A recent report, "Unasked Questions, Unintended Consequences: Fifteen Findings and Recommendations on Illinois' Prison Healthcare System," released by the prison watchdog group, the John Howard Association, focuses a keen and insightful eye on the current state of Illinois' prison healthcare system. The first sentence of the report sets the tone:
"The Illinois Department of Corrections (IDOC) is not just an agency of 27 prisons. It is
also a healthcare system for nearly 50,000 inmates."
Although all 15 recommendations are important, my attention was drawn to their observations concerning the aging prison inmate. With the geriatric population of the state's prisons having increased by 300 percent over the last decade, the number of those nearly 50,000 prisoners with chronic conditions who require assistance with activities of daily living, from dressing to eating to toileting, is growing exponentially. As geriatric social worker Tisha Maschi observes nationally,
"...our elderly prisoner population continues to grow at an alarming rate, forcing our correctional system to act as a nationwide long-term care facility -- something it was never designed to be."
Although the quality of care provided to an elderly inmate should concern us, the overall cost of that care should also demand our attention. In general, all state correctional facilities currently face fiscal crises to various levels, and the expensive care demanded by the needs of geriatric prisoners is quickly rising to the consciousness of state administrations. As the JHA reports:
"It is unclear how Illinois will pay for the housing, treatment, and medical care of this growing elderly inmate population. Indeed, it is unclear how Illinois can currently pay for elderly inmates' housing and care today, which is conservatively estimated to cost $428 million a year, about a third of IDOC's budget. Estimates place the average cost of incarcerating an elderly inmate between $60,000 to $70,000 per year, compared to the $27,000 per year it costs on average to house a general population
inmate. Because the federal government generally does not pay for state inmates' medical care, these costs are borne almost entirely by Illinois taxpayers."
In recent months, many states, including California with SB 1462 and Louisiana with HB 138, have been considering how to better utilize the Compassionate Release program, which tends to impact terminally ill inmates in the final six months of their lives. Although effective prison hospice programs exist, Dixon Correctional for one, a more cost-effective and compassionate choice would be to consider partnering with hospice agencies outside of the prison system who would bring holistic care to the inmate while facilitating life closure with the inmate's significant others and families outside the prison walls.
Studies show that the highest quality and lowest cost care we can offer those at the end of life remains the interdisciplinary, home-based model of care provided by hospices. As someone who has served in hospice care in Louisiana, a state that not only boasts the highest number of incarcerated but also boasts ground-breaking prison hospice programs, I have seen first-hand how the success of compassionate release programs for inmates depends greatly on the quality of relationship between the releasing prison or jail system and the local hospice community. Several factors would be wise to explore:
1) The tax-status of the local hospices. Today, hospices can be both for-profit and non-profit entities, and I will admit that I am a strong proponent for the non-profit hospice world, and in terms of caring for released offenders, my passion for the vision and mission of non-profit hospices only grows stronger. Because inmates participating in the Compassionate Release program are not technically free, meaning that in 2014 the Affordable Care Act's expansion of Medicaid eligibility criteria will still not apply to them as technically incarcerated individuals. So, who will pay for these compassionately released prisoners? The cost and burden of their care will fall upon the charitable dollars of our communities. Our hospice in Baton Rouge made a conscious choice to use charitable dollars to support released inmates and their families, admitting them as non-funded patients, believing that we cannot discriminate among the vulnerable people who need our services. Local hospice boards might want to have this discussion concerning their mission and the use of charitable dollars prior to accepting released inmates.
2) The discharge planning skills of the prison's social workers and nurses. Our hospice team of physicians, nurses, social workers, chaplains and volunteers worked closely with prison staff in the days, even weeks, prior to a release. Countless details need to be addressed in the plan of care, from deciding who will be accountable for medications, to determining how day to day care will be provided, to ordering and delivering the needed medical equipment, to assessing family dynamics, to discussing funeral plans and establishing long term goals for the patient and his or her family and friends. Our staff often went to the prison setting prior to release so that the transition could be made as smoothly as possible. The process of entering a jail or prison can be arduous, so setting up a system prior to a dying patient needing care is wise.
3) The ethos of the hospice team. As hospice staff and professionals we provided released inmates with the same quality care that we provide any other patient. But among ourselves we agonized. Some asked, should the fact that you made a criminal choice earlier in life negate any choice you might want to make at the end of life? Does every person have the right to die "free?"
I struggled, too, because I have lost a loved one to violent crime. Each time I signed the paper to admit a dying prisoner to our hospice program, I thought of Juli. My dear friend, a fellow ballet dancer, 21 years old and a senior in college, Juli was raped and murdered. Juli's convicted killer is now one of our nation's prison inmates. He may one day need hospice care, and so even though this man chose not to treat my friend with anything close to the dignity she deserved, I came to see that he should be treated with the dignity that all human beings deserve. This realization did not come easily, nor quickly, but after years of caring for compassionately released inmates in our hospice program, I found myself changed for the better in how I thought of all incarcerated individuals. In expanding how community hospice programs interact with terminally ill inmates, we can as a society ensure that these released individuals not only receive high quality, dignified care during their final days but also enter a local community that has begun to buy-in to this shift in how we care for and see those incarcerated in our midst simply because they trust the reputation and history of the local hospice who will be coordinating and responsible for their care. As the John Howard Association stresses in their report:
"To reform prison healthcare, we must not only change particular policies and practices inside our prisons, we must change our priorities on the outside as well. We must realize that prison health is public health."
Expanding the usage of the Compassionate Release program can be an important step in that direction.
For more information about my professional journey as a hospice professional caring for inmates in the compassionate release program in Louisiana as well as my personal journey in coming to peace with the aftermath of violent crime in my own life, read here.