1. Assessing Chronic Illness Care in Prison (ACIC-P): A Tool for Tracking Chronic Illness Care in Prison Emily Wang, M.D., MAS Yale University School of Medicine

2. Background Healthcare is constitutionally guaranteed in US prison 80% of patients have a chronic illness; 40% are diagnosed with chronic illness in prison Some prison healthcare systems are embarking on quality improvement programs from chronic illness care

3. Aim To identify a tool to evaluate and direct primary care quality improvement efforts in prison healthcare settings

5. Assessment of Chronic Illness Care (ACIC) Survey designed to help community primary care organizations assess chronic illness care within the 6 components of the Chronic Care Model: – Self-management support – Linkages to community resources – Decision support – Delivery system design – Clinical information systems – Organization of the health system

6. Methods Qualitative study using cognitive interviews to better understand the appropriateness of using the ACIC for the prison setting Content analysis of interviews were based on the four problem types in cognitive processing (comprehension, recall, response, and bias) Participants included 12 prison health providers and administrators (mean time working 10.25 yrs (0.5-17 yrs))

7. Study Procedure Original ACIC Instrument Initial modifications to ACIC instrument ACIC-Prison (ACIC-P)  Reviewed by research team with input from senior leaders of prison systems, and ACIC author  Defined problematic components  Designed Interview probes to assess correctional health providers and administrators interpretation of the ACIC instrument  Training of interviewers and pilot interview  Cognitive interviews with 12 participants  Iterative process of identifying problematic components at post interview debriefing sessions with modification or inclusion of new verbal probes.  Transcribed interview audio records and performed content analysis, with identification of themes and problematic components

8. Results: Cognitive Processing Comprehension e.g. “senior leaders” was interpreted as “... our administrative leadership” and “... my doctor at my medical center” Response: e.g. “addressing concerns of patients and families.” Participants indicated they “don’t deal with families”

9. Results: New Domains for ACIC-P Role of the Department of Corrections e.g., “… if you have a guy with chest pain,..., but you’re also working with the correctional officer to make sure there is security...”. Question 1.6. Custody is [intermittently focuses on chronic illness care, has developed a vision for chronic illness care, but no consistent process for getting there, is committed to chronic illness care, and sometimes engage teams in problem solving and implementation, and consistently engages clinical teams improving patient experiences of care and clinical outcomes.]

10. Results: New Domain for ACIC-P Discharge planning “a unique component of chronic illness care in correctional health” Question 2.4. Linking patients to medical resources after discharge from prison [is not systematically done, is limited to providing a list of resources, is accomplished by a designated person, and is accomplished by coordination between the two healthcare systems. ]

11. Modifications to ACIC DescriptionNumber of itemsPercentage of original ACIC items Unchanged items from original ACIC 1544% Minor modifications of original ACIC items 1338% Completely changed original ACIC items 618% New items not in the original ACIC 2--

12. Summary ACIC is applicable for use in the prison healthcare setting with modifications that reflect the unique nature of practicing primary care in the prison setting

13. Next Steps Administer ACIC-P in two northeastern prison systems to test the psychometric properties of the instrument *among 55 participants

14. Acknowledgements Mentors and Collaborators: Jenerius Aminawung, MD, MPH Ed Wagner, MD, MPH Robert Trestman, PhD, MD Warren Ferguson, MD Carol Bova, PhD Funding: NHLBI Career Development Award (K23 HL103720) NIDA R03 (1R03DA031592 ) CMMI (1C1CMS331071-01-00) Yale Center for Clinical Investigation

15. Thanks