Health Care Behind Bars
The prison inmate population of New Jersey is rife with physical and mental health problems. Fortunately, University Correctional Health Care, part of University Behavioral Health Care, deploys an army of dedicated health care professionals statewide to treat inmates’ needs, producing encouraging results that show lives can be turned around.
Imagine a population of 23,000 people—enough to fill a small city—with an overabundance of health problems, including a disproportionately high incidence of chronic and infectious diseases. The vast majority of the group is male; 17 percent has hepatitis C; and 1 percent is infected with HIV. They don’t get much exercise and are vulnerable to “lifestyle disorders”: obesity, diabetes, heart disease, asthma, stroke. Between 70 and 80 percent have mental illness, almost one-fifth with problems serious enough to hamper daily functioning. Many of these people were heavy smokers and two-thirds were substance abusers. Their stress is sky-high and suicide can be a consideration. A study published in the American Journal of Public Health confirms that American inmates have not only a higher rate of serious and chronic illness than the general population, but also more difficulty obtaining health care both in and out of prison.
These patients are the ultimate captive audience: New Jersey’s prison inmates, housed in 12 facilities, from Bayside State Prison in Leesburg to Northern State Prison in Newark. Although many clinicians may not find correctional health care an attractive career, a dedicated team of professionals has assumed the role of providing the state’s inmates with a full range of medical, dental, and mental health services. These providers are the staff of University Correctional Health Care (UCHC), a division of University Behavioral Health Care (UBHC), which itself is part of Rutgers Biomedical and Health Sciences.
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Alumnus Jeffrey L. Dickert, left, is the chief operating officer for University Correctional Health Care (UCHC) and Christopher Kosseff, right, is president and chief executive officer of University Behavioral Health Care. UCHC was launched in 2005 to provide mental health services for New Jersey’s inmates, the Juvenile Justice Commission, and the State Parole Board. It also provides mental and physical health care services to residents of a group home, 12 facilities for at-risk juveniles, and 10 community sites for parolees classified as lifetime sex offenders.
“Even the most hardened criminals and repeat offenders have rights that are protected by the Constitution. One of them is the right to health care,” says Jeffrey L. Dickert, UCHC’s chief operating officer. “In a civilized society, prisoners should get adequate care; it’s the right thing to do. Providing these services also makes economic sense for New Jersey. Inmates can sue if health care is withheld and this litigation is costly. Those who are denied care may require hospitalization. This costs taxpayers even more money.”
“You wouldn’t be in this line of work if you didn’t believe inmates should receive health care,” says Donald (Rusty) Reeves, UCHC’s director of psychiatry. “Most return to society after three to five years. It’s our goal to return them in better shape than when they arrived.”
UCHC’s history is in part rooted in state politics. “UCHC started as a dream in the early 2000s, and Christopher Kosseff’s vision made it a reality,” says Dickert GSNB’83. “At the time, private companies provided the health care, and it was disorganized and not very good. Psychiatric services were limited, some providers were not licensed, and documentation was inadequate. So NJDOC decided to look in a new direction.”
The New Jersey Department of Corrections (NJDOC) turned to Kosseff, who as UBHC president and CEO was an expert in mental health services, for recommendations about providing correctional care. Kosseff, who will retire in March, assembled a “dream team” of experts and wrote a draft report. Further conversations provided the basis for an agreement, and UCHC was launched in 2005 to provide mental health services for New Jersey’s inmates, the Juvenile Justice Commission (JJC), and the State Parole Board. The impetus for awarding this contract was the settlement of a class-action lawsuit, C.F. v. Terhune, filed in 1996 on behalf of inmates with mental illness who had been denied care. The contract was later expanded to include medical care for inmates and the JJC resident population. The relationship between NJDOC and UCHC has been constructive and long-standing. “We’re guests in the DOC’s house, and we conduct ourselves accordingly,” says Dickert.
Through a combination of clinical services and innovative health education, UCHC has become a model of care, improving outcomes and decreasing hospitalizations and mortality, says medical director Arthur Brewer. He works closely with nursing director Margaret Conrad SN’09, who oversees the large team of nurses delivering much of the care. “We have a strong mission of caring,” says Conrad. “You need the right people with the same mission. If you sense someone is thinking, ‘Who cares about these inmates?’ that person’s mission does not align with ours.”
UCHC’s vast network reaches inmates throughout New Jersey, from a facility like Northern State, a gray fortress near Newark Liberty International Airport, to bucolic Jones Farm, a
minimum-security prison in Ewing that’s actually a working dairy farm. The enormous task is accomplished with a budget of $155 million and a health care team of more than 1,000 practitioners. UCHC also provides services to residents of a group home, 12 facilities for at-risk juveniles, and 10 community sites for parolees classified as lifetime sex offenders who require supervision for the rest of their lives.
A great deal of oversight ensures that no one’s care is overlooked. Upon incarceration, inmates, most of whom are poor and minorities, receive comprehensive health evaluations. Most of them have had limited or no access to health care, and their needs are great. Physicians, physician assistants, or nurses treat inmates with acute and chronic health problems. Four health risk behaviors—lack of exercise, poor nutrition, tobacco use, and alcohol abuse—are responsible for many chronic diseases. “We can diagnose someone with cardiovascular disease or hypertension, but we can’t control their weight,” Brewer says. “It can be difficult to persuade patients to commit to healthful changes. This takes a lot of work.”
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“Most inmates have had years of dysfunctional living in abusive environments,” says psychologist Rich Cevasco, left, UCHC’s lead clinician administrator. “We see serious mental disorders along with substance abuse. And they’re angry about living in a punitive environment. Prison’s a tough place—and for those of us who work here, too.” Cevasco is pictured with Donald Reeves, UCHC’s director of psychiatry, inside the New Jersey State Prison in Trenton.
Inmates’ relative ease in gaining access to health care is better than it is for the public, according to Brewer. Still, a few inmates will refuse care and must sign a waiver saying so. NJDOC and UCHC implemented electronic medical records for patients in 2000, long before the rest of the health care world did. The state-of-the-art system enables any provider at any prison to access an inmate’s chart to see what treatment he or she has received.
UCHC staff engages patients to actively participate in their own health care through several initiatives, including the federally funded Stanford Chronic Disease Self-Management Program. It offers inmates health classes taught by UCHC nurses who receive special training to become peer leaders. One program covers chronic disease; a second addresses diabetes. Conrad, who wrote the grant for the program, says, “We teach small, achievable goals to improve overall health.” So far, more than 1,000 inmates have enrolled.
At a chronic-disease health class held at Jones Farm, eight inmates are listening intently as nurse Leeann Russo talks about weight control. Working with props, including food labels and a paper plate, she talks about portion control and making smart food choices. Amid jokes about prison food, one inmate offers, “What I learned here has helped me lose weight, and I feel better.” The others nod in agreement.
The topic later shifts to the importance of good communication for conflict resolution. Stress can affect health, so inmates learn strategies for coping with prison life. Skillfully touching on the isolation that many inmates feel, Russo encourages the inmates to share their thoughts and feelings with others in a positive way. The inmates break into pairs to practice using the communication skills that Russo has just demonstrated.
“The teachers treat us with respect and explain things until we get it,” one prisoner says later. “They make you feel like your health means something.” Another wrote: “Without your encouragement, I would never have taken the necessary steps to get healthy. I had a physical yesterday and my weight is 262. I lost 80 pounds, and my blood pressure is down, too. Thank you for putting me on the right path.”
The successes of UCHC’s providers include improved blood pressure, cholesterol, and diabetes benchmarks for the New Jersey prison population. A smoking ban implemented in 2012 resulted in a 12 percent drop in pulmonary chronic care visits. Percentages of patients requiring hospitalization decreased, as did the average length of stay. In patients suffering from mental illness, 77 percent said they experienced a reduction in symptoms. Complaints about health care dropped by 25 percent overall since UCHC took over. UCHC received the 2013 New Jersey Hospital Association Excellence in Quality Improvement Award and the New Jersey League of Nurses Corporate Award.
UCHC’s strategies have helped improve inmates’ mental health as well. “Most inmates have had years of dysfunctional living in abusive environments,” says psychologist Rich Cevasco, UCHC’s lead clinician administrator. “We see serious mental disorders along with substance abuse. And they’re angry about living in a punitive environment. Prison’s a tough place—and for those of us who work here, too.” He speaks from experience, having been held hostage at knifepoint by an inmate years ago.
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Roderick Sta Rosa, a physical therapist with UCHC and part of a health care team of more than 1,000 practitioners with the organization, tends to an inmate at the New Jersey State Prison.
All inmates undergo a mental health evaluation within four hours and a psychiatric evaluation within 72 hours of incarceration. Fourteen percent require treatment for severe mental illness, ranging from schizophrenia and major depression to personality and other disorders. Inmates with acute mental illness go to stabilization units—somewhat like a psychiatric emergency room, where they may stay from a few days to a few weeks before moving to inpatient units for short- or long-term care. Patients who cannot be stabilized are committed to Ann Klein Forensic Center, a criminal care facility on Trenton Psychiatric Hospital’s campus. Admissions to Ann Klein have dropped by 80 percent since UCHC took over. “At one time, the state had plans to expand Ann Klein,” Dickert says, “but now there is no need to.”
Inmates needing care will see psychiatrists, psychologists, and social workers, and may also have psychotherapy. “People who are motivated can change, but it is difficult,” says Reeves. “We ask them to examine their lives. Are they satisfied? If not, what can they do differently? While we try to promote a change in behavior, we’re not under any illusions about remaking society. If we can help some people come out of prison in a better state of mind, we’ve done
our jobs.”
The national average of prison suicides is around 15 per 100,000 inmates each year; New Jersey’s prison suicide rate has remained below this rate over the past five years. Inmates who face disciplinary charges, receive bad news from home, or have a change in detention status are at increased risk for suicide, according to Dickert. “Because suicides almost always happen in single cells,” he says, “the DOC came up with a strategy of double-bunking—two inmates in a cell. They always have company, someone to talk to. People are far less likely to kill themselves when they are with someone.”
Correctional health care requires this type of creative thinking as well as specialized clinical skills. Psychologists pursuing correctional health care can earn a master’s degree in forensic psychology, and psychiatrists can take fellowship training in forensic psychiatry, a branch of medicine at the interface of law and mental health. “Traditionally, forensic psychiatry was considered the backwater of psychiatry and was not a desirable career path,” says Reeves. “With the advent of forensic fellowships, the profession gained recognition and prestige, and salaries have increased.” There are more than 30 forensic fellowship programs in the United States, including one that Reeves launched a few years ago at Robert Wood Johnson Medical School. UCHC has two forensic psychiatry fellows, one child psychiatric fellow, and four psychology interns.
Students from the medical and nursing schools within Rutgers Biomedical and Health Sciences may also rotate through the prisons to gain experience. “Many nurses don’t see
correctional nursing as a viable career, but we are trying to change that,” says Conrad. “One deterrent is concern about personal security. I tell potential employees they are safer here than in many general hospitals or psych units. We have correctional officers.”
UCHC offers a thorough orientation to provide new employees with the street smarts required in the prison setting. “The prisoners can be manipulative and some attempt to work the system—maybe try to get a cell phone or have a letter mailed,” says Cevasco. “We teach employees a few simple rules: Never keep a secret for an inmate. And if they ask for something, always say, ‘I don’t know. I’ll ask the sergeant.’”
When their time is up, inmates leave prison with a discharge summary listing all diagnoses, treatments, and medications received. They are given medicines, prescriptions, and names of community health resources. Prisoners with mental illness are advised to see a psychiatrist and UCHC will even make appointments for them, but there is no guarantee that they will follow through.
“We don’t know what happens when inmates leave, but we do hear of some successes,” Cevasco says. “When you try to help a patient, sometimes nothing happens. But other times, you see a shift in the person. They start to get it. They’ve been bucking the system and losing. Some start to realize they can change and improve their lives.” •
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