2016 Houston HIV Care Services Needs Assessment 4

Transcription

1 Early Intervention Services Pg Service Category Definition State Services Hoston HIV Care Services Needs Assessment Early Intervention Services 4 Early Intervention Services Chart Review - The Resorce Grop, Transitional Care Coordination From Jail Intake to Commnity HIV Primary Care - TARGET Center, Dissemination of Evidence-Informed Interventions 12 Models for Improving Linkage to Care for People Living with HIV Released from Jail or Prison - The National Center for Innovation in HIV Care, In Prison, Women are 9 Times More Likely to be HIV Positive - thenation.com, November

2 1 of 47 Service Category Definition - DSHS State Services September 1, Agst 31, 2018 Local Service Category: Amont Available: Unit Cost Bdget Reqirements or Restrictions (TRG Only): DSHS Service Category Definition: Local Service Category Definition: Target Poplation (age, gender, geographic, race, ethnicity, etc.): Services to be Provided: Service Unit Definition(s) (TRG Only): Financial Eligibility: Client Eligibility: Agency Reqirements (TRG Only): Early Intervention Services Incarcerated To be determined Maximm 10% of bdget for Administrative Cost. No direct medical costs may be billed to this grant. Spport of Early Intervention Services (EIS) that inclde identification of individals at points of entry and access to services and provision of: HIV Testing and Targeted conseling Referral services Linkage to care Health edcation and literacy training that enable clients to navigate the HIV system of care These services mst focs on expanding key points of entry and docmented tracking of referrals. Conseling, testing, and referral activities are designed to bring people living with HIV into Otpatient Amblatory Medical Care. The goal of EIS is to decrease the nmber of nderserved individals with HIV/AIDS by increasing access to care. EIS also provides the added benefit of edcating and motivating clients on the importance and benefits of getting into care. This service incldes the connection of incarcerated in the Harris Conty Jail into medical care, the coordination of their medical care while incarcerated, and the transition of their care from Harris Conty Jail to the commnity. Services mst inclde: assessment of the client, provision of client edcation regarding disease and treatment, edcation and skills bilding to increase client s health literacy, establishment of THMP/ADAP post-release eligibility (as applicable), care coordination with medical resorces within the jail, care coordination with service providers otside the jail, and discharge planning. Services are for people living with HIV incarcerated in The Harris Conty Jail. Services inclde bt are not limited to CPCDMS registration/pdate, assessment, provision of client edcation, coordination of medical care services provided while incarcerated, medication regimen transition, mltidisciplinary team review, discharge planning, and referral to commnity resorces. One nit of service is defined as 15 mintes of direct client services or coordination of care on behalf of client. De to incarceration, no income or residency docmentation is reqired. People living with HIV incarcerated in the Harris Conty Jail. As applicable. the agency s facility(s) shall be appropriately licensed or certified as reqired by Texas Department of State Health Services, for the provision of HIV Early Intervention Services, inclding phlebotomy services.

3 2 of 47 Staff Reqirements: Special Reqirements (TRG Only): Agency/staff will establish memoranda of nderstanding (MOUs) with key points of entry into care to facilitate access to care for those who are identified by testing in HCJ. Agency mst execte Memoranda of Understanding with Ryan White fnded Otpatient Amblatory Medical Care providers. The Administrative Agency mst be notified in writing if any OAMC providers refse to execte an MOU. Not Applicable. Mst comply with the Hoston EMA/HSDA Standards of Care. The agency mst comply with the DSHS Early Intervention Services Standards of Care. The agency mst have policies and procedres in place that comply with the standards prior to delivery of the service.

4 3 of 47 FY 2019 RWPC How to Best Meet the Need Decision Process Step in Process: Concil Recommendations: Approved: Y No: Approved With Changes: Date: 06/14/18 If approved with changes list changes below: Step in Process: Steering Committee Recommendations: 1. Approved: Y No: Approved With Changes: Date: 06/07/18 If approved with changes list changes below: Step in Process: Qality Improvement Committee Recommendations: Approved: Y No: Approved With Changes: Date: 05/15/18 If approved with changes list changes below: Step in Process: HTBMN Workgrop Recommendations: Financial Eligibility: Date: 04/25/

5 EARLY INTERVENTION (JAIL ONLY) Early intervention services (EIS) refers to the provision of HIV testing, conseling, and referral in the Ryan White HIV/AIDS Program setting. In the Hoston Area, the Ryan White HIV/AIDS Program fnds EIS to persons living with HIV (PLWH) who are incarcerated in the Harris Conty Jail. Services focs on post-incarceration care coordination to ensre continity of primary care and medication adherence post-release. (Graph 1) In the 2014 Hoston Area HIV needs assessment, 7% of participants indicated a need for early intervention services in the past 12 months. 6% reported the service was easy to access, and 1% reported difficlty. 11% stated that they did not know the service was available. (Table 1) When barriers to early intervention services were reported, the most common barrier type was accessibility (40%). Accessibility barriers reported inclde release from incarceration. GRAPH 1-Early Intervention (Jail Only), % 80% 70% 60% 50% 40% 30% 20% 10% 0% 11% Did not know abot service 82% Did not need service 6% Needed the service, easy to access 1% Needed the service, difficlt to access 4 of 47 TABLE 1-Top 4 Reported Barrier Types for Early Intervention (Jail Only), 2016 No. % 1. Accessibility (AC) 2 40% 2. Interactions with Staff (S) 1 20% 3. Resorce Availability (R) 1 20% 4. Transportation (T) 1 20% (Table 2 and Table 3) Need and access to services can be analyzed for needs assessment participants according to demographic and other characteristics, revealing the presence of any potential disparities in access to services. For early intervention services, this analysis shows the following: More males than females fond the service accessible. More other/mltiracial PLWH fond the service accessible than other race/ethnicities. More PLWH age 25 to 49 fond the service accessible than other age grops. In addition, more recently release and nstably hosed PLWH fond the service difficlt to access when compared to all participants. TABLE 2-Early Intervention (Jail Only), by Demographic Categories, 2016 Sex Race/ethnicity Age Experience with the Service Male Female White Black Hispanic Other Did not know abot service 12% 8% 13% 13% 7% 14% 4% 15% 7% Did not need service 81% 86% 86% 80% 88% 43% 96% 77% 88% Needed, easy to access 6% 5% 1% 6% 5% 43% 0% 6% 5% Needed, difficlt to access 1% 2% 0% 2% 0% 0% 0% 1% 1% TABLE 3-Early Intervention (Jail Only), by Selected Special Poplations, 2016 Experience with the Service Unstably Ot of Hosed a MSM b Care c Recently Released d Rral e Transgender f Did not know abot service 11% 12% 0% 26% 0% 9% Did not need service 78% 82% 100% 26% 97% 86% Needed, easy to access 9% 6% 0% 42% 3% 5% Needed, difficlt to access 2% 1% 0% 5% 0% 0% a Persons reporting hosing instability b Men who have sex with men c Persons with no evidence of HIV care for 12 mo. d Persons released from incarceration in the past 12 mo. e Non-Hoston/Harris Conty residents f Persons with discordant sex assigned at birth and crrent gender Page 59

6 EARLY INTERVENTION SERVICES - INCARCERATED 2017 CHART REVIEW REPORT 5 of 47

7 6 of 47 PREFACE DSHS Monitoring Reqirements The Texas Department of State Health Services (DSHS) contracts with The Hoston Regional HIV/AIDS Resorce Grop, Inc. (TRG) to ensre that Ryan White Part B and State of Texas HIV Services fnding is tilized to provide in accordance to negotiated Priorities and Allocations for the designated Health Service Delivery Area (HSDA). In Hoston, the HDSA is a ten-conty area inclding the following conties: Astin, Chambers, Colorado, Fort Bend, Harris, Liberty, Montgomery, Walker, Waller, and Wharton. As part of its General Provisions for Grant Agreements, DSHS also reqires that TRG ensres that all Sbgrantees comply with stattes and rles, perform client financial assessments, and delivery service in a manner consistent with established protocols and standards. As part of those reqirements, TRG is reqired to perform annal qality compliance reviews on all Sbgrantees. Qality Compliance Reviews focs on isses of administrative, clinical, consmer involvement, data management, fiscal, programmatic, and qality management natre. Administrative review examines Sbgrantee operating systems inclding, bt not limited to, nondiscrimination, personnel management and Board of Directors. Clinical review incldes review of clinical service provision in the framework of established protocols, procedres, standards and gidelines. Consmer involvement review examines the Sbgrantee s frame work for gather client feedback and resolving client problems. Data management review examines the Sbgrantee s collection of reqired data elements, service enconter data, and spporting docmentation. Fiscal review examines the docmentation to spport billed nits as well as the Sbgrantee s fiscal management and control systems. Programmatic review examines nonclinical service provision in the framework of established protocols, procedres, standards and gidelines. Qality management review ensres that each Sbgrantee has systems in place to address the mandate for a continos qality management program. In 2016, DSHS contracted with Germane Soltions to perform chart reviews of specific service categories. These chart reviews change from year-to-year and are determined at the beginning of each calendar year. TRG does not dplicate the chart reviews if a review was condcted Germane Soltions. Therefore, the chart review report for 2017 reslted in no chart review reslts. TRG will resme the monitoring process in However, to assist in the qality analysis of the EIS services, the 2016 data is presented below. QM Component of Monitoring As a reslt of qality compliance reviews, the Sbgrantee receives a list of findings that mst be address. The Sbgrantee is reqired to sbmit an improvement plan to bring each finding into compliance. This plan is monitored as part of the Sbgrantee s overall qality management monitoring. Additional follow-p reviews may occr (depending on the natre of the finding) to ensre that the improvement plan is being effectively implemented. Scope of Fnding TRG contracts with one Sbgrantee to provide Early Intervention Services in the Hoston HSDA.

8 7 of 47 INTRODUCTION Description of Service Early Intervention Services-Incarceration (EIS) incldes the connection of incarcerated in the Harris Conty Jail into medical care, the coordination of their medical care while incarcerated, and the transition of their care from Harris Conty Jail to the commnity. Services mst inclde: assessment of the client, provision of client edcation regarding disease and treatment, edcation and skills bilding to increase client s health literacy, establishment of THMP/ADAP postrelease eligibility (as applicable), care coordination with medical resorces within the jail, care coordination with service providers otside the jail, and discharge planning. Tool Development The Early Intervention Services review tool is based pon the established local standards of care. Chart Review Process The collected data for each site was recorded directly into a preformatted compterized database. The data collected dring this process is to be sed for service improvement. File Sample Selection Process Using the ARIES database a file sample was created from a provider poplation of 927 who accessed Early Intervention Services in the measrement year. The records of 59 clients were reviewed (representing 6% of the ndplicated poplation). The demographic makep of the provider was sed as a key to file sample pll. NOTE: DSHS has changed the file sample percentage which will reslt in a lower nmber of files being reviewed in 2016.

9 8 of 47 Demographics-Early Intervention Services 2015 Annal 2016 Annal Total UDC: 871 Total New: 293 Total UDC: 927 Total New: 279 Age Nmber of % of Nmber of % of Age Clients Total Clients Total Client's age as of the end of the reporting period Client's age as of the end of the reporting period Less than 2 Less than % years years % years % years % years % years % years % years % years % years % 65 years or 65 years or % older older % Unknown % Unknown % % % Gender Nmber of % of Nmber of % of Gender Clients Total Clients Total "Other" and "Refsed" are conted as "Unknown" "Other" and "Refsed" are conted as "Unknown" Female % Female % Male % Male % Transgender Transgender % FTM FTM % Transgender Transgender % MTF MTF % Unknown % Unknown % % % Race/ Ethnicity Nmber of Clients % of Total Race/ Ethnicity Nmber of Clients % of Total Incldes Mlti-Racial Clients Incldes Mlti-Racial Clients White % White % Black % Black % Hispanic % Hispanic % Asian % Asian % Hawaiian/Pac Hawaiian/Pac % ific Islander ific Islander % Indian/Alaska Indian/Alaska % n Native n Native % Unknown % Unknown % % % From 01/01/15-12/31/15 From 01/01/16-12/31/16

10 9 of 47 RESULTS OF REVIEW Intake Assessment Percentage of HIV-positive clients who had a completed intake assessment present in the client record. Yes No N/A Nmber of client with a completed intake assessment in the client record. Nmber of HIV-infected clients in early intervention services that were reviewed. Rate 98% 2% - Intake Assessment Percentage of HIV-positive clients that self-reports being in care (attending a medical appointment) in the last 6 months prior to incarceration. Yes No Unknown N/A (New Dx) Nmber of client with a completed intake assessment in the client record. Nmber of HIV-infected clients in early intervention services that were reviewed Rate 75% 19% 6% - Health Literacy and Edcation: Risk Assessment Percentage of HIV-positive clients that had docmentation of the client being assessed for risk and provided targeted health literacy and edcation in the client record (inclding receipt of a ble book). Yes No Partial N/A (ble book only) Nmber of client records that docmented health literacy and edcation. Nmber of HIV-infected clients in early intervention services that were reviewed. Rate 70% 7% 22% - Health Literacy and Edcation: Medication Adherence Percentage of HIV-positive clients who had docmentation of discssion of medication adherence by the EIS case manager in the client record. Nmber of client records who had docmentation of discssion of medication adherence by the EIS case manager in the client record Nmber of HIV-infected clients in early intervention services that were reviewed. Yes No N/A Rate 63% 37% -

11 10 of 47 Linkage: Newly Diagnosed Percentage of newly-diagnosed clients (incarcerated 30 days or longer) that initiate care throgh the EIS program Yes No N/A Nmber of newly-diagnosed clients (incarcerated days or longer) that initiate care throgh the EIS program Nmber of newly-diagnosed HIV-infected clients in early intervention services that were reviewed. Rate 100.0% 0.0% - Linkage: Medical Care Percentage of HIV-positive clients that accessed a medical provider and obtained an appointment. Yes No N/A Nmber of client records that docment linkage to a medical provider and access to an appointment Nmber of HIV-infected clients in early intervention services that were reviewed. Rate 100.0% 0.0% - Mltidisciplinary Team Conference Percentage of HIV-positive clients who received early intervention services that had at least one mltidisciplinary team conference Yes No N/A Nmber of client records that showed evidence of at least one mltidisciplinary team conference. Nmber of HIV-infected clients in early intervention services that were reviewed. Rate 0% 100.0% 7% Discharge Planning Percentage of HIV-positive clients who had a discharge plan present in the client record. Yes No N/A Nmber of client with a completed discharge plan in the client record. Nmber of HIV-infected clients in early intervention services that were reviewed. Rate 81% 19% 8%

12 11 of 47 Insrance Stats Clients self-reported insrance stats at program entry. Insrance Stats Private Medicaid Medicare Gold Card Medicare/Medicaid VA Uninsred/None Reported 2% 17% 49% 4% 22% 3% 3% HISTORICAL DATA Not applicable for 2016 Chart Review as this is the first time this service category has been presented. CONCLUSIONS Overall, qality of services is good. Throgh the chart review: 98% (56) of clients completed an intake assessment and 81% (44) developed a discharge plan. Of the clients enrolled into the EIS program 100% were linked accessed a care provider; with 100% (6) of the newly-diagnosed clients accessing care. However, only 50% (3) of the newly-diagnosed clients docmented a discharge plan. 75% (40) of clients self-reported accessing medical care within the last six months of entering the EIS program and 51% (30) reported a third-party payer sorce (inclding the HCHD Gold Card)

13 Transitional Care Coordination From Jail Intake to Commnity HIV Primary Care 12 of 47 Intervention Smmary HIV Care Continm LINKAGE Collaborations between pblic health agencies, commnity-based TO CARE organizations, and jail health services have implications for pblic health and safety efforts and have been proven to facilitate linkage to care after incarceration. 1 Medical screenings that happen for all inmates throgh the jail intake process offer an opportnity to implement sch interventions, as do booking processes and intervention intake. 2,3,4 Jordan et al., introdce the concept of Warm Transitions as an integral part of implementing their HIV Continm of Care Model by applying social work tenets to pblic health activities for those with chronic health conditions inclding HIV-infection. 5 Absent a caring and spportive warm transition approach, pre-existing barriers to care and other stressors that come with the experience of incarceration and cycling in and ot of correctional facilities will contine or be exacerbated after incarceration. 6 Withot transition assistance, people living with HIV who are released from jails are at risk of nstable hosing; lack of access to health insrance and medication; overdose de to period of detoxification; exacerbation of mental health conditions de to increased stress; and lack of social spports, when exposed to the same high risk commnities from which they were incarcerated. 7 This intervention is intended for organizations, agencies, and individals considering strengthening connections between commnity and jail health care systems to improve continity of care for HIV-positive individals recently released from jails. The following information is meant to provide an overview of the Transitional Care Coordination intervention to implement a new linkage program to for PLWH to spport their care retention and engagement post-incarceration and as they re-enter the commnity. Professional Literatre The United States has the highest incarceration rates of any indstrialized contry in the world. 8,9 Approximately 1 ot of every 100 people in the United States is incarcerated; 10 and, if rates persist, 1 in 15 Americans will have been incarcerated at some point in their lives. 11 FIGURE 1 De-Instittionalization? Harcort 2006 The U.S. Criminal Jstice System incldes Law Enforcement (police, sheriff, highway patrol, FBI, and others), Adjdication (corts), and Corrections (jails, prisons, probation, and parole). 12 Most incarcerated individals (85%) pass solely throgh jails. Yet most corrections spending is in state prisons, rather than in jails, which are dependent on local fnding. 13,14

14 13 of 47 If rates persist, 1 in 15 Americans will have been incarcerated at some point in their lives. Jails are often the de facto health provider of last resort where people with low income, mental illness, nstable hosing, sbstance se isses, and a range of social and health problems are concentrated. 15,16 Frther, while historic arrest rates tend to mirror the racial and ethnic demographics of the local commnity, the incarcerated poplation is predominantly men of color. 17,18 85% of incarcerated individals pass solely throgh jails Prior to jail admission, many individals may have had barriers to accessing health care and spport services de to strctral ineqalities, inclding poverty, nstable hosing, limited edcational attainment, and n- or nder- employment. 19,20 Co-occrring health and behavioral health conditions (e.g., sbstance abse and mental illness) frther exacerbate access to care isses (see also Figre 1). 21,22 Additionally, people are less eqipped to address health isses when faced with competing compelling needs related to srvival, sch as food and shelter. 23 In these same commnities, health ineqities lead to higher rates of both incarceration and HIV. 24 As a reslt, pblic health professionals working in jail settings have a niqe opportnity to engage a poplation living with HIV and not engaged in care, in need of spportive services to access care after incarceration to achieve viral load sppression. 25,26,27 Jail-based health services treat poplations at high risk for acqiring HIV and offer people an opportnity to know their HIV stats. They may also provide transitional care coordination to facilitate linkage and re-engagement with the health care system after incarceration. 28,29 Jail-based health services have the opportnity to: Offer niversal HIV testing, particlarly in jrisdictions with hyper endemic rates of incarceration, so that the offer of HIV testing in correctional health care settings mirrors that in commnity health settings; 30 Implement interventions to prevent HIV transmission among poplations that move into, dwell in, or leave correctional facilities, while delivering general interventions that decrease intimate partner/sexal violence, promote harm redction and medication adherence, and address sbstance se; Ensre that health services in jails follow international gidelines for HIV care, inclding for the management of HIV comorbidities that occr at high freqency in incarcerated poplations; Promote 2-way, comprehensive commnication between correctional and commnity HIV providers to ensre that there are no gaps in care, treatment, and spportive services as people transition to and from their commnities and correctional facilities. The CDC strongly recommends jail-based HIV testing. 31 Rotine HIV screening in jails is also consistent with the National HIV/AIDS Strategy. 32 Nonetheless, many HIV positive persons in jails are naware of their HIV stats or were not in HIV primary care at the time of jail admission. The majority of people pass throgh jail and are never sentenced to prison bt retrn to the commnities that they left. 33,21,34 The transition period from incarceration back to the commnity is known to be a high risk period for: increased deaths, 35 discontinity of care and treatment (inclding ART), nstable hosing, and opiate overdose. The adverse health otcomes that occr in this high risk period frther nderscore the need for transitional care coordination and spport services. 36,37,28,38 As sch, health

15 14 of 47 departments, local healthcare providers, and commnity-based organizations have a vested interest in the provision of HIV testing, treatment, and linkage to both care and treatment dring and after incarceration. It is sefl for health care and correctional staff to view jails as part of the continm of care rather than independently, since this approach may help encorage strategic retention-in-care planning. Theoretical Basis A behavioral change theory is a combination of, interrelated concepts, definitions, and propositions that present a systematic view of events or sitations by specifying relations amont variables, in order to explain or predict the events or sitations. 39 By gronding an intervention in theory, the component parts are intentionally seqenced to bild off of one another to facilitate a change in health behavior. The original Transitional Care Coordination intervention was gronded in the Transtheoretical Model of Behavior Change (sing Stages of Change to lead to behavior change). 40 The Stages of Change framework explains an individals readiness to change, and provides strategies at six levels of behavior change (precontemplation, contemplation, determination, action, relapse, and maintenance) to move the individal into adopting the new health behavior. The Transtheoretical Model of Behavior Change bilds off of the Stages of Change by adding 10 processes of change that address the process of overcoming barriers, redcing internal resistance to change, and commitment to a new health behavior. These processes are consciosness raising, dramatic relief, selfreevalation, environmental reevalation, self-liberation, helping relationships, conter conditioning, reinforcement management, stimls control, and social liberation. The Model also incldes decisional balance (the benefits and costs of changing) and self-efficacy (confidence in the ability to change health behavior and temptation to engage in nhealthy behavior) as core constrcts. Intervention Components and Activities The central aim of the Care Transitional Coordination intervention is to facilitate the linkage of a client living with HIV to commnity-based care and treatment services after incarceration. Intervention activities inclde identifying and engaging people living with HIV dring the jail stay, identifying right fit commnity resorces, developing a client plan for their time dring and post-incarceration, and coordinating activities needed to facilitate linkage to care after incarceration. These activities need to occr qickly becase jail stays are often brief and the ncertainty arond discharge dates presents a shorter window of opportnity to reach people leaving jail settings. 41 Transitional Care Coordination incldes the following key activities while clients are incarcerated (pre-release): 1. HIV testing or self-disclosre information as well as mental health and sbstance abse information after medical intake screening (occrring in the jail); 2. Recritment (inclding informed consent) and enrollment into the intervention/program after medical intake screening; 3. Intensive case management intervention and individalized discharge plans (typically, within 24 hors and at least within 48 hors of medical intake); 4. HIV edcation, inclding risk redction and treatment adherence conseling, ongoing dring the jail stay;

16 5. Health Insrance and ADAP assistance for post-release sbmission; 15 of Discharge medications / prescription scripts at the time of jail release, inclding arrangements for those released from cort; 7. Providing a health liaison to the corts, which involves collaboration with cort advocates, jdges and prosectors, to provide health information to facilitate placement in commnity programs (inclding skilled nrsing facility, hospice, drg treatment program) and alternatives to incarceration programs; Transitional Care Coordination incldes the following key activities after the clients are released (post-release): 1. Patient navigation (accompaniment, home visiting, transportation assistance) and re-engagement in care after incarceration; 2. Intensive case management after incarceration to facilitate linkage to care for at least 90 days: address needs for food, clothing, and shelter; verify linkages to HIV primary care within 30 days of retrning to the commnity; address ongoing mental health and sbstance abse treatment needs, as assessed; consistent access to health insrance and medication; ongoing care management and social spports after 90 days. Staffing Reqirements The following staff positions need to be developed and filled in order to sccessflly implement the intervention. STAFF TITLE DESCRIPTION Linkage staff PROJECT MANAGER The Project Manager coordinates all aspects of the intervention with jail and commnity-based staff and commnity partners. The Project Manager is responsible for: being the point of contact for the intervention and providing oversight of the project; providing administrative spervision to the care coordinators and the data manager; serving as the health liaison to the corts; and serving as the liaison with local jail administration, the Dissemination and Evalation Center (DEC), and the Implementation Technical Assistance Center (ITAC). CARE COORDINATOR The care coordinator has five primary responsibilities: patient engagement, patient edcation, discharge planning, care coordination, and facilitating a warm transition to the commnity and linking a client to care. Patient engagement dring incarceration. The Care Coordinator is responsible for: client engagement and assessment dring the client s jail stay; and condcting care coordination with jail- and commnity-based organizations. Patient edcation. The Care Coordinator is responsible for: providing patient edcation on HIV, inclding treatment adherence, risk redction as well as a range of other health-related topics (e.g. STI, hepatitis, and TB overviews; prevention strategies and safe sex negotiation; relapse prevention; symptoms evalation, etc.). Discharge planning. The Care Coordinator is responsible for: assessing client needs; developing a plan with client to address basic needs; identifying resorces to facilitate access to commnity health care; and schedling initial linkage appointment.

17 Care coordination for care pon release. The Care Coordinator is responsible for: 16 of 47 completing patient assessment and discharge plan to initiate the process of coordinating care pon release, meeting the person in jail and initiating follow-p to verify linkage to care after incarceration; arranging discharge medications and prescriptions; and obtaining consent to collaborate with external entities and individals (e.g. commnity health providers, social service programs, corts). Facilitating a warm transition to the commnity and linking a client to care. The care coordinator is responsible for: accompanying individals who are newly released to appointments to ensre connection to care; coordinating commnity-based HIV care linkage services; providing home visits, appointment accompaniment, or transportation; condcting, arranging, or coordinating otreach activities to find individals who fall ot of care and facilitate re-engagement in commnity care; assessing and addressing basic needs like hosing, food, clothing, etc.; and transitioning the client to the standard of care after 90 days post-incarceration. CLINICAL SUPERVISOR The Clinical Spervisor is responsible for: Participating in case conferencing (as needed); Providing monthly (or as reqested) individal clinical spervision to care coordinators; and Providing monthly grop clinical spervision to intervention team (as needed) DATA MANAGER This position is responsible for: Consenting patients into the stdy; Collecting and sbmitting data reqired for mlti-site evalation; Coordinating the collection of patient srveys, enconter forms, basic chart data abstraction, and implementation measres, and reporting them to the Dissemination and Evalation Center (DEC); and Providing qality assrance reports and pdates to intervention team abot stdy referrals, enrollment retention, etc. Staff Characteristics All staff involved in the intervention need to be: able to deliver cltrally appropriate services. non-jdgmental and demonstrate empathy, professionalism, bondaries arond personal philosophy/belief systems. geninely interested in working with people incarcerated in jails. reflective of racial and ethnic backgronds of client poplation with langage ability as appropriate to meet client needs (as practicable). able to meet Department of Corrections secrity clearance criteria. willing to conform to Department of Corrections policies and are cognizant of gidelines regarding jstice-involved persons working in jail.

18 Programmatic Reqirements 17 of 47 The following are programmatic reqirements that need to be addressed prior to implementation (prior to enrollment of clients in the jails) in order to facilitate a sccessfl implementation: Establish relationships with the Jail and Department of Corrections to insre ongoing cooperation and spport throghot implementation. Assess what related work is already taking place within the jail. Receive clearance for intervention implementation. Understand what materials and resorces are or are not permissible within the jail and plan yor program accordingly (for example, some jails do not allow laptops inside). Invite corrections to join the collaboration and obtain a commitment for correction officers to provide escort services. Ideally assigned and dedicated officers will work in partnership with the team. Negotiate for dedicated space to condct intervention activities. Appropriate work space is essential to maintain patient confidentiality. Determine role of jail secrity staff in project implementation and involve them in planning. Visit jail facilities to condct a flow analysis. Walk throgh the health services nit and other relevant spaces to learn where services are delivered to identify space amenable to yor program. Strengthen existing relationships with commnity-based organizations that are willing to work with HIV-positive individals leaving jail. Address need for telephone or in-person case conferences with commnity-based organizations dring the jail stay (to facilitate a warm transition). Develop mtal Memorandm of Understanding (MOU) Linkage Agreement with each commnity partner that incldes a commitment to provide data that verifies linkage to care. Assess organizational capacity at commnity-based organizations to insre their ability to consistently provide cltrally competent transitional social spports to each inmate post-incarceration. Identify how access to health records and any Electronic Health Record (EHR) systems (inclding RSR data). Establish a process for commnication and information sharing of participating Ryan White care providers dring and post-incarceration to streamline the client process and activities each client engages in. Providers shold be prepared to address the operational isses involved in working with mltiple jail-based and commnity-based providers of health care as patients are freqently transferred among jails, between jails and prisons, from jail to cort, and from jail to the commnity. Additionally, DEII performance sites mst assess their capacity to condct process and otcome evalation activities dring the fnding period.

19 Costs 18 of 47 The SPNS Jail Linkages projects were deemed cost-effective from a societal perspective 42 with an average cost per client at $4,219. In an analysis of nine sites, the mean cost to sstain linkage to care postincarceration for 6 months was $4, Health otcomes impacting costs (redctions in ED se and self reported nstable hosing and hnger when compared to themselves at baseline and at 6 Month follow p) were fond nder the Transitional Care Coordination intervention inclding a redction in emergency.13, 14 department se and homeless shelter stays Resorces OVERVIEW OF PRIOR SPNS INITIATIVES Enhancing Linkages to HIV Primary Care and Services in Jail Settings Enhancing Linkages: Opening Doors for Jail Inmates. What s Going SPNS: HRSA Consltation Meeting. Enhancing Linkages to HIV Primary Care in Jail Settings: HRSA/CDC Opening Doors: Corrections Demonstration Project for People Living with HIV/AIDS: CREATING A JAIL LINKAGE PROGRAM: TOOLS FROM THE INTEGRATING HIV INNOVATIVE PRACTICES PROGRAM Training Manal: Crriclm: Pocket Gide: Webinar series: EVALUATION RESOURCES Enhancing Linkages to HIV Primary Care and Services in Jail Settings implementation gide and evalation instrments PEER-REVIEWED ARTICLES PROVIDING BACKGROUND INFORMATION ON WORKING IN JAILS AND LINKING INMATES TO CARE Adherence to HIV Treatment and Care among Previosly Homeless Jail Detainees. Contribtion of Sbstance Use Disorders on HIV Treatment Otcomes and Antiretroviral Medication Adherence Among HIV-Infected Persons Entering Jail.

20 19 of 47 Correlates of Retention in HIV Care after Release from Jail: Reslts from a Mlti-site Stdy. An Exploration of Commnity Reentry Needs and Services for Prisoners: A Focs on Care to Limit Retrn to High Risk Behavior. Gender Disparities in HIV Treatment Otcomes Following Release From Jail: Reslts From a Mlticenter Stdy. Gender Differences in Baseline Health, Needs at Release, and Predictors of Care Engagement Among HIV-positive Clients Leaving Jail. Health otcomes for HIV-infected persons released from the New York City jail system with a transitional carecoordination plan. Jail: Time for Testing. Yale University School of Medicine Linking HIV-positive Jail Inmates to Treatment, Care, and Social Services After Release: Reslts from a Qalitative Assessment of the COMPASS Program. Post-Release Sbstance Abse Otcomes among HIV-infected Jail Detainees: Reslts from a Mltisite Stdy. Rapid HIV Testing in Rapidly Released Detainees: Next Steps. Flltext/2009/02001/Rapid_HIV_Testing_In_Rapidly_Released_Detainees_.9.aspx# Transitional Care Coordination in New York City Jails: Facilitating Linkages to Care for People with HIV Retrning Home from Rikers Island. Understanding the Revolving Door: Individal and Strctral-level Predictors of Recidivism Among Individals with HIV Leaving Jail. SOURCES 1 Jordan AO. Linkages and Care Engagement: From NYC Jail to Commnity Provider. New York State Department of Health AIDS Institte, End of AIDS and the Criminal Jstice System. September 16, 2015 [webinar]. Available at: 2 Flanigan TP, Zaller N, Beckwith CG, et al. Testing for HIV, sexally transmitted infections, and viral hepatitis in jails: still a missed opportnity for pblic health and HIV prevention. JAIDS (Sppl). 2010;55(2): S Emory University Rollins School of Pblic Health. Enhancing linkages to HIV primary care and services in jail settings initiative: linkage to social spport services. Policy Brief. Spring Available at: 4 Teixeira PA, Jordan AO, Zaller N, et al. Health otcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan. Am J Pblic Health Feb;105(2): Jordan AO, Cohen LR, Harriman G, et al. Transitional Care Coordination in New York City Jails: Facilitating Linkages to Care for People with HIV Retrning Home from Rikers Island. JAIDS (Sppl). 2013;(2); S Jordan AO, Cohen LR, Harriman G, et al. Transitional Care Coordination in New York City Jails: Facilitating Linkages to Care for People with HIV Retrning Home from Rikers Island. JAIDS (Sppl). 2013;(2); S Rapp RC, Ciomcia R, Zaller N, et al. The role of jails in engaging PLWHA in care: from jail to commnity. AIDS Behav Oct; 17(0 2): S89 S99. 8 Draine J, Ahja D, Altice FL, et al. Strategies to enhance linkages between care for HIV/AIDS in jail and commnity settings. AIDS Care. 2011;23(3): Walmsley R. World Prison Poplation List, 2009 (8th ed.), United Kingdom Home Office Research. Available at: 10 Warren J, Belb A, Horowitz J, et al. One in 100: Behind Bars in America Washington, DC: The Pew Charitable Trsts, Pblic Safety Performance Project HRSA, HAB. Enhancing linkages: opening doors for jail inmates. What s Going SPNS. May Available at: hab.hrsa.gov/abothab/files/cyberspns_enhancing_ linkages_may_2008.pdf. 12 Zack B, Hane L At the Nexs of Correctional Health and Pblic Health: Policies and Practice, American Pblic Health Association Annal Meeting [Presentation] 13 Zack B, Hane L At the Nexs of Correctional Health and Pblic Health: Policies and Practice, American Pblic Health Association Annal Meeting [Presentation] 14 Draine J, Ahja D, Altice FL, et al. Strategies to enhance linkages between care for HIV/AIDS in jail and commnity settings. AIDS Care. 2011;23(3): Spalding AC, Perez SD, Seals RM, et al. Diversity of release patterns for jail detainees: implications for pblic health interventions. Am J of Pblic Health (Sppl). 2010; 1010(1): S

21 16 Draine J, Ahja D, Altice FL, et al. Strategies to enhance linkages between care for HIV/AIDS in jail and commnity settings. AIDS Care. 2011; 23(3): Drg Policy Alliance. The Drg War, Mass Incarceration and Race. Jne Available at: Incarceration_and_Race_Jne2015.pdf 18 Mhammad KG. The Condemnation of Blackness: Race, Crime, and the Making of Modern Urban America. Cambridge, MA: Harvard; Kshel MB, Hahn JA, Evans JL, et al. Revolving doors: imprisonment among the homeless and marginally hosed poplations. Am J Pblic Health. 2005;95: Centers for Disease Control and Prevention. HIV Testing Implementation Gidance for Correctional Settings. Janary 2009: Available at: risk_correctional_settings_gidelines.pdf. 21 Harcort, BE. From the Asylm to the Prison: Rethinking the Incarceration Revoltion. Texas Law Review. 2006; 84:175. Available at: harcort_instittionalization_final.pdf. 22 Metzl JM. The Protest Psychosis: How Schizophrenia Became a Black Disease. Boston, MA: Beacon Press; Zellman H. Philadelphia FIGHT Institte for Commnity Jstice. Establishing the need for an intervention program [Unpblished] 24 Flanigan TP, Zaller N, Beckwith CG, et al. Testing for HIV, sexally transmitted infections, and viral hepatitis in jails: still a missed opportnity for pblic health and HIV prevention. JAIDS (Sppl). 2010;55(2): S Flanigan TP, Zaller N, Beckwith CG, et al. Testing for HIV, sexally transmitted infections, and viral hepatitis in jails: still a missed opportnity for pblic health and HIV prevention. JAIDS (Sppl). 2010;55(2): S Draine J, Ahja D, Altice FL, et al. Strategies to enhance linkages between care for HIV/AIDS in jail and commnity settings. AIDS Care. 2011; 23(3): Teixeira PA, Jordan AO, Zaller N, et al. Health otcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan. Am J Pblic Health Feb; 105(2): Spalding AC, Perez SD, Seals RM, et al. Diversity of release patterns for jail detainees: implications for pblic health interventions. Am J Pblic Health (Sppl). 2010; 1010(1): S Emory University Rollins School of Pblic Health. Enhancing linkages to HIV primary care and services in jail settings initiative: linkage to social spport services. Policy Brief. Spring Available at: careacttarget.org/sites/defalt/files/file-pload/resorces/enhancelinkpolicybriefs.pdf. 30 Centers for Disease Control and Prevention. HIV Testing Implementation Gidance for Correctional Settings. Janary 2009: Available at: risk_correctional_settings_gidelines.pdf. 31 devox A, Spalding AC, Beckwith C, et al. Early identification of HIV: empirical spport for jail-based screening. PLos One. 2012;7(5): devox A, Spalding AC, Beckwith C, et al. Early identification of HIV: empirical spport for jail-based screening. PLos One. 2012;7(5): Spalding AC, Seals RM, Page MJ, et al. HIV/AIDS among inmates of, and releasees from, U.S. correctional facilities, 2006: declining share of epidemic bt persistent pblic health opportnity. PLos One. 2009;4(11): Emory University Rollins School of Pblic Health. Enhancing linkages to HIV primary care and services in jail settings initiative: linkage to social spport services. Policy Brief. Spring Available at: careacttarget.org/sites/defalt/files/file-pload/resorces/enhancelinkpolicybriefs.pdf. 35 Teixeira PA, Jordan AO, Zaller N, et al. Health otcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan. Am J Pblic Health Feb; 105(2): International Advisory Panel on HIV Care Continm Optimization. IAPAC Gidelines for Optimizing the HIV Care Continm for Adlts and Adolescents. J Int Assoc Provid AIDS Care. 2015; Wohl DA, Scheyett A, Golin CE, et al. Intensive case management before and after prison release is no more effective than comprehensive pre-release discharge planning in linking HIV-infected prisoners to care: a randomized trial. AIDS Behav Feb;15(2): devox A, Spalding AC, Beckwith C, et al. Early identification of HIV: empirical spport for jail-based screening. PLos One. 2012;7(5): Glanz K, Rimer BK, Viswanath K. Health Behavior and Health Edcation: Theory, Research and Practice (4th Edition). San Francisco, CA: Jossey-Bass; P Prochaska JO, Velicer, WF. The Transtheoretical Model of Health Behavior Change. Am J Health Promot. September/October 1997;12(1); Nnn A, Cornwall A, F J, et al. Linking HIV-positive jail inmates to treatment, care, and social services after release: reslts from a qalitative assessment of the COMPASS Program. J Urban Health. 2010;87(6): Spalding AC, Pinkerton SC, Sperak H, et al. Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention. AIDS Behav (Sppl). 2013;(2); S Spalding AC, Pinkerton SC, Sperak H, et al. Cost analysis of enhancing linkages to HIV care following jail: a cost-effective intervention. AIDS Behav (Sppl). 2013;(2); S of 47

22 Models for improving linkage to care for people living with HIV released from jail or prison 21 of 47

23 22 of 47 Table of Contents 4 Smmary 6 Introdction 8 Programs & Projects HRSA/CDC Corrections Demonstration Project CDP Project Spotlight: Massachsetts Department of Pblic Health Enhancing Linkages to HIV Primary Care (EnhanceLink) Project START Pls Philadelphia Linkage Program's Care Coach Model Change Team Model in Delaware Stdy 22 Trobleshooting Q&A Credits References

24 23 of 47 Smmary This is a resorce gide for Ryan White HIV/AIDS Program (RWHAP) fnded organizations to provide care to people living with HIV (PLWH) who are leaving prisons and jails and reentering society after incarceration. It describes proven models for linkage to care programs that can help PLWH access healthcare pon release in order to stay healthy, treatment adherent, HIV virally sppressed, and redce their changes of recidivism. With HIV prevalence among state and federal prisons more than three times higher than the general poplation (1.3% compared to 0.4%), 1 correctional facilities offer a niqe opportnity to engage with PLWH and offer care. For many PLWH, this time dring incarceration may be the only time they have access to HIV care. For others, de to intense stigma against HIV and homosexality 2 in hypermascline 3 corrections settings, incarceration may interrpt HIV treatment they were previosly receiving in the commnity. It is essential that AIDS service organizations (ASOs) and commnity-based organizations (CBOs) work with newly released PLWH to ensre continity of care for incarcerated PLWH as they reenter society. The HIV care continm involves five seqential steps: (1) diagnosis of HIV infection, (2) linkage to care, (3) retention in care, (4) receipt of antiretroviral therapy (ART), and (5) achievement of viral sppression. 4 Barriers to accessing care can inclde lack of stable hosing, poverty, mental health and/or sbstance se disorder isses, and lack of access to cltrally competent care. 5 Formerly incarcerated individals often strggle with varios isses, inclding: sbstance se disorders, mental health, family estrangement, lack of spport, lack of employment and hosing after being released back into their commnities. 6 Ths, continity of care for incarcerated PLWH is particlarly important. Interventions that address barriers to engagement in care are vitally important. This resorce gide smmarizes effective models and best practices of linkage to care programs for PLWH who are leaving jail or prison and reentering society. It is based on project reports, training manals and resorce gides on post-incarceration linkage to care programs, inclding the HRSA-CDC Corrections Demonstration Project, HRSA HIV/AIDS Brea s (HRSA HAB s) Special Projects of National Significance Program (SPNS): Enhancing Linkages to HIV Primary Care & Services in Jail Settings Initiative (EnhanceLink), The Bridging Grop s Project START Pls, ActionAIDS Philadelphia Linkage Program s Care Coach Model, and the Change Team Model in Delaware Stdy. Each of these programs is briefly smmarized below. At the end of this gide a trobleshooting Q&A can be fond to address common qestions and concerns. Corrections Demonstration Project (CDP) The HRSA/CDC CDP was a five-year project ( ) that addressed HIV testing and continity of care for incarcerated individals living with HIV. Seven state departments of health were fnded to spport projects that developed effective linkage to care models. It attempted to establish linkages between existing correctional and commnity health services while addressing other social service needs. Effective models sed a combination of health services inclding HIV srveillance, medical and behavioral screening and assessment, prevention edcation and conseling, primary healthcare, and referral linkages. Information is smmarized from their report, Opening Doors 7, and EnhanceLink s Consltancy Report (see next paragraph). 8 EnhanceLink The HRSA, HABs, and SPNS: Enhancing Linkages to HIV Primary Care & Services in Jail Settings Initiative (EnhanceLink) bilt pon the CDP. From , ten grant recipients were fnded, representing 20 separate jail sites. From this pilot project, a training manal was developed that illstrates the effectiveness of jail linkage work, information on components of effective jail linkage programs, best practices, and necessary information to replicate and implement the work of EnhanceLink. The EnhanceLink project highlighted important considerations for starting a sccessfl linkage to care program, sch as research and preparation, data collection, HIV testing, implementation of programs, and reintegration of formerly incarcerated individals back into the commnity. Information is smmarized from their training manal. 9 4

25 24 of 47 Project START Pls The Bridging Grop s Project START Pls was an adaptation of Project START, an individal-level, mlti-session linkage to care and risk redction program for PLWH retrning to the commnity after incarceration. The program provides tools and resorces to increase awareness and redce risk of HIV, STI, and Hepatitis. The program consists of six sessions with each client, working with them one-on-one to serve as a bridge for their retrn to the commnity. The program begins p to 2 months pre-release and contines for 3 months post-release, focsing on linkage to care throgh referrals, social healthcare services spport, and transitional needs spport. Information is smmarized from their fact sheet. 10 Philadelphia Linkage Program s Care Coach Model This was a linkage to care program that incldes two key staff positions: care coach and care otreach specialist. The care coach has smaller caseloads of typically 25 clients, and works one-on-one with clients dring incarceration and post release. Care coaches assisted in the transition from jail-based medical care to commnity-based care. The care otreach specialist worked with a care coach, and served as an advocate, medical escort, and health edcator. This model delivered mlti-tiered services with the engagement of commnity partners. Information is smmarized from their report, Secring the Link. 11 Change Team Model in Delaware Stdy This was a model sed in the National Institte on Drg Abse-fnded Criminal Jstice Drg Abse Treatment Stdies HIV Services and Treatment Implementation in Corrections protocol in the state of Delaware. Research centers teamed with criminal jstice organizations to identify where improvements needed to be made on the HIV care continm in their local facilities. The change team consisted of a change team leader and a team of key staff and personnel, inclding representatives from correctional and commnity agencies. Identifying linkage to care as the area for improvement, the Delaware change team worked to increase commnication between HIV commnity providers and Department of Corrections medical spervisors, decrease administrative brden, and improve HIV testing and edcational material at medical intake. Information is smmarized from the article, Improvements in Correctional HIV Services: A Case Stdy in Delaware. 12 In the following pages, information from each program is smmarized in-depth. For frther gidance, links to the original reports and stdies are provided throghot this report. 5

26 25 of 47 Introdction Each year, approximately 17% of all people living with HIV in the U.S. will spend some time in prison or jail. The United States incarcerates over 20% of the world s prisoners despite having less than five percent of the world s poplation. 13 The U.S. incarceration rate is over for times the world average, with a rate of 693 incarcerated individals per 100,000 residents in 2014, and a total prison poplation of over 2.2 million. 14 According to a 2015 Brea of Jstice Statistics report, the prevalence of HIV among state and federal prisoners is 1.3%, which is more than three times higher than the prevalence in the general poplation (0.4%). 15 In 2010, the rate of diagnosed HIV infections among prisoners was more than five times greater than the rate among those not incarcerated. 16 Each year, approximately 17% of all PLWH in the U.S will spend some time in prison or jail i. 17 Most incarcerated individals acqire HIV in their commnities, prior to incarceration. 18 For many with PLWH, their time in prison or jail is the only time they have access to care, treatment, and spport. For this reason the corrections system is a key site of engagement with some PLWH and an important place to find PLWH who have never been diagnosed or who have been diagnosed bt lost to care. This provides a niqe opportnity for pblic health professionals to access this poplation to provide not only acte care, bt a continity of care that extends back to the commnity, where 90% of people in correctional facilities will retrn. 19 The fact that nearly one in five PLWH cycles throgh the jail or prison system in any given year, and that the vast majority of incarcerated individals will retrn to society and their partners, sposes and families demonstrate the linkage between prisons, commnities, and the overall HIV epidemic. The pblic health sector is increasingly recognizing the opportnity within corrections to contribte to a more sccessfl reentry process for former incarcerated citizens into the commnity. It has been shown that promoting health dring incarceration promotes health in commnities post-release. For example, in a stdy examining the effects of jail sexally transmitted infection (STI) testing on neighborhood chlamydia rates, neighborhood clinics in areas with higher jail testing density fond a seven times greater redction in chlamydia rates (from 16.1% to 7.8%) compared to neighborhood clinics in areas with lower jail testing density. 20 A comprehensive approach that incldes not only standard HIV treatment and edcation bt also enhances continity of care is essential to redcing HIV in correctional facilities and or commnities. 21 The following are sccessfl programs and models that se this comprehensive approach. i According to the Brea of Jstice Statistics: Jails are locally-operated, short term facilities that hold inmates awaiting trial or sentencing or both, and inmates sentenced to a term of less than 1 year, typically misdemeanants. Prisons are long term facilities rn by the state or the federal government and typically hold felons and inmates with sentences of more than 1 year. 6

27 26 of 47 Programs & Projects HRSA/CDC Corrections Demonstration Project From 1999 to 2004, the Corrections Demonstration Project (CDP) addressed HIV testing and continity of care for incarcerated individals living with HIV by fnding projects that developed effective linkage to care models. It attempted to establish linkages between existing correctional facilities and commnity health services while addressing other social service needs. The CDP pblished a 2007 report that describes the development, implementation, barriers, and recommendations from the different models sed in the projects. EnhanceLink, a later project that bilt pon the CDP, created a consltancy report that provides an overview of the CDP. This report discsses general related isses and challenges, data elements, ethical considerations, and an overall smmary of lessons learned and best practices. Information from both reports, Opening Doors: the HRSA-CDC Corrections Demonstration Project for People living with HIV/AIDS 22 and EnhanceLink s Consltancy Report 23 as it relates to the CDP, is smmarized below. The major objectives of the CDP inclded: HIV services in correctional facilities mst inclde collaboration and partnership bilding between corrections, commnity providers, pblic health, and most importantly, incarcerated individals. Getting participation from incarcerated individals in program design may be difficlt, bt it provides valable insight into the services that are trly needed within and otside of corrections. Strategies for bilding partnerships with the commnity inclde leveraging pre-existing relationships between the state s department of health and commnity health providers and identifying CBOs that are able to consistently engage in the project. All in all, a review of the CDP programs showed a recrring theme: the most sccessfl project management strctres were those where one of the collaborating partners led program implementation, and a single individal within the lead organization was in charge of coordinating all project activities. The sccess of the collaboration heavily relied pon the commitment of those in leadership positions, sch as the warden or medical director, at the partnering correctional facility. Program Design Within the CDP, all seven participating states implemented sccessfl continity of care programs in a variety of settings, in- Increasing access to HIV primary healthcare and prevention services; Improving HIV transitional services between corrections and the commnity; and Developing organizational spports and linked networks of comprehensive HIV health and social services. The goal of the CDP was to develop and evalate models for linking networks of health services and correctional facilities for replication by other programs, instittions, and organizations. Effective models inclded activities sch as clinical evalation and treatment, prevention edcation, peer edcation, disease screening, conseling and testing, staff development and training, discharge planning, continity-of-care case management, and prevention case management. 24 Throgh these varios activities, CDP attempted to develop effective collaborations between three systems: corrections, the commnity, and pblic health. Collaboration in Project Management 8

28 27 of 47 clding state prisons, local jails, and yoth service centers. One important finding from the sccessfl continity of care programs was that HIV was often not the most pressing isse for the incarcerated individals. Other isses like hosing, family renification, employment, sbstance se disorders, and mental health treatment had to be addressed before participants were willing to consider HIV treatment and management. Programs mst be holistic and address and prioritize the social isses participants face. Additionally program design mst consider the myriad of policies that affect transition into the commnity, sch as hosing and employment prohibitions for ex-offenders who are felons. Pblic Hosing Agencies are permitted to prohibit admission into the program for history of drg-related criminal activity, violent criminal activity, or other criminal activity that may threaten health, safety or right to peacefl enjoyment of the premises. 25 There is significant stigma related to hiring someone with a criminal record. Many employers ask if potential employees have been arrested or have a criminal record, and may decide not to hire someone based on that response. This common practice and stigma makes it difficlt for previosly incarcerated people with histories of nonviolent crimes to find employment. For implementing the continity of care programs, the seven grant recipients sed a basic model that inclded the following elements: 1. One or more commnity-based organizations (CBOs) worked in the jail and in the commnity to link HIV-infected incarcerated individals to services. 2. Case managers split their time between the jail and the commnity, or one set of case managers worked in the jail and another set worked in the commnity. 3. The case manager met with incarcerated individals living with HIV at the jail at least one time before release to assess post-release readiness, and whether or not there were existing relationships with commnity providers, or if new connections were necessary. 4. The case manager developed a discharge plan that prioritized the particlar services that the incarcerated individal needed and made appointments (ideally) or referrals (minimally) with providers in the commnity. If there was no time to make pre-release appointments for services, appointments for post-release case management were made. 5. In programs where there were two case managers, one in the jail and one in the commnity, the commnity case manager came to the jail to meet the incarcerated individal. 6. When possible, the case manager met the incarcerated individal at the jail gate at the time of release and escorted him or her to the first appointments or hosing. 7. The commnity case manager worked with the previosly incarcerated individal in the commnity to follow p on the discharge plan or make additional linkages to commnity services. Each grantee designed its program to reflect their own individal local conditions and existing relationships. Some grant recipients sed innovative strategies, inclding developing of a transitional hosing program for three months of post-release hosing, forming a partnership with shelters and transitional hosing programs to ensre access to beds, collaborating with a major health center to establish a weekly clinic, and establishing diverse teams of social workers, case managers and peers to provide services. It is important to consider the scope of the new project, inclding what services are already being offered and what services are available in the commnity. It is crcial to not over-promise what services can be delivered, as this can create or worsen a general distrst of service providers. Provided below is a checklist from the Opening Doors report for project development that takes these isses into consideration: What is the big pictre? Who is already advocating for incarcerated individals living with HIV? What is already being done for incarcerated individals living with HIV? How is the jail organized? What existing commnity and criminal jstice resorces and strctres can yo tap into to strengthen yor program? 9

29 28 of 47 CDP Project Spotlight: Massachsetts Department of Pblic Health The CDP provided fnding to the Massachsetts Department of Pblic Health HIV/AIDS Brea (Massachsetts HAB), which implemented the Transitional Intervention Project (TIP). TIP bilt on the Massachsetts HAB-spported, pre-existing HIV-related services sch as prevention, edcation, conseling, testing, and case management. TIP focsed on the following activities: Intensive, commnity-based transitional case management for all previosly incarcerated people living with HIV. Creation of a bridge between HIV services within correctional facilities and existing HIV services in commnity. Evalation of the tility and feasibility of the TIP reintegration model. Provision of and improvement to chlamydia srveillance and treatment. A comprehensive, peer-led prevention and edcation program focsing on HIV, STIs, TB and hepatitis. HIV conseling and testing in jvenile corrections facilities, and referrals to appropriate commnity HIV services. TIP services also inclded assistance with obtaining safe hosing, establishing post-release medical treatment, obtaining health insrance, conseling on HIV treatment adherence, and locating mental health and sbstance se disorder services. Massachsetts HAB contracted with CBOs in six different service regions, and provided management, oversight, training, technical assistance and evalation spport. Massachsetts HAB worked with the CBOs to create eight TIP teams comprised of jail coordinators, infectios disease nrses, case managers and other correctional facility staff. TIP teams referred clients to the program dring incarceration and then focsed on establishing rapport with clients to develop relationships, assess their release needs, and implement client-specific service plans. Barriers to the tilization of TIP inclded the lack of privacy in tilizing the services dring incarceration, fear of being oted and reslting repercssions of stigma and rejection by others, the complexities associated with medication adherence, ndertilization of services and retention difficlties within TIP de to sbstance se disorder relapse, and territorial isses between commnity programs. Client retention and continity is reinforced throgh program flexibility. Avoid gaps in services, which act as a barrier to care and can reslt in loss of clients. De to high prison staff trnover, ongoing edcation of staff is necessary. Participation and spport from parole officers is needed to explain the role of TIP case managers among incarcerated individals. Attention mst be paid to the emotional and spport needs of case managers. According to clients, having a nonjdgmental, respectfl, and accessible case manager is important to the sccess of the program. Barriers to tilization of TIP: Lack of privacy in tilizing services dring incarceration; The complexities of medication adherence; Fear of being oted and the repercssion of stigma; Sbstance se disorder relapse; Territorial isses between commnity programs. To learn more abot the CDP, see: ConsltancyReport_pdate pdf Recommendations for sccess from the TIP program inclde: Transitional case management is effective in meeting mltiple needs, sch as hosing, sbstance se disorder treatment, etc., for sccessfl transition to the commnity. Accessibility of case managers is important: ensre open access. 11

30 29 of 47 Enhancing Linkages to HIV Primary Care (EnhanceLink) Bilding pon the HRSA/CDC Demonstration Project, The Enhancing Linkages to HIV Primary Care & Services in Jail Settings Initiative (EnhanceLink) was a project lanched by the HRSA, HAB, SPNS Program. It soght to fill the research void of evidence-based interventions for identifying high-need clients and best practices for linkage to care. It was fnded to design, implement, and evalate innovative methods for linking incarcerated PLWH into primary care. From , 10 grantees were fnded, representing 20 separate jail sites. EnhanceLink tested 210,267 incarcerated individals for HIV and 1,312 individals tested positive. Of those 1,312 that tested positive, EnhanceLink enrolled 1,270 participants. From this pilot project, a training manal was prodced that illstrates the effectiveness of jail linkage work, best practices, and necessary information to replicate and implement the work of demonstration models fnded nder the EnhanceLink initiative. That information is smmarized below. 26 Tips for Preparation: Laying the Grondwork It is essential to lay the grondwork for a sccessfl jail linkage program. Those interested in starting a new jail linkage program shold first: Explore existing programs and other organizations working within the jail/prison to avoid dplication or starting an intervention withot the capacity to complete it. Understand the cltre of corrections: what is and is not permissible in those environments, cltral competency with incarcerated individals, bilding trst, challenges to adhering to the Health Insrance Portability and Accontability Act (HIPAA), and implications to the proposed program. Secre by-in and create partnerships: Engage entire staff, first targeting high-level decision makers. Host edcation sessions with corrections administrators abot HIV. Find and collaborate with key spporters like opinion leaders in the commnity (e.g., RWHAP Planning Concil, consortia, consmer advisory board members, etc.). Share information and goals p front to allow all parties a voice. Use memorandms of nderstanding (MOUs) to docment services, relationships and reportorial strctres, paired with ongoing conversation and collaboration. Tailor programs to yor commnity and jail settings. Determine how data will be collected, stored, and analyzed. Significant challenges to data collection inclde staff attitdes, chaotic jail environment dring intake, criteria for testing, and timing of testing. There are also important isses that need to be considered specifically when dealing with HIV testing and linkage programs in jail settings. Five central qestions regarding privacy and cltral competency that need to be considered inclde: 1. How will testing be performed in a volntary manner, in light of the new CDC recommendations that sggest incorporating testing into rotine medical services? 2. How will testing be performed in a manner that is sensitive to the psychological impact of an incarcerated individal s learning for the first time his or her HIV stats? 3. How will confirmatory testing be delivered within a brief time period, given the slightly higher false positive testing rate of rapid testing? 4. How will adverse events be monitored? 5. How will protected health information be shared in a manner that facilitates linkages bt does not violate the Health Insrance Portability and Accontability Act (HIPAA)? Tips for Getting Started The EnhanceLink evalation center identified strategies for bilding a strong and sccessfl program. Appropriate and effective information sharing is critical to sccessfl programs, and this incldes having appropriate space for the program in the jail, coordinating the new programs with existing services, athorizing CBOs and health departments to work in the facility, and meeting secrity reqirements. Major components of EnhanceLink activities inclded: Appropriate Staffing It is very important to have a non-jdgmental and cltrally competent staff becase of the sensitive natre and stigma srronding HIV stats. EnhanceLink recommends that the staff inclde any pre-existing mental health staff and hosing conselors in the jail, a health liaison or cort advocate if possible, and someone to begin the process of coordinating care pon release and accompany clients to appointments. EnhanceLink also recommends that an effective referral system between medical staff and staff at partnering CBOs be established. 12

31 30 of 47 HIV Testing Most EnhanceLink grant recipients were already engaged in HIV testing within jails sing rapid HIV testing. However, organizations not already involved in HIV testing bt looking to initiate a program shold consider some important qestions, inclded in a gide by an EnhanceLink grant recipient, Yale University School of Medicine: Is there a medical exam at intake or shortly after? Is there an opportnity to discss HIV testing at orientation? Are there policies that wold impede yor ability to implement a new way of doing testing? Is there space to do the testing and to store spplies? Who will feel threatened by what are yo doing? What can yo do to minimize the sense of threat? How and where will they get their reslts? Timing of Services and Interventions With the short average length of stay, HIV testing shold ideally be done within 24 hors of intake, or at least within 48 hors. As sch, it is important to nderstand barriers and facilitators to HIV testing in correctional settings. The staff shold be familiar with state laws srronding HIV testing and informed consent. Policies where incarcerated individals have to opt-ot of testing rather than opt-in yield greater rates of testing. Privacy and confidentiality shold be prioritized in order to make incarcerated individals feel comfortable getting tested. Staff shold determine private locations within the jail where HIV test reslts can be disclosed. If permitted, providing basic items like toothbrshes or socks can go a long way in increasing client willingness to participate, bt testing mst be volntary and no one shold ever feel coerced into it. If one incarcerated individal receives items, all incarcerated individals shold receive the same items. Before offering testing, EnhanceLink recommends that incarcerated individals be asked abot their HIV stats in a private and sensitive manner to allow for self-disclosre. Those who do self-disclose shold be engaged in a follow-p discssion abot treatment. HIV testing shold ideally be done within 24 hors of intake, or at least within 48 hors. Treatment and Adherence De to the short natre of jail stays, patients may not be placed on antiretroviral therapy (ART) ntil after release. However, even with the short-stay natre of jails, ART shold be started as soon as possible, as immediate initiation is the standard of care. 27 If incarcerated individals will not be able to start ART prior to release, they shold receive edcation abot ART before being released. If a patient is placed on ART, complex regimens with large pill brdens shold be avoided. To avoid drg-drg interactions, the patient s other prescriptions shold be examined and discssed with patients and medical providers. EnhanceLink recommends that the following topics be discssed when initiating treatment with incarcerated individals: Benefits of HIV medication. Misconceptions abot treatment. How medications work. Integrating regimens into daily life. Importance of adherence and conseqences of nonadherence. Common side effects and how to manage them. Dosing and names of medications. Any food reqirements and the effect of ntrition in medication absorption. 13

32 31 of 47 Risk-redction Edcation Risk-redction edcation is important for those at high risk of infection bt who may not be aware they are at risk, or for those who have little knowledge of HIV. Providing this edcation pre-release is important since the time following release has a higher likelihood for engaging in high-risk behaviors. 28 This edcation can be a formal crriclm or incorporated into spport grops that are open to all incarcerated individals to protect patient confidentiality. Considering that jail stays can be short, it may be best to condense topics into fewer sessions. Basic topics to cover inclde: HIV, STI, hepatitis and TB overviews. Strategies for prevention and safe-sex negotiation. Coping techniqes. Commnication strategies for talking with care providers and family. Conflict resoltion. Ntrition information. Symptoms evalation. Relapse prevention. Advance directives. Job training. Wellbeing, inclding exercise, jornaling and spirital needs. Discharge Planning For a sccessfl connection to care post-release, it is important that action is taken from the beginning of the release process. Pre-release case management, retention strategies, and interaction with transitional services need to be prioritized. EnhanceLink recommends the following tips for effective discharge planning: Treat each session like it is the last; discharge within jails can be npredictable. Listen closely to person s concerns and address them, especially triggers associated with poor decision-making. Use motivational interviewing techniqes to prepare incarcerated individals for release. Draft a discharge plan that docments needs and a plan to address each one. Once the release date is known, help the person complete an application for health insrance if needed. Some EnhanceLink participants fond it sefl to have a to do list inclded in their discharge plan that incldes resorces, partner organizations, important tasks, and relevant contacts. Collect mltiple ways of reaching clients post-release. This can inclde the client s spport system, information abot where they hang ot, their street name or nickname, and any identifying tattoos/markers. Linkage Services Treat each session like it is the last; discharge within jails can be npredictable. An important aspect of continity to care is linkage services, which inclde post-release referrals to care, intensive case management, and follow-p. Formerly incarcerated individals have many competing needs, to which HIV care may be a low priority. Sccessfl interventions recognize that basic needs sch as food, clothing, safe hosing, and drg treatment and mental health spport are priorities, and as sch, they promote access and linkage in programs that address those needs. EnhanceLink makes the following recommendations: Formlate and strengthen relationships with commnity resorces, creating spportive relationships between jail and commnity staff, and know what resorces are available. These resorces can inclde healthcare, hosing, mental health and sbstance se disorder treatment, transportation assistance, food services, legal services, employment services and spport grops. Case managers shold offer more intensive and individalized services based on client need. This cold mean focsing on hosing, legal spport, or secring identification. Case managers shold meet releasees at the gate and provide transportation to appointments or transitional hosing, as well as following p with them post-release. For those with sbstance se disorder, consider discssing risks of sharing needles and overdose prevention. Connect them with appropriate therapy sch as inpatient or otpatient care or sober homes. If a client is lost-to-follow p, check re-incarceration first, and then shelters, drg and alcohol facilities, mental health facilities, hospitals, coroner s office, or where they live/ hang ot (depending on what they consented to). 14

33 32 of 47 Case managers shold meet releasees at the gate and provide transportation to appointments or transitional hosing. 10 recommendations from the EnhanceLink evalation center to address re-integration into the commnity 1. All released individals shold be assessed for individalized treatment plans and linked to providers. 2. Program model shold be designed to minimize or eliminate foreseeable barriers. For example: a. Transportation on day of release to transitional hosing shold be provided. b. There is tilization of a nonjdgmental staff that is trained in cltral sensitivity. 3. Primary medical care shold be combined with dentistry and ophthalmology two essential, nmet needs. 4. Case managers shold collaborate with service providers to ensre contining access to care. 5. Care settings shold be chosen based on level of service, commitment and sensitivity to the commnity. 6. There shold be coordination of care by case managers to ensre availability of services. 7. Treatment plans shold be designed to improve patient s HIV medical stats and address social service needs. 8. Intense relapse prevention efforts shold be tilized throgh se of psychiatry and sbstance se disorder conseling. 9. Case managers and otreach workers shold meet clients on their trf to sell the service. 10. Project administrators and edcators shold market their program to other providers and collaborating agencies to disseminate information abot available services. For more information, see: HIV/AIDS Brea, Special Projects of National Significance Program. Training manal: creating a jail linkage program. Rockville, MD: U.S. Department of Health and Hman Services, Health Resorces and Services Administration; file-pload/resorces/jail%20linkage%20program%20 IHIP%20Training%20Manal.pdf 16

34 33 of 47 Project START Pls Project START Pls is an adaptation of Project START, an individal-level, mlti-session linkage to care and risk redction program for PLWH retrning to the commnity after incarceration. It is based on the conceptal framework of incremental risk redction and provides tools and resorces to increase awareness and redce risk of HIV, STI, and Hepatitis. ii Pilot stdies demonstrated that 100% of participants received their spply of medication, 75% received a prescription for their medication, 93% filled their prescriptions, and 96% were linked to HIV care in commnity. A fact sheet was prodced, and key points are smmarized below: 29 Project START Pls began two months before release and contined for three months post-release. Key Points The Project START Pls program consisted of six one-on-one sessions with each client to help them smoothly reintegrate into the commnity and maintain HIV treatment. The program began two months before release and contined for three months post-release. The pre-release sessions focsed on linkage to care, transitional needs, individalized risk behaviors and criminogenic factors (sitations or factors that are likely to case criminal behavior). Sessions inclded information and assistance with enrolling for health insrance, obtaining medical docmentation for medications and prescriptions, referrals to social services, individal goal sheets, needs assessments, and post-release follow-p schedling. The post-release sessions inclded meeting with participants within 48 hors of release at their commnity medical provider s location, assring medication was obtained, assisting in making ongoing referrals and linkages to CBOs, reviewing and pdating goal sheets, providing risk redction edcational materials, and transitioning the participants to longer-term care. For more information, visit: ii One qarter of HIV-infected persons in the U.S are also co-infected with Hepatitis C virs (HCV), and among HIV-infected injection drg sers, HCV is common with 50-90% prevalence. HCV is one of the most important cases of chronic liver disease in the U.S, and liver damage progresses more rapidly in in HIV-infected individals. The U.S Pblic Health Service/Infectios Diseases Society of America gidelines recommend that all HIV-infected persons be screened for HCV infection. ( 17

35 34 of 47 Philadelphia Linkage Program s Care Coach Model With a focs on bilding relationships with clients, health providers, the criminal jstice system, and commnity agencies, this ActionAIDS model was a linkage to care program that inclded two key staff positions: care coach and care otreach specialist. The care coach had smaller caseloads of typically 25 clients, and worked one-on-one with clients dring incarceration and p to 24 months post-release, with services tailored to individal needs. Care coaches assisted in the transition from jailbased medical care to commnity based care and commnicate with parole/probation officers to ensre client nderstanding of the legal parameters of their release. The care otreach specialist worked with a care coach, and served as an advocate, medical escort, and health edcator, ensring consistent collaboration between clients, care coaches and medical providers. The Care Coach Model delivered mlti-tiered services with the engagement of commnity partners. Information from their report, Secring the Link, is smmarized below. 30 Considerations for Program Development For the sccess of any correctional linkage-to-care program, it is crcial to establish relationships with key correctional facility staff and administrators. It is important for interested organizations to discss how the proposed service program cold be helpfl, and shold provide concrete research, program otcomes, and epidemiological data with these key staff and administrators. ActionAIDS, the Philadelphia ASO that created and coordinated the program, developed relationships with the following personnel: City commissioner of jails Chief of medical operations of the correctional facility Wardens, private contracted medical providers Infectios disease doctor of the correctional facility Jail social services Chaplain services Re-entry committee It is also important to identify and develop relationship with commnity agencies and key commnity stakeholders: Commnity HIV medical providers Office of adlt parole and probation Specialized corts within jrisdiction Local pblic health departments Sbstance se disorder treatment and recovery Mental health services Hosing services Programs shold consider their existing HIV testing protocol and personnel who will be involved in the testing. It may also be helpfl to consider hosting monthly collaborator meetings to create stronger ties among the partnering agencies. Action- AIDS tilized these monthly meetings, where the grop spent approximately one hor discssing a client anonymosly. This allowed the care coach to se this information to create a more in-depth service care plan. These meetings also led to stronger ties and expedited client appointments within the collaborating agencies. Transparency and clear program parameters are also two important components of program design and implementation, as well as nderstanding training and secrity clearance protocols and developing a standardized data collection system. Steps to Program Implementation Step 1: Program Referral Protocol The ability to identify potential clients qickly is important for the sccess of a linkage to care program, de to the sometimes qick processing and release cycles. A program shold develop a referral protocol that reflects the type of facility and average length of stay, and allows adeqate and realistic time from referral to intake. Pre-release visits shold also be coordinated to link individals to case management services before release. In some cases, Compassionate Release referrals may be needed if hospice/palliative care wold be more appropriate for an individal. Referrals to the Philadelphia Linkage Program were primarily made within jails throgh: Infectios disease doctors. Electronic medical records. Health services administrations. Jail social services. Hospice. Referrals received from the commnity inclded: Commnity medical providers. Pblic defenders offices. Medical case managers from other agencies. Family members and partners. Client self-referrals. Step 2: Intake and Assessment Upon referral, staff shold condct an intake session with the client at the correctional facility to introdce the program and staff, complete forms, and condct a risk assessment. Dring the 18

36 35 of 47 intake session, the program staff shold also review the service agreement and get ensre that the reqired client consent forms and agreements are completed. ActionAIDS developed the Acity Vlnerability Screening (AVS) tool to refer clients to appropriate services and allocate services to those most in need. It was sed to identify those with the highest need who were then sbseqently placed in the longer-term Care Coach Model service. Those with less need were assigned to short-term linkage services. This assessment is condcted prior to release and repeated every six months for 24 months while the client is engaged in care services. Step 3: Client Engagement and Pre-Release Visits Correctional linkage-to-care programs are dependent on pre-release meetings with clients. Engagement between clients and staff bilds a spportive relationship and facilitates conversations and change. It is optimal to prepare for release one to two months prior to release, bt de to a lack of predictability, it is best to foster a relationship dring every visit. It is important to have a clear and goal-oriented plan, and obtaining appropriate releases of information and completed applications will help expedite client s linkage-to-care pon release. In anticipation of possible high-risk activities clients may engage in pon release back into the commnity, case managers can facilitate discssions abot harm redction, overdose edcation, and secondary prevention dring incarceration. Step 4: First Day-Ot Planning The most important isse to address on the first day ot is hosing, and knowing what resorce are available immediately is the key to ensring linkage to care. The Care Coach Model provides the following considerations when planning for the first day of release: What is the correctional facility s release plan? Does the client have an appropriate and safe environment to go following release? What is the plan for follow-p with staff after release? Does the client need immediate food and clothing resorces? Planning for access to medication at release, especially over the weekend, helps clients remain adherent to medications. Accessing a pharmacy that is familiar with yor program and poplation can make this process easier. Step 5: Immediate Post-Release Follow-p It is essential for staff to make an immediate connection with clients post-release. They shold meet with clients in their home commnities or neighborhoods, or encorage walk-ins to the office. If the assigned case manager is not available, there shold be a backp case manager or intake worker to see the client as soon as possible. The Care Coach Model provides 24-hor access to case management services throgh emergency, on-call coverage, ensring that clients can be connected to services dring evenings or weekends. Step 6: Care Otreach Services In the Care Coach Model, each client is also assigned a care otreach specialist. These are commnity health workers who serve as advocates, medical escorts, and health edcators. They serve as a liaison between the client, case manager, and medical providers. Once the client is in care, the care otreach specialist completes their core appointments in 30 days. These inclde: Department of Pblic Welfare application. Social Secrity Insrance benefits application. Cort cost and fines payment plan. Residency information obtainment. Identification obtainment. Other services that may be necessary inclde phone services, mental health assessment and insrance navigation. Step 7: Transitioning to Longer-Term Systems of Care Sccessfl and comprehensive linkage to care programs help PLWH transitions into long-term systems of care. The Care Coach Model works with clients for p to 24 months to be able to link them to more services and spport their retention in care and medication adherence, ntil they are eventally transferred to general case management. Closre can be difficlt, bt it shold be woven in to all sessions. It is helpfl to have closre gidelines to best serve the client s needs. For more information on considerations for program development and the steps of program implementation, see the ActionAIDS and AIDS United report Secring the Link: 19

37 36 of 47 Change Team Model In Delaware Stdy In 2008, the Criminal Jstice Drg Abse Treatment Stdies (CJ-DATS) was lanched by the National Institte on Drg Abse (NIDA) to better nderstand the organizational isses that affect implementation of evidence-based services in correctional settings. 31 In response to NIDA s priority of HIV care improvements in correctional facilities, the HIV Services and Treatment Implementation in Corrections (HIV-STIC) protocol was developed. 32 This mltisite research program condcted randomized trials to test the effectiveness of a change team process improvement model for improving HIV services in correctional settings, compared to a control that solely received a directive from correctional administrators to improve HIV services. 33 Both experimental and control grops received baseline training abot the HIV service continm, HIV prevalence and isses among offenders, and evidence-based HIV services in corrections for HIV prevention, testing, and linkage to care. The project was composed of nine research centers each linked with a criminal jstice partner organization. The criminal jstice partner (typically an administrator from the criminal jstice organization) decided on which aspect of the HIV services continm needed the most improvement in their local system, sch as prevention, edcation, and testing while incarcerated, and linkage to HIV care pon retrning home. Gided by a modified NIATx (Network for Improvement of Addiction Treatment) process improvement strategy, a local change team consisting of frontline staff who work directly with the HIV services needing improvement was developed. The change process was facilitated by an external coach who was trained in the NIATx treatment model. 34 Among the participating organizations were the Center for Drg and Health Stdies (CDHS) at the University of Delaware and the Delaware Department of Correction (DE DOC). These organizations decided to focs on improving linkage to HIV care for individals retrning home after release. The findings and lessons learned from their stdy, as fond in Improvements in Correctional HIV Services: A Case Stdy in Delaware, are smmarized below. 35 The Change Team Model, Process, and Procedre After the baseline training, the research staff, criminal jstice partner, corrections facility sponsor (typically a DOC administrator), the head nrse for the contracted DOC medical provider and the NIATx coach came together to select the change team leader (CTL) and other members. According to the HIV-STIC protocol, the sggested qalities and credentials of the CTL inclde the ability to interact with all levels of management, lead- 20

38 37 of 47 ership, commnication, delegation skills, experience making changes, energy, enthsiasm, ability to instill optimism, and a goal-oriented and systematic approach. For this site, the head nrse was chosen as the CTL, and other members of the change team inclded staff from a contracted sbstance se disorder treatment facility, other nrses, and representatives from a commnity-based HIV treatment organization. The change team was then presented the NIATx model by the external coach. An important element to the NIATx approach is a walk-throgh of the service that the change team is seeking to improve. 36 This provides the opportnity to improve their nderstanding of what the client experiences when trying to access and participate in services. Experiences and findings from the walk-throgh were presented to the change team and information was then sed to inform goals and develop strategies for improving service delivery. Another important element of the NIAtx approach and the change team model was the rapid cycle testing approach, which inclded monthly meetings to discss changes being made to address barriers sing the Plan-Do-Stdy-Act concept: Plan: Team brainstorms ideas for a strategy to improve a process or service. Do: Team takes those ideas to action and works on implementing change. Stdy: Team tracks barriers, facilitators, and progress Act: Teams adopts, adapts or abandons changes depending on stdied reslts. The goal of these meetings was to engage in discrete and obtainable short-term process goals, which cold be achieved in less time and brden. Once goals are met and progress is being made, meetings were redced to once every other month. Otcomes and Implications for the Ftre Dring the stdy period, only five PLWH were released, making it difficlt to measre improvement at the client level. However, the change team and walk-throgh led to improvements of the process for linking PLWH care pon release. Two sccessfl otcomes inclded: (1) increased commnication between the Department of Corrections (DOC) medical provider and the commnity HIV provider throgh a commnication form containing information on individals being discharged with HIV, their appointments in the commnity, and re-incarceration, and (2) significantly redced discharge paperwork throgh the creation of a standardized form. The original six-page linkage to care discharge form mimicked exactly the forms the commnity HIV provider sed. The change team was able to condense it into a one-page, specific form, sable by both the DOC and the HIV provider. Simple and efficient, this form was ltimately written into DOC policy. Additionally, the change team introdced an opt-ot qestion for HIV testing to the medical intake packet, which sbstantially increased the nmber of HIV tests condcted. These improved HIV testing procedres were not pt into DOC policy, and ths staff training and by-in of the new procedre is important for those facilities that do not have it as protocol. Finally, the change team fond that the HIV edcational packet given to individals at medical intake was otdated and written at a reading level that was too technical and advanced. The change team was able to pdate the material, format it to be appropriate for a fifth-grade reading level, and translated it to Spanish. These changes greatly increased access to the HIV edcational materials. The pdated packet was added to the reqired medical intake packets at each facility. In conclsion, the NIATx model for implementing change provided participants with a process to implement changes, and evalate changes from the start. The walk-throgh and change team process led to ptting the commnity HIV provider and DOC medical provider in direct contact, which ltimately led to a more efficient and standardized process of linking incarcerated individals with HIV to care in the commnity pon release. The walk-throgh and collaborative meetings opened the opportnity to identify barriers and improve them, sch as expanding access to HIV testing and edcation. The change team introdced an optot qestion for HIV testing to the medical intake packet, which sbstantially increased the nmber of HIV tests condcted. 21

39 38 of 47 Trobleshooting Q&A What is the role of ASOs and CBOs in linkage to care programs? As seen throghot this report, ASOs and CBOs played an integral role in all linkage to care programs and projects. For some, like Philadelphia s Linkage to Care program, the ASO Action- AIDS created and coordinated the program. In the change team model program, staff of ASOs were members of the teams and assisted with transitional needs assessments and linking clients to commnity providers. In the EnhanceLink project, the grant recipient varied; some were ASOs and some were departments of health. In the latter case, those organizations and facilities contracted with ASOs for varying needs sch as transitional services sch as hosing or drg se disorder treatment programs, or for staff to act as case workers for the clients. Whether heading the creation and coordination of the program, or contracting with facilities or departments of health, ASOs and CBOS play an integral role in linking released individals to the HIV care they need. not DPH provides primary care. If DPH is a health service provider, then it may be best to have DPH coordinate discharge planning. 39 In the case that DPH is not a health service provider, it may be more appropriate to have a commnity health center or AIDS service provider coordinate the incarcerated individal s discharge planning. However, key personnel within local DPH may be instrmental to program sccess by helping to provide connections to commnity-health service providers and providing epidemiological and srveillance data. 40 What if the prevalence of HIV in commnities and jails/ prisons is low in my area? 41 Areas with low prevalence will not be able to identify a large nmber of new PLWH in jails/prisons nor link a large nmber to care. However, the majority of jails across the contry are small with low HIV prevalence, so it wold be wise to develop models that work in those settings. One strategy may be to clster jails or develop a consortim of jails that apply for a grant together. Linkage to care programs can be costly, how can we control costs and ensre cost effectiveness? 37 The EnhanceLink interventions were fond to be cost effective at an average cost of $4,219 per client. Some cost-effective practices proven by EnhanceLink: Have a case manager work closely with jail medical staff and engage in cross-ctting. For example, obtaining medical records from commnity clinicians to redce lab work dplications and diagnostic evalations. If a client is pre-trial, case managers be able to negotiate to have their home HIV medications to be given in jail. Coordination of medical records. By examining client s past charts and determining if they had been seen in the commnity previosly, a case conference can be established between the commnity doctor and jail medical director to provide specialty care in collaboration. The EnhanceLink interventions were fond to be cost effective at an average cost of $4,219 per client. What role shold local or state departments of pblic health (DPH) play? 38 How can we ensre sccessfl data collection? 42 There are many strategies that can minimize brden and help ensre complete, accrate data sbmission on the effectiveness of the implemented linkage to care programs: Consider and redce brden to both incarcerated individals and providers. Train providers to collect the data (develop a training crriclm, have pdate trainings, se train-the-trainer models). Make instrments similar in content and format to forms crrently in se (as simple as possible). Compile list of freqently encontered problems with the completion of forms. Establish open commnication directly with the providers. Secre by-in and participation from all project partners. Establish conseqences for the evalators of incomplete data sbmission Ensre fll access to medical records for program staff while simltaneosly ensring confidentiality: provide only information that necessary. Consider whether to provide monetary incentives for participants. Create a cltre of compliance with evalation protocols with spport from fnders. An effective linkage program shold be based on clarifying the role of the local DPH. Roles will vary depending on whether or 22

40 39 of 47 What are some strategies to spport individals pon release? 43 The time immediately following release is when clients are most vlnerable. It s important to address their priorities, and offer spport. To avoid relapse, risk-taking behaviors, and ensre a continity of care, EnhanceLink recommends: listening to their stories and concerns. asking open-ended qestions. being nonjdgmental and encoraging patients to be honest abot behaviors. nderstanding where patients are coming from and their priorities. providing transportation services where possible. providing referrals to necessary services, sch as healthcare, food, hosing, and clothing. schedling a meeting with a case manager at the time of release, if possible. accompanying patients to their first medical appointment. spporting patients in meeting parole and probation reqirements Post-release can get complicated, what are the first steps to take? From Philadelphia s Linkage Program 44, some sample first steps that Care Coaches took after release are as follows: Call Correctional Health Services administrator to reqest client s discharge paperwork, inclding: medication list, inclding crrent prescription of ARTs discharge photo identification Update client locator information with crrent information, sch as address and phone nmber. Schedle (or confirm) a medical appointment with the commnity medical provider. Sbmit prescriptions to client-preferred pharmacy, along with method of payment (Ryan White HIV/AIDS Program AIDS Drg Assistance Program (RWHAP ADAP), pharmacetical patient assistance program, etc.) Check insrance stats (throgh the se of yor state s eligibility verification system). Sbmit applications for health insrance/rwhap ADAP as needed. Complete RWHAP certifications and/or other applicable certifications for region. Link client with food and clothing resorces. Link client with emergency shelter, if needed. Link client with sbstance se disorder and mental health treatment as needed. Initial intake assessments have been made, and post-release plans have been established. What shold be done dring the remaining time the client is incarcerated? Once all post-release plans are in order, dring the period of incarceration case managers can facilitate edcational discssions with clients as part of standard edcation in anticipation of possible engagement in high-risk activities pon release. Isses to focs on will be specific to each individal, bt common topics inclde: ART medications, adherence, drg and alcohol resorces, overdose prevention, mental health and trama recovery, disclosre of HIV diagnosis, referrals for vocational services or General Edcational Development (GED) programs. 45 Internal precations need to be taken within the correctional facility to protect the confidentiality of all individals when they are called down for medical care services. What are some ways we can take HIV and stigma into consideration? If an ASO is coordinating the linkage to care program within corrections facilities, consider naming the program independently of the ASO, especially if yor agency is identified as a commnity provider for PLWH, or has the words HIV or AIDS in the name. For example, ActionAIDS is a commnity-based ASO in the Philadelphia area. It called its jail services program the Philadelphia Linkage Program and all printed materials provided do not indicate that it is a program of ActionAIDS. Additionally, internal precations need to be taken within the correctional facility to protect the confidentiality of all individals when they are called down for medical care services

41 40 of 47 Athor Disclaimer Jennifer Bishop Health Policy Fellow, The Fenway Institte MPH Stdent, Boston University School of Pblic Health Editors Tim Wang, MPH Health Policy Analyst The Fenway Institte This pblication was prodced by the National Center for Innovation in HIV Care, The Fenway Institte, Fenway Health with fnding nder cooperative agreement #U69HA27176 from the U.S. Department of Health and Hman Services, Health Resorces and Services Administration, HIV/AIDS Brea. The contents of this pblication are solely the responsibility of the athors and do not necessarily represent the official views of HHS or HRSA. Sean Cahill, PhD Director of Health Policy Research The Fenway Institte Pamela Wilson, MSW, LCSW-C Division of Policy and Data Health Resorces and Services Administration HIV/AIDS Brea 24

42 41 of 47 References 1 Marschak, L., Berzofsky, M., & Unangst, J. (2015, Febrary). Special Report: Medical Problems of State and Federal Prisoners and Jail Inmates, Retrieved from content/pb/pdf/mpsfpji1112.pdf 2 Kpers, Terry A.(2010). Role of Misogyny and Homophobia in Prison Sexal Abse. UCLA Women's Law Jornal, 18(1). clalaw_wlj_ Retrieved from: item/6p54x5qm 3 Toch, H. (1998). Hypermasclinity and prison violence. In L. H. Bowker (Ed.), Research on men and Masclinities: Masclinities and violence (Vol. 10, pp ). Thosand Oaks, CA: SAGE Pblications Ltd. 4 ActionAIDS. (n.d). Care Coach Collaborative Model. Retrieved from 5 Ibid. 6 Gay Men s Health Crisis. (2012). HIV in U.S. jails and prisons: Bilding a national dialoge for change. Retrieved from HRSA-CDC. (2007). Opening Doors: The HRSA-CDC Corrections Demonstration Project for People Living with HIV/AIDS. Retrieved from files/file-pload/resorces/openingdoors.pdf 8 Rollins School of Pblic Health, Emory University: The Evalation and Spport Center. (2007). Enhancing Linkages to HIV Primary Care in Jail Settings. Retrieved from pdate pdf 9 HIV/AIDS Brea, Special Projects of National Significance Program. (2013). Training manal: creating a jail linkage program. Rockville, MD: U.S. Department of Health and Hman Services, Health Resorces and Services Administration. Retrieved from creating-jail-linkage-program-training-manal 10 The Bridging Grop: Project START Pls. (Accessed 2016). Project START for People Living with HIV (PLWH). Retrieved from Sheet.2016.pdf 11 ActionAIDS and AIDS United. (2016) Secring the Link: A Gide to Spport Individals Transitioning Back Into the Commnity from Jail. Retrieved from data/files/site_18/resorces/secring%20link/sif16_secringthelink_final.pdf 12 Swan et al. (2015). Improvements in correctional HIV services: A Case stdy in Delaware. Jornal of Correctional Health Care, 21(2), doi: / Walmsley, Roy. (2016) World Prison Poplation List, 11th Edition. Institte for Criminal Policy Research. Retrieved from downloads/world_prison_poplation_list_11th_edition_0.pdf 14 World Prison Brief and Institte for Criminal Policy Research. (Accessed 2016). Highest to Lowest-Prison Poplation Total. Retrieved from prison-poplation-total?field_region_taxonomy_tid=all 15 Marschak, L., Berzofsky, M., & Unangst, J. (2015, Febrary). Special Report: Medical Problems of State and Federal Prisoners and Jail Inmates, Retrieved from content/pb/pdf/mpsfpji1112.pdf 16 CDC. (2015). HIV Among Incarcerated Poplations. Retrieved from 17 International Association of Providers of AIDS Care: The AIDS InfoNet. (2014). HIV in Prisons and Jails. Retrieved from 18 CDC. (2015). HIV Among Incarcerated Poplations. Retrieved from 19 Hghes, T., & Wilson, D.J. (Accessed 2016). Reentry Trends in the U.S. Brea of Jstice Statistics. Retrieved from Barry et. al. (2008). Is Jail screening associated with a decrease in Chlamydia positivity among females seeking health services at commnity clinics? San Francisco, Sexally Transmitted Diseases, 35(12). doi: / OLQ.0b013e31815ed7c8 21 Conklin, T. J., Lincoln, T., & Flanigan, T. P. (1998). A Pblic Health Model to Connect Correctional Health Care with Commnities. American Jornal of Pblic Health, 88 (8), As cited in GMHC, HRSA-CDC. (2007). Opening Doors: The HRSA-CDC Corrections Demonstration Project for People Living with HIV/AIDS. Retrieved from files/file-pload/resorces/openingdoors.pdf 23 Rollins School of Pblic Health, Emory University: The Evalation and Spport Center. (2007). Enhancing Linkages to HIV Primary Care in Jail Settings. Retrieved from pdate pdf 25

43 42 of HRSA-CDC. (2007). Opening Doors: The HRSA-CDC Corrections Demonstration Project for People Living with HIV/AIDS. Retrieved from files/file-pload/resorces/openingdoors.pdf 25 U.S. Government Pblishing Office. (April 2011). 24 CFR Denial of Admission and Termination of Assistance for Criminals and Alchohol Absers. Code of Federal Reglations. Retrieved from CFR-2011-title24-vol4/CFR-2011-title24-vol4-sec HIV/AIDS Brea, Special Projects of National Significance Program. (2013). Training manal: creating a jail linkage program. Rockville, MD: U.S. Department of Health and Hman Services, Health Resorces and Services Administration. Retrieved from creating-jail-linkage-program-training-manal 27 World Health Organization. (Accessed 2016). HIV/AIDS: Treatment and Care. Retrieved from topics/treatment/en/ 28 Altho AL, Zelenev A, Meyer JP, et al. (2012). Correlates of retention in HIV care after release from jail: reslts from a mltisite stdy. AIDS Behav. doi /s The Bridging Grop: Project START Pls. (Accessed 2016). Project START for People Living with HIV (PLWH). Retrieved from Sheet.2016.pdf 30 ActionAIDS and AIDS United. (2016) Secring the Link: A Gide to Spport Individals Transitioning Back Into the Commnity from Jail. Retrieved from files/site_18/resorces/secring%20link/sif16_secringthe- Link_final.pdf 31 Dcharme, L. J., Chandler, R. K., & Wiley, T. R. A. (2013). Implementing drg abse treatment services in criminal jstice settings: Introdction to the CJ-DATS stdy protocol series. Health and Jstice, 1(5). doi: / Belenko et al. (2013). A clster randomized trial of tilizing a local change team approach to improve the delivery of HIV services in correctional settings: Stdy protocol. Health and Jstice, 1(8). doi: / O Connell et al. (2013). A continm of care model for HIV in correctional settings. In B. Sanders, Y. Thomas, & B. Deeds (Eds.), Crime, HIV and health: Intersections of criminal jstice and pblic health concerns (pp ). New York, NY: Springer Press 34 McCarty et al. (2007). The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and retention. Drg and Alcohol Dependence, 88, Swan et al. (2015). Improvements in correctional HIV services: A Case stdy in Delaware. Jornal of Correctional Health Care, 21(2), doi: / McCarty et al. (2007). The Network for the Improvement of Addiction Treatment (NIATx): Enhancing access and retention. Drg and Alcohol Dependence, 88, HIV/AIDS Brea, Special Projects of National Significance Program. (2013). Training manal: creating a jail linkage program. Rockville, MD: U.S. Department of Health and Hman Services, Health Resorces and Services Administration. Retrieved from creating-jail-linkage-program-training-manal 38 Rollins School of Pblic Health, Emory University: The Evalation and Spport Center. (2007). Enhancing Linkages to HIV Primary Care in Jail Settings. Retrieved from pdate pdf 39 Ibid. 40 ActionAIDS and AIDS United. (2016) Secring the Link: A Gide to Spport Individals Transitioning Back Into the Commnity from Jail. Retrieved from files/site_18/resorces/secring%20link/sif16_secringthe- Link_final.pdf 41 Rollins School of Pblic Health, Emory University: The Evalation and Spport Center. (2007). Enhancing Linkages to HIV Primary Care in Jail Settings. Retrieved from pdate pdf 42 Ibid. 43 Ibid. 44 ActionAIDS and AIDS United. (2016) Secring the Link: A Gide to Spport Individals Transitioning Back Into the Commnity from Jail. Page 20. Retrieved from org/data/files/site_18/resorces/secring%20link/sif16_secringthelink_final.pdf 45 Ibid. 46 Ibid. 26

44 43 of Boylston Street, 8 th Floor Boston, MA nationalhivcenter.org nationalhivcenter@fenwayhealth.org The National Center for Innovation in HIV Care, 2017

45 44 of 47