A Sheriff's Role in Healthcare
The sheriff's job has many functions and responsibilities, and is key to ensuring the local criminal justice system works efficiently. Many only think of a sheriff in the law enforcement capacity—the “lawman” or “crime fighter”—but the reality is, today's sheriff is much more than a police officer.
This position assumes the responsibilities of all components of the criminal justice system: law enforcement, court services, civil process and corrections. My job is a daily balance in the pursuit of justice, coupled with strategic management of the jail's population—including caring for the complex healthcare needs of incarcerated individuals.
Prior to becoming sheriff, I served many roles: corrections officer, police officer, detective, and lastly, jail superintendent. As superintendent, I quickly realized risk management was a primary responsibility, and the jail’s healthcare system was the program with the most potential exposure. Additionally, the inmate healthcare program was the department's most expensive service, typically representing between nine and 13 percent of the total budget (with costs steadily climbing). It was evident our inmate healthcare program needed to be a top focus of concern.
The sheriff has a constitutional responsibility to provide detainees with adequate healthcare. In 2010, the year I became jail superintendent, the department was seeing a trend in inmate litigation challenging the jail's healthcare program. This was consistent with what many jails across the nation were encountering. Most litigation stemmed from medical “wants” versus medical “needs”—a battle that correctional healthcare practitioners continue to face today.
In 2010, the jail population was growing, averaging 480 to 550 detainees daily, which explained much of the rising costs. However, the individuals being incarcerated were more complex patients, with more chronic ailments than we had seen in the past. An alarming number had undiagnosed or underdiagnosed medical conditions and infections, while detainees with significant substance abuse issues were increasingly prevalent.
Offsite visits—either to emergency rooms or elective consults—were frequent occurrences. Individuals with mental health needs were being housed at an all-time high, due to the closure of public psychiatric facilities. The Peoria County Jail had become a de facto mental health facility. All of this combined—the complex issues, high risk factors and cost drivers—led us to prioritize the overhaul of the jail's healthcare system.
An Overhaul of Practices
With the desired outcome of facilitating an efficient, well-managed healthcare delivery system, the solution was to aspire for accreditation of our medical program by the National Commission of Correctional Healthcare. NCCHC required us to define policy and procedures and demonstrate a working practice covering nine general standards of correctional healthcare: governance and administration, safety, healthcare services and support, inmate care and treatment, health promotion and education, special mental health needs and services, clinical records and medical-legal issues.
Two long years of policy and procedure development, changing business practices, and implementation were followed by a rigorous inspection by the accrediting body. In 2012, NCCHC determined we were in compliance with all the essential standards. I am proud to say we are one of six jails in Illinois to have earned this national accreditation.
The jail now has 24-hour medical coverage and full-time mental health staff. A jail physician, mid-level practitioners, psychiatrist and dentist provide advanced care, in addition to regular nursing and mental health professional hours. A comprehensive initial screening of detainees has been implemented, which assists with early recognition and appropriate action for withdrawal indispositions from alcohol and opiates. A chronic clinic was established, treating diseases and ailments such as diabetes, hypertension and COPD.
Consistent training is offered for both security staff to help identify medical and mental health issues and for nursing staff to communicate crucial information to providers and physicians to ensure the appropriate clinical decisions are made. An electronic medical record system was implemented to improve communication among staff and reduce redundancies in care.
A complete overhaul of pharmaceutical services was also completed. Medication costs were identified as a major cost driver when we first reviewed our system. We have since adopted a formulary, increased stock medications, and require meds to be in blister packaging to reduce time spent on medication pass. Routine cost monitoring and review of formulary are now conducted to control spending and advocate savings.
Today there is an emphasis on inmate education and maintaining healthy lifestyles, both in and out of custody. Continuity of care is now a common term, so we developed strategies to assist individuals with their medical and mental health needs post-release. In partnership with Heartland Health Services, a navigator is sent to the jail every week to assist with inmate Medicaid enrollment. We believe this improves health outcomes by streamlining access to care in the community.
Mental Health and Addiction Issues
Prior to accreditation, no true mental health program existed. Instead, the jail often relied on security staff to monitor those suffering from behavioral health issues. In the event of an acute situation, Emergency Response Services would be called to help manage the crisis. This was a dangerous practice, with limited follow-up care.
Today we are partnered with the Human Service Center (HSC), and have full- and part-time mental health professionals who deal with the growing population of individuals suffering from mental illness. Contracting with HSC was deliberate, as it is the primary agency dealing with many of the same individuals with behavioral health needs, both in and out of custody. A cognitive behavioral therapy program has also been developed—focused on anger management, drug and alcohol addiction issues, relationship skills and self-control—with the hope it will have a positive impact on recidivism.
By default, the jail has become a major player in the opioid crisis, as well as other dependency and addiction issues. Both medical and mental health staff members are highly involved in managing this growing population. We started seeing the uptick in opioid usage in 2011. In response, we’ve required medical staff to have a supply of naloxone (opiate reversal antidote) on site at all times. Over the past 18 months, the high number of arrests involving individuals needing to be placed on withdrawal protocol is alarming. This is creating many high-risk, complex care management scenarios, which are impacting both medical and security staff at an unprecedented level.
When I began my career in law enforcement 23 years ago, I never imagined I would have to study Medicaid enrollment, or understand the importance of negotiating your rate upward from WAC (Wholesale Acquisition Cost) instead of downward from the AWP (Average Wholesale Price) to get the best pricing on medications. But as sheriff, you have to wear many hats to effectively manage all duties and responsibilities required by Illinois law. The management of complex healthcare needs probably isn't the typical duty people think of when envisioning a sheriff, but I can assure you it influences the local criminal justice system at a remarkable level. iBi