How to Build or Expand an HIV Jail Linkage Program


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The goal of Integrating HIV Innovative Practices (IHIP) is to enable health care providers to implement proven innovations within their own practices and clinics. This Webinar is the second in a three part series featuring grantees of the Health Resources and Services Administration’s Special Projects of National Significance (SPNS) initiative on Jail Linkages, as they share lessons learned and advice for others hoping to create or expand similar programs.

Learn how to build a new jail linkage program and what to consider for expanding an existing one. Jail Linkages SPNS grantees—including Dr. Timothy Flanigan of Miriam Hospital, Alison Jordan of New York City Department of Health and Mental Hygiene, and Dr. Ann Avery of Care Alliance Health Center describe the steps their programs took to implement their respective jail linkage programs, and provide advice for others hoping to replicate this work.

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How to Build or Expand an HIV Jail Linkage Program

  1. 1. How to Build and Expand a Jail Linkage Program September 27, 2013
  2. 2. Agenda  Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project  Sarah Cook-Raymond, Impact Marketing + Communications  Presentations    from Dr. Anne Avery, The Atlas Program Dr. Timothy Flanigan, Alpert Medical School of Brown University/The Miriam Hospital Alison Jordan, New York City Department of Health and Mental Hygiene, Correctional Health Services/Transitional Health Care Coordination Q &A
  3. 3. IHIP Resources on TARGET Center Website
  4. 4. IHIP Jail Linkage Resources:  Lessons Learned Manual  Implementation Guide  Webinar Series  HIV and Jails: A Public Health Opportunity – archive recording available at  How to Build and Expand a Jail Linkage Program – September 27, 2013 at 12pm ET  Creating Partnerships and Navigating the “Culture of Corrections”- October 3, 2013 at 2pm ET
  5. 5. Other IHIP Resources  Buprenorphine  Training Manual, Curricula, and Webinars on Implementing Buprenorphine into Primary Care Settings  Engaging Hard-to-Reach Populations  Training Manual, Curricula, and Webinars on Engaging Hard-to-Reach Populations  Oral Health  Forthcoming: Training Manual, Curricula, and Webinars on Oral Health and HIV
  6. 6. HIV Testing and Linkage to care in a Jail Setting: Establishing a Successful Program THE ATLAS PROGRAM ASSESS, TEST, LINK: ACHIEVE SUCCESS CLEVELAND, OHIO Ann K Avery, MD
  7. 7. Background: Care Alliance  Federally Qualified Health Center (FQHC)  Primary populations: Homeless  Public Housing  HIV/AIDS  Uninsured/Underinsured  Services:  Primary Health Care for All Ages  Comprehensive Dental Care  Substance Abuse & Mental Health Counseling  Confidential HIV Testing, Treatment & Counseling  2007: 7,500 Patients through over 25,000 Encounters 
  8. 8. Establishing the Program  Received SPNS Grant to establish rapid HIV testing and linkage case management program in the Cuyahoga County Corrections Center.  Brand new program-no other program has presence in the jail related to HIV testing in Cleveland.   Testing was only done in the Corrections Center when court ordered or requested by inmate. In 2007: 386 tests were done by medical staff with 9 positives identified.  Initial Goal: Establish relationship with the Corrections Center.
  9. 9. Goals  Introduce voluntary HIV rapid testing into Cuyahoga County Corrections Center Attach an evaluation component to learn about risk behaviors and HIV knowledge of all inmates  Create jail based; linkage/case management program for HIV + inmates
  10. 10. Establishing the Program  Met with Corrections Center staff to discuss testing program       Need within jail for testing Rules and regulations Staff access to inmates Areas of jail to conduct testing Office space within jail Protocols for testing and medical care follow up  Focus on the benefits to the jail
  11. 11. Implementation      Buy in from jail administration-very supportive and accepting of this project Obtained space in jail-our staff have their own office Hiring personnel Gaining access to jail for staff-all have contractors passes for easy access in and out of jail and to inmates Bringing in all testing and office supplies
  12. 12. Establishing Community Partnerships  Contacted local medical clinics, ASOs, Ryan White Planning groups, and the Cleveland Department of Public Health for support   Opened referral system for medical care and community social services for inmates identified as positive Established resource support from Department of Public Health   Test kits Received support from Ryan White planning groups  Ryan White Part A, Part B, Part C, Case Management Network
  13. 13. ATLAS Program (Assess, Test, Link: Achieve Success)  Program Components  Rapid HIV Testing  Voluntary Rapid Testing Linkage Case Management  Jail based case management  Community Follow Up  Mental Health/Substance Abuse Counseling   Funded by National AIDS Fund  Individual Counseling  Community Linkage
  14. 14. Key Community Partners  Jail Staff  Community Medical Providers  Social Workers/Case Managers  Treatment Providers  Community Planning Councils
  15. 15. Best Practices of Community Networking  Be a familiar face  Be a voice at the table for planning activities  Maintain open and frequent communication  Focus on continuity of care
  16. 16. Time in jail is unpredictable
  17. 17. Barriers/Challenges  Front line jail staff’s attitude towards HIV: stigma  Access to men and women is different-easier to access men  Contraband-broad definition in jail setting, i.e.-no cell phones, cannot walk freely through jail with lancets-program supplies may not be appropriate
  18. 18. Lessons Learned  Offer Educational Opportunities for front line jail staff: through workshops and personal teaching moments  Flexibility/Creativity is Key: adapting to jail environment but still providing quality services; seeking out alternative resources for testingincluding oral swab rapid tests to easily walk through jail; creating new protocols to access female inmates regularly for testing
  19. 19. Ongoing Support  Ryan White Funding  Foundations  City/ County resources  Public health  Local government  Jails  Correctional resources  Local, state and national
  21. 21. The Landscape in Rhode Island  Rhode Island Department of Corrections (RIDOC)  single unified system: jail and prison serving the entire state Intake Service Center (jail) High Security Maximum Security Medium Security Minimum Security Women’s Facilities
  22. 22. The Landscape in Rhode Island  RIDOC and Brown University have worked together for almost 25 years  Continuum of staff providing HIV services in the correctional facility and in the community  HIV testing program in effect since 1989  Sharp decreases in the numbers of persons newly diagnosed with HIV at RIDOC Over a decade ago, 30% of all positive HIV tests in RI were from RIDOC (AIDS Educ Prev 2002; 14: 45-52)  In recent years, approximately 10 new cases a year have been identified at RIDOC   Opt-out testing has been in place, though routine testing would be optimal!
  23. 23. Project Bridge  Project Bridge has served HIV-infected persons leaving the RIDOC for almost 15 years  Using a social work model, the program provided prison outreach and intensive case management to HIV-positive prisoners being released from the RIDOC facilities to facilitate community re-entry and retention in medical care.  Project Bridge team:    engages clients within three months of prison release creates a discharge plan that links clients to medical care at provider of their choice and social services following release provides supportive services to retain clients in care
  24. 24. COMPASS expanded Project Bridge  Challenges related to the provision of services for shorter-term jail detainees  Short and unpredictable lengths of stay, high rates of turnover, and recidivism  Risky population The overarching goals of COMPASS:  To enhance existing services through the implementation of:  a jail-release program of jail-based case mangers and communitybased case managers combined with intensive community outreach  In order to lead to:  improved HIV treatment, substance abuse and social stabilization outcomes for recently released HIV+ jail detainees
  25. 25. COMPASS services provided (jail)  Jail-based encounters   81% of participants received at least one service encounter from jail-based project staff while incarcerated [median 1 (range: 1-35)] Most common services provided:
  26. 26. COMPASS services provided (community)  Community-based encounters  Participants  50 40 30 20 10 0 74% of participants received at least one service encounter from community-based project staff after release median 16.5 (range: 1-130)] Most common services provided: 45 45 40 36 Set up Set up Individual Set up appointments or appointments or counseling/support appointments or equivalent equivalent session equivalent substantive contact substantive contact substantive contact with social services with other provider with other health provider care provider
  27. 27. Linkage to care  Linkage to HIV care was documented for 52% of participants enrolled (broadly defined by self-report, any documented visit with health care provider, or documented PVL/CD4 test in community)  Mean/median days to care after release: 36/24 (range: 2-164) 35% linked within 30 days  14% linked between 31-90 days  6% linked between 91-180 days   Those linked to care within 6 months of release were significantly more likely to have reported a usual health care provider or place where s/he got HIV care at baseline (p=0.01)
  28. 28. General findings  Services inside the jail, such as HIV education and discharge planning, can make a difference  Experience over time also shows value of community-based intervention during the transition period  Engagement in care and viral suppression are possible but interventions may require more than a “one-size-fits-all” approach  Remember the importance of not “overpromising” services – be realistic
  29. 29. Enhancing Jail to Community Linkages: NYC Lessons Learned Alison O. Jordan, LCSW Executive Director New York City Department of Health and Mental Hygiene, Correctional Health Services / Transitional Health Care Coordination Rikers Island, NY
  30. 30. RIKERS ISLAND Vernon C. Bain Center, Bronx Brooklyn Detention Center Manhattan Detention Center Transitional Health Care Coordination
  31. 31. Jail Discharges to NYC Communities by Zip Code and Socioeconomic Status 2004 Over 70% of those released from NYC jails to the community return to the areas of greatest socioeconomic and health disparities. Correctional Health is Public Health
  32. 32. Background The NYC jail system is the 2nd largest in the country with 12 NYC Department of Correction (DOC) facilities • 85,000 new admissions • ADP: 12,300 (most pre-trial detainees) • Average length of stay: 32 days (median closer to 8) The NYC DOHMH Correctional Health Services (CHS) coordinates all medical, mental health and discharge planning • Over 78,000 monthly medical visits • Discharge Planning – Population-based for mentally ill (13k); HIV-infected (2.5k); others at high risk (1.5k) • All jails use electronic health record
  33. 33. Continuum of Care Model Transitional Care Coordination • Opt-in Universal Rapid HIV Testing • Primary HIV care and treatment including appropriate ARVs • Treatment adherence counseling • Health education and risk reduction Jail-based Services • • • • • Discharge Planning starting on Day 2 of incarceration Health Insurance Assistance / ADAP Health information / liaison to Courts Discharge medications Patient Navigation: accompaniment, home visits, transport, and re-engagement in care • Linkages to primary care, substance abuse and mental health treatment upon release Community-based Services • • • • • • • • HIV Primary Care Medical Case Management Health promotion Patient Navigation: accompaniment, home visits, and re-engagement in care Linkages to Care Treatment adherence and Directly Observed Therapy (DOT), as needed Housing assistance and placement Health Insurance Assistance / ADAP
  34. 34. Facilitate “Warm Transitions” a social work approach to public health interventions to facilitate access to care Client Level: • Begin Where the Client is; harm reduction model. • Plan for both options: Stay or Go; treat each session as last Program Level: Expect the Unexpected • Train staff: Motivational Interviewing & stages of engagement in care •Hire those who care & – Meet DOC requirements (i.e. no longer on parole, no new charges 3+ yrs) – Demonstrate cultural competency and understanding of CJ impact – Ability to communicate in clients’ primary language when possible Health Liaison to the Courts Systems Level: • Track outcomes (i.e. post-release linkage to care and 90d follow up) • Arrange transitional services (i.e. discharge medication, after care letter, medical summary / lab reports, transportation, and accompaniment) • Ask community health clinics to set aside walk-in hours
  35. 35. Systemic Barriers • Solutions Challenges Short-term stays are norm • Intake History and PE • • • universal voluntary < 24 hrs • ongoing offer thereafter ~25% leave in 2-3 days ~50% leave within 7 days • Limited time to diagnose • Work from self-reports • Multiple providers • Single oversight • Limited time to start treatment, maintain care • Discharge plan asap • Paper records • Electronic Health Records • Post-release tracking • • engage in housing areas • transport / accompaniment Health Information Exchange removing barriers
  36. 36. Critical Skills Community-Based Organizations Probation Parole Health Dept. Courts Staff Corrections Funders
  37. 37. Establishing Relationships At All Levels: • • • • • • Greet with a smile and a handshake Listen first; then ask Key Questions – How do things work now? What do you need? Can you help me? – Be clear and set realistic, measurable & achievable goals Begin where you can Align expectations with abilities Build trust – Start with winnable battles – Need to share at least 5 positive messages before 1 negative one can be received – Set everyone up to succeed – Set clear expectations and deliver Expect to give more than you receive Within the Correctional System: •Know the Chain of Command – Informal and formal roles – Identify a Champion – Work with those interested •Shared benefits (programs lead to reduced violence, improved security) •Acknowledge additional work for Correctional staff (escort / transport, ensuring your staff’s safety) •Demonstrate that you’re accessible – Visit often; be a familiar face • Know who to approach for: – Jail access and security training – Space in jails to interview clients
  38. 38. Maintaining Partnerships On going communication is essential • Arrange and participate in activities with both corrections and community partners – – – – • • • brown-bag lunches and picnics orientation sessions and Training sessions employee recognition events health and wellness events Offer to provide information sessions during roll call Rotate meeting locations Site Visits: Have jail-based staff visit community locations Lessons Learned: • Don’t shy away from hard work. The biggest skeptic may become your biggest supporter. • Listen to others already doing this work – they know how to navigate the system without interfering with Corrections operations/orders. • Don’t underestimate the power of saying “thank you”. • Word travels fast -- If people have positive (or negative) experiences working with you, others will hear.
  39. 39. Project Enhancements • Improve acceptance of follow up rapid HIV testing – Acceptance rate increased from 30% to 60% • Integrate Court / Parole advocacy – Release rate increased by 20% • Post-release follow-up / tracking – Over 100 followed for 12 months post-release • Integrate with new EHR – eClinical Works correctional system live in all jails – Case management templates implemented 5/13
  40. 40. Program Outcomes 2008-2012 3000 89% n=17,010 self-reported HIV-positive admissions to NYC jails (2008-2012) 91% 2500 2008 2009 78% 2000 2010 2011 2012 74% 1500 1000 500 0 Offered a Plan Received a Plan 2,700 Released with a Plan 2,456 1,910 Linkage to Primary Care 1,420
  41. 41. Linkages Evaluation Outcomes Averages for 249 with 6 month post-release Jail Linkages follow up/clinical review: Client Level Outcomes • Improvements shown by increased CD4 count (372 to 419) • More taking medication (from 62% to 98%) • Fewer report hunger (from 20.5% to 1.75%) • Overall health and mental health improved (SF-12 PCS from 47.9 to 50.4; SF-12 MCS from 44.8 to 47.5) Program Impact Saving lives Saving money • Treatment adherence improved (from 86% to 95%) • Improved viral Load (from 52,313 to 14,044) • Increased proportion with undetectable vL (<48) from 11% to 22% Systems Implications • Fewer homeless in month prior: from 23% to 4.5% • Fewer Emergency Department visits: from .61 to .19
  42. 42. Continuing Enhancements • • • • • • • • • Working w/ NYS Links to enhance and replicate program Preliminary discussions with SNPs to improve access Linkage agreements / Memorandum of Understanding SAMHSA ORP pilot collaborations Bronx Health and Housing Consortium participation Health Liaisons to the Courts Criminal Justice and Health Home workgroup Bronx Health Home pilot SPNS Latino Populations
  43. 43. Contact Us • Alison O. Jordan, Principal Investigator 917-748-6145 • Paul A. Teixeira, Evaluator 347-774-7174 • Jacqueline Cruzado-Quinones, Project Coordinator 917-715-6841
  44. 44. Next steps  Expansion of this model can have broader impacts Project Bridge and COMPASS have merged to be a single program  Coming Home program at St. Luke’s Hospital - medical and supportive services for individuals returning from prison/jail and have any chronic disease(s), provided by formerly incarcerated staff and peers.  Evidence that risk behaviors decreased among hepatitis C infected persons with linkage to care  Other IHIP resources are available online at:  Creating a Jail Linkage Program  Engaging Hard-to-Reach Populations  Integration of Buprenorphine into HIV Primary Care Settings 
  45. 45. Q&A To be informed when these upcoming IHIP resources are ready, sign up for the IHIP listserv by emailing Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications | Twitter: @impactmc1| Facebook: ImpactMarCom | | 202-588-0300