Navigator Case Management

Summary

This patient navigation-enhanced case management intervention improved linkage and retention in HIV care among people with HIV who were leaving jail to return to the community.

Summary

Resumen

Implementation Resources

Implementation Guide

Guia de Implementacion

Intervention Outcomes

• Clients were twice as likely to be linked to care within 30 days of being released from jail.
• Clients were almost twice as likely to be retained in care during the intervention period.

Intervention Components

• Secure Stakeholder Buy-in
• Assess Gaps and Resources and Hire Staff
• Conduct Pre-Release Planning Activities
• Monitor Legal Status of Clients
• Conduct Post-Release Care Plan Activities
• Implement the Care Plan
• Follow-up and Monitor Client Progress
• Graduate Clients

Cost Analysis

Cost information is not currently available. However, you can use the CIE Cost Calculator to create an estimate of the cost of implementing the intervention at your organization.

Challenges and Solutions

Challenge	Solution
Implementing a peer-based model	Involve people with peer-based intervention experience to troubleshoot potential issues. Research examples of peer-based interventions.
Funding	Secure diverse funding to help facilitate best practices for client retention. Work with a local university, foundation, or national substance use or research organizations to assess resources that are available for program services or evaluation.
Geographically distant navigators and clients	Offer flexible office hours to allow for more convenient scheduling and travel time. Provide transportation assistance.
Commitment to social justice among all involved	Convene all parties before implementation to discuss intervention planning and execution through a social justice lens. Also discuss interrelated social justice issues (e.g., mass incarceration of Black and Latinx people, the criminalization of people who use drugs) and explore solutions.

Supplementary Resources

Publications

• A Randomized Controlled Study of Intervention to Improve Continuity Care Engagement Among HIV-Infected Persons After Release From Jails

Job Aids

• NASTAD Brief: The Intersection of Hepatitis, HIV and the Opioid Crisis: The Need for a Comprehensive Response (PDF)
• Needs Assessment Form (PDF)
• Risk Assessment Form (DOCX)
• Transition Plan Form (DOCX)
• Authorization to Release Client Information Form (DOCX)
• Navigator Note Guide (DOCX)
• NASTAD Webinar: Addressing Stigma Surrounding People Who Use Drugs (YouTube Video)
• National Harm Reduction Coalition: Principles of Harm Reduction