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Horticulture Therapy: Letting Nature Nurture

Horticulture Therapy: Letting Nature Nurture

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F
EATURES
Essay Contest on Transitional Planning Practices .7Facility Profile: Indiana Women’s Prison . . . . . . . .8New Mexico MDs Support Opioid Treatment . . . . .9National Conference Preview: New Orleans . . . . .11Antibiotic (Mis)use for Respiratory Viruses . . . . .12Journal Preview: Correctional Internships . . . . . .13Spotlight on the Standards: ClinicalPerformance Enahncement . . . . . . . . . . . . . . . .16Updates Conference Wrapup . . . . . . . . . . . . . . . .20
D
EPARTMENTS
NCCHC News: Schizophrenia Clinical Guidelines . .2Guest Editorial: Jann Keenan on Health Literacy . .3CCHP News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Academy News . . . . . . . . . . . . . . . . . . . . . . . . . . .6Mental Health Emergency Strikes Vegas . . . . . . .10In the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Standards Q&A . . . . . . . . . . . . . . . . . . . . . . . . . .17Exhibitor / Advertiser information . . . . . . . . . . . . .18Classified Advertising . . . . . . . . . . . . . . . . . . . . .19
I
NSIDE
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A Publication of the National Commission on Correctional Health Care
 
CORRECT
CARE
Spring 2004 • Volume 18, Issue 2
Non-Profit Org.US PostagePAIDChicago, IL 60611Permit No. 741
BY JAIME SHIMKUS
W
hat used to bea barren plotof dirt on adrab street acrossfrom the Cook County (IL) Jail now holdslife, delight, triumph,hopes and goals.That may be astretch, but not much when one considersthat the life—flowersand herbs—has beensown and nurtured by  women who, by soci-ety’s measure, don’thave much going forthem: All are former jail detainees who take part in its fur-lough program. Their success in grow-ing and harvesting these plants, anddonating them to local end-users, hasproven a subtle but tangible factor intheir own healing and growth.Now in its second year—and havingexpanded to a second site on the jailgrounds—this horticulture therapy isthe latest initiative of the expressivearts program at Cermak HealthServices, a county agency that pro- vides the jail’s health care. Theexpressive arts program, part of themental health services department,seeks to help inmates through cre-ative outlets such as poetry and jour-naling, visual art and music. While gardening is different, con-ceptually, it’s well-known to havetherapeutic effects. According to the American Horticulture Therapy  Association, “[HT is] a process in which plants and gardening activitiesare used to improve the body, mindand spirits of people.” (See page 14for more information from the AHTA.)That definition describes perfectly  what expressive therapist Eric DeanSpruth, MA, ATR, sought to convey inhis proposal for Cermak’s horticul-ture program. However, the idea firststruck him at a visceral level. As hisproposal noted,“[T]hink about how seeing nature bloomlifts your spirits….Making things grow can boost self-esteem and be a jolt of indepen-dence…. Even if itis only to help relax and unwind, horti-culture therapy canimprove any per-son’s life.” A home gardenerhimself, Spruth hadlong seen wastedpotential in theempty plantingbeds. But since they are in front of the county courthouseadministration building—in an open,public area—it was not feasible fordetainees to work there. However,security was less of a concern for thefurlough participants, who mustcheck in daily at the jail but are freeto live and work in the community.Before approaching the Departmentof Women’s Justice Services and theother agencies that had to be onboard, Spruth found a large landscap-ing firm to donate most of the materi-als and to prepare the plots. He thenpresented a plan that spelled outlogistical details, objectives and ther-apeutic benefits. For the most part it wasn’t a hard sell: “[DWJS executivedirector] Terrie McDermott is a gar-dener herself, and she said OK beforeIeven finished the presentation.”
From Idea to Reality
 With the necessary approvals in place,Spruth invited women in the furloughprogram to lend a hand, and on June4, 2003, the Blooming EntrepreneursEnglish Garden was born. Initially there was some grumbling from skep-tics, but no more:“People are seeingresults, and that is changing their
 National Conference
It will be here before you know it!Get a preview on page 11.
Continued on page 14
Horticulture Therapy: Letting Nature Nurture
BY STEVEN S. SPENCER, MD, CCHP-A
T
he field of correctional health carehas lost its patriarch, and many of us have lost a very good friend.Bernard Harrison, JD, was a lawyer with a strong sense of social justice(see page 10 for a timelineof personal and profession-al achievements). Early inhis career with the American Medical Association, he was instru-mental in shaping the leg-islation that createdMedicare and Medicaid,balancing the goal of improving access to healthcare for the poor andelderly with the interestsof the medical professions.This was no easy task given resistanceto a federal role in health care fund-ing, which was unprecedented in ournation’s history.
Man of Vision
Bernard’s passion for and skill incoalition building served him well inthe early 1970s, when he had the vision and the initiative to undertakethe huge effort of improving the sorry state of correctional health care,another area with no tradition of fed-eral involvement. As an AMA group vice president,Bernard had acquired experience inthe political arena, both locally and in Washington, representing AMA con-cerns even to the Oval Office. With thisexperience and armed with an AMA study of health care in this country’s jails, he was persuasive in demonstrat-ing the need for national standards. Aided by small grants from the fed-eral government and other sources,Bernard and a handful of other pio-neers developed the AMA jail stan-dards. A pilot project in a few jailssuccessfully demonstratedthe feasibility and accept-ability of a voluntary accreditation program,and the effort soon wasexpanded to prisons and juvenile detention and con-finement facilities.The first national confer-ence in this field was heldin 1977. I first metBernard at the secondannual conference, inChicago. All of us attend-ing that gathering were comfortably seated in one hotel meeting room, nocomparison with the thousands thatattend our conferences today.In 1981 the program separatedfrom the AMA and became the inde-pendent National Commission onCorrectional Health Care, co-foundedby Bernard and B. Jaye Anno, PhD,CCHP-A. They recruited the supportand participation of many medical,correctional and law organizations,and persevered in promoting accredi-tation in those difficult early daysbefore the concept gained widespreadacceptance. As time progressed, however, moreand more jails and prisons applied foraccreditation and the Certified Correc-tional Health Professional program
 Bernard P. Harrison, 1922 - 2004
 NCCHC Founder Passes Away After aLifetime of Remarkable Achievement
Continued on page 10
   P   h  o   t  o  o   f   T  a   f   f   i  a  n  y   J  o   h  n  s  o  n   b  y   T   i  n   i  s   h  a   W   i   l  s  o  n
 
To help correctional mental healthcare providers manage patients withschizophrenia, NCCHC has devel-oped new clinical guidelines that arebased, in part, on the AmericanPsychiatric Association’s PracticeGuideline for the Treatment of Patients with Schizophrenia.The need has never been greater.On any given day in the UnitedStates, 2% to 4% of state prisonersand about 1% of jail detainees haveschizophrenia or another psychoticdisorder, compared with 0.8% of theU.S. population as a whole. Providingadequate treatment to inmates withschizophrenia not only helps theindividual by reducing bizarre anddisruptive behaviors but also may make the environment safer forother inmates and for staff.
High-Risk Population
The high prevalence of mentally illinmates is believed to be related tothe deinstitutionalization of patientsin mental health facilities and thedismantling of mental health pro-grams across the country.Left to their own devices on thestreet, these former patients oftenengage in behavior that leads totheir incarceration. Many of theseinmates also have other risk factorsassociated with a higher incidence of  violent behavior (e.g., substanceabuse, neurological impairment,poor impulse control) that may beexacerbated by psychotic symptoms.Because of their idiosyncratic andsometimes provocative behaviors,people with schizophrenia may be athigher risk of being victimized incorrectional settings, and often theirclinical conditions are intensified by overcrowding, hostility and loss of basic freedoms.
Specialized Guidance
NCCHC’s Clinical Guidelines on theTreatment of Schizophrenia inCorrectional Institutions are intend-ed to supplement the APA’s guide-line by focusing on treatment issuesthat are unique to a correctional set-ting. (For useful principles andguidelines on providing psychiatricservices in these settings, consultthe APA publication “PsychiatricServices in Jails and Prisons,” whichcan be purchased at the NCCHC Website or by calling our headquarters.)The schizophrenia guidelinesaddress the following areas:backgrounddiagnosismanagement overview (includingtreatment goals)assessment on entry to the systemfrequency of follow-up visitscontent of follow-up visits (includingassessment and levels of function)use of the assessment to guidetreatment efforts (including conti-nuity of care, treatment strategiesand environmental controls)correctional barriersquality improvement monitors
Free Guidance Online
The seventh in a series of clinicalguidelines geared toward health careproviders working in correctionalsettings, the schizophrenia treat-ment guidelines are the first devel-oped by NCCHCthat deal with men-tal illness. The others offered to datedeal with the following chronic dis-eases: asthma, diabetes, epilepsy,high blood pressure, high blood cho-lesterol and HIV. All of the guidelines can be down-loaded for free at the NCCHC Website. Go to www.ncchc.org, select theResources and Link page, and thenclick on Clinical Guidelines.2SPRING 2004 CorrectCarewww.ncchc.org
Calendar
August 21
CCHP proctored examination, multiple sites(see www.ncchc.org for locations)
August 27
Best Practices in Transitional Planning essaycompetition deadline (see page 7)
October 1
Application deadline for the November 14CCHP and CCHP-A examinations
October 29
Accreditation Committee meetings: HealthServices and Opioid Treatment Program
November 13-17
National Conference on Correctional HealthCare, New Orleans
November 14
CCHP and CCHP-A proctored examinations,New Orleans
Odds & Ends
Catalog keeps growing.
The large number of registrants for NCCHC’s mentalhealth conference demonstrates the pressing need for more resources gearedtoward mental health assessment and treatment in correctional settings. Tohelp, we’ve added three valuable new titles from the well-regarded publishingarm of the American Psychological Association. For product descriptions andordering information, visit the Publications section of our Web site.
Treating Adult and Juvenile Offenders With Special Needs
, edited by JoseB. Ashford, Bruce D. Sales, and William H. Reid. 2001, 518 pages, hard-cover; $49.95
 Acting Out: Maladaptive Behavior in Confinement
, written by Hans Tochand Kenneth Adams, with J. Douglas Grant and Elaine Lord. 2002, 446pages, softcover; $29.95
Treating Chronic Juvenile Offenders: Advances Made Through the Oregon Multidimensional Treatment Foster Care Model
; written by PatriciaChamberlain. 2003, 186 pages, hardcover; $39.95
 NCCHC
News
Spring 2004Vol. 18 No. 2
C
ORRECT
C
ARE
is published quarterly by the NationalCommission on Correctional Health Care, a not-for-profitorganization whose mission is to improve the quality of healthcare in our nation’s jails, prisons and juvenile confinementfacilities. NCCHC is supported by 36 leading national organi-zations representing the fields of health, law and corrections.
A Publication of the National Commission on Correctional Health Care
BOARD OF DIRECTORS
Thomas J. Fagan, PhD (Chair)American Psychological AssociationEugene A. Migliaccio, DrPH, CCHP (Chair-Elect)American College of Healthcare ExecutivesDouglas A. Mack, MD, CCHP (Immediate Past Chair)American Association of Public Health PhysiciansKenneth J. Kuipers, PhD (Treasurer)National Association of CountiesNancy B. White, LPC (Secretary)American Counseling AssociationEdward A. Harrison, CCHP (President)National Commission on Correctional Health CareCarl C. Bell, MD, CCHPNational Medical AssociationH. Blair Carlson, MDAmerican Society of Addiction MedicineKleanthe Caruso, MSN, CCHPAmerican Nurses AssociationRobert Cohen, MDAmerican Public Health AssociationHon. Richard A. Devine, JDNational District Attorneys AssociationCapt. Nina Dozoretz, RHIA, CCHPAmerican Health Information Management AssociationCharles A. FasanoJohn Howard AssociationBernard H. Feigelman, DOAmerican College of NeuropsychiatristsWilliam T. Haeck, MD, CCHPAmerican College of Emergency PhysiciansRobert L. Hilton, RPh, CCHPAmerican Pharmacists AssociationJoRene Kerns, BSN, CCHPAmerican Correctional Health Services AssociationDaniel Lorber, MDAmerican Diabetes AssociationEdwin I. Megargee, PhD, CCHPAmerican Association for Correctional PsychologyCharles A. Meyer, Jr., MD, CCHP-AAmerican Academy of Psychiatry & the LawRobert E. Morris, MDSociety for Adolescent MedicinePeter C. Ober, PA-C, CCHPAmerican Academy of Physician AssistantsJoseph V. Penn, MD, CCHPAmerican Academy of Child & Adolescent PsychiatryPeter Perroncello, CJMAmerican Jail AssociationGeorge J. Pramstaller, DO, CCHPAmerican Osteopathic AssociationPatricia N. Reams, MD, CCHPAmerican Academy of PediatricsSheriff B.J. RobertsNational Sheriffs’ AssociationJohn M. Robertson, MDAmerican College of PhysiciansWilliam J. Rold, JD, CCHP-AAmerican Bar AssociationDavid W. Roush, PhDNational Juvenile Detention AssociationRonald M. Shansky, MDSociety of Correctional PhysiciansThomas E. Shields II, DDSAmerican Dental AssociationJere G. Sutton, DO, CCHPAmerican Association of Physician SpecialistsAlvin J. Thompson, MDAmerican Medical AssociationBarbara A. Wakeen, RDAmerican Dietetic AssociationHenry C. Weinstein, MD, CCHPAmerican Psychiatric AssociationJonathan B. Weisbuch, MDNational Association of County & City Health Officials
CARE
CORRECT
NCCHC’S NEW ADDRESS
1145 W. Diversey Parkway, Chicago, Illinois 60614
Phone
(773) 880-1460
Fax 
(773) 880-2424
E-mail
info@ncchc.org
 Web
 www.ncchc.org
 New Guidelines Aid in Schizophrenia Treatment
Standards for Opioid TreatmentPrograms in Correctional Settings
 With the recent launch of its accredi-tation program for opioid treatmentprograms based in correctional facili-ties, NCCHC has published a set of standards that represent the require-ments for opioid treatment servicesin such facilities. In developing thestandards, we used federal regula-tions and community standards as aguide and modified them to take intoaccount the issues unique to provid-ing services in a correctional facility.Conforming with NCCHC’s
 Standards for Health Services
, the
OTP Standards
are divided into ninegeneral areas: A – Governance and AdministrationB – Managing a Safe and Healthy EnvironmentC – Personnel and TrainingD – Health Care Services andSupportE – Inmate Care and TreatmentF – Health Promotion and DiseasePreventionG – Special Needs and ServicesH – Health RecordsI – Medical-Legal Issues All of the standards are linked tospecific federal regulations andtherefore are essential for achievingNCCHC accreditation. However,some may not apply, in whole or inpart, to a given facility’s program. Accreditation by NCCHC allowsOTPs to obtain legally required certi-fication from the federal Substance Abuse and Mental Health Services Administration. OTPs seeking accredi-tation are eligible for technical assis-tance consultation, funded by SAMHSA, that assesses what may beneeded to comply with the standards. An OTP seeking accreditation neednot be in a facility whose health ser- vices are accredited by NCCHC.To learn more or to order the stan-dards (which cost $29.95) callNCCHC at (773) 880-1460, or visitthe Web at www.ncchc.org.
Copyright 2004 National Commission on Correctional Health Care.Statements of fact and opinion are the responsibility of the authorsalone and do not necessarily reflect the opinions of this publication,NCCHC or its supporting organizations. NCCHC assumes no respon-sibility for products or services advertised. We invite letters of supportor criticism or correction of facts, which will be printed as spaceallows. Articles without designated authorship may be reprinted inwhole or in part provided attribution is given to NCCHC.Send change of address, advertising inquiries and othercorrespondence to Jaime Shimkus, publications editor,NCCHC, 1145 W. Diversey Parkway, Chicago, IL 60614.Phone: (773) 880-1460. Fax: (773) 880-2424.E-mail: info@ncchc.org. Web: www.ncchc.org.
 
 www.ncchc.orgSPRING 2004 CorrectCare 3
BY JANN KEENAN, E
D
S
F
or Susan, apetite, 100-pound woman, takingher daily medica-tion for highblood pressure with a light snackis easy. Eachafternoon shegrabs a banana and a handful of peanuts as she takes her pills. Yet, for Ned, a strapping, 240-pound man who also suffers fromhigh blood pressure, eating a lightsnack means downing two chickensandwiches accompanied by a glassof milk, crackers and cheese.Two patients, two approaches tofollow the same medication instruc-tions. But which patient is doing theright thing? Unfortunately, that’sopen to interpretation.In the example above, the medica-tion instructions are vague and non-descript but most likely will notresult in a deadly medication error.In other cases, however, medicationnoncompliance or an adverse drugreaction due to unclear instructionscan result in a deadly outcome. Ithappens every day in America.The inability to read, understandand act on health information iscalled low health literacy. A person with limited health literacy may havedifficulty reading labels on pill bot-tles, understanding directionsoffered by the doctor or givinginformed consent because of theform’s lofty language.Low health literacy has a negativeimpact on patient care, confusespatients and providers, and takes aheavy financial toll on the healthcare industry. And it is becoming analarming public health issue. According to a recent study by theInstitute of Medicine, low health lit-eracy affects 90 million people in theUnited States and by some estimatescosts the health care system morethan $58 billion annually.For the 2 million inmates residingin the nation’s jails and prisons andthe 11.5 million inmates releasedeach year—populations more likely than the general public to have seri-ous infectious diseases, newly diag-nosed health problems, and languageand cultural issues—low health liter-acy can be dangerous.Fortunately, there is good news.Concern about low health literacy and how it affects patient care isbecoming mainstream with legisla-tors, public health interest groupsand others. As a result, great stridesare being make to quell the problem, with grassroots health literacy initia-tives springing up nationwide toenhance communication in health.The movement is also taking hold inthe pharmaceutical industry, where,for instance, marketers are develop-ing reader-friendly package inserts.
Simple Strategies
Despite this explosion in awareness,day-to-day progress is slow. Part of the challenge is to educate healthcare providers, who may take it forgranted that their patients under-stand them. In fact, providers them-selves may be the best weapon in thefight against low health literacy—and potential errors that can result.The following strategies, while notcomprehensive, are simple and prac-tical ways that health care providerscan improve their daily interactions with inmates to strengthen healthcommunication and comprehension.
Use plain medical English
 Always use easy-to-understand terms when talking with patients. Forexample, providers should use termssuch as “high blood pressure”instead of “hypertension,” “bothsides” instead of “lateral” and “acough that lasts too long” instead of “persistent cough.”
Be specific and avoid jargon
 When giving medication instructions,say “in the morning” or “at night”instead of “a.m.” or “p.m.” When apill must be taken with “plenty of  water,” show the patient an 8-ounceglass of water or two Dixie cups fullrather than leave them guessing.
Draw a picture or use models
People retain and understand infor-mation better when they are shown apicture or model rather than justtalking about a subject. To helpinmates understand a complicatedhealth issue such as arteriosclerosis,draw or show a picture. In the caseof high cholesterol, draw an artery  with plaque stopping blood flow.Mention an easy-to-understand anal-ogy, such as a pipe that is clogged.
Focus on key points
To help inmates clearly understandthe gist of the matter, providersshould select three specific points tosummarize the patient’s illness ormedication compliance.
Understand what the patient understands
Take extra effort to make inmatesreally understand what is being said.Try asking patients to repeat orexplain the information just deliv-ered. This “teach-back” techniquehelps providers know what has suc-cesfully sunk in and what is stillmissing in their instruction.
Take a fresh look at prepared materials
 When using informational pamphletsor brochures, take a fresh look at thematerials alongside the patient. Usea highlighter to call out importantinformation. For example, if apatient has high blood pressure,mark the section in the brochurethat says to avoid salting food.Similarly, highlight pictures oraction words to help the patientunderstand specific activity. If yourpatient needs to do a foot check, cir-cle the picture of a person checkinghis feet and write “do foot check” inthe margin.
Ask the patient to write his or her nameon the brochure
Making the brochure personal willhelp raise the patient’s compliance.
Know your intended audience
If you will be using the brochure withLatino patients, for instance, it is agood idea to have some Latinos inthe photographs or illustrations. If  you aim to reach older inmates,make sure the materials show olderadults. This approach helps patientssee this is “for them.”
Better Outcomes
Undoubtedly, conquering low healthliteracy will not happen overnight.However, if health care providerstake a critical look today at how they communicate information and thebest way to do it in a culturally sensi-tive way, chances are good that theirpatients, whether they will remain ina correctional institution or arepreparing to reenter society, willhave a better chance at positivehealth outcomes.
 Jann Keenan, EdS, is president of The Keenan Group, Inc.—Experts in Health Literacy, a communications firm based in Ellicott City, MD. Reach her by e-mail at jkeenan@erols.com.
The American Medical Associationhas adopted a policy of support forthe National Commission on Correc-tional Health Care’s standards forhealth services and its accreditationprogram. The policy “encourage[s]all correctional systems to supportNCCHC accreditation,” and calls forfinding ways to increase funding forcorrectional health services.Resolution 440 (A-04), Supportfor Health Care Services to Incarcer-ated Persons, was adopted by the AMA’s House of Delegates at itsannual meeting in June. The Houseof Delegates is the association’sprincipal policy-making body.The policy was introduced by the American Association of PublicHealth Physicians, which holds aseat on the House of Delegates. AAPHPalso is a supporting organi-zation of the National Commission.
Improvement Needed
 According to a report in AMA News,physicians widely supported the poli-cy in part because of “recognitionthat illness in prison can spill overto affect the community at large.”The resolution, which describesNCCHC as “the leading organization working to improve the quality” of correctional health care, cites pow-erful arguments for the policy—including the fact that the U.S.Surgeon General views this as animportant public health issue. Otherkey concerns include the following:Correctional health care shouldmeet prevailing community stan-dards, and providers should prac-tice in keeping with contemporary standards.Incarcerated people have a highprevalence of disease and seriousmental illness, as reported inNCCHC’s Health Status of Soon-to-Be-Released Inmates study.“Drastically curtailedcorrection-al budgets have resulted in “insuf-ficient resources.”
A Long History
“The AMA has for over 30 yearsstrongly supported the need forimproved health and mental healthcare in jails and prisons,” saysJonathan B. Weisbuch, MD, MPH, who is AAPHP’s delegate to the AMA. He also serves on NCCHC’sboard of directors.The AMA and NCCHC have a longhistory dating to 1970, when themedical association first began tolook into the conditions of healthservices in jails and didn’t like whatit found. The AMA collaborated withother organizations in a program toestablish jail health care standardsand advise on accreditation. In theearly 1980s, that program evolvedinto the independent NCCHC.“Those of us who labor in the vine- yards of correctional medicine andpublic health thank the AAPHP forintroducing the resolution and the AMA for adopting it,” Weisbuch adds.The resolution is posted online at www.ama-assn.org/meetings/public/annual04/440a04.doc.However, this version does not con-tain the sole amendment to the res-olution, which expands the phrase“health care services” by adding“including mental health services.”
Health Literacy: The Challenges and Opportunities
It’s Official: New AMA Policy Backs NCCHC Standards, Accreditation
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