______Air conditioning in warm weather?

16. Are medical social services professionals available to your department’s population of inmates

directly or to your health services division as

case management consultants? 

_____ Yes _____No

17. Does your department operate or have access

to levels of care ordinarily identified with nursing homes? _____ Yes _____No

18. Does all or part of your department’s physical

plant comply with the Americans with

Disabilities Act?

______All institutions

______Number of institutions

______None
MEDICAL, PROGRAM,

AND HOUSING

CONSIDERATIONS:

REQUIREMENTS FOR

ELDERLY, CHRONICALLY

ILL, AND TERMINALLY ILL

INMATES

Issues To Be Considered

What kinds of approaches, strategies, and programs

are indicated? What kinds of programs and strategies

might be considered?

Specific Questions To Be

Covered

A. Compassionate release

1. Is there a compassionate release/medical parole

program for terminally ill inmates in your

system? 

2. Who initiates the request for compassionate

release?

3. How long does the process generally take?

4. Which agency can grant the release request?

B. Hospice care

1. Do you have a hospice unit for inmates who are

terminally ill? _____ Yes _____No

2. What are the eligibility criteria in terms of:

a.The definition of “terminal illness”?

b.The level of functioning?

c.The type of crime the inmate committed?

d.The diagnosis?

e. Other?

3. Is this a discrete unit?_____ 

Part of the infirmary?____ 

Part of a housing unit?_____ 

An outpatient program?_____

4. How many beds are in the hospice unit? _____

5. How many patients do you usually serve at one

time?_____

6. How many patients in all did you serve last

year?_____

7. Are there dedicated staff for the hospice unit? If

“yes,” what types?

8. Do you use other inmates as volunteers in your

program? _____

9. If “yes,” describe the screening selection

process, the training program, the types of activities they perform, and any rules/restrictions

under which they operate.

10. Do you use any volunteers from the community? If “yes,” describe this program.

11. Do terminally ill inmates in your system issue

advance directives? _____ DNR orders?_____

If “yes” to either, what safeguards are in place

to ensure that they have given noncoerced

informed consent?

12. What is the visitation policy for the terminally ill

patient’s family? Other inmates?

13. Are special foods and drinks available to terminally ill patients at all times? 

_____ Yes _____No

14. Are there or were there institutional barriers

(e.g., security rules, administrative concerns) that

affect your ability to provide support for the

terminally ill in your system? If “yes,” what are

they and how are you addressing them?

15. Do you have hospice programs in all of your

facilities? _____ Yes _____No

If not, how many do you have? _____ 

16. Are terminally ill inmates in all facilities able to

be transferred to a unit with a hospice program?

_____ Yes _____No

147

SITE VISIT CHECKLIST
C. Palliative care

1. Is there a palliative care program in your

facilities? _____ Yes _____No

2. If “yes,” is palliative care available to those with

advanced disease but who have not yet been

defined as terminal? _____ Yes _____No

3. What types of palliative care do you offer?

4. What are the eligibility criteria for receiving it?

5. Does your pain management program include

the use of narcotics? _____ Yes _____No 

If “yes,” did you encounter any resistance from

custody staff? If “yes,” how did you overcome it?

Describe what is available.

7. Do you use an interdisciplinary team in your

palliative care program? 

_____ Yes _____No 

If “yes,” what types of personnel are on it? Who

leads the team? What is the team’s role?

APPENDIX C

148

8. Do you develop individualized care plans for

your palliative care patients? 

_____ Yes _____No

9. Can patients in the palliative care program continue to receive curative care? 

_____ Yes _____No

D. General 

1. Are your end-of-life programs available to

women inmates as well as men? 

Are there any differences in terms of what is

available to women?

2. Are you satisfied with the end-of-life care you

are able to offer currently? If not, what more is

needed?

3. How are your end-of life programs funded?