CorrectCare

Nursing Involvement Essential to Efficient Provision of Chronic Care

by Lorry Schoenly, PhD, RN, CCHP

A significant number of inmates in jails and prisons have chronic conditions that require comprehensive management during incarceration. And as the inmate population ages, the need for quality chronic care—and the cost of delivering such care—escalates. But there are opportunities to minimize costs through the efficiencies and effectiveness of a chronic care management system.

A coordinated program for the provision of chronic care is advocated by the National Commission on Correctional Health Care (see G-01 Chronic Disease Services in the 2008 editions of the Standards for Health Services for jails and prisons). However, implementing an effective system for delivering this care is fraught with difficulties. Even in the community, the health care system has been less than adequate in creating ways to consistently deliver chronic care on a continuum necessary to maximize benefit. Too often, health care is episodic and frequently based on irregular contact to deal with acute conditions without regard to disease progression, behavior management or patient education.

In the corrections environment, management of chronic illness is primarily a medical responsibility, but to be successful, the delivery of chronic care requires a team approach. Nurses play a major role in coordinating the chronic care process and delivering important components of care.

Essential Chronic Care Processes
The nursing role in many clinical processes includes managing the delivery of care. With many components converging to make up chronic care, efforts to streamline the structure of care delivery pay big dividends. Tara Taylor, RN, CCHP, regional director of nursing for Correctional Medical Services, recently led an initiative to increase efficiency in chronic care delivery in the Missouri prison system.

“We reduced redundancy in care delivered by the nurses and physicians in our facilities to promote teamwork and improve outcomes,” she says. “Now our chronic care nurses focus on medication compliance, diets and lifestyle changes.” Taylor is finding that the new approach makes more effective use of nurse time and improves the desired treatment outcomes.

In their revised system, a chronic care nurse sees the patient first and focuses on patient teaching and treatment compliance issues. The inmate then meets with a medical provider for assessment and any needed adjustments to treatment. The nurse’s information and observations enhance the chronic care session.

Information Coordination
A myriad of information needs to be available for a chronic care visit, including recent lab results, diagnostic reports and specialty consults. A designated chronic care nurse is often the team member who coordinates this information and assures that it is available and accessible at the time of the patient visit.

“Our chronic care nurse is familiar with the treatment plan for our inmate-patients and actively manages the many elements of the plan to assure follow-through,” says Debbie Vinson, RN, director of nursing at South East Correctional Center in Charleston, MO. Coordination efforts at South East include reviewing medication administration records for compliance, initiating diagnostics such as EKGs and pulmonary function tests, and checking lab values when they arrive. “Significant results are shared immediately with the medical provider so that adjustments can be made to the treatment plan,” she adds.

Patient Self-Management Advocacy
Patient participation in managing their chronic conditions has been shown to improve outcomes. However, the degree to which patients can engage in self-management in correctional settings varies based on the level of security and philosophy of the facility administration. Nurses have developed and oversee some creative methods for inmate involvement in their health care. A basic KOP (keep-on-person) program allows for self-administration of oral medications and inhalers. Some facilities permit inmates to do their own blood glucose monitoring and even, while being monitored, to administer their insulin. In these situations, nurses must create systems to maintain security while allowing inmate involvement.

Over the last year, McPherson Female Prison in Newport, AR, implemented a diabetes self-management program that includes an inmate-facilitated support group. Peer facilitators, carefully selected from the inmate population, received special training in group process methods and diabetes self-care information.

“The women involved in the program have benefited from a facilitated support group process that allows them to discuss methods to incorporate healthy lifestyle changes into their daily routines while gaining encouragement to persevere,” says Crystal Lavender, RN, director of nursing at McPherson. She has seen many positive outcomes from the support group, including improved blood glucose levels and increased accountability for commissary food choices. In addition, interest generated by the group has led to regular aerobic activities, such as a walking program, coordinated with security.

Patient Education
Patient education is a cornerstone of successful chronic care management and a priority nurse-led intervention. It is common to see patient education on chronic illness in the structure of a specific chronic care visit; however, teachable moments exist any time the inmate-patient is in contact with nursing staff.

“We use every opportunity we have with our patients as a time to reinforce health education,” says Celeste Hunter, RN, director of nursing at Ventress Correctional Facility in Clayton, AL. “Teaching an inmate about chronic hypertension and other chronic diseases occurs during sick-call visits and when distributing KOP medications. Every contact is a favorable condition to teach and promote good health.”

The timing of such education is important for information retention. Emotionally charged diagnoses such as HIV can make learning difficult, especially in the initial period. Nurses like Pam Smyth, RN, infection control nurse at Miami Correctional Facility in Bunker Hill, IN, are careful to let the inmate patient take the lead in how much information they are ready for. She uses a variety of “just-in-time” patient teaching methods to impart vital information in chronic care situations. Building rapport with her patients allows for an ongoing dialogue about sensitive issues.

“I give my patients the ability to seek information when they are ready for it,” says Smyth. “If they need time to think things through, I show them how to get in touch with me when they are ready to hear more.” The health care request process at Bunker Hill allows inmates to ask to see the infection control nurse with questions. Smyth uses a variety of teaching tools, such as visuals, information sheets and lab reviews, to teach about disease processes.

Side-Effect Management
Assisting the patient to remain in the treatment plan is another primary role of the nurse within the chronic care health care team. Once the physician or advanced practice provider has determined a treatment regimen, there are many potential obstacles to overcome. Nurses have regular contact with inmates in the course of medication administration, sick-call visits and segregation rounds.

A nurse regularly administering medications during pill call is able to significantly influence chronic care outcomes. Inmates may mention that a medication is “not working” or is causing a side effect such as stomach upset or rash. Medications may be refused or pill-call sessions missed. A consistent system for dealing with these interruptions in the medication regimen averts potential treatment failures. Many facilities have standards that require intervention if three consecutive doses of a medication are missed. Although systems for follow-up may vary from flagging charts to electronic messaging to providers, the importance of uninterrupted medication to effective chronic care management requires diligence in follow-through.

In addition, the patient may have misconceptions about the purpose of a new medication and thereby avoid doses. Reinforcement of the treatment goals as they relate to the ordered medication can make a difference in the inmate’s adherence to the chronic care program.

Nursing sick-call visits for acute conditions are also opportune moments for nurses to aid chronic care management. For example, an acute condition such as an ingrown toenail can exacerbate hyperglycemia in a diabetic. “We are careful to consider chronic conditions with every patient encounter,” says Kathy Armijo, LPN, CCHP, health services administrator at Guadalupe Correctional Facility in Santa Rosa, NM.

Recently, nurses at Guadalupe observed elevated HgbA1c levels in several inmates assessed during interfacility transfers. Arrangements were made for full medical evaluations, leading to diagnoses of diabetes. Many sites have solid systems for communication among team members so that care is coordinated and links are not missed.

Segregation rounds provide yet another opportunity to regularly monitor chronic illness. Regularly rounding within the inmate’s living environment enables nurses to regularly assess, firsthand, any changes in health condition, treatment and medication compliance, and diet or lifestyle adherence. Early interventions due to astute nursing observations can lead to improved patient conditions.

An Integral Component of Care
A successful chronic care program employs a team approach among a variety of caregivers. Nurses provide an important component of the program due to the clinical systems they manage and the various points of contact they have with inmate-patients. When components of chronic care management are woven into the fabric of nursing care delivery in the corrections setting, positive outcomes result.

— About the author: Lorry Schoenly, PhD, RN, CCHP, is a clinical education manager with Correctional Medical Services and is based in Pennsylvania.

[This article first appeared in the Fall 2008 issue of CorrectCare.]