non‐formulary requests · Reporting on non‐formulary prescriptions by provider · Regular reviews of monthly, quarterly, and annual pharmacy costs as well as opportunities for cost savings · Engaging in performance improvement cycles that can lead to practice and system change Laboratory Services CT DOC’s movement to Quest Diagnostics for laboratory services was an excellent decision which is having a very positive impact on cost and quality. Many staff commented on Quest’s eagerness to partner with CT DOC, and has been demonstrated by its instant responsiveness, flexibility in adapting procedures to CT DOC needs and willingness to bundle (and lower) rates for expensive labs. Quest is playing an instrumental role in CT DOC’s COVID‐19 response. They have added “stat” pick up for urgent lab tests and provided a portal for reporting of test results and data mining. In addition, they have provided on‐site lab tech training. CT DOC is reporting savings of $300‐400K per month or $3.6M‐4.8M per year since subcontracting lab services to Quest Diagnostics. Health Care Functions Off‐Site Care Off‐site services, whether to a specialist office, hospital emergency department, or inpatient hospitalization, creates significant expense for CT DOC because each instance incurs not only the cost of the care itself, but also the cost of transport and security throughout the encounter. The HMA team did not find any specific data on custody costs for transport and security, but they should be part of CT DOC’s analytics. Clearly, more specialty services provided on‐site will reduce those transportation and security costs, as well as clinical costs for care. HMA reviews an e‐consultation model in the below recommendations. Specialty Care NCCHC standards call for timely inmate access to specialty care and that a written summary of assessment, treatment, and follow‐up recommendations accompany the inmate upon return to the facility. Standards call for the jail/prison provider to consider and act on recommendations made by a specialist in a timely manner. Where the facility provider opts not to implement the specialist recommendations, the medical record is expected to show consultation with the specialist on an alternative treatment plan. The process for specialty care has changed considerably from when UConn operated health care to the process now under DOC HSU. UConn had a very restrictive process for specialty referrals, and staff interviewed almost uniformly reported that this significantly limited necessary and timely access to specialty care. 25 · Overall, in 2019, over 90% of specialty requests were approved and appointments completed, averaging nearly 800 per month. In 2020, the pandemic has significantly reduced the number of specialty requests and approvals to only 376 per month. The complete data set for 2020 is not yet available for further analysis. · Under UConn, prison and jail providers had relationships with specialists that afforded collegiality, “curbside” informal consultation, and a single medical record. · Under DOC HSU, restrictions for specialty referral were virtually eliminated, and nearly all referrals are now executed with no review. There is no clear UM process that evaluates, triages, and prioritizes those in need. · Analysis of referrals by specialty for January – December 2019 noted that of the 11,094 specialty requests submitted, 9954 were approved (90%). Commensurate 2020 numbers were not available at the time of this report. · This “open access” to specialty care has created several problematic and unanticipated consequences. o Specialists experienced a large volume of referrals, many of which are clinically unnecessary. o Specialty visits often occur without necessary documentation of patient history, treatment, and work‐up. This lack of documentation may create duplication of diagnostic testing and a delay in providing treatment. Future access for specialty care may also be impacted if post‐visit instructions and directions are not provided. · Nurses review orders and documents that accompany patients returning from off‐site referral and then forward them to PCPs. But there is no policy or practice that ensures the PCP reviews the recommended treatment plan in a timely manner, nor is there a requirement that PCPs document alternatives to the treatment plan recommended by a specialist, inclusive of clinical rationale. This creates inordinate risk of poor outcomes and reduces the actual value of the consultation. o Nevertheless, it appears that CT DOC may be well served by on‐site audiology and dermatology clinics. o Several specialties also warrant consideration for e‐consultation, which would address inmate needs quickly, reduce off‐site specialty visits, and build clinical capacity within primary care for managing common conditions. These include endocrinology, otolaryngology (“ENT”), gastroenterology, dermatology, nephrology, orthopedics, pulmonary medicine, urology, and vascular surgery. This issue is discussed in more detail in the proposed medical model of care and recommendations. Recommendation 26 o Demand for consultations for speech and occupational therapy seem high as well and may indicate the need for on‐site clinics or arrangements for telehealth. o The system may be well served by some mobile diagnostic services. High volume indicates a high cost for transport and