Navigator Case Management for People Leaving Jail

The Navigator Case Management (NCM) intervention helps people with HIV who are incarcerated and are leaving to return to the community. The intervention uses harm reduction, case management, and motivational interviewing techniques to promote healthy behaviors. Enhanced case management including peer support and connection to other needed services both immediately before and after release supports increased linkage to and retention in HIV care for people transitioning to the community from jail.

San Francisco, CA

Evidence-Based Intervention
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Support service delivery model
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Linkage to HIV medical care; Retention in HIV medical care
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People who are incarcerated
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Correctional system; Community-based organization/non-clinical setting
Need Addressed

Nearly one in seven people with HIV exit a prison or jail system each year, and many struggle to access care and treatment upon release.1 Interventions are necessary to connect people with HIV to HIV care and services as they are released, particularly those with co-occurring substance use disorders. Discharge planning and intensive case management programs can help ease the transition back to the community.2

Core Elements
Peer Navigators

The NCM intervention leverages the expertise of patient navigators. These patient navigators work with case managers to best understand and meet the needs of clients, monitor and support adherence to HIV treatment, and help them meet treatment goals after release. Navigators may accompany clients to appointments, and provide mentoring and support. The intervention is most effective when staff represent the population served: patient navigators should be peers with similar backgrounds to the people served (such as lived experience of incarceration and substance use).

Pre-release planning

Case managers work with clients while they are still in jail to assess needs and create an individualized care plan. They meet with each client two weeks before release to complete an assessment of immediate post-release needs, obtain contact information, and make referrals to programs such as Ryan White HIV/AIDS Program (RWHAP) Part B AIDS Drug Assistance Program (ADAP) and other needed services in the community. Case managers also monitor the legal status of the client to anticipate changes to their release or discharge plans.

Post-release planning

Ideally, the case manager and peer navigator meet with the client within 24 hours of their release. In this meeting, the case manager and peer navigator work with the client to develop post-release plans (and update the pre-release plan as needed), and provide a printed appointment schedule, including an individual counseling session with the case manager within 30 days. If it is not possible to meet with the client within 24 hours after release, the case manager may meet with the client while they are still incarcerated to ensure housing and transportation needs are met.

Follow-up support post-release

After release, the case manager continues to monitor client progress along their care plan, and the peer navigator provides as-needed support (such as attending appointments with the client). Staff meet with the client on a predetermined frequency based on client needs and progress. Additionally, clients who have “graduated” from the program may continue to meet as a group to build community. If they have successfully engaged in care, clients generally graduate from the program 12 months after release. 


Originally implemented in the San Francisco County adult jail system, researchers from the University of California, San Francisco conducted a randomized controlled trial involving 270 people with HIV and compared outcomes for clients receiving standard post-release care with clients receiving the NCM intervention, from 2010 to 2013. People in the NCM arm of the study were nearly two times as likely to be linked to and retained in care after release from jail.

Category Information
Evaluation data
  • Medical record data
  • Percent of clients linked to care within 30 days of release
  • Percent of clients retained in care (attended medical visits in each of 3 assessment periods in the follow-up year)
  • Clients in the intervention were twice as likely to be linked to care within 30 days of release (OR = 2.15, CI: 1.23-3.75)*
  • Clients in the intervention were twice as likely to be retained in care for the intervention period (OR = 1.95, CI: 1.11-3.46)*

* statistically significant

Source: Myers JJ, Dufour MK, Koester KA, et al. The effect of patient navigation on the likelihood of engagement in clinical care for HIV-Infected individuals leaving jail. Am J Public Health. 2018; 108(3):385-392.

“The NCM intervention helped to address gaps in transitional care for people leaving jail and demonstrated how patient navigation could support linkage and retention-in-care efforts, and mitigate health and other structural inequities experienced by people with HIV who have been incarcerated.”

Planning & Implementation

Successful replication of the NCM intervention involves a strong community network, attention to each staff member’s roles, careful training, supervision, and compensation for peer navigators, emphasizing “client first” principles, and employing multiple means of intervention promotion.

  • Community network. It is essential to build and maintain partnerships between the jail system and community organizations that can deliver case management and provide healthcare and supportive services. Planning and implementing the NCM intervention is facilitated by each collaborating organization’s commitment to the issues and their client’s self-determination. Because peers have pertinent first-hand knowledge, employing them as patient navigators is an appropriate gateway to working with a criminal justice-involved population—even if the organization has worked with this population before.
  • Staffing. The NCM intervention builds on existing case management infrastructure. Staffing needs include sufficient case manager and peer navigator staffing to work directly with clients, and administrators to manage workflow. The NCM intervention consists of many one-time and ongoing tasks divided among the roles of the intervention team. Recognizing how these roles differ and where they overlap are important for replication. Hiring may be necessary to bring on staff to serve as case managers and peer navigators; lived experience similar to potential clients is ideal. Peer navigator roles should be compensated.
  • Training. Training can include harm reduction, general social work principles, motivational interviewing, assertive community treatment and team-based approaches.
  • Culturally responsive processes. Cultural responsiveness in working with people who use substances and have experienced incarceration is essential to this program. Multilingual staff may be helpful depending on the client population. 
  • Promotional methods. Using a variety of promotional materials (e.g., flyers and referrals) can lead to higher intervention enrollment. Depending on the type of organization, some methods may work better than others. Providers within jails, such as medical staff or case managers, can refer clients to the intervention. While the use of marketing materials may depend on the policies that jails have in place, consider including marketing materials in the medical offices.
  • Various funding sources can be explored to support staff compensation including leveraging RWHAP funding to provide services to people who are incarcerated. Policy Clarification Notice 18-02 specifically allows RWHAP funding to cover needed services in these settings.
  • A robust referral network with local partners makes it easier to connect clients to support services (such as transportation and food assistance) that meet common needs of people leaving incarceration, and that facilitate ongoing engagement in HIV care. 
Lessons Learned
  • Establish relationships with jail health care providers and correctional staff because they are essential for developing and delivering new programs.
  • Understand the policy environment affecting the jail setting where the intervention will take place. For example, in many states, people who are incarcerated are more likely to be underinsured. 
  • Test out the intervention program by developing a protocol and conducting mock client encounters in the jail.
  • Appreciate the correctional culture and functioning of the specific setting for the intervention; jails require strict attention to policies and procedures that other settings may not.
  • Consider working with internal or external staff (e.g., consultants) who have previous experience working with peer-led interventions.
  • To the extent possible, reduce the “distance” (both geographic and in availability) between navigators and clients. Easy access to intervention staff is critical. 
  • Consider offering transportation assistance to clients to reduce burden in making it to appointments.
University of California, San Francisco
Janet Myers, PhD, MPH

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