Comprehensive HIV/AIDS Resources and Linkages for Inmates (CHARLI) and Care Coordination (CC) Collaborative. Care Coordination

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1 Comprehensive HIV/AIDS Resources and Linkages for Inmates (CHARLI) and Care Coordination (CC) Collaborative CHARLI CHARLI Contract Monitor Susan Carr HIV Prevention Unit Virginia Department of Health Care Coordination HIV Care Coordinator Misty Johnson HIV Care Services Unit Virginia Department of Health

2 VDH: History of Correctional HIV Programs Seamless Transition Passive Medication Access Program, part of ADAP CHARLI HIV Prevention (state-funded) 2009-present Care Coordination Special Projects of National Significance 2011-present 2

3 CHARLI Infrastructure CHARLI provides a continuum of services for inmates days before release and for returning citizens that are HIV positive. Contract monitor located at Virginia Department of Health s (VDH) central office Five agencies are contracted- each responsible for their health region and work as a CHARLI team HIV/STI education and testing for all inmates HIV positive inmates Pre-release discharge planning Post-release services for 18 months after discharge 3

4 CHARLI Pre and Post Services Include but not limited to: Linkage to: Assistance with : Care Coordination Medical Providers Medication Substance Abuse Services Mental Health Services Housing Transportation Food Stamps Social Services Employment CLEAR-Choosing LIFE! Empowerment Action! Results! 4

5 CC Program Infrastructure Program is co-located and managed by Virginia s AIDS Drug Assistance Program (ADAP) at central VDH office Managed by 3 Care Coordinators (CCs) Bachelors Degree in related field required Experience with local community outreach and HIV/AIDS services preferred CCs are trained in Motivational interviewing As VDH central office staff, CCs utilize statewide ADAP and Ryan White service databases and use tools such as Lexis Nexis and the National Victim Notification Network (VINE) CCs collaborate with local partners working in their communities including CHARLI program, patient navigators, community health workers, etc. 5

6 CC Program Scope The CC ensures uninterrupted access to medications and medical care for HIV positive individuals recently released from incarceration: Correctional facilities provide supply of medications to clients upon release. CC facilitates access to 30-day supply of medications from ADAP Formulary after release CC expedites enrollment into ADAP and facilitates enrollment into the Affordable Care Act CC addresses barriers to care by providing statewide referral and linkages CC coordinates first medication pick up and monitors all subsequent medication pick ups and medical appointments for 12 months 6

7 CHARLI and CC Partners VA Dept Of Corrections VA Regional and Local Jails Community Partners Correction Stakeholders Headquarters Medical Unit Individual Facility Medical Units Re-Entry Specialists Private Medical Contractor Leadership Individual Facility Medical Units Identify Large Jail Authorities Infectious Disease (ID)Clinics Case managers Community Based Organization Eligibility/intake Access Points Local Re Entry Council Committees Probation and Parole 7

8 Customize the Approach Identify Correctional Facility Market both Programs Develop Relationships Create Working Processes Commitment to Meet Client Needs 8

9 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Clients Enrolled in VDH Correctional Interventions* Current Age as of 12/31/2014 Female, 12 % Age at HIV Diagnosis Male, 88% White non- Hispanic, 17% Hispanic, 1% Black non- Hispanic, 80% Transmission Risk Multi-Race or Unknown, 2% Percent of Correctional Intervention Clients (n=111) Male To Male Sexual Contact (MSM) 37% Injection Drug Use (IDU) 21% MSM & IDU 12% Heterosexual Contact 15% No Risk Factor Reported or Identified 15% *Clients are those who were released from a correctional facility from 1/1/2014 to 12/31/2014 and enrolled in the CHARLI and/or Care Coordination intervention(s) during the same timeframe (n=111) 9

10 A Collective Partnership CC CHARLI Improved Health Outcomes 10

11 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% HIV Continuum of Care: Correctional Intervention Clients vs. Virginia PLWH 100% 86% 82% 97% 55% 91% 41% Correctional Intervention Clients Released from 1/01/ /31/2014 Virginia Persons Living with HIV (PLWH) as of 12/31/2014 (N=23,960) 71% 37% 0% Living with HIV Linked to HIV care within 90 days Evidence of a care marker Retained in HIV care Virally suppressed CHARLI and Care Coordination (Correctional Intervention Clients) HIV Continuum of Care (N=111) Linked to HIV care: CHARLI/Care Coordination clients released from 1/01/ /31/2014 who had a care marker within 90 days post-release Evidence of a care marker: Evidence of care (CD4 or viral load lab, HIV medical care visit, or antiretroviral (ART) prescription) in the 12 months post-release Retention and viral suppression: Measures based on 12 months post-release 11 Virginia s 2014 HIV Continuum of Care (N=23,960 as of 12/31/2014) Linked to HIV care: Percent of persons newly diagnosed in Virginia in 2014 (N=924) who were linked to care within 90 days

12 Questions? CC Resources Website: ion/programs/adap/carecoordinationservices.htm 12

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