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Making HIV Care Connections with Incarcerated Clients

By Odessa Summers,BS
Senior Prison Medical Case Manager

One in seven people living with HIV will pass through the prison system at some point in their life.* ActionAIDS created the Philadelphia Linkage Program, 23 years ago, to support these specific individuals within this marginalized population. Serving primarily those newly diagnosed, and/or those at the highest risk of becoming lost to care, we provide our Case Management services to those incarcerated within the Philadelphia Prison System (PPS).

Prior to becoming an A2C partner, ActionAIDS was only able to provide short term, (three months post release) case management services to HIV positive individuals within the PPS. Often the transfer from our Philadelphia Linkage Program (PLP) would occur before the individual had the ability to maintain stability. Likewise, higher client caseloads limited our opportunity to provide individualized support to our highest need clients. Lastly accessing vital mental health and addition recovery services proved to be challenging within such a limited time frame.

With AIDS United funding, we created two Care Coach and two Care Outreach positions to provide a more focused and individualized approach to discharge planning. Clients are now able to stay engaged in PLP services for up to two years. We have found the extended case management to better stabilize and prepare them for transfer to general case management services.

Through a collaborative partnership with a local outpatient mental health facility, an inpatient drug and alcohol facility, a housing first program and, a Psychiatrist we are able to expedite linkages to mental health services, drug and alcohol treatment, housing, and mental health medications. This comprehensive approach has allowed for individuals to become immediately linked to care services, and minimizes the opportunity that they will become lost to care.

Our designated AU clients have expressed feeling supported by the consistency received in case management and care outreach engagement. The relationship developed, allows for our Care Coaches and clients to work as a team, towards lowered rates of recidivism, engagement and retention to medical care and an overall improved sense of accomplishment and self-esteem.

So how do we choose?

ActionAIDS and our A2C project partners have developed an Acuity Vulnerability Scale (AVS) to identify those individuals most vulnerable and at risk for becoming lost to care upon release from prison and/or a high likelihood of recidivism. Those identified at the highest end of the scale, are enrolled in our long term intervention.

We personally have enjoyed working with a smaller more concentrated case load. It has allowed me the opportunity to develop a greater partnership with each client to better assess their individual needs and support their personal development and sustained medical retention.

Likewise, Action AIDS has benefited from A2C through the development of this program model and the AVS as well as the relationship with our project partners. Working in concurrence, our Care Coaches and Care Outreach Specialists, are better able to meet the urgent needs of our clients, thereby removing barriers and streamlining their access to the other services through our partnerships. Though there are many measurable outcomes, the pride and sense of accomplishment seen through our client’s success is our greatest outcome, and it is beyond measure.


Posted By: Odessa Summers, BS Senior Prison Medical Case Manager, ActionAIDS - Tuesday, July 15, 2014

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