Recommendations, Page 44-45 R1. Create a clear delineation of program responsibilities between corrections and the

Recommendations 17

• R1
  Create a clear delineation of program responsibilities between corrections and the medical provider. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. The Grand Jury report is correct in stating that medical treatment for inmates is mandated by Section 6030 of the California Penal Code, and the standard for that care be set in Title 15, of the California Code of Regulations (CCR). Section 1200(a), of Title 15, establishes the responsibility for health care Services. Section 1200 Responsibility for Health Care Services. (a) In Type II facilities, the facility administrator shall have the responsibility to ensure provision of emergency and basic health care services to all inmates. Medical, dental, and mental health matters involving clinical judgments are the sole province of the responsible physician, dentist, and psychiatrist or psychologist respectively. The Sheriff’s Department, as well as CFMG, has separate Policy and Procedure Manuals, which address the responsibilities of both parties. Section 1029 of Title 15 - CCR, mandates the development of policy and procedures for the facility. California Medical Association (CMA) – Institute for Medical Quality (IMQ), Section 104 mandates that there be specific health services manual of policies and defined procedures approved by the health authority to address all essential health standards. It is the Sheriff’s opinion that there is a clear delineation of program responsibilities between corrections and the medical provider, as outlined in both parties’ policies and procedures.
• R2
  Consider a study to determine the most efficient and economical method to address jail medical issues. RESPONSE: The recommendation has been implemented. The Department is currently working with the County Administrator’s Office (CAO), County Counsel, Department of Health Services and the Risk Management Division of General Services, to determine the most efficient and economical method to provide 1 catastrophic medical services i.e. services provided in an urgent care or hospital facility. A project specifically geared toward evaluating costs the county pays for catastrophic level medical services has begun. The project will focus on whether greater cost efficiencies or cost reductions can be achieved, which is consistent with the original intent of SB 159. For routine medical services available to inmates on a daily basis within the county’s detention facilities, the county has already determined that contracting with a private provider for these services is the most efficient and economical method to provide these services. During the first quarter of FY 06-07, the Sheriff's Department will begin the Request For Proposal (RFP) process to solicit competitive proposals, from qualified providers, for the contract period beginning February 1, 2008.
• R3
  Consider retaining a consultant, possibly an actuary, who is able to do a cost benefit analysis on the alternatives for handling jail medical costs. RESPONSE: The recommendation has been implemented. The County Administrator agrees that a cost benefit analysis is a worthwhile approach to determining the most efficient and effective delivery of hospitalization or catastrophic level services for inmates, and has considered this approach. In the fall of 2005, the County began a study to evaluate costs associated with inmate catastrophic medical care. The study, which is organized in phases, involves County staff from multiple disciplines: detention operation and administration, health services, risk management and legal. It is anticipated that a consultant will be retained in future phases of this work. Further, as mentioned in R2, the Sheriff's Department will solicit competitive proposals through a RFP process.
• R4
  Consider the use of a physician-monitor to review and assess the quality and appropriateness of medical care. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. This recommendation has already been accomplished by the established peer review process already in place, as mandated by Section 106 of the CMA-IMQ standards. Dr. Rick Flinders, an independent physician in the community, comes on site quarterly, to assess the appropriateness of decision-making and the overall quality of health care for inmates treated in and outside the detention facilities. Dr. Flinders also serves on the Quality Assurance Committee and reports his objective findings to both the Sheriff’s Department and CFMG. 2
• R5
  Examine the possibility of obtaining catastrophic insurance coverage for jail medical. RESPONSE: The recommendation has been implemented. Risk Management together with the Sheriff’s Department and County Administrator’s Office reviewed the availability of insurance coverage for this exposure in 2005 and determined this option not to be cost effective.
• R6
  Audits should be conducted by an agency independent of the medical provider. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. Audits of the jail medical programs are conducted by agencies independent of the medical provider as follows: The Public Health Department: has the responsibility of annually auditing the jails medical program to insure it meets the minimum standards of care directed by Title 15 - CCR. The report is provided to the Corrections Standards Authority (CSA) and is maintained on file at the Detention Facilities. The Corrections Standards Authority: conducts audits every two years of both Detention Facilities. These operational audits include, medical and mental health treatment services, to insure they are within the standards set by Title 15. The California Medical Association – Institute of Medical Quality: conducts audits every two years of both facilities to insure that our medical and mental health services are meeting the community standard of care.
• R7
  Make quarterly quality meetings mandatory, with an agenda, attendance log, and minutes, which shall be kept for future reference. All affected departments will send a representative, if the department head cannot be present. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. CFMG and Sonoma County officials have conducted these required meetings every quarter since the contract with CFMG began in February 2000. Attendees include representatives from the Sheriff's Office, Detention Medical, Detention Mental Health, Public Health, and County Counsel. In almost all cases where the actual department head could not attend, there was a representative present. There is always an attendance log for each meeting, as well as an agenda. Minutes are taken and are on file with CFMG at their corporate offices in Monterey, California. 3
• R8
  Negotiate contracts with off-site providers pursuant to SB 159 regarding pricing. A study conducted by the County Administrator (actuarial consultant) will be used to determine whether a contract or no-contract agreement is most advantageous for the county. RESPONSE: The recommendation has been implemented. The Sheriff's Department was successful in negotiating an amendment to our existing agreement with Sutter Hospital, Santa Rosa in December of 2005 to reduce the county’s reimbursement obligation from 80% to 55% of billed charges. Sutter Hospital is the primary care facility for the off-site treatment of inmates requiring hospitalization. The County has been closely monitoring the catastrophic costs for over a year and was closely monitoring SB 159 during the drafting and approval process. While SB 159 has addressed cost issues that were problematic statewide (legislation limits hospital charges to counties for the care of inmates to 110% of hospital costs) this legislation sunsets in 2008. The legislation also only applies to hospital charges if a contract is not currently in place. The County has been under contract with Sutter for about 10 years, the term of which expires in 2016. The project, referenced in R2, will address the issue of negotiating favorable catastrophic care contracts with local hospitals.
• R9
  Develop quantifiable, objective, and empirical standards for measuring the success of the medical program. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. The Corrections Standard Authority (CSA) has established specific standards with respect to inmate health care services. As already indicated, those standards are found in Title 15 -CCR. The Institute of Medical Quality (CMA-IMQ) also has developed additional standards that need to be met before a facility can be accredited. Both CSA and CMA-IMQ perform on-site surveys of the health care delivery system at our facilities to assess how compliant our systems are with those standards. These on-site inspections include: patient medical records; policies and procedures for both the medical program and detention operations; review of records for patients housed in safety and sobering cells; and interviews with the medical, mental health, custody staff, and inmates. The goal of CSA and CMA-IMQ in inspecting our health care systems is to evaluate its overall effectiveness, and the quality and appropriateness of medical care in the jails, based upon established standards. The Departments continued accreditation speaks to the success of delivering quality health care to inmates in our detention facilities. 4
• R10
  Develop quantifiable, objective, and empirical standards for the most economical method for handling jail medical services. RESPONSE: The recommendation has not yet been implemented, but will be implemented in the future. The department conforms to the minimum standards of care as defined in Title 15 in addition to IMQ standards as described in response to R1 and R9. Standards are also described in the department’s policies and procedures manual. Economic evaluations listed in this recommendation related to catastrophic care will be addressed in the components of the project referenced in the response to R2 which is expected to be completed by December 2007. As mentioned, economical methods of delivering day-to-day care to inmates will be addressed through the competitive bid process.
• R11
  Develop a method for determining the actual cost of the medical program to the County. RESPONSE: The recommendation has been implemented. All costs components of inmates medical care already exist in various budget units. The Fiscal Unit of the Department will develop a procedure to compile all inmate medical costs, into one report, that will be prepared on a quarterly basis. The report will include: CFMG contract, catastrophic medical, Mental Health, Inmate Psychiatric Unit (Norton Facility), and transportation of inmates for medical treatments. This will be completed and implemented during the first quarter of FY 06-07.
• R12
  Require expense-based information to be used to determine whether the contract price is commensurate with the cost of services rendered. RESPONSE: The recommendation has not yet been implemented, but will be implemented in the future. A formal request for quarterly information will be sent to the medical services provider, California Forensic Medical Group, requesting an accounting of expenses relative to the contract with the County. This request will be transmitted during the month of August 2006. 5
• R13
  Develop a list of preferred physician providers. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. CFMG maintains a list of competent and stable professional medical specialists in Sonoma County who are willing to accept inmates as patients.
• R14
  The Sheriff's Department and Information Systems Department should explore and develop technological improvements in tracking county jail medical services. RESPONSE: The recommendation has been implemented. The Sheriff and Information Systems Department (ISD) meet regularly to discuss improvements to the existing Integrated Justice System. The Sheriff’s Department has also submitted a request for the purchase of a new jail management software system. The Board of Supervisor’s will consider this request during final budget hearings in August 2006. In anticipation of this new system, the Sheriff’s Department and ISD are working to identify and prioritize system functions. The bid request will include a provision for a program to track county jail medical services.
• R15
  The Sheriff's Department and medical provider should develop alternative methods of distribution for other-than-prescription medications - specifically distribution through commissary or vending machines. RESPONSE: The recommendation will not be implemented because it is not warranted. Non-prescription medications are currently distributed by CFMG and the cost is included in the annual contract. They are given to the inmates at no cost. If these medications were distributed by the Commissary or through vending machines, numerous inmates would not be able to afford the medication and the Inmate Welfare Trust would have to absorb the cost. In addition, inmates would have the ability to “hoard” medications and possibly use them to create other substances or to inflect personal harm by overdosing. The possibility of using the commissary and vending machines, for distribution of non- prescription medication, was reviewed the Inmate Welfare Trust Committee in January 2006. For all the reasons mentioned above, the unanimous vote, of the Committee, was that it was in the best interest of the inmates and the Trust not to pursue this option.
• R16
  Obtain from the medical provider the required insured endorsements. RESPONSE: The recommendation has been implemented. Responsibility for contract management, including obtaining required insurance certificates, is the responsibility of the contract manager in each contracting department. CFMG has maintained the appropriate insurance and waivers, however updated documents were not provided to the department. Upon request, CFMG immediately provided the insurance certificates that are currently on file with the Sheriff’s Department.
• R17
  Create a task force to examine the changing realities effecting health care in the county detention facilities. RESPONSE: The recommendation has been implemented and has been in place since the inception of the contract with the medical service provider. The attendees of the quarterly Quality Assurance Meeting provide the functions that would be addressed by a task force. The attendees include: representatives of the Sheriff’s Department, CFMG, County Mental Health, County Public Health, County Counsel, Doctor Flinders (Sutter Hospital) and others as needed. During these meetings, current practices are evaluated and discussed, concerns and issues are presented and any new information regarding correctional health services are reviewed. When appropriate, subgroups are formed to evaluate identified concerns, new ideas or proposals. These subgroups report to the larger body with findings and recommendations for further discussion and possible implementation. Since the initiation of the project mentioned in R2, several costs saving measures have been implemented. The department was successful in negotiating an amendment to the Sutter agreement, reducing the County payment obligation for catastrophic care by 25% as previously mentioned. A survey of other counties has been conducted to better understand the full range of issues and cost saving options that could be used to improve our project analysis and outcomes. Additionally, the Mental Health Division in cooperation with the Sheriff, District Attorney, and Public Defender is implementing an on site mental health treatment program that will more efficiently and effectively provide intensive mental health services to inmates who previously could only receive these services at the Norton IPU. This change is expected to save the county over $380,000 annually in hospitalization costs as well as provide other transportation and court processing efficiencies. The participants of the Quality Assurance Meeting have responded to the changing realities effecting health care in the County’s detention facilities. c: Board of Supervisors Court Executive Officer County Administrator County Clerk Signatories 7