Project Title:
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Project Overview:
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Special Projects of National Significance Planned Reintegration Opportunities to Gain Release & Access Medical care (SPNS Program)
225 Broadway 23rd Floor
New York, N.Y. 10007
Alison O. Jordan
Executive Director,
212-788-7837
NYC Department of Health and Mental Hygiene (DOHMH)
[on behalf of the Rikers Island Transitional Consortium (RITC), which includes the DOHMH, NYC Department of Correction, Palladia, Women’s Prison Association, Exponents, and The Fortune Society]
1) Summary of Intervention:
DOHMH has established a Continuum of Care model for Persons Living with HIV/AIDS (PLWHA) in City jails that includes testing, treatment and discharge planning. DOHMH, in collaboration with RITC, proposes the SPNS Program as an enhancement to the existing HIV Continuum of Care. This program will provide for the unmet primary care and substance abuse needs of PLWHA by providing linkages to care for people released from City jails within 7 days or to Alternative to Incarceration (ATI) programs for those potentially facing sentences longer than one year. The SPNS program will include identification of clients, assessment of need, discharge plans, and placement in community programs as appropriate, with follow-up to ensure ongoing participation in community health care and services.
DOHMH and RITC have hundreds of project-related community partners, and linkage agreements with entities such as: federally qualified health centers, hospice and skilled nursing facilities, designated AIDS centers, other Ryan White programs, CDC prevention programs, substance abuse treatment programs (SATP) and ATI. The SPNS Program will be in place as soon as Institutional Review Board (IRB) approval is secured and no later than six months from notice to proceed, with key components in place through in-kind contributions.
2) Target Population(s):
Services will be targeted to PLWHA who demonstrate a willingness to participate in community health care and SATP are likely to have a length of stay of less than seven days or likely to be sentenced to one year or more (for ATI).
3) Goals and Objectives: 4 year Goals:
• 90% of PLWHA admitted to City jails will be offered a transitional care plan;
• 75% of those offered a transitional care plan will have a plan prior to release;
• 60% of those released to the community with a discharge plan in place will be connected / returned to care within 30 days of release.
Objectives for the first year of the SPNS Program:
• 1,000 will be screened for SPNS Program;
• Of these 750 will receive a SPNS Program transitional care plan;
• Of these 500 will be connected to primary medical care (including ATI programs) in the community through the SPNS Program upon release from jail.
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