Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH

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 ProvidedHealth Screening for ALL inmates upon arrival & yearlyTB Screening for ALL inmates upon arrival & yearlyAcute & Intermediate Medical and Mental health In-patient CareChronic & Urgent Medical and Mental Health Care (including Crisis and Suicide)Respiratory Therapy and Respiratory IsolationOb/Gyn Care Including Screening OB US of all New Pregnant InmatesHIV ClinicAnti-Coagulation ClinicDental ClinicDialysis CareOrthopedic ClinicVoluntary HIV/Syphilis testingOptometry CareRadiology

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 DashboardParkland Health and Hospital System : Jail HealthDaily Dashboard Date: 8/18 8/19 8/20 8/21 8/22 8/23 8/24 8/25 8/26 8/27 8/28 8/29Jail Sun Mon Tue Wed Thu Fri Sat Sun Mon Tue Wed Thurs

Admissions (Intake) 166 251 269 280 297 248 231 172 276 309 277 315Discharges (Release) 156 242 304 309 314 313 157 164 280 321 341 296Census Adult Census 6322 6287 6242 6247 6218 6163 6274 6345 6258 6259 6224 6251Medical - Acute Care Census (acuity 1) 6 5 5 3 7 7 7 7 4 7 7 10Medical - Intermediate Care Census (acuity 2&3) 77 79 72 77 85 84 84 84 87 82 85 85Psych - Crisis Stabilization Program Census 9 9 8 10 14 11 7 6 8 8 8 8Psych - Acute Care (CBO) Census 165 162 166 169 173 169 172 176 170 174 166 169Medication Management Patients on Medications - Adult 2687 2717 2800 2791 2784 2760 2678 2581 2776 2810 2794 2712Number of Doses Dispensed - Adult 7892 7960 8363 8315 8379 8312 8018 7703 8185 8468 8447 7682Requests Clinician Orders 412 519 675 838 852 802 602 429 710 747 811 753Sick Call Request - General 73 86 89 112 99 123 108 86 136 104 120 125Sick Call Request - Mental Health 22 28 27 32 24 43 20 14 35 41 35 40Encounters Medical Assessment Program Encounters 97 88 92 81 118 107 79 74 76 104 115 110Medical Provider Encounters (MD/PA/NP) 7 197 248 229 229 218 10 7 263 267 321 270Nursing Encounters 639 872 872 991 1022 1175 935 935 1278 952 1146 1149Emergencies Visits 54 37 41 34 53 36 42 35 40 49 53 32Parkland Visits ER Send Outs 8 3 8 9 9 7 7 6 10 11 4 5Jail Pts in Parkland Inpatient 11 11 12 12 13 15 12 9 14 15 15 14Parkland Appts 0 12 12 12 15 11 0 0 12 8 15 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

16

Outline



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 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

0

30

100

80

60

40

20

0

Diagnosed

Linked

to CareRetained

in Care

Prescribed ART

Viral S

uppression

82

66

37 3325

Pat

ien

ts,

%

CDC-Hall, International AIDS conference 2012

Outline



engagement

HIV Testing at Dallas County Jail

Agency When Type #/month

Health Department

Intake 8-noon on weekdays;After in jail

Blood draw 20537

UT Southwestern

After in jail Blood draw 7

Parkland HIV prevention

After in jail, targeting MSM

Oraquick 105 210

Parkland Jail Health

After in jail Blood draw 112

DCHHS testing

2013 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTD

HIV Tested 59 37 48 37 17 16 46 25 32 21 53 52 443

HIV New Positive

0 0 0 0 0 0 0 0 0 0 0 0 0

HIV Previous Positive

0 0 0 0 0 0 2 0 0 0 0 1 3

HIV Negative 59 37 48 37 17 16 44 25 32 21 53 51 440

Agency Time period

# tested

HIV neg

HIV pos

New pos

Prev undx seropositivity

UTSW 2013 89 86 3 3 3.37%

Parkland Jul 2013-Dec 2013

625 622 3 1 0.16%

Parkland Dec 2013-May 2014

1250 -- 3 2 0.16%

UTSW and Parkland HIV jail testing results

Parkland Jail Health

2013 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec YTDHIV

Tested116 100 131 143 111 112 129 116 95 100 111 87 1351

HIV Positive

40 24 36 27 37 28 24 42 26 24 24 18 350

HIV Negative

76 76 95 116 74 84 105 74 69 76 87 69 1001

HIV New Positive

0 0 0 0 1 0 1 0 0 1 0 2 5

HIV+ Seen by

Provider39 24 35 27 37 27 23 40 25 22 23 17 339

On HIV Therapy

29 15 23 19 26 22 12 26 15 16 11 11 225

Released 1 0 1 0 0 0 1 1 1 1 0 1 7

Refused 1 2 0 0 0 1 0 1 0 1 1 1 8% HIV

Positive Tests

34% 24% 27% 19% 33% 25% 19% 36% 27% 24% 22% 21% 26%

Outline



engagement

Snapshot of HIV+ Released InmatesReceiving Case management at Dallas County Jail

December 2012-February 2013

25 receive care from other ASO / out of county

76 Transferred:48 TDCJ7 Reincarcerated21 released to other mandated facility/program

64 Scheduled for Intake/Follow up

30 kept intake/follow up

22 did not keep appointment or are currently out of care

(though CM still attempts linkage)

165 HIV+ InmatesSeen by Case Manager

89 Released to community

12 future visit scheduled

47%

Snapshot of HIV+ Released InmatesReceiving Case management at Dallas County Jail

December 2014-February 2014

45 receive care from other ASO / out of county

73 Transferred:47 TDCJ7 INS/US Marshall2 Reincarcerated20 released to other mandated facility/program

47 Scheduled 40 Contacted for Intake/Follow up

27 kept intake/follow up

7 did not keep appointment 7 unable to contact(though CM still attempts

linkage)

165 HIV+ InmatesSeen by Case Manager

92 Released to community

6 future visit scheduled

58%

Outline



engagement

Achievements to date

Improved communication and collaboration between agencies

Increase in HIV testing Potential support (through CDC) for a

dedicated linkage coordinatorFuture directions:Increase HIV testing further (opt-out/routine)Increase referrals to HARC agenciesIncrease linkage to careMeasure 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

9/11-2/12

6 mo 372 0 0 0

DHHS 1/12-6/12

6 mo 1456 11(3 false

+)

0.75 1

DallasTotal

-- -- 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 Total (% tested)

# positive

% positive

Black 813 (57%)

5 0.6

Hispanic 358 (25%)

1 0.3

White 230 (17%)

4 1.7

Other 12 (0.9%)

1 7.7

Asian 2 (0.1%) 0 0

Pacific Islander

2 (0.1%) 0 0

Native American

1 (0.1%) 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 0Gender Total (%

tested)# positive

% positive

Female 526 (36%) 4 0.75

Male 911 (64%) 7 0.76

Demographic Snapshot HIV+ Inmates Released Dec 2012-Feb 2013

122 male42 female

1 transgender

What do we know about this 165 served while incarcerated?

Average Age: 39Age Range: 20-63

HIV Diagnosis Range: 1990-2012

RACE:102 African American ( 62%)

42 Caucasian ( 26%)18 Hispanic ( 11%)

1 other (<1%)

Documents

Ank Nijhawan, MD, MPH Esmaeil Porsa, MD, MPH