New Option for Initial Health Assessment

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The Initial Health Assessment standard (E-04) in the 2008 editions of the Standards for Health Services for jails and prisons is generating a lot of buzz. The field is very excited about the new approach it offers, yet there are some questions about exactly how it works. This article will spell out the details.

Categorized as essential for both jails and prisons, the revised standard offers two options.

• The full population assessment option requires 100% of inmates to receive initial health assessments.

• The individual assessment when clinically indicated option involves performing assessments on only those inmates determined to be at a high risk for significant health problems.

Your choice will depend on the general health status of the admitting population, available staffing and decisions about the best use of resources in your facility.

Full Population Assessment 
Implementation of the full population assessment option will require all inmates to receive an initial health assessment as soon as possible—but no later than seven calendar days in prisons and 14 calendar days in jails—after admission to the facility.

The full population assessment begins with a review of the receiving screening results and collection of additional data to complete the medical, dental and mental health histories taken at the receiving screening and any subsequent encounters. Vital signs (i.e., height, weight, pulse and temperature) are taken. All of these tasks are to be completed by a qualified health care professional (see definitions above).

A physical examination (as indicated by the patient’s gender, age and risk factors) is conducted by a physician, physician assistant, nurse practitioner, registered nurse or other practitioner as determined by law. The responsible physician must document his or her review of significant findings when the exam is conducted by a physician assistant, nurse practitioner, registered nurse or other practitioner.

The hands-on portion of the health assessment may be performed by a registered nurse only when the RN has completed appropriate training that is approved or provided by the responsible physician.

All findings must be reviewed by a physician when a registered nurse completes the physical. This standard intentionally maintains the role of the physician at a higher level of oversight so that he or she is aware of significant care issues.

The full population assessment option also requires that the initial health assessment include laboratory and/or diagnostic tests for communicable diseases (unless there is documentation from the health department that the prevalence rate does not warrant it), Pap tests, an initial problem list including a diagnostic and therapeutic plan for each problem, and immunizations when appropriate.

Performing initial health assessments on every inmate can reveal underlying clinical findings that may have gone undetected in a receiving screening. It also creates opportunities to provide health education and initiate preventive medicine with every inmate.

Individual Assessment When Clinically Indicated
To qualify for the individual assessment option, a facility must have 24-hour, 7-day on-site health staff coverage. This option requires a comprehensive receiving screening and an initial health assessment as soon as possible, but no later than two working days after admission (this applies to both jails and prisons). The comprehensive receiving screening identifies inmates who are clinically in need of a health assessment and ultimately enables staff to detect health problems early in the process.

Licensed health care personnel conduct a comprehensive receiving screening on all inmates, and the screening must include these additional elements: further inquiry into past history and symptoms of chronic diseases, finger stick on diabetics, vital signs to include blood pressure and further inquiry into medication and dosages where possible.

The clinically indicated assessment begins with a review of the receiving screening results and collection of additional data to complete the medical, dental and mental health histories taken at receiving screening and any subsequent encounters. Vital signs (including height and weight) are taken. All of these tasks are to be completed by a qualified health care professional.

A physical examination (as indicated by the patient’s gender, age and risk factors) is conducted by a physician, physician assistant, nurse practitioner or other practitioner as determined by law. The responsible physician must document his or her review of other clinicians’ significant findings. This option differs from the full population assessment in that a registered nurse may not perform the physical examination as these patients have already been identified as high risk and should be referred to clinicians.

The individual health assessment must also include laboratory and/or diagnostic tests for communicable diseases, such as a tuberculin skin test (unless there is documentation from the health department that the prevalence rate does not warrant it); laboratory and/or diagnostic tests for disease, such as peak flow for asthmatics; Pap tests; and immunizations when appropriate. All assessment data are reviewed by the treating clinician and specific problems are integrated with the initial problem list. Diagnostic and therapeutic plans for each problem are developed as clinically indicated.

Conserving resources for inmates who are at the highest risk may be a cost-effective practice in a high-volume setting. This way, limited resources may be organized in a way that yields the best return. For example, staff could potentially devote more time to inmates with acute or chronic health care needs.

It should be noted that following this option, some individuals may be released without ever having received a health assessment.

A Critical Tool
No matter which option suits you and your staff, the initial health assessment is a critical tool in evaluating and protecting the health of inmates. To recap, the full population assessment commits resources at the “back end” of the process by conducting an initial health assessment on all inmates within seven or 14 (prisons and jails, respectively) days of admission, whereas the individual health assessment places resources at the “front end” of the process through comprehensive receiving screening of all inmates within two days of admission. Both types of health assessment offer advantages to be considered as compliance to this standard is addressed.

[This article first appeared in the Spring 2008 issue of CorrectCare.]

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