Chronic Disease Services


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Our state prison system has implemented a chronic care clinic program. What chronic conditions should we include in our program?

The information you seek is found in standards G-01 Chronic Disease Services and G-02 Patients With Special Health Needs. From NCCHC’s standpoint, any health condition that is considered chronic or that requires multidisciplinary care also requires that an individual treatment plan be developed for regular, ongoing care. Examples of such conditions are listed in G-02. Standard G-01 specifies nine conditions for which the facility is expected to follow national clinical guidelines in treating these diseases. These nine are a first step. The eventual goal is for providers to follow clinical protocols for all chronic conditions.

To find national clinical guidelines, visit Here, links will direct you to various guidelines current in community care, such as those from the Centers for Disease Control and Prevention and the Department of Veterans Affairs, as well as guidelines from the Federal Bureau of Prisons.

— From CorrectCare Volume 31, Issue 3, Summer 2017


How soon should patients with chronic care issues be assessed by a medical provider? Is it supposed to be within 30 days?

The NCCHC standards do not specify a time frame for initiating chronic care; rather, patients should be referred for assessment by a clinician based on their individual clinical needs. Standard G-01 Chronic Disease Services requires that patients with chronic diseases are identified and enrolled in a chronic disease program to decrease the frequency and severity of the symptoms, prevent disease progression and complication, and foster improved function. The chronic disease program should incorporate a treatment plan and regular clinic visits. The clinician should monitor the patient’s progress during clinic visits and when necessary, change the treatment. The program should also include patient education for symptom management.
— From CorrectCare Volume 30, Issue 1, Winter 2016


According to the Chronic Disease Services standard, having a chronic care program with chronic care clinics is an essential element of health care at the facility. However, the standard does not discuss who the provider would need to be for these clinics. Is it OK for the nurse to evaluate the patients at these chronic care clinics rather than a doctor or midlevel provider? Some jails do this with the provider evaluating the patient initially and then just doing chart reviews, rather than having face-to-face encounters with patients. What is the requirement?

The Chronic Disease Services standard for jails (J-G-01) requires that a physician establish and annually approve clinical protocols consistent with national clinical practice guidelines. There is no requirement in the NCCHC standard for a particular clinician or provider to perform specific clinical tasks. There may be requirements or recommendations in the national clinical practice guidelines that the facility uses to guide its care.

Standard J-C-01 Credentials (“Credentialing” in the 2008 Standards), however, makes it clear that qualified health care professionals must have the credentials to perform the tasks they perform. There may be variability in how a program complies with this standard because of variability in state law (and other factors); nurses perform a variety of important clinical functions in accordance with applicable nurse practice acts and local policies and procedures.

In a direct patient care situation, a physician, physician assistant or nurse practitioner having only an initial encounter and never following up (aside from chart reviews) is not good practice for managing chronic care clinics.
— From CorrectCare Volume 28, Issue 3, Summer 2014