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