Initiating a Pro-Active Care Modality Paradigm to Vulnerable Populations: Utilizing the Patient-Centered Medical Home Model for Incarcerated Male Inmates with Asthma
Incarcerated male inmates in the California Department of Corrections & Rehabilitation (CDCR) have poorer outcomes of management of chronic care conditions such as asthma, hypertension, and diabetes than the rest of the general population. The aim of this program is to promote healthy measurable outcomes of inmates with asthma at the Correctional Training Facility, Soledad, one of the 33 facilities that constitute CDCR. Inmates are split into provider-care teams per their CDCR number and followed in the nine clinics at the facility. These inmates were identified, tracked, educated, and followed up using the Patient-Centered Medical Home (PCMH) model. The education and assessments were geared through the Transtheoretical Model (TTM) to determine the readiness of teaching modalities. This program included peer-to-peer education between inmates, group education by the nurse instructor, and RN/PCP (primary care provider) intervention visits. An asthma action plan and severity indexing determined the specific protocols that were followed for this population. Inmates took ownership of their individual health problems, and custody and medical staff worked collaboratively to facilitate timely visits to the clinic and safety concerns of medication accessories. The goal of this program was to decrease unexpected deaths due to asthma to zero per year. A secondary goal was to decrease the number of Treatment & Triage Area (TTA) visits for signs and symptoms of exacerbated asthma by 95%. Outcomes were measured by tracking the number of key indicators, including registered nurse/primary care provider (RN/PCP) visits, assessments and diagnostics tool measurements, subjective control tests, and number of TTA visits.
Cite this paper
Pimentel, M. L. (2019). Initiating a Pro-Active Care Modality Paradigm to Vulnerable Populations: Utilizing the Patient-Centered Medical Home Model for Incarcerated Male Inmates with Asthma. Open Access Library Journal, 6, e5939. doi: http://dx.doi.org/10.4236/oalib.1105939.
American Lung Association (2009) Trends in Asthma Morbidity and Mortality. http://www.lungusa.org/atf/cf/%7B7a8 d42c2-fcca-4604-8ade-7f5d5e762256%7D /ASTHMA%20JAN%202009.PDF
King, M.T., Kenny, P.M. and Marks, G.B. (2009) Measures of Asthma Control and Quality of Life: Longitudinal Data Provide Practical Insights into Their Relative Usefulness in Different Research Contexts. Quality of Life Research, 18, 301-312. https://doi.org/10.1007/s11136-009-9448-4
Ramos, C., Ciaccio, C. and Portnoy, J. (2009) Asthma Control Is Enhanced When Health Plans and Providers Cooperate. Pediatric Annals, 38, 135-142. https://doi.org/10.3928/00904481-20090301-09
Moorman, J.E., Rudd, R.A., Johnson, C.A., King, M., Minor, P., Bailey, C., et al. (2007) National Surveillance for Asthma, United States, 1980-200. 1-54.
Horne, R., Price, D., Cleland, J., Costa, R., Covey, D., Gruffydd-Jones, K., Williams, S., et al. (2007) Can Asthma Control Be Improved by Understanding the Patient’s Perspective? BMC Pulmonary Medicine, 7, 8. https://doi.org/10.1186/1471-2466-7-8
Green, D.M. (2005) History, Discussion and Review of a Best Practices Model for Service Delivery for the Homeless. Social Work in Mental Health, 3, 1-16. https://doi.org/10.1300/J200v03n04_01
Loeb, S. and AbuDagga, A. (2006) Health-Related Research on Older Inmates: An Integrative Review. Research in Nursing & Health, 29, 556-565. https://doi.org/10.1002/nur.20177
Davis, L.M. and Pacchiana, S. (2004) Health Profile of the State Prison Population and Returning Offenders: Public Health Challenges. Journal of Correctional Health Care, 10, 303-331. https://doi.org/10.1177/107834580301000305
Shortell, S.M., Rundall, T.G. and Hsu, J. (2007) Improving Patient Care by Linking Evidenced-Based Medicine and Evidenced-Based Management. Journal of the American Medical Association, 298, 673-676. https://doi.org/10.1001/jama.298.6.673
Robert Graham Center (2014) Policy Studies in Family Medicine and Primary Care: Annual Report. https://www.graham-center.org/content/dam/rgc/ documents/about/annual-reports/RGCAnnual Report2014-2015.pdf
Friedberg, M.W., Safran, D.G., Coltin, K.L., Dresser, M. and Schneider, E.C. (2009) Readiness for the Patient-Centered Medical Home: Structural Capabilities of Massachusetts Primary Care Practices. Journal of General Internal Medicine, 24, 162-169. https://doi.org/10.1007/s11606-008-0856-x
Johnson, S.S., Driskell, M.M., Johnson, J.L., Prochaska, J., Zwick, W. and Prochaska, J.O. (2006) Efficacy of a Transtheoretical Model-Based Expert System for Antihypertensive Adherence. Disease Management, 5, 291-301. https://doi.org/10.1089/dis.2006.9.291
Gambling, T. and Long, A.F. (2006) Exploring Patient Perceptions of Movement through the Stages of Change Model within a Diabetes Tele-Care Intervention. Journal of Health Psychology, 11, 117-128. https://doi.org/10.1177/1359105306058854
Willey, C., Redding, C. and Stafford, J. (2002) Stages of Change for Adherence with Medication Regimens for Chronic Disease: Development and Validation of a Measure. Clinical Therapy, 22, 1-14.
Prochaska, J.O., DiClemente, C.C. and Norcross, J. (1992) In Search of How People Change: Applications to Addictive Behaviors. American Psychology, 47, 1102-1114. https://doi.org/10.1037/0003-066X.47.9.1102
Prochaska, J.O., Redding, C.A. and Evers, K.E. (2002) The Transtheoretical Model and Stages of Change. In: Glanz, K., Lewis, F.M. and Viswanath, K., Eds., Health Behavior and Health Education: Theory, Research and Practice, 4th Edition, Jossey-Bass, Inc., San Francisco, CA.
Wain, R.M. (2007) Motivational Interview vs. Standard Interview with People Screening to Enter the Homeless Veterans Rehabilitation Program: Effect on Rate of Entry, Self-Efficacy and Readiness to Change. PhD Thesis, Pacific Graduate School of Psychology, Palo Alto.
Krouse, J.H. and Krouse, H.J. (2008) Asthma: Guidelines-Based Control and Management. Otolaryngologic Clinics of North America, 41, 397-409. https://doi.org/10.1016/j.otc.2007.11.013
Cook, J., McClure, S., Koutsenok, I. and Lord, S. (2008) The Implementation of Inmate Mentor Programs in the Correctional Treatment System as an Innovative Approach. Journal of Teaching in the Addiction, 7, 123-132. https://doi.org/10.1080/15332700802418758
