Medical Provider
Orientation 2020

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Congratulations on joining the Centurion team! We would like to personally welcome
you. We hope that you enjoy the practice of correctional medicine within the Centurion
family as much as we have.
Our goal at Centurion is to provide excellent health care to our correctional patients
and excellent service to the correctional institutions where we work. We promote
excellence in health care by practicing evidence-based medicine in a cost-effective
manner. We provide excellent service by paying attention to the safety and security of
the institutions where we serve and by being open and transparent in our dealings with
others.
We also want you to be happy and productive during your employment with Centurion .
This orientation program is offered to assist you in being successful in your new role.
One of the core philosophies of Centurion is that we are a team and, as such, we help
each other. You will not be alone as you practice medicine with us. You can always ask
for help and advice from your peers, your regional medical directors and your statewide
medical director.
We will always listen to you. If you ever think of a way that we can improve the quality or
'
scope of our services, please let us know!
Again, welcome to the Centurion team!
Your Colleagues,

Johnny Wu, MD, FACP, CCHP-P
Chief of Clinical Operations
jwu@teamcenturion.com

John P. May, MD, FACP
Chief Medical Officer
j may@teamcentu rion. com

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Re: Provider Orientation
you through the first 90 days of your
Welcome Aboard. The Orientation binder and process are designed to support
employment. This binder includes four parts:
•

review pertinent information
Orientation Checklist: provides a framework on what, when, and who should
over the first 30 days

•

ng critical topics
Reference Manual: provides adequate reading and reference materials addressi

•

to use while getting
Orientation Workbo ok: provides contract and site specific questions for the provider
acquainted with their work location

•

as needed
Contract-Specific: an open area to add any of your own additional resources,

Management System (LMS)
At 90 to 100 days of employment, you are responsible for logging into our Learning
to mark your Orientation process
through Centurion University. At this time, you will complete two steps in order
complete. Those steps are as follows:
1.

Orientation on your
Submit an attestation statement to confirm and record completion of the Provider
learning transcript and;

2.

feedback about your
Complete the online evaluation module, which provides you an opportunity to give
experience

to complete the 45-day feedback
As a final request, if you have not already done so, please take a few moments
survey will provide us valuable
this
from
survey (www.45dayfeedback.com). The feedback and results we receive
es. In addition, you should
insight to be used towards improving the orientation experience for future new employe
meeting . This is a great opportunity
be hearing from your supervisor to schedule your one-on-one 90-day feedback
to review your job expectations, your performance and your future goals.
Thank you,

0/4;c,1~to/1/,,e;c, J, v/al(z°" 1/. Ecl.
Manager, Content and Curriculum
cwanza@teamcenturion .com

Revision 6/2019

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Orientation Checklist

Medical Provider Orientation
Checklist

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INSTRUCTIONS: The purpose of this doctjrnent is to provide a structured format to the orientation experience
and to ensure all pertinent information whether organizational or contract specific is reviewed, discussed, and/or
received. The checklist is designed as a working document for both the employee and assigned contract
representative , therefore space is provided to record actions items as you cover each topic.
The expectation is to complete the checklist within a 30 day timeframe and the recommended format serves as a
guideline on when and how to thoroughly complete the orientation process.

DAY ONE: General Orientation
Meet with your Contract Vice President, HSA and
Human Resource Business Partner to:
-

Action Items

Provide a company overview
Complete Confidentiality, HIPAA & PREA
Review HR orientation and policies
Complete and discuss re-credentialin g

Received HR New Employee Manual

D Yes

tiew completion date

DAY TWO: Structure of Health Services
Meet with your Contract Vice President or HSA to
review Centurion & DOC contract and site level
structure:

Action Items

- Clinical and administrative staff
- Staff roles
- Communicatio n chain
Received contract organizationa l chart

D Yes

Review completion date

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DAY TWO: Job Responsibilities
Meet with your HSA and Medical Director to review:

Action Items

- Clinical job responsibilities
- Administrative job responsibilities
- Performance accountability
- Documentation requirements and expectations

Reviewed job description

OYes

Review completion date

DAY THREE: Contact Information
Meet with your HSA to review:

Action Items

- All pertinent contact information

Received contract specific contact lists

□ Yes

Review completion date

WEEK ONE: Correctional Healthcare
Read supporting chapters from Medical Provider
Reference Manual:
- Chapter 1: The Correctional Environment
- Chapter 2: Security Overview and Awareness
- Chapter 16: Inmate "Wants" vs. Inmate "Needs"

Meet with your HSA and Medical Director to review:

Action Items

- Correctional healthcare philosophy
- Correctional environment
- Maintaining a safe work environment
- P--rovider---role iA- car.a-delivery

Discussed contract specific polices

O Yes

Review completion date

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WEEK ONE: Tour Facility and Office Space
Jet with HSA and DON for tour of the:

Action Items

- Introductions to key facility staff & healthcare staff
- Facility(s)
- Office space

Tour completion date

WEEK TWO: Health Assessments
Meet with Medical Director to discuss:

Action Items

- Contract specific requirements for receiving and
periodic health assessments
- Purpose of health assessment in initial and
ongoing continuum of care

Discussed contract specific requirements

D

Yes

Review completion date

(
WEEK TWO: Sick Call
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 8: Sick Call

Meet with Medical Director and DON to discuss:

Action Items

- General population
- Segregation
- Nurse sick call

Discussed contract specific requirements

D

Yes

Review completion date

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WEEK TWO: Disease Management & Chronic Care
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 10: Disease Management and Chronic
Care Clinics
Meet with Medical Director, DON, and Chronic Care
Coordinator at site to:

Action Items

- Discuss process for tracking and scheduling

Received contract specific disease management
summaries

D Yes

Review completion date

WEEK TWO: Special Needs Inmates
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 15: Special Needs Inmates
Meet with Medical Director and DON to:

Action Items

- Review site specific policies for placement based
on healthcare, mobility, and assisted care
requirements

Discussed contract specific requirements

D Yes

Review completion date

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WEEK TWO: Medication Management
!ad supporting chapter from Medical Provider
Keference Manual:

(

- Chapter 9: Medication Management
Read supporting material from Medical Provider
Orientation Workbook:

-Utilization Management Overview Supplemental
Meet with Medical Director, DON, and Medication
Room Coordinator/Designee to:

Action Items

- Review current formulary

Discussed contract medication ordering process &
non-formulary review process

D Yes

Review completion date

I

,,WEEK TWO: On-Site & Off-Site Emergency Services and Hospitalization & Infirmary Care
i

~e~d supporting chapter from Medical Provider
Reference Manual:
- Chapter 12: On-site Emergency Care, Emergency
Department Services, Hospitalization & Infirmary Care
Meet with your Medical Director, HSA and DON to
review:

Action Items

- On call provider responsibilities
- Management of after care post hospital/ER visit
and return to site
- Infirmary levels of care and staffing
Discussed contract specific requirements

□ Yes

Review completion date

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WEEK TWO: Ancillary Services
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 13: Laboratory, Radiology, EKG and Other
On-Site Testing

Meet with your HSA and DON to review:

Action Items

- Laboratory testing
- Radiology
- Other on-site services
- Sign off & review of ancillary services

Discussed contract specific vendor list

D Yes

Review completion date

WEEK TWO: Specialty Services
Read supporting chapters from Medical Provider
Reference Manual:
- Chapter 11: Specialty Care and Off-site Services
- Chapter 17: Telehealth

Meet with your Medical Director and Corporate/
Regional Telehealth staff, DON, HSA, and specialty
appointment tracking staff to review:

Action Items

- On-site
- Telemedicine
- Off-site

Discussed contract specific requirements

D Yes

Review completion date

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WEEK TWO: Utilization Management

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let with your Medical Director and Corporate UM
staff to review:

Action Items

- Principles
- Process
- Corporate & contract specific UM staff
- TruCare

Reviewed the following:
Contract specific UM Process

OYes

Centurion & contract organizational chart

D Yes

UM policies and procedures

D Yes

UM process flows, Centurion UM P&Ps

D Yes

UM Business Rules and Clinical Statements

D Yes

Appeals process

D Yes

Review completion date

WEEK TWO: Documentation
Read the supporting materials from Medical
Provider Orientation Workbook:
- Correctional Healthcare Documentation
Supplemental
- S.O.A.P Guidelines

Meet with your Medical Director and Medical
Records staff

Action Items

Reviewed the following:
Documentation requirements

D Yes

Contract specific requirements

D Yes

· dical record format and required forms for
.::umentation

D Yes

Review completion date

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WEEK THREE: CQI Responsibilities
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 14: Your Role in Quality Healthcare

Meet with your Medical Director and HSA to review:

Action Items

- Roles/responsibilities in the COi process
- Medical record reviews
- Mortality reviews
- Peer review
- Grievances

Discussed contract specific requirements

D Yes

Review completion date

WEEK THREE: Risk Management
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 7: Risk Management

Meet with your HSA and Corporate Risk Manager to
review:

Action Items

- Incident reporting
- Legal notification

Completed online Incident
Reporting Acknowledgement

D Yes

Discussed contract specific requirements and
chain of command for reporting incidents

D Yes

Review completion date

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WEEK THREE: PA/NP Supervision
f

'et with Medical Director and Corporate Risk
IV!anager to:

Action Items

- Complete review and sign off on collaborative
agreement, if required
- Discuss roles, responsibilities, and provisions of
care by PNNP versus site Medical Director/
Physicians

Discussed contract specific requirements

D Yes

Review completion date

WEEK THREE: Training Expectations and Availability
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 19: Correctional Organizations and
Resources

Meet with Human Resource Business Partner to:
(
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Action Items

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__

•

✓ 1scuss CEU requirements & benefits

Reviewed Centurion University resources

D Yes

Review completion date

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WEEK THREE: Healthcare Services Coordination
Read supporting chapter from Medical Provider
Reference Manual:
- Chapter 18: Mental Health and Physical Health
Collaboration
Meet with Medical Director, HSA and DON to
review:

Action Items

- Mental health services
- Dental services
- Care collaboration
Discussed contract specific requirements

OYes

Review completion date

Supervisor Signature

Date
Employee Signature

Date

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Orientation Resource
Manual

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Medical Provider
Orientation
Reference Manual

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TABLE OF CONTENTS

Chapter 1:

The Correcti onal Environ ment

Chapter 2:

Security Overvie w and Awaren ess

Chapter 3:

Overvie w of Human Resourc es and Credent ialing

Chapter 4:

Orientat ion for Healthc are Staff

Chapter 5:

Prison Rape Elimina tion Act and Forensi c Health
Informa tion

Chapter 6:

HIPAA & Confide ntiality

Chapter 7:

Risk Manage ment

Chapter 8:

Sick Call

Chapter 9:

Medicat ion Manage ment

Chapter 10:

Disease Manage ment/Ch ronic Care Clinics

Chapter 11:

Specialt y Care and Off-Site Services

Chapter 12:

On-Site Emerge nt Care, Emerge ncy Departm ent
Services, Hospita lization, and Infirmar y Care

Chapter 13:

Laborat ory, Radiolo gy, EKG and Other On-Site Testing

Chapter 14:

Your Role in Quality Healthcare

Chapter 15:

Patients with Special Needs

Chapter 16:

"Wants" vs. Medical Needs

Chapter 17:

Telehealth

Chapter 18:

Mental Health and Physica l Health Collabo ration

Chapter 19:

Correct ional Organiz ations and Resourc es

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Chapter 1: The Correctional Environment
Working within a Correctional Setting
Welcome to Centurion and the rewarding field of correctional health care! You are
certain to see pathology that is unusual, face patient management issues different
from
the community and find inspiration from others at Centurion who make this their
advocation; but mostly you will find joy and satisfaction in delivering quality care
that
impacts the lives of others in very meaningful ways.
Whereas traditional medical practice focuses on the dynamic of the
provider and patient relationship, and public health focuses on
the actions of the community to improve overal l health ,
correctional health is a combination of both.
Correctional health care is often practiced within the
model of "population health," that is providing care,
treatment and advocacy to sustain or improve the health
of the entire population, in this case, the patient in front of
you and all of those within the jail or prison facility.

Correctional
Health

Does that seem like a tall order? No worries. You will not go at it alone. Instead,
you
are joining a team of other dedicated professionals at Centurion who find satisfac
tion
each day in delivering a necessary service and making the lives of others better.
Centurion brings together multidisciplinary resources, expertise and support to make
this
successful.
As a member of the healthcare team, you have an important seat at the table of
those
entrusted with the security and operation of the facility. A safe and secure environm
ent
is the first priority of the jail or prison. As health providers, we defer to the rules
and
operation of the security officials to achieve that priority. Security, on the other
hand,
defers to us for the medical judgements and care that is to be provided to ensure
good
outcomes. For this reason, we must be mindful of the roles within the environment
and
adherent to the rules of safety, while conscientiously working in the best interest
of our
patients.
Correctional systems value effective health services. Good treatment makes for
good
security and fewer grievances and complaints from those in jail or prison or families.
Care which is unnecessary wastes resources, takes care away from others and
increases security risks. Good medical providers practice necessary care. They
identify
serious needs and address them.
Good practitioners also learn to work within the often-rigid rules and occasional
limitations of the correctional settings and still achieve the desired outcomes for
the
individual and the whole population. Understanding and respecting these limits
is part of
being a good correctional health care provider. There are, for example, specific
time
periods for patient encounters and other times in which security functions must be
completed. There are established times designated for meals, medication
administration, recreation yard, program activities, such as school, work assignm
ents,
visits and so on. Those in custody must be in their cells for a "count" several times
a
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require all to be locked-down in their
day. There are also times when security concerns
for a few hours or several weeks, yet
cells or movement is limited. Lock -downs can last
requires collaboration and partnership
care and treatment must still be provided. This
with security.
der, it is important to communicate
To be a successful correctional healthcare provi
healthcare and security staff. As a
respectfully and regularly with all members of the
you have in mentoring and teaching
medical provider, you should recognize the role
rvations and experience. It is
other staff, but also being open to their input, obse
scheduled to treat patients in order to
important that you are punctual and present when
is not easy for security staff to ensure
minimize disruptions in the security process. It
available as scheduled. When security
that all persons scheduled for appointments are
able for your appointments and you are
staff has made the effort to have the patient avail
minute, you will disrupt many schedules
late or can to cancel your availability at the last
and can lose credibility among the security staff.
ssion. You are a healthcare provider.
First and foremost, however, be true to your profe
the community medical profession apply
The same ethics, principles and expectations of
patients have limited options of care
to corrections, and perhaps even more so. Your
the profession holds . Patients have
providers , so you must represent the best of what
maleficence. You are to provide them
right to autonomy , justice, beneficence and nonopriate treatment.
your good judgement, professional care and appr

Differences Between Jails and Prisons
both systems are correctional
You will be working in either a jail or prison. While
nts for health services are different.
environments, their missions and the requireme
ing and security for individuals who
Jails are county or city facilities that provide hous
trial on pending charges. Most are there
have been arrested for crimes and are awaiting
s have determined that they are
because they are unable to afford bond or the court
misdemeanors as well as serious
ineligible for a bond . They may be charged with
e individuals who have been convicted
felonies. But jails in many jurisdictions also hous
one or two years . Jails may also house
of a crime but have been sentenced to less than
fer to the state's prison system to
individuals convicted of a crime and awaiting trans
complete longer sentences.
iduals when initially incarcerated, are
Health services within a jail, particularly for indiv
The patients who require health
similar to those found in emergency departments.
er to self or others, be at risk for
services may be psychotic, present a risk of dang
ding alcohol, and be injured as a result
"detoxing" from any number of substances inclu
of a crime. You may often be providing
of altercations during arrest or the commission
little or no information regarding prior
health services based on the patient's report with
and co-occurring psychiatric and medical
treatment. Risks of substance use, withdrawal
cy departments. During the following
conditions are similar to those found in emergen
for a variety of complaints, both big
days of incarceration , patients are seen in the clinic
and small , acute and chronic, new and old.

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A jail population is always churning. Typically,
half of the individuals arrested are
released within seve ral hours to a few days and
are replaced by newly arrested
individuals. Jails may also house those awaiting
trial, some who have been convicted
and sentenced to short sentences (less than 12
months) and persons already sentenced
to state of federal systems but sent to jail to stand
trial on a new charge or serve as
witnesses.
Prisons are state facilities that provide housing
and security for individuals who have
been convicted of crimes and sentenced to more
than one or two years of incarceration.
Prisons and jails designate those in custody at
various security levels (minimum,
medium, close , maximum, supermax). A perso
n's security level is determined by his/her
behavior while incarcerated as well as by the seve
rity of thE~ crime that resulted in the
sentence.
Health services within a prison are similar to those
provided in outpatient ambulatory
care facilities and skilled nursing facilities. Pers
ons admitted to prisons may have been
treated and stabilized while in a jail; however, a
few may be admitted directly from the
community. Some will have remained in the comm
unity on bail until convicted. Others
may return directly to prison from the community
due to a parole revocation.
The first stop for a person entering the prison syste
m is an intake or diagnostic facility.
Most states have separate diagnostic or intake
facilities for males and fema les . There
are many activities performed at the intake facili
ty but the primary responsibilities for
health services are identification of infectious disea
se; identification of patients with
acute mental illness and/or at risk for self-injury
; continuity of care for needed
medications and treatments; and initiation of thera
py and care for newly diagnosed
problems.
Once incarcerated, the level of health functionin
g should be similar to that in the
community. Some patients will maintain stability
with outpatient services or accessing
healthcare with episodic illnesses while others
will require specialized care that is
provided in disease management clinics.
Who is Your "Patient?"
Persons in jail or prison are referenced by many
names, officially or colloquially, such as
"inmate," "prisoner", "detainee", "arrestee," "offe
nder", "convict", "resident" and more.
Individuals housed in jails or detained by the Fede
ral Marshalls are typically called
detainees if not yet convicted. After conviction
and incarceration in a state or federal
prison system, the individuals are typically refer
red to as inmates or offenders.
Incarcerated population may refer to themselve
s as convicts or prisoners but these
terms are generally not used in official communica
tions. Inmate and offender are often
used interchangeably in unofficial communications
. Inmate or offender for official
communications is determined by the preference
of the facility or system.
As a healthcare professional, however, the perso
n in your care is your "patient" and
should be addressed as such. Often times it may
be helpful to ask the patients how they
wish to be addressed as some1individua ls may
be transgend,~r. It is appropriate to
address the patient as "Mr. _ _ " or "Ms.
", or "Patient _ _" as well as introduce
yourself as "Doctor __" or "Nurse Practitioner
__" or "Physician Assistant
"
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g patient
etc. Exchanging greetings is appropriate and contributes to a trustin
ge. Washing
messa
strong
a
sends
attire
relationship. Appropriate and professional
strates to the
demon
also
but
l,
contro
hands between patients is important for infection
patient your professionalism which can increase trust.
responsibilities for
It is also important to appreciate that in corrections you also have
health services for
contributing to the security of your facility . In providing appropriate
'management of the
patients, you will make a significant contribution to the safety and
t."
facility . In a sense , the whole facility is your "patien
the team within the
As noted previously, health service staff are an integral part of
regulations of the facility
correctional setting and compliance with the security rules and
is necessary for the
is a fundamental requirement. Complying with these requirements
also valuable
are
s
officer
tional
Correc
facility's security and for your own protection.
members that
staff
the
are
s
officer
assets when providing health services. Correctional
7 days a week.
day,
a
have the care, custody and control of persons in custody 24 hours
his/her
on
ts
They can provide important information about how the patient interac
ations to you on the
housing unit and with peers. They can offer non-medical observ
of prescribed treatment
patient's progression or regression under different components
deputies and are
are
jails
county
plans and medications. The security staff of most
tional officers (and
correc
than
appropriately called deputies or detention deputies rather
not "guards.")
often do not receive
Security staff, particularly the front-line staff, has a difficult job and
tation is that all of
community respect for their challenging responsibilities. The expec
with important
sionals
profes
as
staff
healthcare staff and contractors will treat security
of security
group
a
find
may
duties. This is not always easy. In many institutions, you
harass
openly
may
staff who do not promote the provision of healthcare services and
in
reports a
inmates. While these allegations may be valid, responding to these
e security and
confrontational manner is counterproductive. We strive to provid
your informal
but
,
issues
illness
l
healthcare staff training in physical and menta
red training.
structu
than
ve
effecti
interactions and guidance with staff can be more
ne security staff, your
Without the development of a collaborative relationship with front-li
will likely be
access to your patients and even the efficacy of your treatments
a collaborative
jeopardized . Further, if security staff do not believe that there is
y may not be
custod
in
s
person
of
ation
relationship , the benefit of their 24/7 observ
align with
will
s
sional
profes
care
shared with you. It is not expected that our health
consider the
to
ted
expec
security staff to the detriment of health services, but you are
provision of
the
ting
responsibilities and potential contributions of security staff in facilita
may
that
s
of action
clinically appropriate health services. Observations and reports
s administrative staff.
compromise health services should be referred to health service
portal, and each contract
Centurion has a model escalation policy accessible through the
should have site-specific escalation policies as well.

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Achieving an effective relationship with the secur ity staff
of your facility is crucial;
however, the way in which you address the reported needs
of individual patients will also
determine your overall effectiveness. Persons in custody
can present a cha llenge
beyond that experienced with patients of the general public
.
Most patients will have a bona fide diagnosis. On occas
ion, you will likely encounter
patients who deliberately use behavior or present with comp
laints or symptoms for their
own gain just as in the community. For example, a patien
t may seek to obtain orders for
certain medications from you or ask you to restrict their work
assignment due to a nonexistent disability. It is never appropriate to dismiss comp
laints without an adequate
evalu ation. Beware the frequent complainer who eventually
presents with a true finding.
On the other hand, you will also encounter patients who
have limited insight into their
own signs and symptoms of illness. They may mislabel
or omit mentioning genuine
symptoms. These miscommun ications may not be intent
ional.
It will take reliance on objective data, collaborative invest
igation with other healthcare
team members and security staff and your professional exper
tise to sort through these
cases. Secur ity and healthcare staff are usually very fam
iliar with attempts at secondary
gain and simply consu lting with them may enlighten you
to a patient's previous history
and patterns of attempts at secondary gain. Patients may
act very differently in their
housing unit or on the yard than they do in your office or
the healthcare unit.
Healthcare staff who do best in correctional settings fee l
comfortable consulting security
staff to ensure adequate information is available when makin
g a diagnosis. Remember,
in corrections, time is on your side as well as the ability to
schedule frequent follow-up
visits with a patient to monitor their progress. It goes witho
ut saying that it is essential
for you to review documentation in the medical record to
develop a comprehensive
picture of the patient. Keep in mind that the patient may
have been in the system for
years and there may be many volumes to the medical record
. There is no requirement
that you review each volume of the record but, depending
upon the circumstance , this
historical information may be helpful to you.

Security and Treatment: A Balance
It can be a challenge to provide health care in a secure setting
. Sometimes healthcare
treatment and security concerns come into conflict or disag
reement, and predetermined
relationships and/or mechanisms to work through differe
nces are needed. New
providers are wise to seek out t he correctiona l officers and
secur ity supervisors working
in the various areas where healthcare is provided. Wheth
er the provider is experienced
or not, form ing working relationships is critica l to doing the
job effectively. A correctional
officer's job is to ensure everyone's safety and security regard
less of the nature of
working relationships. Open communication, mutual respe
ct and teamwork are the
cornerstones to maintaining a balance between security
and treatment.
Introduce yourself to officers/supervisors in your work area
and let them know that you
are new to the facil ity and ask if they can tell you about "how
it works around here" or do
they have any advic e. Let them know that you value their
opinion since they know the
inmates on a continual basis and that you would appreciate
sharing information that may
impact safety or security.

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It is important for you to become familiar with the application
of the Health Insurance Portability and Accessibility Act
(HIPAA) in corrections. There are differences in its
application in the correctiona l environment, and Centurion
offers tra ining on this subject. By way of example:

HIPAA
COMPLIANT

"Health care providers may disclose information to correctional
y
facilities and other law enforcement officials having lawful custod
of the offender if the information is necessary for the provision of
er
health care to the individual; for the health and safety of the offend
those
or
facility
the
at
yees
or other offenders, officers or emplo
transporting the offender; or for law enforc ement or the
administration and maintenance of safety, security and good order."

Nancy Haywood, JD, NCCHC website

g or
On occasion, certain security staff will not be approachable or act uncarin
unconcerned, thinking or acting as if there should be no reason for a working
be some
relationship between healthcare and corrections. Additionally, there may
ers" or "do
"outsid
as
rs
provide
and
correctional officers who perceive healthcare staff
on,
excepti
the
lly
genera
is
gooders" wh o should not be in a correct ional facility. This
occur.
can
it
especia lly in recent times, but it is important to have an awareness that
e." Officers
Also, new staff can be subject to a kind of initial "hazing" or "rite" of passag
they will be
may test new staff to see how they react and what kind of professional
a gate or door for
at
waiting
kept
being
is
le
working with in the environment. One examp
not push the call
and
calm
stay
to
an inordinate period of time. If this happens, it is best
through.
pass
to
buzzer/bell incessantly. Smile or say thanks when you are allowed
compliant
your
Naturally, if there is an emergency or if this practice continues, despite
n persists,
attitude, try first speaking to the particular officer individually. If the situatio
follow the facilityyou should go to your supervisor for advice and guidance. Learn and
arise.
ges
specific escalation policy when such challen
Clinical Boundaries
ess of clinical
The goal of this section is to enhance your understanding and awaren
your safety and
ensure
to
es
practic
e
promot
to
boundaries in the correctional setting and
d in earlier
covere
been
has
l
materia
the safety of others in this workplace. Some of this
critical.
is
tion
informa
sections and may be repeated in other sections because the
a new
Many healthcare staff are new to work in corrections and are experiencing
little or no
had
have
they
which
for
within
those
environment of prison/jail culture and
Initial
media.
the
from
s
perhap
preparation , training or prior knowledge, except
ht frightening.
exposure to the correctional environment can be intimidating and downrig
or offices.
Providers are accustomed to working in teams located in hospitals, clinics
and waiting
Walking down locked corridors that lead to cell blocks, dormitories or yards
to many people.
to be processed into and out of security traps does not come naturally
personnel often
ed
uniform
of
scores
among
staff
Being one of a relatively few healthcare
When the
ed.
develop
t
respec
mutual
requires that social barriers are broken down and

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barriers are overcome, you are likely to be rewarded by valuable observ
ations and
situational learning.

All healthcare staff working in corrections must be acutely aware of the
secure
environment that they work in. They must understand and appreciate
that a correctional
facility has a core mission of providing custody and control. Maintaining
the safety and
security of the facility, all staff and those in custody is paramount. Care
and treatme nt
are integral components of a correctional facility; however, safety and
security will
always take precedence if proposed treatment or any facility function may
jeopardize the
core mission.
Clinical Boundaries
Clinical boundary issues arise when individuals encounter actual or potenti
al conflicts
between their professional duties and social, sexual , religious, or busines
s relationships.
Physlcians 1 psychiatrists, nurse practitioners, physician assistants, psycho
logists,
counselors, nurses, supervisors, and administrators may encounter circums
tances that
pose actual or potential boundary issues.
Boundary issues occur when providers face potential conflicts of interest
, stemming from
what has become known as "dual" or "multiple" relationships. A profess
ional enters into
a dual relationship whenever he/she assumes a second role with the patient
becoming,
for example a "friend," "employer," "teacher," "family member," or "sex
partner." This
can be even more treacherous in the correctional environment than in
the community as
persons in prison are likely to have many other motives for seeking to
create these
secondary relationships, and is the reason there are rules and even laws
prohibiting
such relationships. Such relationships can risk your safety, your family,
the safety of
your colleagues, your clearance into the facility and your professional
licensure.
Another perversion of the professional relationship can occur with the
collection of
forensic evidence. That is not the role of the provider who delivers care
and treatment
to an individual. It is Centurion's policy that treatment staff do not particip
ate in
collecting forensic data, such as sexual assault evidence from an alleged
perpetrator or
conducting forensic evaluations of persons in custody. The classic dual
relationship
dilemma occurs when a healthcare staff member collects forensic evidenc
e that
incriminates the person in custody and then the staff member must testify
against that
person in court or at a disciplinary hearing. This is a conflict since the
healthcare staff
member is both the caregiver and the accuser. When it is necessary to
collect forensic
information or testing, it is better to have that done by someone who does
not, and will
not, have a clinical relationship with the person in question.
Dual relationships occur primarily between healthcare staff and their current
or former
patients but also can occur between professionals and their colleagues.
For example,
writing a prescription for a correctional officer would invite a dual relation
ship and raise
serious ethical concerns. Centurion's professional liability insurance does
not cover such
encounters and covers only the services that Centurion is contracted to
provide to our
government agency clients. It is our policy that healthcare staff should
not give other
Centurion or correctional staff healthcare advice or prescriptions unless
the staff
member is being seen as a formal patient in a scheduled clinic and a patient
chart is
generated and maintained. (Nothing is this paragraph, however, should
prevent a
provider from responding to a medical emergency and delivering initial
care to a
colleague or visitor.)

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The broader subject of professional ethics, to which the topic of boundaries is closely
tied, has received considerable attention in the professional literature, but contemporary
correctional healthcare literature contains relatively scarce discussion of boundary
issues or guidelines for conduct. Much of the available literature focuses on dual
relationships that are exploitive in nature, such as the sexual involvement of healthcare
staff with incarcerated persons. These are certainly important, but there are many more
subtle boundary issues than these egregious forms of ethical misconduct.
Clinical boundaries require healthcare staff knowing themselves, their biases and their
limitations. It is required that we provide care to persons with whom the nature of their
criminal acts or behaviors while incarcerated raise issues of personal or professional
anger, hatred, resentment, revulsion or loathing. It is not common that healthcare staff
have access to criminal charges, but given the "correction's grapevine," often crimes are
known or learned through the media. We treat the patient; regardless of the crime.
While it is doubtful that healthcare staff take a position within a correctional setting in
order to get involved in a romantic/sexual relationship with an inmate, it happens. The
relationship may be same-gender or cross-gender, may seem to be consensual (it is
important to note that incarcerated persons lack the capacity to consent, just as minors
do) or forced and may occur within or outside of a therapeutic relationship. Persons in
custody may be looking for a "mark" and many can easily identify vulnerabilities of staff
members. These relationships are almost always discovered and result in grave
consequences for the staff member (including termination from employment, being
locked out of government agency facilities and reporting to licensure boards) and the
incarcerated person.
The motivation of incarcerated persons in these situations is likely to be beyond a
romantic or sexual interest in the staff member and may include the intent to inflict
physical harm or to coerce the staff member to bring in drugs or other contraband, to
reap secondary benefit such as a monetary settlement, to have sex with others, to aid in
an escape attempt, or to become involved with outside criminal elements or behavior.
When the staff member is licensed, he/she is generally reported to the appropriate
licensure agency resulting in suspension or loss of license for ethical breach and/or
criminal prosecution/conviction. In many states, if an employee is involved in a sexual
relationship with an inmate the employee is charged with, at a minimum, misdemeanor
sexual misconduct or felony rape. This information is presented not only to offer
guidance to the individual provider but to alert providers as a professional member of the
healthcare team to behaviors that may place other members of the team at risk and how
to avoid these pitfalls of "inmate games or cons," as it is commonly referred.
How can these types of situations be prevented? One strong preventive resource is
correctional and healthcare staff looking out for each other. In the examples of boundary
issues provided later, the individual is often unaware of his/her own physical or verbal
behavior and the risks it creates. In a multidisciplinary team or among co-workers who
enjoy strong working relationships, individuals have a responsibility for their own
behavior, but also have a responsibility to help protect co-workers in the correctional
environment. If a co-worker is observed engaging in behavior that may be breaching
boundaries with a patient, the observer should bring the issue privately to the co-worker
and, if disregarded or of a sufficiently serious nature, to a supervisor. Such action is

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truly in the individual's best interest. A primary source of safety and security in
corrections is the appropriately reported potential for jeopardy or harm by all employees.
In summary, you want to maintain a professional relationship all of those in custody.
You want to be viewed as friendly and accessible but not a "friend." One way you can
do this is in the way you address individuals. In most systems the inmate is addressed
as Mr./Ms. and clinicians are addressed as Dr. or Mr./Ms. The formalities may seem
uncomfortable but they are important in establishing and maintaining professional
boundaries.
Strategies Inmates Use to Promote Boundary Violations
Persons in jail or prison often have little to do while incarcerated. Some are carefully
observing you to determine whether you have any personal needs or vulnerabilities.
They will be trying to tell if you demonstrate: a need to be seen as special and different
from other staff members, more caring, more successful; a need to be liked; a need to
disclose personal information and problems; or apparent sexual or financial needs.
Some will be carefully testing you to see if you are willing to play favorites and make
small exceptions and permit liberties or privileges. They will test whether you will permit
some into unauthorized areas; share food or cigarettes; take letters out of the facility; or
provide persons with access to unauthorized telephone calls or computer time.
Doing favors, no matter how small or seemingly inconsequential, is prohibited. Favors
include: allowing a person in custody to use your telephone; passing messages to family
or friends or other inmates; mailing letters; bringing magazines or other any items to a
person in custody or receiving any gifts or tokens of appreciation from a person in
custody or outside contact. Similarly, providing samples of medications is not
acceptable. Although such practices may sometimes occur in community settings, they
should never occur in jails and prisons. For many reasons, all medications require
written medical orders. Persons in custody may use any small exceptions, whether
"favors" or medication samples, as a lever to get you to make larger exceptions. They
may "offer" not to turn you in when they have observed you engage in a lapse on the job
and even offer to help make you "look good" to your supervisors and the institution. An
act as small as offering a person in custody a cup of coffee or a band-aid at times other
than an official clinic visit may be construed as a "favor" and should be avoided.
Fair, firm and consistent behaviors are absolutely required of the individual
healthcare staff member and collectively for the healthcare team . Fair, firm and
consistent treatment requires that the healthcare team know and understand security
rules and regulations, conform to practice guidelines especially relating to special inmate
accommodations such as special diets, lower bunks, and special shoes and to comply
with the established processes for specialty referrals and off-site trips.
"Slippery Slope" of Boundary Violations
As noted previously, healthcare staff rarely, if ever, start out their correctional careers
with a deliberate decision that, at some point in the future, they are going to violate
professional boundaries by giving a patient a special favor or by engaging in sexual
relations. This is probably the last thing on most people's mind as they start a new job.
Usually, violating a professional boundary is the final step of a long process, one that
starts out with small, seemingly trivial behaviors and ends up with much bigger boundary
violations. This process is often described as descending a "slippery slope," because

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the little steps cause the staff member to slide down in the direction of boundary
violations. The further the staff member slides, the harder it is to stop.
Maintaining good clinical boundaries and safe practices involves not just complying with
professional and institutional rules and regulations. It also involves noticing when you
have made a small step onto the slippery slope. Noticing these early warning signs can
help you get off the slope quickly, and get your behavior back inside appropriate clinical
boundaries.
Some of the most frequent early warning signs of a "slippery slope" to boundary
violations include:
•

Not sharing uncomfortable or embarrassing feelings, whether positive or
negative, that you have for a patient with your team or supervisor. The minute
you begin to keep silent about important issues in a case, you are contributing to
a "secret" that the patient can use against you later.

•

Boundary violations are more likely to occur when confidential but important
information is not shared with the rest of the treatment team or security.
Remember, a patient's right to confidentiality does not mean that what he/she
tells you is private and secret. You are a member of a healthcare team, and
important information needs to be shared and discussed in the team. In addition,
if the information is relevant to safety, security or good order in the institution, the
information can and must be shared with security.

•

Making special appointments with the patient outside of normal hours. Meeting a
patient after normal working hours, coming in on the weekends specifically to see
the patient, making arrangements for special levels of privacy to "ensure
confidentiality," and even extending the length of individual encounters can be
precursors to boundary violations. Obviously, it is sometimes necessary to be
flexible in scheduling and emergencies can arise that require you to see a patient
off hours; however, a pattern of unusual contact may mark a slide down the
slippery slope.

•

Not documenting interactions with the patient, or documenting them in a more
cursory fashion than you normally do. Not documenting your interactions is like
keeping them secret, and secrecy is a major contributor to boundary violations.

•

Not holding to the treatment goals and shared treatment tasks in your
interactions. As a general rule, keeping true to the treatment needs and being
firm , fair and consistent will protect you from violating clinical boundaries. In a
correctional setting, it is particularly important to focus on the shared treatment
goals (e.g., improved behavior) and the shared tasks that must be accomplished
to reach these goals (e.g. , specified forms of treatment, such as skills building).
Although a patient's treatment needs can and do change over time, if you permit
your interactions with the patient to deviate significantly from the purposes set
out in the treatment plan, it is likely you are heading down the slippery slope of
making the staff-patient relationship personal rather than professional.

•

Not discussing with your team any differences of opinion about how to treat the
patient; holding grudges against team members or the administration for their

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different opinions; and aligning with the patient in your anger and resentment.
Persons in custody are adept at getting healthcare staff to become their
advocates for special allowances. While it is important to advocate for what is
humane and fair, it is equally important to remain dispassionate and objective. It
is inevitable that, during the course of your career in corrections, clinical and
administrative decisions will be made with which you will disagree. Learning to
live with these decisions and continuing to work closely with your team without
ongoing resentment is an essential skill. If you find yourself siding with a person
in custody against the rest of the team and/or facility administration, you are in
serious danger of being lured into a partnership with that person that will cross
professional boundaries.
•

Finding yourself fantasizing about the patient, whether about "healing" him/her,
sexual relations, fear of being harmed, or wanting to punish, and not
acknowledging these fantasies either to yourself or to a supervisor. Specialties
in clinical training aside, if you unconsciously see yourself, and no one else, as
capable of "curing" or "healing" the patient, you are likely to be fantasizing past
the boundaries of your clinical competence. Most patients require concerted and
integrated team efforts to achieve behavioral improvement.

•

Finding yourself engaging in sexual fantasies involving a patient or wearing
particularly kinds of clothing in the hope that the patient will notice, puts you at
risk of developing stronger feelings of infatuation or "falling in love." While some
sexual feelings are a normal component of adult life, strong and unacknowledged
sexual feelings towards a patient should be discussed with your supervisor.

•

Finding yourself fantasizing angrily about how the person in custody should be
punished, you have likely taken something the person did as a personal betrayal.
The risk here is that you will become punitive in your interactions with the patient.
Discuss these feelings with your supervisor.

•

Finding yourself worrying repeatedly about what the patient is going to do to you
or your family after he/she is released from prison. In small ways, you may find
yourself feeling intimidated and trying to avoid situations in which you have these
unpleasant feelings. This avoidance behavior can add up to a series of "lost
opportunities" and, ultimately, to a failure to acknowledge and report high risk
behavior that threatens or violates institutional security.

•

Worrying about being sued by a patient. Often, persons in custody verbalize
litigious intent when they do not receive a medication or service that they feel
entitled to receive . Some patients attempt to use this strategy to get staff to
comply with unrealistic requests. Fear of being sued can generalize into
healthcare staff practicing "defensively" or making clinical decisions driven by
self-protection and not the best interest of the patient. Again being firm, fair and
consistent services should be the mantra for healthcare staff in corrections.
Centurion has insurance to cover you in the event of a claim relating to your
healthcare services and has a strong in-house legal department that can answer
your questions and talk through your concerns.
Not all inappropriate relationships are of a sexual nature. Any sort of "special
treatment" or levels of inappropriate trust in what the patient tells you can lead to

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inappropriate relationships. Caution should be taken if any patient chooses only
you or requests only you participate in their healthcare.
This section should have increased your awarenes s of the importance of clinical
boundaries in the correctional setting. It should be noted that not all persons in custody
play "games" with staff members. Many will genuinely welcome and respect your
treatmen t efforts. It is not unusual for these persons to report that their healthcare
services were the "best" while they were incarcerated. Experien ce confirms that when
clinical boundarie s are healthy, correctional healthcare can be very rewarding.
There are persons in custody who will do their utmost to improve their situation by
"using" staff. We may view their behaviors as "manipulative," but the patients view these
attempts as "survival" since they are very limited in improving their daily lives. If a
patient can get a "sleep" medication, bottom bunk, job restriction, evening snack, or layin from healthcar e staff when these measures are not clinically necessary, that person
has improved his/her "life."
Working in corrections requires healthcare staff to balance treatmen t and security needs.
You will be treating a population with many needs, and many who neglected themselves
or did not have the means to care for themselves. Being fair, consistent, responsive and
professional will keep you safe. Your practices will receive scrutiny from those in
custody, your healthcare colleagues and the correctional staff.
The correctional staff comes from the public and they see the inmates we treat for many
hours a day over months to years. They develop opinions about the relative value of our
practices in the lives of the inmates and in the running of the facility. While some of
these opinions will be off the mark, there will be a consensu s that develops regarding
healthcare practices that will likely be trending in the right direction and will influence our
ability to practice effectively. Once the correctional staff learns from experience that you
can be effective, responsive and respectful of security rules, you will gain credibility and
cooperation. With the right balance between treatmen t and security, you will enjoy
working in correctional healthcare environment.

Recommendations for further reading on this topic include:
•
•
•

Allen, B., & Basta, D. (1981/2005). Games criminals play: How you can profit by
knowing them. Berkeley CA: Rae John Publishers.
nd
Cornelius, G. (2009). The art of the con: Avoiding offender manipulation, 2 ed.
Alexandria VA: American Correctional Association.
Elliott, B., & Verdeyen, V. (2003). Game over! Strategies for redirecting inmate
deception. Alexandria VA: American Correctional Association.

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Descriptions and reviews of these books are available at Google Books, Amazon
.com
and at the ACA web site aca.org.

How to Work with Patients Who Do Not Like Your Decisions
As a physician, nurse practitioner or physician assistant, you are not running for
political
office. If you are doing your job correctly , there will be times when patients will be
unhappy with you. Your identification of illness and provision of appropriate treatme
nt
will not always coincide with his or her agenda. When a patient with a non-clinical
agenda feels you are not going to give him/her something that he/she wants, or
that you
are about to take away something that he/she desires, the patient may attempt a
number
of strategies targeted at getting you to change your mind.
Threats:
You learn from nursing or security staff that a patient has been selling his/her medicat
ion
to others in his dormitory. You order a blood level, and it comes back zero. You
inform
the patient that you are unable to continue allowing him to hold his medication.
He must
come to the pill window daily. The patient swears to you that he/she has been taking
the
medication no matter what informati.on you have. The patient additionally informs
you
that he/she will file a grievance and report you to your medical board. The patient
may
"take your name" and let you know officiously that you will be hearing from his/her
attorney.
Bargaining:
You obtain reliable information that a patient has not been taking his/her medicat
ion, and
has probably been selling it to peers. You discuss this with the patient who points
out,
by name, a number of other people who have been doing the same thing. The patient
hopes that by providing you with this "inside information," he/she will earn your favor
so
that you will continue the medication that has been prescribed.

Some tips for handling patients unhappy with your decisions:
•

Make your diagnosis based on judicious use of subjective information
supported by careful objective data and observations

•

Document your clinical findings and the patient's reaction.

•

Do not argue with the patient. Stay calm, reinforce your diagnosis, course
of treatment, and the risk/benefit profile of the medications that you have
chosen to start, stop or titrate. Explain your rationale to the patient and
document your rationale explicitly in your progress note. Always schedule
a follow-up appointment to re-evaluate the patient.
If needed, invite another staff membe r to join the conversation and
document his/her presence in your progress note. It is useful to make
controversial or problematic treatment decisions as a case conference
rather than as an individual decision. "We discussed this at our clinical
meeting and the decision was made there to discontinue your medication
(or whatever the issue)." It is harder to argue or manipulate a group.

•

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•

suicide threat), fake the
If a patient's threa t is against himself/herself (e.g. a
suicid e precautions in
on
threat seriously, document, and place the patient
a safe cell.
Systems
Evolution of Correctional Health Care: Courts and Legal

United States was under the
Prior to the 1970s , healthcare in jails and prisons in the
ing public officials and the
direction of county sheriffs and wardens. The public, includ
care of persons in jail or
healthcare community, showed little concern for the health
dy was provided and
prison. Often the healthcare that received by those in custo
controlled by other inmates and "guards."
sed to
In the 1970s the Department of Justice involvement increa
al
Medic
ican
Amer
the
s;
improve medical care in prison
began
Association and the American Public Health Association
and
uals;
individ
writing standards for the care of incarcerated
tional
correc
state and federal courts began to rule against many
facilities.
healthcare.
There are unique legal principles governing correctional
duty to care for that person.
legal
a
s
create
n
Having physical custody of another perso
tion, or serving a sentence
The legal basis for the actual custody, either arrest, deten
dment that guarantees the
amen
al
after conviction, determines the particular constitution
dy in a correctional institution is
access to care, but the legal standard is identical. Custo
d on their keepers for food,
sufficiently restrictive that those incarcerated must depen
The most fundamental
water, clothing, and medical care - the basics of survival.
and health of those
obligation of a jail or prison system is to maintain the life
incarcerated .
Due
A pretrial detainee's right to healthcare comes from the
a
and
t
Process Clause of the Fourteenth Amendmen
convicted person's similar right comes from the Eighth
Amendment's prohibition of cruel and unusual punishment.
While the constitutional basis varies, the liability is the same
for jails and prisons. All persons who are incarcerated are
entitled to the minimal conditions necessary to sustain life
and to avoid needless suffering.
, Estelle v. Gamble (1976),
The first Supreme Court decision to addre ss prison health
was below a constitutional
determined that medical care in the Texas prison system
inmates have a constitutional
level. Estelle and subsequent decisions estab lished that
community.
right to healthcare equal in quality to that available in the
founded in "cruel and unusual
The legal allegations of inadequate care for inmates were
itution. The Eighth
punishment" under the Eighth Amen dmen t to the U.S. Const
been interpreted to
has
nt
ishme
pun
Amen dmen t's prohibition of cruel and unusual
the "serious medical
to
"
rence
require that prison officials must avoid "deliberate indiffe
of the legal
ent
statem
needs" of inmates. There are two critical phrases in the

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obligation of care owed an inmate who has a serious menta
l condition: "deliberate
indifference" and "serious medical need."

Deliberate indifference is a legal term for a mental state
in the same general category as
"intention, " "reckless," or "gross negligence. " From its earlie
st use in 1976, it was clear
that it required more than poor judgment and less than intent
ional acts or omissions
calculated to cause needless suffering .
In Farm er v. Brennan, 511 U,S. 825 (1994), Justice Soute
r states that, "With deliberate
indifference lying somewhere between the poles of neglig
ence at one end and purpose
or knowledge at the other, the Courts of Appeals have routin
ely equated deliberate
indifference with recklessness." Recklessness, however,
does not have a single
meaning in law. Once the Court decided on recklessnes
s as the functional equivalent of
deliberate indifference , it then had to choose between the
more relaxed civil standard
and the more demanding criminal standard .
The major difference between the civil and criminal stand
ards is whether the official
should have known the illness and risks of harm (the civil
standard) or whether the
official had actual knowledge (the criminal standard). The
Court opted for the criminal
law - actual knowledge - version of recklessness but soften
ed the potentially harsh
impact of this standard on plaintiffs. The Court noted that
a plaintiff need not show that
an official actually believed that some harm would occur,
only that there was knowledge
of a substantial risk of harm.
Thus , the first question for liability is what was known. Then
one asks:
• What risks flow from that knowledge?
• What duty is thereby established?
• Was that duty breached?
Unfortunately, there is no single definition for what const
itutes a "serious medical
condition ." The test for seriousness begins with clinical
necessity and not simply what
an inmate may desire. Because the constitutional basis
for the right to treatment is in
the Eighth Amendment's ban against cruel and unusual
punishment, courts tend to
equate seriousness with the needless infliction of pain and
suffering.
The Eighth Amendment requires that prison officials provid
e a system of ready access to
adequate medical care. Examples of inadequate medical
care are:
•
•
•
•
•

Serious denials or delay in access to medical personnel
Denial of access to qualified health care personnel
Failure to perform a screening or take a history necessary
to make a professional
judgm ent
Failure to carry out medical orders
Relying on factors other than medical need to make treatm
ent decisions

Mental health care of persons in custody is governed by
the same constitutional
standard of deliberate indifference as in medical care. A
severe mental illness as
defined by courts is one which causes a significant disrup
tion in the everyday life of an
incarcerated person and which prevents him or her from
functioning in general
population without disturbing or endangering others or self.
The Eighth Amendment

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requires that prison officials provide a system of ready access to adequate mental health
care.
Dental care is also governed by the same constitutional standard of deliberate
indifference. Requirements include attention to dental care particularly if the patient is
suffering pain. Dental care cannot be limited solely to extractions.
Consent decree is a familiar term in the correctional healthcare environment because so
many systems have been or currently are subject to class action litigation alleging
constitutional inadequacies. When it is alleged that the correctional facility or system
does not provide adequate access to appropriate care, lawyers may sue on behalf of a
class of those incarcerated to improve the conditions of confinement for all. In many of
these cases, a judge will attempt to get the parties to enter into a consent decree, where
the lawsuit is settled via a court-supervised agreement to remedy the situation. Many
jails and state correctional systems in the 1980s and 1990s entered into these
agreements to provide the delivery of more comprehensive health care.
The Department of Justice (DOJ) may investigate conditions of
confinement to determine if those condition s violated constitutional
rights of those confined . The DOJ conducts these investigations
pursuant to several United States Codes including the Civil Rights of
Institution alized Persons Act of 1997. Most often when findings show
violation of civil rights, deliberate indifference or other violations of US
Codes, a Memorandum of Agreement is entered into between the
DOJ and the facility oversight entity. This agreement identifies actions to remedy
negative findings and outlines compliance requirements. The Agreement includes
scheduled return investigations and reports.
Correctio nal systems are required to abide by the America ns with
Disabilities Act. Incarcerated persons have initiated lawsuits
when prison and jails fail to provide reasonab le accomm odations
for those with disabilities. The issue of accomm odation extends
beyond physical disabilities to include translato rs and devices
for the deaf, access to new treatmen t modalitie s, etc.

While the minimum federal standards for correctional medical services that are
constitutionally required may be met, healthcare providers may still be liable civilly for
malpractice in the omission or provision of medical care. In other words, meeting
minimal federal requirements is no guarantee that officials responsible for medical care
may be free from liability in state court, under state law. While the deliberate indifference
standard is often actuated to gross negligence, medical malpractice cases are based on
negligence, i.e. a breach of the standard of care that causes the alleged injury. In
general, the best protection against malpractice claims is the provision of correctional
medical care in a manner that meets or exceeds community standards of care.
Correctio nal Lingo

Consistent with most social environments, persons in custody as well as security staff
have adopted short hand expressions for common occurrences and have lingo that is

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unique to their environment. While there is no universal "Inmate/Offender/Prison
er
Dictionary," some more common terms and definitions are offered:
•

Ad-Seg (Administration Segregation): Independent units with increased security
and decreased privileges that are separate from general population and used as
penalty for fighting, causing disturbances and/or danger to others

•

Blocks: Cell houses or living units for incarcerated persons

•

Books: Person's money account at the prison to buy certain items at the store,
stamps, co-pays for medical

•

Chain: Chaining in/chaining out process as in going to or coming from another
location

•

Cheeking: Hiding medication in the mouth for use later - stockpiling for overdose
or, more usually, for use as barter among others

•

Chow Hall: Where those in custody eat

•

C.O: Correctional Officer or Custody Officer. Never refer to these staff as
"guards." The correctiona l hierarchy follows the military or police format with
officers, sergeants, captains etc.

•

Contraband: Any item unacceptable for inmates to possess. Sharps, alcohol
wipes, paper clips, pens, staples, rubber bands, and cell phones are examples of
the many items that may be dangerous or used in bartering within the jail or
prison population. Different institutions have different lists and lists may vary
within an institution based on the classification of inmates. There are severe
penalties including legal ramifications for staff who help or allow incarcerated
persons to possess contraband

•

Count: Times during the day when all traffic or movement of inmates stops and
an accurate count of the incarcerated population is taken. Generally, persons
must be in their assigned housing unit or in an approved location. "Out-counts"
are those who are out of the facility for authorized reasons such as court
appearances, specialist appointments or hospitalizations

•

D-Seg (Disciplinary Segregation): Persons typically placed in disciplinary
segregation for a designated time period as sanction for violation of the
institution's rules

•

Gen Pop or GP: General Population where persons are housed with the least
limitations on movement and independence. Persons in GP typically receive
medications through a medication line process, often can have Keep-On-Person
(KOP) medications, and access healthcare services by submitting a request

•

Hole or The Hole: Isolation ("segregation") cell

•

1.M.U.: Intensive Management Unit, ad seg or "the hole"

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•

Jacket: Prison file containing all information on an inmate

•

Kite: A request for services within the prison such as request for dental or
medical services or request to see prison personnel or in a broad sense, any
written correspondence. Also called "a slip" as in drop "a slip" to see the nurse

•

KOP: Keep-On-Person medications include over-the-counter and prescription
medications that certain facilities allow persons to maintain in their cell. You will
need to become familiar with the medications that can be KOP in your facility and
as importantly which medications can never be KOP

•

Lay-in: Appointment that requires the patient to stay in his/her cell due to medical
condition or to wait for an appointment time

•

Lock-down: When incarcerated persons are confined to their cells

•

Man-Down: Security term for an inmate suffering from a medical issue or injury
that requires medical/nursing assessment/treatment in the yard, housing unit or
cell

•

ODR (Officer Dining Room): Where staff are served meals often at discounted
prices. In many facilities it is considered a prime place to work

•

Med-line or medication line, or pill-line: Area and or time that medications which
are not Keep on Person are administered

•

P.C: Protective custody for inmates who are at risk for physical or sexual assault
from other inmates

•

Sally port: Secure area in a facility where staff and/or vehicles typically enter and
leave

•

Segregation: A disciplinary unit (Ad Seg, D-Seg, "the hole"), used for minor and
major offenses, where prisoners are kept apart from the main population and
denied privileges.

•

Shank: A homemade knife that can be fashioned from many objects such as
toothbrushes, barrels of pens, etc.

•

State Issue: Anything provided by the state such as clothing, shoes, and toiletry
items

•

Store or Commissary: Where inmates may purchase food, health, and many
other items. You should be familiar with the items that are available in the
commissary as diabetic and obese patients need education and many over-thecounter medications may be obtained in the commissary.

•

Ticket: A report documenting the violation of institutional rules

•

Trap: When entering a secure area through a series of locked doors, the area
between two doors is the trap. Security staff control the opening and closing and
passage through the traps

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•

Yard: Main recreation yard for general population inmates
Correctional Environment Summary

The information in this section is intended to provide general knowledge and
understanding of providing healthcare in a correctional environment. This following
space is for your notes and questions. Include information that you need to discuss
with
the Medical Director, the Director of Nursing and/or the Health Services Adminis
trator.
Topics you may want to discuss include:
•
•
•
•
•

Does this system or facility have any active Consent Decrees? If so, what is
medical's involvement.
How do healthcare staff address inmates and what is the expected way inmates
address healthcare staff?
Are there access to healthcare issues?
Do patients report for medications and appointments routinely?
Will I need to go see patients in areas outside the healthcare unit?

NOTES:

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Chapter 2: Security Overview and Awareness
Titles in Correctional Settings

Correctional staff in prisons are typically called correctional officers (COs), security or
custody. In jails, security staff are usually called detention deputies. Addressing security
staff as "guards" is no longer acceptable. The term "guard" is perceived by many
correctional officers as disparaging and disrespectful since their role goes far beyond just
"guarding" inmates. Use of incorrect terminology for referring to correctional staff may
create unnecessary challenges in creating positive working relationships in the institution.
The security system in corrections is run as a paramilitary operation. Correctional
officers serve an important role, providing front-line supervision and control of the
inmates housed at the institution. The primary goals of the correctional officers include
providing security for the institution and community; promoting smooth and effective
functioning of the facility; ensuring incarceration is secure yet humane; and supervising
access to programs and services provided in the institution. Understanding the primary
mission of a correctional institution is important to providing inmate healthcare.
Healthcare must work within the guidelines and assist in maintaining security within the
institution. While in a hospital, the Hospital Administrator is the final decision maker; in
the correctional institution, the Warden/Superintendent is the final decision maker. The
final decision maker in the facility does not focus just on healthcare, but all aspects of
the required services for the inmate. These include food service, access to recreation,
access-to visiting, educational programs, work programs, and maintain security. While
the Warden/ Superintendent is the final decision maker regarding institutional
operations, clinical decisions related to an individual patient's healthcare is the
responsibility of the healthcare clinical leadership.
The correctional supervisory structure for the direct supervision of inmates typically
mimics that of the military. The line of increasing supervision usually beginning with the
Sergeant, progressing to the Lieutenant, Captain, Shift Commander and generally
ending at the Major. It is important to learn the specific hierarchy at your institution and
the appropriate titles and to build positive working relationships with the security
leadership.
Tips to be a Welcomed Guest

As security operations are the top priority for the institution, healthcare staff might be
viewed as "guests" in a correctional institution even though you are an integral part of a
successful program. There are several tips that will help you to be a "welcomed guest"
and create a favorable impression with security staff.
The majority of the information presented here focuses on items that are generally not
allowed in a correctional institution. Items allowed/disallowed in an institution vary by
state and may vary by institution within a state. Reasons for the variances can be
related to the security level of inmates housed at the institution and may also vary based
on the correctional leadership at the institution. It is important to remember, although it
may seem inconvenient or the items disallowed may not seem to make sense, the focus

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behind the decisions is to maintain the safety of all healthcare staff, correctional staff and
inmates.
It is extremely important to know what your institution considers "contraband."
Contraband is routinely defined as any item not authorized, not issued by the institution,
not received through approved channels, or not purchased through the commissary and
whose use could potentially endanger the safety or security of the institution or persons
within the institution.

It is importan t that all staff, including healthca re staff, do not bring items
consider ed contraba nd into the institutio n. Example s of items that may be
consider ed contraba nd include:
•
•

•

•
•
•

•
•
•
•

•
•

Guns or firearms of any type
Knives, tools or other sharp objects not approved by the institutio n. This
includes pocket knives, metal finger nail files, scissors , nail clippers, letter
openers, ice picks, metal can openers, metal hair picks, disposab le razors,
or any other items that could be used as a weapon
Hazardo us and poisonou s chemica ls and gases. These include nail polish
remover, gasoline , thinners, contact cement, alcohol, or any item labeled
"Harmfu l or Fatal if Swallow ed"
Alcoholi c beverage s and other intoxican ts, such as narcotics and illegal
drugs
Ammuni tion or explosiv es
Cell phones, beepers, blackber ries except when authorize d by the facility.
If these are approved , they must be maintain ed on your person at all times
or secured when not in use
Audio and video recordin g devices except when authorize d by the facility.
If these are approved , they must be secured at all times when not in use
Personal radios, CD players and video games
CD and DVD players except when authorize d by the facility
Compute rs, software and jump drives or any device containin g the means
of accessin g the internet or receiving , transmit ting or storing informat ion
electron ically except when authorize d by the facility
Persona l protectio n items such as mace
Maps

Some institutio ns also consider the following as contraba nd:
•
•
•
•
•
•
•
•
•
•

Cigarette s, tobacco products , matches , lighters
Chewing gum
Newspap ers (even if inmates are permitte d newspap ers, staff may not bring
them into the institutio n)
Pornogra phic material
Glass or metal containe rs
Thermal containe rs with glass or removab le inserts
Purses
Food from outside sources
Cash beyond that needed for the vending machine s. We recomme nd no
more than $10
Umbrella s (may be permissi ble if blunt-po inted)

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•
•
•
•

Toothbrushes except as authorized by the facility
Mirrors
Magic Markers
bar
Even small, seemingly innocuous items like chapstick or a chocolate
.
can be contraband if it was obtained outside of the commissary system

s to gain power
Contraband is power for those incarcerated. Contraband allows person
ance of
perform
over others. For enterprising persons, trade in illicit goods and the
work, the
prohibited services are the building blocks of power. With planning and
empire
smallest gambling enterprise has the potential to develop into a large trading
loyalty,
cs,
narcoti
s,
weapon
procure
can
s
inside the walls. With such an empire, inmate
the
of
One
on.
instituti
the
of
y
securit
and outside help, all of which can destabilize the
hing
far-reac
the
s
stimate
most common hazards in corrections occurs when staff undere
of
trade
simple
nature of seemingly harmless, but forbidden goods and services. The
candy, for instance, can be a cover for protection services.
to prevent you
It is important that you know what your institution considers contraband
is not
that
ing
someth
in
from inadvertently "breaking" the rules. If you try to bring
to your car.
item
the
return
permitted, you will be required to place the item in a locker or
ls such as
We do not support staff bringing recreational or religious reading materia
s symbols or
books, magazines and newspapers into the facility. The posting of religiou
or belief
iths
fa
other
of
s
person
that
so
posters should be avoided in the medica l area
systems do not feel alienated or disadvantaged.
want to bring
Staff working in infirmaries and specialized healthc_are units frequently
patients. If the
reading material that they no longer want into the faci lity for use by the
nt that all address
institution approves the reading materials being brought in , it is importa
confidential
and
life
al
person
your
in
labels be removed. It is important that you mainta
in a
riate
approp
ionally
profess
personal information just that ... personal. It is not
.
inmates
correctional environment to share personal information with the
n to
It is not wise to bring in photos of spouses, parents, siblings or childre
outside
in
pating
partici
you
of
photos
s
decorate your office. That also include
le.
possib
as
you
about
little
as
activities. Incarcerated persons should know
Entering and Working in a Correctional Institution
to remember
When entering the institution, there will be numerous steps that you need
those steps
of
Some
unit.
are
and/or will be subject to prior to ever reaching the healthc
and reminders include the following:
Any staff
Ensure that your personal vehicle is locked with the windows rolled up.
who refuse to
member is subject to search at any time. This includes your vehicle . Staff
nary action.
have their vehicle searched when requested could be subject to discipli
to routine
Remember that you work in a correctional institution and may be subject
detector
metal
searches including screening of all items being brought into the facility,
will perform a
device or wand scanning or "pat downs" where an officer of the same sex
that occur
physical screening. Yes, entering a correctional institution mimics the steps
spot
/random
routine
perform
also
may
ons
when traveling through airports. Instituti

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searches. If this happens, do not feel like you are being singled
out. The search es are
conducted for your own safety as well as the safety of all staff.

Only bring in the items that are neces sary to accomplish your
job duties . You and your
belongings will likely be required to go throug h a scann er. Some
institutions will permit a
briefcase that has been inspec ted to enter the institution while
others will require any
belongings and paperw ork to be in a see-through bag . Backp
acks, book bags and gym
bags are strongly discouraged.
Some institutions will permit you to bring in food items; howev
er, others will not permit
personal food items. If you are prescribed medication, bring
only the amoun t of
medication that you will need for the hours that you will be workin
g. Some institu tions
require staff to obtain approval prior to bringing personal medic
ations into the facility.
When you begin workin g at the facility , you will be issued an
identification badge (ID). It
is import ant that the ID be worn consistently in the manne r manda
ted by the facility ,
typically attached to your clothihg or attached to a cloth "chain
" or lanyard around your
neck. If you choose the chain or lanyard, make sure that it is
a type that breaks away to
preclude injury if an inmate should grab it. Your ID should be
on your person at all times
and not hanging on a coat that you are not wearing. If you inadve
rtently leave your ID at
home, some facilities will allow you to use your driver's license
for the day, but you
should not count on this. You may have to return home to retriev
e your ID. If you lose
your ID, you must report it immed iately to your Program Manag
er or design ee. It is
import ant that the Program Manag er or design ee knows of the
loss immed iately to
permit reporting the information to institutional security. Repor
ting missing IDs is crucial
to maintaining the safety and securi ty of the institution.
When you enter or leave the institution, you will likely be require
d to docum ent your
presence in two ways. Health care staff are required to use KRON
OS or a bio-me tric
process, the compa ny's electronic timekeeping system s, to monito
r the hours that you
are on-site . The KRON OS/bio -metric systems are used to track
the hours worked for
emplo yee payroll and also docum ent the hours worked by positio
n for required client
reporting. Failure to clock in/out using KRON OS/bio metric system
will result in
unnec essary follow- up by the admin istrato r or design ee; may
result in time being paid
inaccurately secon dary to missed clock in/clock outs ; and may
lead to discipl inary action .
The correctional institution may also require staff to sign-in and
sign-o ut on a log.
Usually this log is locate d as you initially enter the facility and
go through security
processes. The institutional log serves two purposes. The log
verifies the hours spent
in the facility by health care staff for the client. The log also allows
the facility to know
who is in the secure area of the facility in the event that there
is an inmate disturb ance or
a hostage situation.
There are additional security proces ses that you may be subjec
t to when entering an
institution . The institution may require that you turn in your car
keys. This is a routine
security procedure . In addition to your ID, you may have a bio
scan fingerprint device or
key card that you are required to carry to open doors that must
be used to enter the
institution . Some facilities will provid e and/or require use of a
"body alarm" for all staff.
The body alarm should be mainta ined on your person where
you can .access it in an
emerg ency but should not be kept where it could be easily set-off
by mistake.

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obtain authorized facility keys.
When entering the institution, you may be required to
hcare positions or assigned
Some institutions will authorize designate specific healt
are authorized/required to carry
you
If
duties for a sh ift to carry applicable facility keys.
y and return them when you
facilit
facility keys, you will pick up the keys as you enter the
ity and should not be taken
leave. Access to facility keys is an important responsibil
should never be in a drawer, on
lightly . Keys shou ld be on your person at all times and
inadvertently take facility keys with
a desk, or out of your possession at any time. If you
to the facility immediately to turn in
you when you leave, you will be expected to return
the keys.
other rooms within the healthcare
Doors to storage areas, medication storage areas and
ld be locked at all times. Even
unit where equipment and supp lies are maintained shou
when you are not in the room,
your office door shou ld be closed and locked at all times
on for only certain sets of keys to
even if you are leaving for only a short time. It is comm
healthcare administrator, director
be assigned to the healthcare unit. For example, the
to carry keys that access certain
of nursing, and medication nurse may be authorized
areas within the unit.
rm patient care are different.
Healthcare offices and examination rooms used to perfo
rooms ahd offices shou ld always
When providing care to a patient, the doors to exam
nt services, the doors should be
remain unlocked. When you are not performing patie
time should you leave a patient
closed and locked. It is important to know that at no
If you must leave during an
unattended in an examination or health care office area.
staff or the correctional officer
examination, you must either have another healthcare
is not possible, you should have
come into the exam /office area until you return. If that
. If you are unsure if a
the patient step out into the waiting area until you return
room/office should be locked, ask the security staff.
rtant that you think about what
If you have an office on the healthcare unit, it is impo
family photos, medical records,
personal items you maintain in the office. Do not have
ked. You do not want inmates to
keys/purses/personal items lying around and/or unloc
desk, the inmates will read them.
see pictures of your family. If you have papers on your
Inmates are skilled at reading upside-down!
rules. Please kn ow that the security
You are probably think ing, WOW , there are a lot of
in place to ensure your safety while
procedures will become routine. The safeguards are
tionable, consu lt your supervisor or
in the institution . When in doubt about anything ques
ity-driven atmosphere!
security staff. There are no silly questions in a secur
Tips for Ensuring a Professional Presentation

impact on your development of
Your presentation while in the institution will have an
as well with the patients.
professiona l working relationships with security staff
professional image and comply with
When dressing for work, it is important to present a
code! Attire that may be
the institution's dress code. You need to know the dress
correctiona l environment.
a
for
acceptable in the community may not be appropriate
allowed to wear scrubs as
Many healthcare staff that provides direct care will be
of scrubs to stay away from those
authorized attire. Remember when choosing colors
tip also applies to healthcare staff
colors that are generally worn by the inmates. This
who dress in "street clothes."

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Jewelry should be kept to a minimum. Jewelry that
dangles or is easy to grab, such as
necklaces and dangling earrings, can be used again
st you. Clip-on ties are
recommended for male staff since other ties can be
used against staff, particularly if the
staff member gets too close to an inmate's cell-front
door or food slot. Colognes,
perfume, heavily-scented lotions, provocative clothi
ng and footwear are not appropriate
for correctional work.
A good rule of thumb is to wear attire that shows respe
ct and professionalism but does
not stand out. You want the patients to remember
you for what you do and how you
interact with them, not for how you look. Security staff
has the authority to prevent a
staff member from entering the facility if the staff mem
ber's attire is inappropriate or
provocative.
Consistency, consistency, consistency! Providing
healthcare services for all
patients in the same manner is important to deve
loping a professional image.
Consistency is key in how you provide care, how
you address the patients and
how you treat them. It is critical that you maintain
professional boundaries, do
not gree t or treat persons differently and/or give
the appearance of "favorites."
Safe Practices
The work environment in which healthcare staff pract
iced prior to corrections often
influences how he/she physically and verbally intera
cts with patients. For example,
when providing care in a hospital or nursing home,
healthcare staff may sit or stand
close to a patient or offer a comforting touch on the
arm or back or even a hug in some
situat ions. In the correctiona l envir onment, these beha
viors or gestures for an inmate
can have very different interpretations and implication
s for the patient and correctional
staff. Engaging in personal contact with a patient can
result in security disciplinary
actions for staff that may includ e being "locked out"
by having the staff member's
clearance to enter the facility revoked.
The following strategies are offered as safe practices
for healthcare staff while providing
care in a professional manner.
• When interacting with a patient at cell-front, in a
corridor or non-office area,
maintain at least an arm's length between you and
the individual. The distance
not only helps create a professional interaction but
also builds in safety for you.
The distance minimizes the potential for you to be grabb
ed or hit and provides
distance to allow time for you to react.
•

When walking through cell areas , maintain an adeq
uate distance between you
and the bars. Do not stand with your back to the bars
if persons can come
directly up to the bars.

•

While it is a natural reaction to show empathy in healt
hcare encounters, touching
a patient's arms or body as an expression of comfort
or sympathy is not an
acceptable practice in corrections . Physical touch
may give the patient an
unintended show of intimacy or attraction. Allowing
a patient to touch you can be
viewed as "power" or a potential unacceptable relatio
nship.

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yourself in the
When conducting patient encounters in an office area, position
you to have
allow
to
door
the
room to allow you to be between the patient and
with no
area
an
in
first access to the door. This prevents being barricaded
a plan
Have
access to help in case a patient becomes ag itated or assaultive.
es agitated or
and know how to obtain immediate assistance if a patient becom
violent.

•

care, however,
Entering an inmate's cell is not recommended to provide health
sary to enter a
this may be required for emergent or urgent care. When neces
ea before
cell, ALWAYS allow the correctional officer to secure the cell/ar
entering the area.

•

inmate. It is
Do not allow unwelcome or inappropriate behavior from an
threatening
being
and
important that the inmate understands that yelling
within
occur
can
are not acceptable. Sexual exposure or open masturbation
r or common
your view when you are walking a cell block, in the yard, corrido
ed, go directly
areas. You should not ignore the behavior and as soon as observ
or cell location
to the nearest officer and report the behavior by individual's name
ation unit with
segreg
a
in
or
block
if possible. If it occurs with frequency on a cell
the unit,
on
ce
presen
one or more persons and your responsibilities require
es or escort
request that the unit officer either walk the range prior to your activiti
you while providing clinical services on the unit.

•

•

•

yees can do
Ensure that you know the institution's policy related to what emplo
inmates. A
for
do
OT
CANN
yees
for inmates and, most importantly, what emplo
for
asking
common dilemma known as "the hook" starts with an inmate
r on the
something seemingly simple like asking you to mail a letter for him/he
th is is a
way home although this is a rule violation . If you are unaware that
asking you to do
violation and mail the letter, chances are the inmate will soon be
tell a
to
n
threate
may
inmate
the
something more and when you object,
in to the
gives
yee
emplo
supervisor about the letter. All too frequently, the
arise to
can
and
demand and the "hook" is set. The favors become larger
contraband.
other
serious infractions and criminal offenses like providing drugs or
custody in
Staff "splitting" is a common ploy attempted by some persons in
one staff
from
hing
somet
obtain
to
or
creating issues between staff members
l of
mindfu
be
to
need
staff
All
member that another staff member has denied.
as
well
as
staff
attempts to create barriers between security and healthcare
within
between various healthcare team members. Providing healthcare
healthcare and
institutional rules and maintaining open communication between
security staff are the best defense against such tactics.
like a phone
It is always good practice to ask the inmate requesting something
same and, if
the
er
call or a privilege, if he/she has asked any other staff memb
you to verify
allows
so, what response was given by the other staff member. This
to be
if there is cause for suspicion or if the person might be lying or trying
ant piece of
manipulative. Obtaining the inmate 's account is also an import
succeed at
does
inmate
the
if
rker(s)
information to be able to share with co-wo
getting co-workers at cross purposes.

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•

Do not reveal or share personal information. Sharing perso
nal information about
your family or co-workers with inmates is not appropriate
. Remember that the
walls "have ears" when you are talking with fellow co-wo
rkers regarding personal
information. Ensure that these conversations occur in an
area where inmates
are not allowed and/or cannot easily overhear the conve
rsation. Close office and
break room doors when you are having personal conversatio
ns with other coworkers.

•

It is important when providing healthcare services for a patien
t that you do not
make promises that you may not be able to keep. It is OK
to tell a patient that
you will look into a situation if you really plan to follow throug
h. However, it is
important to keep in mind that you may not be able to do
what you want to
promise. Your credibility will be seriously compromised
if you are unable to
make a "promise" a reality.

•

It is essential that you do not inform patients of the dates
or times for offsite appointments or transfers to another institution.
If a patient becomes
aware of an appointment/transfer date or time, the appo
intment/transfer
must be changed.

•

If you are ever in a hallway or area where inmates are movin
g from one area to
another, do not allow the inmate to walk behind you. Alway
s keep them in your
line of sight.

It is important to remember that boundary violations can
minimize your own safety and
the safety of your co-workers and security staff. Serious
violations can lead to discipline
of an employee. Don't let yourself get caught up in one
of these games. Know the
institution's rules and ask your supervisor if you are unsur
e!
Sharps and Contraband Control
Healthcare staff who work in corrections learn that anyth
ing that can be traded or
modified can be considered contraband. In a prison, almos
t anything can become
contraband including excessive amounts of allowable prope
rty, an altered item, such
as a hollowed-out book or an item that can be made into
a dangerous weapon, such as
a razor blade melted into a toothbrush handle.
As discussed previously, the institution will have an officia
l list of items that are defined
as contraband. However, it is important for healthcare staff
to be aware and
consistently think about items used in the health unit that
also are contraband and can
be used to bring harm or for the manipulation of others.
Often it is something that may
not seem dangerous normally in healthcare areas but cou
ld be dangerous in the hands
of an inmate. Examples include items such as your stetho
scope, reflex hammer,
forceps and other items we may have in our possession
or lying in an area acces sible
to the inmate. Other items such as money, maps, policy
directives, or credit card
receipts can be dangerous if in the hands of an inmate.
Healthcare staff play an important part in maintaining a safe
environment. There are
obvious items and supplies in the health unit that pose a
risk withi,n the institution.
These items include medications that can be abused and
"sharps." Medications that
can be abused include medications beyond those identified
by the FDA as controlled
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medications. "Sharps" is usually used to define objects in the healthcare setting that
can penetrate the skin including, but not limited to, needles, scalpels, razors and sharp
instruments that are used in providing inmate healthcare. Other examples of items that
can be considered "sharps" in the healthcare setting include broken venipuncture
tubes, exposed ends of dental wires as well as metal pens, paper clips and staples.
Healthcare staff coming into a correctional environment will quickly see the significant
focus placed on the monitoring and use of these types of items. Because of the
significant risk posed by items considered "sharps" and controlled medications, health
units are required to maintain limited access and strict accountability for these items.
The accountability is monitored through processes called "counts." Minimum
requirements for the frequency of counts of sharps and controlled medications usually
include: at the change of shift; when stock is added to inventory for sharps or controlled
medications; and when keys for controlling medications and/or sharps change from
person to person.
While nursing and dental services staff are primarily responsible for completing and
monitoring required counts, it is the responsibility of all staff to monitor use and location
of the items as well as to maintain control of the items when in use. It is also important
that these items are properly disposed of in medical waste/sharps containers after use.
Items accounted for through counts but left unattended in an exam room for a patient to
take jeopardize the safety of everyone in the institution.
Security Overview and Awareness Summary
The information in this section is intended to provide general knowledge and
understanding of developing safe work practices and maintaining your safety while
working in a correctional environment. The following space is for your notes and
questions. Include information that you need to discuss with the Medical Director, the
Director of Nursing and/or the Health Services Administrator.
Topics you may want to discuss include:
•
•
•
•
•
•
•
•
•

What is the title of facility administrative staff and how should you address them?
What is the proper title for security staff and how should you address them?
What is the process for entering your facility?
What items are you allowed to bring into the facility with you?
Are you required to carry keys while in the facility? If yes, how to you obtain
them?
What is considered contraband and/or sharps in your facility
What is your responsibility for controlling access to contraband?
What are the requirements for security staff escorts when working in the
healthcare unit?
What are the requirements for security staff escorts when moving within the
correctional facility?

NOTES:

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Chapter 3: Overview of Human Resources and Credentialing Process
Overview

The mission of the Human Resources Department is to support the company's goals
and objectives by providing services that are characterized by fair treatment of staff,
open communications, personal accountability, trust, and mutual respect. The Human
Resources Department seeks to provide solutions to workplace issues that support and
optimize the operating principles of the organization and correctional healthcare. Human
Resources staff are focused on delivery quality customer services for staff and are
committed to recruiting, developing and retaining a qualified healthcare workforce.
The Human Resources team provides staff with information and resources necessary to
be successful in their work with and for the company. In the event you need additional
information, clarification or wish to talk with a member of the Human Resources Team,
contact information can be found at Meet the HR Team on the Centurion intranet/portal.
The Human Resources Department offers a wide array of employee information on the
intranet/portal. You can get log-in and access information from your recruiter, site health
service administrator or director of nursing. The information on the portal is designed to
provide you with "anytime-anywhere" access to current Human Resources information.
Information can be found under the Human Resources tab located along the top header.
Additional information included in this area is specific to Benefits, Credentialing, HR
Administration and Centurion University.
Important Resources

As noted above, the company intranet/portal provides a variety of resources for staff. By
choosing the "Human Resources" tab on the Centurion Portal, you can access
information specific to human resources policy, benefits, recruiting, our employee
referral program, and Centurion University . The information below describes additional
information about resources and can be found on the company portal.
•

Benefits information - describes eligibility to participate, programs and covered
services available by program, forms requiring completion based on benefit elections
and information pertinent to our paid time off program. Information available on the
portal includes the following:
•
•
•
•
•
•
•
•

•

Dental, vision and medical benefits including links to insurers
Flexible spending account
Health savings accounts
Life insurance
401 (k) Retirement Plan
Wellness benefits
Employee assistance program
Discount employee programs available

Centurion University - a continuing education resource for all staff.
One important feature is our online Learning Management System
(LM S) which provides online training and professional development.

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Log on instructions can be found on the portal. This can be done by sending an
email to CenturionUniversity@teamcenturion .com

Human Resources Orientation
Human Resources staff will facilitate new hire orientation specific to completing all
required employee paperwork, providing information on company policies and benefit
programs available to you and helping you understand where/how these resources can
be accessed.
Questions specific to Human Resources and/or benefit questions should be directed to
your immediate supervisor or to the Human Resources Department.

Credentialing
As a healthcare provider, we strive to ensure that individuals recruited to provide clinical
services in correctional facilities have the appropriate training and credentials to perform these
services. We use a variety of resources to establish and document that required healthcare
licenses and credentials have been verified and that the licenses/credentials remain current.
While specific contracts may require completion of additional credentialing, our
Credentialing Process is used as the basis and standard for the company. The process is
designed to meet requirements of state, federal and accrediting organizations specific to
the provision of services in the correctional environment including the National
Commission on Correctional Health Care (NCCHC) and the American Correctional
Association (ACA).
All medical, mental health and dental staff must provide confirmation of compliance with
the licensure, registration, education, and professional standards of the community and be
in full compliance with state statutes and healthcare regulations including professional
boards and other regulatory bodies. All staff authorized to prescribe medications must
have current individual Drug Enforcement Agency (DEA) registration numbers, federal and
state where applicable.
Beyond credentialing, our contracts routinely require some type of security background
check. All healthcare staff is required to submit to and pass a security background
check in order to work within the correctional facility.
Credentials are verified during the recruiting and hiring process based upon primary
sources and recognized registries. When licenses are renewed, the verification of
licensure is repeated. For staff prescribing medication , dentists and doctoral level
licensed psychologists, the National Practitioner Data Bank (NPDB) is also reviewed
annually to ensure that the staff member remains in good standing. Credentials are
reviewed annually on all licensed professionals .
Credential Files are maintained on a share drive. The regional office has access and
utilized those files. Credential files may also be maintained on-site where you provide
healthcare services if required by the contracting agency. Information maintained in the
credential file include copies or verification of current licensing, certification, and

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registration information as required by the state where practicing and are in accordance
with NCCHC and ACA standards and contractual requirements. For contracts where all
credentialing information is maintained in our Regional Office, required information is
shared with healthcare staff administration as required by the contract and accrediting
agencies.
The contract's Program Leadership (VPO/PM/HSA) has overall responsibility to ensure
appropriate completion of the credentialing process and maintenance of current
Credential Files. Credential verification is completed by a credentialing agency and/or
our staff who have received training in the credentialing process. The Regional Office
will be responsible for running monthly reports out of the Credentialing database to
monitor credentialing to look for expired items. These audits are conducted no less than
annually.
While the Program Leadership and designated staff is responsible for tracking, it is also
your responsibility as a licensed/credentialed professional to know the requirements for
maintaining your license in an active and unrestricted manner. If there is a change in
your license or eligibility for license/certification during your employment, you are
required to immediately report information to the Program Leadership. You are also
required to report any investigations or actions that may impact your licensure to the
Program Leadership immediately after your notification.

National Practitioner Data Bahk (NPDB)
As part of our credentialing process, we obtain a report for each practitioner, physician,
nurse practitioner, physician assistant, psychiatrist, dentist, doctoral-level psychologist,
and licensed personnel from the National Practitioner Data Bank (NPDB). The NPDB is
a national central repository of information on malpractice payments or adverse
licensure actions.
NPDB reports provide a history of the following incidents/actions:
•
•
•
•
•
•

Medical Malpractice Payments - amount, when and type of incident
DEA/Federal Licensure Action(s)
State Licensure Action(s) - revoked, restricted, suspended, probation
Clinical Privileges Action(s) - dismissal, suspended, left prior to investigation
Professional Society Action(s) - not permitted to participate
Exclusion or Debarment Action(s)- e.g. Barred from Medicare

This information is reviewed as part of the credentialing process. If information obtained
in the report raises questions or concerns, the information is forwarded to the company
Credentialing Review Committee for further review, clarification and recommendation.
Office of the Inspector General {OIG) List of Excluded Individuals/Entities (LEIE)
OIG has the authority to exclude individuals and entities from Federally funded health
care programs pursuant to section 1128 of the Social Security Act (Act) (and from
Medicare and State health care programs under section 1156 of the Act) and maintains

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a list of all currently excluded individuals and entities called the List of Excluded
Individuals/Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be
subject to civil monetary penalties (CMP).
Individuals found to be on the LEIE database will be terminated from employment.
Rehiring of the individual may be considered once removed from the LEIE.
Credentialing Review Committee
Our Credentialing Review Committees, based on discipline, are responsible to review
NPDB reports as well as any further information obtained for physicians, nurse
practitioners, physician assistants, psychiatrists, dentists, and doctoral-level
psychologists who are seeking employment with us.
The medical provider Credentialing Review Committee is a panel composed of at least
two physicians and representative(s) from Clinical Operations. A minimum of three
members are required for each vote. An alternate physician and an al\ernate Clinical
Operations representative participate in the committee's activities but only vote when
necessary. Members are required to sign confidentiality agreements which prohibit them
from discussing sensitive information outside of the Committee meetings.
The purpose of the Credentialing Review Committee is to review referred cases specific
to credentialing or re-credentialing and provide recommendations to operations/clinical
management regarding employment or continued employment based on review.

Re-Credentialing
Regional Office staff or designee s will track current licensure using the Credentialing
database. You are responsible for knowing the requirements of maintaining your
license, such as continuing education and ensure completion of this and/or other
requirements. Staff will be required to submit renewed licensure and/or certifications
prior to their expiration. Failure to obtain licensure/certification renewals prior to their
expiration may be subject to suspension until the documentation is provided.
Initial and continuing employment with us requires successful completion of credentialing
process.
Human Resources and Credentialing Summary
The information in this section is intended to provide general knowledge and
understanding of our credentialing process and the information available to you through
our Human Resources Department. The following space is for your notes and
questions. Include information that you need to discuss with the Medical Director, the
Director of Nursing and/or the Health Services Administrator.
Topics you may want to discuss include:

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•
•
•
•

Is your credential file complete and accurate? If you have concerns , review with
the person responsible for developing and maintaining the file.
Do you know how to access the Centurion portal and use the Centurion
University CME/CEU offerings?
Do you know how to reach the Medical Director for your facility and the Regional
or Statewide Medical Director?
Do you have any specific benefits or other Human Resources questions or
concerns?

NOTES:

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Chapter 4: Orientation for Healthcare Staff
Overview

tional environment. For many
All new healthcare staff receive an orientation to the correc
to a correctional environment.
members of the healthcare team this is their first exposure
inmate's security experience
The clinical orientation program focuses on aspects of an
provided within this
that impact provision of healthcare and how healthcare is
challenging environment.
practitioners and physician
In addition to this resource manual for physicians, nurse
orientation for all new staff.
the
in
ipate
assistants, our providers are expected to partic
in this manual is on issues
Many of the topics are covered in this manual but the focus
that are directly relevant to providers.
General Topic s Required for All New Staff
Introduction to Corrections
Boundaries and Safe Practices
Confidentiality, HIPAA , PREA
Infection Control and Bloodborne Pathogens
Hazardous Communication
Continuous Quality Improvement
Emerqency Responses
Key Control

Healthcare Overview Required for All New Clinical Staff
Access to Healthcare
Healthcare Requests
Continuity of Healthcare
Documentation
Mental Health Services
Special Healthcare Considerations in Inmate Population
Healthcare Services for Seqregated Inmates
Chronic Disease & Healthy Lifestvle Promotion
Specialty Services
Inmate Death
Tools & Sharps Control
PREA for Medical and Mental Health Staff

Orientation Required For Medical/Nursing Staff
Sick Call & Access to Healthcare
Medication Practices in Correctional Environment
Healthcare Screenings
Initial Health Assessment
Intoxication, Drug Overdose & Withdrawal
Tuberculosis
Wound Care & MRSA
Oral Care
Infirmary Care
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You are required, at a minimum, to review and comp
lete all topics presented in the
General Topics Required for All New Staff. You will
be expected to complete the post
training tests and return the required documentation
to the designated individual at your
site.

You are strongly encouraged to complete the orientation
modules in Healthcare
Overview Required for All New Clinical Staff and Orien
tation Required for Medical/
Nursing Staff. Available orientation modules may vary
slightly from titles listed and/or by
contract. As a medical provider, you are an integral
part of the healthcare team and your
understanding of the processes not only for physical
health but for mental health, dental
services and the important issues relating to security
and administrative activities within
the environment are important to providing comprehen
sive care.
Security Orientation

Many state Department of Corrections and local corre
ctional agencies that contract for
our healthcare services require additional, specific
orientation for "contracted" and "nonsecurity" staff. The purpose of additional required "secu
rity" orientation by a correctional
system for contracted staff is to familiarize staff with
various aspects of policies,
procedures and/or services provided or required to
be provided to inmates housed within
their system or individual facility.
Specific "secu rity" orientation may not be required and/o
r we may negotiate with the
system to determine that topics/information provided
as part of our own new employee
orientation may meet some or all of the required inform
ation.
When additional training is required the following will
be determined by the correctional
system:
•
•

•

•

Amount of training required in hours/days
Timing of the orientation including:
• Prior to providing direct care services
• Within a designated timeframe from new employee
start date
• Training topics required dependent on your role,
clinical versus support
• Additional training requirements
Location of the training
• Individual worksite
• Regional/state training facility
Delivery of training
• Classroom
• Self-study
• Computer/web based
• Supervised on-the-job training

Determination by the correctional agency on required
training is usually dependent on
the type of position and the amount or degree of inmat
e contact associated with staff
roles/responsibilities . The purpose of the "security"
training requirements for contracted
or non-security staff is to increase familiarity of staff
with policies, procedures that will
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ves,
assist in the new staff maintaining a safe and secure work environment for themsel
other staff and the inmate population.

The new employee training required by the correctional agency for healthcare workers
will vary from no additional requirements to up to 40 hours. Completion of required
Department or Agency is considered a requirement for continued employment. Topics
covered vary by correctional agency but often include some of the following:
•
•
•
•
•
•
•
•
•

Use of Force
Computer End User Training for Inmate Management
System
Critical Issues in Gender and Managing
Special Populations
Discriminatory Harassment
CPR / First Aid
Leadership and Hierarchy in Corrections
Elements of Report Writing
Traumatic ll)cident Stress Management
Self-Defense Training

facility
When "security" training is required, the Program Leadership or designee at your
training
While
tion.
participa
will be responsible for coordinating and scheduling your
and
completion is important, we also want to ensure that required healthcare services
programs can be maintained. If you have questions, concerns regarding training
requirements, please discuss with the Program Leadership or designee.
Orientation for Healthcare Staff Summary

The information in this section is intended to provide general knowledge and
understanding of topics provided as part of health services and security orientation.
need
The following space is for your notes and questions. Include information that you
Services
Health
the
and/or
Nursing
of
Director
the
to discuss with the Medical Director,
Administrator.
Topics you may want to discuss include:
•
•
•

What is the process and timing for completion of any required department
security orientation, if applicable for your contract?
What is the process and timeline for initiating and completing employee
orientation resource manual sections?
Who are the staff at the site and regional level to use as resources, mentors
for specific orientation topics?

NOTES:

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Chapter 5: Prison Rape Elimination Act and Forensic Health Inform
ation
Federal Prison Rape Elimination Act (PREA)

The Federal Prison Rape Elimination Act (PREA) governs all employees
and volunteers
working in correctional environments, including healthcare staff. Unfortu
nately, rape and
other forms of sexual aggression do occur in prisons and jails. Followi
ng increased
awareness of sexual violence in correctional institutions, Congress passed
the Federal
Prison Rape Elimination Act (PREA) 2003. The PREA legislation establis
hes a zero
tolerance for sexual violence, including inmate-on-inmate nonconsensua
l sexual acts,
inmate-on-inmate abusive sexual contacts, staff-on-inmate sexual miscon
duct, and staffon-inmate sexual harassment. PREA governs all employees and volunte
ers working in
correctional environments, including psychiatric staff.
Despite efforts to address this challenge, inmates experience sexual assault
s and abuse
at rates that are three or four times greater than the general population.
The most
recent publication of the Bureau of Justice Statistics (June 2018) confirm
s that alleged
sexual victimization rates in adult correctional facilities have continued
to rise:
National Rates of Alleged Sexual Victimization
Adult Prisons and Jails 2005-2011
10000

5

9000

- 4.5

8000

4

7000

3.5

6000

Total Allegations of Sexual
Victimization

3

_

5000
4000

25

-

Substantiated Allegations of
Sexual Victimization

2

3000

1.5

2000

1

1000

0.5

0 -+----L -r-----. ----.....,---""T"" "'-"'--r-_ _......__,........_-+

2005

2006

2007

2008

2009

2010

....,_Ra te per 1,000 Inmates of
Allegations of Sexual
Victimization

0

2011

Source: Bureau of Justice Statistics (January 2014),
Sexual Victimization Report ed by Adult Correctional Authorities, 2009-2
011.
In 2015, 24,661 allegation of sexual victimization occurred, nearly triple
the number
recorded in 2011 (8,768 allegations). Substantiated allegations rose from
902 in 2011 to
1,473 in 2015 (up 63%).
Overall , the rise in these allegations has primarily involved increased reportin
g of
inmate-on-inmate sexual victimization. In 2015, 58% of substantiated
incidents of sexual
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by staff

victimization were perpetrated by inmates, while 42% were perpetrated
members (BJS 2018). The BJS (2018) reported the increase in allegations of sexual
victimization from 2011 to 2015 coincided with the release in 2012 of the National
Standards to Prevent, Detect, and Respond to Prison Rape. As a correctional
healthcare provider, you may be called upon to report, evaluate and/or treat inmates
who have been involved in such behaviors, either as victims or perpetrators.

The PREA legislation applies to all correctional institutions, including jails and prisons;
adult and juvenile facilities; public and private facilities. It had four primary goals:
1)
2)
3)
4)

Establish zero tolerance standard for correctional sexual violence
Make prevention a top priority in each correctional system
Increase accountability of correctional officials
Protect the 8th Amendment rights of inmates/offenders/prisoners/detainees
against cruel and unusual punishment

After the goals were established, a Congressional committee developed regulations to
achieve the goals. In 2009, the committee published draft Standards for the Prevention,
Detection, Response, and Monitoring of Sexual Abuse in Adult Prisons and Jails. After
review, public comment and revision, final National Standards to. Prevent, Detect, and
Respond to Prison Rape were issued in May 2012. These standards were enacted to
prevent, respond to and report sexual abuse, including sexual harassment, in
correctional environments.
It is important for you to be familiar with these standards and what the standards require
of you. Under PREA, all correctional staff including healthcare staff have mandated
reporting requirements when they become aware of any form of sexual abuse or sexual
harassment. Offering a voluntary physical and mental health assessment to the victim is
required once sexual abuse or harassment has been alleged or identified. The initial
examination for the extent of physical injury that may require emergency care is carried
out by healthcare staff. Mental health assessment and treatment must be provided to
the victim if clinically indicated and the victim consents. Assessment and treatment by
mental health staff includes dealing with the trauma as well as assessment of suicidality.
The examination, which includes the collection of forensic evidence from the victim, is
preferably provided at a local medical facility using approved evidence collection
techniques and handling of the evidence for laboratory determination. PREA standards
require that both assessment and treatment must be offered by properly trained
clinicians. Prophylactic treatment for sexually transmitted infections and follow-up care
are offered to all victims.
Assessment and, when appropriate, treatment must also be offered to perpetrators of
inmate-on-inmate abuse. Of course, staff-on-inmate sexual contact, abuse and
harassment are strictly prohibited. We maintain a zero tolerance policy towards such
behaviors. If you become aware of such behavior you must report it to your supervisor
immediately. A report is made to correctional authorities to effect a separation of the
victim from the assailant in their housing assignments.
PREA has many additional elements and requirements that can impact psychiatric and
physical health staff working within correctional facilities. We have developed
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comprehensive staff training on PREA, and you will be receiving the training as part of
your orientation with annual refresher training provided at least every other year. The
client will have specific policies and procedures to ensure compliance with PREA. It is
important for you to be familiar with these policies and to obtain clarification wheneve r
PREA requirements are not clear to you.

Forensic Health Information
Forensic information is physical or psychological data collected from an inmate that may
be used against him/her in disciplinary or legal proceedings. There are instances in the
correctional environment when conducting body cavity searches and blood or urine
testing may be done for legal/forensic reasons, not for medical purposes. Performance
of these forensic procedures by healthcare staff undermine the credibility of the
professional relationship with the inmate/patient and expose healthcare staff to
participation in acts that may be performed without the inmate's consent.
Alternatives to having healthcare staff participate in forensic testing and searches often
include services provided by outside professionals who do not have a therapeutic
relationship and testing that can be performed by trained security staff.
Healthcare staff typically may:
•
•
•

Collect court-ordered laboratory, tests, examinations or radiological procedures
only with the consent of the inmate
Comply with state laws that require DNA blood samples only with the consent of
the inmate
Collect evidence from the victim of sexual assault only with the consent of the
inmate/victim
PREA and Forensic Health Information Summary

The information in this section is intended to provide general knowledge and
understanding of the requirements of the Prison Rape Elimination Act and the
appropriated involvement in forensic health investigations. The following space is for
your notes and questions. Include information that you need to discuss with the Medical
Director, the Director of Nursing and/or the Health Services Administrator.
Topics you may want to discuss include:
• How many PREA Reports are received by the institution?
• How many inmates receive examination and testing at community facilities and
are test reports automatically sent to the facility?
• Do medical staff receive directives for court-ordered healthcare? If so, where are
the correctional system's administrative directives or policies and procedures
maintained.
NOTES:

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Chapter 6: HIPAA and Confidentiality

~
centurion.

Overview

Confidentiality of health/medical information refers to the right to have personal health
records private and the obligations of individuals using/monitoring the personal health
records to ensure the privacy of information is maintained. Maintaining privacy of
medical record information requires healthcare staff to take necessary steps to prevent
re
unauthorized third parties from having access or discovering an inmate's healthca
on
information. The first line of defense in protecting inmate health information depends
our employees. It is important to understand that just as your private healthcare
information is protected, so is the healthcare information of the inmates.
Maintaining Confidentiality of Healthcare Information

when
The first rule in maintaining inmate health information is to be aware of where and
should
ers
encount
re
healthca
All
ion.
informat
you discuss a patient's confidential health
occur in an area that protects the patient's privacy. Medical records should be
maintained in a limited access area when not being used and, when in use, the
healthcare records should never be left open or in an area where inmates have access.
There will be situations where correctional staff may need to be present during an
er that
evaluation/assessment to ensure patient or staff safety. It is important to rememb
as
tiality
confiden
of
rules
same
the
with
correctional staff are required to comply
healthcare staff.
ProtectinS Your Personal Information

staff
While protecting the patient's health information is important, it is also important for
in
noted
As
l!
persona
...
ion
to understand the need to maintain their personal informat
a
to
key
is
inmate
previous chapters maintaining a professional relationship with the
successful and safe work experience. Following are several tips to helping you maintain
your personal information in confidence:
•
•

•
•
•

Be aware of when/where you discuss information about yourself
Avoid sharing personal information with other staff when in a public area
or in an open door room where inmates are waiting or working within
listening distance
Do not bring items to work which contain personal information
Do not engage in discussions with inmates about personal or family
specifics
Always be aware of whereabouts of inmates when discussing personal or
health information
Patient Consen t

The general rules regarding release of a patient's medical record information to
community agencies are consistent with rules in community for release of medical
information. Information contained in the inmate-patient's medical record may be
is
released to third parties only if the inmate-patient, or their healthcare guardian if one
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assigned or appointed , has consented to such disclosure. Therefore, we obtain
written
authorization from a patient when request ing confidential medical information regardin
g
the patient's previous healthcare treatment/history and when we receive an external
request for a patient's medical records.
In instances when information is necessary to ensure medically necessary continui
ty of
care, an inmate-patient's consent to release information regarding current medicat
ions
and the current problem list may not be required.

Limits to Confidentiality in Correctional Settings
While standard practices are followed related to confidentiality of healthcare records,
there are specific circumstances that limit confidentiality in the correctional setting.
All
persons are advised of the rights to confidentiality of their healthcare information
as well
as the specific circumstances which limit confidentiality. This information is provided
to
the inmate at the time of reception into the correctional system.
Many of the limits to confidentiality in correctional settings are the same as
those
present in the community and include:
•
•
•
•

Risk of harm to self
Risk of harm to others
Risk of harm to an identified victim
Ongoing abuse of children, elders, or disabled persons (in some states this
includes individuals with serious mental illness)

There are also limits to confidentiality unique to correctional settings to include
:
•

•
•
•

Risk to safety and security of the institution, such as in the instance of
providing medical isolation secondary to communicable disease or
placement on one-on-one watch due to risk of suicide
Information related to transportation needs, special housing needs and
special diet needs
Issues related to the Prison Rape Elimination Act (PREA)
Abuse or mistreatment of an incarcerated person

Nearly all correctional facilities have policies and regulations regarding reporting
issues
that may lead to a threat to the security of a facility. You will want to be familiar
with the
policies and procedures of your facility. If you have questions or concerns regardin
g
specific situations you should direct those questions to the healthcare department
Program Manager or designee.
Some examples of situations that would be considered a threat to security
include
(but are not limited to) the following:
•
•
•
•

Possession of weapons or weapon making material
Riots, or a 'hit' placed on an inmate or staff member
Plans for escape
Possession of contraband

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Illicit substance use

•

At any time in the course of your work you become aware of any such information you
should immediately report it to your supervisor and the correctional administration.
Failure to report suspected incidents can increase the risk to inmates and staff as well as
result in possible penalties or corrective actions for you.

Health Insurance Portability and Accountability Act (HIPAA}
The guiding principles of HIPAA indicate that you cannot disclose any
inmate-patient healthcare information without proper authorization. The Health
Insurance Portability & Accountability Act of 1996 was designed to ensure protection of
protected health information (PHI). Examples of PHI include inmate-patient's diagnosis,
laboratory reports, allergies and reasons for medical or mental health isolation. HIPAA
further discusses disclosure and sharing of medical record information verifying that
disclosure is permitted only for purpose of treatment, healthcare operation and payment
and discusses the ability to share medical record documentation to perform health
services oversight activities such as quality improvement.
Important reminders when working in corrections and protecting patient health
information include:

•

Never give a patient information from his/her medical record unless otherwise
indicated by a specific policy. Policy may allow patients to request copies of their
records or request an appointment to sit and read their records while supervised

•

Always make reasonable efforts to protect PHI in the work place to include
proper handling and storage of medical records

•

Keep computer screens from view of other staff and inmates, password protect
your computer and do not share or allow others to use your password

•

When faxing or emailing information, mark the transmission as "confidential"

•

Shred all documents that have identifiable information prior to discarding

•

Medical information cannot be shared, copied or removed from the premises
without authority from the institution or for a necessary medical reason

•

Violation of HIPAA has disciplinary and potential legal consequences for both the
staff member and the correctional system

We provide staff training in confidentiality and HIPAA during orientation and annually.
Staff are expected to complete these mandatory trainings.

HIPAA and Confidentiality Summary
The information in this section is intended to provide general knowledge and
understanding of maintaining confidentiality of inmate health information and personal
information in a correctional environment. The following space is for your notes and
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questions. Include information that you need to discuss with the Medical Director, the
Director of Nursing and/or the Health Services Administrator.
Topics you may want to discuss include:
•
•
•
•

What are examples of inmate-patient health information that might be shared,
who can it be shared with, and why might the information be shared?
How and who is responsible for providing information requested by security or
administration staff?
What is the process for obtaining medical records at the facility?
When are consents for health services used at the facility?

NOTES:

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Chapter 7: Risk Management

Overview
ar with the general concept
As a professional healthcare provider, you are no doubt famili
the area in which you
on
and principles of risk management. In the past, depending
hts of incident reports,
practiced, risk management most likely conjured up thoug
reviews, and basically anything
medication errors, missed diagnoses, peer and mortality
one could do to avoid litigation.
Management (ERM). The ERM
A new paradigm for risk management is Enterprise Risk
approach is holistic in nature with the following goals:
•
•
•

To identify risk in all departments and areas of practice
rn and potential
To be proactive versus reactive by identifying areas of conce
exposure
pt to improve outcomes
To promote transparency and communication in an attem

system failures and not to
The ERM approach realizes that many errors are due to
ned to be positive and not
individual actions. Investigations and follow-up are desig
problem and implement
punitive in nature. The intent is to identify the cause of the
.
again
ning
changes to prevent such an occurrence from happe
on an even greater
In the field of correctional medicine, risk management takes
of security available and
importance. Employee safety can be influenced by the level
g in facilities operated by a
the conditions of the facility. Most employees are workin
administrative challenges.
state or county, oftentimes creating additional safety and
this Program is our
Our Risk Management Program is multi-faceted . Key to
employees to report serious
comprehensive Incident Reporting Policies which require
The Legal Department then
incidents and injuries and all litigation and legal matters.
to the insurance carrier(s)
facilitates proper reporting of incidents, events and claims
t of local defense counsel
and, in cases of litigation, ensures the appropriate assignmen
ored closely to ensure that
and coordination of the legal defense. Each case is monit
a close as possible.
ble
legal deadlines are met and the case comes to as favora
e Notices of Depositions,
In addition to actual lawsuits, providers sometimes receiv
or their staff often call a
Subpoenas, requests for records, etc. Outside attorneys
e care. Employees are
provider directly wanting to speak with him/her about inmat
their supervisor and the
notify
to
rather
instructed NOT to speak with the attorneys, but
Legal department will
The
st.
Centurion Legal Department of any verbal or written reque
from the inmate and
e
releas
verify the validity of the request, obtain an adequate signed
intervene with the requesting party, if feasible.

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The same is true of media requests: employees are NOT
to speak without authorization
with media. If approached or contacted by media, kindly
indicate that you are not
perm itted to comment and refer them to your Program Leade
rship.
Additionally, contracts utilize our Online Sentinel Event Log
(oSEL) to identify and track
events, provide real time notification of events to Regional
staff and/or our client as well
as alert CQI leadership and the Legal Department. The oSEL
entries are entered as
events occur and are monitored daily/weekly by the site
and Regional Medical
Director(s) as well as CQI leadership for the contract. Talk
to your CQI staff or Site
administrator to ensure you have access to enter and/or
review your oSEL.
A final aspect of our Risk Management program is comp
liance with regulatory and
accreditation standards. In the field of correctional medic
ine, the National Commission
on Correctiona l Health Care (NCCHC) and the American
Correctional Association (ACA)
are the two main accrediting bodies. Each publishes stand
ards of care which we use in
the development of policies and procedures and clinical
guidelines. (For example, see
model polic y Sentinel Event Reporting and Investigati
on P/J-A-06a).
It is important to remember that not all adverse or unexp
ected outcomes of medical
treatment are caused by negligent acts. Many times it is
determined that such outcomes
are a consequence of the illness or an unpreventable and/o
r unforeseeable complication
of the medical service(s) provided. Even if no Claim arises
from the incident it is still
important to properly report incidents in order to assist in
the development of better loss
control procedures.
Employees are encouraged to consult Centurion's Gene
ral Counsel when in doubt as to
whether or not a matter is reportable under this policy.
If you are interested in making a presentation at a confe
rence regarding your work, write
a paper or publish an article, all such work must be first
vetted and approved by the
comp liance department. In many cases , the client or your
facility must also approve.
Centurion encourages scholarship and dissemination of
best practices, but requires that
such public work first receive proper clearances.
Centurion's Compliance and Legal departments work closel
y with all of our corporate
departments to develop policies that address any aspec
t of potential risk. The
Comp liahce department identifies and analyzes areas of
risk for the company and to
develop strategies to reduce, or mitigate the risk. The Comp
liance department acts as a
coordination point with regard to risk management issues
.
In summary, risk management should be a part of every
one's practice. You are the
eyes and ears of the organization when you are working
on the front lines. Please take
some time to review the Incident eporting Policy: https:
//portal.mhmservices.com/Legal/lncidentReporting/default.aspx. Feel
free to contact the Legal Office
at (404) 34 7-4134 or the Compliance Department at (314)
779-6929 if you have
questions.
Deana Johnson, our General Counsel, has written two CorrD
ocs articles relevant to risk
management. These articles are:
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•

ony of
Anoth er Subpoena Anoth er Day: The Increasing Call for Testim
2
Correctional Healthcare Providers, CorrDocs, Volume 15, Issue

•

16, Issue 4
The Current State of HfPAA in Corrections, CorrDocs, Volume

Anoth er Subpo ena Anoth er Day: The Increasing Call
for Testimony of Correctional Healthcare Providers
CorrDocs, Volume 15, Issue 2
report to the warde n's
Upon arrival to work on a typical Tuesday, Dr. Jones is told to
subpoena to appear in
secretary to pick up some paperwork. There, she is handed a
patients, a man with
court the next day to testify in a case involving one of her inmate
caseload for months.
several significant mental health issues who has been on her
nment she might have
Dr. Jones knew when she went to work in the correctional enviro
she reviewed this
to go to court to defend a prisoner lawsuit or two. However, when
her provision of care to
subpoena , she was shocked to discov er it had nothing to do with
a child deprivation hearing
the inmate: instead, the State was calling her as a witness in
it filed to try and strip the inmate of his rights as a parent.
ony in a variety of
Increasingly, correctional providers are being called to offer testim
matters. Some examp les include:
Inmate challenges to criminal sentences
Inmate challenges to civil comm itment decisions
Domestic matters
Civil rights claims against other providers or correctional staff
is developing and
Set forth below is an analysis of possible reasons why this trend
to testify.
advice on what to do to best protect yourse lf if you do get called

The Benefits to the Lawye r and Litiga nt in Calling
Correctional Providers as Professional Witnesses
ses is necessary to
In many types of court proceedings, testimony from expert witnes
ctice, the plaintiff must
prove a claim or defense. For instance, if you are sued for malpra
to testify that your
present testimony of someo ne holding licensure similar to yours
damage. Such experts
d
allege
the
d
treatment fell below the standard of care and cause
charge a hefty price for their services.
1. Cost
ers do not have sizable
In criminal matters particularly, the prosecutors and public defend
ce, to do an
instan
for
tor,
evalua
ic
budgets for their cases. They can hire a forens
deplete their
funds
those
but
ant
independent psychiatric exam of the criminal defend
atrist to
psychi
tional
correc
limited resources. 1·r, instead, they can get the defendant's
l
crimina
most
Plus ,
testify as to diagnosis, treatment, progress, etc., it is cheap er.
the
t,
their patien
defense attorneys hope a treating doctor is more apt to side with
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defendant, and provide helpful support for their theory of
the case. Once the lawyer

has
you under oath on the stand , he hopes to press you to give
opinions as to the likely state
of mind at the time of the crime, mitigation or the like.
Now that so many states have comprehensive civil comm
itment laws governing crimes
such as sex offenses, public defenders' offices are even
more strapped for resources.
After their clients have been convicted in the criminal arena
, sentenced and served their
time, they now have to fight off the potential for a long-term
civil commitment for the
same offense. The best way to fight this result is to offer
evidence that the inmate's state
of mind has changed and they are no longer a danger to
society. What better way to
accomplish this goal then by having the treating mental health
providers testify in the
inmate's defense?

2.

Credibility

In the purely civil arena, while cost is still a factor, credib
ility is a bigger concern. The
attorneys who issue the subpoenas in civil cases have the
same goal as those in the
criminal cases : get the treating provider to give favorable
testimony about the medical or
mental health condition at issue. In the civil case, however,
the greatest reward is the
ability to argue to the fact finder that the treating provider
is more reliable and credible
than the paid experts of the other side (the "hired guns").
The argument goes like this:
Ladies and gentleman of the jury, you have heard from John'
s
treating doctor at the prison. That doctor has a difficult job
and took
time off from his very busy schedule to come and speak
to you
today. He wasn't paid $2,000/hour like the "doctors" that
the
defendants hired. In fact, he wasn't paid anything over and
above
his normal wages . Unlike the defendants' so-called exper
t, this
prison provider sees John on a regular basis and is in charg
e of his
healthcare. He is far more credible than those witnesses
who have
never even met John and render their so-called expert opinio
ns
based only upon review of a select portion of his volumes
of prison
medical records.
The power in that argument is so strong, it is hard to resist.
Unless you want to become
a participant in the legal proceeding, it is important to know
your rights as a witness and
the risks inherent in your potential testimony.
What Rights Do You Have in Response to a Subpoena?
Many people incorrectly presume that once they receive
a subpoena, they have to obey
it no matter how inconvenient or objectionable. While the
court rules do demand that
legal orders be obeyed, they do not render you powerless.
Subpoenas for medical
records, for instance, do not entitle the issuing lawyer to
spea k to you about your
treatment of the patient. They only cover production of the
requested records.

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to be effective;

Subpoenas for attendance at a trial or hearing require personal service
therefore, Dr. Jones from our storyline above has a legitimate challenge to the trial
doctor.
subpoena she received because it was served on the warden' s secretary, not the
be
Next, subpoen as must provide at least notice of a personal appearance. They should
accompanied by the statutory witness fee.
That brings up the issue of compensation for your lost time from work. The statutory
witness fees run about $25/day, not nearly what most people earn. Many states,
however, have statutes requiring that when professional persons are called as
the
witnesses, they are entitled to compensation for lost time from work rather than
it may
right,
your
standard witness fee. Insisting upon proper compensation is not only
of
cost
encourage counsel to release you from the subpoena rather than incurring the
your appearance.
the
Next, trial subpoenas usually mandate that the witness appear on the first day of
or
hours
for
around
sits
case at the hour it is set to begin. The result is that the witness
the
granted
even days waiting to be called to testify. As a professional, you should be
the
courtesy of being provided a specific date and time to appear by the lawyer issuing
prove
subpoena. Make sure to get that change of date and/or time in writing so you can
the
of
e
issuanc
to
ent
subsequ
given
that you were complying with instructions
subpoena.
e
So, now that you have ensured proper service of the subpoena, insisted upon adequat
have
compensation and narrowed down the time to appear, you take the stand. Do you
any further rights? The answer is yes . While you are obviously obligated to testify
is
truthfully , you are not required to provide the free expert opinions that the lawyer
seeking.

1. Example in a criminal case
If the lawyer asks you the inmate's state of mind at the time of the crime, it is perfectly
legitimate to state you do not know and cannot to a reasonable degree of medical
e after
certainty offer such an opinion. You did not begin treating the inmate until sometim
not
have
and
to
his arrest or conviction. Also, point out you have not been asked
conducted a forensic mental health exam.

2. Example in a civil case
are
If you are asked whether you believe another provider committed malpractice, you
expert
provide
to
forced
allowed to state that you have no opinion . You should not be
might
opinions if you legitimately have not formed them. Do not comment on what you
have done if you were treating the inmate for that condition at that time.
answer
If you are unclear whether or not you are required to give an opinion (rather- than
for
judge
the
ask
patient),
a factual question such as the last time you saw the
for future
clarification. Listen carefully to the response as that answer gives you direction
questions of a similar nature.
What Risks Accom pany Your Testimony?
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1. Does Your Employ er or Professional Liability Insurance Protect You
if You
Testify?
If you work directly for a government agency, you may enjoy some immun
ity from routine
civil claims, such as allegations of medical malpractice. If, instead , you
work for a private
company providing services in corrections, while you don't get those same
protections,
your employer likely provides you with professional liability insurance.
Be careful, however. These protections do not apply once you leave the
realm of
provider and enter the world of witness. Liability insurance is designed
to cover claims
arising out of your provision of care to patients, not claims stemming from
your testimony
in criminal or civil cases. Thus, if you are sued regarding the testimony
you provided,
you may well be on your own in defending the claim.
While you may rightly be thinking that it is hard to win a case against a
provider based
on testimony in a court case, the cost of defending the matter can be stagge
ring.
2. If You Give Them Everything They Want, They Will Likely Call You
Again
If the risk of liability is not enough reason to be careful about what you
say on the stand,
revisit the major theme of this article: attorneys are increasingly calling
correctional
providers as witnesses to give them a benefit they would not otherwise
have: i.e.
inexpensive and/or very persuasive expert testimony. If you willingly provide
those
expert opinions and do not limit your testimony to simple facts of which
you have
personal knowledge, the attorney issuing the subpoena got just what he
wanted.
Word spreads fast. Soon everyone in the public defender or prosecutors'
office is going
to be calling you to court. If, on the other hand, all you did was discuss
your chart notes
and refuse to be led into giving expert opinions, that lawyer is going to
realize there is no
real benefit to calling you as a witness.
Of course, if instructed to answer specific questions by the court, you are
obligated to do
so. That, however, is rarely the issue when it comes to rendering expert
opinions. It is
usually an overly zealous witness who, when the spotlight is placed upon
them on the
witness stand, cannot resist educating the courtroom about anything and
everything.
Think twice before doing so and remember yo.ur rights as the witness.
The Current State of HIPAA in Corrections
CorrDocs, Volume 16, Issue 4
When the Health Insurance Portability and Accountability Act (HIPAA)
was enacted in
1996, one aim was to standardize a set of privacy rules to apply to all
patient's protected
health information. However, for many of us working in correctional healthc
are, HIPAA's
applicability is still far from clear even now, 16 years later.
One main reason for this confusion is the varying positions taken by the
government in
applying HIPAA to corrections. The U.S. Department of Health and Human
Services

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with interpreting and regulating HIPAA, has

(HHS), the government department charged
taken inconsistent positions on the issue over time.

A second major source of confusion lies in the application of HIPAA's electronic
transmission provision to correctional institutions: not only does the application seem
counterintuitive, the result is that HIPAA applies to some correctional systems and not
others. It all depends whether the system electronically transmits certain specific types
of data, explored in detail below.
History
HHS was charged with creating standards for the privacy of medical information. In
doing so, HHS released several versions over time. The competing versions of the
regulations generated misunderstanding among many correctional officials and medical
providers alike.
The original draft regulations, issued in 1999, specifically provided that inmates' health
information was not protected under HIPAA. Many people continue to operate under the
misunderstanding that this original interpretation is still in place. It is not.
HHS later revised this aspect of the regulations and found that "individually identifiable
health information about inmates is protected health information under the final rule." As
such, certain correctional institutions have been required to comply with HIPAA since
April 2003. So why, almost a decade later, is it still unclear which information is
protected and which correctional institutions are impacted?
The Text of HIPAA Does Not Easily Translate For Correctional Institutions
In order to determine whether HIPAA applies to corrections, the natural starting point is
the statute itself. HIPAA applies to covered entities, which are defined as: (1) health
plans; (2) healthcare clearinghouses; and (3) healthcare providers who electronically
transmit any health information in connection with transactions for which HHS has
adopted standards.
HHS has determined that correctional institutions are not health plans or healthcare
clearinghouses. So what about the last choice? HHS now classifies correctional
institutions as healthcare providers. So the remaining question is whether your institution
electronically transmits health information for one of the specific transactions regulated
by HHS.
Of course, most electronic transmission of health information concerns billing and
payment for services or a determination of insurance coverage and rates: i.e. hospitals
sending patient information in order to be paid by Medicaid or private insurance.
However, the electronic transmission provision is broader than that.
There are eight standard electronic transactions regulated by HHS. Although a
correctional institution is unlikely to engage in many of these, the three that could apply
are: (1) transmission of encounter information for the purpose of reporting health care;
(2) requests for the review of health care in order to secure an authorization for the
health care; and (3) payment of healthcare claims from a private/public health plan. It is
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important to note that contracting out the transmission of this information, the provision
of healthcare or both to private entities does not exempt the correctiona l institution from
HIPAA.

So what are the most likely scenarios that would fall under these three types of
electronic transmissio ns? One of the most common is sending patient information to
request approval for a non-formul ary medication or a non-standa rd procedure. If your
institution electronically sends these requests to the person or oversight committee with
authority to approve the request, it just became a covered entity under HIPAA. Another
example would be electronically transmitting health information for purposes of
conducting quality control, audits or other oversight activities. Less likely in the
correctional environmen t is seeking payment of claims from private health insurance, but
it does occur in some systems and, should the expansion of Medicaid currently expected
under the new healthcare law go into effect, even more inmates will have in-patient
hospital care covered by public insurance, necessitating this type of electronic
communication.
So if HIPAA Does Apply, What are the Obligations of Your Institution?
For the average covered entity, HIPAA requires:
• Notifying patients about their privacy rights and how their information can be
used
• Adopting and implementing privacy procedures
• Training employees so that they understand the privacy procedures
• Designating an individual to be responsible for seeing that the privacy
procedures are adopted and followed
• Securing patient records containing individually identifiable health information so
that they are not readily available to those who do not need them
In creating its Privacy Rules, HHS recognized that correctional institutions are not the
same as traditional healthcare institutions and have unique security concerns. Thus, the
Privacy Regulations exempt correctional institutions from compliance with some of the
law's provisions . See 45 Code of Federal Regulation (C.F.R.) § 164.512(k) .

In summary, correctional healthcare providers can disclose an inmate's health
information to the correctional staff or other law enforcement personnel having
custody over the inmate as necessary for:
• the provision of health care
• the health and safety of the inmate or other inmates
• the health and safety of correctional institution personnel
• the health and safety of those personnel responsible for
transporting of inmates
• law enforcement on the correctional institution's premises
• the administration and maintenance of the safety, security, and
good order of the institution
Also, a correctional institution is permitted to deny an inmate's request to obtain a
copy of his medical records if access would create any of the risks outlined
above. Finally, if an inmate has escaped from custody, HIPAA does not restrict the use
or disclosure of an inmate's health information.
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Chapter 8: Sick Call

"'

centurion .

Overview of Sick Call

Sick call is a process in correctional healthcare designed to provide patients with access
to initiate or request medical, dental and mental health services. The method in which
that access is provided will vary depending on security level, layout of the institution and
the scope of services of the institution. The sick call process is required since the
incarcerated persons generally do not have unimpeded access to health care. Access
to care must be available. The sick call process addresses episodic, non-emergent
healthcare needs. The sick call process is an integral component of meeting the basic
principle of access to care for serious health needs established by the Supreme Court in
Estelle v. Gamble.
Sick call services are routinely accessed through a written sick call request, commonly
referred to as a Health Services Request (HSR), sick call request or by the inmates as a
"kite." Correctional officers and other staff can also refer a person for healthcare needs
through a written request, direct communication with the healthcare unit or through
urgent/emergent processes available through the institution (man-down, self-declared
emergency). Inmates have access to emergency/urgent care by declaring an
emergency to the housing officer.
Health Care Requests in general population housing units are usually placed by the
patients in "locked" collection points designated at each institution. The requests are
collected by healthcare staff daily. Requests in units where persons are in locked cells
or with restricted movements are typically collected at the completion of one of the two
medication administration passes that occur in that unit. Each request is date/time
stamped immediately upon return to the healthcare unit after collection. This and other
timed steps in the process provide verification that required timeframes from collection to
triage of the slip to patient encounter with medical staff are maintained.
Health Service Requests are "triaged" by trained nursing staff. Triage refers reviewing
the written request from the patient, conducting a face-to-face encounter and
determining the urgency and healthcare service most appropriate to address the request
or need. Requests are usually defined into one of these categories:
•
•

•

Urgent/emergent
Routine
• Scheduled for nurse sick call
• Scheduled for provider sick call
• Administrative review required (general question regarding services,
complaint about staff, etc)
Routine referral to another service area
• Mental Health
• Dental
• Other non-healthcare area (i.e., religious diet - refer to pastoral services)

For requests that suggest urgent/emergent needs, security staff will be notified of need
to see the patient immediately and coordination will occur to bring the patient to the
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centurion.

hours that a
healthcare unit for assessment. If urgent requests are received during
ed and the
medical provider is not on-site , the appropriate on-call provider will be contact
r. The on-call
nursing evaluation and other pertinent information presented to the provide
ption medications
staff will provide orders and a disposition . Any patient receiving prescri
led for a
schedu
be
will
order
ne
based upon a telephone consultation and telepho
provider appointment for recheck.

-face
For routine medical requests, most standards and contracts require a face-to
nurse sick call
encounter with inmates within 48 hours. This follow-up is addressed in
nurse can
the
ters,
encoun
these
In
nurse.
a
where the inmate has an encounter with
tion; contact
medica
r
counte
e
over-th
handle minor complaints and healthcare needs with
r
provide
the
by
care
for
the provider immediately for advice; or schedule the inmate
t,
contrac
on
based upon timeframes specific to the urgency of the request and based
accreditation standards and site-specific policy.
by dental staff.
Follow-up of a patient's request related to dental services are scheduled
p. For sites
follow-u
for
staff
Routine referral requests are delivered daily to the dental
dental care
nt
emerge
with limited dental services, triaged requests that relate to urgent/
common
for
such as tooth pain are scheduled and assessed using nursing guidelines
healthcare complaints to ensure that care is not delayed.
follow-up by
Mental health services in response to a patient's request is scheduled for
mental health
the
to
daily
d
behavioral health staff. Routine referral requests are delivere
immediately
are
s
service
staff for follow-up. Urgent/emergent requests for mental health
mental
for
ts
referred to mental health staff when on-site. If urgent/emergent reques
not on-site, the
health assistance are received during hours that mental health staff are
behavioral
patient will have a face-to-face encounter with nursing staff and the on-call
tion.
disposi
a
and
orders
p
follow-u
health staff will be contacted by nursing staff for
are
Times and places where sick call is conducted are determined by healthc
ters with
administrative/clinic team and institutional administration. Clinical encoun
privacy and
patients for assessments should be performed in an area that promotes
int.
compla
the
by
d
require
permits the degree of physical examination
each institution.
Sick call is routinely required to be provided five - seven days a week at
s each and
service
t
Medical staff are to ensure that all patients have access to reques
"no shows"
are
every day. There should be a mechanism for follow- up of patients who
the patients
for appointments or "ca ll outs." This follow-up is required to ensure that
y staff in
securit
with
rate
collabo
to
nt
importa
is
It
have unimpeded access to services.
restrict
not
do
staff
security
that
conducting sick call; however, it is critical to ensure
movement unless institutional operation require.
ation units,
For specialized housing areas, such as restricted housing units, segreg
s is usually
mental health units, and special management units, the sick call proces
circumstances,
these
In
unit.
housing
the
outside
modified due to the limited movement
units; verifying
these
in
rounds
cell
access is ensured by medical staff performing cell-toservices as
call
sick
t
reques
to
s
the patient's health maintenance; and allowing patient
specific to
units
other
part of these rounds. In mental health units, infirmary areas and
provided by
be
meeting medical or mental health special needs, access to services may
those units. It
designated nursing/medical providers who follow and monitor patients on
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cen turion .
is important to understand that no matter the level of security or where
patients

are
housed within an institution , all must have timely and routine access to
request and be
provided healthcare services that provide services for medically necess
ary care.
Our generic Sick Call Process Flow is presented below. The flowchart
includes all
healthcare services, including behavioral health, medical, and dental service
s.

Centurion Sick Call Process

Non-Uroen Non-Emergent

Sick Call Reque,ts:

s call rogues! datem,\nbd 19

> Patient location verified
caH pm1enl lisl dO\lilklped
und dilllnbulll<l lo SGC\Jllly as nDOlled
> Patient heallh record pulled

bo re1$1ed ll> adnw!Jlstre6ijQ
m a1 lh.in Clinl~I con1;011lll

> N.or&1no ,

L
If a patient Is a no show:
> Reschedule for next nurse
sick call
> Document refusaVrelease

I Relevant provider
contacted

Research pending issue, provide
communication wilh palient about Iha
fotJow.{Jp provided and documented
or follow-up schedled (appointment,
medication order, etc )

Patienl seen at sick call
and assessment
performed

- . _L
lreall11 mand cafl1111
provlliod by q~liJil!d fl'il/Ht1\
hell\dl or denial b!ff, Of ~y

0Urli~$llllf Us)ng ~p~

nulSing protoai~ldO\lo9',
v.i b•rarerra\ Ill relovMt·

p!Ovldw

5/01/2020

---=-=- l

Patient seen second time by
nursing staff for s1miliar or same
compliant referred to relevant
provider

Treatment and education
provided by qualirled
mental health or denial
staff, or by nursing staff
using approved nursing
protocols/guidelines,
with PRN follow-up

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Primary Care Program and Provider Sick Call

~
centurion .

The key elements of our on-site primary care program include:
•
•
•
•
•

Care by a multidisciplinary team coordinated by a provider
Early identification of healthcare issues
Aggressive case management and coordination
Active participation and education of the patient
Providing timely access to needed on-site services

n
Provider sick call is routinely performed by a physician, nurse practitioner or physicia
sick
ctitioner
care/pra
primary
g
assistant. The following strategies are used in providin
call within the institution:
•
•
•
•
•

Improve patient access to care using the most appropriate level of provider
Plan and manage healthcare based upon early recognition of needs and
evidence-based guidelines
Encourage and facilitate offender involvement in self-care
Use available technology to track and coordinate care
Adopt health goals, measure patient satisfaction, clinical outcome, healthcare
staff performance and improve performance and services provided

to
Services routinely provided as a part of the provider sick call will tend to be similar
The
center.
care
urgent
or
clinic
services provided as part of a general medical practice
p
follow-u
and
services include evaluation and treatment for self-limiting illnesses
.encounters for illnesses not responding to current treatment

Nurse Sick Call
The
The use of nurse-driven sick call is fairly unique to the corrections environment.
a
when
identify
and
care
to
purpose of nurse-driven sick call is to improve access
written
particular health need requires a higher level of care. Nurse sick call is driven by
in
taken
be
to
guidelines. The purpose of these written guidelin es is to outline the steps
providing first aid and interventions commonly provided as self-care in non-correctional
environments. We refer to the written guidelines used by trained nursing staff as
"Guidelines for Common Healthcare Problems," also commonly referred to as nursing
to
protocols. The table of contents for our guidelines is provided on the following page
call
sick
nurse
demonstrate the types of interventions that are included in
to use
Licensed nursing staff practicing within the scope of their licensure are approved
use of
the Guidelines for Common Healthcare Problems after attending training on the
use.
their
in
y
mpetenc
nding/co
understa
of
the guidelines and completing verification
e for
Only approved over-the-counter medications listed in the Plan section of a Guidelin
the
in
defined
not
Common Healthcare Problems are used. Use o'f medications
ner
guidelines requires consultation with and an order from the physician , nurse practitio
the
with
or physician assistant. Policy requires that a patient seen more than two times
ner or
same problem within a month and not yet evaluated by a physician, nurse practitio
or
s
protocol
nursing
of
use
The
staff.
these
to
physician assistant will be referred
e of
guidelines requires initial and annual review and approval indicated by the signatur
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V

centurion,

the Medical Director and Director of Nursing as well as initial and periodic
training/verification of competency of nursing staff that are approved to use them.
Guidelines for Common Healthcare Problems
Table of Contents
Correctional Environment
1. Correctional Environment Documentation
2. "Use of Force" Examination
3. Pepper Spray Exposure
4. Taser (or other Conducted Electrical Weapon) Exposure
Digestive
1. Digestive Documentation
2. Constipation
3. Diarrhea
4. Heartburn (Acid Reflux)
5. Hemorrhoids
6. Vomiting (Nausea)
Head,
1.
2.
3.
4.
5.
6.
7.

Eyes, Ears, Nose, Throat
HEENT Documentation
Cold (Common Cold Symptoms)
Earache And Ear Wax
Eye Foreign Body or Chemical Irritation
Hay Fever (Allergic Rhinitis)
Headache
Nosebleed (Epistaxis)

Dental
1. Tooth Ache
2. Tooth Avulsion
Musculoskeletal
1. Musculoskeletal Documentation
2. Low Back Pain (Lumbar Strain)
3. Strains, Sprains and Minor Trauma
Skin Integrity
1. Skin Integrity Documentation
2. Abrasion
3. Acne
4. Athlete's Foot (Tinea Pedis)
5. Bite/Sting
6. Blister
7. Burn (Minor 1st or 2nd Degree)
8. Dandruff
9. Jock Itch (Tinea Cruris)
10. Laceration
11. Lice (Pediculosis Capitis, Corporis, Pubus)
12. Rash
13. Scabies
14. Shave Bumps (Pseudofolliculitis Barbae)
15. Skin or Soft Tissue Infection (Boil, Infected Wound or Insect Bite) MRSA
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centurion.
Sick Call in Segregation Areas
Segregation is usually defined as special housing units or cells that are used to separate
inmates from the general population housing areas. Individuals receive services and
activities apart from others. Segregation units have many titles that vary from system to
system and may be for disciplinary or protective purposes. In any case the purpose of
segregation areas is to maintain the safety and/or security of the person in custody
and/or the institution.
The importance of segregation to health care is that patients in segregation have limited
ability to access healthcare through the normal process and could have mental or
physical health problems or injuries that deteriorate because of restricted contact. A
process must be provided that allows adequate access, monitoring and provision of
healthcare services.
Patients in segregation typically have access to healthcare by filling out sick call
requests that are collected during daily medication administration. Nursing staff may
also be required to conduct rounds for persons housed in segregation daily or three
times a week. Nursing staff will coordinate triage and associated nursing sick call visit
within the segregation unit, depending on the complaint and ability to appropriately
assess the complaint. Interventions for patients requiring assessment and/or services
that cannot be provided in the segregation unit requires coordination with security staff to
provide services in the healthcare unit or a satellite medical unit that may be within the
segregation area.
It is important to be mindful of the complications involved in transporting persons housed
in a special housing unit to the healthcare unit; therefore, we routinely work with the
facility to identify an area within the segregation/special housing unit to perform
healthcare services that permit privacy of ca1re and ability to perform examination
appropriate to the complaint. However, there are times when the patient's medical
needs require a higher level of care than what can be accommodated in the special
housing unit. When this occurs, we work closely with security staff to communicate the
need and identify a time and process for treatment in the healthcare unit to occur.
Depending on the institution, movement of patients from segregation/special housing
units to the healthcare unit can create the need for complete shut-down of access to the
healthcare unit by other persons and routinely requires multiple security staff to complete
the movement. While providing healthcare services in institutions with large segregation
units can be challenging and usually creates challenges to productivity, the services are
important for maintaining safety of the institutions.

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Sick Call Summary

centurion "

The information in this section is intended to provide general knowledge and
understanding of providing nursing and practitioner sick call services in a correctio
nal
environment. The following space is for your notes and questions. Include informat
ion
that you need to discuss with the Medical Director, the Director of Nursing and/or
the
Health Services Administrator.
Topics you may want to discuss include:
• How is sick call process managed at the facility for patients in general population
and for those in specialized housing units?
What
are the contract-specific guidelines for common healthcare problems (also
•
referred to as nurse protocols)?
• What nursing staff can perform sick call?
• What training do nursing staff receive before conducting sick call?
• How are patients scheduled and/or referred to be seen by the on-site medical
provider?
Are
there specific documentation/templates used to document encounters
•
completed by the medical provider and/or nurse?
NOTES :

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Chapter 9: Medication Management

centurion.

Overview
Medication management in the correctional environment typically differs from community
medication management in two very distinct ways: medication procurement processes
and patient access to medications. Despite these differences, the provider will also
observe medication management techniques that are familiar and consistent with
community primary care provider practices. Some of the similarities include:
•
•
•

•
•
•
•

A formulary process that includes preferred medications for each class and nonformulary review procedures
Initial ordering and renewal of chronic disease medications based upon nationally
accepted guidelines and formulary preferred medications
Reconciliation of medications at the time of intake into the system, return from
hospitalizations or procedures, return from emergency department visits or
specialist appointments and at chronic disease management appointments
Participation in Pharmacy and Therapeutics Committee as requested
Dashboard reports on medication management performance measures
Access to consultant pharmacists who are skiffed in correctional medication
management
Medication compliance monitoring

It is worthy to note that the prevalence of HIV, psychiatric illness, and various forms of
viral hepatitis is much higher in corrections than in the community.

Medication Procurement Processes
Correctional facilities usually receive medications from a pharmacy contractor that
ensures medication management procedures are compliant with federal, state and
contractual rules, regulations and policies. Medications are provided to the institution
either as an inmate-specific prescribed medication or as a stock medication to be used
based upon provider orders. The availability of stock medications and the approved
methods of use are detailed in the Formulary and Pharmacy Manual.
The pharmacy does not typically operate within the institution. New prescription
medication orders that are received Monday through Friday before a predetermined cutoff time are filled and shipped to the institution for next-day delivery. Refill and stock
medication orders may not be completed on a next-day delivery timeframe. It is
important to know the stock medications that are available for initiating treatment during
the evenings and on weekends. The pharmacy contractor will make arrangements for
access to a local back-up pharmacy for urgent situations, but this service should be
infrequently needed when there is compliance with formulary stock medications and
careful medication management practices on-site.
The pharmacy contractor profiles patient prescriptions for the following:
•

Duplicate therapies from medications in the same therapeutic class

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Medication interactions and incompatibilities (including drug-drug, drug-order,

•

and drug-age interactions)
Excessive or sub-therapeutic dosages
Allergies
Non-formulary medications (which may need to be addressed prior to dispensing
the order)
Appropriateness of medication therapy
Medications that are refilled too soon, based on established system-specific
parameters
Medications ordered past the designated stop date
Potential for abuse or misuse
Medications to be administered as directly observed therapy (DOT) only

•
•
•
•
•
•
•
•

Medication order transmission to the pharmacy contractor may be by fax, by web-based
order entry, or by electronic health record interface. You will receive instruction on the
required method for medication order entry. Of course, legibility when using the fax
system is critical. Compliance with the formulary and non-formulary process will
facilitate the patient receiving the medication in a timely manner.
Medication packaging from the pharmacy contractor typically includes:
•

•
•

•
•

•

•

Solid medications dispensed in 30-count blister cards with one unit per bubble.
Blister cards provide a sanitary delivery system and provide protection,
accountability, and ease of delivery
Patient-specific single packets containing of the prescribed medications for that
particular dosing schedule (usually prepared by an automated machine)
Over-the-counter (OTC) medications sent in bulk original manufacturer's
packaging, except when ordered by the provider for individual patients or when
prohibited by law or board regulations. If not sent in bulk, these medications are
dispensed in blister cards
Liquid medications provided in unit-of-use containers, as ordered
Eardrops and liquids provided in original manufacturer containers or repackaged
from their original glass containers into plastic, if requested and when permitted
by FDA. Glass containers are perceived as a security threat as they can be
fashioned into a weapon
Creams and ointments provided in original manufacturer's containers or in plastic
jars, if requested and when permitted by FDA. Metal tubes may be fashioned
into a weapon. Plastic ointment tubes can be used as a weapon by spraying
chemicals or body fluids onto staff or other inmates
IV mixtures shipped compounded, labeled and ready to administer or dispensed
in Mini-Bag Plus packaging for easy self-mixing on site, upon request

Packaging is often impacted by the administration method that is appropriate for
medication prescribed and the security regulations of the institution. This impact on
patient access to medication is discussed below.

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centurion.
Patient Access to Medications
There are three ways that patients may access medications in correctional facilities .
These include:
•
•
•

Medical, dental or mental health provider with prescriptive authority
Specially-trained nursing staff using approved guidelines for minor complaints
using over-the-counter medications (OTC)
Limited number of over-the-counter medications for purchase by patients in the
correctional system's commissary(s)

Access to certain specialty medications requires that an on-site primary care provider
reviews and approves medications recommended by off-site medical staff and
specialists.
You will need to become familiar with the formulary, nursing guidelines OTC list, and
commissary OTC list for your assigned institution(s).
The two ways that medication can actually be taken by an inmate are Direct Observation
Therapy (DOT) medications or Keep-On-Person (KOP) medications.
•

DOT medications must be administered by appropriately trained and licensed
staff approved by the applicable state boards of pharmacy and nursing to
administer medications.

•

KOP (keep on person) medication programs are available in many institutions.
This program allows approved patients to maintain approved medications for
self-administration in a restricted amount. The policies and procedures for KOP
programs vary from system to system, but always delineate which medications
are not approved for KOP, which housing locations are not approved for KOP,
and which inmates may participate in KOP medications. There are certain
medications that are not allowed to be KOP because of abuse potential and/or
the experience of individual system or institution. Medications that are not
allowed to be KOP are all DEA schedule controlled substances, psychotropic
medications, injectables, and in many instances medications that are easily
abused or bartered in the corrections environment such as Benadryl.

DOT medications are administered either from specific medication lines or windows
where patients report for medications or cell-to-cell (or housing unit) administration when
inmates are in segregation or restricted housing areas.
DOT medications are typically administered twice daily. Confer with nursing staff to
identify these times. Patients who need around-the-clock access to medication
administration require housing such as infirmary placement where 24-hour nursing care
is provided.

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9

centurio n.

Regardless of the administration delivery method, it is important to remember:
•

•
•

•
•

Persons in custody do not normally have unlimited access to 24-hour medication
administration. Ask what your facility capabilities are before prescribing any
medication on a PRN basis. For medications which do not require consistent
dosing, however, such as pain medication outside of an acute event, PRN
prescribing is preferred.
Know the medications that are not available for KOP
Understand that pill window and pill lines may create conditions that impact
patient medication compliance, such as long lines, lengthy distances to pill line,
poor weather conditions.
Once daily or twice daily is preferred unless the patient is in the medical
infirmary.
Participation in KOP is a privilege and not a right and that privilege can be
rescinded for non-compliance or abuse.

OTC medications may be available from the commissary. These medications are
maintained and taken by the individual patient purchasing the medication. The Medical
Authority will periodically review the list of available OTC medications. Healthcare staff
has access to an individual's commissary list for review with the patient. Medication
education should include the side-effects of misuse and contraindications of those
commonly available OTC medications such acetaminophen and NSAIDs. You should
become familiar with the practices for prescribing OTC medications at your facility.

Medication and Treatment Compliance
Patients have the right to refuse treatment except in emergency situations in which there
is an imminent risk of danger to self or others or when there has been an administrative
or Court review authorizing involuntary medication. The refusal of treatment should be
an informed decision with the consequences explained to the patient. The refusal
should be in writing and describe the medication and/or services which are being
refused; the risks/benefits of refusing; and alternatives discussed. The requirement for
written refusal generally is satisfied by the signature of the patient on the refusal
document with a witness who acknowledges that the patient read the refusal form or had
it read to him/her in a language understood by him or her. When the refusal becomes a
pattern or has substantial effects on the individual's well-being, the prescribing
practitioner should conduct face-to-face counseling with the patient and document that
discussion in the progress note and obtain a signed release of responsibility.
When a patient does not appear for a scheduled appointment, it can be easy to assume
that the person is refusing treatment and indicate in a progress note that the patient was
a "no-show." There can be many reasons for a patient not coming to an appointment,
however, including decline of mental or physical health status, schedule conflict with
work/school/recreation/court/visitation, unavailability of security staff for movement to the
healthcare unit and more. It is important to follow-up on "no-shows" for the sake of the
individual patient, but also to find out if reasons represent a pattern. Identifying patterns
for "no-shows" or missed appointments and modifying processes is a mandatory practice
in most quality improvement programs as this represents an access to care issue. If the
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centurion ,

ional officers
patient does not appear for a scheduled provider appointment, the correct
has the right
then
patient
The
unit.
are
can be notified and bring him or her to the healthc
ed.
explain
been
have
to refuse treatment after the potential consequences
r, according to
Medication non-compliance can also be an issue in corrections; howeve
it may be an even
Donald Meichenbaum in his book, Facilitating Treatment Adherence,
nt
greater problem outside of corrections. According to Meichenbaum , treatme
40% to
of
range
the
in
is
nity
commu
compliance with recommended treatment In the
led
control
a
is
it
e
becaus
50%. Treatment compliance may be better in corrections
environment where staff scrutinize and report patient behavior.

are most
"Watch-take" or "direct observation" methods of medication administration
patient has
the
verify
to
g
checkin
are
officer
ional
effective when both a nurse and correct
They
staff.
the
ting
distrac
at
s"
"expert
ingested the medication. However, patients are
tial
substan
has
tion
medica
a
are also "expert" at cheeking and palming medications. If
means
all
and
abuse potential, for example an opioid, patients might resort to any
tation of
necessary to accumulate and distribute such medications including regurgi
d into doing so
ingested doses. Some may do this for their own benefit or may be coerce
regurgitate and
by others. Persons with a plan to commit suicide have been known to
later ingestion
for
ts
ressan
antidep
store up lethal doses of medications such as tricyclic
as a single fatal dose.
that are
As you have seen in other practice environments, many medications
les of these
clinically effective have the potential to be diverted or abused. Examp
Seroquel,
to
limited
not
are
but
e
includ
medications in a correctional environment
tamines,
amphe
ts,
gestan
decon
Wellbutrin, Neurontin, muscl e relaxants, Albuterol,
g
sedatin
and
nces
antidepressants, dextromethorphan, any controlled substa
antihistamines.
duties, patients can
If staff observing ingestion are not attentive or are diverted from their
medication
the
tand
unders
to
nt
accept but not ingest the medication. It is importa
l and/or
medica
your
with
compliance policy and process at your facility. Check
nce for
complia
tion
administrative leadership about the process for monitoring medica
your
at
y
DOT and KOP medications as well as the process for medication deliver
assigned institution.
system that
It is important that you receive specific guidelines for your correctional
identify:
•
•
•
•
•

Formulary medications
Non-formulary request process
List of medications that must be DOT
KOP policies and procedures
Access to the pharma cy contractor manual
Pharmacy and Therapeutics Committee

cy and
Our statewide Medical Directors and pharmacists participate in the Pharma
ing the
manag
for
sible
respon
is
ttee
Therapeutics (P& T) Committee. The P& T Commi
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formulary system . The committee is composed of actively practic
ing physicians, other
prescribers, pharmacists, nurses, administrators, quality improv
ement managers, and
other healthcare professionals who participate in the medication-u
se process.
Customarily, P&T Committee member appointments are based
on guidance from the
client, medical staff as well as other clinical and administrative
staff.

The statewide Medical Director chairs the committee and his/he
r assistant or pharmacy
representative serves as secretary. The P&T Committee serves
in an evaluative,
educational and advisory capacity to the medical staff and organi
zational administration
in all matters pertaining to the use of medications (including investi
gational medications).
The P&T committee is responsible for overseeing policies and
procedures related to all
aspects of medication use within the facilities. The P& T Comm
ittee is responsible to the
medical staff as a whole, and its recommendations are subject
to approval by the
organized medical staff as well as the administrative approval
process.
P&T Committees are designed to increase practitioners' knowle
dge about medication
therapy, to improve the safety of medication therapy and to improv
e therapeutic
outcomes. Consideration of patient care and unbiased reviews
of the biomedical
literature are the cornerstone principles of formulary decision-mak
ing.
The P& T Committee is a structured, evidence-based process in
the evaluation of
medications for formulary consideration. The P&T Committee
reviews information that
reflects a thorough, accurate, and unbiased review and analys
is of the evidence
available in the scientific literature. The evaluation process encou
rages objective
consideration of clinical and care delivery information, facilitates
communication, fosters
positive patient outcomes, and supports safe and effective medica
tion ordering,
dispensing, administration, and monitoring . Decisions made by
the P&T Committee
support improved patient care outcomes across the continuum
of care.

Tips for Practicing within a Formulary and
Submitting Non-Formulary Requests
Practicing within a Formulary
•

•
•
•

•

Formularies are well intentioned and are updated frequently to
represent
physicians' and other experts' clinical judgm ent on the use of SAFE
,
APPROPRIATE and cost-effective medications; therapies that
best serve
patients
Providers are encouraged to comply with prescribed formulary
medications. A
medication's cost does not determine its efficacy
Decision to provide proper treatment supersedes cost consideration
s
Use non-pharmacologic treatments such as sleep hygiene, cognit
ive-behavioral
therapy, or relaxation techniques when possible. This approach
reduces
polypharmacy.
Non-Formulary Request can be submitted to prescribe a medic
ation not included
on the formulary.

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Submitting a Non-Formulary Request
Reference evidence-based information to support your request.
Document your drug trials, dosages, clinical response failure, and adverse
effects to expedite review of non-formulary requests
Ask the patient about family history of response to a medication. Such
pharmacogenetic data may predict response in first-degree relatives and support
a non-formulary request
Document pharmacokinetic or pharmacodynamic interactions between the
formulary drug and other medications that the patient is taking.
List known interactions with foods and disease

•
•
•

•
•

Pharmacy Department Medication Management
each
Our Pharmacy Manage ment team monitors the medication prescribing practices
the
to
provided
is
ion
informat
This
er.
month by contract, by site and by prescrib
cific
statewide Medical Director to permit review of facility-specific as well as staff-spe
l
individua
contact
may
prescribing practices. Based on this review, the Medical Director
prescribers or may consider specific training sessions.
In most contracts, the statewide Medical Director meets with the prescribers at least
quarterly to discuss medication practices. Some contracts may handle these
of
discussions through monthly conference calls . Our Corporate Office uses the reports
l
potentia
and
trends
e
prescribing practices to review practices by contract to determin
areas for improvement.
of
If a Medical Director has concerns about the use of a specific medication or group
,
example
For
ion(s).
medicat
these
of
medications, he/she can request a focused report
will
team
ment
Manage
cy
Pharma
after reports of increased abuse of a medication , the
there
provide a utilization report for all patients who are on that medication to ensure that
is a valid diagnosis and need for that medication.
our
We complete an analysis of the current drug cost and utilization trends inherent
for
case
s
busines
the
support
to
data
ful
clients we serve. The analysis elicits meaning
below.
listed
rs
indicato
outcome
change, and also provides the baseline on the current
Some of the areas evaluated are:
•
•
•
•
•
•
•
•
•
•

Current utilization rates/cost trends
Therapeutic duplication in classes
Multiple prescribers for the same inmate-patient
Utilization of hypnotics and benzodiazepines
Prescribing of sub-therapeutic dosing
Analysis of top therapeutic classes, including cost drivers
Analysis of generic utilization patterns
Average number of prescriptions per inmate-patient (polypharmacy)
Analysis of prescriber outliers
Comparison of utilization patterns with national averages

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The Pharmacy Management team serves as a resource for drug information and
will
come on-site to provide pharmacotherapy education , current literature research
reviews
and provide presentations on formulary compliance and cost trends .
Medication Management Summary

The information in this section is intended to provide general knowledge and
understanding of providing healthcare in a correctional environment. The following
space is for your notes and questions. Include information that you need to discuss
with
the Medical Director, the Director of Nursing and/or the Health Services Adminis
trator.
Topics you may want to discuss include:
•
•
•
•
•
•
•
•

Where is the most recent Formulary available?
How are non-formulary requests handled?
What are the medication administration times for this facility?
Do we have KOP medications? If so what medications are not KOP?
What OTC medications are available in the commissary and should inmate
purchasing be encouraged?
What training is needed for medication ordering (i.e. electronic or handwritten
prescribing)?
How is the medication order refill process handled?
How are controlled substances managed?

NOTES:

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centurion.

Chapter 10: Disease Management/Chronic Care Clinics
Overview

s:
Disease managemenUchronic care program is based on the following five principle
Identification and tracking of patients with chronic disease(s)
Application of nationally-recognized, evidence-based clinical guidelines
Promotion of wellness and prevention strategies
Expectation and encouragement for the patient to take an active role in care
Support for the chronic care team

•
•
•
•
•

At minimum the following clinics are offered at each institution:
Pulmonary
Endocrine/Diabetes
Infectious Disease
Cardiovascular including Hypertension
Neurology
Gastrointestinal

•
•
•
•
•
•

ers
Chronic care encounters are based upon disease acuity and control. The encount
patient
as
well
as
es
guidelin
include testing and treatments based on clinical practice
education handouts for use in individual and group sessions. As a primary care
provider you are a consistent part of the chronic care treatment team to provide
management and routine involvement in treatment and care planning . This active
the
involvement includes, at minimum, clinical evaluation every six months based on
.
acuity and control of the patient's chronic disease
and
The nurse assigned to chronic care will educate patients about their specific primary
in
effective
and
involved
more
be
to
patients
r
co-morbid conditions. They will empowe
self-care and management of their health to encourage the patients to:
•
•
•
•

Be proactive and effective partners in their care
Understand the appropriate use of resources needed for their care
Identify precipitating factors/appropriate responses before acute intervention needed
Be compliant and cooperative with the recommended treatment plan

Process Flow
The Chronic Care Clinic process is illustrated on the following page. You will receive
the:
orientation to aspects of the program from the Medical Director that will include
•
•
•
•

Clinics provided at your assigned institution(s)
Resources to evidence-based clinical practices guidelines that form the basis for
chronic disease care
Documentation requirements
Introduction to resources available to the on-site Chronic Care Team for patient
education, complicated case management and other enhancements.

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,,,..
Referral for Chronic Care Clinic from:
• Health screening during intake
• Initial/per iodic health evaluations
• Sick call encounte r
• Periodic reviews of medication profiles

•
•
•
•
•

Chronic Care Plan developed:
Clinic(s) assigned
Initial acuity assigned
Plan of Care completed
Medications prescribed
Schedule for frequency of follow-up
encounters, laboratory testing, etc.

Patient avai lable

Is patient appropria te for Chronic Care Clinic?

Patient assigned to
Chronic Care Clinic

Chronic Care Team initiates
tracking log to include:
• Clinic(s) assigned
• Patient's birth month
• Schedules of follow-up
encounters, laborator y
testine:. etc.

Patient remains in institution

..,,,

Patient fo.llowecl through
routine sick call process

Prior to scheduled visit:
• Verify labs ordered available
• Verify other testing results available
• Verify medicatio n renewal dates
• MAR available

Chronic Care Encounter
with Patient
• Vitals, lab tests, MAR, and
diagnosis reviewed
• ROS and assessment
completed
• Informati on reviewed with
patient
Patient education and
medication counseling
provided
• Chronic Care encounte r
documented in medical record
Plan of Care and Acuity level
updated

_y _
Chronic Care Team Follow-Up
• Note, implemen t and initiate
referrals/orders from encounte r
• Update Chronic Care tracking log
• Schedule follow-up based on Plan
of Care

5101/2020

Patient follawed through sick
call process

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Disease Management/Chronic Care Clinics Summary
and
The information in this section is intended to provide general knowledge
settings.
ional
understanding of disease management and chronic care within correct
that you need
The following space is for your notes and questions. Include information
and/or the Health
to discuss with the statewide Medical Director, the Director of Nursing
Services Administrator.
Topics you may want to discuss include :
•
•
•
•
•
•
•

What types of chronic care clinics are provided?
What is the average number of patients in each chronic care clinic?
How are chronic care clinics scheduled?
Who coordinates and assists with the clinics?
Are there special forms required for documenting chronic care clinics?
le?
Are Disease Management Summary treatment guidelines readily availab
nt for
Are there multidisciplinary team meetings available for discussion of treatme
difficult patients?

NOTES:

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Chapter 11: Specialty Care and Off-Site Services
Overview

As part of healthcare services, we are required to provide not
only primary care but also
ensure access and coordination of specialty care when medic
ally necessary for a
patient. Centurion makes availa ble the res()urce of "RubiconMD"
for all providers.
RubiconMD connects clinicians to a broad range of specialists
through electronic
consultation.
For Specialty services that require face-to -face or in person encou
nters with the
Specialist, th ese are typically provid ed one of three ways:
•
•
•

At on-site clinics at designated institutions or located at one centra
l or regional hub
At specialist office or clinic locations
On-site using teleme dicine capabilities

Specialty services typically includ e but are not limited to :
Audiol ogy
Cardiology
Dermatology
Ear, Nose & Throa t
Endocrinology
Gastroenterology
General Surgery
Infectious Diseases
Nephrology
Neurology
Neurosurgery
OB/GYN
Oncology
Ophthalmology

Oral Surgery
Orthop edics
Orthop edic Surgery
Podiatry
Physic al/Occupational/Speech Thera py
Pulmonology
Radiology
Radiation Thera py
Reconstructive Surge ry
Thorac ic Surgery
Respiratory Thera py
Urolog y
Vascu lar Surgery

Dialysis services including nephrology care is typica lly provid ed
at one centra lized
institution that is usually at or near the reception facilities for male
and fema le patients.
Dialysis services are typically sub-contracte d to an organization
that has experi ence in
providing dialysis in the correctional environment.

Utiliza tion Management (UM)
Our utilization manag ement process will conduct prospective
review of requested
specialty services as well as concurrent and retrospective review
of inpatient and
outpatient services to determine medical necessity
Our specia lty services progra m routine ly demonstrates use of
a two level medical
necessity review as well as an appea ls system . Aspec ts of each
level of review and the
appea ls process are discussed in the grid on the following page.
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Level 1
Review

Review conducted by trained utilization management nursing staff based
on nationally recognized guidelines and Department approved medical
treatment guidelines
Submission of request to the statewide Medical Director if request cannot ,
be approved based on nationally recognized guidelines and Department
approved medical treatment guidelines
At no time will Level I review result in a reduction, denial or termination of
service

Level2
Review

Review conducted by statewide Medical Director or designated qualified
healthcare professional. If request is for specialty oral surgery services,
the Dental Director will conduct the Level II review
Level II review conducted with consideration given to individual inmate
healthcare needs, potential complications at time of the request, agreed
upon policies and procedures, and continuity of care considerations
Statewide Medical Director will consult with the Department and specialty
medical experts when needed
Denial of specialty services request by the statewide Medical Director
requires discussion with requesting primary care provider and/or on-site
Medical Director and provision of alternative treatment strategies

Appeals
Process

i

Primary care providers may appeal initial utilization review denials to the
statewide Medical Director
Appeal process will include submission of the original request, additional
medical history and data pertinent to the appeals review
Statewide Medical Director's appeal review will include case discussion
with the requesting primary care provider and/or on-site Medical Director
Appeal process will be completed and decision provided to the requesting
on-site primary care provider within five business days of receipt of the
appeal
If original decision stands, the requesting primary care provider has option
to request a second appeal

As always, a final decision from the Department will be implemented when ,
-

-

_J

Specialty Care /Utilization Management Process Flow
The flow chart on the next page represents the standard on-site Specialty Care/
Utilization Management Process Flow process. The Statewide Medical Director,
utilization review staff will assist in providing training and answering questions specific to
the process, items requiring review, appeals process and other information specific to
utilization and case management.

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Physician or mid-level provider determines need
for Specialty Care

l
Physician or mid-level provider completes
Specialty Care request form

!
Order is noted and Specialty Care request is
forwarded to off-site care coordinator

Off-site care coordinator logs request
on Specialty Care Tracking Log

..._
Is Utilization Management
review required?
~

No

-.

Yes

-

r

Specialty Care request /supporting
documentation forwarded for review
Review may be completed by:
• Utilization Management staff
• Statewide Medical Director

__,.

Off-site coordinator updates
Specialty Care Tracking log with :
• Date request sent for review
Date request returned from
review

•

,1,

Off-site coordinator schedules appointmen t
with Specialty Care provider

-1 No

l

Does patient attend scheduled
appointment?

_,,.

No

-

-,.

-

Did patient refuse the
appointment?
'--

,.

-

Yes

-

,

No

--

.

Off-site coordinator will update
Specialty Care Tracking log

Patient counseled
Refusal signed

!
Off-site coordinator will inform physician
or mid-level requesting Specialty Care
Review of patient refusal

......

Written provider
recommendation
accompanies
patient

'---{

HI>

"

Patient returns from Specialty
Care appointmen t
Patient seen by nursing staff

~

-

Resolution options include :
Provide
reviewer with additional
•
information and resubmit
• Determine/d ocument alternate Plan
of Care

Yes

Nursing staff contact
Specialty Care
provider to obtain
recommendations

Off-site coordinator will follow-up
with physician or mid-level
requesting Specialty Care if unable to
meet request in documente,J
timeline

Return to physician or mid-level
requesting Specialty Care for resolution

Security is notified of date and time of
appointmen t to arrange transportati on

'-

+
---

~

!
_,,.

Off-site coordinator follows-up
daily on reviews not received

Utilization Management
criteria met?

Off-site coordinator updates Specialty Care
Tracking log with date and time of
appointmen t

-

t~

Yes

...-

l.

,___
Off-site coordinator will
re-initiate the scheduling
process

!
Does appointmen t need to be
rescheduled?

Yes
~

..._

---..

/

No

"

Review of Specialty Care
provider recommendations
Document plan of care
Educate patient on plan

.
r

Schedule for
provider on-site
follow-up visit, as
indicated

~Spec;,lty c,~

eking Log updated

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Centene Resources
s in the nation.
Centene is one of the largest Medicaid managed care organization
ine healthcare
Centene Corporation, a Fortune 500 company, is a leading multi-l
rising number of underenterprise that provides programs and related services to the
insured and uninsured individuals.
chronically ill, lowThe majority of Centene's approximately 2.4 million patients are
and offers a range of
income, disabled citizens. Centene operates local health plans
and commercial
health insurance solutions. It also contracts with other healthcare
health, life and health
organizations to provide specialty services including behavioral
benefits
acy
pharm
and
s,
management, managed vision , telehealth service
entene.com.
www.c
at
ble
availa
management. More inform ation regarding Centene is
centrict
patien
art
The relationship with Centene allows us access to state of the
Following are some of
resources and tools for monitoring and managing inmate care.
the resources available:
ion management
TruCare ™, a patient-centric integrated disease, care and utilizat
evidenceon
based
tools
ss
product. TruCare TM offers clinical appropriatene
stratification
s,
inmate
for
based criteria, customized assessments and care plans
of risk, and tracking/reporting/improvement data.

•

ght for our
Utilization Management (UM) provides support, training and oversi
ement
manag
data
ticated
sophis
ing
utilization management program by provid
and
is,
analys
t,
capabilities for data collection, indicator measuremen
rd and ad hoc
improvement activiti es. Our UM staff will have access to standa
and analyze data
reporting and analysis support as well as the ability to capture
from internal, sub-contractor and external sources.

•

•

•

•

for service
Centene's Electronic Data Warehouse (EDW) is the central hub
l
clinica
of
ng
reporti
information that allows collection , integration, and
vision;
and
claim/encounter data (medical, laboratory, pharmacy, dental
medical
individual and organizational providers); financial information;
ement);
management information (referrals, authorizations, disease manag
ation
inmate information (including demographics); and provider inform
s).
(participation status, specialty, demographic
generate
Centilligence houses all information in the EDW to allow staff to
Centefligence
standard and ad hoc reports from a single data repository , using
indicators and
suite of reporting systems to build and tabulate key performance
level for
provide drill-down capability to the individual provider or inmate
n.
tilizatio
investigation of suspected under- or over-u
on chronic
Nurtur is a health and lifestyle management company focused
to our
diseases. The primary objectives of services provided by Nurtur
ion in recurrent
correctional healthcare staff are to assist in achieving a reduct
g on the
morbidity associated with identified disease condition and in focusin
this by
does
Nurtur
ions.
condit
al
effective control of high cost chronic medic
ent
treatm
ary
isciplin
multid
of
providing individual evaluation and develo pment
case
style
round
grand
ing
plans, providing educational information and perform
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management discussions. All services are coordinated in conjun
ction with onsite healthcare staff to implement and monitor identified interve
ntions.

Specialty Care and Off-Site Services Summary
The information in this section is intended to provide general knowle
dge and
understanding of how specialty medical care is provided in a correc
tional environment.
The following space is for your notes and questions. Include inform
ation that you need
to discuss with the Medical Director, the Director of Nursing and/or
the Health Services
Administrator.
Topics you may want to discuss include:
•
•
•
•
•
•

What paperwork or electronic information must be generated for
a specialist
referral?
What training is needed to initiate and follow-up on specialist referra
ls?
What is the mechanism for you to be informed if an appointment
exceeds the
length of time appropriate for the patient's need?
Will patients returning from specialist appointment be automatically
scheduled for
an appointment to see an on-site provider?
Who schedules appointments
Who are the medical specialists used?

NOTES:

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Chapter 12: On-Site Emergency Care, Emergency Department Services,
Hospitalizations and Infirmary Care

On-Site Emergency Care
In institutions with 24-hour healthcare coverage, our staff provide emergency triage and
stabilization for inmates, institutional employees, contractors, volunteers, and visitors.
That level of care usually is basic life support and first aid awaiting arrival of local
Emergency Medical System (EMS) response team(s). In institutions that do not have
24-hour healthcare coverage and typically house a healthier population, security staff
are trained in basic first aid and life support and will either call EMS in life-threatening
situations, contact healthcare staff at another institution or directly contact the on-call
provider.
All healthcare staff receive training in CPR, Basic First Aid and AED . These requirements
are included in the new employee orientation program, disaster preparedness training and
emergency response training and are provided in close collaboration with the correctional
system and institutional manageme nt teams to ensure our emergency response meet
expectations and needs.
Emergencies within an institution are often referred to "man-down" emergencies.
Healthcare staff are expected to respond to "man-downs" within a four-minute
timeframe, the standard established by the American Correctional Association and many
correctional systems. Our staff are trained on how to respond to health-related
emergencies that occur on or within institutional properties or settings. The "man-down"
training includes:
•
•
•
•
•
•
•

Recognition of signs and symptoms and knowledge of required actions
Administration of Basic First Aid and CPR
Methods of obtaining assistance
Suicide intervention
Signs and symptoms of mental illness, violent behavior
Acute intoxication and withdrawal
Procedures for inmate transfers to appropriate medical facilities

"Man-down bags" and emergency supplies such as oxygen, resuscitation bags, airways
and AEDs are maintained in designated areas of the healthcare unit and remote medical
areas, if applicable. It is important to remember that most institutions will not have onsite advanced life support capabilities.

Emergency Department Services and Hospitalizations
In the correctional environment most often an acute hospitalization is the result of a trip
to an emergency department and less frequently directly from a specialist's office.
Hospitalizations for procedures and/or testing may also be necessary.
Since emergency situations occur 24 hours a day, 7 days a week and provider coverage
is often not available, it is necessary to have trained staff at the facility who understand
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the necessity of contacting the primary care provider or on-call provider prior to
transferring a patient to an emergency department. Communications between the
emergency department provider and staff and the primary care provider on-site or oncall is also required. We advocate the use of SBAR communication techniques when
nursing staff communicate with providers. SBAR techniques and communication tools
are discussed later in this chapter.
When there is a medical order to transfer a patient to an emergency department, the
order will indicate the mode of transportation that is required such as life-support
ambulance, basic ambulance or correctional transportation. This detail is carried out by
the healthcare staff on-site and is necessary to ensure that the security shift commande r
is notified as soon as the order is received or when there is reasonable anticipation of an
order. This notification facilitates emergency vehicle entry into the institution and
arrangement of security escorts for the inmate. Generally, at least two security officers
are required when a patient leaves the institution. The patient's security level dictates
the number of officers and the level of security required.
A patient returning from an off-site medical trip is taken to the healthcare unit prior to
returning to his/her housing assignment. This practice permits healthcare staff to review
orders and aftercare instructions from the emergency department or hospital and have a
face-to-face encounter with the returning inmate. The primary care provider or on-call
provider is contacted when indicated to report the patient's status and to review and
receive orders. Patients returning from an emergency department or a hospitalization
should routinely be scheduled for an appointment with the primary care provider to
complete follow-up needs and discuss/review on-going plan of care with the patient.
Utilization/Case Manageme nt - Inpatient Hospitalization
The utilization management program includes review of concurrent inpatient reviews.
Inpatient hospitalization and emergency department visits resulting in an admission
require coordination with the Utilization Management Program, the treating hospital and
the site primary care provider.
The site will have a process for providing notification to the Utilization Management
Department when a planned or unplanned admission occurs. The primary care provider
and Director of Nursing or designee will work closely with our utilization management
staff to monitor progress, treatment and facilitate timely, appropriate discharge back to
the patient's original institution or to an institution with infirmary capabilities where the
patient's on-going care requirements can be managed.
Communication will be facilitated between the receiving hospital/healthcare facility and
the site by the utilization management team and will include routine care updates
provided to healthcare staff at the sending facility. Discharge planning will begin at the
time of a patient's admission as will the site's planning for any special needs or required
services anticipated at the time of discharge.
Data specific to inpatient and emergency department utilization will be maintained for
each institution and reported monthly to our client. Review of this information will be
incorporated into monthly statistical and quality monitoring review specific to the contract
and individual site.
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Infirmary Care and Utilization

closer
An infirmary is an area of the institution accommodating patients who need
as care
defined
is
care
ry
observation or higher level of healthcare services. Infirma
ring,
monito
provided to patients with an illness or diagnosis that requ ires daily
require a level
medication and/or therapy, or assistance with activities of daily living that
s requiring
of skilled nursing intervention. Not all institutions have infirmaries. Patient
.
infirmary level of care may require coordination for transfer when needed
r or
Healthcare services in infirmaries will be directed by the site Medical Directo
or
Nursing
of
r
physician. Infirmary nursing care will be supervised by the site Directo
on-site
be
will
registered nurse designee seven days a week. Qualified healthcare staff
sound of
and
sight
within
be
will
s
inmate
ry
infirma
24 hours a day, 7 days a week. All
rs and
numbe
the
upon
based
be
will
levels
facility or healthcare staff. Staffing skills and
with
ries
infirma
with
ons
instituti
acuity of inmates within the infirmary. We routinely staff
s
system
ional
correct
sufficient staff to meet the standards of care as indicated in the
policy and consistent with correctional healthcare standards.
care, pre-and
Infirmary care provided includes skilled nursing services, convalescent
as medical
well
as
,
therapy
IV
limited
post-surgical management, limited acute care,
nt will order
assista
an
physici
or
observation monitoring. A physician, nurse practitioner
le 24 hours
availab
be
the infirmary admission of an inmate. A primary care provider will
s an
require
ry
a day, 7 days a week either on-site or on~call. Discharge from an infirma
following actions
order from a physician or nurse practitioner or physician assistant. The
are needed at the time of discharge:
provider
• Discharge note and discharge orders for continuing care from on-site
patient's
the
ses
addres
that
• Discharge summary note from the healthcare staff
status at the time of discharge
• Instructions for follow-up self care and medications given to the patient
ly, when a patient
The provision of end of life care varies in correctional systems. Typical
r will identify
provide
care
primary
a
is determined to be suffering from a terminal illness,
treatment
y
ciplinar
multidis
a
hing
healthcare needs for the patient and assist in establis
may
care
life
End-ofplan for care and support services during the final stages of life.
and
falls
focus on pain management, personal and comfort care needs, safety from
hospice and
injury, and skin integrity preservation. Healthcare staff assigned to provide
and clergy to
related end-of-life care collaborate with mental health staff, security staff,
setting.
the
of
ess
regardl
dignity"
with
provide persons with the care needed to "die
s:
The multidisciplinary treatment plan for end-of-life services typically include
•
•
•
•
•
•

Pain management program
ng abilities
Patient mental status, particularly as it affects healthcare decision-maki
program
spice
care/ho
e
palliativ
a
The Do Not Resuscitate process through
Durable medical equipment
of next
A plan to execute and communicate patient's living will and identification
of kin or guardian to act on their behalf, if necessary
vary
Providers need to be aware of state-specific legal requirements since these
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Emerg ency Respo nse Proces s Flow
The following illustrates the flow of emergency response for a typical facility
with on-site
healthcare staff
inmate Heallllcare £:ine(geney
Code Call

Respond 10 In mate loc !Ion
Perform fli.t Aid/CPR

NO

Actlvate on•site/off-slte

On-site medical Graff
mnduct aS$essment

11111ersenoytr.rnsport
procedures

+
Report inmote'5

Actf,a e

emergc,ncv

transport
proc.M~

Emorgency
transpert may
be a.ctfvated
at anytime If
inmat s

ori-sfte medlcal st•fi IO

nwdl~I

lli_po lnmirte

mtus to rec.eMr,g

<lli~i!(ll~n~

ho-.Dlta1/emergency roo'l'

t

t

condi Ion f:i
deterioratin g
or if medical
staff orders

Obtain nrders from on-site
01 on-call ml!'dlcal stalf

Prepare requir"d
d0<1umenlati0n

t
Pro\/ld~ off-sit mfl.dlcal

On•slt.e.slalf

staff with osseWTientof

complete/f111plemen1

11rna(e'$ medl~~I status

medical order.requ1,rns
lmm~dlat:e attention

+

Notify site '""dlcal
!eader.;hlp, lnstllu tonal
administration and

schodule or compieJ\?.olhtt

orders lrom mtdlcal ,tiff

CQJ/UM ~!aft.ii
reu41ted bv 110Ucv

+

Dcicurnent inc dent on
E.rncr11 nc.y Room Log

Contact sewrltv.ind

YES

NO

return Inmate to prior
hollif~

Notify cu,rtody
PtoYld" req11lred
00Uflca1fon/documentatlon to
senurltv c;I Inmate hou~fn& di;tnge

Arninge ttan.sportallor, 10

provided

Emm1rency Room

•

•

+

Ob!il!l'Vfl .a dlmate<I, dOGi.U'l Ill

f'lotlJv "ur~lni/rntltltal he.!1lh
st ff of observation sllltus

•

Short term observation In medical
unit aller ordered tn!atmenl

011•11,olns. !nnlate amssment

Prqvlde off-•ile m•dlfal stnft

with assessment of Inmate's

♦
Pr pare paperwork

YFS

NO

+

Notify $lie mecdlcaf leader,h!p,
fn1ututlonal adminlstratfon and CQI/UM

5taft a, requlr d

Release 10 houslns unit
Schedule to b<: seen by modkal
st,iffwllhin 24 hr.>urs

COntac rnedlCIII siafr
forordm

t
Document lnddeni on
Em~tsen,v F10om Log

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centurion.
SBAR Communication Tool

) is a standardized way of
Situation Background Assessment Recommendation (SBAR
te with a shared set of
communicating. SBAR assists healthcare staff to communica
tions.
expectations to achieve consistent and organized communica
SBAR stands for:
problem (why we are calling)
• Situation: Providing a concise, brief statement of the
patient examination and
• Background: Providing pertinent and brief results of
find)
you
did
(what
information related to the current situation
(what do you think is going on)
• Assessment: Providing options for what is happening
s (what needs to be done)
• Recommendation: Requesting or recommending action
Process:
er will examine the patient,
1. Healthcare staff member consulting with on-call provid
y prior to calling the
review the medical record and gather pertinent health histor
on-call provider.
ion require appropriate
2. Patients experiencing a crisis or life threatening situat
use of the SBAR
viated
abbre
emergency responses which may necessitate
tion.
activa
process, or bypass altogether and immediate EMS
unication Form to record
3. The healthcare staff member will use the SBAR Comm
to include:
the required information. Minimum information obtained
n
locatio
ng
• Patient name, facility and housi
t tests and off-site care
• Relevant recent healthcare encounters, results of recen
• Code status
• Allergies
• Current medications and compliance history if known
indicated
• Vital signs including pulse oximeter and blood sugar when
• Current mental health status examination
• Current physical health status examination
n of the SBAR document
4. The (A) Assessment and (R) Recommendation sectio
help to guide in:
with the patient
• Communicating your considerations of what is going on
e should be treated;
• Focusing provider responses (orders) for where inmat
what needs to be done; and what follow-up needs to occur.
tion Form must be part of
5. The information documented on the SBAR Communica
the medical record or the
the patient's medical record. This form should be filed in
or scanned into the
information contained on the document should be transcribed
electronic health record.
ented on the appropriate
6. Any orders received from the provider must be docum
health record. Orders
order form within the patient's medical record or electronic
.
should be implemented and the appropriate actions taken

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SBAR COM MUN ICAT ION TOO L
Pre-Communication Preparation
• Assess the patient. If life threatening, activate Emergency
Medical Care.
• Review medical record for most recent healthcare encou
nters
• Obtain list of current medications or copy of current MAR
• Obtain results of recent significant labs or test results

Inmate Name:
Institution

- - - - - - - - - - - - - - - - - Number: - - - - - Housing Location _ _ _ _ _ _ _

Situation (Brie'fl~ describe current situation)

_

Notes

lntrod uce yourself, institution calling from
l am calling about patient
l am concerned about

Background (Briefly state current and (2ertinent history)

Patient is currently/has recently been treated for

Mtal Signs: B/P
Pulse
RR
Temp
Pain Score (1 - 10)
02 Sat
% on
Oxygen OR
Patie nt is complaining about

Room Air

Physical assessment demonstrates
jMental status is
,Skin is

Patient is allergic to
]Code status is
Asse ssme nt (Summary of what you think is going on}
, think the problem is or what might be happening is:

Ri~o mme ndati on (Actions and folloW -U(2}

10 Transfer inmate to Emergency Department
D Other

10 Tests, Medications or Monitoring Needed?
l
□

Call back for the following reasons

□

When do you want to see the patient?

Provider decision must be documented on orde r shee
t
Signature/title __ __ __ __ __ _ Provider Name
/Title _ _ _ __ _ _ _ _ __
Date: _ __
/_ _/_ _ Time:
AM / PM
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On-Site Emergency Care, Emergency Department Services, Hospitalizations and
Infirmary Care Summary

The information in this section is intended to provide you with general knowledge and
understanding of the role of on-site emergency care, off-site emergency department
services, on-site infirmary care, and off-site hospitalizations in correctional healthcare.
The following space is for your notes and questions. Include information that you need
to discuss with the Medical Director, the Director of Nursing and/or the Health Services
Administrator.
Topics you may want to discuss include:
•
•

•
•
•
•
•
•
•
•

Are infirmary services offered at this facility?
If infirmary services are offered at this facility, what is the capacity of the
infirmary, nursing skills provided, staffing levels, typical diagnosis, and typical
length of stay?
If infirmary services are not offered at this facility, where are patients transferred
for infirmary level of care?
How often do emergency "man-down" calls occur in the facility? Are there any
recurring issues?
What is the typical response time of the ambulance? Are there any issues in
emergency services accessing inmates?
What emergency department is used by this facility?
What is the relationship with the emergency department?
Does the emergency department routinely send discharge notes including copies
of lab and other studies for patients released from the emergency department?
How many hospitalizations does this facility average monthly?
Do patients return to this or another facility when discharged from a
hospitalization?

NOTES:

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centurion
Chapter 13: Laboratory, Radiology, EKG and Other On-Site Testing
Laboratory Services
Routine laboratory services are provided to each institution through a sub-contractor
agreement. This agreement is commonly with Bio-Reference Laboratories but may be
another laboratory services provider specific to/or required by use as part of our overall
contract. Specimens are typically picked up from each facility Monday through Friday
and delivered to the laboratory as soon as possible. All laboratory results, except those
requiring a longer processing time, will be provided to the institution within 72 hours and
often results will be returned the next working day. The institution is notified immediately
by telephone of critical laboratory results that indicate a potentially dangerous condition
requiring immediate attention by a provider. Results are routinely provided by fax or by
electronic receipt through a computer interface provided by the laboratory contractor.
Tests, panels and specimen requirements are readily available in a lab reference
manual located at your institution. Typically tests performed on-site (CUA waived)
include capillary blood glucose monitoring, dip-stick urine testing, stool quaiac testing,
urine drug testing (for MAT management), urine pregnancy test, non-routine PT/INR,
peak flow and pulse oximetry. The nursing staff can inform you of how to obtain these
tests and if other point-of-care testing may be available at your site.
Stat laboratory testing is available usually through a contract with a local hospital. The
use of stat laboratory testing should be limited to true medical necessity or in decision
making on whether to send a patient to the hospital. Turn-around time varies by facility
and mostly depends on the accessibility of a specimen courier. The following stat tests
are available at most contracts:

Bio-Reference
Test Code
0035-6
2555-1
0069-5
0053-9
3427-2
0068-7

Test Name
Ammonia
Basic Metabolic Panel (BMP)
C-Reactive Protein (CRP)
CBC
Comp Metabolic Panel (CMP)

CPTCode
82140
80048
86140
85025
80053

-

5743-0

Creatinine Kinase (CPK)
D-Dimer

82550
85379

0083-6
3646-7

DiQoxin Level
Lactic Acid

80162

0119-8

Lithium Level
Lipase

0521-5
0120-6
0084-4
0137-0
0086-9
2163-4

Magnesium
Phenytoin Level
PT/INR
Sedimentation Rate
Troponin - I

83605
80178
83690
83735
80185
85610
85651
84484
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lly transmitted disease
State or county laboratories may provide some testing for sexua
e the treatment and
provid
including HIV testing. In these case, we are often obligated to
follow-up.
Radiology Services

ions using stationary or
Capabilities for body structure x-rays are available at most institut
necessary for patients to
portable radiologic machines. At sma ller institutions, it may be
services are often
be transported to a larger institution for routine X-rays. Radiology
matter the method for
provided by a company with whom we have sub-contracted. No
riately licensed and
providing/performin g X-rays, the X-rays are completed by approp
Interpretation is
s.
image
it
registered technicians that conduct, process and transm
within 24 hours of the
le
completed by a board-certified radiolog ist and results are availab
at larger institutions.
X-ray . On-site fluoroscopy and specia l studies may be available
hospital. In addition,
Emergency radiology services are availab le at the local contracted
be available.
mobile services for mammography, ultrasound, CT and MRI may
EKG Services

ly performed by our
EKG services are available at many institutions and are routine
read and interpret the
trained nursing staff. Generally, the site-le vel provider is able to
these can be
EKG. In the event that you would like a reading by a cardiologist,
day.
a
rs
24-hou
g
transmitted electronically for a stat or routine readin
Ackno wledg emen t of Results and Reports

n designated for
Results of tests that you have ordered will be placed in a locatio
location may be
This
action.
and
on
attenti
information that requires your immediate
used by the system.
is
that
system
either electronic or paper depending upon the record
or written
nic
electro
by
It is your responsibility to review and acknowledge review
further
require
results
signature, date and time. Significantly abnormal test or report
with the
-face
face-to
documentation, modification of a treatment plan and explanation
results, positive or
patient. Patients are to be informed of all laboratory or procedures
t through procedural
negative. This may be by written communicat ion sent to the patien
custody prior to
from
ed
releas
is
t
communication channels. In the event that a patien
nal action or
additio
take
to
d
receiving significant results for which the patient is advise
imes this
Somet
follow-up, notification must be made to the patient and documented.
of
g them the need to
involves a certified letter sent to the address of the patient notifyin
upon proper
follow up for a lab test result which you can make available to them
identification.

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Laboratory and Other Testing Process Flow
A typical process flow for on-site healthcare staff in comp
leting laboratory and other
testing is provided on the following page.

Encounter on-site follow-up - includes
lab, EKG, x-ray and other diagnostics

Order Receiv ed/
Written

POC testing (tests performed onsite with
immed iate results: urine dip stick, occult stool
•
Obtain order (or perform per written
guideline)
•
Prepare equipm ent, if applicable
•
Gather supplie s
•
Perform test, docum ent results
•
Notify provide r of critical value per site
guidelines
•
Obtain orders

Prep:
If prep requires
housin g in
special medical
housin g unit,
follow site
policies for
admiss ion/
monitoring

Note Order

Comple te required
Requis itions

Refer for
Schedu ling or
obtain

ye

l

>

Review
Order

no ----.........;➔i

Comple te
&
docum ent

Update plan,
orders

Comple te
follow-up per

ye

Prepar e callout list
for security
Note if Fastinq

Perform ordered
test & docum ent
comple tion

e
transpo rt
to medical

Obtain
results from
testinq

Order Criteria:
1. Test name
2. Reason for test
3. Status (S
tat/Rou tine)
4. Routin e- timefra me
for comple tion such
as 7 days, 30 days

Prepar e
docum ents & send
for lab proces sing

no

Receiv ed
Notify
orderin g
provide r for
critical labs

Provide r
notified or
Review

Results normal 14(t-- --r Review / Provide /
Docum ent results
no
reviewed with/ provided
to patient and
Follow- up as
docum ented counseling
needed

~

Test Not Comple ted:
•
Determ ine if
released
• Resche dule if No
show
• Refusa l - sign refusal,
resche dule if indicat ed
• Notify orderin g
provide r for critical
labs (INR, drug level,

Result trackin g - needs to
include:
• Daily Monito ring of
testing log (lab, x-ray)
• Determ ine results not
received
• Follow- up with
vendor /review website , if
applicable, for missing
results
• If test unable to be
perform ed
•
Notify provide r
•
Resche dule
based on provide r
input (stat v.
routine \

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centurion.
Laboratory and Other On-Site Testing Summary

and
The information in this section is intended to provide you with general knowledge
nal
correctio
a
in
testing
other
understanding of the process for obtaining laboratory and
that you
ion
informat
Include
environment. The following space is for your notes and questions.
Services
Health
need to discuss with the Medical Director, the Director of Nursing and/or the
Administrator.
Topics you may want to discuss include:
•
•
•
•
•
•
•
•
•

What testing is available on-site?
Where are testing results recorded?
How testing is ordered and scheduled?
What is the typical turn-around time?
Where are results found for provider review?
How are critical values reported to the site and to the provider?
What happens if a patient does not get scheduled test? Is it rescheduled? Is provider
notified?
Are laboratory preferred testing groupings used?
Is a state laboratory used for any testing?

NOTES :

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centurion,,
Chapter 14: Your Role in Quality Healthcare
Principles for Health Services Delivery
Centurion's Purpose Statement provides a consistent understanding across the
organization of
why we are in business:
Transforming the health of the community, one person at a time.
All Centurion staff are expected to fully accept responsibility for
acting in accordance with the following six Centurion Values:
•
•
•
•
•
•

Correctional
Health

Uncompromising Integrity
Collaborative Leadership
Candid Communication
Disciplined Growth
Purposeful Innovation
Entrepreneurial Spirit

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Our success in providing correctional healthcare can be attributed to our ability to attract staff
who share these principles. Correctional healthcare is a challenging profession that requires
the best of people to be effective in their duties.
Our principles for healthcare services include:
•
•
•
•

Healthcare services consistent with community standards
Healthcare services consistent with correctional standards
Healthcare services that are both clinically and cost effective
Healthcare services integrated within a multidisciplinary approach and in collaboration
with the treatment team to help screen, diagnose, and treat

Correctional healthcare requires a multidisciplinary approach to be effective. Providers will
receive inappropriate referrals. These referrals may be due to inadequate triage or the
perception that there are limited alternatives to provider intervention.
Experience has shown that the best approach to quality healthcare is to strictly comply with
providing the right care to the right person at the right time with the planned and expected
outcome being achieved. Patients in custody often have high-risk and complex needs and may
require ongoing frequent medical engageme nt and care. Our on-site healthcare teams focus
heavily on coordination of acute primary care, diagnostic intervention, pharmaceutical treatment,
dental care and services through case manageme nt to identify, prevent, and manage avoidable
admissions, unnecessa ry emergency room use.

Typical Patient Health Benefits Summary
A handout typically provided to patients when entering the correctional system is provided on
the following pages. The handout, Summary of Healthcare Services & What They Mean to You,
briefly outlines the healthcare services that are available to the person incarcerated.
Your responsibility in the coordination and provision of specific services as a member of the
healthcare team will depend on overall contractual requirements, types of inmates housed at the
institution, the institution's mission, and the healthcare services offered at the institution.

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Intake Health
Assessment

All new admissions receive an Intake Health
Assessment. Healthcare staff will schedule this
appointment for you

Intake
Mental Health
Assessment

All new admissions receive an Intake Mental
Health Assessment. Healthcare staff will
schedule this appointment for you

Intake Dental
Examination

All new admissions receive an Intake Dental
Examination. Dental staff will schedule this
appointment for you

Establishes your dental baseline and
develops a dental treatment plan

Routine Sick Call

If you want to be seen in sick call, complete a sick
call slip and deposit the slip in the designated
box. Generally you will see a nurse the next day
unless it is a weekend

Sick call is used when an illness occurs
that you feel you should see medical,
mental health or dental staff for treatment.
This is your access to care for needs that
are not chronic

Chronic Care
Clinic

Infirmary Services

Medications
(prescribed)

Medications
(over the
counter)

If you have a chronic health problem, you will be
scheduled by healthcare staff for Chronic Care
Clinic appointments.

Allows routine monitoring of your chronic
illness by healthcare team. Helps you to
learn about your disease, your
medications and teaches you how to take
care of yourself based on your illness
You will be admitted to an infirmary based on a
Allows healthcare staff to more
medical provider's order. Healthcare staff will
closely monitor your health. Inmates may
coordinate your admission and discharge with
be placed in the infirmary before or after a
security staff based on the medical provider's
procedure/test, after returning from an
orders
emergency department or hospital or
when the provider wants to monitor/watch
how you are feeling
--I-Medications will be prescribed for you by a
Medicines ordered by a provider are an
medical provider, psychiatric staff or dentist
important part of your treatment. Taking
based on your health complaints. You will
them as ordered can help treat or control
receive your medicine from the nurse at a pill
symptoms of your disease and help you
window, at your cell or in your unit usually once or get well or feel better.
twice a day
These are medicines that can be obtained without
an order from a medical provider. Some over the
counter medications will be available in the
commissary

Like Tylenol, Motrin,
Tinactin, dandruff
shampoo, antacids

___ ~ - - -

,__

On-Site
Emergency Care

Periodic Health
Assessment

Establishes your medical care baseline;
provides needed continuity of care for
chronic care, medications
---Establishes your mental health baseline;
provides continuity of mental health
services and medications

You can self refer, may be referred by security
staff or healthcare staff based on a true emerg ent
complaint or healthcare need

These are used for occasional muscle
aches, headaches, stomach upset.
Having these medicines available allows
you to take medicine when you may only
have a cold or other minor illness that
does not require a provider's visit. If the
over the counter medication does not help
you, submit a sick call slip to see a
healthcare staff member
--This allows for medical or mental health
staff to evaluate and provide necessary
healthcare for a life threatening or
potentially life threatening healthcare
problem.

You will be offered health assessments based on
Allows medical to perform a physical
your age, chronic health problems and DOC
exam and check your overall wellness.
policy. Immunizations and testing for tuberculosis _ ~ llows you ~ earn about staying healthy
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centurion
, Why is This Important

mportant Service :. How Do I Access
_

Inmate
Complaints
Medical Records

Co-Pay

Optometry
Services

-- - - - - - - - - - - - --,-Mental health staff will determine your follow-up

Mental Health
Care

Dental Care
I

Hospital
Emergency Care
or Inpatient
Hospitalization

Specialty Care

Women's
Healthcare

-

are completed periodically.___ ____
You can submit concerns about healthcare
services using a sick call slip and drop in
designated box or you can submit an institutional
grievance form
You can request to review their medical records
while still in the facility by submitting a sick call
slip
You may be respons ible for a fee when you
request clinic visits that are not emergencies or
not for chronic healthca re issues. This fee is
determine<!._by the institution ~ t Centurion.
Services will be provided when vision needs are
identified by healthcare staff

needs based on evaluation and ongoing clinic
appointments. You will be scheduled by mental
d
health staff as indicate
------ne follow-up based on
determi
will
staff
Dental
lly indicated dental
medica
and
tion
examina
services. Dental staff will schedule your
ment
-- -- appoint
On-site medical provider will order evaluation if
your complaint warrants further examination in a
hospital emergency room or community hospital
setting

__
and taking ca!: of yours~
Expressing concern s about healthcare
services allows healthcare staff to discuss
and follow-up on concerns in a timely
manner
- - -- - - - Questions about your care are important
to review and discuss with healthcare staff

-------

Accessing routine sick ca ll services
should be based on identified need. All
patients will be seen by healthcare no
matter their ability to pay_ _ _ __

Vision examinations are performed by an
optometrist and eye glasses are provided
when indicated
Allows diagnosis, treatment and individual
or group therapy appropriate for your
mental health diagnosis
Allows evaluation and care for acute and
medica lly indicated dental care. Allows
for learning about the benefits of good oral
hygiene practices
-- - - Access to off-site services for care when
your healthcare needs require services
not provided within the institution

The doctor, dentist or psychiatrist will order
evaluation by a specialty provider such as a
cardiolog ist, orthopedist or oral surgeon to assist
in treating complicated treatment issues. Care
may include evaluation or diagnostic testing

Evaluation by a specialist assists our
medical providers, dentists and
psychiatrists in providin g care and
determining medically indicated treatment

Your healthcare needs related to being a woman
will be addressed at your Initial Health
Assessment, Routine Sick Call and Periodic
Health Assessments

Services will include pre-natal care,
mammograms, testing for sexually
transmitted disease , PAP smears . Other
specific women's healthcare issues will be
identified and treated as medically
indicated

-------~----~-------

Hearing Aids

'-----

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centurion .
Quality Improvement Multidisciplinary Team
The institution's Continuous Quality Improvement (CQI) team will
typically meet each
month. Participation in the meetings and audits is an expectation
for physicians , nurse
practitioners and physician assistants at the direction of the site
and/or statewide
Medical Director. Medical record audits are outlined in an annua
l CQI audit calendar.
Results of these audits are reported to a Statewide CQI comm
ittee and our client.
The CQI committee will identify corrective action to be initiated
based on the results of
the audits. Any corrective action items will be documented. If
no improvement has been
noted in an area identified on a Corrective Action Plan, additional
ideas for corrective
action such as staff training, more frequent monitoring or a chang
e in process will be
discussed and integrated into the plan with progress being monito
red by the committee.
Each institution will maintain a set of institutional healthcare statisti
cs to provide data
regarding on-site and off-site services provided by the individual
healthcare unit. These
statistics will be reviewed at each CQI meeting to discuss any
changes in activity . For
example, a review may reveal that the incidents of inmate medic
ation non-compliance
have increased.
Physicians, nurse practitioners and physician assistants also partici
pate and provide
integral input into the following CQI activities.
Review of Major Occurrences
The CQI program requires that a major occurrence report is initiate
d for any death,
serious suicide attempts requiring off-site or infirmary medical
care , and other significant
patient issues related to healthcare treatment (see Chapter 7,
and oSEL program).
Occurrence reports are also generated for medication errors, advers
e drug reactions,
errors in medical records, errors in medication count reconciliation
s and other healthcare
system gaps. Root cause analysis is one of the tools to effecti
vely identify causal factors
and develop plans of action to monitor and sustain improvement
activities.
Mortality Review Process
A multidisciplinary mortality review of the death of any person
in the custody of a jail or
prison Is an assessment of the clinical care provided and the circum
stances leading up
to a death. The purpose of a mortality review is to ider,lify any
areas of care or the
system's policies and procedures that can be improved.
Mortality reviews are conducted in compliance with the correctional
system 's policy and
correctional standards. The statewide Medical Director and other
medical providers
participate in each review. Mortality reviews are the responsibility
of the Mortality
Review Committee which will include membership of the statew
ide CQI Coordinator,
statewide Medical Director, the correctional system's Medical Directo
r or designee,
medical staff, mental health staff, and facility administration.
Staff are expected to cooperate fully with investigations in the
event of the death of a
person in custody. We have specific policies, procedures and clinica
l guidelines to
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support the mortality review process. Deaths that occur within the institution are
with
reviewed by institutional staff with the client's administrative authorities as the entity
final responsibility for each person incarcerated.
Pa rticipation in an administrative review and complete clinical mortality review is
will
generally required to be completed within 30 days of the death. Issues addressed
include but not be limited to the following :
•
•
•
•

Whether adequate investigations were made to arrive at the correct diagnosis
Whether treatment was available and appropriate
Whether communications between security, medical, mental health and other
stake holders were open and productive
Changes to policies, procedure or guidelines which might be beneficial in light of
the events

it is
Autopsy and toxicology results may not be available within 30 days. In these cases,
autopsy
of
receipt
necessary to reconvene the Mortality Review Committee fo llowing
s
and toxicology reports from the Medical Examiner's Office or the correctional system'
healthcare leadership. At this time the Mortality Review Committee reviews prior
findings in light of the new information.
c issues
The intended outcome of the mortality review process is the identification of systemi
c
systemi
for
s
endation
that may have contributed to the individual's death. The recomm
.
improvements related to an inmate death are incorporated into the CQI Program

Review of Grievances Related to Healthcare
e
A formal grievance system has been developed by all correctional systems in respons
to
s
standard
and
1996
of
Act
to legal mandates including the Prison Litigation Reform
ed.
provide all incarcerated persons a method to have serious needs and issues address
the
has
she
or
Each person is advised at the time of admission to jail or prison that he
es were
right to challenge or grieve conditions of confinement. Formal grievance process
of
established as a mechanism for the incarcerated person to challenge conditions
the
with
ed
associat
res
procedu
The
.
systems
confinement without burdening the court
are
Healthc
agency.
nal
formal grievance process are well defined by the correctio
grievances are investigated and responded to in the manner described in the
correctional system's policies and procedures.
We use patient grievances as another method to identify systemic issues in service
d
delivery that are in need of improvement. Grievance statistics and trending are reviewe
nce
Complia
on
/Centuri
Centene
monthly by the CQI Coordinator and quarterly by the
with an
Committee. Our policy and procedure for responding to patient concerns begins
e
grievanc
formal
informal complaint resolution process and proceeds through the client's
the
resolution process. Attempts to resolve complaints informally are not used to delay
to
grievance process nor restrict the patient's right to file a formal grievance, but instead
ns,
physicia
Our
manner.
timely
a
in
level
lowest
manage the complain-Vconcerns at the
in
nurse practitioners and physician assistants often assist the administrative staff
es.
researching and responding to the informal and formal grievanc

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centurion,
Patient Safety Initiatives
We are dedicated to the reduction and minimization of risk and harm to our patients
in
custody . Our leadership fosters a safety-centered cu lture that encourages staff to
identify opportunities to reduce harm or potential harm to patients or the faci lity.
Patient
safety initiatives focus on strategies that improve clinical practice through policy,
monitoring and a cu lture that supports error reporting . We promote patient safety
through development of a non-punitive, professional and supportive work environm
ent.
Through our CQI processes, each adverse or near-miss clinica l event is analyze
d to
determine the cause. When the cause is due to a failure of policy or procedure,
the
healthcare team collaborates with the client to remedy the issue. When at least
part of
the cause is due to individual competency , loca l supervisory staff, in collaboration
with
regional leadership, will initiate a performance improvement plan aimed at enhanci
ng
clinical skills through training, supervision and on-going monitoring. Depending
on the
specifics of the issue, we may perform a skills competency review, counsel the staff
member, require clinical supervision, require specific training, and/or offer employe
e
assistance.

Peer Review and Supervisory Requirements
The Peer Review Committee works within the CQI Committee framework to ensure
review of the clinical performance of physicians and dentists. Nurse practitioners
and
physician assistants are included in the routine peer review process. The statewid
e
Medical Director will chair the committee and appoint members to this committee.
The
state CQI Committee will assist in the coordination and execution of the annual peer
review process through development of a calendar for annual reviews as well as
monitoring completion of peer reviews throughout the year.
Results from peer reviews are discussed between the reviewer and the staff membe
r
being reviewed. A letter of verification is submitted to the client confirming the
completion of a peer review and is placed in the credential file. This procedure and
process forms for notification of a completed peer review meet correctional standar
ds
and other applicab le ethical standards for the peer review process to ensure
confidentiality of the findings.
Completed peer review audit tools are maintained in a confidential file in the Regiona
l
Office. It is important that the detailed findings of the peer process remain protecte
d and
confidential to support the intent of the process to be a peer-to-peer review of
performance. You should request a copy of the Peer Review criteria for your disciplin
e.
We meet the supervision requirements for nurse practitioners and physician assistan
ts
to comply with the rules and regulations of the respective requirements. This includes
the development and maintenance of collaborative agreements and treatment protocol
s,
if applicable, as well as the professional review by the supervising physician of historica
l,
physical and therapeutic data contained in patient medical records. The frequen
cy and
extent of these reviews will be in compliance with rules and regulations of the State
,
Licensing Boards. Compliance with practice requirements remains the professional
responsibility of the physician and the nurse practitioner or physician assistant.
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centurion ,.
Admini strative Meeting s

You may be asked or required to attend meetings that occur between the
that
Warden/Superintendent/Chief or other Institutional Authority and those departments
s or
meeting
report to him/her. The Institutional Authority or designee may have morning
weekly meetings that you may be asked to attend on an as-needed basis. These
s of
meetings are an important way to address issues and network with other member
the security and program leadership staff.
Healthcare services chair a meeting with the Institutional Authority or designee and
to
members of security leadership typically once a month. You may hear them referred
as MAC meetings. The meeting is dedicated to identifying and solving issues and
good
sharing healthcare reports with the security and health leadership. Investment in
a
provide
to
team
re
healthca
outcomes and process is required of all members of the
provide
we
whom
to
quality health services program for our client and the patients
service.
Your Role in Quality Healthc are Summa ry

and
The information in this section is intended to provide you with general knowledge
notes
understanding of your role in quality healthcare. The following space is for your
,
and questions. Include information that you need to discuss with the Medical Director
trator.
Adminis
Services
the Director of Nursing and/or the Health
Topics you may want to discuss include:
•
•
•
•

Is there an outline or process to follow for mortality reviews?
Who performs my peer review? When are peer reviews performed? Is there a
standard format for peer reviews?
What meetings should I attend?
What types and how many grievances do healthcare services in this facility
receive each month?

Notes:

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centurion .
Chapter 15: Patients with Special Needs
Overview
In the correctional environment, patients with special needs are those who require
periodic medical, mental health, or multidisciplinary care or accommodations beyond
routine maintenance. Typically, persons with chronic diseases are managed in a
chronic
disease program or Chronic Care Clinics for medical conditions and by the mental
health
staff for chronic serious mental illnesses. These programs have been discussed
in
Chapters 10. This chapter will introduce other issues and conditions that require
persons to be followed routinely and aspects of the correctional environment that
influence or impact care decisions.
The medical provider's responsibilities may include determination and recommendation
for work restrictions and/or accommodations and housing needs. Incarcerated
individuals with disabilities are protected under most aspects of the Americans with
Disabilities Act. Responsibility for programming for this population rests with the
government agency and the its legal counsel to review statues and guide the system'
s
responses.
The Master Problem list should identify long-term special needs conditions and the
Plan
in the SOAP note or treatment plan should identify housing recommendations,
supportive or rehabilitative services ordered, and the date for next scheduled provider
appointment.
Compromised Mobility: Wheelchairs, Walkers, Canes
Mobility issues can be a significant problem in corrections for two reasons:
•
•

Many of the facilities are old and built before mobility disability requirements were
adequately recognized or addressed
Commonly used mobility devices represent security safety concerns. For
example, a cane can be used as a weapon in a fight.

The mobility accommodation status of any facility may be as obvious as ramps for
wheelchairs and as subtle as the walking distance to the dining hall or medication
line. It
is the responsibility of medical providers to inform security and classification
departments of the type of device needed and the anticipated duration of the need.
It is
important that the provider recognizes that reclassification to another institution may
be
required but also that the patient may have identified a secondary gain for the transfer
.
Providers should become familiar with the devices that are restricted and alternati
ves
that have been identified. It is also important to know the process for notifying the
facility's classification staff of a patient's short and long term needs.
Other conditions that may limit daily functioning include visual, hearing, and/or speech
impairments. If the impairments are significant, the patient may require
accommodations which will impact their classification and facility placement. The
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provider should become familiar with the classification process used by the correctional
system and the role of a provider in the medical classification and reclassification .
Developm enta I/Intellectual Disabilities

Medical providers can expect to provide interventions for patients with developmental/
intellectual disabilities.
•

Developmental disability is a severe, long term disability that can affect cognitive
ability, physical functioning, or both. The term "developmental disability"
encompasses intellectual disability but also includes physical disabilities. Some
developmental disabilities may be solely physical, such as blindness from birth.
Others involve both physical and intellectual disabilities stemming from genetic or
other causes, such as Down syndrome and fetal alcohol syndrome

•

Intellectual disability refers to a group of disorders characterized by a limited
mental capacity and difficulty with adaptive behaviors such as managing money,
schedules and routines, or social interactions. Intellectual disability originates
before the age of 18 and may result from physical causes, such as autism or
cerebral palsy, or from nonphysical causes, such as lack of stimulation and adult
responsiveness.

Persons with intellectual impairments in custody:
•
•
•
•
•
•
•

Are slower to adjust to routine
Have more difficulty in learning regulations resulting in the accumulation of rule
infractions
Free time is spent in meaningless activities not programs
Are often the brunt of practical jokes and sexual harassment
Desire to seek approval
Have been taught to be compliant
Typically, will "mask" disabilities

These and many other difficulties that are associated with these disabilities place these
persons at risk. The medical provider should collaborate with the mental health team
and corrections staff to identify appropriate housing, use proven communication
techniques, and support efforts to provide for the patient's physical safety.

Care for patients receiving hemodialysis or other treatment for advanced kidney failure is
directed by a contracted nephrologist and provided at a designated facility or location for
men and women. When hemodialysis is performed on-site, the equipment and staff are
often provided by a subcontracted dialysis company that has experience in corrections.
On-site medical providers are part of the multidisciplinary team and provide care for the
co-morbid conditions and episodic needs of such patients.

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centurion."
Overdose and Withdrawal
Jails and State facilities which take individuals directly from the street including those
newly arrested or parole violators are likely to see patients at risk for withdrawal from
drugs and alcohol, and also at risk for drug or rilcohol toxicity or overdose. Meanwhile,
any person in any correctional facility may have access to medications, drugs and
alcohol and may have acute symptoms of overdose and alcohol intoxication.
Overdose should be suspected in any person with an onset of confusion and/or altered
mental status that may range from sleepiness to decreased alertness to coma. Often
cellmates and correctional staff may offer some history or have found evidence of drugs
or alcohol in the cell.
Medical providers in correctional settings should be familiar with the types and
occurrences of overdose and withdrawal among persons under their care. The signs of
opiate overdose (respiratory depression , pinpoint pupils, reduced alertness) should be
quickly recognized. Familiarity with signs, symptoms and treatment protocols is
recommended. The medical provider should also be aware of the capabilities of the
nursing and correctional staff to provide required monitoring and treatment.
Hunger Strikes
There are a variety of reasons for persons in custody to engage in hunger strikes:
•
•
•
•

Protests for some real or imagined right or cause
Manipulation of the system to receive special items
Bring attention to self
Lingering, but serious, suicide attempt

The healthcare team and the correctional agency needs to be prepared to deal with
persons embarking on hunger strike. It has been recommended that hunger strikes
lasting more than two days are supervised by an interdisciplinary team of correctional
and non-corre ctional personnel including clergy, mental health and medical staff and that
the patient be housed in an area that facilitates medical monitoring.
The medical provider's role in a patient's hunger strike is to be advocate for the patient
and meet his or her needs. This includes supervision, monitoring and intervening for
worsening status. ThP. healthcare team should be familiar with the policies and
procedures and guidelines of the agency and Centurion .
At some point, a hunger strike can lead to the necessity of making a decision about
forced-feeding versus the patient's right to refuse medical ahd/or nutritional
interventions. Ethical committees and legal authorities for the correctional system or the
applicable jurisdiction should be apprised when a prolonged , serious hunger-strike
occurs.

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Pregnancy
her incarceration.
It is not uncommon for a woman to be pregnant when she begins
challenging . The
Being pregnant while in custody can be stressful and emotionally
provided in the
as
baby
unborn
and
patient is to receive the level of care for herself
by obstetrical
onsite
ed
commun ity. Sometimes the pre- and post-natal care is provid
Delivery of
rician.
obstet
specialists, sometimes the patient is transported off-site to the
ing or
shackl
t
agains
the child is done in the hospital. Most agencies have prohibitions
A pregnant woman
restraints of pregnant women during transportation or childbirth.
pregnancy.
should not be isolated in a single cell during the later stages of
risk" secondary to
Most pregnancies of women in custody are identified as "high
d with high risk
commonly limited or no prenatal care prior to incarceration couple
care and delivery are
lifestyles including use of drugs or alcohol. Therefore, prenatal
s to dietary, exercise and
directed by a qualified obstetrician. The patient receives acces
s, care of the
education programs during pregnancy. In most correctional system
ng care of
on-goi
and
newborn is not the responsibility of the correctional system
or the newborn
unity
comm
newborn becomes the responsibility of family members in the
to
t returns the institution
becomes a ward of the state at the time of delivery. The patien
by on-site healthcare
after delivery and postpartum care and counseling are provided
who are incarcerated.
staff. Post-partum depression can be more common in women
might need to continue
ing
feed
breast
Women entering a jail or prison who have been
s will store the milk and
facilitie
breast pumping and should be provided a pump. Some
be dumped.
allow family members to pick it up, while others require that it
Special Needs Summary
general knowledge and
The information in this section is intended to provide you with
al attention . The
understanding of the "special needs " of patients who require medic
ation that you need to
follow ing space is for your notes and questions. Include inform
the Health Services
discuss with the Medical Director, the Director of Nursing and/or
Administrator.
Topics you may want to discuss include:
•
•
•
•

facility?
What is the prevalence of persons with "special needs" at the
s and
What is a provider's responsibility for classification determination
communications with security?
Is housing available for patients with "special needs"?
al needs" or is the
Are there templates for documenting treatment plans for "speci
plan documented in the Plan section of a SOAP note?

NOTES:

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centurion .
Chapter 16: "Wants" vs. Medical Needs
Overview

The lives of persons in custody are governed and controlled by
rules, regulations and
expected conformity to these rules and regulations. Most correc
tional facilities have
rules that define clothing and shoes that can be worn by person
s in custody; when and
where they will eat and sleep; what personal belongings they may
possess; and other
restrictions too numerous to detail.
The system's rules and regulations are given to the individual
in custody at admission
into the facility usually in the format of an inmate handbook. It
is beneficial to become
familiar with the inmate handbook because healthcare staff espec
ially medical providers
have the authority or expectation to order many special items and
to issue "lay-ins" to
avoid certain activities or assignments.
While persons may have a medical necessity for special treatm
ent or accommodation,
the medical provider should be alert to the person who wants specia
l "perks" because:
•
•
•

Special "perks" set the person apart from his/her peers and/or
offer special status
Getting special "perks" from medical can be a "game"
Special "perks" can be used to barter for other contraband

The following sections represent a few of the dilemmas that the
correctional healthcare
provider may encounter. The accompanying articles highlight
some common issues
related to "wants." The most effective ways to address these issues
include:
•
•
•
•
•
•

Know the custodial rules at your facility
Know what items are available in the commissary for persons
in custody
Talk with experienced staff to learn the most common requested
"wants"
Learn the fair, firm and consistent response to "wants"
Realize that once you deviate from the fair, firm and consistent
response, other
persons will submit the same requests
Understand that new healthcare providers will be tested

Getting advice and help from seasoned staff for how to handle
requests for "wants" can
help new providers avoid becoming perceived by the inmate popula
tion as an easy
"mark."
Lay-Ins or Work Excuses

Persons who cannot work or participate in programs must have
written excuses from a
medical provider or nurse to "lay-in " or stay in their cells. Person
s have many secondary
gains from missing work assignments, will think of a million excus
es and will cajole the
healthcare staff into granting lay-ins . This is particularly true for
those assigned to
tedious institutional jobs. Programming such as working toward
achievement of a GED
and substance abuse treatment programs are considered a type
of "work" and persons
may request a lay-in from these activities.

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Correctional officers are particularly helpful in informing medical staff when a person in
custody receives a lay-in from work for medical reasons but then witnessed playing
basketball or other activity. Security staff responsible for the activities of a person in
custody will appreciate very judicious use of lay-ins.

Bottom Bunks and Other Extras
One visit to a typical housing areas will help the medical provider understand why
bottom bunks, extra mattresses and extra pillows are desired commodities. These items
have been the cause of arguments, written complaints and even lawsuits. In many
institutions issues related to mattresses and pillows are addressed by Unit Managers or
other similar correctional staff. It is important to identify the staff responsible for these
issues in your facility.
Bottom bunk assignment is first based upon medical needs and requires notification to
the institution's classification or security supervisors. There are a finite number of
bottom bunks and an almost endless request from persons who want them. Your facility
or system may have established medical requirements for bottom bunks. This list helps
medical providers to be fair, firm and consistent; is helpful in responding to grievances
on this issue; and will eventually filter through the inmate "grapevine" and impact the
number of requests.

Shoes
Shoes are issued as part of the correctional uniform. Shoes are also one of the few
items that can differentiate one person from another when allowed to have "special"
issues. Persons in custody may try many ploys to convince medical providers that their
feet are not able to tolerate the system-issued shoes.
Shoe requests handled in a prescriptive manner will reduce or halt these requests.
Decisions based upon documented medical conditions including diabetes, peripheral
vascular problems, or gross foot deformities that cannot be handled by the medical
provider will support consistency among medical providers. However, it is important to
consider:
•
•
•

Podiatry referrals require transportation and often result in orthotic shoes
prescriptions that could be addressed in other ways
Corns and calluses can be handled on-site with pumice stones and occasional
trimming
Arch supports may be available for the patient to purchase from the commissary

The following information written by correctional physician Dr. Jeffrey Keller offers
practical advice on the correctional medical topic of "shoes" found at
www.jailmedicine.com. The information is offered not as an official endorsement but as
an insight into the intricacies of correctional healthcare.

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centurion ,
A Quick-and-Easy Solution to those Pesky "Own Shoes" Requests
Posted on March 6, 2012. www.iailmedicine.com

Everyone who works in corrections is familiar with inmates wanting medical authorization
to wear their own shoes. A typical case would go something like this:" I have chronic
back pain and walking on these hard concrete floors makes it worse. Will you authorize
me to wear my own shoes? You did last time I was in here and it really helped."
We need to keep in mind, however, that allowing an inmate to wear his own shoes gives
that inmate secondary gain . Shoes from home are more comfortable than the typical jail
sandals. Also, any inmate who is granted a special privilege, like wearing his own comfy
shoes, gains status among the other inmates. When we approve inappropria te requests
for "own shoes," we are bestowing prestige upon that inmate. And we are denying that
prestige to those who we refuse. The unfairness of this is not lost on inmates.
Finally," own shoes" are occasional ly used to smuggle contraband into the facility. I
remember one pair that had an ingenious hollow space carved out of the sole that was
not easy to find on a typical security examination. If you routinely grant requests for
"own shoes," you will inevitably get burned in this way
The second important point is that it is the responsibil ity of the security staff to provide
footwear to inmates; not the medical staff. The question we are being asked in these
encounters is this: Is there a medical need for this patient's own shoes? I argued in ''A
Quick and Easy Solution for Second Mattress Requests" that there is never a "medical
need" for a second mattress. That is not the case for footwear.
Orthotics
There are indeed cases when special footwear is medically indicated. In fact, medically
prescribed shoes have a medical name; they are called Orthotics. Examples of orthotics
are walking casts, splints like the CAM walker and special shoes with, say, a special
built-up heel for patients who have one short leg. The key here is that orthotics are 1)
prescribed by a physician and 2) fitted in a medical clinic. They are not purchased "offthe-rack" in a store. This includes arch supports that patients can purchase in a store,
like Dr. Scholl's.
So the first part of this Quick and Easy Solution is this: orthotics, as described above,
may be approved on medical grounds for use within the facility. Orthotics must fulfill
both criteria: they must be both prescribed by a physician and fitted to the specific
patient in a medical clinic. It is not enough to just get your outside doctor to write you a
prescription for your Air Jordan's (as I have seen many times). Orthotics still must also
be cleared by the security staff, however! Orthotics can be used to hide contraband, too.
Orthotics sometimes have metal that could be made into a shank. One inmate with a
short leg had his special built up heel on a pair of pointed-toe cowboy boots that could
be dangerous in a fight and so were not permitted on security grounds.
The second part of this Quick and Easy solution is this: the inmate's own store-boug ht
shoes are never medically indicated. This takes the whole issue of store-boug ht "own
shoes" out of the medical arena entirely. There is no reason for an inmate to go to the
medical clinic to ask - it is not a medical issue. Such requests can be routed to security
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there is never a
to handle. If they want to give "own shoes" to an inmate, they may, but
wear your own
reason for a deputy to say to an inmate, "The only way you will get to
In some jails,
shoes is if medica l approves it," In this system, medica l never does.
d.
involve
seldom
is
l
Medica
,
securit y has taken over the shoes issue entirely
ion.
However, there are a few special cases that require a special discuss
specia l
1. What about diabetics and diabetic foot disease? Don't diabetics need
manag e their
protective footwear? In my mind, this is debatable. Diabetics need to
Jail
wean'ng
this
do
can
they
diabete s proper ly and take care of their feet. I think
to satisfy
found
have
I
solution
footwear. However, others disagree with me. The best
l can
medica
both opinion s is for the jail to purchase slip on or Velcro sneakers, which
them orthotics by
then prescribe to appropriate diabetic patients. Note that this makes
c cJ;nic, at which
definition: they are prescri bed by medica l and hopefu lly fitted in diabeN
sneakers also
jail
bed
prescri
s
patient
these
time foot care is reviewed, as well. Giving
being used to
as
such
ed,
discuss
eliminates the other hazards of "own shoes" we have
smuggle contrab and and enhance status.
non-diabetic
2. What about patient s with neurop athy of the feet? The problem with
it is what the
neurop athy of the feet is that it is hard to objectively evaluate. Often,
not want to get
do
also
I
but
arily,
necess
patient says it is. I don ·t disbelieve my paUent
feet hurt
their
saying
by
Just
into the snuation where inmates can get their own shoes
A better
feet.
tingly
with
s
and tingle. Once they figure that out, I will see a lot of patient
gist,
neurolo
a
solution is to take patients with docum ented neurop athy (they have seen
the
like
rs just
say and have had nerve conduction studies) and fit them with jail sneake
ones we discuss ed for diabetics.
Shaquille O'Neal"
3. What if the Jail does not have the right size shoes? I call this "The
) was booked
pounds
dilemma. What would you do if Shaquille O'Neal (7' 1" tall, 325
shoes. Your
23
into your jail? One immediate problem with Shaq is that he wears size
l issue. This is
facility probab ly does not stock that size. fn my mind, this is not a medica
a clothing issue. If the facility does not have footwe ar that this man can wear, one
is not a medical
solution would be to allow him to wear his own shoes. However, this
issue. There is no need for a medica l memo.
footwear? There
4. Are there any other patients who might qualify for more comfortable
by more
is a long list of other subjective complaints that could potentially be eased
solution is to
comfortable footwear. Rather than going into them one by one, a better
any inmate
place the jail sneake rs we have already discuss ed on commissary, where
of jail, if
Outside
clinic.
l
medica
the
can purcha se them without having to go through
go to a
You
clinic.
l
medica
a
your shoes aren't comfortable enough, you don't go to
s the
inmate
allow
should
shoe store and buy better, more comfortable shoes. I think we
OTC
the
same right by making jail sneakers available on commi ssary as part of
sary, as well.
commi ssary program. Consid er making arch supports available on commis
third trimester of
Some Jails give these jail sneakers to the elderly and to women in their
pregnancy.
facility are:
Summary: The key points in creating an "Own Shoes" policy for your
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cen turion.
1. The only medic-ally necessary footwear is orthotics, which are prescri
bed by a
physician and fitted in a medical clinic.
2. There are no medical indications for "own shoes" from home.
3. Diabetics and neuropathic patients may be fitted with facility-purcha
sed sneakers as
part of their medical management plan.
4. It is a good idea to offer sneakers and arch supports in the commissary
so inmates
can purchase them without having to go through medical.

Dietary Issues
Many prison and jail facilities have adopted heart healthy options that
have replaced or
at least mitigated the problems with institutional food historically filled
with sugars,
starches and fats . Review the Dietary Manual and understand how to
prescribe
medically indicated special diets. Long term special diet needs should
be addressed as
part of chronic care/disease management. Other departments may have
oversight for
dietary issues. Chaplain Services typically have the responsibility to determ
ine religious
diet needs.
Medical providers are gatekeepers for liquid dietary supplements, double
portions at
meal times and/or bedtime snacks . These items have value in the jail
or prison "black
market" and increase the work for security, dietary and medical staff.
Before ordering,
consider these issues and docum ent medical necessity based upon both
subjective and
objective information which may be as basic as confirming weight loss
or "low blood
sugar." Many facilities have criteria related to body mass index and availab
ility of
additional food. Liquid supplements are generally restricted to person
s with issues
related to mastication such as those recovering from mandible fracture
reduction.
Food allergies present issues in the correctional environment includin
g the overdiagnosis which can result in significant food service operational challen
ges. Medical
providers should make distinctions between food allergy and food intolera
nce and
provide education on avoidance. Another article published by Dr. Jeffrey
Keller in June
2012 (www.jailmedicine.com) offers practical advice by in addressing
these differences
follows. The information is offered not as an official endorsement but
as an insight into
the intricacies of correctional healthcare.

"/ Can't Eat That/" Introduction to Food Allergies in Corrections
In my previous incarnation as an emergency physician (before I discove
red ''The Way" of
correctional medicine), I saw a lot of cases of acute allergic reactions.
It is a very
common emerge ncy complaint; I have probab ly seen hundreds in my
career. But when I
began my jail medicine career, I was still unprepared for the sheer volume
of food
allergies claimed by inmates. Who knew so many inmates had so many
food allergies?
Of course most of them don 't. Most just don't want to eat something on
the jail menu.
Inmates believe that if they claim an allergy to a food they dislike, you
cannot serve it to
them. They will claim allergies to tomatoes, onions , mayo, etc., when
really, they just
don 't like these foods. Tuna casserole doesn't seem very popular, for
some reason .
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However, some inmates truly are allergic to some foods and we can potentially harm
them by ignoring their complaint. How do we correctional medical staff sort out the truly
allergic from the "I don't like it" crowd? It is an important question because we certainly
don't want anyone in our care to have a sudden anaphylactic reaction!
To answer this question, we need to understand the mechanism of food allergies, the
overall incidence of food allergies as well as the incident of death, how to accurately
diagnose a true food allergy and what steps to take once we find one. All of this is
important to make accurate risk assessments.
The incidence and causes of food allergies vary markedly with age. For the most part,
food allergies are a problem of childhood. In children, the most common food allergies
are milk, eggs, wheat and nuts. However, most of these allergies abate with time. So a
child who is allergic to eggs most likely will be able to eat eggs as an adult. One
important exception to this rule is peanuts and tree nuts (like almonds, cashews, etc.).
Those allergies tend to persist into adulthood. The most common adult food allergies
are peanuts, tree nuts, shellfish and fish.
True food allergies come in two types. The first are called lgE Mediated Allergic
reactions because the lgE antibody is essential to the reaction. The second type of
allergic reactions does not involve lgE and so, of course, are called non-lgE mediated
food allergies. The best example of this is celiac disease in which patients are allergic to
gluten found in grains. Non-lgE mediated allergic reactions are typically indolent and
chronic and may not be discovered for several years.
lgE is an antibody that is created by the body to react to a specific antigen substance.
This substance can be ragweed pollen, of course, but it also can be food proteins. Later
on, if the person eats the same food to which lgE was created, the protein locks onto the
lgE which causes the release a bunch of inflammatory chemicals, such as histamine,
cytokinens, prostaglandins and leukotrienes.
The most common symptom caused by these inflammatory chemicals is hives, the itchy
splotchy rash we have all seen. The second most common symptom is angioedema,
which is swelling of the face. Angioedema most commonly occurs around the eyes but
also rarely can cause the tongue to swell. Third and less frequently, the allergic reaction
can cause bronchospasm in the lungs, so the patient wheezes as if having an asthma
attack. Finally, the patient can suffer anaphylaxis, which consists of acute vasodilation
leading to hypotension, shock and possibly death.
All of these allergic symptoms occur within minutes of eating. Allergic hives occurring
several hours after eating are probably NOT due to the food.
Of these four allergic symptoms, by far the most common are hives and angioedema.
However, most of the time hives and andioedema are nuisances rather than life
threatening emergencies. On the other hand, anaphylaxis is an acute medical
emergency. Anaphylaxis is the allergic reaction we should fear the most and work to
prevent.
The CDC estimates that approximately 100 deaths from food allergies occur in the US
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per year. Almost all of these deaths occurred in teenagers or young adults who knew
that they were allergic to the food they ate. By far, the most common culprit foods are
peanuts and tree nuts (85%) with shell fish coming in second. In contrast, 400 deaths
due to allergic reactions to penicillin occur every year, most of those occur in people who
have no idea that they are allergic.

Now let's summarize some of the more important points presented so far.
1. Allergies tend to occur in childhood and abate with time.
2. If you were allergic to something as a child, most likely, you will not be allergic as
an adult.
3. The important exceptions to this are peanuts, tree nuts, and shellfish. These
allergies commonly do persist into adulthood.
4. The older you are, the less likely you are to have a severe anaphylactic reaction.
5. The food allergens most likely to produce anaphylaxis are peanuts, tree nuts and
shell fish.
6. Most deaths due to an acute allergic reaction to food have had a previous severe
allergic reaction.
You can use these principles to do a risk assessment for individual patients. Patients at
higher risk of an anaphylactic allergic reaction are those who are younger (late teens,
early 20s) who state an allergy to peanuts, tree nuts or shellfish, and who have had a
previous documented allergic reaction. Patients with a lower risk are older patients who
state an allergy to a low risk food (say onions or peppers) and cannot document a
previous severe allergic reaction. Someone who has had a severe allergic reaction to a
food in the past should be able to tell you about an ER visit, allergy testing, EpiPen
prescriptions and how they avoid the food in restaurants and while shopping.
However, there are other tests that also can help you sort out the confusing cases. The
first is called a CapRAST test. This is a blood test that measures the levels of lgE to a
certain specific allergen, say peanuts. We then draw blood for a CapRAST for peanuts.
A positive result is peanut specific lgE of greater than 2.0 Ku/L. If the test comes back
at, say, 0.35 Ku/L, then the patient is not allergic. The test is quite sensitive but not
specific. That means that you can believe a negative result, but patients with positive
results might still NOT be allergic. The main problem with a CapRast test is that it is
expensive-a round $45. 00! However, that is probably less expensive than the cost in
time and energy putting out a special diet.
A second test is the skin prick test. In this test, the patient's skin is pricked with a small
instrument and a drop of allergen extract is placed on the site. If a patient is truly
allergic, she will form an itchy wheal at the site within 5-15 minutes. The advantage of
this test is that it is cheap and easy to do and the results are immediate. The
disadvantage is that you have to order and store the extracts and be trained in the
procedure, usually by an allergist.
"Food Challenge" tests probably should not be done in a correctional setting. This is
where you simply feed the food to the patient and wait to see what happens. If this is
done in a double blinded fashion, it is the most accurate test of all. Sometimes, patients
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ing it. For example, a patie nt migh t
will have done their own food challe nge without know
and mayonnaise, both of which are
say he is allerg ic to eggs but admi ts to eatin g pasta
made with eggs . He is likely not truly allergic.
likely to cause severe allergic
Of cours e the easie st way to deal with the foods most
not serve shellfish to inmates (if your
react ions is not to serve them at all. Most jails do
If your facility uses tree nuts in
jail does, write me; I would like to know abou t it!)
. Then you won't have to wor,y abou t
cooki es, cons ider elimin ating them from the menu
most priso ns and jails that has the
it. That just leave s pean uts as the food serve d in
great est poten tial to cause allergic reactions.
ive CapR AST test to peanuts, what
Once you have disco vered that a patie nt has a posit
y order a pean ut free diet. Since
shou ld you do then? It may not be enou gh to simpl
l amou nt of allergen contact, you
allerg ic reactions can be trigge red by even a smal
shou ld cons ider these other factors:
commissa,y. Shou ld this
You proba bly have pean ut-co ntain ing items on your
inmate have a comm issa, y restriction?
n, prepa ring pean ut butte r
2. Should this inmate be allow ed to work in the kitche
sand wiche s?
tes who may be eating pean ut
3. Shou ld this inma te be hous ed with other inma
butte r sand wiche s right next to him?
4. What abou t an Epi-p en? Where shou ld it be kept?
1.

confi dent the next time an inmate
Hope fully, this information will make you a little more
patie nt told me once). You can also
says she is allergic to, say, "all vege table s" (as one
testing to write a Polic y and
use these princ iples of risk assessment, histo ,y and
ies. If you need help, emai l me and I
Proce dure for the clinical asse ssme nt of food allerg
will send you mine.
ce, 7th ed.
Adkinson: Middleton's Allergy: Principles and Practi
ntialevidenceplus.com/conlentleee/4
.esse
Essential Evidence: Food Allergy. https:l/www
RGY, ASTHMA & IMMUNOLOGY,
Food allergy: a practice parameter. ANNALS OF ALLE
VOLUME 96, MARCH. 2006.
, Prim Care Clin Office Pract 35 (2008)
4. Food Allergy: Diagnosis and Management, Atkins
119-140.

1.
2.
3.

"Wants" vs. Medical Needs Summary
you with general knowledge and
The information in this section is intended to provide
cerated and how to effectively
understanding of the common "wants" of persons incar
questions. Include information that
handle. The following space is for your notes and
Director of Nursing and/or the Health
you need to discuss with the Medical Director, the
Services Administrator.
Topics you may want to discuss include:
nts that I should be aware of?
• Are there common themes to requests from patie
How are these addressed by healthcare staff?
handled, are there any special
• Where is the Diet Manual, how are special diets
at this facility?
dietary issues such as patient requests for Ensure
issues at this facility?
• Is there a significant problem with bottom bunk
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NOTES:

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Chapter 17: Telehealth
Overview

~
AMERICAN

TELEMEDICINE
Telehealth is the delivery of health-related services through
ASSOCIA TIO N
telecommunication technologies. Telehealth is an expansion of
telemedicine and includes mental health services as well as healthcare staff videoconferencing and training opportunities. Telehealth enables treatment staff to provide
care at a distance. It eliminates travel and access-to-care barriers while supporting
transmission of medical, imaging, bio-signals, and other healthcare information across
hundreds of miles. Rapid advances in technology have made telehealth highly reliable,
with visual and auditory fidelity that is essentially indistinguishable from "in person"
service delivery. Sophisticated equipment now goes well beyond cameras, microphones
and cables. Telehealth routinely includes advanced diagnostic and service delivery tools
for specialty care and HIPAA-compliant encryption and transmission of personal health
information, including the transmission and delivery of telehealth services themselves.
The use of telehealth has expanded rapidly as more agencies have learned that the
services being provided with the use of technology are equivalent in quality and outcome
to those provided in person. With the use of technology, people in remote communities
are now receiving improved access to specialty providers. They no longer have to travel
long distances in order to receive care. Correctional facilities are often found in very
remote parts of a state. In many instances, these are ideal locations for the provision of
telehealth services. The ability to use technology to provide medical and mental health
services assists in improving patient access to care; enhances public safety by reducing
off-site travel; and helps manage costs related to the provision of healthcare, including
the diversion of correctional officers to escort patients to off-site healthcare
appointments.
Our telehealth program is not a "one size fits all" product. We design and tailor each
telehealth program individually to meet the technological and operational needs of the
correctional system. Our approach involves ongoing collaboration with our client and a
thorough analysis of the requirements for each program. We assess each stakeholder's
requirements and evaluate any technology already in place to ensure required services
can be provided as needed in a manner that is consistent with the community standard
of care, national telehealth guidelines, and state and local regulations and standards.
We also ensure that telehealth services are provided in a confidential, HIPAA-compliant
manner. To achieve these goals, each telehealth program must be designed to meet
the unique needs of the correctional system .
Implementation of a telehealth program is not a one step process of installing equipment
and communication lines. Although the technology is essential and an important part of
this process, established protocols, training and ongoing monitoring ensures the success
of the programs. Using information acquired from established American Telemedicine
Association guidelines for the provision of healthcare as a reference, we work directly
with our clients and individual programs to develop individualized policies and protocols
identifying the clinical applications, guidelines for staff credentialing, HIPAA compliance,
training requirements for staff on the use of telehealth services, and ongoing quality
improvement studies.
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We have used telehealth to facilitate clinical case conferences, physician mentorin
g and
re-entry initiatives. Participation in a weekly video conference among all healthca
re
partners in one contract assisted in improving continuity and quality of care for the
patients. Medical Directors have used the telehealth technology to provide face-toface
supervision and mentoring without the need to trnvel long distances. We have also
designed a system to allow the Medical Director to consult with the nurse practitio
ner at
a remote site for more immediate delivery of services for patients requiring this higher
level of consultation without incurring the costs associated with travel to the remote
site.
Telemedicine
As a medical provider practicing in a correctional environment, you will encounter
growing use of telemedicine. Our medical providers can be ensured that protocol
s have
been established to ensure compliance with national telehealth standards, state
professional boards, and local regulations and policies. Training and ongoing support
in
telemedicine are provided for all staff.
With the appropriate peripherals on the video-conferencing equipment, medical
care at a
distance is possible. We invest in technology to ensure that our networks for
telemedicine facilitate quality transmission of video, audio and other health-related
information. Currently, telemedicine is primarily used to provide specialty consulta
tions
for patients. The types of specialty consultations are limited only by the availabi
lity of
specialists with telemedicine capabilities, and telehealth specialists continue to grow.
The process of selecting and receiving approval for a specialist consultation uses
the
same utilization management criteria that are required for in person visits. Since
the
provision of telemedicine services at facilities with a telemedicine unit is coordina
ted
centrally, specialist appointments can be scheduled with the goal of decreasing
inmate
waiting times and maximizing the efficiency of specialty provider clinics. Our program
s
rely on the use of telemedicine for specialty consults as much as is clinically feasible
to
improve access to specialists and reduce off-site transportation. The need to transpor
t
patients to off-site locations for services can be disruptive to the patient, disruptiv
e to the
specialty providers and disruptive to security staff.
Based on the approval of our clients, we implement telemedicine capabilities in
as many
facilities as possible to permit current medical providers to provide coverage at other
facilities for medical provider absences related to vacations and illness. This process
facilitates continuity of care and ongoing access to care delivered I.Jy µroviders skilled
In
correctional healthcare.
Telemental Health Experience
While our telemedicine services are still growing, we already have extensive experien
ce
with the delivery of telemental health. Telemental health includes telepsychiatry
as well
as other mental health services delivered at a distance. We provide thousands
of
individual telepsychiatry contacts annually. Like our telemedicine services, our
telemental health services are expanding rapidly.
Across the United States, use of telepsychiatry has significantly expanded in correctio
nal
environments. Telepsychiatry has enabled contractors and correctional systems
to
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improve the provision of psychiatric services in very remote facilities. The benefits of
telepsychiatry include:
•
•
•
•

Improved access to care
Flexibility in psychiatric coverage
Improved ability to recruit psychiatric staff
Efficiency in care

Telepsychiatry provides an advantage in recruiting and flexibility in staffing remote
facilities. Telepsychiatry can be used as the primary source of psychiatric coverage or to
augment coverage at sites with the video-conferencing technology.
Telemental health has been used to provide face-to-face staff supervision and interfacility treatment planning conferences. Additionally, the use of telemental health in the
re-entry process is gaining use allowing us to facilitate interaction between the soon-tobe released inmate with serious mental illness and the community mental health center
from which they will receive ongoing treatment prior to leaving prison. Research
supports that this visual contact will improve compliance with mental health treatment
upon re-entry, which will ultimately reduce costs for all. This initiative can be readily
adapted for medical services when patients have complex chronic healthcare conditions
and/or acute medical needs and require close monitoring and collaboration upon release
to the community.
In the span of a few short years, we have come a long way in the delivery of telemental
health services. The growth of telemental health services was initially driven by
demand, as there was simply no alternative to deliver services at remote sites using
traditional in-person clinics. However, as psychiatric staff grew more comfortable with
the use of technology for the provision of psychiatric services and saw the capability
allowed for comparable levels of service; the perception changed and has allowed for
continued growth.
We have completed two large scale patient satisfaction surveys to explore whether
patients are as satisfied with services provided through telepsychiatry as with those
services provided on-site. Results from both studies revealed that patients are as
satisfied with telepsychiatry services as they are with psychiatric services received in
person. This is an important finding, because we know that patient satisfaction
correlates with compliance with treatment. Ongoing studies concerning satisfaction are
pursued in all programs providing services through telehealth .
We have also conducted a psychiatric provider satisfaction survey which produced
results supporting the continued use of telepsychiatry. Our providers overwhelmingly
supported the use of telepsychiatry and have appreciated the flexibility this additional
means of providing services has provided as well as the ability to respond more
immediately to patient treatment needs.

Telehealth Summary
The information in this section is intended to provide general knowledge and
understanding of the growing use of telehealth within correctional settings. The following
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space is for your notes and questions. Include information that you need to discuss with
the Medical Director, the Director of Nursing and/or the Health Services Administrator.
Topics you may want to discuss include:
•
•
•
•
•

Is telehealth used at this facility?
If telehealth is used, what services are provided through telehealth?
Are case conferences/training provided through telehealth?
Where are telehealth services provided?
What are the policies for providing telehealth services?

NOTES:

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centurion . .
Chapter 18: Mental Health and Physical Health Collaboration

Overview
The information in this chapter is presented to heighten awareness to the significance of
the impact of patients with serious mental illness in the correctional environment and to
reinforce the need for strong integration and collaboration between medical and mental
health professionals in addressing the needs of this population.
A 2006 Special Report of the Bureau of Justice estimated that 705,600 mentally ill adults
were incarcerated in State prisons, 78,800 in Federal prisons and 479,900 in local jails.
These numbers have continued to rise as mental health cc:1re in our communities has
continued to lag behind the need for care.
In 2010, it was estimated that 40% of all individuals with serious mental illness had been
incarcerated, and about 16% of all inmates suffer from serious mental illness. In county
jails, research indicates that about 31% of female detainees and 14.5% of male detainees
suffer from serious mental illness. In prisons, roughly 20% male inmates and 40% to 50%
of female inmates are receiving psychotropic medications at any given time.

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Psychotropic medications used to treat schizophrenia and bipolar disorders can have side
effects that can exacerbate already high levels of medical comorbidities and
cardiovascular risk factors. This coupled with the accelerated aging rates of incarcerated
individuals and the incidence of age-related dementia contributes to the "perfect storm"
that correctional healthcare professionals face.
In our experience, the foundation of any effective clinical relationship is open
communication and a culture that supports and encourages exchange of information. It
is important for medical providers to collaborate with psychiatric staff and other members
of the mental health team when:
•
•
•
•

Facing unexplained changes in patients with chronic medical and serious mental
health diagnoses
Evaluating or "clearing" patients for admission to acute mental health units with
significant chronic co-morbidities
Caring for patients who require a team approach including "hunger strikes" and
end-of-life care
Ensuring continuity, safety and efficacy of medications that may have serious
side-effects but must be balanced against benefits

One of the most effective means to support collaboration is regularly-scheduled case
conferences devoted to the review of seriously ill dual-diagnosed patients and other
patients identified who may have special needs.
The following articles are intended to encourage exchange of information and ideas and
do not necessarily represent a comprehensive review of this topic and should not take
the place of clinical judgment.
An article written by members of our Clinical Operations team, Dr. Sharen Barboza and
Dr. John Wilson, provides an overview of the importance of multidisciplinary
collaboration between medical and behavioral health staff and an introduction to the
concept of integrated care. The 2013 article, published in CorrDocs, Volume 17, Issue
5, is entitled Your patient is my patient: The need for integrated medical-mental health
care for inmates with serious mental illness.
From emergency intervention and acute care to chronic care and end-of-life services,
coordination and integration of medical and mental health care are essential. Within
correctional populations, coordinated and integrated preventive and chronic care
services are most needed for inmates with comorbid mental and medical illnesses.
Roughly 11 % of the inmate population suffers from both serious mental illness and
chronic medical disease, a figure that is likely to rise as the inmate population ages.
These inmates belong to a high-risk group with an associated life expectancy that is up
to 25 years shorter than that of individuals without serious mental illness.
Mental Illnesses Are Bad for Your Health
Individuals with serious mental illness have more medical illnesses, significantly shorter
life expectancies and higher standardized mortality ratios than the general population.
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Compared to individuals without serious mental illness, individuals with serious mental
illness have double to triple the risk of early death due to medical disease.
Suicide has received the most attention as a cause of premature death among those
for
with mental illness. However, chronic medical disease, not suicide, is responsible
death
re
prematu
60% of the excess mortality and 75%-87% of the years lost due to
10 to
among these individuals. On average, individuals with serious mental illness live
25 years less than those without serious mental illness. This mortality gap may be
than
widening. Similarly, individuals with personality disorders live 17 to 19 years less
those without these disorders.
our
Many individuals with serious mental illness are living and sometimes dying inside
jails
jails and prisons. Rates of serious mental illness are two to four times greater in
serious
of
ce
prevalen
overall
the
and
public,
general
and prisons than they are in the
% of
mental illness in jails and prisons is estimated to be 16%. Approximately 60%-70
n;
conditio
medical
chronic
a
individuals with serious mental illness also suffer from
idity
nearly half of these individuals suffer from two chronic medical conditions. Comorb
among
of serious mental illness and chronic medical conditions may be even higher
24
populations with significant substance use disorders.
Taken together, these figures suggest that 1 out of every 9 inmates suffers from both
serious mental illness and chronic medical illness. For inmates with serious mental
illness, comorbidity of medical and mental illness is the rule, not the exception.
in
Moreover, the inmate population is aging faster than the national population, resulting
increased need for both health and mental health services. With increasing age comes
.
the increasing likelihood of comorbidity and more severe, more complicated disease

Challenges to lhtegrated Services
from
Given the high rates of comorbid medical conditions and decreased life expectancy
and
medical
d
integrate
for
need
the
ns,
conditio
preventable and/or treatable medical
mental treatment is clear. Researchers and policy-makers who study the elevated
d
mortality rates among patients with serious mental illness consistently call for integrate
,
services
of
on
delivery o'f medical and mental health services. Instead of integrati
fragmentation of services is common.
is
Primary care providers in the community are often confronted with the need to diagnos
the
in
training
their
not,
than
often
and treat patients with serious mental illness. More
diagnosis and treatment of serious mental illness is limited. Additionally, many primary
ill
and general medical providers have limited experience working with seriously mentally
ial
patients . As such , providers may be limited in their ability to conduct a different
diagnosis which rules out psychiatric symptoms, provide adequate education in the
context of the mental illness and provide support for treatment adherence. General
medical providers in the community have reported that the primary barriers to seeking
psychiatric services for their patients include poor referral resources and poor followthrough on referrals by patients.

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cent
Theoretically, service delivery in correctional facilities should avoid many of the
challenges to integrated and effective treatment found in the community. Correcti
onal
systems possess unique advantages for integrated service delivery . Treatment
staff are
able to screen the entire population and provide primary medical services and
psychiatric services to all patients who require them. Medical infirmaries and inpatien
t
mental health units are often co-located; chronic care clinics for medical and mental
health services often occur in the same offices. Referrals to psychiatric or other
mental
health providers are relatively easy and there are no issues related to insurance
coverage to confront. Referred patients are often scheduled automatically through
a
centralized system and are seen within stringent timelines set by NCCHC standard
s. At
least in theory, treatment non-adh erence and substance abuse can be quickly identifie
d,
thereby limiting two of the most challenging obstacles to effective chronic care in
the
community.
Despite these potential advantages, medical and mental health services in most
correctional systems are far from integrated. Figure 1 illustrates the typical
organizational structures for medical and mental health services in a prison or jail.
Each
service is organize d vertically and separately. Horizontal integration, in terms of
routine
communication and collaboration between medical and mental health providers,
is
generally limited or absent below the level of senior managers and administrators.

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centurio
ional Institutions
Figure 1: Traditional Vertical Organization of Healthcare Services in Correct

Facility Administrators
(Warden or Superintendent)

I Health Services Administrator
[

I
-

Medical Director

Primary Care
Physicians

I

I

I

Mid-Level
Medical Providers

I
RNs&
LPNs

RNs&
LPNs

RNs&
LPNs

I

Mental Health
RNs&L PNs

I

I
CNAs

CNAs

I

Psychologist/
Mental
Health
·~ ·

Psychiatrists

I

Psychiatric
-·
I

l

I
RNs&
LPNs

I

I

-

Mental Health
Professionals

I

Mid-Level
Psychiatric
Providers

Mental Health
RNs&L PNs

l
Mental
Health

Recreational
and Activity
Therapists

Mental
Health

Specialty Care
Providers

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centurion,
Typically, by the time senior managers or administrators become involved in the
care of
an inmate, a bad outcome has already occurred. Collaboration is after-the -fact,
through
a post-incident failure analysis, root cause analysis , or morbidrty and mortality review.
At
their best, these processes result in improved service delivery through the
implementation of new safeguards and procedures. Even then , the result may not
be
integration of medical and mental health services . Think about your system. Despite
the close proximity of medical and mental health providers within your institution,
how
frequently do joint medical-mental health treatment meetings occur? How often
do an
inmate's primary medical provider and primary psychiatric provider sit in room and
discuss the coordination of care for that individual?
In order to move towards a more integrated service delivery model, medical and
psychiatric providers need to assume joint responsibility for the patient with comorbi
d
medical and mental illnesses . To do that, providers need to be aware of the pitfalls
that
interfere with detection, monitoring and treatment of comorbid conditions and service
delivery models that have resulted in successful integration of medical and mental
health
services.
Pitfalls in Detection, Monitoring and Treatment
What of the link between excess medical comorbidity and excess mortality among
the
seriously mentally ill? Researchers who study the treatment of chronic medical
conditions in individuals with serious mental illness almost universally point to underdetection, under-monitoring and under-treatment of medical conditions compare
d to the
same services in the general population. Problems in health care have been estimate
d
to contribute to 10%-15% of premature deaths nationwide and to 25% of prematu
re
deaths among individuals with serious mental illness. It is critical to recognize
challenges in service delivery for individuals with serious mental illness. Underst
anding
and overcoming these challenges is all the more important in the context of
incarceration, where inmates have a constitutional right to necessary healthcare.
Fear and Stigma
Beyond patient availability and cooperation, at least three factors may contribute
to
under-detection, under-monitoring and under-treatment of medical conditions among
inmates with serious mental illness. The first potential factor is fear of individuals
with
serious mental illness and resulting stigma and discrimination. Researchers have
suggested that healthcare providers perceive individuals with serious mental illness
to
be dangerous and/or possess diminished capacity to understand and follow treatmen
t.
These biases contribute tn decreased delivery of healthcare services. In the context
of
jails and prisons, experience confirms that each correctional system typically has
a
number of high profile inmates with serious mental illness, serious medical illness,
dangerous behaviors and poor levels of cooperation with treatment. Provider
experiences with these inmates can lead to the perception that other inmates with
comorbid medical and mental illnesses will be difficult and problematic. Prejudg
ment
may lead to a generalized reluctance to provide adequate treatment to inmates in
need
of services who have both serious medical and mental health conditions.
While this hypothesis remains under-researched, evidence consistent with provider
biases can be found in patient perceptions. In a recent survey conducted by the
National Alliance for the Mentally 111, patients with serious mental illness reported
that
their psychiatric diagnosis impeded appropriate attention to physical health concern
s.
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Nearly half of the patients surveyed said that doctors took their medical problems less
seriously once the doctors learned of their psychiatric diagnosis. Thirty-nine percent
said their psychiatric diagnosis made it more difficult to obtain access to physical
healthcare.
Diagnostic Bias
The second potential factor reflects not fear and social bias, but diagnostic biases,
including what has come to be known as "diagnostic overshadowing." Although the term
"diagnostic overshadowing" originally referred to the tendency for a diagnosis of
intellectual disability to "overshadow" or eclipse consideration of comorbid mental illness,
the term has since generalized to refer to the tendency for one diagnosis to eclipse
consideration of potential comorbidities. Researchers have suggested that diagnostic
overshadowing may be common in the context of treating individuals with serious mental
illness.
According to this hypothesis, serious mental illness frequently overshadows
consideration of serious medical illness, resulting in under-detection and undertreatment of the medical illness. Diagnostic biases may be most consequential in
emergency care, when serious medical conditions such as hypoxia, delirium, metabolic
abnormalities, or central nervous system infections are misdiagnosed as psychiatric
illness because the patient is already known to suffer from serious mental illness. The
diagnostic overshadowing hypothesis is consistent with patients' reports that their
psychiatric diagnosis made it more difficult to obtain medical care. It is also consistent
with findings that physicians underestimate the probability of medical disease and obtain
fewer appropriate tests when a hypothetical patient has a history of mental illness.
Think about the practices within your own system. How often does a psychiatric illness
"trump" consideration of a medical condition? Do you know of occasions when
diagnostic testing for a medical condition has been delayed or omitted once the
presence of psychiatric symptoms is discovered?
Segmentation/Fragmentation of Services
When medical and mental health care are provided in a segmented or fragmented
service delivery system, shared professional responsibility for comorbidity is difficult if
not impossible to achieve and maintain. There is no doubt that medical and mental
health providers in corrections are stretched, typically beyond capacity, by large
caseloads of seriously ill inmates. Under these conditions, diffusion of responsibility and
failures to communicate and coordinate can readily occur.
Consider your system and the multiple points of contact that are required between
medical and mental health providers. Which profession is responsible for routine
monitoring of serum glucose and lipids for inmates receiving second generation
antipsychotic medications? When significant metabolic abnormalities develop in the
context of treatment with antipsychotics, which discipline is responsible for treatment of
the abnormalities? Who obtains and reads baseline electrocardiograms for inmates
receiving tricyclic antidepressants? When an inmate has a significant change in mental
status while housed in mental health unit, who is responsible for ruling out medical
causes? When an inmate with serious mental illness requires outside medical care, how
are the inmate's medical and mental health treatment needs coordinated to ensure
continuity and consistency across locations? If an inmate refuses necessary medical
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treatment and impaired decision-making capacity is suspected, who conducts the
capacity evaluation? Which profession is responsible for the treatment and
management of inmates with dementia?
Integrated Service Delivery
Although the list of areas in which coordination between medical and mental health
services is potentially endless, an integrated care model of service delivery provides
a
straightforward solution to potential challenges in the medical-mental health interface
.
The integrated care model has a simple goal: care coordination.
Coordination of care for inmates with serious mental illness is best achieved when
dedicated treatment coordinators or "care managers" are built into correctional mental
health staffing models. In the integrated service delivery model, responsibility for
the
coordination of all healthcare needs of inmates with serious mental illness rests
with the
care manager. Structured opportunities for interdisciplinary treatment planning and
consultation among the care manager, medical and psychiatric providers are built
into
the work week. Optimally, providers are co-located and scheduled proximately to
facilitate the inmate's access to care and the coordination of care across disciplin
es.
Organizational and service delivery infrastructure can be redesigned to support
integration of care so that medical screening , monitoring and treatment are inclusive
of
the mental health care manager, who also consults with the psychiatric provider.
Under this model, the care manager is able to integrate all current needs and
interventions into a single treatment plan. In turn, the treatment plan reflects
coordination of a// healthcare services , not just mental health services or just medical
services . The mental health care manager is also responsible for the critical task
of
providing self-management skills training to the inmate to address both medical
and
mental illnesses . These skills, which take into account limitations of both physica
l and
psychiatric symptoms as well as the individual strengths of the inmate, support treatme
nt
adherence and improve treatment outcomes.
Figure 2 illustrates the integrated care service delivery structure. As can be seen,
service delivery is coordinated by the care manager. The inmate with serious mental
illness also takes a central role in this process. Involvement of the inmate as a central
stakeholder rather than a passive service recipient is critical to integrated healthca
re and
consistent with the recovery model.
Figure 2 is not ~n organization chart and does not reflect traditional lines of formal
supervision. While job descriptions and performance expectations need to be redefine
d
and expanded under an integrated service delivery model, supervisory hierarchies
can
remain largely unchanged.
Implementation of integrated service delivery for inmates with serious mental illness
requires significant changes in culture and healthcare delivery models. The introduc
tion
of care managers into the mental health staffing matrix and provision of structure
d time
for medical and mental health staff to collaborate can be associated with addition
al
upfront costs to the correctional system. To offset these costs, improved service
delivery, increased treatment adherence, timely and positive medical outcomes
and
reduction in preventable hospitalizations can be realized, resulting in cost savings
over
time. Programs using integrated care models for service delivery for individuals
with
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serious mental illness have demonstrated success in Medicaid and Medicare patientcentered homes, the Veteran's Administration, and SAMSHA projects involving
community mental health centers. For individuals with serious mental illness, integrated
service delivery either does not increase overall healthcare costs or realizes cost
savings that off-set initial cost increases.
There can be little doubt that inmates with serious mental illness require external and
ongoing support to receive the medical and mental health care they need. It is
challenging enough for medical and mental health professionals to sort out which
symptoms are psychiatric and which are medical; expecting inmates with serious mental
illness to be able to do so and to advocate for themselves effectively is not realistic.
Impairments in functioning, insight, self-care, communication and behavior associated
with serious mental illness make this a particularly vulnerable population. Support in
accessing necessary medical and mental health services is needed. Both medical and
mental health needs must be considered during assessments and treatment
interventions. This is where a care manager is needed. At the center of an integrated
care model is the care manager and the inmate.

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Figure 2: Integrated Service Delivery for Inmates with Serious Mental Illness
Facility Administrators
(Warden or Superintendent)

Health Services Administrator

Medical Director

Psychiatric Director

Primary Care
Physicians

Psychiatrists
Mid-Level Psychiatric Providers

Mid-Level
Medical Providers

Psychologist/Mental Health Director

Mental Health
Medical RNs & LPNs
Mental Health RNs & LPNs
CNAs
Specialty Care
Providers

Recreational
and Activity
Therapists

Mental
Health

122

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centurion ,
and mental
Health and wellness are achieved not only through the delivery of health
tive care,
preven
through
also
but
made,
been
health services once diagnoses have
self-care and
inmate
e
improv
to
ntions
including psychoeducation and behavioral interve
due directly
be
may
ty
mortali
ure
treatment adherence behaviors. Nearly 40% of premat
to
utions
contrib
to patient behavior, and at least some proportion of the genetic
that are
rs
premature death may only be activated in the presence of lifestyle behavio
lifestyle
modifiable. Care managers can help inmates by supporting behavior and
le, research
examp
For
ns.
concer
health
able
changes that address current and predict
mental
serious
and
disease
ascular
has reliably demonstrated a link between cardiov
d
elevate
at
be
yet
not
may
illness. Patients suffering from their first psychotic episode
be
may
stage
risk for cardiovascular disease and primary prevention efforts at this
services
particularly important. Through the integrated medical and mental health
can be
facilitated by a care manager, preventative, health-promoting behaviors
behaviors
health
ted
integra
about
bring
help
supported. Integrated health care services
in the inmate population.
Conclusion
including early
Overall health and wellness are dependent upon access to healthcare,
knowledge
detection and preventive care; trust in the healthcare system; enhanced
exercise and
diet,
ed
improv
t;
suppor
regarding self-care and healthcare; psychosocial
illness
mental
serious
with
s
weight management; and lower rates of smoking. Inmate
through
only
is
need support to access healthcare and attain optimal health. It
of practicing
integrated health service delivery that this can be achieved. The days
in corrections.
fragmented healthcare are coming to an end, both in the community and
ted care.
All healthcare professionals are responsiblE~ for supporting systems of integra
.
patients
our
are
They
He is not your patient. She is not my patient.
cs is the
This article appeared in CorrDocs Volume 17/lssue 5/Winter 2013. CorrDo
tter,
newsle
newsletter of the American College of Correctional Physicians (ACCP)
about the
previously the Society of Correctional Physicians. For more information
.
ed.org
ACCP, go to the website, http ://accpm

Psychiatric Issues in Medical Management:
Information presen ted March, 2013 representing current
practices at Bridge water State Hospital, Bridge water MA

consider as
When patients present with acute symptoms or abnormal lab results, please
may
tions
medica
tric
part of the differential diagnosis the possibility that their psychia
The
inued.
either be causing their symptoms, or may need to be adjusted or discont
n issues
following summary is intended as an overview of some of the more commo
the
at
used
y
typicall
most
tions
medica
caused by, or related to the psychotropic
Bridgewater State Hospital.
Clozaril-Related Concerns:
sialorrhea,
• Patients on Clozaril are at risk for neutropenia, infection, orthostasis,
and aspiration pneumonia.

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•

If a patient presents with a decreased WBC or ANC, please consult the
policy on
Clozaril Prescribing/Monitoring. WBC levels below 3500, or ANC levels
below
2000 REQUIRE an alteration in the administration/monitoring of the medica
tion.

•

Patients who present with a fever or sore throat while taking Clozaril should
be
worked up for neutropenia even if they've had a recent CBC which was
normal.

•

Fever of 101.5 or higher REQUIRES transfer of the patient to the neares
t
emergency room for a stat workup to exclude neutropenia.

•

Because of the potent CNS sedation which this medication can cause,
Clozaril
should not be routinely combined with other CNS sedatives (anti-histamine
s,
benzodiazepines, opiates, barbiturates). If a patient on Clozaril presen
ts with a
change in mental status, or increased sedation/lethargy, consider
adjusting/eliminating concomitant sedatives, and consider obtaining a
serum
level of clozapine (levels in excess of 600ng/ml may be contributing to
the
changes in mental status).

•

Clozaril-related sialorrhea (hypersalivation) has been associated with aspirat
ion
pneumonia.

•

Clozaril has been associated with fatal cases of acute myocarditis. 90%
of cases
occur in the first 8 weeks of treatment. In most of the reported cases there
are
serum elevations of troponin levels. Clinical suspicion of myocarditis in
a Clozariltreated patient is a medical emergency. In patients recently started on
Clozaril,
clinicians should maintain a high degree of suspicion for myocarditis.
This is
especially true if patients present with tachycardia, dyspnea, fatigue, chest
pain,
EKG changes, hypotension, or excessive fatigue . In these instances, an
EKG,
CPK-MB, and troponin level should be ordered, and consideration of transfe
rring
the patient to an emergency room should occur.

Lithium-Related Concerns:
• Patients can present with signs of toxicity which include nausea, vomitin
g,
diarrhea, altered mental status, abdominal cramping, tremor, muscle weakne
ss,
and seizures.

•

Suspicion of toxicity should be confirmed with a stat serum level.

•

The Lithium Prescribing/Monitoring Policy REQUIRES that patients with
a serum
level >1.SmEQ/L be transferred to an emergency room for evaluation.

•

Medications know to increase serum lithium levels are ACE Inhibitors,
diuretics,
and NSAIDS. Serum lithium level elevation can cause renal insufficiency,
BUT
can also be a manifestation of renal insufficiency.

•

Lithium should be held until normal serum levels and renal function can
be
confirmed.

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centurion.,
Antipsychotic Medication-Related Concerns:
cardiac
• As a class these medications can cause hypotension/orthostasis,
a, tremor,
dystoni
conduction abnormalities, and EPS (including akathisia, acute
and Parkinsonism).
Orthostasis is common with Risperdal.

•

Neuroleptic Malignant Syndrome (NMS)
atening
• NMS can occur with any antipsychotic medication and is a life-thre
condition!
•

It is most common with the older neuroleptic medications.

•

changes in
Symptoms include diaphoresis, muscle rigidity, autonomic instability,
mental status, and hyperpyrexia.
Risk factors for developing NMS include: Administration of high-potency
tration,
neuroleptics, high doses or rapid dosage escalation , parenteral adminis
itant
concom
or
ion,
regulat
dehydration , patients in restraints, impaired thermo
infection.

•

•

An elevated CPK is typically present.

•

This condition can be fatal and should be managed aggressively.

•

is
Strong consideration of transfer to an emergency room in suspected cases
prudent.

•

•

transferred
Patients on antipsychotics who present with a fever >101.5 MUST be
to an
rred
transfe
being
they're
to the Infirmary and worked up for NMS, unless
outside facility.
g the
If NMS is suspected, the offending agent(s) should be discontinued pendin
workup and subsequent review by the Director of Medicine.

Hyponatremia-Relate d Concerns:
this
• Hyponatremia occurs frequently in chronically psychotic patients and
or
status
condition should be considered for any abrupt change in mental
diminished level of consciousness.
•

fluid
Patients with Na<130mmol/L MUST be transferred to the Infirmary on
restriction and sodium level monitoring.

•

for
Patients with Na<124mmol/L MUST be transferred to an emergency room
acute evaluation.

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Mental Disorders Secondary to General Medical Conditions
Linda Chuang, MD, Chief Editor: Iqbal Ahme d, MBBS , FRCPsych
(UK)
Updated: Mar 15, 2012
Overview
The psychiatric presentation of a medical disorder can be define
d as "the presence of mental
symptoms that are judged to be the direct physio log ical consequenc
es of a general medical condition,"
according to the Diagnostic and Statistical Manual of Mental Disord
ers, fourth edition, text revision
(DSM-IV-TR). Therefore, understanding common psychiatric sympt
oms and the medical diseases that
may cause or mimic them is of the utmost importance.

However, evaluation of patients who present to hospitals or physic
ians with altered behavior and/or
mentation can be time-consuming and difficult and may lead to
symptoms being quickly and
prematurely dismissed as psychiatric in nature. Nonetheless , the
failure to identify the medical cause of
psychi atric symptoms can be potentially dangerous because seriou
s, and frequently reversible,
diseases can be overlooked. Proper diagnosis of a psychiatric
illness necessitates investigation of all
appropriate medica l causes of the symptoms.
The following features suggest a medical origin for psychiatric
symptoms:
• Late onset of initial presentation
■
Known underlying medical condition
• Atypical presentation of a specific psychiatric diagnosis
■
Absence of personal and family history of psychiatric illnesses
• Illicit substance use
• Medication use
• Treatment resistance or unusual response to treatment
• Sudden onset of mental symptoms
• Abnormal vital signs
• Waxing and waning mental status

Medical and Toxic
Effects
•
•
•
•
•
•
•
•
•

•
•

Alcohol
Cocaine
Marijuana
Phencyclidine (PCP)
Lysergic acid
diethylamide (LSD)
Heroin
Amphetamines
Jimson weed
Gammahydroxybutyrate
(GHB)
Benzodiazepines
Prescription drugs

Medical Disorders That Can Induce Psychiatric Symptoms*

Central Nervous
System

• Subdural
hematoma
• Tumor
• Aneurysm
• Severe
hypertension
• MAningitis
• Encephalitis
• Normal-pressure
hydrocephalus
• Seizure disorder
• Multiple sclerosis

Infectious

Metabolic/Endocrine

• Pneumonia
• Urinary tract
infection
• Sepsis
• Malaria
• Legionnaire
dii;caoc
• Syphilis
• Typhoid
• Diphther ia
• Human
immunodeficiency
virus (HIV)
• Rheumatic fever
• Herpes

•
•
•
•
•
•
•
•
•

Thyroid disorder
Adrenal disorder
Renal disorder
Hepatic disorder
Wilson disease
Hyperglycemia
Hypoglycemia
Vitamin deficiency
Electrolyte
Imbalances
• Porphyria

Cardiopulmonary
• Myocardial
infarction
• Congest ive
heart failure
• Hypoxia
• Hypercarbia

Other
• Systemic
lupus
erythematosus
• Anemia
• Vasculitis

*Adapted from Williams ER, Shepherd SM. Medical clearance
of psychiatric patients. Emerg Med Clin North Am. May 2000;18
(2):185-98 .L<l

This article in its entirety is available on http:llemedicine.medscap
e.comlarticle/294131ove,vi ew. If you are not already a registered Medscape user,
you may go to the
Medscape web site and register.
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Summary
Mental Health and Physical Health Collaboration

general knowledge and
The information in this section is intended to provide
en mental and physical
understanding of the importance of collaboration betwe
and questions. Include
healthcare teams. The following space is for your notes
Director, the Director of Nursing
information that you need to discuss with the Medical
and/or the Health Services Administrator.
Topics you may want to discuss include:
•
•
•
•
•

y?
What mental health services are provided at this facilit
services?
h
healt
al
ment
ve
recei
y
facilit
How many patients at this
us mental illness?
serio
a
with
osed
diagn
are
How many patients at this faci lity
when are they on-site?
Who are the psychiatric providers at this facility and
with the mental health
have
What multidisciplinary meetings do medical staff
team?

NOTES:

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centurion.
Chap ter 19: Corr ectio nal Orga niza tions and Reso
urce s
Ame rican Corre ction al Asso ciatio n
FOUN DED

1870
American Correctional Association (ACA) is the oldes
t and largest international
correctional association in the world. ACA serves all
disciplines with the corrections
profession and is dedicated to excellence in every aspe
ct of the field. From professional
development and certification; standards and accre
ditation; networking, consulting,
research and publications; and conferences ACA is
a resource. The ACA is committed
to its mission of improving practices in correctiona l
systems by helping agencies provide
correctional populations with safe and effective health
service delivery. ACA is the leader
in setting international and national standards for the
quality of life and safety of
correctional systems.

https://www.aca.org/

National Commission on Correctional Health Care
"NCCHC's origins date to the early 1970's, when an
American Medical Association study
of jails found inadequate, disorganized health servic
es and a lack of national standards.
In collaboration with other organizations, the AMA estab
lished a program that in the
early 1980's became the National Commission on Corre
ctional Health Care, an
independent, not-for-prom 501 (c)(3) organization whos
e early mission was to evaluate
and develop policy and programs for a field clearly
in need of assistance.
Today, NCCHC's leadership in setting standards for
health services in correctional
facilities is widely recognized . Established by the health
, legal and corrections
professions, NCCHC's Standards are recommendation
s for the management of a
correctional health services system. Written in separ
ate volumes for prisons, jails and
juvenile confinement facilities, plus a manual for ment
al health services and another for
opioid treatment programs, the Standards cover the
areas of care and treatment, health
records, administration, personne l and medical-legal
issues. These essential resources
have helped correctional and detention facilities impro
ve the health of their inmates and
the communities to which they return, increase the
efficiency of health services delivery,
strengthen organizational effectiveness and reduce
the risk of adverse legal judgments.
Building on that foundation , NCCHC offers a broad
array of services and resources to
help correctional health care systems provide efficie
nt, high-quality care ."
http://www. ncchc. org/

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centurion .
American College of Correctional Physicians
of
The American College of Correctional Physicians (ACCP), formerly the Society
of
ment
develop
onal
Correctional Physicians (SCP), is dedicated to the professi
physicians in the specialty of correctional medicine.
ng
ACCP members are united through the goal of improving public health by examini
issues specific to the incarcerated and identifying solutions for medical professionals.
ACCP meets the needs of correctional physicians through education, advocacy,
networking, and avenues of communication.
The ACCP supports and provides leadership to our members challenged with the
internal and external obstacles to the care of the incarcerated.
NCCHC
A conferences and educational offerings occur annually in conjunction with the
year.
the
Fall Conferences, with additional opportunities and conference during
http: //accpmed.org
Academ y of Correctional Health Professionals
"The Academy of Correctional Health Professionals is the nation's community for
events,
correctional health care. Through publications, educational activities and special
y
the Academy works to connect you with peers from across the country. The Academ
you,
help
to
d
designe
lly
specifica
ge
knowled
and
ion
provides you with the latest informat
the correctional health professional."
http://www.correctionalhealth.org/about/about.html
CorrectCare
"As the official voice of the preeminent organization in correctional health care,
and
CorrectCare is a popular magazine in this unique field. It features news, articles
care
health
commentary on timely and important topics of interest to correctional
s for
professionals. Wide-ranging coverage addresses clinical and administrative practice
health services delivery, medical updates , governmental and other agencies that
influence correctional facilities, law and ethics, professional development and much
more. Each issue also shares news from NCCHC and its supporting organizations.
s of
Published quarterly, CorrectCare has a controlled circulation consisting of member
and
the Academy of Correctional Health Professionals, NCCHC-accredited facilities
other qualified professionals. It is also posted in its entirety online."
http://www.ncchc.org/correctcare

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centurion,,
Correctional Health Care Information
Offered by Centers for Disease Control and Prevention
http://www.cdc.gov/correctionalhealth/default.htm
State Resource Map Includes chronic and infectious disease information, links to
corrections and public health departments, and correctional system overview
Data on Common Health Problems Find the latest statistics on the medical problem
s
and other conditions reported by prison inmates
Scientific Reports and MMWRs Find corrections-related journal articles by CDC
authors
from 2000 to the present disease topics include HIV, MRSA, TB and Hepatitis
Interim Guidance for Correctional and Detention Facilities on Novel Influenza A (H1
N1)
Virus Released in May 2009, this document provides guidance for correctional facilities
during the outbreak of novel influenza A (H1 N1) virus
Recommendations and Guidelines Find CDC's guidance on the prevention, care,
and
treatment of infectious diseases found in correctional settings
Health Education Materials Find brochures and facts sheets on infectious disease
s and
Traumatic Brain Injury for patients and professionals
•
•
•

Research Regulations
Federal Links
Corrections Links
Academic Consortium on Criminal Justice Health

The Academic Consortium on Criminal Justice Health (ACCJH) is a member
organization with a mission to advance the science and practice of health care for
individuals and populations within the criminal justice system. As the academic home
for
its members, ACCJH advances health research, training and care for justice involved
populations
ACCJH members benefit from the resources of an academir. r.ommunity that conduct
s
breakthrough research in correctional health care, and develops and promotes a
broader
and more critical view of the relationships between community and inmate health
care.
httos://www.accj h.org
International Corrections and Prison Association
The International Corrections and Prisons Association (ICPA) is an innovative, learning
platform which enhances international and inter-agency co-operation. ICPA actively
promote policies and standards for humane and effective correctional policies and

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practices, assisting in their development and implementation. ICPA believes
that imprisonment is a last resort and supports the development of alternative
sanctions and community corrections. ICPA believes in integrity and professionalism,
the sharing of ideas and partnerships. ICPA believes in the capacity for positive change
in individuals, their dignity and the duty to protect their rights.
https://icpa.org
Worldwide Prison Health Research and Engagement Network

Worldwide Prison Health Research & Engagement Network (WEPHREN), an open
access collaborative forum for everyone interested in prison health globally, aiming to
improve the health of people in prison through the equitable development of the
evidence base and through capacity building initiatives for health.
https://wephren.tghn .org

NOTES:

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Attorneys Eyes Only

Orientatlon Workbook

Medical Provider
Orientation
Workbook

·~

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centurion."

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How to Use this Orientation Work book
This workbo ok is intende d to help you locate orienta tion resourc es, ask contrac t
and site specific questio ns and create a workin g referen ce guide as you transiti on
into your new role.
The workbo ok is organiz ed to follow the order of the topics reviewe d from the
Provide r Orienta tion Checklist.

1

Medical Provider Orientation Workbook

Revised May 1, 2020

Attorneys Eyes Only

Correctional Environment - Chapter 1 Medical Provider Reference Manual
This following space is for your notes and questions. Include information that you need to
discuss with the Medical Director, DON, and the Health Services Administrator.
Topics to discuss include:

2

•

Does this system or facility have any active Consent Decrees? If so, what is medical's
involvement?

•

How do healthcare staff address inmates and what is the expected way inmates address
healthcare staff?

•

Are there "access to healthcare" issues at this site?

•

Where do inmates report for medications and scheduled/non-scheduled healthcare
appointments?

•

Will I need to go see inmates in areas outside the healthcare unit?

Medical Provider Orientation Workbook

Revised May 1, 2020

Attorneys Eyes Only

•

, who can it be
What are examples of inmate health information that might be shared
shared with, and why might the information be shared?

•

or
How and who is responsible for providing information requested by security
administration staff?

•

What is the process for obtaining medical records at the facility?

•

When are consents for health services used at the facility?

ADDITONAL NOTES :
PREA and Forensic Health Information - Supplemental
that you need to
The following space is for your notes and questions. Include information
Services
discuss with the Medical Director, the Director of Nursing and/or the Health
Administrator.
Topics to discuss include:

•

3

How many PREA Reports are received by the institution?

Medical Provider Orientatio n Workbook

Revised May 1, 2020

Attorneys Eyes Only

•

How many inmates receive examination and testing at community facilitie
s and are test
reports automatically sent to the facility? What role does the site medica
l practitioner
take in follow up for inmates after a reported incident has occurred?

•

What is the reporting process or chain of command if there is a suspec
ted incident?

•

Do medical staff receive directives for court-ordered healthcare? If so,
where are the
correctional system's administrative directives or policies and procedures
maintained?

•

What involvement do medical staff have in court ordered directives?

•

What is the medical provider's responsibility in the PREA process?

ADDITIONAL NOTES :

4

Medical Provider Orientatio n Workbook

Revised May 1, 2020

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Manual
Security Overview and Awareness - Chapte r 2 Medical Provider Reference

need to
The following space is for your notes and questions. Include information that you
discuss with the Medical Director and the Health Services Administrator.
Topics to discuss include:

5

•

What are the titles of facility administrative staff and what is the suggested way to
address them?

•

What are the proper titles for security staff and what is the suggested way to address
them?

•

What is the process for entering your facility?

•

What items are you allowed to be brought into the facility with you?

•

?
Are you required to carry keys while in the facility? If yes, how are keys obtained

Medical Provider Orientation Workbook

Revised May 1, 2020

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•

What is considered contraband and/or sharps in the facility?
(Note: Make a request for a written contraband list, if available)

•

What is your responsibility for controlling access to contraband?

•

What are the requirements for security staff escorts when working in the
healthcare unit?

•

What are the requirements for security staff escorts when moving within
the correctional
facility?

ADDITIONAL NOTES :

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Inmate "Wants" vs. Medical Needs - Chapter 16 Medical Provider Reference Manual
The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director and the Health Services Administrator.
Topics to discuss include:

•

Are there common themes to inmate special requests that I should be aware of?

•

How are these addressed by healthcare staff?

•

Is there a Diet Manual of listing of special medical diets? How are special medical diets
handled? What are the requirements for requesting/ordering dietary supplements, such
as Ensure?

•

What is the process for managing special medical requests (i.e., bottom bunks, special
shoes, and special blankets)? How is medical necessity determined for requests for
these items?

ADDITIONAL NOTES:

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Sick Call - Chapter 8 Medical Provider Reference Manual
The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director and the Director of Nursing.
Topics to discuss include:

8

•

How is the sick call process managed at the facility for inmates in general population and
for inmates in specialized housing units?

•

What are the contract-specific guidelines for common healthcare problems (also referred
to as nurse protocols)?

•

What nursing staff can perform nurse sick call? What are nursing/nursing extender staff
responsibilities in the sick call process?

•

What training do nursing staff receive before conducting sick call?

•

How are inmates scheduled and/or referred to be seen by the on-site medical provider?

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•

Are there specific documentation/templates used to document encounters completed by
the medical provider and/or nurse?

ADDITIONAL NOTES:

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bisease Management/Chronic Care Clinics - Chapter 10 Medical Provider Reference
Manual
The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director, the Director of Nursing and Chronic Care Coordinator.
Topics to discuss include:

10

•

What are the more routine chronic diseases treated at the facility? What resources are
there available for consultation for chronic disease care (i.e., infectious disease
specialists)?

•

What is the average number of inmates in each chronic care clinic?

•

How are the chronic care clinics and associated diagnostic testing scheduled?

•

Who coordinates and assists with the clinics?

•

Are there special forms required for documenting chronic care clinics?

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•

available?
Are Disease Management Summ ary treatment guidelines readily

•

of treatment for
Are there multidisciplinary team meetings available for discussion
complex care patients?

ADDIT IONAL NOTES:

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Special Needs Inmates - Chapter 15 Medical Provider
Reference Manual
The following space is for your notes and questions. Includ
e information that you need to
discuss with tho Medical Director and Director of Nursing.
Topics to discuss include:

•

What types of "special needs" inmates are housed at the
facility? Where are they
housed?

•

What is a provider's responsibility for classification determ
inations and communications
with security?

•

What types of "special needs" inmates can the facility not
manage? Where and how are
these inmates transferred to a facility that can manage those
needs?

•

Are there templates for documenting treatment plans for
"special needs" inmates or is
the plan documented in the Plan section of a SOAP note?

ADDITIONAL NOTES:

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Medication Management - Chapter 9 Medical Provider Reference Manual

need to
The following space is for your notes and questions. Include information that you
discuss with the Medical Director, the Director of Nursing and the Medication Room
Coordinator/Designee.
Topics to discuss include:

13

•

Where can I find a copy of the most recent Formulary?

•

What is the process and forms required to be completed by the provider when
requesting a non-formulary medication? How are the requests handled?

•

What are the medication administration times for this facility?

•

be
What medications are allowed to be KOP? What medication are NOT allowed to
KOP?

•

ing
What OTC medications are available in the commissary and should inmate purchas
be encouraged?

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•

Are medications ordered through e-prescribing? If yes, what training will be provided
and when will training be provided?

•

How is the medication order refill process handled?

•

How are controlled substances managed? What is the philosophy on use and ordering
of controlled substances?

ADDITIONAL NOTES :

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On-Site Emergency Care, Emergency Department Services, Hospitalizations and
Infirmary Care - Chapter 12 Medical Provider Reference Manual

The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director, the Director of Nursing and/or the Health Services
Administrator.
Topics to discuss include:

15

•

Are infirmary services offered at this facility?

•

If infirmary services are offered at this facility, what is the capacity of the infirmary,
nursing skills provided, staffing levels, typical diagnosis, and typical length of stay?

•

If infirmary services are not offered at this facility, where are inmates transferred for
infirmary level of care?

•

How often do emergency "man-down" calls occur in the facility? Are there any recurring
issues?

•

What is the typical response time of the ambulance? Are there any issues in emergency
services accessing inmates?

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•

What emergency department is used by this facility?

•

Does the emergency department routinely send discharge notes including copies of lab
and other studies for inmates released from the emergency department?

•

How many hospitalizations does this facility average monthly?

•

Do inmates return to this or another facility when discharged from a hospitalization?
When returning from an Emergency room visit or hospitalization, when will the provider
be contacted and/or see the inmate for follow up care?

ADDITIONAL NOTES:

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Laboratory and Other On-Site Testing - Chapter 13 Medical Provider Reference Manual

The following space is for your notes and questions. Include information that you need to
discuss with the Director of Nursing and/or the Health Services Administrator.
Topics to discuss include:

17

•

What testing is available on-site?

•

Where are testing results recorded?

•

How is testing ordered and scheduled?

•

What is the typical turn-around time? Routine tests versus Stat tests?

•

How are the results delivered to the provider for review? What documentation is
required by the provider at the time review?

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•

How are critical values reported to the site and to the provider?

•

What happens if an inmate does not get scheduled test? Is it rescheduled? Is provider
notified?

•

Is there a laboratory formulary? If not, are laboratory preferred testing groupings used?

•

Who is the laboratory vendor(s)? If more If more than one vendor, what testing is
performed by each vendor (i.e., state laboratory performs HIV testing only)?

ADDITIONAL NOTES:

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Provider Reference Manual
Specialty Care and Off-Site Services - Chapt er 11 Medical
ation that you need to
The following space is for your notes and questions. Include inform
the Health Services
discuss with the Medical Director, the Director of Nursing and/or
Administrator, and the specialty appointment tracking staff
Topics to discuss include:

request a specialist
What paperwork or electronic information must be generated to
and required
s
referral? How and who will provide training on required proces
paperwork/systems?

•

was completed?
How will the referring provider know that the specialist appointment
there are delays in
or
tment
appoin
the
d
How will the provider know if the inmate refuse
scheduling the inmate for a specialty appointment?

•

•

•

19

scheduled for
Will inmates returning from specialist appointments be automatically
g provider's responsibility
an appointment to see an on-site provider? What is the referrin
ing ongoing plan of
for review of the specia list information and documentation regard
care?

Who schedules appointments?

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Who are the medical specialists used?

ADDITIONAL NOTE S:

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Telehealth - Chapter 17 Medical Provider Reference Manual
need to
The following space is for your notes and questions. Include information that you
and/or
Nursing
of
discuss with the Medical Director, the Regional Telehealth staff, the Director
the Health Services Administrator.
Topics to discuss include:

•

Is telehealth used at this facility?

•

If telehealth is used, what services are provided through telehealth?

•

Are case conferences/training provided through telehealth?

•

Where are telehealth services provided?

•

What are the policies for providing telehealth services?

ADDITIONAL NOTES :

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Utilization Management Overview - Supplemental
Chapter 11, Specialty Care and Off-Site Services, the Medical Provider Referen
ce Manual
presents an overview of the Centurion Medical Management/Utilization Manage
ment program.
The following is offered to expand on the goals of the program and expectations
for your role in
implementing evidence-based healthcare services.
The guiding principles of Centurion's Utilization Management program include:
Inmates have a constitutional right to medically necessary healthcare services.
Healthcare services are provided by a physician-driven system of care.
Healthcare services are provided at the appropriate time within a progression of
illness
and in the best and most secure setting.
Utilization management program is the coordinated review of the interventional strategy
and services provided to the inmate population for inpatient and outpatient services
.
Utilization management process is conducted by utilization management nurses
and
ancillary staff supported by a strong physician team.
Utilization management program is clinically focused and patient-centric.
• Utilization management guidelines are consistent with nationally recognized
evidencebased practices that are within the expected standard of care and provide the clinical
foundation for consistency of medical practice.
Utilization management review process does not interfere or create a delay in providin
g
medically necessary care.
Utilization management program facilitates timely access to healthcare by pre-serv
ice
review of healthcare service requests. Process includes multi-level evaluation,
determination of medical appropriateness and timing of intervention.
Alternative treatment planning is a component of the utilization management review
process when a specialty services request is not found to be medically indicated
after
application of evidence-based guidelines for standard of care.
The utilization management program is metric driven. Information obtained from
the
utilization management program is analyzed to improve management of inmate
medical
care by use of designated metrics and dashboards.
Utilization management is part of a dynamic healthcare management process. Evidenc
e
confirms that the most effective and efficient approach to quality correctional healthca
re is to
consistently manage wellness, chronic medical illness, support aggressive acute
care
intervention, and maximize services provided by on-site healthcare staff.
Centurion has developed Clinical Guidelines to assist on-site providers in determin
ing when a
referral for specialty diagnostic procedures and interventions should be made.
The Clinical
Guidelines are based on current research and professional standards as well as
"best practices"
in correctional healthcare.
The Centurion utilization management program uses three types of reviews: prospec
tive,
concurrent and retrospective. Our process conducts prospective review of requeste
d specialty
services as well as concurrent and retrospective review of inpatient and outpatie
nt services to
determine medical necessity based on McKesson Health Solutions, LLC's lnterQua
l®
guidelines. lnterQua l® provides a clear, consistent, evidence-based platform for
care decisions
that promote appropriate use of services, enhance quality, and improve health outcome
s. We
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use lnterQual® criteria in determining medical necessity and place of service for specialty
referrals, outpatient and ancillary services as well as determining level of care and continued
appropriateness of inpatient care.
Prospective Reviews:
The Centurion utilization management program is supported by a proprietary product,
TruCare TM. TruCare TM is a patient-centric integrated disease, care and utilization management
product that offers clinical appropriateness tools based on evidence-based criteria, customized
assessments and care plans for inmates, stratification of risk, and
tracking/reporting/improvement data.
TruCare TM receives requests for specialty services and permits prospective and concurrent
clinical review using lnterQual® criteria as well as practice statements. In completing
prospective reviews, Centurion offers both a nursing review and physician multi-level review as
needed. The goal is to have the clinical team work together to promote appropriate, timely,
quality care for the inmate.
Initiation of the prospective utilization management review process:
Prior authorization is required for outpatient specialty services/diagnostics and planned
inpatient services. The request for these services is initiated by an on-site provider on a
standardized TruCare TM Prior Authorization form. The form must be completed in its
entirety to indicate if the referral requires urgent or routine processing.
Additional clinical information is submitted with the Prior Authorization form to provide the
information required to apply evidence-based guidelines and ensure informed medical
necessity decision-making.
Requests for specialty services completed by a physician assistant or nurse practitioner
may require review/written approval by the Site Medical Director or supervising physician
prior to submitting for authorization.
The Prior Authorization form and supporting documentation are faxed directly into
Centurion's automated TruCare TM system.
Utilization management staff receive the Prior Authorization and supporting clinical
documentation for the requested services through TruCare TM. The requests are
processed from an electronic queue to streamline the coordination of referrals.
TruCare TM supports the transfer of requests from the utilization management nurses and
physicians when needed.

Initial Utilization Management Clinical Review
Initial clinical review is conducted by the utilization management nurses. If the request does not
include sufficient information to conduct the clinical review, the requesting provider will be notified
and asked to submit additional information.
The clinical review consists of the evaluation of presenting new onset, acute event or episodic
chronic clinical data, possible diagnosis, co-morbid conditions, failed prior therapies if previously
treated, diagnostics completed, current status of condition, and requested medical, surgical, or
diagnostic intervention.
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With any request, the following information is considered :
Review of the submitted information
Determine the type of service being requested
Identify critical information for application of evidence-based criteria/guidelines
Apply the evidence-based criteria/guidelines
Review outcome determination
Determination of setting of care
Review of potential safety concerns
If the request can be approved based on the utilization management nurse's clinical review, the
specialty service is authorized in the TruCare TM system. The provider requesting the specialty
service is notified and the inmate is scheduled for the service.
If the utilization management nurse is unable to approve the request based on the established
criteria, the request will be sent for a physician advisory review. Requests will not be denied
based on a utilization management nurse's review.

Physician Advisory Review
When the clinical review conducted by the utilization management nurse cannot approve a
request, the Statewide Medical Director or designee reviews the clinical information to make a
determination. If unable to make a determination based on the available information, the
Statewide Medical Director will contact the requesting provider for a peer-to-peer discussion of
the referral. The Statewide Medical Director has the option to consult with the Department and
specialty medical experts available through Advanced Medical Review (AMR) for contracted
specialty advisor review on difficult and complex cases.
The physician advisory review and determination is documented in TruCare TM. If the request is
approved, the specialty service is authorized in the TruCare™ system. The provider requesting
the specialty service is notified , and the inmate is scheduled for the service. If the request is not
authorized, an alternative treatment plan is documented and the requesting provider notified.

Appeal Process
Referring on-site providers have the opportunity to appeal the utilization review determination
and recommendations for alternate treatment to the Statewide Medical Director. The appeal
process includes submission of the original request and additional medical history and data that
may be pertinent to the appeals review. The appeal review process for the Statewide Medical
Director will include case discussion with the requesting provider and the on-site Medical
Director. Consensus is preferred, and the Statewide Medical Director will work with the
requesting provider to ensure that the provider is comfortable with the recommendations and
treatment planning final determination is agreed upon and documented.

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Concurrent and Retrospective Review of Emergency Care
Utilization management prior authorization is not required for emergency services. For
unplanned Emergency Department visits or hospitalizations, the utilization management staff
receives notification from on-site healthcare staff of the sending facility. Upon notification of
emergency inpatient hospitalizations, the utilization management staff initiate concurrent review.
Utilization management staff contact the receiving hospital to obtain information and provide
input regarding ongoing treatment needs. Transfer to another inpatient facility with the capacity
to provide the required level of care may be indicated.
For all hospitalizations, utilization management staff begin discharge planning at the time of
admission. Appropriate access to care includes the timely and appropriate use of off-site
services as well as on-site infirmary, skilled nursing beds, and transitional care beds within the
correctional system. The goal of the inpatient utilization management program is to ensure an
inmate requiring inpatient care receives the appropriate follow-up care at a facility with the
capacity to manage his/her medical condition.

Follow-Up When Inmate Returns from Off-Site Specialty Service or Hospitalization
When an inmate returns to a correctional facility from a specialist appointment or hospitalization,
the inmate is brought to the medical clinic. A consult report or discharge summary should
accompany the inmate. Healthcare staff review any paperwork received and a provider is
contacted if orders are needed immediately. An on-site provider reviews the results and
recommendations from the off-site services to determine if the recommendations are clinically
appropriate and medically necessary. The on-site provider documents the review of the off-site
records and his/her recommendation for treatment in the medical record. The plan for
treatment should be reviewed with the inmate in a face-to-face encounter.
If recommendations from a consultant are modified, the reviewing provider must document
justification for the change in the treatment plan. If the provider accepts recommendations for
further off-site services, he/she must initiate a referral for the utilization management process.

Tips for Initiating a Specialty Services Referral
In initiating a referral request for specialty services that can be processed in a timely manner,
the following tips are offered:
•

•

Understand the steps in the referral process. This typically requires completion of a
Centurion Fax Prior Authorization form, completion of a clinical summary outlining the
reasons for the referral and supporting medical documentation such a laboratory testing
and other diagnostic results.
Prior to initiating a referral, review the Centurion Guidelines and consider the following
related to the referral:
•

25

How will this intervention impact the ability of the inmate to perform activities of
daily living?
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•
•
•
•
•

•
•

•

•

How will this intervention impact the ability to stay safe in the prison
environment?
When is the appropriate time for this intervention within this continuum of illness?
How will this intervention impact any comorbid conditions?
What is the outcome that you are anticipating from this intervention?
Are there any barriers to follow-up care or barriers to provision of this intervention
at this time?

If you are referring an inmate for multiple specialty services, complete the referral
process for each service being requested.
When completing the Centurion Fax Prior Authorization form, ensure all information is
legibly entered in the required information boxes as designated by the contract. Indicate
that the referral is "routine" except when the intervention is "urgent" and needs
immediate attention.
When completing the Clinical Summary, provide sufficient information to permit a review
of clinical appropriateness and medical necessity. Also provide any relevant supporting
documentation.
When the referral is completed, ensure that the information is faxed to the Utilization
Management Department. Inform staff who manage the facility's off-site services
process of the new referral to facilitate tracking at the site level.

Communication, Communication. Communication
An effective utilization management program requires the coordination of many members of the
healthcare staff. It is essential that you know which staff are responsible for submitting referrals,
tracking the referral and scheduling process, scheduling inmate transportation for scheduled
appointments, and follow-up for inmates who do not attend scheduled appointments.
Coordinating these elements is complex and your support may be needed. Effective
communication among the on-site healthcare team and with the Utilization Management
Department and security is essential.
If the utilization management nurses request additional information to permit review of one of
your referrals based on evidence-based criteria, submit the information as quickly as possible to
permit timely clinical review. If utilization management determination is delayed, you should
request an update on the status of the process.
If an inmate is unable or refuses to attend an off-site appointment, the team will need your input
in determining if the appointment requires rescheduling. If an inmate's medical condition
changes while awaiting an original scheduled non-urgent appointment, the team will need your
support in determining if the original referral is still clinically appropriate or if the urgency of the
request has changed.
When an inmate returns from a specialty service, you will need to determine if the consultant's
recommendations for further care is clinically appropriate and initiate new referrals as needed.
Utilization management staff may consult with you when considering an inmate's discharge from
a hospital to your facility.
Communication is essential for a successful utilization management program!
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Utilization Management - Supplemental
Include information that you need to
The following space is for your notes and questions.
ation Management staff.
discuss with the Medical Director and Corporate Utiliz

Topics to discuss include:

rtment of the contract? Have their
Who are the staff in the Utilization Management Depa
in the process?
individual roles been explained? What is your role

•

ities in the utilization management
Which healthcare staff at your site have responsibil
es many functions including
program? The utilization management program includ
intments, receipt of specialist
tracking specialty referral process, scheduling of appo
staff members?
information, etc. What are the specific roles of these

•

27

•

your contract to complete
What electronic applications/processes are used in
management reviews?
prospective, concurrent and retrospective utilization

•

Clinical Guidelines?
Have you received a copy of the current Centurion

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28

•

Have you received a copy of the current Centurion
Business Rules?

•

What is the referral process and associated timelines
for completion of referral process
for specialty services in the contract?

•

What guidelines are used by the Utilization Manageme
nt Department to make a prior
authorization decision for requested specialty servic
es?

•

What documentation is required for a specialty servic
es referral? Have the requirements
for completing the Centurion Fax Prior Authorizatio
n form been explained?

•

How do you determine if a referral for specialty servic
es should be designated as "urgent"
or "routine?" What is the timeline for review of a reque
st and the actual appointment
based on designation?

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29

•

If you are a physician assistant or nurse practitioner, does the contract require
review/written approval by the Site Medical Director or supervising physician of your
referrals for specialty services prior to submitting to the Utilization Management
Department?

•

What are the expectations for your involvement in the utilization management process
after you have submittea a referral?

•

What is the process that occurs when the Statewide Medical Director or designee does
not authorize one of your specialty service referrals?

•

What is the process that occurs when an inmate returns from an off-site specialty visit,
emergency room visit or hospitalization? What are your responsibilities when an inmate
is returned to the site after a specialty service visit or hospitalization?

•

Who are you to contact for questions about the utilization management process?

•

Who are you to contact for questions related to the status of a specific referral for
specialty services? Who are you to contact for questions specific to an appointment for
an approved referral?

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•

Why are coordination and communication essential for the utilization management
process in the contract?

ADDITIONAL NOTES:
Your Role in Quality Healthcare- Chapter 14 Medical Provider Reference Manual
The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director and the Health Services Administrator.
Topics to discuss include:

30

•

Is there an outline or process to follow for mortality reviews? What is the provider's
responsibility in the Morbidity and Mortality review and process?

•

Who performs my peer review? When are peer reviews performed? Is there a standard
format for peer reviews?

•

What meetings site and regional, is the provider required to attend?

•

What types and how many grievances do healthcare services in this facility receive each
month? How are the grievances specific to healthcare handled?

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ADDITIONAL NOTES:

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Risk Management - Chapter 7 Medical Provider Reference Manual
The following space is for your notes and questions. Include information
that you need to
discuss with the Director of Nursing and Corporate Risk Manager.

Topics to discuss include:

32

•

Questions or clarifications on the Incident Reporting Policy?

•

What form or forms are used to request medical information from a source
outside the
correctional system? Who obtains the inmate's signature for the reques
t?

•

How long does it typically take to get the information and how will you
know it has been
received?

•

Are there Administrative Directives or Department of Corrections Policies
and
Procedures regarding sharing of inmate health information?

•

What information and how is information shared with security staff?

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•

How is information shared with security staff?

ADDITIONAL NOTES:

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Mental Health and Physical Health Collaboration- Chapter 18 Medical Provider Reference
Manual
The following space is for your notes and questions. Include information that you need to
discuss with the Medical Director, the Director of Nursing and/or the Health Services
Administrator.
Topics to discuss include:

34

•

What mental health services are provided at this facility?

•

How many inmates at this facility receive mental health services?

•

How many inmates at this facility are diagnosed with a serious mental illness?

•

Who are the psychiatric providers at this facility and when are they on-site? Who is
responsible and/or on-call for after hour psychiatric issues and emergencies? Are there
mental health emergencies that the site medical provider is responsible for?

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•

What multidisciplinary meetings do medical staffs have with the mental health team?

ADDITIO NAL NOTES :

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Correctional Healthcare Documentation - Supplemental
Appropriate documentation of services promotes communication and continuity
in the overall
healthcare delivery system. We provide training to our healthcare staff on preparin
g
documentation that reflects the assessment and/or intervention conducted as well
as an
inmate's response to his/her treatment plan. We reinforce that the medical record
is a legal
document in which each staff member has a professional responsibility to docume
nt legibly,
thoroughly and accurately.

While the fundamentals of appropriate documentation will not be reviewed in this
handout,
potential documentation issues in correctional healthcare are offered for your conside
ration .

•

Since healthcare is provided 24 hours a day, 7 days a week in correctional facilities
,
documentation needs to ensure that healthcare staff reviewing the record understa
nd
what has happened with the inmate and the inmate's treatment plan when medical
staff
are not on-site. Documentation is regularly reviewed by our CQI program to ensure
compliance with standards and that care and treatment expectations are met.

•

Avoid negative comments or judgments such as "faking" or "malingering" when
completing inmate-specific documentation. It is important not to engage in negative
documentation such as using other departments or staff member names to place
blame
or argue about an inmate's care. Disagreements in inmate care should be discusse
d
with supervisory/administrative staff for resolution rather than noted in the inmate's
medical record

•

Correctional systems are moving to electronic medical records; however, many systems
still rely on paper medical records. Some systems have a hybrid of electronic medical
records and paper medical records.

•

In systems with paper medical records, it is critical that documentation is legible,
date
and timed, and signed with your name and title. Some systems provide stamps
with
your name and title to facilitate this process. In systems with paper medical records,
it is
also important to have the record available when conducting an inmate encounter.
This
can be a challenge since records are often used by many disciplines and may not
be
readily available at the time of the encounter. When encounters occur without a
record,
there can be gaps in documentation or loose/lost progress notes. Conducting an
evaluation or providing treatment to an inmate without first reviewing the record
should
be avoided as your decisions may be based on incomplete information.
In systems with electronic medical records, it is critical that you receive adequate
training
to be comfortable with using the system. Request assistance when you are unsure
of
how to use various templates and sections of the electronic medical record .

•

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37

•

Correctional healthcare systems may use many standardized forms to ensure consistent
documentation of specific assessments or encounters. Healthcare staff are expected to
fill out forms completely and leave no blanks. Partially completed forms compromise
continuity of care and will be questioned by auditors. Although forms are the most
common form of documentation, you will also be required to write narrative notes of your
encounters . When documentation is provided through progress notes, the structure of
progress notes must comply with the system's requirements. Most correGtional systems
require healthcare documentation in the SOAP format. You should discuss and review
the specific forms and documentation requirements for the contract based on the type of
encounter.

•

Certain procedures and treatment require documented inmate consent or refusal for
care. Obtain consent and document on designated consent form(s) to confirm the
process if the proposed intervention is beyond that implied by the general consent to
treat form signed by the inmate when received by the system.

•

Documentation of inmate services must be completed on the day the service was
performed and prior to leaving the facility. The caveat that "if an encounter is not
documented, there is no proof that it occurred" is true in corrections. If you must make a
late entry, properly document it with the date, the date of the late entry and "late entry"
clearly indicated.

•

Although inmates are a "captive population" in corrections, there are "no shows" for
scheduled appointments. A "no show" occurs when an inmate does not attend his/her
scheduled appointment either due to choosing not to attend or due to a security situation
(lock down, lack of security escort, inmate at court). Security staff may assist in ensuring
that an inmate shows for an appointment. It is important to document in the inmate's
medical record when he/she is a "no show," the reason for the missed appointment and
the rescheduling of the appointment as clinically indicated.

•

Telephone consultations and orders when you are "on-call" will be documented by the
on-site staff. Telephone orders will need to co-signed by a provider in the time frame
required by the system. In some systems, orders may be co-signed by a provider other
than the provider who issued the order.

•

Laboratory, radiology, and other diagnostic reports require your review. Review of the
information requires your signature, date and time on the document reviewed . Review
should include documentation in the progress notes and orders for abnormal findings
that require orders and/or follow-up with the inmate.

•

Specialist reports, hospitalization and emergency room discharge reports require your
signature, date and time on the document reviewed. Review should include
documentation in the progress notes and orders for follow-up and continued plan of care
for the inmate.

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SOAP Documentation Guidelines - Supplemental
S: Subjective
The subjective elements of the patient encounter (that which is expressed by the patient) should
be documented in this section (e.g., patient reports ·of nausea, pain, tingling). Information that
may be reported and included as part of this section include information specific to:
• Presenting complaint and associated functional inquiry, including the severity and
duration of symptoms
• Whether this is a new concern or an ongoing/recurring problem
• Changes in the patient's progress or health status since the last visit
• Review of medications, if appropriate
• Review of allergies, if applicable
• Past medical history of the patient and his/her family, where relevant to the presenting
problem
• Patient risk factors, if appropriate
• Salient negative responses
0: Objective
The measurable elements of the patient encounter and any relevant physical findings from the
patient exam or tests previously conducted are documented in this section and mighUshould
include:
• Physical examination appropriate to the presenting complaint
• Positive physical findings
• Significant negative physical findings as they relate to the problem
• Vital signs
• Review of consultation reports, if available
• Review of laboratory and procedure results, if available
A: Assessment
This section will contain the physician's impression of the patient's health issue including
diagnosis or differential diagnosis.
P: Plan

The physician's plan for managing the patient's condition is described in this section and can
include:
• Discussion of management options
• Tests or procedures ordered and explanation of significant complications, if relevant
• Specialty consultation reports review and ongoing plan of care, if relevant
• New medications ordered and/or prescription repeats including dosage, frequency,
duration and an explanation of potentially serious adverse effects
• Patient education (e.g., diet or exercise instructions, contraceptive advice)
• Follow-up and future considerations
• Specific concerns regarding the patient, including any decision by the patient not to
follow the physician's recommendations

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Documentation - Supplemental
The following space is for your notes and questions . Include information that you need to
discuss with the Medical Director and Medical Records staff.
Topics to discuss include:

39

•

Does this system use an electronic medical record, paper medical record or a hybrid of
electronic medical records and paper medical records?

•

If the system uses a paper medical record, how is access to the records ensured for
scheduled inmate encounters? What is expected when an inmate's medical record is
not available?

•

If the system uses a paper medical record, what are the standardized templates for
healthcare assessments/evaluations/interventions?

•

If the system uses a paper medical record, what is the format expected for progress note
documentation?

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40

•

If the system uses a paper medical record, is there a stamp provided for your signature
and title?

•

If the system uses an electronic medical record, have you been trained in using the
templates in the electronic medical record?

•

If the system uses an electronic medical record, who do you contact when you have
questions about the documentation/input requirements?

•

If the system uses a hybrid, what documentation is expected in the electronic medical
record and what documentation is expected in the paper medical record?

•

When are inmate consents or refusals for care required for a proposed intervention?

•

What are the expectations for documenting inmate "no shows" in the inmate's medical
record and facility tracking?

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•

What are the expectations for co-signing orders provided during telephone
consultations?

•

proposed
Who should be alerted if you do not agree with the intervention/treatment plan
by other staff or departm ent for a specific inmate?

ADDITO NAL NOTES :

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Contract-Specifie

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