By BETSY TAYLOR
Avera eCARE, which offers telehealth in many remote, rural communities in South Dakota, also provides care to another geographically isolated population: inmates at four of the state's penitentiaries.
Clinicians at the Avera eCARE hub in Sioux Falls, S.D., provide telehealth services to patients, including South Dakota prisoners.
Sioux Falls, S.D.-based Avera Health has been delivering emergency and specialty telemedicine to the prisons for more than four years; now it's exploring whether there is a market for e-medicine services in small town jails around the state.
The Pew Charitable Trusts' Stateline website, which analyzes trends in state policy, reported earlier this year that most states are using telemedicine "to some extent" to treat prisoners. "It enables corrections officers to keep potentially dangerous inmates behind bars for treatment rather than bearing the cost and security risk of transporting them to hospitals. And, because more doctors are willing to participate, it makes health care more available for inmates." Stateline found some prisons began using telemedicine in the late 1980s, but said its use has increased significantly with improved technology, electronic medical records and pressure to control rising medical costs.
Remote triage
The state of South Dakota paid for — and Avera eCARE maintains — high-definition telemedicine equipment, including a video camera, monitor and basic diagnostic equipment, in medical services areas at the penitentiaries.
All four prisons with Avera eCARE also have clinicians employed by the state who work on-site. Each prison is staffed Monday through Friday during business hours with a nurse practitioner, physician assistant or physician. Three of the four prisons have nurse staffing around the clock.
An on-site clinician calls Avera eCARE to initiate a telemedicine emergency exam or a consultation with one of the remote telehealth providers during clinic hours. If a medical situation arises after normal prison clinic hours, a nurse or prison supervisor can make the call to Avera eCARE's e-medicine center in Sioux Falls. An Avera eCARE provider, either an advance practice nurse, physician assistant or physician, examines and triages the patient to determine if the illness or injury necessitates an immediate transfer off-site for emergency treatment or follow-up care. Some conditions can be diagnosed through the electronic connection and medication prescribed to the inmate.
Darin Young is warden of the South Dakota State Penitentiary, which houses about 1,550 adult male inmates. He said the e-medicine service is particularly useful when a patient requires medical attention after business hours for the on-site medical services staff. "Illnesses don't necessarily happen at convenient times," he said. "It helps to decide, by filtering: is this something that needs to be seen right now or is it something that tomorrow (the inmate) should be on the sick call list" — to see an on-site care provider. He believes staff feel safer knowing that more medical concerns can be safely resolved in the security of the penitentiary environment.
Larson
Changing expectations
Deanna Larson, chief executive of Avera eCARE, said, "We do ensure these residents are treated with dignity and respect when the calls come in. We take anything that comes in very, very seriously, just as we would with anyone," she said. The Avera eCARE staff in Sioux Falls that takes calls from the prisons takes telehealth calls from other patients, as well.
Larson said when the Avera eCARE program first began, many inmates didn't like it, because a trip to a hospital or a specialist was a welcome chance to travel off-site.
On-site clinical staff at the penitentiaries had to adjust their expectations and their workload, too, when the telemedicine clinicians encouraged more care be provided on site. However, she said over time, she's heard that many on-site clinicians and inmates have become acclimated to remote care, and like having the outside opinion of the clinician through the telehealth link.
And inmates with complex chronic conditions who require specialty-level care are able to take part in telehealth specialist appointments through Avera eCARE's eConsult service. These appointments are scheduled in advance and also eliminate the need to take inmates off-site for many of these visits.
Larson said the chief complaints that receive electronic consultations are "skin concerns, joint and limb pain, abdominal pain, trauma and lacerations, chest pain, neurological symptoms, fainting, nosebleed, shortness of breath, fever and urological complaints." Based on assessment and urgency, the prisoners are referred to appropriate specialists or subspecialists. Avera eCARE has more than 30 specialists and subspecialists available on eConsult, she said. Specialty coverage includes infectious disease, pulmonology and cardiology and others, according to Avera eCARE's website.
Costs and benefits
State authorities say it's hard to determine if telehealth is saving South Dakota money on direct health care costs for prisoners because medical spending fluctuates based on the health of inmates and demand for emergency services in a given year. In a service agreement that runs from Nov. 1, 2015, to Oct. 31, South Dakota will pay $157,750 total for eEmergency telehealth visits at the four penitentiaries where this service is available, said Kayla Tinker, South Dakota Department of Health administrator for correctional health services. (That fee includes maintenance by Avera eCARE of the state's prison telehealth equipment.)
Larson said South Dakota has saved on the costs associated with transporting prisoners from penitentiaries to off-site medical care at hospitals. She said since the telehealth program's inception, about 50 percent of transfers for urgent care and specialty consults from the prisons have been avoided for a total cost savings of about $1 million.
Tinker said specialists who see patients through Avera's eConsult charge separately for those consultations. In South Dakota's state prisons, behavioral health services are provided on-site by behavioral health staff.
Prisoners contribute a small co-pay toward their telehealth visits if they are making money through a work release program, Tinker said. Otherwise, they do not have financial obligations for the visits, which are approved by on-site staff at the prison facilities before they occur.
Young said inmates often have more health concerns than others in their age cohort in the outside world. "These guys are harder on their bodies or they haven't been able to care for their bodies as well as maybe some of the general public," Young noted.
Catching and attending to their medical needs early can save money on more complex health care expenses later on, when some of the inmates may be released back to the community.
Larson said Avera eCARE is exploring whether there is a market for its services in South Dakota jails, where the accused are held awaiting trial. Inmates in these situations undergo initial behavioral health and physical assessment. Expansion to additional states is under consideration, she said.