Linking incarcerated individuals living with HIV to community-care and treatment services upon release from jail is an important element of stopping HIV transmission.
In a poster presented at the Association of Nurses in AIDS Care Conference (ANAC 2019) a team of investigators from Cooper University Medical Center highlighted their work in providing linkage to community care to inmates with HIV in the Camden County Correctional Facility.
According to the abstract, inmates at the facility have their HIV treatment needs met while incarcerated but the lack of transitional care coordination has led many individuals to fall off of the care continuum upon release. This problem is exacerbated by behavioral issues, mental illness, substance abuse, displacement, and the cycle of incarceration.
Transitional care from the corrections setting to primary care in the community is a Special Project of National Significance (SPNS) initiative funded by Health Resources and Service Administration (HRSA) and administered by AIDS United (AU). The authors’ institution, Cooper Early Intervention Program (EIP), received funding to work in partnership with Camden County Jail (CCJ).
The partnership built a staff of a program manager, 2 transitional care coordinators, and a data manager. The program manager, an advanced practice nurse, is responsible for project administration, supervision of staff, and acts as backup data manager. The care coordinators consist of a registered nurse and a social worker who are certified HIV counselors and are tasked with being responsible for patient engagement and education while also serving as health liaisons to the court and coordination of care upon release.
The transitional care coordinators and social workers also meet with clients while they are still incarcerated to determine their needs and to develop a discharge plan by lining up community resources to meet their particular needs.
The authors of the report note that by implementing this program, the EIP could reengage individual lost to care and link diagnosed individuals to treatment.
In the abstract, the authors indicate that this project has encountered both successes and challenges including the turnover of the warden, and a newly implemented bail reform program. The team identifies the greatest challenges to engagement in care as addiction, mental illness, homelessness, and recidivism.
In total, the program enrolled 85 individuals, 72 of whom (85%) were released into the community, 53 (74%) were linked to care, and 35 (69%) were virologically suppressed.
Overall, the authors regard the program as successful in providing linkage to care from jail to community “by educating, individualizing the plan of care, and developing strategies to overcome challenges faced by incarcerated individuals.”
The abstract, “Transitional Care Coordination from Jail to Community-based care: The Nurses' Role,” was presented in a poster presentation on Thursday, November 7, at ANAC 2019 in Portland, Oregon.