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Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH

Improving the HIV Care Continuum in Incarcerated and Recently Released Individuals through Stakeholder Engagement. Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH. Disclosures. We have no actual or potential conflict of interest in relation to this program/presentation. Outline.

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Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH

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  1. Improving the HIV Care Continuum in Incarcerated and Recently Released Individuals through Stakeholder Engagement Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH

  2. Disclosures • We have no actual or potential conflict of interest in relation to this program/presentation

  3. Outline • Overview of the Dallas County Jail • Description of the Dallas HIV/AIDS Re-entry Coalition (HARC) • HIV Testing at the Dallas County Jail • Linkage to care for HIV+ Releasees • Lessons learned from stakeholder engagement

  4. Dallas County Jail, Today • 7thlargest county jail in the US • Average daily intake of 275 new arrestees • Average daily census of 6500 inmates • 84% Male, 16% Female • Health care delivery is entrusted to Parkland Health & Hospital System

  5. Health Care Staff • Medical: • Physicians-16 • Physician Assistants-11 • Nurse Practitioners-5 • Mental Health: • Physicians-8 • Physician Assistants-4 • Nurse Practitioners-3 • Mental Health Liasions-8 • Psychological Accessors-2 • Psychologist- 2 • LVNs- 6 • RNs- 4 • Medical Assistant- 3 • Dental: • Dentist- 2 • Dental Assistant- 2 • Nursing: • Managers- 5 • RNs- 59 • LVNs-78 • Medical Assistant- 21 • Phlebotomy Tech- 2 • Radiologic Technologist- 2 • Respiratory Care Practitioner- 1 • Pharmacy: • Clinical Specialist-2 • Pharmacists-11 • Pharmacy Techs-8 • Optometry: • Optometrist- 0.2 • Medical Assistants- 0.2

  6. Health Services Provided • Health Screening for ALL inmates upon arrival & yearly • TB Screening for ALL inmates upon arrival & yearly • Acute & Intermediate Medical and Mental health In-patient Care • Chronic & Urgent Medical and Mental Health Care (including Crisis and Suicide) • Respiratory Therapy and Respiratory Isolation • Ob/Gyn Care Including Screening OB US of all New Pregnant Inmates • HIV Clinic • Anti-Coagulation Clinic • Dental Clinic • Dialysis Care • Orthopedic Clinic • Voluntary HIV/Syphilis testing • Optometry Care • Radiology

  7. Process Flow

  8. Consent Decree • In 2006, the Dallas County entered a consent decree agreement with the DOJ to address 73 areas of non-compliance with best practice standards for health care and sanitation in the Dallas County Jail (DCJ) • DCJ underwent 8 biannual week-long surveys by DOJ consultants which resulted in the successful exit of the Dallas County jail from the consent decree in November of 2011

  9. Dallas County Jail Today You cannot improve what you don’t measure

  10. Daily Reports • Vitals Completion Report • Glucose Completion Report • Detox Completion Report • Daily Dashboard • Intake Dashboard Report • Emergency Walk-in Report • Daily Tower Productivity Report • Daily Staff Activity Report • HIV Pending Visits Report • Lab/EKG Pending Report • MAP Pending Report • Missed MAP report • Optometry Pending Report • Dental Pending Report • Detox Pending Report • Medical Visit Pending Report • Mental Health visit Pending Report • Nurse Med Management Report • Missed Meds Report • OB/OBGYN Pending Report • PAP Pending Report • Accuflo Scan Touch Report • Sick Call Pending Report • TB Report • Wound Care Report • CBO Report • Parkland Visits Report

  11. Daily Dashboard

  12. Weekly Reports • Dental Appointments Waiting Report • Infirmary Location by Acuity Report • Med Reconciliation • Administration Dashboard • Pharmacy Dashboard • Prescription Dashboard • Pregnant Patient Report • RAT Team Log • Parkland Returns

  13. Monthly Reports • 90 day Chronic Care Patient Report • Chronic Care Report • Coumadin Process Measures • Dental Process Measures • HBA1C Report • HIV Monthly Report • Monthly Lab Report • Med Management Process Measures • Med Pass Process Measures • INR Report • Medical Provider Report • Mental Health Provider Report • Neely Report • Nursing Productivity Report • Nursing Orders • OB/OBGYN Monthly Report • Monthly Insulin Report • Sick Call Report • Specialty Care Process Measures • Intake Process Measures • POCT Summary Dashboard

  14. HIV Monthly Report

  15. Outline • Overview of the Dallas County Jail • Description of the Dallas HIV/AIDS Re-entry Coalition (HARC) • HIV Testing at the Dallas County Jail • Linkage to care for HIV+ Releasees • Lessons learned from stakeholder engagement

  16. What is HARC? • HIV/AIDS Re-entry coalition • A community-level inter-agency collaboration aimed at improving the HIV care continuum in incarcerated individuals • Group of stakeholders from various agencies include: • Case managers • HIV providers • Mental health providers • Substance use treatment providers • Housing services providers • Re-entry counselors • HIV prevention staff • Correctional staff • Pharmaceutical representatives • Local Ryan White administrators

  17. HARC Mission Statement • Improve the continuum of HIV care for incarcerated and recently released individuals: • Improve Jail HIV Testing initiatives • Improve Linkage to Care program to improve access for more patients • Decrease the Community HIV viral load in the jail and in the communities where inmates return to after release • Expand the knowledge of resources available for those incarcerated and recently released • Improve communication between correctional and community stakeholders. • Study the impact of changes implemented by the group on the continuum of HIV care for the recently released

  18. Agencies Represented • Parkland Health and Hospital Systems • UT Southwestern Medical Center • AIDS Arms, Inc. • TCU • Project Reconnect • Homeward Bound • Legacy counseling • City of Dallas Housing • Department of State Health Services • Dallas County Grants Management • Dallas Urban League • AIDS Healthcare Foundation • AIDS Services of Dallas • AIDS Interfaith Network • Gilead Sciences • Bristol-Myers Squibb

  19. Services provided by HARC participants • HIV prevention/ education • HIV/STD testing • HIV medical care • Linkage to care • Case management/ care coordination • Substance abuse treatment • Transportation • Administer grant money • Research • Mental Health counseling • Housing • Emergency aid • Educational services

  20. How are agencies funded? • Federal • HRSA/Ryan White • parts A,B, MAI • CDC • NIH • SAMHSA • HOPWA • State • DSHS • City of Dallas • Dallas supervision and corrections • HUD • Insurance for services • Private/HMOs • Medicare, Medicaid • Ryan White • Value Options • Other Grants

  21. Group priorities for the HIV Care Continuum 100 82 80 66 60 37 Patients, % 33 40 25 20 0 Linked to Care Retained in Care Diagnosed Viral Suppression Prescribed ART CDC-Hall, International AIDS conference 2012

  22. Outline • Overview of the Dallas County Jail • Description of the Dallas HIV/AIDS Re-entry Coalition (HARC) • HIV Testing at the Dallas County Jail • Linkage to care for HIV+ Releasees • Lessons learned from stakeholder engagement

  23. HIV Testing at Dallas County Jail

  24. UTSW and Parkland HIV jail testing results

  25. Outline • Overview of the Dallas County Jail • Description of the Dallas HIV/AIDS Re-entry Coalition (HARC) • HIV Testing at the Dallas County Jail • Linkage to care for HIV+ Releasees • Lessons learned from stakeholder engagement

  26. Snapshot of HIV+ Released Inmates Receiving Case management at Dallas County Jail December 2012-February 2013 165 HIV+ Inmates Seen by Case Manager 76 Transferred: 48 TDCJ 7 Reincarcerated 21 released to other mandated facility/program 89 Released to community 64 Scheduled for Intake/Follow up 25 receive care from other ASO / out of county 47% 22 did not keep appointment or are currently out of care (though CM still attempts linkage) 30 kept intake/ follow up 12 future visit scheduled

  27. Snapshot of HIV+ Released Inmates Receiving Case management at Dallas County Jail December 2014-February 2014 165 HIV+ Inmates Seen by Case Manager 73Transferred: 47 TDCJ 7 INS/US Marshall 2Reincarcerated 20 released to other mandated facility/program 92 Released to community 47 Scheduled 40 Contacted for Intake/Follow up 45 receive care from other ASO / out of county 58% 7did not keep appointment 7 unable to contact (though CM still attempts linkage) 27kept intake/ follow up 6 future visit scheduled

  28. Outline • Overview of the Dallas County Jail • Description of the Dallas HIV/AIDS Re-entry Coalition (HARC) • HIV Testing at the Dallas County Jail • Linkage to care for HIV+ Releasees • Lessons learned from stakeholder engagement

  29. Achievements to date • Improved communication and collaboration between agencies • Increase in HIV testing • Potential support (through CDC) for a dedicated linkage coordinator Future directions: Increase HIV testing further (opt-out/routine) Increase referrals to HARC agencies Increase linkage to care Measure and improve clinical outcomes

  30. Challenges • Progress is slow, resistance to change • Maintaining momentum • Politics– agencies competing for grant funding, clients

  31. Conclusions • It is possible to change a low performing jail system into a high performing one with good leadership • Jail health is a great place for quality improvement • Stakeholder engagement is an important component of process improvement • The HIV Cascade of care in corrections needs to be measured and improved and stakeholder engagement can be a facilitator of change

  32. Dallas RWPC Needs Assessment- Incarceration questions

  33. Dallas RWPC Needs Assessment- Incarceration questions

  34. Dallas RWPC Needs Assessment- Incarceration questions

  35. HIV testing at the jail

  36. Testing venue

  37. Characteristics– DHHS only

  38. Age group (DHHS/Parkland combined)

  39. Demographic Snapshot HIV+ Inmates Released Dec 2012-Feb 2013 What do we know about this 165 served while incarcerated? 122 male 42 female 1 transgender RACE: 102 African American ( 62%) 42 Caucasian ( 26%) 18 Hispanic ( 11%) 1 other (<1%) Average Age: 39 Age Range: 20-63 HIV Diagnosis Range: 1990-2012

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