Institution 434 10 2.30 York Correctional Institution 516 21 4.07 The figure below displays the raw number of ER transports by facility for the period January 1 – October 15, 2020. There were 1,812 ED visits during this period. Variance in ED visit rates are to be expected, based on facility mission, patient population, and staffing. However, the HMA team did not find any evidence of CT DOC analyzing the use of EDs by facility, the reasons for ED visits, or the variance across settings. This should be part of regular central office management and data reporting. It would illuminate opportunities to reduce expensive ED use through several avenues, including providing after‐hours ED or IM consultation to facilities with no providers, increasing point‐of‐care testing, and using the ED for ambulatory care‐sensitive conditions. 244 236 219 170 134 130 127 122 91 90 87 57 53 33 10 5 4 0 50 100 150 200 250 300 29 Inpatient Hospitalizations CT DOC is accessing Medicaid coverage for inpatient admissions of greater than 24 hours for inmates enrolled in Medicaid. This is an important financial management tool and should be optimized. As with ED visits, the HMA team did not find a facility‐specific, regional, or statewide process that analyzes inpatient hospital use for clinical appropriateness or for variance. This should be part of regular facility‐specific population health management and QI, and of central office management and data reporting. ADMINISTRATIVE FUNCTIONS Health Services leadership plays a critical role in setting the culture and expectations at each facility and is ultimately accountable for each facilities’ system performance and health care operations. It is extremely positive that the nursing leadership positions have finally been filled, as there has been a significant and deleterious effect of not having a nursing executive leading the nursing workforce. Time and time again, staff have noted that although the “120’s” provided some leadership to nursing supervisors, there has been a serious absence of nursing leadership for too long. Correctional health care is a health care system with unique challenges. Together, executive health care staff must lead all strategic planning efforts, create an accountable system that relies on system metrics to evaluate the functions of the health care system. This includes the development of a robust and real‐ time quality assurance (QA) program that is based on standard and evidence‐based policy, procedures, and protocols. Strategic Planning The HMA team has noted in many parts of this report that CT DOC currently works hard and is committed to providing ever‐improving inmate health care. Most of the agency’s energy since the UConn transition has been directed to components of the transition and not to the larger whole. The creation of a visual strategic framework that captures five priority domains (see Medical Management Model below), the request for this health care system analysis and the desire for an alternative medical model is evidence that CT DOC leadership is ready to consider a longer view. We recommend that ‐ once this report is digested and a medical model is identified ‐ CT DOC health care leadership frame it under the umbrella of a strategic plan that has clearly articulated objectives, timelines, and measurable outcomes. The strategic plan should cover a four‐ to five‐year period and be regularly and clearly communicated to all CT DOC staff. All QI, staffing, operational, and administrative initiatives should tie directly to the elements of the strategic plan. Recommendation 30 Quality Improvement In keeping with correctional health standards and best practices across the health care system, CT DOC should operate a statewide Quality Improvement Council (QIC) that reflects all health care disciplines, custody health care populations, and administrative departments, e.g. HR, IT (EHR). The QIC will be responsible for the development and implementation of a statewide Quality Improvement Plan (QIP) that is data driven and focuses on priorities. QIP priorities should reflect emerging or extant problems identified through a variety of data inputs. Priorities should also address elements of an overall strategic plan and should reflect the intent of CT DOC’s strategic objectives. The QIC should also identify a calendar of audits/reports conducted across the state that will continuously inform it of emerging problems. This should include, at a minimum, audit/reporting of the following: · Sick call process components · Nursing referral to providers · Wait lists · Specialty care referral components · Infectious disease data · Incidents and other sentinel events · Inmate grievances · Emergency department visits · Prescription medication elements The QIP should be clearly communicated throughout CT DOC and should be acted on by facilities. The QIP should articulate problems and design QI projects that include baseline data, desired outcomes, interventions, responsible parties, timelines, periods for re‐measurement, and remediation. The Council should meet monthly until the first QIP is completed and then possibly move to bi‐monthly or quarterly. In addition, each facility should operate a facility‐specific QIC responsible for implementing the statewide QIP and identifying facility‐specific emerging trends and outliers in the data reported to headquarters. The facility QIC should