Linkages to Care: From Jail to the Community

Issue: Continuity of care for HIV-infected individuals released from jail is an important public health issue. Approximately 5-8% of incarcerated individuals at Rikers Island, New York City's main jail, are HIV-infected. The New York City Department of Health and Mental Hygiene created a national model for continuity of care to provide community standard of care, a discharge plan, and a connection to HIV primary care in the community. Although one-third fail to connect to care after release from jail, DOHMH staff attempt to find this sub-set of the released population and link them to care.

Description: All people held at Rikers Island who are living with HIV are offered care and treatment while incarcerated. The Transitional Health Care Coordination program assists by providing discharge planning, after-care letters, and arranging linkages to community providers. Outcomes for those who are released are tracked to determine whether the individual was seen by a primary care provider within 30 days of release. Those who are not yet connected are then contacted by DOHMH staff that focus on locating and linking those lost to follow-up. Through a variety of resources and field service techniques, 88% of this hard to reach population has been located and 84% of eligible individuals were connected to care.

Lessons Learned: With the right skills, resources, and effort, a large proportion of people can be located and connected to care.

Recommendations: Health departments should take a leadership role and emphasize post-release connections to care for HIV-infected people recently released from jail.