PUBLIC HEALTH MANAGEMENT IN OTHER THAN REGULAR SETTINGS
†††††††††††††††††† †††††††††††††††††† †††††††††††††††††† ††††††††† JENNIFER CHANDLER
††††††††††† For the purposes of the chapter, other than regular settings are places where the population is centrally located or incarcerated.† This chapter will describe public health management issues involving incarcerated juveniles and adults.† Policies, mandates, and the issues facing this system will be described.
HEALTH SERVICES POLICY REGARDING INCARCERATED JUNENILES
††††††††††† The juvenile justice system has long been used as a security setting for juveniles with a variety of mental health issues and disorders.† More juveniles are committing violent crimes and many of these youngsters are affected by a variety of mental health problems and conditions.† Limited funding for treatment and lack of diagnostic information has caused a gap in an already fragmented system leaving the state of Ohio with high recidivism rates in juveniles who continue to be repeat offenders.† Public safety is an additional critical factor as juvenile crime is increasingly more violent in nature.
††††††††††† In 1997 the Ohio Task Force on Mental Health Services was convened to formulate recommendations for the Ohio Department of Youth Services (ODYS) and the Ohio Department of Mental Health (ODMH) regarding issues of treatment and rehabilitation of mentally ill juveniles who are involved at various levels in the juvenile justice system.† Multiple constituents were represented from ODMH, ODYS, Juvenile Court judges and community providers.
††††††††††† Limited available data points to major mental health symptomology among these youth.† Conduct Disorder, ADHD, mood disorders, sleep disorders, psychotic disorders, PTSD, and schizophrenia are among common diagnoses for the youth offenders committing violent crime.† One possible problem that is presently overlooked, according to the National Institutes of Mental Health is the missed diagnosis of bipolar disorder in young people in general.† Many of these youngsters are processed through the juvenile courts for their and the general publicís safety.† Bipolar disorder includes disordered moods, sleep disorders, dangerous manic mood shifts, and unfortunately often presents with co-morbid conditions.† It is a fact that in addition to the already fragile state of bipolar disordered youth, the condition often presents with ADHD symptomology.† When misdiagnosis occurs the youngster is often mistakenly prescribed Ritalin, which can bring about rapid cycling and devastatingly violent responses in bipolar disordered youth.††
An absence of quantitative data has left this system to act based on anecdotal qualitative data and survey data of youth who are currently incarcerated for serious crimes.† A major challenge to the task force is to balance the different philosophies of the two systems involved, with mental health systems delivering individualized treatment services in lesser restrictive settings and correctional facilities designed for sanction and the publicís safety.† According o the task force alternatives to incarceration have not been tested for mentally ill juveniles who are also committing violent crimes.† The challenge is to reconcile the two divergent philosophies and then to utilize the best aspects of both systems together.† There is an additional major gap in data involving young children under age twelve. †††††††††††
With the current system of managed care and less available funding there is a real need for increased effectiveness and efficiency in service delivery.† Identification and efficient use of funding streams is critical according to the task force in order to provide a continuum of care that will reduce recidivism among these youth.† The guiding principle for the task force is built on teamwork and collaboration among agencies to pool resources and to establish a system that will follow these youths across counties.† A strong recommendation has been made for required parental/familial involvement in continuum of care for the youth regardless of custodial responsibility.† Because the issues and needs of youth in the system are different from incarcerated adults, development of cultural and gender specific services is recommended. Meaningful data is also critical for evaluation of quality of service delivery and to identify trends in the population.† There is a need for up to date data technological systems to be put in place to offer an evaluative research component to the system.
††††††††††† A pilot program was proposed by the task force in 1998 and an R.F.P was submitted with a target date for implementation of Fy2000, July 1, 1999.† Consultations with state government officials were suggested to seek availability of funding from Medicaid and Title IV-E sources.† Community level sources would be sought to provide non-federal funding matches.† It is very apparent that the strategies employed for incarcerated adults has not been considered or pursued for incarcerated juveniles as yet.† However, many information resources consider the state of Ohio as leading the way in prison reform in the situation of incarcerated adults.
HEALTH SERVICE POLICY REGARDING INCARCERATED ADULTS
††††††††††† This section will outline policies that have greatly improved health care delivery services to incarcerated adults.† Policies regarding health care delivery of service to incarcerated adults have been established for the purposes of providing unimpeded access to care.† Health care service delivery within this agency includes medical, mental health and recovery services.† The policy is as stated:† It shall be the policy of the Ohio Department of Rehabilitation and Correction to provide health maintenance services and continuity of care to incarcerated offenders under its supervision.† These services shall be accessible to all inmates, shall include an emphasis on disease prevention, and shall reflect a holistic approach in accordance with approved levels of care.
Incoming and Outgoing Health Care
Upon arrival each resident receives a reception medical evaluation.† At that time incoming residents receive written and oral instructions on access to health care.† Residents do not have access to second opinions, medications or related items from outside sources, or outside-sourced medical insurance.† Pre-release physical exams are given to each outgoing resident along with a fifteen day supply of any needed medicine.† Residents must submit medical complaints in writing and must receive a response in writing within five days.† Institutional physicians are prohibited from conducting disability examinations or benefits assessments.† The Office of the Warden is responsible for disability determination.† Residents are provided access to medical attention daily with physicians and medical personnel on call 24 hours a day.
Management of Chronic Illness
††††††††††† †Management of chronic health problems is a comprehensive policy providing residents with information and education (holistic in nature) addressing disease/condition specifics as well as general issues, according to written policy.† Chromic care clinics include hypertension, cardiovascular, seizure disorders, chronic pulmonary disease, diabetes, tuberculosis, and HIV infections (includes sexually transmitted disease).† Individualized treatment plans are developed covering problems, goals, objectives, interventions, evaluation, and treatment regimens.
††††††††††† Physical exams are given every two years to residents ages 49 years and less and annual physicals given to residents age 50 years or more.† Ancillary services are available as well as specialty health services.† Emergency services are readily available but limited in range on the premises, with local hospital emergency rooms utilized when necessary.
Provision of Mental Health Services
††††††††††† In 1995 the Dunn v. Voinovich Consent Decree mandated an upgrade in services provided to residents with serious mental illness. This mandate and its acceptance by ODRC has dramatically impacted the management of health care delivery of mental health services to all affected residents.† The plan is considered strong and expected to minimize the operational disruptions and legal liabilities often experienced with the incarceration of mentally ill adults, according to the executive summary of the Ohio Plan.
Serious mental illness is defined by the Dunn Decree as:† a substantial disorder of thought or mood which significantly impairs judgement, behavior, capacity to recognize reality or cope with the ordinary demands of life within the prison environment, and is manifested by substantial pain or disability.†††
††††††††††† It is now the responsibility of ODRC to identify, treat and manage those residents with clearly defined mental health issues.† A psychiatric case load is now established.† Office treatment space is provided as well as crisis stabilization units (beds).† Mental health staffing levels have increased 500% since 1994 according to the executive summary.† There is a clear effort in this area to address the problems brought about by use of the criminal justice system to house and confine mentally ill violent offenders.† The Ohio Plan is the direct result of a system that is opening up to seriously ill offenders and committing to treatment.† The scope of the plan, however, is limited to seriously mentally ill residents, excluding residents with other varying† degrees of mental illness, anger management, and sex offender treatment and rehabilitation.†
††††††††††† One restructuring move by ODRC is their takeover of operations at Oakwood Hospital, (formerly Lima State Mental Hospital).† According to Sam Hibbs, Director of ODMH, a restructuring and re-naming of state mental health facilities has been undertaken to take away the harshness and negative reputation of the past. State mental facilities have been downsized from seventeen hospitals to nine campuses statewide.† This action was also taken to minimize negative labeling of residents.† Oakwood is now a residential facility used for inpatient psychiatric treatment by ODRC.† Previously ODMH provided psychiatric services and ODRC psychological services, a divergence of services which was a major cause of poor service delivery.† Mental health services are now centralized, enhancing consistency and uniformity in a previously fragmented and ineffective service delivery system.† ODRC is now operating under standards that are consistent with national standards.† The system now evaluates policy annually, is more cost-effective, and assesses quality on a regular basis.† The ODRC quality assurance involves evaluation, prevention of risk, utilization review, infection control, credentialing, and peer review.
Infectious Disease Management and Control
††††††††††† ODRC implements a comprehensive policy designed to provide information, education and protection to correctional staff and inmates.† Procedures are in place to protect staff, such as detailed hand washing and wearing gloves responsibly.† Sharps control procedures are used for eliminating needle sticks.† Scrub uniforms are provided and cleaning products used for eliminating contamination are used with detailed instruction.
††††††††††† Residential testing is provided following sexual activity or sharing of blood or body fluids.† Test results must be provided without delay and results are confidential.† Individualized treatment plans are designed for chronic illnesses such as A.I.D.S. and for sexually transmitted diseases.† Treatment is intensive and ongoing as needed.
It is apparent that the blanket closure of state mental institutions during a previous presidential administration has greatly impacted and overtaxed this countryís justice systems.† Prisons and homeless shelters are now housing sources for mentally ill persons, as more mentally ill are being processed through the justice system and housed in prisons.† Our already overtaxed prison systems have historically fallen short in the areas of rehabilitation and now have the additional responsibility for mentally ill and chronically ill offenders.† Our society is more complex and the prison system is influenced in its actions by this countryís stance regarding human rights.† However, more prisons are being constructed with a trend toward super prisons, specialty prisons and for profit prisons.† The state of Ohio continues to stand as an example, according to the media, as consistently rising to the challenges of providing a system that removes dangerous criminals from the public domain, sanctions criminal behavior, and provides health care services by using proactive and reactive strategies, all implemented under centralized authority.
Ms. Barrie Hafler,† Atascadero State Hospital,† Atascadero, California††††††† ††††††††††††††††††††††† ††††††††††††††††††††††† †††††††††††††††††
Ms. Kay Northrup,† Deputy Director, Office of Correctional Health Care, State of Ohio
Executive Summary:† The Ohio Plan,† Fred Cohen, Bureau of Medical and Recovery Services, State of Ohio
Department of Rehabilitation and Correction:† Policy 320-04† Infectious Diseases
Department of Rehabilitation and Correction:† Policy 320-01† Medical Service Provisions
Department of Rehabilitation and Correction:† Policy 319-10† Mental Health Services Standard Operating Procedures
Final Report and Recommendations:† Ohio Task Force on Mental Health Services to Juvenile Offenders, February 1998 (Ohio Department of Mental Health Homepage).