Current through Register Vol. 63, No. 9, September 1, 2024
(1) Health care
procedures will be conducted in a clinically appropriate manner by
appropriately credentialed personnel in an appropriate setting.
(2) Health care and treatment is authorized
and provided according to priorities established by the Health Services Chief
of Medicine and is subject to peer review. The department is not obligated to
carry out any recommendations or treatment plans formulated by any outside
providers if ongoing care is required. Medical care and treatment is generally
prioritized into the following four levels of care and treatment:
(a) Level 1 Care and Treatment (Medically
Mandatory Care and Treatment): Level 1 care and treatment is defined as care
and treatment that is essential to life and health, without which rapid
deterioration may be an expected outcome and where medical or surgical
intervention makes a very significant difference or has a very high
cost-effectiveness.
(A) Level 1 care and
treatment may include, but is not limited to:
(i) Acute problems, potentially fatal, where
treatment prevents death and allows full recovery, (for example, appendectomy
for appendicitis, repair of deep open wound in neck, myocarditis, myocardial
infarction);
(ii) Acute problems,
potentially fatal, where treatment prevents death but does not necessarily
allow for full recovery (for example, burn treatment, treatment for severe head
injuries, myocardial infarction); or
(iii) Maternity care (for example,
monitoring, delivery, hypertension in pregnancy)
(B) Level 1 care and treatment is generally
provided to all AICs by the department. A treating provider may authorize Level
1 care and treatment. In emergency situations, any qualified licensed DOC
health professional may authorize Level 1 care and treatment.
(b) Level 2 Care and Treatment
(Presently Medically Necessary Care and Treatment): Level 2 care and treatment
is defined as care and treatment without which an AIC could not be maintained
without significant risk of either further serious deterioration of the
condition or significant reduction in the chance of possible repair after
release or without significant pain or discomfort.
(A) Level 2 care and treatment may include,
but is not limited to:
(i) Chronic, usually
fatal conditions where treatment improves life span and quality of life, (for
example, medical management of insulin dependent diabetes mellitus, surgical
treatment for treatable cancer of the uterus, medical management of asthma,
hypertension, etc.);
(ii)
Immunizations;
(iii) Comfort care
such as pain management and hospice type care for the end stages of diseases
such as cancer and acquired immunodeficiency syndrome (AIDS);
(iv) Proven effective preventive care for
adults, e.g., preventive dental care, mammograms, pap smears, blood pressure
screenings;
(v) Acute but non-fatal
conditions where treatment causes a return to previous state of health, (for
example, fillings for dental cavities, medical treatment of various infectious
disorders); or
(vi) Acute non-fatal
conditions where treatment allows the best approximation of return to previous
health (for example, reduction of dislocated elbow, repair of corneal
laceration).
(B) Level 2
care and treatment may be provided to AICs and, when not of an emergency
nature, subject to periodic utilization review and appropriateness by the
Health Services Chief of Medicine. A treating practitioner may authorize Level
2 care or treatment.
(c)
Level 3 Care and Treatment (Medically Acceptable or Appropriate but Not
Medically Necessary): Level 3 care and treatment is defined as care and
treatment for non-fatal conditions where treatment or intervention may improve
the quality of life for the AIC.
(A) Level 3
care and treatment may include but is not limited to routine hernia repair,
treatment of non-cancerous skin lesions, corneal transplant for cataract, and
hip replacement.
(B) Level 3 care
and treatment may be authorized on an individual-by-individual basis or on a
case-by-case basis as follows:
(i) Medical or
surgical care and treatment that can be appropriately done on premises in a
routine clinic and that is within the skills of the attending provider may be
offered at the discretion of the treating provider or may be referred by an
attending provider to the Health Services Chief of Medicine for clinical review
under this rule to determine whether to authorize the medical or surgical care
and treatment.
(ii) Other medical
or surgical care and treatment, including offsite procedures and therapies for
chronic diseases may be referred to the Health Services Chief of Medicine for
clinical review under this rule to determine whether to authorize the medical
or surgical care and treatment.
(iii) Care and treatment described in OAR
291-124-0043 (eyeglasses), OAR 291- 124-0044 (hearing aids, and OAR
291-124-0045 (durable medical equipment) may be authorized as provided in those
rules.
(d)
Level 4 Care and Treatment (Of Limited Medical Value): Level 4 care and
treatment is defined as care and treatment that may be valuable to a certain
individual but is significantly less likely to be cost-effective or to produce
substantial long-term gain or improvement.
(A)
Level 4 care and treatment may include care and treatment of minor conditions
where treatment merely speeds recovery, where treatment gives little
improvement in quality of life, offers minimal palliation of symptoms, or is
exclusively for the convenience of the individual. Examples of Level 4 care and
treatment include but is not limited to tattoo removal, minor nasal
reconstruction, oral aphthous ulcers, elective circumcision, care or treatment
for the common cold or infectious mononucleosis, surgery for
gynecomastia.
(B) Level 4 care and
treatment will not be routinely provided. AICs may be eligible to pay for Level
4 care and treatment as provided in OAR
291-124-0085.
(3) Exceptions to
Levels of Care and Treatment: The four Levels of Care and Treatment are general
categories of diagnoses, therapies, or procedures. Depending on the individual
circumstances, the department may consider additional factors in deciding
whether to provide particular care and treatment. Also, there may be
circumstances in which the level of care or treatment for a certain condition
or disorder may be unclear, or in which it may not be appropriate to apply a
specific level of care and treatment. In any case, a provider may refer an
individual case to the Health Services Chief of Medicine for clinical review
under this rule to determine whether to authorize care or treatment.
(4) Clinical Review: Under appropriate
circumstances, individual cases may be referred to the Health Services Chief of
Medicine for clinical review. The Health Services Chief of Medicine may form a
review committee (sometimes referred to as a "Therapeutic Levels of Care
Committee" or "TLC Committee",) which may include one or more department
providers, the Medical Services Manager, and other appropriate Department
staff. The TLC Committee review care and treatment requests on a case-by-case
basis, with the Health Services Chief of Medicine (or designee) as the final
authority in any review. Factors that the TLC Committee may consider include,
but are not limited to:
(a) The urgency of the
care and treatment, and the length of the AIC's remaining sentenced stay.
Whether the care and treatment could be or could not be reasonably delayed
without causing a significant progression, complication, or deterioration of
the condition and would not otherwise be in clear violation of sound medical
principles.
(b) The necessity of
the care or treatment, including:
(A) Any
relevant functional disability and the degree of functional improvement to be
gained;
(B) Medical necessity, or
the overall morbidity and mortality of the condition if left
untreated;
(C) Pre-existing
conditions, whether the condition existed prior to the AIC's incarceration and,
if treatment was not obtained previously, the reasons for not obtaining earlier
treatment;
(D) The probability the
procedure or therapy will have a successful outcome along with relevant
risks;
(E) Alternative therapy or
procedures that may be appropriate;
(F) The AIC's desire for the procedure and
the likelihood of the AIC's cooperation in the treatment efforts;
(G) Any known risks or benefits relative to
those risks;
(H) Any known costs or
benefits relative to those costs;
(I) Pain complaints or pain behaviors;
and
(J) Any other factors that are
relevant or pertinent in light of the circumstances presented.
(c) When considering whether to
provide devices described in OAR 291-124-0043 (eyeglasses), OAR 291-124-0044
(hearing aids), or OAR 291-124-0045 (durable medical equipment), the TLC
Committee shall consider the AIC's ability to engage in activities of daily
living and ability to access programs, services, and activities of the
institution.
(5)
Therapeutic Diets: Therapeutic diets may be ordered by a treating provider for
an AIC with a medical condition requiring nutritional adjustment that is not
obtainable from the regular food services menu. Diets to achieve weight loss
are the responsibility of the individual AIC.
(6) Work Limitations: Health Services will
screen AICs for work limitations at the assignment supervisor's request.
Ongoing daily review of AIC workers for symptoms of illness that would
interfere with the work assignment is the responsibility of the on-site work
supervisor.
Statutory/Other Authority: ORS
179.040,
423.020,
423.030 &
423.075
Statutes/Other Implemented: ORS
179.040,
423.020,
423.030 &
423.075
