MAKING THINGS BETTER:
Academic Views about Consultative
and Judicial Impact on Correctional
Healthcare
Kenneth Appelbaum, M.D
Jeffrey L. Metzner, M.D.
Robert Trestman, Ph.D., M.D.
DISCLOSURES
 THE AUTHORS HAVE NO CONFLICTS
OF INTEREST TO DISCLOSE
OBJECTIVES:
By the end of the seminar, participants will:
 Become familiar with definitions and
applications of consultations, technical
assistance, settlement agreements and
consent decrees in correctional healthcare
 Understand opportunities to optimize system
benefits from these various interventions
 Discuss and share experiences with these
interventions, particularly as they have
engaged academic opportunities and benefit
1: History
 Right to treatment cases
 Cooper v. Pate (1964),
 Ruiz v. Estelle (1980)
 Bowring v. Godwin (1977)
 Bell v. Wolfish (1979)
 Estelle v. Gamble (1976)
Section 1983 lawsuits
 These cases are filed under Section 1983
of Title 42 of the U.S. Code. Section 1983
lawsuits stem from legislation passed by
the U.S. Congress after the Civil War to
protect Southern African-Americans from
reprisals during Reconstruction.
Early prison cases
 Newman v. Alabama (1977) was the first
case won on the theory that the totality of
conditions in the prison constituted cruel
and unusual punishment.
 Estelle v. Gamble made it clear that a
single episode of medical malpractice was
not equivalent to deliberate indifference
(i.e., was not a constitutional violation).
The Civil Rights of Institutionalized Persons
Act of 1980 (CRIPA, 1980)
 Title 42 also includes Section 1997, the
Civil Rights of Institutionalized Persons
Act of 1980 (CRIPA, 1980), which
empowers the U.S. Department of Justice
to conduct investigations and litigation
relating to conditions of confinement on
behalf of a class of institutionalized
persons in state or locally operated
institutions when there is evidence of civil
rights deprivations.
2: Technical Assistance and
Consultations
 What is TA?
 How to get it
 What to expect
2: Technical Assistance and
Consultations
 What is TA?
 Technical assistance is the coordinated
effort of providing funding, training,
research, and consulting to address
specific issues.
2: Technical Assistance and
Consultations
 advisory capacity
 works with the staff to assess programs and
operations, implement advanced practices,
and improve overall agency operations,
management, programming and services.
http://nicic.gov/TA
2: Technical Assistance and
Consultations
 Assess programs and operations.
 Implement effective practices.
 Improve agency management, operations,
and programming.
 Refine the design, delivery, management,
and evaluation of staff training programs.
 Cover the costs of practitioners' visits to
another agency to observe effective
practices.
http://nicic.gov/TA
2: Technical Assistance and
Consultations
 Most direct technical assistance requires onsite at the
agency for an average of 3–5 days.
 The cost of each direct technical assistance event may
not exceed $10,000

http://static.nicic.gov/Library/022876.pdf
2: Technical Assistance and
Consultations
Examples:
 Managing Mental Illness in Segregation
Units
 Training staff in Motivational Interviewing
 Developing Medication Assisted Therapy
 Suicide Risk Reduction
 And . . .
3: Interventions
 Court orders following a trial
 Consent decree
The Prison Litigation Reform Act
(PLRA) of 1996, 18 U.S.C. Section
3626 (b.)(2)
 The PLRA has had a negative impact on
the legal claims process of inmates. The
PLRA established new procedural
requirements for litigation by prisoners
and significantly limited the ability of the
courts to order relief.
The impact of the PLRA
 Private Settlement Agreements
Current litigation
 Has generally become more narrowed in
focus.
 Correctional mental health system only
 Mental health system in supermax prisons or
in segregation units only
Settlement Agreements: Standard
Elements
The access concept
Cohen, F. (2008). The mentally disordered inmate
and the law 2nd ed. Kingston, NJ: Civic Research
Institute.
The three elements identified for
establishing access in a constitutionally
adequate correctional mental health
system include the following:
(1) adequate physical resources
regarding treatment program space and
supplies,
 (2) adequate human resources concerning
numbers of properly trained and/or
experienced mental health staff who will
identify and/or provide treatment to inmates
with serious mental illness, and
 (3) adequate access for inmates to the
physical and human resources within a
reasonable period of time.
Staffing plan
Prison X shall ensure clinically appropriate
and timely treatment for inmates whose
assessments reveal serious mental illness
or serious mental health needs, including
timely and regularly scheduled visits with
Qualified Mental Health Professionals or
with Qualified Mental Health Staff, with
appropriate, on-site supervision by a
Qualified Mental Health Professional.
Physical Plant
 Prison X shall ensure timely provision of
therapy, counseling, and other mental
health programs for all inmates with
serious mental illness. This includes an
adequate array of structured therapeutic
programming. Prison X will develop and
implement policies and procedures
defining the various levels of care and
identifying the space, staffing, and
programming that are appropriate to each
identified level of care.
Quality Improvement
 QA is one aspect of QI
 QI needs to involve healthcare and custody
staff at all levels
 Impact on system




Institutional cultural changes
Increased resources
Safer environment
Better healthcare and better security
4a: Preparing for the monitoring
visits
 Self-monitoring of the Settlement
Agreement (SA) should be an ongoing
process, not just episodically driven by
monitoring visits.
 Prioritize efforts to achieve compliance
with elements of the SA.
You should know more about your
system than the Monitor.
 Develop reliable management tools
 Need an electronic data base for management
purposes and QI purposes.
 Engage your supervisors and line staff in the
process
 Provide a status update to every provision of
the SA with proof of practice data readily
available.
4b: Preparing for the monitoring
experience
 Review the agreement/ decree in detail
 Understand the Process
 Establish working groups
with empowered team leaders
 Building trust
4b: Preparing for the monitoring
experience
 Supporting change
in corrections:
If you think change can
never happen,
remember smoking!
4b: Preparing for the monitoring
experience
 Gather data consistent with each
element of the decree/ agreement
 When in doubt, discuss with your
attorneys/ AAG’s
 Coordinate and build consensus
4b: Preparing for the monitoring
experience
 Problem solve
 Engage staff proactively: Avoiding a 5th
Column through transparency
 Conduct a Mock visit: full Dress
Rehearsal
 Use this as an opportunity
5: Academic Opportunities
 Education
 Clinical Initiatives
 Program Evaluation and Research
5: Academic Opportunities:
Education
 Involve faculty
 Student involvement
 Staff
 As educators of students
 As students themselves
5: Academic Opportunities:
Clinical Initiatives
 Quality Improvement
 Implementation of Evidence Based
Practice
 Publishing results and process
improvement
5: Academic Opportunities:
Program Evaluation and Research
 Evaluation Design linked to QA and
QI
 Research Studies
OBJECTIVES:
By the end of the seminar, participants will:
 Become familiar with definitions and
applications of consultations, technical
assistance, settlement agreements and
consent decrees in correctional healthcare
 Understand opportunities to optimize system
benefits from these various interventions
 Discuss and share experiences with these
interventions, particularly as they have
engaged academic opportunities and benefit
6: Discussion
 Questions?
 Comments?
 Discuss and share your experiences
with these interventions