1. 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

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
Overview of the Dallas County Jail-Dr. Esmaeil Porsa
Description of the Dallas HIV/AIDS Re-entry Coalition (HARC), including description of members, assessment of resources and priorities (HIV testing, linkage); the development of a mission statement (Dr. Ank Nijhawan)- 3 minutes
HIV Testing at the Dallas County Jail, current practices and data-( Dr. Ank Nijhawan) – 5 minutes
Linkage to care for HIV+ Releasees from the Dallas County Jail, current statistics and efforts at improvement (Dr. Ank Nijhawan)- 5 minutes
Lessons learned from stakeholder engagement, successes and challenges (Dr. Ank Nijhawan)- 2 minutes.

6. Dallas County Jail, Today
7th largest 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

7. Health Care Staff Medical: Mental Health: Dental: Nursing: Pharmacy:
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

8. 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

9. Process Flow

10. 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

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

12. Daily Reports Vitals Completion Report Optometry Pending 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

13. Daily Dashboard Admissions (Intake) 166 251 269 280 297 248 231 172
Parkland Health and Hospital System : Jail Health
Daily Dashboard
Date:
8/18
8/19
8/20
8/21
8/22
8/23
8/24
8/25
8/26
8/27
8/28
8/29
Jail
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Thurs
Admissions (Intake)
166
251
269
280
297
248
231
172
276
309
277
315
Discharges (Release)
156
242
304
314
313
157
164
321
341
296
Census
Adult Census
6322
6287
6242
6247
6218
6163
6274
6345
6258
6259
6224
6251
Medical - Acute Care Census (acuity 1) 6 5 3 7 4 10
Medical - Intermediate Care Census (acuity 2&3) 77 79 72 85 84 87 82
Psych - Crisis Stabilization Program Census 9 8 14 11
Psych - Acute Care (CBO) Census
165
162
169
173
176
170
174
Medication Management
Patients on Medications - Adult
2687
2717
2800
2791
2784
2760
2678
2581
2776
2810
2794
2712
Number of Doses Dispensed - Adult
7892
7960
8363
8315
8379
8312
8018
7703
8185
8468
8447
7682
Requests
Clinician Orders
412
519
675
838
852
802
602
429
710
747
811
753
Sick Call Request - General 73 86 89
112 99
123
108
136
104
120
125
Sick Call Request - Mental Health 22 28 27 32 24 43 20 35 41 40
Encounters
Medical Assessment Program Encounters 97 88 92 81
118
107 74 76
115
110
Medical Provider Encounters (MD/PA/NP)
197
229
218
263
267
270
Nursing Encounters
639
872
991
1022
1175
935
1278
952
1146
1149
Emergencies Visits 54 37 34 53 36 42 49
Parkland Visits
ER Send Outs
Jail Pts in Parkland Inpatient 12 13 15
Parkland Appts

14. 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
PI Project I Confidential Information

15. 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

16. HIV Monthly Report

17. 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
Overview of the Dallas County Jail-Dr. Esmaeil Porsa
Description of the Dallas HIV/AIDS Re-entry Coalition (HARC), including description of members, assessment of resources and priorities (HIV testing, linkage); the development of a mission statement (Dr. Ank Nijhawan)- 3 minutes
HIV Testing at the Dallas County Jail, current practices and data-( Dr. Ank Nijhawan) – 5 minutes
Linkage to care for HIV+ Releasees from the Dallas County Jail, current statistics and efforts at improvement (Dr. Ank Nijhawan)- 5 minutes
Lessons learned from stakeholder engagement, successes and challenges (Dr. Ank Nijhawan)- 2 minutes.

18. 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
Great care in the jail, but much of what is gained is lost after release.

19. 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

20. 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

21. 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

22. 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
May be competing for certain dollars, but coalition intended to be mutually beneficial– improving client’s access to needed services

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

24. 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
Overview of the Dallas County Jail-Dr. Esmaeil Porsa
Description of the Dallas HIV/AIDS Re-entry Coalition (HARC), including description of members, assessment of resources and priorities (HIV testing, linkage); the development of a mission statement (Dr. Ank Nijhawan)- 3 minutes
HIV Testing at the Dallas County Jail, current practices and data-( Dr. Ank Nijhawan) – 5 minutes
Linkage to care for HIV+ Releasees from the Dallas County Jail, current statistics and efforts at improvement (Dr. Ank Nijhawan)- 5 minutes
Lessons learned from stakeholder engagement, successes and challenges (Dr. Ank Nijhawan)- 2 minutes.

25. HIV Testing at Dallas County Jail
Agency
When
Type
#/month
Health Department
Intake 8-noon on weekdays;
After in jail
Blood draw
20537
UT Southwestern 7
Parkland HIV prevention
After in jail, targeting MSM
Oraquick
105 210
Parkland Jail Health
112
Jan:   137 tests, 21 positiveFeb:  126 tests, 24 positiveMar: 151 tests, 13  positive

26. DCHHS testing  
2013
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YTD
HIV Tested 59 37 48 17 16 46 25 32 21 53 52
443
HIV New Positive
HIV Previous Positive 2 1 3
HIV Negative 44 51
440

27. UTSW and Parkland HIV jail testing results
Agency
Time period
# tested
HIV neg
HIV pos
New pos
Prev undx seropositivity
UTSW
2013 89 86 3
3.37%
Parkland
Jul 2013-
Dec 2013
625
622 1
0.16%
Dec 2013-May 2014
1250 -- 2

28. Parkland Jail Health
2013
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YTD
HIV Tested
116
100
131
143
111
112
129 95 87
1351
HIV Positive 40 24 36 27 37 28 42 26 18
350
HIV Negative 76 74 84
105 69
1001
HIV New Positive 1 2 5
HIV+ Seen by Provider 39 35 23 25 22 17
339
On HIV Therapy 29 15 19 12 16 11
225
Released 7
Refused 8
% HIV Positive Tests
34%
24%
27%
19%
33%
25%
36%
22%
21%
26%

29. 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
Overview of the Dallas County Jail-Dr. Esmaeil Porsa
Description of the Dallas HIV/AIDS Re-entry Coalition (HARC), including description of members, assessment of resources and priorities (HIV testing, linkage); the development of a mission statement (Dr. Ank Nijhawan)- 3 minutes
HIV Testing at the Dallas County Jail, current practices and data-( Dr. Ank Nijhawan) – 5 minutes
Linkage to care for HIV+ Releasees from the Dallas County Jail, current statistics and efforts at improvement (Dr. Ank Nijhawan)- 5 minutes
Lessons learned from stakeholder engagement, successes and challenges (Dr. Ank Nijhawan)- 2 minutes.

30. 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
Though CM updates our Data System and EMR in hopes to capture patient entry in our Parkland system upon release from mandated programs. (for example, 116/165 have a “last primary care” appointment in the Parkland EPIC database. 64/116 in 2012)
CM has read only access to the Jail EMR, PEARL. Only provider care plans/medication plan are sent on to TDCJ, etc.
Release date is not revealed, nor available for discharge planning. This affects med discharge plans, CM linkage plans, etc…
In this 3 month cycle, 38% were able to have appointments made for care, not due to efforts on CM’s part.
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

31. Snapshot of HIV+ Released Inmates
Receiving Case management at Dallas County Jail
December 2014-February 2014
165 HIV+ Inmates
Seen by Case Manager
73 Transferred:
47 TDCJ
7 INS/US Marshall
2 Reincarcerated
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
Though CM updates our Data System and EMR in hopes to capture patient entry in our Parkland system upon release from mandated programs. (for example, 116/165 have a “last primary care” appointment in the Parkland EPIC database. 64/116 in 2012)
CM has read only access to the Jail EMR, PEARL. Only provider care plans/medication plan are sent on to TDCJ, etc.
Release date is not revealed, nor available for discharge planning. This affects med discharge plans, CM linkage plans, etc…
In this 3 month cycle, 38% were able to have appointments made for care, not due to efforts on CM’s part.
58%
7 did not keep appointment 7 unable to contact
(though CM still attempts linkage)
27 kept intake/
follow up
6 future visit scheduled

32. 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
Overview of the Dallas County Jail-Dr. Esmaeil Porsa
Description of the Dallas HIV/AIDS Re-entry Coalition (HARC), including description of members, assessment of resources and priorities (HIV testing, linkage); the development of a mission statement (Dr. Ank Nijhawan)- 3 minutes
HIV Testing at the Dallas County Jail, current practices and data-( Dr. Ank Nijhawan) – 5 minutes
Linkage to care for HIV+ Releasees from the Dallas County Jail, current statistics and efforts at improvement (Dr. Ank Nijhawan)- 5 minutes
Lessons learned from stakeholder engagement, successes and challenges (Dr. Ank Nijhawan)- 2 minutes.

33. 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

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

35. 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

36. Dallas RWPC Needs Assessment- Incarceration questions
Top number a little less than expected, but of course not surveying people who are in jail/prison at this time. Should be around 1 in 7 or 14%
Bottom chart begs the question of did you seek medical care/disclose your status and how long incarcerated?

37. Dallas RWPC Needs Assessment- Incarceration questions

38. Dallas RWPC Needs Assessment- Incarceration questions

39. HIV testing at the jail Parkland 9/11-2/12 6 mo 372 DHHS 1/12-6/12
Agency
Dates
Interval
#Tested
#Positive
% pos
New pos
Parkland
9/11-2/12
6 mo
372
DHHS
1/12-6/12
1456 11
(3 false +)
0.75 1
Dallas
Total --
1828
0.6

40. Testing venue Agency Location #Test # Positive % positive Parkland
Kays Tower
372
DHHS
Bookin
780 6
0.77
Pods
325 4
1.2
Kite
116 1
0.86
JDC
192

41. Characteristics– DHHS only
Race
Total (% tested)
# positive
% positive
Black
813 (57%) 5
0.6
Hispanic
358 (25%) 1
0.3
White
230 (17%) 4
1.7
Other
12 (0.9%)
7.7
Asian
2 (0.1%)
Pacific Islander
Native American
1 (0.1%)
Of everyone tested: Blacks 57% White 17% Hispanic 25%

42. Age group (DHHS/Parkland combined)
Total (% tested)
# positive
% positive
12-17
220 (12%)
18-24
437 (24%) 1
0.23
25-34
497 (27%) 4
0.8
35-44
280 (15%)
1.4
45-54
146 (8) 2
55-65
245 (13%)
Gender
Total (% tested)
# positive
% positive
Female
526 (36%) 4
0.75
Male
911 (64%) 7
0.76

44. 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%)
* Only 3 of 165 cases were diagnosed with HIV in Dallas County HHS has placement in “Intake”, but tests are not mandatory. How to increase this rate?
Average Age: 39
Age Range: 20-63
HIV Diagnosis Range: