Evaluation of CSC’s Health Services, 2017

Evaluation Report

File #394-2-96

Evaluation of CSC’s Health Services

Evaluation Division
Policy Sector
March 2017

PDF

Evaluation of CSC’s Health Services

Signatures

Evaluation of CSC's Health Services

Don Head

Commissioner

Date: March 2017

Brigitte de Blois

Director, Evaluation Division

Date: March 2017

Contributions

Authors:

Kendra Delveaux, Senior Evaluation Manager

Colleen MacDonald, A/Senior Evaluator

Ashley McConnell, A/Evaluation Officer

Sheena Bradley, Evaluation Officer

Adam Crawford, Evaluation Analyst

Felicia Tse, Junior Evaluation Analyst

Evaluation Team Members:

Duyen Luong, Senior Evaluator

Hassimiou Ly, Senior Evaluator

Lysiane Marseille-Paquin, Evaluation Officer

Marcie McLean-McKay, Evaluation Officer

Tara Beauchamp, Evaluation Officer

Bertha May, Evaluation Officer

Donna Towns, Evaluation Officer

Elizabeth Loree, Junior Evaluation Analyst

Hortense Kambou, Junior Evaluation Analyst

Joel Ndayubaha, Junior Evaluation Analyst

Kossi Aziaba, Junior Evaluation Analyst

Kristen White, Junior Evaluation Analyst

Alex Lefebvre, Junior Evaluation Analyst

Acknowledgments

The evaluation team is grateful for the assistance provided by the Health Services Sector for their continued support with various aspects of this project. The evaluation team would like to express sincere appreciation to Marie-France Lapierre, Audrey Castonguay and Ginette Clarke for their ongoing efforts throughout the evaluation project. The evaluation team also wishes to extend their appreciation to the Women Offender Sector, Correctional Operations and Programs, and Aboriginal Initiatives Directorate, for their contributions in the pre-evaluation stages of the evaluation. The evaluation team would like to thank all members of the consultative group including Pat Barker (Drumheller Institution), Jennifer Gravelle (Health Services, Region), Peter Desjarlais (Aboriginal Initiatives Directorate), Marnie MacDonald (Women Offender Sector), Peter Glen (Correctional Operations and Programs), Luc Gregoire (Correctional Operations and Programs), Kent Merlin (Performance Management), James Matthew (Regional Operational Prairies Institution), Peter Wickwire (Regional Operational Atlantic Community), and Lynn Stewart (Research Branch) for their collaboration and contributions throughout the evaluation.

The evaluation team would like to express its appreciation to all those who participated in the collection of data at various CSC institutions and contributed valuable information, including Regional Directors, Wardens, District Directors, institutional and community staff members, and staff at NHQ. The evaluation team would like to extend their gratitude to all offenders who contributed to the evaluation by participating in interviews and sharing their overall experiences regarding health services throughout the continuum of care.

We would also like to thank the many branches and sectors of CSC who helped provide data for this evaluation, including the staff in Financial Management Services in the Comptroller's Branch who provided financial data and staff from Strategies, Planning, Measurement and Reporting who provided human resource data.

Finally, the evaluation team would like to thank everyone else who contributed to this evaluation, whose names do not appear here.

Executive Summary

According to section 86(1) of the Corrections and Conditional Release Act (CCRA), CSC is mandated to provide essential health care, and reasonable access to non-essential mental health care that will contribute to the inmate's rehabilitation and successful reintegration into the community.^{Endnote i}

Compared to the Canadian population, offenders demonstrate a higher prevalence of mental and physical health concerns. As well, CSC's offender population is aging. In 2014-15, 24% of federal offenders were 50 years or older and the number of offenders over the age of 50 at admission has risen over the last ten years.^{Endnote ii} In 2014-2015, Health Services accounted for approximately 11% of CSC's total direct program spending. CSC's Health Services represent an important opportunity to address offenders' diverse health care needs throughout the continuum of care, which includes: intake, incarceration, and pre-release and community supervision.

The evaluation focuses on the relevance and performance of CSC's mental, clinical, and public health services. Evaluation questions examine the following areas: relevancy of CSC's health services, effectiveness and efficiency of the intake assessment process, offender access to care and services throughout incarceration, public health education and harm reduction, institutional mental health services, pre-release and community health services and the management and coordination of health services. Given the breadth and complexity of health services within CSC, the evaluation is organized into seven findings in focus for evaluation (FIFEs).

Evaluation Results:

Overall, the evaluation found that CSC's Health Services are relevant and meet the needs of federal offenders. Positive impacts were found regarding institutional mental health care where offenders' had a reduced likelihood of incidents, serious charges and involuntary segregation following treatment. Several key areas were identified for service improvements and recommendations were made to support decision makers with improving the efficiency and effectiveness of CSC's Health Services. Program managers responded to these recommendations. The major recommendations and their associated management responses are outlined below.

Maintain productive relationships with partners who support individuals with mental health disorders. CSC is responsible for providing health services to federal offenders; there is an ongoing need for partnerships to effectively and efficiently deliver these services to offenders.
- In response: CSC will strengthen partnerships to support the delivery of mental health services for federal offenders and will share information and practices related to mental health through the Federal Provincial Territorial Working Group on Health/Mental Health.
Ensure offenders are referred to the appropriate mental health services. CSC has developed a Mental Health Need Scale to assess offenders' mental health need and determine the appropriate level of care required in accordance with its new refined model of mental health care (primary, intermediate, psychiatric hospital). The validity and reliability of this scale are yet to be assessed.
- In response: CSC will assess the validity and reliability of the Mental Health Needs Scale and will strengthen the process for recording and maintaining offender level of need data.
Adopt measures to support a continuum of health care for offenders during their transition from CSC Health Services to provincial/territorial health coverage. Specifically, obtaining health cards and payment for community health services. Procedures in obtaining provincial/territorial health cards vary across regions and depend on provincial/territorial health authority requirements. CSC may cover the cost of some medical expenses in the community if offenders are not covered by provincial/territorial health insurance or other provincial/territorial plans (e.g., disability benefits, drug plans).
- In response: CSC will develop guidelines to obtain, track and store ID at intake; work with Canadian provinces and territories to determine how offenders can better access health care services and disability benefits following their release; and, clarify national guidelines regarding CSC payment for health services in the community.
Increase the efficiency of health-related intake assessments processes. Health services intake assessment tools and processes are effective in identifying offender health needs; however, duplication of offender health information collected through intake assessment processes results in inefficiencies in assessing offenders' health care needs.
- In response: CSC will eliminate the requirement for repeated administration of health assessments and unnecessary repetition of health information between assessment tools. CSC will also ensure health referrals are appropriately recorded and monitored electronically.
Ensure offenders have timely access to health education programs and harm reduction products. Health education programs, particularly those aimed at infectious disease, are associated with increased offender health-related knowledge and related behavioural changes (e.g., reduced risk-taking behaviours). Results of a review indicated that bleach was not always available as required in all CSC institutions and no recent data were available to confirm the accessibility of other harm reduction products (e.g., condoms).
- In response: CSC will provide clear direction and accountability for delivery and tracking of health education programs; monitor the distribution of harm reduction products; and, address any identified accessibility issues.
Continue to implement and report on the Chronic Disease Management Strategy. CSC has implemented policies, guidelines and strategies to address the special health care needs of women and Indigenous offenders. Additional support related to the chronic disease needs of older offenders is required.
- In response: CSC will continue to implement the Chronic Disease Management Strategy and will report on progress against expected results to track and identify gaps in service.

This evaluation will assist CSC in improving the delivery of health services for all offenders across the continuum of care.

List of Findings

Finding 1: Need for Health Services

There is a continued need for delivery of clinical, public and mental health services to CSC offenders.

Finding 2: Alignment with Priorities and Federal Roles and Responsibilities

CSC Health Services are aligned with federal government priorities. CSC is responsible for providing health services to federal offenders, but there is an ongoing need for partnerships to effectively and efficiently deliver services to offenders.

Finding 3: Effectiveness of Health Services Intake Assessment

The overall health services intake assessment tools and processes are effective in identifying offender health needs.

Finding 4: Efficiency of Heath Services Intake Assessment Process

Duplication of offender health information collected through CSC health services intake processes and tools results in inefficiencies in assessing offenders' health care needs.

Finding 5: Access to Clinical, Public and Mental Health Care

CSC offenders have access to clinical, public, and mental health care to address their needs. The majority of offenders receive initial mental health services according to established time-frames; clinical health services are not tracked electronically. Health Services is in the process of implementing an Electronic Medical Record.

Finding 6: Access to Community Health Care Specialists

The provision of community health care specialist services for offenders for non-urgent care is subject to wait times in the community. CSC uses telemedicine (where provincial telemedicine programs are available) to address procedural issues associated with health care specialist appointments in the community. CSC does not systematically collect data regarding referrals to specialist services (in-person or telemedicine).

Finding 7: Transfers

Health services staff and offenders reported challenges to continuity of care and information sharing or documentation during transfers were identified. Inaccurate information sharing may be a result of incomplete documentation in the Health Services Transfer Summary forms.

Finding 8: Information Sharing

Some CSC personnel reported a lack of understanding of the guidelines for sharing of personal health information, and the sharing of health information could be improved. There are opportunities to implement electronic medical records to enhance information sharing.

Finding 9: Health Education Delivery

CSC's health education programs and initiatives target many of the significant health needs of the offender population, but offender access to and voluntary participation in some programs is limited.

Finding 10: Impact of Health Education and Harm Reduction Initiatives

Health education programs, particularly those aimed at infectious disease, are associated with increased offender health-related knowledge and related behavioural changes (e.g., reduced risk-taking behaviours). Results of a review indicated that bleach was not always available as required in all CSC institutions, but no recent data were available to confirm the accessibility of other harm reduction products, such as condoms, dental dams, and lubricants.

Finding 11: Institutional Mental Health Care Outcomes

Institutional mental health care provided in CSC mainstream institutions and RTCs was associated with positive impacts on offenders' behavioural stability following treatment, such as reduced likelihood of incidents, serious charges, and involuntary segregation.

Finding 12: Level of Care Based on Need

The Health Services Sector developed a Mental Health Need Scale to assess the level of mental health need and determine the appropriate level of care required in accordance with the new refined model of mental health care (primary, intermediate, psychiatric hospital). The validity and reliability of this scale have not been assessed, and electronic data on offender scale results have not been consistently recorded.

Finding 13: Regional Complex Mental Health Committees

Regional Complex Mental Health Committees have been established to assist and support institutions in providing an effective continuum of care to offenders with complex mental health needs. The degree to which funds were expended relative to those allocated at the regional level could not be accurately determined because funding was not fully tracked in the financial system.

Finding 14: Routine Discharge Planning and Offender Identification

Processes to assist offenders in obtaining provincial health cards vary across regions and are dependent on provincial/territorial health authority requirements. Procedural challenges associated with assisting offenders to obtain provincial/territorial health cards exist (e.g., prerequisite for a birth certificate, fee requirements, releases to different provinces).

Finding 15: Payment for Community Health Services

According to CSC policy, CSC may cover the cost of some medical expenses in the community if offenders are not covered by provincial/territorial health insurance or other provincial/territorial plans (e.g., disability benefits, drug plans) and have no personal means to pay. Medical expenses covered by CSC in the community vary across regions, which may be related in part to variations in provincial health coverage.

Finding 16: Community Mental Health Services and Clinical Discharge Planning

Community mental health specialists services provided to offenders were associated with lower rates of recidivism; whereas, clinical discharge planning services alone did not appear to have an impact. The number of offenders receiving clinical discharge planning services could not be determined due to inconsistencies in data recording; providing continuity of care is challenging when offenders who receive discharge planning services are released to locations with limited CSC community mental health staff.

Finding 17: Coordination of CSC's Health Services

Following changes to the health services governance structure, there has been greater standardization and integration of health services.

Finding 18: Infectious Disease Treatment: Hepatitis C Virus

CSC expenditures for Hepatitis C Virus (HCV) medication more than tripled from 2013-2014 to 2015-2016 due to a new Canadian approved standard of care. New treatment is more costly, but has resulted in an increased cure rate for individuals with the disease, also reducing the risk of spread of HCV to others.

Finding 19: Health Services for Specific Populations

CSC has implemented policies, guidelines and strategies to address the special health care needs of women and Indigenous offenders. Additional support related to the chronic disease needs of older offenders is required.

List of Recommendations

Recommendation 1: Mental Health Diversion

That CSC maintains productive relationships with partners who support individuals with mental health disorders.

Recommendation 2: Effeciency of Health Services Intake Assessment Tools and Processes

That CSC Health Services endeavour to increase the efficiency of health-related intake assessment processes by considering the following:

Eliminating the requirement for repeated administration of health assessments;
Optimizing and eliminating unnecessary repetition of health information between assessment tools; and,
Ensuring health referrals are appropriately recorded and monitored.

Recommendation 3: Access to Community Health Care Specialists

That CSC Health Services collect data on wait times to access selected specialists services for non-urgent care; and implement strategies (for example increased use of telemedicine where appropriate) if wait times exceed available Canadian benchmarks.

Recommendation 4: Information Sharing

That CSC Health Services improve the understanding of information sharing requirements and limitations, as elaborated in their guidelines, in accordance with privacy laws and other relevant legislation. That CSC Health Services improve timely access to relevant and accurate medical records for Health Care staff. These will be accomplished by:

Finalizing the implementation of electronic medical records to improve accessibility and consistency of health information;
Enhancing awareness of information sharing procedures and "need-to-know" principle among CSC personnel, including concrete examples of where and how the principle should be applied; and
Conducting a review of information sharing issues identified in board of investigation incidents to contribute to existing lessons learned and to inform procedural/policy changes if necessary.

Recommendation 5: Health Education and Harm Reduction

That CSC Health Services ensure that offenders have timely access to health education programs and harm reduction products by:

Providing clear direction and accountability for delivery and tracking of health education programs; and
Monitoring the distribution of harm reduction products (bleach, condoms, dental dams, and lubricants) and addressing any identified accessibility issues.

Recommendation 6: Level of Care Based on Need

That CSC Health Services ensure offenders are referred to the appropriate mental health services by:

Implementing effective management practices to ensure that current information on offender level of need is recorded electronically and that previous records are retained; and
Assessing the validity and reliability of the Mental Health Need Scale.

Recommendation 7: Regional Complex Mental Health Committees

That CSC Health Services:

Track nationally and report on activities and expenditures of funds released to regions through RCMHCs; and
Provide information to institutional staff regarding the role of RCMHCs and identified best practices.

Recommendation 8: Release Planning and Offender Indentification

That CSC adopt measures to address challenges related to offenders accessing health care in the community by retaining or obtaining offender ID (including health cards); and to clarify the policy, guidelines and procedures pertaining to coordinating access to medication while transitioning to the community.

Develop guidelines to support the retention of offenders' ID including health cards;
Establish mechanisms to obtain key ID at intake; and,
Clarify existing release policy related to the requirements for medication at release and provide consistent communications to staff.

Recommendation 9: Access to and Payment for Community Health Services

That CSC improve access to community health services to ensure a continuum of health care for offenders during the transition to provincial/territorial health coverage, by:

Improving partnerships with provincial and territorial health authorities to determine how offenders can better access health care services and disability benefits; and,
Clarifying and communicating policies and procedures related to CSC's coverage (i.e., payment) for health services in the community and requirements for medication at release.

Recommendation 10: Clinical Discharge Planning and Community Mental Health Services

That CSC:

Review the model of community mental health service delivery to ensure that community mental health services are being provided to offenders with the greatest mental health needs.
Ensure that clinical discharge planning activities are tracked in electronic information systems.

Recommendation 11: Specific Populations of Offenders

That CSC Health Services continue to implement the Chronic Disease Management Strategy, with reference to any special needs/requirements for older, women, and Indigenous offenders, and methods for tracking impacts.

Management Action Plan Overview

In response to the recommendations identified throughout the evaluation, CSC has developed Management Action Plans to strengthen the provision of health services across the continuum of care. The Management Action Plans are summarized below, for a copy of a full plan, contact CSC's Evaluation Division.

Management Action Plan for Recommendation 1:

Strengthen partnerships and collaborative efforts in support of the delivery of mental health services to federal offenders by guiding the implementation of CSC's Integrated Engagement Strategy.
Share information and practices relating to mental health through the Federal Provincial Territorial Working Group on Health/Mental Health and for consideration of the Heads of Corrections.

Management Action Plan for Recommendation 2:

Modify health services processes for health care requirements for 24-hour and 14-day assessments.
Streamline health services intake assessment tools to reduce unnecessary repetition of physical health information.
Review of mental health assessment tools to determine if they can be revised/streamlined to eliminate unnecessary duplication of information while maintaining effective identification of offenders with mental health needs.
Implement a new electronic health information system to record information electronically on assessments and referrals.

Management Action Plan for Recommendation 3:

Implement a national approach to tracking offender referrals and services for selected community specialist services.

Management Action Plan for Recommendation 4:

Implement an Electronic Health Information System.
Improve clarity and understanding of information sharing requirements and understanding of "need-to-know" principle (among all Health Services staff, and between Health Services and operations staff).
Identify common issues and lessons learned, and best practices across Boards of Investigations, related to health related information sharing issues.

Management Action Plan for Recommendation 5:

The Regional Directors Health Services and the Director General Clinical Services and Public Health are responsible for ensuring that offenders have timely access to health education programs and harm reduction products.
Streamline and integrate delivery of health education and awareness programs to facilitate delivery and tracking.
Monitoring harm reduction product distribution.

Management Action Plan for Recommendation 6:

Conduct analysis to verify the validity and reliability of the Mental Health Needs Scale.
Strengthen the process for recording and maintaining offender level of need data.

Management Action Plan for Recommendation 7:

Implement a national approach to track and monitor outcomes associated with RCMHC activities in each region.
Ensure accurate recording of expenditures related to RCMHCs in CSC's financial system.

Management Action Plan for Recommendation 8:

Ensure the retention of offenders' ID (e.g., birth certificate, health card) at intake through the development of storage and tracking procedures.
Develop guidelines and procedures to ensure that offenders obtain ID at intake (e.g., birth certificate, health card).
Clarify existing release policy related to the requirements for medication at release and communicate the policy updates to staff.

Management Action Plan for Recommendation 9:

Improving partnerships with provincial and territorial health authorities to remove barriers to accessing health care and disability benefits.
Clarifying and communicating policies and procedures related to CSC's coverage (i.e., payment) for health services in the community and requirements for medication at release.

Management Action Plan for Recommendation 10:

Review CSC's model for community mental health services.
Ensure that clinical discharge planning activities are tracked in electronic information systems.

Management Action Plan for Recommendation 11:

Continue to implement CSC's Chronic Disease Management Strategy.

Signatures
Contributions
Acknowledgments
Executive Summary
List of Findings
List of Recommendations
Management Action Plan Overview
Table of Contents
List of Tables
List of Figures
List of Acronyms
1.0 Introduction
- 1.1 Background
- 1.2 Policy and Legislation
- 1.3 Program Description
2.0 Evaluation Method
- 2.1 Scope of the Evaluation
- 2.2 Approach
- 2.3 Measures
- 2.4 Limitations and Mitigation Strategies
3.0 Findings
FIFE #1: Relevance of CSC's Health Services
- 3.1 Need for Health Services
- 3.2 Alignment with Priorities and Federal Roles & Responsibilities
FIFE #2: Effectiveness and Efficiency of CSC's Health Services Intake Assessment Process
- 3.3 Effectiveness of Health Services Intake Assessment
- 3.4 Efficiency of Health Services Intake Assessment Process
FIFE #3: Offender Access to Care and Services
- 3.5 Access to Clinical, Public and Mental Health Care
- 3.6 Access to Community Health Care Specialists
- 3.7 Transfers
- 3.8 Information Sharing
FIFE #4: Public Health Education and Harm Reduction
- 3.9 Health Education Delivery
- 3.10 Impact of Health Education & Health Reduction Initiatives
FIFE #5: Institutional Mental Health Services
- 3.11 Institutional Mental Health Care Outcomes
- 3.12 Level of Care Based on Need
- 3.13 Regional Complex Mental Health Committees
FIFE #6: Pre-Release & Community Health Services
- 3.14 Routine Discharge Planning and Offender Iindentification
- 3.15 Payment for Community Health Services
- 3.16 Community Mental Health Services & Clinical Discharge Planning
FIFE #7: Management & Coordination of Health Services
- 3.17 Coordination of CSC's Health Services
- 3.18 Infectious Disease Treatment: Hepatitis C Virus
- 3.19 Health Services for Specific Populations
4.0 Conclusion
Appendix A: Policy and Legislation
Appendix B: Need for Health Services
Appendix C: Mental Health Diversion
Appendix D: Effectiveness of Intake Assessment for Specific Populations
Appendix E: Description of Health Education Initiatives
Appendix F: Institutional Mental Health Services
Appendix G: Community Mental Health Services
Appendix H: Clinical Discharge Planning - Roles & Responsibilities
Appendix I: References and Supplementary Information for Specific Populations of Offenders
References

List of Tables

Table 1: Mainstream Institutional Mental Health Treatment – During Treatment vs. Before Treatment
Table 2: Mainstream Institutional Mental Health Treatment – After Treatment vs. Before Treatment
Table 3: RTC Mental Health Treatment: During Treatment vs. Before Treatment
Table 4: RTC Mental Health Treatment: After Treatment vs. Before Treatment
Table 5: CSC Health Services Expenditures, 2012-2013 to 2015-2016

List of Figures

Figure 1: Percentage of Health Services staff who reported that Clinical Discharge Planners spend quite a bit or a great deal of time on the following activities
Figure 2: Percentage of Institutional Health Services Staff who agreed that the new health services governance structure has resulted in improvements in the following areas
Figure 3: Health Services Medication Expenditures, 2012-2013 to 2015-2016
Figure 4: Women Offenders
Figure 5: Indigenous Offenders
Figure 6: Older Offenders

List of Acronyms

ADHD: Attention Deficit Hyperactivity Disorder
APEC: Aboriginal Peer Education Course
BBSTI: Blood Borne and Sexually Transmitted Infection
BOI: Boards of Investigation
CCC: Community Correctional Centre
CCRA: Corrections and Conditional Release Act
CD: Commissioner's Directive
CDP: Clinical Discharge Planning
CHIPs: Choosing Health in Prisons
CMH: Community Mental Health
CMHI: Community Mental Health Initiative
CMHS: Community Mental Health Services
CMT: Case Management Team
CoMHISS: Computerized Mental Health Screening System
CORR: Compliance and Operational Risk Report
CPO: Community Parole Officer
CRF: Community Residential Facility
CSC: Correctional Service of Canada
DBT: Dialectical Behaviour Therapy
ETA: Escorted Temporary Absence
FASD: Fetal Alcohol Spectrum Disorder
FIFE: Finding in Focus for Evaluation
HIV/AIDS: Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
HCV: Hepatitis C Virus
HSPMR: Health Services Performance Measurement Report
IFMMS: Integrated Financial and Materiel Management System
IIS: Intensive Intervention Strategy
IMHT: Institutional Mental Health Team
IPO: Institutional Parole Officer
ISAPW: Inmate Suicide Awareness and Prevention Workshop
LTBI: Latent Tuberculosis Infection
MAP: Management Action Plan
MHNS: Mental Health Needs Scale
MHTS: Mental Health Tracking System
MMTP: Methadone Maintenance Treatment Program
MRSA: Methicillin-resistant Staphylococcus Aureus
NCMHC: National Complex Mental Health Committee
NHQ: National Headquarters
OHIS-EMR: Offender Health Information System-Electronic Medical Record
OMS: Offender Management System
OST: Opiate Substitution Therapy
OTN: Ontario Telemedicine Network
PEC: Peer Education Course
PSR: Psychosocial Rehabilitation
RAP: Reception Awareness Program
RCMHC: Regional Complex Mental Health Committee
RDHS: Regional Director of Health Services
RHQ: Regional Headquarters
RTC: Regional Treatment Centre
SIB: Self-Injurious Behaviour
SLE: Structured Living Environment
SMT: Suboxone Maintenance Treatment
STI: Sexually-Transmitted Infection
TB: Tuberculosis
TBS: Treasury Board of Canada Secretariat
TOR: Terms of Reference
WebIDSS: Web-Enabled Infectious Disease Surveillance System
WED: Warrant Expiry Date

1.0 Introduction

In accordance with the Five-Year Departmental Evaluation Plan, the Correctional Service of Canada (CSC) conducted an evaluation of health services. As per the Treasury Board Secretariat's (TBS) Policy on Evaluation (2009) and the Policy on Results (2016), the evaluation focused on two core objectives: 1) the continued relevance of health services, including the need for health services offered as part of the continuum of care, and their alignment with departmental and government priorities, as well as federal roles and responsibilities; and 2) CSC's performance in delivering health services, as demonstrated through implementation, effectiveness, efficiency and economy.

CSC delivers health services throughout the continuum of care including intake, incarceration and pre-release and community supervision and focuses on the areas of: mental health, public health and clinical services. By delivering efficient and effective health services, CSC encourages offenders to take responsibility for their own health, promotes healthy reintegration, and ultimately contributes to safe communities.^{Endnote iii} These objectives are aligned with four of CSC's corporate priorities:^{Endnote iv}

Safe management of eligible offenders during their transition from the institution to the community, and while on supervision;
Effective, culturally appropriate interventions for First Nations, Métis and Inuit offenders;
Effective and timely interventions in addressing mental health needs of offenders; and,
Efficient and effective management practices that reflect values-based leadership in a changing environment.

The results and recommendations included in this evaluation report will guide CSC's senior management with future strategic policy and decision-making regarding CSC's health services.

1.1 Background

Federal offenders experience many of the same health issues as the general Canadian population. However, compared to the Canadian population, offenders demonstrate a higher prevalence of mental health concerns (e.g., antisocial personality disorder, anxiety disorders, self-injurious behaviour) and physical health concerns (e.g., diabetes, cardiovascular conditions, HIV/AIDS, Hepatitis C).^{Endnote v} Studies have indicated that individuals entering the correctional system already suffer from poor health due to risky lifestyle behaviours, such as intravenous drug use.^{Endnote vi} Further, once they are incarcerated, an individual's health concerns may be aggravated.^{Endnote vii} This may be attributed to a number of characteristics related to the institutional setting, such as shared accommodations, which may expose offenders to new physical health risks, and present opportunities for engaging in high-risk activities that may result in transmission of infectious disease.^{Endnote viii} Moreover, CSC's offender population is aging. In 2014-15, 24% of federal offenders were 50 years or older compared to 45% of the Canadian population and the number of offenders over the age of 50 at admission has risen over the last ten years.^{Endnote ix} With this general increase in the number of older offenders, CSC is likely to experience increased demand to address health needs attributed to aging, such as chronic conditions, cardiovascular conditions, and diabetes.^{Endnote x}

Offenders require access to health services to meet their diverse health care needs throughout their continuum of care. Studies have shown that health services in institutions have positive impacts on offenders' health. One study demonstrated that prison health education had significant long-term effects on offenders' knowledge of the transmission of infectious diseases.^{Endnote xi} Given that the majority of offenders will be released, their prevalent health concerns could have an impact on the communities in which they are released.^{Endnote xii} As such, CSC's health services represent an important opportunity to address offenders' health needs.

1.2 Policy and Legislation

The delivery of health services for Canadians is a shared responsibility between the federal, provincial and territorial governments. CSC is mandated through federal legislation and corporate requirements to provide health services for federal offenders. Section 86(1) of the Corrections and Conditional Release Act (CCRA) states that CSC is obligated to provide every inmate with "essential health care; and reasonable access to non-essential mental health care that will contribute to the offender's rehabilitation and successful reintegration into the community."^{Endnote xiii}

In addition to the CCRA, CSC is guided by a series of internal Commissioner's Directives (CDs) that support legislative obligations. CDs specific to health services include the following:^{Footnote 1}

CD 800 – Health Services: focuses on procedures related to health services delivery, including assessments occurring at intake, responsibilities during medical emergency situations, involuntary admission and treatment at Regional Treatment Centres and childbirth arrangements for pregnant offenders.
CD 843 – Management of Inmate Self-Injurious and Suicidal Behaviour: outlines procedures for assigning suicide watch observational levels, including screening for the risk of suicide, descriptions of high and modified suicide watch and mental health monitoring. Also included are procedures for the use of restraint equipment including reporting requirements, application to pregnant offenders and assessment and monitoring.
CD 578 – Intensive Intervention Strategy in Women's Institutions: provides procedures for Structured Living Environments (SLEs) including admission requirements, assessments, use of the therapeutic quiet room, discharge process and outreach support. The Secure Unit procedures are also presented, including rules and expectations, the role of interdisciplinary teams, treatment planning and movement.

1.3 Program Description

According to the National Essential Health Services Framework, health services are defined as physical and mental health services, which include health promotion, disease prevention, health maintenance, patient education, diagnosis and treatment of illnesses. In accordance with CSC's program structure, health services are delivered in three areas:^{Endnote xiv}

Clinical Services: "assessment, diagnosis and treatment of acute and chronic physical illnesses."
Public Health: "services and resources on a variety of topics (mental health, wellness, infectious diseases, etc.) provided to inmates related to health promotion and education; disease prevention, control and management of infectious diseases and discharge planning for community reintegration."
Mental Health: "assessment, intervention, treatment and support services and discharge planning provided to inmates with mental health needs in the areas of emotion, thinking and/or behaviour."

1.3.1 Intake Activities

During the intake process, offenders undergo health needs assessments, screening and testing and intervention for immediate mental, clinical and public health care needs. Offenders are also provided with disease prevention initiatives along with health promotion and educational activities. Ongoing surveillance and analysis of offender health needs is initiated at intake and continues throughout incarceration.

1.3.2 Incarceration Activities

As per CSC's mandate, essential health services are provided to offenders during incarceration. This includes ongoing screening and assessment as required, and various mental, clinical, and public health interventions. Disease prevention measures, health promotion and education, as well as surveillance and analysis of offender health needs, which were initiated at intake, continue throughout the incarceration period.

Mental Health Services: A range of institutional programs and services are available to address offenders' mental health needs. Primary mental health services consist of individual and group interventions (e.g., sleep hygiene, stress management, counselling), as well as crisis intervention as needed. Offenders who require intermediate mental health care may access high or moderate intensity levels of service, women offenders may also access the SLE. Offenders with acute needs that cannot be addressed within the institution may receive treatment at a RTC.

Clinical Services: Offenders are offered primary care (e.g., dental services, pharmacy services) and chronic disease management. Offenders also have access to community specialists if necessary. In addition, CSC offers infectious disease management including the opiate substitution therapy (OST) program which is made available to offenders with substance abuse problems.

Public Health Services: CSC provides a number of public health educational activities to address infectious diseases, such as the Peer Education Course (PEC), which aims to train offenders as peer counsellors and to provide information on infectious diseases. Offenders may also access harm reduction initiatives (e.g., needle exchange programs, bleach kits, condoms).

1.3.3 Pre-Release and Community Activites

During pre-release, CSC provides routine discharge planning to prepare offenders for transitions in care, including release to the community.^{Footnote 2} Offenders with significant mental health needs may be referred for clinical discharge planning. This process aims to ensure that offenders receive continuity of care by establishing comprehensive plans and transitional services.

In the community, CSC offers essential physical health services for offenders residing in Community Correctional Centres (CCCs) where provincial coverage is unavailable. This may include appointments, dental care, eyewear, and/or equipment and medical devices. In some regions, CSC may provide additional coverage for medication. CSC provides limited community mental health services in select locations to provide support for offenders with significant mental health needs. These services are provided by mental health professionals, and may include monitoring and assessment, education, clinical accompaniment support, mobile services, and community capacity building.

2.0 Evaluation Method

2.1 Scope of the Evaluation

The scope of the evaluation was determined through a number of activities aimed at identifying evaluation priorities, including:

Pre-evaluation consultations with approximately 80 CSC key informants from National Headquarters (NHQ), Regional Headquarters (RHQ), institutions and the community. Consultations were conducted in person, by telephone or by videoconference.
Site visits were conducted at Millhaven Institution and Joyceville Institution to gain a better understanding of the intake assessment process from health services staff members.
Review of documentation including CSC priorities and risks as well as research, audit, evaluation, accreditation and other performance reports.
Risk was assessed at the outset with mental health services representing the highest area of risk for the organization, primarily due to the direct link with corporate risk and priorities and the high sensitivity of this area.

The scope of the evaluation was further refined through ongoing consultations with the Office of Primary Interest (OPI), the Health Services Sector, and key stakeholders which assisted in organizing the health services evaluation into three periods: intake, incarceration and pre-release and community supervision. These three periods reflect the continuum of care provided to offenders by CSC and examines clinical, public and mental health services. A brief description of each period is provided below.

2.1.1 Intake

The evaluation questions related to intake concentrated on intake screenings and assessment tools, as well as specific health services interventions, health promotion activities, and access to health information. The continued need for CSC health services, alignment with government priorities and federal roles and responsibilities were also explored. Specific questions were included in regards to meeting the health care needs of women offenders, Indigenous offenders and older offenders at intake.

2.1.2 Incarceration

The evaluation questions associated with incarceration examined the integration and continuity of health care services, including any challenges or improvements with the new governance structure, health services planning and coordination, and gaps related to accessing health care professionals and health promotion activities. Specific questions were included related to meeting the needs of women offenders, Indigenous offenders and older offenders during incarceration.

2.1.3 Pre-Release and Community Supervision

The evaluation questions for pre-release and community supervision focused on routine and clinical discharge planning and community mental health services. Challenges in regards to offender identification and payment for essential health services were also examined. Specific questions were included in regards to meeting the health care needs of women offenders, Indigenous offenders and older offenders during pre-release and community supervision.

2.2 Approach

The evaluation of CSC's health services used a mixed-method research design, incorporating both quantitative and qualitative methodologies. Several lines of evidence were used to address the evaluation issues and questions, including:

2.2.1 Literature and Document Review

An extensive examination of peer-reviewed literature and internal and external documents was conducted, including:

CSC and other governmental documents and reports (e.g., legislation, policies and regulations, evaluation reports, research reports, audit reports, board of investigations, and other corporate and operational documents);
A review of Canadian public health initiatives;
A review of community health roles and responsibilities;
A review of the prevalence of health issues in the Canadian population and in the offender population;
A review of the methods of diversion for mental health needs from the criminal justice system; and,
An environmental scan of health services in other correctional jurisdictions.

2.2.2 Qualitative Data^{Footnote 3}

Interviews with Offenders: Intake and Incarceration

Offender interviews for intake and incarceration were conducted during institutional visits between November 2014 and January 2015. An interview guide was developed using open-ended and closed-ended questions (such as 5-point Likert-scales, dichotomous and categorical multiple choice questions). Criteria to participate in the intake questionnaire included offenders who were admitted to CSC within the previous 3 to 12 months. The criteria for the incarceration questionnaire included offenders who were incarcerated for a minimum of 15 months or more at CSC at the time of the evaluation. In total, 104 offenders participated in the intake interviews and 149 offenders participated in the incarceration interviews.

The data collected through both questionnaires was entered into Snap Survey software and exported into SPSS and Microsoft Excel. The Evaluation team analyzed qualitative data obtained through open-ended questions using the iterative and inductive^{Footnote 4} process to identify relevant themes. Qualitative data obtained through closed-ended questions were analyzed using descriptive analysis techniques. Frequencies and percentages were calculated based on the number of valid responses to the questions.

Interviews with Offenders: Regional Treatment Centre

Offender interviews were conducted at RTCs located in the Quebec and Prairie regions between January 26 and 29, 2015. An interview guide was developed using open- and closed-ended questions (dichotomous questions and one categorical multiple choice question). In total, 32 offenders participated in the interviews. They were incarcerated for a minimum of 2 months to a maximum of 108 months.

Electronic Questionnaires with Staff

Four electronic questionnaires were developed using Snap Survey software and administered through CSC's Intranet site (InfoNet). The questionnaires solicited the views and experiences of health services and non-health services staff in regards to the delivery of health services to offenders throughout the continuum of care. Respondents were representative of all security levels, regions, genders, and facilities across Canada. In addition, an electronic consultation was developed using Microsoft Word and was sent through Outlook. Data were analyzed using the same process and procedures as used for the offender interviews.

Intake and Incarceration

Intake: this questionnaire was launched in October 2014 and solicited responses from health services staff and managers involved in the delivery of health services during intake. A total of 116 participants responded,^{Footnote 5} all regions participated in the questionnaire.
Incarceration: this questionnaire was launched in August 2015 and solicited responses of health services staff members involved in the delivery of health services to offenders during the incarceration period. A total of 196 participants responded^{Footnote 6} with representation from all regions across CSC.
General Staff – Incarceration and Intake: this questionnaire was launched in July 2015 and solicited responses pertaining to general staff and management experiences with health care services during incarceration. A total of 167 participants responded,^{Footnote 7} all regions participated in the questionnaire.

Pre-Release and Community Supervision

Pre-Release and Community Supervision: this questionnaire was launched in August 2016 and solicited responses from institutional and community health services staff as well as managers involved in the delivery of health services to offenders at pre-release and during community supervision. A total of 291 participants responded,^{Footnote 8} all regions participated in the questionnaire.
Regional Directors, Health Services: this consultation was launched in August 2016 and solicited responses from Regional Directors respecting the responsibilities and processes related to offender provincial health cards, payment of fees and essential health services coverage. All regions participated in the consultation.

2.2.3 Quantitative Data

Automated data

Various sources of automated data were used for the Evaluation, such as:

Offender Data: Data pertaining to mental health referrals, assessments, and services were obtained from the Computerized Health Intake Screening System (CoMHISS) and the Mental Health Tracking System (MHTS) and analyzed using Statistical Analysis System (SAS) software. Additional data related to sub-population profiles, offender characteristics and correctional outcomes (e.g., institutional incidents) were extracted from the Offender Management System (OMS) and analyzed using SAS.
Human Resource Data: Data extracted from the Human Resource Management System (HRMS) database were provided by CSC's Human Resources Management Section. Data on staff classifications, positions and location, as well as data specific to Aboriginal perceptions training were retrieved for FY 2014 to 2016.
Financial Data: Financial data for health services expenditures was retrieved from the Integrated Financial & Material Management System (IFMMS) for FY 2012-13 to 2015-16 and were analyzed using Excel.

2.3 Measures

Analysis of Qualitative Data

The following scale was used throughout the current report to indicate the weight of emerging qualitative themes^{Footnote 9} and to facilitate the interpretation of evaluation results.

A few/a small number of interviewees = less than 25%;
Some interviewees = 25% to 45%;
About half of interviewees = 46% to 55%;
Many interviewees = 56% to 75%;
Most interviewees = over 75%; and,
Almost all interviewees = 95% or more.

2.4 Limitations and Mitigation Strategies

Evaluations face constraints that may have implications for the validity and reliability of the evaluations findings and recommendations. The following table outlines the limitations encountered along with the impact experienced and the mitigation strategies put in place to ensure decision makers have confidence in the evaluation findings and recommendations.

Limitation	Impact	Mitigation Strategy
Missing or unreliable data (e.g., health referrals, wait times, program participation, level of need, financial expenditures, offender identification, clinical discharge planning activities).	Inability to report on the effectiveness, efficiency and/or economy of the health services evaluation.	Unreliable data was excluded from our analyses and recommendations were made to track and record pertinent information.
Sample size too small to conduct analyses and/or draw conclusions: Older offenders (e.g., health services intake assessment screening tool) Women and Indigenous offenders (e.g., impact of mental health treatment on correctional outcomes in mainstream institutions and RTCs)	Comprehensive information for specific populations of offenders is not complete. Inability to analyze the effectiveness and efficiency of services for specific populations (e.g., women and Indigenous offenders) independently.	Older offender health requirements and services were assessed in other components of the evaluation where possible (e.g., health services for specific populations). Women and Indigenous offenders were included in the overall analyses.
Correctional outcomes (e.g., institutional incidents) could be the result of time passing (i.e., outcomes more likely to occur later in an offender's sentence) or participation in mental health treatment.	Difficult to determine the construct validity of the analysis.	A random sample of offenders was selected as a comparison group and arbitrary treatment timelines were implemented to compare results.
During mental health treatment, offenders may demonstrate heightened emotional instability, resulting in correctional outcomes (i.e., institutional incidents).	Difficult to determine if treatment has any significant impact on correctional outcomes during treatment.	Results will be presented to identify that outcomes during treatment are to be interpreted with caution.
A small number of RTC interviews were completed.	Experiences reported only represent a small subset of the population.	Other lines of evidence were used to substantiate and provide further information on data received in interviews.

4.0 Conclusion

The concept of universality respecting health care is outlined in the Canada Health Act,^{Endnote ccix} this means that all Canadians are entitled to access health care in accordance with the health insurance plan of their respective province; in the case of federally incarcerated persons, CSC provides access to health care.

The evaluation found that CSC Health Services are relevant and meet the needs of federal offenders. Positive impacts were found regarding institutional mental health care where offenders had a reduced likelihood of incidents, serious charges and involuntary segregation following treatment. Several key areas were identified for service improvements, such as:

Access to institutional health services, for example limited access to some health education programs, bleach kits and community health care specialists;
Effectiveness and efficiency of the health services intake assessment process, for example duplication of offender health information through intake processes and tools;
Gaps in policy and procedures to support offenders in obtaining necessary ID required to transition from CSC health services to provincial and territorial health services upon release; and
Missing or unreliable data among referrals to specialist services (in person or telemedicine), clinical health services information and the mental health needs scale.

This evaluation will assist CSC in improving the delivery of health services for all offenders across the continuum of care.

Appendix A: Policy and Legislation

A list of Commissioner's Directives that involve a health related component includes:

CD 705: Intake Assessment Process and Correctional Plan Framework
CD 705-3: Immediate Needs Identification and Admission Interviews
CD 702: Aboriginal Offenders
CD 566-12: Personal Property of Offenders
CD 860: Offender's Money

Appendix B: Need for Health Services

Clinical Health Needs

Men Offenders^{Endnote ccx}

34% of male offenders self-reported head injuries, whereas 19% suffer from back pain, and 15% have asthma. With respect to head-injuries, the prevalence pertains to any current or history of head injuries, and may therefore include a broad range of injuries. A review of health files found that 2% of offenders had evidence of recent brain injury.^{Endnote ccxi}
The rates of many chronic conditions (e.g. high blood pressure, high cholesterol, angina, arthritis, etc.) are significantly higher for men offenders over the age of 50 years compared to men offenders under 50 years of age.
A significantly higher proportion of men offenders have asthma (15%) compared to men in the Canadian population (7%).
Indigenous peoples in the Canadian population have an increased risk of developing cardiovascular disease,^{Endnote ccxii} and they comprise a disproportionately high percentage of the incarcerated population (compared to the general population).
Indigenous men offenders have significantly higher rates of head injuries (43%) than non-Indigenous men offenders (32%).

Women Offenders^{Endnote ccxiii}

According to self-reports, 26% of women offenders suffer from back pain followed by head injuries (23%), menopause (19%) and asthma (16%).
A higher proportion of older women offenders have conditions affecting their cardiovascular system (47%) and they also have a higher prevalence of diabetes (17%) compared to younger women offenders (15%; 4%).
Compared to the Canadian women population (10%), a higher proportion of women offenders (16%) have asthma.
A higher proportion of Indigenous women offenders compared to non-Indigenous women offenders have health conditions affecting their central nervous systems (29%; 25%), diabetes (11%; 3%) and ulcers (11%; 6%).

Public Health Needs^{Footnote 148}

The most prevalent public health issues self-reported by men and women offenders are identified below.

Men Offenders^{Endnote ccxiv}

According to self-reports:

HCV (9%) and HIV (1%) are the most prevalent communicable diseases among an admission cohort of federal men offenders.
Indigenous men offenders have a significantly higher prevalence of HCV (16%) and HIV (2%) than non-Indigenous men offenders (HCV 8%, HIV 1%).
Men offenders over 50 years of age have a higher prevalence of HCV (13%) and HIV (2%) in comparison to men offenders under 50 years of age (HCV 9%; HIV 1%).

Women Offenders^{Endnote ccxv}

According to self-reports:

Among an admission cohort of women offenders, the most prevalent self-reported public health issues were HCV and HIV/AIDS (20%).^{Footnote 149}
In addition, the prevalence of HCV and HIV/AIDS was higher among Indigenous women offenders (27%) than non-Indigenous women offender counterparts (17%).
Older women offenders have a slightly higher prevalence of HCV and HIV/AIDS (22%) relative to younger women offenders (20%).

Mental Health Needs

Men Offenders

Common mental disorders among men offenders were: antisocial personality disorder (44%), anxiety disorders (30%), mood disorders (17%), and major mental illness (12%), which includes major depressive disorder, bi-polar I and II disorders, or any psychotic disorder.^{Footnote 150}, ^{Endnote ccxvi}
Indigenous men offenders had higher rates of personality disorders compared to non-Indigenous men offenders with the most pronounced differences being antisocial personality disorder (60% and 40% respectively) and borderline personality disorder (22% and 14% respectively).^{Footnote 151}, ^{Endnote ccxvii}
Men offenders did not engage in self-injurious behaviour (SIB) as frequently as women offenders; however, their SIB are more likely to result in minor and serious injury compared to women offenders whose incidents of SIB are more likely to result in no significant injury.^{Endnote ccxviii}

Women Offenders

The vast majority of women offenders had a psychiatric disorder at some point in their lives. Among the most common were: lifetime prevalence of antisocial personality disorder (83%); experience of a major depressive episode, a type of mood disorder, at some point in their lives (69%), and post-traumatic stress disorder, a type of anxiety disorder, in the past year (31%).^{Footnote 152} Borderline personality disorder was more common in women offenders than in men offenders.^{Endnote ccxix}
Twenty-two percent of women offenders had attempted suicide prior to being admitted to CSC.^{Endnote ccxx}
Indigenous women offenders experienced higher occurrences of conduct disorder than their non-Indigenous women counterparts (64% and 42% respectively).^{Endnote ccxxi}
Although women offenders accounted for 5% of CSC's incarcerated population, they comprised 12% of the offenders who had a SIB incident and accounted for 32% of all SIB incidents. Furthermore, Indigenous women offenders engaged in twice as many incidents of SIB compared to non-Indigenous women.^{Endnote ccxxii}

Appendix C: Mental Health Diversion

Pre-contact with the criminal justice system – crime prevention:

Focus on preventing individuals with mental health needs from coming into contact with the criminal justice system through intervention on risk factors before crime happens.

Post-contact with the criminal justice system – Sequential Intercept Model^{Endnote ccxxiii}

First interactions with law enforcement and emergency services: the goal at this stage of diversion is to divert individuals with mental health needs from arrest by providing alternative treatment options and to decrease risk of harm resulting from these interactions.
There are four models of police-based diversion in Canada:
- Crisis Intervention Teams (CIT) – interdisciplinary community liaison teams;
- Psychiatric Emergency Response Teams (PERT) – police officers are paired with licensed mental health professionals;
- Crisis Mobile Teams (CMT) – behavioural mental health specialists assist police officers in situations involving persons with mental disorders; and
- Informal police diversion – police may refer an individual to community mental health services in lieu of charges (generally for less serious acts or on first-arrest).
Post-arrest (pre-trial): this type of diversion interrupts the standard prosecution process, it occurs between the individual's arrest and their appearance in court. Offenders are diverted from the criminal justice system and referred for treatment or other specialized diversion programs.
There are four elements of the process:
- Appointment of counsel;
- Assessment of the offender;
- Consultation with the victim; and,
- Prosecutorial review of charges and possible diversion. This type of diversion can be requested on behalf of the individual with the mental health need by the defence counsel, crown counsel, police, mental health services, diversion programs, citizens, etc.
Court-based diversion : designed to divert individuals with mental health needs through mental health courts, mental health dockets, or traditional courts with alternative sentencing planning strategies to a judicially monitored diversion program. The focus is on community-based treatment and restorative remedial measures versus prosecution, and may involve a multidisciplinary team (e.g., judge, crown attorneys, mental health workers).
Re-entry planning from jails, prisons, and forensic hospitalization : does not specifically focus on diversion per se; rather, it focuses on continuity of care and successful reintegration (or re-entry) into the community. Preparation for reintegration should begin prior to release. Post release, interventions should support offenders' transition from the prison to the community and help maintain gains made in treatment while incarcerated.
Community corrections and community support : the goal is to divert individuals with mental health needs under community supervision from re-entering the criminal justice system.
Best practices include:
- Mental health screening;
- Managing treatment conditions and technical violations through the use of non-traditional methods that emphasize non-custodial alternatives;
- Use of intensive and specialized case management; and,
- Use of a specialized caseload model (e.g., Have a set of dedicated officers for offenders with mental disorders, reduce officers caseload (typically one third of a traditional caseload); provide officers with sustained training on mental health and other related issues; have officers intervene with offenders directly and coordinate community services)

Sequential Intercept Model Notes

Intercept 1: First interactions with law enforcement and emergency services

Evidence suggests that diversion at this intercept can increase referrals to mental health resources, increase the number of days spent in the community, and reduce the use of force in police interactions with mentally ill offenders.^{Endnote ccxxiv} More generally, however, the research in this area is limited and further evaluation is needed before firm conclusion can be drawn about the effectiveness of mental health diversion at this intercept.

Intercept 2: Post-arrest (pre-trial)

Generally, diverted offenders at this intercept have more time in the community, greater treatment participation, fewer hospital days in the community, fewer arrests (1 year follow-up), less homelessness (1-year follow-up), and more emergency room contacts.^{Endnote ccxxv} It is noted that this research needs to be interpreted with caution due to a small number of studies, differing methodology, and variability in what was considered to be a 'diversion' program.^{Endnote ccxxvi}

Intercept 3: Court Based Diversion

The purpose of mental health courts is to target the root causes of crime committed by individuals with mental health needs (e.g., untreated mental illness) and to help prevent mentally disordered individuals from reoffending. Mental health courts have been associated with fewer arrests and jail days (e.g., an average of 3 days instead of 23 days), reduced recidivism, and lower costs over time (relative to traditional courts.^{Endnote ccxxvii} Further, mental health courts better linked individuals to mental health services and those individuals were more like to stay in a higher level of treatment than individuals not participating in a mental health court program.^{Endnote ccxxviii}

Mental health dockets refer to dedicating a period of time during traditional court (e.g., one afternoon per week) to individuals with mental health needs.

Intercept 4: Re-entry planning from jails, prisons, and forensic hospitalization

Preparation for reintegration (or re-entry) into the community should begin prior to release. Good practice suggests that post-release interventions should support offenders' transition from the prison to the community and help maintain gains made in treatment while incarcerated.^{Endnote ccxxix} This recommendation is in line with CSC's Mental Health Strategy which suggests "dedicated services are required to support a seamless continuity of care from the community to the correctional system and upon return to the community" for offenders with mental health needs.^{Endnote ccxxx}

Intercept 5: Community corrections and community support

Offenders with mental health issues can have trouble complying with their conditions, placing them at higher risk for technical violations, new offences, and new sentences. Revocation prevention strategies include: incentives for compliance with conditions (e.g., reduce frequency of reporting); graduated scheme of responses before employing the most serious response (i.e., revocation of probation/parole); consult with treatment providers before taking action on a violation related to treatment/mental health evaluation and consider treatment alternatives (e.g., refer to more intensive treatment); respond to minor technical violations early to prevent more serious technical violations, establishing agreements and guidelines with service providers regarding the support that they will provide and the actions that will be taken for failure to participate in treatment; and, have mental health professionals help offenders better understand the consequences of their behaviour in terms of sanctions.^{Endnote ccxxxi}

CSC Community Mental Health Specialist services follow an assertive community treatment model in that multidisciplinary teams of professionals provide mentally ill offenders with services tailored to their needs in the community and share responsibility for the offender.^{Endnote ccxxxii} Generally assertive community treatment based programs (relative to 'treatment as usual') were found to be associated with "better criminal justice outcomes (e.g., any conviction, mean jail time), better improvement of substance abuse problems, and improvement in global functioning and economic self-sufficiency".^{Endnote ccxxxiii}

Appendix D: Effectiveness of Intake Assessment for Specific Populations

Indigenous Offenders

Most health services staff members and Indigenous offenders did not report any barriers specific to this sub-population of offenders in completing health status intake assessments.^{Footnote 153}
- Those health services staff members who did identify challenges reported that there were communication or cultural barriers in completing intake assessments for Indigenous offenders (n=10).
Many health services staff members reported that Indigenous offenders interested in following a traditional healing path, "never" or "rarely" had an Elder involved in completing intake assessment tools.^{Footnote 154}
Most (78%, n=18) Indigenous offenders interested in following a traditional health path reported that they did not have an Elder present during health intake assessments, but many (n = 11) reported it would have been helpful.^{Footnote 155}
Indigenous offenders are equally as likely to receive intake assessments (i.e., 24-hour and 14-day) within the appropriate timeframe compared to the whole offender population (Indigenous and non-Indigenous offenders).^{Footnote 156}, ^{Endnote ccxxxiv}

Visible Minority Offenders

Most^{Footnote 157} health services staff members reported that they did not face any challenges completing intake assessments for visible minority offenders.
- Among those who did report challenges, it was noted that there were communication or cultural barriers in completing intake assessments for visible minority offenders (n=15).

Older Offenders

Most health services staff members and older offenders did not report any challenges specific to this sub-population of offenders in completing health status intake assessments.^{Footnote 158}
Some (44%, n=7) older offenders reported having additional health care needs including physical health concerns (e.g., knee pain, osteoarthritis) and other health issues (e.g., heart difficulties, hearing problems, diabetes, and cancer).
- Of those older offenders who indicated that they had additional health care needs, about half reported that the health services intake assessment screening tool did not identify their age-related health needs (n=4).^{Footnote 159}

Women Offenders

Most health services staff members and women offenders did not report any challenges completing intake assessments for women offenders.^{Footnote 160}
Women offenders are equally as likely (or more so) to receive the 24-hour assessment, 14-day assessment, and CoMHISS within the appropriate timeframe compared to the whole offender population (women and men offenders).^{Footnote 161}, ^{Endnote ccxxxv}

Appendix E: Description of Health Education Initiatives

Reception Awareness Program (RAP):

RAP is offered to all newly admitted offenders at reception; however, attendance is voluntary.^{Endnote ccxxxvi} Separate versions of the program are developed and delivered for men and women to address their specific health care needs. RAP provides general information on infectious diseases, harm reduction measures, and related health services and programs offered by CSC.^{Footnote 162}, ^{Endnote ccxxxvii}

Peer Education Course/Aboriginal Peer Education Course (PEC/APEC):

CSC offers PEC and APEC, which are one week training programs^{Endnote ccxxxviii} offered to offender volunteers who want to become PEC/APEC support workers to other offenders.^{Endnote ccxxxix} PEC includes a series of modules dealing with infectious diseases and the provision of peer support to offenders infected and affected by these diseases.^{Endnote ccxl} Similarly, APEC is a one week culturally sensitive training course offered to offender volunteers who want to provide peer support to offenders within the context of the Indigenous culture.^{Endnote ccxli} The goal of APEC is to learn the basic facts of infectious diseases in order to support encourage and empower Indigenous peers to sustain behavioural and lifestyle changes.^{Endnote ccxlii} After participating in the PEC/APEC training program, offenders can be selected to work as Peer Support workers within their institutions. Offenders in need of health service support can than request the services offered through a PEC/APEC support worker.

Inmate Suicide Awareness and Prevention Workshop (ISAPW):

The ISAPW is a three-hour workshop that provides offenders information about suicide including: suicide facts and myths, possible stressors to suicide, signs and symptoms of suicide risk and what to do if someone is thinking about suicide.^{Endnote ccxliii} The program is delivered by personnel from chaplaincy, nursing, programs, and/or volunteers.^{Endnote ccxliv} Commissioner's Directive 843: Management of Inmate Self-Injurious and Suicidal Behaviour highlights the importance of having the Inmate Suicide Awareness and Prevention Workshop available on a regular basis and providing offenders access to the workshop.^{Endnote ccxlv} CSC aims to deliver this workshop at reception centers in an effort to provide the training to all offenders.^{Endnote ccxlvi}

Health Services factsheets:

Health Services offers monthly health promotion and infectious disease prevention factsheets and PowerPoint presentations. The factsheets address specific areas of health concerns, including infectious diseases, chronic conditions, mental health, and general healthy living. Topics may inform on HIV/AIDS, diabetes, TB, heart disease, suicide prevention, and substance abuse.

Appendix F: Institutional Mental Health Services

Mainstream Institutional Mental Health Treatment

**Table 1: Proportional Hazards Regression, Mainstream Institutional Mental Health Treatment & After Treatment Periods Onto Correctional Outcome Likelihood (N = 3, 167)**
			95% Confidence Interval
Variables	B	HR	Lower	Upper
Incidents: All
During Treatment (vs. Before Treatment)	-0.04070	0.960	0.863	1.068
After Treatment (vs. Before Treatment)	-0.09101	0.913*	0.836	0.997
Incidents: Behaviour
During Treatment (vs. Before Treatment)	0.04524	1.046	0.854	1.281
After Treatment (vs. Before Treatment)	-0.07826	0.925	0.794	1.077
Minor Charges
During Treatment (vs. Before Treatment)	0.02530	1.026	0.897	1.173
After Treatment (vs. Before Treatment)	-0.06023	0.942	0.836	1.060
Serious Charges
During Treatment (vs. Before Treatment)	-0.12578	0.882	0.727	1.070
After Treatment (vs. Before Treatment)	-0.35008	0.705***	0.602	0.825
Involuntary Segregation
During Treatment (vs. Before Treatment)	-0.13634	0.873*	0.769	0.990
After Treatment (vs. Before Treatment)	-0.38467	0.681***	0.605	0.765
National Correctional Program Completions
During Treatment (vs. Before Treatment)	0.17865	1.196***	1.078	1.327
After Treatment (vs. Before Treatment)	0.20870	1.232***	1.122	1.352
Education Course/Credit Completion
During Treatment (vs. Before Treatment)	0.02233	1.023	0.901	1.160
After Treatment (vs. Before Treatment)	0.29131	1.338***	1.188	1.508
* p.<.05; p < .01; *p<.001. The log-likelihood test for all models were significant as a whole (i.e., p< .0001) Each model controlled for risk, need, motivation, reintegration potential, age, gender, and Indigenous status. Time interactions were also implemented for variables that violated the proportional hazards assumption. The significance values for the hazard ratios were corrected for dependence using the modified sandwich estimator (Allison, 2010). Assault-related incidents, self-harm, and voluntary segregation are not included due to low number of offenders who experienced that event.

Mainstream Institutional Mental Health Treatment: Indigenous Offenders

**Table 2: Proportional Hazards Regression, Mainstream Institutional Mental Treatment & Post-Treatment Periods Onto Correctional Outcome Likelihood for Indigenous Offenders (N = 802)**
			95% Confidence Interval
Variables	B	HR	Lower	Upper
Incidents: All
During Treatment (vs. Before Treatment)	-0.02019	0.980	0.795	1.207
After Treatment (vs. Before Treatment)	-0.07465	0.928	0.784	1.098
Incidents: Behaviour
During Treatment (vs. Before Treatment)	-0.00847	0.992	0.686	1.434
After Treatment (vs. Before Treatment)	-0.24882	0.780	0.580	1.048
Minor Charges
During Treatment (vs. Before Treatment)	-0.00244	0.998	0.807	1.234
After Treatment (vs. Before Treatment)	-0.07810	0.925	0.751	1.139
Serious Charges
During Treatment (vs. Before Treatment)	-0.06992	0.932	0.639	1.360
After Treatment (vs. Before Treatment)	-0.20298	0.816	0.639	1.043
Involuntary Segregation
During Treatment (vs. Before Treatment)	-0.12117	0.886	0.700	1.122
After Treatment (vs. Before Treatment)	-0.35983	0.698**	0.555	0.877
National Correctional Program Completions
During Treatment (vs. Before Treatment)	0.32006	1.377**	1.137	1.668
After Treatment (vs. Before Treatment)	0.26252	1.300**	1.090	1.551
Education Course/Credit Completion
During Treatment (vs. Before Treatment)	-0.00478	0.995	0.804	1.233
After Treatment (vs. Before Treatment)	0.20521	1.228*	1.002	1.505
* p.<.05; p < .01; *p<.001. The log-likelihood test for all models were significant as a whole (i.e., p< .0001) Each model controlled for risk, need, motivation, reintegration potential, age, gender, and Indigenous status. Time interactions were also implemented for variables that violated the proportional hazards assumption. The significance values for the hazard ratios were corrected for dependence using the modified sandwich estimator (Allison, 2010). Assault-related incidents, self-harm, and voluntary segregation are not included due to low number of offenders who experienced that event.

RTC Mental Health Treatment

**Table 3: Proportional Hazards Regression, RTC Mental Health Treatment & Post-Treatment Periods Onto Correctional Outcome Likelihood (N = 617)**
			95% Confidence Interval
Variables	B	HR	Lower	Upper
Incidents: All
During Treatment (vs. Before Treatment)	0.19464	1.215***	1.087	1.358
After Treatment (vs. Before Treatment)	-0.21539	0.806***	0.714	0.911
Incidents: Assault
During Treatment (vs. Before Treatment)	0.38367	1.468**	1.141	1.887
After Treatment (vs. Before Treatment)	-0.34242	0.710*	0.541	0.933
Incidents: Behaviour
During Treatment (vs. Before Treatment)	0.27319	1.314**	1.099	1.571
After Treatment (vs. Before Treatment)	-0.23994	0.787*	0.654	0.947
Incidents: Self-Harm
During Treatment (vs. Before Treatment)	0.04428	1.045	0.799	1.368
After Treatment (vs. Before Treatment)	-0.41555	0.660*	0.454	0.959
Minor Charges
During Treatment (vs. Before Treatment)	-0.23779	0.788	0.605	1.027
After Treatment (vs. Before Treatment)	-0.05286	0.949	0.679	1.324
Serious Charges
During Treatment (vs. Before Treatment)	-0.36885	0.692**	0.524	0.912
After Treatment (vs. Before Treatment)	-0.37151	0.690***	0.554	0.859
Involuntary Segregation
During Treatment (vs. Before Treatment)	-0.49070	0.612***	0.513	0.731
After Treatment (vs. Before Treatment)	-0.20673	0.813**	0.695	0.951
National Correctional Program Completions
During Treatment (vs. Before Treatment)	-0.22237	0.801	0.565	1.135
After Treatment (vs. Before Treatment)	0.05852	1.060	0.824	1.364
Education Course/Credit Completion
During Treatment (vs. Before Treatment)	-0.28018	0.756	0.548	1.041
After Treatment (vs. Before Treatment)	0.05759	1.059	0.776	1.445
* p.<.05; p < .01; *p<.001. The log-likelihood test for all models were significant as a whole (i.e., p< .0001) Each model controlled for risk, need, motivation, reintegration potential, age, gender, and Indigenous status. Time interactions were also implemented for variables that violated the proportional hazards assumption. The significance values for the hazard ratios were corrected for dependence using the modified sandwich estimator (Allison, 2010). Voluntary segregation is not included due to low number of offenders who experienced that event.

Appendix G: Community Mental Health Services

Table 1: Recidivism Outcomes for Men and Women CMHI and non-CMHI Participants

**Recidivism within 24 months after release**
	Men		Women
	n (%)	N	n (%)	N
CMHS services	74 (30%)	249	9 (27%)	33
CDP services	34 (52%)	65	6 (43%)	14
CDP/CMHS	27 (43%)	63	3 (17%)	18
Non-CMHS	138 (51%)	269	19 (33%)	58

**Recidivism within 48 months after release**
	Men		Women
	n (%)	N	n (%)	N
CMHS services	90 (36%)	249	10 (30%)	33
CDP services	38 (59%)	65	7 (50%)	14
CDP/CMHS	32 (51%)	63	5 (28%)	18
Non-CMHS	165 (61%)	269	27 (47%)	58

Source: MacDonald, S. F., Stewart, L. A., & Feely, S. (2014). The impact of the Community Mental Health Initiative (CMHI) (R-337). Ottawa, ON.

Appendix H: Clinical Discharge Planning - Roles & Responsibilities

The clinical discharge planning process involves coordination among several key staff members whose level of involvement varies according to the offender's health needs.

Roles and responsibilities of clinical discharge planning

The Discharge Planning Matrix Tool,^{Footnote 163} the Discharge Planning and Transfer Guidelines, and the Integrated Mental Health Guidelines outline the roles and responsibilities for CSC staff in relation to CDP.^{Endnote ccxlvii}

The clinical discharge planner is responsible for the following in relation to CDP caseload offenders:^{Endnote ccxlviii}
- Developing discharge/integration plans (i.e., Mental Health Assessment for Clinical Discharge in accordance with the content guidelines for Mental Health Assessment and Treatment/Intervention Plans) that include referrals and follow-ups in the various areas such as Housing; Identification; Community Support; Spiritual/Religious/Cultural/Ethnic, etc.
- Providing the IPO/Community Parole Officer with information for reference in the completion of the Correctional Plan Update, Community Strategy and to assist with other release decision making processes – in accordance with case management timelines.
- Setting up necessary appointments and medication follow up appointments prior to release.
The clinical discharge planner is also responsible for the following:
- Providing brief interventions for offenders when referral for services are two months or less prior to release date or WED; or to address specific needs (e.g., referral to a psychiatrist).^{Endnote ccxlix}
- Responding to referrals for consultation in complex cases.^{Endnote ccl}
The institutional parole officer, as part of offender case preparation is responsible for the following in relation to collaboration and communication with Health Services:
- Submits referral request to Health Services for a consultation to clinical discharge planners.^{Endnote ccli}
- Informs Health Services of upcoming case preparation in advance of 6 months before hearing or release.^{Endnote cclii}
- Informs Health Services of upcoming release 3 weeks in advance (or as soon as possible for last minute releases).^{Endnote ccliii}
- Prompts pre-release case-conference prior to release if significant change is shared in the GIST report provided by Health Services prior to release.^{Endnote ccliv}
The institutional parole officer, is also responsible for the following in relation to managing offender health information:^{Endnote cclv}
- Includes the relevant Health Services information in the Correctional Plan.
- Ensures the Health Status at Discharge: Gist Reports are placed in the offender Case Management file.
- Assists offenders to obtain a provincial health card in the province of the offender's releasing institution, or when an offender is being released to a different province, assists the offender to apply for temporary provincial health coverage in the province of incarceration.^{Endnote cclvi}
The community parole officer, in preparation for an offender's release to the community, is responsible for the following:^{Endnote cclvii}
- Develops the community release strategy in collaboration with the IPO and the clinical discharge planner (where relevant).
- Includes relevant health care needs in the development of the community supervision strategy.
- Participates in pre-release conferences when the offender is subject to a condition (e.g., condition to take a medication).
Institutional nurse, in preparation for offender discharge is responsible for the following:
- Consults with the clinical discharge planner as required to arrange for follow-up appointments for community health care services.

Appendix I: References and Supplementary Information for Specific Populations of Offenders

Women Offenders

Profile^{Endnote cclviii}

As of 2015-16, there were a total of 1,275 women offenders in CSC, representing 6% of the total number of federal offenders (n=22,969),^{Footnote 164} including:
- 691 women offenders in custody, representing 5% of the total in custody population (n=14,646).
- 584 women offenders under community supervision, representing 7% of the total community population (n=8,323).

Prevalent Health Needs^{Endnote cclix}

According to several research reports that examined offender health needs,^{Footnote 165} the most prevalent health conditions for women included: some infectious diseases (e.g., HIV/AIDS, HCV), chronic health conditions (e.g., back pain), and various mental health disorders (e.g., antisocial personality disorder, major depressive episode).

Health-Related Policies and Guidelines

Commissioner's Directive (CD) 800 Health Services: "are sensitive to the needs of Aboriginal and women offenders, and offenders with special needs."^{Endnote cclx}
Commissioner's Directive (CD) 578 Intensive Intervention Strategy in Women Offender Institutions/Units.^{Endnote cclxi}

Health-Related Strategies and Initiatives^{Endnote cclxii}

CSC developed the Infectious Disease Strategy for Women Offenders (2008-2013) as a framework for the prevention, care, and treatment of infectious diseases in order to support women offenders affected by infectious diseases.^{Endnote cclxiii} The Strategy was intended "to prevent the transmission and acquisition of infectious diseases among women offenders during incarceration and to provide appropriate care, treatment and support to those who are infected."^{Endnote cclxiv}
The Intensive Intervention Strategy for Women Offenders was initiated in 1999^{Endnote cclxv} and was developed to better respond to women offenders experiencing self-injurious behaviour, adjustment problems, difficulties with daily living, and/or other emotional or behavioural problems. As part of the Strategy, women offenders are offered Dialectical Behaviour Therapy (DBT), which is a systematic and comprehensive psychotherapeutic intervention approach that involves learning and developing strategies to help regulate problematic emotions and behaviours.^{Endnote cclxvi}
The Peer Mentorship program does not provide therapeutic counselling; rather, it is meant to provide confidential support, and connect offenders to resources and services within and outside the institution. The program provides an opportunity for increased problem solving for individuals and contributes to the personal development and employability of offenders who are trained as Peer Mentors. Implementation of Peer Mentorship is scheduled for 2016-17.^{Endnote cclxvii}

Overall Perceptions of Health Services for Women Offenders^{Footnote 166}

Many staff member respondents agreed that health services were meeting the needs of Women offenders:
Institutional Health Services:
- Health services staff: 71%, n=36
- General staff: 83%, n=40
Community Mental Health Services:
- Health services staff: 72%, n=38
- General staff: 57%, n=52
- Staff reported challenges:
  - A few CSC staff members (n=17) indicated that there were insufficient resources for community mental health, including access to CSC mental health services or other mental health services in the community.

Indigenous Offenders

Profile^{Endnote cclxviii}

As of 2015-16, there were a total of 5,223 Indigenous offenders in CSC, representing 23% of the total number of federal offenders (n=22,969),^{Footnote 167} including:
- 3,778 Indigenous offenders in custody, representing 26% of the total in custody population (n=14,646)
- 1,445 Indigenous offenders under community supervision, representing 17% of the total community population (n=8,323)
As of 2014-15, there were 3,600 Indigenous offenders in custody and 1,356 in the community, representing approximately 22% of CSC's population.^{Endnote cclxix}

Prevalent Health Needs

According to several research reports examining offender health needs,^{Footnote 168} Indigenous offenders were more likely than non-Indigenous offenders to have health needs in some areas of mental health (e.g., antisocial personality disorder) and chronic health conditions (e.g., central nervous system conditions, diabetes) and infectious diseases (e.g., HCV, HIV/AIDS).^{Endnote cclxx}

Health-Related Policies and Guidelines

According to Commissioner's Directive (CD) 702: Aboriginal Offenders, the Institutional Head is responsible for ensuring that offenders are provided with services from an Elder/Spiritual Advisor.^{Endnote cclxxi}
According to the Integrated Mental Health Guidelines, mental health care professionals must "document that Aboriginal Social history has been considered in arriving at a conclusion and recommendations, and integrate a discussion of relevant aspects of this history into assessment reports."^{Endnote cclxxii}

Health-Related Strategies and Initiatives^{Endnote cclxxiii}

The Aboriginal Health Strategy (2009-2012) offered a strategic framework for CSC to improve culturally-appropriate health services for Indigenous offenders, based on the continuum of care (i.e., through intake, incarceration, pre-release, and community corrections) and the Medicine Wheel. The Strategy had three primary goals:^{Endnote cclxxiv}
1. Increase the focus on the health needs of Aboriginal offenders
2. Building capacity for culturally-safe health services^{Footnote 169}
3. Enhancing collaboration within and outside of CSC^{Footnote 170}
An Indigenous culture component was recently added to the Fundamentals of Mental Health Training. The training provides modules that educate on traditional values for Indigenous health, Indigenous social history, symptoms of mental disorder, and resources for working with Indigenous offenders. The modules also focus on applying Gladue principles through case studies.
As of 2016, the Director General, Aboriginal Initiatives sits on the National Complex Mental Health Committee to provide input into appropriate care for Indigenous Offenders with complex mental health needs.^{Endnote cclxxv}

Overall Perceptions of Health Services for Indigenous Offenders^{Footnote 171}

Many staff member respondents agreed that health services were meeting the needs of Indigenous offenders in the institution, but fewer agreed that we were meeting their needs in the community:
Institutional Health Services:
- Health services staff: 65%, n=78
- General staff: 72%, n=69
- Staff reported challenges:
  - Need to address Indigenous health needs in culturally responsive ways (n=12)
  - Insufficient resources (n=6)
Community Mental Health Services:
- Health services staff: 49%, n=34
- General staff: 35%, n=44
- Staff reported challenges:
  - Insufficient resources, including difficulties accessing mental health services in remote locations or on reserve, or insufficient Indigenous staff members or Elders (n=37)
  - Communication or cultural barriers (n=9)
Elder Services:
- Some health services staff respondents reported consulting with Elders regarding Indigenous offenders for:
  - Mental health services (51%, n=66)
  - Clinical health services (28%, n=35)
  - Public health services (9%, n=11)
- Health services staff reported that they consulted an Elder to discuss:
  - Mental health treatment plans or interventions (n=22)
  - Understanding of offenders' cultural beliefs and languages (n=22)
  - Use of culturally sensitive approaches in clinical health care (n=15)
- Health services staff suggested that Elders should be more involved in:
  - Treatments, services, or interventions for offenders (n=18)
  - Communication and information sharing with health services (n=12)
Offender Perceptions:
- Among Indigenous offenders interviewed (n=51):
  - A few (n=3), reported having an Elder present while receiving health care services. Some (n=17) said that it would have been beneficial (e.g., to help navigate the health system, to provide information on traditional health alternatives).

Other Visible Minority Offenders

Profile^{Endnote cclxxvi}

The following table shows the ethnic groupings of all CSC offenders at the end 2015-16.^{Footnote 172} The most common other visible minorities (i.e., non-Indigenous offenders) were Black, Asian, and Other offenders.

Ethnic Grouping	Total (%)
Indigenous	5,223 (23%)
Asian	1,256 (5%)
Black	1,768 (8%)
Caucasian	13,521 (59%)
Hispanic	237 (1%)
Other	964 (4%)

Overall Perceptions of Health Services for Other Visible Minority Offenders^{Footnote 173}

Many staff member respondents agreed that health services were meeting the needs of other visible minority offenders in the institution, but fewer agreed that we were meeting their needs in the community.
Institutional Health Services:
- Health services staff: 66%, n=74
- General staff: 75%, n=71
- Staff reported challenges:
  - Communication and cultural barriers (n=7).
Community Mental Health Services:
- Health services staff: 52%, n=34
- General staff: 29%, n=30
- Staff reported challenges, primarily related to community mental health services:
  - Insufficient resources to meet the needs of visible minority populations (e.g., limited services, lack of information resources; n=18).
  - Language and/or cultural barriers (n=9).

Older Offenders

Profile^{Endnote cclxxvii}

As people age, the risk of ill health or disability increases, as does the demand for health care.^{Endnote cclxxviii} Today, aging Canadians face chronic, mental health, and neurological conditions.^{Endnote cclxxix}
As of 2015-16, there were a total of 6,675 older offenders in CSC, representing 29% of the total number of federal offenders (n=22,969),^{Footnote 174} including:
- 3,544 older offenders in custody, representing 24% of the total in custody population (n=14,646)
- 3,131 older offenders under community supervision, representing 38% of the total community population (n=8,323).

Prevalent Health Needs

According to several research reports that examined offender health needs,^{Footnote 175} older offenders had a higher prevalence than offenders under the age of 50 in some areas, such as chronic health conditions (e.g., cardiovascular system issues, diabetes) and infectious diseases (e.g., HIV/AIDS, HCV).^{Endnote cclxxx}

Health-Related Policies and Guidelines^{Endnote cclxxxi}

According to the National Essential Health Services Framework core essential health services include physical health, mental health, public health, and dental services. Although there are some exceptions, many items relevant to older offenders and/or offenders with physical disabilities (e.g., mobility devices) are provided under special authorization.^{Endnote cclxxxii}
According to the Integrated Mental Health Guidelines, offenders may be referred for admission to RTC if they experience cognitive and/or physical disabilities (e.g., dementia) that are associated with aging and require 24-hour nursing and other clinical care.^{Endnote cclxxxiii}
According to the Federal Correctional Facilities Accommodation Guidelines, "all areas within institutions must be accessible to the disabled, including staff, visitor and inmate activity areas". Although some spaces are not required to be accessible due to the nature of the activities (e.g., control posts, mechanical spaces), a portion of spaces are required to be accessible (i.e., a maximum of 2% of cells/bedrooms and support space within housing units).^{Endnote cclxxxiv} Although these guidelines do not directly address challenges for older offenders, they provide options to address issues of accessibility and mobility, which commonly affect older offenders.
There are a total of 15,364 regular population (rated-capacity) cells within CSC institutions. Of those, CSC provides 428 barrier-free cells, of which 37 are transitional (i.e., health care cells, segregation cells). As such, 391 permanent barrier-free cells represent 2.5% of all accessible spaces across CSC, which is above the 2% requirement in the Federal Correctional Facilities Accommodation Guidelines for CSC as a whole. However, some individual institutions were above the 2% level of accessible cells, whereas others were below.
Barrier-free cells are provided in maximum, medium, and minimum security institutions, women's institutions, multi-level institutions, healing lodges^{Footnote 176} as well as in its RTCs. These cells are distributed in each of the five Regions as follows:
- Atlantic: 43
- Ontario: 111
- Quebec: 75
- Prairies: 115
- Pacific: 84

Health-Related Strategies and Initiatives^{Endnote cclxxxv}

CSC Health Services is currently developing a comprehensive Chronic Disease Management Strategy.
- The Chronic Disease Management Strategy includes seven key health priorities: HIV, HCV, chronic pain, cardiovascular disease, respiratory disease, and the use of antibiotics.
- Although the Chronic Disease Management Strategy is not specifically designated for older offenders, many of the health issues prioritized in the strategy include health issues prevalent among older offender populations.
Health Services conducts screening for "fall risk" as part of the Intake Health Status Assessment for offenders aged 65 and older^{Footnote 177} and/or those with self-care needs (as of August 2015, the age requirement to conduct an assessment for incarcerated offenders has changed from 50 years or older to 65 years or older).^{Endnote cclxxxvi} The assessment examines factors related to activities of daily living.^{Endnote cclxxxvii}, ^{Footnote 178}
The Pacific Region has created a psycho-geriatric unit at the RTC, called Echo, with a Peer Assisted Living (PAL) Caregiver program.^{Endnote cclxxxviii}
- PAL Caregivers are offenders who work in cooperation with staff to assist a peer who has a physical or cognitive disability, in activities of daily living (e.g., help with eating, bathing, dressing, toileting, maintenance of the living environment and mobility).
- Training is provided and offenders applying to the program should be actively engaged in their correctional plan and demonstrate positive working relationships with their case management team.

Overall Perceptions of Health Services for Older Offenders^{Footnote 179}

Some staff agreed that health services were meeting the health-related needs of older offenders in the institution and in the community.
Institutional Health Services:
- Health services staff: 41%, n=52
- General staff: 59%, n=61
- Staff reported challenges:
  - Insufficient resources, services and specialized service providers (e.g., personal care, geriatric specialists, high needs/multiple needs offenders; n=36)
  - Challenges accommodating the needs of older offenders within the existing infrastructure (e.g., provide specialized unit or range for offenders with mobility or age related issues; n=34)
Community Mental Health Services:
- Health services staff: 46%, n=34
- General staff: 34%, n=41
- Staff reported challenges:
  - Insufficient resources, such as palliative care or mental health professionals (n=27)
  - Difficulties finding accommodations (e.g., community care facilities willing to accept them, CCCs/CRFs not equipped for their needs; n=20)
Twenty-nine percent (29%, n=42) of offenders interviewed reported being over the age of fifty; of these, 57% (n=24) reported having age-related health care needs. They reported having age-related needs such as:
- Joint or muscle problems (n=12),
- Cardiovascular conditions (n=5), or
- Other age-related chronic conditions (e.g., diabetes, menopause, etc; n=12).
Older offenders also reported experiencing challenges with the physical layout of the institution (55%, n=12), accessing specialized health care equipment (47%, n=9), and performing daily activities (33%, n=7).
- Offenders interviewed made the following suggestions to address age-related challenges: Offer specialized services (e.g., hearing specialist, pain clinics; n=12);
- Provide access to specialized products and equipment (e.g., eyeglasses, cane; n=11); and,
- Accommodate older offenders through infrastructure changes (e.g., improve wheelchair accessibility; n=10).

References

Endnote i

Corrections and Conditional Release Act, SC 1992, c 20.

Return to endnote i

Endnote ii

Public Safety Canada. (2015). Corrections and conditional release statistical overview. Ottawa, ON: p. 48.

Return to endnote ii

Endnote iii

Infonet. (2016). Health services. Retrieved from http://infonet/eng/Sectors/HealthServices/pages/home.aspx.

Return to endnote iii

Endnote iv

Correctional Service Canada. (2016). Reports on plans and priorities 2016-17. Ottawa, ON: p. 7-12.

Return to endnote iv

Endnote v

Beaudette, J., Power, J., & Stewart, L. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada.; Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.; Derkzen, D., Booth, L., McConnell, A., & Taylor, K. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service of Canada.; Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote v

Endnote vi

Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and other stress-related illnesses. Journal of Health and Social Behaviour 49(1), 56-71.; Stewart, L., Sapers, J., Nolan, A., & Power, J. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.; Thompson, B., & Finch, R. (2005). Hepatitis C virus infection. Clinical Microbiology and Infection 11(2), 87.

Return to endnote vi

Endnote vii

Awofeso, N. (2010). Prisons as social determinants of hepatitis C virus and tuberculosis infections. Public Health Reports 125, 25-33.; Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and other stress-related illnesses. Journal of Health and Social Behaviour 49(1), 56-71.; Williams, N. (2007). Prison health and the health of the public: Ties that bind. Journal of Correctional Health Care 13(2), 80-92.

Return to endnote vii

Endnote viii

Return to endnote viii

Endnote ix

Public Safety Canada. (2015). Corrections and conditional release statistical overview. Ottawa, ON: p. 48.

Return to endnote ix

Endnote x

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart, L., et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote x

Endnote xi

Sifunda, S., et al. (2008). The effectiveness of a peer-led HIV/AIDS and STI health education intervention for prison inmates in South Africa. Health Education & Behavior 35(4), 494-508.

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Endnote xii

Dumont, D., et al. (2012). Public health and the epidemic of incarceration. Annual Review of Public Health 33, 325-329.

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Endnote xiii

Corrections and Conditional Release Act, SC 1992, c 20. Retrieved from http://canlii.ca/t/52129.

Return to endnote xiii

Endnote xiv

Correctional Service of Canada. (2015, July 23). National essential health services framework. Ottawa, ON.

Return to endnote xiv

Endnote xv

Hayton, P. (2007). Protecting and promoting health in prisons: A settings approach. In L. Moller, et al. (Eds.), Health in prisons: A WHO guide to the essentials of prison health (pp. 15-20). Copenhagen, DK: WHO Publications.

Return to endnote xv

Endnote xvi

Stewart, L., Sapers, J., Nolan, A., & Power, J. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote xvi

Endnote xvii

Awofeso, N. (2010). Prisons as social determinants of hepatitis C virus and tuberculosis infections. Public Health Reports, 125, 25-33.; Massoglia, M. (2008). Incarceration as exposure: The prison, infectious disease, and other stress-related illnesses. Journal of Health and Social Behavior, 49(1), 56-71.; Tarbuck, A. (2001). Health of elderly inmates. Age and Ageing, 30(5), 369-370.

Return to endnote xvii

Endnote xviii

Correctional Service Canada. (2015). Commissioner's Directive 800: Health services. Ottawa, ON.

Return to endnote xviii

Endnote xix

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote xix

Endnote xx

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offender (R-332). Ottawa, ON: Correctional Service Canada.

Return to endnote xx

Endnote xxi

Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.

Return to endnote xxi

Endnote xxii

Beaudette, J., & Stewart, L. (2014). Research in brief: Older offenders in the custody of the Correctional Service of Canada (RS 14-21). Ottawa, ON: Correctional Service Canada.

Return to endnote xxii

Endnote xxiii

Stewart, L., Sapers, J., Nolan, A., & Power, J. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote xxiii

Endnote xxiv

Correctional Service Canada. (2014). Public health quarterly report FY 2013-2014. Ottawa, ON.

Return to endnote xxiv

Endnote xxv

Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.

Return to endnote xxv

Endnote xxvi

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service of Canada.

Return to endnote xxvi

Endnote xxvii

Public Health Agency of Caanda. (2013). Tuberculosis in Canada 2013 – Pre-release. Ottawa, ON.

Return to endnote xxvii

Endnote xxviii

Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.

Return to endnote xxviii

Endnote xxix

Statistics Canada. (2013, September 18). Health at a glance: Mental and substance use disorders in Canada. Retrieved from http://www.statcan.gc.ca/pub/82-624-x/2013001/article/11855-eng.htm.

Return to endnote xxix

Endnote xxx

Correctional Service Canada. (2014). Mental Health Branch performance measurement report: Year-end results 2013-14. Ottawa, ON.

Return to endnote xxx

Endnote xxxi

Beaudette, J., Power, J., & Stewart, L. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada.; Derkzen, D., Booth, L., McConnell, A., & Taylor, K. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service of Canada.

Return to endnote xxxi

Endnote xxxii

American Psychological Association. (2012). DSM-IV and DSM-5 criteria for the personality disorders. Washington, D.C.

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Endnote xxxiii

All statistics on self-injurious behaviour were obtained from Power, J., Gordon, A., Sapers, J., & Beaudette, J. (2012). A replication study of self-injury incidents in CSC institutions over a thirty-month period (R-293). Ottawa, ON: Correctional Service Canada.

Return to endnote xxxiii

Endnote xxxiv

Correctional Service Canada. (2015). 2015-16 Report on plans and priorities. Ottawa, ON.

Return to endnote xxxiv

Endnote xxxv

Correctional Service Canada. (2013). Health Services sector priorities for 2013-2015. Retrieved from http://infonet/Sectors/HealthServices?lang=en.

Return to endnote xxxv

Endnote xxxvi

Correctional Service Canada. (2013). Health Services sector priorities for 2013-2015. Retrieved from http://infonet/Sectors/HealthServices?lang=en.

Return to endnote xxxvi

Endnote xxxvii

Government of Canada. (2014). Mental health action plan for federal offenders. Ottawa, ON. Retrieved from http://publicsafety.gc.ca/cnt/cntrng-crm/crrctns/mntl-hlth-ctn-pln-eng.aspx.

Return to endnote xxxvii

Endnote xxxviii

Government of Canada. (2015). Making real change happen: Speech from the Throne to open the first session of the forty-second Parliament of Canada. Retrieved from http://www.speech.gc.ca/en/content/making-real-change-happen.

Return to endnote xxxviii

Endnote xxxix

Government of Canada. (2015). Minister of Public Safety and Emergency Preparedness mandate letter. Retrieved from http://pm.gc.ca/eng/minister-public-safety-and-emergency-preparedness-mandate-letter.

Return to endnote xxxix

Endnote xl

Canada Health Act, RSC 1985, c C-6. Retrieved from http://laws-lois.justice.gc.ca/eng/acts/c-6/page-1.html.; The Constitution Act, 1982, Schedule B to the Canada Act 1982 (UK), 1982, c 11. Retrieved from http://laws-lois.justice.gc.ca/eng/Const/page-15.html#h-38. For further information, see Chenier, N. M. (2014). Federal responsibility for the health care of specific groups (PRB 04-52E). Ottawa, ON: Library of Parliament; Tiedemann, M. (2008). The federal role in health and health care (2008-58-E). Ottawa, ON: Parliament of Canada.

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Endnote xli

Corrections and Conditional Release Act, SC 1992, c 20. Retrieved from http://laws-lois.justice.gc.ca/eng/acts/C-44.6/page-1.html.

Return to endnote xli

Endnote xlii

Thomas, J. (2010). Report on assessment framework for alternative service delivery. Ottawa, ON.; Thomas, J. (2011). Implementing the CSC report on an assessment framework for alternative service delivery: Report for CSC's Executive Committee meeting on October 5, 2011. Ottawa, ON.

Return to endnote xlii

Endnote xliii

Hall, N., & Weaver, C. (2008). A framework for diversion of persons with a mental disorder in BC. Vancouver, BC: Canadian Mental Health Association.

Return to endnote xliii

Endnote xliv

Hall, N., & Weaver, C. (2008). A framework for diversion of persons with a mental disorder in BC. Vancouver, BC: Canadian Mental Health Association.; Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.; Livingston, J., Weaver, C., Hall, N., & Verdun-Jones, S. (2008). Criminal justice diversion for persons with mental disorders: A review of best practices. Vancouver, BC: Canadian Mental Health Association.; Munetz, M., & Griffin, P. (2006). Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatric Services, 57(4), 544-549.

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Endnote xlv

Correctional Service of Canada. (2013). Community mental health service delivery guidelines. Ottawa, ON.

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Endnote xlvi

Statistics Canada. (2007). Canadian community health survey: Mental health and well-being. Retrieved from http://www.statcan.gc.ca/pub/82-617-x/index-eng.htm.

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Endnote xlvii

Friedli, L., & Parsonage, M. (2007). Mental health promotion: Building an economic case. Belfast, IE: Northern Ireland Association for Mental Health.; Hill, J. (2003). Early identification of individuals at risk for antisocial personality disorder. The British Journal of Psychiatry, 182(44), s11-s14.

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Endnote xlviii

Aos, S., Miller, M., & Drake, E. (2006). Evidence-based public policy options to reduce future prison construction, criminal justice costs, and crime rates. Olympia, WA: Washing State Institute for Public Policy.

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Endnote xlix

National Crime Prevention Centre. (2013). The Stop Now and Plan Program – SNAP: Crime prevention in action. Ottawa, ON: Public Safety Canada.

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Endnote l

Farrington, D., & Koegl, C. (2014).The monetary benefits and costs of the Stop Now and Plan Program for boys aged 6-11, based on the prevention of later offending. Journal of Quantitative Criminology, 31(2), 263-287.

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Endnote li

Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.; Sarteschi, C., Vaughn, M., & Kim, K. (2011). Assessing the effectiveness of mental health courts: A quantitative review. Journal of Criminal Justice, 39(1), 12-20.

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Endnote lii

Cowell, A., Broner, N., & Dupont, R. (2004). The cost effectiveness of criminal justice diversion programs for people with serious mental illness co-occurring with substance abuse: Four case studies. Journal of Contemporary Criminal Justice, 20(3), 292-315

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Endnote liii

Centre for Addiction and Mental Health, & Canadian Council on Social Development. (2011). Turning the key: Assessing housing and related supports for persons living with mental health problems and illness. Calgary, AB: Mental Health Commission of Canada.; Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.; Lindberg, A. (2009). Examining the program costs and outcomes of San Francisco's Behavioral Health Court: Predicting success. San Francisco, CA: Office of Collaborative Justice Programs, Superior Court of California, San Francisco County.; Ridgely et al. (2007). Justice, treatment and cost: An evaluation of the fiscal impact of Allegheny Country Mental Health Court. Santa Monica, CA: RAND.

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Endnote liv

Laliberté, D., Rosario, G., Léonard, L., Smith-Moncrieffe, D., & Warner, A. (2014). Results of crime prevention programs for 12 to 17 year olds. Ottawa, ON: National Crime Prevention Centre, Public Safety Canada.

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Endnote lv

Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.

Return to endnote lv

Endnote lvi

Correctional Service Canada. (2014). Nursing intake assessment and medication reconciliation analysis 2013-2014. Ottawa, ON.

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Endnote lvii

Correctional Service Canada. (2014). Mental Health Branch performance measurement report: Year end results 2013-14. Ottawa, ON.

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Endnote lviii

Accreditation Canada. (2014). Accreditation Report: Correctional Services Canada, Health Services. Ottawa, ON.

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Endnote lix

Wilton, G., Stewart, L., & Power, J. (2014). Emerging research results – Agreement among three mental health screening measures (B58). Ottawa, ON: Correctional Service Canada.

Return to endnote lix

Endnote lx

Correctional Service Canada (2014). Health care requirements on reception and transfer. Ottawa, ON.

Return to endnote lx

Endnote lxi

Correctional Service Canada (2014). Computerized Mental Health Intake Screening System version 2.2 – National guidelines. Ottawa, ON.; Correctional Service Canada (2014). Mental health screening. Ottawa, ON.

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Endnote lxii

Wilton et al. (2014). Emerging research results – Agreement among three mental health screening measures (B58). Ottawa, ON: Correctional Service Canada.

Return to endnote lxii

Endnote lxiii

Wilton et al. (2014). Emerging research results – Agreement among three mental health screening measures (B58). Ottawa, ON: Correctional Service Canada.

Return to endnote lxiii

Endnote lxiv

Correctional Service Canada. (2015). Mental Health Branch performance measurement report: Year end results 2014-15. Ottawa, ON.

Return to endnote lxiv

Endnote lxv

Wilton et al. (2014). Emerging research results – Agreement among three mental health screening measures (B58). Ottawa, ON: Correctional Service Canada.

Return to endnote lxv

Endnote lxvi

Wilton et al. (2014). Emerging research results – Agreement among three mental health screening measures (B58). Ottawa, ON: Correctional Service Canada.

Return to endnote lxvi

Endnote lxvii

Corrections and Conditional Release Act, SC 1992, c 20.

Return to endnote lxvii

Endnote lxviii

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote lxviii

Endnote lxix

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON: p. 7.

Return to endnote lxix

Endnote lxx

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON: p. 2.

Return to endnote lxx

Endnote lxxi

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON: Annex A.

Return to endnote lxxi

Endnote lxxii

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote lxxiii

Correctional Service Canada. (2016). Unpublished Health Services surveillance data.

Return to endnote lxxiii

Endnote lxxiv

Correctional Service Canada. (2016). Unpublished Health Services surveillance data.

Return to endnote lxxiv

Endnote lxxv

Correctional Service Canada. (2016). Unpublished Health Services surveillance data.

Return to endnote lxxv

Endnote lxxvi

Correctional Service Canada. (2016). Unpublished Health Services surveillance data.

Return to endnote lxxvi

Endnote lxxvii

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON: p. 14.

Return to endnote lxxvii

Endnote lxxviii

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote lxxviii

Endnote lxxix

Correctional Service Canada. (2015). Commissioner's Directive 800: Health services. Ottawa, ON.

Return to endnote lxxix

Endnote lxxx

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON: p. 1.

Return to endnote lxxx

Endnote lxxxi

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote lxxxi

Endnote lxxxii

Correctional Service Canada. (2012). Towards a continuum of care. Retrieved from http://www.csc-scc.gc.ca/002/006/002006-2000-eng.shtml.

Return to endnote lxxxii

Endnote lxxxiii

Correctional Service Canada. (2015). Mental health branch performance measurement report: Year end results 2014-15. Ottawa, ON.

Return to endnote lxxxiii

Endnote lxxxiv

Correctional Service Canada. (2015). Mental health branch performance measurement report: Year end results 2014-15. Ottawa, ON: p. 13.

Return to endnote lxxxiv

Endnote lxxxv

Correctional Service Canada. (2015). Mental health branch performance measurement report: Year end results 2014-15. Ottawa, ON: p. 16.

Return to endnote lxxxv

Endnote lxxxvi

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote lxxxvi

Endnote lxxxvii

COACH. (2015). 2015 Canadian telehealth report. Toronto, ON.

Return to endnote lxxxvii

Endnote lxxxviii

Correctional Service Canada. (2016). Health Services Ontario Telemedicine Network. Ottawa, ON.

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Endnote lxxxix

Accreditation Canada. (2014). Accreditation report: Correctional Service Canada, Health Services. Ottawa, ON.

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Endnote xc

Glauser, W., Nolan, M., & Remfry, A. (2015). Telemedicine on the rise across Canada. Retrieved from http://healthydebate.ca/2015/06/topic/telemedicine-across-canada.

Return to endnote xc

Endnote xci

Correctional Service Canada. (2016). Health Services Ontario Telemedicine Network. Ottawa, ON.

Return to endnote xci

Endnote xcii

Correctional Service Canada. (2015). Health Services: Expanding the use of telemedicine. Ottawa, ON.

Return to endnote xcii

Endnote xciii

Schaenman, P., et al. (2013). Opportunities for cost savings in corrections without sacrificing service quality: Inmate health care. Washington, D.C.: p. 20.

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Endnote xciv

PEW Charitable Trusts and MacArthur Foundation. (2014). State prison health care spending: An examination. Retrieved from http://www.pewtrusts.org/mwg-internal/de5fs23hu73ds/progress?id=90xXyrs8KPMaqrCmWFgw_Lg5J4mOsLwoxa-1IUpxoP8; Reno, J., et al. (1999). Telemedicine can reduce correctional health care costs: An evaluation of a prison telemedicine network. Washington, D.C.

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Endnote xcv

Reno, J., et al. (1999). Telemedicine can reduce correctional health care costs: An evaluation of a prison telemedicine network. Washington, D.C.

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Endnote xcvi

Ollove, M. (2016). State prisons turn to telemedicine to improve health and save money. Retrieved from http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/01/21/state-prisons-turn-to-telemedicine-to-improve.

Return to endnote xcvi

Endnote xcvii

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote xcvii

Endnote xcviii

Barua, B. (2015). Waiting your turn: Wait times for health care in Canada. Vancouver, BC: The Fraser Institute.

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Endnote xcix

Health Canada. (2012). First Minister's meeting on the future of health care. Retrieved from http://healthycanadians.gc.ca/health-system-systeme-sante/services/quality-qualite/wait-attente/meeting-rencontre-eng.php.

Return to endnote xcix

Endnote c

COACH. (2013) 2013 Canadian telehealth report. Toronto, ON.

Return to endnote c

Endnote ci

COACH. (2013) 2013 Canadian telehealth report. Toronto, ON.

Return to endnote ci

Endnote cii

COACH. (2013) 2013 Canadian telehealth report. Toronto, ON.

Return to endnote cii

Endnote ciii

Glauser, W., Nolan, M., & Remfry, A. (2015). Telemedicine on the rise across Canada. Retrieved from http://healthydebate.ca/2015/06/topic/telemedicine-across-canada.

Return to endnote ciii

Endnote civ

Glauser, W., Nolan, M., & Remfry, A. (2015). Telemedicine on the rise across Canada. Retrieved from http://healthydebate.ca/2015/06/topic/telemedicine-across-canada.

Return to endnote civ

Endnote cv

Correctional Service Canada. (2014). Commissioner's Directive 710-2-3: Inmate transfer process. Ottawa, ON.

Return to endnote cv

Endnote cvi

Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON: p. 3.

Return to endnote cvi

Endnote cvii

Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON.

Return to endnote cvii

Endnote cviii

Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON: p. 4.

Return to endnote cviii

Endnote cix

Canada Health Infoway. (2013). The emerging benefits of electronic medical record use in community-based care. Toronto, ON.

Return to endnote cix

Endnote cx

Health Infoway. (2013). The emerging benefits of electronic medical record use in community-based care. Toronto, ON; Knight, D. (2009). Electronic medical records: Moving jails forward. Retrieved from http://www.corrections.com/news/article/22296-electronic-medical-records-moving-jails-forward.

Return to endnote cx

Endnote cxi

Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON.

Return to endnote cxi

Endnote cxii

Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON.

Return to endnote cxii

Endnote cxiii

Correctional Service Canada (2012). Health services sector 2011-2012 performance measurement report. Ottawa, ON.

Return to endnote cxiii

Endnote cxiv

Correctional Service Canada. (2016). Health promotion. Retrieved from http://infonet/eng/Sectors/HealthServices/PublicHealth/Pages/HealthPromotion.aspx.

Return to endnote cxiv

Endnote cxv

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

Return to endnote cxv

Endnote cxvi

Correctional Service Canada. (2016). Health promotion. Retrieved from http://infonet/eng/Sectors/HealthServices/PublicHealth/Pages/HealthPromotion.aspx.

Return to endnote cxvi

Endnote cxvii

Correctional Service Canada. (2012). Inmate suicide awareness and prevention workshop: Participant's manual. Ottawa, ON.

Return to endnote cxvii

Endnote cxviii

Correctional Service Canada. (2016). Health promotion. Retrieved from http://infonet/eng/Sectors/HealthServices/PublicHealth/Pages/HealthPromotion.aspx.

Return to endnote cxviii

Endnote cxix

Nolan, A., & Stewart, L. (unpublished document, under review). Correctional health promotion and health education initiatives: A review of the literature. Correctional Service of Canada. Ottawa, ON.

Return to endnote cxix

Endnote cxx

Correctional Service Canada (2014). Commissioner's directive 705: Intake assessment process and correctional plan framework. Ottawa, ON: p.3.

Return to endnote cxx

Endnote cxxi

Correctional Service Canada (2012). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

Return to endnote cxxi

Endnote cxxii

Correctional Service Canada. (2014). Performance measurement public health branch report 2013-2014. Ottawa, ON.

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Endnote cxxiii

Correctional Service Canada. (2014). Departmental performance report. Ottawa, ON.

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Endnote cxxiv

Correctional Service Canada. (2015). Public health quarterly report – FY 2014-2015. Ottawa, ON.

Return to endnote cxxiv

Endnote cxxv

Correctional Service Canada. (2014). Performance measurement public health branch report 2013-2014. Ottawa, ON.

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Endnote cxxvi

Correctional Service Canada. (2014). Performance measurement public health branch report 2013-2014. Ottawa, ON.

Return to endnote cxxvi

Endnote cxxvii

Correctional Service Canada. (2014). Performance measurement public health branch report 2013-2014. Ottawa, ON.

Return to endnote cxxvii

Endnote cxxviii

Correctional Service Canada (2013). Commissioner's directive 843: Management of inmate self-injurious and suicidal behaviour. Ottawa, ON.

Return to endnote cxxviii

Endnote cxxix

Correctional Service of Canada (2012). Health services sector 2010-2011 performance measurement report. Ottawa, ON.

Return to endnote cxxix

Endnote cxxx

Zakaria, D., Thompson, J., & Borgatta, F. (2010). The relationship between knowledge of HIV and HCV, health education, and risk and harm-reducing behaviours among Canadian federal inmates (R-195). Ottawa, ON: Correctional Service Canada.

Return to endnote cxxx

Endnote cxxxi

Return to endnote cxxxi

Endnote cxxxii

Nolan, A., & Stewart, L. (unpublished document, under review). Correctional health promotion and health education initiatives: A review of the literature. Ottawa, ON: Correctional Service Canada.

Return to endnote cxxxii

Endnote cxxxiii

Health Canada and the Public Health Agency of Canada. (2014). Evaluation of the federal initiative to address HIV/AIDS in Canada 2008-09 to 2012-13. Ottawa, ON.

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Endnote cxxxiv

EI Saadany, S., et al. (2005). Economic burden of hepatitis C in Canada and the potential impact of prevention: Results from a disease model. The European Journal of Health Economics, 6(2), 159-165.

Return to endnote cxxxiv

Endnote cxxxv

Health Canada and the Public Health Agency of Canada. (2014). Evaluation of the federal initiative to address HIV/AIDS in Canada 2008-09 to 2012-13. Ottawa, ON.

Return to endnote cxxxv

Endnote cxxxvi

Health Canada and the Public Health Agency of Canada. (2014). Evaluation of the federal initiative to address HIV/AIDS in Canada 2008-09 to 2012-13. Ottawa, ON.

Return to endnote cxxxvi

Endnote cxxxvii

Cohen, D., Wu, S., & Farley, T. (2004). Comparing the cost-effectiveness of HIV prevention interventions. Journal of Acquired Immune Deficiency Syndromes, 37(3), 1404-1414.

Return to endnote cxxxvii

Endnote cxxxviii

Cohen, D., Wu, S., & Farley, T. (2004). Comparing the cost-effectiveness of HIV prevention interventions. Journal of Acquired Immune Deficiency Syndromes, 37(3), 1404-1414.

Return to endnote cxxxviii

Endnote cxxxix

Correctional Service Canada. (2013). Sexually transmitted infection guidelines. Ottawa, ON: p.65; Correctional Service Canada. (2014). Commissioner's directive 800: Health Services. Ottawa, ON: p.3.

Return to endnote cxxxix

Endnote cxl

Correctional Service Canada. (2013). Report on the national review of CSC's opiate substitution therapy program. Ottawa, ON.

Return to endnote cxl

Endnote cxli

Correctional Service Canada. (2014). Commissioner's directive 800: Health services. Ottawa, ON.

Return to endnote cxli

Endnote cxlii

Correctional Service Canada. (2015). Guidelines 800-6: Bleach distribution. Ottawa, ON.

Return to endnote cxlii

Endnote cxliii

Correctional Service Canada. (2015). Compliance and operational risk report: Fall 2015 review. Ottawa, ON.

Return to endnote cxliii

Endnote cxliv

Correctional Service Canada. (2015). Compliance and operational risk report: Fall 2015 review. Ottawa, ON.

Return to endnote cxliv

Endnote cxlv

Correctional Service Canada. (2016). Integrated mental health guidelines. Ottawa, ON.

Return to endnote cxlv

Endnote cxlvi

Correctional Service Canada. (2015). Regional treatment centre standardized processes. Ottawa, ON: p. 1.

Return to endnote cxlvi

Endnote cxlvii

Correctional Service Canada. (2012). Towards a continuum of care: Correctional Service Canada mental health strategy. Ottawa, ON.

Return to endnote cxlvii

Endnote cxlviii

Correctional Service Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p. 12.

Return to endnote cxlviii

Endnote cxlix

Correctional Service Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p. 30.

Return to endnote cxlix

Endnote cl

Correctional Service Canada. (2015). Mental health branch performance measurement report: Year end results 2014-15. Ottawa, ON: p. 19.

Return to endnote cl

Endnote cli

Correctional Service Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p. 2.

Return to endnote cli

Endnote clii

Correctional Service Canada. (2012). Towards a continuum of care: Correctional Service Canada mental health strategy. Ottawa, ON.

Return to endnote clii

Endnote cliii

Correctional Service Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p. 22-23.

Return to endnote cliii

Endnote cliv

Infonet. (2016). Suicide and self-injury prevention. Retrieved from http://infonet/eng/Sectors/HealthServices/MentalHealth/Pages/SuicideandSIB.aspx.

Return to endnote cliv

Endnote clv

Correctional Service Canada. (n.d.). Regional complex mental health committees: Terms of reference. Ottawa, ON.

Return to endnote clv

Endnote clvi

Correctional Service Canada. (2016). Unpublished Health Services data.

Return to endnote clvi

Endnote clvii

Correctional Service Canada. (2016). Regional complex mental health committees: Terms of reference. Ottawa, ON.

Return to endnote clvii

Endnote clviii

Correctional Service Canada. (2014). Discharge planning and transfer guidelines. Ottawa, ON: p. 4.

Return to endnote clviii

Endnote clix

Correctional Service Canada. (2014). Discharge planning and transfer guidelines. Ottawa, ON: p. 4.

Return to endnote clix

Endnote clx

Correctional Service Canada (2014). Discharge planning and transfer guidelines. Ottawa, ON.

Return to endnote clx

Endnote clxi

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON.

Return to endnote clxi

Endnote clxii

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON.

Return to endnote clxii

Endnote clxiii

Correctional Service Canada. (2012). Audit of release process. Ottawa, ON.

Return to endnote clxiii

Endnote clxiv

Correctional Service Canada. (2014). Commissioner's directive 712-4: Release process. Ottawa, ON: p. 2.

Return to endnote clxiv

Endnote clxv

Correctional Service Canada (2015). Commissioner's directive 566-12: Personal property of offenders. Ottawa, ON: p.10.

Return to endnote clxv

Endnote clxvi

Inter-provincial Agreement on Eligibility and Portability, as quoted in Correctional Service of Canada. (2011). Offender Identification Cards: Review and Recommendations. Ottawa, ON: p11.

Return to endnote clxvi

Endnote clxvii

Correctional Service Canada (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON.

Return to endnote clxvii

Endnote clxviii

Correctional Service Canada. (2014). Commissioner's directive 860: Offender's money. Ottawa, ON: p. 3.

Return to endnote clxviii

Endnote clxix

Correctional Service Canada. (2014). Discharge planning and transfer guidelines. Ottawa, ON: p. 7.

Return to endnote clxix

Endnote clxx

Correctional Service Canada. (2014). Discharge planning and transfer guidelines. Ottawa, ON: p. 10.

Return to endnote clxx

Endnote clxxi

Correctional Service Canada. (2014). Discharge planning and transfer guidelines. Ottawa, ON: p. 12-13.

Return to endnote clxxi

Endnote clxxii

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote clxxii

Endnote clxxiii

Correctional Service Canada (2016). National Formulary. Ottawa, ON: p.16. Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p. 13. Correctional Service Canada. (2014). Commissioner's directive 712-4: Release process. Ottawa, ON: p. 2 & 5.

Return to endnote clxxiii

Endnote clxxiv

Correctional Service of Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote clxxiv

Endnote clxxv

Correctional Service of Canada. (2015). Integrated mental health guidelines. Ottawa, ON: p. 36, 39.

Return to endnote clxxv

Endnote clxxvi

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p.2 & p.42.

Return to endnote clxxvi

Endnote clxxvii

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p.2.; Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p.5.

Return to endnote clxxvii

Endnote clxxviii

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p.36.

Return to endnote clxxviii

Endnote clxxix

MacDonald, S. F., Stewart, L. A., & Feely, S. (2014). Research Report: The Impact of the Community Mental Health Initiative (CMHI) (Report No. R-337).

Return to endnote clxxix

Endnote clxxx

Allegri et al. (2008). Evaluation Report: Community Mental Health Initiative. Ottawa: ON.

Return to endnote clxxx

Endnote clxxxi

MacDonald, S. F., Stewart, L. A., & Feely, S. (2014). Research Report: The Impact of the Community Mental Health Initiative (CMHI) (Report No. R-337).

Return to endnote clxxxi

Endnote clxxxii

Correctional Service of Canada. (2015). Mental Health Branch Performance Measurement Report. Ottawa, ON: p.61.

Return to endnote clxxxii

Endnote clxxxiii

Correctional Service of Canada. (2015). Mental health branch performance measurement report: Year end results 2014-15. Ottawa, ON: p.28.

Return to endnote clxxxiii

Endnote clxxxiv

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON:p.3 & 41.

Return to endnote clxxxiv

Endnote clxxxv

Correctional Service of Canada. (2014). Community Mental Health Service Delivery Guidelines. Ottawa, ON: p.18.

Return to endnote clxxxv

Endnote clxxxvi

Correctional Service of Canada. (2015). National essential health services framework. Ottawa, ON.

Return to endnote clxxxvi

Endnote clxxxvii

Correctional Service Canada. (2015). New governance structure. Retrieved from http://infonet/eng/Sectors/HealthServices/Pages/governance.aspx.

Return to endnote clxxxvii

Endnote clxxxviii

Accreditation Canada. (2014). Correctional Service Canada, Health Services. Ottawa, ON.

Return to endnote clxxxviii

Endnote clxxxix

Accreditation Canada. (2014). Correctional Service Canada, Health Services. Ottawa, ON.

Return to endnote clxxxix

Endnote cxc

Correctional Service Canada. (2015). Departmental performance report 2013-2014. Ottawa, ON.

Return to endnote cxc

Endnote cxci

Myers, R., et al. (2014). Burden of disease and cost of chronic hepatitis C virus infection in Canada. Canadian Journal of Gastroenterology and Hepatology, 28(5), 243-250.

Return to endnote cxci

Endnote cxcii

Rein, D. et al., (2015). The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus. Clinical Infectious Disease 61(2), 157-68.

Return to endnote cxcii

Endnote cxciii

Canadian AIDS Treatment Information Exchange (CATIE). (n.d.). Prevention and treatment for hepatitis C virus (HCV). Retrieved from http://www.catie.ca/en/treatmentupdate/treatmentupdate-191/anti-hcv-agents/prevention-and-treatment-hepatitis-c-virus-hcv.

Return to endnote cxciii

Endnote cxciv

Rein, D. et al., (2015). The cost-effectiveness, health benefits, and financial costs of new antiviral treatments for hepatitis C virus. Clinical Infectious Disease 61(2), 157-68.

Return to endnote cxciv

Endnote cxcv

Canadian AIDS Treatment Information Exchange (CATIE). (n.d.). About some terms – SVR₁₂ vs. SVR₂₄. Retrieved from http://www.catie.ca/en/treatmentupdate/treatmentupdate-207/hepatitis-c-virus/about-some-terms-svr12-vs-svr24.

Return to endnote cxcv

Endnote cxcvi

Pearlman, B., & Traub, N. (2011). Sustained virologic response to antiviral therapy for chronic hepatitis C virus infection: A cure and so much more. Journal of Clinical Infectious Diseases 52(7), 889-900.

Return to endnote cxcvi

Endnote cxcvii

Correctional Service Canada. (2014). Public health quarterly report FY 2013-2014. Ottawa, ON.

Return to endnote cxcvii

Endnote cxcviii

Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON.

Return to endnote cxcviii

Endnote cxcix

Smith, J., et al. "Treatment outcomes for chronic hepatitis C infection with direct acting antivirals among inmates in federal corrections." Presentation at the Canadian Association for Drugs and Technology in Health (CADTH), National Conference, Ottawa, ON, April 10-12, 2016.

Return to endnote cxcix

Endnote cc

Myers, R., et al. (2015). An update on the management of chronic hepatitis C: 2015 consensus guidelines from the Canadian Association for the Study of the Liver. Canadian Journal of Gastroenterology and Hepatology, 29(1), 19-34.

Return to endnote cc

Endnote cci

Singal A.G. et al. (2010). A Sustained Viral Response Is Associated With Reduced Liver-Related Morbidity and Mortality in Patients With Hepatitis C Virus. Journal of Clinical Gastroenterology and Hepatology. (8): 280-288. Retrieved on September 21, 2016 from, http://www.cghjournal.org/mwg-internal/de5fs23hu73ds/progress?id=LzDy1jjDi96bBAv9UIcPmTGoZH7EeLartCzJBPL5JMc,&dl

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Endnote ccii

Myers RP et al. (2015). An update on the management of chronic hepatitis C: 2015 consensus guidelines from the Canadian Liver Association for the Study of the Liver. Canadian Journal of Gastroenterology and Hepatology. Retrieved on August 30, 2016 from, http://www.liver.ca/files/Professional_Education Partnerships/Information Resources_for_HCP/CASL_Hep_C_Consensus_Guidelines_Update_-_Jan_2015.pdf

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Endnote cciii

Public Health Agency of Canada. (2016). Report on Hepatitis B and C in Canada: 2012. Retreived on September 1st, 2016 from, http://healthycanadians.gc.ca/publications/diseases-conditions-maladies-affections/hepatitis-b-c-2012-hepatite-b-c/index-eng.php

Return to endnote cciii

Endnote cciv

Tianhua, He. et al. (2015). Prevention of Hepatitis C by Screening and Treatment in United States Prisons. Annals of Internal Medicine. 164(2): 84-92.

Return to endnote cciv

Endnote ccv

Correctional Service of Canada. (2013). Commissioner's directive 800: Health services. Ottawa, ON: p. 4.

Return to endnote ccv

Endnote ccvi

Correctional Service of Canada. (2011). Intensive intervention strategy for women offenders. Ottawa, ON.

Return to endnote ccvi

Endnote ccvii

Correctional Service Canada. (2008). Correctional Service Canada contract with the Institut Philippe-Pinel de Montréal. Ottawa, ON.

Return to endnote ccvii

Endnote ccviii

Correctional Service Canada. (2014). The impact of the community mental health initiative (CMHI), R-337. Ottawa, ON.; Allegri et al. (2008). Evaluation Report: Community Mental Health Initiative. Ottawa: ON.

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Endnote ccix

Canada Health Act, RSC 1985, c C-6.Retrieved from http://laws-lois.justice.gc.ca/eng/acts/C-6/page-2.html#docCont.

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Endnote ccx

Unless otherwise cited, the self-reported prevalence rates were derived from Stewart, L., et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

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Endnote ccxi

Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.

Return to endnote ccxi

Endnote ccxii

Government of Canada. (2015). Heart disease – heart health. Retrieved from http://healthycanadians.gc.ca/diseases-conditions-maladies-affections/disease-maladie/heart-disease-eng.php.; Munro, M. (2012, January 26). First Nations need obesity prevention socio-economic issues contribute to hypertension, heart disease and diabetes epidemic, report says. Retrieved from http://www.naho.ca/blog/2012/01/26/first-nations-need-obesity-prevention-socio-economic-issues-contribute-to-hypertension-heart-disease-and-diabetes-epidemic-report-says/.

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Endnote ccxiii

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.

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Endnote ccxiv

Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

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Endnote ccxv

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.

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Endnote ccxvi

Beaudette et al. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada.

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Endnote ccxvii

Beaudette et al. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada.

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Endnote ccxviii

American Psychological Association. (2012). DSM-IV and DSM-5 criteria for the personality disorders. Washington, D.C.

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Endnote ccxix

Beaudette et al. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada.; Derkzen et al. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service Canada.

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Endnote ccxx

Derkzen et al. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service Canada.

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Endnote ccxxi

Derkzen et al. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service Canada.

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Endnote ccxxii

American Psychological Association. (2012). DSM-IV and DSM-5 criteria for the personality disorders. Washington, D.C.

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Endnote ccxxiii

Munetz, M., & Griffin, P. (2006). Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatric Services, 57(4), 544-549.

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Endnote ccxxiv

See for example Compton, M., et al. (2011). Use of force preferences and perceived effectiveness of actions among Crisis Intervention Team (CIT) police officers and non-CIT officers in escalating psychiatric crisis involving a subject with Schizophrenia. Schizophrenia Bulletin 37(4), 737-745.; Steadman, H. J., & Naples, M. (2005). Assessing the effectiveness of jail diversion programs for persons with serious mental illness and co-occuring substance abuse disorder. Behavioural Sciences and the Law, 23(2), 163-170.

C) Watson, A., et al. (2010). Outcomes of police contacts with persons with mental illness: The impact of CIT. Administration and Policy in Mental Health 37(4), 302-317.

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Endnote ccxxv

Thomas, J. (2010). Report on assessment framework for alternative service delivery. Ottawa, ON.

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Endnote ccxxvi

Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.

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Endnote ccxxvii

Sarteschi et al. (2011). Assessing the effectiveness of mental health courts: A quantitative review. Journal of Criminal Justice, 39(1), 12-20.; Thomas, J. (2010). Report on assessment framework for alternative service delivery. Ottawa, ON.

Return to endnote ccxxvii

Endnote ccxxviii

Return to endnote ccxxviii

Endnote ccxxix

Griffiths, C., Dandurand, Y., & Murdoch, D. (2007). The social reintegration of offenders and crime prevention. Ottawa, ON: National Crime Prevention Centre, Public Safety Canada.

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Endnote ccxxx

Correctional Service Canada. (2012). Mental health strategy for corrections in Canada: A federal-provincial-territorial partnership. Ottawa, ON.

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Endnote ccxxxi

Livingston et al. (2008). Criminal justice diversion for persons with mental disorders: A review of best practices. Vancouver, BC: Canadian Mental Health Association.

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Endnote ccxxxii

Hall, N., & Weaver, C. (2008). A framework for diversion of persons with a mental disorder in BC. Vancouver, BC: Canadian Mental Health Association.

Return to endnote ccxxxii

Endnote ccxxxiii

Heilbrun et al. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.

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Endnote ccxxxiv

Correctional Service Canada. (2013). Health Services Sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote ccxxxv

Correctional Service Canada. (2013). Health Services Sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote ccxxxvi

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote ccxxxvii

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote ccxxxviii

Correctional Service Canada. (2015). Health services program: Infectious diseases. Retrieved from http://infonet/eng/Regions/Prairie/OurRegion/Institutions/WebSites/EIFW/OurInstitution/Divisions/Interventions/HealthServices/Programs/Pages/InfectiousDiseases.aspx.

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Endnote ccxxxix

Correctional Service Canada. (2009). Infectious disease strategy for women inmate 2008-2013. Ottawa, ON

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Endnote ccxl

Correctional Service Canada. (2009). Infectious disease strategy for women inmate 2008-2013. Ottawa, ON.

Return to endnote ccxl

Endnote ccxli

Correctional Service Canada. (2013). Health services sector 2012-2013 performance measurement report. Ottawa, ON.

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Endnote ccxlii

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Endnote ccxliii

Correctional Service Canada. (2012). Inmate suicide awareness and prevention workshop: Facilitator's manual. Ottawa, ON.

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Endnote ccxliv

Correctional Service Canada. (2012). Inmate suicide awareness and prevention workshop: Facilitator's manual. Ottawa, ON.

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Endnote ccxlv

Correctional Service Canada. (2013). Commissioner's directive 843: Management of inmate self-injurious and suicidal behaviour. Ottawa, ON.

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Endnote ccxlvi

Correctional Service Canada. (2012). Inmate suicide awareness and prevention workshop: Facilitator's manual. Ottawa, ON.

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Endnote ccxlvii

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.; Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p.5,7, 9 & 10.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON:p.3 & 41.

Return to endnote ccxlvii

Endnote ccxlviii

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON:p.37.

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Endnote ccxlix

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON:p.41.

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Endnote ccl

Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p.5.

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Endnote ccli

Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p.7.

Return to endnote ccli

Endnote cclii

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.

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Endnote ccliii

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.

Return to endnote ccliii

Endnote ccliv

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.

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Endnote cclv

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.

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Endnote cclvi

Correctional Service Canada. (2014). Discharge planning matrix tool. Ottawa, ON:p.2.

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Endnote cclvii

Correctional Service of Canada. (2014). Discharge Planning and Transfer Guidelines. Ottawa, ON: p.9.

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Endnote cclviii

Extracted from the data warehouse in October 2016 for all women offenders, data current up to 2016-04-10.

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Endnote cclix

Derkzen, et al. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service Canada.; Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.

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Endnote cclx

Correctional Service of Canada. (2013). Commissioner's directive 800: Health services. Ottawa, ON: p. 4.

Return to endnote cclx

Endnote cclxi

Correctional Service of Canada. (2013). Commissioner's directive 578: Intensive intervention strategy in women's institutions. Ottawa, ON: p. 5.

Return to endnote cclxi

Endnote cclxii

Correctional Service of Canada. (2002). The 2002 mental health strategy for women offenders. Ottawa, ON.; Correctional Service Canada. (2009). Infectious disease strategy for women offenders 2008-2013. Ottawa, ON. Infonet. (2016). Health promotion. Retrieved from http://infonet/eng/Sectors/HealthServices/PublicHealth/Pages/HealthPromotion.aspx.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON.

Return to endnote cclxii

Endnote cclxiii

Correctional Service Canada. (2009). Infectious disease strategy for women offenders 2008-2013. Ottawa, ON.

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Endnote cclxiv

Correctional Service Canada. (2009). Infectious disease strategy for women offenders 2008-2013. Ottawa, ON: p. 8.

Return to endnote cclxiv

Endnote cclxv

Correctional Service of Canada. (2002). The 2002 mental health strategy for women offenders. Ottawa, ON: p.5.

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Endnote cclxvi

Correctional Service of Canada. (2002). The 2002 mental health strategy for women offenders. Ottawa, ON: p.24.

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Endnote cclxvii

Hartle, Kelly. (May 16, 2016). Implementation of New Peer Mentorship at Women Offender Institutions. Ottawa, ON: Correctional Service Canada.

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Endnote cclxviii

Extracted from the data warehouse, October 2016 for all Indigenous offenders, data current up to 2016-04-10.

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Endnote cclxix

Correctional Service Canada. (2016). Report on plans and priorities 2016-17. Ottawa, ON..; Public Safety Canada. (2015). Corrections and conditional release statistical overview. Ottawa, ON: p. 64.

Return to endnote cclxix

Endnote cclxx

Beaudette et al. (2015). National prevalence of mental disorders among incoming federally-sentenced men offenders (R-357). Ottawa, ON: Correctional Service Canada..; Derkzen et al. (2012). Mental health needs of federal women offenders (R-267). Ottawa, ON: Correctional Service Canada.; Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote cclxx

Endnote cclxxi

Correctional Service of Canada. (2013). Commissioner's directive 702: Aboriginal offenders. Ottawa, ON: p. 3.

Return to endnote cclxxi

Endnote cclxxii

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p.5.

Return to endnote cclxxii

Endnote cclxxiii

Correctional Service Canada. (2010). A wellness path to healthy and safe reintegration: Aboriginal health strategy 2009-2012. Ottawa, ON.; Correctional Service Canada. (2015). Guidelines for sharing personal health information. Ottawa, ON.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON.; Data extracted from Human Resources Management System (HRMS) in September 2016.

Return to endnote cclxxiii

Endnote cclxxiv

Correctional Service Canada. (2010). A wellness path to healthy and safe reintegration: Aboriginal health strategy 2009-2012. Ottawa, ON: p. 6.

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Endnote cclxxv

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p.11.

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Endnote cclxxvi

Extracted from the data warehouse, October 2016 for all ethnic groupings, data current up to 2016-04-10.

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Endnote cclxxvii

Extracted from the data warehouse October 2016 for all older offenders (i.e., offenders over the age of 50), data current up to 2016-04-10.

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Endnote cclxxviii

Canadian Medical Association. (2013). Health and health care for an aging population. Ottawa, ON: p. 2.

Return to endnote cclxxviii

Endnote cclxxix

Public Health Agency of Canada. (2014). Report on the state of public health in Canada. Ottawa, ON: p. 3.

Return to endnote cclxxix

Endnote cclxxx

Nolan, A., & Stewart, L. (2014). Self-reported physical health status of incoming federally-sentenced women offenders (R-332). Ottawa, ON: Correctional Service Canada.; Stewart et al. (2014). Self-reported physical health status of newly admitted federally-sentenced men offenders (R-314). Ottawa, ON: Correctional Service Canada.

Return to endnote cclxxx

Endnote cclxxxi

Correctional Service Canada. (2014). Federal correctional facilities accommodation guidelines. Ottawa, ON.; Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON.; Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON.

Return to endnote cclxxxi

Endnote cclxxxii

Correctional Service Canada. (2015). National essential health services framework. Ottawa, ON: Appendix A.

Return to endnote cclxxxii

Endnote cclxxxiii

Correctional Service of Canada. (2016). Integrated mental health guidelines. Ottawa, ON: p. 28.

Return to endnote cclxxxiii

Endnote cclxxxiv

Correctional Service Canada. (2014). Federal correctional facilities accommodation guidelines. Ottawa, ON.

Return to endnote cclxxxiv

Endnote cclxxxv

Correctional Service Canada. (2011). Falls prevention strategy. Ottawa, ON.; Correctional Service Canada. (2013). Adverse events guidelines. Ottawa, ON.; Infonet. (2015). Aging offenders resource kit. Retrieved from http://infonet/eng/SoloSites/ResponsivityPortal/SpecialNeedsResource/Pages/Aging_Offenders.aspx.; Infonet. (2016). Peer Assisted Living Program (PAL). Retrieved from http://infonet/eng/Regions/Pacific/832rhc/service_delivery/Pages/mental_health_services.aspx.

Return to endnote cclxxxv

Endnote cclxxxvi

Correctional Service Canada. (2011). Falls prevention strategy. Ottawa, ON: p. 9.

Return to endnote cclxxxvi

Endnote cclxxxvii

Correctional Service Canada. (2013). Adverse events guidelines. Ottawa, ON.

Return to endnote cclxxxvii

Endnote cclxxxviii

Infonet. (2016). Peer Assisted Living Program (PAL). Retrieved from http://infonet/eng/Regions/Pacific/832rhc/service_delivery/Pages/mental_health_services.aspx

Return to endnote cclxxxviii

Footnotes

Footnote 1

A comprehensive list of CDs that involve a health related component can be found in Appendix A

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Footnote 2

Transitions in care also include transfers between CSC institutions.

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Footnote 3

The federal government has transitioned from using the term Aboriginal to describe First Nations, Inuit and Métis peoples to the term Indigenous. The transition took place during the evaluation. The data collection instruments used the term Aboriginal; however, the evaluation report has replaced this with Indigenous where applicable.

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Footnote 4

An iterative and inductive qualitative analysis process identifies emerging themes and meaning from data through a repetitive reflexive process (see Srivastava & Hopwood, 2009 and Patton, 1980).

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Footnote 5

The majority of respondents were from the nursing (53.9%, n = 62) and psychology (18.3%, n = 21) groups. The remaining respondents included: social work (7.8%, n =9), clerical (6.1%, n = 7), administrative services (4.3%, n = 5), pharmacy (2.6%, n = 3), welfare programs (2.6%; n = 3), and others.

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Footnote 6

The largest percentage of respondents were from the nursing (46.4%, n = 89) and psychology (24.0%, n = 46) classifications. In addition, questionnaires were completed by respondents in the administrative services (8.9%, n =17), clerical (7.3%, n = 14), pharmacy (3.6%, n = 7), social work (3.1%, n =6), engineering and scientific support (2.6%, n = 5), executive and welfare programs (1.6%, n = 3) classifications.

Return to footnote 6

Footnote 7

The majority of respondents worked in the institutions (94.5%, n = 156) while a small proportion were from Regional Headquarters (RHQ; 5.5%, n = 9). The majority of respondents worked in men's institutions (80.1%; n = 125) while a few (19.8%, n = 31) indicated working in women's institutions. The highest proportion of respondents (38.9%, n = 63) were educators followed by correctional officers (21.6%, n = 35) and employees who work in welfare Programs (19.1%, n = 31). A few respondents worked in administrative services (12.3%, n = 20), the executive group (3.7%; n = 6) and other groups (4.3%, n = 7).

Return to footnote 7

Footnote 8

There were mainly two distinct categories of respondents. The largest percentage of respondents was from case management team (57%, n = 165). About half were community parole officers (53%, n = 87), and a small number institutional parole officers (22%, n = 36), parole office supervisors (13%, n = 21). The other category was health services staff (39%, n = 112). Some of the health services staff were institutional nurses (34%, n = 38), community mental health nurses (26%, n = 29), and a small number of clinical social workers (14%; n = 16). There was a remaining small number of uncategorized respondents (5%, n = 14).

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Footnote 9

This scale has been adapted from Employment and Social Development Canada.

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Footnote 10

Some of the chronic physical health needs can also result in acute episodes (e.g., heart attack).

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Footnote 11

These rates were based on self-report of current or past head injury and may therefore include a broad range of injuries. A review of health files found that 2% of offenders had evidence of current or recent brain injury. See Correctional Service Canada. (2015). Estimates of chronic disease prevalence among CSC inmates. Ottawa, ON: Health Services.

Return to footnote 11

Footnote 12

Mental health need is determined by having at least one mental health treatment-oriented service or stay in a treatment centre in the previous six-months.

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Footnote 13

This refers to a one-month prevalence rate [the prevalence rate for current disorders (i.e. disorders that were present in the month prior to the study)].

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Footnote 14

This refers to a one-year prevalence rate [the sample's continued experiences with an active disorder (i.e. in the year prior to the study)].

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Footnote 15

A lifetime prevalence rate refers to the proportion of a population that has experienced a condition at some point in their life. Such rates are used for personality disorders because they involve enduring patterns of behaviour.

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Footnote 16

CSC is part of the Federal, Provincial, Territorial Heads of Corrections Working Group on Health and Mental Health.

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Footnote 17

CSC partners with governmental and non-organizations across the country that provide supports to offenders with mental health needs, at both the national and provincial levels (e.g., Mental Health Commission of Canada, Canadian Mental Health Association, National Aboriginal Health Organization, etc.).

Return to footnote 17

Footnote 18

This involves collaboration with case management staff members (e.g., institutional/community POs) to assess the psychosocial needs of offenders with mental disorders, identify and develop linkage to community resources, and formulate comprehensive discharge plans to facilitate continuity of mental health services into the community.

Return to footnote 18

Footnote 19

Services include comprehensive assessment & intervention planning, direct service provision such as individual counselling, consulting with case management staff to assist in managing offenders in the community, and advocacy for offenders with mental health needs.

Return to footnote 19

Footnote 20

Conduct disorders in children and youth have been identified as a precursor of antisocial personality disorder in adults, which is a particularly prevalent disorder in the offender population. (Fazel, S., & Danesh, J. (2002). Serious mental disorder in 23000 prisoners: A systematic review of 62 surveys. The Lancet, 359(9306), 545-550).

Return to footnote 20

Footnote 21

MST is a program model that targets youth with serious behavioural issues by addressing the systems or settings related to the problematic behaviour. (MST Services, Inc. (2015). Multisystemic therapy. Retrieved from http://mstservices.com/what-is-mst/what-is-mst.).

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Footnote 22

For instance, among participants in Streets to Homes (a program in Toronto that offers help in finding long-term housing for homeless people), just under one half of sampled participants had mental disorders. Furthermore, the number of arrests and jail admittances were reduced by 56% and 68%, respectively (City of Toronto, 2009), as cited in Centre for Addiction and Mental Health, & Canadian Council on Social Development. (2011). Turning the key: Assessing housing and related supports for persons living with mental health problems and illness. Calgary, AB: Mental Health Commission of Canada.

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Footnote 23

Although this document refers to "assessments," note that assessment processes and tools also comprise a screening component.

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Footnote 24

Falls risk screening is also completed as part of the 24-hour intake assessment. If the screening criteria are met, offenders are referred for the Morse Falls Scale to determine whether fall prevention interventions should be implemented.

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Footnote 25

The Health Status Admission Assessment is also completed as part of the 14-day intake assessment for those who are 50 or older or those with self care needs, to identify any special health care needs for these populations. Note, as of August, 2015, the Health Status at Admission Assessment is completed for those who are 65 years or older or anyone with self-care needs.

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Footnote 26

The types of offender admission pertaining to each assessment are described on p.31 of this report.

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Footnote 27

Percentage of offenders interviewed during intake period who reported that they had completed each of the following intake health assessment tools: 24 hour and 14 day 95% (n=95), infectious disease screening 95% (n=93), and CoMHISS 89% (n=57).

Return to footnote 27

Footnote 28

CSC conducts Boards of Investigations (BOIs) when significant incidents occur as well as Mortality Reviews in the cases on deaths by natural causes. Only health-related BOIs were reviewed for this investigation including: assault of a staff member, assault of an inmate, suicide of an inmate, attempted suicide of an inmate, attempted suicide and subsequent death, self -inflicted injury of an inmate, overdoes interrupted, hostage-taking on an inmate, injury of inmate, death by unknown cause of an inmate.

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Footnote 29

The evaluation examined reports available at the time the evaluation commenced, which included reports that were convened and completed in fiscal year 2012-2013.

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Footnote 30

In most cases where a health intake assessment was completed late, it was the 14-day assessment, all of which were ultimately completed, and there was no evidence within the reports to suggest that the timing of the assessments had an impact on the incident. In one investigation, the Health Status Admission Assessment for offenders who are 50 or older was not completed; however, there was no evidence to suggest that its non-completion had an impact on the incident.

Return to footnote 30

Footnote 31

Less than one-quarter of health services respondents familiar with the tools identified any challenges to accuracy of the 24-hour (23%, n=13), 14-day (22%, n=11), or infectious disease assessment (14%, n=6). Few health services staff reported experiencing challenges referring offenders to health services based on the results of the 24-hour (24%, n=13), the 14-day (20%, n=10), or the infectious disease screening (10%, n=4). Note that number of respondents for each assessment tool varied, due to the fact that only staff members familiar with each of the assessment tools were asked to respond to these questions.

Return to footnote 31

Footnote 32

Based on interviews with a sample of offenders recently admitted to CSC (within 3 to 7 months of admission).

Return to footnote 32

Footnote 33

The following percentages of offenders interviewed at intake disagreed with the timing of intake assessments (14%, n=15). For staff questionnaire respondents, percentage disagreement was: 24-hour (13%, n=8), 14-day (20%, n=11), Infectious Disease Screening (20%, n=9), CoMHISS (32%, n= 7).

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Footnote 34

Note that the effectiveness and over-identification of needs could not be examined for all intake mental health assessment tools since information on referral from other intake tools is not tracked electronically.

Return to footnote 34

Footnote 35

CoMHISS identifies three groups of offenders: (1) Flagged: offenders require mental health follow-up; (2) Unclassified: offenders have a moderate need for mental health services and mental health staff are required to conduct at least a file review to determine whether or not an offender required follow-up mental health assessment or services; and, (3) Screened out: offenders do not require follow-up mental health services.

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Footnote 36

Among offenders who were unclassified, 39.5% (n=602, including 44 offenders admitted to a regional treatment centre) received mental health treatment and 60.5% (n=922) did not receive mental health treatment.

Return to footnote 36

Footnote 37

These percentages are comparable to those reported by Martin et al (2013) who examined the scoring model utilized in the current version of CoMHISS for all offenders admitted to the Pacific Region over a 15-month period from October 2006 to December 2007. See Martin, S., Wamboldt, A., O'Connor, S., Fortier, J., & Simpson, A. (2013). A comparison of scoring models for computerised mental health screening for federal prison inmates. Criminal Behaviour and Mental Health, 23(1), 6-17.

Return to footnote 37

Footnote 38

In order to examine the intake period, treatment-oriented services were only included if they were linked to a referral that was made within 4-months of the offender's admission. Treatment-oriented services included: group or individual counselling; group or individual mental health counselling; psychiatric clinic; skills training, self-care or activities of daily living; suicide or self-injury intervention; and, treatment planning.

Return to footnote 38

Footnote 39

Date of admission to a regional treatment centre was between the offender admission date in fiscal year 2013-14 or 2014-15 to the data extraction date in September, 2015.

Return to footnote 39

Footnote 40

This information was not available, since the sources of other referrals for mental health treatment (other than CoMHISS) are not tracked electronically.

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Footnote 41

1 offender refused the referral and 49 offenders refused at least one mental health service. The service may have been a treatment-oriented service or another service (such as an assessment that may have led to a future treatment-oriented service). Therefore all were included as refusals in this analysis.

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Footnote 42

Other issues may have impacted on these results, including the possibility that CoMHISS referrals or treatment were delayed beyond the initial intake period, or that data entry errors occurred in MHTS.

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Footnote 43

Communication and cultural challenges include language barriers and barriers with the assessment not identifying offenders' mental health issues due to cultural differences surrounding beliefs about mental health.

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Footnote 44

Percentages for staff ranged from 61% for 14-day intake assessment to 73% for COMHISS or infectious disease screening (see Appendix D for more information).

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Footnote 45

This represented the percentage of Indigenous offenders interested in following a traditional healing path who reported that they did not have an Elder present during health intake assessments.

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Footnote 46

The presence of Elders during health intake assessments is not specified in health services guidelines with the exception of CoMHISS where, according to the National Guidelines: Version 2.2 (June 2014), offenders may request the presence of an Indigenous advisor during the CoMHISS assessment.

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Footnote 47

These assessment tools are administered through different sources, formats and timeframes. For example the 24-hour assessment is administered early, it assesses offenders' immediate needs, and it is administered by a nurse. CoMHISS is administered after the 24-hour assessment, collects a broader scope of mental health information (including ADHD and cognitive deficiencies), and it is self-administered by the offender on a computer.

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Footnote 48

Note that many non-health services staff members reported that they did not know whether there was duplication or not. Percentages here are reported out of those staff members who were knowledgeable about the issue.

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Footnote 49

Few staff members (9%, n=4) identified challenges in the efficient administration of the infectious disease screening.

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Footnote 50

Referrals may also be submitted as a result of offender self-referral or staff observation.

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Footnote 51

For duplication of mental health care referrals: occasionally (21%), frequently (60%), always (4%).

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Footnote 52

Health services staff also reported that duplicate referrals came from health services intake assessment tools and staff referrals or offender self-referrals. Health services staff also noted that duplicate referrals are sometimes received from multiple different staff members (e.g., nurses, correctional officers).

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Footnote 53

Once an offender has completed an intake assessment and is determined to require a mental health referral, forms are completed and subsequently reviewed by the Chief Psychologist (or delegate) to determine the appropriate follow-up action. The evaluation team examined mental health services data for a two-year admission cohort (FY 2013-2014 and FY 2014-2015) of all federal offenders admitted with a warrant of committal to a federal institution. It is important to note that offenders admitted to a regional treatment centre are considered to have the highest level of mental health need and their mental health service information are not consistently entered into MHTS. Therefore, referrals within MHTS pertaining to offenders who were admitted to a regional treatment centre were excluded from analysis because the data would not be comprehensive for these offenders.

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Footnote 54

Of all offenders who had at least one referral (n=5643), 42% (n=2368) had only one referral and 58% (n=3275) had multiple referrals (32% received two referrals and 26% received three or more referrals).

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Footnote 55

These 68 offenders accounted for 75 of the referrals cancelled as duplicate referrals. Those referrals that are assigned to a mental health professional may subsequently result in further treatment, or the referrals could be cancelled by the mental health professional for reasons that could include cancellations due to duplicate referrals.

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Footnote 56

MHTS tracks by whom the referrals were made (e.g., mental health staff, health staff, parole officer, offender), but it does not identify the assessment tool from which the referral was made.

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Footnote 57

5% were referred based on all 3 tools; an additional 8% had referrals from both CoMHISS and the 24-hour assessment; 5% had referrals from both CoMHISS and the 14-day assessment; and, 3% had referrals from both the 24-hour and the 14-day assessments.

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Footnote 58

For duplication of physical health care referrals: occasionally (26%), frequently (46%), always (8%).

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Footnote 59

Information on physical health referrals is not currently tracked electronically. Therefore, it was not possible to assess the degree to which multiple referrals for physical health care may be made for offenders through any source of physical health data.

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Footnote 60

Note that a small percentage of staff also reported duplication between each of the four main health services assessment tools and other health related tools conducted at intake. However, respondents did not specifically identify which of the other health related tools included duplicate physical health information.

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Footnote 61

Non-essential clinical health services may consist of orthotics, respiratory devices, chiropractic services, and fluoride treatments. Such services are at the offender's expense; Health Services may assist in coordinating the offender's access to these services.

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Footnote 62

Clinical health related appointments within the last year: 90% (n=122) of offenders reported having had an appointment with a doctor, 61% (n=83) with a nurse and 32% (n=44) with a dentist.

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Footnote 63

"Offenders in CSC who are known to be infected with HIV are offered treatment for infection. Decisions on starting the treatment and remaining on treatment due to side effects, resistance or response are clinical decisions made by the treating infectious disease expert and the patient." (p.14)

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Footnote 64

Intermediate mental health services were not included in the scope of this evaluation due to the fact that intermediate mental health care was not fully implemented in CSC institutions at the commencement of the evaluation.

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Footnote 65

Flow-through population refers to the number of offenders that have been in an institution over a given time period.

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Footnote 66

Mental health services may include counselling, crisis intervention, and skills training.

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Footnote 67

Mental health related appointments within the last year: a few offenders reported having had an appointment with a psychiatrist (24%, n=33), psychologist (21%, n=29), or social worker (3%, n=4).

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Footnote 68

Percentage of flagged offenders who received a follow-up service by region in 2014: Atlantic 99% (n=207); Quebec 98% (n=212); Ontario 99% (n=270); Prairies 93% (n=286); and, Pacific 73% (n=53). Offenders are to receive a follow-up service within 50 days of admission or 40 days from referral.

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Footnote 69

Note that there may be some differences in reporting practices across provinces.

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Footnote 70

The statuses of the other 6 calls were: 1 individual was admitted to the Regional Hospital, 2 individuals refused care and 3 were disposition unknown.

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Footnote 71

Under the U.S. Department of Justice, the U.S. correctional systems included in the review were federal prisons in: Colorado, Pennsylvania, Louisiana, Wyoming, and Texas.

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Footnote 72

Of those, n=19 reported receiving ongoing health care for clinical heath, n=10 for mental health, and n=4 for infectious disease at the time of their transfer.

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Footnote 73

For all five CSC regions included in the CORR monitoring, non-compliance was found in the Atlantic, Quebec, Prairie and Pacific regions.

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Footnote 74

Two groups of health services staff were surveyed for the evaluation: those working with offenders at intake and those working with offenders during incarceration (after penitentiary placement). The information reported in this section was collected from health services staff working with offenders during the incarceration period. However, some general questions related to access to care and information sharing were also asked of health services staff working at intake. Responses of intake staff were scanned for commonality or differences of themes and issues. Overall, the pattern of responses for staff working with offenders at intake was similar to those working with offenders during the incarceration period.

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Footnote 75

For example, a correctional officer may not "need-to-know" the specific medications an offender is taking; however, they may need to know symptoms related to the medication relating to mobility or behaviours that could affect security or case management.

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Footnote 76

Note that these included all BOIs for investigated incidents at the Tier I and II levels in 2013-14 and 2014-15 that had been investigated and completed. Not all 2013-14 and 2014-15 BOI cases had been completed at the time the data was obtained.

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Footnote 77

Implementation in all institutions in Ontario and Pacific, and one institution in remaining regions, is scheduled to begin in September 2016, with full implementation to all institutions scheduled for March 2017.

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Footnote 78

For women, PEC and the Peer Support Program for Women have recently been integrated into a new program called the Peer Mentorship program which is anticipated to be implemented in 2016-2017.

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Footnote 79

Health information and materials are presented both during the intake period (most commonly RAP, ISAPW) and throughout incarceration after penitentiary placement (most commonly PEC/APEC, fact sheets). Two sets of interviews were conducted with two different groups of offenders: at intake and during incarceration (after pen placement). Results in these sections are presented from either of these samples when and where applicable.

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Footnote 80

The expected locations of PEC did not include maximum security, RTC/RPCs, receptions centres and the healing lodge.

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Footnote 81

Not all expected institutions had an active PEC program across the regions, with 4/5 in Atlantic, 7/9 in Quebec, 10/11 in Ontario, 7/9 in Prairie and 7/7 in Pacific.

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Footnote 82

The expected locations of APEC were more in areas with a high population of Indigenous offenders such as Prairie region and in healing lodges.

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Footnote 83

Not all expected institutions had an active APEC program across the regions, with 2/2 in Atlantic, 2/4 in Quebec, 4/4 in Ontario, 10/11 in Prairie and 5/5 in Pacific.

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Footnote 84

Of the offenders who were interviewed, 14% (n=21) participated in PEC and 7% (n=11) participated in APEC to become PEC or APEC support workers, respectively. A few (n=8) offenders reported that they were currently a PEC/APEC support worker/volunteer.

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Footnote 85

Additionally, the narrated version of RAP can be run via monitors in the Health Services waiting room.

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Footnote 86

Most offenders also reported that materials delivered through RAP (97%, n=37), PEC/APEC (95%, n=18), and ISAPW (92%, n=35) were easy to understand.

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Footnote 87

HIV: Men and women offenders who attended health education programs were more knowledgeable about HIV (83%; 86%) than men and women offenders who did not attend education programs (78%; 80%).

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Footnote 88

HCV: Similarly, men and women offenders who attended health education programs were also more knowledgeable about HCV (73%; 78%) compared to men and women offenders who did not attend education programs (68%; 68%).

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Footnote 89

Many general staff also agreed that education programs/materials in general had a positive impact on offenders' awareness of health services and programs in CSC and how to access them (67%, n=30).

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Footnote 90

Direct and indirect costs represent medical costs, labor productivity costs, and loss of quality of life.

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Footnote 91

Other federal government organizations include; the Public Health Agency of Canada, the Canadian Institute of Health Research, and Health Canada.

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Footnote 92

CSC surveillance data indicate the majority of offenders with HIV/HCV infection acquired infection prior to federal incarceration.

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Footnote 93

A more detailed list of these programs and services includes: staff education and training, screening and testing, HIV testing normalization, addictions screening, health education and awareness, anti HIV-stigma campaigns, peer support programs, risk assessment and counselling, vaccination, diagnosis and treatment of viral hepatitis (A&B), substance abuse counselling, opiate substitution therapy, overdose emergency response and counselling, bleach distribution, mental health referral/counselling, condom/dental dam distribution, post-exposure prophylaxis, HIV and HCV treatment, discharge planning, prevention, diagnosis and treatment of TB.

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Footnote 94

These results are from a pre two year and post two years time period.

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Footnote 95

In the two years following MMTP initiation, the proportion of successful program completions or attendance more than doubled for substance abuse programs, increasing from approximately 29% in the pre period to 63% in the post period.

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Footnote 96

The risk of re-incarceration was 36% higher for male non-MMPT offenders compared to MMPT offenders who continued methadone treatments.

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Footnote 97

Health services staff and general staff reported that condoms (99%, n=99; 91%, n=73), bleach kits (83%, n=83; 86%, n=69), dental dams (70%, n=70; 56%, n=45), and lubricants (74%, n=74; 63%, n=50) are available in their institutions, respectively.

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Footnote 98

Intermediate mental health services were not included in the scope of this evaluation because these services were not fully implemented in CSC institutions at the start of the evaluation.

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Footnote 99

Some offenders received treatment at both mainstream institutions and RTCs. These offenders were included in the "RTC group" for analysis. The focus was on the impacts of care received while at a RTC (i.e., "after treatment" outcomes were assessed following RTC treatment, whether or not other treatment may have continued following return to the institution).

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Footnote 100

Institutional charges may differ from institutional incidents, as correctional staff members may resolve an institutional incident informally (CD 580; CCRA section 41 (1) & (2)). Institutional incidents were included for analysis if the offender was identified as an instigator or an associate in the incident.

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Footnote 101

Statistical analysis of voluntary segregation could not be conducted due to low rates of the indicator.

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Footnote 102

In addition to assault, behaviour, and self-harm, other incident sub-categories are recorded in OMS (i.e., possession of contraband, property offences, escapes, and deaths). Although all sub-categories were included in the analysis for "overall incidents," only the three categories with theoretical links to mental health needs were included for sub-incident analysis (i.e., assault, behavior, self-harm).

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Footnote 103

Treatment-oriented services included: mental health counselling: group/individual; psychiatric clinic; skills training/self-care/activities of daily living (ADL); suicide or self-injury intervention; treatment planning; counselling: group/individual. Many offenders had more than one "treatment period," but the treatment period with the most treatment services was selected to be included in the analysis.

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Footnote 104

Separate statistical analyses were not conducted for women offenders due to the smaller number of women offenders receiving mainstream institutional mental health treatment. However, they are included in the overall sample of "all offenders".

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Footnote 105

Separate statistical analyses were not conducted for Indigenous and women offenders due to the smaller number of Indigenous and women offenders receiving treatment at a RTC. However, they are included in the overall sample of "all offenders".

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Footnote 106

Behaviour related incidents include: minor/major disturbances, disruptive behaviour, substance use, disciplinary problems, threats towards staff/others and cell extraction.

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Footnote 107

Offenders in the comparison group were 16.6% (HR = 0.834; 95% CI = 0.770-0.903) less likely to be involuntarily segregated closer to the end of their sentence, compared to the beginning of their sentence.

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Footnote 108

Offenders in the comparison group were 15% (HR = 1.150; 95% CI = 1.028-1.288) more likely to complete an education course or credit closer to the end of their sentence, compared to the beginning of their sentence.

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Footnote 109

Offenders in the comparison group were 21.8% (HR = 1.218; 95% CI = 1.148 – 1.293) more likely to complete a national correctional program in the middle of their sentence compared to the beginning of their sentence.

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Footnote 110

Referrals are reviewed and offenders may not be admitted to a RTC due to their eligibility or lack of consent.

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Footnote 111

This information was extracted from MHTS for this evaluation.

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Footnote 112

Offenders receiving treatment in RTCs in two regions were interviewed (N=32) about their experiences with receiving care. Due to the varied health conditions of this population and the small number of offenders interviewed, the questions were asked in a more open-ended fashion designed to elicit discussion around specific themes related to admission, treatment and services received.

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Footnote 113

Some of the remaining RTC offenders did not report awareness or involvement in treatment planning (21%, n=6). Others reported awareness of the planning process (e.g., having meetings), but did not recall being involved in developing their treatment plan and objectives (32%, n=9).

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Footnote 114

Implementation of intermediate mental health care was completed in April 2016.

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Footnote 115

If offenders are assessed as no need or low need on the MHNS, self-care may also be an option if necessary, for example psycho-educational sessions on a particular mental health topic or skill development.

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Footnote 116

Health Services Sector reported that electronic data on MHNS was not always being entered as required.

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Footnote 117

Use caution when interpreting the results from general staff members due to the small number of respondents.

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Footnote 118

The Audit of Release Process (2012) also found offenders were not always released with their medications.

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Footnote 119

Extracted from the data warehouse on 2016-02-28 for all offenders active on that date. Offenders were coded as having a health card if their most recent record from OMS indicated they had a health card in their possession, in their personal effects, of with a community support person.

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Footnote 120

The Audit sampled release files from the period of April 2010 through March 2011.

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Footnote 121

Based on consultation with Regional Directors of Health Services (RDHSs) in August, 2016.

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Footnote 122

Based on consultation with RDHSs in August, 2016.

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Footnote 123

The Health Status at Discharge: Gist Report includes other health related information related to release, such as any appointments required with community health care specialists and any accommodation needs related to functional and/or cognitive impairment, etc.

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Footnote 124

Included: Clinical Discharge Planners, Community Mental Health Nurses, Clinical Social Workers

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Footnote 125

Note that not all staff responded to this question. Percentages are reported out of the total number of staff responses to this question.

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Footnote 126

Included: Clinical Discharge Planners, Community Mental Health Nurses, Clinical Social Workers.

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Footnote 127

Community-based ID clinics are offered in multiple regions, for example, through community housing resource centres, community health centres, legal clinics, and other community service organisations.

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Footnote 128

This is in addition to community health expenditures in other areas such as mental health and other general administrative, nursing or methadone costs.

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Footnote 129

Source: Integrated Financial and Material Management System (IFMMS), extracted September, 2016.

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Footnote 130

The type of medication dictates the duration of the supply provided at discharge. According to the CSC National Formulary, non-narcotic and non-controlled mediations are generally provided for 14 days; whereas, narcotic and controlled medications (e.g., ADHD medications) are provided for 3-days and at the discretion of the physician. This distinction is not clarified in the Discharge Planning and Transfer Guidelines or CD 712-4 Release Process.

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Footnote 131

This should be interpreted with caution because the risk profiles were not equivalent between groups and the group size for women offenders was too small to allow for survival analysis and only a fixed follow-up analysis was undertaken.

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Footnote 132

Community mental health services provided to offenders may include mental health counselling (individual or group), accompaniment support, suicide or self-injury intervention, assessments, etc.

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Footnote 133

CDP Timeframe: "The timing of referrals for CDP is guided by the offender's anticipated release date, the case management process and the anticipated level of need."

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Footnote 134

Remaining staff members either reported "neither agree nor disagree" (21%, n=30) or "disagree/strongly disagree" (36%, n=52).

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Footnote 135

Our sample included offenders on their first conditional release of FY2014-15, but only if they remained in the community for 30 days or more (this was done to allow time to receive mental health services).

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Footnote 136

Mental health need is defined as any offender who received a treatment-oriented mental health service 6 months prior to their release. Note that this provides an approximation of need. Reliable information from other data (such as the Mental Health Need Scale) was not available. Therefore, the receipt of a treatment-oriented mental health service in the institution 6 months prior to release was used as a proxy indicator of offender mental health need.

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Footnote 137

Absence of mental health need was identified as offenders who did not receive a treatment oriented service 6 months prior to release.

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Footnote 138

The Discharge Planning Matrix Tool was developed in April 2013 as a reference accompanying the Discharge Planning and Transfer Guidelines.

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Footnote 139

Numbers/percentages reflect the number of staff who reported that each of the following categories of staff "frequently" or "always" followed-up on clinical discharge plans.

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Footnote 140

65% (n=50) of staff who responded to this question indicated that at least 20% of offenders were released to area with limited community mental health specialists.

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Footnote 141

Figure 2 shows percentage of staff who agreed that the governance structure impacted specific issues. Remaining staff either disagreed that there had been an impact of the governance structure, or provided a neutral response "neither agree nor disagree".

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Footnote 142

This included both health services and general staff in the institution and the community.

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Footnote 143

Some (31%, n=40) health services staff disagreed or strongly disagreed that the health services for offenders with multiple health care needs are delivered in an integrated manner to best address their needs. A few (16%, n=20) neither agreed nor disagreed that the health services for offenders with multiple health care needs are delivered in an integrated manner.

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Footnote 144

The Mental Health Branch also reports its information disaggregated by sex and Indigenous or non-Indigenous status.

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Footnote 145

Public health planning: 26% (n=23) agreed; 38% (n=33) neither agreed nor disagreed; and 36% (n=31) disagreed. Clinical health planning: 33% (n=32) agreed; 34% (n=33) neither agreed nor disagreed; and 32% (n=31) disagreed.

Mental health planning: 34% (n=37) agreed; 36% (n=39) neither agreed nor disagreed; and 31% (n=34) disagreed.

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Footnote 146

Direct program spending includes strategic outcome spending (custody, correctional interventions and community supervision), but excludes spending on internal services.

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Footnote 147

Research has shown the rate of late relapse occurs in less than 1% of patients.

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Footnote 148

The prevalence rates reported in this section were based on offender self-report upon admission and do not take into account test results completed as part of the intake period. Self-reported rates of infectious diseases may be lower than actual prevalence rates. Some information on prevalence rates for specific groups of offenders in CSC from 2000-2006 is available at http://www.csc-scc.gc.ca/publications/infdscfp-2005-06/tb-eng.shtml.

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Footnote 149

Due to self-reported frequencies of less than five, the prevalence rates for HCV and HIV were reported together in the source research report.

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Footnote 150

These figures are for one-month current prevalence rates.

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Footnote 151

Use caution when interpreting these results given the small number of offenders in the Indigenous group in some categories.

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Footnote 152

Where possible current rates are provided; however, in some cases, only lifetime rates were available.

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Footnote 153

Percentage of Health Services Staff Questionnaire participants reporting no barriers/challenges for Indigenous offenders: 24-hour (82%, n=44), 14-day (80%, n=41), infectious disease screening (86%, n=36) and CoMHISS (72%, n=13). No Indigenous offenders interviewed at intake reported any specific barriers to intake assessments (0%, n = 31).

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Footnote 154

Percentage of Health Services Staff Questionnaire participants reporting that Elders were never or rarely involved in completing intake assessment tools: 24-hour Assessment (64%, n=38), 14-day Health Intake Assessment (61%, n=34), Infectious Disease Screening (73%, n=33); or CoMHISS (73%, n=16).

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Footnote 155

Of those offenders who participated in the current evaluation, 33% (n=34) identified themselves as being Indigenous of First Nations (84%; n=27) or Métis (16%; n=5) descent, and of those 68% (n=23) expressed an interest in following a traditional healing path.

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Footnote 156

24-hour assessment - 97% (n=4192) of the whole offender population (Indigenous and non-Indigenous) were screened within the appropriate timeframe compared to 94% (904) of Indigenous offenders. 14-day assessment – 70% (n=3010) of the whole offender population (Indigenous and non-Indigenous) were screened within the appropriate timeframes compared to 70% (n=659) of Indigenous offenders.

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Footnote 157

Percentage of Health Services Staff Questionnaire participants reporting no barriers/challenges for visible minority offenders: 24-hour (83%, n=45), 14-day (77%, n=39), infectious disease screening (85%, n=34) and CoMHISS (67%, n=12).

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Footnote 158

Percentage of Health Services Staff Questionnaire participants reporting no barriers/challenges for older offenders: 24-hour (80%, n=44), 14-day (86%, n=44), infectious disease screening (88%, n=35) and CoMHISS (75%, n=12). Almost all older offenders who responded to this interview question reported that they did not experience any specific barriers in completing intake assessments (93%, n=13).

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Footnote 159

It is difficult to draw conclusions from this information, given the small number of offenders who identified as an older offender (i.e., over the age of fifty) who participated in the evaluation interviews during the intake assessment period (n=16). Older offender health requirements and services will be assessed in additional aspects of the evaluation where possible.

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Footnote 160

Percentage of Health Services Staff Questionnaire participants reporting no barriers/challenges for women offenders: 24-hour (88%, n=28), 14-day (88%, n=30), infectious disease screening (90%, n=26) and CoMHISS (100%, n=11). Almost all women offenders interviewed at intake reported that they did not experience any specific barriers in completing intake assessments (95%, n=19). Of those offenders who participated in the current evaluation, 20% (n=21) were women.

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Footnote 161

24-hour assessment - 97% (n=4192) of the whole offender population (women and men) were screened within the appropriate timeframe compared to 98% (232) of women offenders. 14-day assessment – 70% (n=3010) of the whole offender population (women and men) were screened within the appropriate timeframes compared to 87% (n=204) of women offenders. CoMHISS – 84% (n=3538) of whole offender population (women and men) were screened within the appropriate timeframes compared to 80% (n=189) of women offenders.

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Footnote 162

Health services staff members reported that RAP included information on the health services available at CSC (87%, n=33), how to access these services (92%, n=35), how to prevent infectious disease in prison (95%, n=36).

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Footnote 163

The Discharge Planning Matrix Tool was developed in April 2013 as a reference accompanying the Discharge Planning and Transfer Guidelines.

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Footnote 164

The total offender population includes all active offenders, who were incarcerated in a CSC facility, offenders who were on temporary absence from a CSC facility, offenders who were temporarily detained, offenders who were actively supervised, and offenders who were unlawfully at large for less than 90 days.

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Footnote 165

Results for physical health were based on a file review of offender self-reported health needs at intake, and results for mental health were obtained from clinical tools used with a sample of offenders.

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Footnote 166

Remaining staff either reported "neither agree nor disagree" or "disagree/strongly disagree".

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Footnote 167

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Footnote 168

Results for physical health were based on a file review of offender self-reported health needs at intake, and results for mental health were obtained from structured clinical interviews used with a sample of offenders.

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Footnote 169

Culturally-safe services are provided by professionals that are aware and understand Indigenous culture and are open and supportive an offender's choice regarding traditional Indigenous healing practices.

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Footnote 170

Collaboration within and outside of CSC refers internally to collaboration between CSC NHQ, RHQs and each institution; between the Health Services Sector and Aboriginal Initiatives Directorate. Externally, collaboration should occur between internal partners and with the Indigenous Community, and at the federal and provincial/territorial level.

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Footnote 171

Remaining staff either reported "neither agree nor disagree" or "disagree/strongly disagree".

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Footnote 172

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Footnote 173

Remaining staff either reported "neither agree nor disagree" or "disagree/strongly disagree".

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Footnote 174

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Footnote 175

Results for physical health were based on a file review of offender self-reported health needs at intake.

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Footnote 176

CSC operated healing lodges.

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Footnote 177

As of August 2015, the age requirement to conduct.

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Footnote 178

Screening for "falls risk" is a Required Organizational Practice under Accreditation Canada.

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Footnote 179

Remaining staff either reported "neither agree nor disagree" or "disagree/strongly disagree".

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Page details

Date modified:: 2017-07-26

Evaluation of CSC’s Health Services, 2017

Contributions

Acknowledgments

Executive Summary

Evaluation Results:

List of Findings

Finding 1: Need for Health Services

Finding 2: Alignment with Priorities and Federal Roles and Responsibilities

Finding 3: Effectiveness of Health Services Intake Assessment

Finding 4: Efficiency of Heath Services Intake Assessment Process

Finding 5: Access to Clinical, Public and Mental Health Care

Finding 6: Access to Community Health Care Specialists

Finding 7: Transfers

Finding 8: Information Sharing

Finding 9: Health Education Delivery

Finding 10: Impact of Health Education and Harm Reduction Initiatives

Finding 11: Institutional Mental Health Care Outcomes

Finding 12: Level of Care Based on Need

Finding 13: Regional Complex Mental Health Committees

Finding 14: Routine Discharge Planning and Offender Identification

Finding 15: Payment for Community Health Services

Finding 16: Community Mental Health Services and Clinical Discharge Planning

Finding 17: Coordination of CSC's Health Services

Finding 18: Infectious Disease Treatment: Hepatitis C Virus

Finding 19: Health Services for Specific Populations

List of Recommendations

Recommendation 1: Mental Health Diversion

Recommendation 2: Effeciency of Health Services Intake Assessment Tools and Processes

Recommendation 3: Access to Community Health Care Specialists

Recommendation 4: Information Sharing

Recommendation 5: Health Education and Harm Reduction

Recommendation 6: Level of Care Based on Need

Recommendation 7: Regional Complex Mental Health Committees

Recommendation 8: Release Planning and Offender Indentification

Recommendation 9: Access to and Payment for Community Health Services

Recommendation 10: Clinical Discharge Planning and Community Mental Health Services

Recommendation 11: Specific Populations of Offenders

Management Action Plan Overview

Management Action Plan for Recommendation 1:

Management Action Plan for Recommendation 2:

Management Action Plan for Recommendation 3:

Management Action Plan for Recommendation 4:

Management Action Plan for Recommendation 5:

Management Action Plan for Recommendation 6:

Management Action Plan for Recommendation 7:

Management Action Plan for Recommendation 8:

Management Action Plan for Recommendation 9:

Management Action Plan for Recommendation 10:

Management Action Plan for Recommendation 11:

Table of Contents

List of Tables

List of Figures

List of Acronyms

1.0 Introduction

1.1 Background

1.2 Policy and Legislation

1.3 Program Description

1.3.1 Intake Activities

1.3.2 Incarceration Activities

1.3.3 Pre-Release and Community Activites

2.0 Evaluation Method

2.1 Scope of the Evaluation

2.1.1 Intake

2.1.2 Incarceration

2.1.3 Pre-Release and Community Supervision

2.2 Approach

2.2.1 Literature and Document Review

2.2.2 Qualitative DataFootnote 3

Interviews with Offenders: Intake and Incarceration

Interviews with Offenders: Regional Treatment Centre

Electronic Questionnaires with Staff

Intake and Incarceration

Pre-Release and Community Supervision

2.2.3 Quantitative Data

Automated data

2.3 Measures

Analysis of Qualitative Data

2.4 Limitations and Mitigation Strategies

4.0 Conclusion

Appendix A: Policy and Legislation

2.2.2 Qualitative Data^{Footnote 3}

Men Offenders^{Endnote ccx}

Women Offenders^{Endnote ccxiii}

Public Health Needs^{Footnote 148}

Men Offenders^{Endnote ccxiv}

Women Offenders^{Endnote ccxv}

Post-contact with the criminal justice system – Sequential Intercept Model^{Endnote ccxxiii}

Profile^{Endnote cclviii}

Prevalent Health Needs^{Endnote cclix}

Health-Related Strategies and Initiatives^{Endnote cclxii}

Overall Perceptions of Health Services for Women Offenders^{Footnote 166}

Profile^{Endnote cclxviii}

Health-Related Strategies and Initiatives^{Endnote cclxxiii}

Overall Perceptions of Health Services for Indigenous Offenders^{Footnote 171}

Profile^{Endnote cclxxvi}

Overall Perceptions of Health Services for Other Visible Minority Offenders^{Footnote 173}

Profile^{Endnote cclxxvii}

Health-Related Policies and Guidelines^{Endnote cclxxxi}

Health-Related Strategies and Initiatives^{Endnote cclxxxv}

Overall Perceptions of Health Services for Older Offenders^{Footnote 179}