Integration of Care Minutes – October 18, 2023


Minutes of the Meeting of the

Integration of Care Committee

Veronica Fortunato & Steve Hemraj, IOC Co-Chairs

Wednesday, October 18, 2023


Watch the Zoom Meeting Here


Committee Members: Ronnie Fortunato (Co-chair); Steve Hemraj (Co-chair); Dorothy Farley; Billy Fields; Deborah Greene; Graham Harriman; Emma Kaywin; Hondo Martinez; Karen McKinnon; Jeff Natt; John Schoepp; Claire Simon; Gretchen Ty

Staff: David Klotz; Melanie Lawrence; Guadalupe Dominguez Plummer; Scott Spiegler; Adrianna E. Meiering; Grace Mackson; Bryan Meisel; Gina Gambone; Doienne Saab; Cristina Rodriguez-Hart

Guests: Emily Wildra, Prison Policy Initiative; Alison Jordan, ACOJA Consulting; Tim Frasca 

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)

Bryan presented an overview of the current NMI program.  HRSA defines Non-Medical Case Management as a support program designed to help people access care and not necessarily to help them stay engaged in care (e.g., no treatment adherence counseling).  Key activities include: assessment, care plan development, timely and coordinated access to health and supportive services, reevaluation and reassessment.  The NMI program in the NY EMA supports RWPA eligible clients who are being held by the jail system and those who have been recently released.  There are two unique components to this program.  One component, provided by the first subrecipient (NYC H+H Correctional Health Services (CHS)) on Riker’s Island, which is the only entity who can provide these services to clients held in NYC’s jail system.  The second component (provided by the Fortune Society) works with clients once they’ve been discharged to support re-entry and link clients to care.  The goals of the program are to provide relevant support services to soon-to-be released and recently released individuals living with HIV to ensure engagement in ongoing HIV medical care and support services.  These map to several objectives in the Comprehensive Integrated Plan.

The program service model is to 1) provide HIV-specific discharge planning to incarcerated individuals living with HIV in New York City correctional facilities to ensure linkage to medical care through referral to medical case management, mental health services, alcohol and substance use, and housing services post-release; and 2) provide time-limited (pre-release and 90 days post-release) assistance with benefits and entitlements, including restoration of Medicaid and ADAP resources, treatment education, risk reduction counseling, linkage, referral and follow-up for recently released individuals living with HIV.  Service offered include: intake assessment and care plan development; case conferencing; transportation, accompaniment; client assistance, coordination with service providers, outreach for reengagement, and verification of maintenance in care at 90 days.

These programs have access to some of the most vulnerable clients and hardest to engage in care across the city.  From 3/1/2023-6/30/2023, CHS was able to offer a transitional care plan for 123 NMI clients who were released from Riker’s Island into the community.  Within the past year, CHS staff reported being able to rely on city funded correctional officers and no longer needing their own, allowing for additional funds to be allocated to direct service provision.  The community partner reports they’ve been able to link clients who are discharged from Riker’s to stable housing via care coordination with HASA. 

Areas of challenge include: the difficulty of working in the NYC Jail System due to COVID-19 and ongoing political debates about the future of the system; a shutdown by the NYC Mayor of all social service programs within the jails in June of 2023; difficulty for CHS staff to meet with clients due to COVID isolation and alarms and Correction Officer orders that prohibit movement in the jail; and uncertainly about the future of Riker’s Island.  The programs are a mix of cost-based and deliverable-based reimbursement.  In April, 2023, CHS notified DOHMH that it would no longer need to fund dedicated Corrections Officers to implement the program and accompany case managers to see clients.  This was welcome news as the program needed to hire six officers at a cost of $100,000 per guard per year to implement services.  The program was able to use these funds to increase line staff pay to offer equitable wages and to support staff retention in an incredibly difficult job, and to pay for hygiene kits to better treat clients with dignity in a notoriously difficult jail system.  They still reduced their annual budget by $405,548 due to this change.

A summary of the ensuing discussion follows:

  • Although HRSA’s guidelines limit the service to engagement but not retention, the Council may want to explore expanding the service to include maintenance in care services for specific time period.
  • There was uncertainty about how the 90-day verification standard was decided. 
  • Riker’s releasees usually serve less than one year and do not have a parole officer.  Some may enter Riker’s while on parole, in which case the parole officer is part of a complicated system of care coordination.
  • The new directive will refer to objectives in the current Integrated Plan.

Agenda Item 3: Perspectives on HIV Service Delivery to Incarcerated and Recently Released

Alison and Emily presented on correctional and community connections regarding HIV care, which have been going on in NYC jails since the 1980s.  Emily presented new data on HIV in prisons (as of 2021).  While trending downward for many years, the rate of HIV in prisons is still far higher than in the general population.  As of 2021, there were 415 PWH in NY State prisons (the majority of whom are from NYC), disproportionately Black.  NY is one of 6 states that offer “opt-in” HIV testing, which means that inmates must request it, although it is offered as part of routine medical exams and discharge planning. 

Statistics show steady declines in the average daily population at Riker’s, but an increase in the number of staff.  Over 70% of releasees return to areas of greatest socioeconomic and health disparities.  HRSA has a SPNS program that facilitates linkage to care for PWH leaving local jails.  HRSA allows the Use of Ryan White funds for Core Medical Services and Support Services for eligible incarcerated and justice involved PWH on a transitional basis and for short-term needs.  Emily described a handbook for providing transitional care coordination involving both jail-based and community-based services.  Data from 2008-12 showed that high percentages of clients were offered a care plan, but far fewer actually followed through with linkage to care.  NYC SPNS program outcomes were described (e.g., 65% of client accepted accompaniment to medical appointment).  She described the benefits of collaborations across systems (e.g., improved health outcomes, overdose prevention, less housing instability) and the collaborators needed. 

The transitional care coordination model was described, which has as core concepts: warm transition, engagement and termination, linkages to care, and continuity of care.  This occurs curing three phases: preparing for after incarceration, transition to community care, community linkage and follow up.  The details of each phase were explained, from intake forms to case closure.  The importance was stressed of addressing barriers (e.g., basic needs) and establishing relationships.  Other details were explored, such as teaching corrections officers about HIV and the importance of language.  It was stressed that when considering the next stage in correctional health, something changes with each new administration.