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In care campaign webinar march 14 2012

in+care CampaignWebinar

March 14, 2012

Ground rules for webinar participation
Ground Rules for Webinar Participation

Actively participate and write your questions into the chat area during the presentation(s)

Do not put us on hold

Mute your line if you are not speaking (press *6, to unmute your line press #6)

Slides and other resources are available on our website at

All webinars are being recorded


  • Welcome & Introductions, 5min

  • Strategies to Maintain Retention in Care Over Periods of Incarceration, 30min

  • Review of Best Practices Collected, 20min

  • Q & A Session, 5min

In care campaign webinar march 14 2012

Strategies to Maintain Retention in Care Across Periods of Incarceration

Brian Montague, DO MS MPH

Division of Infectious Diseases

Warren Alpert School of Medicine at Brown University

Hiv in corrections
HIV in Corrections Incarceration

  • Since the early years of the HIV epidemic, HIV has disproportionately impacted prisoners.

  • In 2008, the HIV prevalence was 1.6% among the state prisoners, representing 20,449 people.3

  • Approximately 150,000 HIV-infected persons, 14% of all Americans with HIV, pass through corrections each year.4, 5

  • The prevalence of HIV within correctional settings ranges from 2.5 to more than 3 times that of the general population with prevalence in high prevalence communities such as Baltimore and Washington D.C. as high as 6.6%.3, 5, 6

  • Minority disparities in HIV care are amplified in corrections

1. Montaner JS, Lima VD, Barrios R, et al. Lancet. Aug 14 2010;376(9740):532-539.

2. Conway B, Tossonian H. Current Infectious Disease Reports. 2011;13(1):68-74.

3. BJS. Bulletin HIV in Prisons 2007-2008. In: Justice, ed. Washington, DC: Department of Justice; 2009.

4. Spaulding AC, Seals RM, Page MJ, Brzozowski AK, Rhodes W, Hammett TM. PLoS One. 2009;4(11):e7558.

5. Boutwell A, Rich JD. Clin Infect Dis. Jun 15 2004;38(12):1761-1763.

6. Solomon L, Flynn C, Muck K, Vertefeuille J. J Urban Health. Mar 2004;81(1):25-37.

Disproportionate impact on minorities
Disproportionate Impact on Minorities Incarceration

  • African Americans are incarcerated at 6 times the rate of whites1

  • HIV disproportionately impacts African Americans

    • 7 times the rate of HIV infection

    • constitute 45% of new HIV infections nationwide2

    • Nearly twice as likely to lack health insurance3

  • Nearly 50% of Ryan White program clients are African American4

1. Sabol WW, West HC, Cooper M. Prisoners in 2008. BJS Bulletin. Washington, DC: US DOJ Bureau of Justice Statistics, 2010; NCJ 228417.

2. Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA 2008; 300:520–9.

3. KFF. The uninsured: a primer. Washington DC: Kaiser Family Foundation, 2010.


Risks on reentry

Risks on Reentry

  • Health gains during the stay in corrections are often lost at the time of reentry

  • CD4 declines, viral load increases at reincarceration and return to care1,2

  • Texas experience: 5.8% fill ARV prescription in time to avoid gap in treatment3

  • Springer et al. Clin Infect Dis. Jun 15 2004;38(12):1754-1760.

  • Stephenson et al. Public HealthRep. Jan-Feb 2005;120(1):84-88.

  • Baillargeon J, et al. JAMA. Feb 25 2009;301(8):848-857.

Patterns of incarceration
Patterns of Incarceration

  • Jails

    • Typically short term stays

    • Often unpredictable time of release

    • Less likely to result in interruption in services

  • Prisons

    • Generally long-term stays

    • Incarceration may lead to termination of Medicaid or other insurance benefits

Common risks
Common Risks

  • Incarcerated persons may lose housing or other social supports during incarceration

  • High rates of substance abuse and other transmission risk events both leading up to incarceration and on reentry

  • Treatment Interruption

    • Incarcerated persons often experience at least short term interruptions in treatment on entry

    • Gaps in treatment frequently occur on release


  • Lack of communication between community and correctional care systems

    • Difficulty determining who is incarcerated and when release is planned

    • Limited coordination regarding care plan

  • Homelessness or lack of reliable contacts for persons on reentry limits outreach

Retention pool
Retention Pool

  • Standard definition is those in care who are at risk of falling out

  • Distinguished from reengagement in which those who are out of care are encouraged to return

Are the incarcerated in care
Are the Incarcerated In Care?

  • May not be seen in clinic during period of incarceration, but:

    • Often intend to return to clinic on release

    • May have access to and continuity of treatment while incarcerated

    • Are high risk for loss to care on release if transitions are not managed well

  • Analogous to those transitioning care to another practice from point of view of retention

Models for supporting retention
Models for Supporting Retention

  • Case management

    • BRIDGE/Compass

  • Active review of incarceration rolls for known patients

  • Recruitment while incarcerated for intensive case management on release

  • Case manager facilitates access to services and may transport or accompany patient to care visits


  • Intervention Group: Jails

    • 71 individuals completed intervention

      • 78% male, 65% African American

      • ⅔from RI and ⅓ from MA

      • 89% reported some insurance benefit available

      • 7 moved out of catchment area on release, 2 were reincarcerated, 1 refused services, 1 died

    • 60 completed follow-up

  • Outcomes

    • 60% made it to first scheduled PCP appointment


  • Intervention Group: Prison (Sentenced)

    • 230 clients enrolled since inception

      • 67% male, 40% African American, 13% Hispanic (60% minority or multiracial)

      • At baseline on release, 49% had no health insurance

      • At completion of the program 18% remained uninsured with pending applications

  • Outcomes 2010-2011:

    • 2010-2011: 31 active patients, 25 seen by case manager and attended 1 or more appointments

    • 7 (24%) lost to follow-up of which 2/7 refused services or were reincarcerated prior to outpatient follow-up

Evaluating the success of your program
Evaluating the Success of Your Program

  • Cannot measure it only by those who link to care

  • Requires linkage of corrections data and clinical data set

  • Outcomes both keeping follow-up appointment and maintaining treatment

Model evaluation strategy
Model Evaluation Strategy

  • Link client level data from Ryan White reporting to corrections release data to create metrics for adequacy of linkage to care

    • In many jurisdictions, Ryan White likely the first payer on reentry

    • CLD reporting includes both dates of service and clinical status measures (CD4 and VL)

    • eUCI identification provides confidential means of linking data sets

Model evaluation strategy validation in ri
Model Evaluation Strategy: Validation in RI

Sentenced Data (6815)

Un-sentenced Data (36061)

Complete Data (42876)


ACI Data(n=10555)

Released back to

the community

10307 Inmates

Matching with HIV Clinic Data (n=1431)

188 Possible Matches

Prison HIV Database Verification

Paper-based Chart Verification

44 True Matches

58 HIV-infected Inmates

102 HIV-infected inmates and 79 linkages

Match results
Match Results

True Match = 102; True Linkage = 79

Match:86, Linkage:77

Name related

Match by name related eUCI

eUCI matching

Match:91, Linkage:82

Match by alias related eUCI

Alias related

Match:157, Linkage:117

Match by names

Match:154, Linkage:114

Match by names, gender

Match by names, DOB

Match:74, Linkage:68

Matching Methods

Name related

Match by names, DOB , gender

Match:74, Linkage:68


Match:177, Linkage:133

Match by alias

Alias related

Match:173, Linkage:129

Match by alias , gender

Match by alias, DOB

Match:81, Linkage:74

Match by alias, DOB , gender

Match:81, Linkage:74

Next steps
Next Steps

  • Assessment of linkage adequacy

    • Time to linkage

    • Clinical status at linkage

  • Once metrics are developed, the goal of these is to inform ongoing efforts towards program improvement

Action steps
Action Steps

  • Define your population: what is the real scope of the problem?

  • Develop communication protocols with local correctional facilities for continuity of care while incarcerated and discharge planning

    • Notification on incarceration and release (similar to hospital best practices)

  • Track incarcerated patients

  • Develop procedures for rapid reintake for persons on release (same day visits)

  • Restore patients to retention pool on release treating them as in care during prior 6 months

  • Case managers if engaged can provide invaluable support.

    • Develop partnerships between clinical providers and ASO’s to support smooth transitions of care

  • Develop strategies to address barriers to retention in this population

In care campaign webinar march 14 2012

Best Practices Exercise

Michael Hager, MPH MA

NQC Manager

In care campaign national data snapshot
in +care Campaign National Data Snapshot

Improvement update discussion
Improvement Update Discussion

  • Interventions

    • ↑ communication (internal and external)

    • ↑ staff/volunteer/intern presence in waiting room

    • ↑ staff/volunteer/intern presence in call center/reception

    • ↑ data integrity maintenance

    • ↑ reliance on performance measure reports appropriate for your service setting

    • ↑ consumer engagement by convening a joint-CAB between agencies that have struggled establishing CABs individually

    • Use more/new data sources to find patients who are ‘lost’

    • Patient navigation programs

Improvement update discussion1
Improvement Update Discussion

B) Barriers

  • Housing Status forces patients to focus on other things

  • Homeless patients are difficult to contact/track

  • Transportation unavailability makes care inaccessible

  • MH/SA comorbidities force providers and patients to focus on those issues first

  • Childcare unavailability makes care inaccessible

  • Challenging to navigate payer changes

  • Lengthy/challenging applications for charity care

  • Varying interpretations of HIPAA

Improvement update discussion2
Improvement Update Discussion

C) Lessons Learned

  • Senior leadership at quality meetings ↑ likelihood for success

  • High patient satisfaction is a strong predictor for high retention

  • Decreased wait times are strongly correlated with patient satisfaction results

  • Screen for and address issues not related to HIV

  • Build trust with patients and then take advantage of that trust

  • Patient orientation offerings help patients feel more comfortable (or at least that your agency is looking out for them)

  • Exit interviews for patients transferring away can provide very clear direction on opportunities for improvement


  • Partners in+care website is live! (check Partners tab)

  • New CAREWare build is available for all 4 Campaign Measures – go to

  • Visit to learn more about NQC Awards Program or to apply

    • Award for Performance Measurement

    • Award for Quality Improvement Activities

    • Award for Quality Management Infrastructure Development

    • Award for Leadership in Quality

    • Award for Consumer Involvement in Quality

In care campaign webinar march 14 2012

Next Steps

  • Campaign Office Hours: Every Monday and Wednesday, 4pm ET

  • Improvement Update Submission Deadline: TOMORROW March 15, 2012, 5pm ET

  • Data Submission Deadline: April 2, 2012, 5pm ET

  • Meet the Author: Dr. Michael Mugavero TOMORROWMarch 15, 2012 at 12:00pm ET

  • April Webinar: Homelessness and RetentionApril 26, 2012, 2pm ET

In care campaign webinar march 14 2012

Campaign Headquarters: National Quality Center (NQC)90 Church Street, 13th floor

New York, NY 10007Phone 212-417-4730