Wayne County Hub Discharge Planning

1. Wayne County HubDischarge Planning Valerie Langley, RN, Nurse Manager Wayne County Hub NC Department of Corrections May 2, 2007

2. Continuous Quality Improvement • Each year, with the help of my team, one or more quality improvement studies are selected. • This year one of our goals is to improve quality of medical support for inmates transitioning into the community

3. Our Focus The focus of the project is to improve discharge planning by: • solidifying the process • establishing facility specific written instructions • Developing a user friendly program for staff

4. Organizing Staff • The bulk of the project was delegated to a seasoned DOC RN who enjoys patient teaching and has a firm understanding of the guidelines under which we work • Support staff consists of Lead Nurses on 1st and 2nd shifts who can oversee and follow through on the process

5. Why Discharge Planning? • Most of our inmate population did not require significant discharge planning • Patient population consists of stable chronic disease patients, manageable medical conditions • Because the patient did not need much, we were doing very little • We wanted to participate in the discharge planning process • We wanted to do something more

6. Strategies • Establish a Standing Operating Procedure • Create a Discharge Planning Book with the necessary tools, policies and forms to carry out the assignment • Designate staff to complete the assignment

7. So, here’s what we do inWayne County • Each week we use the online inmate offender search program to find inmates releasing who have medical problems

8. Triage the Report • Inmates with the earliest release date will be seen first • Inmates who are HIV or AIDS positive will be referred to the outreach nurse for Discharge Planning

9. Triage the Report • The facility social worker will track inmates on active or recent mental health treatment. The nurse will be responsible for addressing other medical needs of these patients.

10. Triage the Report • Inmates who are being treated for TB disease or infection are referred to our infection control nurse who coordinates discharge planning with the appropriate health department.

11. Appointments • Appointments with the facility nurse will be scheduled for inmates being treated for a chronic disease, infection or significant medical condition • Interviews will be scheduled with the nurse for inmates who use the self referral process

12. Self Referral Program • Survey developed and made available to inmates • Inmates pending release can complete the survey and submit to medical • Used as a check and balance system and gives the inmate an opportunity to have concerns addressed

13. The interview will determinethe following: • Does the inmate have an unstable chronic disease, acute medical condition or terminal illness? • Does the inmate have a medical condition that will require specialized care post release?

14. The interview will determinethe following: • Does the inmate have a medical condition that will require a clinic appointment within 2 weeks post release?( i.e.: chemotherapy, radiation, dialysis, physiotherapy etc.)

15. The interview will determinethe following: • Does the inmate have a physical disability that will require a modified home environment which is not currently in place? • Does the inmate require durable medical equipment that he does not have or is unable to financially afford?

16. Positive Responses • Inmates who have a positive response to any of the interview questions will be referred to the facility social worker • Our goal is to complete initial social worker referrals at least 90 days prior to release

17. Negative Responses • Inmates who do not meet the criteria for the social worker case load will be reviewed by medical to ensure the following:

18. Medical Will Ensure: • Refills are requested from Central Pharmacy 10 days prior to release • The inmate has the necessary medical equipment or supplies at home (nebulizer, glucometer, mask, tubing, lancets, glucometer strips etc.)

19. Medical Will Ensure: • The inmate has appropriate supplies for wound care • The inmate is given instructions regarding additional items that will be supplied to him by the medical department upon discharge

20. Medical Will Ensure: • Patient teaching pamphlets are issued to the inmate to educate the patient or family regarding the disease process • All inmates anticipated to leave with medication will sign the Safety Closure Release Form per Health Care Policy

21. Medical Will Ensure: • A discharge instructions form will be completed by the nurse, filed in the medical record and a copy placed in the transition folder

22. Transition Folders The medical staff will ensure the following items are placed in the transition folder: • Health Services Medical Records address • Prescriptions for essential medications

23. Transition Folders • Information necessary to ensure continuity of care upon release as requested by the patient and deemed necessary by the nurse (diagnosis, most recent physicians orders, most recent lab work)

24. Transition Folders • Patient education materials • Health Services Medical Records address • Immunization Records

25. How Does This Benefit the Patient? • Having current medical information allows the patient to present recent health status and treatment regimens to aid in implementing prompt and appropriate care • Having Health Services Medical Records address enables an immediate request if additional information is needed by the outside provider

26. How Does This Benefit the Patient? • Inmates are released with a 10-30 day supply of medications • Having a prescription allows the inmate to receive an additional 30 day supply of medication prior to seeing his provider

27. How does this benefit the community? • Health maintenance is a cost effective way to handle patients • Promotion of health by patient education materials gives continued encouragement and guidance • Failing to maintain health compounds emotional and physical stress upon release

28. How does this benefit the community? • Community providers have necessary information to initiate care • Health Departments are notified in advance of patients to expect for treatment • The Health Department then has patient information and can follow up if patient fails to report

29. Again, Our Goal • To improve quality of medical support for inmates transitioning into the community • We hope in improving our transition of the patients with medical needs we will reduce the burden on the community and give inmates the tools they need to succeed!

30. Questions? Suggestions?

31. Thank You Valerie Langley Wayne County Hub tvd02@doc.state.nc.us