Benefits of Connecting HIV Care to Incarcerated People

Segment Description: Pamela Gorman, RN, ACRN, administrative director of the Cooper Early Intervention Program Expanded Care Clinic in Camden, New Jersey, describes the benefits of connecting care to incarcerated people with HIV.

Interview Transcript (modified slightly for readability):

Gorman: We understand that when persons get incarcerated, a lot of these individuals do not get connected to care.

And if you don't find them while they're incarcerated [you can’t] help them overcome some of the challenges or allow them the opportunity to tell you what those challenges are, so you might be able to start developing a plan of care, to address socioeconomic barriers that they're experiencing, or some of the things that are getting them in jail to begin with, such as substance use disorder, a mental health disorder, having that connection while in jail is huge.

And we really found that that connection, while established in jail, allowed them to look for that individual when they got out. So that connection was really important and the staff found that they had a lot of connection to the patients, not patients at the time, but persons that were incarcerated, and they followed up and they came to the clinic when they got released.

And it allowed them the opportunity to get some of the resources that they needed to connect to care, maybe address homelessness. We connected them with our non-medical case management care coordinators, clinical service representatives, and they actually worked with the state of New Jersey to help find housing for some individuals once they got incarcerated and got out.

We worked with our emergency department. Many of these individuals end up in the emergency department if they get released in the middle of the night. And we established a process for those that didn't have a place to go because that's where they ended up, in the emergency department, and direct connection from the ED [emergency department] to a housing collaborative partner.

That worked really well. The team was very successful. They enrolled 85 persons that were incarcerated. 75 of them, I believe were connected to care. And I believe 50 of them remained connected to care, which is just outstanding.

And even though they may not have stayed in care, they know that this is a resource for them, and they come back. So we might not see them right away, but eventually they do come back into the clinic. And they look for the girls that they met when they were in the jail. And those are the outreach navigators and the outreach navigators stay with them, and help connect them with the nurse navigators and they continue to do the warm handoff, which is the piece of the transitional care coordination that works best.

That's what allows people to make sure that they stay in the continuum of care, because you have to hand them off from one person to the next. And if you don't do that, sometimes miscommunication happens, the patient might end up going out the door before they see key people that will help them get their insurance, get connected to Medicaid, or charity care or whatever other resources we have to help them stay in medical care and maybe help address some of those other issues that they're dealing with.