Just after we published our last blog post, the BOP released 23 revamped policies, dated June 22 – bringing the total of new or revised directives to nearly a hundred this year alone. In that post, we also mentioned the timing – coinciding with pending litigation by the union, which is attempting to overturn its dismissal. If the union is successful in its opposition, it will likely invoke its right to weigh in on policy changes before implementation. If so, even more chaos will ensue. (And this is at a time when the BOP also has announced plans to close 13 low- and medium-security prisons, affecting more than 500 employees!) Every action has a reaction.
Toothless policies
Before we dive into some of the details – many of which are positive – I want to state a caution: PERA’s organizational mantra has always been that the Bureau of Prisons has good policies that can be leveraged to accomplish meaningful correctional reform. The challenge has never been the absence of policy; rather it’s management’s willingness to enforce and be held accountable for it. For instance, the policy on unit management and inmate program review that was updated in February requires the unit manager to attend team meetings. Yet from what I have heard, there has been zero enforcement. That leaves case managers handling these assessments on their own in a sort of paper exercise, instead of what should be a meaningful classification and program review, focused on rehabilitation.
And there are many other examples. Unfortunately, I must conclude that at least some of these policy updates, press releases and facility closures are reactive management decisions aimed more at short-term public relations than improvement of long-term consequences.
The directives that were released in the most recent batch include Internal Audits, which discusses DOJ oversight; Multi-Media Communication, which replaced News Media Authorization; and the Release Preparation Program (RPP), which – a good thing – finally standardizes the curriculum (although I am not holding my breath for the promised quarterly “community resource days”).
The two most interesting of this batch, from a case management perspective, are the new Career and Technical Education Programs directive, which replaced the Occupational Education Programs policy, and the revised Patient Care policy. I consider Patient Care one of the bureau’s most important directives, and it deserves scrutiny.
Patient Care and Medical Services
Some time ago, I began hearing that the bureau was attempting to keep as much treatment local as possible to reduce transfers to federal medical centers. That objective is reflected in the revised Medical Designations and Referral Services for Inmates policy, which states:
“Acute care requiring hospitalization of the inmate will usually be provided in a community hospital near the institution. Most institutions will be able to locally manage hospitalizations between seven and 14 days for acute medical care or surgical procedures followed by one to three post-operative appointments.” Under the previous policy, the threshold was generally five to seven days.
Last October, the BOP updated the clinical treatment guide for care levels (although it left the 2019 guide on the public website until a few months ago). And late last year, we started to hear about inmates being medically reclassified in large numbers – reminiscent of 2018, when the BOP came under scrutiny for downgraded care levels. These two developments go together.
As for the Patient Care policy itself, the changes appear to be a mixed bag. On paper, the policy improves continuity of care, documentation requirements, chronic disease management, telehealth utilization, and reentry planning. The policy also formally incorporates telehealth as a standard health care delivery method and reminds institutions to expedite medically appropriate reduction in sentence (RIS) and compassionate release requests for seriously ill inmates.
At the same time, however, several changes appear designed to provide greater operational flexibility so the bureau can reduce physician involvement. That raises implementation concerns because many institutions remain severely understaffed and are already struggling to provide timely health care access. For example, clinical encounter notes must now be completed by the next business day. Will that still be possible?
Another notable and concerning change is the removal of the section on the Utilization Review Committee, which was a team assembled to approve procedures based on requests from sub-specialists after consultations. It will be interesting to see where this authority will now lie. That should be spelled out.
And then there is the removal of the requirement that a physician approve additions to chronic care clinics (a designation that requires regular, comprehensive medical evaluations). As a result, some inmates with complex cases could receive less direct physician involvement, and facilities may increasingly rely on other health care staff because of staffing shortages, rather than clinical necessity.
Historically, the bureau’s health care problems have not resulted from a lack of policy. Instead, they have stemmed from staffing shortages, transportation limitations, budget constraints and institutional backlogs – of which can cause delays in outside care.
The underlying challenge remains the same: Meaningful reform depends not merely on updating policies, but also on ensuring that institutions have the staffing, other resources, built-in accountability, and leadership necessary to implement them effectively.
