Tools + Tips For Providing Transitional Care Coordination

Tools + Tips For Providing Transitional Care Coordination

January 2017
Author:
IHIP
HRSA HIV/AIDS Bureau
Manual Cover

This handbook details New York City Correctional Health Services’ Transitional Care Coordination intervention model, including program planning, implementation steps, and lessons learned. New York City was a SPNS grantee funded under the larger EnhanceLink study.

This handbook is meant to:

  • Train staff
  • Inform implementation, expansion, and refinement of jail-related care coordination work, and
  • Help organizations strategize how they approach these activities.

The handbook provides insight into negotiating and forming partnerships with other organizations in order to find common ground and advance organizational missions, while maximizing and improving patient health outcomes.

This handbook can assist anyone interested in improving continuity of health care by transitioning clients from jail to community care. The network of organizations that may participate in a Transitional Care Coordination model include health and hospital centers, public health agencies, community-based organizations, Ryan White HIV/AIDS Program recipients and providers, substance use and mental health providers, jail health administrators, and others.

This document can also be used by those inside correctional departments, as well as those outside the system, as long as they demonstrate a caring and nonjudgmental approach and dedication to do this work.

To also read a fact sheet infographic about this work, see the "Transitional Care Coordination Overview."