Improving the HIV Care Continuum in Incarcerated and Recently

Transcript Improving the HIV Care Continuum in Incarcerated and Recently

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

• 7 th 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

Parkland Health and Hospital System : Jail Health Daily Dashboard Date: 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 Emergencies Visits Parkland Visits ER Send Outs Jail Pts in Parkland Inpatient Parkland Appts

Daily Dashboard

8/18 Sun 166 156 6322 6 77 9 165 2687 7892 412 73 22 97 7 639 54 8 11 0 8/19 Mon 251 242 6287 5 79 9 162 2717 7960 519 86 28 88 197 872 37 3 11 12 8/20 Tue 269 304 6242 5 72 8 166 2800 8363 675 89 27 92 248 872 41 8 12 12 8/21 Wed 280 309 6247 3 77 10 169 2791 8315 838 112 32 81 229 991 34 9 12 12 8/22 Thu 297 314 6218 7 85 14 173 2784 8379 852 99 24 118 229 1022 53 9 13 15 8/23 Fri 248 313 6163 7 84 11 169 2760 8312 802 123 43 107 218 1175 36 7 15 11 8/24 Sat 231 157 6274 7 84 7 172 2678 8018 602 108 20 79 10 935 42 7 12 0 8/25 Sun 172 164 8/26 Mon 276 280 8/27 Tue 309 321 6345 7 84 6 176 6258 4 87 8 170 6259 7 82 8 174 2581 7703 2776 8185 2810 8468 429 86 14 74 7 935 35 6 9 0 710 136 35 76 263 1278 40 10 14 12 747 104 41 104 267 952 49 11 15 8 8/28 Wed 277 341 6224 7 85 8 166 2794 8447 811 120 35 115 321 1146 53 4 15 15 8/29 Thurs 315 296 6251 10 85 8 169 2712 7682 753 125 40 110 270 1149 32 5 14 10

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 Chronic Care Report Coumadin Process Measures Dental Process Measures HBA1C Report HIV Monthly Report Monthly Lab Report Med Management Process Measures Med Pass Process Measures INR Report   Medical Provider Report Mental Health Provider Report    Neely Report Nursing Productivity Report Nursing Orders   OB/OBGYN Monthly Report Monthly Insulin Report    Sick Call Report Specialty Care Process Measures Intake Process Measures  POCT Summary Dashboard

HIV Monthly Report

Outline

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      HRSA/Ryan White  parts A,B, MAI CDC NIH SAMHSA HOPWA State  DSHS City of Dallas  Dallas supervision and corrections  HUD  Insurance for services     Private/HMOs Medicare, Medicaid Ryan White Value Options  Other Grants

Group priorities for the HIV Care Continuum

100 80 60 40 20 0

82 66 37 33 25

50 40 30 20 10 0 HIV prevention HIV testing Linkage to care HIV treatment CDC-Hall, International AIDS conference 2012

Outline

HIV Testing at Dallas County Jail

Agency

Health Department UT Southwestern Parkland HIV prevention

When

Intake 8-noon on weekdays; After in jail After in jail

Type

Blood draw Blood draw After in jail, targeting MSM Oraquick Parkland Jail Health After in jail Blood draw

#/month

205  37 7 105  112 210

DCHHS testing 2013 HIV Tested HIV New Positive HIV Previous Positive HIV Negative Jan

59 0

Feb Mar Apr May Jun

37 48 37 17 16 0 0 0 0 0

Jul

46 0

Aug Sep Oct Nov Dec YTD

25 32 21 53 52 443 0 0 0 0 0 0 0 59 0 37 0 48 0 37 0 17 0 16 2 44 0 25 0 32 0 21 0 53 1 51 3 440

UTSW and Parkland HIV jail testing results

Agency

UTSW Parkland Parkland

Time period

2013 Jul 2013 Dec 2013 Dec 2013 May 2014

# tested

89 625 1250

HIV neg

86 622 --

HIV pos

3 3 3

New pos

3 1

Prev undx seropositivity

3.37% 0.16% 2 0.16%

Parkland Jail Health 2013 HIV Tested HIV Positive HIV Negative HIV New Positive HIV+ Seen by Provider On HIV Therapy Released Jan

116 40 76 0 39 29 1

Feb Mar Apr May Jun

100 24 76 0 24 15 0 131 36 95 0 35 23 1 143 27 116 0 27 19 0 111 37 74 1 37 26 0 112 28 84 0 27 22 0

Refused % HIV Positive Tests

1 2 0 0 0 1

Jul

129 24 105 1 23 12 1 0

Aug Sep

116 42 74 0 40 26 1 1 95 26 69 0 25 15 1 0

Oct

100 24 76 1 22 16 1 1

Nov Dec YTD

111 24 87 0 23 11 0 1 87 18 69 2 17 11 1 1 1351 350 1001 5 339 225 7 8 34% 24% 27% 19% 33% 25% 19% 36% 27% 24% 22% 21% 26%

Outline

Snapshot of HIV+ Released Inmates Receiving Case management at Dallas County Jail December 2012-February 2013 165 HIV+ Inmates Seen by Case Manager 76 Transferred: 48 TDCJ 7 Reincarcerated 21 released to other mandated facility/program 89 Released to community 64 Scheduled for Intake/Follow up 47% 30 kept intake/ follow up 25 receive care from other ASO / out of county 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 73 Transferred: 47 TDCJ 7 INS/US Marshall 2 Reincarcerated 20 released to other mandated facility/program 47 Scheduled 40 Contacted for Intake/Follow up 58% 27 kept intake/ follow up 45 receive care from other ASO / out of county 6 future visit scheduled 7 did not keep appointment 7 unable to contact (though CM still attempts linkage)

Outline

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 Assessment Incarceration questions

HIV testing at the jail

Agency Dates Interval #Tested #Positive % pos New pos

Parkland DHHS 9/11 2/12 1/12 6/12 Dallas Total - 6 mo 6 mo - 372 0 0 1456 1828 11 (3 false +) 11 0.75

0.6

1 0 1

Testing venue

Agency

Parkland DHHS DHHS DHHS DHHS

Location

Kays Tower

#Test

372 Bookin Pods 780 325 Kite JDC 116 192

# Positive

0 6 4 1 0

% positive

0 0.77

1.2

0.86

Characteristics– DHHS only

Race

Black Hispanic White Other Asian Pacific Islander Native American

Total (% tested)

813 (57%) 358 (25%) 230 (17%) 12 (0.9%) 2 (0.1%) 2 (0.1%)

# positive

5 1 4 1 0 0

% positive

0.6

0.3

1.7

7.7

0 0 1 (0.1%) 0 0

Age group (DHHS/Parkland combined)

Age

12-17 18-24 25-34 35-44 45-54 55-65

Gender

Female Male

Total (% tested)

220 (12%) 437 (24%) 497 (27%) 280 (15%) 146 (8) 245 (13%)

Total (% tested)

526 (36%) 911 (64%)

# positive

0 1 4 4 2 0

# positive

4 7

% positive

0 0.23

0.8

1.4

% positive

0.75

0.76

What do we know about this 165 served while incarcerated?

Demographic Snapshot HIV+ Inmates Released Dec 2012-Feb 2013 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