Good afternoon everyone, we're about to start the next session. At this time I'm going to go ahead and introduce Dr. Lynn Thickem, who came to Texas Department of Criminal Justice as a United States Public Health Service National Health Service Corps physician. She was first assigned to Huntsville Prison Facility in October 1986, where she served as the Unit Health Authority for two years. She advanced to Central Region Health Authority in 1988, and subsequently opened the Estill Unit Central Region Medical Facility. She's earned a bachelor's degree from Smith College in Northampton, Massachusetts, and a medical degree from the University of Maryland School of Medicine. She's board certified by the American Board of Internal Medicine. She's a fellow of the American College of Physicians and an advanced certified correctional health professional. Dr. Lynn Thickem is also well known nationally for her expertise in correctional health care. She has authored several articles and a chapter in a correctional medicine textbook. She's formerly served as the chair of the American Correctional Association Commission on Accreditation for Corrections, vice chair of the American Correctional Association Standards Committee, and she served as the first co-chair of the American Correctional Association's Correlation of Correctional Health Authorities. She also served on the executive committee of ACA as the treasurer for about two years and president-elect, president of ACA, and immediate past president. In her capacity as a health services division director, she oversees the delivery of medical, nursing, dental, and behavioral health services to more than 130,000 inmates in 100 correctional institutions across the state of Texas. Dr. Thickem, if you could welcome her to this podium. Good afternoon. Thank you so much for that wonderful introduction and welcome all of you who are not native Texans to the great state of Texas. I hope you all have been enjoying your visit thus far. So I'm going to just spend a few minutes giving you a sort of overview of the Texas Correctional System. We are the largest state correctional system in the country. The Federal Bureau of Prisons has more inmates than Texas, and so by count, the Bureau of Prisons is actually the largest. So just a little bit about myself. I'm a native Marylander. I was born and raised in Baltimore. And you say, well, how did you end up in Texas? I've been in Texas for 38 years. Oh, okay. I was in medical school. I was part of the United States Public Health Service, National Health Service Corps. And when I finished my residency training in internal medicine, oh, I can't hear it. Maybe I should use the microphone. Is that better? Okay. So when I finished my residency training, they matched me to the state of Texas. And boy, was I upset. I was like, Texas? I don't know anybody in Texas. I'm an East Coast girl. And I didn't have any family here, no friends, but I came because I didn't want to be in default. And so when we got here, it was about 20 docs that got assigned to Texas. And the Texas Department of Corrections, as it was called then, was in a major class action lawsuit, a very famous lawsuit in corrections known as the Ruiz lawsuit. In fact, it was the largest, it was the longest running class action lawsuit in the history of corrections. We were under the auspices of a federal judge out of the Eastern District of the United States Federal Court in Tyler, Texas. His name was William Wayne Justice. And so we were under the jurisdiction of Judge Justice from 1972 to 2002. So what's that, 30 years? We were under federal oversight. And the Ruiz lawsuit basically transformed the Texas Department of Corrections. When I came, everything about the Texas Department of Corrections was declared unconstitutional. The conditions of confinement were horrible. The healthcare was almost non-existent. They had army medical corps people who had served as corpsmen in the army doing all the healthcare. There were no nurses. So when the 20 docs that were assigned to the Texas, to the state of Texas from the National Health Service Corps, they sent all of us to prison. So none of us went to community health clinics in Houston or Dallas. The commissioner of health at the time in Texas says, no, we're going to put them all in TDC because the state's under this big federal lawsuit and they're paying all these fines. So that's how I got to TDCJ. So let's see if this is working now. So this is our mission statement to provide public safety, to promote positive change in inmate or offender behavior, to reintegrate offenders into the community, and we also, in our mission statement, we assist crime victims. There we go. So when I came, the Texas Department of Corrections ran its own health services. All of the healthcare, employees, everything was run by the department. So as a result of Ruiz and all of the terrible conditions of confinement, it mainly was related to overcrowding. There was a lot of overcrowding. A lot of convicted felons were backed up in county jails waiting to come into the system, but there was no room. So there was a massive building campaign. When I came, there were about 60,000 inmates statewide. And at our peak, right before COVID, we had 154,000 inmates in a hundred different institutions across the state. So as this massive building started to occur, and they started putting prisons all over the state of Texas, all the way up in the panhandle to New Mexico, Oklahoma border, down to literally to the Mexico border. So this massive building, and these prisons were being put in medically underserved areas and health professional shortage areas. And so we were, by the time I came around in 1986, there was still great challenges in recruiting and retaining healthcare staff, all kinds of healthcare staff, nurses, doctors, advanced practice providers, mid-levels, PAs and nurse practitioners, and just ancillary healthcare staff. So I said, what the state leadership said, we've got to do something about this. I mean, we've got to build these prisons. We've got to get all of these convicted felons out of the county jails, and we've got to bring them in. But we can't provide the healthcare. And why this was important was Judge Justice had created what is called a special master's office. And the master's office really had oversight of the day-to-day operations at the prison. And the master's office had appointed a physician from Baylor College of Medicine, who served as the physician monitor for healthcare. And the court came up with a plan called the Comprehensive Healthcare Plan, where they looked at all of the units in TDCJ, and unit by unit, they created a staffing plan for each unit. And TDCJ had to adhere by court order to those staffing plans. Well, they couldn't do it. And so Judge Justice imposed fines. So as long as we were out of compliance with the staffing levels that we were supposed to have at these units, there were fines imposed on the agency. And the agency spent millions and millions in fines. So with all of this as a background, this really led to us moving to this system that we call Correctional Managed Healthcare. So again, I've kind of summarized it for you, but the key influences were the unprecedented expansion of the criminal justice system capacity, you know, that we went up to 100 units. And then, of course, the state was experiencing some fiscal challenges as well, budget resources. Right. And that's the same thing there. So other factors that contributed to the need for change was, of course, healthcare costs were rising. We were seeing unprecedented numbers in inmates with infectious and communicable diseases, particularly HIV, AIDS, and TB. The prison population was aging. That was a big factor. There were difficulties in recruitment and retention. Let me just go back to the aging of the prison population. It was during the time that the three strikes you're out law. So, you know, people that were getting sentenced were getting sentenced to very long prison sentences. And then there was prison litigation, the Ruiz lawsuit. And then the university medical schools found themselves in a position where they had a shrinking patient base and limited opportunities for teaching in their various components of their medical education mission, their nursing school, their PA school, their medical school. And then the last factor in Texas, in West Texas was more sparsely populated. And in some areas, there was one community hospital in a hundred mile radius. And many of the rural hospitals were in danger of failing fiscally because they couldn't compete. And because it was so not very populated, then they were really having some issues of keeping their doors open. So, the comptroller of the state, who was John Sharp at the time, began doing a number of performance reviews. And he concluded in this report against the grain that was published in January of 1993 that a managed care health system should be established for inmates of the Texas Department of Criminal Justice. And then he also concluded that the system should be governed by a board comprised of officials from TDCJ, which is the prison system, and two of the state academic health sciences centers, the University of Texas Medical Branch and the Texas Tech University Health Science Center. The state auditor came that same year and did a follow-up audit on TDCJ health services review. And they agreed with the comptroller's report and against the grain that the state should develop and implement a comprehensive managed health care plan with the hope that the health care costs, which were spiraling due to all of the mandates of the Ruiz court and also the fact that we were just growing by leaps and bounds, that we needed to try to control some of those costs. So what is correctional managed health care? How do we define it in Texas? It's a strategic partnership between the Texas Department of Criminal Justice and two of the state academic health science centers, the University of Texas Medical Branch at Galveston and the Texas Tech University Health Science Center. Those are the three state entities. All three are funded by our state legislature that came into partnership with this initiative. We're focused on a shared mission, which is to develop a statewide health care network that provides TDCJ inmates with timely access to a constitutional level of health care while also controlling costs. How many of you know what I mean when I say constitutional level of health care? Okay. All right. I'll fill you in. All right. So Texas, again, on the national front, there was a landmark case in 1976. The case was filed, Estelle versus Gamble. William Estelle was the director of the Texas Department of Corrections. Some of you went on a tour of the Estelle unit. Yes. That's named after him. Okay. And so Gamble was an inmate on one of the units that's about, I don't know, six miles down the road, the Ellis unit. Oliver Gamble was his name. So this case, Estelle versus Gamble, went all the way up to the Supreme Court. The issues in the case was a bale of hay fell on Gamble, and he sustained some sort of orthopedic injury, right? He was seen, I believe, a total of 18 or 20 times. Dr. Ojo will get into the case a little bit. But certain things were not done for him, but he had access to health care. So to basically summarize, the Supreme Court, in looking at this case, surmised that deliberate indifference to a serious medical need of an offender constitutes the warning infliction of cruel and unusual punishment. And under the Eighth Amendment of the United States Constitution, an individual has the right to be free from cruel and unusual punishment. So from that case, three basic rights evolved for inmates, prisoners. These are rights that you and I, as citizens, do not have. The first right is they have the right to access care. The second right is they have a right to a professional judgment, meaning they have a right to be assessed and evaluated by appropriate credentialed staff. When I first came to Texas, you had all kinds of people practicing medicine without a license, literally. So they have a right to a professional judgment. And the third right is they have a right to receive care that has been ordered. So the Department of Correction and the state has to provide access to care. They have to provide appropriately credentialed staff to see and assess and evaluate patients. And then they have to deliver that care, have to have enough resources, budgets, et cetera. So that's Estelle versus Gamble. Every Department of Corrections across the country, the Bureau of Prisons, we all fall under that. It's a landmark case and it governs. And most of the lawsuits, you hear that prisoners are very litiginous. They are. I guess I'm the third most sued person in the state of Texas. My name is on every health care lawsuit. But these are not tort claims. They're not malpractice lawsuits. They're civil rights. They're alleging deliberate indifference to their serious medical need under the Eighth Amendment. So you have these three state entities, the prison systems and two state medical schools that were ordered to come together and put this Correctional Managed Health Care Plan in place in the state of Texas. And then all of this was codified in statute. And what they did is they created a Correctional Managed Health Care Committee that your esteemed colleague, Dr. Mills, was part of our committee at one time when the University of North Texas was in membership at the committee. So this is a map of the state of Texas and it shows where all of our prison units are located. Everything to the west of that line is in the Texas Tech sector. So they have about 25,472 inmates. This is a little dated in their sector of the state. And then the University of Texas Medical Branch had 111,000. They had the line shared. The split is about 80-20 between UTMB and Texas Tech. So the Correctional Managed Health Care Committee, this is how we are organized. Of course, the governor of the state and the legislature that passed the legislation. The governor appoints several of the six of the members of the Correctional Managed Health Care Committee and then the three state entities that have to implement and operationalize the program. So here's the statutory authority. It was passed in 1993 as Senate Bill 378. It's now codified in the Texas Government Code, Chapter 501.131, in case any of you want to look that up. And it establishes a 10-person committee. One member employed full-time by the department, which is TDCJ. That member is appointed by the executive director. And one thing I'll say about that, you notice as we'll go down in the statute, it requires certain members to be physicians. But the TDCJ member is not required to be a physician. But guess who's the member? I got appointed to be the member for TDCJ. Then the next one is a member who has to be a physician and they are employed by the University of Texas and they're appointed by the University of Texas president. The next member has to also be a physician and is appointed by the Texas Tech president. And then you have two other members. So far in the statute, you're getting four mandated positions that have to be physicians. So two members who are physicians, each of whom is employed full-time by a medical school other than UTMB and Texas Tech appointed by the governor. And that's how Dr. Mills became a member. The University of North Texas was up for appointment. And so he was the physician member appointed from the University of North Texas. We began with, the governor went alphabetically. So the first two appointees were from the Texas A&M, University Health Science Center and the Baylor College of Medicine. And then we had the University of Texas Dell Medical School, which is in Austin, was the second round. And I believe Dr. Mills was in that round. Okay. And then the next, so we've got 1, 2, 3, 4, 5 so far, right? And then we have two members also appointed by the governor who are mental health professionals. Now these mental health professionals don't have to be psychiatrists, but one of them happened to be a psychiatrist. The other one is a licensed professional counselor. And then the governor appoints two public members who are not affiliated with TDCJ, that's the department, or with any of the contracting entities, that means UTMB or Texas Tech. And at least one of them is licensed to practice medicine in the state of Texas. That person or that appointee is actually appointed by the governor as the presiding chair of the Correctional Managed Health Care Committee. He's independent from UTMB, Texas Tech. He actually works for Baylor Scott & White. He's an emergency medicine physician. His name is Dr. Robert Greenberg. He's our chair. And then the state Medicaid director appoints the ad hoc non-voting member, ex officio, that also helps us with costs. And really the main charge statutorily for the committee is to establish a statewide provider network, which they actually delegate that down to the two universities. And they establish also all of the policies and procedures for our program. And there's some other functions that they perform that I'll get in shortly. But one of the charges in statute is that the legislature and the governor wants us to try to maximize the use of state medical schools to the extent possible, rather than contract with private vendors. So these are the Correctional Managed Health Care members. Dr. Greenberg, our chair. The current two medical schools that are on the committee are Texas Tech El Paso. Dr. Edwards is an internist. And then we have the University of Texas Houston Health Science Center, the McGovern Medical School. Dr. Julia Heiner, she's a geriatrician, a geriatric internist. And then we have Dr. Burris. He is a psychiatrist. He's one of the mental health appointees in private practice. We have one position vacant. The other public member besides Dr. Greenberg is Chris Coons, who worked in health care administration. And then there I am for the TDCJ representative. Dr. Philip Kaiser is the UTMB representative. He's also the public health authority for Galveston County, Texas. And then Dr. Cynthia Jumper, who is vice president of governmental affairs and professor of internal medicine at Texas Tech University Health Science Center. So this 10-member committee is the oversight committee for health services in the department. So here are the roles and responsibilities. The committee does all of the clinical policy oversight. All of the policies that we promulgate are promulgated under the umbrella of the correctional managed health care committee. So we have a big general policy and procedure manual. We have an infection control policy and procedure. We have pharmacy and therapeutics. We have therapeutic diets. You know, we have a lot of policies and procedures. And the way that works is we have joint committees that have representation from UTMB, Texas Tech, and from my division, the health services division. And we all work collaboratively together in developing and promulgating policies. And then those policies go up through what we call the joint medical directors group, which is the medical director for UTMB, which is Dr. Owen Murray, the medical director for Texas Tech, Dr. Denise DeShields, and then finally to me, the medical director for TDCJ. And then once we sign off on them, then it goes to the committee for adoption. All right, so the other things that the committee does, they do a liaison activities, especially with the Board of Criminal Justice. There's a Texas Board of Criminal Justice. There are nine members, all appointed by the governor of the state. They have oversight of our agency. And so Dr. Greenberg goes to their meetings. He gives reports on the status of the health care in the agency. So those are some of the types. They advise the board. If the board were thinking about constructing a new prison somewhere or a new mission, it's the job of the committee to instruct the board how health care would be impacted. They also assist us during the legislative session when we go and have to ask for a budget. TDCJ has a very large budget, $6.3 billion. Our budget is a two-year budget. The health care portion of that is $1.7 billion. So health care is the largest line item in the TDCJ budget. So it's lots of dollars. And then the committee is involved with establishing procedures for oversight of our quality of care monitoring, which both the universities and my division do jointly. We jointly monitor the quality of care. And then they have dispute resolution. So if I get mad with Dr. Ojo at UTMB and we can't resolve it, not necessarily Dr. Ojo, but his boss, Dr. Murray, the medical director, then the chairman comes in and arbitrates our dispute. And if he can't do it, then it goes before the full committee and whatever the committee decides is binding on the parties, on TDCJ, UTMB. Same thing if UTMB and Texas Tech have a disagreement, they are the dispute resolutors. So the university providers do the entire continuum of care, unit-based care, specialty care, hospitalizations. They do pharmacy, all the pharmacy services, our behavioral health services. I'm sorry that's repeated there twice. They do our utilization review and utilization management. They arrange all of the provider network of community hospitals. If you remember that map with a hundred prisons, we can't send everybody down to Galveston to our prison hospital. So UTMB has about a hundred and forty-eight hospitals and their provider network of hospitals across the state. If we have emergencies on our prisons and we have to transfer somebody to an emergency room, and even on occasion they have overnight stays or short hospital stays. So UTMB has arrangements with all of these hospitals in their sector of the state. And then Texas Tech probably has 49 hospitals in their provider network. They're involved with me. Statutorily, I have in that government code, there's a section 501.150 that specifies what the department must do. And one of the things that we have to do is ensure access to care because that gets back to the constitutional standards with Estelle versus Gamble. We conduct compliance audits or periodic audits at the medical units and we monitor quality of care in cooperation with the university. So we have a statewide QIQM plan that we jointly develop. The chairman of the committee signs off on it and we do a lot of quality monitoring together. The university providers do provide a limited amount of employee health services to TDCJ employees on the units. You know, sort of first aid, emergency care type thing, but nothing like a real employee health. And then these are all the things TDCJ does. All of the money comes to TDCJ. The health care budget is in our budget. It's a line item in our budget and we do all of the contracting with UTMB and Texas Tech and the resource allocations to them. We take the lead with the legislature in terms of the legislature appropriation requests, the LAR, to ask for funding for health care along with the rest of our agents. We do all the contract coordination and then those monitoring activities there are really what my division does. And then we have another division called business and finance that do all of the financial monitoring. We have an office of public health within my division that we did not contract to the university. So we are the liaison with the Department of State Health Services. We do all of the reporting in all the surveillance with infectious communicable diseases to what we call DSHS, the Department of State Health Services. And then we have office that says the health services liaison. There are 254 counties in the state of Texas. We intake inmates from all 254 counties. Prior to COVID, our annual intakes were about 66,000 a year. I have an office that's health services liaison office and now I have a mental health services liaison office of all registered nurses and they work with those 254 counties on a daily basis, intaking inmates with special medical or mental health needs. So for example, I'll give you an example. If there's an inmate in the county that's on dialysis, we have to schedule his intake in so there's continuity of care. There's no break. These nurses work with the county jails to schedule when PDCJ will intake that person so there's no disruption in their dialysis. If say Harris County Jail down in Houston has an inmate that's state-ready, meaning the prison system has to take him, our time is up, he has to come to prison and say he's in Ben Taub Hospital or the Houston Medical Center, then these nurses along with, we usually involve Dr. Ojo, sometimes I'm involved, we coordinate the transfer of that inmate from Ben Taub Hospital to our hospital in Galveston so that TDCJ legally accepts them when we have to. So it's a lot of that. Active TB, you know, we get involved in all kinds of coordinating. And then people who are acutely psychotic, we get the mental health services liaison nurse, which is our behavioral health nurse, gets involved in bringing those inmates directly into one of our inpatient behavioral health units. We have three of those. We have one in Lubbock called the Monfort unit, we have one up in Rust, Texas, the Skyview unit, and we have one in Sugar Land, the Scott unit. So we have 1,500 inpatient mental health beds. And then we have some more crisis management beds at one of our female units in Gatesville, Mountain View, and then we have one up in Amarillo in the Texas Tech sector that has crisis management beds. So it's very, very busy, you can imagine. We have sheriffs calling, you know, they all want to get rid of their high-dollar, high-cost inmates. They, you know, they'll call me, Dr., you know, this guy's costing me a fortune, you need to take him right now. And I'm like, I can't. I, you know, it's legal things. They have to be state ready, it's a pen packet, it's all kinds of things. Do you have a question? Okay. So we had a guy, he paroled out, he was on dialysis from the Estelle unit, he went to Galveston County. That night he was back in custody in the Galveston County Jail. The next day the sheriff's called me to get him. No, we can't get him that quick. He's got to go through the, you know, be processed. So that happens on a daily basis. I have irate sheriffs who want to get rid of these inmates that's costing them a bunch of money. All right, so why has this, what has been the benefit of this relationship with these academic health science centers for TDCJ? Well, one, it is allowed TDCJ to share the risk of providing health care, but I can't tell because my name is still on every lawsuit. The universities are on some, but I'm always on it with them. So the second thing is it's enabled and supported TDCJ's expansion into these areas that are medically underserved or health professional shortage areas. The universities, you know, it's much more attractive to work for a state university medical school than the prison system. You know, there's still a lot of stigma and a lot of misinformation, miseducation about medicine at the level of the state prison system. You know, a long time ago it was this idea that the only types of docs that work in prison were impaired or had restricted licenses or, you know, something's wrong. But you can see by the credentialing of me and Dr. Odo, we're board-certified internists, we're fellows of the American College of Physicians, and most of our docs are board-certified. Okay, so the other thing that the universities brought in is a more cost-effective model. They've created centers of clinical excellence where we have been able to cohort groups of inmates and really deliver services more efficiently. We have everything in TDCJ. We have hemophiliacs, so we have a center of clinical excellence for inmates with hemophilia. We have inmates that come in with solid organ transplants, that had heart transplants, lungs, pancreas, livers, so we created an area of clinical excellence for them. We have 46,000 inmates that have hypertension. We have 9,000 diabetics. I mean, it goes on and on. We have 22,000 inmates that are over the age 55. We call them our geriatric inmates because their physiologic age is about 10 years older than their chronologic age, so if they're 55, they got the physiology of a 65-year-old. We have 35,000 inmates on our outpatient mental health caseload, and that's really a tragedy in correctional medicine. The depopulation of the mental health hospital long ago, most of those people have ended up in the criminal justice system. That's why we've got 2,000, close to 2,000 inpatient behavioral health or psychiatric inpatient beds. All right, so let me try to hurry up and wrap it up. So that enabled cost-effective services and having academic health science centers deliver care to outpatients, out inmates, the same centers that deliver care to the citizens of the state of Texas has really overall increased the stature of our health care program. What have been the results? The results have been we've been able to increase our access to care. We have been able to improve the quality of care and to some extent control costs. The lessons we've learned, first and foremost, mutual respect is critical to our mutual success. The culture of an academic health science center and the culture of a correctional center is totally diametrically opposed, so we both had to make adaptations and understand each other. The joint process of establishing all of these joint committees, where we jointly plan and decide how the health care delivery systems would flow, it wasn't easy. It was challenging, but now we've got it down to a science and it works very well. There is also a need to have a clear understanding of each partner's role and responsibility. The medical school's expertise is in health care and health care delivery systems. The Department of Criminal Justice expertise is in maintaining custody of convicted felons, public safety. So once you can understand that those two dynamics and meld them, then things work well. And then you have to have tolerance for differences in organizational cultures is key. You know, the fact that TDCJ maintained a health services division, it would have never worked bringing the universities in solo without that, because we are the bridge, the liaison with the wardens, the correctional officers. You know, I can call any warden in the state and command the same respect from that warden as the prison director, because I'm part of their system, you know. And then developing, accepting, and fostering common goals is and was essential.

Correctional Managed Healthcare

Texas Department of Criminal Justice

Dr. Lynn Thickem

prison healthcare

University of Texas Medical Branch

Texas Tech University

Ruiz lawsuit