Objectives. Good Medicine in Bad Places. MetroHealth Correctional Health Program 7/25/2018

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Good Medicine in Bad Places MetroHealth Correctional Health Program Thomas A Tallman, DO, FACEP, CCHP Objectives Define the scope of correctional medicine. Causes of recidivism?

1 Good Medicine in Bad Places MetroHealth Correctional Health Program Thomas A Tallman, DO, FACEP, CCHP Objectives Define the scope of correctional medicine. Causes of recidivism? What can we treat in the jail with limited resources? Based on the cases presented, does medical decision making differ from the ED environment? Greatest cost concerns and how to control them. How to make bioethical decisions based on cases presented. How can we deploy telehealth services? Lets look at some challenging specialty populations. 1

2 Disclosure Commercial interests none Financial relationships none Conflict of interest none Americans jailed annually 2

abuse among inmates is higher than the general population Difficulties delivering healthcare in prisons including

3 Among the pressing factors affecting prison healthcare spending include: An aging inmate population (inmates 50+ are the fastest-growing demographic) Prevalence of infectious and chronic diseases, mental illness, and substance abuse among inmates is higher than the general population Difficulties delivering healthcare in prisons including long distances from hospitals and other providers and challenges finding willing doctors, particularly specialists 3

4 The Justice Center Culture Shock Living 24/7 by someone else's rules Sterile environment Jail / Prison lifestyle more stable than lifestyle before 4

unnecessary consults Ortho Cards Derm, Wounds

5 Correctional medicine Correctional medicine=/=conventional medicine Chronic disease management Pain management: challenging, impossible? Necessary consults vs. unnecessary consults Ortho Cards Derm, Wounds Labs and imaging Cost efficient care is key Don t exaggerate sense of responsibility 5

6 MetroHealth Program Facilitate better and more comprehensive care, Increase the health and wellbeing of prison populations, Address chronic disease management, Improve outcomes Drug treatment initiatives Vivitrol, buprenorphine Eliminate expensive transport of inmates to hospitals for consultation or treatment Did you expect Chronic diseases: back pain, asthma, arthritis, cancer, diabetes, and heart disease The total annual cost of healthcare due to pain is estimated at $560 billion to $635 billion in just the U.S., when accounting for medical costs of pain care and the economic costs from disability, lost wages, and productivity. Large percentage of mentally ill or drug addicted offenders, and a pressing need to treat their illnesses, chronic diseases, chronic pain, and other issues that occur at the same rate as the general population. The large aging population of prisoners, with prisoners ages 50 and older the fastest-growing segment of the population, is a main driver in the increase of healthcare costs costs being borne by the taxpayers. 6

Increasing Jail Populations $120,000 $100,000

Comparison 2017-2018 340b Initiated January 2017

$82,296 $79,621 $66,313 $53,013 $60,093 $59,725

7 Increasing Jail Populations $120,000 $100,000 $80,000 $60,000 $40,000 $73,326 Pharmacy Expense Comparison b Initiated January 2017 $87,412 $111,601 $95,929 $93,762 $92,837 $84,802 $82,296 $79,621 $66,313 $53,013 $60,093 $59,725 $43,508 $32,394 $112,402 $99,469 $100,798 $20,000 $

8 So what does a C.O. do? 8

Inmate Management Direct Supervision: Officer present in pod 24/7 Prevents incidents & controls behavior Maintain security and assure safety Objective Classification: Assure appropriate level of

9 Inmate Management Direct Supervision: Officer present in pod 24/7 Prevents incidents & controls behavior Maintain security and assure safety Objective Classification: Assure appropriate level of custody Assess risk and needs Obtain baseline status of physical and behavioral health EHR: EPIC Monthly random chart reviews Provide one-on-one feedback Medical decision-making- document your thinking Keep up with charting throughout the shift Close charts My door is open 9

10 MetroHealth County Corrections Healthcare Transport Summary MONTHLY ED TRANSPORTS 2016 ED Transports 2017 ED Transports ED Transports January February March April May June July August Septemb er October Novemb er 2016 ED Transports ED Transports ED Transports Deceme ber MetroHealth County Corrections Healthcare Transport Summary MONTHLY 123 OUTPATIENT TRANSPORTS 2016 Outpatient Transports 2017 Outpatient Transports Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec, 2016 Outpatient Transports Outpatient Transports Outpatient Transports

11 Train like you play and play like you train 10 December 2015 Dr. Noeller and his sim team came to train in the jail 4 scenarios All hands participated Get familiar with our roles during REAL medical emergencies NP s and PA s = team leaders Delegate staff to assignments Recorder In-service to familiarize staff with emergency pack ACLS providers- know meds and Lifepak 12 11

12 Characteristics of the Jail Population Jail population is diverse: Both genders Juveniles and adults Dangerous and vulnerable Minor and serious offender First timer and career criminals Physically fragile and mentally ill Chemically addicted Characteristics of the Prison Population Prison population is generally: Same gender Same legal status (sentenced as punishment for the conviction of a state crime) Same custody level (minimum, medium, maximum, close confinement) 12

13 Correctional Medicine Before 1775, imprisonment was rarely used as a punishment for crime. Since that year, however, incarceration rates have grown exponentially, creating the need for physicians in correctional institutions. Correctional medicine began, in its most rudimentary form, in Victorian England, under the health reforms promoted by wealthy philanthropist and devout ascetic John Howard and his collaborator, well-to-do Quaker physician John Fothergill. 13

Organizations to know American College of Correctional Physicians (ACCP) National Commission on Correctional Healthcare (NCCHC) Ohio Department of Rehabilitation and Corrections (ODRC) American

14 Organizations to know American College of Correctional Physicians (ACCP) National Commission on Correctional Healthcare (NCCHC) Ohio Department of Rehabilitation and Corrections (ODRC) American College of Correctional Physicians The American College of Correctional Physicians (ACCP) [1] is a non-profit physician organization founded in August, 1992 as national educational and scientific society for the advancement of Correctional Medicine. The ACCP supports and provides leadership to our members challenged with the internal and external obstacles to the care of the incarcerated. CorrDocs is the official newsletter of the ACCP, providing current information on the latest College activities and news on correctional medicine. 14

317794 49 year old male with PMH including CAD, COPD, Diabetes, GERD presenting to the ED for right sided weakness and numbness.

15 year old male with PMH including CAD, COPD, Diabetes, GERD presenting to the ED for right sided weakness and numbness. Recently seen at metro for neurologic symptoms, imaging was negative, examined by Dr Bahntge from neurology at that time and found to have non-neurologic findings. Today patient states he was walking at jail when he had sudden onset right sided numbness and weakness around 4 PM. States he was unable to ambulate due to weakness. In ED complains or right sided facial weakness and numbness, left arm and leg numbness and weakness 15

The Recommendations of JNC 8 Participation in NCCHC The ACCP holds a permanent position on the Board of

16 Rectal Contraband. What Would You Do? How Should We Handle Inmate Requests for their Medical Records? How Does Jail Medicine Differ From Prison Medicine? Changes in Hypertension Treatment? Why Yes! The Recommendations of JNC 8 Participation in NCCHC The ACCP holds a permanent position on the Board of Directors of the National Commission on Correctional Health Care (NCCHC), providing physician input regarding professional policies and practices. 16

17 So what do we do at CCJ? Hepatitis C in Injection-Drug Users A Hidden Danger of the Opioid Epidemic March 29, 2018 N Engl J Med 2018; 378:

Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Condition Estimated # of releases w/ Cond n Total # in US Pop n w/ Cond n Releases as %

18 Percent of Total Burden of Infectious Disease Found Among People Passing Through Correctional Facilities, 1996 Condition Estimated # of releases w/ Cond n Total # in US Pop n w/ Cond n Releases as % of US Pop n w/ Cond n AIDS 39, ,000 17% HIV+ 98, , , % HepBsAg+ 155, million 12-16% Hep C million 4.5 million 29-32% TB disease 12,000 34,000 35% Hammett TM, Abt Associates, Nat l HIV Prevention Conf. Aug 1999 Time for some cases 18

19 Proceed with Caution 19

20 Burned! 20

Bioethics consults The case of 0421281 He is a 58 y/o with a long history of etoh abuse and Hep C (dx 2007) who was offered hep C treatment many years ago (2009) but was unable to start tx due to

21 Bioethics consults The case of He is a 58 y/o with a long history of etoh abuse and Hep C (dx 2007) who was offered hep C treatment many years ago (2009) but was unable to start tx due to continued polysub abuse. He came to jail in January with c/o belly pain and weight loss and a 3.2cm solid mass, strongly suspicious for HCC, was seen on US with a repeat in March having grown slightly. He was released in March, did not follow up for imaging or liver consults on the outside, and is back in jail. He cannot perform MRI due to metal in the eye, so I have ordered 4 phase CT for further eval. Last labs show INR prolonged at 1.2, platelets of 51, and transaminases ~2xULN. Prognosis is overall not great, and this is HCC until proven otherwise. 21

Endocarditis 34 year old female with a history of Endocarditis with stenotrophomonas INTERVAL EVENTS: readmitted to Hillcrest Hospital last month and left AMA incarcercated last week (outstanding

admit to UH (patient signed out AMA due to family situation). who denies IDU since 7/2017, however recent blood cutures 5/2018 with Burkholderia which is suggestive of possible IVDU.

22 Endocarditis 34 year old female with a history of Endocarditis with stenotrophomonas INTERVAL EVENTS: readmitted to Hillcrest Hospital last month and left AMA incarcercated last week (outstanding warrant) at County Jail I spoke with Dr Tallman ASSESSMENT: Complicated medical surgical psychosoical issues Likely burholderia PVE n setting of OUD with prior AVR TVr and CIED (12/2017) and recent admit to UH (patient signed out AMA due to family situation). who denies IDU since 7/2017, however recent blood cutures 5/2018 with Burkholderia which is suggestive of possible IVDU. States has not used and has now competed 6 weeks of IV rx. Discussed with patient need for rehab and possible use of Suboxone. She is currently opposed to subxone but is considering vivitrol. Transporting inmates with disabilities 22

23 Altercations Ortho : left femur fx secondary to GSW : GSW left hand (march 2018) :Pt a 33 yo spanish-speaking M presenting via Elite from OSH Lutheran s/p GSW to R tibia with tibia fx, pulses intact. 23

More ortho 22 year old Right handed male with no significant past medical history who

$Gunshot injury is noted with markedly comminuted fracture of the base of the right 5th$ metatarsal at the attachment of the peroneus brevis tendon with multiple tiny bullet

metatarsal at the attachment of the peroneus brevis tendon with multiple tiny bullet

24 More ortho 22 year old Right handed male with no significant past medical history who presented to MHMC on 5/18/2018 after sustaining a GSW. Patient states he was in a barber shop when he was shot in the chest, Right foot. Gunshot injury is noted with markedly comminuted fracture of the base of the right 5th metatarsal at the attachment of the peroneus brevis tendon with multiple tiny bullet fragments. There is a markedly comminuted fracture of the calcaneus secondary to the penetrating gunshot injury. So you want to be a dermatologist 24

25 Diagnosis? More rashes 25

26 My foot hurts Wound management 26

27 Back from Metro 27

28 Collecting evidence Shot in the foot 28

29 Bad decisions More bad decisions 29

30 MRSA 30

31 Seizures Most often drug or alcohol withdrawal CIWA COWS Noncompliance Self-medication Heroin instead of Keppra Manipulators GSW s bad for tattoos Trauma services at UH and Metro Discharged from hospital to jail 31

32 32

Escape artist SO0300369 Endorsing swallowing a whole entire plastic spoon (witnessed by police officer) because he was trying to kill himself. Feels that it's stuck in his chest, no current SOB.

33 Escape artist SO Endorsing swallowing a whole entire plastic spoon (witnessed by police officer) because he was trying to kill himself. Feels that it's stuck in his chest, no current SOB. +pain in chest with swallowing. States he used to be on psychiatric meds, stopped taking them 1 month ago. Was hospitalized 1 month ago for SI. Has swallowed various objects in the past including razors, spoons, batteries. Per EMS patient reportedly jumped from a toilet while in jail and struck his head. Unsure if he had LOC at that time. He is currently in restraints as patient reportedly has a history of swallowing foreign bodies. Notified by ED physician that patient was ambulating back to room after propofol sedation and grabbed a temperature probe off of the Dynamap machine and bit off the metal piece (estimated about 5 inches) and swallowed it. This was in the presence of two CCC guards 29 yo male with PMH of seizures, Hep-C, IVDU, Endocarditis, DVT, Bipolar, ADHD, admitted from prison after swallowing a pen resulting in hypopharyngeal wall laceration and pneumomediastinum. 33

34 Suicide attempts 2 successful attempts 4.5 years Medical emergency called on radio First responders Media relations Two Cuyahoga County Jail inmates die from suspected drug overdose, hanging in one week CLEVELAND, Ohio -- Two inmates at the Cuyahoga County Jail died in one week -- one from a suspected drug overdose and another from a suspected hanging, according to medical examiner records reviewed by cleveland.com. Esteben Parra, 32, died June 27 of a suspected drug overdose. He had amphetamines, THC and cocaine in his system at the time of his death, according to the medical examiner's preliminary findings. 34

Behavioral health Behavioral health = Recidivism

2014 and is projected to spend $49 million in

35 Behavioral health Behavioral health = Recidivism The Ohio Department of Rehabilitation and Correction spent $41.7 million on mental healthcare and medications in 2014 and is projected to spend $49 million in Mental-healthcare spending is on top of the $22,836 annual overall cost per inmate. 35

36 Goals Competency assessment Restoration Competent to stand trial 5 mental health agencies 170/ month Innovation Telehealth 36

37 Solutions available now CARDIOLOGY RADS ID DERM TELE NEURO PSYCH 37

38 Virtual visit In Touch Health jointly ventured into the creation of the RP- VITA (Remote Presence Virtual + Independent Telemedicine Assistant) Robot, which can completely revolutionize telemedicine. MetroHealth portal will allow doctors to evaluate, treat, and track the prescribed regimens and ensure the highest quality and efficiency of care. Telepresence 38

140 120 100 MetroHealth County Corrections Healthcare Transport Summary MONTHLY 123 OUTPATIENT TRANSPORTS 2016 Outpatient

19 20 18 13 0 Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov.

39 MetroHealth County Corrections Healthcare Transport Summary MONTHLY 123 OUTPATIENT TRANSPORTS 2016 Outpatient Transports 2017 Outpatient Transports Jan. Feb. Mar. April May June July Aug. Sept. Oct. Nov. Dec, 2016 Outpatient Transports Outpatient Transports Outpatient Transports Kites 39

40 Kites Kites 40

41 Kites The opioid epidemic 41

Drug and Alcohol Withdrawal A Win-Win for Opioid Abuse Treatment Throughout the majority of my career in emergency medicine, I would have to say that the patient I dreaded the most was the patient

42 Drug and Alcohol Withdrawal A Win-Win for Opioid Abuse Treatment Throughout the majority of my career in emergency medicine, I would have to say that the patient I dreaded the most was the patient with drug seeking behavior. In the end, my goal was often to just get them out of the ER as quickly and painlessly as possible. And as anyone knows who has worked in this field very long, that was seldom successful. 42

MEDICATION-ASSISTED TREATMENT (MAT) From the jail to Recovery Housing Setting What are the clinical considerations in prescribing Vivitrol (Naltrexone) to treat opioid use disorder (OUD)?

43 MEDICATION-ASSISTED TREATMENT (MAT) From the jail to Recovery Housing Setting What are the clinical considerations in prescribing Vivitrol (Naltrexone) to treat opioid use disorder (OUD)? Review barriers and facilitators to the integration of MAT into current behavioral healthcare settings. Discuss our strategy to plan and successfully implement MAT into recovery housing setting. Evidence-based practice. Current Public Health Crisis CURRENT PUBLIC HEALTH CRISIS (Local) No. of Fatal Cases due to heroin/fentanyl in May City of Cleveland Residents 26 - Suburban Residents- Brecksville, Brook Park, Chagrin Falls, Cleveland Hts., East Cleveland, Lakewood (2), Maple Hts., Mayfield, Mayfield Hts., Oakwood, Olmsted Twp., Parma (5), Parma Hts., Strongsville and (5) out of County residents Aurora, Chesterland, Elyria, Newbury and North Ridgeville. VICTIMS Victims ages range from Male victims; 13 Female victims 8 African American victims; 36 Caucasian victims; (1 Hispanic victim) EXPONENTIAL RATE OF INCREASE In 2015, one person died every day in Cuyahoga County from a drug overdose. 43

44 What are we doing? In 2016, during January and February, one person died every day in Cuyahoga County from a heroin or fentanyl overdose. January was a record for fentanyl deaths, broken again in February. Starting March 10, 2016 to months end, two people died every day in Cuyahoga County from a heroin or fentanyl overdose as well as from May 25th until the end of the month and set a new record for fentanyl deaths. At least 184 victims died already in

45 Thus far Opinion: Physicians Need Training On Caring For Patients With Addiction History. 45

46 Intake Buprenorphine (Subutex) Pregnant females with opioid use disorder Methadone less desirable option 46

47 How to Save a Life with Naloxone in the Event of an Opioid Overdose MetroHealth Project DAWN Emily metz emetz@metrohealth.org At the end of the day.. 47

Increasing Jail Populations Healthcare Communication How does the physician-patient relationship translate to the County Corrections Center? Inmate satisfaction scores?

48 Increasing Jail Populations Healthcare Communication How does the physician-patient relationship translate to the County Corrections Center? Inmate satisfaction scores? Technical knowledge valued over interpersonal skills Exaggerated sense of responsibility Practitioner-inmate relationship Establish the visit Develop the relationship Engagement 48

49 49

50 THE END 50

Heroin & Fentanyl Related Deaths in Cuyahoga County

Thomas P. Gilson, M.D. Cedar Avenue, Cleveland, Ohio A National Association of Medical Examiner s (N.A.M.E.) accredited office CUYAHOGA COUNTY MEDICAL EXAMINER S OFFICE Heroin & Fentanyl Related Deaths