Securing the Link: A Guide to Support Individuals Transitioning Back Into the Community From Jail by AIDS United

SECURING THE LINK A Guide to Support Individuals Transitioning Back Into the Community from Jail

Presen ted By Now known as Action Wellness

This report is based upon work under Grant No. 10SIHDC001 and supported by the Social Innovation Fund (SIF), a program of the Corporation for National and Community Service (CNCS). Opinions or points of view expressed in this document are those of the authors and do not necessarily reflect the official position of, or a position that is endorsed by, CNCS or the Social Innovation Fund program. The Social Innovation Fund is a program of the Corporation for National and Community Service, a federal agency that engages millions of Americans in service through its AmeriCorps, Senior Corps, Social Innovation Fund, and Volunteer Generation Fund programs, and leads the President’s national call to service initiative, United We Serve. For more information, visit NationalService.gov.

The Social Innovation Fund requires a one-for-one match at the national and local levels. National match funders include: Abbott Laboratories Bristol-Myers Squibb Broadway Cares Chevron Corporation Dr. David E. Rogers Innovation Fund Eagle Bank Elton John AIDS Foundation Ford Foundation Fred Eychaner Gilead Sciences

H. van Amerigen Foundation Janssen Therapeutics John Taylor Memorial Fund Levi Strauss Foundation M∙A∙C AIDS Fund Macy’s Foundation Orasure Technologies ViiV Healthcare Walgreens Company Walmart Company

Suggested Citation: ActionAIDS and AIDS United. Securing the Link: A Guide to Support Individuals Transitioning Back Into the Community from Jail. Washington, DC. 2016. ActionAIDS, now known as Action Wellness, is a Philadelphia, PA-based organization, committed to creating an AIDS-free generation through a combination of proven strategies. Our services include case management, HIV testing, prevention education, supportive housing, HIV treatment as prevention, and volunteer services. Through our work in partnership with people living with HIV/AIDS, we seek to sustain and enhance their quality of life. Our Board of Directors, staff, and volunteers are committed to including and assisting people from our diverse community. Learn more at www.actionaids.org AIDS United’s mission is to end the AIDS epidemic in the United States. We seek to fulfill our mission through strategic grantmaking, capacity building, policy/advocacy, technical assistance, and formative research. Learn more at www.aidsunited.org

Now known as Action Wellness

1216 Arch Street, 6th Floor Philadelphia, PA 19107 www.actionaids.org Phone: (215) 981-0088

1424 K Street, NW, Suite 200 Washington, DC 20005 www.aidsunited.org Phone: (202) 408-4848 Fax: (202) 408 1818

LETTER FROM ACTIONAIDS DEPUTY EXECUTIVE DIRECTOR ELIZABETH HAGAN

This guide is one outcome of a three-year initiative that ActionAIDS was fortunate to implement as part of the Social Innovation Fund grant from the Corporation for National and Community Service and AIDS United. ActionAIDS has provided medical case management services to incarcerated individuals living with HIV in the Philadelphia jails since 1991 through our program, the Philadelphia Linkage Program. In 2012 we were awarded a grant from AIDS United to implement a more concentrated level of care for clients. First of all, we are thankful to AIDS United for their financial and logistical support and for providing necessary guidance throughout the 3-year project. We are also grateful to our community partner organizations, COMHAR, Gaudenzia, and Pathways to Housing. Their investment in the program was invaluable. We have established relationships with our community partners that have allowed us to expedite care for our clients. These relationships are continuing beyond the life of the grant. An initial goal of our monthly meetings was to develop an Acuity Vulnerability Scale that was reliable and valid. Our Program Evaluator, Hal Shanis, helped us analyze the data and provided technical support throughout the whole grant period and the Acuity Vulnerability Scale is included in this guide. Special thanks to Bruce Herdman, MD, chief of medical operation at Philadelphia Prison System, for his support and input throughout the grant. Johns Hopkins University collected data for the project and performed cost analysis and quantitative validity measures. Katie Kramer and Barry Zack, CEOs and principal consultants of The Bridging Group, edited the guide. AIDS United provided additional copyediting and financial and logistical support for document layout, which was completed by Impact Marketing + Communications. Lastly, a huge thank you to the staff at ActionAIDS who were part of this initiative. The Care Coach Model was a success because of the people invested in making it work. I am proud to work with such a committed and passionate group of people.

Elizabeth A. Hagan MEd Deputy Executive Director ActionAIDS

CONTENTS

Letter from ActionAIDS Deputy Executive Director iii Introduction

About AIDS Unitedâ&#x20AC;&#x2122;s Access to Care Initiative 3 Overview of ActionAIDS and the Care Coach Model 4 Considerations for Program Development 8 Steps to Program Implementation 14 Conclusion Appendix

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INTRODUCTION

“More than 2 million people in the United States are incarcerated in federal, state, and local correctional facilities on any given day. . . . Most inmates with HIV acquire it in their communities, before they are incarcerated.”1 The time after incarceration is one of increased vulnerability and former inmates may be particularly susceptible to drug overdose, suicide, or re-arrest.2 Often individuals are uninsured even if they had (or were eligible for) Medicaid or Medicare in the past because their benefits may have been suspended or terminated upon incarceration and they may not know how to reactive them upon release. Without linkage interventions, barriers to care that existed prior to entering a correctional facility remain. The primary goal of a correctional linkage-to-care program is to support and assist incarcerated individuals living with HIV who are at increased risk for becoming lost to follow-up upon release. Programs provide comprehensive discharge planning prior to release and linkage support post-release, thereby minimizing drop-off rates along each stage of the HIV care continuum. A successful re-entry linkage-to-care intervention can provide the “link” between the correctional facility and community medical care, thereby maintaining or improving clinical health status, such as nondetectable viral load. Correctional linkage programs meet linkage and engagement services as called for in the Affordable Care Act.3 When

When successful, these interventions can decrease HIV transmission, reduce recidivism, improve quality of life for individuals and, ultimately, for communities.

Center for Disease Control and Prevention (CDC). HIV Among Incarcerated Populations. Retrieved February 24, 2016 from www.cdc.gov/hiv/group/ correctional.html. 2 Binswanger IA, Stern MF, Deyo RA, et al. Release from Prison—A High Risk of Death for Former Inmates. N Engl J Med. 2007.356(2): 157–165. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2836121/ 3 Health Resources and Services Administration, HIV/AIDS Bureau, Special Projects of National Significance Program. Training Manual: Creating a Jail Linkage Program. Rockville, MD. 2013. Available at: https://careacttarget.org/sites/default/files/file-upload/resources/Jail%20Linkage%20Program%20IHIP%20Training%20Manual.pdf. 1

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successful, these interventions can decrease HIV transmission, reduce recidivism, improve quality of life for individuals and, ultimately, for communities. This guide offers considerations and step-by-step program procedures for organizations looking to develop a linkage-to-care program with individuals transitioning out of correctional facilities and back into local communities. The guide highlights the ActionAIDSâ&#x20AC;&#x2122; Philadelphia Linkage Programâ&#x20AC;&#x2122;s Care Coach Model as an exemplary and comprehensive linkage to care program model of success. ActionAIDS is an AIDS United Social Innovation Fund grantee.

A B O U T A I D S U N I T E D ’ S A C C E S S T O C A R E I N I T I AT I V E

The AIDS United Access to Care (A2C) initiative supported innovative, evidence-based, collaborative programs that connected thousands of low-income and marginalized people living with HIV to supportive services and health care. All funded projects within the A2C portfolio developed a team of organizations that collaborated to reduce barriers along the HIV care continuum, provided innovative solutions to longstanding access problems, and changed the way that systems operate in their communities. The AIDS United Social Innovation Fund was inspired by the first ever United States National HIV/AIDS Strategy, which emphasized the necessity of public-private partnerships to help end the HIV epidemic. The Social Innovation Fund, a program of the Corporation for National and Community Service and 14 national private funders, supported 12 innovative, evidence-based, collaborative programs working in communities across the country to connect thousands of low-income and marginalized individuals living with HIV to care and support services. Social Innovation Fund projects were supported by a rigorous national evaluation conducted by Johns Hopkins University. Grantees informed one another as well as other initiatives across the country, and their successes put them at the forefront of the innovative, evidence-based, collaborative care necessary to end the HIV epidemic in the United States. Learn more at: www.aidsunited.org/a2c

The Social Innovation Fund was inspired by the first ever U.S. National HIV/AIDS Strategy, which emphasized the necessity of public-private partnerships to help end the HIV epidemic.

OVERVIEW OF ACTIONAIDS AND THE CARE COACH MODEL

Founded in 1986, ActionAIDS provides client- and consumer-centered services with the mission that No one should face AIDS Alone. It was in that spirit that the agency expanded their case management services into the Philadelphia county jails. Since 1991, ActionAIDS has maintained a presence in the Philadelphia county jails known as the Philadelphia Prison System,* including their Philadelphia Linkage Program whose primary goal is to ensure linkage to medical and social services for people with HIV as they transition from the jail back into the community. The Philadelphia Linkage Program provides discharge planning and HIV linkage services to clients who are in jail. A primary objective of the program is to develop a connection with clients while they are in jail and retention of clients in health care at the crucial, yet challenging, transition from the correctional facility back into their community. A significant portion of the incarcerated population living with HIV has an unmet need. Statistics provided by Dr. Bruce Herdman, chief of medical operation for the Philadelphia Prison System, indicate that “80% of the patients we see within the jails come from medically underserved areas, with only 8% having medical assistance, and an average reading level of 4th grade.”4 Because of inter-related factors including poverty, limited educational opportunities, and limited

* Philadelphia Prison System is a county jail overseen by the City of Philadelphia. 4 B.W. Herdman, July 2015. [Personal communication].

The HIV Care Continuum The HIV care continuum is a tool that clearly shows the series of steps from the time a person is diagnosed with HIV through the successful treatment of their infection with HIV medications. The national continuum demonstrates a dropoff in the percentage of individuals in the United States who make it from diagnosis (86%) to linkage to medical care (80%), and reflects an even greater dramatic drop-off in those retained in medical care (40%). Even fewer individuals receive a prescription for life-saving antiretroviral medications (37%) or achieve viral suppression (30%). Source: CDC. Understanding the HIV Care Continuum. December 2014. Available at: www.cdc.gov/hiv/pdf/dhap_ continuum.pdf.

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upward social mobility, as well as law enforcement’s focus on street crime and drug-related offenses, the Philadelphia county jails are a significant societal nexus. To address these challenges, the ActionAIDS correctional linkageto-care program model was designed. It engages individuals while incarcerated in order to minimize gaps between diagnoses (or a history of not being treated for HIV), provide linkages to community medical providers upon release, and support clients in achieving retention in care and viral load suppression. In doing so, clients can successfully move along the HIV care continuum. In particular, the Philadelphia Linkage Program’s Care Coach Model focuses on building relationships with clients, correctional health providers, the criminal justice system, community agencies, and medical providers. The Care Coach Model includes two key staff positions: care coach and care outreach specialist (COS).

The correctional linkageto-care program model engages individuals while incarcerated to minimize gaps between diagnoses, provide linkages to community medical providers upon release, and support clients in achieving retention in care and viral load suppression.

The care coaches work one-on-one with clients during their incarceration and up to 24 months post release. Services are client centered and tailored to individual needs. An integral care coach activity is communicating with parole/probation officers to ensure the client understands the legal parameters of their release. The care coaches also assist clients in making the transition from jail-based medical care to community-based medical care without treatment interruptions and link clients to the resources they need. Upon release, clients are linked to health care providers; HIV medications; community resources like food banks and clothing; and social support programs, such as mental health care, drug and alcohol treatment, HIV education programs, available temporary or emergency housing, and public benefits programs. The care outreach specialist (COS) works with a care coach to provide one-on-one support to clients after release. The COS serves as an advocate, medical escort, and health educator, as well as offering moral support to help clients stabilize their health care, medication regimen, and linkage to social services. The COS assists clients in getting to offices to activate public benefits including medical assistance coverage such as Medicaid, Medicare, Ryan White AIDS Drug Assistance Programs (ADAP), and Social Security Insurance. COS can also provide client direction on establishing payment plans with the court system. The COS ensures consistent collaboration between clients, care coaches and medical providers.

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Once clients are released from jail, a care coach and/or the COS work with the clients to prioritize the following:

obtaining photo identification activation of medical benefits linkage to a medical provider attendance of 2–3 medical visits.

These are critical benchmarks in helping the client become established in the community. The transfer from a care coach to a long-term case manager occurs up to two years after the client has been released from jail.

When clients stabilize their health care and housing, they concurrently decrease their risk of recidivism.

The Philadelphia Linkage Program Care Coach Model delivers multitiered care services. The model includes engaging other community partners, such as mental health service providers, drug and alcohol use treatment providers, and housing services providers specifically for individuals with mental health and recovery issues. Each one of the partnering agencies offers another layer of supportive services to increase the likelihood of post-correctional independent living. When clients stabilize their health care and housing, they concurrently decrease their risk of recidivism.

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A CARE COACH MODEL SUCCESS STORY: ROBERT

“Robert” is a 49-year-old, African American male with a 26-year history of homelessness, incarceration, limited social support, and no income. Robert was diagnosed with HIV and AIDS in 2010. Robert has historically struggled with engagement in medical appointments and medical case management. Since his enrollment in January 2013 with care coach services, Robert’s adherence to medical care has improved greatly. Robert attended 4 out of 5 appointments in 2013, 3 of 4 appointments in 2014, and all 3 of his three medical appointments in 2015.

Many factors affect a client’s ability to be adherent to medical care and medications.

A COS escorted Robert to all of his medical appointments in 2013 and 2014. Having a staff escort allowed Robert to focus less on the fact that someone might identify him at the doctor’s office and, instead, concentrate on the value of medical care. Robert now feels comfortable at the medical office and attended all of his appointments in 2015 on his own.

Robert had also struggled with HIV medication adherence in the past. Due to homelessness, he stored his belongings in a city park where he often lost or had his medications stolen. To help address this, the care coach dispensed Robert’s medications into weekly pill trays and held onto the remaining pills until the following week when more would be dispensed. Dispensing weekly pill trays has allowed the care coach to closely monitor Robert’s medication adherence and continue conversations with him as needed. In 2012, Robert’s CD4 count was 300. As of 2015, his CD4 count had increased to 496. Robert had a long history of recidivism. Robert committed a crime in 2009 and had difficulty reporting to his probation officer since that time because of untreated mental health symptoms and substance abuse. Robert had been arrested for violations of probation more than five times for the same case. Upon his 2014 discharge from the Philadelphia Prison System, Robert reported to his probation officer and at this time had no active bench warrant. This was the first time in 10 years that he was out of jail for more than a month and without a bench warrant. Because Robert currently has no bench warrant, the care coach was able to complete housing applications, and Robert is now living in a one-bedroom apartment that is 100% subsidized. Robert’s story illustrates the myriad factors impacting client adherence to medical care and medications. For Robert, those factors included homelessness, incarceration, and lack of income, outstanding warrants, and HIV stigma. As these factors were eliminated or reduced, he has been able to live a happy and healthy life.

C O N S I D E R AT I O N S F O R P R O G R A M D E V E L O P M E N T

Establishing Relationships with Key Correctional Facility Personnel Establishing relationships with key correctional facility staff and administrators is crucial to the success of any correctional linkage-to-care program. Organizations interested in doing this work should be prepared to discuss how the proposed service program(s) could be helpful to the correctional facility and its surrounding community. Organizations should Helpful Questions to Ask provide concrete research or program outcomes Does the facility conduct HIV testing upon along with epidemiological data from their local health department to support the need for intake? proposed services and outline how the organization ° If yes, is it opt-in or opt-out? will meet those needs.

•

° When are test results shared?

In addition, organizations should research existing health services within the local correctional facility and the correlating gaps in services that may exist. This can help ensure proposed services aren’t already taking place. It may also be useful to contact the health services administrators in the intake unit of the correctional facility or system to discuss health screenings for those newly detained (e.g., What are the HIV testing policies and practices?).

•

Do they have an infectious disease

•

Who are the key medical care personnel

provider within the facility? that you can support by offering your services?

•

What is their history of community collaboration?

For example, ActionAIDS developed relationships with the following Philadelphia county jail personnel:

city commissioner of jails chief of medical operations warden(s) private (contracted) medical provider

infectious disease doctor jail social services chaplain services re-entry committee.

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Establishing Relationships with Key Government and Community Agencies Organizations also need to identify and develop relationships with community agencies and key community stakeholders within local government systems. The participation of collaborating organizations helps ensure that services meet the wide range of client needs, are promptly available for clients upon release from the correctional facility, and are coordinated and monitored. It is important to choose partnering agencies that have a shared vision and are guided by a mutual philosophy and concern for the target population. The success of the Philadelphia Linkage Program is a result of collaborative relationships with community-based service providers, including those described below.

Community HIV Medical Providers. First and foremost, assess if there is an existing medical provider that works both inside the correctional facility and in the community. If such an agency exists, explore whether they would share medical records. Agencies should identify as many

local HIV medical providers available for clients post release. Providers should be screened for accessibility (e.g., What is the current wait time for appointments?), location (e.g., Are they in a “neutral” and accessible location for clients?), and cultural competency (e.g., Do they have a good history of working with individuals released from correctional facilities?).

Office of Adult Parole and Probation. Often clients have stipulations set forth by the court as conditions for release. There are reporting requirements that need to be upheld and ongoing communication between the parole or probation officer and the client. Having a positive working relationship with the local department of parole/probation can further support clients in their goals of completing the terms of their probation. Programs must obtain client permission to establish this relationship, and clients may revoke permission at any time. Often, clients are unclear about what is expected of them and the care coach can work with the probation department to help clarify the steps necessary to remain in good standing. In certain circumstances, the care coach can work with the Probation Officer to determine the course of action that would best serve an individual in terms of recovery services placement, nursing care facilities, or in meeting other needs. Finally, an established relationship between the care coach and parole or probation department can help locate clients if they become lost to care, and help re-establish continuity of services upon reengagement.

Specialized Courts within Jurisdiction. Research whether the service area has courts that are tailored to address specific offenses. For example, in Philadelphia there is Project Dawn Court, which was established to hear cases of women who have multiple prostitution cases and offer alternative options in lieu of jail time. Treatment court and mental health court are similar examples of courts addressing issues of non-violent crimes related to drugs and mental health, respectively.

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Local Public Health Departments. Connect with key personnel within the local public health department. These individuals may be instrumental to program success by helping to provide epidemiological and surveillance data as well as connections to community-health service-providers.

Substance Use Treatment and Recovery. Partnering agencies should offer comprehensive treatment and recovery services that are focused on the target population. For example, if the primary target population will be women of childbearing age, partner agencies should have the ability to provide residential and/or outpatient services for all women, including expectant mothers and women with dependent children.

Mental Health Services. Likewise, a partnering provider for mental health services would ideally provide an array of services for adults with mental illness, for those with intellectual or developmental disabilities, for those with autism spectrum disorder, and include specialized services for individuals with co-occurring recovery issues and those who are affected by HIV/AIDS. The partner agency should also have the capability to provide bilingual services as appropriate to the service area.

Housing Services. Housing upon release is an utmost priority. Safe housing is associated with retention in medical care, HIV medication adherence, life stability, and reduced recidivism.5 ActionAIDS follows a “Housing First” model when addressing chronic homelessness. The fundamental belief that housing is a basic human right, and establishing a standard for services driven by consumer choice that supports recovery and community integration has been vital to success.

Consider hosting monthly collaborator meetings to create stronger ties among collaborating agencies. ActionAIDS utilizes these monthly collaborating partner meetings to share expertise in the areas of mental health, psychiatry, drug and alcohol treatment, and housing resources. At each meeting, the group spends approximately one hour discussing a client anonymously. The care coach is able to use this information to create a more in-depth service care plan. These collaborator meetings also lead to stronger ties among partners and lead to expedited client appointments within the collaborating agencies.

Consider hosting monthly collaborator meetings to create stronger ties among collaborating agencies.

Bureau of Justice Assistance, Re-Entry Policy Council. Homelessness and Prisoner Re-Entry. n.d. Available at: www.endhomelessness.org/page/-/ files/1082_file_RPC_Homelessness_one_pager_v8.pdf

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Transparency and Program Parameters Transparency and clear program parameters are two important components of program development and implementation. These components are important both when approaching correctional facility administrators, and throughout service delivery. Organizations need to determine whether they will provide medical case management, legal advocacy, and linkage to community medical care. Organizations should assess whether they have a community partner or a program component with an emphasis on vocational training and, if so, whether this be incorporated into the jail program. Establishing where services will be provided is also central to a proposed program plan and to program development. Setting geographic parameters for service delivery will allow organizations to focus their efforts and better control the process of data collection, program evaluation, and assessment throughout the development of program services. Regardless of an organizationâ&#x20AC;&#x2122;s specific program service provisions and parameters, it is important to be concise and clear when establishing protocols and program procedures to ensure consistency in delivery. It is important to be transparent with prison administrators and security staff about what the organization

is proposing to provide and what the potential benefits will be for the facility, the clients, and the health services department. It is also crucial to explain what the program is not and what services will not be provided for clients, such as legal representation. Finally, organizations should recognize what resources the correctional facility will need to provide in order to implement the program, such as custody staff supervision, security escorts, and program space. Recognizing that these resources are â&#x20AC;&#x153;costsâ&#x20AC;? to the facility will add greatly to your credibility within the criminal justice system.

Training and Security Clearance Training and security clearance protocols will vary from correctional system to correctional system. It is usually standard that any outside agency staff working within a correctional facility will need to pass a security clearance and attend some level of safety training. For example, ActionAIDS staff is required to attend safety training conducted by the City of Philadelphia for access to people incarcerated with the Philadelphia county jails. This process includes a three-day training and clearance that is required for all care coaches working within the jails. Be mindful too that each correctional facility has protocols for entering and leaving the facility when conducting official visits with clients. In order to ensure ongoing access to clients and program sustainability, it is not enough to simply complete the correctional training and clearance requirements; they must be adhered to every time a staff member enters or exits a correctional facility.

Considerations for Staffing and Smaller Case Loads Due to high client need, ActionAIDS care coaches have smaller caseloads (typically 25 clients) that allow them to provide more individualized services, meet with clients more frequently, and better address post-release crises so often found with this population. The frequency of client meetings varies based on need, ranging from daily to monthly.

The frequency of client meetings varies based on need, ranging from daily to monthly.

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Smaller caseloads also facilitate care coaches’ ability to escort clients to important medical and social service appointments. Given client needs, including severe mental illness, low levels of literacy, and trauma histories, escorting clients to appointments allows them to feel more comfortable and additionally helps remove barriers to medical care. This specialized and focused intervention is associated with improved client retention in care and subsequent medication adherence.

HIV and Stigma: Program Considerations The societal stigma surrounding HIV/AIDS has been well documented throughout the history of the epidemic. This stigma follows an individual to the confines of correctional facilities and can often result in resounding fear, discrimination, and isolation. As such, when developing a corrections facility-based linkage-to-care program, consider naming the program independently of your AIDS service organization (ASO), especially if your agency is identified as a community provider for people living with HIV within your service area or has the words “HIV” or “AIDS” in the name. ActionAIDS clearly identifies itself as just that, a community-based ASO in the Philadelphia area. In an effort to maintain confidentiality within the correctional facility and provide services to clients in a timely manner, the agency named its jail services program the Philadelphia Linkage Program. Printed materials and business cards that are provided to clients inside the jails do not indicate that the Philadelphia Linkage Program is a program of ActionAIDS, reducing the opportunity for clients who engage with the program to be singled out within the jail. Internal precautions are also taken within the jail to protect the confidentiality of all individuals when they are being called down for medical care services.6

Data and Evaluation It is important to develop a standardized data collection system that includes tracking of client-level and program-level data. Agencies should develop a robust data management and quality assurance program that oversees and manages all program data and routinely reports on program outcomes. The following data is a sample of data points that can be tracked to measure the outcome of a linkage-to-care program:

linkage to community medical provider retention in medical care adherence to ART regimen reduced recidivism rates reduction in social stigma.

Client-level data can be used to assess the ongoing needs of individual clients. Client-level data can include various categories including: demographic information, comorbidities, household income, as well as retention in medical care, treatment adherence, viral load, and CD4 data. In gathering this data, a variety of 6

B.W. Herdman, July 2015. [Personal communication].

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tracking tools may be utilized, such as a risk assessment (for example the Acuity Vulnerability Scale used by ActionAIDS), service care plans, and psychosocial assessments. Data collected should be used to measure program outcomes and impact. Data can also be used to review service trends that help agencies to modify and improve their programs. Program supervisors may use data collected as a management tool to ensure that all clients are receiving thorough services. Measures such as CD4 count, viral load, and frequency of medical visits may be additional data points to review clientsâ&#x20AC;&#x2122; improvement in the program. As part of the AIDS United-funded Care Coach Model, Johns Hopkins University developed a client survey data collection tool, which was administered to clients at baseline, and in sixmonth increments over the course of 24 months. This self-reported data captured individualsâ&#x20AC;&#x2122; perceptions on health status, barriers to medical care, HIV stigma, and perceived need for additional support services, such as mental health or housing.

S T E P S T O P R O G R A M I M P L E M E N TAT I O N

There are generally seven primary jail linkage-to-care program implementation steps. These include:

Step 1: Program Referral Protocol Step 2: Intake and Assessment Step 3: Client Engagement and Pre-Release Visits Step 4: First Day Out Planning Step 5: Immediate Post Release Follow-up Step 6: Care Outreach Services Step 7: Transitioning to Longer-Term System of Care

To provide an overview of these steps and their associated processes, see the figure below.

Incarceration

HIV Testing

3 First Day Out Planning

5 Release from Jail

Positive Result

Client Engagement in Pre-Release Case Management Visits

Intake Assessment (AVS) PLP General Program

Immediate Post-Release Follow-Up

Care Outreach Specialist

Continued Care Coaching

Program Referral

Transition to Long-Term Medical Case Management

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Step 1: Program Referral Protocol

What to Keep in your Client Folder when Visiting Correctional Facilities

The ability to identify potential clients as quickly as possible upon entry into a correctional facility is important to the success of a correctional linkage to care program because individuals can be processed through the correctional facility and released within days (or even hours) of intake (especially in a jail setting). Depending on the type of facility and average length of stay, a program should develop a referral protocol that allows adequate and realistic time from point of referral to initial intake, in addition to pre-release visits that ensure the individual is linked to case management services before release. The Philadelphia Linkage Program also receives Compassionate Release referrals from the correctional facility as determined by the medical provider within the jail. Requests for assistance in compassionate release is based on the need for expedited release due to unforeseen and extraordinary circumstances such as a terminal illness in which hospice/palliative care would be a more appropriate setting for an individual.

Helpful Hint Prior to a correctional facility visit, check to see if the facility has a way to confirm if the client is still incarcerated within the facility and identify current housing location to avoid any unnecessary confusion or missed opportunity to connect with client.

Copy of permission from security to enter facility

List of important correctional facility contacts and phone numbers

An updated client list

Business cards

List of community medical providers

Blank copies of releases of information forms and all other appropriate documentation

Referrals to the Philadelphia Linkage Program are primarily made from within the jail through the following:

infectious disease doctor electronic medical records health services administration jail social services hospice.

Referrals are also received from the community, including:

community medical providers public defenders’ offices medical case managers from other agencies family members and partners client self-referrals received by phone and mail.

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Step 2: Intake and Assessment Upon receipt of referral for linkage-to-care services, staff should conduct an intake session at the correctional facility with the client. The intake is a comprehensive session, in which the client is introduced to program services, meets program staff, and completes critically important administrative intake forms and assessments. The initial intake can take up to 1 ½ hours to complete. During the intake process, the following activities may occur:

helps staff to identify which clients are most vulnerable within the service population and at highest risk for being lost to care upon release. An individual’s environment, engagement in medical services, social economic standing, and overall stability upon arrest are likely to reflect what these life circumstances will be upon release.

“[In jail sessions] are where building blocks take shape” –ActionAIDS case manager

review of standard service agreement

completion of client consent forms and agreements, including a consent form for release of client information completion of initial assessment of the client’s risk and needs.

A key task in the intake session is to complete a risk assessment with the client. This assessment

ActionAIDS developed the Acuity Vulnerability Screening (AVS) tool to refer clients more effectively to appropriate programs and to allocate services for clients most in need. ActionAIDS developed an initial Acuity Tool during the formative phase of its program, and then tested and refined this assessment instrument during the course of the program to ensure it was targeting the clients with the highest need and risk of being lost to care.

Sample Intake Packet

Individuals are assessed on various criteria in the Acuity Vulnerability Screening tool, including:

Risk Assessment: Acuity Vulnerability Screening Tool (AVS)

(See Appendix for Sample Forms)

q Notice of Privacy Practice Consent Form

q Authorization to Request/Release Information to a Single Provider

q Authorization to Request/Release Information to Multiple Providers

q Medical Case Management Agreement

q Correctional Facility Authorization for Release of Medical Records

q Acuity Vulnerability Screening Tool

history of substance use history of mental illness income stability HIV education/awareness adherence to medications and compliance to medical care history housing stability community relations stability legal issues (including probation and/or parole) medical vulnerability cultural vulnerability language sexual identity.

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All criteria are scored on a three-point range: one (1) being the lowest level of need indicated and three (3) being the highest. Total scores are then added together indicating the individual’s level of care needs: Mild (9–14), Moderate (15–21), or Severe (22–27). Clients with great need who score on the high end of the spectrum (severe) are placed in the more comprehensive and longer-term Care Coach Model program. Clients with less need are assigned to a general case management program for shortterm linkage services. The AVS is conducted prior to release and is repeated every six months over a 24-month period of time while the person remains engaged in care services. The extended engagement, ongoing stability, and consistent care offerings are intended to reduce need by engaging clients with necessary medical and social support services. This creates sustainable support systems, improved independence, and favorable health outcomes.

The extended engagement, ongoing stability, and consistent care offerings are intended to reduce need by engaging clients with necessary medical and social support services. This creates sustainable support systems, improved independence, and favorable health outcomes.

Step 3: Client Engagement and Pre-Release Visits Meeting with individuals while they are incarcerated is a unique and vital program component for a correctional linkage-to-care program and helps lead to positive client outcomes. Early introduction and engagement between clients and staff fosters a supportive relationship for clients upon release and facilitates earlier conversations around behavior change, creating a space for clients to contemplate what their goals will be upon release from the correctional facility. During the first visit, the care coach works with the client on completing referral, assignment and intake forms. Because many prisoners have limited reading skills, care coaches may read forms to clients and explain difficult words. This second visit is scheduled within two weeks after the first. This helps build continued rapport between the case manager/care Coach and client as they work together on release planning. Staff continue to visit clients (both sentenced and non-sentenced) on a monthly basis until they are released. Throughout this time, clients and the case manager/care coach are building a trusting professional relationship that increases the likelihood that the client will continue to engage with services upon release.

Things to Work on while Client Remains Incarcerated Through consistent interaction and assessment, preparation for release begins and continues on an on-going basis with each official visit. Though it is optimal to prepare for release one to two months prior to release, this is not always possible as clients can be released without notice from a jail setting. It is important that organizations establish a relationship with the client during each official visit to encourage their continued engagement in

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care upon release. Having a clear and goal-oriented care plan enables clients and staff to work towards the same goals. Obtaining appropriate releases of information and applications prepared and signed by clients while they are incarcerated will also help expedite their linkage to medical care, health insurance, social security insurance, and various other resources upon release. During the period of incarceration, case managers/care coaches can also facilitate discussion with clients about secondary prevention, harm reduction, and overdose prevention as part of standard education in anticipation of possible high-risk activities and behaviors in which clients may engage upon release back into the community. Though a comprehensive list of issues to focus on while a client remains incarcerated is specific to each individual client, common topics include: antiretroviral treatment medications (ART) adherence to medications medical linkage and retention (internal and external) drug and alcohol resources overdose prevention mental health and trauma recovery disclosure of HIV diagnosis/partner notification services secondary HIV prevention ° sexually transmitted infection (STI) screening, counseling on condom use, local needle exchange programs, gynecological (GYN) care, and family planning post-release needs ° local housing and shelter resources, food kitchens and food banks, drop in centers, and showers available for public use. ° parole/probation issues ° legal follow-up referrals for vocational services/general education development (GED) degree.

Step 4: First Day-Out Planning When planning for client release from a correctional facility, it is very important to help them plan for their first day of release. Planning for the first day is crucial for the client in terms of accessing services and not becoming lost to care. Clients are often released outside of normal business hours and, thus, may not be able to contact staff immediately upon release. Assessing clients’ release history can also be very beneficial in the development of their release plan. Many clients may return to the environment (people, places, and things) where they lived prior

to incarceration and that may have led to their arrest. Advance planning with clients about their immediate release needs may help clients to identify their most pressing needs as well as their options. Additionally, it is important to know what resources are available for homeless and unstably housed clients and accessible immediately upon release. It is important to have an honest conversation with clients before they are released if housing resources are limited. Consider the following when planning for the first day/night of release: 1) What is the correctional facility’s release plan? Does the correctional facility release people during specific hours? Are these times during “regular business hours” when service agencies are most likely open? Is the correctional facility known to release people outside of those hours? Does the correctional facility provide medications at release and, if so, how many days is the supply? Does the correctional facility provide a written medication prescription? Does the correctional facility provide ID? Does the correctional facility provide a medical discharge summary?

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Do clients receive a copy of their discharge plan upon release? Does the correctional facility provide any transportation assistance at release? 2) Does the client have an appropriate, and safe environment to go following release? If not, where are the closest shelters/recovery houses? What are their hours? Do they take people after hours? For recovery houses, is there a cost and, if so, how is it covered? (You may have to educate recovery house staff about the release process from correctional facility and turnaround times for public benefits.) Are meals included at the residence? 3) What is the plan for follow-up with staff after release? Are appointments set-up in the community where the client lives or do they need to travel to care? Does the client have office hours and contact information to the communitybased organization(s) where they’re being referred? Does the facility allow walk-in appointments or do they need to make an appointment in advance? What is the preferred mode of communication? ° Do staff have work-only cell phones that clients are permitted to call, if necessary? ° Do clients have cell phones? ° Can clients text staff? 4) Does the client need immediate food and clothing resources? If so, the client should know how to access these very important resources. Submitting

referrals to any resource prior to release is the best way to prepare. Providing the client with as many resources, such as hygiene products, transportation vouchers/tokens,

clothing, and food can greatly reduce a client from engaging in risky behavior that can result in re-arrests or becoming lost to care. What are the hours? ° Are the resources open on the weekend? ° What will clients need to confirm their identity? ° Can the referral be complete prior to release? 5) Planning for access to medication at release, especially over the weekend, helps clients remain adherent to medications. Accessing a pharmacy that is familiar with your program and population can make the medication process easier. What are the free medication programs? Can medication paperwork be prepared prior to release? What pharmacies are open late and on the weekend? Is the pharmacy aware of special programs? In summary, the single most important issue to address on the first day is housing. As long as a client has a concrete plan for safe and supportive housing and an organization has consistently made an effort to engage with them while they are in a correctional facility, the client is likely to present for services upon release. Do not become discouraged if at the first meeting the client is focused on what free resources you can provide to them. This is typical, more often than not; they have lost everything, including public benefits, and they are coming to you because they are attempting start on the “right foot.” Preparing for the first night of release is crucial to ensure linkage to care from corrections facility to community. The key to a successful linkage program is knowing the

resources that are available immediately or with little wait time. This may call for your agency to do advocacy and education work with other agencies in order to get the resources this population needs.

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Step 5: Immediate Post-Release Follow-up When a client is released from the correctional facility, it is time to set the wheels in motion. Staff spend significant time cultivating the client/staff relationship while an individual is incarcerated, and it is now an opportunity to “show up” for clients in real time. Being there to make that immediate connection with clients upon release is critical. Clients may be very vulnerable at the time of release, and often are released without housing or supports in place, sometimes returning to the streets and placing themselves at high risk for rearrest. As such, staff may need to meet with clients in their home communities or neighborhoods, and/or should encourage walk-ins to the office. Should an assigned case manager or care coach not be available, the client should be seen by a backup case manager or intake worker as soon as possible. This backup case manager or intake

worker can help begin the medical linkage process and an appointment should be scheduled with their primary care coach to begin the re-entry process and establish their probation reporting schedule. Ideally, backup is always available within the agency in a client-centered care services environment. For example, ActionAIDS provides 24hour access to case management services through emergency, on-call coverage. If an individual is released during the evening or weekend hours, support is available to ensure the client can be connected to care services.

Step 6: Care Outreach Services In addition to post-release case management services, a comprehensive correctional linkage-tocare program may also offer care outreach services for clients post release. At ActionAIDS, in an effort to best support newly released clients, each client

Sample First Steps after Release: Care Coaches

• Call Correctional Health Services administrator to request client’s discharge paperwork, including: ° medication list, including current prescription of ARTs ° discharge photo identification

• Update client locator information with current information, such as address and phone number • Schedule (or confirm) a medical appointment with the community medical provider • Submit prescriptions to client-preferred pharmacy, along with method of payment (ADAP, pharmaceutical patient assistance program, etc.)

• Check insurance status (through the use of your state’s eligibility verification system) • Submit applications for health insurance/ADAP as needed • Complete Ryan White certifications and/or other applicable certifications for region • Link client with food and clothing resources • Link client with emergency shelter, if needed • Link client with drug and alcohol and mental health treatment as needed

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is also assigned to a care outreach specialist. care outreach specialists are community health workers who provide individualized client support in the community after release. They serve as advocates, medical escorts, health educators, and provide moral support. Care outreach specialists also serve as liaison between the client, case manager, and medical providers, ensuring each are on the same page. In addition to linking clients to their medical providers, once the client is engaged in care, the care outreach specialist has 30 days to complete core appointments.

“Go home, kiss your mother, and come to our offices.” –Patsy Fitzgerald Core appointments are defined as: 1. 2. 3. 4. 5.

Department of Public Welfare application Social Security Insurance benefits application Court cost and fines payment plan Residency information obtainment Identification obtainment.

Other care outreach specialist support services include: Accessing phone service Accompanying client to mental health assessments Assisting with health care navigation Assisting in insurance navigation services and enrollment.

Step 7: Transitioning to Longer-Term Systems of Care While immediate linkage to medical care post-release is a primary goal of correctional linkage-to-care programs, the most successful and comprehensive linkage-to-care programs will also help clients to identify and link to other services providers. This will help clients meet a wider range of life needs after they are released back to the community. Most linkageto-care programs cannot meet all client needs in an ongoing manner and, thus, should make an effort to link clients to longer-term systems

of care. At ActionAIDS, care coaches are able to work with clients for up to 24 months. With this extended period of time, care coaches are able to link clients with more services, support their retention in care and medication adherence, and further prepare clients for the eventual transfer to general case management. Closure (coming to the end of a program or relationship) with clients can be difficult, yet it can also be a very important component of a successful program. Working on closure with clients should begin at the very first session and be woven in to every session thereafter. How closure looks and feels will vary. In some cases, it may be clear that clients have developed an attachment to the program and/or the staff, but not as clear in other cases. In any event, it is helpful to the staff to have closure guidelines to best serve the needs of the clients.

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A CARE COACH MODEL SUCCESS STORY: MIGUEL

Miguel is a 49-year-old, heterosexual, married (separated), Puerto Rican male. Miguel is bilingual, but prefers to speak Spanish. At the time of intake, Miguel also reported asthma, hepatitis C (HCV), partial hearing loss, and arthritis. Miguel has very limited social support. Both of Miguel’s parents are deceased, and Miguel has almost no contact with his family, who all live in Puerto Rico. Miguel has a 20-year-old daughter, who lives in Puerto Rico, but Miguel has no communication with her. No one is aware of Miguel’s HIV status, apart from his care coach, medical doctor, and probation officer. Miguel was diagnosed with HIV in 2010 while he was incarcerated in the Philadelphia Prison System. Miguel reports that he is afraid to disclose his status due to fear of discrimination and stigma. Miguel also has a mental health diagnosis of major depressive disorder and a 25-year history of daily heroin use. Miguel dropped out of school in the 10th grade and has no income. Miguel’s risk history and life story are all too common among incarcerated individuals who have not successfully accessed and utilized available treatment and service options. These factors, along with his history of recidivism, lack of employment or housing, and lack of family support indicate that Miguel needed comprehensive support and treatment. When the care coach first began working with Miguel, he often reported feeling depressed and suicidal. The care coach linked Miguel to a Spanish-speaking inpatient treatment center. Miguel now receives weekly, mental health treatment and is stabilized on mental health medications. Miguel’s care coach was also able to assist Miguel in applying for Social Security Insurance (SSI), and Miguel is now working with an attorney to file an appeal for a denied SSI case. Miguel also historically has struggled with adherence to medical care. During his first year of enrollment in the care coach program, Miguel attended 1 out of 4 scheduled medical appointments. In his last year with the program, Miguel attended all five of his scheduled medical appointments. Miguel has maintained a suppressed viral load for the entirety of the program. Miguel’s current CD4 count is 745. While working with his care coach, Miguel was also able to complete treatment for HCV and is now HCV-free. Today, Miguel is sober and living in an HIV housing program. He attends intensive outpatient treatment three times per week and has finished his parole and probation this year with no pending court cases. This is the first time that Miguel has not been under court supervision since he moved to Philadelphia in 2010. Miguel was able to accomplish many of these goals because of the increased linkages and support he was provided by his care coach. In the past, Miguel was turned away when he presented to an agency without an appointment. Due to the care coach’s reduced case load, she was able to see Miguel and assist him with acute needs on a more frequent basis. She was also able to access immediate mental health and drug and alcohol services through the program collaborators. In addition, Miguel was linked with a care outreach specialist who was able to complete public benefit applications with Miguel and meet with him when the care coach was unavailable. Miguel is in the process of transferring to a general, community-based case manager who will be able to collaborate with Miguel on his long term goals.

CONCLUSION

Correctional linkage-to-care programs that succeed in supporting people living with HIV when they are released from a correctional facility are those that take a comprehensive approach. Management of or treatment for HIV will most likely not be a primary focus for individuals after release from a prison or jail. Where to sleep, what to eat, and making sure not to become re-arrested are often more pressing and important priorities. HIV medical care, mental health and substance use treatment, medical insurance, and other important challenges can only be addressed once basic needs are addressed. It is critical for programs to address all the issues identified by clients and care coach to best support reintegration into the community. If meeting all client needs requires involvement of more than one agency, then collaboration must be prioritized; identifying community partners and creating access to specialized services is a central element of a success correctional linkage-to-care program. The Philadelphia Linkage Program’s Care Coach Model addresses all of these interrelated issues with a comprehensive approach that improves both linkage and retention in HIV care and, thus, provides a successful model program.

APPENDICES

Appendix A: Sample Consent Forms Notice of Privacy Practice Consent Form

25 25

Authorization to Request/Release Information to a Single Provider

Authorization to Request/Release Information to Multiple Providers

Appendix B: Sample Intake Forms Medical Case Management Agreement

29 29

Correctional Facility Authorization for Release of Medical Records

Appendix C: Acuity Vulnerability Scale (AVS)

SAMPLE CONSENT FORMS N O T I C E O F P R I VA C Y P R A C T I C E C O N S E N T F O R M Your Agency Name & Agency Logo This form is an agreement between you, ______________________________________ and Your Agency Name. In this form “You” includes contact between Your Agency Name, yourself, and your emergency contact if you have written his or her name here: _____________________________________. “We” will refer to Your Agency Name, including staff, volunteers, and contractors. When we provide service to you, we will be collecting what the law calls Protected Health Information (PHI) about you. We may need to share this information or some of your information to help us provide the best service to you. We may need to share this information to arrange payment for service or to verify to our funders that we have provided the stated service, and for quality assurance and supervision purposes. By signing this form, you are acknowledging that you have read the Notice of Privacy Practices (NPP) agreement, and that you are agreeing to let us use the information in the manner and extent to which it is explained in the NPP form. We are required by Federal Law to have a formal Notice of Privacy Practice and to ask you to sign this consent form acknowledging that you have offered a copy of and agree with the policy. In the future we may change the Notice of Privacy practice. If we do change it, we will inform you, and you can get a copy of the form. If you are concerned about some of your information being shared in the manner outlined in the Notice of Privacy Practice, you have the right to ask us not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell us what you want in writing and we will do our best to accommodate your request, though we are not required to agree to the limitations. We will inform you if this is the case. After you have signed this consent, you have the right to revoke it, in writing, and we will comply with your wishes about using the information from that time on. “By signing this consent, I am agreeing that I have been offered a copy of the Your Agency Name’s Notice of Privacy Practice (NPP), and I have read the NPP or it has been explained to me, and I understand it.” Please initial your choice:

________ “I ACCEPT a copy of the NPP.”

_________“I DECLINE a copy of the NPP.”

______________________________________________________________ Client Signature

____________________________ Date

______________________________________________________________ Witness

____________________________ Date

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A U T H O R I Z AT I O N T O R E Q U E S T / R E L E A S E I N F O R M AT I O N T O A S I N G L E P R O V I D E R Your Agency Name & Agency Logo I, ______________________________________, hereby authorize ______________________________________ Organization/Contact Info

and Your Agency Name to release the following confidential information to one another: HIV status, medical information, general information, demographic information, mental/emotional history, and/or substance abuse history This release is reciprocal. I am giving my permission for both parties identified above to communicate back and forth with one another. I understand that all information obtained by Your Agency Name will

remain confidential and will only be available to Your Agency Name staff and volunteers as necessary for me to receive services. I am aware that I may rescind this authorization any time by notifying Your Agency Name. I am further aware that, unless rescinded, this authorization to release information will expire on the date indicated below.

Notice Regarding Confidential Information In compliance with Act-148, Confidentiality of HIV Related Information, dated November 29, 1990, be advised that all information from confidential records are protected by Pennsylvania law. Pennsylvania law prohibits the agency receiving information from making any further disclosure. Further disclosure requires written consent or must be authorized by the Confidentiality of HIV Related Information Act. A general authorization for the release of medical or other information is not sufficient for this purpose.

NOTE: Authorization must be signed by the client or the next of kin if the client is a minor. If an individual is physically or mentally incompetent, the Power of Attorney may sign for the client. If authorization is signed by someone other than the client, please state reason. ______________________________________________________________ Client Signature

____________________________ Date

______________________________________________________________ Witness

____________________________ Date

THIS RELEASE EXPIRES ON: __________________ (up to two years later)

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A U T H O R I Z AT I O N T O R E Q U E S T / R E L E A S E I N F O R M AT I O N T O M U LT I P L E P R O V I D E R S Your Agency Name & Agency Logo I, _______________________________________________, hereby authorize the providers initialed below:

Provider:

Contact Info:

Social Security Administration

Department of Public Welfare

Public Health Management Corporation

Emergency Contact:

HIV Primary Care:

Pharmacy Choice

Email Address:

Other

Permit Access Initial & Date:

Rescind Access Initial & Date:

___________

and Your Agency Name to release the following confidential information to one another: HIV status, medical information, general information, demographic information, mental/emotional history, and/or substance abuse history To download a Word version of this appendix, visit aidsunited.org/securinglink. 27

A U T H O R I Z AT I O N T O R E Q U E S T / R E L E A S E I N F O R M AT I O N

(continued )

This release is reciprocal. I am giving my permission for Your Agency Name and the parties identified above to communicate back and forth with one another. I understand that all information obtained by Your Agency Name will remain confidential and will only be available to Your Agency Name staff and volunteers as necessary for me to receive services. I am aware that I may rescind this authorization any time by notifying Your Agency Name. I am further aware that, unless rescinded, this authorization to release information will expire on the date indicated below.

______________________________________________________________ Client Signature

____________________________ Date

______________________________________________________________ Witness

____________________________ Date

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SAMPLE INTAKE FORMS MEDICAL CASE MANAGEMENT AGREEMENT Your Agency Name medical case managers are here to help you keep active in treatment, get connected to resources, improve health outcomes, and boost dialogue and satisfaction with providers. Medical case management is always provided at no cost to the client. Medical case management at Your Agency Name is tailored for you Medical case managers are here to support your efforts and your goals. It is a flexible program designed to help you access support and to take action to protect your health. You will work with your medical case manager to create support systems and identify useful resources. Our case managers do not make decisions for you. They will support you in your goals. Ultimately, our medical case managers help you take action and help you make informed service choices. Information received is COMPLETELY CONFIDENTIAL. Resources provided may include: Medical: physicians, inpatient services, home health care and hospice, drug trials, and pediatric care Pharmaceutical: access copay assistance, medications, smoking cessation tools, nutritional shakes, and skin treatment products Financial: Social Security Insurance, Department of Public Assistance, and Veterans Administration benefits; disability benefits; emergency funds for housing, food subsidies and programs, long-term housing subsidies, etc. Practical: home-delivered meals, legal, housing, support at appointments, and childcare services Support: transportation help, clothing and kitchenware resources, buddy services, counseling, support groups, spiritual/religious counseling, pediatric services, and secondary risk-related education Your medical case manager agrees to: Contact you by phone at least once a month. Meet with you in person at the office or, as needed, in the community. Attend two medical appointments with you to your HIV provider in a year. You agree to: Contact your medical case manager by phone at least once a month. Tell your case manager if your address or phone number changes. Tell your case manager when you go into the hospital or other facility. Identify goals and obstacles with your case manager. For your case to remain active with Your Agency Name these specific conditions must be met (Initial): _____ You and your medical case manager will meet for one scheduled face to face appointment every 3 months. _____ You will attend at least two HIV medical appointments each year. _____ You and your medical case manager will document your goals and treatment adherence every 3 months. To download a Word version of this appendix, visit aidsunited.org/securinglink. 29

MEDICAL CASE MANAGEMENT AGREEMENT

(continued )

Clients have the right to: Receive quality services from qualified personnel. Be treated with dignity and respect at all times. Have privacy and confidentiality protected. Refuse any service or treatment. Participate in service choices and treatment planning. Review your records with a clinical staff person. Clients have the responsibility to: Maintain respectful and dignified behavior with staff. Provide accurate and complete information relevant to case management. Participate in service choices and treatment planning. Keep the case manager advised of any changes. Do not bring drugs, alcohol, or weapons to the agency. If a staff person has reason to believe that there is a significant risk that you will harm yourself or another person, or that there is evidence of physical or sexual abuse, we are required by law to release information without your consent, in order to access help for you.

Filing a Complaint If you have a complaint or a concern about our services, and have been unable to resolve the concern with your medical case manager, please call Agency Phone Number and ask to speak with Title.

Disruptive Incidents The agency prohibits the possession of drugs, alcohol, or weapons on the premises. The agency prohibits disruptive or abusive behavior. If a client brings drugs, alcohol, or weapons, they will be asked to leave before any further interaction. Bringing drugs, alcohol, or weapons onto agency property or engaging in disruptive or abusive behavior may result in a service suspension of up to one month. I am aware of options for Case Management Services in the local area and have chosen Your Agency Name as my Case Management provider. I have been made aware of client rights and responsibilities and have been offered a copy of this agreement.

______________________________________________________________ Client Signature

____________________________ Date

______________________________________________________________ Medical Case Manager Signature

____________________________ Date

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C O R R E C T I O N A L FA C I L I T Y A U T H O R I Z AT I O N F O R R E L E A S E O F M E D I C A L R E C O R D S

I, ______________________________________________________ , (Name of Patient)

hereby authorize _________________________________________ (Name of Correctional Facility)

Identifying Information Prison/Jail ID #: ______________ Date of Birth: ________________ AKA: ________________________

to release all medical records and all Information related to my treatment to: Your Agency Name: ____________________________________________________________________________ Agency Address: ______________________________________________________________________________ Agency Phone Number: ________________________________________________________________________ This authorization extends to all records in the possession of Name of Correctional Facility, including those that It has received from other providers, and including, if they exist, those relating to treatment for drug or alcohol abuse, mental health treatment, testing as to HIV status, and treatment for HIV or AIDS or other diseases or conditions. This authorization is effective Immediately and shall remain in effect for ninety (90) days. I agree to hold harmless Name of Correctional Facility and its agents from any actions and from all liability regarding the release of these records. Name: ______________________________________________________ Date: ____________________________ Witness: ____________________________________________________ Date: ____________________________

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A C U I T Y V U L N E R A B I L I T Y S C A L E ( AV S ) ACUITY VULNERABILITY SCALE For each criterion below, rate your client on a scale of 1–3. Total scores will fall into one of these ranges: Mild: 9–14 Moderate: 15–21 Severe: 22–27 Programs may wish to focus resources on clients in the “severe” category , followed by “moderate” and then “mild.”

Name: ______________________________________________ Date: __________________ Client #: _________________ Criteria History of substance abuse Score _____

History of mental illness Score _____

Income stability Score _____

HIV education/ awareness Score _____ Adherence to medications and compliance to medical care Score _____

No current difficulties with addictions, including alcohol and drugs.

Past problems with addiction, less than one year in recovery. Current addiction but is willing to seek help in overcoming addiction. Recognizes drug use negatively impacts life.

Current addiction; not willing to seek or resume treatment. Compliance only because of external circumstances. Fails to realize impact of addiction on life. Current substance abuse has impact on pregnancy, ability to parent, adherence with medications or has resulted in child/children being removed from home. (Active addiction correlates with recidivism.)

History of mental health but symptoms stable for more than 1 year.

Observed untreated mental health symptoms that interfere with functioning. Medications prescribed for mental health and/or hospitalization.

History of mental health/disorders treatment in client and/or family. Experiences acute episode and/or crisis. Severe stress/unaddressed trauma or family crisis. Danger to self or others. Needs immediate psychiatric assessment/evaluation.

Has steady source of income which may be in jeopardy. Occasional need for financial assistance. Stable income. History of fairly consistent employment.

Working illegally (e.g., prostitution) or relying on a source of income that is unstable. Waiting for outcome of benefits applications.

No income. Benefits denied. Immediate need for emergency financial assistance. Minimal employment history. Intense advocacy and time needed to secure stable income.

Understands service system and is able to navigate it. Clear understanding of HIV disease, but has not yet made it an integral part of lifestyle.

Needs assistance navigating service system. Needs assistance or additional information on understanding HIV disease.

Understanding of service system significantly impaired. Ignorant of HIV disease progression. Unable to make informed decisions regarding health. Doesn’t understand medications.

Adherent to medications as prescribed for more than 6 months without assistance. Currently understands medications. Able to maintain primary care. Keeps medical appointments as scheduled. Lack of medical care does not impact health.

May miss appointments on occasion. Adherent to medications as prescribed less than 6 months and more than 3 months with minimal assistance. Keeps majority of medical appointments.

Misses taking several doses of scheduled meds weekly. Misses at least half of scheduled medical appointments. Resistant to taking medications or attending medical appointments. Uses ER for primary care. Lack of medical care impacts health

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ACUITY VULNERABILITY SCALE Criteria

Housing stability Score_____

Support system stability Score _____

Legal Score _____

Medical vulnerability Score _____

(continued )

Clean, habitable apartment or house. Living situation stable, but may be threatened for some reason.

Needs short-term assistance with rent/utilities to maintain stable housing. Housing is in jeopardy due to projected financial strain or housing is marginally habitable. Formerly independent person temporarily residing with friends orÂ relatives.

Eviction eminent or currently homeless. Home completely uninhabitable. Living in shelter. Recently evicted. Needs assistedliving facility, unable to live independently.

Has supports, but not necessarily reliable and stable, some gaps in honesty with others. Some disclosure, but to a limited number of important people in his/her life.

Gaps exist in support system. Family and/or significant others are often unavailable when crisis occurs. Only partially disclosed with others about HIV. Lack of disclosure is interfering with life.

No stable support system accessible. Only support is provided by professional caregivers; has not disclosed to important people or has no significant confidents.

Understands parole/probation and importance of keeping appointments and following through with court discharge plan.

Sporadic parole violations. Unreliable, late and missed appointments with legal system.

Excessive number of missed appointments with legal system, repeated arrests. Problems with authority figures, resistant to direction. Barriers caused by courtstipulated requirements.

Has other medical problem(s) but problems do not require specialized care.

Other medical problem(s) require regular care. Non-HIV medical issue(s) causes significant impact on quality of life (e.g., dementia, stroke, liver problems). Non-HIV issues may exist but drug and mental health issues may prohibit awareness.

Other medical problem(s) if untreated will lead to death. New debilitating diagnosis causes irrevocable harm.

Please use additional category for applicable clients: Criteria Cultural vulnerability/ language/sexual identity Score _____

Client often needs translation or sign language interpretation. Client may by functionally illiterate and needs most written materials, including forms explained. Client may be experiencing moderate barriers to services due to provider lack of cultural or sexual identity sensitivity.

Client is completely unable to understand or function within the service system, is in crisis situation and needs immediate assistance with translation or culturally sensitive system interpreters and advocates. Lack of sensitivity to sexual identity creates severe barriers.

Total Score _________ *Scoring may include .5 gradations Comments: __________________________________________________________________________________________

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