“I don’t have to do this all by myself”: Systems Navigation to Ensure Continuity of HIV Care for Persons Leaving Prison

Abstract

Ensuring continuity of and retention in care after release from prison is critical for optimizing health outcomes among people living with HIV. As part of a large federal initiative, we conducted qualitative interviews (n = 24) with individuals living with HIV and recently released from prison in four states to understand their experiences in different navigation interventions to improve access to HIV care post-release. Interventions were delivered only in prison, only in the community, or in both settings. While the interventions varied by design, overall, participants appreciated the breadth of support received from interventionists, including health system navigation, case management and social support. Even when individuals leaving prison were returning to clinics that they were familiar with, systems navigation supported continuity of care. Our findings elucidate why navigational support was instrumental, and underscore the value of a variety of types of navigation programs in facilitating continuity of care and reintegration post-prison.

Lessons Learned from Applying a Modified Learning Collaborative Model to Promote Change in Regional and Statewide HIV Care Systems

“…A handful of strategies centered on correctional settings while others focused on the use of care and surveillance data to create lists of clients who were out-of-care or at-risk of falling out of care. Various articles have been published documenting the results of the Systems to Care Linkage initiative, a select group of which are discussed below [14][15][16][17][18][19][20][21].…”

“…With new approaches for using surveillance data to identify persons who are out care, alternative referral paths for SBC are being explored [18]. Fuller et al interviewed a subset of clients (n = 24) who had been or were about to be released from prison within the previous 18 months and received navigation services from Louisiana, Massachusetts, North Carolina and Wisconsin [19]. An array of challenges was described post-release and often related to transitioning into the community.…”

“…Interventionists helped participants access medical and support services and navigate the health care system. Most participants felt they had learned skills that would be useful to them and expressed confidence in their abilities to manage care in the future [19].…”

“…Koester et al note that the LC model was an effective structure that allowed sufficient time for key staff to come together and work towards a common vision [19]. However, the SPNS initiative was structured in a way that required the funded State Health Departments to select and commit to specific interventions during the award process.…”

“…Massachusetts also shifted to an acuity-based medical case management system which has been implemented statewide and which utilizes an acuity scale that was developed and piloted as part of this project. Koester et al noted the LC model facilitated consensus building and with increased contact among stakeholders, effective communication channels were developed and relationships were established or strengthened [19].…”