Chronic Disease Services Spotlight
The most authoritative resources for correctional health care services, the NCCHC Standards are continually updated to reflect the latest evidence and best practices in meeting professional, legal and ethical requirements in delivering correctional health care services. The 2018 editions have been revised, reorganized and simplified to improve their usefulness.
Many Spotlight on the Standards columns highlight standards that are often misinterpreted, leading to a variety of compliance concerns. Standard G-01 Chronic Disease Services is one that often presents challenges, especially to physicians. Each of the compliance indicators must be properly understood and interpreted.
A Closer Look at the Language
The standard requires that patients with chronic disease are enrolled in a chronic disease program. An effective chronic care program depends on an effective receiving screening process (see Standard E-02) to identify these patients.
This task is more complicated than it may seem as patients do not always provide an accurate health history at intake. A healthy inmate may have ulterior motives and falsely claim to have a chronic disease—for example, seizures (to be assigned a lower bunk) or diabetes (to get extra food). Conversely, patients may knowingly omit information for reasons such as avoiding certain housing assignments or gaining access to recreational activities. And some patients may be unable to provide information because of communication difficulties, cognitive impairment or even decreased consciousness.
These scenarios pose a challenge to health staff who must identify the patients who need to be enrolled in the chronic care program and maintain accurate lists of these patients and health record master problem lists.
The responsible physician must understand the components of a chronic disease program. A well-designed program includes a treatment plan with regular clinic visits during which clinicians monitor the patient’s progress and update the treatment as needed. An effective program also includes patient education for symptom management.
In summary, a high-quality chronic disease program quickly identifies the patient population (e.g., those with diabetes), schedules each patient for an initial evaluation by a clinician and ensures that patients are individually managed. Patient management includes appropriate clinical monitoring (e.g., examinations, diagnostic studies), patient education and adjustment of treatment as needed.
Protocols for Chronic Diseases
The responsible physician should establish and annually approve clinical protocols consistent with national clinical practice guidelines. These are not the same as nursing assessment protocols. Clinical guidelines are for use by physicians and midlevel providers to guide and align clinical practice, especially for well-understood chronic diseases. The guidelines are used to assist clinical decision making, assess and assure the quality of care, educate patients, guide the allocation of health care resources and reduce the risk of legal liability for negligent care.
Clinical protocols are required for, at a minimum, asthma, diabetes, HIV, hypertension, major mental illnesses, seizure disorder, sickle cell disease and tuberculosis. Jails and prisons must also have a protocol for high blood cholesterol and juvenile facilities should have one for ADHD.
Nationally recognized and accepted clinical guidelines exist for many diseases commonly seen in corrections. NCCHC does not promulgate clinical practice guidelines, but our website (www.ncchc.org/other-resources) offers a wealth of resources to help in developing guidelines.
Documentation
The established guidelines should be used consistently and documentation in the health record should confirm that the protocols are being followed. To improve consistency, many health administrators create templates and flow sheets for use when documenting chronic care visits.
The health record should reflect how frequently the patient needs to be seen by a provider; this is commonly determined by the degree of disease control. Providers should note trends in the patient’s condition (e.g., poor, fair, good) and status (e.g., stable, improving, deteriorating). By reviewing the patient’s history and progress over time, the provider can optimize the treatment plan. In contrast, a strictly episodic and symptom-based approach can lead to increased morbidity, mortality and cost.
If diagnostic testing is required, the type and frequency should be noted, as well as orders for special diets, exercise and medication. Success in minimizing symptoms is best achieved through health professional–patient teamwork in understanding how to control chronic diseases. Therefore, patient teaching is crucial. The health record should reflect that the patient has received education on diet, exercise, medication and adaptation to the correctional environment.
While guidelines do not replace clinical judgement nor are meant to restrict sound medical practice, they do serve as a reliable point of reference that can assist providers in selecting appropriate diagnostic studies, medications, referrals and so forth. Finally, when there is clinical justification to deviate from the established protocol, it should be documented in the health record.
The Bottom Line
Compliance with standard G-01 supports efficient and clinically sound management of patients with chronic disease. Patients benefit from regular clinic visits for evaluation and management by health care providers. The best system is one in which treatment plans are based on current chronic care protocols addressing total disease management. System effectiveness should be assessed regularly through the continuous quality improvement program.
[This article first appeared in the Summer 2017 issue of CorrectCare.]