title: Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island.
abstract: New York City (NYC) jails are the epicenter of an epidemic that overwhelmingly affects Black and Hispanic men and offer a significant opportunity for public health intervention. The NYC Department of Health and Mental Hygiene instituted population based approaches to identify the HIV-infected, initiate discharge planning at jail admission, and facilitate post-release linkages to primary care. Using a caring and supportive 'warm transitions' approach, transitional care services are integral to continuity of care. Since 2010, over three-quarters of known HIV-infected inmates admitted to jails received discharge plans; 74 % of those released were linked to primary care. The EnhanceLink initiative's new Health Liaison, a lynchpin role, facilitated 250 court-led placements in medical alternatives to incarceration. Transitional care coordination programs are critical to facilitate continuity of care for people with chronic health conditions including the HIV-infected returning home from jail and for the public health of the communities to which they return.
authors.affiliation: Correctional Health Services, New York City Department of Health and Mental Hygiene, New York, NY, USA, ajordan@health.nyc.gov.
authors.forename: Alison O
authors.initials: AO
authors.lastname: Jordan
authors.forename: Louise R
authors.initials: LR
authors.lastname: Cohen
authors.forename: Graham
authors.initials: G
authors.lastname: Harriman
authors.forename: Paul A
authors.initials: PA
authors.lastname: Teixeira
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Cruzado-Quinones
authors.forename: Homer
authors.initials: H
authors.lastname: Venters
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D019090:Case Management; D003266:Continuity of Patient Care / Q000458:organization & administration*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009518:New York; D010351:Patient Discharge; D011329:Prisoners / Q000706:statistics & numerical data*; D011330:Prisons; D016730:Program Development; D011795:Surveys and Questionnaires; D055815:Young Adult