Healthcare Behind Bars
Courtesy of HDR Architecture Inc., © 2013 Robert Benson
The State of California Department of Corrections and Rehabilitation California Health Care Facility in Stockton, Calif., features corrections bunks and a security-grade medical gas enclosure in an inpatient dormitory setting.
Courtesy of HDR Architecture Inc., © 2013 Robert Benson
Natural light is incorporated in a medical nursing unit at the State of California Department of Corrections and Rehabilitation California Health Care Facility in Stockton, Calif.
There were 2.2 million people incarcerated in the U.S. in 2014, with 1.5 million in state or federal prisons, according to the Bureau of Justice Statistics. This makes the U.S. home to the greatest number of incarcerated individuals in the world. The U.S. Constitution requires healthcare to be provided to inmates, and in fiscal year 2011, states spent $7.7 billion on correctional healthcare—one-fifth of their overall expenditures, reports the Pew Charitable Trusts.
In addition to healthcare complications associated with aging, inmates are commonly diagnosed with alcohol or drug abuse disorders and mental illness. Many may not have had substantial access to healthcare prior to incarceration and without proper treatment often continue to deal with these conditions upon release, putting inmates at risk for recidivism and potentially causing public health issues to be introduced back into communities. Given the constitutional mandate and obvious need to provide healthcare services to incarcerated individuals, it’s important that treatment spaces in prisons and jails be designed for effective care delivery while meeting the safety and security needs of patients and staff.
Variations in care environments
A few certification organizations focus on correctional health facilities, including the American Correctional Association and the National Commission on Correctional Health Care (NCCHC); however, there aren’t specific space standards or guidelines covering healthcare in correctional environments. This means the level of care delivery can vary from state to state and sometimes from facility to facility. Most states provide a medical and mental health screening area, clinic space (with exam rooms, a procedure room, and basic imaging), dental area, “sick call” where requests for medical consultations are made (usually located in housing units), and an infirmary for overnight acute care.
States with a smaller inmate population typically provide medical and mental health assessments, light treatment, and some skilled nursing within a facility, as well, with all other care—such as surgery, specialized imaging, orthopedics, cancer care, and dialysis—outsourced to a local hospital. States with a larger prison population often provide more in-house care, including specialty exam/treatment, dialysis, chemotherapy, and acute medical and mental health inpatient treatments. Many states also now provide or are developing hospice and palliative care programs. Emergency/trauma care, surgery, and childbirth are typically treated in a hospital.
Balancing safety and healing
Although care levels may vary, all correctional health environments must focus on maintaining the safety and security of the inmate-patient and the staff. For example, healthcare inherently involves items that could be used as weapons, including syringes and medicines, so it’s important to keep in-room storage to a minimum. Locking up all supplies that need to be stored within the room and maintaining accurate accounting of those items can further improve safety. All medical staff should be able to easily and discreetly call for officer assistance in an emergency, as well.
However, even within the most hardened facility, designers must still create spaces that promote healing and improve outcomes. Evidence-based design solutions used in traditional medical facilities can also be successfully applied within the correctional health environment, including:
- Sense of safety. Threats of violence constitute a significant source of stress for inmates. Any inmate-patient who appears weak or vulnerable can become a target for a predatory inmate. Arranging spaces to achieve clear lines of sight for staff, combined with adequate supervision, will add to the sense of safety, limit chances of violence, and reduce patients’ overall stress level.
- Nature view. Patients experience less stress and pain if they can view nature and other positive distractions. While this is a tremendous challenge in a correctional environment where security precludes the use of large glass openings due to cost and vulnerability to attacks, a view to the sky can be provided with clerestories that are inaccessible to inmates. If windows or clerestories are not achievable, the use of a nature mural can provide a positive effect.
- Noise. Noise is a frequent problem in correctional healthcare environments due to the abundance of hard surfaces, clanging doors, mechanical equipment, and televisions. Products that can mitigate this problem and improve overall well-being include security ceilings with perforations backed with sound batts, surface-mounted acoustical panels located high on the wall and out of reach, and high-performance carpeting in common spaces.
Patient care rooms
Inpatient care in a correctional facility can be delivered in a variety of rooms based on the type of service: for example, in open wards for post-surgical recovery, observation, and skilled nursing; semi-private rooms for skilled nursing and behavioral health; or private rooms for acute medical and behavioral care.
The type of bed within each room setting is driven by the type of care provided and the security classification of the inmate-patient. For example, if an inmate-patient is removed from the general population to an infirmary area for pre-procedure preparations, that individual may still be housed with a corrections bunk. Inmate-patients in the infirmary for post-surgical recovery may be housed with a corrections-style articulating bed, while patients in the infirmary for acute care will require a hospital bed. Because of the potential of the articulating bed and hospital bed parts to be used as a weapon, the inmate-patient will be housed in a bed most appropriate for their care to ensure the safety of both the staff and the inmate-patient.
The choice of headwall in the patient room will also be based on the medical acuity level and security level of the inmate-patient. If the individual is in an acute setting, a standard medical headwall can be used. However, if the inmate-patient is in a sub-acute setting, a security-grade medical gas enclosure with an articulating door that closes off the points of connection to the headwall should be used to reduce the risk of self-harm and harm to others, and protect the medical gas connections.
Patient room design must provide good visibility for staff and corrections officers, which can be accomplished by using safety glass in the corridor wall to allow for observation of the patient without entering the room. Though a correctional patient room doesn’t need to account for a family area, the layout should allow for maneuverability of the patient and equipment and can range from a standard 6-by-8-foot cell to a 300-square-foot high-acuity room. Other factors, such as the type of care being provided, the security classification, and the required flexibility of the inpatient units, can affect the size of the room, as well.
Other space considerations
Additional clinical and ancillary support spaces, such as imaging or procedure rooms, are sometimes considered to treat patients in-house in lieu of sending them to a local health facility. Providing these additional services can help reduce transportation costs and security concerns associated with transferring inmates, but expected volume must be considered to ensure the construction and maintenance of these services are cost effective. It’s also critical to consider the regulatory issues that come with these spaces. For example, the addition of an operating room will also require sterile processing and prep/recovery components. Defining operational need and cost-containment strategies can help determine what other support spaces make sense for a facility.
Whether designing for a small or large inmate population, the design community has an opportunity to create a safe and secure healing environment for the more than 2 million incarcerated individuals in the U.S. The goal is to bring the best in medical and mental healthcare environments to the secured environment.
David Redemske is a health planning principal and a research fellow studying healthcare in the corrections environment at HDR (Chicago). He can be reached at firstname.lastname@example.org. Laurence E. Hartman, AIA, is a vice president with HDR. He can be reached at email@example.com. Gail Dahlstrom, MHSA, is a clinical programmer with HDR. She can be reached at firstname.lastname@example.org.