Transitional Health Care Coordination: Linking Incarcerated People Living With HIV/AIDS to Care and Services in the Community
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1 The North American Housing and HIV/AIDS Research Summit VIII: Tackling the Social Drivers of HIV Transitional Health Care Coordination: Linking Incarcerated People Living With HIV/AIDS to Care and Services in the Community Nilda Ricard Director of Health Services and Drop-In Center September, 14, 2015 Washington D.C.
2 The Fortune Society Building People, Not Prisons The Fortune Society s vision is to create a world where all who are incarcerated or formerly incarcerated can become positive, contributing members of society. The Fortune Society offers housing, employment, education, mental health, health, and family services to approximately 4,500 formerly incarcerated men and women each year. Our program models are frequently recognized, both nationally and internationally, for their quality and innovation. 2
3 Drop-in Services Connects Clients to Immediate Care The Fortune Society s Drop-in-Center works in collaboration with The Department of Health & Mental Hygiene and the New York City Department of Correction to provide Discharge Planning to individuals with HIV from all New York City jails. Upon release, Drop-In-Center staff will pick up and escort these individuals in an agency van, and connect them to medical care and other ancillary services. Once their immediate needs are met, clients are then referred to Fortune s other supportive reentry services. 3
4 Presentation Overview New York City Department of Correction Drop-In Center s Service Delivery Model Program Outcomes and Achievements Drop-In Center as a Model for Policy Implementation 4
5 New York City Department of Correction
6 NYC DOC Population Statistics Rikers Island is the second largest jail facility in the U.S with an average daily inmate population of approximately 11,800 Rikers Island is divided into 10 jails that together can house as many as 15,000 inmates at once The NYC DOC also operates four borough jails, 16 court detention facilities, and three hospital prison wards. SOURCE: NYC. (2015, September 2). Facilities Overview. Retrieved September 2, 2015, from
7 NYC DOC Population Statistics NYC DOC Population Demographics Average Daily Population 11,827 Annual Admissions 81,758 Community Releases 60,000 / year Length of Stay mean=53 days; median~8d Male 91% Female 9% Non-Hispanic Black 54% Hispanic 33% Non-Hispanic White 8% Source: NYC Department of Corrections Mayoral Report Annual releases from NYC DOC Report of Discharges by zip code for CFY 14
8 Drop-In Center s Service Delivery Model Client Intakes NYC DOH Referrals & Enrollment Client Engagement During Incarceration Pre-Release Services Discharge Plan Development Follow-Up Sessions Discharge & Post-Release Follow-Up Agency Pick-Up Post-Release Needs Assessment
9 Client Intakes NYC DOH Referrals & Enrollment DOH assign clients based on projected release dates Detained clients are referred to Court Advocacy Fortune s information is distributed to clients sentenced to state prison Client Engagement During Incarceration Drop-In Center staff offer services to those referred by DOH (accept or reject) Monthly (or more) face-to-face sessions and Interactions Discussions are conducted regarding Treatment Adherence
10 Pre-Release Services Discharge Plan Development Begin process of accessing medical documents Assess housing needs for release (If homeless assist with housing placement) Begin process of assessing Benefits/Entitlements (Public Assistance, SSI, etc.) Follow-Up Sessions Conduct last follow-up appointment before client is released Request hold form Arrange van pick-up date with Fortune Society Gather all of client s required medical appointment/referral letters
11 Discharge & Post Release Services Agency Pick-Up Van picks up client from correctional facility on release date Client is taken for a hot meal and then transported to Fortune Society Drop-In Center staff escorts client to first appointment Post-Release Needs Assessment Continue to provide transportation/escorts to future client appointments Connect client with additional needed services (G.E.D., Mental Health, etc.) Begin aggressive outreach for clients who have Fallen Out of Care
12 Program Outcomes and Achievements Totals Releases Linked to Care 155 (83%) 172 (80%) 327 (82%) 90-Day Follow-Up 122 (79%) 142 (83%) 264 (81%)
13 Program Outcomes and Achievements 2015 Drop-In Center Statistics March April May June YTD Totals # Referred by DOH Overall Accepted (Intakes) % Accepted Service 82% 81% 70% 71% 76% % Retained in Care with 90 Day Follow-Up Encounters 100% 100% 79% 86% 91%
14 Drop-In Center Policy Implementation The Drop in Center is my second family. The staff has done so much to help me even when I did not want to help myself. They never gave up. I know I can always count on them. - P. Smith, Fortune Client Fortune s Drop-In Center Represents a National Model for HIV Service Delivery in Jails and Prisons The Drop-In Center Seeks a Broader Application of Individual Transformation, Community Health Engagement, and Stakeholder Partnerships Working to Enhance the Linkage and Retention in Care for Formerly Incarcerated PLWHAS
15 Q & A Drop-In Center Contact: Nilda Ricard Director of Drop in Center & Health Services 625 West 140 th Street New York, NY nricard@fortunesociety.org
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