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When Prisons Need To Be More Like Nursing Homes

Anthony Alvarez (C), age 82, is walked to a medical appointment by Phillip Burdick, a fellow prisoner and member of the Gold Coats program at California Men's Colony prison in 2013 in San Luis Obispo, California. The Gold Coats program is a volunteer care program where healthy prisoners volunteer to take care of elderly prisoners who either need general assistance with mobility and every day life or who also struggle with Alzheimer's and dementia. (Photo by Andrew Burton/Getty Images)

America’s prison population is rapidly graying, forcing corrections departments to confront the rising costs and challenges of health care in institutions that weren’t designed to serve as nursing homes.

Between 1995 and 2010 the number of inmates age 55 and up almost quadrupled, owing in part to the tough-on-crime sentencing laws of the 1980s and 1990s, according to a 2012 ACLU report.  In 2013, about 10 percent of the nation’s prison inmates — or 145,000 people — were 55 or older. By 2030, the report said, one-third of all inmates will be over 55. At the same time, it is widely accepted that prisoners age faster than the general population because they tend to arrive at prison with more health problems or develop them during incarceration.

Caring for elderly inmates can often cost up to twice as much as caring for younger ones. In North Carolina, however, it costs an estimated four times as much. During the fiscal year 2006-2007 — its most recent figures — the state’s corrections department spent $33,824,060 on health care for inmates over 50, a 35 percent increase from just two years earlier.

Despite these runaway costs, there is no national oversight to determine how prisons handle the challenges of an aging population, says Marc Stern, a consultant in correctional health care.

“If a Medicaid or Medicare auditor walked into [a large urban hospital] to do an audit,’’ Stern said, “they would say, ‘OK, where’s your geriatric unit? Where’s your dementia unit?’ It’s part of the audit process, it’s part of the intelligence phase that is part of being part of a national organization.”

But some states are confronting the costs and the problems. Here is a look at some innovative programs in New York, California and Connecticut.

New York: The Unit for the Cognitively Impaired

Some inmates read books and lift weights to keep occupied. In the Unit for the Cognitively Impaired at the Fishkill Correctional Facility in upstate New York, it’s board games and bingo.

This unit, the first of its kind in the country, is specially designed to meet the needs of inmates with dementia-related conditions. It is part of the state’s medical hub at Fishkill, a medium-security prison 70 miles north of New York City. The 30-bed unit, opened in 2006, is set up to resemble a nursing home more than a prison ward. The walls are painted white and the lights are bright, intended to elevate and stabilize mood. Inmates are allowed to walk freely around the unit (wandering is common for those with dementia or related conditions). The staff includes specially trained physicians, nurses, clinical psychologists, psychiatrists, social workers, and corrections officers. The average age of the unit’s 24 inmates is 62.

In most other state prisons, if an inmate with dementia is placed in a medical facility, it’s not one specifically equipped to deal with the condition, Stern said. “If there is one patient who is a little demented and tries to get up from his chair, he gets strapped to a chair periodically and somebody goes in to feed him, things like that. You help them with their activities of daily living, but you’re not necessarily taking a more broadly based geriatric approach, assessing their geriatric needs, anticipating their new geriatric needs, trying to prevent harm, for example.”

Medical needs aside, this unit and the staff’s training offer important protections for these patients, because prison is a stressful and a potentially dangerous environment for inmates with dementia.

“Being able to hear an alarm, being able to drop to the ground if you’re ordered to do so, those are prison activities of daily living that if you can’t do, you can get in a lot of trouble,” Stern said. Sudden outbursts or wandering is punishable misbehavior. Additionally, inmates with dementia are more likely to be bullied or have their belongings stolen.

Care in this unit is expensive, which may be why more states have not copied the model. In 2012, according to the state corrections department, it cost $93,000 per bed annually, compared with $41,000 in the general prison population.

“As a basic design I think it’s very important that they have [the Unit for Cognitively Impaired],” said Jack Beck, director of the Prison Visiting Project at the Correctional Association of New York, a nonprofit inmate advocacy group allowed by the state to inspect prisons. The biggest problem, Beck said, is the program’s limited scope. “I would say they’re serving only a small part of the population that needs these services.’’

California: Gold Coats

California has taken a less expensive and more unconventional approach. Inmates with dementia and other age-related impairments are cared for by other, healthy inmates with good records. The Gold Coats — the caretakers wear gold-colored jackets — assist patients with daily tasks such as dressing, shaving, showering, and other personal hygiene. They escort patients to the dining hall, and to the doctor. They act as companions, protecting their patients from being bullied, and make sure they get food at meal time. The Gold Coats also lead exercise classes and activities designed to stimulate memory. There are Gold Coat programs at 11 California prisons.

“We just don’t have the staff available to serve all of those needs,” said Dr. Cheryl Steed, the Clinical Psychologist for the Developmental Disabilities Program at the California Men’s Colony, a medium-security prison located on the central California coast, where the program was started about 20 years ago. For their services, Gold Coats are paid $50 a month — which is very good by prison job standards.

Barry Hughes, a former Gold Coat who was paroled in 2012, remembers that staffers would often awake him in the middle of the night, particularly if one of his patients was having an episode, or had a bathroom-related accident. “They might say, ‘Oh, let’s get Hughes for this because we know there is a bond there,’” he said.

The Gold Coats at the Men’s Colony go through extensive training. Dr. Steed reviews topics like the effect of dementia on behavior, how to communicate with low-functioning patients and how to avoid caregiver burnout. The local chapter of the Alzheimer’s Association has prepared a video specifically for the program, as well as a manual on dementia.

One of the biggest challenges of the job, Hughes says, was dealing with prison staff who weren’t properly trained to deal with cognitively impaired inmates. He remembers a time when a nurse was giving one of his patients his medication. She didn’t properly get his attention, which is a nuanced skill when working with patient with dementia. The patient became surprised and took a swing at her. For this, Hughes says, the patient was put in solitary confinement.

Hughes, who served 25 years for first degree murder, says the job “taught me to listen to hear, instead of to respond. It made me more confident in my own abilities, because of that my integrity was strengthened.’’  He now works as a health technician at a veterans hospital in Los Angeles and volunteers as a hospice nurse.

Connecticut: 60 West Nursing Home

It may seem like a logical solution: parole those who are too frail to take care of themselves, much less commit another crime, and place them in nursing homes outside of prison.

“The prison population is aging, some become cognitively impaired, you have to wonder what the use of them being incarcerated is and if we can adequately care for them in our prison system,” says Dr. Kathleen Maurer, Director of Health Services at the Connecticut Department of Correction.

Officials in Connecticut tried, and failed.

“We would call 50 homes and they would all say, ‘Thanks, no, we don’t really want that person.’ Because they’re trying to attract people that are paying, and more attractive clients,” said Judith Dowd, Director of Health and Human Services at the Connecticut Office of Policy and Management. In other words, nursing home staff didn’t want to tell private clients that their family member would lying in a bed beside a convicted felon.

So, Dowd and officials from the state’s departments of Mental Health and Addiction Services, Correction, and Social Services decided to build their own nursing home for those to difficult to place elsewhere.

The 60 West Nursing Home in Rocky Hill, a bedroom community south of Hartford, opened its doors in May 2013. It is run by a private nursing operator, iCare, under a state contract. At present, about a third of the 60 patients there were referred from the Department of Corrections. Most of the other patients were referred from the state’s psychiatric hospital, and a handful from the community — people who showed up at local mental health facilities or a hospital emergency room and who needed nursing-home care.

But as soon as it opened, it encountered obstacles: Rocky Hill was not pleased with its new neighbors, and the federal government has so far opposed granting Medicaid reimbursement.

The town has sued to shut it. Citing zoning restrictions, the town argues that 60 West should be considered a prison/penitentiary, rather than a nursing home. Rocky Hill says it also fears that if nursing-home care for inmates becomes more common, rules on admission will eventually be loosened to allow more dangerous patients to be admitted, potentially endangering neighborhood.

At the same time, the federal government has declined to certify 60 West as Medicaid eligible, because of the unlikely event that an ailing inmate could recover and be returned to prison. Inmates aren’t eligible for Medicaid, and with the prospect, however unlikely, that some patients could once again be incarcerated, the government is arguing that the patients are ineligible, and thus the entire facility is ineligible. The owners are considering an appeal.

Nonetheless, officials from several other states have expressed interest in the Connecticut model, Dowd said, but they are waiting to see whether the state can resolve the Medicaid issue.

“It is an issue that we’re going to have to deal with in this country,”  Dowd said. “And we think we’ve figured out the solution.”

An earlier version of this article incorrectly identified Dr. Cheryl Steed as chief psychiatrist at the California Men’s Colony.

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Aging California Cost and Quality Medicaid Mental Health States