Solutions: Increase the Efficiency of the Texas Department of Criminal Justice
(1) Improve medical access and treatment within prison walls, especially with regards to infectious diseases. Prisoners, on average, require more health care than most Americans because of poverty, substance abuse, and lack of access to medical services in the free world. Texas, however, only spends $7.42 on health care per inmate per day, a number significantly lower than rates in California and New York.[i] In addition, Texas prison health care is already borderline unconstitutional, according to officials at University of Texas Medical Branch at Galveston (UTMB), which, along with Texas Tech, manages Texas’ prison health care facilities.[ii]
Medical access and treatment is imperative in prisons, particularly with regards to infectious diseases. The spread of (HIV) is especially common in prisons and jails. In 2006, the United States Centers for Disease Control and Prevention (CDC) found that the estimated prevalence of HIV infection is nearly five times higher for incarcerated populations than for the general U.S. population.[iii] Likewise, people in prison are more likely to die of AIDS than other Americans – their rate is 1.5 times that of the general population between the ages of 15-54.[iv] Texas, meanwhile, has the third largest HIV positive population among state prison systems in the nation.[v]
According to the CDC, Hepatitis C is also rampant in U.S. prisons, affecting more than 40% of the national prison population – making it the most prevalent infectious disease. A study conducted by the University of Texas Health Science Center found infectious diseases such as Hepatitis C to be the most prevalent disease category of Texas prisoners, at 29.6%.[vi] This number is substantially higher than those reported for the general population.
Without preventive measures, inmates will continue to contract HIV and other infectious diseases. Additionally, vulnerable populations (such as those with Hepatitis C and HIV) must be given consistent and diligent care, including regular doctor visits and the ability for inmates to administer their own medications, thereby eliminating the need to stand in dangerously long pill window lines. (These window lines have been linked with the development of drug-resistant strains of HIV and Hepatitis C, because those waiting for medication are not always able to receive it before the window closes, causing an inconsistent administration of necessary medications.[vii]) It is imperative that qualified staff at individual units have the ability to implement care when necessary and honor UTMB or Tech caregivers’ orders once the inmate has returned to the unit following diagnosis or treatment recommendations.
Failure to provide necessary care will continue to leave the state open to costly liability and ongoing exposure to lawsuits concerning inadequate health services. Furthermore, if Texas’ prison health care services are declared unconstitutional in federal court, the state could face the pricey and embarrassing prospect of relinquishing control of prison health care to a federal court receiver. This happened in California in 2005, causing health care costs to explode, including mandated new payments of $10 million per year for the salaries of the consulting team.[viii]
But there are public health implications for those leaving the system as well. During FY 2007, approximately 1,400 HIV-positive individuals were released from TDCJ.[ix] In addition, an estimated 4,500 individuals with Hepatitis C were released in 2007.[x] A small number of individuals with other diseases were also released: for example, 16 individuals were released while receiving treatment for tuberculosis.[xi]
The State must ensure that prevention measures are fully enforced so that other inmates – as well as spouses/partners, friends, and children of inmates – will not contract communicable diseases. A key part of the re-integration process is having and maintaining a healthy family unit. The devastation of contracting an infectious disease like HIV completely disrupts any efforts to re-enter society and become self-reliant. Pre-release planning to manage HIV and AIDS would ensure that networks are in place prior to these individuals rejoining our communities.
(2) Strengthen the efficiency of TDCJ’s Offender Grievance Program. TDCJ must ensure that this Program is effectively addressing inmates’ concerns with regard to medical care, without reprisal for filing a grievance.
(a) Improve access to forms. While grievance forms are available in the law library, some individuals may not have access or reason to use that library, therefore making the grievance forms unavailable. TDCJ should ensure that grievance forms are accessible by all, as well as provide clear instructions on completing them. To better guarantee access to the information, these materials should be provided in common areas, such as the recreation room and cafeteria.
(b) Increase the grievance filing period. TDCJ’s current grievance process allows inmates only 15 days from the date of the incident to grieve. This amount of time is usually insufficient for those inmates who are ill, injured, or otherwise unable to properly grieve their complaint. By allowing for a longer time period in which to grieve and by making the grievance officers more accountable for the integrity of the grievance process, the State can increase the efficiency of the Offender Grievance Program as well as increase the safety of both inmates and prison staff.
(c) Clarify grievance decisions. After inmates file an initial grievance (Step 1), the grievance officers respond with either a denial of the inmate’s request or agree to further investigate the inmate’s claim. Step 1 responses from grievance officers should be specific as to why an inmate’s request was denied. (In other words, a one-line response denying action should be discouraged.) By providing specific reasons and details as to how a decision was reached, the grievance program will be more efficient and lessen the likelihood of the inmate filing an appeal with the central grievance office (Step 2), which would decrease that office’s workload.
(d) Create independence on grievance boards. Grievance boards are comprised of TDCJ correctional officers who have been promoted to the grievance officer position, creating a clear and inherent conflict of interest when inmates file complaints about mistreatment by guards (likely the former colleagues of grievance panel members) or the lack of available services by TDCJ. The Governor should appoint a board at least partially composed of independent members who are not and never were employed by TDCJ. This group should review inmates’ more serious grievances; also, their credentials, expertise, and decision patterns should be made public to constituents. Having at least one independent board member would allow for more objectivity throughout the grievance decision-making process, as well as allow for a practical evaluation of the weaknesses in the Offender Grievance Program.
(e) Protect truthful guards. Due to the nature of a correctional officer’s work, it is often difficult to provide truthful testimony regarding events that involve an officer and an inmate. TDCJ should offer “whistle blower” protection for corrections staff persons that wish to come forward with information about events described in an inmate’s Step 1 grievance form.
(3) Increase correctional officers’ salaries to decrease turnover. Currently, Texas faces an enormous shortage of correctional officers, due in part to the lack of competitive salaries. In efforts to address this chronic personnel shortage, TDCJ must be given the resources necessary to provide much needed raises for these officers, which will allow for the recruitment and retention of highly qualified individuals.
As an additional employment incentive, as well as to improve employee morale and retention, the state should create a pilot program for loan repayment assistance for individuals attending Sam Houston State University (SHSU) who agree to serve as correctional officers for a certain amount of time. Prior to qualifying for loan reimbursement, students should hold a bachelor’s degree from SHSU, have maintained good academic standing while there, and complete at least one year of employment as a full-time correctional officer in Texas within two years of graduation.
Note: With more guards and less turnover, prison conditions should improve: acts of violence will decrease, gang formation will be discouraged, and incoming contraband will be reduced. Staff will have a safer workplace.
(4) Improve communication strategies between criminal justice and treatment agencies to meet the State’s public safety needs. Texas should fund and expand the ability of TDCJ institutional administrators, their medical care contractors (UTMB and Texas Tech), probation, parole, health and human service departments, and the community-based service providers who contract with them to effectively communicate and coordinate their resources. Currently, many criminal justice agencies do not communicate with each other, due in part to the absence of uniform datasets across agencies. For instance, probationers and parolees tend to be concentrated in “high stake” communities, yet probation and parole do not share data or coordinate strategies and services.[xii]
Tracking data and sharing information about individuals who receive or have received social services, mental health services, substance abuse services, or health services from a particular agency will help practitioners implement evidence-based practices: it will allow them to match risk level and criminogenic needs to responsive interventions, which has been proven to increase the success of clients.
Management of information could best be accomplished by an Interagency Coordinating Council for Data Sharing (Council), which could facilitate the interagency coordination of information systems, including the creation of standards for sharing information electronically under appropriate controls to ensure that confidential information remains confidential. Agencies could report to the Council regarding their implementation of various policies and procedures, and every two years the Council could evaluate the efficiency and effectiveness of the information sharing system.
Ultimately, agencies must be given incentives and provided with resources to share information, making their supervision strategies more effective and better assisting judges and treatment providers. Creating gateways of communication between departments will allow supervisors to provide a holistic service to increase the success rate of those under supervision.
In addition, agencies must be encouraged to share best practices. The Community Justice Assistance Division at TDCJ should compile an annual report to be distributed to practitioners that assesses the successes and failures of all programs using evidence-based outcome measures. Post-completion program evaluations should include an examination of rates of recovery, employment, and educational attainment.
(5) Adopt a Public Health Model of Correctional Care to ensure inmates, correctional staff, and the public lead healthy and productive lives. The Public Health Model of Correctional Care focuses on connecting local care providers, including public hospitals, local clinics, teaching institutions, and doctors in private practice, with correctional institutions. This model is especially effective because inmates receive a medical treatment plan upon intake and are held to that plan throughout their contact with the criminal justice system. After release, their plan of care continues; recently released prisoners remain with the same provider that treated them during their incarceration. This continuum of care is essential during the re-entry process.
The Hampden County Correctional Center in Massachusetts currently uses a public health model and has become a national example of effective correctional medical care. Their model emphasizes five elements as the basis for all their services and programs: (a) early assessment and detection, (b) prompt and effective treatment at a community standard of care, (c) comprehensive health education, (d) prevention measures, and (e) continuity of care in the community upon release.[xiii] The model also lists key elements for successful implementation of their model, which includes support from high-level correctional administrators and a commitment to collaborate openly with state agencies and non-profit health organizations.
The benefits of adopting a public health model for prison health care are numerous and can include improved inmate and community health, improved public safety and correctional staff safety, improved use of the health care system, cost savings for communities, and high quality health care at a cost no greater than the national average. In fact, the Hampden County Correctional Center reported spending $.66 less for medical care per inmate per day than the largest jails nationally.[xiv]
Implementing a public health model for correctional care could also decrease recidivism by allowing a continuum of care after inmates are released into the community, thus increasing ability to manage their own medical care and lives. Another major benefit of the model is the dramatic decrease in the use of the emergency room as a primary care giver for released individuals. This would save communities thousands of dollars per year in rising hospital care costs.
Note: The Hampden County Correctional Center has a step-by-step manual explaining implementation that could be easily tailored to meet local needs.
[i] Matt Clarke, “Texas Prison Health Care: On the Brink of Unconstitutionality, Again,” Prison Legal News, May 2008.
[ii] Ibid.
[iii] United States Center for Disease Control and Prevention, “HIV Transmission Among Male Inmates in a State Prison System – Georgia, 1992-2005,” Morbidity and Mortality Weekly Report, April 21, 2006.
[iv] Natasha H. Williams, Ph.D., Prison Health and the Health of the Public: Ties That Bind, (2006), http://www.communityvoices.org/Uploads/TiesThatBind_00108_00150.pdf.
[v] ACT UP Austin, Prevention of HIV Infection in Texas Prisons Fact Sheet, http://www.actupaustin.org/index_files/Facts.htm.
[vi] Jacques Baillargeon, Ph.D. and others, Disease Profile of Texas Prison Inmates, (April 2002), http://www.ncjrs.gov/pdffiles1/nij/grants/194052.pdf.
[vii] Bill Bishop and Mike Ward, “Pill Window: In wait for daily doses, inmates and frustrations pile up,” Austin – American Statesman, December 17, 2001.
[viii] Don Thompson, “Cost of federal oversight of state prisons draws fire,” Associated Press, January 19, 2007.
[ix] Jeff Baldwin, e-mail message to Ana Yáñez-Correa, May 13, 2008.
[x] Ibid.
[xi] Ibid.
[xii]Presentation by Tony Fabelo, Ph.D., Justice Reinvestment: A Framework to Improve Effectiveness of Justice Policies in Texas, Austin, TX, 39, 2007.
[xiii] Hampden County Sherrif’s Department, A Public Health Model for Correctional Health Care, (October 2002), http://www.mphaweb.org/documents/PHModelforCorrectionalHealth.pdf.
[xiv] Ibid.