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

Transitional Care Coordination (TCC) connects individuals with HIV who are incarcerated with a transitional care coordinator to facilitate access to HIV primary care and other community-based services and supports, following their transition from jail back to the community. TCC aims to establish vital linkages between jail-based and community-based HIV care, and may be implemented by community-based organizations, clinics, health departments, or jails. Cooper Health System, Southern Nevada Health District, and the University of North Carolina Chapel Hill were implementation sites for this Ryan White HIV/AIDS Program (RWHAP) Part F Special Projects of National Significance (SPNS) Transitional Care Coordination: From Jail Intake to Community HIV Primary Care (TCC) intervention. Eighty percent of the 229 clients released into the community across the three sites were virally suppressed six months post-release from jail.

Las Vegas, NV

Camden, NJ

Chapel Hill, NC

Evidence-Informed Intervention
Icon for Intervention Type
Outreach and reengagement activities
Icon for HIV Care Continuum
Linkage to HIV medical care; Viral suppression
Icon for Ending the HIV Epidemic in the U.S. Pillar
Treat
Icon for Focus Population
People who are incarcerated
Icon for Priority Funding
RWHAP SPNS
Icon for Setting
RWHAP-funded clinic or organization; Correctional system
Need Addressed

Many individuals with HIV who are incarcerated are released to the community with no linkages to community-based HIV care. Without transitional support, these individuals have a high likelihood of experiencing gaps in care, which affects their ability to reach and/or maintain viral suppression successfully.

“The transition from incarceration back into the community is known to be a high-risk period for increased deaths, discontinuity of care and treatment (including antiretroviral therapy [ART]), exacerbation of mental health conditions, unstable housing, and opiate overdose.”

Core Elements
Partnership with local jail

Support and cooperation with the local jail is essential to the success of the TCC program. RWHAP providers serving as the TCC sites established a memorandum of understanding (MOU) with a local jail, outlining the roles and responsibilities of each party to ensure that transitional care coordinators have the information and resources needed to transition clients successfully to community HIV care following their release.   

Transitional care coordinator

The transitional care coordinator—employed by the RWHAP provider—facilitates a warm transition to the community through patient engagement, education, discharge planning, and care coordination. Transitional care coordinators must find the appropriate community resources that support each client’s unique needs during their transition to community-based care.  

Transitional care plan

Prior to release, transitional care coordinators meet with each client to assess their interest in the program, conduct a review of their medical and social needs, and to provide HIV education, and develop a transitional care plan. Coordinators update plans continually to ensure that they meet each client’s broader needs, including access to food, housing, and transportation, as well as their health care needs.

Warm transition to medical care and community resources

To facilitate the client’s connection to HIV primary care within 90 days of release, the transitional care coordinator sets up the client’s initial appointment with an HIV care provider, arranges transportation, and may also accompany the client to the appointment. The coordinator also provides discharge medication, if necessary. Through the implementation of the transitional care plan, the transitional care coordinator ensures linkages to community resources, provides health education, and provides health care coverage assistance.  

Outcomes

From 2016–2019, a total of 268 people with HIV identified in jail were served across the three sites. Of the clients released to the community (n=229), connection with community-based HIV care and viral suppression were measured post-release.

Category Information
Evaluation data Key informant interviews, patient encounter forms, and site visit reports
Measures

Percentage of clients who:

  • Were linked to community HIV primary care
  • Were virally suppressed
Results
  • 28% of clients were linked to community HIV care within 30 days post-release
  • 45% of clients were linked to community HIV care within 90 days post-release
  • 53% of clients were connected with community HIV care within 120 days post-release
  • 80% of clients were virally suppressed at 6 months post-release (compared with 58% at baseline)

Source: Dissemination of Evidence-Informed Interventions. Transitional Care Coordination: From Jail Intake to Community HIV Primary Care (2020).

“Clients who had an encounter with their transitional care coordinator within one week post-release, were significantly more likely to link to HIV primary care within 30 days (p < 0.001).”

Planning & Implementation

Partnership with jails. Each TCC team built upon and formalized relationships with local jails. The development of MOUs facilitated ongoing collaboration between community agencies and the local jail. The MOU outlined how the TCC team and jail staff should work together and established critical resources, such as in-jail escort services by corrections officers, access to space for private conversation, and communication around jail release timelines.

Staffing. The TCC sites included two full-time transitional care coordinators, a part-time project manager, and a part-time clinical supervisor. Transitional care coordinators carried caseloads of 20–25 active clients at a time. Transitional care coordinators’ job descriptions included: experience working in a jail or social service settings; the ability to support clients in a non-judgmental manner using person-centered approaches; and bilingual skills that align with the client population. Transitional care coordinators received training on the culture of corrections to support staff in applying care coordination experience in non-traditional settings, such as jails.

Client eligibility. Clients with HIV who were eligible for the TCC intervention were identified in jail through HIV testing, or self-reporting during medical intake within the jail.

Costs, funding and technical support. The TCC sites were funded through RWHAP SPNS. The average cost per participant per year was $3,185 (in 2019 dollars). The costs included salary and fringe benefits for TCC staff, materials, transportation costs for staff and clients, and overhead rates. Start-up costs averaged $34,874 per site. Activities were supported by the Dissemination of Evidence Informed Interventions (DEII) Dissemination and Evaluation Center and the DEII Implementation Technical Assistance Center.

Sustainability

The RWHAP agencies that received SPNS funding to implement the intervention have leveraged other RWHAP funding sources to sustain it with adaptations. Agencies adapted by expanding the intervention to focus and serve other vulnerable populations who are at risk of falling out of care; using existing positions in clinics to fill the TCC role; and being flexible on the time limit of the intervention to meet individual clients’ needs.

Lessons Learned
  • It is important to identify an internal champion to foster and maintain buy-in for the TCC program at the local jail. The role of the internal champion is critical in establishing and maintaining relationships with jail staff, creating an organizational culture supportive of the TCC program, and helping establish community support and resources.
  • TCC job descriptions must align with both jail and clinic or agency policies to ensure transitional care coordinators are eligible and prepared to work in both settings.
  • Establishing strong relationships with correctional officers within the jail is crucial. This includes sharing information and resources on HIV, attending existing correctional officer meetings to share information on the TCC program, and participating in informal gatherings such as meals.
  • Learning about the jail’s release process will mitigate against unpredictable release timelines. The TCC program may be able to leverage the relationships established with jail personnel to receive updates around clients’ release timelines to best support all clients’ transition to the community.
  • The MOU should specify how the jail and TCC program share client-level information, including how to obtain HIPAA consent to coordinate care with other service providers. Staff should be trained on how to use, and what to capture within, the jail and agency electronic health records.
Contact
Cooper Health System
Pamela Gorman
Project Director
Southern Nevada Health District
Xichun Wang
University of North Carolina
Dr. Claire Farel
Program Medical Director

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