BOP Program Statement 6031.06 § 2

a. Advanced Practice Provider (APP). For the purpose of this program statement, an APP is a

Nurse Practitioner or Physician Assistant.

b. Advance Directive. For the purpose of this program statement, an advance directive is a

written instrument, sometimes referred to as a living will or other similar document, by which an

inmate expresses their health care wishes in the event of a terminal or irreversible condition. The

advance directive will be utilized by medical providers to guide care when the inmate lacks the

capacity to make their own health care decisions.

The advance directive may address the inmate’s wishes concerning the withholding or

withdrawal of resuscitation, life-sustaining, or other types of medical care.

The advance directive may prescribe the appointment of a non-Bureau of Prisons (Bureau) proxy

decision-maker for these health care decisions.

c. Ambulatory Care (Outpatient Care). Ambulatory Care refers to health care services

provided to inmates who are housed in the general population or other routine housing settings

and who present to a medical or dental treatment area to receive scheduled or unscheduled

services. Ambulatory care is intended for inmates whose medical, dental, or mental health

conditions can be safely evaluated and managed without continuous monitoring, nursing

observation, or intense assistance with activities of daily living. Services may include routine

clinical encounters, chronic care management, preventive services, diagnostic evaluation,

medication administration, specialty consultation, and minor procedures. Inmates receiving

ambulatory care maintain independent functioning and do not require ongoing skilled nursing

intervention outside the encounter period. Inmates who receive ambulatory care return to their

housing unit after the medical service has been provided.

Examples of Ambulatory Care settings/services include but are not limited to:

 Medical Clinic. Designated clinical area for outpatient medical evaluation, treatment,

medication administration, and follow-up services.

 Dental Clinic. Designated clinical area for outpatient dental evaluation, preventive care,

treatment, and procedures.

d. Clinician. A health care professional who is both licensed or certified, and credentialed to

provide direct care within the scope of their education and discipline. The duties assigned to

clinicians are based on their licensure and scope of practice, and not all clinicians can perform

the same responsibilities.

e. Comprehensive Medical Evaluation (CME). A comprehensive medical evaluation includes

a thorough history, physical examination, review of diagnostic reports, formulation of an active

problem list, and development of a treatment plan. This evaluation can be captured in the

electronic health record through a History & Physical (H&P) encounter, a 14- or 30-day

encounter, or a Chronic Care Clinic encounter.

f. Do Not Resuscitate (DNR) Order. A DNR order is the attending physician’s directive,

recorded in the inmate’s health record, to withhold or withdraw extraordinary life-sustaining

measures.

g. Durable Medical Equipment (DME). DME is reusable, medically necessary equipment

prescribed by a doctor for use in the home to manage an illness or injury.

h. Electronic Health Record (EHR). The EHR is used by authorized staff at all Bureau

facilities to document medical, dental, mental health, and ancillary support care or treatment.

Refer to the Program Statement Health Information Management for further information.

i. Enhanced-Ambulatory Care (Intermediate Care). Enhanced-Ambulatory Care (EAC)

refers to health care or observation services provided to inmates who require increased

monitoring, temporary separation from the general population, or accommodation for medical,

mental health, infection control, or operational reasons, but who do not require infirmary-level

care or continuous on-unit nursing presence. Inmates in these settings may receive some or all

health care services at the bedside or housing location due to clinical condition, security

considerations, or operational necessity. Qualified health care professionals are available through

institutional response procedures, but nursing personnel are not continuously stationed within the

unit at all times. These settings may be used for short-term observation, isolation, quarantine,

stabilization, pre- or post-procedural monitoring, behavioral observation, or transitional care

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when outpatient management alone is insufficient but inpatient nursing care is not clinically

indicated. Inmates who receive enhanced-ambulatory care are not housed in general population

and require overnight stays to receive the intended service.

Examples of EAC settings/services include but are not limited to:

 Airborne Isolation and Quarantine Settings. Designated areas used to separate inmates

requiring infection prevention precautions or communicable disease monitoring.

 Medical Observation Beds. Short-term observation beds used to monitor clinical status,

treatment response, or recovery from minor procedures or acute conditions.

 Suicide Watch/Restraint Cells. Secure observation settings used for inmates requiring

continuous behavioral or safety monitoring with coordinated medical and mental health

oversight.

 Special Housing Unit (SHU) for Medical Purposes. SHU placement utilized for

medical isolation, trip preparation, clinical monitoring, or other medically indicated

purposes.

 Stepdown Unit. Transitional housing area used to support gradual reintegration or

stabilization following higher-acuity medical or mental health care.

 Specialized Housing Unit. Housing area designated for inmates requiring modified

environments, increased observation, or specialized operational support related to health

care needs.

j. Health Services Unit (HSU). The HSU is the department that provides health services at

each Bureau institution. The HSU is cooperatively managed by the HSA and the CD and

oversees all aspects of primary care, ancillary, and specialty services, delivered on site or via

telehealth, completed by Bureau staff or contractors. Staffing complements vary for each HSU,

with consideration given to the total facility population size, medical and mental health care level

designations, and assigned missions.

k. Inmate. Ward of the Attorney General in Bureau custody.

l. Infirmary Care (Inpatient Care). Refers to inpatient-level health care services provided to

inmates whose medical, surgical, psychiatric, palliative, rehabilitative, or functional care needs

cannot be safely managed in an ambulatory or enhanced-ambulatory setting and who require

ongoing skilled nursing care, daily clinical monitoring, or assistance with activities of daily

living for a period generally exceeding 24 hours. Infirmary-level care is defined by the scope and

intensity of services provided rather than by a specific physical location. Patients receiving

infirmary care require timely access to qualified health care professionals, including nursing

personnel who are readily available at all times when patients are present. Care may include

medication and treatment administration, wound care, rehabilitation services, behavioral health

stabilization, chronic disease management, hospice or end-of-life care, or close clinical

observation requiring continuous health services capability.

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Admission to and discharge from infirmary-level care is governed by medical orders or approved

clinical protocols. Inmates who require Infirmary Care have clinical needs that prevent them

from being housed in general population or EAC settings.

Examples of infirmary settings/services include but are not limited to:

 Nursing Care Center (at MRCs). Designated inpatient unit providing skilled nursing

and supportive care services for medically complex inmates.

 Long-Term Acute Care. Extended inpatient medical or nursing care provided through

contracted community facilities for inmates with chronic or disabling conditions.

 Sub-acute / Skilled Nursing Facility. Licensed or contracted facility providing skilled

nursing, rehabilitative, and supportive care services beyond the capabilities of institution

outpatient care.

 Outside Hospital Admission (e.g., acute care, long term acute care). Community

hospital placement for inpatient medical, surgical, psychiatric, or specialty treatment

requiring services unavailable within the institution.

 Dementia Unit. Licensed or contracted facility providing specialized inpatient setting

designed for inmates with cognitive impairment requiring structured supervision and

supportive nursing care.

 Short Stay Unit (SSU). Nursing Care Center unit intended for short-duration skilled

nursing care, stabilization, monitoring, or recovery from acute illness or procedures.

 Comfort Care. Inpatient or residential care focused on comfort, symptom management,

and supportive services for terminally ill inmates.

m. Licensed Independent Practitioner (LIP). For the purpose of this program statement, an

LIP is a licensed and credentialed physician or dentist.

n. Life Sustaining or Life Prolonging Procedures. Life sustaining or life prolonging

procedures include any medical intervention or procedure that uses artificial means to sustain a

vital function or artificially prolong life (e.g., mechanical ventilation and dialysis).

o. Medical Classification. Medical classification is a system by which the Bureau assigns a

medical and mental health care level both to inmates and Bureau facilities. For inmates, the care

level is determined by their medical needs and based primarily on the chronicity, complexity,

intensity, and frequency of interventions and services that are required, as well as an inmate’s

functional capability. For facilities, the care level is based primarily on the clinical capabilities

and resources of the institution and the surrounding community, as well as specific medical

missions (e.g. dialysis, oncology, etc.). Classifying both the inmate and facility allows the

Bureau to match inmate medical and mental health needs with a facility resourced to care for

those needs.

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p. Medical Referral Center (MRC). MRCs provide a full range of diagnostic and therapeutic

services consistent with the individual mission, and a wide range of inpatient specialty

consultative and treatment services.

On-site services provided include, but are not limited to:

 Inpatient Services

 Enhanced-Ambulatory Care Services

 Ambulatory Care Services

 Behavioral Health Services

 End-of-Life Care Services

 Surgical Services

 Laboratory Services

 Physical Therapy and Rehabilitation Services

q. Next of Kin. Next of kin refers to a person’s closest living relative by hierarchy (hierarchical

order varies by state):

 Surviving Spouse

 Biological or legally adopted children

 Parents

 Siblings

In the context of hospitalizations, Health Insurance Portability and Accountability Act (HIPAA)

Privacy Rules authorize the notification of next of kin, as indicated by the succession of

hierarchy or established medical power of attorney.

r. Observation Area. The observation area provides accommodations of limited duration for

inmates who are being treated for noncritical illnesses, recovering from surgery, or requiring

observation for medical and/or mental health conditions, and who do not require inpatient care.

s. Proxy Decision Maker. For purposes of this program statement, a proxy decision maker is a

person authorized to make health care treatment decisions for an inmate who is incapacitated and

unable to make and/or communicate such decisions themself. The term proxy decision maker is

used generally in this program statement and may refer to a person named in an advance

directive, formally executed power of attorney, or as appointed by a court. The authority,

parameters, and procedures for creating such proxies are governed by the laws of the state in

which the institution operates.

Under no circumstances will another inmate be appointed as proxy decision maker. Additionally,

a Bureau staff member will not be appointed as a proxy decision maker.

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t. Team Medicine. Team Medicine is the conceptual framework by which clinical,

administrative, and ancillary health care personnel (employed and contracted) work

collaboratively to deliver health services to inmates.

u. Telehealth. Telehealth refers to the use of electronic communication technologies to facilitate

access to care, provide health care services, and improve the health of inmates.

v. Terminal Condition. A terminal condition means an incurable or irreversible medical

condition for which, in the attending physician’s opinion, death will likely occur within a short

time regardless of the application of medical interventions.