PROJECT OVERVIEW:
• Correctional Health: Health care and transitional care plans in NYC Jails
• NYC Hispanics = 22.8% of population; 33% of Jail system
• 1/3 of all Hispanics receiving RW services in NYC admitted to NYC jail.
• Estimate 30% of Hispanics in jail identify being of Puerto Rican descent.
• Jail setting presents unique opportunity to engage: at high risk and
unaware of HIV status, repeat refusers, and out of care.
• Sub-population: victims of domestic sex trafficking.
• Enroll 200 Latino/as of Puerto Rican descent detained in NYC jails.
RIKERS ISLAND
Vernon C. Bain Center, Bronx
Brooklyn
Detention
Center
Manhattan
Detention Center
Transitional Health Care Coordination
ENHANCE HIV CONTINUUM OF CARE MODEL
•Enhance HIV Testing approach
•Provide culturally sensitive HIV
care and treatment to those of PR
descent
•Integrate lessons learned from
cultural sensitivity training into
treatment counseling, Health
education/risk reduction sessions
Jail-based Services
Transitional Care
Coordination
• Discharge Planning, Patient Navigation
conducted by those who demonstrate
competency in culturally sensitive approaches to
patient re/engagement
• Linkages to primary care, substance abuse and
mental health treatment providers that
demonstrate competency in culturally sensitive
approaches to patient engagement and
maintenance in care.
Community-based
Services
• Enhance provider network for those of PR
descent for HIV Primary Care, Medical
Case Management, Health promotion
Patient Navigation, Linkages to Care
• Treatment adherence and Directly
Observed Therapy (DOT), conducted as
appropriate
PARTNERS AND COLLABORATORS
• THCC has linkage agreements with an extensive network of
community providers for HIV Primary Care, Housing, Behavioral
Health, and Care Management throughout the NYC area.
• Rikers Island Transitional Consortium (RITC) and its Consumer
Advisory Group led by THCC includes NYC Correction, Exponents, The
Fortune Society, Palladia and Women’s Prison Association.
• Contract partners funded through other sources include the Bronx
Health Home, ASCNYC, Damian Health Center and Osborne Assoc.
• Collaborators: Cultural sensitivity training facilitators include the
Bronx Health and Housing Consortium, One Stop Career Center of
Puerto Rico, NYU’s Center for Latino Adolescent and Family Health
and Girls Educational & Mentoring Services(GEMS).
INTERVENTION DESCRIPTION
• Setting is the NYC jail system: includes jails on Rikers Island and those
in Manhattan, Brooklyn, and the Bronx. DOHMH oversees all medical
and mental health care provided to persons held in NYC jails.
• Study population is currently incarcerated, HIV+ and at risk men and
women who self-identify as Puerto Rican.
• CHS clinicians will receive cultural awareness training; enrollees will be
referred to similarly trained partners in the community.
• Majority of THCC staff are jail-based Patient Care Coordinators (PCC)
who meet with clients in the jails, assess each client’s needs and work
with the client to come up with an appropriate and comprehensive care
coordination plan for when they return to the community.
INTERVENTION DESCRIPTION
• Participants will be recruited by PCC as they routinely meet with clients
within 48hrs of admission. Those eligible for study will be seen and
followed by staff specially trained on the research study protocol who
will explain the study, obtain informed consent, and enroll participants.
• NYU experts to provide cultural awareness training to jail and
community-based providers (health educators, discharge planners,
clinicians, schedulers) who engage patients in the continuum of care
• PCC provide transitional care coordination services in a culturally
sensitive approach using motivational interviewing and a ‘warm
transitions’ approach. TTM will be used to assess readiness for change.
• Extra efforts will be made to identify victims of sex trafficking /trade
and connect them to appropriate community-based organizations.
LOCAL EVALUATION
• Assess:
1) Changes in delivery of culturally appropriate care and ability to
identify victims of sex trafficking;
2) Maintenance in care of clients and their satisfaction with community
providers;
3) Changes in health and social outcomes for participants (CD4, VL,
ED utilization, SF-12, housing stability and food security, etc).
• Project team is known to the DOHMH IRB from prior SPNS study and
other applications. Key staff to prepare IRB application; Janet
Wiersema, the project coordinator, to manage and submit application.
LOCAL EVALUATION
• Mixed methods approach with a qualitative, formative study and a
quantitative assessment of outcomes.
• Quantitative assessments include clinical markers of health from
medical record, self-reports of ART adherence, ED and hospital
utilization, housing stability, and patient satisfaction.
• Pre- and post-training assessment of providers’ cultural awareness.
• Qualitative data recorded and analyzed using a grounded theory
approach; other data analyzed using appropriate statistical methods.
• Publication & Dissemination: Findings to be distributed to provider
networks at local meetings and national conferences. Policy briefs and
manuscripts prepared for publication in peer-review journals.
PROJECT TIMELINE
Q1: Hire staff, Identify training providers, develop qualitative study plan
Q2: Submit ETAC-reviewed qualitative study plan to local IRB, Identify scope
of cultural competency training needs.
Q3: Obtain IRB approval and conduct qualitative study and use results to
inform interventions. Obtain approval for interviewing protocol in jails.
Q4: Upon receipt of IRB approval from, initiate baseline surveys to
incarcerated patients. sense of clients’ attitudes and needs, we will
implement our training intervention with the CHS staff.
Initiate provider trainings / interventions after administering baseline survey.
CONTACT INFO:
 Alison O. Jordan, LCSW , Principal Investigator
ajordan@health.nyc.gov 347-774-7170 917-748-6145
 Jackie Cruzado-Quiñones, Program Operations Consultant
jcruzado@health.nyc.gov 347-774-7171 917-715-6841
 Paul A. Teixeira, DrPH, MA, Program Evaluator
pteixeira@health.nyc.gov 347-774-7174
 Janet Wiersema, MPH, Project Coordinator
jwiersema@health.nyc.gov 347-774-7177