security. These include radiology and diagnostic imaging, computerized tomography (CT) scans, magnetic resonance imaging (MRIs), and ultrasonography. o There is a high rate of referral for internal medicine (IM), which CT DOC should have the capacity to provide internally using its own staff. CT DOC needs to consider internal centralized IM consultation across CT DOC providers. · Referrals by facility are not evaluated nor are individual PCPs monitored for their referral practices. · There is no policy or practice by which the PCP tracks patients referred for specialty care but not yet seen. This creates very high risk for clinical deterioration where referrals are incomplete. · Incomplete referrals are not appropriately tracked. · Better data on all features of specialty care would enable leadership to make informed decisions about PCP training, e‐consultation, UM practices, on‐site clinics, and more. · The system needs both a high‐functioning UM process and e‐consultation capacity that are integrated to ensure timely access to care for complex conditions. · The IT component to this process cannot be overlooked. With respect to contracting for specialty care, despite DOC having issued two RFPs for outpatient care, only UConn was responsive. As they engage most of the health care specialists in the community, this has significantly limited DOC’s ability to negotiate and manage the contractual relationship, and UConn continues to provide much of the off‐site care for DOC patients. For many specialty services including orthopedics, dialysis, and podiatry, CT DOC pays UConn a flat monthly rate that covers a set number of patients or encounters. Funds are not credited to CT DOC if the number of patients served in a month is less than the cap. If volume exceeds the cap, scheduling is delayed. CT DOC reported that new negotiation is underway to address that circumstance. In the meantime, this contractual arrangement does not serve CT DOC well and jeopardizes timely access to specialty care for CT DOC inmates. Other services are billed at a negotiated fee‐for‐service rate. Some services, such as radiology, are paid at the Medicaid rate, but others are based on the negotiated rate between the specialist and DOC. Recommendation 27 Off‐Site Visits to Emergency Departments Managing referral of patients to local hospital emergency departments (EDs) is challenging for correctional settings. Most ED visits do not become inpatient admissions, which implies that care could have been managed in primary care. But some suspected conditions, such as possible heart attacks, progress too quickly to safely manage “in house.” In addition, prisons and jails have choices to make about what point‐of‐care diagnostics and emergency trained providers to provide in the correctional setting. Large urban jails are developing “Emergency Room Observation” (ERO) capacity in partnership with local EDs. In these arrangements, an ED physician staffs the jail/prison ERO unit, which is equipped with advanced point‐of‐care diagnostics. Transports to the ED are minimized and patients needing admission are admitted directly from the ERO setting at the jail/prison. The HMA team was not able to ascertain whether this option would be feasible for CT DOC. In interviewing physicians and conducting chart audits, we learned the following: · Providers believe their ED referrals were appropriate, and chart audits found ED referrals to be prompt. · Lack of 24/7 provider coverage leads to “risk aversion” and subsequent ED referrals when no provider is present. · Facilities sent proper documentation with patients to the ED in 92% of cases reviewed. · EDs sent documentation back to the facility with the patient in 88% of cases reviewed. · Patients returning from the ED were seen by a qualified health professional in a reasonable timeframe in 92% of cases reviewed. o Patients were usually evaluated by nursing, not a provider. o Nurses enter orders in the discharge summary where available, but it is not clear whether the provider reviews, approves, and executes them. · Facility health care staff do not keep logs of ED visits that note the reason for referral; logs are kept by custody and reflect custody officers’ perception of the reason for referral, but these are not reliable for use in determining appropriateness of referral. The table below shows wide variation in the rate of transport to ED per 100 inmates in August 2020, ranging from 0 to 6.67. Snapshot: Emergency Room Transport during August 2020 Period: (Rate of ER transports per 100 inmates) Facility Aug 2020 ADP ER Transports Rate Bridgeport Correctional Center 598 7 1.17 Brooklyn Correctional Institution 321 Not avail. 0.00 Carl Robinson Correctional Institution 807 13 1.61 Cheshire Correctional Institution 1098 14 1.28 CRCC Corrigan Building 611 16 2.62 28 Snapshot: Emergency Room Transport during August 2020 Period: (Rate of ER transports per 100 inmates) CRCC Radgowski Building 239 1 0.42 Garner Correctional Institution 521 11 2.11 Hartford Correctional Center 733 13 1.77 Manson Youth Institution 215 8 3.72 MWCI MacDougall Building 1403 32 2.28 MWCI Walker Building 410 2 0.49 New Haven Correctional Center 607 15 2.47 Northern Correctional Institution 90 6 6.67 Osborn Correctional Institution 988 23 2.33 Willard‐Cybulski Correctional