May 7, 2008

DRO: Detainee Health Care

Background

The US Immigration and Customs Enforcement (ICE), Office of Detention and Removal Operations (DRO) is responsible for ensuring safe and humane conditions of confinement for detained aliens in federal custody, including the provision of reliable, consistent, appropriate and cost-effective health services.  ICE takes great care to ensure the safety and well being of each of the hundreds of thousands of individuals who come through our detention facilities each year. ICE has put plans and processes in place with the Division of Immigration Health Services (DIHS) and medical professionals to provide care for all those detained, including those who may encounter a medical emergency while in custody. When an ICE detainee is hospitalized, the hospital assumes medical decision-making authority, including the patient’s drug regimen, lab tests, X-rays and treatments. 

DIHS is a stand alone medical unit consisting of U.S. Public Health Service Officers and contract medical professionals who work under their supervision.  It serves as the medical authority and provider of care for detainees housed in DIHS-staffed detention centers, and DIHS also oversees the financial authorization and payment for off-site specialty and emergency care for detainees in ICE Custody. Prior to October 1, 2007, ICE received the medical services of DIHS through the Health Resources and Services Administration which is part of HHS. ICE and HRSA ended that agreement for a variety of reasons including: HRSA's inability to fill DIHS vacancies in a timely manner and its unwillingness to provide PHS officers to support ICE law enforcement missions. The detail was accomplished via an MOA between DHS (signed by OHA)  and HHS.  The MOA also covers PHS resources elsewhere within DHS.  Since October 1, 2007, ICE provides administrative support and oversight to DIHS.   However, DIHS remains solely responsible for detainee health care and for serving as the Medical Authority for ICE.

Key Facts and Statistics

Nearly 1.5 million individuals have come through detention facilities since ICE was created in 2003.  Each of them received taxpayer-funded comprehensive medical screening and, for those remaining in ICE custody at least 14 days, a comprehensive physical examination.  Each received specific treatment, as medically necessary.  Care management was provided by the DIHS or local Intergovernmental Service Agreement (IGSA) contractor at a cost of more than $360 million. ICE spent more than $90 million in fiscal year FY 2007 alone.

On any given day, ICE houses up to 33,000 immigration detainees in more than 300 facilities nationwide. The average stay is 37.5 days. Each ICE detainee is medically screened after arriving in ICE custody.  In FY2007, of the 184,448 screenings, 34% (63,628 individuals) were identified as having chronic conditions, most had hypertension or diabetes.  Many of these detainees first learned of their medical ailment or received medical care and treatment for the first time due to this comprehensive screening. In FY 2007, DIHS performed twenty-four biopsies totaling $21,148.08.

In addition, in FY 2007 alone, ICE detainees received some significant non-routine treatments.  Coronary Bypass - $45,741.12*

• Cardiac Defibrillator Implant with Cardiac Catheter - $43, 339.64*
• Trauma to the skin, subcutaneous Tissue & Breast - $41,425.75*
• Coronary Bypass with Cardiac Catheter - $29,049.36*
• Respiratory System Diagnosis with Ventilator Support - $25,993.06*
• On May 4, 2008 a detainee in ICE custody received an emergency operation for acute appendicitis. ICE regularly provides treatment for potentially life threatening situations such as cardiac arrest, kidney disease; high risk pregnancy, hypertension, and diabetes.  The very low mortality rate among ICE detainees provides testimony to the effectiveness of this care.
  *Cost of each procedure

Also in FY 2007:
   DIHS facilities completed:

• 711,719 detainee visits
• 703,319 direct observed therapy medication administrations
• 210,182 prescriptions
• 190,883 general medical/chronic care clinic visits
• 184,448 intake screenings
• 135,658 X-rays via teleradiology
• 97,620 sick call visits
• 87,017 physical exams
• 23,224 mental health visits
• 16,885 dental visits
            
  Chronic disease visits by disease category:
• 6,264 hypertension
• 3.614 diabetes
• 1,521 TB/INH
• 1,302 asthma
• 565 HIV/AIDS
• 559 seizure
   
  DIHS staff also provided 711,719 detainee visits (a 45% increase over FY06).  \
• These visits included:
• 131,792 chest x-rays during intake screening
• 16,885 dental visits
• 23,224 mental health visits
• 56,828 short stay unit visits
• 190,883 chronic disease visits
• 87,017 physical exams’
• 97,620 sick call visits
• 703,319 pill line distributions
  
  DIHS filled 210,182 prescriptions and there were 967 hospital admissions.

Quality Assurance and Oversight

ICE strives to maintain safe, secure and humane detention conditions and quality healthcare.

We make every effort to enforce all existing standards and whenever possible, to improve upon them.  When we find that standards are not being met, we take immediate action to correct deficiencies and when we believe that the deficiencies cannot be corrected, we relocate our detainees to other facilities.

Steps we have taken during the past 12 months are indicative of our commitment to detainee care. Some key examples include:

• Involving the NGO Community, DHS Civil Rights and Civil Liberties Office, and detention experts from outside of ICE in rewriting our Detention Standards into a performance based format. Not only will these new standards, scheduled to be implemented later this year, provide an update to the existing standards that were written in 2000, but they will be more effective in evaluating and where necessary adjusting the quality of detention being provided to those in our custody.
• Awarding two contracts with companies recognized for their expertise in detention management. Detention professionals from Creative Corrections are now performing the annual detention facilities inspections formerly performed by ICE employees on a collateral duty basis. Detention experts from the Nakamoto Group are now serving as on-site, full time quality assurance inspectors at our 40 largest facilities and will be performing the same function on a regional basis for all our other facilities.
• Creating the Detention Facilities Inspection Group (DFIG) within the ICE Office of Professional Responsibility (OPR). The DFIG, implemented in February, 2007 provides objective oversight and independent validation of the detention facility inspection program. It also conducts immediate focused reviews of serious incidents involving detainees.

Since the beginning of calendar year 2004, to date, there have been 71 detainee deaths. While a single death of an ICE detainee is a serious matter, it is important to keep in mind the total number of individuals in ICE detention and consider especially that mortality rates at ICE facilities have significantly decreased over the past several years. In particular, ICE facilities showed estimated death rates per 100,000 detainees for FY04, FY05, FY06, and FY07 are 10.8, 6.8, 6.7, and 3.5, respectively.

To address the needs of the growing number of detainees, the psychologists and social workers of DIHS have provided 31,697 different types of psychological services and/or patient contacts that impact detainees in a positive manner.  

In the last 12 months, DIHS psychologists and social workers have been successful in managing a daily population of between 1,350 to 2,160 detainees with serious mental illnesses.  In that time frame, there have been no suicides.

Detainee Health Process

Each ICE detainee undergoes a health screening within the first 24 hours of admission to an ICE detention facility. This screening includes evaluation of the individual’s medical, dental and mental health status. A health history is taken (through an interpreter if needed).  ICE detainees also receive a more detailed physical examination within fourteen days of admission to an ICE detention facility.

Individuals who have acute or chronic healthcare needs are referred to a primary care provider for medical treatment. Those found to have infectious disease are placed in the appropriate healthcare setting and receive treatment for their condition.  Patients with diseases such as HIV/AIDS are treated in accordance with nationally recognized standards and guidelines.  This care may be given on-site or off-site, as appropriate for the individual patient’s clinical condition. Pregnant detainees are referred to community obstetrics specialists to assure that appropriate prenatal care is delivered.

The DIHS medical staff and the Epidemiology Branch monitor tuberculosis (TB) cases to ensure continuity of care, whether the detainee is to be released from custody into the United States or returned to his or her country of origin. ICE coordinates the repatriations to home countries of 205 individuals with active or suspected active tuberculosis.  Coordination includes making arrangements with foreign nations’ tuberculosis control programs for patients to be received at the port of entry on arrival and ensured completion of treatment without interruption. DIHS seeks to minimize threats to public health domestically and globally and prevent transmission of drug-resistant and multi-drug-resistant tuberculosis.

Quality of Care

Each facility housing ICE detainees has a written plan for delivery of 24-hour emergency health care or when immediate outside medical attention is required. All facilities have current arrangements with nearby medical facilities or health care providers for health care not provided within the facility. These arrangements require appropriate custodial officers to transport and remain with the detainee for the duration of any off-site treatment or hospital admission.

Each facility has a mechanism that allows detainees to request health care services provided by a physician or other qualified medical officer in a clinical setting. Detainees, especially those who are illiterate or do not speak English, can receive help in filling out the request slip for the so-called sick call process.

Each detainee who is identified with a chronic-care issue is treated and educated on self-care needs, and appropriate treatment and follow-up are coordinated.  DIHS includes more than 684 doctors, nurses, and other health care professionals.  Whoever the service provider, ICE detainees receive appropriate health services consistent with community standards and the ICE mission. 

DIHS utilizes applicable health care standards from the American Correctional Association (ACA), the National Commission on Correctional Health Care (NCCHC), the Joint Commission, and the ICE National Detention Standards to evaluate the care provided to detainees.  All DIHS healthcare providers who care for detainees are licensed and credentialed under the same guidelines as those serving the U.S. Bureau of Prisons and in other federal or community facilities. 

U.S. Immigration and Customs Enforcement (ICE) was established in March 2003 as the largest investigative arm of the Department of Homeland Security. ICE is comprised of five integrated divisions that form a 21st century law enforcement agency with broad responsibilities for a number of key homeland security priorities.