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Testimony of Lisa Harrell-DeLamater, Ph.D.

Clinical Director, Center for Community Alternatives (CCA)
Before the New York State Assembly Committee on Health,
Committee on Correction Health Care in New York State Prisons

November 14, 2003

Thank you for the opportunity to address the New York State Assembly Committees on Health and Correction on behalf of the Center for Community Alternatives (CCA). I am speaking today in support of efforts to improve the delivery of health care services for people incarcerated in New York State correctional facilities. The Osborne Association also joins CCA in these comments and recommendations.

CCA has been funded by the New York State Department of Health AIDS Institute (AI) to deliver a range of HIV-related services to prisoners. As a criminal justice agency whose purpose is to reduce reliance on incarceration through alternatives to incarceration and reentry programs, CCA developed HIV-specific services in response to the growing need for these services among the clients we serve.

The Osborne Association introduced HIV-related services to prisoners through the AIDS in Prison Project, the first such telephone hotline in the country. CCA was the first community-based agency to deliver HIV services directly in State prisons, beginning in 1994 about three years prior to the start of the AI's Criminal Justice Initiative. This original effort had CCA responding to request for services in prisons throughout the State, with a focus on discharge planning.

In 1997, the AI wisely expanded and systemized services to many prisons throughout the State through the Criminal Justice Initiative (CJI) that organizes eight community-based providers, including CCA and the Osborne Association to serve prisons in nine hubs throughout the State. CJI is funded by an interagency transfer of funds from the Department of Correctional Services (DOCS) to the Department of Health. Because CCA has offices in both upstate and downstate New York , we are one of the major community-based providers of HIV services in the State, working in 15 prisons in three out of nine hubs.

There are many others testifying here today who will speak to the need for improvements in prison health care. Our purpose is to augment that testimony by suggesting that the criminal justice initiative offers a model that might be expanded to a broad range of health conditions in an effort to improve care for prisoners and those released from prison. While there remain many challenges in the work that is undertaken through this initiative, I will highlight what seems to be working and offer suggestions about how to strengthen and expand this work.

1. The Criminal Justice Initiative demonstrates the capacity for interagency cooperation between the Department of Correctional Services and the Department of Health. Through this executive level cooperation, that includes the redeployment of funds, community-based providers have been granted access to prisoners for the purpose of delivering HIV-related services. While certainly these relationships have taken time to develop, and while they remain uneven due to insufficient resources, or, in some cases, different perspectives of individual Superintendents, nonetheless, in many prisons in our State, community-based agencies have the ability to provide a range of services. CCA and Osborne for example provide support services, Anonymous HIV counseling and testing, education and discharge planning.

2. The Criminal Justice Initiative demonstrates the need for and value in having health care services overseen by an agency with expertise in health care and by providers that prisoners will be comfortable with and trust, and who are able to forge the "inside outside" connections so critical to larger public health interests and successful prisoner reentry. With all due respect to the Department of Correctional Services, its primary function is custodial in nature and security-focused. The CJI initiative shows the benefit of utilizing the talents and skills of organizations whose missions are focused on creating a continuum of services that may begin during incarceration, but continues after release. We have been told by the prisoners who we serve, that health care provided with some independence from DOCS engenders greater confidence about medical confidentiality. We all know that trust of one's health care provider is considered vital whether one is outside in the community or inside prison walls. Absent trust, an individual is unlikely to disclose ailments or symptoms, and follow medical advice.

3. The Criminal Justice Initiative demonstrates an effective form of "technology transfer" and quality assurance. The Department of Health is the State agency charged with protecting and promoting the health of New Yorkers through prevention, science, and quality assurance. As such, the Department has the expertise to hold those who deliver health care services accountable for the quality of those services, to ensure that providers are using appropriate technology and methods and providing up-to-date information. For example, community-based agencies funded by the AIDS Institute are required to follow approved protocols, can access affordable training that keeps us abreast of the latest information about HIV, AIDS and effective interventions and new medications and treatment regiments.

4. The Criminal Justice Initiative reflects the recognition that health conditions in prisons are a public health concern. With most prisoners returning home to communities, it is vital that health care and health education be attended to while people are incarcerated, and is a focus of prisoner reentry. Thousands of prisoners return to their communities each day. Many struggle with multiple disorders including emotional and cognitive impairments, substance abuse and dependency, under- and untreated medical conditions and mental health problems, that place them, their families and the larger community at continued health risks. It is wise from an individual and public health perspective to make use of the time of incarceration to address the multiple health concerns of prisoners that contribute to their risk for re-incarceration and negatively impact the health and well-being of the community.

Because of the considerable success of the Criminal Justice Initiative, we recommend that this approach be extended and expanded to all health care matters. It is imperative that the State improve diagnosis and care of prisoners with Hepatitis C, substance abuse, mental illness, and HIV/AIDS. In addition, we offer suggestions based upon our experience regarding additional policy changes that should be enacted in order to improve the health of prisoners and better safeguard the communities to which they return.

1. Management and Treatment: The Centers for Disease Control (CDC) identify correctional health as an entry point for positively improving the health and safety of the community as a whole. The management and treatment of serious and chronic medical and behavioral disorders needs to be improved. Individuals with a history of criminal justice system involvement have high rates of health, substance abuse and mental health problems. Many have multiple diagnoses, e.g., HIV+ substance abuser with mental illness. These medical and behavioral problems play a role in precipitating and maintaining their criminal justice system involvement. These same behaviors may also impair the individual's ability to manage their health problems, through poor treatment adherence, or may increase public health risks associated with risky sexual behaviors or substance use.

Although correctional health services may provide quality health care at times, this is inconsistent and a function of policies reflecting the perspective of individual facilities' medical services and the facility Superintendent. Thus, problems have been encountered in ensuring that ill inmates receive liquid nutritional supplements to improve diet and that food is available at non-meal times so that medications can be tolerated. Side effects produced by medications are not consistently treated with appropriate palliative care, and medical and behavioral specialists are not provided or not provided in a timely manner to assist inmates with problems that develop secondary to their illness or as a result of their medications. Furthermore, medication changes and potential side effects are not adequately explained and fearful inmates coping with severe medical problems under adverse conditions are made unnecessarily anxious and then uncooperative in their care.

Behavior change with severely troubled individuals and the medical management of seriously and chronically ill individuals requires sophisticated interventions provided by highly trained and experienced treatment specialists working under the supervision and guidance of behavioral and physical health departments. We recommend that medical and behavioral treatment and management of inmates in the care and custody of the State be placed under the supervision of the New York State Department of Health and its co-ordination with the Office of Mental Health and the Office of Alcohol and Substance Abuse Services or some other specially convened independent medical and behavioral health care provider.

2. Re-Entry Services: Changing the serious and chronic medical and behavioral conditions with which inmates struggle requires intensive and long term change strategies which should be implemented from the beginning of incarceration until release. Preparation for reentry should begin early in a prison sentence using the time for education, skill building, behavior assessment and change, and medical treatment and interventions. Providing these resources reduces the risk that prisoners will commit crimes leading to re-incarceration and increases the safety, health and stability of the families and communities to which they return. Inmates have multiple needs which are significantly correlated with their criminal history, and mental health and medical problems. These needs include poor educational levels, lack of employment-related skills, mental illness, substance abuse, medical conditions, housing resources and family problems. When inmates are released without adequately addressing these needs through assessment, training and treatment, recidivism rates are high and the quality of community health and safety is negatively influenced. Furthermore, inmates returning to their communities frequently lack the skills or knowledge to seek services or have difficulty gaining access to the services they need. Thus, long term behavior change programs connected to re-entry services that begin pre release and offer a continuum of community-based services are essential if incarcerated clients are to effectively transition to the programs and services to which they are referred at release. It is also imperative that a system be developed and fully implemented that ensures that prisoners be eligible to access medicaid and other public benefits immediately upon release to ensure continuity of treatment and community stability.

3. Medical Oversight and Treatment Standards: Guidelines regarding the training, certification and services provided by medical and behavioral services experts are established by state agencies and professional organizations with expertise in health, psychology and psychiatry, substance abuse and social service. Their special knowledge also enables these organizations to effectively educate and advocate for the public they serve. Subordinating medical care to entities whose primary mission is maintaining public security creates conditions that undermine the ability of medical and social service staff to develop the policies and procedures, care guidelines and standards, and control and accountability necessary to ensure high quality treatment practices. Thus, medical confidentiality, the quality of record keeping and transfer of medical information, and the oversight of medical procedures and personnel are jeopardized. Qualified medical experts such as the Department of Health and their collaborators should provide the medical oversight and treatment standards, guidelines and procedures for medical services to inmates in state facilities.

4. Resources: The Department of Corrections has attempted to meet the medical and behavioral needs of the inmates in their care and custody without being provided with sufficient resources. Currently salaries for pharmacy and medical staff are below market rates which makes it difficult for them to attract the most qualified pharmacy, medical and behavioral services staff. Additionally, hiring freezes prevent filing vacant positions resulting in serious staffing shortages in medical services. It is strongly recommended that salaries for pharmacy, medical and behavioral services staff be reviewed and increased. In addition, inmate rehabilitation is adversely effected when treatment and intervention is not provided through bilingual, and racially and ethnically diverse staff who understand the cultural and ethnic concerns, traditions and perspectives of people of color.

Thank you for the opportunity to share our thoughts today and for your efforts to improve health care for people in prison.