CorrectCare

KOP Glucometers in Prison? It’s Working Great in California

by K. Ball, DO, CCHP

As chief medical executive at Calipatria State Prison, a maximum security male facility, I oversee health care for more than 4,000 inmates. In 2008, I had an idea for improving care for patients with diabetes.

I felt that inmates needed to increase their responsibility in controlling their diabetes, and that if I could provide glucometers for self-monitoring, they would have better control and outcomes. After obtaining approval from the California Department of Corrections and Rehabilitation and my warden, I initiated a pilot program.

Health program specialist Lita Martin and I spent many hours creating a local operating policy for the program. To determine what the policy needed to address, we considered all aspects of the program, such as choosing and issuing glucometers, dealing with damaged meters, exchanging supplies, patient refusals and parties responsible for program specifics.

The glucometer and lancet device were selected based strictly on safety issues and, for the lancet device, also from a public health angle. We chose a self-retracting six-lancet device, feeling that it was somewhat tamperproof and so small that it could not be used as a weapon or for tattooing very well. For the glucometer, we picked a 17-strip barrel device. The barrel housing was acceptable to custody and also seemed tamperproof. For medical, we like the number of strips as it lessens the number of exchanges.

During this process we also had discussions with custody about housing. Housing units typically rotate who is released first to chow. There had been complaints of delays in feeding after insulin was administered, leading to hypoglycemic events, and sometimes the insulin was given after chow instead of before. Given our concerns about irregular feeding times and delays in insulin administration, the warden approved my request that all diabetic inmates be housed in the same building on each yard and that they consistently be released first for meals. We believe this contributes to better control and fewer adverse outcomes.

Policy Details
The diabetes self-care program policy was approved in January 2009 and we announced our intentions to all staff. A team of health professionals educated medical staff affected by the program, explaining the details and expectations.

The policy has evolved over time, with a few revisions to make it more practical. These are some of the highlights:

• The primary care provider will issue a medical permit to each program participant allowing him to self-test and carry his diabetic supplies. The permit identifies the items that may be carried, such as glucometer, drums, cartridges, plastic carrying case, alcohol swabs, batteries, lancet device and self-test diary.

• Nursing staff conduct weekly logging of the glucometers and supplies distributed. The patient is assigned supplies based on the frequency of testing ordered by the primary care provider. Every Sunday, nursing collects all used drums and cartridges and distributes new ones (on a one-for-one basis) along with alcohol swabs as needed. They also inspect the glucometers for tampering or other problems.

• The patient may dispose of the used strips and alcohol swabs in the regular trash.

• Diabetic supplies are the property of the patient and will accompany the patient upon transfer to another institution or parole.

• The initial glucometer and the weekly distribution of supplies are provided at no charge. If a glucometer is deliberately damaged, the patient may be required to purchase a replacement.

• Custodial disciplinary action will be taken if any of the following occur:
 – Patient willfully damages or abuses the glucometer.
 – Patient tampers with the glucometer and/or diabetic supplies.
 – Diabetic supplies are missing.
 – A patient not enrolled in the program is found in possession of a glucometer or diabetic supplies.

• To ensure that their insulin is readily accessible, type 1 diabetes patients will not receive job assignments that are off the institution grounds.

• Any patient refusing to participate in the program completes a refusal of examination and/or treatment. The patient’s blood glucose levels will not be checked by nursing except when presenting with symptoms or prior to insulin administration.

Our pilot facility was B yard, which has about 1,000 general population inmates. The goal was to enroll all 18 of the diabetic inmates into the program. To get started, a team of health professionals (chief physician, director of nursing, nurse supervisors, RNs, health program specialist and senior lab technologist) met with the inmates in a classroom setting. They presented general education on diabetes (basic physiology, monitoring calories, signs and symptoms, red flags) followed by in-depth teaching on glucometer use.

Two patients refused participation, but later accepted. All participants signed consents demonstrating understanding of program participation, expectations and how supplies would be distributed. On this same day, we gave them the glucometers, medical permits and supplies.

Signs of Success
Data collected three months into the program showed mild improvements in patient health. The participants’ average HbA1c level decreased to 6.60 from 7.01 before the pilot. A sample look at blood glucose checks for one participant found an average pre-pilot level of 233; this decreased to 120 during the pilot.

Analysis of the triage and treatment area log also suggests improved outcomes. In the 12-month period before the pilot, the 18 participants made 10 visits due to hypo/hyperglycemic events; at the three-month assessment, no visits had been made. Diabetes-related emergency room visits also decreased.

At three months we also conducted a survey of the 16 original participants. All replied “yes” in response to questions regarding satisfaction with the program, improved knowledge, improved health condition and better awareness of the diabetes disease process. In addition, 12 assigned a top score of 5 on a satisfaction rating scale, with the other participants assigning a rating of 4.

The survey also yielded uniformly positive write-in comments from the patients, such as “Very good, thank you!”; “Glucometer helps [patient] control his diet, I dropped from 238 to 220 lbs!”; and “Very happy to be part of program!” (For anecdotal reports from the field, see box above.)

Given the success of the pilot, in fall 2009 we expanded the program to all of the general population yards. At the time we had about 200 diabetes patients (the number is now about 120). Again we began with education. The consent forms were signed and the glucometers were issued. The program is second nature now; all general population diabetes patients receive the glucometer kit and weekly exchange of supplies based on their provider’s recommendations for self-testing. (The glucometers are not allowed in the administrative segregation units, but I understand that the San Quentin prison has a pilot program in ad seg.)

As far as more current data, this has been a bit difficult to obtain as only eight patients remain of the original pilot program. However, in October 2011 the average of all HbA1c levels in the general population was 6.81, reflecting an improvement from the average of 7.35 in 2008. Also, review of triage and treatment logs shows that the number of general population visits for hypoglycemic events was nine in 2006 but only one in 2010.

What We’ve Learned
I believe that the greatest benefit of the diabetes self-care program is the ability for the patients to take ownership of their chronic disease management. To self-monitor and manage their diabetes decreases their sense of helplessness and increases their autonomy. We were impressed to see the pride they took in the program, and to date we have had no reports of abuse. There have been very few refusals to participate; usually the refusals are from inmates who are in denial about their disease, and sometimes with time they accept and consent.

The second greatest benefit is the impact on nursing. This program has reduced greatly the nurses’ workload because they used to do the blood glucose checks as ordered by the primary care provider. They still check prior to insulin administration or for symptomatic patients, but not at any other times, even for those refusing glucometers.

The expenditure (about $10,000 per year) has not risen much because we used to give glucometers and supplies to diabetic inmates upon release; now it is an upfront cost. And we do see savings through reduced staff hours spent with these patients, fewer complications and fewer ER visits.

As far as program weaknesses, we would like the patients to be more faithful in keeping their dairies and bringing their glucometers or diaries to their clinic visits. Many only give recollections of their readings. We hope in the near future to add infrared readers to the providers’ computers; by waving the glucometer over the reader, all of the stored data will appear on screen for easier monitoring.

Also, for more than a year we have asked that all patients bring all medications to every chronic care visit. I feel this would help the provider and the patient in the management of chronic diseases, including diabetes, but this has been a struggle to implement.

But these glitches do not detract from the overall success and value of our diabetes self-care efforts. I recently gave a presentation on the program to a gathering of chief executive officers and chief medical executives from CDCR’s 33 adult institution. The CDCR’s federally appointed receiver so applauded our innovative vision and implementation of the program that he directed all 33 institutions to follow our lead. Since then, I have been part of a statewide committee helping to formulate a policy for statewide use. It is predicted that by early 2012, all diabetic inmates in the CDCR general population will have glucometers, and improved outcomes will follow.

— About the author: K. Ball, DO, CCHP, is the chief medical executive at Calipatria State Prison, part of the California Department of Corrections and Rehabilitation.

[This article first appeared in the Fall 2011 issue of CorrectCare.]