Patients With Special Health Needs
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 www.ncchc.org/federal-clinical-guidelines. 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
Custody staff often seek medical clearance before using pepper spray on an inmate. Does this act of clearance, giving the “yea or nay,” qualify as partaking in a disciplinary proceeding? Does such an act undermine the intent of the forensic information standard? One can argue that if health staff did not participate, it would cause more harm than good (because those with contraindications would be sprayed). However, reasonable people could conclude that any participation undermines the credibility of health professionals.
The answer relates to standards A-08 Communication on Special Needs Patients and I-03 Forensic Information. The responsible physician decides how health services will respond. Usually the physician is the staff member to determine what would prohibit an inmate from being sprayed because of possible negative consequences. The determination may be done at the time of the incident, or it may be done routinely as part of the initial health assessment, with a notation in the same place in each health chart. The wording of the “clearance” should be simply that there is or is not any health contraindication to the use of pepper spray for the inmate. The physician is not giving an order for the spray nor saying that it is OK to use it.
All health and custody staff should be able to reference a written protocol as to any health intervention required after the spray is used. Any inmates who do receive pepper spray are taken to medical staff for appropriate interventions.
You imply that health staff may not participate in disciplinary proceedings. Actually, health staff may consult in disciplinary hearings or decisions provided that they do not make the decision. In such cases, health staff, including mental health staff, should indicate whether any health or mental health condition may have contributed to the behavior in question. Health staff also may alert custody to the potential negative effects on the inmate of the proposed disciplinary action, and to help find appropriate alternate measures if the disciplinary action is contraindicated.
— From CorrectCare Volume 21, Issue 4, Fall 2007
We want to revise our health services staffing plan to improve efficiency. Our ADP is roughly 4,000. The jail standards give general guidance on how many hours our physicians must be on site, but how do we factor in time spent by physician assistants and by specialists?
The Staffing standard (J-C-07) intends that prescribing clinician time must be sufficient to prevent unreasonable delay in patients receiving necessary care. Because of variability among inmate populations NCCHC does not mandate an exact clinician-to-patient ratio, but the general guideline is that the staffing plan includes at least one physician on site 3.5 hours per week for each 100 inmates, regardless of facility size. However, this number is not among the compliance indicators for accreditation.
Where permitted by state law, midlevel providers (e.g., nurse practitioners and physician assistants) under the supervision of a physician can substitute for a portion of the physician’s time seeing patients. It is up to each facility to determine staffing based on its unique inmate needs and to provide justification if physician hours are less than we suggest, or if midlevel hours are used to cover part of the physician’s time. Finally, on-site time of specialists, including psychiatrists, does not count toward the basic primary provider time.
— From CorrectCare Volume 24, Issue 1, Winter 2010
What is NCCHC’s position on the use of residents or physicians-in-training in correctional settings?
This is covered in standard C-01 Credentialing in all three sets of Standards (jails, prisons and juvenile facilities). Compliance Indicator 3 states, “Health providers do not perform tasks beyond those permitted by their credentials.” The Discussion section elaborates: “Students in the various health professions may receive training in correctional environments, so they may supplement services under the supervision of appropriate qualified health care professionals just as they would in a community setting.” Orientation to the correctional setting and to their tasks is required so that the trainees “do not perform tasks beyond those permitted by their student status” and are able to practice safely and professionally.
Student involvement, whether at beginning or advanced levels of training, benefits the inmates and facility health staff, and gives the students an excellent introduction to the correctional health care field, whether or not they choose to work in this end of the public health continuum.
— From CorrectCare Volume 19, Issue 2, Spring 2005
Given the national nursing shortage, could a paramedic take the place of an RN in an infirmary for the night shift? Paramedics can do assessments, which LPNs cannot.
In all three sets of standards (jail, prison and juvenile), the basic requirement for infirmary staffing is that the patients are within sight or sound of a health staff member at all times. This staff member does not have to be an RN, but must be someone authorized by the responsible physician who can meet the needs of the patients on a particular shift. The patients’ acuity levels and the types of services they need will determine the level of staff required. For example, if IVs are being given and only RNs may give this level of care in your state, then an RN would be needed. If the patients’ acuity level is lower and the services they require are within the scope of practice of a paramedic, a paramedic could work on that shift. In all cases, however, an RN must be on site in the infirmary at least once every 24 hours to review care, the functioning of the infirmary, etc. Whether the paramedic is a member of the health staff also matters. Officers who happen to be paramedics but are on duty functioning as officers could not do "double duty" under this standard.
— From CorrectCare Volume 16, Issue 3, Summer 2002