Appendix: Additional Information about the EnhanceLink Initiative and the Multisite Evaluation
Purpose: This Appendix will provide more information about the EnhanceLink initiative and the multisite evaluation.
Name of Initiative and Funding Agency: The U.S. Department of Health and Human Services (DHHS), Health Resources
and Services Administration’s (HRSA) HIV/AIDS Bureau’s Special Projects of National Significance (SPNS) funded the
initiative entitled: “Enhancing Linkages to HIV Primary Care and Services in Jail Settings” (EnhanceLink).
Grantee Organizations: From 2007 - 2012, the SPNS program awarded 10 cooperative agreements to organizations to
implement and evaluate models for linkages to healthcare and other needed services for people living with HIV who
were leaving jails. These grantee organizations were located in Atlanta, GA; Chester, PA; Springfield, MA; Cleveland, OH;
Providence, RI; New York, NY; Philadelphia, PA; Chicago, IL; Columbia SC; and New Haven, CT. A year previously, the
SPNS program awarded a cooperative agreement to the Rollins School of Public Health of Emory University, with Abt
Associates serving as subcontractor, to establish the Evaluation and Support Center (ESC) to design and implement a
multisite evaluation for the project and provide technical assistance. Names of the EnhanceLink Working Group
members are shown in Appendix Table 1. During this formative year, the ESC held a consultancy meeting and a
subsequent report was published.1
Description of Initiative: The goals of the initiative were to design, implement and evaluate innovative methods for
identifying and linking people living with HIV/AIDS who are in jail or recently released with HIV primary care and ancillary
services to support continuity of care. After establishment of the programs by the 10 demonstration grantees, a paper
describing the initiative was published in the journal AIDS Care in 2011.2 Demonstration sites varied by foci of
intervention, grant funded services, and specific target population.
Program recruitment and enrollment: Recruitment and enrollment practices into services varied by demonstration site.
Separate from the enrollment in the multisite evaluation, demonstration sites had the option to define additional
inclusion and exclusion criteria for their programs (e.g., gender, mental health status, etc.).
Multi-site Evaluation Study Design: The study was a prospective longitudinal cohort study.
1
Program-level data: Aggregated data were collected by the 10 EnhanceLink grantee organizations and their local jail and
community-based partners. Data were reported on quarterly program summary (QPS) forms following a calendar year
beginning with January 1 and ending on December 31. The QPS form was developed in part based on similar forms for a
prior HRSA SPNS Corrections Demonstration Project3,4 and adapted for the present set of grantees and jail settings. Two
pilot sites began collecting and reporting QPS data in the third quarter of 2007; all had begun by July 1, 2008. Programlevel data collection ended on March 31, 2011. Open text fields allowed grantees to provide further descriptions of
contextual issues or comments about data reporting.
Client-Level Data (CLD): Individuals enrolled in SPNS services were invited to participate in the collection of CLD for the
MSE of EnhanceLink. A few sites started piloting data collection at the client level in 2008; CLD data collection ended in
October 2011. Enrollment in the CLD MSE study was contingent upon the individuals’ meeting, at minimum, three
criteria: 1) client provided informed consent, 2) client started baseline interview during, or within 7 days of release from,
index incarceration, and 3) client started baseline interview before having 3 encounters with program staff for service
delivery. Eligible, consenting clients agreed to be followed for six months post-discharge from their index incarceration
when they enrolled in EnhanceLink.
See Appendix Table 2 for a summary of CLD collected and Appendix Figure 1 for a flowchart regarding collection
of data. Baseline and Follow-up Interviews were largely based on the Addiction Severity Index Lite (ASI-Lite)5 and the
Short-Form 12™ Health Survey, Version 2 (SF-12v2).6 Both the ASI-Lite and the SF-12v2 are standardized tools that are
proven to be valid and reliable.7,8 Demonstration sites were given the option of collecting supplemental data related to
childhood trauma, social support, and HIV risk behavior (see Appendix Table 3) as part of the Baseline and Follow-up
Interviews. The Baseline and Follow-up interviews were available in English and Spanish.
There was some variability in the methods by which some data were collected. For example, some
demonstration sites worked with collaborating agencies that completed client encounter forms and medical abstraction
forms, while other sites relied upon program staff to complete them.
2
Clients could disenroll from the MSE for any reason at any time. Common reasons for disenrollment included
being sent to prison, relocation out of the catchment area, or declining to participate in the CLD collection. Clients were
welcome to continue to receive EnhanceLink services even if they disenrolled from the MSE. In practice, if a client
disenrolled from, or stopped participating in, EnhanceLink services, grantees often stopped following such clients for the
CLD portion of MSE, but this was not a practice advocated by the ESC.
Data Management: Both types of multisite evaluation data (i.e., quarterly program summary data and data at the client
level) were entered into a web-based data reporting interface and data management system developed for this project.
Demonstration sites worked closely with the ESC on data quality assurance activities. Logic checks of data were
performed at periodic intervals to check for errors in data—queries were sent back to sites for clarification and
correction. The final multisite evaluation data sets were downloaded and made available to the EnhanceLink
investigators in November 2011 through a secure file transfer protocol website.
Data Limitations: Data elements of analyses could be pulled from multiple forms--similar data elements were captured
on multiple forms. Many analyses reflected in the manuscripts limited the study population to those clients eligible to
contribute to a specific outcome of interest. Analyzing numerous data elements increased the likelihood that some data
points may be missing. Depending on the analyses, limiting the number of variables analyzed permitted a broader
inclusion of subjects. Missing data were due to clients’ being lost-to-follow-up, incomplete data sources (e.g., laboratory
testing not completed), and limited or no access to data (e.g., laboratory studies may have been conducted but record
extractor had no access to the medical chart).
Institutional Review Board Approval: The Institutional Review Boards of the Rollins School of Public Health of Emory
University and Abt Associates approved the multisite study. The study was then approved and overseen by the 10
individual sites’ Institutional Review Boards. A Certificate of Confidentiality from HRSA was also obtained for the study.
3
Appendix Table 1. EnhanceLink Work Group: Members as of 8/17/12
Site
AID Atlanta
AIDS Care Group
Baystate Medical Center
Care Alliance Health Center
NYC Department of Health and Mental Hygiene
Philadelphia FIGHT
The Miriam Hospital
University of Illinois, Chicago
University of South Carolina
Yale University AIDS Program
Emory University/Abt Associates Evaluation & Support
Center
Study Staff
Jean Porter, MPA
Jeffrey Porterfield, PhD
Naja Harvey, MPH
John Freshley
Antoine Mikel
Ann Ferguson, MSN, RN
Irshad Shaikh, MD, MPH, PhD
Howell Strauss, DMD
Thomas Lincoln, MD, CCHP
Dominique Simon-Levine, PhD, MPH
Maureen Desabrais, MMEd, LSW, LADC1
Ann Avery, MD
Rachel Ciomcia, MSW
Rhoderick Machekano, PhD, MPH
Alison O. Jordan, LCSW
Jacqueline Cruzado Quinones
Paul Teixeira, DrPH, MA
Mary Coco
Jeffrey Draine, PhD
Pat Fitzgerald
Beth Hagan
Liat Kriegel, MSW
Kevin Moore, PsyD
Jane Shull, MSW
Sarah Smith, PA-C
Hannah Zellman, MSW
Timothy P. Flanigan, MD
Helen Loewenthal, MSW
Lauri Bazerman, MS
Larry Ouellet, PhD
Chevy Williams, PhD
Dorothy Murphy, RN
Jeannette Webb
Divya Ahuja, MD, MRCP
Richard Rapp, PhD
Adrena Harrison, RN, MSN, ACRN
Monetha Gaskin, MPH, CHES
Mark Sellers, MSW
Frederick Altice, MD
Maua Herme
Ruthanne Marcus
Anne Spaulding, MD, MPH
Paula Frew, PhD, MA, MPH
Shalonda Freeman, PhD, MPH
Kimberly Jacob Arriola, PhD, MPH
Chava Bowden
Cristina Booker, MPH
Liza Solomon, MHS, DrPH
Theodore Hammett, PhD
Sofia Kennedy, MPH
4
Stephen Resch, PhD
Lisa LeRoy, PhD, MBA
Meredith Pustell
Sarah W. Ball, ScD, MPH
Christopher T. Flygare, MA
Ryan N. Kling, MA
Rebecca Sweetland
Lauren C Messina, MSPH
Bryan In-Ho Kim, DVM, MPH
Koo-Whang Chung, MPH
Marc Cunningham, MPH
Matthew S Stein, MSPH
Health Resources and Service Administration
Adán Cajina, MSc
Melinda J. Tinsley, MA
Pamela Belton
Jessica Xavier, MPH
5
Appendix Table 2. Instruments and Forms for the EnhanceLink Multisite Evaluation
Instrument or Form and content
Client Enrollment Information Form
 Basic Enrollment Information
 Inclusion Criteria
 Consent
 Booking Charges
Baseline Interview
 Index Incarceration Details
 Family/Social Relationships
 Living Conditions
 HIV and Health
o Adherence
 Medical Status & Health Insurance
 Drug/Alcohol Use
 Psychiatric Status
 Criminal Justice History/Legal Status Questions
 Employment/Support Status
o Education
o Income
 Overall Health & Well-being
 Demographics
 Childhood Trauma (Supplemental Module I)
 Social Support (Supplemental Module II)
 Risk Behavior (Supplemental Module III)
o Sexual Behavior
o Injection Drug Use
Jail Based Event Record Form
 Continuity-of-Care Related Service Event Activities
o Needs Assessment
o Information to Locate Client in Community After
Release
o Individual Counseling/Support Session
o Disease or Medication Management Education
Session
o Coordinating Services for Client in the Facility
 HIV-Related Medical Treatment
 Non-HIV-Related Medical Treatment
 Mental Health Treatment
 Substance Abuse Treatment
o Transition/Discharge Planning
 HIV Primary Care
 Substance Abuse Treatment
 Mental Health Care
 Housing
o Court Advocacy
 Administrative Events
o Client No Longer in the Program
o Client Released From Index Incarceration
Jail Chart Review Form
 Abstractions From Chart
Data Collection
Order
Must Precede All
Data collected
Frequency per in presence of
Client
client
1
No
Precedes all but
Client Enrollment
Form
1
Yes
As Events Occur
Several
No
(Limit of one per
client per staff
member each
day.)
Within 4 weeks of
client release from
1
No
6
o
HIV Diagnosis Information & Tests Results
 CD4 Count
 Viral Load
o HAART Initiation
o Other Tests/Diagnoses
 TB
 Mental Illness
 Substance Disorder
o Prophylaxis Initiation
o Medical Record Transfer Status
30-day Post Release Status Summary Form

Release Information
o Re-incarcerations
 Coordination of Services
o HIV Primary Care
o Other Non-HIV Medical Services
o Substance Abuse Services
o Mental Health Care
o Housing
o Employment
 Discharge Plan Follow-up and Participation in Services
o Case Management
o Medical Care
o Mental Health Treatment
o Substance Abuse Treatment
o Housing
o Employment
o Benefits
 Income/Cash Benefits
 Medical Benefits
o Incentives
 Planning Document Summary
Community Based Event Record Form
 Continuity-of-Care Related Service Event Activities
o Needs Assessment
o Individual HIV Prevention/Education Session
o Individual Counseling/Support Session
o Disease or Medication Management Education
Session
o Coordinating Services for Client
o Tracking and Locating Activities
 Administrative Events
o Re-Incarceration
o Client No Longer in Program
6-Month Follow Up Clinical Review Form

Outpatient Health Care Management/Maintenance
o Dates of Outpatient Clinic Visits for Healthcare
o Tests Performed & Results
 CD4 Count
 Viral Load
 Syphilis
o HIV Treatment/HAART Status
index incarceration
Between 5 and 7
1
months after release
from index
incarceration
No
6-Month Follow-up Interview
 Instances of Re-incarceration Since Index Incarceration
Between 5 and 7
1
months after release
Yes
Within 2 weeks of
1
30-days after release
from index
incarceration
Varied by site
As events occur
No
Several
(Limit of one per
client per staff
member each
day.)
7













Family/Social Relationships
Living Conditions
HIV and Health
o Adherence
Medical Status & Health Insurance
Drug/Alcohol Use
Psychiatric Status
Criminal Justice History/Legal Status
Employment/Support Status
o Education
o Income
Health & Well-being
Client Satisfaction
Childhood Trauma (Supplemental Module I)
Social Support (Supplemental Module II)
Risk Behavior (Supplemental Module III)
o Sexual Behavior
o Injection Drug Use
Quarterly Program Summary Form
 Aggregate reporting of:
o HIV Testing in Participating Jails
o Recruitment
o Caseload, Jail Releases, Disenrollment, and MSE
Participation
o HIV Treatment
from index
incarceration
Within 30 days of
end of reporting
period
Quarterly per
grantee
No
Forms available at: www.enhancelink.org on the Center for the Health of Incarcerated Persons Website, Emory
University.
8
Appendix Table 3. EnhanceLink Grantees’ Use of Supplemental Client Interview
Questions
AID Atlanta
Atlanta, GA
AIDS Care Group
Chester, PA
Philadelphia Fight
Philadelphia, PA
Yale University
New Haven, CT
University of South Carolina
Columbia, SC
Miriam Hospital
Providence, RI
New York City Department of
Health and Mental Hygiene
New York, NY
Baystate Medical Center
Springfield, MA
Care Alliance Health Center
Cleveland, OH
University of Illinois at Chicago
Chicago, IL
Childhood Trauma
Questions
Social Support Questions
HIV Risk Behavior
Questions
--
--
--
--
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--
--
√
√
--
√
√
√
√
--
--
√
--
--
--
--
--
--
--
√
√
√
√
√
9
Appendix Figure 1. EnhanceLink Multisite Evaluation Data Collection Flowchart
10
References
1.
2.
3.
4.
5.
6.
7.
8.
Spaulding AC, Arriola KRJ, Ramos KL, et al. Enhancing linkages to primary care in jail settings. Journal of
Correctional Health Care. 2007;13(2):93-128.
Draine J, Ahuja D, Altice FL, et al. Strategies to enhance linkages between care for HIV/AIDS in jail and
community settings. AIDS Care. 2011;23(3):366-377.
HRSA, HIV/AIDS Bureau. Opening Doors. The HRSA-CDC Corrections Demonstration Project For People Living
With HIV/AIDS. December 2007. Available at: ftp://ftp.hrsa.gov/hab/opening_doors.pdf. Last accessed 23
February 2008.
Robillard A, Garner J, Laufer F. CDC/HRSA HIV/AIDS intervention, prevention, and continuity of care
demonstration project for incarcerated individuals within correctional settings and the community: part I, a
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Addiction, University of Pennsylvania/Philadelphia VA Medical Center. 1997.
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Cacciola JS, Alterman AI, McLellan AT, Lin Y-T, Lynch KG. Initial evidence for the reliability and validity of a “Lite”
version of the Addiction Severity Index. Drug and Alcohol Dependence. 2007;87(2–3):297-302.
Cheak-Zamora NC, Wyrwich KW, McBride TD. Reliability and validity of the SF-12v2 in the medical expenditure
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