Integration of Care Minutes – November 8, 2023


Minutes of the Meeting of the

Integration of Care Committee

Veronica Fortunato & Steve Hemraj, IOC Co-Chairs

Wednesday, November 8, 2023


Watch the Zoom Meeting Here


Committee Members: Ronnie Fortunato (Co-chair); Steve Hemraj (Co-chair); Raffi Babakhanian; Gregg Bruckno; Dorothy Farley; Deborah Greene; Graham Harriman; Emma Kaywin; Hondo Martinez; Jeff Natt; John Schoepp

Staff: Guadalupe Dominguez Plummer; Johanna Acosta; Adrianna Eppinger-Meiering; Faisal Abdelqader; Grace Mackson; Gina Gambone; Doienne Saab; Cristina Rodriguez-Hart; Kimbirly Mack

Guests: Ellie Epstein; Allison Denzi; Cecilia Clarity; Louis Gonzalez; Stefan McCollough; Nilda Ricard; Ann Travers; Nestor E.

Agenda Item 1: Welcome, Roll Call & Moment of Silence

Ronnie and Steve opened the meeting followed by introductions and a moment of silence.  The minutes from the June 21, 2023 meeting were approved with no changes.

Agenda Item 2: Overview of Ryan White Part A (RWPA) Non-Medical Case Management for Incarcerated/Recently Released (NMI)

Ronnie and Steve opened the meeting followed by introductions and a moment of silence.  The minutes from the October 18, 2023 meeting were approved with no changes.  Graham announced that Melanie Lawrence has moved to a position with the Public Health Clinics.  There will be a posting to fill the position, and in the meanwhile, the Department is identifying someone to staff the committee in the interim.  

Agenda Item 2: Non-Medical Case Management for Incarcerated/Recently Released (NMI): Program Data

Faisal presented an overview of data from the current NMI program, starting with program goals (have at least one face-to-face transitional services session prior to release and to achieve linkage to a health care provider in the community within 30 days of their release).  NMI staff are trained to use a ‘warm transitions’ approach to linkages, applying social work tenets to public health activities for those with chronic health conditions including HIV infection. The NMI program offers a ‘one-stop’ model of coordinated care where non-medical case management, housing assistance, substance use and mental health treatment, and job readiness support and social services are provided after incarceration through effective discharge planning and routine follow-up by program staff.  Client demographic Data for GY 2022shows that most clients are male, Black, and between 30-49.  The proportion of those infected through heterosexual contact is higher than the general HIV population.  Enrollment was broken out by priority populationsThe total of active enrolled clients(those who have received at least 1 service in the year) increased slightly from 498 in 2020 to 522 in 2022.  The numbers of service units in most service types saw big increases from 2020 to 2021 as the program rebounded from COVID.  Regarding payer of last resort and systems-level considerations, healthcare services provided to the incarcerated are not covered by 3rd party payers.  States are prohibited from using Medicaid money to cover healthcare services for inmates unless they are taken to a hospital or nursing home outside the carceral facility.  Upon release, Medicaid is reinstated.  New York hopes to become the first state to provide Medicaid coverage to prisoners up to 30 days before their release and has applied for a federal waiver to accomplish this.  Fortune Society’s NMI program provides linkage to care for recently incarcerated individuals to ensure engagement in care.  Their work seeks to transition PWH to longer term Medical Case Management.  The recipient will continue to monitor the situation for updates to ensure that services delivered under NMI are adherent to POLR requirements.  Clients enrolled in NMI can also take advantage of transportation, case management, and substance use screenings/referrals through the NYS AIDS Institute, HASA, Medicaid Health Homes, Special Needs Plans, and the Ryan White Part B program. 

Post-linkage to care data showed that a post-linkage visit within 12 months of initial linkage to care was done for 94% of clients in 2019, but fell to 89% in 2022.  The program may see an increase for 2022, as seen in other service types as programs rebound from COVID. 

Gina presented updated 2020-22 expenditure data. The allocation decreased from $4.1M in 2020 to $2.3M in 2022 due to a reduction in the CHS contract as they do not have to fund correctional officers to accompany case managers anymore (due to a change in DOC policy), which was a major expense. Savings were used for toiletry kits and increasing core staff salaries to retain staff.  Actual expenditures were at about 86% of the original allocation.

A summary of the ensuing discussion follows:

  • It is not uncommon for an incarcerated person to have an intake in one contract year, but have the linkage service in the following year.
  • All people under age 30 are grouped together due to small numbers, but most people under 18 are in the juvenile justice system.
  • Access to inmates has always been dependent on corrections officers, but only the mechanism for paying for them has changed.

Agenda Item 3: NMI Client and Provider Perspectives

Gina presented a summary of responses to IOC questions to NMI providers.  Representatives from the Fortune Society explained that they updates the CHS on client’s progress via phone or when reporting to the NYC jails.  Staff conduct monthly face-to-face follow-up with clients while in custody.  All clients are offered transportation to be provided on the day of their release.  For those who are homeless, the program will place them in our emergency housing or escort them to HASA for housing placement.  For those who do not accept Transportation or are released from court or on bail, staff conduct immediate outreach and follow up within the first 48 hours via phone or home visit.  The program ensures the client begins the process of applying for/re-activating their Public Assistance, SNAP, and Medicaid, and if applicable SSI, and that they connect with the medical provider identified on their discharge plan.  Other services are provided, including a range of wrap-around services.

CHS reported that when a patient accepts a referral to Fortune, RCS staff share some basic identifying demographic information, important details regarding their likely discharge date (next court date and/or information about possible release), and some health information.  After a client has met with Fortune to complete their intake CHS provides additional records and information as is relevant to support the discharge plan and/or as requested by Fortune.  Once a patient accepts the referral to Fortune and signs a release, CHS staff maintain regular communication with Fortune.  A CHS case manager working directly with the patient in the facility is in communication with the assigned Fortune case manager and helps to facilitate case conferences with the patient.  CHS shares the discharge plan with Fortune staff and keeps them informed of any case disposition updates.  RCS leadership also communicate with Fortune leadership to confirm referrals and releases.  When discharge dates are known, CHS also coordinates with Fortune to offer transportation assistance.  

RCS staff work to identify patients eligible for NMI services within one business day of admission to jail and attempt to meet with them as soon as possible to offer services and complete a program intake, typically within a few days.  RCS staff work to create a discharge plan and make any necessary referrals as soon as possible, given the unpredictability of most jail releases.  Staff continue to meet with patients throughout their incarceration and update the discharge plan as needed.  Upon release from jail, CHS provides patients with their discharge plan and medication, and if working with Fortune, notifies Fortune of the release.  For patients that are not engaged by Fortune, CHS staff will attempt to contact the patient directly, and/or outreach any collateral contacts the patient identified to confirm whether the patient has been able to execute the plan and/or offer additional assistance.

Upon admission to jail, CHS offers all patients HIV testing as part of the medical intake process.  Patients may also be offered testing at follow up appointments and/or can request to be tested at any time throughout their incarceration by calling the health triage line or speaking with a CHS staff person.

Ellie explained how CHS staff are based at Riker’s in the facility where new admissions happen.  Within 24 hours of admission inmates complete a medical intake and staff can see who has reported an HIV infection for tested positive.  The client then meets with CHS staff, who offer case management and start a discharge plan, as discharge dates are unpredictable.  They identify a community provider/clinic and work to identify help for housing and can make referrals to Fortune Society. 

Nilda explained how Fortune tries to meet with the client that CHS has identified while they are still at Riker’s to start coordinating care.  Louis explained the process for seeing the client, coordinating with Riker’s staff, and conducting intake and follow up.  They then prepare for transition back into the community and connecting them to medical care.  If the client is being transferred to State prison, they make a plan for eventual release. 

A summary of the ensuing discussion follows:

  • CHS respects client autonomy, and if someone refuses to disclose their HIV status or refuses treatment, CHS works with them to understand that they are independent from DOC and get clients to enter care.  CHS also makes opportunities for care available beyond the program (e.g., through the Reentry Center).
  • CHS also contracts with a provider of drop-in community reentry services for anyone who’s been in NYC custody in the last 2 years.
  • Fortune staff are also present at parole and probation offices to offer services.
  • CHS has pharmacy and nursing departments that help ensure uninterrupted provision of medications, as well as planning for continued medications upon release.  They work to activate Medicaid and other coverage upon release too.

Nilda led a discussion with Nestor a Fortune client, who shared his experiences post-incarceration and his struggles with medication and the significance of proper care, medication, and documentation for homeless individuals.  Nilda pointed out that Nestor’s unique situation, complicated by immigration issues, hindered his access to necessary paperwork and services.  Nestor shared his personal experiences with the SRO system and incarceration and emphasized the need for outreach programs to support individuals coming out of drug use or homelessness, as well as the importance of a safe space for these individuals to work towards their goals.  There was discussion on some of the challenges clients face upon release, with CHS noting that they are open until midnight to help people released at night.  They also provide “walking” medications in case someone is released from court.  The importance of a warm handoff to a provider was stressed.  The difficulty of connecting people to substance use treatment was described.