Continuity of Care During Incarceration

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Standard E-12, Continuity of Care During Incarceration, is meant to ensure that patients receive health services in keeping with current community standards as ordered by clinicians. Continuity of care is a broad concept that also encompasses issues addressed elsewhere in the Standards. This particular standard, however, focuses directly on the treating clinician’s professional responsibilities to ensure continuity of care from admission to discharge, and is of concern in all areas of health, mental health and dental care.

This standard was revised for the 2008 editions of the Standards for Health Services for jails and prisons and now encompasses some important aspects of care that had appeared under different standards in the 2003 editions. Let’s take a look at how the updated standard reflects these elements.

Physician chart review was part of the Continuous Quality Improvement Program (A-06) in the 2003 editions. The 2008 Standards have placed this critical function into Compliance Indicator 8: “Physicians’ clinical chart reviews are of sufficient number and frequency to assure that clinically appropriate care is ordered and implemented by attending health staff.”

Physician clinical chart review is an evaluation by a physician of the timeliness and appropriateness of the clinical care provided to patients. The number and frequency of chart reviews are expected to increase if significant problems are identified.

Similarly, periodic health assessments were addressed under the Health Assessment (E-04) standard in the 2003 Standards. This topic now falls under Compliance Indicator 7 in Continuity of Care: “The responsible physician determines the frequency and content of periodic health assessments on the basis of protocols promulgated by nationally recognized professional organizations.”

Certain elements of the health assessment are repeated at an appropriate frequency as determined by the responsible physician in consideration of the age, gender and health needs of the inmate population, consistent with the recommendations of professional organizations.

Other Nuances
There are some additional nuances to the 2008 standard, as well. Compliance Indicator 1 remains essentially the same: “Ordered diagnostic tests and specialty consultations are completed in a timely manner, with evidence in the record of the ordering clinician’s review of the results. If changes in treatment are indicated, the changes are implemented or clinical justification for an alternative course is noted.” However, the 2008 standard now requires that the clinician reviews the findings with the patient in a timely manner.

A new addition to the standard, Compliance Indicator 2 states that when an inmate returns from an emergency room visit, the physician sees the patient, reviews the discharge orders and issues follow-up orders as clinically indicated. If the physician is not on site, designated health staff contact the physician on-call to review ER findings and obtain orders as appropriate.

The same principle of review and follow-up applies to the new Compliance Indicator 3: “When an inmate returns from hospitalization, the physician sees the patient, reviews the discharge orders and issues follow-up orders as clinically indicated. If the physician is not on site, designated health staff immediately review the hospital’s discharge instructions and contact the facility physician for orders as needed.”

Reviewing medical orders and instructions when an inmate returns from an off-site health facility helps to ensure continuity of care. A proactive health services program may schedule clinician visits automatically following diagnostic testing, specialty consultation, ER visits or hospitalization. Such visits serve as a safety net to ensure that any treatment recommendations are reviewed, followed or revised as appropriate.

Compliance Indicator 4 states that clinicians use diagnostic and treatment results to modify treatment plans as appropriate. Compliance Indicator 5 follows with the statement that if changes in treatment are clinically indicated, clinical justification for an alternative course is noted.

Individual treatment plans are addressed in Compliance Indicator 6. These are used to guide treatment for episodes of illness. The format for planning may vary, but should include, at a minimum, the following elements:

a. The frequency of follow-up for medical evaluation and adjustment of treatment modality
b. The type and frequency of diagnostic testing and therapeutic regimens
c. When appropriate, instructions about diet, exercise, adaptation to the correctional environment and medication

The planning may be recorded on specific forms or in the progress notes, with outcomes recorded until the health issue is resolved. Episodes of acute illness are resolved more quickly and negative health consequences are avoided when the treatment is planned, documented and monitored.

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

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