ank nijhawan, md, mph esmaeil porsa, md, mph
DESCRIPTION
Improving the HIV Care Continuum in Incarcerated and Recently Released Individuals through Stakeholder Engagement. Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH. Disclosures. We have no actual or potential conflict of interest in relation to this program/presentation. Outline. - PowerPoint PPT PresentationTRANSCRIPT
IMPROVING THE HIV CARE CONTINUUM IN INCARCERATED AND RECENTLY RELEASED INDIVIDUALS THROUGH STAKEHOLDER ENGAGEMENT
Ank Nijhawan, MD, MPHEsmaeil Porsa, MD, MPH
Disclosures We have no actual or potential conflict of
interest in relation to this program/presentation
Outline Overview of the Dallas County Jail Description of the Dallas HIV/AIDS Re-
entry Coalition (HARC) HIV Testing at the Dallas County Jail Linkage to care for HIV+ Releasees Lessons learned from stakeholder
engagement
Dallas County Jail, Today• 7th largest county jail in the US
• Average daily intake of 275 new arrestees
• Average daily census of 6500 inmates
• 84% Male, 16% Female
• Health care delivery is entrusted to Parkland Health & Hospital System
Health Care Staff• Medical:
– Physicians-16– Physician Assistants-11– Nurse Practitioners-5
• Mental Health:– Physicians-8– Physician Assistants-4– Nurse Practitioners-3– Mental Health Liasions-8– Psychological Accessors-2– Psychologist- 2– LVNs- 6– RNs- 4– Medical Assistant- 3
• Dental:– Dentist- 2– Dental Assistant- 2
Nursing: Managers- 5 RNs- 59 LVNs-78 Medical Assistant- 21 Phlebotomy Tech- 2 Radiologic Technologist- 2 Respiratory Care Practitioner- 1
Pharmacy: Clinical Specialist-2 Pharmacists-11 Pharmacy Techs-8
Optometry: Optometrist- 0.2 Medical Assistants- 0.2
Health Services ProvidedHealth Screening for ALL inmates upon arrival & yearlyTB Screening for ALL inmates upon arrival & yearlyAcute & Intermediate Medical and Mental health In-patient CareChronic & Urgent Medical and Mental Health Care (including Crisis and Suicide)Respiratory Therapy and Respiratory IsolationOb/Gyn Care Including Screening OB US of all New Pregnant InmatesHIV ClinicAnti-Coagulation ClinicDental ClinicDialysis CareOrthopedic ClinicVoluntary HIV/Syphilis testingOptometry CareRadiology
Process Flow
Consent Decree
• In 2006, the Dallas County entered a consent decree agreement with the DOJ to address 73 areas of non-compliance with best practice standards for health care and sanitation in the Dallas County Jail (DCJ)
• DCJ underwent 8 biannual week-long surveys by DOJ consultants which resulted in the successful exit of the Dallas County jail from the consent decree in November of 2011
Dallas County Jail Today
You cannot improve what you don’t measure
Daily Reports Vitals Completion Report Glucose Completion Report Detox Completion Report
Daily Dashboard
Intake Dashboard Report
Emergency Walk-in Report
Daily Tower Productivity Report
Daily Staff Activity Report
HIV Pending Visits Report
Lab/EKG Pending Report MAP Pending Report Missed MAP report
Optometry Pending Report Dental Pending Report Detox Pending Report Medical Visit Pending Report Mental Health visit Pending Report
Nurse Med Management Report Missed Meds Report OB/OBGYN Pending Report PAP Pending Report Accuflo Scan Touch Report Sick Call Pending Report TB Report Wound Care Report CBO Report Parkland Visits Report
Daily DashboardParkland Health and Hospital System : Jail HealthDaily Dashboard Date: 8/18 8/19 8/20 8/21 8/22 8/23 8/24 8/25 8/26 8/27 8/28 8/29Jail Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thurs
Admissions (Intake) 166 251 269 280 297 248 231 172 276 309 277 315Discharges (Release) 156 242 304 309 314 313 157 164 280 321 341 296Census Adult Census 6322 6287 6242 6247 6218 6163 6274 6345 6258 6259 6224 6251Medical - Acute Care Census (acuity 1) 6 5 5 3 7 7 7 7 4 7 7 10Medical - Intermediate Care Census (acuity 2&3) 77 79 72 77 85 84 84 84 87 82 85 85Psych - Crisis Stabilization Program Census 9 9 8 10 14 11 7 6 8 8 8 8Psych - Acute Care (CBO) Census 165 162 166 169 173 169 172 176 170 174 166 169Medication Management Patients on Medications - Adult 2687 2717 2800 2791 2784 2760 2678 2581 2776 2810 2794 2712Number of Doses Dispensed - Adult 7892 7960 8363 8315 8379 8312 8018 7703 8185 8468 8447 7682Requests Clinician Orders 412 519 675 838 852 802 602 429 710 747 811 753Sick Call Request - General 73 86 89 112 99 123 108 86 136 104 120 125Sick Call Request - Mental Health 22 28 27 32 24 43 20 14 35 41 35 40Encounters Medical Assessment Program Encounters 97 88 92 81 118 107 79 74 76 104 115 110Medical Provider Encounters (MD/PA/NP) 7 197 248 229 229 218 10 7 263 267 321 270Nursing Encounters 639 872 872 991 1022 1175 935 935 1278 952 1146 1149Emergencies Visits 54 37 41 34 53 36 42 35 40 49 53 32Parkland Visits ER Send Outs 8 3 8 9 9 7 7 6 10 11 4 5Jail Pts in Parkland Inpatient 11 11 12 12 13 15 12 9 14 15 15 14Parkland Appts 0 12 12 12 15 11 0 0 12 8 15 10
Weekly Reports• Dental Appointments Waiting Report• Infirmary Location by Acuity Report• Med Reconciliation • Administration Dashboard• Pharmacy Dashboard• Prescription Dashboard
• Pregnant Patient Report• RAT Team Log• Parkland Returns
Monthly Reports 90 day Chronic Care Patient Report
Chronic Care Report
Coumadin Process Measures
Dental Process Measures
HBA1C Report
HIV Monthly Report
Monthly Lab Report
Med Management Process Measures
Med Pass Process Measures
INR Report
Medical Provider Report
Mental Health Provider Report
Neely Report
Nursing Productivity Report
Nursing Orders
OB/OBGYN Monthly Report
Monthly Insulin Report
Sick Call Report
Specialty Care Process Measures
Intake Process Measures
POCT Summary Dashboard
HIV Monthly Report
16
Outline Overview of the Dallas County Jail Description of the Dallas HIV/AIDS Re-
entry Coalition (HARC) HIV Testing at the Dallas County Jail Linkage to care for HIV+ Releasees Lessons learned from stakeholder
engagement
What is HARC? HIV/AIDS Re-entry coalition A community-level inter-agency collaboration aimed at
improving the HIV care continuum in incarcerated individuals Group of stakeholders from various agencies include:
Case managers HIV providers Mental health providers Substance use treatment providers Housing services providers Re-entry counselors HIV prevention staff Correctional staff Pharmaceutical representatives Local Ryan White administrators
HARC Mission Statement Improve the continuum of HIV care for incarcerated and
recently released individuals: Improve Jail HIV Testing initiatives Improve Linkage to Care program to improve access for more
patients Decrease the Community HIV viral load in the jail and in the
communities where inmates return to after release Expand the knowledge of resources available for those
incarcerated and recently released Improve communication between correctional and
community stakeholders. Study the impact of changes implemented by the group
on the continuum of HIV care for the recently released
Agencies Represented Parkland Health and
Hospital Systems UT Southwestern
Medical Center AIDS Arms, Inc. TCU Project Reconnect Homeward Bound Legacy counseling City of Dallas Housing
Department of State Health Services
Dallas County Grants Management
Dallas Urban League AIDS Healthcare
Foundation AIDS Services of Dallas AIDS Interfaith
Network Gilead Sciences Bristol-Myers Squibb
Services provided by HARC participants
HIV prevention/ education
HIV/STD testing HIV medical care Linkage to care Case management/
care coordination Substance abuse
treatment
Transportation Administer grant
money Research Mental Health
counseling Housing Emergency aid Educational
services
How are agencies funded? Federal
HRSA/Ryan White parts A,B, MAI
CDC NIH SAMHSA HOPWA
State DSHS
City of Dallas Dallas supervision and
corrections HUD
Insurance for services Private/HMOs Medicare,
Medicaid Ryan White Value Options
Other Grants
Group priorities for the HIV Care Continuum
030
100
80
60
40
20
0
DiagnosedLinked
to CareRetained
in Care
Prescribed ART
Viral Suppression
82
66
37 3325
Patie
nts,
%
CDC-Hall, International AIDS conference 2012
Outline Overview of the Dallas County Jail Description of the Dallas HIV/AIDS Re-
entry Coalition (HARC) HIV Testing at the Dallas County Jail Linkage to care for HIV+ Releasees Lessons learned from stakeholder
engagement
HIV Testing at Dallas County JailAgency When Type #/monthHealth Department
Intake 8-noon on weekdays;After in jail
Blood draw 20537
UT Southwestern
After in jail Blood draw 7
Parkland HIV prevention
After in jail, targeting MSM
Oraquick 105 210
Parkland Jail Health
After in jail Blood draw 112
DCHHS testing
2013 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD
HIV Tested 59 37 48 37 17 16 46 25 32 21 53 52 443
HIV New Positive
0 0 0 0 0 0 0 0 0 0 0 0 0
HIV Previous Positive
0 0 0 0 0 0 2 0 0 0 0 1 3
HIV Negative 59 37 48 37 17 16 44 25 32 21 53 51 440
Agency Time period
# tested
HIV neg
HIV pos
New pos
Prev undx seropositivity
UTSW 2013 89 86 3 3 3.37%Parkland Jul 2013-
Dec 2013
625 622 3 1 0.16%
Parkland Dec 2013-May 2014
1250 -- 3 2 0.16%
UTSW and Parkland HIV jail testing results
Parkland Jail Health
2013 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTDHIV
Tested116 100 131 143 111 112 129 116 95 100 111 87 1351
HIV Positive 40 24 36 27 37 28 24 42 26 24 24 18 350
HIV Negative
76 76 95 116 74 84 105 74 69 76 87 69 1001
HIV New Positive
0 0 0 0 1 0 1 0 0 1 0 2 5
HIV+ Seen by
Provider39 24 35 27 37 27 23 40 25 22 23 17 339
On HIV Therapy
29 15 23 19 26 22 12 26 15 16 11 11 225
Released 1 0 1 0 0 0 1 1 1 1 0 1 7
Refused 1 2 0 0 0 1 0 1 0 1 1 1 8% HIV
Positive Tests
34% 24% 27% 19% 33% 25% 19% 36% 27% 24% 22% 21% 26%
Outline Overview of the Dallas County Jail Description of the Dallas HIV/AIDS Re-
entry Coalition (HARC) HIV Testing at the Dallas County Jail Linkage to care for HIV+ Releasees Lessons learned from stakeholder
engagement
Snapshot of HIV+ Released InmatesReceiving Case management at Dallas County Jail
December 2012-February 2013
25 receive care from other ASO / out of county
76 Transferred:48 TDCJ7 Reincarcerated21 released to other mandated facility/program
64 Scheduled for Intake/Follow up
30 kept intake/follow up
22 did not keep appointment or are currently out of care
(though CM still attempts linkage)
165 HIV+ InmatesSeen by Case Manager
89 Released to community
12 future visit scheduled
47%
Snapshot of HIV+ Released InmatesReceiving Case management at Dallas County Jail
December 2014-February 2014
45 receive care from other ASO / out of county
73 Transferred:47 TDCJ7 INS/US Marshall2 Reincarcerated20 released to other mandated facility/program
47 Scheduled 40 Contacted for Intake/Follow up
27 kept intake/follow up
7 did not keep appointment 7 unable to contact(though CM still attempts
linkage)
165 HIV+ InmatesSeen by Case Manager
92 Released to community
6 future visit scheduled
58%
Outline Overview of the Dallas County Jail Description of the Dallas HIV/AIDS Re-
entry Coalition (HARC) HIV Testing at the Dallas County Jail Linkage to care for HIV+ Releasees Lessons learned from stakeholder
engagement
Achievements to date Improved communication and collaboration
between agencies Increase in HIV testing Potential support (through CDC) for a dedicated
linkage coordinatorFuture directions:Increase HIV testing further (opt-out/routine)Increase referrals to HARC agenciesIncrease linkage to careMeasure and improve clinical outcomes
Challenges Progress is slow, resistance to change Maintaining momentum Politics– agencies competing for grant
funding, clients
Conclusions It is possible to change a low performing
jail system into a high performing one with good leadership
Jail health is a great place for quality improvement
Stakeholder engagement is an important component of process improvement
The HIV Cascade of care in corrections needs to be measured and improved and stakeholder engagement can be a facilitator of change
Dallas RWPC Needs Assessment- Incarceration questions
Dallas RWPC Needs Assessment- Incarceration questions
Dallas RWPC Needs Assessment- Incarceration questions
HIV testing at the jailAgency
Dates Interval
#Tested
#Positive
% pos New pos
Parkland
9/11-2/12
6 mo 372 0 0 0
DHHS 1/12-6/12
6 mo 1456 11(3 false
+)
0.75 1
DallasTotal
-- -- 1828 11 0.6 1
Testing venue
Agency Location
#Test # Positive
% positive
Parkland Kays Tower
372 0 0
DHHS Bookin 780 6 0.77DHHS Pods 325 4 1.2DHHS Kite 116 1 0.86DHHS JDC 192 0 0
Characteristics– DHHS only
Race Total (% tested)
# positive
% positive
Black 813 (57%)
5 0.6
Hispanic 358 (25%)
1 0.3
White 230 (17%)
4 1.7
Other 12 (0.9%)
1 7.7
Asian 2 (0.1%) 0 0Pacific Islander
2 (0.1%) 0 0
Native American
1 (0.1%) 0 0
Age group (DHHS/Parkland combined)
Age Total (% tested)
# positive % positive
12-17 220 (12%) 0 018-24 437 (24%) 1 0.2325-34 497 (27%) 4 0.835-44 280 (15%) 4 1.445-54 146 (8) 2 1.455-65 245 (13%) 0 0
Gender Total (% tested)
# positive
% positive
Female 526 (36%) 4 0.75Male 911 (64%) 7 0.76
Demographic Snapshot HIV+ Inmates Released Dec 2012-Feb 2013
122 male42 female
1 transgender
What do we know about this 165 served while incarcerated?
Average Age: 39Age Range: 20-63
HIV Diagnosis Range: 1990-2012
RACE:102 African American ( 62%)
42 Caucasian ( 26%)18 Hispanic ( 11%)
1 other (<1%)