Chronic Disease Services

The information you seek is found in standards P-F-01, Patients with Chronic Care and Other Special 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.

P-F-01, compliance indicator #4, requires clinical protocol for the identification and management of chronic care diseases or other special needs that include, but are not limited to:

    • Asthma
    • Diabetes
    • HIV
    • Hyperlipidemia
    • Hypertension
    • Mood Disorders
    • Psychotic Disorders

NCCHC requires that “clinical protocols are consistent with national clinical practice guidelines” in compliance indicator #3.

— From CorrectCare Volume 31, Issue 3, Summer 2017. Updated April 4, 2022.

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

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