Advancing pharmacy practice behind prison bars

Bina ensures that inmates get the best possible care


September 01, 2012 – Like most pharmacy leaders in large health systems, RADM Chris A. Bina, PharmD, encourages his staff to provide patient-centered care. But unlike pharmacists in other health systems, Bina’s team provides pharmacy services to a unique patient population: 178,000 inmates at 117 correctional institutions across the nation. Another 39,000 individuals are located at contract facilities, halfway houses, or home confinement.

As the Chief Pharmacist for the Federal Bureau of Prisons (BOP), Bina has launched numerous specialized pharmacy programs and elevated the role of the pharmacist among staff and inmates alike. “Our pharmacists serve as medication use experts, help promote wellness and manage disease, and maximize health outcomes in collaboration with other members of the health care team,” said Bina.

During his 21-year tenure at BOP, Bina has worked to implement new pharmacy initiatives and improve patient outcomes. Bina believes that correctional health is linked to public health. In corrections, 95% of all patients in the system will eventually be released back into the community from which they came.

“It is important that an [inmate’s] disease is controlled, whether it is diabetes, hypertension, hepatitis, or HIV. If they don’t know how to take care of themselves or they don’t know how to take a medication or how a disease is transmitted, the situation perpetuates once they are released,” said Bina, who is also a commissioned officer in the U.S. Public Health Service (USPHS). “It is our responsibility as pharmacists to ensure that patients are well educated and know how to take their medications so they can go back to the community and [successfully] deal with their health problems.”

New programs

BOP is a billion-dollar-a-year health care industry with about $67 million in annual medication expenditures. BOP has about 300 pharmacy positions, including 180 pharmacists, and most are commissioned officers in USPHS, although there are a handful of civil service pharmacists as well. Pharmacists within BOP process around 4.5 million prescriptions a year at 93 filling pharmacies at correctional facilities located in 35 states.

Bina began working for BOP through a student program in 1992. “I realized I was making a difference and I wouldn’t be happier anywhere else, given the impact I was making,” he said. In 2000, Bina moved from a BOP institution in Missouri to the central office in Washington, DC, where he accepted the position of chief pharmacist. “I set out not to conform to the way pharmacy was being practiced, but to conform pharmacy practice into a way that benefits the system and the patient, in collaboration with other providers,” said Bina. Under his leadership, pharmacists provide care at the fullest extent of their training and licensure, and dozens of BOP pharmacists perform protocol-based primary and specialty care activities through collaborative practice agreements with physicians.

In 2005, Bina implemented an HIV program staffed by clinical pharmacy consultants who reviewed patients’ electronic medical records (EMRs) on a regular basis to evaluate medication regimens, monitor viral load, and review all the key HIV clinical indicators. “In 2004, our nondetectible viral load was about 32% across the system,” said Bina. “I knew it could be better than that, so the HIV clinical pharmacy consultants program was proposed, and within a few years, our nondetectible viral load has gone up to a little over 82%.” He has also implemented a hepatitis pharmacist consultant program and initiated plans to launch a mental health program.

EMR access is especially important in the prison system, which has a transient population of inpatients, outpatients, and long-term care patients. “We have to be able to capture all that information within the EMR, and the [electronic system] has really improved the continuity of care as patients move from one institution to another,” said Bina.

Similarities and differences

Working as a BOP pharmacist is similar in some ways to working as a pharmacist in a large health system. “A lot of it is the same as far as the core aspects of pharmacy and the practice of medicine, but there are some things that are very different,” said Bina.

One of the main differences is that approximately 25% of patients in the federal prison system are not U.S. citizens. “Many of our patients are from a lower socioeconomic class, and this may be first time they have had access to health care,” explained Bina. “There’s often a lot of interesting pathology that comes into our system, since a lot of these inmates have lived fairly hard lives. The physiological age of the patient is often more advanced [than] their chronological age due to their hard lifestyle.”

Another difference between BOP and a traditional health system is the formulary. Some of BOP’s formulary is based on security. “For example, handcuff keys can be made out of certain inhalers, and we have to be cognizant of that,” said Bina. “Other products may be flammable because they have a high alcohol content. Other special issues to watch out for are what Bina calls nontraditional drugs of abuse. “[Inmates] use or abuse some psychiatric medications, and even a particular blood pressure medication can be abused because of the way it acts in the body,” he said.

Pharmacists at BOP facilities respond to emergencies that may be medical or nonmedical. For instance, if there is a fight among inmates, then pharmacists will respond alongside all of the other employees at the institution, regardless of their professional discipline. Bina is often asked how safe is it to be a pharmacist at a prison. “For many of the inmates, this is the first time anyone has cared about their health,” he said. “The [inmates] are very appreciative of the health care staff.”

Because BOP is a closed government system, “we are held to a higher scrutiny compared [with] a traditional health system,” said Bina. Institutions are accredited by the American Correctional Association and closely monitored by the Environmental Protection Agency and DEA. Most BOP institutions are also accredited by the Joint Commission.

Distributing medications

In a health system, pharmacists visit patients in their hospital rooms or patients pick up their prescriptions from a pharmacy. At BOP, it works a little differently, Bina noted.

Pharmacy is integrated throughout the health services areas of correctional facilities, but a complicating factor can be the security level of a particular institution and the mission of the institution. For instance, a detention center houses unsentenced inmates between their court appointments. “Many times these inmates cannot mix with inmates in the same institution,” said Bina. “Sometimes we don’t know an inmate’s background, or certain inmates have to be separated.”

In this situation, health care providers, potentially including the pharmacist, visit the different floors of the facility to distribute medications and counsel patients. “Health care providers also visit patients who are in special housing units,” which are designed to separate inmates from the facility’s general population for disciplinary or safety and security reasons. If a patient is placed in ones of these units, then the health care provider goes to them. “In a run-of-the-mill prison where there’s [a] general population, inmates come to health services, which include pharmacy services to be rendered,” Bina added.

Looking ahead

With the implementation of disease-specific pharmacy programs under way, Bina is now turning his attention to streamlining the prescription fulfillment process. “We’re looking at [creating] a central fill for our agency that would take all refills and all nonurgent first fill medications,” said Bina. “If we can centralize the inventory and make the process more efficient, then we can dedicate more time to improving patient outcomes and expanding opportunities for disease state management.”

Bina is dedicated to his challenging career path and proud of the work he’s done. Practicing with the motto, “It takes a team to raise an outcome,” Bina feels like he’s accomplished much: “I’ve gotten more thank yous behind prison walls than I ever did working in the private sector.”

A new model of health care delivery

A 2011 report to the U.S. Surgeon General, Improving Patient and Health System Outcomes Through Advanced Pharmacy Practice, highlighted the valuable role pharmacists can play in delivering expanded patient care services.

The report is framed around several focus points that use evidence-based data to demonstrate how pharmacists can provide patient care services throughout the entire health care delivery system; these include performing patient assessments, having prescriptive authority, and developing treatment plans. “The whole concept [of an expanded pharmacy role] is illuminated within that report,” said RADM Chris Bina, PharmD, Chief Pharmacist for the Federal Bureau of Prisons, who was one of several contributors to the report. The report also includes a compendium of published peer-review articles that showcase positive patient and health system outcomes with pharmacist involvement.

The objectives of the report include obtaining advocacy from the U.S. Surgeon General to recognize pharmacists as health care providers and pushing past the discussion phase to move toward implementation. “We are looking at this as the linchpin that the pharmacy profession can use to tether itself to [in order to] standardize pharmacy practice across states and move things forward in an evidence-based, cost-effective manner,” said Bina. “This is a landmark report that will be referenced 20, 30, 40 years from now as the time that pharmacy practice was able to change within the country.”

Amy K. Erickson, MA