MISSION SEEMINGLY IMPOSSIBLE: COMMUNITY PLACEMENT OF CHRONIC CARE INMATES.
A. A block from a pre-20th century prison. B. A file of an inmate who has a lengthy violet offense rap sheet, multiple medical conditions and a phychiatric diagnosis. C. An obsolete portable computer.
B is the correct answer. Just about every corrections professional can relate to the statement: "The larger the file, the more difficult to manage the case." The above-mentioned file includes a 14.2-pound medical file that was generated in less than a four-year period. An additional 6 pounds, known as the inmate jacket, contains nonmedical documentation such as legal documents, conviction history, transfer summaries from other state correctional institutions and a summary of classification data.
The inmate mentioned above, who is referred to as inmate 1, has been charged with armed robbery and burglary and was sentenced in October 1992 for a maximum of 10 years. He was paroled, pending an approved home placement plan in March 1998. However, he was released nearly three years later, after serving about 70 percent of his time in Pennsylvania state correctional institutions. The time served was not unusual; more than half of Pennsylvania's inmates serve past their minimum sentences.
Inmate 1's prior offenses date back to 1974 and he has a lengthy history of mental illness: He was diagnosed with paranoid schizophrenia in 1973 and has been admitted to state mental hospitals at least eight times since he was 18. From May to August 1996, he was at South Mountain Restoration Center, a specialized forensic facility within the Department of Public Welfare, where he was diagnosed with schizo-affective disorder. Without sufficient medication and monitoring, his behavior would become quite irrational and cause possible harm to himself and others. As a result of a stroke, he was non-ambulatory and his right side was almost completely paralyzed from his foot to his neck. At best, he was only able to stand and needed assistance with basic tasks, such as showering.
Obviously, the inmate needed a plan that would consider his medical, mental health and public safety requirements. In the past, attempts to place the inmate were unsuccessful because existing community facilities only provide management of mental illnesses and were not equipped to provide the level of medical care he needed. His applications were declined and he was disappointed and depressed, and remained in prison. Thus, creating an acceptable home plan for the Pennsylvania Board of Probation and Parole (PBPP) was rather bleak. However, the challenge was met by the cooperation of three distinct state and county agencies - State Corectional Institute(SCI) Laurel Highlands, the Allegheny County Department of Human Services Forensic Support Program and PBPP.
In July 1995, Somerset State Hospital announced it would be closing. Uncertain of what the institution would become, the closing would result in a major economic loss for the area, as well as individual job losses. At the same time, the Pennsylvania Department of Corrections (DOC) was dealing with a large increase in aging inmates with medical needs. The DOC was reviewing the management of these chronic care inmates and their options in addressing this increase.
Joining security and public safety applications with Somerset State Hospital staff who had extensive treatment experience appeared feasible. The hospital provided a well-maintained sewage, electric and housing infrastructure, which resulted in a major cost benefit. Further, there was state political support to receive government funds to convert the state mental institution into a secure and specialized correctional institution. Thus, a plan was created to retrofit the hospital into a prison environment, including security features such as electronically activated steel doors and extensive video surveillance.
On July 1, 1996, SCI-Laurel Highlands opened. Inmates were chosen from the statewide correctional population. In addition, approximately 80 inmates with chronic care medical needs were included as part of the first-year inmate population. For the first two years, these inmates, who were minimal security risks, were housed without a perimeter fence. No major incidents occurred.
At the time, SCI-Laurel Highlands' mission was to house inmates who needed some medical supervision, but also could function independently. However, due to the tremendous need for medical beds, the mission statement has been modified to reflect skilled medical care providing 24-hour coverage from physicians to nurse aids. SCI-Laurel Highlands eventually will house 600 general population inmates and 250 long-term care inmates. Construction is to be completed by December. The administration also is discussing a significant enlargement of the long-term care bed capacity. One of the housing units originally slated for personal care will be converted into a long-term care unit, requiring additional structuring and modifications, such as a call-bell system for each inmate.
From a cost accounting basis, the placement of paroled inmates or those who have served their maximum sentences is an increasing concern. This concern translated to a need to establish a systematic approach that would allow sufficient time for approved inmate placement into appropriate community care facilities. The average annual cost for SCI-Laurel Highlands inmates is $66,000 each. Other Pennsylvania state correctional institutions average $27,000 per inmate per year. The average health care cost per inmate at SCI-Laurel Highlands from 1999 to 2000 was $16,362, while it was $3,000 per inmate in other state correctional facilities. Thus, SCI-Laurel Highlands will serve as "the hospital" for the department with the shared responsibility of placing inmates with multiple medical or physical needs into the community.
Department of Human Services Forensic Support Program
To provide quantity and quality health care services within the state correctional system, the DOC provides a central director of psychological services who is responsible for mental health care internal audits in all facilities and overseeing quarterly meetings of professional psychological staff. A component of these meetings involves various community provider presentations of services available for paroled or "maxed out" inmates. Providers new to the market usually maintain a high level of admission criteria while seeking referrals possibly to avoid safety tasks and expensive medical coverage. However, the Allegheny County Department of Human Services Forensic Support Program was an exception to that rule. A program was established in Allegheny County that provides services to inmates who are diagnosed with mental illnesses and major chronic medical conditions. Further, inmates interested in living in Allegheny County would be accepted.
The third major agency involved in community placement is PBPP. The board has the power to grant parole and reparole (inmates brought back to prison due to parole violations) to offenders serving a maximum sentence of two or more years. Parole agents within each state correctional institution act as a liaison for the parole board's actions and the inmate population. Part of the parole agent's responsibility is obtaining an acceptable parole plan for each of the inmates under his or her jurisdiction.
The traditional role of a psychologist is evaluation and treatment, rarely delving into case management. However, since there was no identified individual whose task would involve continuity of care placement of chronic care inmates, a psychologist manager was appointed.
The role of the psychologist via case management is marketing specialized facility inmates to Allegheny's Forensic Support Program and eliciting Kathleen Carney, SCI-Laurel Highlands parole agent, to facilitate parole placement.
Fortunately, neither salesmanship nor elaborate explanation was necessary. Amy Kroll, director of the Allegheny County Department of Human Services Forensic Support Program, and Carney were able to read between the lines of continuity of care issues regarding SCI-Laurel Highlands' chronic care population. They understood that medical expenses and available medical providers would eliminate most community placements. They were highly receptive to any strategy that would result in an acceptable community-based care plan.
A significant factor in cooperation among the three agencies was their enthusiasm for and understanding of the purpose and value of appropriate continuity of care. The outcome would be measured by whether the board accepted these plans and whether a successful transition into the community was achieved.
In October 2000, Kroll and forensic support specialists Charles Miller and Paula Nelson drove approximately 80 miles to interview inmate 1, who turned out to be highly motivated, cooperative and a good candidate for placement.
In December 2000, Kroll and Miller returned and presented a lengthy service plan that was signed by inmate 1. Stipulations included recurring mental health treatment, adhering to curfews, working with a financial planner and refraining from illegal drugs and alcohol use.
Mandated compliance medication was stated as "includes any IM medication" (intramuscular via needle). The signed service plan was submitted for parole review and within one month's time, inmate 1 was paroled. Four months later, a follow-up report by Miller was sent to SCI-LaurelHighlands with a note that inmate 1 "has adjusted well and continues to do so." They had begun to taper his medication, noting that his stability changes were being closely monitored. He also is receiving physical therapy to increase his range of motion. The only problem identified was that he was spending his weekly allowance all at once. Staff members now are working with him on budgeting. Miller is pleased that this former chronic care inmate is doing well at a personal care boarding home. The second inmate to be placed was more difficult.
Nearly 30 years ago, inmate 2 abducted an 18-year-old female who he physically restrained and sexually assaulted numerous times, and threatened at knife-point. The rape and kidnapping were planned as the perpetrator disabled the woman's vehicle and then offered his assistance. He spent his first 15 years of incarceration destroying or damaging correctional facility property, threatening inmates and staff, and committing other institutional offenses. He became blind after a brain tumor was removed and he currently has a diagnosis of intermittent explosive disorder in remission.
Since his transfer to to SCI-Laurel Highlands in July 1997, after serving 18 years of a maximum 45-year sentence, he had remained incident-free and actively participated in the relapse prevention model sex offender therapeutic program. Initially, he was highly distrustful and was somewhat repetitious regarding "war stories" of his time in other prisons, but successfully responded to a cognitive behavioral approach, taking responsibility for his actions.
In spring 1999, the parole board continued final action on inmate 2's case, pending an evaluation to determine the availability of a residential plan that was male-only and had mandatory sex offender treatment. Carney wrote a lengthy letter in an attempt to find various placements for the inmate. One potential provider wrote back that "people of that type are funded at the rate of approximately $60,000 annually," but the provider estimated his supervision would cost $185,000 annually. Further, the particular county did not have sufficient funds to accommodate that type of placement. In another county, a refusal was based on the fact that inmate 2 had a documented IQ of 59. This IQ, which was taken when the inmate was younger, attending public school, conflicted with results taken by the DOC in 1976, when tests showed the inmate had an IQ of 83. The county used the 59 score and rejected him. It also stated there was a three-year waiting list. There appeared to be no residential resource.
In early October 2000, PBPP continued this case pending "receipt of information -- Forensic Placement Evaluation." Inmate 2 was interviewed during the same time frame as inmate 1. Since inmate 2 was a sex offender, he would not be allowed to live within one-half mile of a school and/or playground, as a requirement in Allegheny County, which exceeds state law. In the beginning of March, Kroll and Nelson presented a plan to inmate 2. Similar to inmate l's plan, it stated: "I will work with the Greater Pittsburgh Guild for the Blind and any other agency deemed appropriate by my treatment team to help with mobility training and/or basic needs." Mental health efforts were to include stress and anger management training and sex offender programming.
At the time this article was written, PBPP had not yet decided on the submitted plan. Kroll and Nelson indicated that they would be able to keep a bed open for inmate 2 until July.
Obstacles and Solutions
Sentencing is for longer time periods, with the inmate population consequently aging and needing a higher level of medical care. One solution is to create distinct institutional case manager positions whose full-time responsibilities is to place these special needs inmates. An additional solution is to coordinate and create community-based facilities that accommodate elderly and sick inmates who cannot live independently. Placement obstacles can be overcome through public policy efforts that integrate and create a continuum of services within the correctional institutions and community corrections centers. This mission seemingly impossible is actually quite possible as has been demonstrated.
Edward L. Haberman, Ph.D., is a licensed psychologist manager at SCI-Laurel Highlands, a member of the American Association for Correctional Psychology clinical member of Association for the Treatment of Sexual Abusers and the co-author of Mental Health Consumers Guide to Involuntary Court Commitments.
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|Author:||Haberman, Edward L.|
|Date:||Aug 1, 2001|
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