Mental Health Performance Measurement in Corrections

International Journal of Offender Therapy and Comparative Criminology Volume 53 Number 6 December 2009 634-647 © 2009 SAGE Publications 10.1177/0306624X08322692 http://ijo.sagepub.com hosted at http://online.sagepub.com

Steven K. Hoge New York University School of Medicine

Robert B. Greifinger John Jay College of Criminal Justice, The City University of New York

Thomas Lundquist Carnegie Mellon University, Pittsburgh, PA

Jeff Mellow John Jay College of Criminal Justice, The City University of New York

Correctional facilities have become, by default, one of the largest providers of mental health care for patients with serious mental illness. In its 2002 Report to Congress, the National Commission on Correctional Health Care has reported that most facilities do not provide quality mental health care, nor do they conform to nationally accepted guidelines for mental health screening and treatment. This article describes the product of a consensus panel of correctional health care experts, charged to develop performance measures, based on nationally accepted standards, for selected elements of psychiatric treatment behind bars, aimed to improve the quality of care. Performance measures were developed for medication adherence, suicide prevention, mental health treatment planning, and sleep medication usage. Keywords: correctional health care; psychiatric performance measurement; medication adherence; suicide prevention; mental health treatment planning; sleep medication use

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stablishing methods and processes to improve mental treatment for patients in correctional facilities is of urgent importance. The quality of mental health care provided in correctional institutions is widely regarded as inadequate. Numerous authoritative reports have cited a litany of deficiencies with respect to mental heath treatment in jails and prisons (Center for Mental Health Services, 1995; Correctional Association of New York, 2004; National Commission on Correctional Health Care [NCCHC], 2002a, 2002b; Steadman & Veysey, 1997). In a recent report to Congress,

Authors’ Note: Please address correspondence to Jeff Mellow, PhD, Department of Law, Police Science & CJ Administration, John Jay College of Criminal Justice, The City University of New York, 899 10th Avenue, Room 422T, New York, NY 10019; e-mail: [email protected].

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the NCCHC (2002a, p. 32) reported that “most prisons and jails do not conform to nationally accepted health care guidelines for mental health screening and treatment.” The purpose of this article is to describe the results of a consensus panel held in February 2007 to develop performance measures for selected elements of psychiatric treatment behind bars. There is evidence that the quality of mental health care in correctional settings is declining. Manderscheid, Gravesande, and Goldstrom (2004, p. 870) compared data from federal surveys conducted in 1988 and 2000 and concluded that “the growth in prison facilities and the growth in prisoner populations are outstripping the more meager growth in mental health services” and warned that services are becoming less available. The end result is that many mentally ill inmates are receiving inadequate treatment or, worse, no treatment at all. Examining the status of mentally ill state prisoners due to be released within 12 months, Beck (2000) found 43% had not received treatment.

Improving the Quality of Care The movement to improve the quality of health care services in correctional settings has a constitutional foundation, first articulated in Estelle v. Gamble (1976). A thorough review of the impact of litigation on mental health care is beyond the scope of this article. However, it is fair to say that the courts have been effective primarily by requiring facilities to provide inmates with greater access to professional health care providers. Courts have generally acted by articulating broad principles (e.g., the Estelle court prohibited “deliberate indifference” to serious medical needs), leaving details of implementation to others. A recent review of the Civil Rights of Institutionalized Persons Act (1997), the federal legislation enabling the investigation and litigation of federal constitutional inadequacies in health care in jails and prisons, found that the chief criticism related to vagueness of standards (National Council of Disability, 2005). Providers and institutional authorities complained that it was not clear what standards were applied by experts hired by the U.S. Department of Justice when they conducted Civil Rights of Institutionalized Persons Act investigations. This lack of specificity, it was argued, has led to confusion, demoralization, and a loss of credibility for the process. The NCCHC has undertaken the mission of setting health care standards for correctional settings. NCCHC periodically publishes Standards for Health Services, covering treatment, records, administration, and related topics in jails, prisons, and juvenile facilities (NCCHC, 2003a, 2003b, 2004). The NCCHC Standards for Health Services articulates accreditation guidelines regarding structural and policy elements of service delivery for correctional facilities. But these standards were not intended to provide detailed guidance regarding treatment and management.

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Following a recent study regarding the health needs of soon-to-be-released inmates (summarized in a report to Congress), the NCCHC reviewed existing national clinical guidelines and found that none adequately addressed the difficulties of providing health care in correctional institutions (NCCHC, 2002a, 2002b). Consequently, the NCCHC established expert panels to review clinical practice guidelines and other evidence-based medical practices for adaptation for use in correctional settings. The NCCHC articulated the need for elaboration of clinical guidelines to help correctional health care professionals effectively manage diseases commonly found in jails, prisons, and juvenile confinement facilities. To date, the NCCHC has issued a single guideline on mental disorders, one regarding the treatment of schizophrenia in correctional settings (NCCHC, 2006). The schizophrenia guideline provides general background information on the disorder, accepted treatments, and management strategies, as well as a discussion of barriers to care in correctional settings. Outside the correctional arena, health care systems have increasingly turned to the strategies of evidence-based medicine to improve the quality of health care. Evidence-based medicine is based on the principle that health care should be grounded in a comprehensive understanding of the scientific and clinical literature. Clinical practice guidelines summarize the knowledge regarding treatment and management strategies for diseases, clinical pathways provide structure to the management and decision-making process, and performance measurements provide a method to assess outcomes. Food and Drug Administration approval for the use of psychotropics in children and adolescents varies widely, although standard practice among experts generally follows along lines parallel to the adult standards elaborated here. For specific recommendations regarding the use of psychotropics in adolescents in the juvenile justice system, sources that are aimed directly at child and adolescent psychiatric practice, as well as the practice parameters promulgated by the American Academy of Child and Adolescent Psychiatry, should be consulted.

Performance Measurement and Private Correctional Health Care Providers For-profit private correctional health care providers (PCHCPs) now provide a substantial share of the market, reportedly accounting for $3.0 billion of the approximately $7.5 billion allocated each year to correctional health care (Robbins, 1999). Governmental agencies have increasingly turned to privatization of correctional health care for reasons related, in whole or part, to improving the quality of health care. Correctional administrators openly acknowledge a lack of expertise in managing health care delivery and budgets. Correctional authorities contract with PCHCPs to assume a broad array of responsibilities, including the tasks of staff recruitment, retention, and oversight; utilization management of specialty care and hospital care;

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and pharmaceutical management, with the expectation that the costs and quality of health care will be improved. There is ongoing debate regarding whether privatization of correctional health care is sound policy, based on anecdotes, some of which receive wide media attention. There has not been a systematic comparison of public versus privately operated correctional health care. Such a study would be difficult to accomplish. However this debate is resolved, there appear to be a number of reasons to expect PCHCPs to be capable of improving the quality of care. First, PCHCPs compete for contracts on the cost and quality of care to be provided. These private companies have quality assurance and improvement divisions that are charged with the development and monitoring of care through performance measures. These measures may be internally generated, based on prior experience, contractually determined, or both. Finally, for reasons of reputation and cost containment, both governmental oversight agencies and PCHCP have sought to minimize financial losses from malpractice or other health care–related litigation.

Materials and Methods On February 24, 2007, the Prisoner Reentry Institute at John Jay College of Criminal Justice hosted a roundtable discussion regarding the creation of mental health performance measurements, based on nationally accepted standards, adapted for the correctional environment. In a prior roundtable discussion, mental health performance measurement emerged as ripe for consensus development for several reasons. Clinical guidelines related to mental health treatment in correctional settings emerged as being less settled and perceived as “in flux” when compared with care for medical conditions prevalent behind bars, such as diabetes, HIV/AIDS, and asthma. All PCHCP participants recognized the importance of mental health standards in view of the large numbers of afflicted inmates under their care; the morbidity and mortality associated with mental illness, including suicidality; the side effects of medication; and problems of nonadherence. The roundtable had 29 participants, including 17 from large private correctional and behavioral health providers and six correctional psychiatrists and one correctional psychologist, most of who are independent and active as experts in prison and jail litigation. The goals of the roundtable were agreed on prior to the meeting: to reach consensus on meaningful performance measures in correctional mental health care. It was agreed that the group would try, whenever possible, to reach consensus and that the measures must be quantitative so that they could be tracked and trends could be traced over time. The group agreed that the measures should be clearly defined so that data could be readily extracted from charts with good reliability. Moreover, the measures should be based on nationally accepted standards in the field. The methods employed at the meeting were described in a report summarizing the findings of a previous roundtable discussion (Mellow & Greifinger, 2007). Briefly,

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staff from John Jay College of Criminal Justice organized and moderated the session, with assistance from one of the independent mental health professionals. Topics for discussion were introduced, discussed, and notes were taken on a large easel pad. Participants expressed their thoughts on the topic under discussion. Internet access was available and was used, in some cases, to download and review published practice guidelines. At the end of each topic and at the end of the 6-hour session, the moderator summarized the findings. Consensus was reached on nearly every subject.

Performance Measures Adherence Ensuring adherence to medication is a critical aspect to the provision of quality mental health care in correctional settings. Complete or partial nonadherence to treatment leads to substantial morbidity and mortality and is associated with significant impairments in functioning. There is evidence that the duration of untreated psychosis is correlated with poorer prognosis in individuals with schizophrenia (McGlashan, 1996; Wyatt, 1991). In civilian settings, the inability or unwillingness to comply consistently with a medical regime is a major cause of relapse and hospital admission among individuals with schizophrenia, and—once hospitalized— patients who do not accept medication are more likely to be disruptive and to be subjected to seclusion and restraint. Medication noncompliance is a major contributing factor to relapse in psychotic disorders and adversely affects the efficacy of treatment for affective disorders. There is evidence that criminal arrest is related to nonadherence and relapse (Quanbeck et al., 2004). Prompt and regular treatment is important to functional recovery, which is a predicate for independent living and reentry. In correctional settings, the following goals are reasonable. First, health care providers should be providing assurance that the right person is getting the right medication at the right time. Second, adherence and nonadherence to medication must be documented. Finally, health care providers must identify significant nonadherence, which must be brought to the attention of the responsible prescribing psychiatrist, who can then assess the reasons for nonadherence and craft appropriate clinical interventions. These interventions will range from clarification of misunderstanding regarding the prescribed medication, negotiation regarding the medication (dosage, scheduling, brand, etc.), or involuntary treatment if necessary. Recommendations • The medication administration record documents the nursing staff’s actual administration of medication to patients and, therefore, should be used as the primary measure of adherence. Patients’ refusal of medication should be clearly documented on the medication administration record.

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• The mental health providers (vendors or agencies) should establish clear policies and procedures regarding how to respond when medications are not administered. At a minimum, these policies should require that the responsible physician be notified when significant nonadherence occurs and the procedures by which notification will occur and be documented. • Significant nonadherence requiring notification should include, at a minimum, any of the following: ❍ Three consecutive doses are missed. ❍ A dose is missed on three consecutive days. ❍ Fifty percent or more of a single medication is missed over the course of a week. ❍ One dose of a depot medication is missed. • Documentation by the responsible physician should acknowledge receipt of notification that nonadherence has occurred and describe the clinical response taken.

Monitoring for Side Effects and Toxicity In any setting, monitoring for side effects and toxicity are important aspects of quality care. All medications carry some level of risk and may produce morbidity and mortality. Side effects may lead to treatment nonadherence with all the attendant problems and complications discussed above. Finally, attention to the problematic aspects of treatment demonstrates clinical concern for the overall well-being of the patient, which strengthens the therapeutic alliance. This effort is particularly important in the care of correctional mentally ill patients, who are often alienated from their families, communities, and civilian systems of care. The roundtable participants reached consensus on a number of areas related to side effects of medication. Abnormal Involuntary Movements First-generation antipsychotic medications (e.g., haloperidol, chlorpromazine) carry a significant risk of producing abnormal involuntary movements, primarily tardive dyskinesia (TD). TD is characterized by rhythmic, oral-buccal (cheek) movements. TD may progress to involve movements of the head, neck, and shoulder girdle. The risk of producing movement disorders is related to time; for each year of treatment, there is a 4% to 8% risk of developing TD per year on medication (American Psychiatric Association Task Force, 1992; Glazer, 2000). Greater vulnerability to the development of TD is associated with older age, history of antipsychotic-induced Parkinsonian symptoms (other abnormal movement symptoms), female gender combined with postmenopausal status, affective disorder diagnoses, concurrent general medical disease, and use of high doses of antipsychotic medications (Lehman et al., 2004). Second-generation antipsychotic medications appear to carry a greatly reduced risk for TD, estimated to be approximately one tenth of that for first-generation antipsychotic medications (Lehman et al., 2004).

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TD may be irreversible; early detection and discontinuation of antipsychotic medication is often effective in reducing or eliminating abnormal movements. The standard tool for assessment is the Abnormal Involuntary Movement Scale (AIMS; Guy, 1976). The American Psychiatric Association (APA) recommends that patients receiving first-generation antipsychotic medications be assessed every 6 months and those on second-generation antipsychotic medications every 12 months (Lehman et al., 2004). Patients at high risk for TD, the APA suggests, should be assessed for involuntary movement more frequently. The roundtable participants believed that given the complexities of correctional care (transfers within and across facilities, different clinicians, etc.) a single measure of performance should be established. Moreover, the use of a standard tool, such as the AIMS, will minimize variability in assessment. The roundtable participants also emphasized that the measures should set minimum standards. In all areas (not solely abnormal movement assessments), clinicians may choose to increase the frequency of assessments, tests, or other interventions, when indicated. Recommendations • Abnormal involuntary movements should be assessed at baseline (the initiation of antipsychotic treatment). • Reassessments should be performed, at a minimum, every 6 months, regardless of whether a first- or second-generation antipsychotic medication is prescribed. • A standardized assessment tool, such as the AIMS, should be employed and documented.

Lithium Lithium is widely used in the management of patients with bipolar disorder and may be used as adjunctive treatment for patients with depression, psychotic disorders, or other disorders. Lithium has toxic effects on the kidneys and thyroid gland and may be teratogenic. In addition, as with many medications, therapeutic and acute side effects are dose related. Lithium has been in use for two generations; thus, the clinical experience and guidance regarding its use is extensive. As summarized by the APA in practice guidelines for the treatment bipolar disorder, pretreatment testing serves multiple purposes: (a) establishing baseline values to aid interpretation of subsequent tests, (b) tests to determine conditions that may require a different treatment or other treatment, and (c) tests to determine conditions requiring alteration of standard dosing (APA, 2002). Prior to the initiation of lithium treatment, the APA recommends the following: a general medical history, a physical examination, blood urea nitrogen and creatinine levels (both tests of kidney function), pregnancy testing, thyroid function evaluation, and an electrocardiogram (ECG) for patients over 40 years. The APA also notes that some authorities suggest a complete blood count.

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Following initiation of treatment, the APA notes that the frequency of monitoring of levels depends on the individual patient’s situation, but should be no less than every 6 months for stable patients. The frequency of monitoring should be based on the stability of levels in the individual patient and the degree to which the patient can be relied on to notice and report symptoms. The APA recommends that kidney function should be tested every 2 to 3 months for the first 6 months of lithium treatment and then every 6 to 12 months in stable patients. The roundtable participants endorsed most of the APA recommendations; however, no consensus could be reached on the use of ECGs in men over 40 years. Some participants felt that ECGs had little value as a screen in this context; others felt that it would be problematic to obtain ECGs in smaller jails. Recommendations • Pretreatment workup should include evaluation of kidney function (creatinine and blood urea nitrogen), thyroid function tests, complete blood count, and pregnancy testing for female patients. • A lithium level should be drawn 10 days after implementation of treatment and following any change in dosage. • In jails, a lithium level should be drawn every 3 months at a minimum, even if there have been no dosage changes and the levels have been stable. • In prisons, if there have been no changes in dosage and the levels have been stable for at least two successive quarterly tests, then the subsequent tests can be performed at 6-month intervals as long as they remain clinically stable. ❍ Pretreatment workup: ❍ Kidney function ❍ Complete blood count ❍ Thyroid function ❍ Pregnancy testing ❍ History and physical examination ❍ Monitoring levels: ❍ After any change, level needs to be checked within 10 days ❍ Routine monitoring ❍ In prison, every 3 months for two checks; if stable, then less frequently ❍ In jails, every 3 months ❍ Monitoring laboratory tests: ❍ Thyroid function and kidney function should be checked each quarter for 6 months (twice) ❍ Thereafter, yearly unless greater frequency is clinically indicated ❍ Documentation—According to the APA guidelines, there should be an affirmative statement in progress notes that indicate labs, evaluation for presence of side effects and toxicity, and other clinically relevant data.

Valproic Acid Valproic acid is often prescribed for the treatment of bipolar disorder and, increasingly, to manage patients with impulse control problems. In comparison to lithium,

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it has a wide therapeutic index. The most common problems associated with valproic acid treatment are sedation and gastrointestinal distress. Valproic acid may cause hepatic transaminase elevations (suggesting liver abnormalities) and, less commonly, leucopenia (low white blood cell count) and thrombocytopenia (low platelet count). The APA recommends that a general medical history be taken, with particular attention to liver, blood, and bleeding abnormalities (APA, 2002). Prior to initiation of treatment with valproic acid, the APA recommends baseline liver function and hematologic testing. The APA did not make recommendations regarding measurement of drug levels or other laboratory values after the onset of treatment. However, the APA guidelines indicated that most psychiatrists perform blood and liver function tests at a minimum of every 6 months. The roundtable participants took note that chronic viral hepatitis C is prevalent among the jail and prison population, placing them at greater risk for hepatotoxicity from valproic acid. The consensus, therefore, was to require routine monitoring following the initiation of treatment. Recommendations • Prior to initiation: ❍ Complete blood count ❍ Liver function ❍ Pregnancy, in females • Monitoring of labs: ❍ Liver function every 6 months for 1 year, annually thereafter ❍ Levels should be checked within 30 days of any change in dose ❍ All laboratory results should be acknowledged in physician’s progress notes

Metabolic Syndrome Antipsychotic medications, particularly the second-generation medications, have been implicated in the patients’ development of a metabolic syndrome. The metabolic syndrome is characterized by weight gain, insulin resistance, and hyperlipidemia. The APA has issued guidelines regarding the monitoring of lipids, glucose, weight, and body mass index (BMI), which the roundtable participants adopted in its recommendations. The APA recommends that vital signs be monitored as clinically indicated; the roundtable participants believed that some level of performance should be specified for patients in jails and prisons. Recommendations • For anyone on antipsychotic medications, weight should be checked at baseline, then monthly for 3 months, then quarterly thereafter. Body mass index should be calculated at least quarterly. • Lipid profile recommended for anyone on antipsychotic medications: at baseline, 12 weeks, and every 5 years thereafter.

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• Glucose testing for second-generation antipsychotic medications: fasting blood sugar at baseline, 12 weeks, and then annually. (In facilities where fasting blood sugars cannot be assured, A1c hemoglobin is a viable alternative.) • Vital signs initially, at 2 months, then quarterly.

Suicide Prevention The roundtable participants all recognized the importance and the challenges of preventing suicides in jails and prisons. There was agreement that suicide prevention required a comprehensive approach, with involvement of correctional administration and custody staff as well as the health care team. The National Center on Institutions and Alternatives has elaborated a framework for suicide prevention that encompasses all facility staff. This approach was strongly endorsed by the roundtable participants. There was considerable discussion regarding how specific performance measures could be, given the current state of the art regarding suicide risk assessment. It was agreed that it was possible to articulate accepted, measurable standards for assessment in correctional settings. Following a serious suicide attempt, as defined by policy, it was agreed that there should be standards for the morbidity and mortality review. It was agreed that several areas should be covered by the review, even though it is not possible to articulate a reliable way to review the quality of the process. Recommendations • There should be universal screening at the time of arrival at the facility. An empirically validated measure, such as the Brief Jail Mental Health Screen suicide mental health screen should be employed (Steadman, Scott, Osher, Agnese, & Robbins, 2005). • All patients who screen positive should receive a referral to a mental health staff member for evaluation. All inmates deemed to be an acute risk should be placed on suicide watch immediately and be immediately referred to the mental health team. • All screeners and all staff in direct contact with inmates should receive training regarding suicide in inmates. Training logs should be kept for all contact staff. • Morbidity and mortality reviews should be conducted for all serious suicide attempts. The reviews should include an assessment of the following, at a minimum: ❍ Suicide watches (if applicable): Were logs kept as defined by policy? ❍ Were assessments and orders done within time frames specified by policy, by the disciplines and teams required? Assess adequacy of documentation. ❍ Review of the referral process. ❍ Sample negative screens: Were significant cases missed? ❍ Sample positive screens: Were appropriate referrals made and accomplished in a timely manner? ❍ Was evaluation of the index case adequate? ❍ Was communication among responsible individuals adequate in the time period leading up to the event?

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Treatment Planning All roundtable participants agreed that treatment planning should meet basic standards. It was agreed that providing detailed specification of treatment planning was beyond the scope of our task. Correctional institutions operate several kinds of treatment settings: inpatient, residential (step-down or intermediate), crisis care, and outpatient. The level of detail in treatment plans should be based on the level of care and, to the extent reasonable, should correspond to those found in similar civilian settings. Recommendations • Everyone who is placed on the mental health case load should have a treatment plan. • Basic standards for treatment plans should be evident in the documentation, including the following: ❍ Written plans based on clinical assessment and the correctional environment, documented on a separate, easily identified form; plans should be documented on a separate, easily identified form. ❍ Caregivers should be identified, reflecting multidisciplinary input. ❍ Treatment goals should be specified. ❍ Interventions should be specific. ❍ Follow-up should be specific. ❍ Treatment plans should be individualized. ❍ Plans should reflect the length of care and transition to the community. ❍ Plans should reflect patient involvement. ❍ Planned disposition should be specific for those nearing discharge from custody: ❍ All plans should be periodically updated. Updates should occur as specified below: ❍ Outpatient: at least annually ❍ Crisis: at least weekly ❍ Residential: initial plan within 1 month; thereafter, at least quarterly ❍ Inpatient: acute weekly; long-term, quarterly

Sleep Medication A common problem in correctional settings is the prescription of sleeping medications. Many correctional facilities are noisy and some inmates may have a legitimate problem sleeping. However, prescription drugs—especially sedative ones, such as sleeping medications—are often misused, hoarded, and trafficked in these settings. The roundtable participants expressed concern about the widespread and chronic use of these medications in the face of authoritative evidence that they are only effective for short-term problems. Recommendations • Sleeping medication should only be prescribed when there is a clear diagnosis that warrants treatment, such as a sleep disorder, or short-term (30 days or less) treatment of depression-related sleep disturbance.

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• Sleeping medication may be used on a short-term basis for bereavement. • Long-term treatment should be rare and the necessity of treatment should carefully be documented.

Conclusion The primary finding is that the roundtable format was extraordinarily successful: PCHCPs—with the participation of psychiatric consultants and academics—were able to reach consensus on a number of performance measures that ranged across the gamut of correctional mental health care. In some respects, perhaps, this is not surprising. The participants, who were very experienced in providing services, consulting, and managing health care services in jails and prisons, undoubtedly drew from a common set of experiences, frustrations, and concerns in forming their views about quality mental health care. If PCHCPs could reach consensus so readily, one might wonder why mental health care is so deficient in some correctional institutions. The group agreed that substantial compliance with the performance measures outlined in this article would markedly improve the quality of health care in the majority of jails and prisons in the United States. The answer, of course, is that there is an important difference between establishing measures and achieving compliance. Problems in any one of the following may undermine quality, regardless of the articulated performance expectations: recruitment and retention of professional staff, implementation of quality management programs, creation of adequate information technology systems, adequate funding, and establishment of effective working relationships with correctional administration and staff. Although performance standards may be but one link in the chain to quality care, they represent a critical link. Contrast the correctional health care system with the health care in the community. In community institutions, care is heavily regulated and monitored by a number of accrediting bodies and oversight agencies, holding them to increasingly evidenced-based standards of performance. There are several reasons for this. Large payors (private and public) pay for a substantial amount of care in the community. These payors understand the nature of health care services, have a strong stake in improving quality, and can wield significant power over providers to achieve their goals. As a result, they are able to require adherence to standards through accreditation and oversight. Insurers have also promoted the dissemination of information regarding health care outcomes and other quality measures, with the hope that people will shop for the best providers of care. Correctional health care, though improving, still does not meet the community standard of care. Moreover, stakeholders in correctional health care have not yet achieved the power and organization necessary to require universal adoption of evidenced-based standards of performance. In many jurisdictions, performance expectations behind bars are set by the local correctional administrators and/or legislatures, who often are inexperienced with the

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complexity of health care delivery in general, not to mention the even more complex environment of corrections. In addition, the budget process often has a large influence on how the performance expectations are established and how “quality” is defined for health care service delivery behind bars. If the request for proposal is poorly defined or asks for too much additional input or alternative proposals, correctional leadership and regional legislative representatives can become quickly overwhelmed by the variety of proposals they receive with differing levels of cost-effectiveness married with the promise of quality health care delivery. The net result is that the expectations for health care performance in jails and prisons are often a matter settled between the correctional administrators, local legislative leadership, and, often, the private vendors. Although many state and local officials set out seeking “quality care,” they often find themselves bound by fiscal constraints and contracting rules that drive them to the lowest cost provider. Quality of care becomes an afterthought. This unintended outcome is exactly what the budget process and the request for proposal procedures are programmed to achieve. The PCHCPs universally agree that better, more specifically delineated performance measures focused on improved clinical outcomes and issues will improve the quality of health care. Of course, there is no single innovation that will result in high-quality health care in correctional settings; the existing problems are systemic and multifaceted and will require a broad front of changes in the status quo. Basically, what is required is that correctional agencies make a strong commitment to providing high-quality care to prisoners, on par with the level of commitment held by large payors in the community. These payors are similar to correctional agencies in their desire to reduce health care costs, but they have recognized that the path to efficient, humane care requires attention to quality, not simply a narrow focus on costs. Governmental agencies responsible for the contracting of services for correctional health care must accept that quality care involves performance measurement, accreditation audits, and related functions that carry costs to the PCHCPs and themselves. These are worthy investments. This article summarizes the effort to define standards for mental health care in correctional settings. In our view, the establishment of industry performance standards is a necessary step toward improving the quality of services. This is a challenge for government agencies. What is envisioned is a marketplace where PCHCPs are expected to adhere to the industry standards. This would raise the bar, helping to ensure better patient outcomes consistent with community standards.

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