Creating a Jail Linkage Program Curriculum: Creating a Linkage to Care Intervention


In this chapter


Major activities of a jail linkage program include enrollment, intensive case management, discharge planning, and followup,10 with the goals of connecting with HIV-positive individuals in jail and linking them to and retaining them in care upon release.

What is a Jail Linkage Program? Jail Linkage Program Steps at a Glance

  1. HIV testing or inmate self disclosure, and mental health and substance abuse screenings;

  2. Recruitment and enrollment into the program;
  3. Pre-release intensive case management intervention (typically started within the first 24 hours and at least 48 hours) and creation of individualized discharge plans;
  4. Ongoing while in jail: medical care, and HIV and risk reduction education;
  5. Post-release intensive case management (continuity of care) linkages to address mental health and substance abuse treatment needs, HIV primary care, and basic survival needs.

Source: Special Projects of National Significance (SPNS) Program Enhancing Linkages to HIV Primary Care in Jail Settings Initiative EnhanceLink Program Description Form. 2012. [Unpublished.]

Considerations for New Jail Programs

EnhanceLink did not have a single model, but there were common characteristics across sites. This work requires flexibility to match jail population needs with community resources. It is important that organizations considering this work really look at how to adapt to their specific organization, community, and the jail in which they’ll be working.11

When considering a new jail program, begin discussions with individuals and organizations most interested in this work and keep their perspectives in mind. Recognize that this work takes time, and have reasonable expectations before you get started.12

A jail’s number one priority isn’t public health; it’s safety.13 This includes controlling inmate movement and visitor movement.14 Working in the jail is very different than working in the community. As a community provider, you are the guest and at all times must abide by the jail’s rules, and understand the structure and staffing hierarchy of the jail where you’re working.15 Review “Culture of Corrections” in the accompanying training manual if you haven’t already.

Before a community-based organization reaches out to a jail, they should do the following:

  • Research the local correctional setting. This can be done through online Web site research, speaking with leaders in the community, and talking to
    other organizations who may be working within the jail. Community-based organizations should be knowledgeable about and understand the correctional setting when approaching the jail; this includes what services are currently provided.
  • Identify the benefit you’re providing to the jail and to key jail personnel. Community-based organizations need to present the value-add of having them work within the jail rather than an impression of increasing workload or costs. Determine service gaps you can help fill, and tie your work to mutual interests and priorities. If jails are lacking in something
    that you can provide, that something might be your “in.”16
  • Identify a champion within the jail. It’s important to have an influential jail administrator on your side to help work through administrative hurdles and secure further correctional buy-in.17
  • Determine the feasibility of a jail linkage program. See the EnhanceLink initiative evaluation center program checklist.

What should organizations anticipate?

Anticipate a lot of meetings with high-level administrators as well as meetings with jail medical staff. Ask the jail staff questions rather than telling them what it is you would like to do in their space. Listen to them with an open mind and talk through how you might be able to work together. Flexibility and open lines of communication are musts.

Working in the jail will take time and clearance. This typically requires a background check and fingerprinting. Regardless of badge type, you are always a visitor who must adapt to the jail requirements.

You are building on an existing structure, so adapt and build within that structure.18 Once the program is in place, ensure any newly proposed activities or changes to the current structure are discussed with the jail administrator and you receive a confirmatory letter from them.19

Working in the jail: questions to consider

You may have found answers to these questions through researching the jail or have additional questions of your own. These are not meant to be exhaustive but rather a jumping-off point to think through how to work within the jail:

  • What is the jail’s perspective toward HIV?
  • What is the prevalence of known HIV?
  • Is testing taking place within the jail, and if so, how is it conducted (e.g., opt-in versus opt-out) and who is conducting it?
  • How are HIV-infected inmates cared for or treated?
  • Are sufficient medical services available to handle HIV care within the facility?
  • Are members of your team allowed to move through certain areas of the facility unescorted, or will they need an escort?
  • If they need an escort, can arrival time be coordinated?
  • What times is custody staff busy with count or unit transfers? Are there better/worse times of day for them to help you? How will inmates be called down to meet you?
  • What are the times for certain scheduled activities within the jail, including meals and scheduled nursing assessments (e.g., diabetes, hypertension, drug detox)?
  • Where are the Officer stations?
  • What areas will you have access to?
  • What percentage of inmates go on to prison?
  • What are you allowed and not allowed to bring in (e.g., phone, computer, pagers, pens, paperclips, stapled documents)?
  • What services does the jail need that your organization might offer?20-22

What are the common institutional barriers?

It is important to identify challenges up front. These often include the following, to which your program will have to adapt:

  • Missions of correctional system and public health initiative may be viewed as conflicting.
  • Lockdowns are a reality and will cause delays.
  • Competing jail priorities may cause delays or even interrupt your interviews; these may include meal times, visitation hours, religious services, or alarms.23
  • Accessing patient medical histories can be difficult.
  • Talk to inmates, however. Many grantees found that inmates will tell them what services they need if asked.
  • If you have staff with histories of incarceration, know that they may not be cleared to work in the jail even if they have passed requirements with your organization’s human resources department.

Startup takes time, and there will be bumps in the road navigating different work cultures, security, and permissions. Be patient and persistent to get through all the organizational levels, however, as it’s worth it. It is important to realize that every issue doesn’t necessitate push-back; pick your battles.

What are the common patient barriers?

  • Intoxication/inability to consent. Some individuals may be acutely intoxicated when admitted into the jail and unable or unwilling to participate in an intervention at this time. To overcome this, grantee sites consequently created multiple points in time following incarceration to offer HIV testing and linkage services.24
  • Unknown length of stay. Many individuals are pretrial detainees, so whether they’re leaving or staying a day, a week, a month, or a year is unknown.25 Educational and discharge planning sessions may need to be condensed for this reason.
  • Mistrust. Lack of trust both of the jail and medical establishments have left some communities, particularly communities of color, reticent to participate in a linkage program, or to undergo HIV testing.26,27

Who should organizations partner with?

  • Organizations in the jail. To start, identify any local organizations that may already be working within the jail and whether you might be able to partner; see “Checklist for Project Development” and don’t reinvent the wheel. There can be huge advantages in working with an organization that has history within the jail, the knowledge of how things work, as well as the spectrum of services being provided either directly by the jail or by other community-based organizations that are there.28
    If other groups are working in the jail, share lessons learned,29 identify mutual interests, and discuss what service gaps may exist for your organization to fill. In doing so, you can create a stronger continuum of care without duplicating services.30
    If there is an organization within the jail whose skills overlap with those of your agency and that typically competes for funding, it may take a little longer to iron out roles and clarify that you’re hoping to complement their work. Meetings between respective organization heads can be advantageous, as institutional buy-in at the top can improve greater organizational buy-in overall.
  • HIV primary care and supportive services. Identify key community stakeholders and bring them into the planning process. In particular, create partnerships with organizations such as HIV primary care and support services you plan to refer patients to at discharge.
  • Parole Officers. Recognize that parole officers are also important community partners. There might be, however, some growing pains in creating a working collaborative relationship as this department is often overworked and their service offerings are not as controlled as those of jail staff.31 Overall, EnhanceLink grantees found parole officers not only to be familiar with the system but sometimes able to track down individuals postrelease when the community-based organization could not.
  • Ryan White case managers. Perhaps the most frequently cited community partnerships were with Ryan White case managers. EnhanceLink grantees stressed connecting with Ryan White case managers up front and involving them in early discussions and planning as well as linking to post discharge.

What should community organizations keep in mind?

  • With all partnerships, make sure to be transparent about what you hope to achieve; this will help avoid “turf wars” or a fear of “patient poaching.”
  • In many cases, community partners ended up with more clients in the end because releasees were linking to their services and fewer were falling out of care.32
  • Develop goals, a mission statement, and a flowchart of proposed operations to ensure all partners are “on the same page.”
  • Don’t make assumptions. Talk to the people you’re hoping to help as a kind of “litmus test” between perceived need and actual need.
  • Recognize that whenever people move from one system to another, barriers will inevitably exist. Work to identify such obstacles up front and discuss ways to overcome them.

How to formalize partnerships

  • MOUs. Consider creating a memorandum of understanding (MOU) with partners. Recognize, however, that a piece of paper is only that. You need to build trust.
  • Standardize paperwork. Creating standardized consent paperwork can help formalize and streamline the process.33 Reportorial roles need to be discussed and documented across partnering sites. In addition, sites will need to discuss how medical data and personal patient information may be shared (e.g., many grantees discussed this issue up front with community partners and had permission sheets available for patients to sign when they met with the case manager in jail).

What service provisions should organizations be aware of?

  • Space to work in and consult with patients can be difficult to find and not always ideal.
  • Privacy is relative. Be aware of challenges to confidentiality, and work with jail supervisors to educate corrections officers regarding the Health Insurance Portability and Accountability Act (HIPAA) and any local HIV confidentiality laws. This may mean modifying activities (e.g., patient education, interviews) with both HIV-positive and -negative individuals to avoid disclosure; and avoiding the use of HIV or AIDS in your organization name or program.
  • Equipment may be hard to come by and require ingenuity to rethink work processes (e.g., computers and phones may not be allowed or may take time to get into the jail or gain access to the jail system).
  • Understand how patient information provided to you will be shared with jail authorities and how jail medical staff information may be shared with you.

Review the section on Expanding Jail Intervention Work to learn more about establishing a jail linkage program.

Partnership Building Tips to Consider

  • Don’t shy away from the hard work. Meet with the biggest skeptic in the jail—whether a community player or a Department of Corrections staff. They may eventually become your biggest supporter.
  • Listen. Listen. Listen. Individuals and organizations already in the jail know how to work in this setting and how to do so without interfering with Department of Corrections operations or orders.
  • Don’t underestimate the power of a “thank you” in breeding good will.
  • Word of mouth goes far. If others have positive or negative experiences working with you, others in the jail will find out.

Source: New York City Department of Health and Mental Hygiene, Rikers Island Transitional Consortium. Special Projects of National Significance Planned Reintegration Opportunities to Gain Release & Access Medical Care. Final report. 2012. [Unpublished.]

Take-Away Messages

  • Do your homework. Know what services are in the jail and who is delivering them. Know what services you hope to refer inmates to upon release, and create partnerships with those organizations.
  • Know your sales pitch. How can you fill in service gaps?
  • Be on everyone’s radar. To avoid “turf wars,” embrace transparency.
  • Relationship building takes time. Account for this in your timeline and rollout of your program.
  • Working in the jail takes ingenuity. What you’re used to on the outside may not be what you have access to on the inside.
  • MOUs are paper, not partnerships. MOUs are just the beginning. There needs to be follow-through.
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