Continuity of medication and solving problems unique to the correctional setting

preso FATMany of the issues that nurses confront in the correctional setting while advocating for patients and their treatment are because health care is not the main goal, the burden of disease is great, and the population is transient with high turnover among inmates.

Problems with medications that arise from the setting: The most common problem in this category are inmates who do not show up to take medication at the prescribed time. While patients have a right not to take a medication in the correctional setting the patient must communicate this to the nurse by stating their refusal. The mere absence of a patient is not a refusal but a “no show” instead. There are many reasons why an inmate doesn’t appear to take their medication; it could be that they are at an appointment, in court or attending a program. It could also be that they have been moved to another part of the correctional facility or transferred to another institution entirely. It could be that no officer has let the inmate out of the cell or the housing unit. The nursing action to a “no show” is to follow up to find out where the inmate is and determine if the dose can be given later. Repeated instances of “no shows” need to be reported to the supervisor so that a systemic correction can be ma

Another problem is having the wrong medication delivered. Because there are so many inmates and they may have very similar names the pharmacy may dispense the wrong medication or staff may incorrectly identify the patient’s and put their medication in the wrong place in the med room or on the cart. This is one of the reasons for insisting upon two forms of identification and checking the medication against the MAR. When inmates have similar names, use of capital letters, color coding or some other way to easily distinguish one from the other is a practical solution.

Nurses who work in hospitals and other major health care settings have the advantage of quick access to the pharmacy for stat or urgent orders. Correctional nurses most often work in facilities that do not have an on-site pharmacy and in fact may use a mail order pharmacy located miles away. And yet there are times when an inmate arrives or an incident happens and a medication is needed quickly. Many of these types of situations can be anticipated (anaphylaxis, for example and medication epinephrine) and the medication stocked at the facility. Imagine though, an inmate arrives who is on the newest HIV medication and no other medication is a clinically appropriate substitution. It doesn’t make sense to stock some of every medication just in case there is a need. Instead, most facilities have made arrangements with a local pharmacy with 24 hour – seven day a week service to provide medications that cannot be obtained timely from the regular dispensing pharmacy. The nurse will be the one responsible for contacting the pharmacy and making arrangements for delivery once the provider has given the medication order. Correctional facilities without access to a backup pharmacy to fill urgent and stat orders jeopardize the health and safety of inmates.

Problems with medications arising from the burden of disease: Inmates as a population are sicker than the general community. There are many studies which have demonstrated the burden of disease among correctional populations. The majority take prescription medications, not only for one or more chronic medical diseases but often for a mental health disorder as well. Polypharmacy is a problem in correctional settings. The impact on nurses is an explosion of inmates on med line or who need KOP meds delivered, lengthy MARS that need to be transcribed and kept updated, and an increasingly complex patient care situation that can produce adverse events. Also the patients themselves, in this case, inmates, expect providers to treat conditions that many of us who live in the community would either not experience, ignore or treat ourselves without use of prescription medication. Because patients in correctional facilities see different providers, medications may be prescribed by one without being aware of what else the patient is receiving. A solution to this is to bring patients on multiple medications to the attention of the medical director or senior medical professional for review. These are patients perhaps better assigned to see one provider and for medical and mental health providers to collaborate when making treatment decisions. These are also patients whose treatment would benefit from pharmacy consultation.

Because of the presence of so many mentally ill persons in prisons and jails nurses are also likely to be involved in administration of involuntary medication to patients. State law and other aspects of law will govern the use of involuntary medication in your facility and you need to familiarize yourself with these requirements; hopefully your facility will have a policy and procedure. Many patients who have gone through the process of having an involuntary medication order put in place are very cooperative with the process. Medication may also be administered involuntarily in a psychiatric emergency; again, be familiar with your facility’s policies and practice as well as state law so that you are prepared if this becomes necessary.

Problems with medications arising from inmate movement: Missing medications are a huge problem, especially in large jails and prisons with multiple locations where medications are administered. If an inmate is moved from housing block A to D block, and a different medication cart is used for these two housing units, the nurse administering medication in block D isn’t going to have the inmate’s medication when it is time to administer it, unless the nurses are informed that the inmate has been moved before the next med administration and someone moves the medication from one cart to another. In this same scenario, if the inmate takes the medication KOP, it gets put into his property when he is moved and he cannot access it until the property is inventoried and returned to him. Solutions to this problem center on improving the timeliness of notification by custody to health care and nursing accountability to put the medication in the new location. For KOP a solution is to ensure prompt processing of property or providing a way for the inmate to bring the medication with them to the new location.

The problem of transfers is even more profound when an inmate is transferred from one correctional jurisdiction to another, from a county jail to a state prison and visa versa, from one county jail to another or one prison to another, from a jail to the Marshall’s Service to a series of jails for brief stays while being transported across country to another correctional facility. Nurses play a key role in providing a written transfer summary that includes a list of the inmate’s medical problems, the medications they are taking, recent labs and pending appointments. When this is not done it may be because the nursing staff did not receive timely notice of the transfer. If you receive an inmate from another facility who reports that they were taking medication it is best to contact the facility to verify the information and follow up until you succeed in receiving it.

Discharges is another problem area. When inmates return to the community, it is a well-established standard that they receive a supply of medication sufficient to ensure continued treatment until they are seen by a provider in the community. Again lack of timely notice that the inmate is being discharged is the culprit. Solutions to this problem are to work with classification officers to anticipate the probable discharge date. Inmates can also be good sources of information about probable discharge dates and provide information about the resources they use for health care while in the community. Some jails initiate discharge planning at the time of intake and provide inmates with information about how to obtain bridge medication until they see a community provider. Most facilities have processes in place to let inmates take the medication already dispensed, to provide a container of especially prepared discharged medication or for the inmate to go to a local pharmacy to pick up medication prescribed by the provider at the correctional facility within a couple days of discharge. The nurse’s role usually is to ensure the discharge prescription has been written, the patient has their medication upon release or has been provided with information about how to obtain the medication from a community pharmacy.

Managing and monitoring continuity of medication

One of the most important factors affecting patients’ willingness to follow the treatment plan is whether their symptoms are relieved and new ones not experienced (Ehret et al. 2013, Mills et al. 2011). If patients don’t feel better, they are not going to continue following treatment recommendations. Increasing adherence to prescribed medication has greater impact on health outcomes than any other specific form of medical treatment (Brown & Russell 2011, Sabaté 2003). Monitoring patients closely for symptom response, addressing side effects promptly and eliminating barriers and other reasons for medication discontinuity increase the likelihood of treatment success (Vellegan et al. a. & b. 2010). These three interventions are within correctional nurses’ independent scope of practice and can therefore be implemented without provider orders.

Specific steps correctional nurses can take to support the patient’s continuity of care in medication treatment are to:

  1. Notify custody staff of patients whose medication requires:
    • Dietary restrictions or a special diet for patients with diabetes or those taking MAO inhibitors for example.
    • Work restrictions such as not driving or using machinery when a patient is taking medication that causes sedation.
    • Canteen restrictions when for example a patient’s salt intake or carbohydrates must be limited.
    • Housing restrictions such as a lower bunk for a patient taking medication that causes dizziness or medically supervised housing for patients on medication that needs close monitoring (rehydration for example)
    • Environmental precautions: such as limiting exposure for patient’s taking heat or light sensitive medication.
  2. Schedule Follow up appointments with:
    • Nursing to check adherence by review of the MAR or the patient’s own medication if on KOP, to collect serial data such as blood pressure, weight, blood glucose and to find out from the patient if they are feeling better (intended effects) or experiencing side effects (unintended effects). Patients with poor adherence should be seen weekly while those with better adherence can be seen monthly or quarterly.
    • The patient’s provider(s) to review labs, discuss progress, symptom relief, side effects, adherence and adjust prescribed treatment as necessary. Provider appointments should be scheduled to coincide with the availability to lab and other monitoring measures as well in time to see the patient to re-order medication.
  3. Schedule lab and other monitoring measures to coincide with and take place in advance so that the data is available for review and discussion with the patient at provider appointments. Be familiar with common lab work recommended for medications you are responsible for providing to patients and help providers remember to order these when appropriate.

What problem areas do you experience with medication treatment that you believe are unique to the correctional setting? Do you have solutions to any of these problems that haven’t been discussed in this post? Please share your comments by replying in the comments section of this post.

For more about supporting medication treatment and continuity of care see Chapter 6 Chronic Conditions and Chapter 12 Mental Health in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Brown, M. T. & Bussell, J.K. (2011) Medication adherenace: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114.

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W. & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125.

Sabaté, E., ed. (2003) Adherence to Long Term Therapies: Evidence for Action. Geneva Switzerland: World Health Organization. Accessed January 24, 2015 at http://www.who.int/chp/knowledge/publications/adherence_report/en/

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 a.) Assessment of adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (1) 34-45.

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2010 b.) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice, 16 (5) 306-324.

Photo credit: © mag – Fotolia.com

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