NSPHC Interview Guide

ATTACHMENT F: NSPHC Interview Guide

OMB No. XXXX-XXXX: Approval expires XX/XX/XXXX

Notice - Public reporting burden for this collection of information is estimated to average 4 hours, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to: CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXX-XXXX).

State: ­­­­­­­­­­­ __________________________ Interviewer: ___________________________________

Initial Contact: Name: ­_________________________ Title: ____________________

Phone Number: _____________________ Date: _________________

Notes:

Additional Contact: Name: ­_________________________ Title: ____________________

Phone Number: _____________________ Date: _________________

Notes:

Additional Contact: Name: ­_________________________ Title: ____________________

Phone Number: _____________________ Date: _________________

Notes:

Summary of Data Collection Process: Date of Completion: ___________

1) Determine whether inmate health care services are contracted, and the type of contracting model (with a private company, a university, or other health care provider in the community), as of year-end 2011.

Specific Services:

Health care services	All contracted	Some Contracted	None (all DOC provided)	Don’t know	Follow up name; Contact information
a) Mental health	□	□	□	□
b) Pharmaceutical	□	□	□	□
c) Dental	□	□	□	□
d) Laboratory Services	□	□	□	□
e) Radiology	□	□	□	□
f) Medical (excluding all of the above)	□	□	□	□

Notes:

Employee Type	Number of FTE employees
	DOC	Contracted	Exact number or estimate? If needed, follow up contact information:
Mental health a) Psychiatrists (MD, DO
b) Psychiatric physician assistants
c) Psychiatric nurses (PMHCNS, NP)
d) Clinical psychologists (PhD, PsyD, MS)
e) Clinical social workers (LCSW)
f) Other mental health staff
Pharmaceutical g) Pharmacists (DPh, RPh)
h) Other pharmaceutical staff
Dental i) Dentists (DDS)
j) Dental hygienists/assistants
k) Other dental staff

2. Determine how many FTE’s are dedicated to the prison system’s health care services. This should include both contracted and non-contracted staff. Because of changing numbers of employees, ask for December 31, 2011.

Employee Type	Number of FTE employees
	DOC	Contracted	Exact number or estimate? If needed, follow up contact information:
Medical only l) Physician assistants (PA)
m) Nurse practitioners (NP)
n) Other nurses (RN, LPN, LVN)
o) Surgeons (MD, DO)
p) All other physicians (MD, DO)

Notes:

3A) Determine whether the prison system provided these services on-site (in a DOC facility) between Jan 1, 2011 and Dec 31, 2011

Services	On-site		Don’t Know
	Yes	No	Don’t Know	Follow up contact information:
a. Inpatient mental health care (overnight)	□	□	□
b. Outpatient mental health care	□	□	□
c. Inpatient medical health care (overnight)	□	□	□
d. Outpatient medical health care (i.e., infirmary or sick call)	□	□	□
e. Chronic care clinics	□	□	□
f. Dental care	□	□	□
g. 24 hour physician or nurse coverage
h. Emergency department care	□	□	□
i. Inpatient surgeries/operations (overnight)	□	□	□
j. Outpatient surgeries/operations	□	□	□
k. Long-term/nursing home care (geriatric, assisted living, etc.)	□	□	□
l. Hospice care	□	□	□

3B) Determine whether the prison system provided these services off-site between Jan 1, 2011 and Dec 31, 2011.

Services	Off-site		Don’t Know
	Yes	No	Don’t Know	Follow up contact information:
Inpatient mental health (overnight)	□	□	□
b. Outpatient mental health	□	□	□
c. Inpatient medical health care (overnight)	□	□	□
d. Outpatient medical health care (i.e., infirmary or sick call)	□	□	□
e. Dental care	□	□	□
f. 24 hour physician or nurse coverage
g. Emergency department care	□	□	□
hi. Inpatient surgeries/operations (overnight)	□	□	□
i. Outpatient surgeries/operations	□	□	□
j. Long-term/nursing home care (geriatric, assisted living, etc.)	□	□	□
k. Hospice care	□	□	□

4. Determine if and how these services were provided between Jan 1, 2011 and Dec 31, 2011.

Services	On-site	Off-site/In Community	Telemedicine Consultation	Not Available	Don’t Know: Follow Up Contact
Specialty Services a. Cardiology	□	□	□	□
b. Psychiatry	□	□	□	□
c. Dialysis	□	□	□	□
d. Oral surgery	□	□	□	□
e. Gynecology	□	□	□	□
f. Obstetrics	□	□	□	□
g. Optometry	□	□	□	□
h. Ophthalmology	□	□	□	□
i. Orthopedics	□	□	□	□
j. Oncology	□	□	□	□
Diagnostic Tests k. Cardiac catheterization	□	□	□	□
l. High sensitivity fecal occult blood test (FOBI)	□	□	□	□
m. Hemoglobin AIC test (HAIC)	□	□	□	□
n. Sigmoidoscopy	□	□	□	□
o. Colonoscopy	□	□	□	□
Services	On-Site	Off-Site/In Community	Telemedicine Consultation	Not Available	Don’t Know: Follow Up Contact
p. Colposcopy	□	□	□	□
q. CT scan	□	□	□	□
r. ECG (EKG)	□	□	□	□
s. Mammography	□	□	□	□
t. MRI	□	□	□	□
u. Ultrasound (excluding hand-held dopplers and bladder scanners)	□	□	□	□
v. X-rays	□	□	□	□
Therapies w. Restorative/rehabilitation/ physiatry	□	□	□	□
x. Physical/occupational therapy	□	□	□	□

Notes:

4. Determine what the admissions process for the prison system entails (length, steps, general process).

4. Determine whether the prison system tests inmates for the following infectious diseases during the admissions process, the testing criteria (all inmates or specific inmates), and how/if records are kept on screening numbers and results.

Infectious Diseases	Yes	No	Testing criteria and record keeping	Don’t Know: Follow Up Contact
a. Hepatitis A	□	□
b. Hepatitis B	□	□
c. Hepatitis C	□	□
d. Gonorrhea	□	□
e. Chlamydia	□	□
f. Syphilis	□	□
g. Tuberculosis (PPD)	□	□

Notes:

4. Determine whether the prison system tests inmates for the following health concerns during the admissions process, the testing criteria (all inmates or specific inmates), and how/if records are kept on screening numbers and results.

Health Concerns	Yes	No	Testing criteria and record keeping	Don’t Know: Follow Up Contact
b. Pregnancy	□	□
c. Elevated lipids	□	□
d. High blood pressure	□	□

4. Determine whether the prison system conducts the following on inmates during the admissions process, the testing criteria (all inmates or specific inmates), and how/if records are kept on screening numbers and results.

Tests	Yes	No	Testing criteria and record keeping	Don’t Know: Follow Up Contact
a. Routine dental exam	□	□
b. ECG (EKG)	□	□
c. Chest x-ray	□	□

Notes:

4. Determine whether the prison system screen inmates for the following mental health concerns during the admissions process, and how many were screened between Jan 1, 2011 and Dec 31, 2011?

Tests	Yes	No	Testing criteria and record keeping	Don’t Know: Follow Up Contact
a. Mental health problems (excluding suicide risk)	□	□
b. Suicide risk	□	□
c. Traumatic brain injury	□	□

4. How many total inmates were in the custody of your state’s prison system on (END DATE FOR ADMISSION RANGE)?

4. How many inmates were admitted to your state’s prison system between (INSERT DATE RANGE HERE)?

4. Determine what major challenges/issues the DOC is currently facing in regards to the delivery of health care.

Notes: