The goal of Integrating HIV Innovative Practices (IHIP) is to enable health care providers to implement proven innovations within their own practices and clinics. This Webinar is the second in a three part series featuring grantees of the Health Resources and Services Administration’s Special Projects of National Significance (SPNS) initiative on Jail Linkages, as they share lessons learned and advice for others hoping to create or expand similar programs. Learn how to build a new jail linkage program and what to consider for expanding an existing one. Jail Linkages SPNS grantees—including Dr. Timothy Flanigan of Miriam Hospital, Alison Jordan of New York City Department of Health and Mental Hygiene, and Dr. Ann Avery of Care Alliance Health Center describe the steps their programs took to implement their respective jail linkage programs, and provide advice for others hoping to replicate this work.

1. How to Build and Expand a Jail
Linkage Program
September 27, 2013

2. Agenda
 Introduction
to SPNS Integrating HIV Innovative
Practices (IHIP) project
 Sarah Cook-Raymond, Impact Marketing +
Communications
 Presentations



from
Dr. Anne Avery, The Atlas Program
Dr. Timothy Flanigan, Alpert Medical School of Brown
University/The Miriam Hospital
Alison Jordan, New York City Department of Health and
Mental Hygiene, Correctional Health Services/Transitional
Health Care Coordination
Q
&A

3. IHIP Resources on
TARGET Center Website

4. IHIP Jail Linkage Resources:

Lessons Learned Manual

Implementation Guide

Webinar Series
 HIV and Jails: A Public Health Opportunity – archive
recording available at careacttarget.org/ihip
 How to Build and Expand a Jail Linkage Program –
September 27, 2013 at 12pm ET
 Creating Partnerships and Navigating the “Culture of
Corrections”- October 3, 2013 at 2pm ET
www.careacttarget.org/ihip

5. Other IHIP Resources

Buprenorphine
 Training Manual, Curricula, and Webinars on Implementing
Buprenorphine into Primary Care Settings

Engaging Hard-to-Reach Populations
 Training Manual, Curricula, and Webinars on Engaging
Hard-to-Reach Populations

Oral Health
 Forthcoming: Training Manual, Curricula, and Webinars on
Oral Health and HIV

6. HIV Testing and Linkage to care in a
Jail Setting:
Establishing a Successful Program
THE ATLAS PROGRAM
ASSESS, TEST, LINK: ACHIEVE SUCCESS
CLEVELAND, OHIO
Ann K Avery, MD

7. Background: Care Alliance
 Federally Qualified Health Center (FQHC)
 Primary populations:
Homeless
 Public Housing
 HIV/AIDS
 Uninsured/Underinsured
 Services:
 Primary Health Care for All Ages
 Comprehensive Dental Care
 Substance Abuse & Mental Health Counseling
 Confidential HIV Testing, Treatment & Counseling
 2007: 7,500 Patients through over 25,000 Encounters


8. Establishing the Program
 Received SPNS Grant to establish rapid HIV testing and
linkage case management program in the Cuyahoga
County Corrections Center.
 Brand new program-no other program has presence in
the jail related to HIV testing in Cleveland.


Testing was only done in the Corrections Center when court ordered
or requested by inmate.
In 2007: 386 tests were done by medical staff with 9 positives
identified.
 Initial Goal: Establish relationship with the Corrections
Center.

9. Goals
 Introduce voluntary HIV rapid testing into
Cuyahoga County Corrections Center
Attach
an evaluation component to learn about risk
behaviors and HIV knowledge of all inmates
 Create jail based; linkage/case management program
for HIV + inmates

10. Establishing the Program
 Met with Corrections Center staff to discuss testing
program






Need within jail for testing
Rules and regulations
Staff access to inmates
Areas of jail to conduct testing
Office space within jail
Protocols for testing and medical care follow up
 Focus on the benefits to the jail

11. Implementation





Buy in from jail administration-very supportive and
accepting of this project
Obtained space in jail-our staff have their own office
Hiring personnel
Gaining access to jail for staff-all have contractors
passes for easy access in and out of jail and to
inmates
Bringing in all testing and office supplies

12. Establishing Community Partnerships
 Contacted local medical clinics, ASOs, Ryan White
Planning groups, and the Cleveland Department of
Public Health for support


Opened referral system for medical care and community social
services for inmates identified as positive
Established resource support from Department of Public
Health


Test kits
Received support from Ryan White planning groups

Ryan White Part A, Part B, Part C, Case Management Network

13. ATLAS Program
(Assess, Test, Link: Achieve Success)
 Program Components

Rapid HIV Testing
 Voluntary Rapid Testing
Linkage Case Management
 Jail based case management
 Community Follow Up

Mental Health/Substance Abuse Counseling


Funded by National AIDS Fund

Individual Counseling

Community Linkage

14. Key Community Partners
 Jail Staff
 Community Medical Providers
 Social Workers/Case Managers
 Treatment Providers
 Community Planning Councils

15. Best Practices of Community Networking
 Be a familiar face
 Be a voice at the table for planning activities
 Maintain open and frequent communication
 Focus on continuity of care

16. Time in jail is unpredictable

17. Barriers/Challenges
 Front line jail staff’s attitude towards HIV:
stigma
 Access to men and women is different-easier to
access men
 Contraband-broad definition in jail setting, i.e.-no
cell phones, cannot walk freely through jail with
lancets-program supplies may not be appropriate

18. Lessons Learned
 Offer Educational Opportunities for front line
jail staff: through workshops and personal teaching
moments
 Flexibility/Creativity is Key: adapting to jail
environment but still providing quality services;
seeking out alternative resources for testingincluding oral swab rapid tests to easily walk through
jail; creating new protocols to access female inmates
regularly for testing

19. Ongoing Support
 Ryan White Funding
 Foundations
 City/ County resources
 Public health
 Local government
 Jails
 Correctional resources
 Local, state and national

20. THE EVOLUTION OF CORRECTIONSBASED HIV TESTING AND LINKAGE
TO CARE PROGRAMS:
THE RHODE ISLAND EXPERIENCE
Timothy P. Flanigan, MD
Alpert Medical School of Brown University/The Miriam Hospital

21. The Landscape in Rhode Island
 Rhode Island Department of Corrections (RIDOC)

single unified system: jail and prison serving the entire state
Intake Service Center
(jail)
High Security
Maximum Security
Medium Security
Minimum Security
Women’s Facilities

22. The Landscape in Rhode Island
 RIDOC and Brown University have worked together for almost
25 years
 Continuum of staff providing HIV services in the correctional
facility and in the community
 HIV testing program in effect since 1989
 Sharp decreases in the numbers of persons newly diagnosed
with HIV at RIDOC
Over a decade ago, 30% of all positive HIV tests in RI were from
RIDOC (AIDS Educ Prev 2002; 14: 45-52)
 In recent years, approximately 10 new cases a year have been
identified at RIDOC


Opt-out testing has been in place, though routine testing
would be optimal!

23. Project Bridge
 Project Bridge has served HIV-infected persons leaving the
RIDOC for almost 15 years
 Using a social work model, the program provided prison
outreach and intensive case management to HIV-positive
prisoners being released from the RIDOC facilities to
facilitate community re-entry and retention in medical care.
 Project Bridge team:



engages clients within three months of prison release
creates a discharge plan that links clients to medical care at
provider of their choice and social services following release
provides supportive services to retain clients in care

24. COMPASS expanded Project Bridge
 Challenges related to the provision of services for shorter-term jail
detainees
 Short and unpredictable lengths of stay, high rates of turnover,
and recidivism
 Risky population
The overarching goals of COMPASS:
 To enhance existing services through the implementation of:
 a jail-release program of jail-based case mangers and communitybased case managers combined with intensive community
outreach
 In order to lead to:
 improved HIV treatment, substance abuse and social stabilization
outcomes for recently released HIV+ jail detainees

25. COMPASS services provided
(jail)
 Jail-based encounters


81% of participants received at least one service encounter
from jail-based project staff while incarcerated [median 1
(range: 1-35)]
Most common services provided:

26. COMPASS services provided
(community)
 Community-based encounters

Participants

50
40
30
20
10
0
74% of participants received at least one service encounter
from community-based project staff after release median
16.5 (range: 1-130)]
Most common services provided:
45
45
40
36
Set up
Set up
Individual
Set up
appointments or
appointments or counseling/support
appointments or
equivalent
equivalent
session
equivalent
substantive contact substantive contact
substantive contact
with social services with other provider
with other health
provider
care provider

27. Linkage to care
 Linkage to HIV care was documented for 52% of participants
enrolled (broadly defined by self-report, any documented visit with
health care provider, or documented PVL/CD4 test in community)
 Mean/median days to care after release: 36/24 (range: 2-164)
35% linked within 30 days
 14% linked between 31-90 days
 6% linked between 91-180 days


Those linked to care within 6 months of release were significantly
more likely to have reported a usual health care provider or place
where s/he got HIV care at baseline (p=0.01)

28. General findings
 Services inside the jail, such as HIV education and discharge
planning, can make a difference
 Experience over time also shows value of community-based
intervention during the transition period
 Engagement in care and viral suppression are possible but
interventions may require more than a “one-size-fits-all”
approach
 Remember the importance of not “overpromising” services – be
realistic

29. Enhancing Jail to Community Linkages:
NYC Lessons Learned
Alison O. Jordan, LCSW
Executive Director
New York City Department of Health and Mental Hygiene,
Correctional Health Services / Transitional Health Care Coordination
Rikers Island, NY

30. RIKERS ISLAND
Vernon C. Bain Center, Bronx
Brooklyn
Detention
Center
Manhattan
Detention Center
Transitional Health Care Coordination

31. Jail
Discharges to
NYC
Communities
by Zip Code and
Socioeconomic Status 2004
Over 70% of those
released from NYC jails
to the community
return to the areas of
greatest socioeconomic
and health disparities.
Correctional Health is Public Health

32. Background
The NYC jail system is the 2nd largest in the country with
12 NYC Department of Correction (DOC) facilities
• 85,000 new admissions
• ADP: 12,300 (most pre-trial detainees)
• Average length of stay: 32 days (median closer to 8)
The NYC DOHMH Correctional Health Services (CHS)
coordinates all medical, mental health and discharge planning
• Over 78,000 monthly medical visits
• Discharge Planning – Population-based for mentally ill (13k);
HIV-infected (2.5k); others at high risk (1.5k)
• All jails use electronic health record

33. Continuum of Care Model
Transitional Care
Coordination
• Opt-in Universal Rapid HIV
Testing
• Primary HIV care and
treatment including
appropriate ARVs
• Treatment adherence
counseling
• Health education and risk
reduction
Jail-based Services
•
•
•
•
•
Discharge Planning starting on Day 2 of incarceration
Health Insurance Assistance / ADAP
Health information / liaison to Courts
Discharge medications
Patient Navigation: accompaniment, home visits,
transport, and re-engagement in care
• Linkages to primary care, substance abuse and mental
health treatment upon release
Community-based Services
•
•
•
•
•
•
•
•
HIV Primary Care
Medical Case Management
Health promotion
Patient Navigation: accompaniment, home
visits, and re-engagement in care
Linkages to Care
Treatment adherence and Directly Observed
Therapy (DOT), as needed
Housing assistance and placement
Health Insurance Assistance / ADAP

34. Facilitate “Warm Transitions”
a social work approach to public health interventions to facilitate access to care
Client Level:
• Begin Where the Client is; harm reduction model.
• Plan for both options: Stay or Go; treat each session as last
Program Level:
Expect the Unexpected
• Train staff: Motivational Interviewing & stages of engagement in care
•Hire those who care &
– Meet DOC requirements (i.e. no longer on parole, no new charges 3+ yrs)
– Demonstrate cultural competency and understanding of CJ impact
– Ability to communicate in clients’ primary language when possible
Health Liaison to the Courts
Systems Level:
• Track outcomes (i.e. post-release linkage to care and 90d follow up)
• Arrange transitional services (i.e. discharge medication, after care
letter, medical summary / lab reports, transportation, and accompaniment)
• Ask community health clinics to set aside walk-in hours

35. Systemic Barriers
•
Solutions
Challenges
Short-term stays are norm • Intake History and PE
•
•
• universal voluntary < 24 hrs
• ongoing offer thereafter
~25% leave in 2-3 days
~50% leave within 7 days
•
Limited time to diagnose
• Work from self-reports
•
Multiple providers
• Single oversight
•
Limited time to start
treatment, maintain care
• Discharge plan asap
•
Paper records
• Electronic Health Records
•
Post-release tracking
•
• engage in housing areas
• transport / accompaniment
Health Information Exchange
removing barriers

36. Critical Skills
Community-Based
Organizations
Probation
Parole
Health Dept.
Courts
Staff
Corrections
Funders

37. Establishing Relationships
At All Levels:
•
•
•
•
•
•
Greet with a smile and a handshake
Listen first; then ask Key Questions
– How do things work now? What do
you need? Can you help me?
– Be clear and set realistic,
measurable & achievable goals
Begin where you can
Align expectations with abilities
Build trust
– Start with winnable battles
– Need to share at least 5 positive
messages before 1 negative one
can be received
– Set everyone up to succeed
– Set clear expectations and deliver
Expect to give more than you receive
Within the Correctional System:
•Know the Chain of Command
– Informal and formal roles
– Identify a Champion
– Work with those interested
•Shared benefits (programs lead to
reduced violence, improved security)
•Acknowledge additional work for
Correctional staff (escort / transport,
ensuring your staff’s safety)
•Demonstrate that you’re accessible
– Visit often; be a familiar face
• Know who to approach for:
– Jail access and security training
– Space in jails to interview clients

38. Maintaining Partnerships
On going communication is essential
•
Arrange and participate in activities with both corrections and community partners
–
–
–
–
•
•
•
brown-bag lunches and picnics
orientation sessions and Training sessions
employee recognition events
health and wellness events
Offer to provide information sessions during roll call
Rotate meeting locations
Site Visits: Have jail-based staff visit community locations
Lessons Learned:
• Don’t shy away from hard work. The biggest skeptic may
become your biggest supporter.
• Listen to others already doing this work – they know how
to navigate the system without interfering with Corrections
operations/orders.
• Don’t underestimate the power of saying “thank you”.
• Word travels fast -- If people have positive (or negative)
experiences working with you, others will hear.

39. Project Enhancements
• Improve acceptance of follow up rapid HIV testing
– Acceptance rate increased from 30% to 60%
• Integrate Court / Parole advocacy
– Release rate increased by 20%
• Post-release follow-up / tracking
– Over 100 followed for 12 months post-release
• Integrate with new EHR
– eClinical Works correctional system live in all jails
– Case management templates implemented 5/13

40. Program Outcomes
2008-2012
3000
89%
n=17,010 self-reported HIV-positive admissions to NYC jails (2008-2012)
91%
2500
2008
2009
78%
2000
2010
2011
2012
74%
1500
1000
500
0
Offered a Plan
Received a Plan
2,700
Released with a Plan
2,456
1,910
Linkage to Primary Care
1,420

41. Linkages Evaluation Outcomes
Averages for 249 with 6 month post-release Jail Linkages follow up/clinical review:
Client Level Outcomes
• Improvements shown by increased CD4 count (372 to 419)
• More taking medication (from 62% to 98%)
• Fewer report hunger (from 20.5% to 1.75%)
•
Overall health and mental health improved (SF-12 PCS from 47.9 to
50.4; SF-12 MCS from 44.8 to 47.5)
Program Impact
Saving lives
Saving money
• Treatment adherence improved (from 86% to 95%)
• Improved viral Load (from 52,313 to 14,044)
• Increased proportion with undetectable vL (<48) from 11% to 22%
Systems Implications
• Fewer homeless in month prior: from 23% to 4.5%
•
Fewer Emergency Department visits: from .61 to .19

42. Continuing Enhancements
•
•
•
•
•
•
•
•
•
Working w/ NYS Links to enhance and replicate program
Preliminary discussions with SNPs to improve access
Linkage agreements / Memorandum of Understanding
SAMHSA ORP pilot collaborations
Bronx Health and Housing Consortium participation
Health Liaisons to the Courts
Criminal Justice and Health Home workgroup
Bronx Health Home pilot
SPNS Latino Populations

43. Contact Us
• Alison O. Jordan, Principal Investigator
ajordan@health.nyc.gov 917-748-6145
• Paul A. Teixeira, Evaluator
pteixeira@health.nyc.gov 347-774-7174
• Jacqueline Cruzado-Quinones, Project Coordinator
jcruzado@health.nyc.gov 917-715-6841

44. Next steps
 Expansion of this model can have broader impacts
Project Bridge and COMPASS have merged to be a single
program
 Coming Home program at St. Luke’s Hospital - medical and
supportive services for individuals returning from prison/jail and
have any chronic disease(s), provided by formerly incarcerated
staff and peers.
 Evidence that risk behaviors decreased among hepatitis C infected
persons with linkage to care
 Other IHIP resources are available online at:
www.careacttarget.org/ihip
 Creating a Jail Linkage Program
 Engaging Hard-to-Reach Populations
 Integration of Buprenorphine into HIV Primary Care Settings


45. Q&A
To be informed when these upcoming IHIP resources are ready,
sign up for the IHIP listserv by emailing scook@impactmc.net.
Connect with Us
Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications |
Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300