As the correctional demonstration project comes to an end, there are many things to con­sider that will help ensure a smooth transition as your agency leaves the correctional institu­tion. Planning for the end of the project can be one of the most challenging obstacles each project must address. Four years of navigating the system for HIV+ inmates has lead us to careful planning to ensure that the efforts and progress made by each correctional demon­stration project continue after the project ends in September 2004.

Transition efforts should be carefully coordinated with other community based organizations and corrections staff to ensure a continued seamless transition into the com­munity for the target population. Here are some suggestions to prevent gaps in service from occurring once the project ends.

• As soon as possible, inform clients of the exact date the project will end. Offer support and continue to navigate the system for clients that will be released within three months after the end of the project. Whenever possible, make initial referral contacts with community based organizations and provide each client with a general list of service providers that may be able to assist them post-release.
  
  
• Make individual checklists for each client on what they can do to ensure a smooth transi­tion into the community. The checklist may include who and how to receive appropriate referrals for essential medical, care and sup­port services and what each client should bring to their first appointments (i.e. list of medica­tions, recent lab work, diagnosis, etc.)
  
  
• Make sure clients know how to ask for their medical records from the medical department. Provide them with a list of HIV service pro­viders and services offered in the communities they plan to reside in after they are released.
  
  
• Coordinate a meeting with all social service, mental health, medical and substance abuse treatment staff at the correctional institution. Plan and prevent active clients from falling through the cracks. Obtain consent to discuss individual cases with each team of providers. Set up separate team meetings consisting of the client, social service staff, case manager, medical care provider, and if applicable, men­tal health staff to discuss pre and post release needs as identified by the correctional demon­stration project in individual discharge plan­ning and case management sessions.
  
  
• Create a directory of contact information and resource guide for the correctional institution that your project makes referrals to the most.
  
  
• Share an example of a comprehensive dis­charge plan for an HIV+ inmate with the other department heads within the institution that now will be responsible for care and dis­charge planning needs. Discuss with correc­tions staff barriers to care, how to navigate the disconnected system effectively, and share any lessons learned.
  
  
• Contact community based organizations that receive referrals regularly from your program staff working on the demonstration project and inform them of the new contact person from the institution that may be mak­ing referrals after the correctional demon­stration project ends.
  
  
• Help other departments within the correc­tional institution coordinate and continue the already established programs by your project. Programs may include one or more of the fol­lowing: Peer education, HE/RR classes, and support groups. Share effective curriculum and teaching strategies that will help each department continue to reach and educate the target population on HIV/AIDS