Spotlight on the Standards

Understanding ‘Health Assessment’: More Than a Physical

As children, or even as adults, we all have played some variation on this word game: I say a word, and you reply with the first word that pops into your mind. That was the idea behind the long-running television game show “Password,” in which pairs of contestants tried to prompt their partners to guess “the word” by using one-word clues.

If prompted by the hint “assessment,” many involved in accreditation likely would blurt out but one response: “physical!” But they would be wrong. Why? This response omits many aspects to assessing the health of an individual.

Simple Questions...
The intent of essential standard E-04 Health Assessment is the same in all three versions of the Standards for Health Services (jail, prison and juvenile): “...that clinicians assess and plan for meeting the health needs of the individual.”

Do you understand how to meet this intent? How would you respond to the following questions? Think about it carefully before you read the answers!

Question 1: What is needed for a health assessment?
   A. If you replied, “a hands-on-physical,” you would be but partially correct. In fact, NCCHC requires seven (adult settings) or eight (youth facilities) components for a health assessment. These include, but are not limited to, review of receiving screening results; collection of data to complete medical, dental and mental health histories; recording of vital signs; physical examination, including breast, rectal and testicular exam as indicated (with pelvic and PAP required for women in prison settings); laboratory/diagnostic testing for communicable diseases; immunizations as appropriate; and initiation of therapy.

Question 2: When must the initial health assessment be performed?
   A. In all likelihood, those who work in prisons and youth facilities would respond “7 days” and those in jails “14 days.” However, the correct answer must reflect the wording of Compliance Indicator 2: “As soon as possible, but no later than 7 [14 for jails] calendar days” after arrival. The timing also depends on clinical need as discovered in the receiving screening findings for the individual (E-02).

Question 3: If a facility completes the initial health assessments as required, is it in full compliance?
   A. Would you say “yes”? The correct answer is “maybe”! Full compliance requires periodic health assessments, as well. Notice that Compliance Indicator 4 does not say “annual” assessments, and that both the timing and extent of this periodic assessment are to be defined by “protocols promulgated by nationally recognized professional organizations.”

Question 4: Is there way to meet the intent of this standard other than by complying with the indicators?
   A. This one is tricky, and again the answer is “maybe.” Depending on the content and extent of the facility’s health screening process at intake, the intent of this standard may be met in other than the usual manner, although this would be rare.

Multilayered Process
In our survey work, we have found that some correctional health professionals have an incomplete grasp of the full intent of the Health Assessment standard. What contributes to this simplistic understanding of what was meant to be a many layered clinical process?

Each field develops its own vocabulary, and health practitioners are no different. We use verbal shortcuts to share information quickly. It then becomes all too easy to forget that there is more to the procedure than the mnemonic used to identity it.

When it comes to evaluating compliance with standards, we may tend to focus on what is perceived to be the most important aspect of a standard. At times “most important” becomes the aspect that is most easily counted, measured or just plain tangible. For example, it is easy to see if jail inmates received a health assessment by Day 14. It takes more effort to see that an inmate identified as an insulin-dependent diabetic at receiving screening, in need of immediate orders for insulin and diet set upon admission, is fully evaluated by a physician or midlevel practitioner as soon as possible.

Other issues may make it difficult to gather all pertinent health assessment data. Such factors may include the volume of intake, problems getting receiving screening forms into the medical record, inability to get the inmate to the clinician on time, delay in obtaining lab results or even unexpected absences of co-workers.

But we should not become disheartened. The correctional health care field is not unique in the daily tug between expediency and effectiveness, or between mere adequacy and complete professionalism. Community-based practitioners face different challenges but still manage to contend with no-shows, health insurance, managed care and utilization review, to name a few.

How can we tell if we are meeting our goals? One way is to employ performance measures as part of continuous quality improvement initiatives. The 2004 Juvenile Standards introduce this concept for the Health Assessment and several other standards. The recommendation is presented as a performance measure in this way:

“100% of the time, when a health problem is identified subsequent to the initial health assessment that should have been identified during the initial assessment, but was not, a CQI analysis of the root cause is initiated, and (where indicated) appropriate action is taken to mitigate any negative outcome for the youth involved.”

The expectations for this performance measure are as follows:

“Measure #2 requires the practitioner to check the youth’s initial health assessment each time a new health problem is identified that, with good medical practice, should have been picked up during the initial health assessment process. Evaluation of how well the facility is doing can be accomplished by maintaining a log that requires the current treating practitioner to record particulars that allow designated staff to follow up and identify where the process went wrong. This method of identifying problems is ongoing and directly linked to caregiver interactions with the patient.”

Since health care is both science and art, clinical practice and the requirements of basic community care will change over time. As part of the continuum of public health care, correctional health care practice will change accordingly.

Likewise, compliance indicators may and should evolve over time, but there will be little change when it comes to the intent—the reason for assessing the health of inmates entrusted to our care.

(This article first appeared in the Winter 2005 issue of CorrectCare.)

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