Patient Escort's Impact on Access to Care
As National Commission on Correctional Health Care surveyors, we are seeing more and more gaps in staffing, not only correctional staffing but also on the health care side. We have all suffered through a shift that was short-staffed, but since COVID-19, staffing shortages in corrections are at an all-time high. This article shares some recent survey experiences so that jail command staff can learn from others.
We all know that the incarcerated population must have access to care to meet their serious health care needs. This is a fundamental principle on which all NCCHC standards are based and the basic principle established by the U.S. Supreme Court 1976 landmark case Estelle v. Gamble. At an alarming rate, correctional facilities are having difficulty meeting the immediate health care needs of those incarcerated due to staffing challenges. During several recent surveys we noticed a concerning trend that is about more than staffing, it is also about facility culture–what is allowed by staff and how that rubs off on inmates’ behaviors.
On a recent survey while observing a medication pass, several male inmates standing at the windows of the surrounding pods were performing lewd and inappropriate acts in front of the female nurses and survey team. Neither the custody staff escorting the female nurses nor the housing unit’s assigned custody staff attempted to intervene and address the inappropriate behavior. This is a cultural issue, possibly a training issue, that could lead to delayed care and potential medication errors.
As the survey continued, one night no medications were passed to the inmates in that housing area—the same area where inappropriate and lewd acts were witnessed and tolerated. Nursing staff reported that officer night coverage was short-staffed and they did not have an officer to escort them on the medication pass, leaving the nurses too uncomfortable and worried for their safety to pass medications.
The nursing staff also had concerns about being distracted and making a medication error with the amount of inappropriate activity that takes place daily. The surveyors agreed that the inmate behaviors coupled with short-staffing were indeed safety issues, for both staff and patients.
The surveyors met with facility administration to describe what they had been told. The administration immediately began addressing the staffing gaps and cultural challenges. What was observed during the survey was not what the new leadership team wanted, and they were thankful for NCCHC’s presence and observations. NCCHC recommended that the facility undertake a comprehensive review of the delivery of health services. The current system was inadequate to ensure that patient care was timely—that is, that a patient could be seen by a clinician, be given a professional clinical judgment, and receive care that is ordered without unnecessary delay. The facility was to immediately remove unreasonable barriers to inmates’ access to health care services, which included an assessment of understaffed areas, underfunded care, operational inefficiencies (specifically with medication pass routes, lock down times, and staffing needs), and decide on how to evaluate whether there was an organized system of care. The leadership team was engaged and moving in the right direction when the survey concluded.
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JIM MARTIN, MPSA, CCHP Vice President, Program Development jamesmartin@ncchc.org
AMY PANAGOPOULOS, MBA, BSN, RN Vice President, Accreditation National Commission on Correctional Health Care amyp@ncchc.org
NCCHC Jail Commander Conversations: Patient Escort's Impact on Access to Care
The purpose of the Jail Commander Conversation is to provide an easy-to-use tool that gives the commander an opportunity to have a more in-depth conversation with the health care team about the health care operations. These topic areas are selected since NCCHC surveyors are seeing trends in survey items needing additional attention.
Why Is This Important? Patient escort is an increasingly important area for commanders to focus on. Access to care is not solely the responsibility of the health care team or health care vendor, as patients need to be escorted to receive services. Since the onset of COVID-19, staffing levels in the correctional setting have dwindled, often leaving gaps in coverage causing delays in timely care (i.e., delayed assessments by health care professionals, late medications, delayed treatments, sick call encounters, and delayed diagnosis, etc.). These delays open the facility up to unnecessary risk and potential litigation concerns.
Standard J-D-06 Patient Escort and Standard J-A-01 Access to Care go hand in hand since access to care rests on the ability of the incarcerated population to request and receive health care services in a timely fashion. Patient escort by custody staff is a critical piece of the process to ensure that patients are seen in a timely fashion. Access to timely health care is the main tenet of deliberate indifference, ensuring timely medical care for serious health care concerns.
With this article, we urge commanders to work with health care staff to understand if there are delays in care caused by lack of staff to escort patients to
clinical appointments (including medical, mental health, and dental services). This data is invaluable when understanding health care operations. Sample Survey Observations from Recent Surveyors' Findings
Observations related to administrative meetings and reports:
- There is a significant delay for patients to receive dental care. During an interview with the dental staff (and confirmed during chart review), they stated that patients with an acute toothache and/or swelling are scheduled to be seen in four to six weeks. Delays were due to lack of custody staff to escort patients to dental clinic.
- During the survey, it was observed that one night no medications were passed to inmates in one specific housing area due to officer coverage. Nursing staff stated officer night coverage was short-staffed and they did not have an officer to escort them on the medication pass, leaving the nurse uncomfortable for her safety to pass medications to the patients in specific housing units.
- Wound care was delayed by two days due to lack of patient escort.
- Backlog of 88 patients was noted during the survey for medical appointments related to health care requests. Delays were due to lack of patient escorts. The issue was also complicated by the lack of nursing and medical staff.
- High-risk pregnant female missed 4 obstetrics appointments due to officer staffing shortage leading to no patient escort for appointments.
- A review of several health records showed patients did not have pertinent labs completed for their chronic medical conditions and patients whose chronic illness was poorly controlled were scheduled to be seen again in six months. Three diabetic patients whose status was “out of control” had no laboratory tests ordered and no follow-up exam scheduled. Patients who have normal laboratory results are not notified of the results. Upon working with the health care team, they stated the delays mainly had to do with no patient escorts available to escort inmates to the clinic.
Potential contributing Factors:
Custody leadership not aware of the health care backlogs, delays in treatment or delays in medication pass.
- Lack of understanding that officer/custody staffing impacts health care operations
- Disconnect and no open communication between jail administration and health care administration
- CQIs and/or data not conducted or collected to understand operational needs and impacts
- Medication pass operations can be evaluated to provide for safer conditions, specifically with high-risk populations. Medication pass to these housing units may benefit if these areas are temporarily locked down when med pass operations occur in the unit and inmates approach the med cart individually to ensure optimum safety and privacy.