Fall - National Commission on Correctional Health Care

C
rrectCare
Fall 2011 | Volume 25 | Issue 4
™
The magazine of the National Commission on Correctional Health Care
KOP Glucometers in Prison?
It’s Working Great
in California
The Right Way to
Deal With Outside
Physicians
Small Jail Makes
Big Strides in Care
2011 Award Winners
Take the Spotlight
National Commission on Correctional Health Care
1145 W. Diversey Parkway, Chicago, IL 60614
The National Commission on Correctional Health Care presents
Updates in Correctional Health Care
Preventing Recidivism:
Where Do You Fit In?
May 19-22, 2012
z San Antonio
Join your colleagues in a vibrant forum where you will advance your
knowledge and skills while earning up to 25 hours of continuing education credit, networking with colleagues and enjoying the beautiful
and historic Alamo City. This meeting will feature presentations on
a broad array of correctional health care topics as well as a special
series focusing on the role of correctional health services in reentry
programming and prevention of recidivism.
For more information,
visit www.ncchc.org or email conference@ncchc.org.
CorrectCare™ is published quarterly by the National Commission on Correctional Health Care, a not-for-profit organization
whose mission is to improve the quality of health care in our nation’s jails, prisons and juvenile confinement facilities.
NCCHC is supported by the leading national organizations representing the fields of health, law and corrections.
contents
12
Features
Departments
4 New Position Statement
2 NCCHC News
3 Guest Editorial: Why Multi-
Addresses Chronic Pain
8 Award Winners Take the
Spotlight at National Conference
12
KOP Glucometers in Prison?
It’s Working Great in California
16
The Right Way to Deal With
Outside Physicians
18
Correctional Nursing Practice
(Part 8): Regulations, Standards
and Policies
24
Facility Profile: Small Jail Makes
Big Strides in Care
cultural Awareness Is Important
25
26
News Watch
Journal Preview: Triage Critical
for Toothache Complaints
27
28
Clinical Briefs
30
CCHP Page: 20th Anniversary
a Smash Success!
32
36
Field Notes
Juvenile Voice: Psychological
First Aid for Youth
Standards Q&A
Our Independence Matters
The National Commission on Correctional Health Care has no membership or dues.
NCCHC does not require any affiliation to be considered for accreditation, certification or
employment as a consultant or surveyor, or to serve on committees or the board of directors. NCCHC staff and spouses are not allowed to accept gifts or consulting fees from those
we accredit or certify. NCCHC is impartial, unbiased and expert. And dedicated only to recognizing and fostering improvements to the field of correctional health care.
C rrectCare
Fall 2011 | Volume 25 | Issue 4
™
BOARD OF DIRECTORS
Carl C. Bell, MD, CCHP (Chair)
National Medical Association
Judith Robbins, LCSW, CCHP-A (Chair-Elect)
National Association of Social Workers
Peter C. Ober, PA-C, CCHP (Immediate Past Chair)
American Academy of Physician Assistants
Patricia N. Reams, MD, CCHP (Secretary)
American Academy of Pediatrics
Thomas J. Fagan, PhD (Treasurer)
American Psychological Association
Edward A. Harrison, CCHP (President)
National Commission on Correctional Health Care
Patricia Blair, JD, CCHP
American Bar Association
Eileen Couture, DO, CCHP
American College of Emergency Physicians
Kevin Fiscella, MD
American Society of Addiction Medicine
Robert J. Gogats, MA
National Association of County and City Health Officials
Joseph Goldenson, MD
American Public Health Association
Robert L. Hilton, RPh, CCHP
American Pharmacists Association
Renee Kanan, MD
American College of Physicians
JoRene Kerns, BSN, CCHP
American Correctional Health Services Association
Ilse R. Levin, DO
American Medical Association
Douglas A. Mack, MD, CCHP
American Association of Public Health Physicians
Nicholas S. Makrides, DMD
American Dental Association
Pauline Marcussen, RHIA, CCHP
American Health Information Management Association
Edwin I. Megargee, PhD, CCHP
International Association for Correctional and Forensic Psychology
Charles A. Meyer, Jr., MD
American Academy of Psychiatry and the Law
Eugene A. Migliaccio, DrPH
American College of Healthcare Executives
Ronald C. Moomaw, DO
American College of Neuropsychiatrists
Robert E. Morris, MD, CCHP
Society for Adolescent Health and Medicine
Joseph E. Paris, MD, CCHP-A
Society of Correctional Physicians
Joseph V. Penn, MD, CCHP
American Academy of Child and Adolescent Psychiatry
Peter E. Perroncello, MS, CCHP
American Jail Association
George J. Pramstaller, DO, CCHP
American Osteopathic Association
Sheriff B. J. Roberts
National Sheriffs’ Association
David W. Roush, PhD
National Partnership for Juvenile Services
Jayne Russell, MEd, CCHP-A
Academy of Correctional Health Professionals
Ryung Suh, MD
American College of Preventive Medicine
Ana Viamonte Ros, MD
Association of State and Territorial Health Officials
Patricia Voermans, MSN, CCHP-RN
American Nurses Association
Barbara A. Wakeen, RD, CCHP
American Dietetic Association
Henry C. Weinstein, MD, CCHP
American Psychiatric Association
Nancy B. White, LPC
American Counseling Association
Ronald Wiborg, MBA, CCHP
National Association of Counties
Copyright 2011 National Commission on Correctional Health Care. Statements of
fact and opinion are the responsibility of the authors alone and do not necessarily
reflect the opinions of this publication, NCCHC or its supporting organizations.
NCCHC assumes no responsibility for products or services advertised. We invite
letters of support or criticism or correction of facts, which will be printed as space
allows. Articles without designated authorship may be reprinted in whole or in
part provided attribution is given to NCCHC.
Send correspondence to editor Jaime Shimkus
NCCHC, 1145 W. Diversey Pkwy., Chicago, IL 60614
Phone: 773-880-1460; Fax: 773-880-2424
editor@ncchc.org; www.ncchc.org
NCCHCnews
Get in Tune With CHORDS
Although measurement underlies quality improvement
efforts within facilities, it does not enable examination of
performance on a large scale, in comparison with peers.
For that, benchmarking is essential. Such benchmarking is
commonplace in community-based hospitals and health
networks, which rely on these data not only for quality
improvement but also to satisfy payor requirements.
To date, however, the correctional health care field has
done very little benchmarking of health care performance,
although it could greatly enhance quality and effectiveness of
care. This is due, in part, to a lack of robust, uniform performance measures tailored to the unique correctional setting,
as well as the absence of a way for facilities to share data.
These major obstacles will soon be a thing of the past.
Building on a chronic disease data reporting program it
initiated several years ago, NCCHC is now working with
leaders of a variety of correctional systems throughout the
country to establish a national performance measurement
system called CHORDS (Correctional Health Outcome and
Resource Data Set). Broadly speaking, CHORDS will consist
of the following elements:
• Standardized performance measures, with an emphasis
on effectiveness of care, availability of and access to care,
use of services, cost of care and others
• A data repository to establish regional and national
benchmarks for participants
• Data reporting capabilities to help correctional systems
track, trend and compare data over time
This important effort has the potential to impel quality
improvement in correctional institutions across the nation
and, ultimately, benefit the public health. Stay tuned for
updates as the project progresses.
Board Member Update
Carl C. Bell, MD, CCHP, became board chairman at the annual board meeting on Oct. 16 in Baltimore. Bell knows well the
work of the National Commission: He is a founding member of the board of directors who served as chair in 1991. An
expert in correctional psychiatry, he will focus on prevention as well as violence reduction in incarcerated populations during his term (see the next issue for a profile). He represents the National Medical Association on the board.
At that same board meeting, Judith Robbins, LCSW, CCHP-A, was selected as chair-elect. She has represented the
National Association of Social Workers since it became a supporting organization in 2005. Robbins directs a statewide
mental health program for pretrial youth through a contract with Connecticut’s judicial branch and has been heavily
involved with NCCHC’s juvenile health committee.
Welcome to Two New Board Members
• Joseph Goldenson, MD, representing the American Public Health Association: Employed by the San Francisco Depart­
ment of Public Health, Goldenson is the medical director of the San Francisco jail, a position he has held for 20 years.
• Ilse R. Levin, DO, representing the American Medical Association: Employed by Unity Healthcare, Levin is a staff attending
physician at the Washington DC Department of Corrections and the Reentry Clinic, providing care to inmates and halfway house residents.
Calendarof events
February 18
CCHP exam, regional sites
March 16
Accreditation committee meeting
May 19-22
Updates in Correctional Health Care
conference, San Antonio
May 20
CCHP exam, San Antonio
June 22
Accreditation committee meeting
July 20-21
Boot Camp Series: Medical Directors
and Health Administrators
July 22-23
Correctional Mental Health Seminar
For the complete list of CCHP exams, including regional
exam sites, see ncchc.org/cchp.
In Other News ...
New Position Statement and Guidelines for Disease Management
The policy and standards committee complete work on, and the board adopted,
three documents in October. All are available at ncchc.org, Resources section.
• Position Statement: Management of Chronic Pain (see page 4 for 10 key points)
• Guideline for Disease Management: Adolescent Obesity
• Guideline for Disease Management: Adolescent Sickle Cell Disease
AMA Resolution on Correctional Health Care
The American Medical Association reaffirmed its support of correctional health care
this year when it adopted a resolution titled Maintaining AMA’s Commitments to
Public Health and Correctional Health Care. The resolution was submitted by the
American Association of Public Health Physicians. Both groups are supporting organizations of NCCHC and are represented on its board of directors.
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Guesteditorial
Why Multicultural Awareness Is Important
by Mark Fleming, PhD
O
ver the years, the field of
mental health counseling has
become increasingly aware
of the critical importance of not only
recognizing diversity but also implementing multiculturally aware practices
when working with clients.
In our attempts to be multiculturally
aware, it is imperative to recognize that issues around diversity include not only race but also gender, disability status,
residency status, sexual identity, geographical location,
socioeconomic status, political affiliation and religious identity, to name a few. As practitioners, it is incumbent upon
us to recognize the importance of multicultural awareness,
be cognizant of the potential pitfalls from a lack of awareness and use appropriate practices to heighten awareness in
ourselves, others and the systems in which we work.
Multicultural awareness in corrections is important for a
variety of reasons. First, there has been an emergence for a
greater attendance to an ever-increasing diverse population.
In recent years, it has become more evident that the traditional theoretical orientations and assessments are inappropriate for clients from certain cultural backgrounds. As
a result, the American Psychological Association published
guidelines on working with ethnically and linguistically
diverse populations.
Second, an increased understanding of diversity increases
a counselor’s repertoire of skills and perspectives by adding a fourth dimension to the three traditional helping
orientations (psychodynamic, humanistic-existential and
cognitive). This fourth dimension helps the counselor to
understand the client in the context of the client’s cultural
lens, thereby minimizing therapist projections and potential
negative feelings of countertransference.
Third, awareness challenges the assumption that one
approach to counseling is transferable to all clients. As clinicians, we must engage in the daily practice of seeing each of
our clients as unique individuals who must be accepted and
respected. Awareness is critical in that unintentional isms are
as serious and harmful as intentional isms. For example, if a
therapist asks a male inmate if he has a wife, the therapist
has engaged in heterosexism. A more appropriate question
would be if the inmate has a significant other or partner.
When a practitioner lacks awareness of multicultural
issues, there is a greater potential for harm to the client and
to the therapeutic relationship. This harm may manifest in
many ways, including the therapist forcing his or her worldview on the client, the therapist conceptualizing a patient
through a culturally biased lens and the client feeling as if
the therapist is culturally insensitive, with the result that the
client does not fully engage in the process of therapy.
Without an active attempt to increase one’s awareness
of diversity issues, biases can easily interrupt or undermine
the therapeutic process. Without understanding the values
and belief systems of our clients, we are destined to engage
in treatment from our own worldview as opposed to the
client’s worldview. Biases can impair a counselor’s ability to
diagnose and plan appropriate interventions. Biases can also
interfere with a counselor’s conceptualization of causes of
and solutions to the client’s problems, or with the ability
to accurately discern the difference between internal and
external causes of the client’s problem.
Heightening Awareness
There are no quick ways to heighten awareness in ourselves,
others or the systems in which we work. The most lasting
ways are processes that must be initiated over time and
gradually worked into the fabric of the individual or the system. There are several ways in which practitioners can begin
the process of heightening awareness both at the individual
and systemic levels.
Individually, practitioners must first and foremost engage
in a journey of self-discovery regarding their own biases
and assumptions and how these may play out in a therapeutic environment. Secondly, practitioners must be sure
not to impose personal beliefs on the client or the system.
Lastly, it is incumbent upon the practitioner to strive for an
increased awareness into multiculturalism through trainings, seminars and classes.
In the correctional environment, one of the primary ways
to heighten awareness is through a diversity mission statement. The system also must work diligently to recruit, retain
and promote individuals from diverse backgrounds. The
correctional system and all of its subsystems must foster a
welcoming and inclusive environment. This can be achieved
by building a tradition of inclusion even amid a history of
exclusive practices. Having translators available, establishing
policies that directly address employees who use discriminatory language and behaviors, and offering flexible benefits
and service plans that meet the needs of all employees are
other ways to heighten awareness.
As we move rapidly into the 21st century, an increased
awareness of the importance of multiculturalism and diversity in correctional settings will be an ever-present issue. As
individuals and systems strive to meet the needs of all cultural identities of inmates and employees, practices at both
the personal and systemic levels must be fully integrated.
Though the task may seem daunting, the journey can be
achieved one step at a time.
Mark Fleming, PhD, is director of behavioral health services,
Corizon, St. Louis, MO. He presented on this topic at three
NCCHC educational conferences in 2011.
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Fall 2011 • CorrectCare
New Position Statement
Addresses Chronic Pain
It is important to evaluate and manage inmates with chronic pain. NCCHC’s new position statement on the topic
emphasizes that corrections clinicians should be knowledgeable and skilled in the management of this challenging
problem and seek training as necessary. Below are the 10
key points of the statement. Find the complete document,
including introductory information, at ncchc.org.
Position Statement
1. Chronic pain is a distinct clinical entity, requiring an
understanding of pain mechanisms, evaluation, and treatment options.
2. Because a fundamental knowledge of the correctional
health care environment and their patients is needed, properly trained primary care clinicians are uniquely qualified to
treat chronic pain in correctional settings.
3. Medical directors and other responsible health authorities should facilitate and encourage appropriate training
covering the requisite skills to make reliable diagnoses,
establish appropriate treatment plans, and monitor progress
for patients with chronic noncancer pain.
4. Nationally recognized guidelines regarding the care
and treatment of chronic pain should be referenced and
adapted to the correctional environment.
5. Chronic pain should be addressed like other chronic
medical conditions, in a systematic, objective, structured manner beginning with diagnosis and treatment planning and proceeding with structured and regular monitoring of progress.
6. Clinicians should establish measurable treatment
goals for chronic pain and measure progress against them.
Treatment goals should be discussed with the patient but
determined by the clinician. They must be functional in
nature, measured against the patient’s established baseline,
and monitored. The elimination of chronic pain is usually
not a realistic goal. Patient expectations must be addressed
early. Patient self-report may not be completely reliable but
should be included in the assessment.
7. Most chronic pain can be managed through primary
care clinicians. However, an interdisciplinary team approach
is often beneficial, and specialty care, including pain management, should be available for patients whose function
and chronic pain are not improved with treatment and for
patients requiring end-of-life care.
8. Accepted and evidence-based therapeutic options
should be available when medically necessary. A multifaceted and biopsychosocial approach is optimal when possible.
Policies banning opioids should be eschewed.
9. Medication use should be judicious. Benefits and risks
for the patient (including abuse) and the facility (potential
for diversion) must be considered, recognizing that problems with substance abuse, chemical dependency, and
management of prescription medications are common in
correctional populations.
10. Continuity of care planning is important, including
consideration of resources and reentry into the community.
Care coordination should be ensured to avoid interruption
in pain treatment.
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Award Winners Take the Spotlight at
NCCHC’s 2011 National Conference
T
he National Commission’s annual awards pay tribute
to leaders and innovators that have enriched the
correctional health care field. We applaud the 2011
recipients of these prestigious awards, which were presented Oct. 17 during the opening ceremony of the National
Conference on Correctional Health Care, held in Baltimore.
Bernard P. Harrison Award of Merit
NCCHC’s highest honor, this award is presented to an
individual or group that has demonstrated excellence and
service that has advanced the correctional health care field,
either through an individual project or a history of service.
The award is named after NCCHC’s cofounder and first
president.
Steven Shelton
Fred Cohen
Steven R. Shelton, MD, CCHP-A
Now in his 27th year at the Oregon Department of
Corrections, Dr. Steven Shelton is perhaps the longest
tenured corrections medical director in the nation, having
held that position for the past 18 years. His longevity is no
fluke. Dr. Shelton is renowned for exceptional performance
as a leader, innovator and advocate for correctional health
care. His efforts benefit not only his own system but also,
through education, information sharing and mentorship,
systems across the country.
Dr. Shelton’s correctional career began in 1984 when he
joined ODOC as staff physician. Formerly a nurse, he had
attained an MD degree a few years earlier and was working
in community settings, including his own urgent care clinic.
In the early days he would see inmates in the morning
hours when his private practice was closed. As the prison
system and health care needs expanded, so did his involvement. Over time he became staff physician at five prisons
and chief medical officer at two prisons, and in 1993 he
became the system’s medical director.
Among his achievements, Dr. Shelton developed the
concept known as therapeutic levels of care, which uses
defined standards and case discussion to determine the
medical necessity of various treatments. Because this
approach was adopted by the state’s medical assistance
program, it ensures that inmates receive a community standard of care. Dr. Shelton also developed nursing protocols
for early first-line intervention. Both approaches have been
used in many other systems. He also transformed processes—and attitudes—related to patient sick call and self-care.
The man behind these innovations possesses a rich combination of traits that has earned him the devotion of his
staff and respect of his peers. One hallmark of his leadership
is his success in building a staff of highly capable clinicians.
He is committed to professional development and mentorship, and oversees a continuing education program that
draws clinicians from county jails and neighboring states.
He also nurtures strong relationships with specialty providers. “He is an exemplary role model. No staff members
leave and they just keep getting better in their practices,”
says a colleague. He also models creativity, empathy and, in
every sense of the word, caring. Despite his high-level role
overseeing health services for 14,000 inmates, Dr. Shelton
continues to practice direct patient care.
With all 13 ODOC facilities accredited, Dr. Shelton is
closely allied with NCCHC’s mission. He also strives to help
the field. He lends his expertise as a physician surveyor
for NCCHC’s accreditation program, and his educational
presentations are too numerous to count. He fosters professionalism by serving on the Certified Correctional Health
Professional program’s board of trustees. He himself has
been a CCHP since 1993, earning Advanced status four
years later. He also is a charter member of the Society of
Correctional Physicians and has served as its president.
Overall, Dr. Shelton has organized an outstanding system
of health services and staff development that has improved
health care access, utilization and patient satisfaction. He
gives generously to the correctional health community,
sharing his knowledge at all turns. He excels at building alliances for the betterment of all.
B. Jaye Anno Award of Excellence in
Communication
This award pays tribute to innovative, well-executed communications that have had a positive impact on the field
of correctional health care, or to individuals for bodies of
work. The award is named after NCCHC’s cofounder and
first vice president.
Fred Cohen, LLM
Correctional professionals who need to stay abreast of
important court rulings—but don’t have time to pore over
the arcane details of myriad lawsuits—know exactly where
to turn: the Correctional Law Reporter. Launched 22 years
ago by Fred Cohen, LLM, and his longtime collaborator
William Collins, JD, this bimonthly newsletter, first produced
at a kitchen table, soon grew into the most respected periodical of its kind. It also was the catalyst for the formation
a year later of the Civic Research Institute, which continues
today as an independent publisher of reference and practice materials for professionals in the social sciences and law.
A national authority on correctional health law, Mr.
Cohen possesses special expertise in mental health law
and is the author of the two-volume reference work The
Mentally Disordered Inmate and the Law, now in its second edition, as well as executive editor of the Correctional
Mental Health Report. He also has written numerous case
books, treatises and articles on law and deviance.
Mr. Cohen’s vast knowledge of these topics developed
over a long career that encompasses many aspects of corrections and the law. A graduate of Yale Law School, he has
been a full professor at a number of leading law schools
and is a founder of the Graduate School of Criminal Justice,
State University of New York at Albany, where he developed the law component of its PhD program. He has been
the court-appointed monitor in several lawsuits pertaining
to correctional mental health, medical and dental care in
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Fall 2011 • CorrectCare
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Ohio, and has conducted investigations or served as a consultant in several other states, often on mental health topics. He also was a reporter to the American Bar Association’s
Juvenile Justice Standards Project and served on the ABA
task force revising correctional standards.
Characteristically, Mr. Cohen’s response upon notification
of the award was humble and humorous: “I am surprised
and honored to receive the Anno Award. Writing is an isolated activity and to learn in this fashion that someone is
reading and applauding is wonderful.”
NCCHC Facility of the Year Award
This prestigious award is presented to one facility selected
from among the nearly 500 prisons, jails and juvenile facilities accredited by NCCHC.
Lehigh County Prison, Allentown, Pennsylvaniai
This year marks 25 years since Lehigh County Prison
attained initial NCCHC accreditation, but this silver anniversary is not why the facility is being honored as Facility
of the Year. Rather, it is in recognition of current excellence
in health services delivery, continuity of care and staff professionalism.
Despite its name, Lehigh County Prison functions as a
maximum-security jail and is surveyed under NCCHC’s
jail standards. Its latest accreditation survey found 100%
compliance with applicable standards. That level of achievement is common for the facility, which has an average daily
population of about 1,100 and annual admissions of about
5,600.
Since 2003, the facility has used a contract management
company to provide integrated medical, dental and mental
health services. Health staff are on site around the clock.
The team has frequent meetings to discuss administrative,
nursing and quality improvement issues, and someone from
facility administration is always present and participates in
problem solving decisions.
With such a well-run operation, it is hard to single out
specifics to highlight. Among the areas that receive high
marks are chronic disease management, nursing care, diagnostic services, mental health, dental care, pharmacy services, infection control, emergency management and discharge
planning. Receiving screening is always timely, and detainees
are rapidly assessed for detoxification, suicidal ideation and
medication needs. Likewise, initial health assessments are
consistently timely. Each inmate also receives an annual
examination. One way to assess performance is through
customer satisfaction, and here Lehigh County Prison
shines: The facility receives health care grievances from less
than 2% of the population.
Such excellence doesn’t arise overnight. In this case, 25
years of continuous compliance with the standards has
cultivated a workplace where staff pride and dedication
to quality are the norm. This culture also depends on the
example set by the warden and assistant warden, both of
whom have served at the facility for more than 20 years.
Under their strong, steady leadership, the facility has established a stable health services department with a solid history of performance.
NCCHC Program of the Year Award
This award recognizes programs of excellence among the
thousands provided by accredited prisons, jails and juvenile
facilities.
“The Group” Weight Reduction Program
Wyoming Honor Conservation Camp, Newcastle
That sloped walk up to the health services building turned
out to be a good thing for a couple dozen inmates at the
Wyoming Honor Conservation Camp. After complaints by
certain individuals about shortness of breath and sore legs,
the warden concluded that their excess weight
and overall poor health were the culprits. He
asked the health services team to come up
with a plan. Thus was born Self-HeLP (Healthy
Lifestyles Program), an effort known as “The
Group.”
Part of the Wyoming Department of
Corrections, WHCC provides vocational, educational and other programming to an average
daily population of about 300 men. Although
Lehigh County Prison
exercise activities have long been offered, The Group was
conceived in July 2010. It has evolved since the early days of
informal meetings with a small group of inmates referred by
health staff. As it became clear that many of the men did
not understand the concept of self-care for chronic conditions or how lifestyle choices affect health, the education
component became formalized. An important milestone
occurred in September 2010, when health staff began to
record participant weight, blood pressure and other health
measures at each weekly meeting.
Another major step was in December, when
the recreational activities specialist added
structured exercise to the program. To ensure
privacy, because some participants would have
been reluctant to exercise with other inmates
present, the warden approved use of the gym
during count time. In addition, the food service
department was enlisted to provide healthy
choices for meals and snacks. These foods are
Wyoming Honor Conservation Camp
available to all inmates.
Although the total number of participants is small, their
results are impressive. A July 2011 report noted a total of
196 pounds lost since recording began. Looking at individual outcomes, some of these men have made astonishing improvements. One lost more than 40 pounds in three
months. Another reduced his LDL cholesterol from a whopping 547 to 167. A diabetes patient is no longer dependent
on insulin. Many participants reduced their blood pressure.
A bonus: These inmates also benefit from greater self-confidence, reduced anxiety and better social skills due to the
support they give each other.
Calling the program a “best practice for Wyoming corrections,” the DOC director is encouraging its implementation
in other facilities.
To see more photos from the awards ceremony, visit our
Facebook page, facebook.com/NCCHC.
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Fall 2011 • CorrectCare
StrongerTogeth
At Corizon, we work tirelessly to be the best provider of
correctional healthcare. When our strength and dedication is
paired with yours, we both find purpose. By working together,
our collective vision becomes a reality. Innovations become
customized solutions. Efforts become results.
We provide care and service—to our clients, our patients and
our communities. By working with us, you make it happen.
And we’re both stronger together.
www.corizonhealth.com
ther
Always striving. Ever better.
KOP Glucometers in Prison?
It’s Working Great in California
by K. Ball, DO, CCHP
The program is
second nature
now; all general population
diabetes patients
receive the glucometer kit and
weekly exchange
of supplies based
on their provider’s recommendations
A
s chief medical executive at Calipatria State Prison,
a maximum security male facility, I oversee health
care for more than 4,000 inmates. In 2008, I had an
idea for improving care for patients with diabetes.
I felt that inmates needed to increase their responsibility in controlling their diabetes, and that if I could provide
glucometers for self-monitoring, they would have better
control and outcomes. After obtaining approval from the
California Department of Corrections and Rehabilitation
and my warden, I initiated a pilot program.
Health program specialist Lita Martin and I spent many
hours creating a local operating policy for the program. To
determine what the policy needed to address, we considered all aspects of the program, such as choosing and issuing glucometers, dealing with damaged meters, exchanging
supplies, patient refusals and parties responsible for program specifics.
The glucometer and lancet device were selected based
strictly on safety issues and, for the lancet device, also from
a public health angle. We chose a self-retracting six-lancet
device, feeling that it was somewhat tamperproof and so
small that it could not be used as a weapon or for tattooing
very well. For the glucometer, we picked a 17-strip barrel
device. The barrel housing was acceptable to custody and
also seemed tamperproof. For medical, we like the number
of strips as it lessens the number of exchanges.
During this process we also had discussions with custody about housing. Housing units typically rotate who
is released first to chow. There had been complaints of
delays in feeding after insulin was administered, leading to
hypoglycemic events, and sometimes the insulin was given
after chow instead of before. Given our concerns about
irregular feeding times and delays in insulin administration,
the warden approved my request that all diabetic inmates
be housed in the same building on each yard and that they
consistently be released first for meals. We believe this contributes to better control and fewer adverse outcomes.
Policy Details
The diabetes self-care program policy was approved in
January 2009 and we announced our intentions to all staff. A
team of health professionals educated medical staff affected
by the program, explaining the details and expectations.
The policy has evolved over time, with a few revisions to
make it more practical. These are some of the highlights:
• The primary care provider will issue a medical permit
to each program participant allowing him to self-test and
carry his diabetic supplies. The permit identifies the items
that may be carried, such as glucometer, drums, cartridges,
plastic carrying case, alcohol swabs, batteries, lancet device
12
Fall 2011 • CorrectCare
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and self-test diary.
• Nursing staff conduct weekly logging of the glucometers
and supplies distributed. The patient is assigned supplies
based on the frequency of testing ordered by the primary
care provider. Every Sunday, nursing collects all used drums
and cartridges and distributes new ones (on a one-for-one
basis) along with alcohol swabs as needed. They also inspect
the glucometers for tampering or other problems.
• The patient may dispose of the used strips and alcohol
swabs in the regular trash.
• Diabetic supplies are the property of the patient and
will accompany the patient upon transfer to another institution or parole.
• The initial glucometer and the weekly distribution of
supplies are provided at no charge. If a glucometer is deliberately damaged, the patient may be required to purchase a
replacement.
• Custodial disciplinary action will be taken if any of the
following occur:
– Patient willfully damages or abuses the glucometer.
– Patient tampers with the glucometer and/or diabetic
supplies.
– Diabetic supplies are missing.
– A patient not enrolled in the program is found in possession of a glucometer or diabetic supplies.
• To ensure that their insulin is readily accessible, type 1
diabetes patients will not receive job assignments that are
off the institution grounds.
• Any patient refusing to participate in the program
completes a refusal of examination and/or treatment. The
patient’s blood glucose levels will not be checked by nursing except when presenting with symptoms or prior to
insulin administration.
Our pilot facility was B yard, which has about 1,000 general population inmates. The goal was to enroll all 18 of the
diabetic inmates into the program. To get started, a team
of health professionals (chief physician, director of nursing,
nurse supervisors, RNs, health program specialist and senior
lab technologist) met with the inmates in a classroom setting. They presented general education on diabetes (basic
physiology, monitoring calories, signs and symptoms, red
flags) followed by in-depth teaching on glucometer use.
Two patients refused participation, but later accepted. All
participants signed consents demonstrating understanding
of program participation, expectations and how supplies
would be distributed. On this same day, we gave them the
glucometers, medical permits and supplies.
Signs of Success
Data collected three months into the program showed
mild improvements in patient health. The participants’
average HbA1c level decreased to 6.60 from 7.01 before the
pilot. A sample look at blood glucose checks for one participant found an average pre-pilot level of 233; this decreased
to 120 during the pilot.
Analysis of the triage and treatment area log also suggests
improved outcomes. In the 12-month period before the
pilot, the 18 participants made 10 visits due to hypo/hyper-
glycemic events; at the three-month assessment, no visits
had been made. Diabetes-related emergency room visits
also decreased.
At three months we also conducted a survey of the 16
original participants. All replied “yes” in response to questions regarding satisfaction with the program, improved
knowledge, improved health condition and better awareness of the diabetes disease process. In addition, 12 assigned
a top score of 5 on a satisfaction rating scale, with the other
participants assigning a rating of 4.
The survey also yielded uniformly positive write-in comments from the patients, such as “Very good, thank you!”;
“Glucometer helps [patient] control his diet, I dropped from
238 to 220 lbs!”; and “Very happy to be part of program!”
(For anecdotal reports from the field, see box on page 14.)
Given the success of the pilot, in fall 2009 we expanded
the program to all of the general population yards. At the
time we had about 200 diabetes patients (the number is
now about 120). Again we began with education. The consent forms were signed and the glucometers were issued.
The program is second nature now; all general population
diabetes patients receive the glucometer kit and weekly
exchange of supplies based on their provider’s recommendations for self-testing. (The glucometers are not allowed in
the administrative segregation units, but I understand that
the San Quentin prison has a pilot program in ad seg.)
As far as more current data, this has been a bit difficult
to obtain as only eight patients remain of the original pilot
program. However, in October 2011 the average of all
HbA1c levels in the general population was 6.81, reflecting
an improvement from the average of 7.35 in 2008. Also,
review of triage and treatment logs shows that the number
of general population visits for hypoglycemic events was
nine in 2006 but only one in 2010.
What We’ve Learned
I believe that the greatest benefit of the diabetes self-care
program is the ability for the patients to take ownership
of their chronic disease management. To self-monitor and
manage their diabetes decreases their sense of helplessness
and increases their autonomy. We were impressed to see
the pride they took in the program, and to date we have
had no reports of abuse. There have been very few refusals
to participate; usually the refusals are from inmates who are
in denial about their disease, and sometimes with time they
accept and consent.
The second greatest benefit is the impact on nursing.
This program has reduced greatly the nurses’ workload
because they used to do the blood glucose checks as
ordered by the primary care provider. They still check prior
to insulin administration or for symptomatic patients, but
not at any other times, even for those refusing glucometers.
The expenditure (about $10,000 per year) has not risen
much because we used to give glucometers and supplies
to diabetic inmates upon release; now it is an upfront cost.
And we do see savings through reduced staff hours spent
continued on page 14
13
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Fall 2011 • CorrectCare
Glucometers
(continued from page 13)
Reports From the Field Point to Success
• Calls for diabetic care have changed from general
to specific in nature. For example, instead of custody
reporting that the inmate is not feeling well, the report
may say, “The inmate said he is diabetic and his blood
sugar is high; can you come and check him?”
• Noticing a low number in a patient’s diabetic log, an
RN asked what happened. He replied, “I was feeling sick
and anxious so I checked my blood sugar before calling
the officer. It was low so I ate something and felt better.
I checked it again later and it was normal so I went back
to bed without needing intervention.”
• A patient reported, “I know that when I eat too much
my blood sugar gets out of control for two or three days,
so I’m paying more attention to what I eat.”
• Another patient said, “I check my blood sugar to see if
the medication is working; this reassures me.”
• An RN observed that the patients do not see the glucometer as a toy but as an instrument that may help to
save their lives. “I’m impressed with how carefully they
treat the glucometer. I have not noticed any sabotage or
tampering. I often perform the exchange of supplies and
have no problems to report.”
• Custody reports no problems with the pilot program.
In fact, the associate warden for health care said, “This
pilot has been successful.”
with these patients, fewer complications and fewer ER visits.
As far as program weaknesses, we would like the patients
to be more faithful in keeping their dairies and bringing
their glucometers or diaries to their clinic visits. Many only
give recollections of their readings. We hope in the near
future to add infrared readers to the providers’ computers;
by waving the glucometer over the reader, all of the stored
data will appear on screen for easier monitoring.
Also, for more than a year we have asked that all patients
bring all medications to every chronic care visit. I feel this
would help the provider and the patient in the management of chronic diseases, including diabetes, but this has
been a struggle to implement.
But these glitches do not detract from the overall success
and value of our diabetes self-care efforts. I recently gave a
presentation on the program to a gathering of chief executive officers and chief medical executives from CDCR’s 33
adult institution. The CDCR’s federally appointed receiver
so applauded our innovative vision and implementation
of the program that he directed all 33 institutions to follow our lead. Since then, I have been part of a statewide
committee helping to formulate a policy for statewide use.
It is predicted that by early 2012, all diabetic inmates in
the CDCR general population will have glucometers, and
improved outcomes will follow.
K. Ball, DO, CCHP, is the chief medical executive at
Calipatria State Prison, part of the California Department of
Corrections and Rehabilitation.
NCCHC Accreditation
Recognition From the Most Respected
Name in Correctional Health Care
For more than 30 years, NCCHC has worked with administrators across the country to ensure that health care provided
in their facilities is effective, efficient, and meets constitutional requirements. Our success — and the success of facilities
accredited by NCCHC — is unsurpassed.
Leading the Way in Every Way
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NCCHC’s standards are widely recognized by the medical profession and the courts
NCCHC’s standards are the benchmark for measuring a facility’s health services system
NCCHC is unmatched in our correctional health care expertise
NCCHC’s independence assures an unbiased evaluation of your compliance with standards
NCCHC accreditation gives greater public confidence and professional satisfaction in the work you do
No other accreditation comes close to receiving the professional acceptance and recognition that goes with NCCHC
health services accreditation. Isn’t it time you became NCCHC accredited?
For more information on NCCHC accreditation, contact us at:
(773) 880-1460 • accreditation@ncchc.org • www.ncchc.org
Accreditation Ad 2011 half.v CC.indd 1
14
Fall 2011 • CorrectCare
7/14/11 12:11 PM
www.ncchc.org
REYATAZ is a registered trademark of Bristol-Myers Squibb.
©2011 Bristol-Myers Squibb, Princeton, NJ 08543, U.S.A.
687US11VC07201
08/11
Printed in U.S.A.
The Right Way to Deal With Outside
Physicians
by Jeffrey E. Keller MD
T
hose of us who practice medicine in jails frequently
(Frequently? Daily!) run into the thorny issue of
our relationship to the doctors who care for our
patients outside of the jail.
When patients are in our jails, we are responsible for
them; they are our patients. But these patients also have
doctors outside of the jail that perhaps they have been seeing for years. The inmate considers their outside physician
to be their “real” doctor, not us. (Throughout this article, I
am going to use the term “doctors” rather than the more
generic “practitioners.” I do not mean to slight nurse practitioners or physician assistants. What I say applies to them,
as well.)
What brought this topic to mind is a case that occurred
in one of my jails recently. A patient came to jail with a prescription pad filled out by his outside physician authorizing
him to have a double mattress, an extra blanket and an
extra pillow. (There was no note requiring us to feed him
pizza every Friday night—he must have forgotten to ask
for that.) So I was left in a little dilemma. What should I do
about this note? Ignore it? Allow the inmate to have the
extra comfort items?
Dealing with inmates’ outside physicians can be tricky,
but I have found (mostly through sad experience) that
there is definitely a right way and a wrong way to handle
these encounters. The right way involves recognizing three
important points:
1. The outside physician is not authorized to write orders
for patients in the jail; she does not have staff privileges in
the jail setting.
2. Inmates like to pit the outside doctors against the jail
doctors to get their way. It is a form of manipulation. It
needs to be recognized as such.
3. The easiest and most time-effective way to defuse
this situation is to speak to the outside physician directly
and come to a joint decision of what will be done for the
patient in jail.
Staff Privileges
The first core issue here that was misunderstood both by
the patient and the outside physician is one of staff privileges. Just like hospitals, jails and prisons have a staff privilege
system. If a patient of mine is admitted to the local hospital,
I cannot write or call in orders. To be able to do so, I would
have to formally apply for staff privileges at that hospital.
Even then, I could not write orders for a patient at the hospital unless I was the admitting or attending physician. This
staff privilege system is common to all medical establishments. I likewise cannot call in orders at the local nursing
home or walk into the urgent care center across the street
and start seeing patients.
It is the same thing at a jail or a prison. To practice medicine in a correctional facility, a physician must be granted
staff privileges at that facility. Who grants these privileges?
The person with legal authority to operate the facility. In
the case of almost all jails, that would be the sheriff and the
jail administrator.
What this means, of course, is that I, as the medical director of the jail, have no obligation to honor any outside
physician’s orders. In fact, the
outside physician cannot
make orders; she has no staff
privileges. If I or the other jail
medical providers think that
an outside physician’s recommendations are a good idea,
we must rewrite the order; it
has to come from us. On the
other hand, if I, in my professional judgment, think that
an order from an outside
physician is inappropriate, I
am under no obligation to
follow it. I should, of course,
document exactly why I made this decision so there is no
question later.
Inmate Manipulation
But this does not solve the problem raised by this outside
physician’s orders and the patient’s insistence that we have
to follow them. What the patient is doing here is the classic and common inmate game of pitting two physicians
against each other. This happens all of the time in jail.
Inmates will say that their outside physician wants them to
be on certain medications, have a special diet, wear their
own shoes and so forth. If I, as the jail physician, say no to
these requests, then the inmate feels that he or she has a
legitimate grievance: “My outside doctor has prescribed X
and you won’t let me have it. My outside doctor is my real
doctor and knows me and my medical problems way better than you do.”
This is a very common and sometimes successful
method of inmate manipulation. If I do not recognize this
as a type of manipulation, the inmate ends up becoming a
spokesperson for the outside physician.
Direct Communication
By far, the best way to deal with this problem is to call the
outside physician by telephone and come to common
ground. I have found this to be quite easy and pleasant
for the most part. Inmates paint their outside physicians
as fanatically insistent upon the inmate getting what
the inmate wants. But that is not true most of the time.
Outside physicians are, for the most part, thoughtful, reasonable and helpful.
And so it was in this case. I called the outside physician and explained the jail policy about extra mattresses
and other comfort requests. She admitted that she didn’t
16
Fall 2011 • CorrectCare
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Three Key Principles
To summarize, there are three principles of dealing with
orders of a physician outside of the jail system:
1. Recognize that outside physicians do not have privileges to practice within the jail. You as the jail doctor
may agree with their recommendations or disagree,
but you are the ultimate decider. It is important for
the inmate and the outside doctor to understand this.
2. Inmates tend to pit their outside physicians against
the jail doctor as a type of manipulation to get what
they want. This must be recognized as manipulation.
3. The best way to counter this manipulation and to
defuse the whole situation is to speak personally with
the outside physician and come up with a joint treatment plan for the inmate while in jail.
know much about jail medical procedures and that she
had written that note only because the patient begged her
to. I asked if she would support me in my determination
of appropriate housing for this patient’s medical condition
and, of course, she agreed. By the end of the conversation,
we were chatting like old comrades. I gave her my personal
cell phone number in case she had any questions about
future patients who might end up in jail.
And finally, I could report to the patient that I had personally talked to his outside physician and that we had
jointly developed a housing and treatment plan for him
while he was in jail and this would not include an extra
blanket, extra mattress or extra pillow. Problem solved. He is
no longer able to play one doctor versus another.
Added Benefits
There are lots of added benefits to calling the outside physician in cases like this. It consumes much less time than
fighting with the patient over the course of several clinic
visits and grievances. It develops personal contacts in the
outside medical community. If I have
a question in
this particular
doctor’s field, I
can call her for
help. The doctor also knows
more about
the jail and
jail medicine than she did before. We now have a rapport
that will come in handy the next time one of her patients
ends up in jail. The next time one of her patients asks her to
authorize special treatment in jail, she will know not to do
this (or at least to call me first).
Note that requesting medical records would not have
achieved the same results. In fact, requesting medical
records would have accomplished nothing and wasted
time. The act of calling and speaking personally to the outside physician is the key.
As usual, this strategy worked wonderfully in this case.
Once I told the inmate that his outside doctor and I agreed
on the treatment he would receive in jail, he had nothing
further to say. He never brought the subject up again. He
never wrote a grievance. And this is such a common problem, I will probably use this strategy again tomorrow!
Jeffrey E. Keller, MD, is the medical director of the Ada
County Jail in Boise, ID, and the Bonneville County Jail in
Idaho Falls, ID. He also is a frequent speaker at NCCHC
conferences. Contact him at jkeller@badgermedicine.com.
Medical  Mental Health
Dental  Pharmacy
201 17th Street NW, Suite 300, Atlanta, GA 30363
404.760.0296
www.correctionalmed.com
17
www.ncchc.org
Fall 2011 • CorrectCare
Correctional Nursing Practice:
What You Need to Know (Part 8)
NCCHC’s Certified Correctional Health Professional program offers specialty certification for RNs. The CCHP-RN certification is the formal recognition of the specialized knowledge, skills and experience specific to the practice of nursing in a correctional setting. Whereas nursing licensure establishes legal authority for an individual to practice nursing, specialty certification reflects achievement of the special knowledge and skills needed for a particular practice area. This column, written
by members of the CCHP-RN task force, discusses various areas of correctional nursing practice covered in the CCHP-RN
exam outline. This will assist nurses preparing to take the exam as well as explain the key concepts of the specialty for the
novice correctional nurse. Learn more about the CCHP-RN program and exam at www.ncchc.org/cchprn.
Regulations, Standards and Policies
To be identified as a profession, a discipline must meet criteria that include having established standards of practice
and regulation of the practice. In the profession of nursing,
regulation is an important component in ensuring safe and
competent practice. Nursing consistently ranks No. 1 of all
professions in Gallup’s annual honesty and ethics survey.
Confidence is supported when nurses thoroughly understand and comply with all regulations and standards.
As in the larger health care industry, correctional health
care systems are subject to regulation. Importantly, laws and
rules that pertain to nursing in the community also apply in
the correctional setting. However, issues related to regulations, standards and compliance with nurse practice acts
and scope of practice are not always well understood by
correctional nurses and sometimes do not gain the expected level of knowledge, compliance and value.
Because nursing practice has a significant impact on
health care delivery, patient safety and patient outcomes,
regulation of the profession and individual nursing practice
is necessary. The practice of nursing is regulated at the state
level through administrative rules (laws) and civil procedures. Licensure is one method of validating knowledge
and competence. Individual states license and regulate the
profession through their nursing boards, while the National
Council of State Boards of Nursing works to create uniformity and consistency in nursing practice and standards.
Many other government agencies—federal, state and
local—also issue regulations, standards and guidance to
assure safe and appropriate nursing care. At the federal
level, the U.S. Department of Health and Human Services
is the principal agency for protecting the health of citizens.
HHS regulates through 11 divisions, including the Centers
for Disease Control and Prevention, the Food and Drug
Administration and the Office of the Inspector General. At
present the Centers for Medicare and Medicaid Services
has little impact on correctional health care, except, for
example, when a facility receives federal funding, such as
reimbursement for dialysis. However, that may change as
provisions of the health care reform law are implemented.
Correctional health systems and their employees are
expected to comply with applicable laws and regulations.
The monitoring and oversight of these systems may not
be as visible as in health care settings in the community.
Nevertheless, these functions are important. Correctional
facilities have a federal mandate to provide appropriate
health care for individuals detained and incarcerated. If a
facility fails to ensure safety and fails to meet the serious
medical needs of those incarcerated, this likely will lead to
litigation and court monitoring.
Several nongovernmental organizations also issue useful
standards and other guidance. With respect to health care,
the National Commission on Correctional Health Care’s
Standards are the most recognized and well-accepted.
Many facilities strive to meet these standards for accreditation even if they are not accredited because compliance
improves quality and limits liability risk. Other organizations, such as the American Public Health Association, the
American Nurses Association and the American Psychiatric
Association, also publish standards and recommendations
on aspects of health care in corrections. The correctional
nurse must understand these standards and ensure that
nursing practice is consistent with them. In all cases, measuring and monitoring systems is essential.
Nurses must also understand and comply with the policies and procedures established at their facilities. Policies
and procedures provide guidance, standardization and consistency in practices, and failure to comply places the nurse,
patient and institution at risk. For example, the patient may
be at risk of endangerment, while the nurse and institution
may be subject to litigation if poor patient outcomes occur.
Policy topics are wide ranging. Applicable laws and standards should be incorporated into institutional policies,
procedures and protocols for the correctional nurse. For
example, they should reflect federal and state regulations
for reporting public health concerns, conditions of abuse,
rape, communicable diseases, trauma, unexpected and
expected deaths and care of the mentally ill. Regarding
standards, NCCHC standards address topics such as access
to care, quality improvement, grievance mechanisms,
patient and staff safety, medication services, screening and
assessment, patient restraint and much more.
When developing policies, nurses are expected to know
and understand the American Nurses Association’s standards for nursing practice, administrative nursing and the
specialty of corrections nursing. Nurses and their leadership
are held accountable to these standards as well as the nursing social policy statement and code of ethics.
Mary V. Muse, MS, RN, CCHP-RN, CCHP-A, is chief nursing
officer, Wisconsin Department of Corrections, Madison. This
column is coordinated by Lorry Schoenly, PhD, RN, CCHPRN, an independent consultant specializing in correctional
health care and social media; she is based in Pennsylvania.
For correspondence, write to editor@ncchc.org.
18
Fall 2011 • CorrectCare
www.ncchc.org
The National Commission on Correctional Health Care and the Certified
Correctional Health Professionals Board of Trustees are pleased to announce
CCHP CERTIFICATION FOR
REGISTERED NURSES
l Specialty certification for nurses
working in the correctional setting
l Recognizing the work you do and the
difference you make
l Exclusively for nurses already CCHP
certified
l From the most widely accepted
correctional health care certification
program
Certification in correctional nursing makes a difference—to the patients whose care is provided by
certified correctional nurses, to employers who must staff their facilities with skilled and experienced correctional nurses, and to the individual nurse who attains the CCHP-RN© credential.
Certification Makes a Difference – Do You?
For more information or to obtain an application, visit
our Web site at www.ncchc.org/cchprn. You may also
contact us at cchp@ncchc.org or 773-880-1460.
The first once-daily
Single Tablet Regimen
One tablet, once daily, alone
or in combination, on
an empty stomach,
preferably at
bedtime1
FOR ADULT PATIENTS WITH HIV-1 IN YOUR CORRECTIONAL FACILITY
*
…
3 MEDICATIONS IN 1
ADDS UP TO A COMPLETE
HIV REGIMEN
ATRIPLA can be used alone or in combination
with other antiretroviral agents.1
ATRIPLA is the only DHHS-preferred HIV regimen available as
1 pill daily for antiretroviral-naïve patients.2
INDICATION
• ATRIPLA is indicated for use alone as a complete regimen or in combination with other
antiretroviral agents for the treatment of HIV-1 infection in adults
IMPORTANT SAFETY INFORMATION
WARNINGS: LACTIC ACIDOSIS/SEVERE HEPATOMEGALY WITH STEATOSIS and POST-TREATMENT
EXACERBATION OF HEPATITIS B
• Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been
reported with the use of nucleoside analogs, including tenofovir disoproxil fumarate (DF),
a component of ATRIPLA, in combination with other antiretrovirals
• ATRIPLA is not approved for the treatment of chronic hepatitis B virus (HBV) infection, and
the safety and efficacy of ATRIPLA have not been established in patients coinfected with HBV
and HIV-1. Severe acute exacerbations of hepatitis B have been reported in patients who have
discontinued EMTRIVA® (emtricitabine) or VIREAD® (tenofovir DF), which are components
of ATRIPLA. Hepatic function should be monitored closely with both clinical and laboratory
follow-up for at least several months in patients who are coinfected with HIV-1 and HBV and
discontinue ATRIPLA. If appropriate, initiation of anti-hepatitis B therapy may be warranted
*Pill not shown at actual size.
DHHS = Department of Health and Human Services.
References: 1. ATRIPLA Prescribing Information. Bristol-Myers Squibb & Gilead Sciences, LLC; March 2011. 2. Panel on
Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults
and adolescents. Department of Health and Human Services. January 10, 2011. http://www.aidsinfo.nih.gov/contentfiles/
AdultandAdolescentGL.pdf. Accessed January 12, 2011.
ATRIPLA is a registered trademark of Bristol-Myers Squibb & Gilead Sciences, LLC. EMTRIVA, HEPSERA, TRUVADA, and VIREAD are registered trademarks of Gilead Sciences, Inc.
SUSTIVA is a registered trademark of Bristol-Myers Squibb. All other trademarks are owned by third parties.
©2011 Gilead Sciences, Inc. All rights reserved. ST10118 08/11
Important Safety Information About ATRIPLA
Contraindications
• ATRIPLA is contraindicated in patients with previously demonstrated clinically
significant hypersensitivity (e.g., Stevens-Johnson syndrome, erythema multiforme,
or toxic skin eruptions) to efavirenz, a component of ATRIPLA
• Coadministration of ATRIPLA with bepridil, cisapride, midazolam, pimozide,
triazolam, or ergot derivatives is contraindicated, since competition for CYP3A by
efavirenz could result in inhibition of metabolism of these drugs and create the
potential for serious and/or life-threatening adverse reactions
• Concomitant use of ATRIPLA with voriconazole, atazanavir (with or without
ritonavir), St. John’s wort (Hypericum perforatum) or St. John’s wort-containing
products is not recommended
Warnings and Precautions
Coadministration with Related Products
• Since ATRIPLA contains efavirenz, emtricitabine, and tenofovir DF, ATRIPLA
should not be coadministered with SUSTIVA® (efavirenz), EMTRIVA, VIREAD,
or TRUVADA® (emtricitabine/tenofovir DF). Due to similarities between
emtricitabine and lamivudine, ATRIPLA should not be coadministered with
drugs containing lamivudine, including Combivir ® (lamivudine/zidovudine),
Epivir ® or Epivir-HBV® (lamivudine), Epzicom ® (abacavir sulfate/lamivudine),
or Trizivir ® (abacavir sulfate/lamivudine/zidovudine)
• ATRIPLA should not be administered with HEPSERA® (adefovir dipivoxil)
Psychiatric Symptoms
• Serious psychiatric adverse experiences, including severe depression
(2.4%), suicidal ideation (0.7%), nonfatal suicide attempts (0.5%), aggressive
behavior (0.4%), paranoid reactions (0.4%), and manic reactions (0.2%), have
been reported in patients receiving efavirenz. In addition to efavirenz, factors
identified in a clinical study that were associated with an increase in psychiatric
symptoms included a history of injection drug use, psychiatric history, and
use of psychiatric medication. There have been occasional reports of suicide,
delusions, and psychosis-like behavior, but it could not be determined if efavirenz
was the cause. Patients with serious psychiatric adverse experiences should
be evaluated immediately to determine whether the risks of continued therapy
outweigh the benefits
Nervous System Symptoms
• Fifty-three percent of subjects reported central nervous system symptoms (including
dizziness [28.1%], insomnia [16.3%], impaired concentration [8.3%], somnolence
[7.0%], abnormal dreams [6.2%], and hallucinations [1.2%]) when taking efavirenz
compared to 25% of subjects receiving control regimens. These symptoms usually
begin during Days 1-2 of therapy and generally resolve after the first 2-4 weeks of
therapy; they were severe in 2.0% of subjects, and 2.1% of subjects discontinued
therapy. After 4 weeks of therapy, the prevalence of nervous system symptoms of
at least moderate severity ranged from 5% to 9% in subjects treated with regimens
containing efavirenz. Nervous system symptoms are not predictive of the less
frequent psychiatric symptoms
New Onset or Worsening Renal Impairment
• It is recommended that creatinine clearance (CrCl) be calculated in all patients prior
to initiating therapy and as clinically appropriate during therapy with ATRIPLA, and
routine monitoring of CrCl and serum phosphorus be performed for patients at risk of
renal impairment, including patients who have previously experienced renal events
while receiving adefovir dipivoxil. ATRIPLA should not be given to patients with CrCl
<50 mL/min. Renal impairment, including cases of acute renal failure and Fanconi
syndrome (renal tubular injury with severe hypophosphatemia), has been reported
with the use of tenofovir DF. ATRIPLA should be avoided with concurrent or recent
use of a nephrotoxic agent
Reproductive Risk Potential
• ATRIPLA may cause fetal harm when administered during the first trimester to
a pregnant woman. Women should not become pregnant or breastfeed while
taking ATRIPLA. Barrier contraception must always be used in combination with
other methods of contraception (eg, oral or other hormonal contraceptives).
Because of the long half-life of efavirenz, adequate contraceptive measures
are recommended for 12 weeks after discontinuation of ATRIPLA. If the patient
becomes pregnant while taking ATRIPLA, she should be apprised of the
potential harm to the fetus
Please see Important Safety Information, including Boxed
WARNINGS, for ATRIPLA and brief summary of Full Prescribing
Information on adjacent pages.
Rash
• Mild-to-moderate rash is a common side effect of efavirenz. In controlled
clinical trials, 26% of subjects treated with efavirenz experienced new-onset
skin rash compared with 17% of subjects treated in control groups. ATRIPLA
should be discontinued in patients developing severe rash associated with
blistering, desquamation, mucosal involvement, or fever
Hepatotoxicity
• Liver enzymes should be monitored before and during treatment in patients
with underlying hepatic disease, including hepatitis B or C infection; in patients
with marked transaminase elevations; and when ATRIPLA is administered
with ritonavir or other medications associated with liver toxicity. A few of the
postmarketing reports of hepatic failure, including cases in patients with no preexisting hepatic disease or other identifiable risk factors, were characterized by
a fulminant course, progressing in some cases to transplantation or death. Liver
enzyme monitoring should be considered for patients without pre-existing hepatic
dysfunction or other risk factors
Decreases in Bone Mineral Density
• Bone mineral density (BMD) monitoring should be considered for patients who
have a history of pathologic bone fracture or are at risk for osteopenia. Decreases
in BMD have been seen with tenofovir DF. Cases of osteomalacia (associated
with proximal renal tubulopathy and which may contribute to fractures) have been
reported in association with the use of tenofovir DF
Seizure
• Use ATRIPLA with caution in patients with a history of seizures. Convulsions
have been observed in patients receiving efavirenz, generally in the presence
of known medical history of seizures
Immune Reconstitution Syndrome
• Immune reconstitution syndrome has been reported in patients treated with
combination antiretroviral therapy, including the components of ATRIPLA
Fat Redistribution
• Redistribution/accumulation of body fat has been observed in patients receiving
antiretroviral therapy
Adverse Reactions
• In Study 934, through 144 weeks, the most frequently reported Grades 2-4 adverse
reactions reported in ≥5% of subjects receiving efavirenz + emtricitabine
+ tenofovir DF were diarrhea (9%), nausea (9%), fatigue (9%), depression (9%),
dizziness (8%), sinusitis (8%), upper respiratory tract infection (8%), rash event
(7%), headache (6%), insomnia (5%), anxiety (5%), and nasopharyngitis (5%)
• The most common adverse reactions (incidence ≥10%, any severity) occurring
in Study 934 include diarrhea, nausea, fatigue, headache, dizziness, depression,
insomnia, abnormal dreams, and rash
• Skin discoloration, associated with emtricitabine, may also occur
Drug Interactions
• Coadministration of ATRIPLA with didanosine should be undertaken with
caution. Patients receiving this combination should be monitored closely for
didanosine-associated adverse reactions
• Lopinavir/ritonavir has been shown to increase tenofovir concentrations.
Patients on lopinavir/ritonavir plus ATRIPLA should be monitored for tenofovirassociated adverse reactions. ATRIPLA should be discontinued in patients who
develop tenofovir-associated adverse reactions
• Coadministration of ATRIPLA and atazanavir is not recommended. Efavirenz
and tenofovir DF have been shown to decrease concentrations of atazanavir.
Atazanavir has also been shown to increase tenofovir concentrations
• Saquinavir should not be used as the only protease inhibitor in combination
with ATRIPLA
See Full Prescribing Information for complete list of drug-drug interactions.
Hepatic Impairment
• ATRIPLA is not recommended for patients with moderate or severe hepatic
impairment because of insufficient data; use caution in patients with mild
hepatic impairment
Dosage and Administration
• The dose of ATRIPLA is 1 tablet (containing 600 mg of efavirenz, 200 mg of
emtricitabine, and 300 mg of tenofovir DF) once daily taken orally on an empty
stomach. Dosing at bedtime may improve the tolerability of nervous system
symptoms. ATRIPLA is not recommended for use in patients <18 years of age
or in patients with CrCl <50 mL/min
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SFB0001A_AtrpBrf0311_7x9wip2_live 6/2/11 5:06 PM Page 1
ATRIPLA® (efavirenz 600 mg/emtricitabine 200 mg/tenofovir
disoproxil fumarate 300 mg) tablets
Brief Summary of Prescribing Information. For complete prescribing information consult official package insert.
WARNINGS: LACTIC ACIDOSIS/SEVERE HEPATOMEGALY WITH STEATOSIS and
POST-TREATMENT EXACERBATION OF HEPATITIS B
Lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported with the use of nucleoside
analogs, including tenofovir disoproxil fumarate, a component of ATRIPLA, in combination with other antiretrovirals [See Warnings
and Precautions].
ATRIPLA is not approved for the treatment of chronic hepatitis B virus (HBV) infection and the safety and efficacy of ATRIPLA have
not been established in patients coinfected with HBV and HIV-1. Severe acute exacerbations of hepatitis B have been reported in
patients who have discontinued EMTRIVA or VIREAD, two of the components of ATRIPLA. Hepatic function should be monitored
closely with both clinical and laboratory follow-up for at least several months in patients who are coinfected with HIV-1 and HBV
and discontinue ATRIPLA. If appropriate, initiation of anti-hepatitis B therapy may be warranted [See Warnings and Precautions].
INDICATIONS AND USAGE
ATRIPLA® (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) is indicated for use alone as a
complete regimen or in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults.
CONTRAINDICATIONS
ATRIPLA is contraindicated in patients with previously demonstrated clinically significant hypersensitivity (e.g., StevensJohnson syndrome, erythema multiforme, or toxic skin eruptions) to efavirenz, a component of ATRIPLA.
Contraindicated Drugs: For some drugs, competition for CYP3A by efavirenz could result in inhibition of their metabolism
and create the potential for serious and/or life-threatening adverse reactions. Drugs that are contraindicated or not
recommended for use with ATRIPLA include: bepridil, cisapride, midazolam, pimozide, triazolam, voriconazole, ergot
derivatives, or St. John’s wort (Hypericum perforatum).
WARNINGS AND PRECAUTIONS
Lactic Acidosis/Severe Hepatomegaly with Steatosis: Lactic acidosis and severe hepatomegaly with steatosis, including
fatal cases, have been reported with the use of nucleoside analogs including tenofovir DF, a component of ATRIPLA, in
combination with other antiretrovirals. A majority of these cases have been in women. Obesity and prolonged nucleoside
exposure may be risk factors. Particular caution should be exercised when administering nucleoside analogs to any patient
with known risk factors for liver disease; however, cases have also been reported in patients with no known risk factors.
Treatment with ATRIPLA should be suspended in any patient who develops clinical or laboratory findings suggestive of lactic
acidosis or pronounced hepatotoxicity (which may include hepatomegaly and steatosis even in the absence of marked
transaminase elevations).
Patients Coinfected with HIV-1 and HBV: It is recommended that all patients with HIV-1 be tested for the presence of
chronic HBV before initiating antiretroviral therapy. ATRIPLA is not approved for the treatment of chronic HBV infection, and
the safety and efficacy of ATRIPLA have not been established in patients coinfected with HBV and
HIV-1. Severe acute exacerbations of hepatitis B have been reported in patients who are coinfected with HBV and HIV-1 and
have discontinued emtricitabine or tenofovir DF, two of the components of ATRIPLA. In some patients infected with HBV and
treated with emtricitabine, the exacerbations of hepatitis B were associated with liver decompensation and liver failure.
Patients who are coinfected with HIV-1 and HBV should be closely monitored with both clinical and laboratory follow up for
at least several months after stopping treatment with ATRIPLA. If appropriate, initiation of anti-hepatitis B therapy may be
warranted.
ATRIPLA should not be administered with HEPSERA® (adefovir dipivoxil) [See Drug Interactions].
Drug Interactions: Efavirenz plasma concentrations may be altered by substrates, inhibitors, or inducers of CYP3A.
Likewise, efavirenz may alter plasma concentrations of drugs metabolized by CYP3A [See Contraindications and Drug
Interactions].
Coadministration with Related Products: Related drugs not for coadministration with ATRIPLA include EMTRIVA
(emtricitabine), VIREAD (tenofovir DF), TRUVADA (emtricitabine/tenofovir DF), and SUSTIVA (efavirenz), which contain the
same active components as ATRIPLA. Due to similarities between emtricitabine and lamivudine, ATRIPLA should not be
coadministered with drugs containing lamivudine, including Combivir (lamivudine/zidovudine), Epivir, or Epivir-HBV
(lamivudine), Epzicom (abacavir sulfate/lamivudine), or Trizivir (abacavir sulfate/lamivudine/zidovudine).
Psychiatric Symptoms: Serious psychiatric adverse experiences have been reported in patients treated with efavirenz. In
controlled trials of 1008 subjects treated with regimens containing efavirenz for a mean of 2.1 years and 635 subjects
treated with control regimens for a mean of 1.5 years, the frequency (regardless of causality) of specific serious psychiatric
events among subjects who received efavirenz or control regimens, respectively, were: severe depression (2.4%, 0.9%),
suicidal ideation (0.7%, 0.3%), nonfatal suicide attempts (0.5%, 0%), aggressive behavior (0.4%, 0.5%), paranoid reactions
(0.4%, 0.3%), and manic reactions (0.2%, 0.3%). Other factors associated with an increase in the occurrence of these
psychiatric symptoms were history of injection drug use, psychiatric history, and receipt of psychiatric medication at study
entry; similar associations were observed in both the efavirenz and control treatment groups. In Study 006, onset of new
serious psychiatric symptoms occurred throughout the study for both efavirenz-treated and control-treated subjects. One
percent of efavirenz-treated subjects discontinued or interrupted treatment because of one or more of these selected
psychiatric symptoms. There have also been occasional postmarketing reports of death by suicide, delusions, and
psychosis-like behavior, although a causal relationship to the use of efavirenz cannot be determined from these reports.
Patients with serious psychiatric adverse experiences should seek immediate medical evaluation to assess the possibility
that the symptoms may be related to the use of efavirenz, and if so, to determine whether the risks of continued therapy
outweigh the benefits [See Adverse Reactions].
Nervous System Symptoms: Fifty-three percent (531/1008) of subjects receiving efavirenz in controlled trials reported
central nervous system symptoms (any grade, regardless of causality) compared to 25% (156/635) of subjects receiving
control regimens. These symptoms included dizziness (28.1% of the 1008 subjects), insomnia (16.3%), impaired
concentration (8.3%), somnolence (7.0%), abnormal dreams (6.2%), and hallucinations (1.2%). Other reported symptoms
were euphoria, confusion, agitation, amnesia, stupor, abnormal thinking, and depersonalization. The majority of these
symptoms were mild-moderate (50.7%); symptoms were severe in 2.0% of subjects. Overall, 2.1% of subjects discontinued
therapy as a result. These symptoms usually begin during the first or second day of therapy and generally resolve after the
first 2–4 weeks of therapy. After 4 weeks of therapy, the prevalence of nervous system symptoms of at least moderate
severity ranged from 5% to 9% in subjects treated with regimens containing efavirenz and from 3% to 5% in subjects
treated with a control regimen. Patients should be informed that these common symptoms were likely to improve with
continued therapy and were not predictive of subsequent onset of the less frequent psychiatric symptoms [See Warnings
and Precautions]. Dosing at bedtime may improve the tolerability of these nervous system symptoms [See Dosage and
Administration (2) in Full Prescribing Information].
Patients receiving ATRIPLA should be alerted to the potential for additive central nervous system effects when ATRIPLA is
used concomitantly with alcohol or psychoactive drugs.
Patients who experience central nervous system symptoms such as dizziness, impaired concentration, and/or drowsiness
should avoid potentially hazardous tasks such as driving or operating machinery.
New Onset or Worsening Renal Impairment: Emtricitabine and tenofovir are principally eliminated by the kidney; however,
efavirenz is not. Since ATRIPLA is a combination product and the dose of the individual components cannot be altered,
patients with creatinine clearance <50 mL/min should not receive ATRIPLA. Renal impairment, including cases of acute renal
failure and Fanconi syndrome (renal tubular injury with severe hypophosphatemia), has been reported with the use of
tenofovir DF [See Adverse Reactions]. It is recommended that creatinine clearance be calculated in all patients prior to
initiating therapy and as clinically appropriate during therapy with ATRIPLA. Routine monitoring of calculated creatinine
clearance and serum phosphorus should be performed in patients at risk for renal impairment, including patients who have
previously experienced renal events while receiving HEPSERA. ATRIPLA should be avoided with concurrent or recent use of
a nephrotoxic agent.
Reproductive Risk Potential: Pregnancy Category D - Efavirenz may cause fetal harm when administered during the first
trimester to a pregnant woman. Pregnancy should be avoided in women receiving ATRIPLA. Barrier contraception must
always be used in combination with other methods of contraception (e.g., oral or other hormonal contraceptives). Because
of the long half-life of efavirenz, use of adequate contraceptive measures for 12 weeks after discontinuation of ATRIPLA is
recommended. Women of childbearing potential should undergo pregnancy testing before initiation of ATRIPLA. If this drug
is used during the first trimester of pregnancy, or if the patient becomes pregnant while taking this drug, the patient should
be apprised of the potential harm to the fetus. There are no adequate and well-controlled studies of ATRIPLA in pregnant
women. ATRIPLA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus, such
as in pregnant women without other therapeutic options.
Antiretroviral Pregnancy Registry - To monitor fetal outcomes of pregnant women, an Antiretroviral Pregnancy Registry
has been established. Physicians are encouraged to register patients who become pregnant by calling (800) 258-4263.
Rash: In controlled clinical trials, 26% (266/1008) of subjects treated with 600 mg efavirenz experienced new-onset skin
rash compared with 17% (111/635) of subjects treated in control groups. Rash associated with blistering, moist
desquamation, or ulceration occurred in 0.9% (9/1008) of subjects treated with efavirenz. The incidence of Grade 4 rash
(e.g., erythema multiforme, Stevens-Johnson syndrome) in subjects treated with efavirenz in all studies and expanded
access was 0.1%. Rashes are usually mild-to-moderate maculopapular skin eruptions that occur within the first 2 weeks of
initiating therapy with efavirenz (median time to onset of rash in adults was 11 days) and, in most subjects continuing
therapy with efavirenz, rash resolves within 1 month (median duration, 16 days). The discontinuation rate for rash in clinical
trials was 1.7% (17/1008). ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) can be
reinitiated in patients interrupting therapy because of rash. ATRIPLA should be discontinued in patients developing severe
rash associated with blistering, desquamation, mucosal involvement, or fever. Appropriate antihistamines and/or
corticosteroids may improve the tolerability and hasten the resolution of rash.
Hepatotoxicity: Monitoring of liver enzymes before and during treatment is recommended for patients with underlying
hepatic disease, including hepatitis B or C infection; patients with marked transaminase elevations; and patients treated with
other medications associated with liver toxicity [See also Warnings and Precautions]. A few of the postmarketing reports of
hepatic failure occurred in patients with no pre-existing hepatic disease or other identifiable risk factors [See Adverse
Reactions]. Liver enzyme monitoring should also be considered for patients without pre-existing hepatic dysfunction or other
risk factors. In patients with persistent elevations of serum transaminases to greater than five times the upper limit of the
normal range, the benefit of continued therapy with ATRIPLA needs to be weighed against the unknown risks of significant
liver toxicity [See Adverse Reactions].
Decreases in Bone Mineral Density (BMD): BMD monitoring should be considered for HIV-1-infected subjects who have
a history of pathologic bone fracture or are at risk for osteopenia. If bone abnormalities are suspected then appropriate
consultation should be obtained. In a 144-week study of treatment-naive subjects receiving tenofovir DF, decreases in BMD
were seen at the lumbar spine and hip in both arms of the study. There was a significantly greater mean percentage
decrease from baseline in BMD at the lumbar spine in subjects receiving tenofovir DF + lamivudine + efavirenz compared
with subjects receiving stavudine + lamivudine + efavirenz. Changes in BMD at the hip were similar between the two
treatment groups. Twenty-eight percent of tenofovir DF-treated subjects vs. 21% of the comparator subjects lost at least
5% of BMD at the spine or 7% of BMD at the hip. Clinically relevant fractures (excluding fingers and toes) were reported in
4 subjects in the tenofovir DF group and 6 subjects in the comparator group. Tenofovir DF was associated with significant
increases in biochemical markers of bone metabolism, suggesting increased bone turnover. Serum parathyroid hormone
levels and 1,25 vitamin D levels were also higher in subjects receiving tenofovir DF. For additional information, consult the
tenofovir DF prescribing information.
Cases of osteomalacia (associated with proximal renal tubulopathy and which may contribute to fractures) have been
reported in association with the use of tenofovir DF [See Adverse Reactions].
Convulsions: Convulsions have been observed in patients receiving efavirenz, generally in the presence of known medical
history of seizures. Caution must be taken in any patient with a history of seizures. Patients who are receiving concomitant
anticonvulsant medications primarily metabolized by the liver, such as phenytoin and phenobarbital, may require periodic
monitoring of plasma levels [See Drug Interactions].
Immune Reconstitution Syndrome: Immune reconstitution syndrome has been reported in patients treated with
combination antiretroviral therapy, including the components of ATRIPLA. During the initial phase of combination
antiretroviral treatment, patients whose immune system responds may develop an inflammatory response to indolent or
residual opportunistic infections [such as Mycobacterium avium infection, cytomegalovirus, Pneumocystis jirovecii
pneumonia (PCP), or tuberculosis], which may necessitate further evaluation and treatment.
Fat Redistribution: Redistribution/accumulation of body fat including central obesity, dorsocervical fat enlargement
(buffalo hump), peripheral wasting, facial wasting, breast enlargement, and “cushingoid appearance” have been observed
in patients receiving antiretroviral therapy. The mechanism and long-term consequences of these events are currently
unknown. A causal relationship has not been established.
ADVERSE REACTIONS
Efavirenz, Emtricitabine and Tenofovir DF - The following adverse reactions are discussed in other sections of
the labeling [See Boxed Warning and Warnings and Precautions]: Lactic acidosis and severe hepatomegaly with steatosis,
severe acute exacerbations of hepatitis B, psychiatric symptoms, nervous system symptoms, new onset or worsening renal
impairment, rash, hepatotoxicity, decreases in BMD, and immune reconstitution syndrome.
For additional safety information about SUSTIVA (efavirenz), EMTRIVA (emtricitabine), or VIREAD (tenofovir DF) in combination
with other antiretroviral agents, consult the prescribing information for these products.
Adverse Reactions from Clinical Trials Experience: Study 934 was an open-label active-controlled study in which 511
antiretroviral-naive subjects received either emtricitabine + tenofovir DF administered in combination with efavirenz
(N=257) or zidovudine/lamivudine administered in combination with efavirenz (N=254). Grades 2–4 adverse reactions,
based on treatment-emergent adverse events, at a frequency ≥5% in subjects receiving efavirenz, emtricitabine and
tenofovir DF and zidovudine/lamivudine + efavirenz (active control) through 144 weeks, respectively, were: diarrhea
(9%, 5%), nausea (9%, 7%), fatigue (9%, 8%), depression (9%, 7%), dizziness (8%, 7%), sinusitis (8%, 4%), upper
respiratory tract infections (8%, 5%), nasopharyngitis (5%, 3%), rash event (7%, 9%), headache (6%, 5%), insomnia
(5%, 7%), anxiety (5%, 4%), and vomiting (2%, 5%).
In Study 934, the most common adverse reactions (incidence ≥10%, any severity) for components of ATRIPLA, included
diarrhea, nausea, fatigue, headache, dizziness, depression, insomnia, abnormal dreams, and rash.
In Study 073, subjects with stable, virologic suppression on antiretroviral therapy and no history of virologic failure were
randomized to receive ATRIPLA or to stay on their baseline regimen. The adverse reactions observed in Study 073 were
generally consistent with those seen in Study 934 and those seen with the individual components of ATRIPLA when each
was administered in combination with other antiretroviral agents. In addition to the adverse reactions in Study 934 and Study
073 the following adverse reactions were observed in clinical trials of efavirenz, emtricitabine, or tenofovir DF in combination
with other antiretroviral agents.
Efavirenz - The most significant adverse reactions observed in subjects treated with efavirenz are nervous system
symptoms, psychiatric symptoms, and rash [See Warnings and Precautions]. Selected adverse reactions of moderatesevere intensity observed in ≥2% of efavirenz-treated subjects in two controlled clinical trials included pain, impaired
concentration, abnormal dreams, somnolence, anorexia, dyspepsia, abdominal pain, nervousness, and pruritus. Pancreatitis
has also been reported, although a causal relationship with efavirenz has not been established. Asymptomatic increases in
serum amylase levels were observed in a significantly higher number of subjects treated with efavirenz 600 mg than in
control subjects.
Emtricitabine and Tenofovir DF - Adverse reactions that occurred in at least 5% of treatment-experienced or treatmentnaive subjects receiving emtricitabine or tenofovir DF with other antiretroviral agents in clinical trials include arthralgia,
increased cough, dyspepsia, fever, myalgia, pain, abdominal pain, back pain, paresthesia, peripheral neuropathy (including
peripheral neuritis and neuropathy), pneumonia, rhinitis and rash event (including rash, pruritus, maculopapular rash,
urticaria, vesiculobullous rash, pustular rash and allergic reaction). Skin discoloration has been reported with higher
frequency among emtricitabine-treated subjects.
Laboratory Abnormalities: Efavirenz, Emtricitabine and Tenofovir DF - Laboratory abnormalities observed in Study 934
through 144 weeks were generally consistent with those seen in previous studies; significant observations in ≥1% of
subjects include: any ≥Grade 3 laboratory abnormality (30%, 26%), fasting cholesterol (>240 mg/dL) (22%, 24%), creatine
kinase (males >990 U/L, females >845 U/L) (9%, 7%), serum amylase (>175 U/L) (8%, 4%), alkaline phosphatase (>550 U/L)
(1%, 0%), AST (males >180 U/L, females >170 U/L) (3%, 3%), ALT (males >215 U/L, females >170 U/L) (2%, 3%),
hemoglobin (<8.0 mg/dL) (0%, 4%), hyperglycemia (>250 mg/dL) (2%, 1%), hematuria (>75 RBC/HPF) (3%, 2%),
glycosuria (≥3+) (<1%, 1%), neutrophils (<750 mm3) (3%, 5%), and fasting triglycerides (>750 mg/dL) (4%, 2%) in tenofovir
DF group and zidovudine group, respectively. Laboratory abnormalities observed in Study 073 were generally consistent with
those in Study 934. Additionally, Grade 3/4 elevations of bilirubin (>2.5 x ULN), pancreatic amylase (>2.0 x ULN), serum
glucose (<40 or >250 mg/dL), and serum lipase (>2.0 x ULN) occurred in up to 3% of subjects treated with emtricitabine
or tenofovir DF with other antiretroviral agents in clinical trials.
Postmarketing Experience: The following adverse reactions have been identified during postapproval use of efavirenz,
emtricitabine, or tenofovir DF. Because postmarketing reactions are reported voluntarily from a population of uncertain size,
it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Efavirenz - Abnormal coordination, abnormal vision, aggressive reactions, agitation, allergic reactions, arthralgia, asthenia,
ataxia, cerebellar coordination and balance disturbances, constipation, convulsions, delusions, dyspnea, emotional lability,
erythema multiforme, flushing, gynecomastia, hepatic enzyme increase, hepatic failure, hepatitis, hypercholesterolemia,
hypertriglyceridemia, hypoesthesia, malabsorption, mania, myalgia, myopathy, neuropathy, neurosis, palpitations, paranoia,
paresthesia, photoallergic dermatitis, psychosis, redistribution/accumulation of body fat [See Warnings and Precautions],
Stevens-Johnson syndrome, suicide, tinnitus, tremor, and vertigo. A few of the postmarketing reports of hepatic failure, including
cases in patients with no pre-existing hepatic disease or other identifiable risk factors, were characterized by a fulminant course,
progressing in some cases to transplantation or death.
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Emtricitabine - No postmarketing adverse reactions have been identified for inclusion in this section.
Tenofovir DF - Abdominal pain, acute renal failure, acute tubular necrosis, allergic reaction including angioedema, asthenia,
dyspnea, Fanconi syndrome, hepatic steatosis, hepatitis, hypokalemia, hypophosphatemia, increased amylase, increased
creatinine, increased liver enzymes (most commonly AST, ALT, gamma GT), interstitial nephritis (including acute cases), lactic
acidosis, muscular weakness, myopathy, nephrogenic diabetes insipidus, osteomalacia (manifested as bone pain and which
may contribute to fractures), pancreatitis, polyuria, proteinuria, proximal renal tubulopathy, rash, renal failure, renal
insufficiency and rhabdomyolysis.
The following adverse reactions, listed above, may occur as a consequence of proximal renal tubulopathy: rhabdomyolysis,
osteomalacia, hypokalemia, muscular weakness, myopathy, hypophosphatemia.
DRUG INTERACTIONS
Efavirenz: Efavirenz has been shown in vivo to induce CYP3A. Other compounds that are substrates of CYP3A may have
decreased plasma concentrations when coadministered with efavirenz. In vitro studies have demonstrated that efavirenz
inhibits CYP2C9, 2C19, and 3A4 isozymes in the range of observed efavirenz plasma concentrations. Coadministration of
efavirenz with drugs primarily metabolized by these isozymes may result in altered plasma concentrations of the
coadministered drug. Therefore, appropriate dose adjustments may be necessary for these drugs. Drugs that induce CYP3A
activity (e.g., phenobarbital, rifampin, rifabutin) would be expected to increase the clearance of efavirenz resulting in lowered
plasma concentrations.
Emtricitabine and Tenofovir DF: Since emtricitabine and tenofovir are primarily eliminated by the kidneys, coadministration
of ATRIPLA (efavirenz 600 mg/emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg) with drugs that reduce renal
function or compete for active tubular secretion may increase serum concentrations of emtricitabine, tenofovir, and/or other
renally eliminated drugs. Some examples include, but are not limited to, acyclovir, adefovir dipivoxil, cidofovir, ganciclovir,
valacyclovir, and valganciclovir.
Coadministration of tenofovir DF and didanosine should be undertaken with caution and patients receiving this combination
should be monitored closely for didanosine-associated adverse reactions. Didanosine should be discontinued in patients
who develop didanosine-associated adverse reactions. Suppression of CD4+ cell counts has been observed in patients
receiving tenofovir DF with didanosine 400 mg daily. Atazanavir and lopinavir/ritonavir have been shown to increase tenofovir
concentrations. ATRIPLA should be discontinued in patients who develop tenofovir-associated adverse reactions.
Coadministration of atazanavir with ATRIPLA is not recommended. There are insufficient data to support dosing
recommendations for atazanavir, with or without ritonavir in combination with ATRIPLA.
Efavirenz, Emtricitabine and Tenofovir DF: Other important drug interaction information for ATRIPLA is summarized below.
The drug interactions described are based on studies conducted with efavirenz, emtricitabine or tenofovir DF as individual
agents or are potential drug interactions; no drug interaction studies have been conducted using ATRIPLA. The list includes
potentially significant interactions, but are not all inclusive.
Established and Other Potentially Significant Drug Interactions*: Alteration in Dose or Regimen May Be Recommended
Based on Drug Interaction Studies or Predicted Interaction
Antiretroviral agents: Protease Inhibitors — Atazanavir: ↓atazanavir concentration, ↑tenofovir concentration.
Coadministration of atazanavir with ATRIPLA is not recommended. Coadministration of atazanavir with either efavirenz or
tenofovir DF decreases plasma concentrations of atazanavir. The combined effect of efavirenz plus tenofovir DF on atazanavir
plasma concentrations is not known. Also, atazanavir has been shown to increase tenofovir concentrations. There are
insufficient data to support dosing recommendations for atazanavir or atazanavir/ritonavir in combination with ATRIPLA.
Fosamprenavir calcium: ↓amprenavir concentration. Fosamprenavir (unboosted): Appropriate doses of fosamprenavir and
ATRIPLA with respect to safety and efficacy have not been established. Fosamprenavir/ritonavir: An additional 100 mg/day
(300 mg total) of ritonavir is recommended when ATRIPLA is administered with fosamprenavir/ritonavir once daily. No change
in the ritonavir dose is required when ATRIPLA is administered with fosamprenavir plus ritonavir twice daily. Indinavir:
↓indinavir concentration. The optimal dose of indinavir, when given in combination with efavirenz, is not known. Increasing
the indinavir dose to 1000 mg every 8 hours does not compensate for the increased indinavir metabolism due to efavirenz.
Lopinavir/ritonavir: ↓lopinavir concentration, ↑tenofovir concentration. A dose increase of lopinavir/ritonavir to 600/150 mg
(3 tablets) twice daily may be considered when used in combination with efavirenz in treatment-experienced patients
where decreased susceptibility to lopinavir is clinically suspected (by treatment history or laboratory evidence). Patients
should be monitored for tenofovir-associated adverse reactions. ATRIPLA should be discontinued in patients who
develop tenofovir-associated adverse reactions. Ritonavir: ↑ritonavir concentration,↑efavirenz concentration. When
ritonavir 500 mg every 12 hours was coadministered with efavirenz 600 mg once daily, the combination was associated
with a higher frequency of adverse clinical experiences (e.g., dizziness, nausea, paresthesia) and laboratory abnormalities
(elevated liver enzymes). Monitoring of liver enzymes is recommended when ATRIPLA is used in combination with ritonavir.
Saquinavir: ↓saquinavir concentration. Should not be used as sole protease inhibitor in combination with ATRIPLA.
CCR5 co-receptor antagonist — Maraviroc: ↓maraviroc concentration. Efavirenz decreases plasma concentrations
of maraviroc. Refer to the full prescribing information for maraviroc for guidance on coadministration with ATRIPLA.
NRTI — Didanosine: ↑didanosine concentration. Higher didanosine concentrations could potentiate didanosine-associated
adverse reactions, including pancreatitis and neuropathy. In adults weighing >60 kg, the didanosine dose should be
reduced to 250 mg if coadministered with ATRIPLA. Data are not available to recommend a dose adjustment of
didanosine for patients weighing <60 kg. Coadministration of ATRIPLA and didanosine should be undertaken with
caution and patients receiving this combination should be monitored closely for didanosine-associated adverse
reactions. For additional information, please consult the Videx/Videx EC (didanosine) prescribing information.
Other Agents: Anticoagulant — Warfarin: ↑or ↓warfarin concentration. Plasma concentrations and effects potentially
increased or decreased by efavirenz.
Anticonvulsants — Carbamazepine: ↓carbamazepine concentration, ↓efavirenz concentration. There are insufficient data
to make a dose recommendation for ATRIPLA. Alternative anticonvulsant treatment should be used. Phenytoin, Phenobarbital:
↓anticonvulsant concentration, ↓efavirenz concentration. Potential for reduction in anticonvulsant and/or efavirenz plasma
levels; periodic monitoring of anticonvulsant plasma levels should be conducted.
Antidepressant — Sertraline: ↓sertraline concentration. Increases in sertraline dose should be guided by clinical
response.
Antifungals — Itraconazole: ↓itraconazole and hydroxy-itraconazole concentration. Since no dose recommendation for
itraconazole can be made, alternative antifungal treatment should be considered. Ketoconazole: ↓ketoconazole concentration.
Drug interaction studies with ATRIPLA and ketoconazole have not been conducted. Efavirenz has the potential to decrease
plasma concentrations of ketoconazole. Posaconazole: ↓posaconazole concentration. Avoid concomitant use unless the
benefit outweighs the risks.
Anti-infective — Clarithromycin: ↓clarithromycin concentration, ↑14-OH metabolite concentration. Clinical significance
unknown. In uninfected volunteers, 46% developed rash while receiving efavirenz and clarithromycin. No dose adjustment
of ATRIPLA is recommended when given with clarithromycin. Alternatives to clarithromycin, such as azithromycin, should be
considered. Other macrolide antibiotics, such as erythromycin, have not been studied in combination with ATRIPLA.
Antimycobacterials — Rifabutin: ↓rifabutin concentration. Increase daily dose of rifabutin by 50%. Consider doubling the
rifabutin dose in regimens where rifabutin is given 2 or 3 times a week. Rifampin: ↓efavirenz concentration. Clinical
significance of reduced efavirenz concentration is unknown. Dosing recommendations for concomitant use of ATRIPLA and
rifampin have not been established.
Calcium channel blockers — Diltiazem: ↓diltiazem, desacetyl diltiazem, and N-monodesmethyl diltiazem concentrations.
Diltiazem dose adjustments should be guided by clinical response (refer to the full prescribing information for diltiazem). No
dose adjustment of ATRIPLA is necessary when administered with diltiazem. Others (e.g., felodipine, nicardipine, nifedipine,
verapamil): ↓calcium channel blocker. No data are available on the potential interactions of efavirenz with other calcium
channel blockers that are substrates of CYP3A. The potential exists for reduction in plasma concentrations of the calcium
channel blocker. Dose adjustments should be guided by clinical response (refer to the full prescribing information for the
calcium channel blocker).
HMG-CoA reductase inhibitors — Atorvastatin: ↓atorvastatin concentration, Pravastatin: ↓pravastatin concentration,
Simvastatin: ↓simvastatin concentration. Plasma concentrations of atorvastatin, pravastatin, and simvastatin decreased with
efavirenz. Consult the full prescribing information for the HMG-CoA reductase inhibitor for guidance on individualizing the dose.
Hormonal contraceptives — Oral: Ethinyl estradiol/Norgestimate: ↓active metabolites of norgestimate. A reliable method
of barrier contraception must be used in addition to hormonal contraceptives. Efavirenz had no effect on ethinyl estradiol
concentrations, but progestin levels (norelgestromin and levonorgestrel) were markedly decreased. No effect of ethinyl
estradiol/norgestimate on efavirenz plasma concentrations was observed. Implant: Etonogestrel: ↓etonogestrel. A reliable
method of barrier contraception must be used in addition to hormonal contraceptives. The interaction between etonogestrel
and efavirenz has not been studied. Decreased exposure of etonogestrel may be expected. There have been postmarketing
reports of contraceptive failure with etonogestrel in efavirenz-exposed patients.
Immunosuppressants — Cyclosporine, tacrolimus, sirolimus, and others metabolized by CYP3A: ↓immunosuppressant.
Decreased exposure of the immunosuppressant may be expected due to CYP3A induction by efavirenz. These
immunosuppressants are not anticipated to affect exposure of efavirenz. Dose adjustments of the immunosuppressant may
be required. Close monitoring of immunosuppressant concentrations for at least 2 weeks (until stable concentrations are
reached) is recommended when starting or stopping treatment with ATRIPLA.
Narcotic analgesic — Methadone: ↓methadone concentration. Coadministration of efavirenz in HIV-1 infected individuals
with a history of injection drug use resulted in decreased plasma levels of methadone and signs of opiate withdrawal.
Methadone dose was increased by a mean of 22% to alleviate withdrawal symptoms. Patients should be monitored for
signs of withdrawal and their methadone dose increased as required to alleviate withdrawal symptoms.
*Please see Full Prescribing Information (Table 4) for additional information; this list is not all inclusive.
USE IN SPECIFIC POPULATIONS
Pregnancy: Pregnancy Category D [See Warnings and Precautions]
Nursing Mothers: The Centers for Disease Control and Prevention recommend that HIV-1 infected mothers not
breast-feed their infants to avoid risking postnatal transmission of HIV-1. Studies in rats have demonstrated that both
efavirenz and tenofovir are secreted in milk. It is not known whether efavirenz, emtricitabine, or tenofovir is excreted in
human milk. Because of both the potential for HIV-1 transmission and the potential for serious adverse reactions in nursing
infants, mothers should be instructed not to breast-feed if they are receiving ATRIPLA (efavirenz 600 mg/
emtricitabine 200 mg/tenofovir disoproxil fumarate 300 mg).
Pediatric Use: ATRIPLA is not recommended for patients less than 18 years of age because it is a fixed-dose combination
tablet containing a component, tenofovir DF, for which safety and efficacy have not been established in this age group.
Geriatric Use: Clinical studies of efavirenz, emtricitabine, or tenofovir DF did not include sufficient numbers of subjects aged
65 and over to determine whether they respond differently from younger subjects. In general, dose selection for the elderly
patients should be cautious, keeping in mind the greater frequency of decreased hepatic, renal, or cardiac function, and of
concomitant disease or other drug therapy.
Hepatic Impairment: ATRIPLA is not recommended for patients with moderate or severe hepatic impairment because there
are insufficient data. Patients with mild hepatic impairment may be treated with ATRIPLA; however, because of the extensive
cytochrome P450-mediated metabolism of efavirenz and limited clinical experience in patients with hepatic impairment,
caution should be exercised in administering ATRIPLA to these patients [See Warnings and Precautions and Clinical
Pharmacology (12.3) in Full Prescribing Information].
Renal Impairment: Because ATRIPLA is a fixed-dose combination, it should not be prescribed for patients requiring dosage
adjustment such as those with moderate or severe renal impairment (creatinine clearance <50 mL/min) [See Warnings and
Precautions].
OVERDOSAGE
If overdose occurs, the patient should be monitored for evidence of toxicity, including monitoring of vital signs and
observation of the patient’s clinical status; standard supportive treatment should then be applied as necessary.
Administration of activated charcoal may be used to aid removal of unabsorbed efavirenz. Hemodialysis can remove both
emtricitabine and tenofovir DF, but is unlikely to significantly remove efavirenz from the blood.
Efavirenz - Some patients accidentally taking 600 mg twice daily have reported increased nervous system symptoms. One
patient experienced involuntary muscle contractions.
Emtricitabine - Limited clinical experience is available at doses higher than the therapeutic dose. In one study single doses
of emtricitabine 1200 mg were administered to 11 subjects. No severe adverse reactions were reported.
Hemodialysis treatment removes approximately 30% of the emtricitabine dose over a 3-hour dialysis period starting within
1.5 hours of emtricitabine dosing (blood flow rate of 400 mL/min and a dialysate flow rate of 600 mL/min). It is not known
whether emtricitabine can be removed by peritoneal dialysis.
Tenofovir DF - Limited clinical experience at doses higher than the therapeutic dose of tenofovir DF 300 mg is available. In
one study, 600 mg tenofovir DF was administered to 8 subjects orally for 28 days, and no severe adverse reactions were
reported. The effects of higher doses are not known.
Tenofovir is efficiently removed by hemodialysis with an extraction coefficient of approximately 54%. Following a single
300 mg dose of tenofovir DF, a 4-hour hemodialysis session removed approximately 10% of the dose.
PATIENT COUNSELING INFORMATION and FDA-APPROVED PATIENT LABELING
Drug Interactions: A statement to patients and healthcare providers is included on the product’s bottle labels: ALERT: Find
out about medicines that should NOT be taken with ATRIPLA. ATRIPLA may interact with some drugs; therefore, patients
should be advised to report to their doctor the use of any other prescription, nonprescription medication, or herbal products,
particularly St. John’s wort.
Information for Patients: Patients should be advised that: ATRIPLA is not a cure for HIV-1 infection and patients may
continue to experience illnesses associated with HIV-1 infection, including opportunistic infections; they should remain under
the care of a physician when using ATRIPLA; the use of ATRIPLA has not been shown to reduce the risk of transmission of
HIV-1 to others through sexual contact or blood contamination; patients should be advised to continue to practice safer sex
and to use latex or polyurethane condoms to lower the chance of sexual contact with any body fluids such as semen, vaginal
secretions or blood; patients should be advised never to re-use or share needles; the long-term effects of ATRIPLA are
unknown; redistribution or accumulation of body fat may occur in patients receiving antiretroviral therapy and that the cause
and long-term health effects of these conditions are not known; ATRIPLA should not be coadministered with SUSTIVA,
EMTRIVA, VIREAD, or TRUVADA, or drugs containing lamivudine, including Combivir, Epivir, Epivir-HBV, Epzicom, or Trizivir.
ATRIPLA should not be administered with HEPSERA [See Warnings and Precautions].
Patients should also be advised that:
• lactic acidosis and severe hepatomegaly with steatosis, including fatal cases, have been reported. Treatment with
ATRIPLA will be suspended in any patients who develop clinical symptoms suggestive of lactic acidosis or pronounced
hepatotoxicity [See Warnings and Precautions].
• they should be tested for hepatitis B virus (HBV) before initiating antiretroviral therapy. Severe acute exacerbations of
hepatitis B have been reported in patients who are coinfected with HBV and HIV-1 and have discontinued EMTRIVA or
VIREAD, which are the components of ATRIPLA.
• renal impairment, including cases of acute renal failure and Fanconi syndrome, has been reported. ATRIPLA should be
avoided with concurrent or recent use of a nephrotoxic agent [See Warnings and Precautions].
• decreases in BMD have been observed with the use of tenofovir DF; BMD monitoring may be performed in patients who
have a history of pathologic bone fracture or at risk for osteopenia [See Warnings and Precautions].
• take ATRIPLA orally on an empty stomach and that it is important to take ATRIPLA on a regular dosing schedule
to avoid missing doses.
• central nervous system symptoms (NSS) are commonly reported during the first weeks of therapy with efavirenz. Dosing at
bedtime may improve the tolerability of these symptoms, which are likely to improve with continued therapy. Patients should
be alerted to the potential for additive effects when ATRIPLA is used concomitantly with alcohol or psychoactive drugs.
Patients should be instructed that if they experience NSS they should avoid potentially hazardous tasks such as driving
or operating machinery [See Warnings and Precautions and Dosage and Administration (2) in Full Prescribing Information].
• serious psychiatric symptoms have been reported in patients receiving efavirenz. If they experience severe psychiatric
adverse experiences they should seek immediate medical evaluation. Patients should be advised to inform their physician
of any history of mental illness or substance abuse [See Warnings and Precautions].
• a common side effect is rash. Rashes usually go away without any change in treatment. However, since rash may be
serious, patients should be advised to contact their physician promptly if rash occurs.
Reproductive Risk Potential: Women receiving ATRIPLA should be instructed to avoid pregnancy [See Warnings and
Precautions]. A reliable form of barrier contraception must always be used in combination with other methods of
contraception, including oral or other hormonal contraception. Because of the long half-life of efavirenz, use of adequate
contraceptive measures for 12 weeks after discontinuation of ATRIPLA is recommended. Women should be advised to
notify their physician if they become pregnant or plan to become pregnant while taking ATRIPLA. If this drug is used during
the first trimester of pregnancy, or if the patient becomes pregnant while taking this drug, she should be apprised of
the potential harm to the fetus.
Bristol-Myers Squibb & Gilead Sciences, LLC.
Foster City, CA 94404
ATRIPLA is a trademark of Bristol-Myers Squibb & Gilead Sciences, LLC. EMTRIVA, TRUVADA, HEPSERA and VIREAD are
trademarks of Gilead Sciences, Inc. SUSTIVA is a registered trademark of Bristol-Myers Squibb Pharma Company.
Reyataz and Videx are registered trademarks of Bristol-Myers Squibb Company. Pravachol is a registered trademark of
ER Squibb & Sons, LLC. Other brands listed are the trademarks of their respective owners.
© 2011 Bristol-Myers Squibb & Gilead Sciences, LLC.
ST9225
SF-B0001A-03-11
Based on: 21-937-GS-008
697US08PBS00205
March 2011
Facilityprofile
Small Jail Makes Big Strides in Care
by Jaime Shimkus
I
t was a cause for celebration at the San Miguel County
Detention Center when it achieved NCCHC accreditation last July. The warden, Patrick Snedeker, even
arranged a special meeting with the county commissioners
during which the accreditation certificate was presented by
NCCHC cofounder B. Jaye Anno, PhD, CCHP-A.
Snedeker, who has been warden for eight years, had long set
his sights on this goal for the jail,
which is in Las Vegas, NM. “The
people we serve are residents
of our community and we are
entrusted with a great deal
of responsibility for them,” he
says. “Health services is a critical component, so we want to
reflect the best practices and
national standards.”
The fact that the jail is a small
The health care team (L-R): Mark Maestas, accreditation instructor, Concepcion Peralta, medical officer, Deborah Johnson, pro- facility, with an average daily
vider, Noemi Jauregui, health services administrator, Rita Torres, population of about 113, was
president/CEO, and Brenda Calderon, medical officer.
no deterrent. In fact, its small
size and limited internal resources have been the catalyst for
several innovative achievements aimed at improving care in
a cost-effective manner.
The accreditation process was set in motion about two
years ago when a nonprofit agency, Health Care Partners
Foundation, was contracted to assume full responsibility
for provision of health services. (Mental health services are
provided by the Behavioral Health Institute, a state-owned
psychiatric hospital.)
HCP had handled certain health management services
for several years prior, but, says HCP president and CEO Rita
Torres, “When we gained complete control of the medical
units, we were able to establish policies and procedures
based on NCCHC’s standards. We could then ensure that
everything was being done appropriately.”
At that time, Deborah Johnson, PA-NP, came on board as
the facility’s medical care provider. She had been through
the NCCHC accreditation process twice before while working at the New Mexico State Penitentiary and helped in
bringing the jail into compliance with the standards. The
whole team embraced the idea of becoming accredited,
says Johnson. “We work really hard to deliver quality care.”
Quality Through Collaboration
Another way the jail is striving to improve quality is through
creative partnerships. Case in point: Project ECHO, a telemedicine program offered through the University of New
Mexico School of Medicine. The program was created to
provide specialty care for chronic and complex diseases
for community health clinics in rural and underserved
areas, but Snedeker saw its value for incarcerated patients.
Program officials agreed and now the jail has technology
that enables access to telepsychiatry and about a dozen
medical specialties, including hepatitis C. “It is difficult to
provide specialty care in a small facility,” says Torres. “Project
ECHO makes a tremendous difference in managing those
high-risk cases, and it doesn’t cost us anything.”
Better yet, case review by specialists has decreased costs
by having expert opinion on what is medically appropriate.
As an example, Johnson says that substituting pricey antipsychotics for older medications when appropriate has led
to dramatic reductions in pharmaceutical expenditures.
Also related to Project ECHO is an inmate peer assistance program being developed for jails with San Miguel
serving as the pilot. It involves two types of activities. In
one, inmates are trained to educate their peers on how to
reduce hepatitic C and HIV risks related to injection drug
use. In the other, inmates provide continuous suicide watch
in the interim between checks by a corrections officer.
The partnerships don’t stop at the state line. Due to a
shortage of medical providers in New Mexico, Torres and
Johnson have worked with Colorado State University,
Pueblo, to develop a two-year residency and fellowship for
its graduate nurse practitioner students. In the program,
which began this year, students spend the first year in rotation through correctional facilities, including San Miguel,
and the second year in a fellowship at a single site. The students will receive specialty training (including the NCCHC
standards) through a community college near the jail.
The Bottom Line
The jail met yet another goal this year when it completed
its transition to electronic medical records. “This will assist
with continuity of care,” says Torres, “and will make it so
much easier for maintaining accreditation.”
As a whole, these efforts to improve quality of care also
pay off financially. According to a June 2011 report on medical services, the medical budget has not increased in any
of the past seven years and is actually below the 2004 level.
In fact, cost savings have enabled the addition of services
and staff, with an increase in patient medical visits for better
continuity of care.
Explaining the motivation for these forward-thinking
efforts, Torres says, “We believe that with vulnerable populations such as inmates, if you have good continuity of care
and good community partnerships, you can attain cost
savings and good quality of care based on accreditation
standards and best practices.”
Jaime Shimkus is the editor of CorrectCare. Contact her at
editor@ncchc.org
24
Fall 2011 • CorrectCare
www.ncchc.org
Newswatch
Minor Drug Offenders Diverted From Seattle Jails
A pilot program designed to reduce crime and save public
safety dollars in Seattle will also reduce the number of drug
offenders, many of them repeat offenders, booked into
jails and sentenced to prisons. Launched in October in a
downtown neighborhood, “law enforcement assisted diversion,” or LEAD, gives police officers the discretion to take
nonviolent offenders engaging in low-level crimes such as
public intoxication or drug possession straight to treatment
in the community. King County’s prosecuting attorney says
this approach is an evolution of the drug court model that
takes the justice system out of the equation. The program
will undergo evaluation to gauge its success. About 90% of
arrests made by Seattle police are for possession or selling
of small amounts of drugs so, if implemented citywide (or
beyond), LEAD’s impact on jails could be significant. Grants
from five private foundations are providing $4 million over
four years to pay for services such as substance abuse treatment, housing assistance, job training and education.
Primary sources:
• stateline.org/live/details/story?contentId=612828
• npr.org/2011/11/25/142704483/treatment-not-jail-for-lowlevel-drug-crimes
Florida Bill Targets Restraint of Pregnant Inmates
Florida legislators have introduced a bill that would regulate
the shackling of incarcerated pregnant women. Titled the
Healthy Pregnancies for Incarcerated Women Act, SB 524
prohibits use of restraints on an inmate known to be pregnant during labor, delivery and postpartum recovery except
in “an extraordinary circumstance.” Other provisions require
that the accompanying corrections official remove all
restraints at the request of the treating health care professional, and that the corrections official explain the extraordinary circumstance in writing within 10 days.
A similar bill failed In the last session. The Department
of Corrections said it already has guidelines for restraint of
pregnant women and prohibits restraint of those in labor.
Jails in the state, however, do not uniformly have such policies, according to an article in the Florida Independent,
citing jail standards promulgated by the Florida Sheriffs
Association.
This topic has received much national attention in the
news media and in reports by organizations such as the
ACLU and the Rebecca Project for Human Rights, which
has examined state policies on shackling and advocates for
an end to this practice. NCCHC’s position statement calls
for avoiding use of restraints during pregnancy, particularly
labor and delivery, with eight specific recommendations.
• Primary source: floridaindependent.com/56211
• Position statement: ncchc.org/resources
Violence Reduction Through Knitting
Yes, knitting, as in needles and yarn. And focused concentration, goal setting and accomplishment in a communal
setting. Started by a retired community volunteer, a weekly,
two-hour knitting group at the Jessup Pre-Release Unit, a
male minimum-security penitentiary in Maryland, has seen
success that surprised administrators. There’s a waiting list
to join the group, in which inmates have learned how to
make woolly hats and stuffed dolls. Ground rules for participation keep the men on their best behavior and, anecdotally, the warden has noticed reduced rates of violence. “My
whs_2nd_NCCHC_ad.qxd 8/14/08 5:38 PM Page
mind is on something soft and gentle,” said one inmate.
• baltimoresun.com/features/bs-ae-knitting-behindbars-20111111,0,2032786.story
1
At Wexford Health, we take our responsibilities seriously. That’s why
we have been a trusted partner to more than 250 correctional facilities
across the country, helping them to control costs without sacrificing
quality of care, cutting corners, or inappropriately denying services.
The pride we take in meeting your needs is plain to see.
MEDICAL
MENTAL HEALTH
DENTAL
PHARMACY
STAFFING
EMR
UTILIZATION MANAGEMENT
412-937-8590
SALES@WEXFORDHEALTH.COM
CLAIMS PROCESSING
TELEMEDICINE
25
www.ncchc.org
Fall 2011 • CorrectCare
Triage Critical for Toothache Complaints
Odontogenic pain (toothache) is common among inmates
and often leads to requests for urgent care. However, scope
of dental care provided varies widely as some facilities do
not have dental clinics or dental professionals on site at all
times. “[I]t is critical that midlevel providers and physicians
triage and manage these patients until a dentist can resolve
the problem,” write Jay Shulman, DMD, MSPH, and Donald
Sauter, DDS, MPA, in the January 2012 issue of the Journal
of Correctional Health Care.
The article presents the etiology and diagnosis of toothache along with the authors’ opinion of the standard of
care for patient management and several recommendations. Key points are summarized here.
Common nontraumatic causes of tooth pain are tooth
fractures, pulpitis (inflammation of living tissue within the
tooth), decay through the enamel, abscess and cellulitis (diffuse inflammation of connective tissue caused by a spreading bacterial infection below the skin surface).
All inmates experiencing dental pain should have access
to timely and definitive dental treatment. Patients complaining of a toothache should be examined by a midlevel
provider, physician or dentist within 24 hours. All facilities
should have a triage protocol to assist nondental clinicians.
The nondentist clinicians need to receive training by a dentist in how to conduct a competent, well-documented oral
examination. From this information, the clinician can then
separate patients who need expedited evaluation by a dentist from those who can be stabilized using analgesics and
Subscribe Today
antibiotics and then given a regular dental appointment. A
consulting dentist should be available to assist in the triage
when necessary.
While palliation is appropriate at the time of the initial
complaint, treatment by a dentist is necessary to resolve the
problem. The article also provides guidance for treatment,
including oral infections. Importantly, when the physical
examination suggests no infection or a localized infection,
antibiotics should not be given.
Patients who are given antibiotics should be treated by a
dentist while there is a therapeutic blood level of the antibiotic. A patient who returns with complaints after two days of
antibiotic therapy needs immediate reevaluation by a midlevel provider, physician or dentist to determine if the infection is progressing to cellulitis or spreading to fascial spaces.
Finally, progress of patients awaiting a dental appointment should be monitored with frequency consistent with
the differential diagnosis.
JCHC Volume 18, Issue 1
Nonviolent Communication Training and Empathy in
Male Parolees — Elizabeth Marlow, PhD, C-FNP, Adeline
Nyamathi, PhD, C-ANP, William Grajeda, RAS, Newt
Bailey, Amanda Weber, and Jerry Younger
Recidivism Rates Among Mentally Ill Inmates: Impact
of the Connecticut Offender Reentry Program —
Karen Kesten, MS, CCHP, Erin Leavitt-Smith, MA, LPC,
Douglas Rau, PhD, Deborah Shelton, PhD, RN, NE-BC,
CCHP, Wanli Zhang, PhD, Jesse Wagner, MA, and Robert
Trestman, PhD, MD
Compliance with Bloodborne Pathogen Standards at
Eight Correctional Facilities — Everett Lehman, MS,
Janice Huy, MS, Susan Viet, PhD, CIH, and Ahmed
Gomaa, MD
Editor
Edit
Guideline, Education, and Peer Comparison to Reduce
Prescriptions of Benzodiazepines and Low-Dose
Quetiapine in Prison — Rusty Reeves, MD
VVisit JCHC’s website at
An Innovative Approach to Pharmacy Management in
a State Correctional System — Rita Marcoux, RPh, MBA,
Jason Simeone, PhD, Matthew Colavita, and E. Paul Larrat,
RPh, PhD
John R. Miles, MPA
http://jchc.sagepub.com
• Subscribe online
• Recommend to your librarian
• Access a free sample issue online
• Experience SAGE Journals Online
powerful reference linking
The Official Journal of the
National Commission on
Correctional Health Care
Treatment of Odontogenic Pain in a Correctional Setting
— Jay Shulman, DMD, MSPH, and Donald Sauter, DDS,
MPA
Exploring Scope of Practice Issues for Correctional
Facility Nurses in Montana — Amanda White, BSN, and
Laura Larsson, PhD, MPH, BSN
Each issue also has a self-study exam that offers continuing education credit. Academy of Correctional Health
Professionals members receive JCHC (print and online)
as a benefit of membership. To learn how to obtain
JCHC, contact Sage Publications: 800-818-7243, ext. 7100;
order@sagepub.com; http://jchc.sagepub.com.
26
Fall 2011 • CorrectCare
J08040450_1088084_JCHC_Ad_4.5x4.75.indd 1
4/17/2008 11:04:36 AM
www.ncchc.org
Clinicalbriefs
Tooth Scaling May Reduce Heart Attack, Stroke
In a study of more than 100,000 people in Taiwan, those
who received tooth scaling by a dentist or dental hygienist had a 24% lower risk of heart attack and 13% lower risk
of stroke compared to those who never had a cleaning.
Protection was greatest in those who received scaling at
least once a year. None of the participants, who were followed for an average of seven years, had a history of heart
attack or stroke when the study began. Professional tooth
scaling appears to reduce inflammation-causing bacterial
growth that can lead to heart disease or stroke, according
to a cardiology specialist quoted in Dentistry IQ’s article
on the study, which was presented at the American Heart
Association’s Scientific Sessions in November.
• dentistryiq.com/index/display/article-display/ 6666867567/
articles/dentisryiq/hygiene-department/2011/11/scalingheart_health.html
Hepatitis C Deaths Exceed HIV Deaths
Analysis of death statistics from 1999 through 2007 found
that the hepatitis C death rate surpassed that of HIV in
about 2006, a function of death rates declining for HIV
but rising for hepatitis C. The findings were reported by a
Centers for Disease Control and Prevention researcher at
the annual meeting of the American Association for the
Study of Liver Diseases in November. These data probably
underreport HCV mortality because many infections have
not been diagnosed. Another study presented at the meeting suggested that as many as 800,000 new cases could be
diagnosed under a proposed screening approach that uses
universal testing by birth cohort (1945-1965).
• medpagetoday.com/MeetingCoverage/AASLD/29552
‘Epidemic’ of Prescription Painkiller Overdoses
Deaths from overdoses of prescription painkillers have
more than tripled in the past decade, according to a Nov.
1 report from the CDC. Overdoses involving narcotic pain
relievers like hydrocodone, methadone, oxycodone and
oxymorphone kill more Americans than heroin and cocaine
combined, the CDC director said. Key factors are increased
use of such painkillers for nonmedical reasons along with
growing sales. The CDC also released an issue brief highlighting key public health issues related to prescription
painkiller overdoses and science-based policy actions that
can be taken to address them. These issues are recognized
in NCCHC’s new position statement on the management
of chronic pain in correctional settings.
• Report: cdc.gov/vitalsigns/PainkillerOverdoses
• Issue brief: cdc.gov/homeandrecreationalsafety/rxbrief
• Position statement: ncchc.org/resources
Promising Treatment for Rx Painkiller Addiction
Sustained treatment with Suboxone (a combination of
buprenorphine plus naloxone) reduces opioid abuse in
people addicted to prescription painkillers, according to
research by the National Institute on Drug Abuse, part of
the National Institutes of Health. Published in the Archives
of General Psychiatry, this was the first randomized largescale clinical trial using a medication for the treatment of
prescription opioid abuse. Results show no added benefit
from the addition of intensive opioid dependence counseling. Unfortunately, patients had a high rate of relapse once
the medication was discontinued, indicating a need for
more research on how to sustain recovery.
• nida.nih.gov/newsroom/11/NR11-08.html
Be a part of
the solution.
Opportunities include:
Health Services Administrators, Psychiatrists,
Physicians, Nurses, Directors of Nursing,
Mental Health Professionals, Dentists,
Nurse Practitioners and Regional Managers.
To find out how you can be a part
of the solution, visit us online at
correctcaresolutions.com
27
www.ncchc.org
Fall 2011 • CorrectCare
Juvenilevoice
Psychological First Aid for Youth
The application of first aid for medical injury is ubiquitous.
There is a well-established consensus for response to physical crisis. Unfortunately, says psychiatrist Carl Bell, MD,
CCHP, the same is not true for mental crisis. But Bell would
like to change that, and he thinks juvenile justice settings
are optimal places to establish policies and procedures for
psychological first aid.
It’s not that the concept is unknown, says Bell, who has
CHP’s foCus on CaRe management
Has reduced ouR Costs.”
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been writing about and presenting on the topic for at least
a decade. Often psychological first aid is used in large-scale
disasters or crises. But it is not applied routinely in juvenile settings, where so many youth are victims of trauma.
According to a 2009 study of more than 26,000 adults in
five states, 59% reported at least one adverse childhood
experience (see Morbidity and Mortality Weekly Report,
Dec. 17, 2010), and 9% reported five or more. This study
excluded incarcerated people, and among that group prevalence of childhood trauma is most likely higher, Bell says.
Based in Chicago, Bell is the director of the Institute for
Juvenile Research and a clinical professor of psychiatry
and public health at the University of Illinois School of
Medicine. He also is president and chief executive officer of
the Community Mental Health Council and Foundation. A
founding member of the NCCHC board of directors, he has
long served on the NCCHC juvenile health committee.
Just as correctional staff receive regular first aid training,
they also should be given training on psychological first aid,
including how to recognize symptoms of trauma, Bell recommends. Upon being admitted to the facility, every youth
would be screened for history of mental health trauma.
Staff would also be on the alert for symptoms, both during
screening and throughout the youth’s stay at the facility.
When a youth in crisis is identified, the staff member
would apply first aid based on guidelines for age and symptoms. “It is not counseling, not in-depth psychotherapy.
It is very simple,” says Bell. For example, if a fifth-grader is
disturbed by grief after witnessing a family member being
killed, the response would be to help the child retain positive memories as he or she works through the more intrusive traumatic memories.
Guidelines for psychological first aid are available from
the National Child Traumatic Stress Network. Although
they are designed for disaster and crisis situations, the principles apply to other settings, Bell says. In 2007 he served
as an expert panel member in development of the Mental
Health First Aid Guidelines Project for Traumatic Events of
the ORYGEN Research Centre, University of Melbourne,
Victoria, Australia.
“Psychological first aid absolutely should be implemented
routinely in juvenile justice settings—and all community
settings, too,” says Bell. “It really does help.”
Resources
• Mental Health First Aid Guidelines, ORYGEN Research
Centre, University of Melbourne, Victoria, Australia
mhfa.com.au/cms
866.932.7185 • cHPdeLIVerS.com
28
CHP2283_CorrectCare_Ad_FINAL.indd 1
Fall 2011 • CorrectCare
• Psychological First Aid Field Operations Guide,
National Child Traumatic Stress Network
nctsn.org/content/psychological-first-aid
3/7/2011 3:51:56 PM
www.ncchc.org
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CCHPpage
20th Anniversary a Smash Success!
The buildup to the CCHP anniversary celebration was
exciting, and now that it’s over we can sit back and enjoy
the memories. Held during the National Conference on
Correctional Health Care in October, activities included
contests, prizes and a special luncheon featuring a stirring
talk by NCCHC cofounder Jaye Anno, PhD, CCHP-A. With
great knowledge, insight and humor, she recounted a brief
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Professional program and highlighted the importance of
professional certification in this challenging discipline. By
the end of her talk, every attendee was even more proud to
be a CCHP.
That sense of accomplishment and pride was heightened with the screening of the winning entry in the “I Am
a CCHP” video contest. Submitted by Patrick Vance, MPA,
CCHP, the two-minute video is expertly produced and
beautifully synthesizes Vance’s personal journey in this field
and the larger lessons about the value of CCHP certification. Vance is a health services administrator at the Oregon
Department of Corrections. His prize: free registration to
the 2012 Updates conference. See his inspiring video at
facebook.com/ncchc.
Several drawings took place before the National
Conference. The biggest prize—free registration to the
conference—was set aside for a random drawing from the
August group of CCHP examinees. Congrats to Matthew
Meehan, LPN CCHP! In addition, 15 CCHPs won gifts such
as dayplanners and business card holders with the CCHP
logo. Find their names at ncchc.org/cchp/20years.html.
Finally, those remarkable CCHPs who have participated
in the program continuously for 20 years received a special
enhancer to adorn their CCHP pin and let the world know
of their accomplishment.
Congratulations Are in Order!
• The board of trustees welcomes Carol Shepard, BSN,
CCHP, the top vote-getter in the August election.
Shepard started in this field 23 years ago as a jail director
of nursing and quickly rose through the ranks. Today she
is regional vice president for Armor Correctional Health
Services, West Palm Beach, FL. She has been a CCHP for
10 years and an accreditation surveyor for two years.
• The board also congratulates the latest group of professionals to earn CCHP certification. Effective Oct. 1 our
ranks grew with 135 new CCHPs and five new CCHPRNs. Find a list of their names at ncchc.org/cchp.
CCHP Exam Dates
February 18
Multiple regional sites
May 20
San Antonio, TX
August 18
Multiple regional sites
October 21
Las Vegas, NV
We are seeking additional sites for regional exams, as well
as CCHPs to proctor the exams. If you would like to participate, contact the CCHP manager at 773-880-1460 or
cchp@ncchc.org. Learn more at ncchc.org/cchp.
30
Fall 2011 • CorrectCare
www.ncchc.org
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Fieldnotes
This department features news and information from
NCCHC’s supporting organizations and other partners that
share our goal of promoting quality health care in correctional institutions. If your organization has news to share,
please contact editor@ncchc.org, 773-880-1460.
Board Member Receives Multiple Honors
NCCHC board member Ryung Suh,
MD, MPP, MBA, MPH, is enjoying a
successful year. Suh, who joined the
board in October 2010 representing
the American College of Preventive
Medicine, is CEO of a health care
consulting and research firm based
in Washington, DC; among other
work, he also holds senior faculty positions at Georgetown
University and other institutions.
• He received the William Kane Rising Star Award at
ACPM’s annual meeting in February. The award honors a
member of ACPM who has demonstrated a commitment
to preventive medicine and the potential to make significant contributions to the field of preventive medicine.
• In June, Suh and Atlas Research cofounder Mark
Chichester together were named the 2011 Small Business
Person of the Year by the DC Chamber of Commerce. They
were honored for their successes and commitment to the
District of Columbia’s business community, and in particular their commitment to civil service and work to address
health equity.
• Also in June, Suh was elected to the board of trustees
of the American Association of Public Health Physicians.
AAPHP is a supporting organization of NCCHC.
• Visit the “News” section at atlasresearch.us
NCCHC Surveyor Receives Pharmacy Award
Charles Lawrence, Sr., RPh, PD,
CCHP, was honored by the
Washington DC Pharmaceutical
Association for outstanding community service. Lawrence developed and implemented policies and
procedures in the DC Department
of Corrections to ensure that its
pharmacy services met all federal
and local pharmaceutical codes.
One of the most prestigious awards in the field of community pharmacy, the Bowl of Hygeia Award is presented
annually by state pharmacist associations, including
that in DC. It is sponsored by the American Pharmacists
Association Foundation and the National Alliance of State
Pharmacy Associations. Lawrence has served as a surveyor
for NCCHC’s accreditation program since 1995.
• pharmacist.com/Content/NavigationMenu/GrantsAwards/
BowlofHygeia/default.htm
Past SCP President Receives Start Award
Lynn Sander, MD, FSCP, CCHP,
is this year’s recipient of the
Armond Start Award, the highest honor a correctional physician can receive. It is presented
by the Society of Correctional
Physicians for leadership in correctional medicine, with criteria
that include adherence to the
highest ethical standards and
dedication to research, publication and training. Sander has been involved in correctional
health care for 25 years, serving as the medical director of
the Denver County Jail and as a federal health monitor for
the U.S. Department of Justice. A national advocate for the
rights and health care of incarcerated patients, Sander is
known for excellence in patient care and high standards in
education and research. As president of SCP from 2005 to
2007, she brought the organization to a position of leadership. The award is named for the late Armond Start, the
physician who founded SCP. In the photo above, Sander is
pictured with SCP president Michael Puerini, MD, CCHP-A.
Stay Informed With the Academy Insider
The Academy of Correctional Health Professionals is
launching a new resource. The Academy Insider is a weekly
e-news brief that delivers timely, relevant news about correctional health care and related topics directly to your
inbox. The Academy Insider is also available as a mobile
application. For Apple iPhone and iPod Touch, go to the
App Store, search for “MultiBriefs,” download the app free
of charge and then add the Academy feed. Android phone
users may access the app by searching for “MultiBriefs” at
the Android Marketplace. In addition, a complete archive
of past issues enables users to search for news on topics of
interest and to explore the most popular past articles.
• Subscribe: multibriefs.com/optin.php?achp
• Archive: multibriefs.com/briefs/achp
New Name for American Dietetic Association
Effective January 1, the ADA will become the Academy
of Nutrition and Dietetics. Founded in 1917, the ADA is
the world’s largest organization of food and nutrition professionals. In announcing the change, the organization’s
president cited consumer confusion about where to find
the most qualified nutrition expertise. “An academy is ‘a
society of learned persons organized to advance science,’”
said Sylvia Escott-Stump, MA, RD, LDN. The new name
“promotes the strong science background and expertise”
of the members, who are primarily registered dietitians.
“Nutrition science underpins wellness, prevention and treatment.... Adding ‘nutrition’ communicates our dedication to
improving the nation’s health.”
• www.eatright.org
32
Fall 2011 • CorrectCare
www.ncchc.org
Exhibitor Opportunity
Updates in Correctional Health Care
San Antonio • May 19-22
Correctional health professionals of all disciplines will convene in Alamo City, a perennial favorite conference destination,
for Updates 2012. The meeting will feature a broad array of health topics plus a special series on the role of correctional
health services in reentry programming and prevention of recidivism. Our highly motivated attendees come to advance
their knowledge, earn continuing education credit and network with colleagues. They also come to connect with the many
companies that can help them meet the challenges of providing quality care to incarcerated populations, exploring new
ideas and proven solutions for managing the complex operational and clinical demands of health care delivery to inmates.
Maximize the Opportunity
With 2.3 million individuals incarcerated in the United
States, serving their wide-ranging health care needs is a big
business. In fact, the nation’s correctional facilities spend
roughly $7 billion each year to provide this governmentmandated care. Just as in the community, services span the
spectrum, from acute care to chronic disease management
to routine care, including dental and mental health, along
with substance abuse treatment, prevention and health
education. That’s a big challenge—and a big opportunity for
companies that serve this market.
Build Relationships With the Best
Our multidisciplinary audience is a microcosm of the health
care field at large. They are the leaders—and emerging leaders—in this field. Connecting with these influential professionals extends your reach to the departments, facilities and
staff they work with every day.
Effective Outreach
• Exhibitions are the #1 source for attendees who make purchasing decisions.
• Exhibition leads cost 56% less to close than field sales calls.
• Exhibitions allow you to reach an average of 88% of
unknown prospects.
Source: The Center for Exhibition Industry Research (CEIR)
Exhibitor Benefits
• 3 days of exhibit hall activities
• 2 full conference registrations per 10’ x 10’ booth
• Discounted full registration for up to 5 additional personnel
• 75-word listing in the Final Program (deadline applies)
• Electronic attendee lists for pre- and post-show marketing
• Free basic listing in NCCHC’s online Buyers Guide
• Discounted advertising in meeting programs & CorrectCare
• Lead retrieval technology available for rental on site
• Opportunity to participate in raffle drawings
• Priority booth selection for the 2012 National Conference
Sponsorship Opportunities
Where Will You Find
Your next Great hire?
Find your next lead with the National Commission on
Correctional Health Care mailing list, a proven tool to reach
over 30,000 physicians, nurses, mental health care providers,
medical directors, nurses and other allied health professionals
and administrators. Pinpoint your audience by job title, work
setting and demographics. No other marketing channel allows
you such a targeted marketing opportunity.
www.InfocusLists.com/Datacard/NCCHC
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Enhance your presence and maximize marketing dollars
through these outstanding opportunities.
• Premier programming: Educational sessions and breakfast/
luncheon programs give attendees a fresh experience while
giving your company exclusive exposure.
• Final proceedings: Marked with your company’s name, the
flash drive enables attendees to continue their learning with
the concurrent session PowerPoint presentations.
• Exhibit Hall reception/luncheon/breaks: Attendees will
appreciate your contribution as they gather in this highenergy center to mingle and network throughout the day.
• Smaller opportunities with big impact: Promote your
company name while enhancing the attendee experience
by sponsoring the conference bags, lanyards, water bottles,
badges, banners and more.
• Customize your contribution. NCCHC will work with you
to develop a personalized package tailored to your needs
and your budget.
Registration Information
The Updates conference provides the perfect opportunity
to meet with important contacts and raise your profile
in this specialty field, so reserve your space now. Standard
booth sizes are 10' x 10'; double-size and premium spaces
are available. To obtain an Exhibitor Prospectus with details
and a reservation form, email NCCHCexhibits@ncchc.org
or call 773-880-1460.
34
Fall 2011 • CorrectCare
www.ncchc.org
Classifiedads
MARKETPLACE
Special Savings! 10% discounts are offered for
Academy members (single copies) and bulk
purchases of a single title. (Excludes alreadydiscounted items.) To order or for a catalog,
visit www.ncchc.org or call 773-880-1460.
Standards for Health Services in Juvenile
Detention and Confinement Facilities (2011)
This edition is modeled after the 2008
Standards for jails and prisons but takes into
account the issues unique to juvenile settings and populations. The Juvenile Standards
address nine general areas: health care services and support, inmate care and treatment, special needs and services, governance
and administration, personnel and training,
safety, health records, health promotion and
medical-legal issues. This edition features a
user-friendly format; standards on current
issues such as patient safety and clinical performance enhancement; clear compliance indicators that define expected outcomes and aid
in self-assessment; guidelines for facilities of
various sizes; best practices recommendations;
and appendices on legal obligations, quality
improvement and more. Glossary and index.
Published by NCCHC. Soft cover. $69.95
CCHP Items
A s the Cer tif ied Correctional Health
Professional program celebrates its 20th year,
be sure to stock up on these professional items
adorned with the CCHP logo. Find product
descriptions and order online via the publications catalog at ncchc.org.
• CCHP Pin Enhancer to mark 5, 10, 15 or 20
years of participation in the program. $10
• CCHP Business Card Case, a stylish way to
tote your business cards. $8
• CCHP Cup and Coaster, 11 oz. white porcelain cup with coaster that can serve as a lid to
keep beverages warm. $7.50 for one, $6 for two
• CCHP Executive Organizer with mini binder, calendar, address book and more. $20
(2012 refills: $9)
About CorrectCare™
CorrectCare is the quarterly magazine of the
National Commission on Correctional Health Care.
Its mission is to publish news, articles and commentary of relevance to professionals in the field of
correctional health care.
Subscriptions: CorrectCare is mailed free of
charge to members of the Academy of Correc­
tional Health Professionals, key personnel at
accredited facilities and other recipients at our
discretion. To see if you qualify for a subscription,
submit a request online at ncchc.org or by e-mail
to info@ncchc.org. The magazine is also posted at
ncchc.org.
Change of Address: Send notification four weeks
in advance, including both old and new addresses
and, if possible, the mailing label from the most
recent issue. See page 1 for contact information.
Editorial Submissions: Submitted articles may be
published at our discretion. Manuscripts must be
original and unpublished elsewhere. For guidelines,
contact Jaime Shimkus at editor@ncchc.org or
773-880-1460. We also invite letters or correction
of facts, which will be printed as space allows.
Advertiser Index
SIMPLIFIND
Tap into the incredible network of the National
Comission on Correctional Health Care
with the NCCHC Buyers Guide. Powered by MultiView,
the Guide is the premier search tool for correctional
healthcare practitioners. Find the suppliers and
services you need, within the network of the
association you trust.
Simplifind your search today at www.ncchc.org.
American Board of Addiction Medicine............................ 36
Atripla (Gilead Sciences) ..........................................................20-23
CCHP-RN Specialty Certification................................................ 19
Complera (Gilead Sciences)......................................................... 5-7
Corizon......................................................................................................10-11
Correct Care Solutions........................................................................ 27
CorrecTek........................................................................................................... 4
Correctional Health Partners......................................................... 28
Correctional Medical Associates............................................... 17
GEO Group................................................................................................... 33
InFocus Lists.................................................................................................. 34
Journal of Correctional Health Care......................................... 26
Medi-Dose..................................................................................................... 29
MHM Services...........................................................................................BC
NCCHC Accreditation........................................................................ 14
NSU Healthcare......................................................................................... 30
Reyataz (Bristol-Myers Squibb) .................................................. 15
Spectra Diagnostics..............................................................................IBC
Sustiva (Bristol-Myers Squibb) .................................................... 31
Wexford Health Sources.................................................................... 25
Updates in Correctional Health Care.....................................IFC
35
www.ncchc.org
Fall 2011 • CorrectCare
Standards Q & A
Expert Advice on NCCHC Standards
by Jennifer E. Snow, MPH, CCHP, and
Scott Chavez, PhD, MPA, CCHP-A
Defining ‘Isolation’ in Suicide Prevention
Q
There has been some debate as to the interpretation
of the Suicide Prevention Program standard (Y-G05) in the new 2011 Standards for Health Services in
Juvenile Detention and Confinement Facilities. Compliance
indicator #1d states: “Potentially suicidal juveniles are
monitored on an irregular schedule with no more than 15
minutes between two checks. If, however, the potentially
suicidal juvenile is placed in isolation, constant observation
is required.”
Our debate comes in understanding what is meant by
“isolation.” Is it used to refer to those youth on suicide
precautions in a room by himself/herself or does it refer to
more of a punitive status, as in the youth was placed in isolation for behavioral issues in addition to suicide precautions?
I contend that it is the former and the latter is generally
referred to as “segregation” rather than “isolation.” Another
option is that both interpretations are incorrect. Either way,
we want to ensure that we have the correct interpretation.
A
This is a great
question. You are
correct that the
standard is referring
to the first interpretation of isolation. When
a youth is placed on
suicide precautions
in a room alone, then
constant observation
should be conducted.
Opioid Treatment
Programs
Q
We are thinking
about starting a
methadone program in our jail, but we
don’t know where to
begin. What advice can
you give us?
A
If you are considering an
opioid treatment program using
methadone, by federal
law, OTPs based in correctional facilities must
obtain certification
from the Substance Abuse and Mental Health Services
Administration. To become certified, the OTP first must be
accredited by a federally approved body—which NCCHC
is, and we offer OTP accreditation. The NCCHC Standards
for Opioid Treatment Programs in Correctional Facilities are
based on federal regulations but address the special nature
of care provided in correctional facilities as well as the necessarily limited focus of such treatment in this setting. For
more information, including how to obtain the Standards,
visit our website: ncchc.org/accred/OTP.html.
Inmate Orientation Information in Spanish
Q
I am helping a jail get ready for its accreditation survey.
I am told that there is not really a Spanish-speaking
population in this community. In that case, do they
still need to have the inmate orientation information in
Spanish as well as English?
A
Standard J-E-01 Information on Health Services does
not state that inmate orientation information must be
written in Spanish. The third compliance indicator says,
“Special procedures ensure that inmates who have difficulty
communicating (e.g., foreign speaking, developmentally disabled, illiterate, mentally ill, deaf) understand how to access
health services.” Therefore, if there isn’t a community need
to pre-print information in Spanish (or other foreign language), at least there should be a procedure in place so that
appropriate efforts are made to ensure that inmates understand how they can access health services. For example, a
language line or local translator might be available in the
event a Spanish-speaking inmate arrives. Keep in mind that
if the bulk of your population speaks only Swahili, then you
should accommodate these inmates.
Transfer Screening Time Frame
Q
Standard E-03 Transfer Screening says that “qualified health care professionals review each transferred
inmate’s health record or summary within 12 hours of
arrival.” Does it mean within 12 hours after the inmate arrives
at the new jail and is in housing? Or does it mean within 12
hours of the chart’s arrival at the new jail?
A
The standard intends that within 12 hours of the
inmate’s arrival at the facility (emphasis added), a qualified health care professional should be reviewing the
health record or summary to ensure continuity of care.
Jennifer E. Snow, MPH, CCHP, is NCCHC’s director of accreditation. Scott Chavez, PhD, MPA, CCHP-A, is NCCHC’s vice
president and liaison to the policy and standards committee.
Send your question to accreditation@ncchc.org.
36
Fall 2011 • CorrectCare
www.ncchc.org
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