Elder care: Louisiana initiates program to meet needs of aging inmate population.

In Louisiana, an inmate sentenced to life in prison is likely to die there, unless a court intervenes or the sentence is commuted by joint action of the board of pardons and the governor. There are 3,014 inmates with life sentences and approximately 1,850 more who have "practical life" - mandatory sentences so long as to effectively preclude release. These inmates represent the future of the already growing population of older inmates, a population that brings with it an increased potential for medical problems and emergencies, circumstances that often develop sooner in prison populations.

In 1980, 281 inmates (4.5 percent of the institutional population) were 50 years of age or older. In 1990, there were 857 (4.6 percent), and at the end of January 1998, there were 1,275 (7.4 percent). Truth-in-sentencing laws will push these numbers higher. More inmates will remain in prison for longer periods of time. And more inmates will grow old in prison.

Current Circumstances

In 1992, the Louisiana Legislature created a crime victims' "bill of rights," which, among other provisions, gave victims more say in probation and parole proceedings. Victim advocates argued that issues other than cost and risk must be considered when weighing the release of inmates from prison, regardless of age. In 1993, the state legislature passed a law excluding inmates sentenced for first- and second-degree murder from medical parole, even if they are terminally ill or permanently incapacitated.

After Congress enacted the Violent Crime Control and Law Enforcement Act of 1994, which offered construction grants and other incentives to states that ensure violent offenders remain incarcerated for substantial periods of time, the Louisiana Legislature passed a law requiring inmates who commit a crime of violence on or after Jan. 1, 1997, to serve 85 percent of the time imposed before qualifying for release. The state's first comprehensive felony sentencing guidelines, implemented in January 1992, were repealed, effective August 1995, amid insistent claims that they existed to shorten sentence lengths.

An Approach to the Challenge

Inmates in Louisiana state institutions live in dormitories in the general population - unless their behavior or assessed physical, mental or emotional needs indicate that cell block housing is required. This is true of geriatric inmates (the term used here to mean "aging" rather than "of advanced age"), just as it is of teen-age newcomers to the system, HIV-positive inmates, inmates with mental retardation and/or mental illness, and others. In that sense, older inmates are just one of various groups of special needs inmates within the state correctional system. Like the others, the elderly live in the general population as long as they can do so safely. For those who cannot live in the general population, the department has concentrated on upgrading medical and mental health services at the Louisiana State Penitentiary (LSP) at Angola in order to satisfy the needs of the department's most seriously medically and mentally ill offenders.

Intent on overcoming the constant shortage of doctors and nurses at LSP, the administration increased salaries for doctors and registered nurses, offered remodeled and modernized housing on the grounds to medical staff, and increased the hours of contract physicians.

Angola is in a rural area, and the prison is surrounded on three sides by the Mississippi River and bordered on the fourth side by the ravine-laced Tunica Hills. It is 59 miles from Baton Rouge and about 140 miles from New Orleans. The isolation that once made it the perfect place for a prison also made it a challenging location to maintain a full complement of necessary medical and mental health personnel. Once these limitations were acknowledged, other sites were examined for development of specialized units and services.

Special Needs Facilities

One special needs facility is being developed near Shreveport as a satellite of the David Wade Correctional Center (DWCC). Named the Dr. Martin L. Forcht Jr. Clinical Treatment Unit and referred to as Forcht-Wade, the unit will house male inmates who, by virtue of age and/or physical impairment, can best be handled in a special needs facility. The unit occupies the site of the old Caddo Parish Detention Center, which was donated by the parish to the state for development as a special needs facility. It is being renovated with assistance from federal crime bill funds. In September 1999, when renovations are complete, 330 of the unit's total 555 beds will be for special needs offenders.

Forcht-Wade is well-suited to serve as a special needs facility. It is close to the Louisiana State University Medical Center (LSUMC) in Shreveport, the premier teaching facility in the region. Plans are being developed to use medical center staff as consultants and to provide important medical components such as physical and occupational therapy through contracts with LSUMC's School of Allied Health Care.

A team of Forcht-Wade administrators, medical staff and the facility architect visited the Federal Medical Center in Fort Worth, Texas, and met with staff. Administrators are working with the Department of Gerontology of Northeast Louisiana University in Monroe to better prepare themselves to understand and serve the special needs of an aging population.

Currently, 166 beds at Forcht-Wade are occupied by minimum custody inmates who are housed there to help with renovations not provided by outside contractors. After renovations are complete, those beds will continue to be filled by inmates who are able to maintain the grounds and provide other service functions.

For four years, DWCC has shared a telemedicine linkage with LSUMC. Telemedicine technology utilizes interactive video and specialized diagnostic equipment to enable off-site physicians (usually in a hospital setting) to examine patients who are with medical personnel in a prison's infirmary. This arrangement has increased efficiency and decreased security risks. Where telemedicine is appropriate, a consultation that would require a 135-mile round-trip drive and two security officer escorts can be handled in about 45 minutes without taking inmates outside the secure perimeter of the institution. Telemedicine also has supported recruiting efforts by enabling physicians at DWCC's relatively isolated site to interact with medical colleagues. When Forcht-Wade is fully operational, the service will be expanded to that unit.

The Elayn Hunt Correctional Center (EHCC), located just outside the Baton Rouge metropolitan area and about 50 miles from New Orleans, was identified as the appropriate site at which to provide enhanced medical and psychiatric care in the system. Patients from LSP's Clinical Treatment Unit II were transferred to EHCC.

Planning and design monies have been authorized for a new 600-bed facility, which, when completed, will serve as a skilled nursing/mental health/HIV-AIDS facility and will deliver acute and chronic medical and mental health care. It will add new clinical areas and inpatient housing units, and supplement the state health care authority's efforts by providing services that have occupied but do not require a hospital's resources, including: infirmary care, frequent medical monitoring, long-term skilled nursing home care and hospice care. This facility also will be constructed with the help of federal crime bill monies. Funding for the required 10 percent state match has been included in this year's capital outlay budget request.

Meanwhile, pending completion of new special-needs beds at EHCC and DWCC, 70 existing beds have been set aside for the frail, elderly and infirm at EHCC, 120 at LSP and 30 at the Dixon Correctional Institute, where most male inmates requiring dialysis are housed. The Louisiana Correctional Institute for Women currently has 20 beds available for elderly or infirm inmates.

Special Programs

In 1991, an inmate suffered a heart attack while on his job; another, while watching television in his dorm. Before EMTs arrived, inmates recall, no one knew what to do. Major J. Lee Walker, director of Emergency Medical Services at LSP, was struggling with the same issue. Distances and standard security devices such as double interlock gates, where one door must slide shut before the other opens, complicate EMT access. One inmate, motivated by what he'd witnessed, submitted a detailed proposal to organize CPR classes for inmates.

Walker recalls that it took almost two years to put in place a program to train inmates in CPR. Two certified trainers from the prison's EMS department taught CPR to 20 inmate volunteers. Seventeen completed the first course and received certification as A-Level Basic Life Support practitioners, authorized by the American Heart Association to administer CPR. Some of the group wanted to learn more, but EMS personnel had other major responsibilities. CPR equipment is costly, and funds were an early obstacle. Inmates elected to use monies from the inmate-generated welfare fund to buy CPR mannequins, a television monitor, a videocassette recorder, training videos and other visual aids. The American Heart Association donated 30 instructor manuals.

Early newspaper reports quoted Walker as saying he would consider the program a success if 25 percent of the population learned CPR. By the summer of 1996, inmate CPR instructors had taught a six-hour CPR course to more than 2,000 inmates at LSP.

In February 1995, LSP's Emergency Medical Services Department earned certification as an advanced support service, the highest level for private or public ambulance operators in Louisiana. In 1997, LSP added telemedicine access, which allows immediate diagnostic assessment of inmates by physicians at the Medical Center of Louisiana (MCLA) in New Orleans, otherwise a round-trip of almost 250 miles.

Summary

Throughout the system, proactive health care measures for the aging population are coming into place. Annual TB testing of inmates and staff is mandatory. Regular age, appropriate health screenings are part of routine medical care. Inmate peer counseling addresses behaviors that increase the risk of HIV infection, heart attack and other diseases. Medical co-payments have been added as a means of curtailing abuse of prison medical services. Security officers certified as EMTs are widely used. Establishing additional telemedicine links between other prisons and large public hospitals is being pursued. Emergency medical furlough for inmates also remains an option.

The challenge of a growing and aging population, limited funds and public demand is great. We may, however, have access to more resources and choices in meeting it than we realize. We may need to centralize specialized programs but not necessarily all in one place; move specialized programs close to major population areas; tap crime bill monies; develop the ability to use emerging technologies; take advantage of training opportunities and grant monies; educate legislators, news media, victim advocates and the public about issues, choices and options; and innovate, innovate, innovate.

That's our job. In this, as in other tough situations, corrections professionals must find a way to balance public safety concerns and public demands for a government that operates with economy and efficiency and responds appropriately to legitimate correctional interests.

Jean Wall, an executive officer in the Louisiana Department of Public Safety and Corrections, is director of the department's Crime Victims Services Bureau. Contributors without whose help this article could not have been written are Warden Kelly Ward, David Wade Correctional Center, Assistant Warden Gary Frank, Executive Staff Officer Cathy Jett and Maj. Lee Walker of Louisiana State Penitentiary; and Executive Management Officer Dora Wheat.