Barriers to Health Care in Prison Screening and Intake Problem 1. Failure to identify all HCV positive inmates. 2. Failure to providing testing when requested by inmates. 3. Failure to advise inmates of HCV positive tests. 4. Failure to timely respond to requests for testing and test results. 5. Denial of testing because of claims of “no risk” behaviors without meaningful evaluation. 6. Lack of understanding or ignoring the reality of what constitutes “risk behaviors” by medical staff. 7. The Education component at intake is seriously inadequate, provide inaccurate and misleading information. Solution/Demand 1. All inmates should be asked questions regarding risk factors for HCV infection during their entry evaluations and all inmates reporting risk factors for HCV infection should be tested for anti-HCV.See, Prevention and Control of Infections with Hep Viruses in Correctional Settings: MMWR 1/24/03 (CDC). CDC also has forms for use in this interview process. NIH Consensus Statement 2003. 2. All inmates reporting risk behaviors must be referred for HCV testing within thirty (30) days of the evaluation and must provide the test results to the patient within fifteen (15) days of receipt from the lab. The patient must be seen by a physician within 15 days of the receipt of the result to explain the results. If the patient is HCV anti-body positive this consult referral should also include a referral to the HCV Education Program 3. All inmates who request an HCV test irrespective of risk behaviors should be given the test within 30 days of request and must provide the test result to the patient within 15 days of receipt from the lab. 4. All inmates who have risk behaviors must be referred to the HCV/HIV counseling for education on transmission methods and risk behaviors. This counseling program must include comprehensive discussion on HCV risk behaviors and transmission methods and the risks of ongoing drug and alcohol use. 5. All inmates with risk behaviors and who have not yet been tested for HCV must be identified and tested for HCV within six months of the implementation of the Settlement Agreement. Once those existing inmates have been identified and tested, they must be referred as set forth in this Plan. 6. The HCV Policies should include a definition section to include the identification of the “risk behaviors” discussed here. 7. DOC shall commence statistical record keeping of all inmates who request testing, who are mandatorily referred for testing and all HCV positive tests received. DOC will keep statistics on the time elapsed from initial referral to the initial test and from the time thereafter to referral to the Education Program and full work up. DOC shall report these statistics to class counsel and to the legislature at regular intervals: bi-annually for class counsel, and annually for the legislature. Post Test Counseling and HCV Education Problem 1. Failure to conduct adequate counseling and education on risk behaviors, and fails to provide adequate information on risk reduction behavior. 2. Failure to provide adequate and complete information on the historical pathology of HCV, symptoms, disease history and potential risks of treatment or non-treatment. 3. Failure to provide adequate, balanced and fair information to inmate/patients on the risk/benefits of the delay of testing and/or treatment. 4. Failure to obtain medically/legally sufficient informed consent from inmate/patients on treatment or non-treatment. 5. Failure to provide appropriate education and drug/alcohol rehabilitation as part of the “treatment protocol” for HCV. 6. Using physicians and/or medical personnel with significant lack of understanding of disease process, symptoms, education on disease history, potential prognosis of HCV in individualized patient which in turn creates more fear and uncertainty. Solution/Demand Intake 1. DOC shall provide copies of all information presently delivered to inmates at intake concerning “risk behaviors” to Plaintiffs counsel or identify which documents already provided in discovery constitute those documents; 2. DOC shall, in consultation with public health specialists and infectious disease experts, update and expand on the initial intake education to include information in compliance with CDC and NIH standards including the following: a. Prevention of HAV, HBV and HCV infection should be incorporated into education intake program: b. Information at intake should include, if not already, the modes of transmission of infectious hepatic diseases, methods of prevention, including risk reduction and immunization. c. Information at intake should include written materials on the disease. The materials should be reviewed by plaintiffs and community based experts on public health risks and infectious diseases. d. Information at intake should be given to inmates to give them an overview and explanation of the HCV Education Program and the protocols for evaluation and treatment. This Program should include the basics outlined in this document and must be approved by Plaintiffs and outside medical experts. The relevant inmate/patients should be provided complete and detailed, accurate information on the Program and the fact that the information is given to the inmate must be documented in the patients’ chart. e. The information given at intake should be reviewed on an annual basis for updates and modification as the standard of care or medical procedures change. The updates should be submitted to plaintiffs counsel for review and approval prior to use. f. DOC shall use the CDC and NIH education pamphlets, videotapes and education materials where available and appropriate. 3. Those inmates who are identified with “high risk” behaviors at intake shall be referred to the HCV Education Program as part of the full work up of the disease. The referral for the full work up shall be made within 30 days of the confirmation of the positive test result. 4. Upon completion of the full medical work up, the patient/inmate shall receive education on the disease in compliance with the NIH and CDC standards. 5. The Intake education component should be provided in forms which are appropriate for the language and literacy skills of the participants. HCV Education Program 1. DOC shall develop and institute the HCV Education Program as outlined here. Each qualifying HCV positive patient/inmate shall be entitled tot participate in the program as often as necessary to address the concerns and issues of the particular patient. 2. The HCV Education Program shall be developed within the parameters set forth by the 2002 NIH Consensus Statements and updates together with recommendations made by the CDC. The Program shall be subject to quality control, peer review and regular updates and modifications as the stated standard of care guidelines are modified and updated. 3. As part of the work up conducted by medical, each patient shall be referred to the HCV Education Program. The referral shall be charted in the patient’s medical file. 4. The HCV Education Program shall include an initial consult with the physician who shall in detail explain the disease course, expected progress of the disease, the results of all tests in the full work up including blood tests and biopsies. The physician shall explain the expected treatment course and the time line for that treatment. The discussion and education component shall be documented in the patients file. The patient shall then be referred to additional components of the education program. 5. The information provided by the physician shall include at a minimum that which is identified in the existing NIH Consensus Statement and by the CDC together with the present state of the art explanation of the disease course, the natural history of the disease, the meaning and relevance of the various tests and the importance of the biopsy and results. The physician shall fully explain treatment options. 6. The DOC physician shall refer the patient to the HCV Education Program which shall include, without limitation, the following information a. Prevention of HAV, HBV and HCV including information concerning modes of disease transmission, methods for prevention, including risk reduction and immunization, disease outcomes and options available. b. An integrated health education and risk reduction program shall be established in each facility and a written plan of health instruction shall be completed by each inmate/patient. c. Such instruction shall address the range of issues relevant to the diverse developmental and cultural diversity of correctional populations, and should include basic skill development, literacy and home economic aspects as tools needed to avoid behaviors that result in acquisition of HIV, hepatitis and other blood borne transmitted infections. d. Such instruction shall be in the relevant language and all materials shall be translated into at least Spanish for those Spanish speaking patients. Such instructions shall be made in a manner to assist those inmates with reading or learning disabilities and mental impairments. e. Teachers should be trained professionals or inmate peers with specific training to teach comprehensive skills programs, including health education. f. A system for periodic evaluation, updating and improvement of the education program should exist. g. Documentation of hepatitis A or hepatitis B vaccination should be included in the medical record within the correctional system, as well as in any medical record provided to other health care providers and in addition, the vaccinated person should be provided with a personal immunization record. h. DOC shall permit and use peer groups to provide ongoing support and information on HCV, medical advancements and the various expectations of the disease progress and medical care. i. DOC shall provide copies to all inmates in the HCV Education Program of the current DOC HCV Treatment Guidelines, the current NIH Statements and current CDC disease information either through access to community advocates, delivery of the information through the peer groups, access to the internet or other valid and reasonable sources. j. DOC at each facility should establish links with community and public health facilities, and as available, immunization registries, to ensure tracking and completion of hepatitis A and Be series. k. Persons with chronic HBV or HCV infection • should be counseled regarding preventing transmission to household, sexual and drug use contact including risk reduction and condom use. • provided referral for hepatitis B vaccination of contacts. • counseled regarding ways to reduce further liver damage, including severely limiting alcohol use and drug use, afforded substance abuse treatment when appropriate; • and provided aftercare that includes medical followup. Medical Workup for Inmates with Chronic HCV Problem 1. Failure to adequately screen and test patients with high risk behaviors. Initial interviews are inadequate and information contained in the initial evaluation are rarely accessed by physicians or simply ignored as part of the diagnostic process. 2. Refusing to test patients without a physician referral to do so, and most physicians will not order the test unless and until there are repeated requests and grievances. 3. Relying exclusively on the ALT reading to recommend treatment. This is a dangerous standard which falls below all accepted medical practices. Also requiring six months of 2X normal elevations of ALT. Experts indicate there is no scientific or medical support for this and is a dangerous derivation from the accepted standard of care. Many of the policies are designed to delay and deny as many patients from care as possible. Most of the delays and barriers are not based on scientific data and deviate from the accepted standard of care. 4. Physicians will not advise the patient of test results including those indicating present infection. This results in several years delay in evaluation and treatment and has resulted in several needless deaths. 5. Being aware of the NIH Consensus statement and CDC recommendations and not changing its practice of initial evaluation and work up of chronic HCV patients. Solution/Demand 1. DOC shall refer all patients with HCV positive test for full work up within 30 days of the positive test. The full workup shall be completed within 30 days of referral and the results of all tests shall be delivered to the patient within 15 days of receipt by the medical staff. Any patient with single elevated ALT shall be referred on for evaluation for treatment. Any patient with normal ALT shall be monitored as set forth below. Anything not within accept range is abnormal. The full work shall include initial consult with physician and full advise and education by physician, CBC and chem screen tests, initial liver function tests and biopsy. 2. Any patient with HCV positive test and normal ALT shall be given HCV RNA test to confirm present infection. 3. Any patient with HCV positive test and normal ALT shall be given 3 separate tests for ALT test at six month intervals. If all three are within normal range the patient maybe monitored yearly thereafter. If the patient has a single elevated ALT reading that patient shall be referred for full work up. NOTE: Need to define “normal range”. Need definition section to HCV guidelines. 4. DOC shall automatically schedule all inmates to return to medical to review their lab work and there shall be a medically appropriate person available to explain the lab results and the expected treatment plan. The appointment to review lab work shall be automatically made by DOC staff within 14 days of the receipt of lab results. The date and time lab results are received shall be noted in the file and the date and time the patient is called to the infirmary shall be noted in the chart. 5. No steps in initial work up shall be referred to TLC for review. 6. Every HCV infected patient shall have a treatment plan created in consult with the patient. The patient shall be provided a copy of the treatment plan and the fact of delivery of plan to patient shall be charted in the patients medical file. 7. DOC shall keep a tracking system of all HCV infected patients and shall be able to provide information on the status of any given patient including, without limitation, the following: a. Date of tests; b. Results of tests; c. Date of next appointment or tests; d. Status of disease; e. Status of progress in A/D Rehab; f. Status of progress in Education Program; g. The number of patients testing positive; h. The number of patients who received biopsy; i. The number of patients who receiving A/D Rehab; j. The number of patients in HCV Education Program; k. The number of patients taking anti-viral treatment; l. The number of patients with HIV and HCV; m. The number of patients with cirrhosis; n. The number of patients referred to outside physicians o. The performance of DOC in meeting the time-lines set forth in this agreement. 8. In accord with the reporting requirements set forth below, DOC Shall have six months to create and to update the database noted in item 7 above. At that time DOC shall make a report to the court and the plaintiffs counsel on the status of the database and the statistics accrued to date. Thereafter, in accord with the terms of the final settlement decree, the reports will be made to the plaintiffs counsel on a bi-annual basis, as required by the settlement decree and biennially to the legislature. Substances Abuse Treatment Problem 1. Requiring substance abuse treatment for all patients before any additional work up or treatment. 2. Requiring substance abuse treatment for patients without adequate screening and confirmation of substance abuse problem with specific patient. 3. Placing burden on patient to “prove” they either do not have history of high risk behaviors or have already undergone substance abuse treatment. 4. Failure to adequately chart the existence of high risk behaviors or the need for substance abuse treatment in any specific patient. 5. Failure to fund and provide standard of care, meaningful substance abuse treatment for most inmates except those within one year of release. 6. Requiring that inmates take AA or NA for an unspecific and fluctuating amount of time prior to even being considered for work up or treatment. Solution/Demand 1. DOC shall utilize the recommendations on substance abuse treatment as set forth by the NIH Consensus Statement and CDC Guidelines for the treatment of incarcerated persons. 2. If DOC requires A & D treatment as part of the overall treatment of HCV, DOC shall fund and provide adequate and sound substance abuse treatment programs for all inmates at all institutions. This treatment shall not be limited to those within one year of release and s hall not be dependent on AA or NA. 3. Many inmates who were in custody in the late 1980s and early 1990s went through mandated DOC substance abuse treatment and have records of this in their files. DOC medical staff shall be responsible for confirming this information before mandating the patient complete A & D treatment. If the patient previously completed A & D treatment and has no evidence of ongoing substance abuse issues, that patient will not be required to take substance abuse treatment. 4. Those inmates with a history of recent substance abuse may be referred to the A & D program simultaneously with the work up and the substance abuse treatment shall be considered part of the “treatment” for HCV. Recent substance abuse shall include any positive UA results or disciplinary action for substance abuse within six months of the work up. 5. DOC did not know whether A&D treatment was available to inmates yet makes it a prerequisite for necessary medical treatment. Also that AA is not religious based and “it is better than nothing” and is “not a whole lot to ask of anybody”. These are not legitimate scientific explanations for the mandate of treatment and AA. NOTE: Numerous judicial decisions have found that requirements of AA/NA attendance to violate the Establishment Clause because they are religious based. In re Garcia, 106 Wn. App. 625, 24 P3d 1091 (Div. 1, Wash CA, 2001); Bausch v. Sumiec, 139 F. Supp. 2d 1029 (E.D. WI 2001); Alexander v. Schenk, 118 F. Supp 2d 298 (ND NY 2000); Warner v. Orange County Depart of Probation, 173 F. 2d 120 (2d Cir 1999) Warner v. Orange County, 968 F. Supp 917 (SDNY 1997); Griffin v. Goughlin, 88 NY2d 674 (1996); Warner v. Orange County, 115 F. 3d 1068 (2d Cir 1997); Kerr v. Farrey, 95 F. 3d 472 (7th Cir. 1996); and, Nusbaum v. Terrangi, 210 F. Supp 2d 784 (ED Va 2002. It will no longer be permissible to allow AA/NA to substitute for substance abuse treatment for inmate/patients. AA/NA shall not be mandated prior to evaluation or treatment and shall not be recommended, referred or required by DOC for anything. 6. In those patients who are referred for A& D treatment without evidence of recent substance abuse the evaluation and treatment shall commence as required in these recommendations and s hall not be delayed until the patient completed substance abuse treatment. Time Left to Serve Problem 1. DOC will not commence anti-viral treatment and in many instances even will refuse evaluation if the patient/inmate lacks sufficient time on their sentence to complete the evaluation 2. Presently, treatment for genotype 1 requires approximately one year; genotype 2 and 3 require approximately 26 weeks. 3. Under these guidelines and amendments to the written policies DOC will have no longer than 120 days from initial request for test through biopsy to complete the initial work up. In all qualifying patients treatment should commenced at that 120 day mark. 4. In almost all instances DOC will delay up to four years from testing until treatment decision is made and then will deny because the patient lacks sufficient time on sentence. Various doctors in DOC have written affidavits and testified that the time left to serve requirement includes anywhere from 2 _ years to six months. There is no consistency and this provision is left to the vagaries of medical staff. Solution/Demand 1. If DOC treats patients according to the time lines set forth in the agreement undue delay will no longer be a serious issue. All physicians indicate that treatment should not be interrupted mid-stream and suggest that if treatment cannot be completed all at once, it not be commenced until such time as the patient can receive the full course. However, this is not to suggest that the lab work and even biopsy be delayed. 2. Because the release of infected prisoners is a critical nationwide health issue some compromise on this particular point must be reached between the parties. Plaintiffs are willing to acknowledge that those patients with a very short prison term in many instances can be released into the community without the anti-viral treatment provided that adequate testing, evaluation and informed consent precedes that determination. 3. Presently, DOC relies upon projected “release” dates which are really parole settings and may have little bearing on the actual date of release of the inmate. Therefore, Plaintiffs will insist that the policies be modified to clarify that the time left to serve barrier to treatment include the presumption that it only includes those serving time on Matrix sentences or determinate Measure 11 sentences; anyone who is a parole prisoner cannot be denied treatment if his anticipated parole hearing date is within the one year or 26 week cut of date. 4. The time left to serve basis for denial must be modified to include the time required be based on the genotype of the virus and the needed time for treatment. 5. If a patient c an serve most of treatment time in custody and will only require a month without treatment, DOC will provide that released patient at least one month of medication to complete the treatment course and will assist the patient in transition community based health care planning. 6. If, during the course of the implementation of this plan, the State Health Plan, the Social Security administration and/or the Veterans’ Administration will allow prisoners to apply for and qualify for benefits on the first day of their release, the restrictions on “time left to serve” disqualifications in this agreement will be modified. 7. The present limitation on “time left to serve” as a barrier to treatment shall not be imposed if the patient’s medical condition may be compromised within the “time left to serve”. Mental Health Prohibitions Problem 1. Using the potential of mental health issues as a basis for denial of treatment as well as even the full workup. Mental health issues are not a recognized countraindicator to work up and evaluation and all patients regardless of mental health issues must receive work up. 2. Failure to adequately document the scientific and factual basis for denial of treatment or evaluation when the putative reason are mental health issues. 3. Presently DOC fails to refer most patient who are being rejected based on mental health issues to experts for more complete evaluation. Solution/Demand 1. If any physician denies a patient for evaluation and work up for “mental health” reasons those reasons must be stated specifically an clearly in the chart and all scientific and factual basis must be included. If a physician is not relying on contemporaneous or current information that physician must refer the patient to a mental health specialist for complete work up to assess the “mental health” reasons for denial of treatment and evaluation. 2. The only real valid countraindicator to use of the antiviral medication is serious clinical depression and evidence of suicidal ideation. If a physician is going to deny treatment for this reason the patient must be fully informed and sign an acknowledgment of the information and the basis for refusal. The consult and informed consent must be contained in the medical chart. 3. If a patient has depressive issues which can be treated with medication the physicians shall refer that patient to an appropriate specialist for evaluation and the medication shall be provided for the patient. Treatment for Patients/Inmates in Special Housing Units Problem 1. Presently, there is a uniform undisputed denial of a wide range of medical care for patients who are confined to DSU, IMU and SMU. Of particular concern are those who are segregated for disciplinary reasons. 2. The denial of medical treatment for HCV infected patients who are in special housing units. The reasons for denial are not based on medical reasons, are punitive and cause inordinate harm and suffering. 3. Many inmates who have been diligently documenting and grieving their lack of HCV care have been disciplined for “abuse of infirmary” and placed in “the hole” and denied care or disease management. These are gross violations of the standard of care, are punitive and violate the 8th Amendment. Most of these instances have been documented by the inmates through kytes, grievances and the responsive documentation from DOC staff. Solution/Demand 1. All inmates/patients who are confined to special housing units will receive the same level of medical care on the same time lines as all general population inmates. 2. Anyone who is in a special housing unit for the use of controlled substances may have their treatment delayed in accord with these policies but cannot have their evaluation and work up delayed because of their living conditions. 3. DOC shall provide a recommended management plan for assessing, evaluating and monitoring patients who are confined to special housing units. Monitoring of Treatment Problem 1. Failure to adequately monitor treatment by ordering too many of the wrong tests and too few of the correct ones. 2. Failure to inform the patient of necessary tests, the results and the meaning of the results in the overall treatment plan. 3. Failure to maintain adequate medication on hand and have frequently run out of the anti- viral treatment. Many prisons have not completely switched to PEG-interferon combination therapy. 4. Failure to provide adequately trained personnel who understand the complexities of the disease, symptoms and are unable to provide balanced and adequate education. 5. DOC fails to provide palliative care for t hose who are the most seriously ill to ease their symptoms and to provide comfort care. Solution/Demand 1. DOC shall do full work up including biopsy as note previously. Thereafter, continuing blood work is only important in those patients with no ALT elevation. 2. DOC shall address the concerns through full informed consent and the Education Program outlined above. 3. DOC shall commence using PEG-interferon combination therapy for all qualifying patients and shall do the various viral load and blood tests in accord with the manufacturers recommendations. 4. DOC shall provide training to all medical staff and/or shall insure that a medically trained specialists is available to all HCV infected patients for chart review, consultation and ongoing disease management. 5. DOC shall immediately begin to provide palliative and comfort care to all patients with cirrhosis or end stage liver disease to ease their pain and suffering. This includes referral to outside specialists, development of an end of life treatment protocol, providing Durable Power of Attorney and Living Will counseling and hospice care when and where appropriate. 6. As part of the settlement plan contained herein, Defendants shall permit a quality control review of randomly selected charts on a biannual basis. The charts shall be selected by Plaintiffs counsel and/or Plaintiffs’ experts from the master list created by DOC. The charts shall be reviewed by the panel of experts for compliance with the medical standard of care, the newly revised and updated HCV Policies and this agreement. The process for review shall be created by the parties as part of the final settlement. Anti-viral Treatment of HCV Problem 1. Denying anti-viral treatment on a fairly broad basis without scientific standards. 2. Submitting virtually all treatment decisions for HCV to a committee which is not always composed of physicians. These committees statistically deny biopsies and anti-viral treatment at a great disproportionate rate and rarely includes a hepatic or contagious disease specialist and rarely do the various members of the committee have access to the patient chart in order to conduct appropriate peer review and consult. 3. Committees denying significant requests for treatment despite recommendation to the contrary from outside community based specialists. This is a violation of the standard of care and causes significant harm to patients. 4. Failure to provide treatment to appropriate patients in accord with the CDC and NIH standards. Solution/Demand 1. DOC shall modify its written policies regarding the administration of the anti-viral treatment to comport with the existing NIH and CDC standards as well as following the treatment prioritization of the states Health Plan. 2. DOC shall administer anti-viral treatment in accord with the recommended dosage and duration for all HCV positive patients with at least Stage 2 or 3 fibrosis, or. Grade 3 or 4 Inflammation or any combination of any of those. DOC shall administer the necessary viral load tests and blood work in accord with the drug manufacturer’s guidelines and the CDC recommendations for the duration of the treatment. 3. DOC shall administer genotype and viral load testing immediately prior to the commencement of treatment for qualifying patients. 4. DOC shall refer patients with Stage 4 fibrosis and cirrhosis to outside specialists for a complete evaluation and shall follow the recommendations on treatment of the outside specialist. 5. DOC shall refer all cirrhotic patients to outside specialists for full work up and the creation of a treatment plan and thereafter shall follow the recommended treatment plan. 6. No treatment decisions for HCV or anti-viral treatment shall be referred to the TLC. 7. Anti-viral treatment shall commence within 120 days of initial testing for all appropriate patients. Medical Records Problem 1. Problems with medical charts being tampered with, altered or individual documents missing. 2. Sloppy record keeping, medical data is not being properly charted and information is being ignored which should be charted. 3. Non-physicians rewriting physicians orders and changing medication scheduling and disease without consulting with physicians. 4. Not complying with standard of care requirements from the maintenance and management of medical records. 5. We have some information from outside sources that some medical staff are advising prisoners to copy their medical files as a prophylactic measure because “things turn up missing.” 6. Failure to allow inmates complete access to their medical rile and charges an inordinate amount to copy in violation of new statutory provisions. Patients are presently charged $1.25 per page and indigent inmates are frequently not allowed access to their medical files. Solution/Demand 1. The only way to properly fix this problem is to ascertain the source of the misconduct. If the problem is simple negligence, then quality control and quality assurance measures recommended by the AMA and the Joint Commission on Standards and Practices will be able to address those issues. However, if the problem is intentional DOC has the duty to ascertain who is involved and remove them from employment. 2. Plaintiffs will insist on a complete evaluation and assessment of the present record keeping management system at all prisons. DOC will pay for the assessment and will follow all recommendations by the outside experts. DOC will have six months from the implementation of this settlement agreement to conduct the assessment and another six months to implement the recommended changes. 3. Plaintiffs will insist that any individual who is responsible for manipulating, destroying, altering or unlawfully tampering with official medical files be immediately terminated from employment. Plaintiffs will insist that an investigation be conducted in accord with procedures set up by the parties. 4. For the terms of the settlement agreement, periodic quality assurance and quality control tests of the completeness of medical records will be conducted in accord with procedures set up by the parties. 5. DOC shall immediately commence charging inmates for copies of their medical files at a rate of .25 per page and shall in no way charge more than is allowed by new legislation. 6. DOC will allow an inmate to access and review his medical file within 15 days of a request by the inmate. DOC will allow the inmate to copy the documents he desires at a rate in compliance with new statutory provisions. DOC will provide the copies to the inmate within 15 days of the request for copies. DOC will not require a HIPPA release form if the copies are being delivered to the patient personally. DOC will allow indigent inmates to have access and copies of their medical file free. Community Transition Problem 1. Failure to provide almost no counseling or assistance to inmates who are leaving the system. 2. Most inmates cannot apply to, nor qualify for, outside public healthcare services while incarcerated. Thus inmates cannot submit nor complete an application for state health care assistance, VA medical services or Social Security Disability while incarcerated. Changes should be advanced in this area. 3. Providing information packets on the location of physicians, health care clinics, or offices of public support services. Failure to provide information and assistance of inmate in the completion of application packets, addresses of where to send those packets, and failure to assist with the obtaining of medical records and files. Most inmates lack sufficient education or literacy ability to complete the packets or applications on their own and there is a significant absence of such support. Solution/Demand 1. DOC shall provide information on transition issues to all inmates with HCV and who are released to the community. The information shall include a list of public resources which at a minimum include at least one contact address in the community for information on public assistance, the States Health Plan, the VA benefits or social security. 2. DOC shall access and make available application packets for all released prisoners to apply for social security, the States Health Plan and VA benefits or, in the alternative, allow counselors from each of those organizations to come to the prisons to meet with prisoners and provide information and assistance. 3. The information provided by DOC shall be in the appropriate language for the prisoner. 4. DOC shall make the information accessible for those inmates who have literacy or comprehension difficulties. Intake Questions to Identify “At Risk” Patients 1. Have you ever received blood by transfusion? 2. Have you ever received an organ donation? 3. Have you ever used illegal drugs? 4. Have you ever injected drugs with a needle? 5. Have you ever injected drugs by nasal ingestion (snorting)? 6. Have you ever shared needles or ‘works” when shooting or snorting drugs? 7. Have you ever had sex with a prostitute? 8. Have you had unprotected sex? 9. Have you had sex with multiple partners? 10. Have you had homosexual sex? 11. Have you ever been exposed to the blood from someone else in a fight, accident or other exposure? 12. Have you ever had sex wit ha partner who was infected with HIV/HCV? 13. Have you ever worked in the health care profession and became exposed to blood? 14. Have you ever consumed alcohol? On an average how much did you consume prior to prison? 15. Have you ever had a tattoo? 16. Have you ever shared a razor or toothbrush with an infected person?