Promoting wellness and independence of older persons in CSC custody

Canada, like many countries, is experiencing population aging. This demographic shift, along with an increase in late life sentencing and longer sentences have resulted in a growing number of older persons in federal custody, although overall the Correctional Service Canada’s (CSC) population remains relatively young. In contrast to the wider Canadian population where 16.1% are over 65 years, within CSC 5% of individuals in custody are 65 years of age or older. However, the larger "older" group, 50-64 years of age, consists of 20% of individuals in custody.

In response to the need to address this specific population, CSC has developed a national policy framework that will build on current programs and services and promote wellness and independence among its older persons in custody (OPiC). The framework was informed by domestic and international research and in consultation with expert stakeholders in the fields of geriatrics, gerontology, law, culture, Indigenous health and correctional health. It is holistic and emphasises a person-centred, age, gender and culturally appropriate and multi-dimensional approach that supports health and wellbeing, programming, appropriate living accommodations, community engagement and partnerships.

The framework is evidenced based and will be informed by the results of a comprehensive needs assessment of OPiC. The needs assessment includes several components: 1) the lived experience and personal perspective of OPiC; 2) a review of the prevalence of chronic diseases; 3) an assessment of functional, cognitive and social care needs; 4) a review of the physical living environment; and, 5) discussions with CSC health care and operational staff.

As OPiC are not homogeneous, attention will be given to specific groups including: Indigenous people, those residing in Treatment Centres, and those receiving specific programming (psychogeriatric/assisted living). The history of incarceration will also be included as an important factor.

Consistent with the correctional, aging and health literature, the framework will address a number of key topics including staff training, the special needs of women, dementia, living arrangements, discharge planning, end of life care, the needs of Indigenous people, assessment and screening, peer support, programs, falls, nutrition, health promotion, community engagement and partnerships, and use of restraints and transportation.

Discussions and consultations with experts in the fields of gerontology, geriatrics, correctional health, ethics and community stakeholders will be ongoing. The policy framework is intended to be a living document that will evolve as relevant data and information become available.

Although this document is referred to as a "policy framework" in practical terms it is a hybrid of a framework and a strategy. This document will be updated and revised as relevant data and information become available. The process of consultation with experts in areas of older persons in custody, geriatrics, correctional health care, ethics, end of life care, and community stakeholder engagement is ongoing.

One of the hallmarks of the approach of this Policy Framework is that implementation is concurrent with the development and ongoing refinement of the framework. For example, one of the primary drivers on designing and developing care and supports will be the results of the needs assessment (personal interviews with older persons; understanding the prevalence of chronic diseases; functional, cognitive and social care needs etc.) and these assessments and interviews will inform the individual care plans of OPiC

The purpose of this document is to provide a framework and a blueprint on how CSC is moving to implement a holistic approach to supporting wellness and independence of the older person, population in federal custody.

The framework was developed in response to the need to address older persons in custody (OPiC) as a specific population. Although the correctional literature was extensively reviewed in the preparation of this document, a summary of the literature will not be replicated in the document. However, it is important to offer a general commentary on the literature. The voluminous correctional literature largely consists of duplication and repetition of the same information. Moreover, the quality of the information is considered to be generally poor. For example, Turner and Trotter (2010) in their review of the literature, noted that "… most of the currently available information has been collected through small-scale studies, newspaper articles or government reports^Footnote1. "More recently, Stevens et al 2017^Footnote2, in a systematic review of the literature over the period 2006 to 2016, on the efficacy of aged care interventions for older prisoners, found that of 1186 titles and abstracts, 760 were duplicates. Furthermore, of 393 screened against eligibility criteria, 46 papers were examined for inclusion and of those only 7 articles were identified as meeting criteria for inclusion (2 quantitative studies and 5 qualitative studies). The author also noted that the quantitative studies were of low quality, relying on small sample sizes.

CSC’s framework is anchored in evidence and informed by consultations and discussions with domestic and international experts^Footnote3 in the fields of geriatrics, geriatric assessment, and corrections, who gave freely of their time and shared their expertise and research with CSC. Their expertise will help to inform, strengthen and enrich existing CSC services and programs that facilitate healthy aging of CSC’s older persons in custody (OPiC).

Correctional Service Canada (CSC) is mandated, under the Corrections and Conditional Release Act (CCRA), to provide every inmate with essential health care^Footnote4 that conforms to professionally accepted practices, and reasonable access to non-essential mental health care that will contribute to the inmate’s rehabilitation and successful reintegration into the community.^Footnote5 Within CSC, the provision of health services is governed by the Health Sector and guided by Commissioner’s Directives 800 "Health Services" and its associated guidelines and documents. Consistent with health services in the wider Canadian community, CSC’s health services are accredited by Accreditation Canada.

Underpinned by the values of respect, fairness, professionalism, inclusiveness and accountability, CSC’s Health Services vision is to improve offender health that contributes to the safety of Canadians and its’ mission is to provide offenders with efficient, effective health services that encourage individual responsibility and promotes health and wellness.

CSC manages and maintains 43 institutions across 5 regions of Canada (Atlantic, Quebec, Ontario, Prairies and Pacific), 91 parole offices, 15 Community Correctional Centres, and 200+ Community Residential Facilities.

Health Services within CSC are provided by a wide range of regulated and non-regulated health professionals in Primary Health Care Centres located within correctional institutions, intermediate mental health programs, regional hospitals and regional treatment centres (psychiatric care). CSC relies on community health care for services and specialist consultations that are not available within CSC or can not be managed within CSC such as: paramedic and hospital emergency services, hospitalization, advanced diagnostics (MRI, CT Scan). More detailed information on CSC health care services and programs is provided in Annex B.

As illustrated in Figure 1, the Correctional Service Canada (CSC) population is relatively young In contrast to the wider Canadian population where 16.1% are over 65 years,^Footnote6 within CSC 5% of individuals in custody are 65 years of age or older (65+). Moreover, of the 65+ group, less than 1% are women and approximately, 3% are individuals of Indigenous ancestry.

However, the larger "older" group, 50-64 years of age, consists of 20% of individuals in custody. Similar to the 65+ group, the proportions of women and Indigenous persons remain relatively small, less than 1% and 3.7% respectively.

Figure 1 - Source: Data Warehouse. Data current up to the Mid-Year of FY 2017-2018

Figure 2 (below) shows that over the past five years the increases in both the overall 50+ (inclusive of 65+) and the 65+ are constant.

Figure 2 Increases 2013-2017 of proportion of older adults in CSC custody

Moreover, a closer inspection of changes within 5 year increments (Figure 3) shows no particular spikes in rates.

Figure 3 Annual Growth Rate 2013-2017 of older adults age 50+ in five year age increments.

Numerically, in 2018, there are 2833 individuals in custody age 50+ (2,736 men and 97 women) and within that group 707 are age 65+ (693 Men and14 women).

The age group 65+ is also disproportionately distributed across Canada with 29% residing in institutions in Ontario, 28% in Quebec,19% in Pacific, 14% in the Prairies and 10% in the Atlantic.

Although the Correctional literature suggests that offenders are 10 to 15 years physiologically older than their chronological age,^Footnote7 there is no consensus on what age constitutes an ‘older’ person in custody and definitions of older vary from 45 years and older to 65 years, and older^{Footnote8,Footnote9}. For example, "… the definition of an older prisoner in the United States varies by state, with starting ages ranging from 50 to 70 years (Williams et al^Footnote10). It is noteworthy that according to Williams et al 2012, the "empirical evidence for accelerated aging of prisoners is lacking."^Footnote11 Others have gone further to state, that "caution should be used when using chronological age exclusively to define the onset of old age."^Footnote12 According to Aday (2013)^Footnote13 and Williams et al 2012,^Footnote14 ‘older’ is best defined as a combination of chronological age and functional/cognitive abilities.

Given the lack of empirical evidence on what factors constitute "older," in a federal correctional system, CSC, is adopting an evidenced based approach to understanding and addressing the needs of OPiC, rather than relying on speculation and/or anecdotal evidence reported in the correctional literature. As no single indicator or data source can provide all the information needed to build an evidence-based approach, CSC is conducting a comprehensive multidimensional needs assessment to gather information and test assumptions about what constitutes an older Federally incarcerated population in Canada.

In order to manage the ambitious scope of this approach, CSC will be pragmatic and proceed in two phases beginning with studying persons 65+ (Phase I) and subsequently studying the 50-64 age group (Phase II).

The approach to thinking about and responding to OPiC is grounded in a multi-dimensional holistic perspective, informed by culture and gender at different stages and transition points. It addresses the needs of OPiC in various domains of health: physical, emotional, spiritual, mental health and well-being.

The holistic approach to responding to the needs of OPiC (illustrated on page 9, Figure 4) was developed by a multidisciplinary Health Care Advisory Committee^Footnote15. The Committee includes representatives from several national professional associations (Canadian Association of Indigenous Physicians, Canadian Indigenous Nurses Association, Canadian Nurses Association, Canadian Psychological Association, Canadian Geriatrics Association, Canadian Association of Gerontology) as well as the specialty of Occupational Therapy, and Medicine and representatives from CSC’s administration. More recently, an Indigenous Elder and a representative from the NGO, Dementia Justice, were added.

Figure 4. Holistic Approach to Responding to the Needs of OPiC developed by CSC’s HCAC November 8-9, 2017

In keeping with this approach, emphasis will be on supporting persons in custody as they move from independence to dependence (see Annex C) with the goal of supporting individuals to remain independent, and age in place as long a possible through early identification, diagnosis, and management of chronic disease. Attention will also focus on issues often associated with aging such as but not limited to: falls, depression, dementia, nutrition, incontinence, oral health, and social isolation.

CSC provides extensive health care services to persons of all ages in custody including older persons. Currently, when an older person presents with complex health conditions, care is managed on a case by case basis. Until now however, there has not been a comprehensive strategic approach specifically aimed at responding to the multidimensional care and custody needs of older persons from a population health perspective.

Responding to the unique needs of OPiC, while maintaining safety and security, is complex and requires collaboration among all sectors within CSC with responsibilities in the areas of health, Aboriginal Initiatives, Women’s sector, food services, security, programs, spiritual/pastoral, infrastructure etc.

As mentioned above, understanding the needs of OPiC requires a multidimensional approach and as such, the needs assessment will be comprehensive and informed by a number of different perspectives: Listening to the lived experience of OPiC through one-on-one personal interviews; reviewing the prevalence of chronic diseases; assessing the functional, cognitive, and social wellbeing of OPiC (using standardized tools); considering the perspective of health care providers and operational staff; and conducting an environmental scan and a review of infrastructure requirements.

The needs assessment will be conducted in two phases (Phase I and Phase II). Phase I will focus on all individuals 65+ and Phase II will focus on a sample of those in age groups 50-64. This approach is necessary because of the scope of the study. The assumption is that those in the 65+ group will have higher needs than those in the 50-64, therefore the former will be given the priority. However, women in the 50-64 age groups will be included in Phase I, given they are underrepresented in the 65+ group. It is important to underscore that the needs assessment is more than data collection. The approach involves individual assessments that will become part of the individual’s health care record for use by their treatment team.

OPiC are not a homogeneous group and therefore the needs assessment will include a number of sub-categories of OPiC population including:

• Gender;
• Self-declared ethnicity: Indigenous Peoples, Blacks;^Footnote16
• OPiC receiving 24-hour inpatient care (Treatment Centres);
• OPiC receiving specific programming (Psychogeriatric Unit; Bowden Assisted Living Unit (see Annex D for a description of these programs); and,
• History of incarceration. Quite apart from gender, ethnicity and culture, older persons may have different health care, psychological, spiritual and psychosocial needs depending on their history of incarceration. The correctional literature generally describes three groups of older persons based on incarceration patterns.^Footnote17 The first group consists of those who have grown old in custody as a result of lengthy sentences’ imposed when they were younger. The second group consists of recidivists who have aged while going in and out of incarceration over a long period of time. And the third group consists of those who were incarcerated for the first time in their 50s or 60s. Stojkovic (2007^Footnote18) includes a fourth group, namely individuals sentenced to shorter incarceration late in life. Separating these groups is challenging, therefore the need assessment will focus on two broad categories, namely: a) those who were incarcerated later in life for the first time; and b) all others.

Consistent with the holistic approach of putting the person at the centre, the needs assessment will begin by valuing the voice of the OPiC. In Phase I, all OPiC 65+ (>700 individuals) will be invited to share their experience and perspective in one-on-one personal interviews with a CSC nurse. The interview will be guided by a series of questions, however, participants will be encouraged to speak freely on any respect of aging in custody. The discussion questions were developed in consultation with the Chair of CSC’s Citizen Advisory Committee^Footnote19 (see ANNEX E for the Interview Guide).

As people grow older, a variety of factors can diminish their quality of life: combinations of multiple chronic diseases, disabilities, cognitive losses, mobility losses, psychological problems and social isolation, together with the aging of the body’s various biological systems.^Footnote20 Consequently, as part of Phase I, in 2017, CSC reviewed the prevalence of chronic diseases of OPiC age 65+ (>700, predominantly men). The preliminary results of the review revealed a high prevalence of chronic diseases, generally higher in most categories than the prevalence in wider Canadian 65+ population.

CSC is collaborating with the University of Waterloo^Footnote21 and Mount Sinai Health System^Footnote22 to assess all 65+ OPiC 65+, who consent to participation (>700 individuals). A CSC Primary Care Physician, a CSC Psychiatrist, and a CSC Nurse are also collaborators on the study and this will assist with interpretation and application of the findings in a correctional context. Although the data will be aggregated to better understand the physical, cognitive and social needs of those age 65+, individual results will be placed on the individual’s medical chart for follow-up by their health care team.

The study will use the InterRAI Contact Assessment (CA) tool, a brief assessment tool comprised of 39 clinical observations that identifies common physical, cognitive and social issues that may need attention. It uses tested clinical observations and decision-support scales to provide severity and risk screening. The assessment will generate an Urgency Algorithm (AUA) score that stratifies individuals into six groups based on the severity of their presenting issues and their likely need for further geriatric assessment and intervention.

The assessment will produce clinical outputs in the following areas:

• Potential Cognitive Impairment
• Communication
• Potential Delirium/Acute Confusional State
• Behaviour
• Hallucinations or Delusions
• Potential Depression and Anxiety
• Potential Substance Abuse
• ADL Limitation
• Instrumental ADL Limitation
• Falls
• Dyspnea
• Severe Pain
• Weight Loss

Learning from the experience and expertise of CSC health care providers^Footnote23 will not only inform an understanding of the OPiC population, but will illuminate the strategy on issues related to organization of resources; factors related to access to services; and training.

In Phase I, therefore, providers will be asked for their observations and opinions on key service areas such as: integration and coordination of services; resources; wait times; infrastructure challenges; access to specialized services (diagnostics; labs; hospitalization etc.). Providers, particularly those involved in discharge planning, will also be asked about access to and availability of community "housing" resources.

In a correctional setting, Correctional staff (Correctional Officers, Parole Officers, Social Programs Officers etc.) have most of the day-to-day contact with persons in custody and their role in identifying changes in behaviours, new behaviours, the social connectedness of individuals etc. can not be overstated. As a result, their perspective will be sought by use of a questionnaire, and personal interviews as required.

One of the challenges for correctional environments is how to adapt Institutional facilities primarily designed for younger persons, to accommodate an aging population. Often, facilities cannot sufficiently accommodate wheelchairs or walkers ^Footnote24 and health care equipment (large beds, lifts, tubs etc.). A living environment that can accommodate older persons is important in facilitating "aging in place," where key elements are the ability to " … live safely and independently …" for as long as needed."^Footnote25 In other words, to facilitate aging in place, the physical design of the living space must be considered.

Various elements of physical space are necessary to enhance and/or prolong independent living such as alternatives to stairs, grab rails; shower seats can make a difference to someone with even small levels of mobility impairment. Issues around sensory impairment should also be considered as older persons can have higher levels of visual and hearing impairment compared to younger persons in custody. Therefore, elements of the prison environment such as notice boards, posters and signage need to be considered.

In addition, the noise level in prisons can often make it challenging for those with hearing impairments to hear verbal instructions.^Footnote26 To assess the physical environment within CSC, a checklist has been developed (adapted from Good Practice Guide; Working with Older Prisoners, RECOOP, Org.UK). A walk through of each institution using this checklist will help identify potential accessibility issue for OPiC. (SEE ANNEX F Physical Environmental Check List).

When considering a policy framework that addresses the needs of OPiC, there are a number of subject areas, though relevant to other age groups, are particularly important to older persons.

Williams et al 2012^Footnote27 and a panel of 29 national experts, in correctional health care, academic medicine, nursing, and civil rights, identified 9 priority areas relevant to a comprehensive policy agenda for older prisoner health care: 1) defining the older person, 2) correctional staff training, 3) definition of functional impairment in prison, 4) screening for dementia, 5) recognition of the special needs of older women prisoners, 6) geriatric housing units, 7) issues for older adults upon release, 8) medical early release, and, 9) prison-based palliative medicine programs.

Defining an OPiC as well as the definition of functional impairment have been addressed earlier in this document (see Sections 3 and 4.3 respectively). The remaining 7 areas will be addressed in the following section along with additional priority areas:^Footnote28 understanding and responding to the needs of Indigenous OPiC, Assessment and Screening, Peer Support, Programs, Falls, Nutrition, Health Promotion, Restraint Transportation of older persons and, Community Engagement and Partnerships.

CSC is collaborating with Queen’s University, Department of Medicine and Division of Geriatrics^Footnote29 and the Centre for Studies in Aging and Health, Providence Care to develop training and orientation modules for CSC Health Care professionals, Correctional staff, and CSC Administrative staff.

The training modules, as part of pilot testing, are being offered via web x, on-line and in-person and cover topics such as aging changes relevant to health and care of older people, components of a comprehensive geriatric assessment, polypharmacy and principles of prescribing for older offenders, dementia, depression, falls, incontinence, common chronic conditions, end of life care, etc.

CSC will continue to build staff capacity to recognize and respond appropriately to the health and psychosocial needs of OPiC. (See ANNEX G Training Modules)

Dementia is the umbrella term for neurodegenerative diseases that significantly interferes with a person’s ability to maintain the activities of daily life. According to Livingston et al (2017), the term dementia is considered demeaning and stigmatizing by some and therefore the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5 uses the term "major neurocognitive disorders^Footnote30." Nevertheless, the term dementia continues to be widely used. Dementia is a chronic progressive condition in which there is deterioration in cognition function beyond what might be expected from normal ageing, affecting memory, thinking, orientation, comprehension, calculation, learning capacity, language, judgement and behaviours.^Footnote31 According to national data (2013-2014), over 402,000 seniors age 65+ live with a dementia diagnosis. Of these, two-thirds are women. After the age of 65, the risk of being diagnosed with dementia doubles every five years.^Footnote32

Currently older persons in CSC custody who present with cognitive impairments are managed on a case by case basis. Based on discussions with experts in the field and a review of the literature, there does not appear to be consensus recommendations regarding when an older person should be screened for dementia. One suggestion was that there is no benefit to screening persons 65+ for dementia given that cognitive impairments would be evident in context of ongoing identification and management of chronic diseases. However, others^Footnote33 suggest that there should be mandatory screening at age 65.

According to the Canadian Task Force on Preventative Health Care, screening asymptomatic adults 65 years of age or older for cognitive impairment is not recommended, while screening is recommended for individuals with cognitive impairment (e.g., loss of memory, language, attention, visuospatial or executive functioning, or behavioural or psychological symptoms) or who are suspected of having cognitive impairment by clinicians, family or friends.^Footnote34 Similarly, the Lancet Commission on Dementia Prevention, Intervention, and Care (2017) concluded that "screening all older people for dementia is not recommended because benefits are unclear."^Footnote35 However, the Lancet Commission strongly endorses prevention initiatives as one of the ways forward in responding to dementia (the diagram in Annex H, taken from, Livingston et al 2017 summarizes the strategy). The latter recommendation is consistent with the 2016 update on age-appropriate preventive measures and screening for Canadian primary care providers.^Footnote36

Apart from the lack of consensus on when to screen, there is also a lack of consensus on the most appropriate assessment and screening tools (Velayudhan et al 2014^Footnote37). Other considerations, include cultural appropriateness^Footnote38 of the instrument and the burden on both the older person and on human resources of unnecessary screening and assessing.

When considering Indigenous Peoples, there is limited epidemiological research and the information available is not of high quality.^Footnote39 The latter notwithstanding, the prevalence of dementia among indigenous populations is considered to be higher than for non-Indigenous populations and some studies suggest that dementia may occur as much as 10 years earlier in Indigenous people compared to non-Indigenous people in Canada or may begin much later depending on the type of dementia. Moreover, studies suggest that age-related dementias among Indigenous people in Canada are not being diagnosed early enough to benefit from care and supports.^Footnote40 Specific to First Nations, the prevalence and incidence of dementia has been identified as an emerging health concern.^Footnote41

1. The inteRai CA, will provide a measure of potential cognitive impairment. A subset of individuals showing possible cognitive impairment will be assessed for dementia. This initiative will be undertaken in collaboration with the department of psychology at a University in Western Canada.^Footnote42
2. CSC will incorporate the recommendations of the age-appropriate preventive measures and screening for Canadian primary care providers; the recommendations of Lancet Commission on prevention, namely, "… active treatment of hypertension in middle aged (45-65 years) and older people (aged older than 65 years) without dementia to reduce dementia incidence," and interventions for other risk factors including "… exercise, maintaining social engagement, reducing smoking, and management of hearing loss, depression, diabetes, and obesity."^Footnote43

"Women in prison are often even more affected and have disproportionately higher level of mental health, suicide, self-harm, drug dependence and other health needs compared to men in prison."^Footnote44 Women in prison also have higher rates of co-morbid conditions than men in prison.^Footnote45 However, information on the health and wellbeing needs of older women in custody is limited. Although the older women offender population is relatively small in comparison to their older male counterparts, it is important to develop an evidenced based understanding of this population, as they present a unique set of challenges in their assessment and care within institutions and communities.^Footnote46

The needs assessment described in this document (interviews with older women, review of the prevalence of chronic diseases, functional assessment, staff interviews) will inform CSC’s approach. From a prevention perspective, specific screening required for older women will be implemented, including but not limited to bone density, cervical cancer, and mammography, etc.^Footnote47, ^Footnote48 There are several needs that may be unique to the older woman offender. For example, women typically sustain more injuries related to falls and are at a greater risk of breaking a bone as a result of falling, in part due to lower bone density after menopause and higher rates of osteoporosis.

There is debate about whether or not OPiC should be living in age specific units (or institutions, such as is common in the United States) or remain in an integrated setting.^Footnote49, ^Footnote50 In contrast to the expectations that an age specific housing model is better able to provide specialized medical services, Thivierge-Rikard and Thompson (2007),^Footnote51 found that age specific geriatric units do not necessarily improve the care of OPiC. The correctional literature also cautions about the potential risk of aged-based units leading to the ‘ghettoisation’^Footnote52 and the greater neglect of OPiC as they may become further removed from mainstream view. Moreover, older persons, who are well behaved and compliant, have been found to provide a positive calming influence on younger prisoners that would be lost in an age specific unit model.^Footnote53

It is obvious that both opportunities for integrated living (within the mainstream population) and aged-based accommodations are necessary. The principle of aging in place supports living in an integrated environment until circumstances are such that age specific accommodations are required (functional limitations and /or vulnerability issues - protection from victimization or intimidation). This approach is supported by the correctional literature,^Footnote54 CSC’s experience and consultation with external experts.^Footnote55 What is unknown, at this point is the capacity requirements. The combination of the feedback from older persons, the level of chronic diseases, the results of the inteRai CA (functional, cognitive, and social care needs), feedback from health care and correctional staff, the number of OPiC and institutional regional location will enable CSC to better address this question.

To assess the physical environment within CSC institutions, a checklist was developed (as noted on page 13 and a copy can be found in Annex F) and further reviewed and revised in collaboration with the Chair of the CSC’s Citizen Advisory Committee.^Footnote56 A walkthrough of each institution, using this checklist, will be used to identify potential accessibility issues for OPiC.

Discharge planning within CSC is the process that prepares an individual for transitions in care. It is client-centered and includes comprehensive planning and close collaboration among all those involved in the process. It addresses the physical, mental, emotional, social, cultural and spiritual needs of individuals to ensure post-release access to health care and community resources after a period of incarceration. Emerging evidence suggests that there are service provision and integration deficits at key transition points for older persons, such as on entry to and on release from prison.^Footnote57 Release from prison can pose an additional challenge for older individuals. For example, those who have served long sentences may have become institutionalized^Footnote58 and for those convicted of sexual offences there may have been a breakdown in their community support network including family. Finding a family doctor and/or finding suitable and affordable seniors housing can be a challenge for older persons in mainstream society, adding a criminal record, presents even more difficulties.

The number of offenders who are discharged with long-term and/or continuous health care needs is increasing. In order to support the seamless transition in care of offenders with on-going health care needs, discharge needs are to be identified in a timely manner and arrangements for medical follow up are to be made prior to release.^Footnote59

To enhance discharge planning and ensure a continuity in care, CSC can strengthen its existing discharge planning process by proactively engaging outside agencies to ensure all required assessment and planning is completed in advance to facilitate a smooth transition.

Adapting CSC pre-release medical/functional assessments, etc. to mirror what receiving community agencies require will help facilitate discharge planning in a timely manner. Promoting in-reach wherever possible, building relationships and rapport will help eliminate stigma and ensure stronger collaboration with outside agencies. Opportunities could be explored to help facilitate community partnerships such as developing an equipment loan program to help bridge gaps in the community that facilitate healthy aging.

In Canada, palliative care and hospice care are used to refer to the same thing.^Footnote60 According to the Canadian Medical Association^Footnote61, palliative care is an approach where the focus is on improving the quality of life "… associated with life-threatening illness, through the prevention and relief of suffering by means of early identification, assessment and treatment of pain and other symptoms, physical, psychosocial and spiritual." The Canadian Palliative Hospice Association^Footnote62 uses the term "life-limiting" (instead of "life-threatening") illness with "any prognosis" …" but adds the parameter of life-limiting illness^Footnote63 that is "usually at an advanced stage." In other words, although palliative care can be of a long term nature, more often than not it applies to individuals with limited time to live.

With respect to palliative care in prisons, a review of the literature by Maschi, Marmo and Han (2014^Footnote64) identified the most common features as " … the use of peer volunteers, multidisciplinary teams, staff training, and partnership with community hospices." CSC’s palliative care policy and services are consistent with the generally accepted guidelines of the Canadian Hospice Palliative Care Association as well as the care provided in prisons in other jurisdictions. For example, services are provided by a multidisciplinary team (physician, nurses, social worker, parole officer, clergy/Elder, palliative care specialist, psychologist etc.) and often delivered in collaboration with community hospitals and related specialists clinics (cancer clinic; pain clinic). Family and significant others are involved based on the wishes of the patient and the availability and willingness of family and other supports to engage in the process.

Apart from the quality and comprehensiveness of palliative care services itself, the health care physical environment is considered a key contributor to effective palliative care.^Footnote65 Some of the suggested elements of a palliative care room include: natural light, light fixtures, clocks, artwork and plants, area for family to have private conversations, access to multi-faith room for ceremonies, comfortable furniture for family and friends, televisions, etc.^Footnote66 In addition, the palliative care setting will need to accommodate Indigenous spiritual practices such as smudging.

According to Williams et al (2011^Footnote67), incarceration is based on four principles, namely: "retribution through deprivation of liberty when other punishment is deemed insufficient, rehabilitation through drug treatment or educational programs, deterrence to committing future criminal acts, and incapacitation through separating prisoners from society to enhance public safety." Compassionate release, is considered when an offender’s terminal illness sufficiently undermines these four principles. In other words, compassionate release is appropriate for offenders who "… are too sick or too cognitively impaired to be aware of punishment, too sick to participate in rehabilitation, or too functionally compromised to pose a risk to public safety."

In Canada, parole by exception may be granted to an offender not yet eligible for day and/or full parole.^Footnote68 One of the criteria for application is being diagnosed terminally ill and confirmation from a medical practitioner that the offender is in an advanced stage of a terminal illness. Offenders serving a life sentence imposed as a minimum punishment or an indeterminate sentence are not eligible for parole by exception unless they are terminally ill.

It is the position of many, that palliative care should not be provided in correctional settings. In particular, the view is that persons requiring end of life care, including palliative care, should be released to the community on compassionate grounds. The correctional literature notes, however, that in most jurisdictions, although legislative mechanisms exist for compassionate release, the success rate is extremely limited.^Footnote69, ^Footnote70, ^Footnote71 The latter is also true for Canadian Federal Corrections.

Arguments for compassionate release on medical grounds, notwithstanding, the medical judgement component of the process remains significantly challenging. For example, Williams et al (2011^Footnote72), note that compassionate release "… requires that physicians not only predict limited life expectancy but functional decline as well." Furthermore, the common causes of natural death in custody (advanced liver, heart, and lung disease, and dementia) are ones where prognosis is difficult to establish.^Footnote73 Even in the case of more predictable diseases, such as cancer, "functional trajectories vary and are unpredictable, often declining only in the last weeks of life."^Footnote74 Another challenge is that "prognostication can create a catch 22."^Footnote75 That is, if application for release on medical grounds is made too soon, while the terminally ill offender is still capable, the chances of success are reduced. On the other hand, if the application is made too late, the offender may die before the process can be completed.

Espousing compassion on principle is very different from the practice of compassion as evidenced by "prosocial motivation or behaviour."^Footnote76 Consequently, in corrections, discharge planning (or planning for other forms of extended community tenure), at the best of times, is difficult for reasons of stigma, competition for limited community resources, and public safety concerns. The interaction of these variables with the challenge of providing assurance to the community organizations that illness substantially mitigates public safety risk increases the complexity of an effective and timely transition plan.

In 2016 Canada enacted legislation that enables adults capable of giving consent to be granted medical assistance in dying based on a number of criteria including having a "… grievous and irremediable medical condition …"^Footnote77 CSC has put in place policy that ensures that offenders have access to this end of life care procedure. In developing the policy CSC consulted with medical professionals, provincial health authorities, hospitals and community stakeholders.

1. Provision of palliative care within CSC
   • In collaboration with a community palliative care expert and ethicist CSC will review and revise the palliative care guideline to ensure it continues to meet community practices.
   • CSC will explore opportunities via contract agreements with provincial community palliative care practitioners (Provincial Health Authorities) to provide and/or lead palliative care for terminally ill persons within CSC institutions.
   • CSC will review current practices to identify and address any barriers to narcotic prescriptions and administration that may be impinging on the provision of pain management and good palliative care practice.
   • CSC will review current palliative care settings (CSC Regional Hospitals) to identify areas for improvement, in particular, the review will focus on areas identified in the correctional literature as important contributors to good care (physical space - accessibility, size of room, space, color and décor, noise, furnishings etc.; access for family/friends/ peers; access to religious ceremonies; availability of video-conferencing to connect to families; availability of required medical equipment - lifts, bed etc.)
2. Early Release
• Nationally monitor the timelines and quality of each step in the process from the designation of terminal illness to submission to the Parole Board of Canada and decision.
3. Provision of palliative care in the community

• Within CSC’s legislative authority, explore opportunities via contract agreements with provincial community based palliative/hospice care facilities for the provision of care.

While, the current number of older Indigenous persons in custody (inclusive of First Nations, Métis and Inuit) within CSC is relatively small (3% of 65+; and 3.7% of 50-64), Indigenous persons make up a significant proportion of the overall federal in custody population, accounting for 26 percent of all persons in custody (2015-16).

According to Beatty and Berdahl (2011), the fact that the Indigenous population is smaller than the non-Indigenous population in Canada, "Canadian researchers and policymakers have paid limited attention to the health care needs of Aboriginal seniors."^Footnote78 Moreover, they highlight the fact that policy should reflect how care for older persons can be adapted to address the needs of Indigenous older persons.

Addressing the needs of older Indigenous persons in custody, requires an awareness and understanding of the impacts of colonization historically and present day. Sensitivity to the history of Indigenous peoples in Canada and respect for traditions, cultures and languages of Indigenous peoples are important in advancing health, wellness of Indigenous OPiC. This means, for example, adopting a practice of routinely considering social history when responding to complex medical conditions requiring a comprehensive assessment. This is particularly relevant given the impact of childhood trauma on health in later life, for example Radford et al (2017)^Footnote79 noted the potential impact of childhood on the emotional health and dementia for older Aboriginal Australians.

Emphasis will be on promoting healthy aging, maximizing abilities and where possible minimizing the decline in overall health. Spiritual and psychosocial needs will also be assessed in order to respond to issues that may become more acute as age increases such as isolation, regret, guilt and fear of dying in custody or dying alone.

While not exclusive to older indigenous persons, CSC has initiated a project on inclusion of Indigenous practices in health care. Recognizing the role of Indigenous healing practices and traditions in health and wellness outcomes and the lack of information on this topic in the correctional literature, CSC has contractually engaged a physician^Footnote80 from the Canadian Indigenous Physicians Association of Canada to establish a framework for incorporating Indigenous worldview(s) and western worldview(s) that promotes the equitable value of traditional medicine in the healing process. The framework will focus on how to treat various health conditions and/or concerns such as but not limited to mental health / psychiatric; infectious diseases; harm reduction (Methadone/Suboxone); chronic diseases; health promotion and prevention.

Although this initiative is not exclusive to older persons, this work will nevertheless complement CSC’s approach to chronic disease management and align with the holistic approach to promoting wellness and independence of OPiC.

CSC currently administers an Activities of Daily Living (ADL) assessment to those 65+ (and to other age groups as needed) at Intake and to individuals who reach the milestone of 65 while in custody.

If InterRAI CA (used in the research collaboration with the University of Waterloo and Mount Sinai Health System) proves to be useful and operationally feasible, CSC will consider adopting this standardized tool at Intake and as needed throughout the delivery of care in custody.

Peer to peer support in a correctional environment is "support provided and received by prisoners who share similar attributes or types of experience. Prison peer support workers provide either social or emotional support or practical assistance to other prisoners on a one-to-one basis or through informal social networks."^Footnote81 Although considered a helpful practice, there is little quantitative evidence of clinical effectiveness for peer-based interventions for prison health ^Footnote82.

In 2014, a systematic review of the effectiveness and cost-effectiveness of peer-based interventions to maintain and improve offender health in prison settings concluded, that the majority of studies were of poor methodological quality, with only five judged to have good internal validity.^Footnote83 The literature does suggest, however, that there are potential benefits to peer support including adjusting to prison life, reducing isolation, positive role-modeling, promoting healthy lifestyles and a decrease in levels of drug use^Footnote84. There are reports in the literature that being a peer worker is associated with positive health and that peer support services can provide an acceptable source of help within the correctional environment and can have a positive effect on recipients.^Footnote85

Some of the strengths of peer support that have been identified are: peers are better at engaging offenders; peers are more effective at sharing information and knowledge; individuals can act as successful role models; in custodial settings they can form pro-social communities that realise wider benefits; and, peers can support managerial and front-line staff.^Footnote86 Some weaknesses include: the pool of suitable prisoners may be small (younger inmates may not be emotionally ready); high rates of peer turnover (peer attrition resulting from transfers, releases etc. identified as an issue at the Nova Institution for Women in Canada); security breaches; competence and confidentiality; maintaining appropriate boundaries (the ambiguity of the role; peer member may develop friendships; boundaries between staff and peer mentors can be an issue); underlying tensions with peer role (underlying gang involvement); and, peers may require considerable support (may pose additional labour and time on staff).^Footnote87

Specific to the UK, peer support is an increasingly significant aspect of the health care system as emphasis shifts from treatment to the promotion of health and well-being. Peer to peer support programs have been identified as a means of identifying and responding to the social care needs of inmates. These programs however are not to be a substitute for professional care. Suggested potential roles and parameters of a peer supporter include:

• managing and maintaining nutrition (*cutting up and transporting food is permitted but not assisting with eating and drinking)
• personal hygiene and toilet needs (*not intimate personal care)
• dressing (maintaining personal appearance)
• emotional support
• helping to keep the cell tidy
• assisting with mobility
• facilitating learning
• providing practical assistance (*not organizing medication)^Footnote88.

CSC has significant experience with peer-support, though not all specific to "older" persons. For example, peers (CSC’s PEC program^Footnote89) have been active as health promoters in the area of infectious diseases and general health. In addition, peers have been active in assisting older and/or disabled persons in custody throughout CSC, albeit, in the absence of any national policy guidance. One area where peers have been systematically utilized over a number of years is CSC’s Peer Assisted Living (PAL) Program at the Regional Treatment Centre in Abbotsford, B.C. Recently CSC conducted an ethics analysis of the program^Footnote90. The review found that the PAL Program was consistent with the literature on peer to peer support in a number of areas and made recommendations for improvements including enhancing the peer selection; more training for peers on the importance of respecting confidentiality; and the need for a peer support/wellness model.

There is sufficient information (though not empirical evidence) to support the inclusion of peer-support as a component of OPiC. However, the latter will be further informed by the feedback from ongoing personal interviews with OPiC.

National policy will be established to govern future peer initiatives and will include guidance on the selection process; training (including issues of confidentiality; wellness orientation); quality improvement mechanisms (such as provider/receiver satisfaction feedback). In addition, opportunities for a formal evaluation project will be identified.

OPiC have the same need for purposeful activity as persons in custody of younger ages. Like those in mainstream society, some older persons over the age of 65 may still wish to work while others may wish to pursue more leisurely activities. According to the literature however, programs are often designed with the younger persons in mind and as a result OPiC can find programs meaningless especially in the areas of education, vocational and exercise programs.^Footnote91

The above, notwithstanding, a recent systematic review of aged care interventions for OPiC found no significant effects of aged care interventions. The limited qualitative research articles reviewed however, suggested aged care interventions can have a positive influence on health and social outcomes for OPiC when the intervention targeted the specific health and well-being needs of the older person in custody population while at the same time addressing barriers to participation and facilitating engagement among older adults in custody.^Footnote92

Given the finding that there is a need for better informed practices to meet the range of the needs of persons in custody^Footnote93, the results from the functional, cognitive, social needs assessment of older persons in combination with the feedback from OPiC, through personal interviews, will inform CSC programming for older persons. In addition, the results of the scan of physical environmental will provide additional context for the delivery of appropriate CSC programs for OPiC.

In August 2017, CSC updated its Fall Prevention and Management Guideline. The purpose of the guideline is to ensure those at risk for falls are identified and managed appropriately in a consistent manner that contributes to patient safety and identify opportunities for improvement in fall prevention.

At admission, individuals who are 65 or older are assessed using the Morse Falls Scale. Individuals already in custody are assessed when they reach the age 65 milestone. Individuals at any age who are considered to be at risk for falls are also assessed with the Morse Falls Scale. A review of 721 individuals (707 men, 14 women) age 65 and older, within CSC, found that 99.5% (n=718) had a completed Morse Falls Scale assessment on file and 21 % of those rated as high risk of falling and 21% rated as low risk received falls prevention interventions. (See ANNEX I for Falls Algorithm).

1. Results from the InterRAI CA assessment will provide an additional assessment of older persons at risk for falls. This information will be used to re-evaluate and revise, as needed, the Falls Prevention Program.
2. Areas for improvement based on a review of the literature include the need to establish formal age appropriate exercise and strength training etc.
3. The results from the scan of the physical environment will inform where improvements are needed to ensure safe mobility in CSC institutions.

CSC’s national food menu for all age groups within CSC aligns with the recommendations of Canada’s Food Guide. Special diets are provided for medical, religious and cultural reasons on a case by case basis. Currently within CSC vitamins and other supplements are provided based on an identified medical need. The menu is flexible and responsive to variation in needs. Currently, some vitamin supplements are not available on the CSC National Drug Formulary, such as vitamin D.

Based on a review of the evidence and the agreement of the National Pharmacy and Therapeutics Committee, CSC will revise the formulary to address any identified gaps related to the provision of vitamin supplements for OPiC.

Health promotion materials are provided to all persons in custody at Intake, and on a monthly basis during incarceration. In addition, specific high concern topics are addressed as needed such as health promotion information in response to the Opioid crisis in Canada, information related to specific outbreaks (Flu, for example) etc.

Information is communicated by posters, handouts, electronically via monitors in the waiting rooms of Primary Health Care Centres, and via peer-coordinators (Peer Education and Coordinators - PEC; Aboriginal Peer Education Coordinators - APEC; Peer Mentoring Program for women - PMP), etc. The following are examples of topics of monthly health promotion information that are specifically relevant to the needs of OPiC: Depression, Self Injury, Healthy Aging, Falls, Heart Health, HIV and Aging, Good Mental Health, Menopause, Stroke, Respiratory Problems, Osteoporosis, Alzheimer’s Disease, Flu vaccination, Exercise etc. (See ANNEX J: for samples of Health Promotion materials).

CSC will continue to provide health promotion information on the topic of aging and related issues such as brain health, dementia, the importance of social connections, frailty, exercise, etc. In addition, a strategy on the prevention of elder abuse will be implemented.

Emphasis will be placed on engaging community organizations and the development of partnerships to help respond to the needs of OPiC. Building on existing community partnerships including the engagement of volunteers, can help address the stigma that many older persons’ experience upon release.

Establishing dialogue and communication early with long term care facilities and other residential housing options can help to ensure effective transition and continuity of care. Working with and engaging Indigenous expertise to ensure cultural interpretation as it relates to communication, language, assessment and community based services will be critical.

CSC is partnering with Trent University^Footnote94 and CSC’s Citizen Advisory Committee to examine the experiences of older persons in custody as they transition from institutions into the community. The project will develop a community-based approach for tracking the reintegration of older individuals on parole, and evaluate the approach in a survey, interview and focus group based study of the experiences of older individuals on parole in the Peterborough (Ontario) region.

Older and advanced age does not automatically imply diminished physical and/or mental capacity and consequently reduced public safety risk. However, according to the UK Prison and probation Ombudsman Independent Investigations,^Footnote95 the use of restraints should be proportionate to the actual risk posed by the older person in custody in the context of their current health condition. This is particularly important when transporting seriously ill or disabled older persons. Furthermore, correctional transport vehicles used to escort older persons to medical appointments should be properly equipped to accommodate wheelchairs, and otherwise accommodate the needs of those with disabilities.

1. Review the policy on restraint for transportation of older persons for medical care and the use of a threat risk assessment process based on the severity of medical conditions or disabilities.
2. Review the suitability of the CSC transport vehicles.

CSC is engaged in a number of initiatives that, while not specific to OPiC, complement and potentiate efforts to address the needs of OPiC. The following are brief descriptions of some of these initiatives.

In 2016-17, CSC Health Services implemented an Electronic Medical Record and this has enabled quality improvement in the areas of integration of physical and mental health in one chart; continuity of care at transition points (transfers); ability to collect data related to the prevalence of chronic diseases.

Telemedicine is an important initiative that has enabled CSC Health Services to access a wide ranges of specialty services without the inconvenience of transporting the incarcerated person to the community. The use of telemedicine is more widespread in the Regions of Ontario, Prairies and Atlantic. Specialists accessed include: infectious disease, urology, respirology, renal dietician, Congestive Heart Failure Clinic, cardiology, dermatology etc.

Physician engagement is critical to advancing quality improvement within any health care system. In 2017, Health Services established a National Medical Advisory Committee^Footnote96 (NMAC) consisting of a Primary Care Physician and a Psychiatrist from each region of CSC, along with senior administrative staff.

In 2017, Health Services established a process to record wait time from Primary Care referral to when seen by specialist. The findings will be reviewed after 1 year and ongoing, against wait times published annually by the Fraser Institute ("Waiting Your Turn: Wait Times for Health Care in Canada."). CSC Health Services will monitor wait times for OPiC.

Health Services, with the assistance of an external physician consultant^Footnote97 is reviewing its Primary Care Model. As part of this process, CSC Health Services will assess opportunities to strengthen the multidisciplinary team, including increasing access to physiotherapy, and increasing the clinical role of pharmacist.

Health Services has implemented a national dental services monitoring process. CSC will monitor and report on the use of dental services and wait times for OPiC. CSC will consult with experts on dental care for seniors to determine the best approach in terms of screening schedules.

CSC has a multiyear chronic disease strategy that includes addressing diabetes, cardiovascular disease, respiratory diseases, and infectious diseases (see Annex K). The approach to chronic disease management within CSC involves reviewing medical charts and collecting data on the prevalence, and establishing a clinical Guidance document with metrics than can be monitored and reported on.

Consistent with lessons learned from the UK^Footnote98, CSC will establish a process that requires treatment plans for older persons with complex health needs, that integrate both primary physical health and mental health care.

1. Diabetes
   The diabetes Guidance document was implemented in 2016 and provides evidence-based guidance to healthcare professionals on the diagnosis and management of diabetes, facilitates national consistency and the achievement of recommended clinical targets among federal inmates. This guidance is based on the Canadian Diabetes Association (CDA) guidelines.
2. Cardiovascular (CV) Disease
   A similar process will be followed for cardiovascular disease/ heart disease, whereby the prevalence rate will be established and a Guidance document with clinical practice metrics will be developed to enable follow up and reporting of treatment outcomes.
3. Respiratory Disease
   As noted above a national Guidance Document on respiratory disease with metrics will be developed.
4. Infectious Diseases
   CSC has a longstanding successful approach to screening, testing, treating, and monitoring and reporting on results related to chronic infectious diseases (HIV, HCV) and this will continue.

CSC’s goal is to provide inmates with evidence based pain management that can be safely administered in a secure setting. CSC, in collaboration with the CSC National Medical Advisory Committee and CSC National Pharmacy and Therapeutics Committee, is working to develop a Chronic Non-Cancer Pain Management guidance document supporting an integrated model of pain management. This model (refer to Annex L) will encompass the evaluation of both the physical and psychological components of an individual’s pain in the diagnosis and assessment of pain and offer appropriate non-pharmacological (Cognitive Behaviour Therapy, physiotherapy, yoga, mindfulness, exercise, traditional Indigenous healing methods) in addition to pharmacological treatment options to best manage pain.

This guidance document will include recommendation related to assessment and monitoring pain in CSC offenders, including OPiC. This approach to pain management is currently being conducted as a small pilot initiative in one institution whereby a multidisciplinary team (i.e. nurses, physician, physiotherapist, psychologist) utilized a range of strategies (e.g. cognitive behaviour therapy, yoga, exercise, education) to address the needs of a group of individuals suffering from chronic pain.

1. Antimicrobial Stewardship:
   The primary focus of an antimicrobial stewardship initiative is to optimize antimicrobial use to achieve the best patient outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety. Health Services has adopted a multiyear approach. With the assistance of expertise from the Division of infectious diseases, University of Ottawa and The Ottawa Hospital, CSC Health Services identified current antibiotic use and trends within CSC and is currently involved promoting the proper use of antibiotics and minimize unnecessary use. OPiC will benefit from this strategy and as required the strategy can be tailored to specifically address the needs of OPiC.
2. Poly-Pharmacy and Deprescribing
   Safe and effective medication use is an essential component of optimal care. As such, CSC follows National/Provincial standards of practice to ensure individuals in custody receive prescribed medications in a safe and effective manner.

As OPiC are often on a larger number of medications and therefore at risk of multiple side effects or drug interactions, CSC is developing a new medication review process specific to the OPiC population to ensure optimal use of medications. This will involve the discontinuation ("de-prescribing") of medications seen as unnecessary or inappropriate and/or introduction of new medications shown to improve outcomes for chronic conditions commonly faced by older offenders, including dementia.^Footnote99 De-prescribing focuses attention on stopping medication to improve outcomes and decrease risks associated with polypharmacy in older people such as adverse drug reactions, functional and cognitive decline and falls.^Footnote100 Paying attention to polypharmacy and deprescribing is part of Health Services goal of increasing the clinical role of pharmacists in medication reviews and continuity of prescriptions. CSC pharmacists have reviewed the number of medications prescribed to OPiC and are collaborating with physicians to systematically review those on multiple medications with a view to achieving optimal prescribing.

CSC operates a dialysis program in collaboration with a local teaching hospital in Kingston, Ontario. There are plans to expand the availability of dialysis in the Ontario region and after completion of the project there will be capacity to accommodate up to 16 individuals per day (on two sites over several shifts). Hemodialysis and peritoneal dialysis are also available in other regions such as the Pacific Institution. Dialysis treatment is also provided at CSC’s Regional Psychiatric Centre (RPC) with a partnership between the RPC and the University of Saskachewan Hospital. While this initiative benefits offenders of all ages, it is particularly important for older persons from the perspective of reducing the disruption of having to be transported to a hospital several times per week.

Health Services is currently moving towards implementing a national suicide framework based on the Interpersonal-Psychological Theory (IPT) of Suicide. The IPT posits three central constructs to explain why individuals engage in suicidal ideation and behaviour, namely, thwarted belongingness, perceived burdensomeness, and acquired capability.^Footnote101

While the framework is not specific to OPiC, the approach is one that aligns well with the approach required by this age group. For example, Cukrowicz et al 2011, studied perceived burdensomeness and suicide ideation in older adults and concluded that "… perceived burdensomeness accounts for significant variance in suicidal ideation, even after predictors such as depressive symptoms, hopelessness, and functional impairment are controlled."^Footnote102 More recently, Jahn et al 2013^Footnote103 also concluded that perceived burdensomeness is an important suicide risk factor in older adults.

CSC’s Women’s Offender Sector has a well established peer mentorship program, though not specifically focused on older women, includes older women. Peer Mentorship is a non-judgemental approach used by women offenders to assist one another in coping effectively with their present circumstances. Peer Mentorship is not a form of therapeutic counselling, but rather it is inmate-initiated confidential support, information sharing and guidance related to the availability of appropriate resources and services within and outside the institution. It is a gender specific approach with the goal of empowering women offenders and increasing self-efficacy.

Benefits of Peer Mentorship include an opportunity for increased problem solving at the lowest level, support within the institution for women offenders to cope with various situations, and the personal development of inmates who are trained as Peer Mentors. Peer Mentors acquire and strengthen transferable skills, such as communication, problem solving, teamwork, and record keeping, to increase their employability.

Peer Mentors are selected on their ability to express sympathy and set healthy boundaries, be non-judgemental and maintain confidentiality, possess good communication skills, problem solving skills and the ability to work under minimum supervision. The peer mentorship role is strengthened by 33 hours of training and a certificate of completion. This training is supplemented by ongoing workshops and education as needed.

The individuals listed below were consulted on areas specific to their experience and expertise and were not consulted on this document in particular; and therefore the listing of their name below is not intended in any way to imply their endorsement of this document or CSC’s approach to addressing the needs of older persons in custody.

• Federal Bureau of Prisons United States (October 30, 2017, teleconference)
  • Discussion on their approach to addressing the needs of aging prisoners; aging in place, assessments, disability and aging, physical environment, staff training, self-managed care.
• Dr. Ruth Finkelstein^Footnote104, Columbia University, New York (November 2, 2017, teleconference.):
  • functional age and chronological age, informal support in prisons, young inmates providing support, vison and hearing, mobility aids and supportive foot wear; nutrition, older women in prison, staff training, younger groups 50+, physical accommodations.
• Dr. Bruce Stevens^Footnote105, Charles Sturt University, Australia. (November 27, 2017 teleconference):
  • intervention programs for older inmates, peer programs.
• Dr. Samir Sinha MD, DPhil FRCPC^Footnote106, Sinai Health System and the University Health Network, Toronto (December 5th and 6th, 2017 teleconferences)
  • Aging well, geriatric assessments, Indigenous population, InterRAI assessment (functional, cognition, social needs); geriatric syndromes, dementia, falls, other psychological issues (bullying, fear of dying, grief), screening, life course approach, collaborative opportunities.
• Dr. Wayne Warry^Footnote107 and Dr. Kristen Jacklin^Footnote108, University of Minnesota (December 15, 2016, teleconference)
  • Dementia and culture, assessment and screening, Indigenous population, trauma
• Janet McElhaney, M.D., FRCPC, FACP^Footnote109, Geriatrician, Health Sciences North, Northern Ontario School of Medicine (January 5, 2018, teleconference)
  • Dementia, mental illness, chronic disease, functional decline, risk factors, dementia and Indigenous people; compliance with medications, cultural safety, holistic approach to wellness
• Heather Campbell^Footnote110, Dementia Justice(in-person January 23, 2018).
  • Screening for dementia, medications and dementia, capacity and consent for care, the intersection of the dementia and the legal system, etc.
• Dr. Brie Williams^Footnote111, University of California (San Francisco), School of Medicine ( January 17, 2018, teleconference)
  • Housing older persons in custody; older person’s units; inmate councils, literacy, bullying, early release, dementia; assessment, risk factors, etc.)
• Governor Lynn Saunders^Footnote112, HMP (Her Majesty’s Prison) Whatton Prison, UK. (March 14, 2018, teleconference).
  • Dementia, palliative care, choice of where to die, use of volunteers from the community, Peer Support Programs, dementia friends training, memory (reminiscing) training for inmates, assessing and recognizing dementia in prison environment, resettlement, caregivers, older women, nutrition, minority groups.
• Public Health England - Jane Leaman^Footnote113 and Sunita Sturup-Toft^Footnote114 (March 5, 2018, teleconference)
  • dementia, palliative care, peer support, programs, physical accommodations, social care, women, assessments, nutrition, dental care, mental health, needs assessments, data needs, integration to community, intersection of health care and security.
• Dr. Mike Harlos^Footnote115, MD, CCFP (PC), FCFP, Winnipeg. (March 15, 2018, teleconference)
  • Goals of care, use of opioids in palliative care, pain management, education of staff, importance of protocols, collaborating with local palliative care teams.
• Dr. Harvey Max Chochinov^Footnote116, OM, MD, PhD, FRCPC, FRSC (March 8, 2018, teleconference)
  • palliative care, collaboration with community palliative care experts.
• Dr. J. Stephen Wormith^Footnote117, University of Saskatchewan (March 9, 2018 teleconference)
  • Dementia screening, culture and dementia.

CSC provides continuity of care and service provision to all inmates across the various transitions within federal custody: admission/ intake; during incarceration including transfers, and, discharge/release.

Upon arrival, all persons regardless of age entering CSC, undergo a comprehensive general health assessment (including a review of medications); screening and testing for infectious diseases; mental health screening and assessment; screening for suicide risk; and brief orientation and health promotion education. Recognizing that adapting to prison life can be challenging, access to culturally relevant spiritual and psychosocial care including access to Elders is provided. Individuals 65+ are assessed using an age relevant tool (includes a standardized falls assessment) and level of functioning and mobility are considered in the decisions of placement within the institution.

Within each of CSC’s institution there is a Primary Care Health Centre staffed by nurses, mental health professionals (including registered psychologists, mental health nurses, mental health practitioners), contract physicians, psychiatrists, and dentists. The model is clinic based, where multidisciplinary services are available during the day. CSC provides ongoing acute, chronic, emergency, and mental health care.

CSC’s Mental Health Strategy is founded on five key components, falling along a continuum of care from intake through to warrant expiry (end of sentence). The components are: (1) mental health screening at intake; (2) Primary Mental Health Care; (3) Intermediate (high and moderate intensity) Mental Health Care; (4) Psychiatric Hospital Care at Regional Treatment Centres; and (5) transitional care for release to the community (Clinical Discharge Planning and Community Mental Health).

CSC has interdisciplinary Mental Health Teams to coordinate the provision of mental health services to offenders and facilitate interdisciplinary case consultation. These teams are responsible for identifying needs and service requirements, prioritizing services, discussing current clinical, operational and case management issues/concerns, short and long-term goals, roles and responsibilities of all staff intervening with offenders with high needs, and emergent mental health issues.

CSC Health Services has a comprehensive Public Health agenda with guiding documents on topics including but not limited to cleaning best practices, discharge planning, gastroenteritis (Norovirus) outbreaks, hand hygiene, immunization, infection prevention and control, influenza, MRSA (methicillin-resistant staphylococcus aureus), sexually transmitted and blood borne infections, tuberculosis and viral hepatitis.

Most CSC institutions designated Public Health Nurse who oversees/leads this portfolio. A focus of public health includes immunization program for offenders including targeted campaigns during flu season and immunization aimed at aging offenders.

On admission to CSC offenders are provided with the Reception Awareness Program (RAP) which focuses on educating inmates on infectious disease and how to protect themselves. In the main stream institutions there is also a Peer Education Counselor (PEC) program. This program allows offenders to approach a trained peer regarding infectious diseases and other health related concerns. The program is led by a PEC coordinator with the assistance of trained volunteers. These trained members are able to provide basic information on infectious disease, health promotion and safety and can also refer the ‘patient’ to appropriate Health Services contacts for further follow up. National Headquarters Health Services regularly issues fact sheets and posters (some also available in Power Point version) and a wide array of health topics.

CSC’s goal is to provide inmates with evidence based pain management that can be safely administered in a secure setting. CSC is working to develop a process to support a culture shift from traditional pain management strategies to a more comprehensive, multidisciplinary holistic pain management approach.

Basic diagnostic tests are performed on-site by registered clinicians. Procedures such as phlebotomy, x-ray exams and ultra-sound exams can all be performed onsite. When more advanced diagnostic procedures are required (MRI/CT Scan/Bone Density Scan etc), CSC engages services of community partners who can provide the required service.

CSC provides medication coverage to Federal Inmates in Canada. Five regions provide coverage to 43 Federal Institutions, some of which are affiliated with treatment centres and/or 24 hour hospitals. The CSC National Formulary is a list of medications which CSC will fund when providing essential medical care to federal offenders. It was created following the formation of the CSC National Pharmacy & Therapeutics Committee (October 2007). The committee is made up of physicians, pharmacists, nurses and ad-hoc members comprised of various expertise.

CSC operates 5 Regional Pharmacies across the country that provide medications to patients in accordance with the National Formulary. There is a National Pharmacy and Therapeutics Committee that reviews the National Formulary twice yearly. The committee is comprised of a multidisciplinary representation from clinical and non-clinical area’s Nationally. The Senior Medical Advisor and National Pharmacist are responsible for reviewing requests for exceptions to the National Formulary.

Access to specialty services that are available to the general public in the community are also provided to offenders in CSC custody. The services would be consistent with most provincial health plans and CSC’s Essential Health Services Framework. These services can be utilized via several means; in person visit by specialist to the institution, in person visit by the offender to the community clinic/hospital, Telemedicine or physician to physician consultation (telephone, written or E-consult).

CSC partners with local community hospitals and specialty centers to obtain a multitude of specialty services such as advanced diagnostic imaging (MRI/CT/Ultrasound, etc.). Surgical procedures, ongoing disease management (cardiac, cancer etc.), Pain Management, Palliative Care, Gender Dysphoria, Gynecological, Obstetrical etc.

Essential dental care focuses on relieving pain and infection, managing disease and providing education on preventative oral hygiene. For essential dental care services covered by CSC that are beyond the ability of the institutional dentist to perform, offenders are referred to local community specialist for treatment.

As part of CSC’s efforts to provide timely care and enhance community safety, Telemedicine has become a more utilized means of accessing specialty care. Utilizing Telehealth / video, a patient connects with a healthcare provider via telephone/video. Tele-homecare healthcare professionals are able to monitor an offender’s health status remotely. This allows a nurse at the regional hospital (which is staffed 24 hours a day, 7 days a week) to assess an offender when there is no health care staff at the respective Institution. The benefit of this service is to provide timely assessment and follow up, increased community safety and cost effective treatment choices.

In an effort to ensure a seamless release from prison, regardless of age, a comprehensive discharge plan is developed including health care referral and arrangements for follow up care where required. Those offenders who are on prescribed medications are released with a 2 week supply of most medications. In addition, they are provided with an information package which they can share with their next care provider; a list of current prescriptions is included in this release package.

• Registered Nursing care
• General Practitioner physician services
• Emergency Response/Care
• Comprehensive general health assessment on admission to CSC.
• Screening for infectious diseases (STBBI, HIV, Hepatitis)
• Medication reconciliation (on admission, transfer and discharge)
• Wound care
• Pain management (acute)
• Health Promotion Education
• Routine screening and follow up of health concerns as identified by offender
• X-ray/ultrasound
• Dental care
• Optometry
• Hearing assessments
• Respiratory assessments (CPAP)
• Acute injury management by onsite nursing/physician staff
• Physiotherapy
• Counselling (Health promotion/Education)
• Diagnostic procedures (phlebotomy, PAP smears, stool collection etc.)
• Fall Assessments
• Regional Hospital - 24 hour nursing care; transition point from community hospital to parent (home) institution
• Registered Dietician
• Obstetrical care
• Public Health (Outbreak management)

Ongoing multidisciplinary chronic disease management (CSC health service staff, General Practitioner, Community Specialists)

• Diabetes
• Cardiac care
• Respiratory care
• Wound care
• Pain management (chronic)
• Infectious Disease treatment
• Gender Dysphoria
• Opiate Substitution Therapy
• Palliative/End of Live care (including MAID)
• Dialysis
• Physiotherapy

• Mental Health assessment
• Regional Treatment Centers
• Suicide Assessment
• Mental Health Treatment (CBT, DBT, Medications, Group Treatment)
• Psychology services
• Psychiatry services
• Crisis support

Pain Management/Occupational Therapy

Access to specialty services that are available to the general public in the community are also provided to the offenders in CSC custody.

The services would be consistent with most provincial health plans and CSC’s Essential Health Services Framework.

These services can be utilized via several means; in person visit by specialist to the institution, in person visit by the offender to the community clinic/hospital, Telemedicine or physician to physician consultation (telephone, written or E-consult).

CSC partners with local community hospitals and specialty centers to obtain a multitude of specialty services such as advanced diagnostic imaging (MRI/CT/Ultrasound etc.), Surgical procedures, ongoing disease management (cardiac, cancer etc.), Pain Management, Palliative Care, Gender Dysphoria, Gynecological, Obstetrical etc.

• Wheelchairs
• Walkers
• Canes
• Crutches
• Back Braces
• Elbow/Wrist supports
• Artificial limbs
• Specialty braces
• Hospital bed
• Long handled shoe horn
• Reaching tool/grabber
• Long handled sponges
• Grab bars
• Shower chair
• Stability pole
• Dosettes/compliance packs
• Inmate support workers
• Personal Support workers
• Specialty mattresses to maintain skin integrity
• Compression stockings
• Hearing aids
• Braille material

Enabling Technology

• Telemedicine; E-consults, RACES (Rapid Access to Consultative Expertise (BC)
• Electronic Medical Record
• Electronic Pharmacy system

Discharge Planning and Release

• Comprehensive discharge planning (Referral, arrangement for follow-up care, medications (consistent with National formulary), OST transition to community clinic etc.

Living Accommodations

• Consultation with respect to appropriate living area based on health needs

Working Assumptions

The Psychogeriatric (E) Unit is staffed with an interdisciplinary team (nurse, physician, spiritual leader, parole officer, correctional program officer, psychologist, social worker, etc.), that provide care to individuals (men) with physical and/or mental health conditions and/or brain injuries. The goal of the (E) Unit is to provide interventions and services within a safe, therapeutic environment that are individualized and responsive to the special needs of the men being served.

Clinical interventions provided in the (E) Unit are both group and individually based. The Unit works in collaboration with the medical hospital, sharing both caregiver resources and clinical support, overnight support and short term stays.

The Psychogeriatric (E) Unit (64 beds) provides Peer Assisted Living (PAL) to those inmates who can no longer live safely or independently in a regular institutional environment due to complex health care needs (physical, mental, and/or cognitive deficits as a result of aging or medical concerns). These inmates require daily assistance from staff and/or peers to manage transfers, mobility or activities of daily living (eating, bathing, dressing, toileting and grooming). Some PAL clients may only require a short term placement before returning to their parent institution.

The peers (24 caregivers) who provide assistance in the (E) Unit are provided training and education and on going support. Admission to the PAL Caregiver program is based on the individual being actively engaged in their correctional plan and must have demonstrated positive working relationships with their case management team.

In addition, 8 Long Term Workers (LTW’s) are also present on the E-Unit. LTWs are inmates who work closely with staff to ensure all of the required unit jobs in the E-Unit are completed such as cleaning, emptying garbage cans, cleaning range showers, pick up; delivery and placement of meal trays from the kitchen, etc. LTWs must be physically capable of the work, demonstrate a positive outlook, be flexible with respect to duties and get along well with other LTWs. As with the PAL Caregiver Program, inmates applying to the program must be actively engaged in their correctional plan, and demonstrate positive working relationships with their case management team.

The Assisted Living Unit at Bowden is a 14 bed Assisted Living Unit (ALU) staffed with medical professionals including nurses, psychologists, and social workers. Access to programming include counselling, pet therapy, House of Healing, Assertiveness Communication Group, Cognitive Distortions and Mood management.

Recreation, rehabilitation support, physiotherapy, and occupational therapy are also provided including yoga, meditation, senior exercise and walking groups. In addition to medical staff, the ALU has 17 trained Peer Assistants that assist with patient care and activities of daily living.

Residents in the ALU are of various ages, including those aged 65+. All have chronic and complex medical conditions such as but not limited to cancer, angina, congestive heart failure, depression, personality disorder, traumatic brain injury, etc. and require assistance with activities of daily living.

All patients have ongoing comprehensive medical assessments and an individualized Nursing Care Plan. The Unit has barrier-free paths of travel, slip-resistant and tactile strips in contrasting colors on landings, tread edges, and shower floors, pocket talkers, etc.

Annex E - Personal interviews with older persons in CSC to inform planning on a framework for older persons^Footnote118

Thank you for agreeing to meet with me. Corrections is looking at ways to improve meeting the needs of older persons in custody and we would like to have your feedback. I have a few questions for you that will take about 20-30 minutes. There are no right or wrong answers. Speak as freely as you can. Your name is not attached to any of my notes. Feel free to provide feedback on other topics if you wish. Your participation is completely voluntary.

Date; Institution.

Gender Orientation (if self identified)

Inmate Age (if they are ok providing it)

1. There are lots of views on what is an ‘older’ offender in terms of ‘age. What do you consider to be an "older" person in CSC? (do you feel old yourself? Do you think it is about ‘age’ or about how you ‘feel’ in terms of being ‘older’?)
2. On a scale from 1-10 where 10 is the BEST possible, how satisfied are you with your overall ability to live comfortably here? Tell me a little bit of why you chose that number? What is life like for you here (tell me about your current living arrangements (range/room/single or double bunked/ shower/access to Health Care- including dental care /recreation/spiritual/get around safely)?
3. In your view, is there anything that could be improved - anything that could be done better to make your life - as an older person- better?
4. What are your views about older offenders living together in a special older person’s units? Should there be a choice? Why or why not?
5. Tell us about your feelings of safety? (follow-up prompts as needed: is there anything that could be done to help you feel safer? Prompt- have you ever been bullied or seen anyone being bullied? Have you been a victim of elder abuse or seen anyone being a victim of elder abuse?)
6. Tell me about your spiritual needs? Are they being met? Is there anything that could be improved in this area?
7. On a scale from 1-10 where 10 is Excellent and 1 is poor, how would you rate your overall health? What health or dietary needs, if any, do you have?
   Excellent, Good, Poor
8. On a scale of 1-10 with 10 being the best possible, how well do you think your health needs are being met? Why did you give that number? What changes could help meet your health needs better? Do you use any mobility aids (walker, wheelchair, cane, etc.)?
9. How do you spend your recreation time (after the work day/on weekends) (work/recreation/social activities/spiritual etc.)? How easy is it for you to access recreational space/activities? Are there any programs here that older inmates use? Do you think your age has any impact here in terms of access?
   Work Location.
10. What more do you think could be done inside to make you as ready as possible to do what you want to do when you are released?
    Prompts:
    • Will you go back home/to your community?
    • Will you be accepted back / be allowed to return to your home community?
    • Will you have support reintegrating into your community, family, friends?
11. What is your experience on getting older and your relationship with others (other inmates; health care staff; correctional in the institution in terms of how they relate to you?
12. My next question is about your social circle. Tell me about who you consider family or friends? Who are you close to? Are they able to visit you? How often do you have visitors (family, friends, outside agencies, volunteers)?
13. Tell me about your experience with "peer-support/caregiver" (receiving or giving) and your general views?
14. As you get older, what, if anything worries you about getting older while in custody? (what do you worry about the most? Do you worry about getting older…getting sick…getting dementia, dying in here, etc.?).

Additional Notes

That’s the end of my questions. Is there anything else you would like to tell me or suggest that would improve services to older offenders?

Name of Institution:

Date:

Conduct a ‘walkthrough’ of the institution and living area of older persons to review accessibility
(Source: Good Practice Guide; Working with Older Prisoners; RECOOP.Org.UK; *adapted for Canadian Federal Prison Context)

Each area will be accessed based on the availability of the following: grab rails, non-slip floors, lighting at appropriate level, signage, wheel chair accessibility, call systems at appropriate levels, fully accessible program/cultural areas, water temperature controls, adapted phones for hearing or sight impairment, large print books or audio tapes, ramps, salted walkways, wheel chair trays, disability cutlery, wheel chair accessible medication window, accessible washrooms, special transportation vehicles, programs for OPiC to promote social connections, flexible workplaces for OPiCs, printed information in large font, etc.

Day 1: ½ day in-person in Kingston with ongoing access to self-paced learning library resources

Topics: Introduction to care of Older Offender

• Demographic and social trends in relation to aging
• Important aging changes relevant to health and care of older offenders
• Frailty in older offenders: importance, common causes and how to recognize/assess
• Key components of Comprehensive Geriatric Assessment within a Periodic Health review and screening process for Older Offenders
• Polypharmacy and principles of prescribing to older offenders

Day 2: ½ day in-person in Kingston (could be offered by videoconference/webinar if necessary) with ongoing access to self-paced learning library resources

Topics: Assessing and Managing Common Geriatric Syndromes:

• Dementia
• Delirium
• Depression
• Falls
• Incontinence

Series of 6 x 1 hour monthly facilitated webinars with ongoing access to self-paced learning library resources

• Approach to Common Chronic Diseases in Older Offenders
• Suggested topics based on preliminary consultations to be covered include:
  • Diabetes Mellitus and skin issues (inclusive of ulcers) in the older offender
  • Common Cardiovascular issues - CHF, AF, PVD
  • Common Neurological issues - CVA, PD, other EPS, Neuropathies
  • Common Bone and Joint issues - Osteoporosis, Polyarthropathy, PMR
  • Pain and EOL issues
  • Managing Psychosis in older offender
  • Transitions/discharging the Older Offender

½ day in-person in Kingston with ongoing access to self-paced learning library resources

Topics: Introduction to care of Older Offender

• Demographic and social trends in relation to aging
• Important aging changes relevant to health and care of older offenders
• Frailty in older offenders: importance, common causes and how to recognize/assess
• Adapting Age-Friendly Community and Active Aging Principles to the Canadian Correctional Systems

½ day in-person in Kingston with ongoing access to self-paced learning library resources

Topics: Introduction to care of Older Offender

• Important aging changes relevant to health and care of older offenders
• Recognizing and responding to Frailty and vulnerability in older offenders: Communicating effectively with older and frail adults, including those with cognitive, mood and sensory challenges
• Practical guide and tips to maximizing function of older adults

Taken from: Livingston G, Sommerlad A, Orgeta V, Costafreda S C, Huntley J, Ames D, Ballard C, Banerjee S, Burns A, Cohen-Mansfield J, Cooper C, Fox N, Gitlin LN, Howard R, Kales HC, Larson EB, Ritchie K, Rockwood R, Sampson EL, Samus Q, Schneider LS, Selbæk G, Teri L, and Mukadam N (2017). Dementia prevention, intervention, and care, The Lancet Commission, Lancet, 390, 2673-2734

Falls Algorithm within the context of CSC

Health Promotion examples

Image 1.

Image 2.

Image 3. This image is a continuation of Image 2.

Chronic Pain Management Cycle