A University-State-Corporation Partnership for Providing Correctional Mental Health Services

In September 1998 a partnership between the University of Massachusetts Medical School (UMMS) and Correctional Medical Services, Inc. (CMS) began providing health care services to the Massachusetts Department of Correction. Along with other areas of cooperation and overlap, UMMS assumed primary responsibility for the management of the mental health program, while CMS had primary responsibility for the management of most of the remaining health care services. The collaboration combined CMS's experience in privatized correctional health care with UMMS's experience in public-sector mental health services and training programs. The main goals of the partnership were expansion of mental health services, recruitment of staff, and development of training programs.

Although privatization of correctional health services has become common since 1973, when the Rikers Island jail became the first system to be privatized (1,2,3,4), the participation of medical schools in providing those services remains rare (1). Commentators for many years have been calling for affiliations between teaching hospitals and penal institutions (5,6), but few have described examples of successful collaborations. In this article we examine the contributions that a medical school can make in partnership with a private vendor and a state department of correction as well as the advantages of such a partnership. We also assess the achievements of the UMMS's partnership with CMS and the Massachusetts Department of Correction, some of the ongoing challenges, and the elements needed for success. We hope that our experience will stimulate other medical schools to become involved in correctional health care services.

Benefits to the private vendor and the department of correction

How does a partnership with a medical school benefit both a private vendor of correctional health care and the department of correction that it serves? The association with a medical school, especially one that has experience in public-sector psychiatry, has advantages for both the vendor and the department of correction. The prevalence of serious mental disorders among inmates exceeds that in the general community by a factor of three to four for men and five to seven for women (7). Inmates who have mental disorders are at risk of decompensation, poor adjustment, and disciplinary infractions (8,9,10). The resources and expertise of a medical school can help a private vendor meet the challenges that such inmates pose.

A medical school can provide valuable assistance in other areas, including specialty care and the recruitment and training of non-mental health medical professionals. By partnering with a medical school, a correctional system can enhance the quality of its health care program, and a private vendor may increase its own likelihood of acquiring or retaining a contract to provide services.

Medical school affiliation should help ensure a high quality of both diagnostic and treatment services. As centers for research and training, medical schools typically maintain state-of-the-art practices. Their vanguard position in care rendered to the broader community increases the likelihood that they will provide "the same level of mental health services to each patient in the criminal justice process that should be available in the community" (6). Correctional administrators can expect a medical school to deliver rational, effective, and cost-efficient assessment and intervention services.

The ability of a medical school to fulfill its commitment to high-quality services depends largely on the recruitment and retention of skilled professionals. In this area, perhaps more than in any other, a medical school can make a valuable contribution to correctional services. Correctional systems have had difficulty recruiting and retaining adequate numbers of qualified health care professionals (1,11,12). Although many dedicated and talented clinicians have always chosen to work in penal settings, correctional employment has suffered from a poor image for many years (11,13).

However, a program managed by a respected medical school has a greater likelihood of improving the stature of correctional work and attracting competent clinicians. The reputation and credibility of a medical school can help with the recruitment and retention of staff who desire an affiliation with a teaching institution and the relative assurance of the high-quality programming that it provides. Faculty appointments, continuing education activities, and opportunities to participate in research and teaching also help attract competent staff.

In addition, training programs provide a feeder system for recruiting high-quality young professionals into a correctional system. For example, UMMS's experience with training programs in the Department of Correction and other public-sector settings indicates that trainees are more likely to seek posttraining jobs in places in which they worked as students.

Along with attracting high-quality staff, the research, training, and continuing education programs of a medical school help staff maintain their skills and competencies. The presence of students and trainees stimulates professional staff to stay current in their knowledge and skills. In addition, medical schools typically have expertise in practical and applied research that can improve the care and treatment that a system provides.

Benefits to the medical school

How does participation in correctional health care benefit a medical school? For UMMS, correctional health care provides an opportunity to further advance its mission of providing high-quality health care services to the citizens and agencies of Massachusetts. For example, UMMS's psychiatry department has spent more than two decades as an integral partner with the Massachusetts Department of Mental Health. Faculty of the psychiatry department have developed creative approaches to managing many of the most violent and severely mentally ill patients in the state, providing services within inpatient and outpatient programs of the Massachusetts Department of Mental Health in the least restrictive settings.

The UMMS division of public-sector psychiatry has received national recognition and awards for the innovative programs it developed to provide efficient, high-quality, and cost-effective care. Expanding services to include the correctional population in the custody of the Department of Correction—a sister state agency—was a logical and obvious next step for a medical school that was already deeply involved in providing public-sector service.

Movement into correctional health care makes fiscal sense for medical schools. Recent years have witnessed a rapid increase in the number of inmates as well as an expansion of their health care needs, especially mental health care. As some community mental health services have contracted, the need for correctional mental health services has expanded.

The statistics are sobering. Between the mid-1950s and the mid-1990s, the number of state hospital beds decreased from about 340 per 100,000 population to 30 per 100,000, while incarceration rates increased from about 100 per 100,000 to 450 per 100,000 (7,14). According to a 1999 survey by the U.S. Bureau of Justice, 16 percent of male state prisoners have a mental illness, which is four times the community rate, and 24 percent of female state prisoners have a mental illness, which is six times the community rate. Nationally, state and federal prisons house about 190,000 inmates who are mentally ill (15).

In Massachusetts, more than 2,000 of a total Department of Correction inmate population of about 10,300 are part of the active mental health caseload. Inmates need psychiatric services, and medical schools—especially those that have public-sector experience and commitment—are well-equipped to assist correctional departments in meeting those needs.

In addition to increasing the clinical revenue base while providing a valuable public service, involvement in correctional services creates potential opportunities for medical schools to expand their research and training programs. The correctional mental health literature is sparse. There is still much to learn about the effectiveness of interventions and programs in correctional settings. Academic faculty members often have an interest and a background in research, and corrections provides fertile soil in which to work. Prisons also provide rich opportunities for training rotations. The medical school gains from the expansion in the number of high-quality sites for clinical teaching, and the trainees add value to the correctional system.

Challenges and accomplishments

What have been the challenges and accomplishments of the Massachusetts experience? During the three-year contractual relationship that began in September 1998, the UMMS partnership with CMS and the Department of Correction resulted in some frustration along with much success in several areas, including staffing, training, and clinical programs.

Staffing

The fact that there were two employers—UMMS and CMS—occasionally led to staffing difficulties. Although UMMS employed all the psychiatrists and doctoral psychologists, the medical staff and most of the nondoctoral mental health clinicians continued to work for CMS. At times, this arrangement caused some confusion over reporting relationships and human resources matters. In addition, differences between the two employers in fringe benefits and rules about paid time off engendered feelings of inequity among staff.

The realities and frustrations of working in a penal setting can sometimes hinder the recruitment and retention of staff. Some people experience the prison environment as oppressive and the inmates as intimidating. Others take offense at security procedures and have difficulty relating to security staff. Not everyone has the flexibility and temperament for correctional work.

Despite these obstacles, after UMMS became involved, the Massachusetts correctional mental health program saw an influx of highly qualified staff. The number of licensed mental health staff increased by about 40 percent, and some vacancies that had been designated as master's-level positions have been filled by doctoral-level professionals.

However, the most dramatic changes occurred in psychiatric staffing. At the start of the contract, just under ten full-time-equivalent (FTE) psychiatrists provided care to more than 10,000 inmates and 300 patients at Bridgewater State Hospital, a maximum-security forensic psychiatric hospital run by the Department of Correction. The system now includes more than 21 FTE psychiatrists. Six of the ten psychiatrists who already worked in the system continued their employment through UMMS. Another 19 part-time or full-time psychiatrists are currently employed in the system; of these, 16 are board-certified, four have advanced fellowship training, and eight were already UMMS faculty members and took positions under the Department of Correction contract. The experience and training of our correctional psychiatric staff rival those found anywhere else in the public or private sector.

Several factors account for the popularity of our psychiatric positions. Psychiatrists function as part of a multidisciplinary mental health treatment team that works in association with facility-based general medical providers. Some of our new hires had a long-standing interest in working with the historically underserved correctional population. The quality assurance provided by the involvement of UMMS encouraged them to pursue this interest. Many inmates have attested to these individuals' sense of duty by expressing appreciation for the compassionate and competent care they had received. Reasonable caseloads allow adequate time for visits and follow-up with a relatively light burden from managed care restrictions and paperwork. Competitive compensation, commitment to ongoing training, and an absence of mandatory on-call responsibilities have added to the attractiveness of these positions.

Training

Security constraints can create obstacles for training programs. Correctional systems require all new employees to undergo extensive orientation about rules and safety procedures. This helps prevent potentially dangerous infractions, such as the introduction of contraband items into the facility. Prisons limit the access of persons who have not completed adequate orientation. Such persons typically must be escorted at all times while they are in the prison, and they cannot meet alone with inmates. These restrictions can create serious barriers for mental health trainees who want to do relatively brief or part-time correctional training rotations.

Although some training rotations of less than a few months' duration have proved difficult to arrange, many other training and educational programs have borne fruit for the system. UMMS established an internship for two full-time psychology interns to conduct testing at Bridgewater State Hospital and at the main Department of Correction reception facility for male inmates. Two full-time UMMS forensic psychology postdoctoral trainees and two full-time UMMS forensic psychiatry fellows conduct forensic evaluations and provide treatment at the state hospital. UMMS obtained accreditation for the forensic psychiatry training positions from the Accreditation Council of Graduate Medical Education.

The medical school also has had modest success in arranging elective rotations for medical students and psychiatric residents. In addition, four summer and eight full-year social work internships have been created for students from three area schools. The trainees provide valuable clinical services and rewarding teaching opportunities for our staff. Talented former trainees who have the skill and temperament for correctional work have filled many of our staff positions in social work, psychology, and psychiatry.

The system has also benefited from new continuing education and other academic activities. Quarterly mental health case conferences have been instituted at all ten of the major prison facilities in the state. Senior clinical administrative and consultative staff from the statewide correctional mental health program attend these presentations, which typically involve the more challenging and interesting cases at each facility. Faculty members from the UMMS psychiatry department who are not affiliated with the Department of Correction conduct other case conferences and seminars. UMMS also organizes annual full-day correctional mental health conferences, which have been well attended and well received by medical, mental health, and security staff from the Department of Correction. These staff members also have access to on-site and videotaped UMMS grand rounds and other educational programs.

As an academic medical center, UMMS can pursue training opportunities that would not otherwise be available to the correctional system. For example, the program successfully applied for a Pfizer Visiting Professorship award, which funded a three-day visit by a national expert in correctional psychiatry who has served as a consultant or court monitor reviewing correctional mental health services for the U.S. Department of Justice and in 27 states. In addition to educational presentations by the visiting professor, our program had the rare opportunity to get an intensive review and valuable feedback on our clinical and academic activities in a nonadversarial context.

Clinical programs

Programmatic innovations met with their own unique complications. The Department of Correction tempered its enthusiasm for clinical enhancements with a healthy dose of caution. Proposed changes in policies, procedures, or programs typically receive careful scrutiny with a paramount concern for safety. Delays have occurred before implementation of some clinically beneficial changes. In other instances, space and physical plant constraints made it necessary to adapt programs to the available resources.

Nevertheless, policies, procedures, and programs have evolved in many positive ways. Among the more significant innovations was the development by UMMS in conjunction with the Department of Correction of a 50-bed male rehabilitation program and a 36-bed female residential treatment unit. Staffed by a multidisciplinary team of mental health clinicians and psychiatric rehabilitation professionals, these programs provide structured environments that include group psychosocial rehabilitation for inmates with mental disorders who have difficulty functioning in prison. The programs offer an alternative to hospitalization for some patients by providing an intermediate level of care between the general community and the hospital. Inmates learn the skills necessary to participate in available correctional programming and, in the case of those who are about to complete their sentences, to function appropriately in the general community.

Consistent with the limited literature on residential treatment units and similar programs, our experience suggests that the programs reduce the number of serious rule infractions, disciplinary problems, crisis care episodes, suicide attempts, and hospitalizations (16,17). At Bridgewater the challenge has been to augment hospital functions in line with the identity of the facility as a prison. Efforts have focused on supporting the professional development of the staff and enhancing hospital-based programs.

Along with a twofold increase in the number of psychiatric staff and a threefold increase in the number of rehabilitation staff, other enhancements include establishment of a professional staff organization and added expertise in psychometrics, neuropsychology, neuropsychiatry, and forensic evaluation services. The hospital, which recently received a facility-of-the-year recommendation from an accreditation team from the National Commission on Correctional Health Care, is actively pursuing first-time accreditation by the Joint Commission on Accreditation of Healthcare Organizations.

Public recognition

The accomplishments of the Department of Correction's mental health program over the past three years have not gone unnoticed outside the department. For example, in August 2000 an editorial in the Boston Globe praised the department's treatment program for prisoners who have mental disorders (18). Some community mental health professionals, politicians, and interested members of the general public have taken note of the high quality of services in the department's facilities. Such positive recognition is refreshing for a well-intentioned correctional administration. Too often, correctional agencies—even those that provide proper care —receive only negative and critical attention.

Elements of success

What are the elements of success for a correctional mental health program that is managed by a medical school? If a medical school hopes to succeed as a provider of correctional mental health services, it must be prepared to prove its credibility. Prisons are not mental health centers. Security requirements almost always trump clinical needs. Clinicians must become familiar with correctional rules and must learn to communicate and work effectively with security staff (19). Correctional officers and administrators will not respond well to ivory-tower academics who do not appreciate security needs.

Medical schools with experience in serving public-sector patients who have severe and persistent mental illness may find it easier to acclimate to the correctional setting than schools without such experience. Other schools, as well as some clinicians, may lack the necessary disposition to work collaboratively with security staff or to treat inmates. However, persons who have a suitable temperament can build mutual trust and respect with correctional professionals and can experience the rewards of providing good care to often-appreciative inmates.

The credibility of the medical school or of any other service provider also rests on its willingness to address practical problems. For example, sensitivity to fiscal issues can be achieved through efforts to educate and encourage psychiatrists to prescribe the least expensive medication regimens whenever possible. The program also must demonstrate an unqualified readiness to help security staff manage inmates with character disorders who engage in severely disruptive behavior.

When a medical school enters into a partnership with a private for-profit vendor of correctional health care, the two organizations must find common interests in the midst of sometimes conflicting cultures. In overly simplistic terms, a program designed by a medical school may be built primarily around the perceived clinical needs of the system. If the system will not support a program that is dedicated to providing a level of service that meets or exceeds the broader community standard, the medical school is likely to walk away from the project. In contrast, a program designed by a private for-profit vendor may be built primarily around perceived budgetary limits. If the program cannot be delivered with an adequate profit margin, the private vendor is unlikely to bid on the contract.

However, despite the apparently disparate bottom-line agendas, medical schools and private vendors can find common interests that allow them to collaborate on clinically appropriate—and financially viable—programs. Neither can succeed if they pursue their primary agendas exclusively. A medical school must manage its programs in a fiscally responsible way that recognizes budgetary realities. Although it might not seek to make a profit in the traditional sense, it still needs to deliver services and cover overheads within funding limits.

Similarly, a private vendor will succeed only if it provides programs that meet the needs of its correctional client while generating corporate profits. The vendor's ability to obtain and retain contracts depends largely on its record of delivering appropriate and cost-efficient services. Emphasizing common interests and recognizing the strengths that each organization brings to the relationship can help forge an effective partnership.

On their end, correctional administrators need to be committed to serving the needs of inmates who have mental disorders. This commitment must include efforts to obtain adequate funding to meet staffing and resource needs, such as providing a modern formulary. A flexible rather than domineering approach to problem solving can facilitate a constructive resolution of tensions between custodial and health care needs. Cooperation on these issues requires a core of mutual respect and shared values. For example, the Massachusetts Department of Correction recognizes that providing appropriate treatment to inmates who have mental disorders not only enhances safety and security but also is simply the right thing to do. In states that have less enlightened administrations, medical schools may find that reasonable collaboration is difficult, if not impossible.

Even under the best circumstances, many challenges will remain. The disparate cultures and missions of corrections and mental health can occasionally lead to conflict despite overlapping goals and values. Formal and informal interactions at the levels of both line staff and administrative staff provide a framework for ongoing resolution of these issues (19). If a medical school and a correctional department manage to build a foundation of trust and respect, they may find, as we have, that the rewards of the partnership far outweigh the frustrations.

Dr. Appelbaum and Mr. Manning are affiliated with the University of Massachusetts Medical School in Worcester. Mr. Noonan is with the Massachusetts Department of Correction in Milford. Send correspondence to Dr. Appelbaum, Director, Correctional Mental Health, Health, and Criminal Justice Programs, University of Massachusetts Medical School, 120 Front Street, Suite 700, Worcester, Massachusetts 01608 (e-mail, [email protected]).