Same with nurses due to their specialty care facilities. So no one ever looks to come here full time. And the chiefs here know that we are posting positions to be filled with [temporary staff]. And so the cycle goes.” To overcome the cycle of temporary-staff usage, enable the sustainability of change, and maintain the spirit and knowledge of the implementation through consistent staff, a separate program was developed Nursing positions had the highest number of vacancies overall and also carried the highest fill rate. An analysis was commissioned to understand the ratio of clinical-position staffing relative to workload. Time-motion studies were carried out and combined with human resources initiatives designed to place employees in“hard-to-fill” posts. The result of these efforts was a program dedicated to nurse staffing designed to work hand in hand with CCM implementation, ultimately enabling sustainability of the overarching transformation effort.For health care quality improvement efforts to be sustainable in a correctional environment, local physician and nurse champions are required . Also important is an interdisciplinary implementation team involving a variety of health care team members. In the custodial health care setting, correctional officers are key stakeholders. Hence, identifying a local custody champion to be part of the interdisciplinary team was critical. The team of interdisciplinary champions was provided sufficient release time to participate in training and development in the areas of quality improvement, the chronic care model, and clinical diabetes content. Gaining the support of the custodial personnel who are responsible for prisoner control and safety related to health care needs was essential to overcome the institutional barrier. Correctional officers, and more specifically their captains and assistant wardens of health care, were brought into the primary care team meetings to be educated and trained on the methodology and processes. Feedback was received from team members on how to improve existing processes. The CCI implementation team decided that, as cultural change agents,vertical garden hydroponic they ought to be provided time to plan, implement, and disseminate change after inculcating an understanding of what the change meant for them, their particular departments, and their coworkers.
In this custodial environment, a reliance on one’s teammates and coworkers for success and safety was paramount, much as in work environments with nuclear reactors. In the receivership experience, champions were selected based on their expressed interest in serving as a catalyst for change in their pilot site; they were also identified as excellent clinicians who were respected by their peers. Physician involvement is critical to a successful change effort and program implementation within a health care delivery setting . Among the champions, the physician leaders’ commitment to the model and the change it represents must be asserted from the beginning. In order to achieve the goal of developing workforce competencies after receivership, several local institutions’ chief medical officers were recruited as the core project team’s clinical leaders. Practicing physicians and nurse consultants were recruited as quality improvement advisors.Health care delivery system design for prisons is a significant challenge. Contrary to models of care delivery external to the correctional environment, the primary mission of the institution from the custody perspective is security; health care delivery is procedurally treated as secondary. Typically, prisons are constructed with little or no space for clinics or medical supply storage. To implement a new CCM, the fundamental delivery system design had to start with the basics of creating adequate space for exam rooms so that the interdisciplinary team could provide integrated patient care. Once the issue of clinic space was addressed, the delivery system was changed to shift from a siloed, single-provider approach to a patient-centered team model. The Chronic Disease Management Program’s pilot prison sites adopted a managed-care-based primary care model and redefined the care team’s roles and definitions from a traditional solo provider medical model to an interdisciplinary team model. Treatment of inmate-patients was thus transformed to enable a more comprehensive level of care with each visit, with the goal of increasing quality of care and reducing the need for future medical visits.
Given the state government’s bureaucratic structure and a heavily unionized workforce, it was necessary to create new job classifications in the organizational structure as permanent positions—for example, nurse executive, nurse clinical care coordinator, nurse case manager, and medical assistant. In California, state employees are unionized, and as a result managing labor relations proactively during the delivery system design was critical to minimize employee grievances, union resistance, or both. Transparency and proactive collaborative approach were the keys to minimizing resistance from the unions. Planned group visits or health education classes proved to be a strong component of the delivery-system design in the correctional system.At the time of the program’s design the California prisons did not have enterprise-wide information technology connectivity and most clinic areas had no access to computers. The pilot prison sites therefore used the Chronic Disease Electronic Management System’s Disease Registry for asthma and diabetes as a temporary solution. As additional staffers were needed to perform data-entry functions and there was limited physical clinic space, the adoption was challenging. Some pilot prisons employed a low-tech, manual, tickler-file approach of tracking inmate-patients with chronic conditions. To overcome the identified institutionalized barrier of using memorized manual processes and tools to perform work, the benefits of the new systems were discussed during learning collaborative sessions. Additionally, continuing educational unit needs were identified and promised for delivery through new automated solutions. Communications were coordinated with other departments concerning other aspects of computerization to be implemented within the facilities as some of these programs were generally well accepted by staff. Staff also saw self-management support as reducing workload, and this further contributed to their acceptance of the changes.Confinement for high-security inmates is the primary obstacle to implementing self management support. Custodial concerns and rules greatly inhibit the inmate-patients’ ability to perform aspects of self-management of routine care. For example, some prisons prohibit the use of a medical device known as a drug delivery spacer due to it being physically sharp with the potential to be converted into a weapon.
Serum glucose monitoring and insulin injections are typically performed by a licensed vocational nurse instead of by the patient. Despite the custodial constraints against self-management,vertical farm tower peer education was successfully utilized as a prominent strategy for promoting health education and compliance for inmate-patients at lower security levels. While clinical and custodial staff had institutionalized aversion to dealing with inmates on an educational level, the cultural processes by which inmates tend to mentor other inmates was strong. As described by an associate warden of health care who was involved in the pilot program, “they, particularly the older ones or the ones trying to get themselves together—like for parole or if they found God—are all about educating each other or at least other inmates who they talk to. I knew back then I wasn’t going to tell my officers to deal with making sure they got their information on how to control their disease, but I knew they’d be passing back and forth any sort of knowledge that worked for them that they got in triage or somewhere else.” The custodial supervisor in the above passage was describing the exact institutional obstacle of organizational process that was discussed at the outset of the planning process. Custodial personnel were concerned with one issue—custody concerns. Nothing else mattered. To attempt to alter this highly institutionalized method of thought and process of organizational behavior was not the point of the CCM program, nor was it even considered feasible. Utilizing a train-the-trainer approach via another highly institutionalized process—that of inmate-to-inmate communication channels—was the preferred approach for successful implementation of the model and improved treatment outcomes. In order to make best use of the inmate communication channels to enable self management and to better understand the obstacles to self-management within this setting, a rudimentary analysis was performed. Two primary factors were identified during this analysis: self-efficacy and health literacy. From discussion sessions with the mental health clinicians, it was known that self-efficacy was a limiting factor for improving health in this population. Self-efficacy is generally defined as a person’s perception that she or he has the intrinsic capability to attain a goal . The second limiting factor identified was health literacy, which, given the average educational level of seventh grade, was considered an impediment to self-management. While health literacy does not specify a certain level of understanding within a given point of time concerning one’s health, it does consider the inmate-patient’s ability to understand and follow a clinician’s general instructions. A study of diabetic patients of various ethnic backgrounds found evidence that improvements in self-efficacy were associated with improvements in diabetes care outcomes . After controlling for ethnicity and health literacy levels, researchers found that increasing self-efficacy was related to patient self monitoring. On the basis of this and related research, the implementation’s management team concluded that nothing needed to be done immediately to improve health literacy or self-efficacy. It was felt that, as treatment outcomes improved over time, these related concerns would be naturally addressed and could be revisited as the program evolved. Patient education would be enhanced at the treatment encounter, and as treatment outcomes and inmate-patient experience improved due to better coordination of care, overall health literacy would improve due to the natural inmate communication channels.
The community at large typically marginalizes the incarcerated. Due to the high rate of recidivism, parolees become part of the broader community when released and then return to the prison environment, potentially repeating this cycle several times. If not treated in the prisons, chronic conditions and communicable diseases eventually become public health problems. While under the custodial confines of the state, the incarcerated also access the specialty services and acute care from community providers when health treatment considerations warrant such visits. Hence, care coordination, case management, and discharge planning are critical functions connecting the inmate-patients with their communities. Clinical staff within CDCR performs these specialty care visits. Community resources for the newly paroled, however, were and continue to be scarce. Community-level integration efforts with CDCR were not viewed as a priority by agency staff. While such efforts could have been integrated into CCM planning, they were not—perhaps due to agency staff’s overwhelming workload. While the literature does not currently state that community-prison integration is a primary aspect of successful CCM implementation, it is here argued to be significant due to recidivism. Unfortunately, however, it was not picked up as an element of overriding concern. The prison health care reform effort in California did not address the linkage with the community through provider-network development and community partnership. However, preliminary steps were taken to establish the public-private partnership with the local public health agencies. Discharge planning for the parolees was also deemed critical as it helped ensure continuity of care and avoided burdening the emergency departments in the community. This chapter has reviewed the process by which the new structure and processes proposed by the private-sector chronic care model were implemented within the public correctional setting. The challenges to implementation were met by carefully modifying the technical details of the program to fit the institutional context of the environment and the people who operate within it. Program level of analysis was introduced as a concept helpful for understanding the nature of departmental behavior because this project required collaboration and motivation at the program level, not at the overall organizational-mission level. This is an important concept that will carry over to the next chapter, where management behavior is explored. The actions considered by managers are reviewed at the program level of analysis in order to better understand both the motivation of this employee level and how their actions can be best guided to enable program implementation success.The ability of managers to transform organizations is an often-visited topic, debated by various disciplines within both academic and practitioner settings. Successful implementation of a program is a learning opportunity for scholars of many domains because numerous associations between the variables of performance and outcomes can be drawn. The literature specific to implementations within the public sector, particularly those studies looking at leaders to manage the change, provides many examples of failure . Peeking through the fog of these tales of derailment are the few stories of hope: implementations that provide evidence of success despite the odds.