Clinical Pathways and

Care Planning

in the Correctional Environment

Cathi Montague RN, Midwife, ENB998, MClinNsg, FCENA

NMF, SA Prison Health Service

Central Adelaide Local Health Network

@cathimon

SA Health

SA Context

~2,400 beds/ 8 sites

~7,500 churn p.a.

Images credit:

www.computerworld.com

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#SoMe & grow me – 24/7!

#FOAMed #FOANed

Free Open Access

Medical /Nursing

Education

@cathimon #CSH15 #CorrectionalSvs

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Health – What is YOUR model?

Not important / Not applied?

Biomedical - condition without disease. Just OK / medication managed? Physical well-being

Holistic -

psychological, social, spiritual, cultural, physical.

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Australian incarceration figures

‘I don’t work in a prison service – this is nothing to

do with my work’

‘Prisoner health is the responsibility of prison

health services / the states / the prisoner…’

‘Prisoner health is too expensive, there are other

more important priorities….’

5

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Prisoner Characteristics – % change

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Chronic Health Conditions

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Weighty Matters…

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http://creativitycentral.squarespace.com/creativity-central/2009/6/14/thinking-outside-the-box-what-box.html

Constraints and Opportunities to thinking

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CHALLENGES FOR HEALTH IN PRISONS

http://patientsafetyed.duhs.duke.edu/

Challenges for health in prisons

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Drivers for Change

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Wicked problems?

A problem whose solution

requires a great number of people

to change their mindsets and behaviour

is likely to be a wicked problem

Source: Wikipedia

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Promoting a health culture and health care team that actively

supports and engages the patient in a proactive, health promoting

and early intervention manner at every interaction through:

• Dignity and respect

• Encouraging and supporting participation in decision making about health

• Communicating and encouraging informed sharing of health information

as required for the best possible care of the individual - that also balances

the right to privacy with the needs of other non-health providers to deliver

informed care and management.

• Fostering collaboration in health service design, delivery and evaluation.

NSQHS Standard 2 – Partnering with Consumers

Patient Centred Care

in the correctional setting

Further information? Australian Commission on Safety and Quality

in Health Care - Patient and Consumer Centred Care http://www.safetyandquality.gov.au/our-work/patient-and-consumer-centred-

care/

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Pathogenic:

• Why and what factors cause disease

• Find medical treatments

Salutgenic

• Identify wellness factors that maintain and

promote health.

Dilani, 2008

Pathogenic and Salutgenic Approaches

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SAPHS Health Care Pathway

SUB-ACUTE INPATIENT SERVICE:

Step Up / Step Down

OUTPATIENT MANAGEMENT:

Acute ; Trauma; Review; Medication

OUTPATIENT MANAGED HEALTH NEEDS:

BBV. STI; Chronic Disease; ATOD

LOW LEVEL HEALTH NEEDS: Medication Management / Health Reviews /

Stable Health Promotion; / Education

Mens / Womens Health

15

Rehabilitation? Aged Care?

Palliative Care? Disability Support?

Admission

Health Risk

Assessment

Comprehensive Health

Needs Assessment

Pre-release / Discharge planning Annual Health Review /

Clinical Pathways / Care planning

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Are:

• Evidence based tools that:

• assist all healthcare staff to plan, deliver and capture

coordinated, effective and timely care that meets identified

patient needs and goals.

• aim to improve standardisation of care against best practice

• reduce unjustified variations in clinical practice.

Aren’t:

• The only way to define or document health care needs, delivery or

timeframes for care.

• An ‘over-ride’ for individual clinical judgment, assessment or intervention

Care Plans and Clinical Pathways

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Well established clinical practice tool that seeks to improve patient

health outcomes through:

Meaningful patient participation in the care planning process –

through discussion and collaboration to establish health goals.

Health Goals should be SMART goals:

‘Simple, Measurable, Achievable, Realistic and Timely’

Improved communication between members of the multi-

disciplinary team to work together with the patient to progress

identified goals

Improved tracking of interventions / items requiring progression

or attention

Care plans work as a quick ‘at a glance’ guide to what issues / health needs

are being (or are required to be) addressed for the individual patient.

Care Plans Why, What, Who, Where, When

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What is a care plan?

A single document that captures all identified health needs

and care goals for an individual patient in one location.

Patients should only ever have one care plan in place at any

one time.

Ideally care plans are multi-disciplinary and can be shared

with the individual patient as a handheld health record.

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Who?

> needs a care plan?

• All patients with:

o >1 identified health need

o >1 clinical pathway being utilised at a time.

o complex or multiple health needs where a

clinical pathway is not available

o A variance or need identified on their

clinical pathway requiring further strategy /

SMART goal to manage.

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Who?

> starts a care plan?

• Can be any health team member.

• SAPHS requests nursing items on care plans are

approved by a senior nurse

> adds to a care plan? • Any SAPHS clinical member of staff (nursing, medical or

allied health) can add an item to a care plan in response

to an identified patient need – however:

o should involve the patient in discussion and

agreement (informed consent)

o must be communicated to other care-givers

e.g. through handover, documentation in the health record

to see Care Plan for further information.

o Must have the initial and delegation of the person

adding the item to the care plan.

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• START:

within one week of admission for all patients with

multiple / complex / chronic health needs

Or at any subsequent stage as required.

• STOP:

When the patient is discharged

When / if all health conditions are resolved, the care

plan can be stopped.

When?

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> Why?

• Developed against best practice guidelines and evidence

based care

• They can assist with:

Identifying appropriate sequences and timeframes of clinical

interventions, mile-stones and expected outcomes for a

homogenous patient group

Consistent coordinated care

Effective resource use

Capture of variations to the expected course of care

Clinical Pathways Why, What, Who, Where, When

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What?

• A standardised, evidence-based single document that

captures the patient journey (and patient deviation

from that journey) over a defined time frame

• For a single acute or chronic health condition that

has a predictable clinical course for the majority of

patients.

• Patients may therefore have several different clinical

pathways in place at a time, according to their health

needs.

• Supports long clinical entry documentation by

exception – all expected interventions are recorded

on the pathway, not in health record progress notes.

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Template example

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Example Clinical Pathway:CDM-Hepatitis C

Development Process:

Literature review:

• ASHM recommendations

• Medicare Items

• National /International Practice

Clinical SAPHS staff review

Clinical Governance review

Expert S.A. Specialist review –

Nursing and Medical

Clinical Governance Endorsement

Education and Implementation

Ongoing support and review

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Who?

> needs a clinical pathway? All patients with a health condition for which SAPHS has an endorsed

clinical pathway.

> starts a clinical pathway? Can be commenced by Nursing or Medical Staff.

> adds to a clinical pathway? All SAPHS clinical staff (nursing, medical or allied health) should work

to the Clinical Pathway.

The patient should be involved in education and informed consent/

refusal to the individual pathway healthcare interventions

Variations must be communicated to other care-givers e.g. through

handover, documentation in the health record to see Clinical Pathway

Variance Number and provide further information on the variance in

the health record if required.

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Variances

A deviation from the expected course of health

for the patient.

Currently documented on pathway, with brief

reference to the variance in the clinical progress

notes.

• Complex or lengthy variances are entered into the

clinical progress notes, with a brief reference on the

pathway.

Aim: to analyse written variances to try and

develop a standard ‘code set’ of commonly

occurring variances.

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• START:

At the time of identification of a health

condition for which SAPHS has an

endorsed clinical pathway available.

• STOP:

When the health condition is resolved.

When?

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Where to from here?

> Continue to develop and release clinical

pathways over time in accordance with key

priority areas.

> Pathway use and information will be audited

over time to establish required improvements

or adjustments to pathways and undertake

variance analysis as a part of the quality

cycle.

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Current Pathways / Development

> Annual Health Check

> Chronic Disease Management (CDM)

• Diabetes

• Cardiac

• Respiratory

Asthma Action Plans implemented as required

• Hepatitis C

> In development – a longer list based on clinical priorities

• Mental Health Care Plan

• Hepatitis B

• HIV

• CDM: Neurological, including seizures

• Palliative Care

SA Health

‘Clinical Pathways provide an evidence based standardised care process

which ensure quality care, an interdisciplinary approach and an ability to

monitor and undertake variance analysis.

Patient participation is increased in care when a partnership model is

utilised.

From a business management perspective, there is increased ability to

manage clinical budgets and use information to further develop activity

weighted funding’

Elizabeth Sloggett, SAPHS Clinical Risk Manager

‘Clinical Pathways help me see at a glance what care or intervention

my patient needs, and when. They’re a great reminder for all staff to

be able to undertake required care when I’m not here to undertake

my portfolio clinic’ SAPHS RN

‘Clinical Pathways and Care Plans greatly assist in complex case

management review and planning especially where negotiation, inter-

agency communication and up-escalation are required to identify high

needs or clinical risk’ Cathi Montague, NMF-Clinical Care Systems

SA Health

Mr. A – an amalgam patient

Admitted to prison with known COPD

Admission to Prison Stage 1 Health Assessment – flags

risks

High triage priority for comprehensive Stage 2 Health

Assessment Pathway, which identifies:

BSL 20

Palpitations

Abdominal distension and night sweats

Nurse triages as high priority for medical officer

assessment AND

Commences Clinical Pathway:CDM-Respiratory

Discusses a plan of care with Mr A, includes symptom

recognition and escalation

Commences care plan that addresses clinical and patient

led action items.

Offers patient copy of care plan to hold where appropriate

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Peace:

It does not mean to be in a place where there is no noise, or trouble, or hard work. It means to be in the midst of those things, and still be calm in your heart. Anonymous

QUESTIONS?