I'd like to introduce my colleague, Dr. Ojo. We are very, very fortunate to have Dr. Ojo. So Dr. Ojo is an Associate Professor of Medicine in the Department of Internal Medicine, and he is the Chief Medical Officer and Chief Physician Executive for the TDCJ Hospital in Galveston, Texas. We actually have a freestanding prison hospital on the campus of the University of Texas Medical Branch. It was built in 1983 using inmate labor. So it's the only hospital of its kind in the nation. Dr. Ojo received his Doctor of Medicine degree from the College of Medicine at the University of Lagos, Nigeria. He did postgraduate training in obstetrics and gynecology, residency at the William Harvey Hospital in Ashford, England, and he did an internal medicine residency at the Cook County Hospital in Chicago. Dr. Ojo is very enthusiastic about education and teaching. His passion is in the practice of evidence-based medicine, inpatient medicine, and teaching rounds, as well as bedside physical examinations. Dr. Ojo has been nominated several times for the Department of Medicine Excellence in Teaching Award. In 2005, he received the inaugural John P. McGovern Award from the UTMB McGovern Academy of Oslerian Medicine for modeling the ideals of compassion, scientifically sound patient-driven care exemplified by Sir William Osler. Dr. Ojo currently serves on many educational committees. He's board certified in internal medicine as well as hospital medicine. And I present to you, my colleague, Dr. Ojo. And at this time, we just want to also award Dr. Ojo. The Dr. John Mills has a long and distinguished career of service to his country, medical education, his profession, and our college. He served as a helicopter pilot in Vietnam and is a 1979 graduate of the Michigan State University College of Osteopathic Medicine. His MPH is from the University of Michigan and he also holds an MS in anatomy from Michigan State University. He completed a residency in aerospace medicine in 1983 and currently serves as an associate professor of community medicine at the University of North Texas Health Sciences Center. He maintains board certification in preventive medicine, correctional medicine, and aerospace. Dr. John Mills is a founding member of our college and has been a loyal and contributing member throughout its existence. His involvement has included service as division chair of aerospace medicine, residency inspector, chair of the education evaluation committee, trustee, and was a college president in 1993. He has been recognized as a fellow in the college and as a distinguished fellow. He also served on the American Osteopathic Board of Preventive Medicine and as a member of the AOA postdoctoral training and review committee. Dr. Mills worked tirelessly on the graduate medical education program standards for fellowship training in correctional medicine. He wrote many test questions for the certifying exam and was recognized as the founder of correctional medicine. By the college in 2014, he has traveled extensively meeting with other correctional medicine physicians, provider groups, and regulators to raise awareness of our efforts to provide an educational home for correctional medicine professionals. He epitomizes the word ambassador. In 2015, AOCOPM honored Dr. Mills by beginning the John Mills commemorative lecture in correctional medicine. So at this time to just award the commemorative lecture correctional medicine award to Dr. Ojo. I learned something really interesting about Dr. Ojo. I've told this story a lot about Dr. Mills. The board and the AOA Committee on Jurisdiction, when he granted us authority to begin correctional medicine as a discipline, they said, you know, I know it'll take y'all two or three years to create an item bank. And John went and held himself up in a hotel somewhere in Galveston and wrote most of the test questions within a few weeks. I didn't know Dr. Ojo was part of that effort as well. So he wrote a lot of your items that's now in the correctional medicine exam. And for that, sir, we all thank you. All right, good afternoon. How are we doing? Well, welcome to Texas for those of you who are here for the first time. The Texas Houston Livestock and Rodeo is ongoing right now. So if you'd like to tuck your legs, there's one waiting for you. Oh, he did? All right. All right, so I'm gonna start with, I like Aristotle a lot. He said here, excellence is never an accident. It is always a result of high intentions and say effort, intelligence, execution. In other words, we've gotta be intentional about excellence. Doesn't just happen with happenstance or wishing. All right, so that's the objectives for today. All right, did you guys know this? Show of hands, I was aware of this. It's a shame, isn't it? We're in 2024 in the greatest nation in the world and we're still seeing this. Okay, real quick. I'm gonna talk about some things nationally and then come to Texas and then come to Correctional Care and then come to UTMB. So on this slide, a couple of things. The things in blue, national. The things in red are germane to the state of Texas. So you can see Dr. Lindicombe talked about the Eighth Amendment and all that that happened in 1789. The famous Estelle versus Gamble case that really set the tone about how healthcare was gonna be delivered to inmates nationally. And then the eighth wonder of the world, Hospital Galveston, the TTCJ Hospital and Clinics was built in 1983. And then in 1994, like Dr. Lindicombe said, the state of Texas coined Correctional Managed Care. All right, so I was gonna go into the Estelle v. Gamble case but I wouldn't do it. Dr. Lindicombe has done a good job of it. The cost of care is no reason, it's not an excuse why these guys should not get the care that they need. All right, there are different models about how healthcare is delivered in prisons. There's a hybrid model. There's a model where the Department of Correction for the state does it. And then there's a Texas model where academic medical centers are delivering the healthcare. There are only two states in the nation that do what we do in Texas. It's Texas and New Jersey. Georgia used to do that as well, but it changed. Obviously, there are benefits, there are pros and cons for each. All right, so I'm gonna bring it home, Texas. You saw this slide with Dr. Lindicombe, Correctional Managed Care in 1994. The state of Texas faced with rising healthcare costs and quality and the oversight of a federal judge decided to bring this managed care experience to it. And it has really, really worked. There are three big players, TDCJ and the two academic medical centers working together to ensure these guys have constitutionally adequate access to care. Again, map of Texas, you see all those dots are prison units. To the east are the folks who come to UTMB, my university. And to the west are folks who go to the Texas tech sector. What do we have? We have 1,500 mental health in acute inpatient facilities. We have regional medical facilities. All primary care and psychiatric care and nursing care is done at the prison units. And those of you who went to Estelle, the walls and board unit, you would have seen that yesterday. We have infirmary beds, we have sheltered housing units, you name it, we have it. And then obviously we have the flagship hospital, Galveston, if I can find it, right there. And I'll talk about it as we go on, obviously. All right, that's our census. Like Dr. Lincoln said, prior to COVID, we had about, at our max, there were 154, 155,000 inmates in the state of Texas. We are actually now number one in terms of state correctional prison volume, not a thing we're proud about, but it is what it is. So, but we've dropped since COVID, but we continue to have a cohort of patients whose numbers are going up. Patients who are 55 and older. That number is about 20, almost 20,000 now. And you guys know, like Dr. Lincoln said, even though they're 55, they behave 10 years older. And these are guys who are heavy utilizers of healthcare resources. So that's one of our cost areas in Texas. And you can see our mental health numbers. All right, I'm gonna bring it home to UTMB. You can see, again, that contract was signed in 1994. You can see the partners. In our sector, we sit about 80 facilities. Just currently, our population of inmates in our sector, obviously, is just under 110,000. We have just under 3,000 employees. And the second largest dialysis center in the state of Texas from uncontrolled hypertension and diabetes prior to these patients coming to Texas. A lot of things are done at the unit level, primary care. And we have a lot of hospitals, obviously, that we partner with to ensure these patients get acute care services when they need them. Again, things that happen at a facility, telemedicine. Did I say telemedicine? In our sector of the state, we do just about 100,000. Well, they can't, they can't because what we do is statutory. The state of Texas has it in its statute that it must be done by UTMB and Texas Tech. So you can come as a UTMB president and think you can get away, I mean not really, not quite. You've got to go through the legislature. All right. One of the things I didn't say is I'm going to just show a couple of real life cases that we've dealt with. Question. We have some online viewers. Oh, OK. Yeah. The question. Go ahead. Yes. OK, so the question was, could the universities give us a notice that they wanted to terminate the contract? And the response is no, because it's statutorily mandated through appropriation riders on the Department of Criminal Justice Appropriations Bill that we shall contract with the University of Texas Medical Branch and the Texas Tech University Health Science Center for unit-based care. There's silence about tertiary care, specialty care, and hospitalization. So in theory, the department could put out a bid if we wanted to, or we could take a section of the state or something. But the universities provide the entire continuum of care. And so because we're all funded by the legislature, UTMB's funded by the legislature, Texas Tech's funded by the legislature, TDCJ, we will follow the mandates of our state leaders. That's the politically correct answer. No, our contracts are all, they provide the entire continuum of care. Now I will say this, each universities have subcontractors. The model in Texas Tech is different from the model at UTMB. And remember that slide I showed you about endangered rural hospitals in West Texas? So when managed healthcare started, UTMB assumed all of the healthcare staff that TDCJ employed that was on the units. So one day they were TDCJ employees, the next day they became University of Texas Medical Branch employees. In West Texas, it was a little different. The rural hospitals, they have this Texas Organization of Rural Hospitals, TORCH. Many of them were in big financial problems because of the sparse populations. So the legislature wanted us to develop a model where we could save those hospitals for the community. So what Texas Tech does is they contract with some of these local hospitals and the local hospitals actually staff our units. That gives them a financial base to keep them solvent and open because they're gonna get their money every single month from the prison. They come over, they see all patients take care, ambulatory clinic setting, and then they have that as a solid financial infusion of cash, right? To keep them open. And then Texas Tech supplements that with providers. So for example, Abilene, we have a unit up there. The nurses, the unit health administrator, the medical records people, the clerks, all of those are employed by Hendricks Medical Center Community Hospital. But the providers are employed by Texas Tech, the dentists, the physicians, the advanced practice providers, the mid-levels, the PAs and nurse practitioners. But Texas Tech manages all of it. So the Hendricks Medical Center, the community hospital, is actually a subcontractor to Texas Tech. TDCJ just contracts with Tech and gives them the money and then they can subcontract out. Does that make sense? Okay. All right. Very nuanced, right? Very, very. I'm gonna share a couple of cases. I have a few of them scattered throughout this presentation. George Washington, 34-year-old male inmate has hepatitis C. And this was when, I put this together when the direct acting agent just came out. And you guys know they were above $100,000 for a 12-week course. And the question here was, should George be treated for hepatitis C, an inmate? And the price of the drug then was $110,000. Yes or no? Yes. So the answer is yes. The cost of therapy can never be an issue where they don't get treatment. So that was the teaching point there. All right, clinical services. What do we have? I can see our chronic disease numbers. We have just under 2,000 HIV patients, about between 8,000 to 10,000 diabetic patients. And you can see our cardiovascular numbers. We have a prevalence of hepatitis C of about 14%, which you guys know if you have hepatitis C long enough, you would have cirrhosis and HCC. And so you can see our hepatitis C numbers. If you walk in prisons in Texas or walk in my hospital, you will be very, very comfortable dealing with decompensated cirrhosis because that's like one of our bread and butter cases that we see on a regular basis. Yes, sir. Just under 2,000, the actual number is just under about 1,800. Yes. Yes. Our HIV positive patients statewide is, the number is 1,784. I can go back to that slide again. Oh, no, our current population is at 132,000. And actually we got more than that, about 134. We have 25 and 12. We've got 3,700 waiting to come in from county jails. So you can see- And we're going up. The judges have just started running all these courts post-COVID and they are sentencing people. Again, for ESRD patients, about 217. We have them in two centers of excellence, at Carl Young Unit in Texas City, and the Estelle Unit, which you guys visited a couple of days ago. You can see the cost per treatment compared to the cost in the free world. And you can see CVC reduction numbers. We try, our push is for fistulas and grafts on our patients and rather than PAMCATs and central line accesses. Mental health caseload, Dr. Lindicombe mentioned this. You can see our numbers over the years. We had a slight dip just prior to COVID and during COVID, but that number is coming up again. All patients who have cancer in our sector of the state are treated at UTMB. The only times we have to send them somewhere is when they need stem cell transplants, then we send them to MD Anderson because obviously for stem cell, you got to do more to be proficient at it. We have a very robust virology department that reports to me with all our HIV treatment, hepatitis C, hepatitis B. One of the things we're so happy about, we now do universal testing, opt-out universal testing for hepatitis C. One of the states in the nation who does that. So we're very, very pleased about that. And you can see, oh, you can see our SVR rates, 98% sustained virologic response for our patients. That's better than what any other community in the nation can show you guys. So- You can call up the state to start on treatments and think back to doing the things we've got on. Yeah, yeah. We are a public health model because we have a captive population. We can treat, we can educate and do prevention. So we definitely are one of those special populations, corrections of public health. Optometry, we do optometry exams, diabetic retinal scans, oculoplasticity. And all this happens at the prison units. You can see our volumes and numbers. Just last year we partnered with a private optometric company called IEC and they visit all our units and see all our patients and the partnership is working really, really well. Pharmacy, one of the big things in CMC, we dispense, our pharmacy dispense just under 5 million prescriptions on an annual basis. We have a centralized pharmacy. It's in Huntsville, just down the road and it dispenses medications to all the prison units in the state of Texas. We are very fortunate to be able to tap into the 340B federal program. And that really helps discounts the prices we pay for drugs. That 340B program saves the state of Texas over a hundred million dollars annually. Yep, so that's another benefit. That's why it's not going anywhere. That's why the legislature will not let UTMB pull out ever. But a little bit about the 340B program. UTMB as a university had 340B. Texas Tech does not have it, right? UTMB qualified as a disparate hospital because of the amount of indigent care they provide to counties. And so when they became the provider for 80%, our inmates became covered in the program. And so, yeah, they're saving us 200 million in pharmacy costs over a biennium. And actually in that statute, I cited, there's statutory language, that we have to maintain that, the committee. So our major cost drivers from a pharmacy standpoint, HIV, Hep C, psychotropic drugs, and all these programs really help us add to that, you know, 340B savings that the dollars that the 340B program brings to the state every year. We have a baby and mother bonding initiative that came into use in the state of Texas. That came into effect, I think about 10 years ago. Mothers who are low custody and have short sentences qualify for this program, but they have to be vetted. And they're allowed to leave, actually leave with their babies in a communal setting, somewhere in Houston. Works really well, I'm really proud. We're really proud of this program. It takes, we have a capacity of about 22 mothers on an annual, on a yearly basis. They receive all kinds of education and skills to help them transition better into the community when they're done. All right, another case. Yes, sir. How long do you have that program? Do you have any statistics on those children? Do those children do better than? I knew that question was gonna come up. We don't have statistics on the children, but we have statistics on the mother. They have one of the lowest recidivism rate in the state. They were actually in a residential setting in Houston at a place called the Santa Maria House, it's a hostel. They have other contracts there. They have, I believe, bearer prison contracts and some Harris County contracts. And our inmate mothers, they're still considered inmates and in custody, but they're allowed to live there. UTMB vets them or screens them for mental health and any medical issues. And then PDCJ does all of the custody. We also look at their child protective, if they've been involved with the Child Protective Agency and things like that. So this out, the current mayor of Houston, John Whitmire, he was a state senator in our legislature, probably 50 years. And for 50 years, he was the chair of the Senate Criminal Justice Committee. And he actually passed legislation for this program more than 10 years ago. And this is one of the most highly successful programs we have in TDCJ. And we measure the success also by the fact that most of these mothers never come back into prison. All right, I have another. Oh. Oh, they've come, yeah. They were pregnant when they came in. They were not impregnated in prison. No. Yeah, Dr. Ojo, did you have some stats on the number of deliveries y'all do down there? Yes, I have that in my head. All right, so another case, 42-year-old with liver cirrhosis from hepatitis C, came in with decompensated cirrhosis. He had a male score of 30, not a candidate for liver transplant, no family history on file. The hepatology team feels that the patient is terminal and we should change the ethos of care from curative to a palliative model. Patient is confused and lacks decision-making capacity. Question, should the team discontinue therapy and transition to hospice care? Any takers? All right, so yeah, so the way we handle, so the point I was trying to make here is there really is no difference in the way you handle this in the free world. That's the point I was trying to make. There's no difference. I get these calls from our community. People are so, when the CEO, when they have an inmate in front of them, they forget their medicine. No, no, it's the same thing. It's the same process. So that's the point I was trying to make here. All right, ambulatory operations. You can see our disease numbers. Again, rapidly growing, 55 and older. HIV, hypertension, cardiovascular disease. We have it all. And counters for the year, throughout the years, FY21 to FY23. You know, our patients, you know, it's a lot of work. There's a lot of work going into keeping them healthy. That 55 and older group I talked about has just under 20,000. Ethics. You know, being deprived of your liberty doesn't mean you should be in inhumane conditions. And the same ethical principles that apply in the free world apply here, in the incarcerated population. So autonomy, you know? Patients have a right to say no. Two caveats, though. They've got to have what? Decision-making capacity. And you can't have a communicable disease. We draw the line there. All right? Non-malfeasance. You know, first, do no harm. Again, just like in the free world population. Beneficence. Everything you do for an inmate, just like a free world patient, should be in the best interest of the patient. It just makes decision-making easier. And then obviously, confidentiality speaks for itself. Obviously, there are some ethical challenges caring for the incarcerated population. LGBTQ, did I say LGBTQ? That's gonna have to get to the Supreme Court eventually for us to decide where we go. Solid organ transplant. You can count on the fingers of one hand or two how many inmates in the history of incarceration have had solid organ transplant while incarcerated. And then gender dysphoria. All right, again, ethical principles are the same as the free world. There really isn't no, there are some correctional nuances, but there really is no big differences. All right, another one. A death row inmate. Came in for end-stage CHF exacerbation, was determined to have end-stage heart disease. Cardiology concurs and feels that transition to comfort care services will be in his best medical interest. Is it okay to, oh, are we, is it okay to discuss? Oh, no, not that one. Let's go back. Yep. DNR and end-of-life, is it okay to have end-of-life conversations with a death row inmate? Again, no, it's the same. It's the same as the free world, no different. All right, telemedicine. We do tons of telemedicine statewide, about 160,000 telemedicine visits a year. We are actually leaders. People call us from all over the world, not just the nation, to ask how we've been very successful at it. We do it for all kinds of things. All special, pharmacy, dialysis, name it. We have figured out how to use telemedicine to deliver that service, and it works. Obviously, now, telemedicine's become a big deal ever since COVID, but we've been doing telemedicine since the mid-1990s. And a couple of providers seen telemedicine. It saves us about $6.3 million annually. Another case, patient, 82-year-old, with ESLD and severe dementia. He's not responding to treatment. We think his stamina, what are the next steps? Again, the same principles, just like we do in a free world patient, nothing different. All right, again, quality of care. Just gonna show some of our quality numbers, UTMB. We use HEDIS, which is the Healthcare Effectiveness Data and Information Set, the national body that talks about quality, and you can see how our quality numbers in CMC compare with the national standards. And these are the definitions for all those, for that slide I just showed you. All right, one more case study. 74-year-old with ESLD and myelodysplastic syndrome. His meditation waxes and wanes. His prognosis is very, very poor. He did not give an advanced directive previously. The question is, should the team continue to transfuse him even though his stamina has myelodysplastic syndrome? Any takers? Yes, you do the same thing. You will look for a next of kin, a family member. If you don't have one, then the hospital's multidisciplinary team and ethics come together and make a decision and move forward. All right, Hospital Galveston, the eighth wonder of the world, it's a prison hospital, was built in 1983, joint commission accredited, the only maximum security prison hospital on the campus of a major academic medical center in the United States. We talk about the Iron Triangle a lot at Hospital Galveston. We all know these patients must have access to healthcare. It behooves all of us to make sure it's done at quality and at cost, so we can go back to the state legend and say, hey, see how good of a job we're doing. You can see our mission, vision, and values. I'll just show you some of our metrics for FY23. You can see over the last few years, case mix index, discharges, average daily census. We talked about that 55 year, 55 and older cohort with rising numbers. I'll tell you this, so in the, about five, six years ago, our discharges, most patients, about 80% of our discharges will go to general population, meaning they could do or perform their own activities of daily living. You can see that change now. Our patients are getting sicker, as evidenced by our case mix index. All right, okay, our discharges for FY23, average length of stay, patients are staying longer in the hospital, and our case mix index patients are getting very sick. All right, our best care, our quality efforts in the hospital is anchored around best care. The ethos that we will deliver the right care at the right time in the right way for the right person and have the best possible results, every patient, every single time, that's what we stand, hold ourselves accountable for. Ethos, it's gonna be safe. Patients are not gonna develop hospital-acquired conditions in our hospital. It's gonna be timely, it's gonna be efficient, and we're gonna make sure it's equitable. Our aspiration is to have zero, zero, zero, zero central line infections, zero UTI infections, zero surgical site infections, that's our aspiration. How are we doing? We don't wanna see reds, but it's just tough. These are sick, sick patients staying longer in the hospitals, but we're putting things in place to ensure next, at the end of this fiscal year, FY24, most of this reds will be gone, hopefully. All right, mortality, we'll review all deaths in the hospital, we'll categorize them into three, expected, without opportunity, expected with opportunity, and unexpected. Actually, you all know we all want everybody in this category, right? So in FY22, two fiscal years ago, we had 90 deaths. In FY23, they just finished, I thought of that. Yes. And our mortality index, observed versus expected, you want that number less than one, and we're really doing really well in the hospital. Re-admissions is one that we struggle with, some patients are just hospital dependent, and if you think about it, a patient leaving their prison unit and coming to my hospital is similar to, is akin to any of you here going to the Reed Skelton, they don't wanna go back. All right, so that's why my re-admission numbers doesn't work too well. Hospital acquired, it's a great hospital, Dr. L. Hospital acquired conditions and patient safety indicators, again, by month, we track central line infections, we know we track infections, perioperative DVTs, ulcers, and falls. And you can see how we're doing, you wanna see more zeros, this is the only time when you wanna see zeros on any scholarship. Our ambulatory operations, we have contractual obligations with TDCJ, when a patient is deemed urgent, we will see them within 10 days, expedited within 30 days, and routine within 90 days. These are visits over the last fiscal years, we have been having some challenges with no-shows, you can see that, but we're working collaboratively with TDC, Dr. Lindicum, and TDCJ to help bring that number down. You can see our surgical cases and our telemedicine visits. Why does this all matter? Well, you know, the state has told us these patients have to be taken care of. We are a tertiary academic medical center, and we wanna take care of patients. So we also pride ourselves on being a high-value practicing organization, these are the domains, we have antibiotic stewardship, blood bank stewardship, labs stewardship, imaging, and opioids. So in May 12, 2022, one of our patients, one of our inmates escaped, and three weeks after he escaped from prison, he killed five people. And so it became imperative that we change, had a paradigm change in how our healthcare delivery model. Well, it was a three-pronged approach, robust telemedicine, unit-based imaging studies, and a hub-and-spoke approach for specialty and subspecialty care. What does that mean? Well, what have we done? So we've started taking, and historically, prior to this, it used to be every patient came to Galveston for specialty and subspecialty outpatient care. Now we're changing that. We're taking our specialists to the prison units to see these patients, and the show rates have been remarkable, excess of 95%. Actually, on one, recently, actually March 8, we went to the Hughes Unit in Gatesville, and we flew our orthopedic surgeons there. I was there with them. And so when we got there, we had scheduled 52 patients, and they said, eight patients said no. I'm like, okay, they are allowed to say no, but I want them to tell me to my base. So I actually suited up and went, it was a high-security custody patient, so I went to each cell, Mr. Jones, and they all said, you know what, we'll come see you. And so this model of going to see patients in their unit, it works. So we saw all the patients that were scheduled that day were seen in clinic, and it was really wonderful and a sight to behold. So that's hub and spoke. Robust telemedicine is where we are, again, increasing our telemedicine efforts where it makes sense. Obviously, for ophthalmology, probably not. For ENT, probably not. Unit-based imaging studies, we've started doing MRIs at our prison units. Now we have five units where we're doing MRIs. We're gonna continue to expand that over the years, and we've also committed to doing all elective ultrasounds at the prison units. So again, this is how, this genie's out of the box. This is a model moving forward, and this is what we're gonna continue to commit to to ensure our patients have access to care. Obviously, we have our challenges, our aging population, you know, changing epidemiology. Have you guys heard about candida auris? We are dealing with that, all right? Mental, okay. Candida auris is a yeast that was first discovered in Japan in 2009 and in the United States in 2016. It is notorious for three reasons. One, it's a multi-drug-resistant organism. That's number one. Number two, and so it's resistant to most antifungals. Number two, once it gets on an environmental surface or your hospital or wherever, it's very difficult to eradicate. Number three, when patients are colonized with candida auris, as I'm speaking to you today, there is no known method of decolonization. So you can imagine this. So you are incarcerated, right, which is bad, and then you are now isolated. So you can imagine the mental anguish, right, that these patients are going through from candida auris. Yeah, and so that's something we're... The other thing I wanna say about our struggles with this, we've really had pseudo-outbreaks, which means we've identified people that are colonized, but they don't have active infection. I think we had one case that was a sepsis case that died, but we've been in close partnership with our Department of State Health Services, Infection Control. They've been guiding us with this issue, and we've had at least three teleconferences with the CDC. The Bureau of Prisons is now, the Federal Bureau of Prisons is now having issues as well. We had a teleconference with the Bureau and CDC and us to kind of learn from us. But the problem is you cannot keep these inmates isolated and contact isolation throughout their incarceration. And because we are a congregate setting, at what point do we let them go back to their housing and general population? And that's where we've really tried to hone in with the CDC for guidance and our Department of State Health Services. So they spent a long time in isolation. Really that area of Estelle they wouldn't take you to is because we had candida auris over there and we didn't want to take visitors in that area. That's where we've been housing a lot of them. So it's really a dilemma and we're not, I mean, even the CDC is not sure how we should proceed in a congregate setting. So some will say, well, just go ahead, go ahead and let them go back into the general population. But we have such, I mean, you see the numbers there, those elderly people about, I would say about 35% of our population is chronically ill. So we have a lot of immunocompromised inmates in general population. So we start letting all these colonized candida auris people infiltrate that general population and we could really end up in a mess. So we're being ultra conservative these individuals as we identify them. All right, I think that's my last slide. I wanna close with Aristotle again. He says, we are what we repeatedly do. Excellence therefore should not be an act, but a habit. Thank you very much.

Dr. Ojo

TDCJ Hospital

correctional medicine

evidence-based medicine

John P. McGovern Award

Dr. John Mills

Texas prisons

healthcare models