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San Diego County Jail Changing Medical Model For Needs Of Long-Term Inmates

San Diego County Jail Changing Medical Model For Needs Of Long-Term Inmates
San Diego County Jail Changing Medical Model For Needs Of Long-Term Inmates
Alfred Joshua, MD, chief medical officer, San Diego County Sheriff's Department.

MAUREEN CAVANAUGH: This is KPBS Midday Edition, I am Maureen Cavanaugh. One of the side effects of prison realigned and is being seen in the medical care of being dispensed at San Diego County jails, all felonies prisoners sentenced to longer than a year in jail used to be sent to Saint state prison, now all non-serious nonviolent nonsexual offenders are kept in County jails for as long as ten years, this means that the variety and rarity of illness has increased dramatically, San Diego County has a new chief medical officer for the Sheriff's detention services Bureau and he is introducing something of a managed care system for County jails to focus on follow-up in the community for discharged inmates, I would like to welcome the medical chief Alfred Joshua, welcome to the program. Now how is this job presented to you what you are being hired, what did the County say that they needed in medical care now that they will be in jails longer? ALFRED JOSHUA: Really it has shifted prior to alignment, to afterward, before jails were place where inmates would be up to a year, if they were there for any period longer they could be transferred to the prison system, but that meant for medical care is when you do urgent care complaints as well as urgency of care, [ [ CHECK AUDIO ] ]while they are in the jail you there getting treated on the outside, after realignment they could be sicker or older, and we need to focus on more preventative stuff and disease management, at the same time really focusing on ways how do we reduce recidivism or repeat offenders coming back into the system, historically jails have never been having infrastructure for this long-term approach, that is really the shift that we're implement and out. MAUREEN CAVANAUGH: You've been in the job for about two months, or three months, even evaluating the medical facilities that are now in place? ALFRED JOSHUA: Yes, the jails of always provided high-quality cost-effective care for all inmates, what we have done is looked at the model and said how can we still provide that high-quality cost-effective care but still do it in the paradigm of more preventative services, as well as collaboratively with the community resources out there so that individuals are transitioned appropriately back into the community, we look at three different areas sent one is standardization of problem processes, cutting it down so we can make them more successful with their release from us as well, and also standardized medical supplies and using all of the evidence-based guidelines in order to really say is this efficacious and something that is needed, we have also developed a lot of critical pathways such as blood pressure and diabetes so we're really following these people in jail, and secondly we have freely derided in immediate services, we even prior to my arrival we have had assessed successful filing of the country where psychiatrist can see a patient through telemedicine in one of our facilities, but this is a lot us to do is expand the capacity for mental health providers in our jail system and we are putting to expand this to all branches of mission, so dermatology and specialty clinics receive this route, and lastly collaboration with the community, for the affordable care act with the benefits that a lot of places are really talking to get each other, and the incentive was not there before but now it really is, we're looking at health information exchanges and other community resources that we can successfully create a healthier population. That is the goal, create healthy inmates said that when they are going to continue the community that they will be healthier and really be productive members back in the society. MAUREEN CAVANAUGH: Do find that there are certain types of medical conditions that jail inmates have more frequently than the general population? ALFRED JOSHUA: Yes, the majority of our patients or inmates of the situation are under the age of forty and most people would think that this would be a relatively healthy population, but there are a lot of things of which the inmate population more than other places, for example for mental health of the egg burden on the jail system, 20% of our inmates on psychotropic medications about almost about two thirds of our inmates have a history of substance or alcohol are called abuse or mental illness, is the huge burden for this population and on top of that we have individuals that have uncontrollable high blood pressure or diabetes of a common with these comorbid but it conditions that and we're working on stabilizing them and transition them to be successful of the community upon release. MAUREEN CAVANAUGH: And as emission before, it's stabilization is the kind of thing that jails are so good at before, but now you have to deal with chronic conditions, how prepared are this facilities in the jail Ford dealing with ongoing medical conditions that inmates will be suffering during the time in the years that there To jail? ALFRED JOSHUA: Historically we have done a great job with chronic disease management, what has happened before the we deal with and four. Time such a year, and now we have to really be think it and say if somebody's going to be with us for five or ten years, a sure that they have the right immunization programs of the rights greeny works, all of this is going to be built into our system and one of the benefits of also in our process going forward is procuring new medical record systems with the focus of disease management and collaboration with many partners and so really it's being billed as we speak. MAUREEN CAVANAUGH: You are familiar with the fact that a lack of access to medical care in state prison is one of the reasons that we find that with a be one of 109 and present rampant in the first place, I'm wondering what kind of wait time to inmates face in order to get medical care now? ALFRED JOSHUA: We have been it very format forecheck, our inmates we have clicks for basic medical care and orthopedics and even specialty centers for HIV as well as dental, it's a fairly quick turnaround time at this time, we really appropriately managed to make sure that people who are really sick are seen in a very timely manner and have community standards of how nations are being seen, it is actually being fairly efficient.: When he's a fairly efficient you give us a specific time? If some is not feeling well how long do they have to wait be seen by a physician? ALFRED JOSHUA: Essentially all of our gets the can be put in to be seen by a physician by the same day or sent out to the emergency department or they can be it is a more nonurgent complaint they can be seen until they are seen by a physician but they are seen fairly expedited. MAUREEN CAVANAUGH: As you say, this is interesting jails are providing conference of care like dental and eye exams and things of that major, give civic sense of how dramatic that change is for the county jail system. ALFRED JOSHUA: You really have to look at the population and the last year we had over 92,000 bookings and our nursing tracks on the intake and we're seeing over fifteen eight 5800 people and the jails of San Diego County's of the population has grown an A.B. 109 now accounts for about 30% of the population, so it is a fairly large number of inmates that we're seeing related to this issue, so it is a shift in that aspect. MAUREEN CAVANAUGH: And how much is this costing the county? ALFRED JOSHUA: Again we have been actually fortunate with that we're finding cost-effective ways to deal with it, will always need more resources to deal with expansion of programs and expansion of our facilities, but we have been pre-fortunate in the sense that we have a very strong leadership, only down to deputies and medical stuff that have tried to build a better system, I think this collaborative approach of this sheriff's department as well as with the collaborative approach of our partners in the community have made its that we are not absorbing the huge cost of this could be. MAUREEN CAVANAUGH: Not a huge cost, but actually how much or is it costing the county? ALFRED JOSHUA: Our budget last year for medical was about $66 billion, and that has got up since years prior. MAUREEN CAVANAUGH: Is the state providing the funds to make up that expansion? ALFRED JOSHUA: Originally in the A.B. 109 billing there was a specific source of revenue built-in Ford, and now you would have to ask to see the checks of the county, the belief is that there is a revenue source that is come into the county for that. MAUREEN CAVANAUGH: And for what you are saying to my said understanding correctly, you are tempting attempting in the process of building a managed care health system that San Diego County jails? ALFRED JOSHUA: Again it will affect what we're seeing before with the standardization, but we're really trying to do is create that model of managed care and it starts with standardization of processes for making sure that our sense incentives are aligned with community providers providers as well as contracting medical providers as well as finding more accountability with our staff and having the appropriate utilization among inmates, is really a balanced approach but that is the goal and the vision going forward. MAUREEN CAVANAUGH: One big expect of this vision for overall care is discharge planning, our County jails following up with inmate who need continuous care? As he said your goal is inmates coming back to the society are actually healthy. ALFRED JOSHUA: Bring all of that work is being done and is been done over the last few years since A.B. 109, and the probation has taken a very proactive approach in trying to do this, from minute attention standpoint we're really working collaboratively with David, we have mental health clinicians and discharge planners essentially identifying these high-risk individuals in trying to give the resources such as scheduling visits and courses and types of medications, so that they will be successful going back and it's an difficult and strenuous process that will require a lot of resources but we are making a lot of headway. MAUREEN CAVANAUGH: How is it working so far? You have any feedback on this? He said that this is that going on since the start of realignment, has there been any feedback is how the discharge buddies working? ALFRED JOSHUA: The actual metrics and stuff are being developed as we speak, and anecdotally I have heard positive stories of patients that are being successfully transitioned back, the real recidivism way, if inmates are not coming back, it could really tell us if they are then being stabilized from a medical standpoint or mental health and substance abuse, where they getting the appropriate social services so they get housing and other things so that they can transition successfully from there. MAUREEN CAVANAUGH: From your vantage point how much this successful management of mental health or substance abuse problems actually affect the idea that somebody will come back to jail, and whether they will reoffend and be back in county jail? ALFRED JOSHUA: For my personal standpoint those two are one of the most important factors, especially with substance abuse it's very troubling, you can ask family members who deal with these individuals, to really get back into having a job, and being able to take care of your family and being a productive lifestyle, it's something that we're hopefully going to be able to help them develop coping mechanisms coping mechanisms and outpatient resources for the can deal with the situation and magic, it's the same with mental health and the real burden of society terms of resources and what it taxes on the individuals being rather as well as these individuals, we can have them stabilize the medication and these are regiments that they can be compliant to, I believe that we can get a much more successful individuals that are really being transitioned back into society MAUREEN CAVANAUGH: And in speaking with Max Jenkins the county probation chief as you know, his main goal is to charge get as many people to serve their sentences in some alternative way, either rehabilitation programs or under house attention or some other type of sentence, so that they will be spending so much time in Jeff, I'm wondering does County medical services have anything to do with alternative programs? People who are sentenced to spend their sentence or part of it in some other way besides being an inmate in county jails? ALFRED JOSHUA: So the service department is responsible overall and Mister Jenkins to give more insight into that aspect of it, from our standpoint from the detention side we're try to make sure that they are stabilized and again, identifying those people that we can successfully transition in that direction, but we did we do work with pussy with probation to get that to happen MAUREEN CAVANAUGH: And how do you hope that continuing care for inmates or former inmates is actually going to reduce recidivism in any jails? ALFRED JOSHUA: So, I feel back to the substance abuse and mental health, if they are stabilize the get the appropriate resources whether it be social resources or with certain medications, but they are able to transition back into productive lifestyle. MAUREEN CAVANAUGH: Let me talk about you for a moment if I may, do have some experience with treating people who were inmates because he treated them as a clinician while you're at UC San Diego is that right? What have you learned from that experience? ALFRED JOSHUA:, The inmate population is very unique, some of the issues that are affecting other people you would for the general population, there's a lot more case of certain things, and a lot of it is substance abuse and alcohol of dependence, it's one of the key things that you will see a lot of the patient struggle with, and as a physician you have to be very cognizant about that, because you don't want to feed people's addiction behavior, but at the same time you also want to do what is right for them critically and you are also educating them about other issues such as high blood pressure or diabetes and tried to get them compliant on a regiment that they're going to be successful while there outside of jail. MAUREEN CAVANAUGH: My last question to you, what will he have some sort of metrics to be of the CU whether or not these programs are working for what needs to be tweaked to work a little bit get better? ALFRED JOSHUA: I am hopeful in the next few month, in the old conflict ICE in terms of any kind of metric is always about the data that we receive and it's really we need to make sure that we develop systems appropriately to make sure that we are measuring the right things and in terms of measuring were citizen recidivism and how healthy the population is it's going to be important for us as a whole. MAUREEN CAVANAUGH: I've been speaking with Doctor Alfred Josh tried he is the San Diego County jails medical chief, thank you so much. ALFRED JOSHUA: Thank you for having me.

Prison realignment has had a significant impact on San Diego County jails. A report released by SANDAG this month shows more than one-third of all the inmates in San Diego County jails are now offenders who previously would have served their time in state prison.

The county is building more jail space to house the increasing number of inmates being housed at county facilities. The county continues to hire deputies and probation officers in order to meet the new demand.

Lack of access to medical care in state prisons was a significant part of the problem that eventually resulted in prison realignment. Ironically, one of the side effects of prison realignment in San Diego is being seen in the medical care being dispensed at San Diego County jails.


All felony prisoners, who were sentenced to longer than a year in jail, used to be sent to state prison. Now all non-serious, non-violent and non-sexual offenders are kept in county jails, in some cases for as long as 10 years.

This means the variety and severity of illness that has to be treated in county jails has increased dramatically.

San Diego County has a new chief medical officer for the Sheriff's detention services bureau. Dr. Alfred Joshua said he's introducing something of a managed care system for county jails, with a focus on follow-up in the community for discharged inmates.