New York City Department of Health and Mental Hygiene, Rikers Island, NY

Pay it Forward: Building New Opportunities for Success by Replicating the NYC SPNS Jail Linkages Model in Puerto Rico and the Bronx

The New York City Department of Health and Mental Hygiene’s Correctional Health Services (CHS) is responsible for the provision of health care to all those held in NYC jails. CHS offers HIV testing, care and treatment and provides transitional care coordination for HIV patients leaving jail. CHS’s Transitional Health Care Coordination (THCC) will implement its HIV Continuum of Care Model (HCCM), an innovative evidence-based Practice Transformative Model (PTM) model, to enhance linkages to HIV care for people living with HIV and returning home after incarceration.

THCC will collaborate with Damian Family Care Centers in the Bronx and Queens, NY and the One Stop Career Center of Puerto Rico, to expand their medical care, case management capacity and ability to care for their HIV patients. THCC will provide technical assistance to address the gaps in their service delivery systems needed to implement the HCCM. This will include how to establish relationships with incarcerated persons living with HIV prior to release from jail; facilitating their linkages to community care after incarceration; and supporting their maintenance in care and adherence to ARV medication. The project seeks to achieve a “warm transition” for those returning home from jail to increase the number achieving viral suppression, as well as sustaining improved community health