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Spotlight on the Standards
With
Combined Standards, Less Is More
The first
Spotlight column on the 2003 adult Standards focused on
standards that had been “split” to achieve better clarity
and specificity. This time we consider the three cases in which
standards were combined to achieve the same goals. In each case,
the revision task force asked “why” the standard existed,
“what” its requirements were meant to accomplish and
“how” the desired outcome could best be presented.
Access to
Care
Inmate access to care for
routine and ongoing health concerns was addressed in previous
versions by the standards on Daily Handling of Non-Emergency
Medical Requests (J-34, P-35) and Sick Call (J-35, P-36). Now
these are combined into one standard that, like its
predecessors, is essential for accreditation purposes:
Nonemergency Health Care Requests and Services (J-E-07, P-E-07).
Essential to
the foundation of a health services delivery system, the process
of addressing routine health needs can be viewed as a continuum:
a request for help, evaluation of the request’s urgency,
assessment of the condition, and appropriate treatment or
referral. This continuum begins with the inmate experiencing a
health concern and ends with successful resolution of the
concern or treatment of the condition.
The new,
seamless standard requires four things: ability of the inmate to
request help directly from health staff for nonemergency
concerns daily (defined as 7 days a week, including holidays);
triage of health requests at least once every 24 hours by health
or health-trained staff; face-to-face sick call assessment and
treatment as appropriate (generally within 24 hours [72 on
weekends] when the sick call request is not clear as to the
concern or when the clinical content of the request warrants);
and a clinic visit to midlevel, physician, mental health, dental
or other specialty providers in a timely fashion based on the
presenting clinical need.
Segregated
Inmates
In former standards on
health care services for segregated prisoners—P-39 Health
Evaluation of Inmates in Disciplinary Segregation (essential),
P-45 Health Evaluation of Inmates in Administrative Segregation
(important)—the reason inmates were isolated from general
population determined how often and to what extent their health
was monitored. A second concern was their ability to access
health care as freely as those in population. For jail settings,
the assumption was that segregation was the same regardless of
the reason (J-43 Health Evaluation of Inmates in Segregation
[important]).
In reality,
health concerns surrounding segregation relate to the isolation,
sensory overload and deprivation that such living conditions can
cause. The conditions of isolation, not the reason for the
separation, dictate the intensity of health monitoring required
to identify and address changes in health status.
The conditions
of confinement and the degree of restriction also may affect the
ability to request health care. Segregated inmates must have
free access to health staff to voice their health concerns and
have them addressed, and the experience of isolation must not
harm their physical or mental health. Health monitoring contacts
must be meaningful and allow sufficient interaction for such
assessments to take place.
The combined
standard Segregated Inmates—J-E-09 (important), P-E-09
(essential)—now defines three categories of segregation, each
with different monitoring requirements.
Extreme
isolation refers to conditions in prisons sometimes termed “supermax,”
in which inmates are seen by staff or other inmates fewer than
three times a day. These individuals are isolated in single
cells, frequently do not talk with officers who deliver meals,
recreate alone, and must be restrained when they leave the cell.
This type of isolation generally is not found in jail settings,
and even in maximum security facilities may apply to just one or
two housing tiers. Generally inmates with serious mental health
disabilities are, by policy or law, not housed under such
conditions. Even for the most stable individual, these
conditions may precipitate mental health or health difficulties,
so daily contact by medical health staff and at least weekly
contact with mental health staff is required.
Limited contact
inmates, also in single cells, are most likely referred to by
custody staff as being in “disciplinary segregation.” This
type of isolation exists in a significant number of prisons and
large jails. Under these conditions, health checks three time a
week by medical or mental health staff should be able to
identify developing problems and ensure access for health care.
The third
category might best be called “separated” (from general
population) but not segregated (from each other) and often is
known as voluntary or administrative segregation. Prison inmates
may serve their time in this setting, as opposed to being moved
in and out of the unit. In jails, most segregation is
characterized as this level. Here weekly health checks by
medical or mental health staff assure free access and monitoring
of health status.
Oral Care
Formerly, the prison
version had one standard on oral care, P-36 Dental Care
(essential), but the jail version had two, J-32 Oral Screening
(essential) and J-40 Dental Treatment (important). In crafting
the revision, we found that just one standard, now called Oral
Care (J-E-06, P-E-06 [essential]) was the better method.
Oral care also
is a continuum of services: screening for problems, education on
good oral hygiene, a formal examination by a dentist and
prioritized treatment that reflects professional practice
guidelines. While time frames for these services differ in the
jail and prison settings, related to the anticipated length of
incarceration, the underlying principles remain the same. Oral
services would be incomplete if these areas were not attended
to. Addressing all aspects in one standard provides a more
comprehensive picture of what and how care is accessed.
(This article first appeared in the
Summer 2003 issue of CorrectCare.)
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