TRANSITIONAL HEALTH CARE COORDINATION NYC DEPT. OF HEALTH AND MENTAL HYGIENE CORRECTIONAL HEALTH SERVICES ALISON O. JORDAN JACQUELINE CRUZADO-QUIÑONES PAUL A. TEIXEIRA JANET WIERSEMA

PROJECT OVERVIEW: Correctional Health: Health care and transitional care plans in NYC Jails NYC Hispanics = 22.8% of population; 33% of Jail system 1/3 of all Hispanics receiving RW services in NYC admitted to NYC jail. Estimate 30% of Hispanics in jail identify being of Puerto Rican descent. Jail setting presents unique opportunity to engage: at high risk and unaware of HIV status, repeat refusers, and out of care. Sub-population: victims of domestic sex trafficking. Enroll 200 Latino/as of Puerto Rican descent detained in NYC jails.

RIKERS ISLAND Manhattan Detention Center Brooklyn Detention Center Vernon C. Bain Center, Bronx Transitional Health Care Coordination

ENHANCE HIV CONTINUUM OF CARE MODEL Enhance HIV Testing approach Provide culturally sensitive HIV care and treatment to those of PR descent Integrate lessons learned from cultural sensitivity training into treatment counseling, Health education/risk reduction sessions Jail-based Services Discharge Planning, Patient Navigation conducted by those who demonstrate competency in culturally sensitive approaches to patient re/engagement Linkages to primary care, substance abuse and mental health treatment providers that demonstrate competency in culturally sensitive approaches to patient engagement and maintenance in care. Transitional Care Coordination Enhance provider network for those of PR descent for HIV Primary Care, Medical Case Management, Health promotion Patient Navigation, Linkages to Care Treatment adherence and Directly Observed Therapy (DOT), conducted as appropriate Community-based Services

PARTNERS AND COLLABORATORS THCC has linkage agreements with an extensive network of community providers for HIV Primary Care, Housing, Behavioral Health, and Care Management throughout the NYC area. Rikers Island Transitional Consortium (RITC) and its Consumer Advisory Group led by THCC includes NYC Correction, Exponents, The Fortune Society, Palladia and Women’s Prison Association. Contract partners funded through other sources include the Bronx Health Home, ASCNYC, Damian Health Center and Osborne Assoc. Collaborators: Cultural sensitivity training facilitators include the Bronx Health and Housing Consortium, One Stop Career Center of Puerto Rico, NYU’s Center for Latino Adolescent and Family Health and Girls Educational & Mentoring Services(GEMS).

INTERVENTION DESCRIPTION Setting is the NYC jail system: includes jails on Rikers Island and those in Manhattan, Brooklyn, and the Bronx. DOHMH oversees all medical and mental health care provided to persons held in NYC jails. Study population is currently incarcerated, HIV+ and at risk men and women who self-identify as Puerto Rican. CHS clinicians will receive cultural awareness training; enrollees will be referred to similarly trained partners in the community. Majority of THCC staff are jail-based Patient Care Coordinators (PCC) who meet with clients in the jails, assess each client’s needs and work with the client to come up with an appropriate and comprehensive care coordination plan for when they return to the community.

INTERVENTION DESCRIPTION Participants will be recruited by PCC as they routinely meet with clients within 48hrs of admission. Those eligible for study will be seen and followed by staff specially trained on the research study protocol who will explain the study, obtain informed consent, and enroll participants. NYU experts to provide cultural awareness training to jail and community-based providers (health educators, discharge planners, clinicians, schedulers) who engage patients in the continuum of care PCC provide transitional care coordination services in a culturally sensitive approach using motivational interviewing and a ‘warm transitions’ approach. TTM will be used to assess readiness for change. Extra efforts will be made to identify victims of sex trafficking /trade and connect them to appropriate community-based organizations.

LOCAL EVALUATION Assess: 1) Changes in delivery of culturally appropriate care and ability to identify victims of sex trafficking; 2) Maintenance in care of clients and their satisfaction with community providers; 3) Changes in health and social outcomes for participants (CD4, VL, ED utilization, SF-12, housing stability and food security, etc). Project team is known to the DOHMH IRB from prior SPNS study and other applications. Key staff to prepare IRB application; Janet Wiersema, the project coordinator, to manage and submit application.

LOCAL EVALUATION Mixed methods approach with a qualitative, formative study and a quantitative assessment of outcomes. Quantitative assessments include clinical markers of health from medical record, self-reports of ART adherence, ED and hospital utilization, housing stability, and patient satisfaction. Pre- and post-training assessment of providers’ cultural awareness. Qualitative data recorded and analyzed using a grounded theory approach; other data analyzed using appropriate statistical methods. Publication & Dissemination: Findings to be distributed to provider networks at local meetings and national conferences. Policy briefs and manuscripts prepared for publication in peer-review journals.

PROJECT TIMELINE Q1: Hire staff, Identify training providers, develop qualitative study plan Q2: Submit ETAC-reviewed qualitative study plan to local IRB, Identify scope of cultural competency training needs. Q3: Obtain IRB approval and conduct qualitative study and use results to inform interventions. Obtain approval for interviewing protocol in jails. Q4: Upon receipt of IRB approval from, initiate baseline surveys to incarcerated patients. sense of clients’ attitudes and needs, we will implement our training intervention with the CHS staff. Initiate provider trainings / interventions after administering baseline survey.

CONTACT INFO:  Alison O. Jordan, LCSW, Principal Investigator  Jackie Cruzado-Quiñones, Program Operations Consultant  Paul A. Teixeira, DrPH, MA, Program Evaluator  Janet Wiersema, MPH, Project Coordinator