Download pptx - Janet Mohle-Boetani, Deputy Medical Executive, Public Health,CCHCS

CORRECTIONAL MEDICINE: A PUBLIC HEALTH APPROACH

Janet Mohle-Boetani, Deputy Medical Executive, Public Health ,CCHCS

Public Health in Corrections Public Health/Medicine comparison Why public health in corrections? Public Health Framework

Exercises on public health interventions Public Health in Corrections: challenges Public Health in CCHCS Exercises on public health and primary

care Summary

Medicine:Public Health Crosswalk

Medicine Public HealthFocus Patient Population

Intervention Treatment/disease management – prevent harm after disease (tertiary prevention)

Prevention- of exposure (primary prevention) or disease after infection (secondary prevention)

Constitutional Care/Not deliberate indifference

Access to Care Consulting Public Health to get access

Community Standard of Practice

Evidence-Based Guidelinesfor care/hospitalization

Evidence-Based Guidelinesfor outbreak control/prevention

Measurement Vital signs, individual labs

# of cases, % of pop, rate of disease

Medicine: Public Health Crosswalk

Medicine Public HealthCharting Labs over time Cases over time,

Epidemic curve

Investigation Compare methods of treatment (clinical trial)Determine risk factors for survival after diagnosis

Compare methods of preventing disease.Determine risk factors for disease.

Quality Measures % of pop with lab values indicating good control(e.g.,HbA1c)

% of pop offered or received preventive measure (HIV screen, flu vax)

Public Health In Corrections: the 7 Cs Risk for CDs– 3 Cs

Correctional staff, Concentrated Communicable Diseases, Crowded Environment

Why- 4 Cs Constitutional right, Control CDs,

Continuity of Care, Community public health impact

Risks for CDs in corrections- 3 Cs Correctional Staff

Introduce influenza, pertussis, tuberculosis May work while symptomatic No occupational health program

Concentrated communicable disease (high prevalence) TB (25%), Hepatitis (40%), STIs

Crowded Environment- 175% capacity High incidence of chicken pox (transmission

from shingles) TB transmission

Public Health in Corrections: Why? The 4 Cs

Constitutional care/civil right to no deliberate indifference

Control communicable diseases in prison Prevent exposure (Env. Mitigation/hand hygeine/ condoms?) Prevent infection (vaccinations [disease with higher rate

than gen pop vs other diseases) Detect disease/infection (screening/surveillance:

TB/varicella) Isolation (ill)and quarantine (exposed during incubation

period): influenza, norovirus Offer intervention to those exposed to communicable

diseases (contact investigation) Continuity of care with community for communicable

diseases- e.g., tuberculosis treatment on admit and after parole

Public health in Corrections- Why? (the 4th C): Community Pub Health Impact

Opportunity to impact an underserved population

Problem Intervention

Unhealthy habits Stop smoking, healthy food, respiratory etiquette, hand hygeine

Poor access to preventive services

Offer vaccinations, HIV screening and early intervention

High prevalence of communicable diseases (TB and Hep C)

Offer screening and treatment

Community: Incarcerated Treatment inside: Impact outside

TB infection

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Public Health Framework

Ongoing Prevention Programs Primary (infection)

Vaccinations

Secondary (disease among infected) LTBI Rx

Tertiary (disease complications) TB case management

Episodic: Outbreak Control

Agent(SNITCH) IntroductionSusceptible PopulationContact (Infectious/Susceptible)

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PH Diseases/Pathogens: CCHCS

S N I T C H

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PH Disease/Pathogens: CCHCS

Shingles/Skin Diseases (MRSA)/STDs/Scabies

Norovirus infections Influenza Tuberculosis Chickenpox/Coccidioidomycosis HIV/Hepatitis

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Outbreak Control, CCHCS 2011

Component Intervention/Decrease

Agent introduction method:1) 2) 3)4)5)

Susceptible population

Contact between Infectious and Susceptible

Outbreak Component/Intervention 1

Introduce Agent Intervention

Employees Jail/Community Reactivation (TB) Environment (cocci) Visitors

Occ Health Program RC screening LTBI treatment Env. Mitigation Notices/screening

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Step/Component

Intervention/Decrease

Agent introduction:1) 2) 3)4)5)

Susceptible population1)2)Contact between Infectious and Susceptible

Outbreak Components/Intervention 2

Step/Component Intervention

Susceptible Population Unvaccinated

Immunocompromised (susceptible to severe cocci)

Vaccinations

Exclude from Cocci endemic area

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Step/Component

Intervention/Decrease

Agent introduction:1) 2) 3)4)5)

Susceptible population

Contact between Infectious and Susceptible

1)2)3)4)5)

Outbreak Component Intervention 3

ComponentContact between infectious and susceptible population

InterventionIsolation (separate diseased)Quarantine (separate exposed)HandwashingRespiratory HygieneCondomsDecrease overcrowding

Realignment (AB109)

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Step/Component

Intervention

Agent Introduction:1)Employees2) jail/community3) Reactivation (TB)

4) Environment (cocci)5) Visitors

• Employee health/ATD regs• RC screening• LTBI treatment• Recent TST converter monitoring• Environmental mitigation• Notices during influenza season

Susceptible population Influenza vaccinationsOther vaccinations (varicella, Tdap)

Contact between people Handwashing/Resp HygeineCondomsIsolation/QuarantineAB109

Challenges of Public Health in Corrections

Isolation from mainstream public health Inmate vs occupational health issues : role of

healthcare in public health contact investigations

Personal medical care/public health overlap Disease management (HIV, TB, STDs, viral

hepatitis): chronic care vs public health clinics Prevention: public health campaigns vs public

health clinics vs incorporate into primary care Transfer of medical information: jail/prison,

prison/community Quality management: standard measures?

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Public Health in CCHCS by Functional Unit

HQPolicies/

GuidelinesConsultation

PH NursingOperationalize

(Toolkits/consult)

InstitutionsImplement Programs

Epi/SuveillanceEvaluate Programs

Track Outcomes

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Goal: Change in Public Health Practice in CCHCS

From To

Disjointed/Fragmented

Reactive Isolated Fear-based Thriftless/High

Cost

Systematic Proactive Integrated Evidence-based Saving resources

Disjointed to Systematic

Outbreak Reporting – Email notes

No surveillance, dependent on state statistics for # of cases of TB

Written guidance for TB control

Use of state form, electronic Systematic surveillance-

outbreaks, TB disease, cocci, influenza (during H1N1)

Targeted eval of TB cases >6mos in CDCR (missed ops for prevention)

Guidance/Trainings for MRSA, norovirus, influenza, TB, chickenpox/cocci, HIV screening

Reactive to Proactive

Norovirus: 200-500 cases and institutions shut down for weeks

Massive TB contact investigations- institution shut down for weeks, yards on med holds for months, incomplete investigations

Influenza Outbreaks- massive 200-500 cases, mass vaccinations after the outbreak was detected

Clusters of 10-20 cases, no shut downs

Targeted and complete investigations- usually 20 inmates/employees per CI

Most outbreaks are fewer than 10 cases, effective isolation/quarantine, vaccination in the fall

Isolated to Integrated

No statewide PH committee participation

Minimal regional PH committee participation

Isolated within CCHCS

Active participation in CCLHO-CD, CTCA, Cocci WG

Formal structured meetings by regional PHNs with hospitals and local health departments

Participation in HQ committees (eg, RC), collaborate with nursing, QM, IT, and UM

Fear-Based to Evidence-Based Laborious HIV

counseling for screening- backlogs

Massive TB contact investigations (e.g., all ees at an institution) Emphasis on testing

Respiratory isolation and massive contact investigations for shingles

No condoms: fear of use as contraband

HIV opt out screening- quality measure 85% screened at RCs

Targeted TB contact investigations (usually 20 inmates and 10 staff) Emphasis on LTBI Rx for

infected

Resp iso for chickenpox not localized shingles Limited CIs for shingles

Condom distribution feasibility study- no evidence of abuse

Thriftless/High Cost to Saving

Tuberculin Testing on Transfer between institutions

Reactive to chickenpox- screening and vaccination AFTER exposure

Coccidioidomycosis- Ongoing morbidity and high costs

Screen for TB disease not infection on transfer- Saves $2 million each

year

Varicella prevention- targeted screening and vaccination BEFORE exposure Saves $1.3 million/5 years

Environmental Mitigation ($200K) + evaluation

Exercise: Public Health and Primary Care

What options are there for increasing access to public health clinical services in corrections?

Should public health be integrated into primary care? Pros and cons of integration

How could public health be integrated into primary care?

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Public Health and Primary Care – Level 1 (individual)

Free access to care for respiratory symptoms and rashes Problem list: TB disease, recent TB infection, LTBI

treatment PH clinical services in primary care (combine appts)

Immunizations (prim and tertiary prevention) LTBI treatment (sec prevention) STD treatment (prim, sec, tertiary prev)

TB case management (tertiary prev) primary care team Hospital discharge planning for suspect/confirmed TB

patients (team plans for DC when pt admitted) Continuity of medications when discharged from hospital Appropriate discharges to the general population

Community standard vs discharge into high risk population

Public Health Clinical Services- Options

Access to Public Health Clinical Services

Chronic Disease (30%)

Primary Care, integrate with annual TB screening

No Chronic Disease (70%)

Campaigns, Public Health Clinics, integrate with annual TB screening

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PH and Primary Care- Level II (registry based)

Registry of recent TB infections (within 2 years)

Registry of patients on LTBI treatment

Registry of patients with Hepatitis C

Exercise: Quality Measures What are some key public health

quality measures?

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PH and Primary Care- Level III(pop based assessment)

Vaccination coverage by population Recent infections- monitoring for 2

years by population LTBI treatment- completion of 9 mos

in 1 year by population TB treatment-completion in 1 year by

population

Public Health In Corrections Summary: the 7 Cs Risk for CDs– 3 Cs

Correctional staff, Concentrated CDs, Crowded Environment

Why- 4 Cs Constitutional right, Control CDs,

Continuity of Care, Community public health impact

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Public Health in Corrections: Summary

Prevention Programs

Standard Practice

Primary Care Primary (infection)

Vaccinations

Secondary (disease among infected) LTBI Rx

Tertiary (disease complications) TB case management

Communicable Disease

Outbreak ControlConstitutional Care*Call Public Health

Agent(SNITCH) IntroductionSusceptible PopulationContact (Infectious/Susceptible)

Public Health in Corrections in a nutshell

Control Communicable

Diseases Concentrated in

the incarcerated population

Crowded environment

Prevention programs

Primary care setting

Population-based assessments