Fishkill Prison  - (Diet Issues are discussed at the end of this entry) 
The day started with a quick visit to George Washington's main Headquarters, Newburg, during the American Civil war which was on the way from my accommodation to Fishkill Prison.

Firstly a very big thanks to Superintendent William Connolly, Dr Carl Dr Carl Koensberg, Dr Joseph Avantzo, Paula Butler(Deputy Superintendent  & Lynn Cortella (RN1) for their time and support over the day.  A presentation of the facility was provided by all – followed by questions and answer and then a tour.

Fishkill Correctional Facility is a medium security prison in New York, USA and was constructed in 1896. It began as the Matteawan State Hospital for the Criminally Insane. For 80 years, Matteawan State Hospital was one of the nation's most famous institutions for the "furiously mad." It began to phase out in the 1960's when the courts restricted the state's power to imprison the mentally ill.  The whole Fishkill facility is now spread over 738 acres, 148 buildings most of which are over 100 years old). There is 7 miles of perimeter fencing!. Fishkill also now houses the Regional Medical Unit (RMU) for Southern New York's prisons. There are about 1700 prisoners in the facility housed in two general population housing complexes. The main building has 26 dormitory style medium security housing units. (this area was not toured) 
This study’s main interest is the newly built (2006) Regional Medical Unit, a free standing building devoted entirely to providing comprehensive medical care. There are five such RMU’s in New York State which as a State has a prison population of 50,000; compared to Victoria with approximately 4,700 and Australia as a whole approximately 29,000. (New York State total population is approximated at 19.7 million compared to Victoria general population of 5.6 Million and Australia general population is estimated to be now 22.7 Million)  In short the incarceration rate per head of population appears to be about  twice that of Australia.
The RMU is impressive. It opened  in 2006 to provide a calm, comforting and safe environment for inmates. It specialize in the treatment of inmates with dementia-related conditions such as Alzheimer’s disease. The average age of inmates housed in the unit is 62 — 25 years older than the average age system wide. 

There is a Pre Entry Cognitive Assessment tool and Dr Joseph Avanzato said he would email / post the assessment tool as well as the power point presentation. Apparently not all the tool is now used as it was found to be too time consuming and complex. Some referrals are now taken from other prisons based on information shared during the referral process and the unit at times is being used as an assessment centre. 

The RMU has 80 beds in total, spread over 4 levels. The secure facility is more Spartan and clinical than draconian and correctional in character, with the “white-walled” feel of a hospital rather than the steel and concrete finish of a prison. There are wide corridors and wide doorways.  All doors are heavy and secure in nature (a challenge for an aged prisoner to open, yet providing security for the vulnerable). The whole facility is well ventilated and some of the single rooms have pressure controlled ante chambers for infection control purposes. The design is essentially hospital / clinical like in nature. All floors are level and there are no bunks or obvious trip hazards. There is no easy access to the outside / sun on the face for prisoners. Whilst it was possible to access the outside – it was not easy for an polder prisoner who needed assistance with ambulation.

There was evidence of high low beds with cot sides but no aged care type high low beds (bed goes all the way to the floor); on discussion about this issue staff indicated they could and would access such a bed if required. 

There was obvious access to equipment and medical treatment for prisoners, walkers, wheelchairs and a full complement of medical treatments on offer within the RMU (It is really like a hospital with an aged care facility attached to it. I was informed that both State and Federal laws mandate health support for prisoners. It appears that the prisoners receive a high level of health support.

In the USA, The legal reasons for providing health care to prisoners were stipulated in the 1976 Supreme Court Estelle v. Gamble decision, in which the Court held that deprivation of health care constituted cruel and unusual punishment [1], a violation of the Eighth Amendment to the Constitution. This interpretation created a de facto right to health care for all persons in custody, whether convicted (prisoners) or not (pretrial detainees). The decision also brought forth the concept of "deliberate indifference," a legal definition that prohibits ignoring the plight of prisoners who need care and translates into a mandate to provide all persons in custody with access to medical care and a professional medical opinion. Correctional authorities and health care professionals who infringe this right do so at their peril and may be prosecuted in federal or state courts (Rold WJ. Legal considerations in the delivery of health care services in prisons and jails. In: Puisis M. Clinical Practice in Correctional Medicine. 2nd ed. Philadelphia, PA: Mosby-Elsevier; 2006:520-528.)

Corrections Health support is fully funded by the Department of Corrections state of NY. As mentioned the RMU complex runs like a regional hospital (Australia) or medical unit (US). It incorporates 60  “inpatient style beds:” 30 for Cognitively Impaired (CIU) , 30 Long Term Care (LTX) (aged Care) & 20 infirmary beds (sub acute care). It is staffed by medical staff, Psychiatrist, Psychologist, Registered Nurses (Div 1 & 2 Oz translation) and carers. There is also a social worker a recreational therapist (positioned not currently filled) and pastoral care linked to the unit. It is interesting to note that a Correctional Medical Position is seen as a good option as it was suggested the work provided a better work life balance than private practice in the USA.

There is an obvious correctional officer overlay with the care that is provided; there appear to be less numbers of correctional staff in the LTC and the CIU than the infirmary. (This seemed appropriate) Staff are obviously dedicated to improving care and situation for older and ill prisoners with examples of humanity shared during discussion. Some prisoners are trained in hospice care support but prisoners are not involved in direct care. Of interest was our discussion around a prisoner care model. A key issue of concern for the group interviewed was the issue of risk associated with “carer error” and the potential litigation that could ensue  – hence the need for professional staff. (An example of litigation by a prisoner was sited where the prisoner claimed ill effects from passive smoke from a staff member smoking!)
Onsite specialities supplied by the RMU include: radiology, pharmacist x 4  proving 6000 prescriptions a month , 5 dental care staff , emergency care, primary care, dialysis =6 chairs, dietetics and other speciality care like phototherapy & telemedicine – it appears that all but surgery was performed in the DMU.

 The UCI occupies the entire third floor of the prison’s four-story medical centre. The unit is akin to a maximum-security environment inside a medium-security prison, allowing it to accept inmates of any security classification from any facility throughout the state system.
Among the programs operated at Fishkill is the Correctional Industries (Corcraft) program. Inmates manufacture beds, chairs and computer furniture for sale to state and local governments. They also fabricate to order heavy gauge steel speciality items, such as security doors and windows, for correctional and psychiatric institutions. There is a recreation staff member for DMU but the position is not currently employed and there was no real evidence of an obvious recreation program at time of visit. They do have puppies behind bars (Google this for the video – it is quite inspirational) which is well received by prisoners and staff alike.  
They have a transition program and a person (Lynn Cortella – Registered Nurse) managing the program; Lyn indicated that there were about 14 – 17 prisoners that could be released but as they had no facility who would accept them – they remained in prison. They were trying to build a formal relationship with an service provider. Discharge /release , overall, was not a problem for bed or wheelchair bound inmates it was the older more active clients (who needed some care support) that presented placement problems. There is a well documented accreditation process for the correctional facility as a whole.
A key issue during the day tour was the discussion round risk:

• The risk prisoner presents of  another offence or violence
• The  risk perception of the corrections system which is understandably risk adverse (there is no tolerance for error from the public / media) 
• The risk perception by public  particularly if the crime committed (no matter how long ago) is of significant public  interest) (and hence the real possibility that some prisoners are in a category that will never be released; thus requiring a commitment from the correctional system to provide for aged care needs within the correctional system itself.

These risk perceptions are typical of the same discussions within the Victorian context 
It was a privilege to tour the Fishkill facility and again I thank the staff for their support.
No photo’s were able to be taken though I may access some from the power point if provided. Photo’s provided have been sourced from Google Images and are consistent with what was observed today at tour.

 Diet – breakfast was not as challenging as I imagined. Yes there was an abundance of pastries, cake (muffin), and waffles to choose from but i was able to settle for a bowl of cereal, yogurt and a slice of toast with coffee (it was black). This would have sustained all day until dinner (I think) but.... I was obliged to have one pastry (with an apricot topping and a custard topping) - (as a courtesy of course); many were on offer. Pastries appear to be the thing in the US. For dinner I went to the local diner and had a broiled (grilled) steak.... – I then realise the order comes with a large salad entrée (with oil and vinegar -  as opposed to the cheese dressing or thousand island), accompanying teh steak (plate size) are chips and cord and carrot. 60 minutes on the exercise bike may help reduce some of the damage!

Tomorrow it is off to Washington DC on my way to Deerfield Prison, Virginia - about an 8 hour drive in all.