D-3C The Basics: What Does Facility Administration Need to Know About Correctional Health Care ( CE/CME) (Healthcare

1. D-3C  The Basics: What Does Facility Administration Need to Know About Correctional Health Care (CE/CME) (Healthcare/ Security)

2. Basic Issues in Correctional Healthcare Jim Sokol, BSN, RN Regional VP, Mid-Atlantic Conmed Dean Rieger, MD, MPH Chief Medical Officer Correct Care Solutions

3. Presentation Goals Discuss Constitutional underpinnings for care inside the walls Differentiate between federal and state issues Expose novice custodial administrators to the basics of correctional health care

4. Case Study #1 • James, 30 y.o. w/ life sentence • Chief Complaint: rash from weight bench • Observation: rash consists of a slightly whitened area; there is no infection, no weeping, no itch…just the discoloration He wants medication to make the rash go away Do you send him to the dermatologist for diagnosis and advice regarding treatment?

5. Case Study #2 • Ginny, 25 y.o. – has four month sentence for meth possession • Observation: teeth are severely ground down and those remaining are brown with deep caries; her gums are painful, bleeding, and swollen She wants her remaining teeth extracted and to receive dentures while she is with you Do you need to extract the teeth? Do you provide her with dentures?

6. Case Study #3 • Jane, 66 y.o. w/ 2 yrs left on 18 yr imprisonment • Chief Complaint: requesting a new wheelchair • Observation: arthritis in both hips, and recently developed a stomach ulcer thought to be related to her use of ibuprofen to help relieve hip pain • Health services personnel want to refer her to an orthopedic surgeon Will you give her a wheelchair? Will you send her to the orthopedic surgeon? Will you support hip replacement surgery?

7. Case Study #4 • Mark, 55 y.o. ex-smoker, leaving prison in 3 months • Chief Complaint: coughing a small amount of blood-flecked phlegm • Observation: no other symptoms • Health services staff want to work him up for possible lung cancer Should you proceed to expend these resources now, at the end of his confinement, or should you defer this work up until after release from prison?

8. Foundational Issues • Deliberate Indifference • State laws, regulations, other • Malpractice • Accreditation

9. Deliberate Indifference Case from Texas hit the Supreme Court in 1976; decision cited the Eighth Amendment to the Constitution • Serious medical condition • Deliberate indifference What do these terms mean What is included?

10. Deliberate Indifference II Inmates complain that they have a right to… Do they? You must understand deliberate indifference better than the inmate Inmate claim that they have lots of rights…that they do not.

11. Malpractice Your clinical personnel have to worry about malpractice What is malpractice? Four elements: • Patient provider relationship • Care provided in a negligent manner • Patient has been damaged • The negligence caused the damage Custody can be deliberately indifferent but cannot commit malpractice

12. Accreditation Accreditation makes it easy • Create the context for Constitutional care • Helps insure that you address all aspects • Reassures outside agencies that you are doing the right things Without accreditation questions arise • What is wrong in the facility? • What is not being provided to the inmates? • Is something being hidden?

13. Inmates Rights Deliberate indifference is a civil right accorded to inmates • Access to care • Access care from an appropriate provider • Receive care that has been ordered by a provider Courts assume that care ordered has been ordered because it addresses a serious medical condition. This default assumption may be wrong.

14. No Right To Just because inmates want something does not mean they have a right to it: • No right to choose provider at any level • No right to determine where care will be provided • No right to distinguish between serious and nonserious care (this is reserved to the health care professional

15. No Right To Just because inmates want something does not mean they have a right to it: • No right to care irrespective of cost • No right to care irrespective of remaining confinement time

16. Pause . Questions on deliberate indifference?

17. Conservation of Resources Provide good care efficiently Implications of Deliberate Indifference towards resource preservation. You and your staff control the care process. Short stay facilities may mitigate costs by ROR or other legal means

18. Service Components Physical health needs Mental health needs Dental health needs It is not necessary to provide every imaginable type of care but it is necessary to address mainstream care expectations. Think family practice not herbology.

19. Physical Plant Appropriate space • Exam • Office • Storage • Pharmaceuticals and sharps • Waiting room

20. Support Utilities • Water, light, electricity • Internet Supplies and equipment

21. Personnel Health care practitioners Mental health practitioners and professionals Nurses and other professional support personnel General support staff Don’t forget appropriate current credentials!

22. Clearance Process Arresting officers and use of hospital emergency departments Assessment at your front door prior to acceptance in • By officers • By nurses

23. Front Door Processes Receiving screening Disposition for housing, diet, special needs Health Assessment (general intake physical exam) Necessary lab and/or diagnostic screening Referral for care identified in front door processes

24. Ongoing Care Identification and initiation of care for chronic diseases Access to care for routine needs (sick call) Access to care for urgent needs Access to care for needs identified by “others”

25. Care That Cannot Be Provided On Site Think: • Complex machinery • MRI, CT, • X-ray and Ultrasound – mobile? • Emergency Room • Hospital • Nursing Home • Specialist

26. Pharmaceutical Services Commissary Prescription Keep on Person (May Carry) One Dose at a Time (DOT) No-miss medications Essential medications Discontinuing community prescriptions Release medications?

27. Return To Community Community Interface usually uncontrolled Serious medical condition untreated may mean return to confinement • Mental Illness and nuisance violations • Substance abuse Costly necessary treatment-”Come and get me”

28. Health Record “Permanent” record of care delivered Tells the story in forms and language Explains clinical decisions made during confinement Protects the facility and staff Facilitates continuous care upon release or return to confinement

29. Continuous Quality Improvement CQI Cycle: • How are we doing? • Is it good enough? • What can we do better? • How do we implement it? • Did it work? • No? Then come up with another way. • Yes? Then look at something else.

30. CQI Elements Structure Process Outcome

31. CQI Elements Structure Process Outcome

32. CQI Elements Structure Process Outcome

33. The Future Affordable Care Act will affect hospital pricing and payments and may even provide care in certain types of outpatient circumstances, much still TBD and varying in “opt-in” and “opt out” (Medicaid expansion) states

34. Thank You Questions? James Sokol BSN RN Dean Rieger MD MPH Conmed Correct Care Solutions