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 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.

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

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

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

Process Flow

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

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

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

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

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

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

HIV Monthly Report

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.

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.

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

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

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

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

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

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.

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

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

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

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%

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.

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

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

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.

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

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

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

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?

Dallas RWPC Needs Assessment- Incarceration questions

Dallas RWPC Needs Assessment- Incarceration questions

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

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

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%

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

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 2012. 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: 1990-2012