Pay it Forward Transitional Care Coordination

One Stop Career Center of Puerto Rico (OSCC-PR) implemented Pay it Forward to increase workforce capacity to connect Puerto Ricans with HIV to community-based HIV care and social supports following release from jail. Pay it Forward included training of OSCC-PR staff in the Transitional Care Coordination (TCC) model. Eighty percent of clients who were supported by Pay it Forward in Puerto Rico were still in HIV care 12 months after release.


Implementation Guide
Evidence-Informed Intervention
Evidence-Informed Intervention
Icon for Intervention Type
Outreach and reengagement activities
Icon for HIV Care Continuum
Linkage to HIV medical care; Retention in HIV medical care
Icon for Focus Population
People who are justice involved
Icon for Priority Funding
Icon for Setting
Correctional system; Community-based organization/non-clinical setting
Need Addressed

People with HIV transitioning out of incarceration back to their communities often need support connecting to social services, such as housing, transportation, and employment assistance, as well as to community-based HIV care. Past studies have demonstrated that the TCC model improves continuity of HIV care. The TCC model includes both incarceration-based education and services and linkages to community support.

In Puerto Rico, many people with HIV experience stigma because of their HIV status, which may be confounded by stigma associated with history of incarceration, substance use disorder, and gender identity. Therefore, the Pay it Forward model requires a prepared workforce and a network of community-based providers that can provide culturally-responsive support. 

Core Elements
Staff training

OSCC-PR employment and housing specialists were trained on HIV education and risk reduction, outreach and engagement, transitional care planning, coordination with service providers, and patient navigation after incarceration. With the skills and knowledge gained from these trainings, OSCC-PR staff worked as care coordinators and implemented the evidence-informed TCC model.

TCC model

Following training, OSCC-PR staff served as transitional care coordinators. The TCC model includes working with jails to identify incarcerated people with HIV, conducting a comprehensive assessment of support needs, and the development of a transitional care plan to support the person’s return to the community. Transitional care coordinators then linked clients to community-based HIV care and social services after they returned to the community.

Community partnerships

OSCC-PR leveraged existing relationships with community-based housing, employment, and transportation providers. These relationships were expanded to address the specific needs of people with HIV transitioning out of jail. Agreements and Memorandums of Understanding (MOUs) formalized these relationships and integrated the providers into the OSCC-PR organizational operations.


OSCC-PR identified transportation as a key barrier for people needing to access community-based services. To address this barrier, OSCC-PR purchased a government surplus van to support clients’ transportation needs. However, the cost associated with the upkeep of the van and hiring a dedicated driver was not sustainable. The project eventually shifted to ride sharing services to support clients’ transportation needs. OSCC-PR staff also often accompanied people to community-based providers to ensure a warm transition.


The original evaluation study was conducted in Puerto Rico between November 2015 and July 2018. Data was collected at three time points: 1) baseline measures taken during incarceration, 2) first follow-up at 6 months after incarceration, and 3) second follow-up at 12 months after incarceration. Following the implementation of the TCC model, 54 of the 58 people with HIV transitioning to the community from jail were linked to community-based HIV medical care. Most of those connected to community support, and were retained in care at six and 12 months.

Evaluation data
  • Participant surveys
  • Clinic visit information
  • HIV lab values
  • Number of formal partnerships established with community-based services
  • Percent of clients linked to community-based HIV medical services and retained in HIV care after six and 12 months
  • Over 60 MOUs with community-based service providers across Puerto Rico (housing, primary care, employment, and other social services)
  • 93% of eligible clients were linked to community-based HIV medical care after incarceration
  • 86% were retained in care six months after incarceration
  • 78% were retained in care 12 months after incarceration

Source: Wiersema J, Cruzado-Quinones J, Cosme Pitre CG, et al. (2020). Support Persons Living With HIV and Returning to the Community After Incarceration in Puerto Rico. AIDS Education and Prevention. 32(3):181-195.

Planning & Implementation
  • Incorporating effective approaches. The Pay it Forward mission and initiative design built upon two preceding Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) initiatives: Jail Linkages (also known as the Correctional Health Access Initiative) and the Latino Access Initiative. While the Jail Linkages initiative established the TCC model embedded in the Pay it Forward project, the Latino Access Initiative focused on addressing cultural responsiveness and stigma associated with HIV care within the Puerto Rican community.  
  • Staff training. The Pay it Forward team identified and trained OSCC-PR staff in the TCC model, leveraging the staff’s existing knowledge of community resources to build a workforce with specialized expertise to support people with HIV transitioning from jail to the community. 
  • Partnership with correctional facilities. OSCC-PR established collaborative relationships with 13 of Puerto Rico’s 32 correctional facilities. OSCC-PR conducted HIV outreach and education in jails and prisons across Puerto Rico to engage correctional staff and gain access to correctional facilities and patient health records. 
  • Community provider network. OSCC-PR built a network of community providers leveraging its existing community-based provider network. OSCC-PR formalized and expanded its existing network to reflect the needs of people with HIV transitioning back to the community from jail. Community providers included medical care, HIV primary care, housing, substance use treatment, syringe exchange, support services, and case management. 
  • Transportation to appointments. OSCC-PR secured transportation to support people in accessing needed services and keeping appointments. Staff often accompanied people to their appointments, providing a warm transition to community-based services. 
  • Local expertise. Pay it Forward leveraged the community and cultural expertise of OSCC-PR staff who were knowledgeable about their communities and local resources. Formal agreements with community providers built upon rapport and trust established through existing partnerships.
  • Originally funded by a RWHAP SPNS initiative with New York City Correctional Health Services, to support the sustainability of the Pay it Forward initiative and the TCC model, the OSCC-PR team developed The Puerto Rico Employment, Housing and Health Resource Guide.
  • This guide is available at no cost to network providers through the RDE Systems eCOMPAS® platform.
  • The guide includes a map of Puerto Rico flagged with resources including medical care, housing support, employment supports, and care coordination. Sustainable funding for Pay it Forward is currently being explored.
Lessons Learned
  • Agencies should leverage and build upon existing relationships with community-based organizations to establish a robust and engaged network. Identifying local champions can help facilitate introductions to new community-based organizations. 
  • Formalizing partnerships with MOUs helps create synergy between medical and support service providers to address social determinants of health such as housing, employment, and transportation. 
  • The project found that costs associated with ride sharing services were lower than those associated with van upkeep and a driver. In addition, through ride sharing, Pay it Forward could serve multiple people at once and better accommodate client schedules. 
  • A diverse advisory council with stakeholders can ensure the model is responsive to local community needs and dynamics. 
  • Transportation supports should be a key component of the intervention to reduce access barriers that people transitioning back to the community may experience when making and keeping appointments with service providers.
ACOJA Consulting
Jacqueline Cruzado-Quiñones

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