PARTICIPATING PROJECTS

Massachusetts Department of Public Health

Partners and Collaborators
Funding was provided to the Massachusetts Department of Public Health, HIV/AIDS Bureau (HAB), which implemented the Transitional Intervention Project (TIP), a statewide public–private partnership that provided intensive case management services to support the reintegration of inmates living with HIV/AIDS back into the community. The project built on HIV-related services that were already in place in correctional facilities and supported by HAB, such as prevention and education, counseling and testing, and case management. The State was divided into six regions for delivery of services. HAB provided management oversight, training and technical assistance, and evaluation support to a contracted CBO in each of the six service regions, as follows:

SPAN (Boston and mid-central Massachusetts)
Ruah Breath of Life (Boston region)
Great Brook Valley Health Center (central region)
South Shore AIDS Project (southeast region)
Health and Education Services (northwest region)
Brightwood Health Center (western region).

A comprehensive array of services existed in Massachusetts prior to the CDP, and the services continued during the demonstration project. County jails and State prisons provided primary medical care; HIV prevention and education (inmates and staff); HIV counseling and testing; and case management, including mental health services, support groups, and discharge planning. The Offices of Community Corrections offered peer-led HIV, STI, TB, and hepatitis prevention and education services and an extensive system of community service linkages. The Department of Youth Services (DYS) provided HIV prevention and education services; primary medical care; HIV counseling and testing; and a wide range of case management, psychological, and structured recreation services.

Supplementary components of TIP were a chlamydia screening program for male arrestees at the Nashua Street Jail in Boston, a peer-based HIV education and prevention program at all Offices of Community Corrections, and HIV counseling and testing in juvenile corrections facilities.

Model
Upon implementation of the TIP project, the prevalence of HIV/AIDS, substance abuse, and hepatitis C in the prison population was high and was a major concern among program planners and officials, especially with regard to the female population. TIP sought to determine the extent of inmates’ service needs for transition and reintegration into their home communities upon release, focusing on the following activities:

Intensive, community-based transitional case management for all HIV-positive inmates released from all 19 State prisons, all 13 county jails, and all 62 DYS facilities
Creation of a bridge between HIV services “behind the wall” and existing HIV services in the community to improve the quality of life and reduce morbidity and mortality for incarcerated and recently released HIV-positive inmates
Evaluation of the utility and feasibility of the TIP reintegration model
Provision of and improvements to chlamydia surveillance and treatment to reduce the incidence of STIs, including HIV, in jail settings.
A comprehensive, peer-led prevention and education program focusing on HIV, STIs, TB, and hepatitis in 22 community correction center sites, including evaluation of the utility and feasibility of the model
HIV counseling and testing in the 62 juvenile corrections facilities and referrals to appropriate community HIV services, including TIP.

Through participating CBOs, HAB funded eight TIP teams. The teams, which comprised jail coordinators, infectious disease nurses, and case managers in prisons along with other correctional facility staff, referred clients to TIP during incarceration (preferably 6 months prior to release). Teams then focused on the frontline reintegration work of establishing rapport with the clients before release so that relationships could be maintained postrelease and during the follow-up period. TIP case managers from clients’ home regions worked with them during incarceration to assess their release needs. When released, TIP staff implemented a client-specific service plan.

In jails and prisons, clients usually learned about TIP through HIV coordinators and HIV nurses. TIP services during incarceration included helping clients focus on what they wanted to do after release, assistance completing forms and applications, finding and arranging appropriate housing, discussing and setting up postrelease medical treatment and other appointments, and building a trusting relationship between client and case managers.

Postrelease services included assistance with acquiring health insurance and other benefits, finding a primary care physician skilled in HIV care, counseling on HIV treatment adherence, locating mental health and substance abuse treatment services and other community services, and obtaining transportation and safe housing. After 6 months of intensive case management, it was hoped that clients would have developed the capacity to function on their own.

TIP functioned under the premise that successful client transition and reintegration into the community would decrease the likelihood of substance abuse relapse, return to high-risk behaviors, reincarceration, AIDS morbidity and mortality, and potential for AIDS transmission. The result would be healthier and safer communities.

An evaluation component was included to apprise project management and case managers of what worked, identify emerging client issues and needs, and redirect program activities and resources to maximize client participation.

LESSONS LEARNED: Massachusetts Department of Public Health

Barriers to utilization of TIP were as follows:

Lack of privacy in utilizing TIP services during incarceration
The complexities associated with helping clients stay on their mental health medications and off drugs
Fear of being “outed” and the repercussion of stigma and rejection by other inmates and corrections officers
Underutilization of services and difficulty with retention in TIP as a result of substance abuse relapse
Territorial issues between community programs

Recommendations for continued success were as follows:

Transitional case management is effective in helping inmates living with HIV meet multiple needs to ensure successful transition to the community. Clients believed that they would be worse off without TIP.
Accessibility of case managers is important: Efforts must be made to ensure that clients have open access to their case manager.
Program flexibility reinforced client retention and continuity.
Inmates returning to the community have significant medical, mental, and substance abuse needs that can undermine the quality of life and support available within the community.
Transitional case management can reduce recidivism.
TIP services must be “one stop” and address multiple needs. Persistent and consistent efforts should be made to help releasees stay healthy and practice safe behaviors.
Gaps in services are a barrier and result in loss of clients.
Inmates with substance abuse issues require longer, more intensive case management.
Because of high prison staff turnover, ongoing education of staff is necessary.
Participation and support from parole officers is needed to explain the role of TIP case managers among inmates.
It is important to sustain linkages with service providers within correctional settings and the community.
Attention must be paid to the emotional and support needs of case managers.
Special attention needs to be given to retaining case managers who are nonjudgmental and respectful of their clients. According to clients, those issues, along with accessibility, were important to the success of the program.
The need for a particular service did not change appreciably between intake assessment, monitoring events, and case review.