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D-1BÂ Challenges in the Delivery of Jail Healthcare: What Can Go Wrong Will Go Wrong ( CE/CME) ( Healthcare/Jail ). Challenges in Correctional Healthcare. Jim Sokol , BSN, RN Regional VP, Mid-Atlantic Conmed. Dean Rieger , MD, MPH Chief Medical Officer Correct Care Solutions.
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What Can Go Wrong Will Go Wrong
Jim Sokol, BSN, RN
Regional VP, Mid-Atlantic
Dean Rieger, MD, MPH
Chief Medical Officer
Correct Care Solutions
The largest population of non-compliant patients seems to be Diabetics. While there are lots of patients who do watch their diets, some diabetics allow their wish for Commissary snacks to override their need for health. We have seen patients who come into the clinic unresponsive with a 6am blood sugar of 20 (very low!!!!) and return in the afternoon with a BS of 550 (amazingly high). The wide range of numbers makes caring for them difficult when they have no interest in caring for themselves.
On rare occasion a simple conversation as well as some disease specific education can assist the patient to take care of themselves and be compliant with medical advice, but sometimes, unless we can restrict Commissary purchases, we are doomed. Documentation is the key to protecting the facility; if the patient will not take care of himself or herself, at least we can create a medical record that demonstrates that patient’s responsibility for the failure.
We also recognize that it may take multiple efforts at education to get a patient to become more adherent to medical advice; this is no different from any other behavior change. It does not happen at once.
Medications given on a Timely Basis.
Medication pass time has a tendency to grow and grow, irrespective of the number of medications prescribed. Certainly by limiting the number prescribed the need for long pass times can be curtailed, but sometimes a bigger challenge is getting our patients to respond in a timely manner to scheduled medication passes. Some patients won’t wake up until someone calls specifically for them. Others just feel like doing other things, important things like watching television. And then they come late, expecting nursing personnel to vary their pass times and behaviors to suit the inmate’s convenience.
In general the best response to these behaviors is to inform the patient that the medications are available during a specific time slot and not to make individual allowances. When medications must be provided in order to accomplish important treatments, we must remember that the inmate is required to be where we direct him to be. The inmate can be ticketed for being out of place if he misses medication. This is not a misconduct for declining medication, which he can do; this is a misconduct for failing to present himself to the medication line. And if he winds up in segregation for a while; well, at least when the nurse arrives to pass medications he is available.
Medication being given properly
I think I would leave this one out. This is aimed at correctional/custodial employees and they should have little to do with medication administration. Rather I think some general comments on CQI might be appropriate. Let’s talk.
Medication errors will always occur. The trick is to do whatever you can to ensure they do not happen often. What would be an acceptable number of medication errors in a one year period? If your answer is none, that is a great expectation. It may not be a realistic expectation, but as long as we are striving for that number we cannot go wrong. One issue that has been found is improper documentation on the patient’s MAR. Doctors changing orders that are improperly transcribed onto a patient MAR can cause a nurse to miss a dose or worse give the patient to much of a medication. This is just one example of how an error can occur. One way to help ensure proper medication delivery is an EMR. This allows the nurses to see the medications and dosages while the patient is right in front of them. Something here about not pre-pouring meds would also be a good idea.
Under the deliberate indifference standard we are obligated to provide care necessary to treat serious medical conditions. Sometimes staffing inadequacies interfere with this ability. There are two types of staffing challenges that we face. One type develops when we are simply budgeted to have too few medical professionals to meet the population’s needs. The second type develops when funding is adequate but we are unable to fill our staff with adequate numbers of trained and competent professionals.
The first type must be addressed proactively; those who manage the budgets must understand our obligations and must address them. If they do not, and you, the custodial professionals, are the ones who are here responsible, nothing will make the system function properly.
The second type is a challenge of a different order. How do we attract health care professionals to work inside an environment which may be old, ugly, and behind locked gates, when they can just as well work in a clean middle class environment with patients who are happy to be there, who have chosen to be there? It takes a special type of professional to want to work in corrections, to recognize that professional satisfaction often comes from doing the right thing rather than from seeing a grateful client. When we do find these, we need to make it easy for them to work with us. Security clearance processes that take months to complete will certainly interfere with our ability to hire the right professionals. Maybe we have to pay them more to work “inside the walls.” (This has been referred to as the corrections tax.) We have to understand the market for the professionals we need, and to find ways to make sure that they find job satisfaction with us, even if we treat them in a special manner because of their rarity. And with the Affordable Care Act poised to create a primary care shortage, our challenge is likely to become even more difficult.
What is a hunger strike? In corrections, we term any refusal to eat or drink adequate amounts of food and liquids a hunger strike. This is different from the community definition which is based upon the political hunger striker. We see hunger strikers of several types:
Those who are seriously mentally ill and stop eating and/or drinking because of psychosis or simple fixed delusions
Those who are not mentally ill and stop eating and/or drinking in an attempt to manipulate the system, whether for political purpose or for specific personal gain
Those who, for either of the above reasons, do not stop eating and/or drinking, but do not eat or drink adequate quantities.
The first thing we must do is try to determine what is happening. Is there a serious mental illness contributing to the hunger strike? If so, we must treat it. With remission of psychosis or delusions, the hunger strike will usually go away. During that period, of course, we may need to go to court for treatment orders or hospitalize a patient to obtain necessary care.
If mental illness is not an issue, we ought to understand the purpose for the hunger strike. While we do not want an inmate to “control” us through self injurious behavior, neither do we want an inmate with a legitimate grievance to go with that grievance unaddressed.
During all of this we need to monitor the inmate as closely as may be required to prevent significant self harm. Our legal partners (think “attorneys”) need to be involved early. The courts usually, but not always, decided on the side of preventing serious self harm through hunger striking. And after all, if self harm is going to occur, isn’t it better for it to happen only after the court so directs?
Finally we need to remember that individual facilities do not have a lot of hunger strikers. Although I interact with many health services administrators regarding hunger strikers, most of them see no more than one or two a year, if that many. I cannot expect them to understand how to manage these difficult patients.
In the outside community therapeutic diets are restrictions placed on persons based upon medical needs. This is different in correctional settings, where therapeutic diets often result in increased meal choice. Also, in our settings, therapeutic diets often represent challenges to food services, both in preparation and in delivery. So what do we need to do with regards to these diets?
As usual, considerations of deliberate indifference can give us the answer. Treatments necessary to treat serious medical conditions need to be provided; treatments not necessary do not. That approach, as so often happens with the concept of deliberate indifference, gives us both a minimum below which we must not go and a maximum above which we need to go.
Right away we know that diets not necessary to treat serious medical conditions need not be provided, at least through medical services. Vegetarian and other preference diets, even those desired for religious reasons, ought not be prescribed by clinical personnel.
What do we do when we provide a therapeutic diet and the inmate goes on the regular diet line? The approach here must be individualized. Sometimes it may be appropriate to stop the diet, documenting well the reasons for the action. At other times it may be clinically better to have partial adherence than no adherence at all. This applies also to commissary food obtained despite its inconsistency with a therapeutic diet. (Some facilities permit clinical services to forbid access to commissary foods and some don’t. Different approaches may be developed depending upon access. It is really handy when health services personnel can easily determine what is being purchased from the canteen.)
Finally, what is a minimum set of routine therapeutic diets that a facility needs? Before answering this question, consider whether a heart healthy diet might be appropriate instead of a classical high carbohydrate high salt high fat regular diet. Many persons benefit from this as a basic diet, and this approach would mean that your inmates with hyperlipidemia or cardiovascular conditions would not require any therapeutic diet at all. Consider at the same time whether your diet contains too many calories. In truth, for all except the largest and most aggressively exercising adults, 2500 calories per day is more than enough.
A minimum diet list might include (on rare occasions others might be needed):
Mechanically modified (soft, full liquid, etc)
Heart healthy (see above comments)
Diabetes (three meal pattern for those not receiving insulin, four meal pattern for those receiving insulin, and three calorie levels for each type approximately 1800, 2200, and 2500)
Notice the absence of the bland diet – which has never been shown to be useful in any condition. Notice also the absence of the double portion diet. This is another diet that has next to no clinical indications.
Seriously mentally ill patients and the specific problems of dehydration and psychogenic polydipsia
Serious mental illness is a serious medical condition and we have to be responsive to it. In fact, the right to receive necessary treatment for serious mental illnesses along with the disappearance of many community mental health resources has led to the ever-increasing numbers of seriously mentally ill in our jails and prisons. That process is a different lecture, but it emphasizes for us the extent of the problem.
Mental illness as currently defined includes substance abuse disorders, personality disorders, and so-called axis one disorders (the multi-axial diagnostic system is disappearing along with DSMIV, but again, that is not the topic for this lecture).
Substance abuse disorders cannot really be treated in short stay settings simply because the length of time required to treat is too long for the setting. In long stay settings substance abuse disorders may require greater or lesser amounts of treatment, depending upon policies and laws.
Personality disorders are deeply ingrained, inflexible patterns of relating, perceiving, and thinking serious enough to cause distress or impaired functioning. Personality disorders are usually recognizable by adolescence or earlier, continue throughout adulthood, and become less obvious throughout middle age. We do not have effective ways to treat personality disorders although some approaches have shown promise in helping motivated individuals modify their behaviors. Again, in short stay settings “treatment” is impossible. In long stay settings treatment may be offered but its utility, especially over the long term, is questionable. Here the deliberate indifference standard tells us that treatments without efficacy do not have to be provided. To the extent, however, that we can successfully affect personality disorders so that the individual does not reoffend (or improves behavior during confinement), it is the “right thing to do.”
And now we are left with the Axis One disorders, which include the developmental disorders and the major mental illnesses such as schizophrenia and mood disorders. These usually require treatment in both short and long stay facilities, and appropriately trained and licensed personnel should be available to guide care. Treatment for these conditions is kind of like a sink; the process will accept as much as you are willing to pour in. Therefore, along with your staff, you must set limits that respond to serious needs while avoiding attempts to achieve perfect stability or interventions that may “feel good” to the provider but don’t really affect the patient’s status.
Medications used to treat serious mental disorders can be very costly, but there are usually inexpensive alternative medication choices which are equally effective. Depending upon your local laws and courts, and the attitude of your providers, you may be able to reduce costs by changing medications in an intelligent and safe manner.
Watch out for placement of seriously mentally ill patients in poor condition in segregation. In many cases the courts have found such placement to be improper and to represent cruel and unusual punishment. Since so many seriously mentally ill inmates have only been arrested because of nuisance violations, things such as sleeping in a parking lot or urinating in public, it is of especial concern when such arrestees and inmates wind up seriously disturbed and in segregation.
SMI and refusing treatment
Now you are faced with an inmate who is seriously mentally ill, typically with a schizophreniform disorder, and treatment is being refused. The patient may be overtly psychotic, may be refusing food and drink, or may be inattentive to basic hygiene needs. No matter the precise presentation, he is, in the parlance, “gravely disabled.”
Grave disability due to mental illness is grounds for forced treatment in corrections in one of two circumstances. The first is under emergency circumstances when harm is imminent, in which case local (state) laws must be followed and careful documentation created. Emergency psychotropic medication is typical for no more than one or two doses and often the patient must be seen directly by the prescriber. The other circumstance is when there is ongoing grave disability and harm is more pervasive and less immediate. This is only applicable to sentenced offenders, under the Supreme Court decision in Washington v Harper. This decision created a process for forcing treatment without resorting either to the courts or to outside mental health hospitals.
When neither emergency nor non-emergency psychotropic drug treatment is appropriate (for whatever reason), support from the local emergency room may be sought. Emergency rooms may hospitalize into a general or mental health hospital, depending upon the location and the resources available.
When none of the above will work, it is possible to request a court to order treatment. Treatment orders are rare within correctional facilities, but they can do the trick when circumstances are desperate. You need to work with your legal support structure to bring this off.
But other than these options, our inmate patients do have the right to refuse care.
Appliances and ADLs
Inmates show up with braces, wheelchairs, and all sorts of assistive devices. It is security’s job to make sure that the item is safe and does not contain contraband; it is medical’s job to make sure that the device is necessary to treat or support a serious medical condition. Blanket disapprovals (“We don’t permit any…) are a set up for a lawsuit.
This is perhaps the single most dangerous clinical challenge in short stay facilities. Withdrawal from many drugs is life threatening, and many of these drugs are prescription medications. Alcohol withdrawal is not simply a matter of the shakes; severe withdrawal, or DTs, can result in cardiovascular collapse and death. To be sure, withdrawal from any sedative or hypnotic medication can do the same thing. Perhaps the worst prescription drug from the standpoint of withdrawal is Xanax, or alprazolam. This is a short acting benzodiazepine that is very popular both with patients and prescribers, and withdrawal can begin in only a matter of hours. The faster acting the sedative hypnotic, the more likely it is to have a severe withdrawal syndrome. Don’t assume that the inmate will just “sleep it off” or get over it.
Withdrawal from sedative hypnotic drugs, including alcohol, is properly managed by providing a slower, longer acting medication that has sedative hypnotic properties of its own, but from which withdrawal is so slow that a severe withdrawal syndrome is unlikely to result. The safest and most commonly used drug for this purpose is Librium, or chlordiazepoxide, a benzodiazepine with a half life of about XXXX. Also commonly used in residential or hospital withdrawal settings is Ativan, or lorazepam, which has a reasonably long half life but is somewhat more difficult to administer. The differences in usage are not particularly important for the purposes of this discussion.
Make sure that your short stay facility providers understand sedative hypnotic withdrawal and manage it closely.
Withdrawal from opiates such as heroin or oxycontin also present problems especially in the short stay setting, but the opiate withdrawal syndrome is more painful and debilitating than actually dangerous. As opiates leave the body all of the previously damped down nervous system processes come back on line, with a vengeance. The GI tract picks up causing nausea and vomiting. The muscles, large and small become active, with actions as small or goosebumps or pilorection or as large as frank shivering. And the pain pathways which were previously unnoticed are alive, causing diffuse and often severe pain. But unless there is an underlying disease such as heart disease and the withdrawing inmate simply cannot tolerate the stress, or the patient is pregnant, opiate withdrawal is not inherently dangerous and is simply treated symptomatically.
Pregnancy requires special mention; during opiate withdrawal placental infarction may occur, causing fetal loss. For this reason no one other than a high risk obstetrical specialist should consider permitting an opiate addicted pregnant patient to withdraw. Continuing or initiating opiate therapy during pregnancy may be challenging; it is good to work closely with your local methadone clinic and high risk OB provider so that you are not blind sided when faced with this problem.
Some controlled substances will need to be used in your system, whether they are employed to provide cross tolerance for alcohol withdrawal management or to provide relief from pain. What is important is to make sure that any usages are truly necessary, and that the supplies and pills administered are well controlled and counted. Missing controlled substances may result in a visit from the DEA, which is never a good thing.
Self injurious behavior
What about these inmates who cut themselves, pierce themselves in other than cosmetic ways, or insert unusual objects in their bodies? It only takes one such inmate to disrupt an entire facility, and little bit of blood goes a long way.
Self injurious behavior can usually be categorized in one of a few ways.
Inmates who are seriously mentally ill and injure themselves due to command hallucinations or delusions that are a product of the disorder. These inmates need to have the underlying disorder treated and the behavior will usually go away.
Inmates who have a lifetime pattern of reducing anxiety by injuring themselves, usually by cutting, but sometimes by other behaviors such as piercing or pulling hair. Such inmates may be partially responsive to medications or involvement in counseling or supportive programming, but success in managing such inmates is measured by reduction in frequency and not be elimination of the behavior.
Inmates who are frankly manipulative, demanding special privileges, classification changes, or other concession. If the demand is reasonable and should have been met anyway…then meet it. Otherwise, these inmates should find themselves in segregation managed strictly.
Inmates swallow lots of things. Plastic utensils, razor blades, unknown drugs, hygiene items, you name it. The first reaction of custodial personnel and, unfortunately also of some medical personnel, is “get it out.” ER and general surgeons are only too happy to oblige. What items are actually dangerous?
First a few facts about swallowed items. Most, even the sharp ones, will pass on their own. The tightest part of the GI tract is the upper esophagus just behind the throat, so it if was swallowed it was not too large to pass all the way. Even items like tooth picks or razor blades will usually pass quite safely, although patients who swallow items with the potential to pierce the intestine do need monitoring. Items that are dangerous include:
Batteries – they may burn holes in the intestine
Bags of drugs or unknown drugs – they may kill with little notice
Known toxic drugs – don’t underestimate the ability of an over the counter medication such as acetaminophen to kill
But that’s about it. The rest will pass. Inmates who are swallowing in order to be manipulative will rapidly give up the practice once they learn that it will no longer result in a trip. Those who are swallowing because of underlying severe mental disorders are, of course, another story; they need treatment.
When the medical need conflicts with the security requirement
This conflict is very common and comes out in a few common ways
Trips off site are difficult because staff or vehicle availability
Appliances or assistive devices represent security risks
Medications prescribed represent a risk to the security of the facility
The Supreme court actually intervened in these conflicts when it made its decision in Estelle v Gamble; care necessary to treat serious medical conditions must be provided. So ask a few questions:
Is the medical condition serious?
Is the care necessary?
Is the care necessary now?
Is there an alternative to the care that will address the problem?
Is the security concern real or imagined?
Usually one or another of these options will do the trick, or at least it will so long as medical and security remember that, underlying everything, they are partners.
Drugs just cost too much
Control of pharmaceutical cost is actually too broad a topic to cover thoroughly in this setting. However, there are a few ideas that can help:
Find a pharmacy that specializes in correctional health care and shop for overall pricing. Your cost will be made up of a medication acquisition cost plus a dispensing fee.
Make sure you understand and take advantage of opportunities to return drugs for credit.
Understand that certain highly expensive medications will have to be provided; if you are able to utilize alternative funding sources (insurance, Medicaid, 340b pricing, whatever), do it.
Make sure you are providing medications necessary to address serious medical conditions and not medications used for nonserious care
Include your prescribers in your concerns; share the info with them
I don’t have enough officers to conduct all these medical transports
This is a tough circumstance; all you can do is work with your health services personnel to insure that they understand the deliberate indifference standard, that the care provided is care that must be provided, and that trips off site occur because there is no option but to go off site.
Threats to sue
Inmates threaten to sue when they are not kept happy. Inmates are not happy when they don’t get what they want when they want it. They have a right to receive care necessary to treat serious medical conditions, but all aspects of that care are under the control of the correctional facility health services professionals. Make sure that necessary care is being provided in a reasonable manner and you will be able to withstand any lawsuit.
Remember that the deliberate indifference standard is the “bible” of correctional health care. Understand it and follow it. Work closely with your legal advisors.
The hospital won’t return inmates to us
All too often hospital personnel including physicians fail to understand the capability of the correctional facility to care for patients. This leads to a few additional hospitalization days as they attempt to treat patients so that they could return to independent living at home or even to additional days in the hospital because the inmate tells staff that he won’t receive ongoing treatment if he is discharged!
This requires advanced planning and several simultaneous activities:
There should be a contract that establishes a formal relationship between the correctional setting and the hospital. Within this contract hospital personnel should be given the opportunity to visit the correctional facility.
Contracts should provide for “claims reviews” in which the hospital’s request for payment can be modified. It is impermissible for correctional facility personnel to dictate hospital discharge BUT it is very permissible for correctional facility personnel to inform hospital personnel that they have used the hospital in a manner akin to an expensive hotel and that portions of the hospital bill (the excess days) will not be paid for.
In order to facilitate appropriate movement in and out of the hospital, established communication channels at admission, discharge, and during continuing hospitalization are very helpful.
Access to mental health facilities is so restricted
Event-mentally ill patients are often arrested for “nuisance offenses,” but they are often psychotic and disorganized. Such patients are often in the condition they are in because they have refused treatment. What do you do with a severely mentally ill patient who truly requires medication to help treat their condition when they continue to refuse? You can simply let them refuse, but this is rather cruel, prolongs the confinement, and creates increased risk for even more disorganization, if not failure to take care of basic health and hygiene needs. What do you do?
This is best planned for in advance. If adequate and competent mental health personnel are serving the correctional facility, there will hopefully be opportunities for emergency psychotropic medication (although this option varies by state and organization) AND existing relationships with off site mental health services. Hospitalization may be required. In the worst emergency circumstances hospitalization through the general hospital emergency room may be required.
For sentenced offenders, additional options exist in the form of forced psychotropic medication provided to address grave disability secondary to mental illness as authorized by the Supreme Court in Washington v Harper. Use of this statute requires a fairly complex program capable of providing due process to the inmate patient before forced medication is initiated. It has the advantage of covering non-emergent treatment for many months at a time.
Reasons for non-adherence
Example - Diabetes
Necessary to administer medications timely
How do you walk the edge between delivering necessary care and maintaining facility control?
What do you have to provide?
Therapeutic diets are a routine part of supportive health care
Preference diets are not a clinical decision
Consider commissary usage when considering therapeutic diets
What is a hunger strike?
What are the major types of hunger strikes?
What are our obligations regarding hunger strikes?
When do we go to court?
When do we force nutrition?
Politically sensitive issue
Supreme Court has determined that a woman has a right to elective pregnancy termination, although states have identified varying restrictions on pregnancy termination
Seek legal counsel and recognize that restrictions will result in litigation.
Growing Correctional population ever since the 1950s
Correctional population includes serious and nuisance offenders
Obligation to treat
Advocacy groups very involved in correctional mental health care
Special problem of mental illness in segregation
What will emergency psychotropic medication do?
When is it appropriate?
How about long acting medication in emergencies?
Washington v Harper and refusal of care
How about restraints?
No fluids – death in as little as a few days
Some psychotic inmates simply stop eating and drinking
Obligation to intervene quickly
Usually avoidable death
Drink too much water and wash out electrolytes
First episode unpredictable
Rarely occurs in hot weather when exercising athletes overdue water
Cutting, swallowing, other?
A little bit of blood goes a long way
Why do they do it, and what do you do about it?
Does your health care staff really understand how to respond?
Drugs and medications
Major challenge in short stay facilities, not so much in long stay settings
Four major types:
Can a facility simply refuse to use any controlled substances?
What is required when controlled substances are used?
Hospitals keep patients too long
Hospitals demand return visits
Hospitals don’t send information back with the patient (except that darned patient information sheet)
What can you do?
Every state has mental health units that will treat inmates
Treat on site what you can – reasonably!
Don’t give up at “no!”
Consider Washington v Harper for sentenced inmates
Wheelchairs, braces, special shoes, canes and crutches, shower chairs…
Clinical needs and security needs will conflict
Drugs just cost too much.
Return to the basics
Yes, they are. Understand:
Work with your legal partners and identify in advance those circumstances likely to lead to litigation
Support CQI programs
Saved for last in the hope that the other issues would run longer
Management of pain is a community problem that leaks into the correctional world.
Opiate use challenges are recognized by essentially every medical practice board in the country
Usage requires history, examination, treatment plan, patient engaged in care
Discontinuation at entry requires evaluation and documented decision
In short stay settings it is often impossible to develop full information and staff must make decisions with limited knowledge.
In long stay settings there is time to obtain outside records and the thoroughly assess as decisions are made
We have selected a limited group of challenges.