Continuity and Coordination of Care During Incarceration


In the 2014 revision of the Standards for Health Services for jails and prisons, significant changes were made to standard E-12 Continuity and Coordination of Care During Incarceration. This essential standard has compliance indicators that cover all aspects of care from the time an inmate enters the facility until the inmate leaves. It requires that all aspects of care are coordinated and monitored from admission to discharge.

Coordinated care means integration of medical, mental health, dental and nursing services—along with specialty consultations as needed—to improve clinical outcomes. However, ensuring that a sound system is in place presents many challenges, which we will address throughout this article.

Examples of the Standard’s Requirements
Clinician orders must be evidence based. It is important for the facility’s responsible physician to base his or her clinical guidelines on accepted medical practice. This helps guide facility providers toward evidence-based treatment orders. National clinical practice guidelines for chronic care disease processes (and others) are updated continuously by organizations such as the Federal Bureau of Prisons and NCCHC supporting organizations.

Orders must be implemented in a timely manner. The responsible health authority should look at the process for order transcription. Are there any delays due to shortage of staff, knowledge of staff, pharmacy restrictions, transport availability, health record availability and so forth?

Documentation requirements are also specified in this standard. The health record should reflect the following occurrences:

• There are clinically justified deviations from the standard of practice
• Diagnostic tests are reviewed by the treating clinician
• Treatment plans are modified as clinically indicted by diagnostic tests and treatment results
• Patients returning from outside appointments (hospital, specialty consult) are seen by qualified health care professionals
• Discharge orders and follow-up care are implemented
• Specialty consultations are reviewed and acted upon
• Deviations from recommendations by consultants are clinically justified

A notable change to the standard is its strong focus on engaging patients in the development of their treatment plans. This allows a degree of ownership on the part of the patient and supports better compliance with treatment plans and better outcomes. Therefore, the health record must confirm that information is shared and discussed with the patient when treatment plans are developed or changed and when test results are received. The standard is clear that all test results must be shared and discussed with the patient; it does not matter if the testing was done for screening or diagnostic purposes.This may be accomplished by scheduling follow-up appointments for the patient with the most appropriate qualified health care professional. Form letters for screening tests indicating normal results can also be used as long as the letter does not indicate specific disease processes or contain positive results.

The responsible physician should determine the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations. For example, a yearly physical exam in a young healthy male is not a community standard of care. However, a yearly TB screen for all detainees in a correctional facility is a recommended standard.

Checking the System
This standard has many areas that could be studied in the continuous quality improvement program of the facility. Data collection could begin by conducting the chart reviews that are required by this standard and identifying areas of deficiency. The chart reviews should be completed by members of a multidisciplinary team as well as by clinicians during clinical encounters to ensure true integration of all aspects of care. Multidisciplinary team meetings are also of great value to discuss complex patients.

While other standards address elements of the patients’ total care, this standard focuses directly on the health staff’s ability to integrate all of these individual compliance standards while ensuring a continuum of care from admission to discharge.

[This article first appeared in the Spring 2015 issue of CorrectCare. NCCHC thanks Jeffrey Alvarez, MD, CCHP, for his assistance with this column. Alvarez is the medical director of Maricopa County Correctional Health Services, Phoenix, AZ. He is also a physician surveyor and trainer for NCCHC.]

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