Initiating a Pro-Active Care Modality Paradigm to Vulnerable Populations: Utilizing the Patient-Centered Medical Home Model for Incarcerated Male Inmates with Asthma

摘要

Incarcerated male inmates in the California Department of Corrections & Rehabilitation (CDCR) have poorer outcomes of management of chronic care conditions such as asthma, hypertension, and diabetes than the rest of the general population. The aim of this program is to promote healthy measurable outcomes of inmates with asthma at the Correctional Training Facility, Soledad, one of the 33 facilities that constitute CDCR. Inmates are split into provider-care teams per their CDCR number and followed in the nine clinics at the facility. These inmates were identified, tracked, educated, and followed up using the Patient-Centered Medical Home (PCMH) model. The education and assessments were geared through the Transtheoretical Model (TTM) to determine the readiness of teaching modalities. This program included peer-to-peer education between inmates, group education by the nurse instructor, and RN/PCP (primary care provider) intervention visits. An asthma action plan and severity indexing determined the specific protocols that were followed for this population. Inmates took ownership of their individual health problems, and custody and medical staff worked collaboratively to facilitate timely visits to the clinic and safety concerns of medication accessories. The goal of this program was to decrease unexpected deaths due to asthma to zero per year. A secondary goal was to decrease the number of Treatment & Triage Area (TTA) visits for signs and symptoms of exacerbated asthma by 95%. Outcomes were measured by tracking the number of key indicators, including registered nurse/primary care provider (RN/PCP) visits, assessments and diagnostics tool measurements, subjective control tests, and number of TTA visits.