Author: Ofogh, Kaveh
Date published: September 1, 2010
Journal code: AMJA
In 2004, when now-retired Superintendent Lee Noble was tasked with opening the new Southwest Virginia Regional Jail in rural Virginia, he and his transition team needed a way to manage the primary health care, dental care, and mental health services for approximately 1,300 inmates for a jail system entailing four separate facilities-all located more than an hour's drive from one another and holding inmates from 10 different localities.
The challenge of launching such a complex system would require a seamless orchestration of personnel, equipment, scheduling, and expertise. With 30 years of experience working in correctional facilities and 10 of those years working in the private correctional facilities management industry, Noble was the right man for the job. Yet, despite his extensive experience and comfort with health care models, Noble and the transition team wanted to do things differently, more effectively, and less expensively than the existing models allowed.
First and foremost, Noble and then Assistant Superintendent Stephen Clear (now the current superintendent) recognized they required a highly sophisticated and streamlined system to provide adequate care to the inmates while still minimizing the cost to taxpayers, who were not pleased with the idea of spending taxpayer money on health care services for incarcerated individuals. (At the State level, the Virginia Department of Corrections budget is about $1.4 billion - or roughly 7 percent of the budget for the entire Commonwealth. About 10 percent of this amount goes toward inmate health care costs, which amounts to $25 per inmate per day in State facilities.)
Because the Southwest Virginia Regional Jail Authority was building all new correctional facilities, the transition team had the opportunity to custom-build the medical system from the ground-up, a challenge they embraced.
Medical Department from Scratch
In order to establish fully functional correctional facilities, Noble and Clear had to design a health care system that would be capable of adequately responding to a wide variety of medical conditions.
"Jails receive offenders directly from the street and sometimes must provide lifesaving care when people arrive with alcohol or illicit drug overdoses," Noble says. "At the very least, an assessment of physical and mental health is completed at booking. But arrestees also arrive in booking with immediate medical needs as well as conditions that may have been neglected before they were brought to the jails."
Pre-existing medical conditions that correctional facilities must treat include such chronic conditions as diabetes, heart issues, asthma, emphysema, etc, In addition to basic medical, dental, and mental health services, jail facilities must also be capable of providing pharmacy services for inmates. "Those pharmacy services are an integral part of the medical challenges," Noble says.
Opportunity for a New System
Noble and Clear had three options for managing the medical departments:
* As superintendent and assistant superintendent, they and their team could manage the medical departments alone.
* They could privatize the medical department.
* They could state their ideal scenario in a request for proposal and see who, if anyone, would respond with a reasonable solution.
For about 80 percent of correctional facilities across the Nation, managing the medical department internally has been the preferred approach. This method helps administrative staff stay up-to-date on the daily medical conditions of the inmates, ensures the administrative team retains control of all sectors of the correctional facility, and helps facilities keep track of their real medical costs. However, many correctional facilities struggle to hire the right medical staff and effectively train them for work within the facilities. Moreover, many administrators do not have the background or expertise required to stock a medical department with the right amount of supplies. As a result, they end up spending more money and working harder than needed in order to manage their medical departments.
Although they had experience managing health care for correctional facilities, Noble and the transition team recognized they needed to partner with an outside resource in order for the facilities to be effective at limiting health care costs to taxpayers while providing standard community care for inmates. However, because of the silo effect created by the privatization solution, this is often regarded as an unpopular solution among correctional facilities that need to closely manage their spending, maintain control of all aspects of their facilities, and provide the best possible health care for their inmates. (Editor's note: The phrase "silo effect" is currently popular in business and organizational communities to describe a lack of communication and common goals between departments in an organization.)
"Some correctional facilities, although very few, contract with a private company to provide all medical services, including staff and equipment," Noble says. "This solution often creates a division between agency staff and medical company staff that must be managed through negotiation and often legal means. We wanted to avoid that."
As a result of the negative aspects of privatization, the process to adopt has been slow. Despite the fact that private companies have provided medical services since the 1970s, only about 20 percent of the correctional facilities in the United States partner with companies that manage privatized medical departments.
Although they wanted to partner with an outside resource, Noble and Clear were determined to find their own health care solution - one that would allow them to stay in control of the operations within their correctional facilities without being solely responsible for the management and implementation of all aspects of the medical department.
"In the fall of 2004, we issued a request for proposal for medical services with requirements that were somewhat unusual in that the successful responding physician or company was charged with providing medical, dental, and psychiatric services for one price," Noble says. "Our approach was not privatization, but emphasized provider services under contract while the jaŘ authority maintained control over nurse staffing and off-site services." According to Noble, this was the first request for proposal of its type for a Virginia facility and was ground-breaking in scope.
A Different Health Care Option
Noble, Clear, and their team received several proposals for medical department solutions, but only one included the integrated services that the team required. That proposal came from a former Virginia emergency room physician who had been working in the medical departments of correctional facilities for a decade. The doctor was in the midst of launching a company designed to service the exact needs that Noble and Clear had identified.
"[He] was the only respondent to our proposal request who was able and willing to provide the integrated medical, psychiatric, and dental services at all our jail sites required by our request," Noble says.
Included in the proposal was a customized solution for the agency that involved providing the jail with one physician who would rotate throughout the its four facilities, negotiate lower pharmaceutical costs on behalf of the jail, develop custom medical department procedures for the facilities, assist with the hiring of the nursing staff, and advise Noble on the type and quantity of tools required for each medical department.
Noble says the proposal provided opportunities for a partnership relationship rather than the traditional service contract in which a jail simply engages a physician, a psychiatrist, and a dentist separately, and then asks a nurse or even a non-medical staff person to manage medical services. In addition, the proposal included the implementation of psychiatric consultations via the use of live video conferencing.
The Southwest Virginia Regional Jail Authority issued the doctor and his team an initial contract, Noble says. This marked the beginning of a cohesive partnership between the correctional facility and medical services company that has saved the jail authority a significant amount of money and time.
"Jails are like fingerprints," says a company representative. "Even if two jails have 500 inmates each, they are not the same. The principles are the same, but they are very different; the managers and nurses are different. The demographics of the area are different. Two facilities cannot afford to have identical policies and guidelines, so you can't just copy guidelines from one facility and use them in another. You have to customize guidelines for each facility."
Compared to the previous other county and city jail systems, the jail has reduced its pharmacy costs by more than 50 percent, emergency room trip costs by 80 percent, and negotiated lower lab service rates that have reduced the costs of lab services by approximately 70 percent, compared to the costs other jail facilities pay.
Noble, Clear, and their jail managers further reduced health care expenses in their correctional facilities through the implementation of telemedicine, an option that enables inmates to meet with top psychiatrists throughout the country via video conferencing technologies.
The medical services company estimates that 10 to 15 percent of inmates suffer from a mental illness requiring psychiatric involvement in their care. Traditionally, inmates who need special health care needs, such as psychiatric care, were transported to outside specialists. This method of providing suitable health care not only increases security and liability risks, it also increases medical costs to correctional facilities.
Alternatively, psychiatrists can travel to correctional facilities to provide care in-house, yet this method decreases the efficiency of the psychiatrist. If, and when the option is available, many psychiatrists are reluctant to settle in rural communities where jails are often located, requiring them to travel significant distances to provide those facilities with services.
One viable solution to both problems is to provide jails with in-house psychiatrists via live teleconferencing systems. With telemedicine, a psychiatrist can meet with 20 to 25 inmates per day without having to spend hours driving from jail to jail or relocating to a rural community simply to work with inmates in a jail. This is because the initial mental health screening has been done by a qualified mental health professional who is onsite. The system makes it easier for correctional facilities to service the needs of their inmates while, simultaneously, saving the facilities money. Telemedicine reduces liabilities for the jail by providing adequate and timely mental health services.
"Psychiatrists are our safety net for people who are profoundly mentally ill," says Lance Forsythe, superintendent of Virginia's Southside Regional Jail, one agency that uses telemedicine. "Through teleconferencing equipment, we have access to a high-quality psychiatrist whom there's no way we would attract to a small rural town. Good psychiatrists leave rural communities quickly because they have so many opportunities to work elsewhere. And if a psychiatrist does drive in from out of town, you have to ask, 'Why isn't this person sitting in an office making $200 an hour?' Their capabilities are also compromised when they've spent one to two hours driving to get here and are tired. Telemedirine is the best you can do as a rural jail. I would never be able to afford someone who has the background and framing of the psychiatrist we are able to use with the telemedicine system."
In addition to ensuring inmates have access to experienced psychiatrists, telemedicine also helps correctional facilities increase the. volume of inmates who can have timely appointments with the qualified mental health professional. "As the number of inmates who require psychiatric care increased, the problem of not having enough psychiatric support became more acute," says Bruce Conover, superintendent of Virginia's Northwestern Regional Adult Detention Center, a system that began using telemedicine three years ago. "Telemedicine resolved that problem."
Forsythe and Noble's jails are among the handful of Virginia-based facilities that pay a fixed amount for the teiemedicine services, regardless of how many inmates require attention. "If, in a given week we have 15 inmates with severe problems, the psychiatrist will see them all, and we don't pay more," Forsythe says. "For a small jail, the real advantage is to put a cap on the services, rather than paying individually."
Telemedicine also eliminates the expense of inmate transportation, which not only requires the use of a facility vehicle, but also requires that two security officers escort an inmate to a specialist, increasing liability and security risks. "No longer do we have to transport inmates for psychiatric care, requiring officers as escorts," Conover says. "Telemedicine saves time and is far more cost effective than what we had been doing."
"Telemedicine is the future," Noble says. "Jails not using it for at least psychiatric services are wasting money and increasing the risks inherent in moving people to off-site locations."
KAVEH OFOGH, M. D.
For almost 15 years, Dr. Kaveh Ofogh has provided medical and mental health services for correctional institutions within the Commonwealth of Virginia with the goal of delivering the community standard of care to incarcerated individuals. Dr. Ofogh has been a guest speaker at State and national forums, including the National Commission of Correctional Health Care and the American Jail Association. To contact him, call 804-433-1040, or e-mail firstname.lastname@example.org.
To contact Lee Noble, former superintendent of the Southwest Virginia Regional Jail Authority, e-mail lnoble728@ gmail.com; Stephen Clear, Superintendent, Southwest Virginia Regional Jail Authority, call 276-739-3520; Bruce Conover, Superintendent, Northwestern Regional Adult Detention Center, call 540-665-6374; and Lance Forsythe, Superintendent, South Side Regional Jail, call 434-634-2254.