Transcript Wayne County Hub Discharge Planning

Wayne County Hub
Discharge Planning
Valerie Langley, RN, Nurse Manager
Wayne County Hub
NC 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 in
Wayne 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 determine
the 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 determine
the 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 determine
the 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 Langley
Wayne County Hub
[email protected]