wayne county hub discharge planning valerie langley, rn, nurse manager wayne county hub nc...

Wayne County HubDischarge Planning

Valerie Langley, RN, Nurse Manager

Wayne County HubNC Department of Corrections

May 2, 2007

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

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

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

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

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

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

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

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.

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.

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

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

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?

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.)

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?

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

Negative Responses

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

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.)

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

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

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

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

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)

Transition Folders

Patient education materials

Health Services Medical Records address

Immunization Records

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

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

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

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

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!

Questions?

Suggestions?

Thank You

Valerie LangleyWayne County Hubtvd02@doc.state.nc.us