Correctional Health Care Systems and Collaboration With Academic Medicine

A jail or prison is the health care setting for millions of patients in the United States. Nevertheless, correctional health care remains largely an enigma to mainstream medicine and largely disregarded by academic medicine. The article by Raimer and Stobo¹ in this issue of JAMA describes an uncommon, if not unique, relationship between academic medicine and a correctional health care system. In this model, 2 Texas medical schools assumed the responsibility for delivery and oversight of the medical care for inmates under the jurisdiction of the Texas Department of Criminal Justice. Direct university involvement in correctional health care resulted in a more structured delivery of health care services using evidence-based medicine, greater access to subspecialists (particularly through telehealth), improved clinical outcomes for chronic illnesses, and cost savings for the state of Texas.

Despite the apparent improvements in the Texas correctional health care system since its reincarnation in 1994, a decade later, US academic medicine remains largely uninvolved with correctional health care elsewhere in the country. The reasons for this are uncertain and little studied but universities may overestimate security concerns, become stymied with logistical barriers, misunderstand federal restrictions on research involving prisoners, and undervalue the strategic importance of correctional medicine to public health. Correctional systems, on the other hand, may view academic medicine as intrusive and naively unaware of security concerns, while miscalculating the benefits of academic expertise in not only improving the quality of inmate health care but also maximizing the use of limited fiscal resources. The article by Raimer and Stobo¹ poses important considerations for both universities and correctional systems at a time when delivering inmate health care is increasingly complex and expensive.

Managing large numbers of inmates with multiple serious health problems is now commonplace in correctional medicine. According to information contained in a series of Bureau of Justice Statistics reports, 31% of state and 23.4% of federal inmates surveyed in 1997 had a physical impairment or mental condition² ; during the same year, 52% of state and 34% of federal inmates were under the influence of alcohol or other drugs at the time of their offenses³ ; 10% of state inmates, as of mid-year 2000, were receiving psychotropic medications⁴ ; and at year-end 2001, 2% of state and 1.2% of federal prison inmates were diagnosed with human immunodeficiency virus infection.⁵

The actual extent of health conditions across US jail and prison populations, however, is unknown and probably underestimated. Most published data are gleaned from inmate self-reports or represent summations of known diagnosed conditions, rather than from true random or all-inclusive prevalence studies that would more accurately measure disease burden, particularly for frequently underdiagnosed conditions, such as hypertension, diabetes mellitus, chronic infectious diseases, and mental illnesses.

From a clinical standpoint, managing individual patients with multiple health problems, such as substance abuse, chronic hepatitis C virus infection, human immunodeficiency virus infection, latent tuberculosis infection, and depression, is a common challenge for correctional practitioners; however, similar patients are rarely encountered by many of the physician consultants who are locally available to advise correctional practitioners. Clinical decision making within the correctional setting is further complicated by the paucity of evidence-based treatment data involving inmate populations. Standard treatment recommendations are often based on clinical trials that have involved comparatively healthier community-based populations and may not translate directly to the correctional setting.⁶

The inherent complexities of correctional medicine warrant a greater involvement of university-based medicine in multiple spheres—most importantly, training health care professionals for future careers in correctional health care, providing subspecialty consultations for difficult cases, assisting with the development of clinical practice guidelines, and evaluating treatment interventions and outcomes among inmate-patient populations. As demonstrated in the Texas correctional system, stronger links between academic and correctional medicine can be mutually rewarding. Inmates with complicated medical conditions gain access to tertiary subspecialists through telehealth without leaving the confines of prison, while university physicians gain valuable experience managing a subset of patients not readily encountered in many academic centers.

The involvement of the state of Texas university medical system with correctional health, however, extended beyond direct patient care. The 2 state medical schools approached the more daunting challenge of managing a health care system with a very sick patient base. This relationship developed during an era when managed care was evolving.⁷ Most health care systems are no longer engaged solely in fiscally focused efforts, such as utilization review, drug formulary enforcement, hospital case management, and bill adjudication. Cost containment remains an important goal but managed care efforts increasingly target both the process of health care delivery and the actual quality of care provided to patients.^{8 - 9} Common strategies for improving patient care include implementing specific disease-management strategies, using multidisciplinary patient care teams,¹⁰ measuring and assessing clinical outcomes, viewing patient safety as a system's priority,¹¹ and expanding patient education, with the goal of enhancing the role of the patient in clinical decision making.¹²

Formally evaluating the effectiveness of managed care systems is extremely difficult, yet vital to advancing medicine and therefore a legitimate challenge for academic medicine. Understanding the essential organizational and operational factors that improve health care quality and contain health care costs is crucial as managed care systems use new models and apply new technologies. Correctional medicine, both justly and unjustly criticized in the past, now ironically provides a unique managed care environment for critically assessing health care quality. Unlike in the community, access to health care is legally mandated in US jails and prisons. Inmates are reliably available for prevention efforts, chronic care appointments, and treatment interventions. Medical care is provided within a consistent highly structured setting to patients who live in environments that are increasingly devoid of secondhand smoke, enforce sobriety, and limit access to illicit drugs. These factors enhance the opportunities for improving health care quality and provide an opportunity for academic medicine to assess the effectiveness and cost efficiency of different health care delivery models and specific treatment interventions.¹³

Increased efforts by universities to support and evaluate correctional health care could also promote general public health. Future US public health care priorities, as outlined by Healthy People 2010¹⁴ and the Centers for Disease Control and Prevention,¹⁵ include in part the elimination of health care disparities among racial and ethnic minorities, violence prevention, containment of infectious diseases, and improvements in the treatment of addiction and mental illness. These national goals can only be achieved by targeting affected patients, such as inmate populations.^{16 - 17} A recent proposal by the US surgeon general highlighted the strategic importance and overall role of correctional medicine in advancing public health, and should help to emphasize society's role in assisting released inmates with serious health needs.¹⁸ Viewing inmate health as the shared responsibility of correctional systems and community health care organizations and support networks recognizes the frequently underappreciated facts that nearly all inmates return to their communities and many subsequently return to prison. For example, an estimated 67.5% of state prisoners released in 1994 were rearrested within 3 years and an estimated 39.6% of federal inmates released in 1997 were rearrested or revoked within 3 years.^{19 - 20} These repeat incarcerations and releases affect not only inmates but also their families and communities.²¹

Although bolstering the public health role of corrections and addressing inmate reentry concerns are laudable goals, many key related questions remain unanswered, including: What infection control strategies best protect correctional workers and inmates? How can drug abuse treatment strategies be improved to reduce inmate relapse and recidivism? What case management practices will ensure the continuity of care for released inmates with serious medical and mental health conditions? A greater investment by academic medicine in evaluating questions such as these would advance public health by guiding policy development, programming, and resource allocation both inside and outside US jails and prisons. Furthermore, real time collaboration would be helpful in better understanding evolving public health issues of mutual concern, such as current methicillin-resistant Staphylococcus aureus outbreaks that are affecting university hospitals, communities, and correctional systems.^{22 - 24}

During the past several decades, the field of correctional medicine has made enormous strides despite marked budgetary constraints in many jurisdictions and the universal challenge of managing ever-sicker inmate populations. Improvements in direct patient care have been supported and validated by accrediting organizations, such as the National Commission on Correctional Health Care, the American Correctional Association, and the Joint Commission on Accreditation of Healthcare Organizations.

The future of correctional medicine seems promising from several perspectives. Correctional systems have proven that advanced medical treatments can be effectively delivered to patients, as demonstrated by the decline in AIDS deaths among inmates soon after the availability of highly active antiretroviral therapy.⁵ Collaborations between correctional systems and public health agencies, although relatively uncommon, are now well documented and are largely successful.²⁵ University-based, corrections-related health degree programs, such as forensic nursing, are beginning to prepare students for potential careers in correctional health care. The next hurdle for correctional medicine is achieving greater integration with the broader medical community. Whether this occurs will depend in no small part on the willingness of correctional systems and academic institutions to develop joint strategies, disavow prejudices, and explore new relationships, such as that described by Raimer and Stobo.¹ Such collaborations are of national importance because they will serve a pivotal role in promoting public health and protecting public safety.