Unlocking the door to chronic disease management in custody
5 December 2014 Last updated:
8 December 2014
Unlocking the Door to Chronic Disease Management in Custody
Justice Health & Forensic Mental Health Network (JH&FMHN)
The Justice Health & Forensic Mental Health Network’s Care Navigation Support Program commenced in March 2011 and aims to improve the health of patients with chronic disease whilst in custody as well as connecting them to community services upon release to ensure their continuum of care. Following three years of implementation, this current initiative relates to the redesign of the Program to increase patient access through improved identification of patients with chronic disease and the application of risk stratification to measure a patient’s risk of hospitalisation for appropriate management of care.
To improve patient outcomes with the Care Navigation Support Program (CNSP) by increasing access to the program for all patients with chronic conditions and targeting those at most risk of hospitalisation through the implementation of risk stratification.
Redesign success will be measured through the reduction of unplanned hospital presentations and admissions and an increase in enrolments.
- Improved patient experience and outcomes
- Improved access to care and patient flow
- Standardised care plans and reduced hospital admissions
- Improved staff experience and efficiency
JH&FMHN patients are a highly vulnerable population whose health needs are often complex and can impact on their offending behaviour. In 2012, almost one in three Australian prison entrants (32%) reported having a chronic disease1. People in custody also have a high prevalence of risk factors for chronic disease including smoking, high blood pressure, obesity, and high levels of drug and alcohol use2. Also in May 2014, 19% of all unplanned hospital presentations or admissions had a chronic related discharge diagnosis. The incidence of chronic disease and co-morbidities has continued to rise, creating challenges.
The Care Navigation Support Program is a local adaption of the NSW Chronic Disease Management Program – Connecting Care in the Community which aims to improve the health of patients with chronic disease through the provision of 'Care Navigators' to monitor patients with chronic disease in the custodial setting as well as connecting them to community services upon release to ensure their continuum of care.
Existing eligibility into the CNSP is based on consent, and a patient having one or more of 15 chronic conditions* as well as a self-reported unplanned presentation or admission to hospital for chronic disease in the preceding 12 months. Obtaining patient consent to ‘opt in’ to the CNSP and the requirement for staff to determine whether a patient has one of the eligible chronic conditions during reception screening has led to missed opportunities for enrolment into the CNSP. Of the 45% total NSW prison population in May 2014 that has one or more chronic disease alerts, only 13% were enrolled in the CNSP, indicating that many patients with a chronic disease were not accessing the program.
Despite access issues to the CNSP, enrolments have steadily increased since commencement of the Program, and as at the 1 March 2014, the five Care Navigators had a total current case load of 1178 patients, an average of 236 patients per Care Navigator. This increasing case load however has created difficulties in effectively monitoring the patients, resulting in an administrative workaround of categorising patients on their frequency of appointment activity rather than direct clinical assessment.
This resulted in the need to increase resource efficiency through the redesign of the CNSP to improve access for all patients with chronic disease, as well as introduce a risk stratification model to ensure Care Navigators were monitoring those with highest risk of hospitalisation based on clinical judgement and risk stratification.
* CNSP 15 chronic diseases for eligibility into the program – Coronary ischaemic syndromes, valvular heart disease, asthma, coronary obstructive pulmonary disease, chronic liver disease, chronic kidney disease, cancer, epilepsy, stroke, depression, arthritis, musculoskeletal problems, osteoporosis, diabetes, eye disease, oral disease.
The Care Navigation Redesign prioritised four specific solutions to address the presenting issues:
- Solution 1. Simplify the enrolment process through the elimination of patient consent and increasing access to the program for all chronic disease patients, not just those patients that matched the previously identified 15 chronic conditions.
- From 3 November 2014 patients will no longer have to consent to the Program, as of this date, eligible patients will be referred to the Program and it will become ‘usual care’ for anyone with a chronic condition, thereby increasing access to the Program.
- Solution 2. Revise the Program’s Patient Administrative Scheduling System Creating a Referral to Care Navigation Support Program instructions and provide CNSP PAS referral refresher training to increase referrals to the Program.
- Following extensive meetings with the PAS (Patient Administrative System) team and Manager Information Management, the PAS Creating a Referral to Care Navigation Support Program instructions were reviewed and sections relating to consent processes were removed and updated.
- Additionally Clinical Applications Business Process – Care Navigation Support Program business processes were reviewed and updated.
- Refresher referral training has also been held at three key Correctional reception centres for staff in November 2014.
- Solution 3: Develop and launch a CNSP enrolment guide advising new changes to the CNSP for reception screening staff.
- An enrolment guide called Important new changes to the Care Navigation Support Program was developed and approved at the statewide JH&FMHN’s Clinical Operations Committee meeting on 21 October 2014 and was communicated to all staff via an Important Notice on the intranet on 22 October 2014. Additionally the guide was laminated and additional copies were sent to 32 adult Correctional Centres as well as a copy of the Important Notice.
- Included in the CNSP enrolment guide were clear easy instructions on how to enroll a patient into the CNSP using the new Risk Stratification guide as at 3 November 2014. Additionally, the guide also included a CNSP patient flow, the first time this had been documented and communicated to staff.
- Solution 4: Develop and introduce a measure to predict risk of hospitalisation (risk stratification guide).
- A Risk Stratification guide was developed to be used by clinical staff at reception in conjunction with their clinical judgment to identify whether a patient is at “severe” or “chronic” risk of hospitalisation. This Risk Stratification guide was approved at the statewide JH&FMHN’s Clinical Operations Committee meeting on 21 October 2014 and was communicated to all staff via an Important Notice on the intranet on 22 October 2014.
The Program is available in 32 adult correctional centres and Long Bay Hospital in NSW.
The initiative is being evaluated through three measures following implementation on 3 November 2014:
- Increase in referrals to the CNSP
- Increase in total number of enrolments
- Decrease in percentage of unplanned hospital presentations and admissions for patients with a chronic disease discharge.
The current redesign of the program is being developed as part of the ACI’s Centre for Healthcare Redesign (CHR) Program.
Defining the scope at project commencement is essential as well as continued engagement and problem solving with stakeholders.
- AIHW. (2013). The health of Australia’s prisoners 2012 Cat. No. PHE 170. AIHW: Canberra.
- AIHW. (2010). The health of Australia’s prisoners 2009 Cat. No. PHE 123. AIHW: Canberra.
- NSW Agency for Clinical Innovation. NSW Chronic Disease Management Program – Connecting Care in the Community: Service Model 2013
- NSW Agency for Clinical Innovation. Chronic Disease Management Self-Assessment Tool
- American Academy of Family Physicians. Risk-Stratified Care Management and Coordination
Sharon JacobsManager Service Development & Quality, Custodial Health
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3016
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