Supporting HIV care through education and innovation

Getting Started

Getting Started

September 2013
Author:
IHIP
HRSA HIV/AIDS Bureau

In this chapter

“I don’t do doctors; I don’t do appointments; I don’t do court. Nothing! If it didn’t have to do with from the block of my house to the block where the drug dealer was, I did not go . . . I had my own little circle of life . . . if it wasn’t for [EnhanceLink staff member] or anyone I wouldn’t have anything that I have right now. And I have a lot . . . I have another appointment. My doctors do want to keep track of me because it’s the beginning. She said for the first couple of months she wants to see me every month, and I think that’s to see how I’m getting along emotionally, how I’m coping.” 3

— EnhanceLink participant

The intervention strategies recommended for jail settings include increasing HIV case-finding through additional or expanded testing; effectively engaging HIV-infected persons into care (in-reach); providing ART treatment (either directly or through community health system linkages); improving continuity of and retention in care post-release; and initiating secondary prevention interventions.5,50

The EnhanceLink evaluation center identified some strategies for building a strong and successful program. “[M]any administrative issues are involved in implementing programs. Appropriate and effective information sharing is critical to successful linkage programs, including:

  • Having appropriate space for the program in the jail;
  • Coordinating the new program with existing services;
  • Authorizing community-based organizations, public health departments, and other outside organizations to work in the facility; and
  • Meeting facility security requirements.” 51

Characteristics that may influence a jail program design include prevalence of HIV in the community and within the jail; average daily jail population; and mean and median length of stay. 51

Overview of a Jail Linkage Program

Major components of EnhanceLink activities will be described in more detail in the following pages. To provide context of what a jail linkage program looks like at a glance, some common steps were taken by EnhanceLink grantees, including:

  • HIV testing or inmate self disclosure, and mental health and substance abuse screenings;
  • Recruitment (including informed consent) and enrollment into the program;
  • Pre-release intensive case management intervention (typically, within 24 hours and at least within the first 48 hours) and individualized discharge plans;
  • Medical care and HIV education, including risk reduction, ongoing while in jail; and
  • Post-release intensive case management (continuity of care) linkages to address mental health and substance abuse treatment needs, HIV primary care, and basic survial needs. 31

SPNS Grantees and AIDS Education and Training Centers (AETCs) Team Up

Some sites utilized their local AIDS Education and Training Center (AETC) to provide training and additional support while implementing their jail initiative. The South Carolina local performance site of the AETC, for example, provided onsite and distance based HIV education training sessions to jail medical staff.

The Pennsylvania/MidAtlantic AETC provided technical assistance in the development of this manual and the associated implementation and pocket guides.

Source: University of South Carolina Research Foundation. The South Carolina linkage program for inmates (SCLPI). Final report. 2012. [unpublished.]

Staffing

Having nonjudgmental, culturally competent staff that both want to be engaged in jail work and with inmates is integral to a successful program. 31 Specific positions may vary by the size of the jail population being served and the community-based organization’s internal capabilities. At some grantee sites, roles included different titles or persons were charged with multiple roles. While titles for staff varied across grantee sites, many of the responsibilities to perform the steps outlined above were similar.

All EnhanceLink participants were HIV-positive so they were either initially engaged by an HIV tester or they self disclosed. If HIV testing is taking place and being administered by jail medical staff, an effective referral system between medical or testing staff and the community-based organization is essential. 43 In some grantee sites, the jail medical staff included persons who split their time between the site and a community clinic where inmates would be referred upon release. This approach assisted with continuity of care but was not always feasible. In sites where jail medical staff (i.e., no outside facility staff) performed HIV testing, inmates with a positive result were promptly referred to an individual to discuss medical needs. In some cases this person was called a medical case manager or a patient care coordinator. (See also “Linkage Services.”) At EnhanceLink sites where mental health staff and housing counselors existed within the jail, these onsite staff members were brought in as inmate needs dictated. Patient educators or health educator/risk reduction counselors offered health education to inmates. 31 (See also “Risk Reduction Education.”)

The following information may be helpful to those who wish to establish and evaluate a jail program, EnhanceLink grantees had a principal investigator or program evaluator; some of the larger sites had research assistants and data managers as well. In some cases, the principal investigator also served as the head of the entire grantee project, while other sites differentiated management of the project and oversight of the data and evaluation. 31 Requirements for maintaining confidentiality may differ—and be more difficult—for research than for clinical management. Evaluation and proof of a program’s effectiveness helps facilitate community support and aid in sustainability efforts. 43

Discharge nurse, facility coordinator, linkage coordinator, or resource coordinator were varying titles for the person responsible for beginning the process of coordinating care upon release. 31 At many sites, the same staff person met the participant in jail and then initiated followup post-release. 43 Community-based individuals accompanied releasees to appointments to ensure connection to care while care outreach workers were responsible for seeking individuals who fell out of care. 52 (See also “Discharge Planning.”) Some sites, like Philadelphia FIGHT, added additional support in the form of faith and community-based mentors and peers. 43

Some EnhanceLink grantees had capacity to create a health liaison or court advocate position, and those that did not expressed a desire to add this service to further bolster support for those they serve. In the case of Riker’s Island, the court advocate was a key position that sometimes prevented an individual from being placed in jail and, instead, helped broker an agreement with the courts for the individual to go into hospice, inpatient substance abuse treatment, or an alternative site. As one EnhanceLink participant at AIDAtlanta summarized, “I met with an [EnhanceLink] case manager several times. The court advocacy was very significant. I probably would have gone to prison without it. The program played a valuable part in me getting off the streets. We put a plan together to help me get out, also an individual service plan and counseling. It gave me hope to think I had an opportunity.” 40

The role of the court advocate was to develop relationships with courts, and assist nonviolent detainees, including those on parole violations to be admitted into behavioral health treatment programs, mental health treatment programs, residential substance treatment programs, or specialized medical care (e.g. nursing home, hospice) in lieu of detention. This advocacy work requires patient consent and entails contact with attorneys, prosecutors, and court liaisons as well as acceptance from health care providers. The court advocate brings health and social service program acceptance letters and electronic health record reports to court. Confidentiality continues to be a concern and the patient/inmate needs to give informed consent and be an active participant in the planning. Not all justice systems or judges have the same approach or views; however, some EnhanceLink grantees did have success with a court advocate approach. As one grantee summarizes,

A unique and important part of these efforts has been advocacy in the criminal justice system. Clients are often treated more favorably in court when there are representatives from a program accompanying the client. The criminal justice ‘system’ views involvement with a ‘program’ as a positive step—and particularly when the program can offer help with housing, transportation and supportive ‘wraparound’ services that include transportation to probation and parole and court hearings. 5

HIV Testing

According to the EnhanceLink Evaluation Center,

“Many public health interventions—such as the administration of tests, as well as delivery of results and medical treatment—require multiple days to complete. Given how many persons exit jails rapidly, the provision of interventions during the initial days of incarceration may be challenging. One notable exception is HIV testing.” 1

The CDC Rapid HIV Testing in Jail Demonstration Project, funded from 2004–2006, demonstrated feasibility of rapid HIV testing in jails. Many findings from the study can be used to target services and testing; for example, one finding of particular importance is that 39 percent of newly identified HIV cases were among inmates whose only disclosed risk factor was heterosexual sex. Programs that target inmates for HIV testing based solely on reported risk factors may have omitted these individuals, leading the CDC to recommend routinized testing to better identify HIV infection and to reduce stigma. 4

Identification of HIV infection is a critical first step in ensuring HIV-positive individuals are linked to appropriate care and services. 4 Jails often provide HIV testing although it is less common and less systematic than in prisons. 51 Regarding testing time and costs, the EnhanceLink Evaluation Center summarized

Rapid test kits are administered on site and do not need a special license or extensive training. All types of rapid tests take 20 minutes or less from start to finish. This allows inmates to get their results immediately rather than requiring jail staff to track them down later. Most commonly, an oral swab or finger stick is done rather than a blood draw. Any reactive test still needs further testing but negative tests do not. . . . The costs of rapid and traditional HIV testing may vary by region and institution but generally the costs are less than $20, and perhaps less than $10, per test depending on the type of test performed. 20

Traditionally, early detection and case finding have not sufficiently linked inmates with community-based services upon release; 53 intake into and discharge from jail present opportunities for these activities.53-56 For the EnhanceLink project, “HIV-infected persons were offered and enrolled in linkage services at each of the grantee sites. Some of the referrals came from the jailbased testing programs, where some individuals may have learned of their HIV status for the first time. Others had a previous diagnosis confirmed by testing during the current jail stay. Still others had a previous HIV diagnosis, often occuring during a previous incarceration, and entered the initaitive without HIV testing on the new jail entrance.” 57

Nearly all EnhanceLink grantees were already engaged in HIV testing within jail facilities before the SPNS initiative grant. Before EnhanceLink, however, grantees did not have much capacity to do linkage work or did not have data to show which linkage activities were most effective. EnhanceLink funding enabled grantees to increase the amount and intensity of case management and linkage services to those found to be HIV positive and, in some cases, to bolster testing efforts. There were a few sites where HIV testing and jail intervention programs were being started. The implementation guide that accompanies this manual outlines steps for both new and expanding programs.

Important Questions When Establishing HIV Testing in Jails

For community-based organizations not readily involved in HIV testing within jails but looking to initiate such a program, the Yale University School of Medicine EnhanceLink grantee created a valuable guide, available in full here: https://careacttarget.org/content/jail-time-testing-institute-jail-based-hivtesting-program-training-manual. Some important questions they recommend considering include:

  • “Is there a medical exam at intake or shortly after?
  • Is there an opportunity to discuss HIV testing at orientation?
  • Are there programs that inmates routinely participate in individually or in groups where they can be reached?
  • What is the best shift within the jail environment?
  • Are there policies that would impede your ability to implement a new way of doing testing?
  • Is there space to do the testing and to store supplies?
  • Who will do the testing? Who will collect and process confirmatory testing? Is there staff buyin? Who will do the paperwork?
  • Is it necessary to provide financial support to the institution?
  • Who will feel threatened by what you are doing? What can you do to minimize the sense of threat?
  • Who are your champions? Who are your allies and who can help push your mission?
  • How and where will inmates get their results?
  • Will results become part of the jail medical record?
  • What is the procedure for a reactive rapid test?"

Source: Altice FL, Sylla LN, Cannon CM, et al. Jail: time for testing. Institute a jail-based HIV testing program. Yale University School of Medicine. n.d. Available at: https://careacttarget.org/content/jail-time-testing-institute-jail-based-hivtesting-program-training-manual.

Timing of Services and Interventions

As mentioned earlier in this manual, community-based organizations need to identify what services are currently taking place within the jail, including HIV testing, which often varies from jail to jail. Medical examinations that include HIV testing may occur at different places—during pre-booking, booking, post-arraignment, at their first medical encounter, or at other points. 51 Due to short average length of inmate stay, however, EnhanceLink grantees conducted HIV testing within 24 hours of intake if possible, or at least within the first 48 hours.50,58 The majority of testing took place at intake, although many sites created multiple opportunities for HIV testing through either medical visits, med lines, or self-referral sick call.30,43

Community-based organizations must understand their State laws surrounding HIV testing and the type of informed consent required. Opt-out strategies have resulted in greater rates of testing than opt-in strategies. 19

“HIV testers need to be well trained . . . as well as being compassionate and skilled in working with clients with low literacy and comprehension of the [lesbian, gay, bisexual, transgender] LGBT communities.” 43 HIV testers also need to be aware of safety issues and confidentiality. 44

With maximum privacy, inmates can use a “request to see” form at any time to request an appointment. The form requires only the name and/or position of the person they would like to meet; it does not disclose the reason for the visit. This is available to all inmates regardless of HIV status to ensure confidentiality. In addition, all data, forms, and documents are kept without individual identifiers. Discussions with patients must be confidential—something difficult to achieve in a jail setting. Determining locations to provide HIV test results and conduct assessment is an important point to negotiate with jail administration.

In working with inmates, staff will have more success if they are warm and friendly; inmates greatly appreciate receiving basic items from grantees (e.g., toothbrushes and toothpaste, clean socks, clean underwear) if permitted. For example, in Riker’s Island, grantee staff found that allowing inmates to take a shower and have some basic hygiene materials went far in increasing client willingness to participate in an HIV test. It is important, however, that testing be voluntary, and communitybased providers must avoid the appearance of coercion by giving inmates anything in return for engagement in HIV testing. If one inmate receives items, all inmates should receive the same items.

Always ask patients about their HIV status before offering testing, because some may self disclose, as was the case for many EnhanceLink participants. Individuals who self disclose should be asked about whether or not they are on treatment, if they have notified their partners, and whether they have an HIV or primary health care provider.

Treatment and Adherence

“I thought, why live? I’m still going to die. That was the way I was thinking. I didn’t want to take medication. . . So all those years I was with no medication so I got really sick . . . Now I want to go through medication and I think I do want to live. I want to take my medications. I want to go to the doctor. [EnhanceLink] brightened up my spirits a little bit . . . Really when I got locked up, and I met [EnhanceLink staff member] and went [in]to the program, and being clean, I guess made me just want to keep on living . . . I’ve been on my medication for 2 months now and I feel much better . . . I’m loving it.” 3

— EnhanceLink Participant

Inmates often have unmanaged HIV and other untreated infectious diseases when they enter jail. 7 Without linkage-to-care programs, many individuals being released do not connect to HIV primary care and begin HIV treatment. 59 Inmates already prescribed ART seldom continue it after jail release, and virological and immunological outcomes worsen. 60 In order to achieve viral suppression, ART must be taken as directed once started. Data from the HIV Prevention Trial Network study (HPTN 052) demonstrates the benefit of ART in preventing HIV transmission, 41 and jails linkage work continues this effort.

Five factors contributing to treatment outcomes for releasees include:

  1. “adaptation of case management services to facilitate linkage to care,
  2. continuity of [combination] ART,
  3. treatment of substance use disorders,
  4. continuity of mental illness treatment, and
  5. reducing HIV-associated risk-taking behaviors as part of secondary prevention.” 60

If a patient is placed on ART, complex regimens with large pill burdens should be avoided if possible. A patient’s other prescriptions should be examined prior to administering ART and discussed with patients and medical providers to avoid drug-drug interactions. Because jail stays are short, many EnhanceLink participants were not placed on ART until after they were released and connected to care. Pre release patient education about ART, however, was offered. For releasees on ART, many sites provided a small supply of medications and/or a prescription for medication.

Important topics to cover with inmates when discussing treatment include:

  • the benefits of HIV medication: its value in preventing progression to AIDS and reduction in HIV complications, including opportunistic infections;
  • addressing misconceptions about treatment;
  • how medications work;
  • integrating regimens into daily life;
  • importance of adherence and consequences of nonadherence and treatment interruptions;
  • common side effects and suggestions how to manage them;
  • dosing and names of medications; and
  • any food requirements and the effect of nutrition in medication absorption.

Risk-reduction Education

Jails offer an opportunity to provide HIV risk reduction education to those at high risk for infection but who have little knowledge of HIV or do not view themselves at risk.19,61 Grantees must be cognizant of detainees’ health literacy levels when providing education.20,62 Providing pre-release risk reduction information is important since “the time immediately following release from incarceration imparts great risk for engaging in high-risk behaviors, including relapse to drug use and unprotected and/or transactional sex,” 29 which is yet another reason to include risk-reduction discussions with inmates.

EnhanceLink grantees also provided education on additional HIV and health-related topics. Although these varied according to the population within each jail, these basics were covered:

  • HIV, STI, hepatitis, and TB overviews,
  • Prevention strategies and negotiating safe sex,
  • Techniques to deal with fear, fatigue, pain, depression, grief and loss, isolation, and anger management,
  • Communication strategies for talking with health care providers and family,
  • Conflict resolution,
  • Nutrition information,
  • Symptoms evaluation,
  • Relapse prevention (including post acute withdrawal syndrome),
  • Advance directives,
  • Job training, including mock interview/role playing, and
  • Overall wellbeing, including exercise, journaling, and spiritual needs.34,36

Community-based organizations may also want to consider counseling regarding legal issues that surround HIV, such as nondiscrimination and criminalization or enhanced punishment due to infection (e.g., prostitution, reckless endangerment for unprotected sex).

As one EnhanceLink participant stated, “For people that are HIV [positive], their main issues, their emotional issues, their soul issues, their spiritual issues…to me, from my experience and from what I see, [these] are the most critical things.” 3

Some grantee sites formalized their curriculum while others incorporated HIV and risk reduction education into broader support groups open to the entire jail population. In no cases did EnhanceLink grantees limit their educational classes to only HIV patients due to concern around confidentiality and stigma. This enabled patients to feel safe and, in some cases, spurred inmates who had opted out of testing to opt in after learning more about HIV infection. One grantee site operated a family member/loved one support group within the jail and open to all inmates; they advertised this by putting up flyers and sending out letters as well as reaching out to after-incarceration support systems to recruit participants. 31

It is important to consider that jail stays may be short when scheduling presentations as discharge can happen quickly. Because of this, several grantee sites condensed their educational topics into fewer sessions in an effort to cover more topics before inmates were discharged.

Discharge Planning

Discharge planning involves pre-release enhanced/intensive face-to-face case management, 63 and retention strategies need to be embedded into it from the beginning. 43 It is important to talk with both jail staff and detainees about a possible discharge date, recognizing that this is made difficult based on jail settings’ unpredictability. 31

The more interaction with transitional services prior to release, the better the chance for connection to care and, therefore, viral suppression. 30 However, because discharge within jails can be unpredictable, case managers should act as if each session is their last (as there may be time for only one meeting).17,30

The case manager should listen closely to inmate stories and concerns, including perceived challenges to care, as well as fears about release and HIV status (particularly if newly diagnosed), and try to address these. Release from jail represents a vulnerable time for individuals; therefore, it is important to discuss triggers associated with poor decisionmaking and risktaking. EnhanceLink case managers were often familiar with stages of change and used motivational interviewing techniques 45 (which include precontemplation, contemplation, preparation/determination, action/willpower, and maintenance or relapse). 64

Two discharge plans were drafted. One for the inmate who remains incarcerated and moves on to prison, the other for the inmate who is released into the community. The latter should “document when the patient was last in care prior to incarceration, the patient’s sources of social support and housing options, and potential obstacles to appropriate post-release care, along with strategies to address these obstacles.” 30 Each identified need should be documented and a plan established to address those needs. When the release date is known, application for public health insurance (as applicable), such as Medicaid, Medicare, and/or ADAP coverage, should be completed.

Some grantee sites provided inmates with a copy of their discharge plan; however, grantees and inmates need to be careful with paper plans—that they do not create inadvertent disclosure. In all cases, inmates should be notified when and if changes are made to it, upon which they should be given a copy of the new plan. Some EnhanceLink participants found it helpful to be given a “to do” list as part of their discharge plan to help them remember important tasks, and a list of community resources, including STD clinics, syringe exchange programs in the community, and a list of partnering community-based organizations along with relevant contact names and numbers. 40

“The goal of initiating social services at the point of discharge is to appropriately link multiple service providers to a client to achieve successful reintegration into the community; maintain healthy behaviors, including adherence to HIV care; reduce risky behaviors; and reduce recidivism.” 20

It is important to collect multiple and varied ways of reaching clients after they have been released into the community since housing and phone numbers may change. Grantees collected emergency contact information including the person’s support system as well as information about where the person hangs out, their “street name” or nickname, and any identifying tattoos or other markers. 31

Linkage Services

Linkage services include post-release referrals to care coupled with intensive case management and followup. Having a consistent advocate (whether a case manager or navigator) can create a sense of trust and rapport. In instances where an inmate is being linked to another provider, “soft handoffs” or “warm transitions” are very important. 43

Poor retention in HIV primary care is associated with increased mortality. 65 Because former inmates face many competing needs, engaging in—and retaining—HIV care may be low among their priorities. 29 After jail inmates are released, basic needs, such as food, clothing, safe housing, and even drug treatment and mental health support, often take precedence over HIV care. The most successful interventions recognized this and promoted access to and linkage in programs that meet these needs. Maslow’s hierarchy of needs provides an important framework for a successful linkage-to-care program.4,60

Linkage services provide a continuum of care from jail to the community; the goal is to do so with as little interruption as possible. To be effective and link jail releasees to the vast array of services they may need in the community means formulating or strengthening relationships with partnering organizations, knowing what community resources are available, and creating supportive relationships between jail- and community-based staff. Community partnerships varied from site to site in scope, involvement, and past working history. Collaborations included health care facilities, housing, social services, mental health, substance abuse treatment and, where possible, transportation assistance, food services, legal services, employment services, and support groups. 45

Case managers responsible for linkage services went beyond the traditional tenets of case management to offer more intensive and individualized services. Activities varied based on the capacity of each EnhanceLink grantee site and the resources available within their communities. In addition, some EnhanceLink sites focused their grant monies on those areas of need hardest to meet in their jurisdictions, such as housing. All EnhanceLink sites linked releasees to HIV primary care, substance abuse and mental health treatment, and public medical insurance, and sought to address basic survival needs as much as possible. Some sites also connected releasees to legal support (e.g., child support). A big issue for many releasees is securing identification (e.g., Social Security card, birth certificate, driver’s license, or other government identification), which EnhanceLink grantees either helped assist with or connected releasees with Ryan White case managers at partnering sites for assistance.3,4

Transitional care coordination may also include providing a copy of a patient’s laboratory results, processing ADAP or Medicaid (or other) insurance applications, and identifying ways to share health information between providers (with patient consent). 30 “Many jail settings provide mechanisms for medication continuity of care, including providing the medication that remains in a prisoner’s prescriptions, or pharmaceutical programs through which 30 days of medication can be ordered upon discharge and delivered to the service provider in the community. Community-based medication support/subsidies for gaps in insurance coverage, such as Ryan White ‘emergency medication,’ were frequently accessed to minimize treatment interruption. Local Ryan White-funded case management agencies will be aware of the existence of such resources.” 43

Factors that may enhance linkage include extent of HIV testing within jail; timeliness in delivering HIV test results; capacity to provide health services; extent of coordination with community service organizations; and program involvement to facilitate favorable court treatment. 30 Some strategies for supporting inmates upon release include

  • listening to their stories and concerns.
  • asking open-ended questions.
  • being nonjudgmental and encouraging patients to be honest about behaviors.
  • understanding where patients are “coming from” and their priorities.
  • providing transportation services where possible.
  • providing referrals to necessary services, such as health care, food, housing, and clothing.
  • scheduling a meeting with a case manager at the time of release, if possible.
  • accompanying patients to their first medical appointment.
  • supporting patients in meeting parole and probationrequirements.8,41

Whenever possible, case managers should meet releasees at the gate and transport them to critical service appointments, and continue to follow patients postrelease. 63 (Note, the time for this activity varied among grantees as staff capacities allowed.)

When possible, EnhanceLink grantees offered transportation assistance and, in some cases, provided transportation from the jail gate to transitional housing, as well as to releasees’ first medical appointment. When this was not feasible, grantees offered bus tokens or other transportation assistance within their capacity.

For releasees with substance use issues, linkage coordinators should consider discussing the risks of sharing needles and injection equipment, as well as overdose prevention and, in particular, should link them to substance abuse treatment. EnhanceLink grantees connected individuals with a range of substance abuse therapy, from inpatient to outpatient to sober homes (which sought to address drug use and unstable housing issues simultaneously). “Without appropriate diagnosis and treatment, drug relapse upon release exceeds 85 percent, which contributes to poor health outcomes.” 39 Left untreated, this vicious cycle of relapse and of recidivism will continue. 39

Several EnhanceLink grantees had previously established opioid substitution treatment with buprenorphine at their community health clinic sites or had worked with community partners who offered such a service. As grantee Yale University School of Medicine summarized, “By identifying [people living with HIV/AIDS] PLWHA before jail release, we could identify prisoners with DSM-IV criteria for opioid dependence and get them started on buprenorphine BEFORE relapse to drug use.” 66 (To learn more about how to integrate buprenorphine into HIV primary care and access training materials, visit www.careacttarget.org/ihip.)

When patients failed to attend medical appointments, EnhanceLink grantees made phone calls or sent letters, but ensured they had permission to do so and, for confidentiality reasons, did not disclose patient HIV status. For many sites, checking reincarceration was a first step in looking for a lost-to-followup client; shelters, drug and alcohol facilities, mental health facilities, hospitals, and coroner’s offices were also checked when patients could not be found. 43 Followup may take the form of neighborhood and street outreach, where workers attempt to find the releaseee by going to where they live or hang out (depending on information shared and what followup they consented to). 31

Recommendations from the EnhanceLink Evaluation Center to Address Re-Integration of Jail Inmates into the Community:

  1. "All released detainees are assessed for individualized treatment plans and linked to providers that offer a continuum of services under the observed and coordinating leadership of a deployed case manager.
  2. The program model would be designed so that foreseeable barriers are minimized or eliminated to the point that is fiscally feasible and possible when linking systems with conflicting missions (e.g., corrections systems and public health initiatives).
    • Transportation is provided from the jail on day of release to transitional housing within the community that provides substance abuse treatment.
    • Utilize a nonjudgmental staff trained in cultural sensitivity to minimize and eliminate [insensitivity and enhance inclusiveness].
  3. Primary medical care is combined with dentistry and ophthalmology, two essential unmet needs of the target population.
    a. Coordination of care is used to promote easy access for consultation on complicated medical histories, helping to expedite treatment planning.
    b. Programs should be efficient with minimal waiting time for all appointments.
  4. Case managers collaborate with service providers to help keep all client records up to date and to ensure continuing access to care.
  5. The care settings [should be] chosen based on their level of service, and commitment and sensitivity to the community.
  6. There is coordination of care by the case managers to ensure that their services are available during the reintegration process.
  7. Treatment plans [should be] designed to improve the patient’s HIV medical status and address social service needs.
  8. Intense relapse prevention efforts should be utilized through the use of consult/liaison psychiatry and substance abuse counseling.
  9. The case managers and outreach workers, [when possible should] meet clients on their turf to ‘sell the service.’
  10. The project administrators and educators market their program to other providers, including known collaborating agencies. Medical and dental society meetings; informational gatherings; AETC lectures; local AIDS consortia; social service agencies; and religious groups should all be targeted to disseminate information about the available services.”

Source: Emory University Rollins School of Public Health. Enhancing linkages to HIV primary care and services in jail settings initiative: linkage to social support services. Policy Brief. Spring 2010;1(2):4.

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