Continuity of Care During Incarceration

Idaho
Department
of Correction Standard
Operating
Procedure
Title:
Continuity of Care During
Incarceration

1 of 2

401.044
Version:
4
Adopted:
03/11/1999

Kim Brown, Chief of the Division of Management Services, approved this
document and it was published on 09/08/2026.
Open to the public: Yes No
SCOPE
This standard operating procedure (SOP) applies to all Idaho Department of
Correction (IDOC) healthcare services staff, residents, and contract medical
providers.
Version Summary
Version 4: This SOP renumbers previous SOP 401.06.03.044 v3.0. This version
updates terminology and includes specific timeframes for reviewing diagnostic tests
and specialty consultation recommendations.
TABLE OF CONTENTS
Scope ....................................................................................................... 1
Table of Contents ........................................................................................ 1
A. Statutory Authority ................................................................................. 2
B. Board of Correction IDAPA Rule ................................................................. 2
C. Governing Policy Statement ...................................................................... 2
D. Purpose ................................................................................................ 2
E. Responsibility ......................................................................................... 2
F. Definitions .............................................................................................. 3
G. Standard Procedures ............................................................................... 4
1. Clinical Practice .................................................................................. 4
2. Diagnostic Tests ................................................................................. 4
3. Treatment Plans ................................................................................. 4
4. Specialty Consultation ......................................................................... 4
5. Compliance........................................................................................ 5
H. References ............................................................................................ 5

Document
Number:
401.044
4

Title:
Continuity of Care During
Incarceration
Number:
2 of 3

Idaho Department of Correction

A. STATUTORY AUTHORITY
1. Idaho Code § 20-217A, Appointment of Director – Salary – Powers and Duties
2. Idaho Code § 20-244, Government and Discipline of the Correctional Facility –
Rules and Regulations
B. BOARD OF CORRECTION IDAPA RULE
06.01.01.401, Medical Care
C. GOVERNING POLICY STATEMENT
1. It is the policy of IDOC and its contractors to provide proper medical, dental,
psychiatric, and psychological services and treatment to residents incarcerated
under its jurisdiction. All health care must be provided in accordance with the
National Commission on Correctional Health Care (NCCHC) Standards for Health
Services in Prisons.
2. Nothing in this SOP overrides or relieves contract medical providers of any
obligation or responsibility stipulated in their respective contractual
agreements.
D. PURPOSE
To ensure that residents receive health services and follow-up in keeping with
providers’ recommendations, orders and nationally recognized standards that
govern evidence-based practices while providing a continuum of care from intake
to discharge.
E. RESPONSIBILITY
1. Health Services Director
a. Review and approve (prior to implementation) all applicable contract medical
provider owned policies, procedures, and forms.
b. Monitor the contract medical provider’s performance to ensure compliance
with all healthcare-related requirements provided in respective contractual
agreements, this SOP, and in NCCHC standard P-E-12, Continuity of Care
During Incarceration.
2. Contract Medical Provider
a. Implement and practice all provisions of this SOP, unless specifically
exempted by written contractual agreements.
b. Ensure that all aspects of this SOP and NCCHC standard P-E-12 are
addressed by applicable contract medical provider policy and procedure and
are enacted by facility health services administrators.
c. Ensure all applicable contract medical provider owned policy, procedure, and
forms are submitted to the health services director for review and approval
prior to implementation.
Document
Number:
401.044
4

Title:
Continuity of Care During
Incarceration
Number:
3 of 4

Idaho Department of Correction

3. Site Medical Director
a. Establish and monitor processes to ensure that contract clinical staff follow
external medical specialist recommendations, or if a treatment plan is
developed which differs from the external medical specialist
recommendations, sufficient justification for the alternative treatment plan is
documented in the resident’s electronic medical record.
b. Jointly responsible for training staff and establishing contract medical
provider procedures and systems of control to ensure that healthcare
services staff are appropriately trained to perform the duties described in
this SOP.
4. Facility Health Services Administrator
a. Ensure the presence of an adequate number of appropriately trained contract
staff and materials are available to meet the requirements of this SOP.
b. Establish and monitor applicable contract medical provider owned policies
and procedures to ensure that all elements of this SOP and NCCHC standard
P-E-12 are accomplished as required.
c. Ensure that continuous quality improvement recommendations are applied to
continuity of care processes (see SOP 401.006, Continuous Quality
Improvement Program).
d. Jointly responsible for training contract staff and establishing contract
medical provider procedures and systems of control to ensure that contract
healthcare services staff are appropriately trained to perform the duties
described in this SOP.
F. DEFINITIONS
1. Contract Medical Provider: A private company or other entity that is under
contract with the Department to provide comprehensive medical, dental,
and/or mental health services to IDOC’s incarcerated resident population.
2. Correctional Management System (CMS): A digital platform used by
correctional agencies to store, manage, and analyze comprehensive data
about individuals throughout their entire criminal justice process, including
intake, sentencing, incarceration, parole, and probation, allowing for informed
decision-making regarding their supervision and rehabilitation. This includes
systems such as Reflections, CIS, and Atlas.
3. Facility Health Services Administrator: The contract medical provider
employee who is primarily responsible for overseeing the delivery of
contracted medical and behavioral health services in an IDOC correctional
facility.
4. Health Services Director: The IDOC employee primarily responsible for
oversight of auditing and monitoring services provided by the contract
medical vendor.
Document
Number:
401.044
4

Title:
Continuity of Care During
Incarceration
Number:
4 of 5

Idaho Department of Correction

5. Qualified Health Professional: A physician, physician assistant, nurse
practitioner, nurse, dentist, mental health professional, or other health
professional who — by virtue of education, training, credentials, and
experience — is permitted by law (within the scope of professional practice)
to educate, train, evaluate, provide services, and care for patients.
6. Resident: A person who has been convicted of a crime against the laws of
the state and ordered into the care and custody of the Board of Correction.
Resident includes any use in Idaho law, Board of Correction rule, or IDOC
policy or procedure of the terms “offender(s),” “prisoner(s)”, “inmate(s)”,
“incarcerated person(s)”, or any other term referring to a person residing in a
correctional facility in the care and custody of the Board of Correction.
7. Site Medical Director: The highest-ranking contract physician in an IDOC
facility.
G. STANDARD PROCEDURES
1. Clinical Practice
a. Clinician orders must be evidence-based and implemented in a timely
manner.
b. Deviations from standards of practice must be clinically justified,
documented, and shared with the patient.
2. Diagnostic Tests
a. Diagnostic tests must be reviewed by the contract medical provider in a
timely manner, not to exceed seven calendar days.
b. Test results must be shared and discussed with the patient within 72 hours of
receipt of the result excluding weekends and holidays.
3. Treatment Plans
a. Treatment plans must be modified as clinically indicated by diagnostic tests
and treatment results.
b. Treatment plans must be shared and discussed with the patient.
4. Specialty Consultation
a. Recommendations from external medical specialist consultations must be
reviewed and acted upon by the provider in a timely manner.
b. Any changes in specialty treatment recommendations must be clinically
indicated and justification for the alternative treatment plan must be
documented and shared with the patient within 14 days of the decision.
c. Upon return from a specialty consultation, urgent care, emergency
department visit, or hospitalization, the resident must be seen by a qualified
health professional to ensure proper implementation of the discharge orders
and to arrange appropriate follow-up.
Document
Number:
401.044
4

Title:
Continuity of Care During
Incarceration
Number:
5 of 5

Idaho Department of Correction

5. Compliance
Compliance with this SOP and all related IDOC-approved protocols will be
monitored by the health services director (or designee) using this SOP, clinical
practice guidelines, routine reports, planned audits, program reviews, and
record reviews.
H. REFERENCES
1. Cited Documents
a. NCCHC, Standards for Health Services in Prisons, Standard P-E-12,
Continuity and Coordination of Care During Incarceration
b. SOP 401.006, Continuous Quality Improvement Program
– End of Document –