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IMPROVING THE HIV CARE CONTINUUM IN INCARCERATED AND RECENTLY RELEASED INDIVIDUALS THROUGH STAKEHOLDER ENGAGEMENT Ank Nijhawan, MD, MPH Esmaeil Porsa,

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Presentation on theme: "IMPROVING THE HIV CARE CONTINUUM IN INCARCERATED AND RECENTLY RELEASED INDIVIDUALS THROUGH STAKEHOLDER ENGAGEMENT Ank Nijhawan, MD, MPH Esmaeil Porsa,"— Presentation transcript:

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

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6 Dallas County Jail, Today 7 th 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: –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 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 Parkland Health and Hospital System : Jail Health Daily Dashboard Date: 8/188/198/208/218/228/238/248/258/268/278/288/29 JailSunMonTueWedThuFriSatSunMonTueWedThurs Admissions (Intake) Discharges (Release) Census Adult Census Medical - Acute Care Census (acuity 1) Medical - Intermediate Care Census (acuity 2&3) Psych - Crisis Stabilization Program Census Psych - Acute Care (CBO) Census Medication Management Patients on Medications - Adult Number of Doses Dispensed - Adult Requests Clinician Orders Sick Call Request - General Sick Call Request - Mental Health Encounters Medical Assessment Program Encounters Medical Provider Encounters (MD/PA/NP) Nursing Encounters Emergencies Visits Parkland Visits ER Send Outs Jail Pts in Parkland Inpatient 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

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 16

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

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

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

23 Group priorities for the HIV Care Continuum Diagnosed Linked to Care Retained in Care Prescribed ART Viral Suppression 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

25 HIV Testing at Dallas County Jail AgencyWhenType#/month Health Department Intake 8-noon on weekdays; After in jail Blood draw 205  37 UT Southwestern After in jailBlood draw7 Parkland HIV prevention After in jail, targeting MSM Oraquick 105  210 Parkland Jail Health After in jailBlood draw112

26 DCHHS testing 2013JanFebMarAprMayJunJulAugSepOctNovDecYTD HIV Tested HIV New Positive HIV Previous Positive HIV Negative

27 AgencyTime period # testedHIV negHIV posNew posPrev undx seropositivity UTSW % ParklandJul Dec % ParklandDec May % UTSW and Parkland HIV jail testing results

28 Parkland Jail Health 2013JanFebMarAprMayJunJulAugSepOctNovDecYTD HIV Tested HIV Positive HIV Negative HIV New Positive HIV+ Seen by Provider On HIV Therapy Released Refused % HIV Positive Tests 34%24%27%19%33%25%19%36%27%24%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

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

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

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

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

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39 HIV testing at the jail AgencyDatesInterval#Tested#Positive% posNew pos Parkland9/11- 2/12 6 mo DHHS1/12- 6/12 6 mo (3 false +) Dallas Total

40 Testing venue AgencyLocation#Test# Positive% positive ParklandKays Tower37200 DHHSBookin DHHSPods DHHSKite DHHSJDC19200

41 Characteristics– DHHS only RaceTotal (% tested) # positive% positive Black813 (57%)50.6 Hispanic358 (25%)10.3 White230 (17%)41.7 Other12 (0.9%)17.7 Asian2 (0.1%)00 Pacific Islander 2 (0.1%)00 Native American 1 (0.1%)00

42 Age group (DHHS/Parkland combined) AgeTotal (% tested)# positive% positive (12%) (24%) (27%) (15%) (8) (13%)00 GenderTotal (% tested) # positive% positive Female526 (36%)40.75 Male911 (64%)70.76

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


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