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
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:
–
–
–
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
 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
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
Sun
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Mon
Tue
Wed
Thurs
166
156
251
242
269
304
280
309
297
314
248
313
231
157
172
164
276
280
309
321
277
341
315
296
6322
6
77
9
165
6287
5
79
9
162
6242
5
72
8
166
6247
3
77
10
169
6218
7
85
14
173
6163
7
84
11
169
6274
7
84
7
172
6345
7
84
6
176
6258
4
87
8
170
6259
7
82
8
174
6224
7
85
8
166
6251
10
85
8
169
2687
7892
2717
7960
2800
8363
2791
8315
2784
8379
2760
8312
2678
8018
2581
7703
2776
8185
2810
8468
2794
8447
2712
7682
412
73
22
519
86
28
675
89
27
838
112
32
852
99
24
802
123
43
602
108
20
429
86
14
710
136
35
747
104
41
811
120
35
753
125
40
97
7
639
88
197
872
92
248
872
81
229
991
118
229
1022
107
218
1175
79
10
935
74
7
935
76
263
1278
104
267
952
115
321
1146
110
270
1149
Emergencies Visits
Parkland Visits
ER Send Outs
Jail Pts in Parkland Inpatient
54
37
41
34
53
36
42
35
40
49
53
32
8
11
3
11
8
12
9
12
9
13
7
15
7
12
6
9
10
14
11
15
4
15
5
14
Parkland Appts
0
12
12
12
15
11
0
0
12
8
15
10
Jail
Admissions (Intake)
Discharges (Release)
Census
Adult Census
Medical - Acute Care Census (acuity 1)
Medical - Intermediate Care Census (acuity 2&3)
Psych - Crisis Stabilization Program Census
Psych - Acute Care (CBO) Census
Medication Management
Patients on Medications - Adult
Number of Doses Dispensed - Adult
Requests
Clinician Orders
Sick Call Request - General
Sick Call Request - Mental Health
Encounters
Medical Assessment Program Encounters
Medical Provider Encounters (MD/PA/NP)
Nursing Encounters
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
Monthly Reports
 90 day Chronic Care Patient Report
 Medical Provider Report
 Chronic Care Report
 Mental Health Provider Report
 Coumadin Process Measures
 Neely Report
 Dental Process Measures
 Nursing Productivity Report
 HBA1C Report
 Nursing Orders
 HIV Monthly Report
 OB/OBGYN Monthly Report
 Monthly Lab Report
 Monthly Insulin Report
 Med Management Process Measures
 Sick Call Report
 Med Pass Process Measures
 Specialty Care Process Measures
 INR Report
 Intake Process Measures
 POCT Summary Dashboard
HIV Monthly Report
16
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
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
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






parts A,B, MAI


CDC
NIH
SAMHSA
HOPWA
State

DSHS
City of Dallas


Insurance for services
HRSA/Ryan White



Dallas supervision and
corrections
HUD



Private/HMOs
Medicare, Medicaid
Ryan White
Value Options
Other Grants
Group priorities for the HIV Care
Continuum
100
82
Patients, %
80
66
60
37
40
33
25
20
0
50
40
30
20
10
0
HIV prevention
HIV testing
Linkage to care
HIV treatment
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
HIV Testing at Dallas County Jail
Agency
When
Type
#/month
Health
Department
Intake 8-noon
on weekdays;
After in jail
After in jail
Blood draw
20537
Blood draw
7
UT
Southwestern
Parkland HIV
prevention
Parkland Jail
Health
After in jail,
Oraquick
targeting MSM
105 210
After in jail
112
Blood draw
DCHHS testing
2013
HIV Tested
HIV New
Positive
HIV
Previous
Positive
HIV
Negative
Jan
Feb
Mar Apr May
Jun
Jul
Aug
Sep
Oct
Nov
59
37
48
37
0
0
0
0
0
59
37
Dec YTD
17
16
46
25
32
21
53
52
443
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
1
3
48
37
17
16
44
25
32
21
53
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
3.37%
Parkland
Jul 2013Dec 2013
625
622
3
1
0.16%
Parkland
Dec 2013- 1250
May 2014
--
3
2
0.16%
Parkland Jail Health
2013
Jan
HIV
116
Tested
HIV
40
Positive
HIV
76
Negative
HIV New
0
Positive
HIV+
Seen by 39
Provider
On HIV
29
Therapy
Released 1
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
YTD
100
131
143
111
112
129
116
95
100
111
87
1351
24
36
27
37
28
24
42
26
24
24
18
350
76
95
116
74
84
105
74
69
76
87
69
1001
0
0
0
1
0
1
0
0
1
0
2
5
24
35
27
37
27
23
40
25
22
23
17
339
15
23
19
26
22
12
26
15
16
11
11
225
0
1
0
0
0
1
1
1
1
0
1
7
1
Refused
2
0
0
0
1
0
1
0
1
1
1
8
% HIV
Positive 34% 24% 27% 19% 33% 25% 19% 36% 27% 24% 22% 21% 26%
Tests
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
Snapshot of HIV+ Released Inmates
Receiving Case management at Dallas County Jail
December 2012-February 2013
165 HIV+ Inmates
Seen by Case Manager
89 Released to community
64 Scheduled for
Intake/Follow up
76 Transferred:
48 TDCJ
7 Reincarcerated
21 released to other mandated
facility/program
25 receive care from other ASO
/ out of county
47%
30 kept intake/
follow up
12 future visit
scheduled
22 did not keep appointment
or are currently out of care
(though CM still attempts linkage)
Snapshot of HIV+ Released Inmates
Receiving Case management at Dallas County Jail
December 2014-February 2014
165 HIV+ Inmates
Seen by Case Manager
92 Released to community
47 Scheduled
40 Contacted for
Intake/Follow up
73 Transferred:
47 TDCJ
7 INS/US Marshall
2 Reincarcerated
20 released to other mandated
facility/program
45 receive care from other ASO
/ out of county
58%
27 kept intake/
follow up
6 future visit scheduled
7 did not keep appointment
7 unable to contact
(though CM still attempts linkage)
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
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 AssessmentIncarceration questions
Dallas RWPC Needs AssessmentIncarceration questions
Dallas RWPC Needs AssessmentIncarceration questions
HIV testing at the jail
Agency
Dates
Interval
#Tested
#Positive
% pos
New
pos
Parkland
9/112/12
6 mo
372
0
0
0
DHHS
1/126/12
6 mo
1456
11
(3 false
+)
0.75
1
Dallas
Total
--
--
1828
11
0.6
1
Testing venue
Agency
Location
#Test
# Positive
% positive
Parkland
Kays Tower
372
0
0
DHHS
Bookin
780
6
0.77
DHHS
Pods
325
4
1.2
DHHS
Kite
116
1
0.86
DHHS
JDC
192
0
0
Characteristics– DHHS only
Race
Black
Hispanic
White
Other
Asian
Pacific
Islander
Native
American
Total (%
# positive
tested)
813 (57%)
5
358 (25%)
1
230 (17%)
4
12 (0.9%)
1
2 (0.1%)
0
2 (0.1%)
0
1 (0.1%)
0
% positive
0.6
0.3
1.7
7.7
0
0
0
Age group (DHHS/Parkland combined)
Age
Total (% tested)
# positive
% positive
12-17
220 (12%)
0
0
18-24
437 (24%)
1
0.23
25-34
497 (27%)
4
0.8
35-44
280 (15%)
4
1.4
45-54
146 (8)
2
1.4
55-65
245 (13%)
0
0
Gender
Female
Male
Total (%
tested)
526 (36%)
911 (64%)
# positive
4
7
% positive
0.75
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%)
Average Age: 39
Age Range: 20-63
HIV Diagnosis Range: 1990-2012