Correctional facilities house a significant number of inmates with chronic disease. While the goal of a chronic disease program is to decrease the frequency and severity of the symptoms, prevent disease progression and complication, and foster improved function, appropriate chronic disease care ultimately affects a patient’s ability to work and lead a healthy lifestyle once returned to the community. Empowering patients to manage their own health and health care through education and involving them in taking better care of their disease is an important aspect of chronic disease management.

Standard G-01 Chronic Disease Services requires that the responsible physician establish and annually approve clinical protocols that are consistent with national clinical practice guidelines (those presented by national professional organizations and accepted by experts in the respective discipline) for the management of chronic diseases.

You may want to consider the clinical guidelines adopted by NCCHC. These guidelines address the most problematic health issues seen among inmates (with distinct sets for adults and youth) and were adapted for correctional settings from nationally accepted guidelines prepared by organizations such as the National Institutes of Health; the American Diabetes Association; the National Heart, Lung, and Blood Institute; and the U.S. Department of Health and Human Services. While our guidelines take into account the unique barriers to appropriate treatment that are commonly found in correctional facilities, they do not replace individual clinical judgment based on a specific patient’s presentation.

Total disease management is the best system for improving patient outcomes. Appropriate baseline laboratory and other testing data should be obtained and recorded in the health record. NCCHC highly recommends the use of flowsheets to track chronic care patients so that their history and progress can be monitored over time, rather than episodically. Regular clinic visits for evaluation and management are of obvious benefit to these patients. Total disease management requires clear indicators of the degree of control of disease and often the more subtle distinction as to whether the condition is stable, improving or deteriorating. NCCHC’s Definitions of Disease Control and Clinical Status are also posted online. The purpose of the definitions of control is to help the clinician keep treatment goals in mind. Clinical status refers to more subtle subjective and objective changes since the previous visit.

People often ask why NCCHC considers HIV a chronic disease rather than infectious. We define chronic disease as an illness or condition that affects an individual’s well-being for an extended interval, usually at least six months, and generally is not curable but can be managed to provide optimum functioning within any limitations the condition imposes on the individual. The HHS HIV/AIDS Bureau states that "…long-term complications have put HIV infection in the realm of chronic diseases rather than of infectious diseases, which usually respond to short-term clinical interventions" (see A Guide to Primary Care for People With HIV/AIDS). NCCHC does recommend that patients enrolled in an HIV program be monitored by an HIV specialist who will initiate and change therapeutic regimens as medically indicated.

The 2008 standard also states that a list of chronic care patients should be maintained and chronic illnesses noted on the master problem list. A properly completed problem list provides easy access to critical patient health information for clinicians and may improve patient safety.

The new standard also calls for more specific documentation that clinicians are following chronic disease protocols. Medical records should note the frequency of follow-up for medical evaluation; adjustment of treatment modality as clinically indicated; the type and frequency of diagnostic testing and therapeutic regimens; appropriate instructions for diet, exercise, adaptation to the correctional environment and medication; and clinical justification of any deviation from the protocol. Also available on the NCCHC Web site are forms for chronic disease initial baseline, clinic follow-up and a nursing flowsheet, along with instructions for their use. These forms may assist you in documenting chronic care visits. All NCCHC guidelines and forms are reviewed routinely and updated as necessary.

NCCHC also recommends that the management of chronic care patients be monitored through the continuous quality improvement process, and our guidelines suggest quality improvement monitors.

Aggressive management of chronic disease should significantly reduce morbidity and mortality. The concept of chronic disease care in correctional settings has been evolving; concentrating on total disease management with teamwork between clinicians and patients will help improve clinical outcomes.