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FEATURE STORY 04/01/2007
Author: Daniel Sean Kaye  
Treating the Most Neglected Patients
When you think of nursing, your first image might not be working in a correctional institution. But, many times, because of a lack of education and a disinterest in healthcare, the people who end up in prisons are certainly some of the patients who need the most help. And for some nurses, like Tami M. Hefner, RN, FNP-C, site manager for Georgia's CorrectHealth, meeting that need is nothing short of a calling.

Hefner's interest in nursing began with a gift. "I was 5 years old and on my birthday my aunt gave me a nurses' kit with a hat. I know it might sound [silly] but it was [as simple as that]," she says, adding that when she was growing up women's career choices were limited to nursing, teaching or becoming hairdressers. But her desire to help the sick made becoming a nurse a great decision, not merely a default position. "I don't think you could be a good nurse if you didn't want to help people," she says. "It is an honorable profession."

After spending nearly 40 years in various areas of nursing, Hefner realized she was always coming back to family care as the area she enjoyed the most. "When I was an LPN at a family practice group, [I saw that] the doctor there took time with people. He exhibited such an interest in them. Not just the illness, but the person," she says. "He got to know their children and grandchildren. [I wanted to be] somebody you saw at the store, who would talk to you about what the doctor said, who you could ask questions if you had concerns." This sort of connection, Hefner feels, is crucial when you're talking about teaching people about health. "I felt then and feel now that the good health habits learned early impact every area of life and prevent health problems as we grow older," she says.

The more she heard about the need for healthcare information in the lives of inmates, the more she felt she was needed there. It was while she was meeting the requirements for recertification by working at the Georgia Diagnostic and Classification Prison in Jackson, Georgia, that Hefner was first introduced to Dr. Carlo A. Musso, the CEO of CorrectHealth. "The rest was an act of the Lord. He put me in the right place at the right time," she says.

While there were initially no openings at CorrectHealth, Hefner pursued a job and in mid-September 2005, heard from Dr. Musso and, "I began working for CorrectHealth on October 1, 2005 and absolutely love it," she says. "There is always something new every day and the client population is one who, in most cases, has neglected their health or has had only sporadic exposure to healthcare. The need is so great for healthcare education and the opportunity is there to help so many."

CorrectHealth, headquartered in Jonesboro, Georgia, began five years ago after Dr. Musso saw the need for improvement in inmate medical care in the county jails. Today, CorrectHealth provides health services to approximately 17 county detention centers in Georgia and has recently begun services in Louisiana. Hefner's time is divided up between White County Detention Center in Cleveland, Georgia; Lumpkin County Detention Center in Dahlonega, Georgia; Union County Detention Center in Blairsville, Georgia; Barrow County Detention Center in Winder, Georgia; and Clarke County Correctional Center in Athens, Georgia.

"The focus of CorrectHealth is to offer healthcare to a population whose previous care has been anywhere from minimal to poor, and without evaluation, management or prevention of chronic illness," says Hefner. CorrectHealth offers immunization services and daily sick call, dispenses free necessary medications for inmates, and provides healthcare education as often as possible, says Hefner.

The company offers monthly Chronic Care Clinics, which cover everything from prisoners' rampant blood pressure (which Hefner describes as horrendous) to treatment for Hepatitis, HIV and asthma. The clinics are important because the population most likely to wind up in prison often have health concerns far outside of their ability to manage alone. Before they were incarcerated, most with diabetes, for example, spent the money that should go toward insulin on cigarettes, alcohol or drugs, says Hefner. Or they bought unhealthy food and sweets because they made them feel good. "They don't understand how much this behavior hurts them," she explains.

The prisoners' involvement in the chronic care clinics comes from the intake screenings, where physicals are conducted and immunizations are administered. The center also screens for drug use, drinking, smoking, TB, chronic illnesses and what pills the inmates are supposed to be on. "The most frequent diagnosis that I encounter is untreated or under-treated hypertension," says Hefner. "Tobacco abuse, drug abuse and STDs are also very common diagnoses." She says that tobacco abuse includes smoking and dipping. "I'd say about 98 percent [of inmates] smoke. I get one or two a month that don't," she says.

Overseeing the sites' daily sick call clinics is one of Hefner's responsibilities. She answers questions by cell phone and cares for individual patients when the site's LPN needs her. Once or twice a week she visits each location. That means on Monday, Wednesday and Friday mornings, you'll find her at the White County Detention Center; on Monday and Friday afternoons at the Lumpkin County detention Center; all day Tuesdays and Thursday morning at Barrow County Detention Center; on Wednesday afternoons at the Union County Detention Center; and Thursday afternoons at the Clarke County Correctional Center. The inmates who need her for NP sick call have been seen by the LPN at daily sick call but need an advanced level of management.

Working within the prison system is difficult, but for Hefner it was a terrific opportunity to do important work. "Even as a small child, I wanted to be a policeman," she says. "[When this job came up], I thought, ‘this is my chance'. It combines both my love of [what police officers do] and helping people [health-wise]. [Before they came here], the inmates had no healthcare. They had everything wrong with them they could have wrong with them: teeth, STDs, high blood pressure. It was an opportunity to educate."

In fact, Hefner feels very strongly that this is a calling. "I knew from the first time I walked through the gates and heard [them] shut that I was home," she says, adding that only once in 11 years of working in corrections has she been scared at work, when inmates in a maximum security prison took over a dorm and trapped officers in with them. "I locked myself in a concrete drug room [until it was over]," she says.

Hefner feels she has met all of the educational goals she has set for herself, but because of the health needs of her patients, there is a need to read articles and get involved in continuing education projects. "There are always new management ideas to improve healthcare for my clients," she says. Still, clinically speaking, Hefner feels she couldn't be happier. "The company I work for is supportive and focused on improving healthcare for an underserved and, in some cases, a forgotten population."

But it's Dr. Musso, her boss, who she feels has made her career choice such a pleasant, positive one. "[Dr. Musso] is there for me. He sees each site I go to [and] let's me do, on my own, what I can do. He let's me make choices. If I have a question on this pill or that pill, I can call him and he not only tells me what to do, but why. He is great. He listens. If I say something ought to be changed—equipment or supplies—he trusts me. I consider him a mentor and a friend."

Despite her love for her work, Hefner acknowledges challenges, such as the prisoners' lack of healthcare knowledge. "Many inmates have no clue of the increased health risks that their actions will bring in the future," she says. "The most common recurring statement is, ‘Well, everyone was doing it and it was fun,'" she says. But educating the inmates is the aspect of her job she loves the most. "Sometimes ‘the light' actually comes on, and [I feel that] maybe, just maybe, something I said will make a difference in their life at a time when they are down and out and feel that nobody cares about them," she says. In fact, she hopes to, one day, research what impact health education plays in the lives of former inmates, and whether it actually makes a positive difference in their healthcare.

Perhaps the greatest concerns for NPs working within Georgia's healthcare system, says Hefner, are in the areas of autonomy, prescriptive authority and improved consistent indigent care. In Georgia, for example, NPs' autonomy is limited, as they are required to be in collaboration with an MD. "A lot of doctors are overworked, overbooked and understaffed," she says. "They don't have time to sit and talk to people. [So it's up to the NPs to find] time to talk." Hefner notes that she tries not to use confusing clinical terms with her clients. She makes sure that she explains the information so that they can understand it. "I have to use common, everyday talk," she says.

Regarding prescriptive authority, Georgia holds the record of being the only state in the nation where NPs are allowed to call in prescriptions but not allowed to write them. "I can send inmates home with prescriptions that last until they can see a doctor," she says, "but if they have no money for a doctor, that's it. They are out of luck. I can't help them."

The problem with indigent care, says Hefner, is that it is not consistent. "Many programs are started but soon fizzle out due to lack of funding, lack of community interest or just simply lack of knowledge, leaving the poor and/or uninsured to fend for themselves or do without," she says.

For those considering a career working with detention and corrections facilities, Hefner offers advice. "Always keep your eyes open. Know where the officers are. Always have an officer between you and an inmate. If you are alone with them, sit next to the door so you can make a quick getaway," she says. And while her children and husband have finally grown used to the danger level of her work, it is mostly because they know her so well. "They used to be worried about me," she says. "But now they know I'm not going to do anything stupid."

Regardless of how needy the inmate might be, says Hefner, you still have to remember they are prisoners. "Sometimes I get my leg pulled, but not too often. Sometimes [what we're doing here] works. I just have to trust the good Lord. He asks us to try. Most of us have been down and out," she says. "Somebody had to put out a hand to us."

The crucial thing to understand about Hefner is that she feels this work is very important and is aiming to make a difference in the quality of correctional facility healthcare. In spite of their personal problems, she is there to help people live a healthier lifestyle. "I guess my passion for fighting for the underdog shows through, even though the clients I serve are, in most cases, in the position of the underdog due to their own actions."

Tami M. Hefner, RN, FNP-C, received a master's degree in science with a major in nursing from North Georgia College and State University in Dahlonega, Georgia. She is certified by the American Academy of Nurse Practitioners and the American Nurses Credentialing Center.

Daniel Sean Kaye is a writer from the Philadelphia area. He is on the Editorial Staff of NEWS-Line for Nurse Practitioners.
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