Transitional Care Coordination in New York City Jails: Facilitating Linkages to Care for People with HIV Returning Home from Rikers Island
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New York City (NYC) jails are the epicenter of an epidemic that overwhelmingly affects Black and Hispanic men and offer a significant opportunity for public health intervention. The NYC Department of Health and Mental Hygiene instituted population based approaches to identify the HIV-infected, initiate discharge planning at jail admission, and facilitate post-release linkages to primary care. Using a caring and supportive ‘warm transitions’ approach, transitional care services are integral to continuity of care. Since 2010, over three-quarters of known HIV-infected inmates admitted to jails received discharge plans; 74 % of those released were linked to primary care. The EnhanceLink initiative’s new Health Liaison, a lynchpin role, facilitated 250 court-led placements in medical alternatives to incarceration. Transitional care coordination programs are critical to facilitate continuity of care for people with chronic health conditions including the HIV-infected returning home from jail and for the public health of the communities to which they return.
KeywordsJail HIV Linkages Discharge plan Warm transitions Care coordination
The authors gratefully acknowledge Thomas Frieden, Thomas Farley, Fabienne Laraque, Beau Mitts, Amanda Parsons, Anthony Santella, Jonathan Santos Ramos, and the Correctional Health Services leadership team for their vision and leadership; Sam Amirfar, Robin Cagey, Joanna Eavey, Traciah John, Tatiana Tikhonko, and the DOHMH HIV Surveillance and Research unit for their contributions to this study; Press Canady, Allison Dansby, Brenda Ortiz-Rivera, Cheryl Moorehead, the Rikers Island Transitional Consortium, and our dedicated staff for making a difference every day. This publication was made possible by a Grant through the U.S. Department of Health and Human Services (DHHS), Health Resources and Services Administration, HIV Bureau. The content of this publication does not necessarily reflect the views or policies of DHHS. Responsibility for the content of this report rests solely with the named authors.
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