Technical Assistance Report Focused Assessment of Health Services James T. Vaughn Correctional Center This report details findings from a five-day sitedetails visit, May 8-12,from to a This report findings Idaho State Correctional Institution. site visit, March 7-8, 2018, to James T. Vaughn Correctional Center, Smyrna, Delaware May 2018 Technical assistance by NCCHC Resources, Inc., is a professional activity that is completely separate from accreditation by the National Commission on Correctional Health Care and in no way guarantees accreditation, reaccreditation, or any other outcome of a survey. Resources, Inc. FOCUSED ASSESSMENT OF HEALTH SERVICES JAMES T. VAUGHN CORRECTIONAL CENTER EXECUTIVE SUMMARY Following a security disturbance at the James T. Vaughn Correctional Center on February 1, 2017, an independent review was conducted to discover issues and make recommendations regarding improvement of various areas of operation within the compound. Recommendation 9.1 of the review states that the Delaware Department of Correction ?should conduct an independent assessment of the health care and mental health care provided at the Consequently, the Department of Correction engaged Resources, Inc. (NRI), to assess the effectiveness of the daily inmate sick call process and its overall efficiency. Specific objectives were to assess and provide recommendations in the following areas: 0 Evaluate the quality of health services based on compliance with the Standards for Health Services in Prisons (2014 edition), with focus on health services policies and procedures pertaining to nonemergency health care requests and services sick call) 0 Review information (via charts, procedures, policies, interviews, etc.) pertaining to requests for sick call visits and care, as well as medical, behavioral and mental health, and dental care (all policies were cross-referenced with standards) 0 Review the overall process for managing nonemergency health care services and the timing between the initial request for sick call visits, delivery of care, and referral to a higher level of care 0 Review the process and frequency of sick call appointment rescheduling Two subject matter experts conducted a two-day on-site assessment that entailed gathering information and data through observation, interviews, and review of policies, health records, reports, and other documentation. Overview of Findings 0 Inmates are aware of the sick call process, but did not report receiving any instruction on how to access health care during intake orientation or receiving a handbook. 0 Waiting room space in the main clinic is limited and, due to the large volume of patients, some patients wait for hours to be seen or may be returned to their unit without being seen. 0 We found no obvious trends of sick call refusal due to the co-pay program. 0 Inmates reported being confronted by health staff with disrespectful or rude behavior. 0 Security staff shortages and mandatory overtime are causing fatigue and poor performance, as well as tension with health staff and the inmate population. 0 Security escort for off-site health services is perceived as compounding the staffing problems. Focused Assessment of Health Services 1 We thank the staff at the James T. Vaughn facility for their assistance and professionalism during the on-site visit. This cooperation enabled us to gather the data and conduct the review. Resources, Inc. Introduction INTRODUCTION Following a security disturbance at the James T. Vaughn Correctional Center on February 1, 2017, Delaware Governor John Carney issued an executive order establishing an independent review team to investigate and report on any conditions at the prison that contributed to the situation. The independent review team?s final report, issued in August 2017, makes numerous recommendations for improvement at the prison. With regard to health services, Recommendation 9.1 of the final report states that the Delaware Department of Correction ?should conduct an independent assessment of the health care and mental health care provided at the Consequently, the Department of Correction engaged Resources, Inc. (NRI), to conduct an assessment and to provide recommendations based on the findings. The present study was designed primarily to assess the effectiveness of the daily inmate sick call process and its overall efficiency. Project Objectives 0 Evaluate and provide feedback on the quality of health services based on compliance with the National Commission on Correctional Health Care?s Standards for Health Services in Prisons (2014 edition) 0 Assess health services policies and procedures pertaining to nonemergency health care requests and services sick call) 0 Recommend policy and procedure changes that can result in improved sick call process and overall health care efficiency and effectiveness 0 Review information (via charts, procedures, policies, interviews, etc.) pertaining to: 0 Requests for sick call visits and care: medical, behavioral and mental health, and dental The overall process for managing nonemergency health care services 0 The timing between the initial request for sick call visits, delivery of care, and referral to a higher level of care 0 Review the process and frequency of sick call appointment rescheduling, including its effect on the timing of care 0 Provide a written final report based on the observations made during the assessment Methods The team consisted of two subject matter experts?one physician and one administrator? who conducted an on-site review on March 7-8, 2018. The team?s first step was to select the key data sources and gather information necessary to come to a comprehensive conclusion regarding the availability, effectiveness and efficiency of patient sick call. The data were obtained from direct observation of sick call; review of policies, health records and other relevant documents; and interviews with inmate, security staff, and health staff. More specifically, as outlined in the project scope of work, activities included the following: 1. Interviews with key prison personnel to discuss patient movement and personnel availability and their effect on policies, procedures, and programs that affect health services, particularly on the sick call process Focused Assessment of Health Services 3 Resources. Inc. Introduction 2. Interviews with key contractor medical and behavioral health personnel to assist with department-wide assessment and evaluation 3. Review of the relevant health policies and contractor site-specific procedures in comparison with standards Review of the medication administration process Inspection of the pharmacy (medication room) and the medication distribution system Examination of nursing sick call protocols Examination of equipment and supply needs for the medical unit 9051.09?? Review of security staff training regarding signs and of medical conditions, first aid and cardiopulmonary resuscitation, and suicide prevention 90 Assessment of behavioral health sick call services through an examination of health records 10. Recommendations concerning other incidental findings that the subject matter experts may notice while evaluating the sick call process The NRI team was assisted by facility staff who familiarized us with the clinical area; provided documents for review, both in paper and electronic formats; aided us in navigating the electronic health record (EHR) system; and gave us access to relevant policies and documentation. In addition, escorts were provided to gain access to areas on the compound where interviews were conducted. Once the data were collected, we were able to focus on the relevant information, looking for patterns, trends, and themes regarding patient sick call, and brainstorming possible solutions to any issues that were uncovered through the review process. We also relied on the Standards for Health Services in Prisons as the basis of this review, especially with regard to effective processes relative to sick call. Findings are reported in the following sections: Interviews Electronic Health Records Sick Call Co?Pay System Patient Movement Patient Backlogs See the Recommendations section of the report for our suggestions for improvement. Focused Assessment of Health Services 4 Sick call See Appendix for NCCHC standard P-E-07 Nonemergency Health Care Requests and Services (essential) Estelle v. Gamble “Qualified health care professionals” include physicians, physician assistants, nurses, nurse practitioners, dentists, mental health professionals, and others who by virtue of their education, credentials, and experience are permitted by law to evaluate and care for patients. triage Nursing assessment protocols Timeliness a Resources. Inc. Sick Call Explained A face-to-face evaluation of a sick call request includes several steps: Welcome the patient (establish therapeutic milieu) Elicit and listen to the patient?s description of the health concern (subjective data) Examine the patient and collect data (objective data) Assess the patient and critical judgment) Establish a plan of care (inform and educate the patient) Evaluate plan effectiveness (ensure patient understanding) Follow through on the plan (patient advocacy) Focused Assessment of Health Services 6 Resources. Inc. Findings: Evidentiary Data EVIDENTIARY DATA Direct Observation of Sick Call Sick call is held in the clinic area for the lower custody units. The waiting room space in the main clinic area is limited. Regular sick call will result in up to 40 patients waiting to be seen for medical, dental, or mental health issues. We observed a large number of patients waiting to be seen by the appropriate provider on the days of our visit. The high volume of patients being called to sick call is a challenge for inmates, health staff, and security staff, both on the compound and in the health clinic area. Patients reported that they have waited in the clinical area for hours, only to be sent back to their units when the provider had reached the limit of patients he/she could see in a day. This is a source of contention for inmates. Security staff also mentioned this as a source of frustration, as many of these patients required a security escort to the clinic, only to later be returned to their unit. Sick call in the Special Housing Unit (SHU) and the Maximum-High Housing Unit (MHU) is held in the exam rooms that are on each high-security housing unit. Patients are brought into the holding cells to await the clinical encounter with the nurse. Overall, the patients interviewed expressed very little frustration or contention with the process. According to these patients, sick call occurs 7 days per week and is rarely interrupted, unless there is a security emergency such as a fight. When this occurs, sick call is rescheduled in a prompt manner. Review of Relevant Policies The facility provided us with the manual that outlines all health care policies. We reviewed the following policies: 0 Nonemergent Health Care (Sick Call) 0 Fee for Services (Co-Pay) 0 Medical Autonomy 0 Information on Medical Services 0 Security Escorts 0 Medical Grievances All relevant policies that we reviewed were cross-referenced with the appropriate standard as recommended by Review of Patient Health Records One major issue that affects daily work is that the EHR has many drawbacks and interferes with the effective delivery of health care. This will be discussed in the Electronic Health Records section of this report. Focused Assessment of Health Services 7 Resources. Inc. Findings SECTION 1 INTERVIEWS Inmate Interviews We interviewed a sampling of inmates from SHU, MHU, segregation, and general population. All inmates were asked the same questions, which touched on topics such as availability of health service request forms, the fee-for-service (co-pay) process, and any education from facility staff regarding access to health care. The responses revealed that sick call is occurring and that patients are able to see providers. They also revealed the following issues and concerns: 0 Inmates know how to request sick call using the forms provided. However, they unanimously said that when they arrived at the facility there was no orientation or education on how to access health services, and that there is no inmate handbook describing the process. The process seems to be something that is learned from other inmates on the housing unit. 0 Fee-for-service programs are common in correctional facilities, as are charges of $4 to be seen and $2 for medication. While some inmates expressed dislike for the co-pay system, we saw no trends that seemed to prevent the collective population from requesting care. One issue?reported more than once and mentioned in the February grievance log?is that inmates would be charged weeks or months before the service was rendered. In one case, an inmate said that he requested to be seen by the dentist. A co-pay was charged to his account and, at the time of our visit, he had been waiting more than 6 weeks. This creates distrust and could dissuade inmates from attempting to access the health care system. 0 Several inmates said that they receive good care depending on which health staff were attending. There were reports of health staff being short tempered with patients and displaying inappropriate social skills. It was reported that some inmates would refuse pill call if certain nurses were on duty because they felt they would not be treated respectfully. Concerns about this type of treatment could hamper inmates? desire to seek medical care. 0 Some patients have anxiety due to past events at the facility. One inmate said that he had a diagnosis of a on his thyroid and wanted a biopsy, but was concerned. When pressed on the issue, he revealed anxiety stemming from a media-publicized misdiagnosis of one patient?s medical issue. In describing his diagnosis and interaction with his provider, it appears his treatment regimen may be appropriate. However, given the general mistrust created by the media news story, health staff should take time to communicate issues to patients in order to prevent individual anxiety that can feed into the collective tensions. Security Staff Interviews We interviewed security staff of various ranks and who worked in different posts throughout the facility. The topics discussed included patient access to health care, interruptions of health services for emergency facility operations), escorting of patients to the health clinic or to appointments, sharing of health-related concerns between health staff and custody staff, conflicts in policies between custody and health care, and patient privacy. The unanimous response to questions regarding the sick call process is that sick call request forms are available and are picked up daily by nursing staff, and appointments are made based on priorities determined by health care professionals. Focused Assessment of Health Services 8 Resources. Inc. Findings Our interviews with security staff revealed the following concerns: 0 Security staff position control numbers are down and the staff shortage is considerable. This has created mandatory overtime of at least one to two extra shifts every 2 weeks. For some, the overtime contributes to fatigue and lack of desire to perform at their highest ability. This is reported as a factor that creates tension between security staff and health staff. 0 Security staff report frustration with a perceived lack of safety practices within the main clinic area. Several staff said that they have expressed concerns to shift and facility leadership about the high volume of patients waiting to be seen in the clinical waiting area, feeling that it is a primary safety concern within the compound. At the same time, there was unanimous agreement that patients are being called to the clinic area for appropriate health care issues. That makes the issue unavoidable but is a large source of tension within security staff ranks. 0 Another point of contention is the volume of escorts to off-site appointments. It was reported that at times up to 19 officers were doing off-site escorts within a single shift. We did not verify this. However, the contention is that with short staffing and high volume of staff going off-site, it creates a strain on safe numbers of security staff available on the compound. This safety issue also strains the relationship between security staff and health staff. Health Staff Interviews Health care staffing numbers have recovered to levels that preceded the events of 2/1/17. The staffing model is adequate, but the following staffing vacancies were noted at the time of the review. In nursing, there are vacancies in many key areas that are being covered by other nurses, which sometimes causes critical functions to be left unattended to due to lack of time. 1 staff physician 0 5 charge nurses 0 1 dental hygienist 9 registered nurses 0 1 medical records clerk 5 licensed practical nurses 0 1 medical unit clerk Key findings from our interviews are as follows: 0 One major issue that affects daily work is that the EHR has many drawbacks and interferes with the effective delivery of health care. 0 The sick call process structure does not empower providers to have control over their own schedules. 0 Patients who need to be seen for chronic conditions) may not get seen in a timely manner because the system is geared to favor patients who present with complaints. 0 Nursing staff is tasked with addressing complaints that are not related to health care. 0 The grievance process is not clearly defined for health care matters. This process will be addressed by a separate work group. 0 Patient wait times in the main clinic are long and increase the likelihood that a patient will refuse a visit. 0 Seeing pretrial detainees is a challenge due to court schedules. 0 Visits with legal professionals, which utilize privacy rooms and security staff, can interfere with the sick call process. Focused Assessment of Health Services 9 Resources, Inc. Findings SECTION 2 ELECTRONIC HEALTH RECORDS The facility?s EHR program is which was implemented in April 2014. As noted in Section 1, health staff reported that the system interferes with the effective delivery of health care. The system is slow and frequently loses data. Connectivity is clearly an issue. The way that the workflow is set up on is inefficient in many cases and requires extra clicks in order to accomplish simple tasks. Staff universally use ?work-arounds? to place documentation in the chart. For example, they enter data on Microsoft Word documents, then ?copy and paste? the data into RT. Documentation is often done after hours due to the fact that data entry is time intensive. One medical provider who sees 12-15 patients per day reported working 80-100 hours per week in order to complete documentation. Scheduling for mental health and visits is done on an Excel document rather than because a built-in process on automatically schedules incorrect appointment types and inappropriate follow-up times. ?Emergency? visits are automatically scheduled within 24 hours on This language is not consistent with a 24-hour visit; changing ?emergency? to ?priority? is more appropriate. A lab interface does not exist. Currently, labs are printed out, signed, and then scanned into the record. Medication renewals are inefficient and cumbersome. The pharmacy contractor faxes a list to the facility. The provider must then order medications one by one into Late entries in are a common occurrence due to slow or poor connectivity and the risk of losing documentation. Some forms require that a nurse enter an code for a diagnosis. Since nurses are not supposed to diagnose conditions, this step should be reconsidered. Furthermore, searching for an diagnosis in order to complete a note slows the workflow for nursing staff. Providers are not using the chronic care module consistently due to system slowness and the risk of losing documentation. The physical exam section is used by some providers. All progress notes get saved into the same section of the chart, making it difficult to quickly access information There is no search function (by provider name or specialty) to find prior documentation. Follow-up visits may be deleted by staff members incorrectly, but there is no effective way to track this process to recover visits. Scheduling of visits: if a patient isn?t seen one day, the appointment does not automatically ?roll over.? Rather, health staff must manually reschedule the visit. This creates the risk of a patient visit being missed completely. Focused Assessment of Health Services 10 Resources. Inc. Findings SECTION 3 SICK CALL Nursing staff pick up and triage the sick call forms. In the SHU and MHU, the forms are picked up twice daily during medication pass, and in the other housing units, they are picked up at the designated drop box once daily. Nursing staff triage the sick call forms consistently in accordance with the written policy and see the patients in a timely manner. The NRI team does not have concerns about the timeliness of form pick-up or triage. However, we observed the following concerns related to sick call documentation in SOAPE (subjective, objective, assessment, plan, education) notes are documented, usually using the ?copy and paste? method from Microsoft Word into the templates. This method of data entry is used out of necessity, due to the time-consuming nature of documenting in and the risk that data will be lost while writing a note in This work-around adds extra steps to the documentation process but has been found to be more time efficient than documenting directly in 0 Sick call forms are scanned into the record but are not attached to the RT note. 0 Nurses are triaging many complaints that are not related to medical issues, which is not good use of medical staff time. For example, they receive requests for pencils and lotion. SECTION 4 CO-PAY SYSTEM According to policy, inmates receive a written explanation of the co-pay program at the time of admission. Charges for health care are $4 for sick call and $2 for medications. Health staff do not collect fees. Services excluded from the co-pay program include the following: Admission health screening Health assessments required by policy 0 Emergency care 0 Infirmary care 0 Ordered laboratory and diagnostic service 0 Diagnosis and treatment of contagious/communicable disease 0 Any chronic care clinic, including any mental health service, which also includes ordered medications to maintain health Charges are not assessed when seen by one or more providers for the same problem three times in a 7-day period. Furthermore, health care is not denied because of inability to pay. Inmates may use the grievance process to lodge complaints about the co-pay program. Grievance and other relevant data are reviewed to verify that the co-pay program does not impede access to care. In ourjudgment, the copay system is not punitive and does not impede access to health services. Focused Assessment of Health Services 11 Resources. Inc. Findings SECTION 5 PATIENT MOVEMENT We identified the following concerns regarding patient movement for health services: Mandatory overtime hours for security staff reportedly results in an assignment at the clinic. 0 Identification by security staff of patients who need urgent or emergent care may be impeded by excessive fatigue. 0 Patients on work assignments have difficulty getting seen in the clinic due to their work schedules. 0 Unsentenced inmates also have difficulty getting seen in the clinic. At times, court schedules may interfere with clinic visits. 0 Legal visits can interfere with sick call workflow, as privacy rooms are used by attorneys visiting their clients. SECTION 6 PATIENT BACKLOGS Backlogs on schedules exist for certain disciplines, physical therapy in particular. This can lead to obstacles in access to care. Some patients may find other ways to access to care, for example, by claiming an emergency for nonurgent conditions. This was stated by more than one inmate during the interviews. Focused Assessment of Health Services 12 Resources. Inc. Recommendations RECOMMENDATIONS Sick Call Overall, sick call for all disciplines is greatly hampered by an inadequate electronic health record system. Extensive revamping or replacement of and overall improvement of information technology infrastructure are necessary. Without these changes, staff productivity will continue to be severely limited. Complaints that are not related to health problems should not be part of the sick call process. A separate process should be developed to address requests for extra items. The sick call process should be restructured so that a provider visit is not mandated after a patient escalates a complaint through nursing. A chart review by a provider will usually suffice. A provider can then determine the next course of action. Health Records Issues surrounding the EHR need to be remedied in order for health staff to deliver effective health care and to limit liability concerns. 0 This includes addressing issues with connectivity and slowness. 0 Major workflow restructuring within the program is also needed. 0 Being able to document visits in real time at the site of the patient visit at the clinic in the SHU) allows for delivery of optimal patient care. This is rarely done due to issues of connectivity and slowness. Health services should develop a standard to ensure that all staff indicate when they have documented a late entry. Sick call forms should be attached to the sick call documentation Patient Movement Health services should conduct a process study to address the high volume of patients that are brought into the clinic waiting room, sometimes for hours, to be seen for sick call or by a provider. A comprehensive look at patient movement is needed. Close coordination between medical, dental, mental health, and security is needed to optimize movement of patients. An innovative approach to scheduling of visits should be considered to have patients seen during times when staff are usually not present in the building. 0 For example, rotating staff during evening hours or weekends to aid in patient movement and staying caught up with sick call can reduce the strain that happens during peak hours. The staff hours can then be ?flexed? in order to minimize overtime. For patients who are on work assignments, health care staff and security should coordinate to ensure that they are seen outside of work hours. For unsentenced inmates, coordinating visits with security in advance can help reduce obstacles to delivering prompt health care. Focused Assessment of Health Services 13 Resources. Inc. Recommendations 0 Coordination between health care staff, security, and attorneys who visit clients is needed to reduce interference with sick call workflow. Patient Backlogs Backlogs on schedules should be addressed and a plan implemented to reduce the backlog over a defined period of time 60 days). 0 Prioritization of visits and workflow analysis should be done to ensure access to care in a reasonable amount of time for a wide array of patients. Focus on identifying follow-up visits that may provide little patient benefit and cancelling these visits. 0 Patients should receive more materials on self-care. Patient Education 0 Use patient education forms and postings on bulletin boards to increase health literacy and reinforce health care policies. This has the potential to improve the efficiency of the sick call process through reduced complaints. 0 Regular use of patient information sheets also can help to increase health literacy. These sheets can be handed out during nursing/provider visits and posted on bulletin boards in the housing units. Examples of topics include the following: Latent tuberculosis Hepatitis and Dental problems Substance misuse Sprains/strains Upper respiratory infections Constipation/diarrhea Acid reflux Extra items 00000000 0 The focus should be on self-care and over-the-counter remedies. Communication 0 Provide training that focuses on communication between custody staff and health staff, as well as between health staff and inmates. Reinforce to staff that it is unacceptable to have rude or demeaning conversations during patient encounters. Employ a more empathic form of daily communication to ease the inmate populations? collective anxiety and tensions that arise after a major disturbance. Staffing 0 Work to improve nursing staffing. 0 Conduct a study that addresses recruitment of nurses and other health staff. Focused Assessment of Health Services 14 Resources. Inc. About Resources, Inc. DISCLAIMER Technical assistance by Resources, Inc., is a professional activity that is completely separate from accreditation by the National Commission on Correctional Health Care and in no way guarantees accreditation, reaccreditation, or any other outcome of a survey. ABOUT RESOURCES, INC. A nonprofit organization, NRI works to strengthen mission: to improve the quality of health care in prisons, jails and juvenile detention and confinement facilities. NRI leverages expertise in correctional health care to provide customized education and training, preparation for accreditation and professional certification, performance improvement initiatives, and technical assistance to correctional facilities interested in health care quality improvement. For more information, contact us at or call (773) 880-1460. Focused Assessment of Health Services 15 Rasou rcos. Inc. Appendix APPENDIX: STANDARD P-E-07 Patient Care and Treatment NONEMERGENCY HEALTH CARE REQUESTS AND SERVICES mm! Standard All inmates have the opportunity daily to request health care. Their requests are documented and reviewed for immediacy of need and the intervention required. Quali?ed health care professionals respond to health senaces requests and conduct clinicians clinics on a timely basis and in a clinical setting. Compliance Indicators 1. Oral or written requests for health care are picked up daily by quali?ed health care professionals and rriaged within 24 hours. When a request describes a clinical a face-to-l'ace encounter between the patient and quali?ed health care professional occurs within 48 hours (72 hours on weekends). 2. When responding to health services requests. quali?ed health care professionals make timely assessments in a clinical setting. Quali?ed health care professionals according to clinical priorities or. when indicated. schedule patients as clinically appropriate. 3. All inmates. regardless of housing assignment. have access to regularly scheduled times For nonemergency health services sick call). 4. The frequency and duration of response to health services requests is sufficient to meet the health needs of the inmate population. 5. All aspects of the standard are addressed by written policy and det'med procedures. De?nitions Daily means 7 days per creel?. including holidays. Request for health care refers to oral or written petitions for medical. dental. or mental health services. These requests are to be documented. Responding to health service: requests is the medical. dental. and mental health evaluation and treatment of an ambulatory patient in a clinical setting by a quali?ed health care professional. (?lime-tan '3 ohm: is a designated time and place for physicians. nurse practitioners. physician assistants. dentists. or mental health clinicians to respond to health services requests. ("hmcat setting refers to an examination or treatment room apmopriatcly supplied and equipped to address the patient ?s health care needs (see D-OJ Clinic Space. Equipment. and Supplies). 83 Focused Assessment of Health Services 16 Rasou rcos. Inc. Appendix National Com-ism on Correctional Halli Curr Triage is the sorting and classifying of inmates? medical. dental. and mental health requests to determine priority of need and the proper place for health care to be rendered. Discussion This standard intends that inmates? routine health care needs are met. There are many ways to satisfyr this standard. Inmates can accw the health care system by walking into a clinic and making an appointment. writing their requests on slips that are dropped into a locked box (these are picked up by health staff who go to all housing areas). telephoning a nurse in the clinic. or using sign-up sheets in the dining hall or housing area. In all cases. we should be taken to protect the con?dentiality.' of inmates' health concerts (see 11-09 Privacy of Care and H-02 Confidentiality?r of Health Records). A disposition is tnade and noted on the health request form or in a log or appointment book patient requested to appear at the next regularly scheduled period for none-mergent care. dental appointment Made. referred to Not every nonen?tergetteyr health services request requires an appointment: however. when a ntedical. dental. or mental health request describes a clinical a face-to-face encounter between the patient and a health professional is required. The frequency and duration of providing mnemergency health services may vary according to facility size. Correctional institutions with a hi 3h proportion of segregated inmates or special needs patients may require more frequent opportunities for nonemergency health sen-"ices or extended hours to accommodate all requests and needs. When indicated. referral to the clinician?s clinic is made for the inmate to see a physician or midlevel practitioner. In general. when a patient presents for nonemct?gency health services more than two times with the same complaint and has not seen a physician. he or site receives an appointment to do so. When quali?ed health care professionals are not on duty within a 24-hour period. health-trained correctional staff. using facility protocols established by the legal and health authorities. review and respond to iruttates' health care requests (see (3-08 Health Care Liaison). Because better disposition decisions are lilter to result. it is recommended that quali?ed health care professionals with the most experience triage and assess inmate health care requests. Focused Assessment of Health Services 17