Transitional Care Coordination: From Jail Intake to Community HIV Primary Care

 

This intervention is part of the Dissemination of Evidence-Informed Interventions project—the first SPNS project of its kind to apply a rigorous implementation science approach and evaluate intervention replication and fidelity of evidence-informed intervention models across the country.

This transitional care coordination intervention has been informed and adapted from the best practice findings of a past SPNS initiative that yielded successful HIV care continuum outcomes among client participants.

A Jail + Public Health Intervention

Jails concentrate marginalized individuals with a range of social and health problems into one place. Jails offer a window of opportunity to intervene and connect with this otherwise hard-to-reach population. Collaborations between public health agencies, community-based organizations, and jail health services have implications for public health and safety efforts and have been proven to facilitate linkage to care after incarceration.

Replication Package Resources

These evidence-informed intervention resources were developed to support interested sites in replicating this intervention and the necessary implementation processes.

Training to Implement

Additional Information

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About this Intervention

  1. What is it?
    An evidence-informed intervention for strengthening connections between community health centers and jail health care systems.
  2. Why is it needed?
    Without transitional assistance, people with HIV who are released from jail are at risk of: unstable housing; lack of access to health insurance and medication; overdose due to period of detoxification; exacerbation of mental health conditions; and lack of social supports when exposed to the same high-risk communities from which they were incarcerated.
  3. Who can deliver it?
    Organizations, agencies, clinics, health departments and jails.
  4. How do I use these resources?
    These resources are meant to support replication of the intervention. Manuals outline replication processes and curricula support training activities. Additional resources help provide insight from grant recipients or from other areas of the project.

Care and Treatment Interventions (CATIs)

An outcome of the Dissemination of Evidence-Informed Intervention project is the development of Care and Treatment Interventions (CATIs). These are replication resources that have been tested across the country on four key evidence-informed intervention topics. CATIs help arm Ryan White HIV/AIDS Program recipients with tested SPNS models that they can apply at their sites, clinics, and jurisdictions to advance the HIV care continuum and in advancing the goals to Ending the HIV Epidemic (EHE).