Continuity of Care

Continuity of care is a process that must involve the patient and all members of the health care team. The correctional health care team should work to manage all care delivered and should always strive for quality in delivery of that care.

Patients are seen by a number of providers for various types of encounters in many locations in the facility, which leads to concern about the potential for fragmentation of care. Correctional nurses play an essential role in the coordination of care for the patient. Nurses must embrace their role as a patient advocate and work closely with other members of the health care team to ensure that each patient’s needs are met in a timely manner.

Nurses are the eyes and ears of the health care program, typically providing care 24 hours a day, seven day a week at most correctional facilities. For all patients, the initial intake encounter is the first opportunity for the nursing staff to identify both immediate and long-term patient needs. The nurse must then communicate those needs to the appropriate members of the health care team and ensure that any care ordered is completed in a timely manner.

Nurses interact with patients during many other types of encounters, including sick call, disease management encounters, urgent visits, patient education sessions and medication administration. Each encounter is an opportunity for the nurse to identify potential patient need and to ensure that each identified need is appropriately addressed.

Common Challenges
All correctional facilities present unique challenges to the nursing team. For example, jails are typically fast-paced environments with a great deal of emphasis on the intake process. The rapid entry and exit of inmates presents a critical challenge to the nursing team. It is essential that the nursing team work closely with custody staff to identify inmates held in intake areas who have the greatest need of an initial evaluation. The nurse must ensure that those individuals are seen within appropriate periods of time and their needs are addressed.

Prison nurses usually focus on care needs for a population that will be in the facility for longer periods of time. Care here can focus on long-term care issues while being ever aware of the opportunity to identify a new need through the various nursing encounters that occur.

In both settings, nurses must ensure that their evaluation and interview skills are sharp so they can obtain the best possible information from the patient to develop a clear clinical picture of the patient’s needs. Nursing is vital to the success of positive patient outcomes and it critical that the nurse makes appropriate nursing decisions and takes appropriate measures for each patient encounter.

Certain aspects of care present a risk of disrupting the continuity of care. One of these is medication administration. This is one of the most challenging aspects of care for the correctional nurse due to the volume of medications administered combined with the processes necessary to obtain the medications in a timely manner, account for the medications, ensure the medications are available for each patient even if transferred within a facility, obtain renewed medications and document administration of medications and noncompliance. It takes strong teamwork and diligence to ensure that each patient is given all medications ordered by providers.

Another threat to continuity of care arises during the transfer process. It is essential that clear communication flows between the sending and receiving facilities. That communication should include information about current treatments, medications, scheduled appointments and diagnostic studies. The information to be shared should give the receiving facility a clear picture of the current treatment needs of the arriving patient.

Continuity of care can suffer when we are not functioning at our best level of performance. Correctional nurses must be keenly aware of the stressful environment in which they work on a daily basis. The nurse is continually faced with a high volume of work in challenging working conditions and, at times, conflict with custody staff, other health care team members or patients. There are times when the nurse is unable to gain appropriate access to patients or feels frustrated with the overall constraints of a custody environment.

Nurses must recognize those challenges and the impact they may have on their daily decision making. They must be vigilant to not let themselves become insensitive to patient need because of the stress they themselves experience. Burnout and failure to rescue a patient in need can easily occur in the correctional health care setting, and when it does, there can be dire consequences for the patient. The nurse manager must constantly guide and coach staff members on how to address this burnout. The focus of all actions must remain on the patient.

Well-Defined Processes
To address the needs of the patient population, correctional facilities should have clearly defined processes, including policy, procedure, forms and communication plans. Use of national standards that guide correctional health care is also valuable. Nurses are responsible to clearly understand each clinical process and to carefully follow those processes in their daily activities. Knowing and understanding the standards for their practice setting helps the nurse know how to properly handle the daily challenges that can arise. Just one failure to follow facility processes to address patient need can result in a negative patient outcome.

Correctional nurses have a responsibility and obligation to their patients to ensure that medical, mental health, and dental care is coordinated and monitored from admission to discharge (NCCHC Standard J-E-09, 2018; Correctional Nursing: Scope and Standards of Practice, third edition, 2020). Inherent in the provision of continuity of care is the involvement of the patient and all members of the health care team. Due to the potential fragmentation of services provided to incarcerated persons, it is essential that correctional nurses embrace their role as patient advocate and work closely with other members of the health care team and their custody colleagues to ensure that each patient’s needs are met in a timely manner. Patients may see multiple providers in various types of encounters in locations inside and outside the facility. Correctional nurses play an essential role in the coordination of care for the patient.

Correctional nurses are foundational to the health care program, typically providing care 24 hours a day, seven days a week at most correctional facilities. For all patients, the initial intake encounter is the first opportunity for the nursing staff to identify immediate and long-term patient needs. The correctional nurse must then communicate those needs to the appropriate members of the health care team and ensure that any care ordered is completed in a timely manner. Correctional nurses interact with patients during many other encounters, including sick call, chronic disease management appointments, urgent visits, patient education sessions and medication administration. Each encounter is an opportunity for the nurse to identify potential patient needs and to ensure that each identified need is appropriately addressed.

Challenges to Continuity and Coordination of Care
Correctional facilities present unique challenges to the correctional nursing team.

Typically, jails are fast-paced environments with emphasis on the intake process. The rapid entry and exit of incarcerated persons present a significant challenge to the correctional nursing team in identifying and addressing patient needs. It is essential that the correctional nursing team work closely with custody staff to identify persons held in intake areas who have the greatest need for an initial evaluation. In addition, the correctional nurse must ensure that all individuals admitted to the facility are seen promptly and their needs are addressed.

In comparison, correctional nurses working in the prison setting usually focus on care needs for a population that will be in the facility for longer periods of time. This focus most often involves long-term/chronic care issues, although it is vitally important that the prison correctional nurse is able to identify a new health need or abnormal condition during the various nursing encounters that occur.

In both settings, correctional nurses must ensure that they are proficient in physical evaluation and interviewing skills so they can obtain the information from the patient that will enable the development of a clear clinical picture of the patient’s needs and an appropriate treatment plan addressing those needs. Correctional nursing practice is vital to positive patient outcomes and it is imperative that correctional nurses make appropriate nursing decisions and provide appropriate nursing interventions for each patient encounter. Providing evidence-based care and engaging in continuing education are two factors that impact appropriate correctional nursing practice.

Threats to Continuity and Coordination of Care

Inherent in the environment in which correctional nurses practice are potential challenges to our ability to provide appropriate continuity and coordination of care. These include medication administration processes, frequent transfers to and from the facility, and the physical and mental status of the correctional nurse.

Medication administration, procurement, and management are processes that may be challenging in the correctional environment due to the volume of medication administered; the inability to obtain certain medications so the therapy remains uninterrupted; the necessary documentation that may impact on timeliness of administration; the transiency and transfers of our population; and the important need to provide patient education, potentially at administration and upon refusal. It takes diligence and strong teamwork to ensure that each patient receives all ordered medications.

Another threat to continuity and coordination of care arises during the transfer process. Clear communication between the sending and receiving facilities is essential and should include the patient’s pertinent health history; current treatments; prescribed medications; and scheduled appointments, referrals, and diagnostic studies. The information should give the receiving facility a complete picture of the current treatment needs of the arriving patient and the process should be followed for each transferring patient. In addition, the receiving correctional nurse should feel comfortable calling the sending facility with any questions.

Correctional nurses work in a stressful environment, and continuity and coordination of care can suffer when correctional nurses are not functioning at their highest level of performance. Challenges to correctional nursing practice include a high volume of work; conflicts with custody staff, coworkers, and patients; difficulty accessing patients to provide care; lack of supplies necessary to conduct patient care; lack of management support; and in general, providing patient care in a facility where health care is not the primary mission. In addition, research has shown that nurses suffering from lack of sleep, as may occur with too much overtime or too many shifts in a row, make many more errors than those who come to work refreshed. Correctional nurses must recognize these challenges and the impact they may have on their decision making ability. They must be vigilant to monitor themselves for insensitivity to their patients’ needs because of the stress they, themselves, are experiencing. Burnout and failure to rescue a patient in need are two very serious situations that can occur and may result in significant negative consequences for the patient. Correctional nurses must always remember that our practice is patient-centered.

Ensuring Continuity and Coordination of Care

To address the health care needs of incarcerated patients, correctional facilities should have clearly defined processes for health care, including policies, procedures, forms, and communication plans. The nationally recognized NCCHC Standards, created by experienced correctional health leaders and tested in the Courts, are an excellent place to start.

Correctional nurses are responsible for understanding each clinical process followed at their facility and carefully adhering to those processes in their daily activities. They should know and follow their state nursing scope of practice and their Correctional Nursing: Scope and Standards of Practice, which will guide their patient-centered care in the correctional environment and will help them address the potential daily challenges that may arise. They should be knowledgeable about the nursing care they provide or may potentially provide and should be life-long learners. The correctional nurse should be aware of the communication processes in the facility, including how to contact providers, make appropriate referrals, document care ordered, and care provided, as well as the patient’s response, so that other members of the health care team are aware and can provide subsequent care per the treatment plan and patient need.

Continuity and coordination of care requires an interdisciplinary team approach that includes our custody colleagues and our patients. Processes must be clearly established and followed by the health care team. Correctional nurses have an obligation to their patients and themselves to maintain their health, their knowledge base, and always practice within their scope. Correctional nurses are integral to continuity and coordination of care for all incarcerated persons at their facility.

Author Lori Roscoe, DNP, PhD, APRN, CCHP-RN, is the Accredited Provider Program Director for NCCHC, co-chair of the NCCHC Nursing Education Subcommittee, and a member of NCCHC’s  Multi-Disciplinary Education Committee.  Through her companies, The Correctional Nurse LLC and Correctional HealthCare Consultants LLC, Dr. Roscoe provides accredited continuing education specialized for correctional nurses and maintains CorrectionalNurse.Net, a blog about correctional nursing practice, and offers professional consulting services in correctional healthcare operations, staff training and legal matters.