Continuity of Care During Incarceration

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This column addresses “what’s new” in the 2011 Standards for Health Services in Juvenile Detention and Confinement Facilities but the discussion of standard E-12 also applies to jail and prison settings.

Continuity of care is a concern in all areas of health care—medical, mental health and dental. In juvenile detention and confinement facilities, we want to ensure that all aspects of health care are in keeping with current community standards and that juveniles receive treatment and diagnostic tests ordered by clinicians.

Physician chart review was part of the Continuous Quality Improvement Program standard (A-06) in the 2004 edition of the Juvenile Standards. The 2011 edition has placed this critical function into compliance indicator (CI) #7 of Y-E-12 Continuity of Care During Incarceration: “Physicians’ clinical chart reviews are of sufficient number and frequency to ensure that clinically appropriate care is ordered and implemented by on-site health staff.” You will notice that the concept of physician chart review is a bit different in the 2011 Y-E-12 standard.

NCCHC defines physician clinical chart review as an evaluation by a physician of the timeliness and appropriateness of the clinical care provided to patients. The previous standard for CQI recommended conducting clinical chart reviews of about 5% of all patients’ health records on a quarterly basis. We now generally see physicians conducting their chart reviews on a monthly basis; however, it is up to the discretion of the responsible physician as to how often and how many health records are reviewed. The number and frequency of chart reviews are expected to increase if significant problems are identified.

It is important to note that this review is not the clinical performance enhancement review described in Y-C-02; rather, it is best described as the physician’s review of the totality of care. Here, the physician isn’t focusing on a single clinician’s care in a particular health record for the purpose of enhancing that clinician’s performance. Instead, the physician is determining whether the care provided at the facility is acceptable from admission to discharge. How is continuity of care? Should the patient have been referred from sick call to the clinician sooner? Are appropriate outside consultations ordered? Did the consultation occur? Was it timely? Do clinicians document their review of results? Do additional diagnostic studies need to be ordered for this patient? These are the types of questions the physician might consider during chart review.

Follow-Up Protocols and Treatment Plans
The 2011 standard also highlights the need for protocols in the event a youth returns from an emergency room visit or hospitalization (see CI #2 and #3). In either case, the physician should see the patient, review the discharge orders and issue follow-up orders as clinically indicated. If the physician is not on site when a youth returns from the emergency room, designated health staff should contact the on-call physician to review ER findings and obtain orders as appropriate. And, if the physician is not on site when a juvenile returns from hospitalization, designated staff should immediately review the hospital’s discharge instructions and contact the facility physician for orders as needed. The Discussion section of the standard goes on to note that in proactive health systems, clinician visits are automatically scheduled following diagnostic testing, specialty consultation, ER visits and hospitalization. Qualified health care professionals should review the medical orders and instructions when a juvenile returns from an off-site health facility to ensure continuity of care, and the visits also serve as a safety net to ensure that any treatment recommendations are reviewed, followed or revised as appropriate.

The updated standard expects that treatment plans be used to guide treatment for episodes of illness and that they include the elements noted in the new compliance indicators #6a-c; clinicians should use diagnostic and treatment results to modify the treatment plans as appropriate (CI #4). When diagnostic tests and specialty consultations are completed, the clinician should review the findings with the patient in a timely manner (new CI #1c). If changes in treatment are indicated, the changes should be implemented or clinical justification for an alternative course should be noted, as reflected in CI #5. Documenting in the health record that the “loop has been closed” with the patient helps to ensure that continuity of care is in place.

Episodes of acute illness are resolved more quickly and negative health consequences avoided when the treatment is planned, documented and monitored. The format for the treatment planning may vary, but should include, at a minimum, the frequency of follow-up for medical evaluation and adjustment of treatment modality; the type and frequency of diagnostic testing and therapeutic regimens; and, when appropriate, instructions about diet, exercise, adaptation to the correctional environment and medication. Outcomes should be recorded until the health issue is resolved.

Some responsible health authorities use a standardized form to ensure that all elements of treatment plans for episodes of illness are documented in the health record, but a special form is not necessary to achieve compliance with the standard. For example, all treatment plan elements could be documented in the health record progress notes.

Lastly, please note that although periodic health assessments are included in E-12 in the jail and prison versions of the Standards, this activity remains under the Y-E-04 Health Assessment standard for juvenile detention and confinement facilities.

[This article first appeared in the Summer 2011 issue of CorrectCare.]

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