population. We point to two examples of CT DOC deviating from the recommended practice below: · CT DOC Custody can assign people to infirmary beds. This is an inappropriate allocation of limited clinical resources and interferes with medical autonomy. Recommendation Recommendation 20 · The infirmary is used for inmates needing CPAP machines, those with mobility or other ADA constraints, and those with dementia. None of these populations/conditions are appropriate for infirmary care, absent other qualifying clinical issues. One significant consequence is that CT DOC infirmary beds do not reduce the use of inpatient hospital services. To ensure infirmary is operated according to the best practices, CT DOC infirmary care policy should require the following: · An admission diagnosis and provider order · Daily rounding by provider and nursing staff · Discharge orders · Discharge orders implemented Our chart review showed the following performance outcomes rates: Key Infirmary Performance Indictor Cases (%) Indicator Met N = 186 Provider Admission Order 54% Daily Provider Rounds 19% Shift Nursing Rounds 55% Discharge Order 55% Discharge Orders Implemented (documented) 57% Lastly, CT DOC might consider having a clearly defined policy and procedure manual for infirmary care. Special Populations Today’s prison systems deal with many special populations, each with unique health care needs and many with special legal protections. Because the HMA team was not able to conduct site visits, we are insufficiently informed to evaluate how CT DOC serves the health care needs of the following populations: · Women, especially pregnant women · Youth (in the adult correctional system) · Inmates with HIV/AIDS · LGBTQ populations, especially inmates with gender dysmorphias · Inmates with physical disabilities · Inmates with Traumatic Brain Injury Recommendation Recommendation 21 · Inmates needing support with activities of daily living · Inmates with developmental disabilities CT DOC should, in its strategic planning, develop a process for evaluating how facilities serve each of these populations, mitigating any deficiencies, updating policies, and building regular review into performance assessment. Compliance with requirements of the Americans With Disabilities Act (ADA) is extremely important in this arena. With respect to CT DOC’s aging population and those needing skilled nursing, HMA notes that Connecticut is the first and only state in which Medicaid has approved a nursing home (60 West) for parolees. We strongly encourage CT DOC to revisit this arrangement (consistent with all appropriate legal, regulatory, and other matters) and determine whether current (and additional) CT DOC inmates are eligible for parole to this facility or others that may be developed like it. Given the aging of the incarcerated population, this opportunity is of extraordinary importance. Complex Care Management Complex care management is an important component of any health care system managing a large population of adults. As an example, the Connecticut Medicaid program explicitly identifies program requirements for complex care management. Features include risk assessment to identify high‐risk/high‐ utilization cases; a multi‐disciplinary care team; a single, comprehensive, integrated care plan for each person by the care team and within specified timeframes; review of the care plan at least every 90 days; re‐assessment every six months; and specific caseload requirements for case managers. A sample of Husky Care program requirements for complex case management is included as Appendix 5. Every correctional facility has inmates with complex clinical needs. Examples include cancer diagnoses, transplant candidates, and inmates with multiple acute and chronic illnesses. CT DOC manages complex cases through its Patient Prioritization & Transportation (PPT) program with communication between the facility‐level Primary Care Provider, PPT/case manager, the Regional Chief Operating Officers (RCOO), and external clinical providers. Systemwide, there are approximately 11 facility PPT case managers and one PPT unit supervisor in the central office who manages direct liaison with UConn specialty groups and serves as the primary scheduler arranging all transfers and transportation to outside medical services. Facility‐based case managers are sometimes tasked with liaising with local community consultants for outside scheduling when UConn consultants are not available. The process appears to be ad hoc, and it is unclear if there are appropriate systems in place to track complex cases that are regularly reviewed by a care management team and central office leadership. As CT DOC refines its model for medical management, it should include a plan for centrally tracking complex cases, managing resources, access to services, and transfers, and providing support to the facility’s medical and custody teams housing the inmates. The process should tie to UM authorization processes and systemwide bed Recommendation Recommendation Recommendation 22 management. It should also include reporting that integrates on‐site, pharmacy, and off‐site service utilization. Finally, roles for statewide and facility‐specific case management functions should be