Attachment 9 - IGSA Health Delivery System Profile.PDF

CDF Health Delivery System Profile *Proposed Medical Staffing Matrix is required that describes the disciplines, number of FTE/PTE.

EXHIBIT VI – 5

Sample Health Delivery System Profile

Institution Name: Date:

Program Services Offered? Number To Be

Served Daily Yes No I. Medical

A. Basic ambulatory care

1. Intake _ _ ______

2. Sick call ______

3. Medical distribution ______

4. Chronic disease clinics

a. Diabetes ______

b. Hypertension ______

c. Other (list): _______________________________________________ _ _ ______

B. Ancillary services

1. Laboratory _ _ ______

2. Radiology ______

3. Pharmacy ______

4. Other (list): _________________________________________________ _ _ ______

II. Mental Health A. Basic care

1. Intake _ _ ______

2. Postadmission evaluation ______

3. Counseling

a. Individual ______

b. Group ______

4. Other therapies

a. Recreational ______

b. Occupational ______

c. Other (list): _______________________________________________ _ _ ______

5. Special programs

a. PREA ______

b. Crisis intervention ______

c. Suicide prevention _ _ ______

B. Psychiatric consultation _ _ ______

C. Infirmary care

1. Acute (# of beds_______) _ _ ______

2. Extended (# of beds_______) ______

3. Negative pressure (# of beds_______) ______

EXHIBIT VI – 5 (continued) Sample Health Delivery System Profile

Program Services Offered? Number To Be

Served Daily Yes No III. Dental

A. Basic care

1. Intake _ _ ______

2. Repair and maintenance (e.g. fillings) ______

3. Prevention ______

4. Prophylaxis ______

5. Prostheses ______

6. X ray ______

7. Lab _ _ ______

IV. Other A. General administration _ _ ______ B. Quality assurance ______ C. Health education ______ D. In-service training ______ E. Housekeeping ______ F. Medical records: electronic or paper _ _ ______

V. Custody A. Basic security _ _ ______

B. Escort (in-house)

1. Patients _ _ ______

2. Staff _ _ ______

C. Transport (outside) _ _ ______

EXHIBIT VI – 6

Sample Facility Profile

Institution Name: Date:

I. General statistics (use most recent data or projections) What is the maximum capacity of the facility: _____________

A. Average daily population (ADP) ______ B. Total annual population ______ C. Average length of stay (LOS) ______ D. LOS breakdowns (n or %)

< 1 month ______ 1 - 2 years ______ 1 - 3 months ______ 3 - 5 years ______ 4 - 6 months ______ 6 - 10 years ______ 7 - 12 months ______ > 10 years ______

E. Custody class (n or %) Minimum ______ Maximum ______ Medium ______ Close ______

F. Housing status (n or %) General population ______ Special medical/mental health housing ______ Protective custody ______ Administrative segregation ______ Disciplinary segregation ______ Other (list): ___________________________________________________ ______

II. Population characteristics A. Gender (n or %)

Male ______ Female ______ B. Age (n or %)

< 18 ______ 41 - 60 ______ 18 - 25 ______ 61 - 75 ______ 26 - 40 ______ > 75 ______

III. Special considerations A. Identify any security regulations that affect the delivery of health services (e.g., “administrative segregation inmates may be moved only one at a time” or “disciplinary segregation inmates may be moved only one at a time and require two officers to escort”).

B. Identify all decentralized health services (i.e., those provided in inmate housing areas rather than the health services unit);

for example, “all medication distributed cellside” or “medication distributed cellside for all segregated inmates”, etc.

CDF Proposed Staffing Matrix for Name of Facility

Position Filled Vacant Shift 1 Shift 2 Shift 3 Total

LPN/LVN

Psychologist Social Worker Physician Assistant Nurse Practitioner

MRT

Physician Assistant Nurse Manager Physician Psychiatrist

RN

Pharmacist Pharmacy Tech X-ray Tech Dental Assistant Dentist Total

*Based on a # bed capacity all Male/Female/Juvenile

• Complete with only proposed applicable staff required

• If there are comparable disciplines not listed on the staffing matrix please edit accordingly.