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

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

IHIP Resources on TARGET Center Website

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

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

T H E A T L A S P R O G R A M A S S E S S , T E S T , L I N K : A C H I E V E S U C C E S S

C L E V E L A N D , O H I O A n n K A v e r y , M D

HIV Testing and Linkage to care in a Jail Setting:

Establishing a Successful Program

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

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.

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

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

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

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

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

Key Community Partners

Jail Staff Community Medical Providers Social Workers/Case Managers Treatment Providers Community Planning Councils

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

Time in jail is unpredictable

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

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 testing-including oral swab rapid tests to easily walk through jail; creating new protocols to access female inmates regularly for testing

Ongoing Support

Ryan White Funding Foundations City/ County resources Public health Local government Jails

Correctional resources Local, state and national

THE EVOLUTION OF CORRECTIONS-BASED HIV TESTING AND LINKAGE

TO CARE PROGRAMS: THE RHODE ISLAND EXPERIENCE

Timothy P. Flanigan, MD

Alpert Medical School of Brown University/The Miriam Hospital

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

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!

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

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 community-

based 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

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:

COMPASS services provided (community)

Community-based encounters 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

01020304050

Set upappointments or

equivalentsubstantive contactwith social services

provider

Set upappointments or

equivalentsubstantive contactwith other provider

Individualcounseling/support

session

Set upappointments or

equivalentsubstantive contact

with other healthcare provider

Parti

cipan

ts

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)

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

Enhancing Jail to Community Linkages:

NYC Lessons Learned

New York City Department of Health and Mental Hygiene,

Correctional Health Services / Transitional Health Care Coordination Rikers Island, NY

Alison O. Jordan, LCSW Executive Director

RIKERS ISLAND

Manhattan Detention Center

Brooklyn Detention

Center

Vernon C. Bain Center, Bronx

Transitional Health Care Coordination

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

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

Continuum of Care Model

• 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

Transitional Care Coordination

• 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

Community-based Services

Facilitate “Warm Transitions”

Client Level: • Begin Where the Client is; harm reduction model. • Plan for both options: Stay or Go; treat each session as last

Program Level: • 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

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

Expect the Unexpected

a social work approach to public health interventions to facilitate access to care

Health Liaison to the Courts

• Short-term stays are norm • ~25% leave in 2-3 days • ~50% leave within 7 days

• Limited time to diagnose • Multiple providers • Limited time to start

treatment, maintain care

• Paper records

• Post-release tracking

• Intake History and PE • universal voluntary < 24 hrs • ongoing offer thereafter

• Work from self-reports • Single oversight • Discharge plan asap

• engage in housing areas • transport / accompaniment

• Electronic Health Records

• Health Information Exchange

Challenges Solutions

removing barriers

Systemic Barriers

Health Dept.

Courts

Probation

Community-Based Organizations

Corrections

Funders

Parole

Staff

Critical Skills

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

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.

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

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

Program Outcomes 2008-2012

2,700 2,456 1,910 1,420

89%

91%

78%

74%

0

500

1000

1500

2000

2500

3000

Offered a Plan Received a Plan Released with a Plan Linkage to Primary Care

20082009201020112012

n=17,010 self-reported HIV-positive admissions to NYC jails (2008-2012)

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 • 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

Linkages Evaluation Outcomes

Saving lives Saving money

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

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

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

Q&A

Twitter: @impactmc1| Facebook: ImpactMarCom |www.impactmc.net | 202-588-0300

Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications |

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