9th October 2012
Again I was made very welcome to another prison in the USA; the State Correctional Institution at Laurel Highlands; Pennsylvania’s only prison that is specially tasked with handling sick and elderly prison inmates.
The prison is set outside the small town of Somerset (population of approximately 6,300) and is located about 70 miles southeast of Pittsburgh and just a twenty-minute drive from the field where Flight 93 plunged to the ground on 9/11.
Care of older prisoners (and prisoner in need of medical care) is provided around-the-clock at Laurel Highlands. There are approximately 1400 inmates at the correctional centre. Approximately 320 of this number are inmates that would be considered suitable for aged care within the Australian Aged Care system.
Many of the patients / inmate group have conditions such as Alzheimer’s disease, physical disability, cancer and pulmonary disorders. There is also a very busy dialysis with 15 (+2) chairs treating about 74 prisoners with Haemodialysis. (I am curious to what appears to be a high rate of dialysis; it seems proportionally much higher than what I have heard of with the Victorian prison population – A study for another time!) Men fill the chairs in three shifts on Mondays, Wednesdays and Fridays. Two more shifts come Tuesdays and Thursdays.
Laurel Highlands, as a prison opened in 1996 in buildings that once was the Somerset State Hospital; it is now a minimum security facility (Level 2 of 5) The prison has two “skilled care units” housing a total of about 100 inmates, many of whom are transferred from other prisons within the state. The building went though another update / upgrade about 7 years ago (2005)
The average inmate age is 44, the highest in the state system; which you would expect as it is the key referral centre for older prisoners in need of extra support. There is an assessment tool, used for referral. Not every old or sick inmate makes it to Laurel Highlands.
The prison's medical team also provides such advanced services as tuberculosis treatment and ventilator support. Laurel Highlands' annual per-inmate cost is nearly 30 percent higher than the state-wide average; something you would expect as there is a higher cost to care for prisoners who need extra assistance with care.
There are about 320 inmates who live in the prison's medical unit, which offers both “skilled” and personal care. Not all of the 320 are elderly; many are younger with disabilities and or medical needs that require daily medical support. Many need assistance with activities of daily living: they may need to be reminded to take showers, or require help cutting their food or dressing and undressing.
The prison medical staff includes approximately 26 registered nurses, 42 licensed practical nurses and 30 certified nursing assistants. There is one employed Director of Medicine and other contracted physicians. There is an onsite dental service, physiotherapist, social worker, counsellors. There is also a prisoner helper system, similar to what was observed at Deerfield prison where prisoners assist with “non direct/personal care”: cleaning, assistance with ambulating, assistance with different support programs like recreation and hospice support.
A recreation program is well defined and arranged by one dedicated recreational therapist, who engages a team of prisoner volunteers to coordinate recreational programs – “ A League” of a variety of activities that adds some stimulation and interest to prison life.
One of the benefits of retrofitting an old hospital for prison use is that many aged related design issues (flat surfaces, wider corridors, lighter doors, larger bathroom and shower areas have been already addressed. There are no bars on the windows (some medical treatment areas do have bars for security). There are grab rails and all floor areas are level. There were no obvious trip hazards. Showers are equipped with seats. There are even shower tables for inmates who can't sit up. For inmates with mobility problems, staff bring meals, rehabilitation and religious services to the unit. There were obvious wheelchairs and walking frames around the facility. Day and lunch rooms were of a “grand” size and much of the building was light and “airy”. It was not that easy for older prisoners to access the outside; but the outside views and areas were the best I have seen: Large grasses areas with large cyclone fences and razor wire. Laurel Highlands is in an undulating rural area so the autumnal views were quite spectacular and comforting (the interior felt less prison like)
Correction officers are on guard in the units 24 hours a day; like Deerfield, the guards presence was subtle (most of the time) and mostly respectful. It is important to remember it is a prison and there are also younger more agile prisoners in the mix, that no doubt from time to time need reminding of acceptable behaviours. As it is a low security prison and many inmates are frail, dors to inmates' rooms are not locked, but prison staff can activate automatic doors to quickly contain any problems. There is also a nearby restricted housing unit (RHU) where “problem” inmates can continue to receive care.(this is more like a high security unit). There was no segregation of prisoners because of certain offences they had committed – this was questioned, and I was told offences were a private matter. (this will need further analysis and understanding)
Inmates who are terminally ill and still have time left on their sentences have two choices: die in prison or hope they qualify for Pennsylvania’s compassionate release program. Typical of what has been seen so far during this study, there are stringent guidelines for medical release. Corrections officials or a prisoner may petition a temporary suspension of sentence for release to a treatment facility or hospice only if it can be shown that the inmate will receive more appropriate care and they pose no threat to the community, and that they are seriously ill and likely to die within a year. If any of those circumstances change, authorities can petition to have the inmate sent back to prison. In short, a terminally ill inmate with time remaining will almost certainly die in prison. More than 400 men have died at Laurel Highlands since it opened in 1996. As has been discussed in New York and Virginia, requests for medical / compassionate release are rarely granted. Apparently three Laurel Highland’s inmates have applied. One was denied, and the others died before a decision could be made. The prison releases inmates' remains to their families. Unclaimed remains are cremated and buried in marked, numbered graves. Inmates who enter the “skilled-care” unit sign advance directives and terminally ill inmates may have more privacy and longer visits. The prison's hospice program provides specialized nutrition, chaplain visits and other comfort measures. As previously mentioned, inmate volunteers are trained and will sit with those who are dying.
It was refreshing to spend time directly with nursing and other care staff. Discussions really assisted to understand some of the complexities (differences) that need to be considered for establishing an aged care program within a prison system:
- The importance of providing a secure and accountable medication system. All medications were in extra / extra secure areas and many more medications were crushed than you would normally expect in your average aged care facility (this is about ensuring ingestion and preventing “resale” of medication)
- All sharps, instruments, needles, syringes, razors, podiatry equipment etc were accounted for (as you would for medications) by a count system; supported by several routines such as bundling in packs of fives, tens, twenties or fifty; the use of “shadow boards for equipment like scissors, nail trimmers scalpels etc.- to make counts easier.
- The use of canvas pouch bags for carrying items like syringes to prisoners for insulin and or other injectables. Each bag had a “count in” and “count out” procedure
- The use of in house sterilising to more easily account for movement of instruments in and out of the prison system
- Many cupboard and or medical packs (like a resuscitation bag) had plastic lock systems. If the plastic lock had been broken a full count of all equipment in the bag / locker was required.
- Routines for medication seem linked custodial processes like count times and or different movement of prisoners
- There was a far greater accountability for every item of stock; a more thorough stock in a stock out process
Initially the processes seem quite daunting and time consuming but staff assured me that it was just something that you became used to and ensured greater safety and security for all (staff and inmates alike).
There appeared a much greater knowledge of the prison population’s health issues. As an example, the infection surveillance nurse could confidently quote: 280 inmates had Hep C, 8 inmates had Hep B (This seemingly low number was explained: In 1992 there was a “compulsory” Hep B immunisation program in high schools), 29 inmates with HIV; there was an active TB surveillance program (BCG vaccines were not mandated in USA like Australia)
Transition for older prisoners was coordinated by a full time social worker. The complexities experienced were similar to other prisons thus far visited. Prisoners for release were identified about 6 months in advance and supported with applications for any form of assistance they may be entitled to (medicaid, disability pensions etc). Processes for application are at least as bureaucratic as Australian systems so any prisoner who has cognitive impairment needs the assistance (I tried to navigate myself through the on line system one evening and became “dizzy” with the questions forms etc.(no comments please!) Most prisoners who were old and very frail were usually able to be accommodated in nursing homes as there is a State and Federal reimbursement system that made the care of this group viable for aged care providers. More notorious (public interest prisoners) in this frail aged category were more difficult to place but if really required there were State “owned” / run aged care facilities that would usually house this sort of prisoner. (Something that could be further considered by Victoria who has State managed aged care facilities)
The social worker indicated that a more difficult prisoner to find housing on release was the younger more able bodied disabled prisoner (55 – 65). Rooming houses / homeless shelters were often the only option. But this sort of transition was not usually successful as health care needs, and the minimal personal care needs were usually not able to be met, resulting in some sort of failure of accommodation and sometimes the same prisoner would be reunited with the custodial system.
Again there was much interest, curiosity and praise of Wintringham, when it was explained that these were the sort of guys that we often provided care for. Wintringham services are needed in the USA!
I cannot thank the staff of Laurel Highlands enough for their welcome and the open way they shared information. I had my first prison lunch!: Broccoli and Cheese sauce soup and salad (I could have had roast beef and mash, but I said no – remember the diet!)
Following my visit to Laurel Highlands Correctional Facility – I took a detour to Flight 93 National Memorial – another humbling experience...
Tomorrow I drive to Pittsburgh to connect with a flight to St Louis and then a drive to Jefferson City in readiness for my tour of the Aging Offenders Management Team on the 11th of October.