Correctional health providers are being called to radically change the system of helping patients manage chronic diseases such as hypertension and diabetes.

U.S. Surgeon General Richard Carmona, MD, MPH, CCHP, has said that the “entrenched episodic treatment approach” leads to higher morbidity, mortality and costs. Speaking at the 2003 National Conference on Correctional Health Care, he advocated a total disease management approach that includes adequate counseling about self-care responsibilities. He also exhorted the audience to focus on improving health literacy among the incarcerated, and called for an emphasis on prevention.

A barrier to changing health behaviors, however, lies in patients’ health beliefs.

Beliefs and Behavior
Many of us in the healing professions in the 21st century have beliefs that include the importance of self-care and of attention to nutrition, exercise, stress management and adherence to specific health care guidelines and recommendations when we do develop chronic diseases. We’re likely to agree to some degree with these statements from the Health Locus of Control scale. (The scale measures the degree to which individuals believe their health is controlled by internal or external factors.)
• If I take care of myself, I can avoid illness.
• When I feel ill, it’s often because I have not been getting the proper exercise or eating right.
• I am directly responsible for my health.

A person with these beliefs will take an interest in nutrition, in oral hygiene, in simply washing hands.

However, many of the patients in correctional facilities have not paid attention to health promotion behaviors, and are perhaps more likely to have beliefs similar to these statements, also from the Health Locus of Control scale:
• Good health is largely a matter of good fortune; people who never get sick are just plain lucky.
• Most people do not realize the extent to which their illnesses are controlled by accidental happenings; no matter what I do, if I am going to get sick I will get sick.
• There are so many strange diseases around that you can never know how or when you might pick one up.

People with these beliefs may not even be aware of health promotion behaviors, or may consider them to be too much trouble or futile. Information is not sufficient to bring about significant change in health beliefs and behaviors. It is essential to make patients aware of their tacit beliefs so that they can examine them and then change them.

The Health Belief Model is helpful in explaining individuals’ health behaviors. Developed in the 1950s by social psychologists with the U.S. Public Health Service, the model is based on the understanding that a person will take a health-related action if he (1) feels that a negative health condition can be avoided; (2) has an expectation that by taking a recommended action, he will avoid a negative health condition; and (3) believes that he can successfully take a recommended health action.

This ties in to the concept of self-efficacy, necessary for an individual to tackle the challenge of changing habitual unhealthy behaviors, such as being sedentary, smoking or overeating.

Education Is Key
All well and good, the frontline correctional health care provider may think, but how am I supposed to challenge and change health beliefs and all the while still take care of urgent needs?

It begins with education. NCCHC standard F-01 Health Education and Promotion requires that “health education is offered to all inmates; all patients are provided individual health instruction.” At minimum, brochures on a variety of health topics should be available; resources such as audio- and videotapes and classes also are useful.

But what if patients’ health beliefs or literacy skills do not move them to study brochures, play tapes or attend classes?

One solution is the use of small group medical appointments. Kaiser Permanente has done extensive research on small group appointments in the past 15 years and has found that they increase compliance with health care recommendations, improve patient satisfaction and reduce health care expenses.

The single patient medical appointment system developed over a century ago, when most physician visits were for acute injuries and infections. Over time, as life expectancy has increased, the majority of medical interactions have come to deal with chronic illnesses and syndromes, issues that require lifestyle changes rather than immediate intervention.

But it’s rare to be able to adequately discuss management of complicated medical situations in a 15-minute appointment or while simultaneously providing treatment.

In the community, group-visit programs, also known as shared medical appointments and cluster visits, have emerged to provide a level of patient education and follow-up that office visit schedules seldom allow. Group visits are appointments with a physician that take place in a supportive group setting. While the physician sees as many as 15 patients in the 60- to 90-minute visit, each patient spends the entire visit with the doctor. It’s a positive experience on both sides.

Group Visit Models
The group visit concept translates well to the correctional setting, especially because the “appointment” need not always be with a physician. Indeed, it often may be appropriate for nurses—the front-line providers in many cases—to lead such groups.

Many types of medical problems lend themselves to the group-visit format, particularly those that are common, costly and responsive to lifestyle changes. Among the conditions that can be addressed effectively using group visits are asthma, congestive heart failure, coronary artery disease, depression, diabetes, GERD, irritable bowel syndrome and obesity. The format also is useful to improve patients’ oral health self-care.

Three general models for the shared medical appointment exist. Depending on the patient population profile, any or all would be appropriate in a correctional setting.

First is the cooperative health care clinic (CHCC), created for older patients who require frequent, broad- spectrum care. Second is the disease- specific CHCC, an ongoing, diagnostically exclusive group that helps patients manage chronic disease.

The third model is the drop-in group medical appointment. Intended for established patients who need a more comprehensive approach to their follow-up care, DIGMAs usually are effective for patients who might otherwise need a disproportionate amount of visits or time, including patients who:
• need routine follow-up care
• have relatively stable chronic illness but require mind-body care, more time with their physician, periodic surveillance and monitoring, or closer follow-up care
• are noncompliant or come for frequent return visits
• have extensive informational, emotional or psychosocial needs
• are the “worried well”

To challenge health beliefs, to empower patients to take responsibility for their health and to effect change in health behaviors, it is necessary to think beyond what is covered in typical office visits.

Group visits are most effective if they involve dialogue, not lecture. It’s important to establish a respectful group culture and to find out what people know—and what they think they need to know. The concept of constructivism tells us that when we learn, we are building upon what we already know or believe, and that we learn best experientially, by making connections and reaching conclusions ourselves.

As always, audiovisual materials and handouts enhance the effectiveness of presentations and the application of information by patients.

Proven Results
Use of well-structured group appointment models can have many benefits, as numerous studies in the medical literature have shown.

Kaiser Permanente has found that such models reduced emergency room visits, hospital admissions, use of skilled nursing facilities and referrals to specialists. They also saved money: The cost of care per member per month was nearly $15 lower for the group participants than for the controls, despite the extra expense of running the groups. Studies also show that participants were more likely to get flu and pneumonia shots and to practice other health promotion behaviors, and they experienced higher levels of satisfaction.

While correctional populations are unique in many ways, it’s not difficult to envision the positive effects from improving inmates’ awareness of and motivation to practice healthy behaviors. Foremost, it would lead to better health. But it also would lessen the strain on health resources and budgets for medications and urgent care.

Small group appointments may not appear overnight in correctional settings, but the development of formats and content tailored to specific illnesses can be a goal for the future..