Response to the Office of the Correctional Investigator’s Report - Aging and Dying in Prison: An Investigation into the Experiences of Older Individuals in Federal Custody - February 2019

Promoting Wellness and Independence among Older Persons in CSC Custody

On behalf of the Correctional Service of Canada (CSC), I would like to acknowledge the important contribution and partnership of the Office of the Correctional Investigator (OCI) and the Canadian Human Rights Commission (CHRC) in producing a significant report 'Aging and Dying in Prisons: An Investigation into the Experiences of Older Individuals in Federal Custody'. The following response reflects CSC's commitment to learning from this investigation and continually improving services being provided to older individuals in federal custody.

Canada, like many countries, is experiencing a demographic shift in its population; in 2018, 29% of adults were 65 years of age and over. While the overall federal institutional population has significantly less representation with 5% age 65 years and over, we have seen an increase in the number of older individuals age 50 years and over from 3,236 (21%) in 2012-13 to 3,460 (25%) in 2019. Older persons in custody are a diverse group with different backgrounds, challenges, needs and experiences. Responding to the unique needs of an older population and maintaining safety and security is complex and requires a collaborative approach within CSC and partnerships with communities.

Recognizing the need for a comprehensive strategic approach specifically aimed at responding to the multidimensional care and custody needs of older persons, in 2017, CSC created a multidisciplinary Health Care Advisory Committee (HCAC) with membership from several national professional associations. In 2018, CSC developed a policy framework entitled, Promoting Wellness and Independence - Older Persons in Custody (2018). In keeping with the advice from HCAC, the policy framework is integrated, person-centred, age, gender and culturally appropriate. It is multi-dimensional and supports health and wellbeing, programming, appropriate living accommodations, community engagement and partnerships. The framework builds on current programs and services and promotes wellness and independence among its older population in custody. This approach was informed by domestic and international research and in consultation with expert stakeholders in the fields of geriatrics, gerontology, law, culture, Indigenous health and correctional health.

I am pleased to see that most of the recommendations in the report are consistent with CSC's policy framework "Promoting Wellness and Independence - Older Persons in Custody (2018)." While the following responses to each recommendation highlights the various change initiatives completed and/or underway, we recognize that considerable work remains in order to fully address all of the issues raised by the OCI and CHRC. CSC is committed to ongoing quality improvement with the goal of maintaining optimal wellness and quality of life for older persons in custody.

1. We recommend that an independent review of all older individuals in federal custody be conducted with the objective of determining whether a placement in the community, a long-term care facility or a hospice would be more appropriate.

CSC recognizes the importance of appropriate placements for older persons in custody in order to meet their health care needs, and began renewed efforts in this area as of 2017. CSC agrees that each older offender case merits a review.

In 2018-19, CSC collaborated with the University of Waterloo and conducted functional screening assessments of over 500 men age 65 and older and women age 50 and older, to identify those with potential functional and cognitive needs. The data will be independently analyzed by the University of Waterloo and available in the fall of 2019. The results will provide CSC with a better understanding of the aging population, their health care needs and most appropriate placement.

Beginning in the fall of 2019, CSC will continue the assessment process with a representative sample of men age 50 to 64. This work will follow the same methodology as above and will be completed in fiscal year 2020-2021.

As outlined in CSC's response to the 2017-2018 OCI Annual Report (Recommendation 5), CSC is committed to continuing to work with community partners to facilitate the transfer of inmates to appropriate community housing, including long-term care facilities, external hospice and palliative care facilities.

2. We recommend that CSC develop a separate and distinct Commissioner's Directive specific to older individuals, which ensures that their specific needs and interests are identified and met through the provision of effective and adapted programs, services and interventions.

CSC agrees with the importance of providing specific policy direction that identifies and addresses the needs of older persons in custody.

CSC's case management, programming and policy framework is based on the Risk-Need-Responsivity Model, which has been shown to be appropriate for all offenders, including older individuals in custody. Based on this framework, adaptable correctional plans, which focus on an individual's specific needs and risks, are the case management strategy that works best for offenders of any age.

That being said, CSC will develop separate procedural guidelines in policy, which are evidence-based and address the management, supervision and rehabilitation of older offenders, as well as any age-specific vulnerabilities.

3. We recommend that CSC provide staff with training in age-related needs - physical, social and psychological - as well as training on how to identify, respond to and appropriately manage behaviour related to dementia.

CSC understands that building capacity to recognize and respond appropriately to the health and psychosocial needs of older persons in custody, including those with dementia, is important.

In January 2017, CSC began collaborating with Queens University's, Department of Medicine and Division of Geriatrics and the Centre for Studies in Aging and Health, Providence Care for the development of education/awareness and orientation modules for health and operational staff. The modules were piloted this fiscal year in one region.

Feedback from the participants will help to inform updates and revisions to the modules. Once completed, additional pilots will take place next fiscal year to determine next steps for a national roll out.

4. We recommend that CSC re-examine its use of force training and policy to incorporate best practices and lessons-learned regarding use of force on older individuals (including those using mobility devices).

CSC has reviewed and updated its training and policy on incident interventions, with the implementation of the Engagement and Intervention Model (EIM) taking place in January 2018, which replaced the previous Situation Management Model (SMM).

As a part of the 2017-2018 OCI Annual Report (Recommendation 9), it was recommended that CSC conduct an evaluation in 2018-2019 of its EIM. CSC's Departmental Evaluation Plan 2018-2023 included an evaluation of the Engagement and Intervention Model. This evaluation is scheduled to commence in 2019 and will incorporate best practices and lessons-learned regarding use of force on older individuals.

5. We recommend that CSC offer appropriate work options (including accommodated options) for older individuals who want to and can continue working. In addition, regardless of whether an older individual can work, CSC should provide a reasonable living allowance to meet personal needs.

Staying active and engaged contributes to healthy aging. Creating environments and opportunities for older persons in custody to engage in ability-appropriate work and social activities can help facilitate wellness and promote social inclusion. It provides an opportunity for older persons in custody to engage in health promotion activities that promote physical and cognitive functioning, thereby enhancing their quality of life. Offenders are encouraged to adopt healthy, prosocial lifestyles and use their time meaningfully. Participation in employment assignments contribute to this goal.

CSC will continue to identify opportunities for older persons in custody to participate in employment assignments that are responsive to their needs and limitations, and to ensure that they have the appropriate resources to meet their personal needs. Notably, in consultation with older offenders, CSC will identify what meaningful work opportunities could be implemented within its institutions.

6. We recommend that vulnerable populations (older offenders and those with mental and/or physical health issues) be monitored daily during lockdowns by professional health care staff.

CSC is committed to patient centred care for all persons in custody, including older persons. It is important to note that age alone does not imply health vulnerability.

Firstly, it is important to note that CSC strives to limit instances and the extent of lockdowns. For individuals who have become vulnerable in terms of their mental/physical health functioning, there are existing processes in place for ongoing monitoring of their health, including during lockdowns. For example, medications and health assessments are provided on the range during lockdowns. Moreover, inmates, or someone on their behalf, can also request health care services during a lockdown.

CSC will include the practice of daily health care visits during a lockdown in a policy guideline that will be developed and introduced by January 2020. Emphasis will be placed on the health needs of more vulnerable individuals, which can include older individuals.

7. We recommend that CSC designate facilities for older individuals who want to live in such areas-and that such facilities are designed or retrofitted to ensure physical accessibility.

In 2017-2018, Health Services began a comprehensive needs assessment of its older population. The results of the comprehensive needs assessment, including analysis by the University of Waterloo of the results of a functional screening assessment of those ages 65+, will provide CSC with a population profile of its aging population.

Preliminary analysis of the discussions with about 500 older persons in custody suggest there is a need for both age specific units as well as opportunities for integrated living (within the mainstream population). The functional assessment and further consultation with older persons will inform ongoing multiyear planning.

8. We recommend that CSC create dedicated spaces and times where older individuals can assemble and socialize during institutional working hours, and allow them access to communal prison services during working hours (e.g. library, gym, canteen, visitation, cafeteria, hobby shop and yard).

See Recommendation # 9 for a combined response to both.

9. We recommend that social programs staff organize age-appropriate and disability-appropriate leisure, wellness and recreational opportunities (e.g. stretching, walking, aerobics, yoga, card games).

Staying active and engaged contributes to healthy aging. Creating environments and opportunities for older persons in custody to engage in ability-appropriate work and social activities can help facilitate wellness and promote social inclusion. It provides an opportunity for older persons in custody to engage in health promotion activities that promote physical and cognitive functioning, thereby enhancing their quality of life. Offenders are encouraged to adopt healthy, prosocial lifestyles and use their time meaningfully. Participation in leisure, wellness, and recreational opportunities contribute to this goal.

CSC is exploring options, in consultation with older offenders, with respect to soliciting a range of age and disability-appropriate wellness activities that could be integrated into institutional routines and facilitated by Social Program Officers (SPO) in institutions.

CSC will oversee the integration of these activities into institutional routines, including having dedicated spaces as feasible, while also engaging community experts to complete recreational assessments with older offenders. This will allow for a better understanding of their needs and functional limitations, and the implementation of tailored recreational opportunities.

10. We recommend that CSC introduce standardized peer assistance and peer support programs across all institutions. These programs should be modeled along the lines of the caregiver program at Pacific Regional Treatment Centre, including a comprehensive manual, recurring training and ongoing support to peer caregivers.

CSC recognizes the importance of peer support and has various peer support programs across the country for a variety of different offender needs. In addition to the Pacific Regional Treatment Centre model, CSC also has peer health educators in many institutions across the country, a 24/7 Peer Offender Prevention Service (POPS) at Stony Mountain Institution and a Peer Mentorship Program in women's institutions.

CSC agrees that peer support plays an important role in assisting individuals within the correctional environment and will develop a series of nationally consistent peer support modules and related training.

11. We recommend that where the death of an offender is reasonably foreseen, CSC and the Parole Board be required to use proactive and coordinated case management to facilitate the offender's safe and compassionate release to the community as early as possible.

Further to a similar recommendation (recommendation 4) made in the 2017-2018 OCI Annual Report, CSC fully supports the importance of proactive and collaborative case management for offenders for whom their death can be reasonably foreseen and is working with the Parole Board of Canada to improve results in this area.

As a response to the recommendation, CSC issued clarification to all parole officers that pursuant to section 121 they must consider all release options for offenders who meet the criteria for exceptional parole. CSC also implemented a new palliative care Alert in the Offender Management System.

Furthermore, CSC began tracking inmates diagnosed with terminal illness at the national and site level to ensure prompt referrals are made to the Parole Board for release. CSC is committed to ongoing leadership in this area to ensure offenders with terminal illness are promptly referred to the Parole Board of Canada for release consideration and as such, we will continue to monitor the results and data in order to identify and implement areas for improvement.

Specific to early release within the context of life limiting illnesses, CSC is monitoring the timelines of the process from the designation of terminal illness to submissions to the Parole Board of Canada and subsequent decision.

In addition to the aforementioned steps undertaken, CSC is currently developing communication tools (i.e. fact sheets for all staff and inmates as well as posters) in order to foster a better understanding of Parole by Exception and encourage inmates to discuss their interest and eligibility for this release option with their case management team.

12. We recommend that the Minister of Public Safety review and assess release options (e.g. medical and/or geriatric parole) for older and long-serving offenders who do not pose undue risk to public safety, and propose amendments to the Corrections and Conditional Release Act (CCRA) as appropriate.

Response of the Minister of Public Safety and Emergency Preparedness

The Government of Canada is committed to an ongoing review of the criminal justice system, including changes to the Corrections and Conditional Release Act. On October 16, 2018, our Government introduced Bill C-83, An Act to Amend the Corrections and Conditional Release Act and another Act, which will transform federal corrections by eliminating segregation in all institutions and implementing a new correctional interventions model to promote rehabilitation in a humane and secure environment. The Bill also includes proposed amendments to strengthen health care governance; address the specific needs of Indigenous offenders; and better support victims of crime. As part of our ongoing review, we continue to explore ways to strengthen all forms of conditional release, including release options for older and long-serving offenders who do not pose undue risk to public safety. We thank the Office of the Correctional Investigator and the Canadian Human Rights Commission for this recommendation which will inform future work on this issue.

13. We recommend that release planning for older offenders include retirement financial planning, and the management of personal affairs, such as making a will and planning for the end stages of life.

Offenders currently have access to resources which can provide helpful financial planning information, including library services, pre-release fairs, job fairs, and community resource expositions, and other local offerings. CSC will engage the regions to continue to facilitate opportunities to increase offenders' access to community resources.

14. We recommend that CSC enhance partnerships with outside service providers and reallocate funds to create additional bed space in the community and secure designated spots in long-term care facilities and hospices for older individuals who pose no undue risk to public safety.

CSC is creating a multi-year national community accommodation plan, to be updated regularly by National Headquarters, which will identify current population profiles, projected upcoming releases, and available accommodation capacity. Accommodation gaps to be identified by regions will be based on national mapping of needs vs. bed capacity. CSC has also initiated the development of a comprehensive solution for both bed-inventory management and the matching of offenders to community facilities, including waitlists.

As outlined in our response to Recommendation 1, CSC is committed to continuing to work with community partners to explore all potential opportunities secure bed spaces in appropriate community housing, including long term care facilities, external hospice and palliative care facilities, in all cases where conditional release or exceptional parole for offenders is approved by the PBC.

15. We recommend that CSC fund and implement an integrated and comprehensive National Older Offender Strategy immediately. The strategy should:

1. reflect the recommendations made in this report;
2. go beyond an "aging in place" approach, including the mandatory and ongoing review of release options for older individuals who do not pose undue risk to public safety;
3. examine, respect and respond to the intersectional characteristics and needs of older individuals in federal custody; and
4. establish a timeframe for assessing, retrofitting and, where necessary, building facilities under CSC authority to ensure accessibility.

CSC fully supports the importance of an integrated and comprehensive approach for older persons in custody. In May 2018, CSC approved the policy framework entitled Promoting Wellness and Independence - Older Persons in CSC Custody. The framework is comprehensive and identifies priority areas for action for the Service. The policy framework was informed by domestic and international research and in consultation with expert stakeholders in the fields of geriatrics, gerontology, law, culture, Indigenous health and correctional health. However, CSC recognizes that older persons in custody are a diverse group with different backgrounds, challenges, needs, and experiences. As such, CSC will review, and amend as required, this Framework in light of the report’s recommendations.

Aging in place as defined by the Government of Canada (ESDC) means 'having the health and social supports and services' needed 'to live safely and independently in your own home or your community for as long as you wish and are able.' Putting in place programs and services that help facilitate aging in place, promotes healthy aging and wellbeing. The concept of respecting an individual's preference for accommodation and bringing the social and health supports to the individual, no matter their location, is equally important in a correctional environment.

Aging in place does not mean or imply a preference for older persons in custody to remain in custody beyond their eligibility for earliest possible release. CSC is committed to ensuring all offenders are as healthy as they can be and are prepared for a safe and timely reintegration into the community. In addition, for offenders who meet the criteria for exceptional parole based on health needs, which can include older persons in custody, but is not exclusive to this group, CSC has undertaken to clarify the policy expectations and monitor results as previously described in order to ensure terminally ill offenders are considered for early release.

As previously mentioned, and as outlined in the policy framework, Promoting Wellness and Independence - Older Persons in Custody (May 2018), CSC is conducting a comprehensive needs assessment, the results of which will provide a population profile of the health care needs of its older population. The initial results of Phase 1 will be available in late fall 2019. Guided by the same approach as Phase 1, Phase 2 will begin next fiscal year. This work is expected to be complete in fiscal year 2020-2021.

CSC recognizes the importance of appropriate accommodations for older offenders and others with mobility or other health needs. As mentioned earlier, CSC began a three-step process in 2017-2018 to better understand the needs of this population including preferences and infrastructure requirements that promote healthy aging. This initial work will be completed in 2019-2020 at which time more detailed accommodation planning will be initiated.

In addition to this more comprehensive approach to address the population health and accommodation needs of older persons in custody, CSC will continue to work to accommodate offenders' health needs on an individual basis.

16. We recommend that CSC significantly reallocate existing institutional resources to community corrections.

CSC is establishing a long-term plan for the management of community accommodation, building on the community capacity analysis that was completed as part of its 2017 internal strategic review. This will provide an integrated, national, long-term approach that will be responsive to operational needs in each region, including the capacity to meet the projected growth and population profile. As part of this work, CSC is collaborating with internal and external stakeholders to develop funding strategies that address community requirements.

Funding mechanisms to respond to offender population requirements in the Community Based Residential Facilities (CBRF) for beds exist and are adjusted on an annual basis, with a 2.5% increase being implemented as of April 1, 2019.