HEALTH RESOURCES AND
SERVICES ADMINISTRATION

Bureau of Health Resources Development
Office of Science and Epidemiology

 

 

Progress and Challenges in Linking
Incarcerated Individuals with HIV/AIDS
to Community Services

JUNE 1995
PUBLIC HEALTH LIBRARY

   
 
 

BERKELEY

LIBRARY
UNIVERSITY OF
CALIRORNIA
Page

11

37
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104

Table of Contents £

Executive Summary

Progress and Challenges in Linking Incarcerated Individuals with HIV/AIDS to
Community Services: An Overview

The ETHICS Project: Linking Ex-Prisoners with HIV/AIDS to Community
Services

Case Management for HIV Prevention Among Drug-Involved Arrestees
The Rhode Island Prison Release Program

Specialized Medical and Social Service Interventions for Inmates with HIV in
Maryland

Cermak Health Services: Linking Pretrial Detainees with HIV/AIDS to
Community Services

The Philadelphia Linkage Program
Executive Summary

With the impetus of initiatives like the Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act of 1990, correctional administrators and health care professionals
have begun to recognize the critical role that prisons can play not only in identifying and
treating HIV infection while the individual is incarcerated but in combining medical
management during incarceration with linkages to community services upon release from
prison. This monograph describes six programs that deliver such services in the criminal
justice system. Four programs received Title II Ryan White funding for Special Projects of
National Significance (SPNS). Funded in fiscal year 1991, these programs address the
linkage of incarcerated and recently released inmates with HIV/AIDS and their families to
community services. Two additional programs that have delivered services to this population
but received funding from other Federal entities are also described in this publication.

The six projects described in the monograph include:

1) The ETHICS Project: Linking Ex-Prisoners with HIV/AIDS to Community
Services, a SPNS project, conducted by The Fortune Society (New York, New York);

2) Case Management for HIV Prevention Among Drug-Involved Arrestees, a jointly
sponsored project of the National Institute of Justice and National Institute on Drug
Abuse, conducted by Abt Associates in two sites (Washington, D. C. and Portland,
Oregon);

3) The Rhode Island Prison Release Program, a SPNS project, conducted by the
Rhode Island Department of Health in collaboration with the Rhode Island Department
of Corrections (Providence, Rhode Island);

4) Specialized Medical and Social Service Interventions for Inmates with HIV in
Maryland, a SPNS project, conducted by the Maryland Department of Public Safety
and Correctional Services (Baltimore, Maryland);

5) Cermak Health Services: Linking Pretrial Detainees with HIV/AIDS to
Community Services, a project supported by Titles II and IIIb of the Ryan White
CARE Act, conducted by Cermak Health Services (Chicago, Illinois); and

6) The Philadelphia Linkage Program, a SPNS project, conducted by The Circle of
Care (Philadelphia, Pennsylvania).

In addition to basic project descriptions, the monograph highlights each project's successes,
barriers and issues, and proposed strategies for overcoming them. Project evaluation and
dissemination activities are also addressed. These projects are models that illustrate
considerable success in linking inmates to medical and community services, providing support
to people who are changing behavior patterns, and reducing recidivism rates.
Progress and Challenges in Linking
Incarcerated Individuals with HIV/AIDS
to Community Services: An Overview

Christine J. Hager, Gloria Weissman, and Marilyn M. Massey

The estimated incidence of Acquired Immunodeficiency Disease Syndrome (AIDS) in
1992 was 195 cases per 100,000 in State and Federal corrections systems in the United States
(U.S.) compared with 18 cases per 100,000 in the entire population; that is, the incidence
among prison inmates was 14 times higher than among the U. S. population in general
(Hammett, 1994; Vlahov, et. al., 1991). The higher AIDS incidence rates among
correctional inmates are predictable given the concentration in these populations of
individuals with histories of high-risk behaviors, particularly injection drug use (Hammett,
1994). Each year more prisons list AIDS as the leading cause of death (Brewer and
Derrickson, 1992) Finally, an estimated 17,479 inmates (2.2 percent of the incarcerated
population) are infected with Human Immunodeficiency Virus (HIV).

Despite the high number of incarcerated individuals infected with HIV and AIDS,
medical care in prison for inmates has received relatively little focused attention. Few
prisons deliver HIV-specific medical care or discharge planning to link released inmates with
necessary community services. However, prisons can play a central role in identifying and
treating HIV infection. Programs that combine medical management during incarceration
with linkages to community services upon release can have a strong, long-lasting impact on
the health of individuals and their communities. For many incarcerated people living with
HIV, incarceration may provide the first opportunity to access HIV testing, counseling,
specialized medical care, and psychosocial support.

This monograph describes six programs that deliver services such services in the
criminal justice system. Four of these programs were funded by the Ryan White
Comprehensive AIDS Resources Emergency (CARE) Act of 1990 which provides that up to
10 percent of the funds in Title II be set aside for grants to Special Projects of National
Significance (SPNS). In fiscal year 1991, four projects were funded by SPNS to address the
linkage of incarcerated and recently released inmates with HIV/AIDS and their families to
community services. Each SPNS project has a dual purpose: 1) to provide services to
clients through innovative service delivery designs; and 2) to provide valuable knowledge
that will advance the quality of care for people with HIV/AIDS. In addition to the four
SPNS projects that collaborated with correctional institutions, two additional projects
delivering services to this population are described in this publication; both of which received
funding from other Federal entities.

The six projects described in this monograph include:

1)

2)

3)

4)

5)

6)

The ETHICS Project: Linking Ex-Prisoners with HIV/AIDS to Community
Services, a SPNS project, conducted by The Fortune Society (New York, New
York);

Case Management for HIV Prevention Among Drug-Involved Arrestees, a
jointly sponsored project of the National Institute of Justice and the National
Institute on Drug Abuse, conducted by Abt Associates in two sites,
(Washington, D.C. and Portland, Oregon);

The Rhode Island Prison Release Program, a SPNS project, conducted by
the Rhode Island Department of Health in collaboration with the Rhode Island
Department of Corrections (Providence, Rhode Island);

Specialized Medical and Social Service Interventions for Inmates with HIV
in Maryland, a SPNS project, conducted by the Maryland Department of
Public Safety and Correctional Services (Baltimore, Maryland).

Cermak Health Services: Linking Pretrial Detainees with HIV/AIDS to
Community Services, a project supported by Titles II and IIIb of the Ryan
White CARE Act, conducteded by Cermak Health Services (Chicago, Illinois);
and

The Philadelphia Linkage Program, a SPNS, conducted by the Circle of
Care (Philadelphia, Pennsylvania).

GOALS OF THE PROJECTS

While the specific goals of the projects varied because they were working with
different systems of service delivery and contacted individuals at different points, each sought
to link incarcerated individuals and recently released inmates with HIV/AIDS to community
services. All of the projects included case management as part of their intervention. They
sought to counsel and test people for HIV and to link people with HIV to appropriate medical
and social services. While some projects concentrated on the delivery of discharge planning
services using case management techniques, others attempted to integrate medical and case
management into a continuum of services. Secondary goals of these projects included
decreasing recidivism and discouraging high-risk behaviors associated with HIV transmission.
SUCCESSES

All of the projects evaluated their successes, noted the barriers to accomplishing their
goals, and recommended solutions. Their successes focused on three factors:

1) Changes in behavior. Clients were assessed with respect to their adoption of
healthier behaviors and the avoidance of criminal activity;

2) Linkages to services. All projects tracked the extent to which clients achieved access
to needed health, social, educational, and subsistence resources and services.

3) Process accomplishments. Assessments were made with respect to client participation
rates, as well as the strengths and barriers in staffing and implementing the
interventions.

Overwhelmingly, the most important factor contributing to the success of the projects
was the personal connection between the client and the case manager or health care provider.
Establishing mutual trust takes time, skill, and perseverance on the part of the client and the
staff. Once trust was established, personal relationships between clients and staff remained a
key factor in successful interventions and interactions often continued after the client was
officially "discharged" from the program.

The other factors identified as key elements for project successes included 1) the case
management approach, 2) staff skills and training, 3) intra- and interagency network of
referrals, 4) client participation in discharge planning, 5) use of former clients as service
providers, and 6) recognition of HIV as a problem by the jail and prison systems and the
community agencies.

BARRIERS

The authors of these project descriptions are candid about their problems, the barriers
they encountered, and their strategies for overcoming their success obstacles. They identified
some common barriers:

Inadequate access to health and social services. The availability of adequate
community-based HIV prevention and treatment, as well as social and human, services
is key to assisting inmates to reintegrate successfully into their communities. Long
waiting lists, limited placements, and increasing demands for services make it difficult
to establish linkages with community services.

Staffing constraints. Extremely high caseloads, inadequate training, and management
instability have resulted in staff burnout, dysfunctional behavior, and excessive
turnover. More attention and resources need to be devoted to staff supervision and

support.
Lack of knowledge of the correctional system and client referral sources. The
projects stressed the importance and the challenges of cooperating with the criminal
justice system and the community. The early and continued collaboration of
correctional system staff in project planning is paramount.

Lack of discharge planning prior to inmate release. Inadequate discharge planning
results in gaps in medical care, delays in accessing entitlements and critical social
services, and missed opportunity to build a trusting relationship with the client and
smooth the transition for the client with family members.

Difficulties in maintaining accurate data. Program and client assessments were often
constrained by the lack of resources and training for data gathering and
recordkeeping, as well as by special processing requirements of the prison system.

Communication difficulties. Literacy and foreign language barriers increased the
diffficulty of communicating information to inmates.

MAINSTREAM ISSUES

Each of these projects was aware of society's shortcomings in providing the necessary
resources to assist this population. The authors of the project papers emphasized the
following needs:

HIV testing and counseling. Prisons must recognize their central role in the
identification and treatment of HIV infection in the community. Prisoners account for
a relatively large proportion of the HIV-seropositive population. Incarceration may be
the first opportunity an inmate accesses HIV testing. counseling, and specialized
medical care;

Enhanced and immediate postrelease support. An immediate caring link is needed to
increase the released inmates’ ability to navigate the especially difficult first days after
release and to overcome the stigma of a prison record as well as the violent and
antisocial culture of prison;

Expanded discharge planning. In addition to addressing HIV and medical concerns,
discharge planning must respond to issues such as sexual behavior, substance use,
criminal activity, family/neighborhood, entitlements, employment and income.
Adequate resources must be made available for them.

Lack of services and support. The effectiveness of case management is limited when
the demand for available services and resources outstrips the supply. The lack of
essential human services such as food, housing, employment, and substance abuse
treatment lead to relapse in drug use, other high-risk behavior, and reincarceration.
Meeting these needs for women is especially challenging.
SUMMARY OF PROJECTS

This section summarizes the strategies, successes, and challenges in linking
incarcerated and recently released inmates with HIV/AIDS to community services. Each
description addresses project goals and objectives, a profile of the client population, the
nature of the intervention, staff, funding, successes, barriers, evaluation methods, mainstream
issues, and project dissemination activities.

The ETHICS Project: Linking Ex-Prisoners with HIV/AIDS to Community Services
(The Fortune Society; New York, New York)

The ETHICS (Empowerment Through HIV Information, Community, and Services)
Project was established in 1989 by The Fortune Society, a walk-in service agency in New
York City for released prisoners and youth at risk. Fortune was founded on a principle of
ex-offenders helping ex-offenders help themselves, and the organization retains a strong
commitment to prisoners’ rights, advocacy, and community education. The Fortune Society
made HIV education and services the highest priority of the agency after recognizing that
almost all of its clients and most of its staff were living with HIV, affected by loving
someone with HIV, and/or fearful of becoming infected with HIV.

The Fortune and ETHICS programs provide services in an accepting, self-help,
community atmosphere. A majority of the staff have experienced incarceration, substance
abuse, or both. These men and women serve as powerful role models for The Fortune
Society clients and are responsible in large part for the program's success. Clients learn to
take charge of their lives and make social service systems work for them. The Fortune
Society interjects information about HIV and the ETHICS Project into all activities of the
agency to encourage clients to feel comfortable about revealing their HIV status and to seek
services.

The ETHICS Project established two goals: 1) to meet the complex social and medical
needs of newly released prisoners who have HIV/AIDS; and 2) to help these clients modify
their self-destructive behaviors and adopt healthier, more productive ones. To reach their
goals, the ETHICS Project employs several strategies: HIV education and outreach, treatment
referrals, a supportive drug-free environment, and a proactive access to care approach.

During the 4 years since its inception, the ETHICS Project has found that linking ex-
offenders living with HIV with community resources requires an innovative, holistic service
delivery strategy. The ETHICS model of reaching recently released prisoners and
empowering them to help themselves provides valuable information and guidance to
policymakers and providers of HIV/AIDS services. The project's aggressively enterprising
approach to accessing services has resulted in a rich referral network for their clients. The
program also reports impressive results in clients' abstinence from drug use and other high-
risk behaviors. As a result of staff observations and ongoing client feedback, the program
also has achieved an extensive understanding of the factors leading to successful outcomes as
well as responses to the many challenges in linking ex-offenders living with HIV with
community services. This knowledge has presented numerous opportunities for innovative
solutions and program refinement.

Case Management for HIV Prevention Among Drug-Involved Arrestees (Abt Associates;
Washington, DC and Portland, OR)

This program, sponsored by the National Institute of Justice and the National Institute on
Drug Abuse and conducted by Abt Associates, was organized as an experiment to test the
effect of case management in reducing HIV related high-risk behaviors among heavy drug
users who had been arrested, booked, and released. In addition, qualitative studies provided
important insights into the process of case management.

Participants of the project were drawn from two sites: one in Portland, Oregorn and
another from Washington, D.C. The approximately 1400 arrestees who volunteered to
participate in the project were assigned at random to case management or to two less
intensive comparison conditions:

* "Control" condition or minimal intervention, where participants viewed a
videotape and received a guide to relevant services;

* Intermediate intervention condition, where participants were exposed to one
counseling and referral session with a specialist in addition to viewing the
videotape and receiving the referral guide; or

* Enhanced intervention condition, where participants were assigned for 6
months to case management that emphasized referrals to community agencies
in addition to viewing the videotape and receiving the referral guide.

The principal outcome of interest in this project was decreased high-risk behavior
associated with HIV infection. Additional outcome measures were decreased drug use,
increased exposure to both drug treatment and self-help programs, and decreased recidivism.
The entire population of project participants appeared to adopt lower risk behavior across
almost all measures. In general, if measured outcomes accurately reflect the impact of case
management, the reported reductions in heavy drug use are significant. All participants
reduced their drug use, often dramatically, and increased use of substance abuse treatment.
Participants also reported dramatic reductions in illegal activity. Case management
participants reduced their criminal behavior and time in jail more than the other groups.

The Prison Release Program (Rhode Island Department of Health/Department of
Corrections; Providence, RI)

Rhode Island, with a population of approximately 1 million people, has an inmate
population of about 2,500 men and women. Approximately 4 percent of the men and 12
percent of the women test positive for HIV at any given time. The Rhode Island Department
of Health, in cooperation with the Department of Corrections and the Miriam Hospital,
Brown University AIDS Program, developed the Prison Release Program. This program was
developed in response to a disproportionately high HIV seropositivity rate for the inmate
population and a treatment program that ended for inmates upon release from prison. The
goal of the Prison Release Program is to link inmates with agencies that can provide them
with or assist them in obtaining medical care, psychosocial support, and substance abuse
treatment. The objectives are to extend these services to inmates while still in prison and to
facilitate linkages to appropriate resources upon discharge.

From July 1992 through August 1993 a total of 115 inmates participated in the Prison
Release Program. The program evaluates all inmates with HIV prior to their release from
prison and identifies needs for medical appointments, financial assistance, drug treatment, and
housing. Through the Prison Release Program, prison-based case managers maintain contact
with former inmates, attempt to continue their service plans, and coordinate their postrelease
progress.

The primary measure of success of the program is the extent to which inmates link with
community resources after release. All inmates, upon release, are given medical
appointments and counseling regarding appropriate treatment and case managers follow their
progress. Individuals then receive appointments to obtain financial assistance, referrals to
community housing agencies, and followup sessions with substance abuse treatment agencies.
Over 75 percent of the program clients have succeeded in following up with their medical
appointments and substance abuse treatment.

Before the Prison Release Program, it was not unusual for individuals to be in and out
of prison six times a year. Since instituting the program, recidivism has declined. Among
female clients, for example, there has been an impressive decrease in recidivism.

Specialized Medical and Social Service Interventions for Inmates with HIV in Maryland
(Maryland Department of Public Safety and Correctional Services; Baltimore, MD)

A second program that focused on medical management and discharge planning for
incarcerated individuals with HIV operated within the State of Maryland correctional system.
The Maryland Division of Corrections (DOC) houses 21,000 offenders, with a HIV
seropositivity rate of approximately 8 percent for men and 15 percent for women. The goals
of the DOC program are to expand medical treatment options for inmates with HIV and to
maintain continuity of those services in the community for released inmates.

These goals are accomplished by three program emphases: medical case management,
expeditious medical parole, and clinical trial participation for targeted inmates. As soon as
an inmate is diagnosed with HIV, case management services begin with regular contacts. A
release date is anaticipated and an aftercare plan developed at least 3 months before the
anticipated release. The DOC implements a medical parole procedure for inmates with
endstage HIV disease if their condition precludes their compromising public safety. Access
to experimental drugs in federally funded clinical trials is another treatment option made
available to inmates through a collaborative arrangement with the Johns Hopkins University.

Medical case management has resulted in discharge planning services for 320 inmates
while awaiting release and linkages have been established with a number of community
agencies. Among the inmates released on medical parole since 1991, none have been
reincarcerated for violent crimes and only five for nonviolent crimes. The program has also
succeeded in expanding access to investigational drug protocols via clinical trial programs.

Linking Pretrial Detainees with HIV/AIDS to Community Services (Cermak Health
Services; Chicago, IL)

Cermak, as the health care provider at the Cook County Department of Corrections in
Illinois, provides comprehensive medical, dental, psychiatric, and substance abuse services to
approximately 9,000 pretrial detainees drawn from communities within Chicago and suburban
cook County. The majority of detainees testing positive for HIV were asymptomatic and
listed their main risk for infection as injection drug use; many indicated injection drug use
plus sexual behavior as risk factors.

Cermak's first goal is to provide an array of prevention, advocacy, and discharge
planning services. It offers educational information on HIV infection and AIDS as well as
other chronic diseases. It also teaches risk reduction and behavior modification techniques
and provides HIV counseling and testing. Its second goal is to help clients meet their needs
for ongoing treatment after discharge by directing individuals to appropriate community
services and enabling those individuals to continue care in the community. Clients
voluntarily participate in case management services that begin with an initial interview with
each detainee with a diagnosis or a history of HIV infection. The needs of an interested
client are assessed and a treatment plan is set based on those needs and the existence of
services. Clients are then seen regularly and linked to needed community services.

Project success is defined as the achievement of positive behavioral changes as well as
the delivery of appropriate support services, and the establishment of contact by the client to
community services. While the uncertain outcome of court cases and the potential for clients
to unexpectedly "bond out" makes it difficult for case managers to establish linkages and
reduce waiting time for ancillary services, over time the program has established a network
of community agencies willing to work with clients. In addition, many program participants
have achieved behavioral changes. The current rate of recidivism for the entire corrections
facility is 30 percent; Cermak's clientele receiving case management services has a recidivism
rate of 8 percent.

The Philadelphia Linkage Program (Circle of Care; Philadelphia, PA)

The Philadelphia Linkage Program was funded by SPNS as a project of The Circle of
Care, a pediatric, adolescent, and family AIDS demonstration project in Philadelphia, PA.
The program sought to link incarcerated persons with appropriate community services before
and after their release from prison. Initially, the program also had a goal of linking the
families of inmates with The Circle of Care's family services. However, because of inmates’
reluctance to divulge names of family members, the focus was changed to individual case
management. Case managers met with the inmates and conducted assessments of their needs.
Then, they followed the inmates for 3 to 6 months after release to ensure that they accessed
services.

The program confirmed the value of the case management approach. It also identified
problems and possible solutions in planning such projects. For example, the program
learned the importance of knowledge of the prison system and the prisoner's culture.
Attempts to link inmates with family members also proved more difficult than expected
because few of the inmates had any contact with their families and few had disclosed their
HIV status to family members. Second, bureaucratic delays and difficulty finding work space
in the prison hampered attempts to start the program. Third, turnover in case management
staff affected the program's ability to develop relationships with inmates and to provide
meaningful discharge planning.

Greater interaction and planning with the prison social workers, security, and other staff
was identified as essential for a successful program, as was effectively publicizing the
program and recruiting participants. The authors of this project paper emphasize the need for
interaction case managers to spend time building trust with clients before attempting to link
with family members.

CONCLUSIONS

These projects are models of what can be done by supporting people with HIV while
they are in prison and assuring that they receive necessary services when they are released.
All of the projects emphasized the need for personalized attention and involvement of the
client in his or her care. The needs for services include those specifically related to
HIV/AIDS (e.g., medical followup, prescription drug treatments, and case management), but
all of the projects stressed the importance of helping released inmates obtain basic services
such as safe housing, food, drug rehabilitation, social support, employment, and education.

Several of the projects noted that women present multiple, complicated needs for
services for themselves and their families. Locating drug rehabilitation slots, housing, and
other community services are particularly difficult for women.

The project descriptions in this monograph illustrate considerable success in linking
inmates with medical and community services, providing support to people who are changing
behavior patterns, and reducing recidivism rates. In addition, all of the project descriptions
emphasize the importance of establishing relationships between the medical team, case
managers, and inmates prior to discharge. The extent to which clients develop postrelease
plans is extremely useful for negotiating referrals, setting up medical appointments, and
continuing contacts after discharge. The period immediately after discharge is crucial and a
supportive relationship with in-prison case managers appears to help reduce recidivism rates.

To be effective, linking inmates with community services must begin in prisons and jails
and must continue when clients are released. To insure successful reintegration of clients
into the community and medical management of HIV is a big challenge. People at all points
of contact--community organizations, correctional facilities, caregivers, family members, and
case managers--need to be involved. When they are, the rewards to clients, families, and
society are impressive. Given the increasing prevalence of HIV in State and Federal prison
systems, these projects provide effective, informed models for addressing the concerns of
incarcerated and recently released individuals with HIV/AIDS.

REFERENCES

Brewer TF, J Derrickson (1992). AIDS in Prison: A Review of Epidemiology and
Preventive Policy. AIDS 6:623-628.

Hammett, T (1994). 1992 Update: HIV/AIDS in Correctional Facitlities. Abt Associates,
Inc., Cambridge, MA.

Blahov, D, TF Brewer, KG Castro, JP Narkunas, ME Salive, J Ullrivh, A Munoz (1991).
Prevalence of Antibody to HIV-1 Among Entrants to US Correctional Facilities. The Journal
of the American Medical Association. 265 (9): 1129-1132.

AUTHORS

Christine J. Hager, Ph.D., Economist
Gloria Weissman, M.A., Deputy Director

Office Of Science and Epidemiology

Bureau of Health Resources Development
Health Resources and Services Administration
5600 Fishers Lane, Room 7A-07

Rockville, MD 20857

Marilyn M. Massey, M.P.H.
President

MasiMax Resources, Incorporated
1300 Spring Street

Suite 511

Silver Spring, MD 20910

10
The ETHICS Project: Linking Ex-Prisoners
With HIV/AIDS to Community Services

Tracey Gallegher and JoAnne Page

Since its inception 27 years ago in New York City, The Fortune Society has served
incarcerated and recently released prisoners by offering them a support network and helping
them to access the resources they need to return to the community. Fortune was founded on
a principle of ex-offenders helping ex-offenders help themselves. It retains a strong
commitment to prisoners’ rights, advocacy, and community education.

The Fortune Society is a walk-in service agency for released prisoners and youth at
risk. Annually, more than 2,000 people benefit from Fortune’s outreach and discharge
planning efforts while in prison. Another 1,000 recently released prisoners receive referral
and on-site services, including tutoring, job training and placement, counseling, treatment for
substance abuse, court advocacy, and HIV-related case management.

In 1989 The Fortune Society made HIV education and services one of the highest
priorities of the agency. In New York State, HIV-related illnesses and complications of
AIDS are the leading cause of death among ex-prisoners. From 14 to 16 percent of the
60,000 prisoners in the State’s corrections facilities are infected with HIV.! Of the 86,000
offenders incarcerated each year in New York City, 25.9 percent of the women and 12.3
percent of the men test positive for HIV.?

Fortune began to address the urgent need for HIV-related services specifically through
the establishment of the Empowerment Through HIV Information, Community, and Services
(ETHICS) Project. This project was funded by the Health Resources and Services
Administration (HRSA) as one of its Special Projects of National Significance (SPNS).
During the 4 years since its organization, the ETHICS Project has found that linking ex-
offenders living with HIV with community resources requires an innovative, holistic service
delivery strategy. The ETHICS Project emphasizes client initiative and client-staff
interaction to help clients access an array of needed services.

PROJECT DESCRIPTION
Goals

Typically, ETHICS clients are HIV symptomatic and struggling with deteriorating

11
health. They need medical care, assistance in obtaining entitlements, drug-relapse
prevention, housing, clothing, civil legal services (including living wills), food employment,
home health care, and education. In addition, many HIV-symptomatic prisoners receive
woefully inadequate discharge planning. Delays in acquiring benefits after discharge from
prison jeopardize their health and motivation.

The ETHICS Project recognized that, despite their many needs, ex-offenders living
with HIV have great difficulty obtaining help. As a result of incarceration and living with
HIV/AIDS, they often feel isolated, depressed, and powerless. Most lack the skills and self-
confidence needed to navigate New York City’s fragmented service delivery system; they
respond to the red tape and other barriers with hostility or resignation. They seldom receive
any guidance or referrals for services. Thus they remain without needed resources.
However, unless they access these services, they are at high risk for resuming previous
activities— substance abuse, unprotected sex and prostitution, and criminal activity. To
respond to these conditions, the ETHICS Project established two goals:

¢ To meet the complex social and medical needs of newly released prisoners who
have HIV/AIDS; and

¢ To help these clients modify their self-destructive behaviors and adopt healthier,
more productive ones.

Profile of Client Population

To participate in the ETHICS Project, individuals must test positive for HIV infection
and have a history of involvement with the criminal justice system. Disqualifying
characteristics include severe mental illness or active psychosis, active drug abuse requiring
medically supervised detoxification, violent and/or abusive behavior, and bringing weapons
on the program site.

Clients come to ETHICS with a host of critical health and social service needs.
Typically, they are symptomatic and facing deteriorating health. Most need a place to live;
approximately 70 percent are homeless at some point during program participation. Virtually
all new clients are unemployed; approximately 95 percent do not have jobs. The average age
of clients is 36 years.

Sources of Clients. The ETHICS Project relies on client self-referrals, referrals from
other Fortune programs, and referrals from external sources such as prison staff and service
providers in the community. ETHICS refrains from aggressively recruiting clients because
the demand for services, especially case management services, exceeds the number of
Fortune's staff available to provide them. Figure 1 illustrates the distribution of sources
from which clients are referred to ETHICS, and Table 1 lists the specific referral sources.

12
A sample of 114 ETHICS clients provides a snapshot of client demographics and
substance abuse history. These data reveal some differences between ETHICS clients and
those who participate in other Fortune programs, for example, ETHICS clients are more
likely to be women and/or Hispanic with histories of substance abuse.

Friends, Relatives,
Agencies (10.00%)

 
 
  

Other Fortune Outreach (48.00%)

Units (17.00%) 5%

- Q

LE DCE NE
1 EEE WE LC CEE
FICCI SCONE ut al

Within Prisons (25.00%)

Figure 1. Client Population by Referral Source

Gender Distribution. Approximately 38 percent of ETHICS clients are women, as
compared to approximately 11 percent of those in New York State correctional institutions.
The high number of women participating in ETHICS may be related to the outreach activities
of a an ex-offender volunteer who made weekly visits to the Taconic Correctional Facility
(where she had been incarcerated) for 36 weeks, conducting educational workshops and
providing counseling to women inmates. A group of women became regular participants in
the weekly sessions. A surprisingly high percentage of these prisoners who received
postrelease referral dates to visit the Fortune Society came to Fortune for an initial visit and
were retained by the ETHICS Project.

Ethnic Distribution. The ETHICS Project attracted a higher percentage of Hispanic
clients (48 percent) than is represented in the New York State prison system (32 percent),
perhaps because the ETHICS staff member who visited 5 upstate New York prisons, a
Hispanic man, conducted outreach activities in Spanish as well as English. African
Americans constituted 32 percent of the ETHICS population; 19 percent were white.

13
Ethnic/Gender Breakout. Hispanic men are the largest group of ETHICS clients
(30.70 percent), followed by African-American men (20.18 percent). This distribution is
different from what we would have expected, because more African-American men are
imprisoned in New York State and seek assistance at Fortune Society. Figure 2 illustrates
the combined ethnic/gender profile of the ETHICS population.

 

Table 1. Sources of ETHICS Clients and
Sources of Information about ETHICS Referrals

 

Self-Referrals, triggered by:
¢ Word-of-mouth
¢ Workshops taught by ETHICS staff in schools, churches, community centers
¢ Articles in Fortune News, the agency’s monthly newspaper circulated in prisons nationally
4 Public television, which airs a relevant video
¢ Listings about Fortune programs in resource guides and program directories
Referrals from Other Fortune Programs

¢ For Fortune clients who have specialized HIV-related needs requiring ETHICS’ intensive case-
management

4 For Fortune clients who have come to terms with their HIV status sufficiently to benefit from the
ETHICS case management approach

Referrals from Prisons, from:

4 Parole Officers

4 Other prison staff

4 Follow-up contact with ETHICS staff who conduct workshops for prisoners
Referral from Community Service Providers

4 Hospitals

¢ Drug Treatment Programs

4 Shelters

4 Social Service Agencies

 

 

 

14
Nature of the Intervention: The ETHICS Modified Case Management Model
To achieve the project goals, ETHICS uses several strategies:
4 HIV education and outreach to prisoners;

¢ HIV education and related services within the context of health education, career
development, and other programs that are sought by recently released prisoners;

4 Promptly delivered services, either onsite or through referrals to providers in the
community;

4 A combination of onsite services and offsite referrals in a treatment plan that is
tailored to the needs of each client;

¢ A safe, supportive drug-free environment, staffed by counselors and volunteers
who are ex-prisoners, former substance abusers, and/or people living with HIV;

and

4 An emphasis on both staff and client initiative and participation in getting clients
access to care.

Caucasian Women

  
   
 
 
 

(10.00%) African American
Hispanic/Latino Men
id (20.18%)

(17.54%)

African American \§

Women
(12.28%)
mus Hispanic/Latino
Caucasian Men Ce)

(11.40%)

Figure 2. Ethnic/Gender Profile of ETHICS Population

15
The ETHICS Project follows an intensive, comprehensive approach to case
management that extends beyond the basic needs assessment and referral process used in
more traditional models. Key aspects of ETHICS case management include:

¢ Treatment plans tailored to the client’s needs;

¢ Intensive use of counseling (both individual and group support sessions) to prepare
clients for referral to outside services and to support them during the often difficult
process of accessing and using these services;

¢ Communication with the client prior to release, either through prison outreach
visits or through responding to prisoner correspondence, whenever possible;

¢ Ongoing structure and no set time limits, i.e., clients can enter (or reenter) the
program at any time and participate as long as they want;

# A broad referral network of services provided within The Fortune Society or by
organizations in the community;

¢ An array of activities to help clients live with HIV, including wellness seminars,
support groups, social activities, and one-on-one counseling;

¢ Integration of HIV-related education with other services, allowing earlier HIV
intervention and greater client retention than would otherwise occur; and

¢ Reliance on staff and volunteers who are ex-offenders, former substance abusers,
and people infected with HIV.

Each of these elements is incorporated into the three phases of ETHICS case management
described below.

Phase I: Counseling and Needs Assessment. ETHICS clients are assigned a case
manager who remains with them while they are in the program. The initial counseling
sessions are meant to help clients feel at ease with their case managers and to facilitate the
needs assessment. The case manager seeks the client’s acknowledgement of his or her basic
needs. The intensity and duration of case management is primarily determined by the
individual needs of each client. Although most clients are involved from 6 to 8 months, no
end dates are set, and some clients participate even longer. Typically, the most urgent case
management needs are medical evaluation and care; safe, suitable housing for the short term;
clothing; and assured access to nutritious meals.

Case management is intensive at the beginning because clients usually have many

social service and medical needs. ETHICS clients receive one-on-one counseling, up to three
times a week during the first 3-6 weeks. Each session lasts approximately 45 minutes.

16
In these sessions, clients are allowed to express their feelings freely and to talk about their
most immediate and distressing problems. Staff have found that clients with HIV often need
hours of counseling before they have enough hope and confidence in the future to follow
through on referrals and make the best use of the services.

Phase II: Referral and Followup. Once the most urgent needs of clients are met,
case managers begin to focus on long-term needs, including permanent housing and medical
care. For example, if clients are using drugs or have had a substance abuse problem, they
are encouraged to begin relapse prevention activities, using ETHICS drug treatment services
or another community-based program. During this phase of case management, case
managers also analyze and research entitlements appropriate for clients and assist them with
entitlements applications and advocacy.

Clients are involved, to the greatest extent possible, in developing their treatment
plans and coordinating their referrals. This gives the clients a sense of accomplishment and
the knowledge necessary to deal successfully with service providers once they have left the
ETHICS program.

ETHICS refers its clients to community-based organizations located in the
neighborhoods where clients live, tailors the referrals to meet individual client needs (e.g.,
programs oriented to particular ethnic and/or language groups or support groups serving gays
and lesbians) and offers a wide array of mainstream and alternative modalities or approaches
(e.g., acupuncture).

Clients are asked to sign confidentiality release forms so that Fortune can coordinate
services with referring agencies and keep abreast of client progress with offsite programs.
Twice monthly, counselors conduct a telephone case conference with the primary counselor
at the referring agency. In addition, the senior case manager meets weekly with each
counselor. The supervising case manager and the primary case manager review case notes
and discuss the progress made by individual clients toward achieving case management goals.

During this period, clients receive individual counseling as needed, usually a
minimum of one session per week. Each ETHICS counselor sees 10 to 13 clients. These 1-
hour sessions address more deeply rooted counseling concerns, such as disclosing HIV status,
living with HIV/AIDS, fear of dying and physical suffering, and incidents of victimization
and abuse in the client’s past. Clients also learn how to manage their leisure time and
receive basic life skills training.

Phase III: Counseling, Stabilization, and Social Reintegration. After referrals have
been made and clients have followed-up, they are encouraged to remain with the ETHICS
Project for an additional 2-4 months. During this time, through services provided at The
Fortune Society, clients participate in an array of activities that promote wellness and help
them pursue serious life-change goals. These activities include:

17
® Social and Fitness Activities. Clients socialize informally in the ETHICS living
room, and they frequently share meals with staff and volunteers. They can also
participate in organized events, such as picnics, bowling, movies, cultural events,
and, on one occasion, fishing on a party boat. Clients are also encouraged to take
advantage of in-house fitness classes, such as yoga and tai chi chuan, or participate
in fitness activities for ETHICS clients at the local YMCA.

¢ Support Groups. The ETHICS Project runs three weekly support groups. Two of
the support groups are composed of ETHICS clients. ETHICS-trained peer
volunteers attend the third support group. On average, three out of four support
group sessions address a specific topic; the fourth session is open-ended.
Examples of topics for support groups include "Caretaking—When Your Partner
Relapses" and "Managing Leisure Time." Support groups are semistructured;
ETHICS staff facilitate group discussion. Usually, the staff who lead the support
groups consult other staff, as well as their case notes, to tailor the discussion to
issues that a majority of clients are confronting at that time. All sessions are
facilitated by a staff member; on occasion, a trained peer volunteer assists a staff
member in leading the discussion.

Counselors are responsible for encouraging clients to participate in a support
group; however, all support group participation is voluntary. On average, five to
ten clients attend each support group. A total of 15-30 persons attend the support
groups in any given week. ETHICS graduates sometimes elect to continue their
participation in a support group, even though their cases have been closed.

® Educational Seminars on Health and Nutrition. Representatives from God’s Love
We Deliver, an HIV service organization based in New York City, conduct
seminars at least bimonthly at Fortune. The seminars last 2 hours or more and are
offered to clients and personnel throughout the agency and to clients from other
agencies. In the past, workshop topics have included general nutrition, learning
how to access home delivery of food, and nutritional supplements.

® Advocacy Activities. Clients are encouraged to attend conferences, rallies, and
roundtable meetings sponsored by AIDS activist groups. Through these activities,
clients can help educate the public about AIDS issues and advocate for rational,
aggressive public policy regarding AIDS and HIV. Clients are also encouraged to
take advantage of other services in the community, such as the lunch program
provided by Gay Men’s Health Crisis and the dinner and groceries program
provided by Momentum.

ETHICS often invites members from the HIV/AIDS advocacy community to
address clients and discuss broad issues affecting the HIV/AIDS community in
New York City and the Nation. As a result of these efforts, some clients join
groups involved in community education, organizing, and lobbying. Some clients

18
are also trained to become community educators and gain experience in public
speaking.

& Peer Education Training. Through support from the New York AIDS Fund,
Fortune has developed a training curriculum for HIV peer educators. Training
workshops address such topics as "HIV 101," social bias, listening skills,
homophobia, diversity, and sensitivity. Four to five times a year, 12 trainees
attend an 8-week training course to become HIV peer educators. A majority of
trainees are graduates of the ETHICS Project; the remainder come from other
Fortune programs and other social service agencies in the area. ETHICS seeks
individuals with the maturity and sensitivity necessary to empathize and
communicate effectively with new clients. Although having HIV is not a
requirement, all peer volunteers who are not living with HIV have been affected
by HIV, having loved someone with HIV or AIDS.

® Celebration of Success. Approximately twice a year, ETHICS holds a graduation
ceremony to honor participants who have successfully completed the program.
These celebrations serve as important rites of passage for many clients as they
receive a certificate and recognition from peers and counselors.

Staff

The Fortune Society pursues an affirmative action policy with regard to the
recruitment of former offenders and persons affected by HIV/AIDS as counselors, case
managers, and HIV educators.

Its staffing approach is deliberately diverse to maximize sensitivity to the culture,
language, and life experiences of its clientele. Fortune believes that trained, talented former
offenders and recovering substance abusers can overcome some of the initial barriers in
developing client-counselor relationships more quickly than persons who have not lived
through the prison or drug experience. Staff members who are former offenders also speak
the language of former offender clients. They know the clients’ fears and defenses, are
aware of the conditions experienced in prison, and understand the rigors of transition.
Because of their own experience with high-risk lifestyles, staff and volunteers are quick to
notice signs of such activities as renewed drug use, and they speak assertively with clients
about subtle changes in dress or behavior that might pass unnoticed or untranslated by
persons with only straight-world life experiences.

More than 75 percent of the staff is African American or Hispanic, and approximately
two thirds are ex-offenders and/or people in recovery. Eleven of its 22-member Board of
Directors are people of color and 10 members are ex-offenders and/or recovering substance
abusers. The ETHICS Project recruits persons living with HIV for the administration of the
program and the provision of services. Candidates are considered for employment only

19
when they demonstrate compassion, commitment, and imagination in addition to concrete
skills in effectively managing cases and caseloads.

Search committee members who interview candidates for ETHICS Project
counselor/case manager positions are also, in large part, former offenders and recovering
substance abusers themselves. They listen carefully to gauge job candidates’ willingness to
discuss their transitional issues and their awareness of their personal risks or self-destructive
behavior. Committee members expect to hear candidates acknowledge their difficulties and
express some understanding of the emotional and behavioral dynamics associated with
recovery and transition. However, candidates must make clear their understanding that they
cannot necessarily apply their own experiences directly to clients.

The ETHICS project’s current staff structure calls for a project director, a senior case
manager, three case managers, an administrative assistant, and trained peer volunteer
educators.

Project Director. The project director administers the ETHICS Project.
Responsibilities include supervising professional staff, preparing reports to funding agencies,
further developing linkages with other service providers, accessing ongoing HIV-related
training for ETHICS and Fortune staff, and expanding and enhancing service provision. In
addition, the project director coordinates ETHICS’ public education and lobbying efforts,
such as inviting speakers to the program site and training ETHICS participants to educate the
public about HIV-related topics. The project director holds weekly unit meetings in which
the staff discuss problematic cases, service delivery concerns, and other program and
administration issues. The project director is actively involved in the Mayor’s Voluntary
AIDS Task Force and in an HIV technical assistance consortium organized by the New York
City Department of Health.

Senior Case Manager. The senior case manager, working under the project director,
supervises the three case managers. This entails weekly supervisory sessions with each case
manager to review client progress and ensure that services are being coordinated. The senior
case manager conducts ongoing training for the case managers on case management,
counseling techniques, and proper documentation of client charts. In addition, the senior
case manager belongs to a number of HIV-related task forces throughout the city.

Case Managers. Case managers conduct prison outreach, plan discharge (when
possible), admit new clients, and counsel and manage cases of ETHICS participants.
Average caseloads range from 10 to 13 cases. Case managers conduct site visits of various
programs to which ETHICS clients are referred. These programs include medical service,
drug treatment, transitional housing programs, HIV support groups, and the social services of
other agencies. Case managers participate in community HIV groups and task forces
throughout the neighborhoods from which clients come and conduct "safer sex" workshops
for all of Fortune’s clients.

20
HIV Coordinator. The HIV coordinator maintains monthly calendar of ETHICS
activities, setting up appointments for speaking engagements in the community, record
keeping, and greeting walk-in clients and making them feel comfortable. The HIV
coordinator also supervises the trained volunteer peer educators.

Trained Volunteer Peer Educators. The ETHICS Project trains many of its peer
volunteers. Working 10-20 hours a week for a 16-week-period, the volunteers provide
crucial support for new ETHICS clients. They accompany clients, if necessary, to
appointments with medical and social service providers to ensure that clients receive services.
They counsel clients, spend time with them, serve as "buddies" and, by their example,
reinforce program goals of sobriety and self-help. In turn, their work with new clients
reinforces the peer volunteers’ commitment to a stable, productive, healthy lifestyle.

Peer volunteers testify at hearings, participate in conferences on the needs of ex-prisoners
living with HIV, and conduct workshops on HIV/AIDS issues for ETHICS clients. They
also provide clerical help and staff Fortune's HIV telephone hotline.

In addition, peer volunteers join staff in prison outreach efforts by conducting
workshops, recruiting clients, and corresponding with prisoners living with HIV. While they
are incarcerated, many prisoners are willing to disclose their HIV status in a letter but tell no
one else. Consistent and reliable correspondence provides a vital link and engenders hope
for the individuals. At the same time, the trained peer volunteers who respond to this
correspondence benefit as well. Such letter writing reinforces engagement and retention by
creating a community of support for persons in and outside of prison.

Funding

Because Fortune’s HIV services are provided throughout the agency, with intensive
services provided by ETHICS, the $680,157 in funding reflected in the chart below
represents the total of Fortune's HIV-related programming, not just services provided
directly by ETHICS. Fifty-four percent of Fortune's funds come from the New York State
Department of Health, 32 percent from Title IT of the Ryan White CARE Act SPNS, and 14
percent from Title I of the Ryan White CARE Act (Table 2). In addition to payment for
direct services, these contracts pay for necessary support functions, including bookkeeping,
reception/switchboard, keeping computer records on clients, and clerical assistance.

PROJECT SUCCESSES

The ETHICS Project developed outcome measures to correspond to its two general
goals:

# To meet the complex social and medical service needs of newly released prisoners
who have HIV/AIDS; and

21
 

Table 2. Expenditures by Source of Funding

 

 

 

NYS AIDS Ryan White/ Title I
Institute SPNS
Salaries $229,250 $136,000 $65,800
Fringe benefits 55,547 32,953 15,943
Occupancy 43,322 25,500 2,520
Other expenses (e.g., equipment, supplies) 36,881 23,889 12,552
Total Budget $365,000 $218,342 $96,815
¢ To help these clients modify their self-destructive behaviors and adopt healthier

more productive ones.

With regard to the first goal, ETHICS tracks the rates of success in accessing and
directly providing needed services. The measures used to indicate outcomes include:

¢

¢

® © © o

Percentage of clients seeking entitlements who were satisfied:
Percentage of clients seeking goods or clothing who received them:
Percentage of clients requiring housing who were housed;
Percentage of clients requiring medical attention who received it;
Percentage of clients seeking employment who found jobs;

Percentage of clients who wished to further their education who were enrolled in
an education program; and

Percentage of clients self-identifying as substance abusers who remained abstinent
during involvement with ETHICS.

With regard to the second goal, ETHICS relies on rates of program retention and
sobriety as proxies for positive "behavioral change." The outcome measures of interest are:

¢

¢

Average length of time clients participated in the project; and

Percentage of clients remaining sober and clean during participation.

22

 
The ETHICS Project believes that sobriety is among the most reliable proxies for "positive
behavioral change." In the staff’s experience, drug relapse is strongly associated with other
self-destructive behaviors such as sharing needles, prostitution, unsafe sex, and involvement
in criminal activity. Fortune tracks sobriety through self-report, staff observation, and
behavioral indicators. Most clients who experience drug relapse drop out of the program or
change their behavior in negative ways.

Length of Time in Program

ETHICS clients remained involved with the program for an average of 8 months--a
surprisingly long time, considering that this population is usually transient and hostile to
intervention.

Abstinence from Drug Use

Of the 114 ETHICS clients recorded, 102 (89.5 percent) reported significant histories
of substance abuse. The records of 24 ETHICS clients who received alternative-to-
incarceration and HIV services show an average of 10 years of use for cocaine/crack abusers
and 14 years for heroin abusers. Primary drugs used were heroin (60 percent) and
cocaine/crack (40 percent), with daily use prior to incarceration.

Staying drug-free is a surrogate indicator of low-risk behavior. Clients reported that
when they use alcohol or other drugs, they are less likely to use condoms; conversely, when-
they are working toward healthy goals, they feel they have a reason to protect their future
and their use of condoms increases. Given the large percentage of clients who reported
substance abuse histories (102 of the 114 studied), the results are impressive; 81 percent of
those identifying abstinence from drugs as a need and 69 percent reporting significant
substance use histories remained abstinent during the period of their involvement with
ETHICS.

Accessing Services

ETHICS staff tap into a rich referral network to access needed services for their
clients and are aggressively enterprising. For example, ETHICS graduates working for other
medical and social service providers have proven to be an invaluable resource. One graduate
who now works in an area hospital helps Fortune expedite admissions of clients in
emergency situations. Another staff member’s mother works in a hospital and helps ETHICS
negotiate the application processes to access medical services. ETHICS also frequently
barters for services with other providers. Project records indicate that 114 clients accessed
services while they were involved with the program (Table 3).

23
 

 

Table 3. Rates of Success by Needs Categories

Needs Category Clients Presenting Need Clients Meeting Goals
(n=114) (%)

Medical Attention 86 100

Entitlements 84 98

Abstinence 83 81

Clothing 63 100

Housing 56 93

Employment 16 88

Education 6 100

 

 

 

Case Histories

"John." John is an African-American man in his thirties. He had a 15-year history
of injection drug use and tested positive for HIV when he came to The Fortune Society after
being released from prison. He was homeless and in need of medical attention. According
to him, he had not received a copy of his medical records when he was released so he had no
documentation of his HIV serostatus and could not qualify for entitlements. ETHICS Project
staff arranged to have John seen immediately by a medical professional, who helped him
obtain the necessary medical records to link him with services. Project staff assisted him in
obtaining entitlements and locating permanent housing. John saw his ETHICS counselor
every day for the first 2 months and twice weekly for the remainder of the 4-month period.
He received counseling for relapse prevention, early childhood sexual abuse, safer sex
practices, health maintenance, and other issues. He is doing well, his health has improved,
he received his GED, and he is now attending college.

"Leni." Leni is a 40-year-old woman with HIV who came to Fortune after serving
10 years in prisons in four States for grand larceny. She was frightened and disoriented
when she came to Fortune and needed to learn how to support herself. She had to contend
with many complications that had arisen due to her illness and she wanted to mend her
relationship with her teenage daughter, who resented her mother for being in prison.
Fortune counselors helped Leni get the medical care she needed and the benefits for which
she was entitled through the Division of AIDS Services. Fortune arranged housing and
further support through Services for the Underserved, a nonprofit agency. Her relationship
with her daughter improved, partly because Leni secured a home and received counseling.

Leni volunteered at Fortune 3 days a week as an HIV peer counselor and visited

Taconic Correctional Facility once a week to provide HIV education to the women inmates.
She says that going back to the prison where she was incarcerated was her therapy as well.

24
"It gave me a boost. I liked to be there for people to see that, hey, I’m doing good."
Once Leni’s daughter visited Taconic with her. The women cried when her daughter
expressed her feeling about her mother’s illness and the future; she is proud of her mother
and glad to have her home. Leni visited schools and churches on her own time, giving
presentations on HIV to young people. Recently, to preserve her health, Leni has reduced
her volunteer activities.

"Darion.” Darion, a 27-year-old African-American man, came to Fortune 2 months
after his release from prison. He was in denial about his serostatus and extremely
introverted. As a result of the patience and persistence of Darion’s counselors and peer
volunteers, Darion began to feel more comfortable with the ETHICS unit and began to
address HIV-related concerns. He found the social activities provided through ETHICS
especially helpful. He was concerned about how to organize his leisure time and stay drug
free. Darion learned that living with HIV did not preclude having fun and that it is possible
to socialize without using drugs. He participated in drug-free social activities such as
bowling and theater.

Darion’s counselor worked hard to gain access to an HIV clinic known for its case
management team, its flexible approach to working with hard-to-reach clients, and its
convenient location. Although the clinic had reached capacity and had no available slots,
Darion’s counselor made a minimum of 12 contacts over a 3-week period and leveraged a
slot based on favors owed for accepting referrals from the clinic. Such "bartering for
services" is especially effective in getting clients limited services. Accessing a slot in this
clinic proved to be vitally important and increased the likelihood that Darion would achieve
his case management goals and comply with medical treatment. Darion now works as a HIV
coordinator and counselor.

FACTORS LEADING TO SUCCESSFUL OUTCOMES

Since its inception, the ETHICS model has evolved as a result of staff observation
and ongoing client feedback. The ETHICS unit’s approach to addressing substance abuse
and drug relapse illustrates how the ETHICS model has been refined over its 4 years of
operation. For example, during its first year of operation, the program offered only short-
term counseling and a limited number of referrals; once a client was referred to the New
York City Division of AIDS Services, his or her case was considered closed. Since then,
ETHICS has added long-term counseling and case management, support groups, seminars on
nutrition and health, peer counseling, and record keeping.

Emphasis on Staff Training
Fortune makes available to its staff numerous training sessions to support their
continuing professional development. Training includes 8 weeks of intensive training on

HIV/AIDS; pre- and posttest counseling in collaboration with the New York State
Department of Health/AIDS Institute; relapse prevention counseling provided in-house by

25
Fortune’s Deputy Executive Director; and training on death, dying, bereavement, and group
facilitation conducted by Narcotic and Drug Research, Inc., known nationally for its training
on HIV/AIDS and substance abuse.

The 8-week training program on HIV/AIDS meets four times a week to provide staff
members with little or no prior experience in the field of AIDS/HIV the basic skills needed
to assist clients. The issues presented during this training include the following:

4 Federal and State client confidentiality regulations;

¢ HIV and nutrition and health;

*

New York City and New York State human rights laws and AIDS-related
discrimination;

¢ Working with the resistant client;

¢ Relapse prevention counseling;

¢ Organizing and facilitating an effective support group;

¢ Death, dying, and bereavement;

¢ Pre- and post-HIV test counseling

4 Ongoing in-service training in Humanistic Counseling Techniques.

A key to the success of the ETHICS program is the ability of staff to overcome many
of the initial barriers to developing client-counselor relationships. In client satisfaction
surveys and discussions, Fortune clients cite the staff interaction as one of most important
reasons for their participation.

Strong Collaborative Relationships with Other Service Providers

Fortune believes that no single program can effectively meet the treatment needs of all
clients. Therefore, it maintains strong working relationships with many other HIV, social,
and medical service providers. This enables Fortune counselors to make effective referrals
for a wide array of services. The key consideration in deciding whether to refer a client for
off-site services is the client’s treatment needs. Sometimes clients are referred to residential
drug treatment because they need the structure and intensive treatment those programs

provide. They may be referred to other day outpatient drug treatment programs because of
the modalities, program structures, or treatment philosophies offered.

26
Fortune regularly invites service providers to visit its offices and learn about its onsite
programs. In addition, before the ETHICS unit refers clients to another agency or program,
an ETHICS staff member will conduct a site visit, meet with program staff, and, if possible,
sit in on a support group. The criteria for considering client referrals to a particular agency
or program include the caliber of counseling services given, expertise in the provision of
HIV services, success in working with ex-offenders, location (e.g., access, degree of drug
and crime activity in the area), ability to advocate effectively for services, and history of
working collaboratively with sister agencies.

On several occasions, the ETHICS Project has entered into linkage agreements with
agencies to which ETHICS clients are referred. Such agreements help formalize referring
relationships and clearly spell out the mutual responsibilities of the two organizations.

In addition, for those clients who sign confidentiality release forms, ETHICS staff conduct
telephone case conferences twice monthly with the primary counselor at the referring agency.
Such collaboration and close coordination results in both agencies remaining involved in
clients’ treatment planning, even following referral to offsite services. Each year, ETHICS
sponsors an event to honor the service providers to which it refers clients. This
"Appreciation Ceremony" recognizes programs and individual counselors for the valuable
contributions they make to ensuring a continuum of care for shared clients.

Effective Intraagency Referrals

Whenever possible, ETHICS staff tap into Fortune’s onsite services. Many times,
clients with HIV graduate from a Fortune program to ETHICS. Four Fortune programs are
particularly worth noting.

The In-House Substance Abuse Treatment Services (SATS) unit, licensed by New York
State’s Office of Alcoholism and Substance Abuse Services, offers outpatient treatment for
clients on probation or parole. Participants receive individual counseling at least once a
week, as well as group counseling and discussion. SATS concentrates on relapse prevention,
lifestyle change, and the pursuit of positive goals that lead to independent, drug-free living.
Counselors use a variety of methods to engage clients, including individual and group
therapy, family counseling, intensive case management, acupuncture, art classes, and yoga.
Group discussions deal with issues such as self-esteem, personal problems, male and female
roles, drug and alcohol use, and relapse triggers clients may encounter in daily life. Social
and recreational activities expose clients to healthy and positive social experiences and
provide them with new options for drug-free use of their free time. Those who successfully
complete the SATS program celebrate with staff and friends at joyous graduation dinners.

The Court Advocacy/Alternatives to Incarceration (ATI) program serves carefully
selected defendants, including those with AIDS. By being placed under Fortune’s
supervision, defendants can avoid incarceration or earn reduced sentences. ATI participants
come to Fortune for individual counseling, group discussions on such topics such as
parenting and the work force, and other services. Most clients start by reporting to Fortune

27
five times a week and stay for 6 months, with specific goals, such as getting a GED or
finding a job. The program includes a substance abuse relapse-prevention component.
Clients self-refer to ATI with open court cases and are referred by judges, prosecutors, and
defense attorneys. Recently, Fortune provided ATI services to 24 defendants with AIDS to
save these people from the health-threatening stress and poor medical care found in prisons.

Career Development is needed by most ex-offenders who go to Fortune because they
have little or no stable work history. Clients are often desperate to find work immediately
and cite the need for a job as their foremost priority. A 3-day career development workshop
teaches crucial job-hunting skills, including how to discuss criminal convictions and
substance abuse history with a prospective employer; how to conduct a newspaper and
telephone job search; and how to construct an effective resume. Videotaped and mock
interviews enable clients to observe how they look to others so they can discuss problems
with counselors and other participants. A job developer works with each participant, guiding
the job search, developing a resume, and encouraging the client to go to interviews.
However, in keeping with Fortune's emphasis on self-help, the workshop teaches participants
how to conduct an independent job search.

Job retention seminars help clients who have been out of the job market for a long
time but who demonstrate potential for becoming responsible workers. The seminars cover
budgeting, employee’s and employer's rights, self-confidence, decision making, and
prevention of relapse into crime and substance abuse. As a result of the program, job
retention has improved dramatically for Fortune’s clients.

Educational Services are provided to clients. They receive one-on-one tutoring,
tailored to their individual needs, in basic literacy and mathematics to GED test preparation
and beyond. Fortune offers day, evening, and Saturday hours, so students who find jobs can
continue with their studies. Students stay in the program as long as they like and work at
their own pace, attending tutoring sessions twice a week for an hour or more. Each student
is tested after 24 lessons to measure progress. All tutors are volunteers, trained and
supervised by Fortune’s six staff teachers. In 1992, Fortune opened a computer lab,
complete with eight terminals and a full-time instructor. Clients learn word processing skills
and use the educational software to study reading, math, geography, and spelling on their
own.

Effective Engagement of Clients

Most clients who are referred to the ETHICS Project elect to participate in the
program. However, a small minority reject services. It is likely that they have recently
learned of their HIV seroprevalence and have not yet disclosed it to close family members or
friends. Often, these individuals return to Fortune once they accept their HIV status and
decide to seek assistance. The program deliberately allows participants to enter, drop out,
and return, or to reject services and later seek them when they have come to terms with their
HIV status and are better able to take advantage of the services.

28
Clients receive intensive, individual attention. This approach is reassuring for clients
who during their first visit to Fortune report feeling terrified and scared, not in control of
their lives, powerless, in denial of their HIV status, impatient, nervous, distrustful, and
worried about discrimination and rejection. Intensive personal care results in improved client
retention, which is essential to positive behavior change. Such efforts include extended and
intensive individual counseling, the pairing of new clients with more experienced buddies or
trained volunteer peer educators, and simply spending social time with clients. Although
ETHICS clients cannot stay overnight at the Fortune facility, the ETHICS living room
provides them with a quiet, comfortable place to rest and talk with ETHICS staff, volunteers,
and other clients. Clients also report that they find great relief in being with other people
who are living with HIV/AIDS and with counselors who express faith in them. In addition,
client focus groups reiterate the importance to the clients of having a counselor who is a
former offender in promoting their continuation with the program and providing an "ex-
offender friendly" agency that reinforces a feeling of safety and love.

Extensive and Effective Use of Volunteers

After they have achieved stability in their own lives, many clients want to serve
others and continue their involvement with the ETHICS program by volunteering at Fortune.
These volunteers expand the ETHICS Project’s ability to provide services and peer support.
In addition, their newly assumed responsibilities help reinforce such case management goals
as sobriety and stability. Other clients use their skills at other AIDS-related organizations.
Giving them that opportunity benefits both them and their work site, as well as the
community.

Peer educators, who have made positive changes in their own lives and with whom
clients can identify, play an indispensable role in creating an atmosphere conducive to growth
and change. Peer educators are able to reinforce positive behavior change, encourage clients
to make maximum use of ETHICS services, and help clients to be optimistic about their
future.

Cost-Effectiveness

Case management is an extremely labor-intensive process; a single concrete problem
may take a case manager half a day to resolve. Nevertheless, because case managers are
known and respected in the community, they are able to place clients in permanent housing
in a short period of time (within 2-3 months). Permanent housing costs an average of $550
per month, instead of $200 per day in typical temporary housing such as "welfare hotels."
Similarly, linking clients with medical care providers ensures not only more personalized
care but also a tremendous saving over the costs of emergency rooms. Perhaps the greatest
saving is that medical complications, including opportunistic illnesses, can be diagnosed and
treated early, rather than advancing to later stages when they may require extreme
intervention, including sustained hospitalization.
BARRIERS ENCOUNTERED AND RECOMMENDATIONS

The ETHICS Project has encountered many challenges in linking ex-offenders living
with HIV with community services. These challenges provide opportunities for innovative
solutions and further program refinement. Some of these obstacles and recommended actions
are outlined in this section.

Noncompletion of Program

Drug relapse is one of the major reasons for noncompletion of the ETHICS program.
Of the 83 identified substance abusers participating in ETHICS, 16 either lost contact or
relapsed. A very high percentage of ETHICS clients present histories of long-term, multiple-
drug use, crack cocaine and heroin being the most common drugs used. For recently
released prisoners, maintaining sobriety, especially during the period immediately following
their release from prison, often proves to be an unattainable goal without sustained support
and effort. Other reasons clients do not complete the program include 1) transferring to a
different unit or agency, 2) getting rearrested, or 3) leaving the area. Fortune implemented a
computerized record-keeping system to better document dropout rates and reasons for
attrition.

Limitations on Counseling/Program Capability

Ready access to counseling for clients with HIV is necessary to address the difficult
issues associated with adjusting to new lifestyles and new life goals. Fortune staff counsel
clients during office hours only; for some clients, the hours spent away from Fortune present
temptations that prove stronger than their determination to resist.

Dissatisfactions reported by clients have helped ETHICS refine its program. For
example, clients expressed dissatisfaction with the lack of services in the evening, sO
ETHICS arranged for each staff member to work one evening a week, added an evening
support group, and allotted more time for case management during the client’s initial
involvement with the project. In addition, ETHICS has addressed this service gap by
referring clients to programs that provide services during the early and late evening and
during weekend hours. ETHICS also encourages "the buddy system,” where more
experienced clients make themselves available to newer clients.

Additionally, ETHICS staff found that clients who are ill have difficulty keeping
appointments, and embarrassment or frustration about missing a scheduled appointment may
deter some clients from trying again. Recognizing the instability of many recently released
prisoners and their distrust and ambivalence about seeking services, ETHICS developed a
flexible, open admission policy. ETHICS encourages clients to walk in, without an
appointment, any time Monday through Friday, 9 a.m. to 5 p.m.

30
Staff Training, Burden, and Turnover

Generally, the ETHICS program has found that caseloads of 10-13 clients per case
manager are manageable and reasonable. However, since it is impossible to anticipate client
intake rates in advance, frequently case managers have caseloads of 15 and 16 clients.
During high-intake periods, an additional staff person could make a vital difference in
ETHICS’s ability to meet client needs. One primary counselor is assigned to each client, but
regular staff conferences about each individual client ensure consistency and coordination.

Counseling clients with grave and dire needs is draining and stressful for all staff;
therefore, Fortune implements strategies for relieving such strains and addressing concerns of
staff members about difficulties in managing stress. Efforts include providing staff with
training opportunities, organizing staff retreats, and raising issues during staff meetings and
supervisory sessions. ETHICS also refers its case managers to outside support groups for
HIV caregivers. Ideally, case managers attend support groups without their clients so they
can discuss their concerns openly. Whenever possible, clients attend support groups led by
staff members other than their own case managers, a practice that exposes each client to at
least two staff members and decreases the effects of turnover.

Inevitably, some staff will leave Fortune’s programs to advance their careers, pursue
salary increases, or take on additional responsibilities with other agencies. Clients may
abandon the program when a staff member leaves the agency for another job or, more rarely,
if a staff person to whom a client has become attached experiences a reversal in his or her
own struggle.

Staff Drug Relapse

Because a majority of staff are in recovery, Fortune believes drug relapse by some
staff to be inevitable. Given that staff serve as role models for clients, the drug relapse of an
individual counselor can present a serious threat to the progress of clients who have
developed a strong attachment to this individual.

Fortune pursues a multipronged strategy to reduce the likelihood of staff relapse and
to minimize the disruptive impact of any occurrences. Fortune nurtures and builds the 12-
step philosophy into its programs and strongly emphasizes the ongoing nature of recovery.
Second, the ETHICS unit tries to involve individual clients with more than one counselor so
that clients avoid becoming overly dependent on one staff member.

MAINSTREAM ISSUES

There are several social, cultural, and resource issues over which ETHICS has no
control, but that still affect the program. The ETHICS Project has identified three areas in
which further development and enrichment of services would help clients become stable after
being discharges from prison, improve intervention, and provide a continuity of care for

31
prisoners with symptomatic HIV disease. Several strategies have emerged to address these
issues.

Need for Expanded Discharge Planning

Because of current resource limitations the ETHICS project does little discharge
planning. Generally, interactions with clients begin when they are released from prison and
arrive at The Fortune Society for assistance. Experience indicates that this approach misses
two critical windows of intervention—the prerelease planning period and the period
immediately after release. The lack of adequate discharge planning results in gaps in medical
care and delays in accessing entitlements that can seriously endanger clients’ health.

Prerelease intervention offers the opportunity to carefully plan the prisoner’s return to
the community, ensure that documentation is in order, begin processing entitlements,
schedule clinic appointments, and establish critical services such as food and housing.
Discharge planning allows staff and volunteers to build a trusting working relationship with
the client prior to the crisis-ridden release period.

An essential part of discharge planning should be outreach to family members of those
prisoners who have given their consent to such contact. The period before release offers a
chance to reach family members when their motivation to be supportive is highest and before
the stresses associated with the period of release have set in. This is an optimum opportunity
to intervene in a manner that will smooth the transition for the client and the family. Family
members need to be given an opportunity to anticipate the issues and process the feelings
surrounding the prisoner’s return and to arrange for the supportive services that they might
need. In addition, prerelease contact with family members would provide program staff with
an opportunity to independently assess whether the prisoner’s family will be a help or a
hindrance to the prisoner’s health, stability, and sobriety upon release. Discussions with
prisoners whose family members are involved with drugs or unstable might suggest that
alternative housing will be needed.

Need for Enhanced Support During Initial Postrelease Period

The second critical window of intervention occurs immediately upon the prisoner’s
release. State prisoners released to New York City arrive at a bus terminal located in an
area with easy access to drugs and sex, the two most pressing desires. To be most effective,
intervention should begin by meeting released prisoners as they step off the bus, helping
them through their initial fear and disorientation, starting them in a positive direction, and
providing an immediate and caring link that will increase their ability to navigate the first
excruciatingly difficult and precarious days after release.

Non-HIV-related crises affect many released prisoners when they arrive at Fortune.

These concerns include the use of nonprescription drugs, homelessness, and lack of income.
Other challenges include overcoming the stigma of a prison record and remaining drug free.

32
Finding a job is a tremendous challenge, particularly for those with little or no education,
and supporting oneself, much less a family, on the wages most ex-prisoners can earn is
difficult. Released prisoners speak of "prisonization"—the accommodation to the violent and
antisocial culture of prison, which can make it difficult to stay out of trouble once released.
They struggle to remain drug free in neighborhoods infested with drugs, where all of their
former social life revolved around getting high. Each of these needs must be handled before
HIV-related concerns can be effectively addressed.

By working with the New York State Department of Correctional Services and the
Division of Parole, organizations such as The Fortune Society can greatly improve discharge
planning. Presently, The Fortune Society is developing a proposal to identify prisoners with
HIV and link them with necessary services upon release.

Lack of Appropriate Housing

Although the ETHICS program is usually able to find its clients housing, the number
of transitional housing facilities that are safe (i.e., crime free and drug free) is very small.
Many prisoners symptomatic with HIV are held in prison beyond their release date because
they lack housing. Sometimes the housing located requires unacceptable compromises in
terms of clients’ physical safety or risk to sobriety. Short-term, closely supervised
transitional housing is badly needed and currently lacking for prisoners returning to
communities from which most prisoners come, for clients whose housing situation becomes
unstable or unsafe, and for clients whose personal stability would benefit from a structured,
drug-free environment.

Lack of Necessary Medical Records

Clients discharged from prison without proper documentation of their HIV
seropositivity and their previous medical care present another serious barrier to assuring
¢ atinuity of medical care and applying for Medicaid. Health-threatening delays occur in
receipt of such benefits as medical and dental care, prescription medication, and home health
care. Clients without records may wait weeks to get a clinic appointment and undergo blood
tests again, further extending their wait by 2 weeks. Such delays hamper acquisition of
benefits, jeopardizing clients’ health and motivation.

Insufficient Number of Appropriate and Effective Drug Treatment Slots

Unfortunately, New York City does not provide adequate access to drug treatment,
and many clients face long (sobriety threatening) waiting lists prior to entry into residential
drug treatment. In addition, many of the traditional therapeutic communities fail to engage
and retain Fortune clientele. Thus, there is a need not only for expanded traditional drug
treatment programs, but for innovative and additional treatment approaches and modalities.

33
Fortune would like to develop an intensive, in-house drug treatment intervention.
Such an effort could entail long-term planning for a residential treatment program or
expansion of activities during hours when the agency is closed. It might involve the
establishment of a short-term residence to keep newly recovered substance abusers away
from their accustomed "places and faces" and provide a safe and supportive haven during
crises that jeopardize clients’ stability. Currently, the financial resources are not available to
implement such a program.

Lack of Adequate Funds

Many community-based organizations address the problems mentioned, but they are
overwhelmed by the breadth of the problems and are unfamiliar with Fortune’s clientele.
They need significant increases in funding to better serve the people who need their help.
More organizations such as The Fortune Society that provide a holistic, friendly environment
for people released from prison, particularly those with HIV, are needed. One of The
Fortune Society’s core beliefs is that dollars spent expanding the prison system could have a
greater impact on crime if they were spent improving the impoverished communities that
nurture most prisoners.

~ EVALUATION METHODS

The Fortune Society evaluated the ETHICS Project using case histories, client
satisfaction surveys, focus group interviews, and intensive case reviews. The ETHICS
orientation of individual attention was extended to the assessment of the program; case-
specific reports of the needs, experiences, and outcomes of individual clients added a useful
dimension to the program’s perspectives on program and client accomplishments. Clients
also rated their satisfaction with the ETHICS program by responding to client satisfaction
surveys. Questions included 1) Did your counselor give you adequate help in attaining your
goals? and 2) What was the most important service you received at Fortune? ETHICS
refines its programs in response to dissatisfaction noted on the client satisfaction surveys.

Focus groups conducted in November 1992 and January 1993 asked clients to reflect
on their experiences and to answer two questions: 1) How did you feel during your first
visit to Fortune? and 2) What helped you to remain in the program? The ETHICS project
director acted as primary interviewer, following a structured format.

In addition, when supervisors review client folders with case managers, any unmet
client needs are noted on supervision note forms, together with an action plan for meeting the
needs. The project director and senior case manager conducted an intensive folder review to
assess each client’s needs at intake and at 90-day intervals to determine whether the needs
had been met when the client exited the program.

34
DISSEMINATION OF THE PROJECT CONCEPT

ETHICS developed the following activities and materials to inform people about its
services and culture:

® Brief video documentary about the program. Through interviews with staff and
volunteers, this video conveys the methods and the culture of the ETHICS
program.

® Brochure about the program. Aimed primarily at potential clients, this attractive
brochure contains a substantial amount of information about the ETHICS
program’s services and culture.

& Comprehensive evaluation of the program. Completed in December 1993, this
report has been shared with the AIDS Institute of the New York State Department
of Health, the HIV Center for Clinical and Behavioral Studies, Daytop Village,
and Gay Men’s Health Crisis. Fortune wanted to share its case management
model and increase the likelihood that the special needs of recently released
prisoners will be taken into consideration as the AIDS Institute develops its own
protocols for case management and COBRA implementation.

® 1994-5 ETHICS dissemination and technical assistance program. This program,
funded by SPNS, was designed to help expand the availability of effective
counseling, case management, and other services for ex-prisoners living with HIV
by training organizations to provide these services. The Fortune Society serves as
a demonstration site for HIV-related services to ex-offenders, but it is anticipated
that the organizations receiving intensive training in the ETHICS model will adopt
or adapt it to their own and their clients’ needs. It is hoped that this program will
result in more organizations in New York City offering high-quality HIV-related
services to ex-prisoners.

In December 1994, an orientation to the program was presented, and commitments
to train four agencies were formalized. The program includes the following
elements:

- A preliminary needs assessment of the agency;

- 25 hours of a comprehensive interactive curriculum on HIV/AIDS
(January-February 1995);

- 25 hours of hands-on training at Fortune (February-March 1995);

- Individualized plan for technical assistance (March 1995);

35
- Weekly contact from Fortune staff on progress and needs for technical
assistance (March-July 1995);

- Evaluation of training/technical assistance program and of agency’s
progress (March-July 1995); and

- Followup evaluation of agency (by April 1996).

Fortune is planning other activities that will include outreach to organizations that
serve high-risk populations. Recently, ETHICS staff presented their program to social
workers, medical doctors, and counselors at the Columbia Presbyterian Hospital HIV Center
for Clinical and Behavioral Studies. Future presentations of this sort can incorporate ideas
on how programs could replicate the ETHICS model. More media coverage of the needs of
ex-prisoners living with HIV would create a climate favorable to legislators’ funding of
programs that would help meet the enormous need.

NOTES

1. Data from Criminal Justice Initiative, a joint program of the New York State
Department of Health and the New York State Department of Correctional Services.

2. Data from "Baseline HIV Needs Assessment, City of New York, Title I EMA: HIV
Seroprevalence Estimates and Service Needs Assessment for the Five Boroughs of New York
City," October 1993. Issued jointly by the New York City Department of Health and the
Mayor’s HIV Health and Human Services Planning Council.

AUTHORS

Tracey Gallegher
Project Director

JoAnne Page
Executive Director

The Fortune Society, inc.

39 West 19th Street
New York, New York 10011

36
Case Management for HIV Prevention
Among Drug-Involved Arrestees

Michael Gross, William Rhodes, Catherine Conly, Tammy Enos
Theresa Mason, and Linda Truitt

People at risk for exposure to the human immunodeficiency virus (HIV), including
heavy drug users who have been arrested, often cite their preoccupation with multiple life
needs (e.g., job, housing or shelter, and drug treatment) as interfering with their motivation
to address HIV risk behaviors. Given the complexity of needs of many persons at risk for
HIV infection, case management is a recommended means of addressing drug injection and
use and other HIV risk behaviors (Ashery 1992; Martin and Scarpitti 1993; McLellan et al.
1993; Centers for Disease Control 1993). Case management typically combines the
following components: assessment, treatment planning, linkage, referrals, monitoring, and
advocacy (Weil et al. 1985; Anthony et al. 1988; Applebaum and Austin 1990). It may also
include elements of counseling, therapy, or social support (Rothman 1991).

Because case management focuses on leveraging services that are difficult to access, it
is particularly appropriate for persons with both criminal and drug involvement. Because of
the large at-risk population filtering through the criminal justice system, there is an
opportunity to educate inmates about HIV prevention. However, correctional agencies have
limited ability to take proactive steps to reduce the spread of HIV (Hammett et al. 1992;
Wish et al. 1990:). Most arrestees are released within hours of arrest. Those convicted
often avoid jail and prison where they might be exposed to HIV prevention programs.

An intervention to reduce risk behaviors related to sex and drug injection implicated
in the transmission of HIV was integrated into a broader research project aimed at reducing
drug use and recidivism and at increasing the use of substance abuse treatment services.
Sponsored by the National Institute of Justice and the National Institute on Drug Abuse, case
management was delivered for 6 months to drug-involved arrestees released after booking.
Approximately 1,400 arrestees participated in the project between August 1991 and April
1993 in two sites, the District of Columbia and Portland, Oregon. Although participants
were recruited from an arrestee population, case management was strictly voluntary. High
levels of participation were sustained without either criminal sanctions for noncompliance or
material rewards for participating.

In the project, participants were randomly assigned either to case management or to
one of two alternative treatment groups. Outcomes measured by self-report were consistent

37
what features required improvement. Taken together, these data suggest how, with specific
refinements, the case management model might improve outcomes associated with HIV
prevention for this population.
PROJECT DESCRIPTION
Goals and Objectives

The overall goal of the HIV intervention was to determine the effectiveness of case
management in reducing HIV-related, high-risk behaviors among heavy drug users who had
been arrested, booked, and released. The outcome objectives for high-risk HIV behavior
were the following:

¢ To decrease the use of unsterile drug injection equipment;

# To decrease unprotected sex with other than monogamous, HIV-seronegative
partners;

¢ To increase use of drug treatment and self-help programs; -

¢ To decrease self-reported criminal activity and incarceration.
Specific process objectives were the following:

¢ To learn how best to conduct a case management intervention and

¢ To identify barriers to implementing a case management intervention and their
solutions.

Profile of the Client Population

Project Sites. The populations for the project were drawn from jurisdictions where
the courts, sheriff, and other criminal justice authorities would cooperate with the study,
which included not interfering with recruitment or random assignment of participants or
seeking sites’ assistance with supervisory functions. An extended site selection process
permitted documentation of the following site capacities:

¢ Sample sizes sufficient to detect program effectiveness:

¢ Experience in conducting followup studies or other evidence of an ability to

maintain contact with the study population in order to achieve high followup

rates;

# Expertise in providing case management to similar populations; and

38
# Experience in conducting behavioral research.

The Treatment Alternative to Street Crime (TASC) agency in Portland, Oregon, and
the Bureau of Rehabilitation in Washington, D.C., met the above criteria and had long-
established working relationships with the corresponding pretrial supervision agencies in their
respective cities. Because TASC and the Bureau of Rehabilitation had ongoing contractual
relationships with the criminal justice system, project interventions were delivered through
new operational units that had no visible association with the criminal justice system or the
parent organization. The operational units were given new agency titles.

In Portland, the TASC agency established the Rose Center, an office located near but
clearly separate from local court and jail settings. In Washington, D.C., the Bureau of
Rehabilitation, a local agency with decades of experience providing services to substance-
abusing clients referred from the criminal justice system, established the Community Health
Awareness Project (CHAP). CHAP’s location was readily accessible to arrestees released
from the District’s combined court and lockup facility. The offices at both sites were on
public transportation routes. They were designed to help participants feel comfortable, with
lounge seating in waiting areas equipped with coffee, sodas, and snacks.

Demographic Characteristics of Participants. At both sites, nearly 700 arrestees,
three fourths men, volunteered to participate in the study. In both cities, African Americans
were represented proportionally higher in the study than in the criminal justice system
population (Table 1). In Washington, D.C., almost all participants were African American;
in Portland, one-third were African American. More than one-third of the recruits in both
cities had not completed high school.

Substance Use History. Enrollment in the project was not restricted to injecting drug
users: however, one-fifth of those recruited in Washington and over half of those recruited in
Portland were injecting drugs in the month before they were arrested (Table 2). Among
current injectors, 23 percent in Washington and 39 percent in Portland shared injection
equipment. More than one-third of the Washington sample had injected drugs at some point
in the past, as had two-thirds of the Portland sample. Almost half of those recruited in
Washington and more than one-third of those recruited in Portland were using heroin,
cocaine, or both, at least four times a week at the time of arrest; most other participants used
drugs at least weekly.

Risk of Sexual Transmission. Only 7 percent of the Washington sample reported
having high-risk partners (injection drug users), but another 10 percent were unsure of their
partners’ level of risk. Consistent with higher rates of drug injection in Portland, 20 percent
of the sample had an partner who injected drugs. Another 6 percent had multiple partners
whose level of risk was unknown. Nine percent of the Washington sample and 3 percent of
the Portland sample indicated that they exchanged sex for money or drugs.

39
 

 

 

 

Table 1. Participant Characteristics
Washington, D.C. Portland, Oregon
LC . Baseline CJS Baseline CJS
Characteristic Participants Population’ Participants Population’
(%) (%) (%) (%)
(n=673) (n=57,960) (n=696) (n=21,445)
Gender
Men 74 84 74 80
Women 26 16 26 20
Race/Ethnic
African-American 95 81 34 25
White 3 18 51 57
Other/Unknown 2 4 15 18
Age (years)
18-19 1 12 7 14
20-29 30 39 33 35
30-39 50 31 41 32
40-49 16 12 17 14
50+ 3 6 2 5
Education (n = 7,585) (n = 1,141)*
11 years or less 44 43 37 35
High school/GED 52 42 59 59
Bachelor degree 4 15 4 6
Notes: Percentages are rounded.
CJS refers to criminal justice system.
Sources:
' D.C. Metropolitan Police Department (preliminary figures)
* Oregon Uniform Crime Reporting
* Pretrial Services Agency of D.C.
* Drug Use Forecasting System (1990)

 

 

 

Half of the sexually active sample in Washington and 60 percent of the sexually active
sample in Portland said that during the month before they enrolled in the study they never
used condoms with any of their partners. These rates were the same for sexually active
participants who either injected drugs or were sexually active with partners who injected
drugs. Consistent with findings in other projects, 75 percent of sex workers in Washington
and 55 percent of sex workers in Portland reported that they used condoms always; 17
percent in Washington and 24 percent in Portland reported that they used condoms
sometimes.

40
 

 

Table 2. Drug Use and Injection During the Month Before Baseline
Drug Use and Drug Injection* Washington, D.C. Portland, OR
(n=673) (n=696)
% %
Heavy heroin (= 4 times/wk) 19 13
Percentage of heroin users also:

Using cocaine/crack daily or weekly 66 57

Injecting drugs 84 95
Heavy cocaine/crack** (= 4 times/wk) 28 25

Injecting drugs 7 55
Weekly cocaine/crack** (< 4 times/wk) 35 30

Injecting drugs 6 4
Injected drugs 21 51

Users who shared needles 5 20

* Categories are mutually exclusive.

*% Includes amphetamine use at same rate in Portland.

 

 

 

Criminal Activity. Self-reported criminal activity was similar in both cities.
Participants said they had committed 13-14 crimes in the month before enrollment, yielding
an average income for the month of $450-$500. Over half of these crimes involved drug
dealing.

Service Needs. The populations in both cities had multiple needs, especially for
employment, health care, counseling, and housing (Table 3).! Portland reported greater
needs for psychiatric care, housing, and social support. A larger percentage of clients in
Portland had a high composite need score (49 percent) than in Washington (24 percent).

Nature of the Intervention

Project Design. The interventions in this project focused on two sets of factors
believed to be associated with behavioral change: 1) social support, including perceptions of
peer norms favoring risk reduction and encouragement from others to change behavior; and
2) removal of practical barriers that might discourage behavioral change. Volunteers who
agreed to participate in the project were assigned at random to one of three intervention
conditions (Figure 1):

41
l.

3.

Minimal intervention or "control" condition. Participants viewed a videotape
developed specifically for this population and received a guide to relevant
services in their community. The videotape sought to motivate help-seeking
behavior about drug use and HIV prevention through health promotion
techniques consistent with the health belief model, social marketing principles,
and social learning theory. It emphasized the existence of community support
for behavior change in the forms of drug treatment, support groups, and self-
help programs. (See Appendix A and Gross et al. 1992.)

Intermediate intervention condition. In addition to viewing the videotape and
receiving the referral guide, each participant attended one face-to-face
counseling and referral session with a referral specialist. The referral
specialist completed a needs assessment, then recommended an action plan
comprising a staged sequence of referrals tailored to the participant.

Enhanced intervention condition. In addition to viewing the videotape,
receiving the referral guide, and attending the counseling session, participants
were assigned for 6 months to the case management program.

 

Table 3. Need for Social Services Before Baseline

 

 

Service Need

Washington, D.C.

Portland, Oregon

(n=673) (n=696)
% %
Health 47 54
Psychological counseling 44 37
Psychiatric care* 36 47
Housing 29 49
Social support 24 35
Full-time employment 82 84
Income:
$300 or less 35 38
$301 to $799 31 32
$800 or more 34 30
% Evidence of mental illness, based on Referral Decision Scale.

 

 
 

BOOKING
- show video
- identify drug users

 

 

 

 

 

POSTRELEASE

- recruit drug users
- baseline interview

 

 

 

0 - 72 hours postarrest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTROL INTERMEDIATE ENHANCED
videotape videotape videotape
referral guide referral guide referral guide
one-time referral case management
session (6 months)
oO UP IN VIEW

90 days after randomization

 

 

 

 

 

 

 

END INTERVE : P INTERVI

180 days after randomization

 

 

 

Figure 1. Process of Recruitment, Randomization, Intervention, and Data Collection

43
Project staff recruited substance-abusing arrestees (identified in Portland through self-
reports and in Washington through urine analyses) as they were released from jail after
booking? (Figure 1). Volunteers were asked to report to the project site for a full
description of the program. After securing their informed consent and completing locator
information forms, project staff conducted structured interviews with arrestees at baseline and
3 and 6 months later.

The purpose of the interviews was to learn whether behavior improved between the
baseline and the third-month interviews, whether improvement was sustained between the
third-month and sixth-month interviews, and whether improvement was greater for the case
management group than for the other two groups. At the conclusion of the baseline
interview, each participant was randomly assigned to one of the three experimental groups by
a staff member who had no information about the results of the interview or knowledge of
the client’s level of HIV risk or other factors salient to the intervention.

At the conclusion of the project, researchers interviewed 33 case management clients
and compared case files to their descriptions of the case management. Interviews by the case
managers and by the other staff with six other arrestees not assigned to the case management
group provided information about strategies, barriers to service delivery, support for
behavioral change, and attitudes about HIV prevention.

Approach to Case Management. The design of key program elements relied on the
experience and judgment of the agencies contracted to implement the projects in Portland and
Washington, D.C. The contracting agencies were told to hire appropriate case managers; to
identify qualified supervisory staff and arrange for staff training; to broker and monitor
access to relevant services; and to provide adequate protocols and forms for conducting needs
assessment, treatment planning, and clinical monitoring. The sites were given latitude in
implementing case management consistent with their understanding of best practices.
Nevertheless, their contracts stipulated minimal parameters, including:

¢ An average caseload size of 30 per full-time case manager. An average of two
face-to-face contacts and two telephone contacts per month was established as a
minimum level of service to each active participant.

¢ Required categories of community service providers with which to negotiate
formal referral arrangements and agreements. Given constraints inherent in the
criminal justice system, case management emphasized referrals to community
agencies that could deliver comprehensive HIV prevention services. These
included drug treatment programs, HIV counseling and testing sites, HIV
prevention programs, and other key health and human service agencies (e.g., job
training, employment counseling, medical clinics).

Because "compliance" was to be strictly voluntary, case managers were held
accountable for preventing attrition of participants in case management and for their use of

44
referrals. That is, case managers were told that a critically important part of their job was to
engage clients in the case management process and to motivate them to seek help from
appropriate sources. Case managers were encouraged to be creative and were afforded wide
latitude in the methods they could use. Program coordinators were encouraged to be flexible
about making reassignments without blame if the first case manager assigned did not

establish satisfactory rapport with the participant.

Staff

Sites were encouraged to hire case managers who could empathize with the client
population and who had compatible racial/ethnic backgrounds. Minimal educational and
experience credentials were not specified, based on the assumption that specific skill deficits
would be addressed by in-service training and continuing supervision.

The project coordinator at each site was responsible for selecting and directing staff
and ensuring consistency in case management and data collection. Other staff identified
relevant social services, negotiated agreements, produced a referral guide, and evaluated
local service agencies.

Half of the case managers in Portland and all case managers in Washington, D.C.,
had bachelor degrees; the remainder had completed high school. Many had social service
experience in social work, probation, and drug counseling. Others came with hands-on
experience in crisis intervention, AIDS education, or client advocacy. Three of nine case
managers in Portland and one of five in Washington, D.C., acknowledged histories of drug
or alcohol abuse; all had been in recovery less than 5 years. None of the case managers had
a known criminal history.

Additional office staff at both sites included a receptionist, recruiters, interviewers,
and social service coordinators. For many participants, the receptionist in each office
became a key point of contact; these staff members were a consistent, highly visible
presence. Recruiters were stationed at the jail, court, or pretrial supervision offices to
identify potential study participants and provide them with information on the project.

In Portland, the roles of interviewer and case manager were kept separate. In Washington,
D.C., case managers conducted some interviews but never with their own clients.

PROJECT SUCCESSES

The principal outcome of interest in this project was decreased high-risk behavior
associated with HIV infection, that is, reductions in unprotected sex with other than
monogamous, HIV-seronegative partners, and in use of unsterile injection equipment.
Additional outcome measures were decreased drug use, increased exposure to both drug
treatment and self-help programs, and decreased recidivism as measured by self-reported
criminal activity and time incarcerated during the followup period. The entire population of
project participants seemed to adopt lower risk behavior across almost all measures,

45
irrespective of the intensity of intervention to which they were assigned. Broadly speaking,
case management had a measurable impact on reducing drug use and crimiral behavior. It
was not demonstrably successful at reducing risky sexual behavior, however, and the
evidence about improved needle hygiene is equivocal.

Participation Levels

The intervention group assigned to case management participated at a high level. Of
the 229 participants assigned to case management at CHAP in Washington, D.C., only one
had no contact with a case manager. Twenty-six percent met or exceeded the original goal
of 24 contacts. Significantly more women than men received 24 or more contacts (36
percent versus 23 percent, respectively; p = .05). The majority (62 percent) had two or
more contacts of some sort each month. Each of five case managers carried an average
caseload of 33 participants, with a range from 30 to 42. In Portland, 94 percent (217) of all
case management participants had at least one case management session; 35 percent had two
or more contacts a month. Maximum caseloads ranged from 10 to 40 clients per case
manager, with an average case load of 22.

Both programs were more office based than expected. In Washington, D.C., only 17
percent of all face-to-face contacts with case managers occurred outside the office; in
Portland, 11 percent occurred outside the office. A case manager physically accompanied a
participant to a referral site in only 2 percent of contacts at either program. On the other
hand, the availability of case managers at the project office made it feasible to encourage
drop-in visits by clients, a flexibility they seemed to value.

Of the 228 individuals assigned to case management in Washington, D.C., three-
fourths or more received at least one referral to each of the following: HIV testing,
employment, alcohol and drug abuse treatment, and self-help groups. More than 90 percent
of CHAP participants received at least one referral to drug or alcohol abuse self-help groups
and drug and alcohol abuse treatment programs (Table 4). Of the 217 case management
participants at the Rose Center in Portland, Oregon, 52 percent were referred to drug and
alcohol abuse treatment (Table 5). The next most frequent referrals were to employment-
related services (45 percent), housing assistance (39 percent), and financial assistance (35
percent). When participants resisted taking advantage of referrals because of previous
negative experiences with social service agencies, drug treatment services, and criminal
justice agencies or logistical impediments, case managers continued to meet with them to
help them evaluate earlier experiences and barriers, reinterpret them, and renew their
motivation to get help.

Outcomes Related to HIV Prevention

Because the Washington, D.C., sample had few needle users, changes in needle use
practices were examined only in Portland. All participants reduced needle sharing and

46
 

 

Table 4. Washington, D.C.: Case Management Participants Referred by Service Category
Service Category Percentage of Clients
(n=228)
Self-help group 91
Drug/Alcohol treatment 90
Employment 73
HIV testing 72
Medical 64
Education/Training 63
Legal 56
Housing 54
Financial 49
HIV/AIDS prevention and education 27
Psychological counseling 25
Social/Recreational 21
Dental 12
Contacts with no specified referral 86
Miscellaneous (e.g., child care, transportation, and 48
paperwork)

 

 

 

increased needle cleaning (Table 6). Case management participants were most likely to
increase needle hygiene, but the sample was too small to establish statistical significance.

In both cities, significantly fewer participants reported multiple partners between baseline and
followup interviews (Tables 6 and 7). Sexually active participants appeared to increase their
use of condoms in Washington, D.C., but not in Portland. Case management was associated
with no additional incremental reduction in sexual risk behavior.

Outcomes Related to Drugs and Crime

All participants reduced their drug use, many dramatically, and increased participation
in drug treatment (Tables 6 and 7). Case management participants reduced drug use to a
greater extent than participants assigned to the other two intervention groups in both cities
(Figures 2 and 3). In Washington, D.C., case management participants were significantly
more likely to be in a drug treatment program based on self-reports (Figure 4). In Portland,
self-reported enrollment in treatment was not measurably greater for case management
participants (Figure 5), except for the subgroup of clients who received higher doses of case
management. (Dose was measured as the number of contacts with case managers.)
Compared with public treatment records, entry into treatment is overreported by all Portland

47
participants.’ On the other hand, treatment enrollment records show that, self-report
notwithstanding, case management participants were more likely than others to receive
treatment.

 

 

Table 5. Portland, Oregon: Case Management Participants Referred by Service Category
Referral Target Percentage of Clients
(n = 217)

Drug/Alcohol treatment 52
Employment 45
Housing 39
Financial 35
HIV testing 24
Education/Training 23
Self-help group 22
Medical 20
Psychological counseling 20
Legal 16
Dental 12
HIV/AIDS prevention and education 12
Social/Recreational 5
Contacts with no specified referral 92
Miscellaneous: (e.g., child care services, pediatric medical care, 56

transportation agencies, detoxification programs, assistance with

obtaining birth certificates and other paperwork, assistance with

resume writing, providing referral letters, jail visits, receipt of social

services information/ literature, and receipt of bus tokens)

 

 

 

Participants in this project, many of whom were under criminal supervision for part
of the period of enrollment, reported dramatic reductions in illegal activity compared to the
prearrest period (Tables 6 and 7). Case management participants reduced their criminal
behavior and their self-reported time in jail more than other participants (Figures 6 and 7).
In Washington, D.C., the reported reduction in criminal involvement was corroborated by
criminal justice system data showing that case management participants were less likely to be
rearrested than were other participants. For Portland, secondary data from the Oregon
Justice Information Network show no difference across intervention groups with regard to
rearrest or reincarceration. However, those data appear to be incomplete: 16 percent of the
project sample could not be matched with these records for the corresponding period.

Magnitude of the Impact

If measured outcomes accurately reflect the impact of case management, the reported

48
reductions in heavy drug use are significant. During the followup period, heavy drug use
was reported by an estimated 23 percent of the case management participants and 30 percent
of the other participants in Washington, D.C. In Portland, approximately 30 percent of the
case management participants reported heavy drug use during the followup , compared with
approximately 35 percent of the other participants. These success rates are comparable to
results for outpatient drug-free treatment. For 6 months of services, case management costs
approximately $2,400 per arrestee in Washington, D.C., and $1,800 per arrestee in
Portland,* which is comparable to the average cost of an episode of drug treatment ($2,640),
although more costly than outpatient treatment only ($790).°

Extensive analyses were performed to determine whether case management increased
the use of services. Referrals offered to individual case management clients were not
strongly correlated with needs reported on the baseline interviews. Use of services other
than drug treatment was not significantly greater for case management participants than for
participants assigned to the less intense interventions.

 

Table 6. Behavior Change and Case-Management Impact, Portland, Oregon

 

Target Behavior Prevalence at Prevalence* at Impact of Case
Baseline (%) 6 months (%) Management

Substance abuse related

Heavy drug/alcohol use 76 27 ? (p=0.10)
Drug treatment 22 38 X
Needle sharing 39 2 X
Always clean 26 38 X
Never clean 39 27
Sexual risk
Multiple partners 21 11 X
Never use condoms 42 33 X
Crime-related
Illegal activity 60 25 v (p=0.05)
Rearrest 25 X
% All changes from baseline to 6 months are significant for the cohort as a whole except for the

"never clean" needles outcome among those share (n=164). Exposure to treatment is measured
by public records and agrees with self-report only when dose of case management is considered
in estimating the impact of case management.

? denotes a trend that does not reach statistical significance.

X denotes no significant change.

v denotes statistically significant change.

 

 

 

49
 

Table 7. Washington, D.C.: Behavior Change and Case Management Impact

 

Target Behavior Prevalence at Prevalence at Impact of Case
Baseline (%) 6 months (%) Management

Substance abuse related

Heavy drug/alcohol use 86 23 v (p = 0.01)

Drug treatment 13 27 v (p < 0.04)
Sexual risk

Multiple partners 29 12 X

Always use condoms 37 57 X

Crime-related

Illegal activity 62 14 v (p = 0.05)
Incarceration 18-27 v (p = 0.05)
* All changes from baseline to 6 months are significant for the cohort as a whole except for the

“never clean" needles outcome among those share (n=164). Exposure to treatment is measured
by public records and agrees with self-report only when dose of case management is considered
in estimating the impact of case management.

v denotes statistically significant change.

X denotes no significant change.

 

 

 

The statistical results may understate the effects of case management on behavior.
First, a tendency to underreport socially undesirable behaviors during the baseline interview
or the 6-month interview would tend to underestimate any improvements specifically
associated with case management.® Second, case management tends to keep people out of
jail, so that reductions in drug use or criminality among clients without case management
could result in part from lack of opportunity for criminal activity and possibly drug use.
Similarly, opportunities for participants without case management to commit crimes and to
engage in targeted high-risk behaviors during the reference period just before the interview
may have decreased during the period of interest if they were reincarcerated. Third, random
assignment to the case management group included participants who clearly are unsuitable for
case management services; therefore, the success rate among self-selected clients might be
higher than in this experiment.

This project achieved positive effects on drug use, drug treatment, and recidivism
despite a variety of obstacles and limitations. These results lay important groundwork for
integrating a public health approach into a criminal justice setting. Case management may
have played an effective part in improving retention in those services that the participants
used or in improvement in the use of the services. The importance of case management

50
 

 

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51

 
 

 

 

 

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52

 
 

 

 

 

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53
might have less to do with making referrals and may be more a function of helping to solve
problems associated with receiving services (e.g., practical concerns such as transportation
and child care and attitudinal problems arising from contact with less responsive agencies or
less empathic providers). The absence of critical services such as adequate HIV prevention
programming in a community may also be addressed through case management. Evidence
suggests that case management as practiced in these two sites fulfilled these roles and did not
operate exclusively by linking clients to services, although a more sensitive needs assessment
and systematic surveys of provider agencies would have been valuable to clarify this issue.

Long-term, in-depth case history interviews of case management participants contain
ample testimony of the importance of the case manager’s role in motivating efforts at self-
improvement. Important dimensions of that role include providing support during periods of
crisis, enhancing clients’ self-esteem by emphasizing their past accomplishments and current
strengths, and encouraging sustained improvement without blaming or recriminating
participants when they relapse. Even individuals who participated infrequently expressed
favorable attitudes about the relationship with their case manager, reflecting the value of
talking to someone who cared. Development of rapport between staff and participant became
a catalyst for behavioral change.

BARRIERS ENCOUNTERED AND RECOMMENDATIONS

Inasmuch as case management did have an impact on drug- and crime-related
behaviors, refinements of the case management approach might improve those outcomes and
might increase the likelihood of an impact on HIV-related risk behaviors. During the
implementation process, a number of barriers were encountered and overcome, resulting in
initial refinements of the approach.

Setting and Condition of Prospective Participants During Recruitment

Although the period following booking and release is the time when the recruitment
pool is largest, interventions with an arrested population pose procedural problems.
An intensive intervention cannot be carried out in the jail environment because facilities are
seldom designed for either group education sessions or confidential interviews. Booking and
release usually occur within 2 or 3 days and often on the same day. During that period,
arrestees often are inebriated or in withdrawal and otherwise suffering from the stress of
incarceration. Some topics seem unsuitable for a jail environment. For example, teaching
needle-cleaning techniques or safe sex practices runs counter to the criminal justice message
that drug use and prostitution are illegal. Thus, lockups and booking facilities were used in
this project as points of contact with prospective participants, but the interventions occurred
in the community. As a result, case managers were perceived as unlike "typical" parole or
probation officers, but as "friends" who could be trusted with information about illicit
behavior. These programs had an identity as "new agencies," without overt associations with
the criminal justice system, which apparently increased their appeal.

54
Agencies with reputations for conducting criminal justice system supervision may
have difficulty separating the coercive components of the criminal justice system and the
supportive and trust-related aspects of case management. On the other hand, the combination
of capabilities and experiences— working in the context of the criminal justice system,
familiarity with addiction and drug treatment modalities and services, experience working
with the affected demographic groups, and knowledge of HIV prevention strategies—may be
difficult to find in a community-based agency.

Voluntary Participation in Services

Even the parent agencies doubted that volunteers would participate in case
management without sanctions for noncompliance or material incentives for compliance.
Open-ended case study interviews suggest that the absence of criminal sanctions actually
strengthened the rapport between participants and providers by helping case managers
convince participants of their authentic concern.

Case managers developed flexible and creative approaches for engaging participants,
including the following:

¢ Eliciting participants’ interests and favorite activities (such as sports, music, their
families) and then engaging them in conversation about those things;

¢ Contacting participants by telephone or by mail to show continuing interest in
their progress and to keep them informed about developments in the community
that might be beneficial to them;

# Developing a telephone relationship with friends and family of participants when
the participants were unavailable to respond to the call;

# Mailing special announcements (about job or training possibilities) and personal
notes (e.g., for birthdays); and

¢ Meeting participants at their homes or in the community, visiting them in jail,
taking them to lunch on occasion, and personally accompanying them to agencies.

Concern About Confidentiality and Usual Reporting Requirements

Although the intervention programs recruited from the criminal justice system, they
did not provide the criminal justice system with any information about their clients. Local
officials were concerned about this prohibition against releasing information about clients’
positive accomplishments to criminal justice system authorities. Their concern was addressed
by pointing out that referral agencies could provide such information.

55
Inadequate Staff Training and Instability of Supervisory Staffing

Several factors suggest that training and stability of clinical supervision of service
delivery staff need to be taken seriously. Problems attributable to inadequate training and
supervision include unevenness in the delivery of services and episodes of dysfunctional staff
behavior (e.g., bickering, hostility, and inappropriate personal relationships between staff and
clients).

Instability associated with management changes and two periods of uncertainty about
continuity of funding led to staff turnover. In Portland, three different individuals served as
full-time project coordinators (one of whom resigned during the initial start-up period).
Reassignment of case managers to other duties necessitated the hiring of additional staff.
Over the life of the project, nine individuals served as case managers in Portland and six in
Washington, D.C.

Testimony from case managers at both sites about staff dissension and burnout
suggests that case management projects must devote attention and resources to supervision
and staff support. Periodic review and revision of treatment or "action" plans and insistence
on a carefully planned termination process are minimal requirements. Given the fluidity of
the case manager role and the value in case managers relaxing some of the traditional
provider-client boundaries (e.g., by meeting with clients outside the office or by working to
build rapport through self-disclosure), clinical supervision assumes an even more important
role. Factors such as productivity and record keeping are valid indicators of job performance
and appropriate considerations for managerial oversight of staff performance. Qualitative
aspects of job performance (e.g., thoroughness of assessment, comprehensiveness of
treatment planning, and appropriateness of referrals) should be addressed in the context of a
clinical supervision process that is clearly distinguished from administrative management.

Also, to provide effective HIV prevention counseling, less experienced staff require
substantial training on routes of HIV transmission, techniques of HIV prevention education
and counseling, strategies for counseling clients with HIV infection, and clinical issues in the
client-case manager relationship.

Targeting the Duration and Recipients of Treatment

An arbitrary increment of 6 months may not be the optimal duration for this or other
approaches to reducing HIV risk behavior. For some individuals, the period is too long; for
others, too short. A high proportion of participants reported histories of psychiatric
hospitalization or other indications of mental illness. These individuals may require long
exposure to intensive case management, combined with professional mental health services,
in order to achieve any meaningful improvement. In severe cases, dealing with such clients
may be beyond the means of case management programs. Other individuals, well served by
a relatively brief initial period of intensive case management to help them get back on their
feet may benefit from further case management services on an as-needed basis thereafter.

56
In addition to a more flexible and responsible method for assessing the appropriate
duration of treatment, future projects might consider developing methods to focus resources
on those participants most likely to benefit from case management. Qualitative findings
suggest that persons who benefit most from intensive case management are those who are
motivated to change, who are able to sustain prosocial and stable lifestyles at least for
intermittent periods, and who lack current access to social support. Development of an
effective screening method to identify such individuals would contribute to more efficient use
of limited resources.

Program or Service Termination

Many case management participants were disappointed when informed that their case
manager was closing their case and ending their participation in the program. Both sites had
official policies about termination, but these policies were carried out erratically.
Termination must be integrated into treatment planning and thoroughly discussed with clients
to assure that gains made through program participation are not threatened by the abrupt end
of service provision.

MAINSTREAM ISSUES
Limitations Imposed by the Criminal Justice System

Traditional probation and parole can be considered a form of case management
(Rothman 1971). Case management within the criminal justice system has a surveillance as
well as a supportive role, but it may be associated with pretrial supervision and a variety of
correctional programs for community-based supervision. The goal of probation to reduce
criminal activity differs from the goal of decreasing high-risk behaviors associated with HIV
infection, which may be best achieved by linking participants to community HIV prevention
programs through case management.

Unfortunately, the criminal justice system presents some restrictions that seriously
limit program design for HIV prevention. As a condition of funding, the Justice Department
prohibited needle-hygiene instruction and required promotion of sexual abstinence or mutual
monogamy as instruction on safer sex. Given that restriction, the only way to provide
sustained counseling and education for HIV risk reduction was to link participants to
community programs that could deliver comprehensive HIV prevention counseling.
Consistent with the criminal justice system’s emphasis on refraining from illicit behavior and
a program philosophy at the project sites that other behaviors would not change until
addiction was addressed, both programs emphasized elimination of drug use as a means of
reducing HIV risk behavior. However, while effective at reducing heavy drug use, this
strategy had no significant effect on HIV risk behavior.

This approach to HIV prevention was too indirect to be effective for three reasons.
First, recovery is a fragile achievement and relapse is common. Second, participants do not

57
always follow up on referrals. Third, the community may not have adequate HIV prevention
programs for this population.

Given the opportunity, adequate training, sufficient direction, and consistent
supervision, case managers are well positioned to provide sustained counseling about
reducing risk of HIV infection through education about injection drug use and sexual risk.
Although the integrity of the criminal justice system is a concern, these projects established
that a clear boundary can be maintained between case management and the supervisory
activities of the criminal justice system. Such a separation should allow a relaxation of
restrictions on the content and approach of semiautonomous programs conducted under
criminal justice system auspices to permit a more direct and comprehensive HIV/AIDS
intervention.

HIV prevention counseling should be individualized. Because the case management
process leads to a comprehensive picture of the individuals life situations, crafting such
tailored HIV counseling and education is possible. Thus, a case manager working with a
client attempting to remain abstinent from drugs would reinforce that intention and would not
emphasize instruction in needle hygiene or access to needle-exchange programs unless there
was a significant likelihood of relapse. In contrast, for clients not motivated to reduce their
injection drug use, case managers might continue to emphasize the possibility of drug
treatment while ensuring that these clients are aware of methods to prevent parenteral
transmission of HIV. With regard to sexual risk reduction, similarly tailored messages might
be delivered, in which case managers affirm that abstinence or mutual monogamy with an
uninfected partner are the surest means to prevent sexual exposure to HIV but counsel clients
with multiple unknown or high-risk partners about how to use condoms effectively.

Scarcity of Services and Opportunities

In 86 percent of CHAP contacts and 92 percent of Rose Center contacts, case
management contacts did not involve a referral . On those occasions, case managers met
with the participants to discuss their status, changing needs, and progress in finding
assistance. Such conversations were especially likely when an appropriate service provider
could not be identified. For instance, when drug treatment slots were full, case managers
continued to meet with participants to plan alternative strategies or to discuss ways of coping
until participants could make other arrangements.

Inevitably, the effectiveness of case management is limited by the availability of
services and opportunities in the community. For example, it is difficult to persuade clients
to enter job training programs in settings where high rates of unemployment exist. And few
cities have enough inpatient substance abuse treatment slots subsidized by public funds.
Drug treatment was not the only service for which demand outstripped supply, but also
psychiatric and dental care. In those situations, case management in effect becomes
"waiting-list management."

58
EVALUATION METHODS
Data Collection

Process forms were completed from case management records at every contact
(telephone and face-to-face) between project staff and all participants (including case
managers or others). These one-page forms recorded referral targets, location of contact,
whether the referral appointment was scheduled in advance, and intensity of the referral as
measured by whether the case manager made a referral, called the referral on the
participant’s behalf, or accompanied the participant to the referral.

Observers for each site made impromptu visits, certified that participants were
assigned randomly, reviewed forms for data accuracy and completeness, inspected case
management files for evidence of breadth and depth of service delivery, observed staff
meetings, and interacted informally with project staff. On-site monitoring provided early
warning of operational problems such as deficient rates of recruitment, inconsistencies in or
misunderstanding of certain items on the interview forms, noteworthy inconsistencies in
performance among service delivery staff, and insufficient followup rates. Other members
of the research staff frequently visited the Portland and Washington sites.

At the conclusion of the project, evaluators completed a total of 33 open-ended case
study interviews with case management clients and 10 such interviews with arrestees assigned
to the other two groups. These interviews focused on the context and consequences of the
incident arrest and, for case management clients, on incentives and disincentives to
participate, the nature of the case management relationship, and factors that may have
facilitated or inhibited case management effectiveness. Evaluators examined these
participants’ case files to compare their descriptions of the process with the case managers’
documentation of the course of treatment. Researchers completed open-ended interviews
with all case managers and project staff. These interviews focused on philosophies of case
management, case management strategies, barriers to service delivery and supports for
behavioral change, and attitudes about HIV.

Secondary data about program participants and about similar arrestees who did not
participate in the project were analyzed for validation of and comparison with the outcome
data. For Washington, D.C., the analysis used criminal histories and drug test data
following arrest and release from jail for 7,585 arrestees. For Portland, the analysis used
similar data on criminal histories (n = 1,408) and data about substance abuse treatment
following arrest and release from jail (n = 331). The project did not require urine testing
for several reasons. Maintaining both the fact and the appearance of a strict separation from
the criminal justice system was essential, and participants associated urine testing with
criminal justice system supervision. In addition, urine testing is an indicator of recent drug
use but cannot reveal the duration or intensity of drug use. Finally, if urine testing were
voluntary, it could introduce self-selection among participants who otherwise are willing to
answer interviews.

59
Baseline and Followup Interviews

To measure change, the researchers used repeated measures on an instrument
designed expressly for this project. By 1991, researchers sponsored by National Institute on
Drug Abuse had gained considerable experience interviewing injection drug users and their
sexual partners about HIV-related behaviors (Brown et al. 1993, NOVA Research Company
1992) in the context of the a National AIDS Demonstration Research program of community-
based outreach demonstration projects. They modified previous instruments, given concerns
about reliability and response rates,” and added scales to measure other factors relevant to
the program and evaluation: social desirability (scales designed to measure a respondent’s
propensity to deliver socially desirable responses to questions); service needs; and attitudes
regarding help-seeking, drug treatment, and HIV preventions.

Data Concerns

Two concerns arose in considering the conclusions about the impact of case
management: 1) the lack of data about service use (systematic spot checks, period surveys of
key target agencies, or clinical record abstractions) and 2) the lack of information about the
extent to which case management sessions included elements other than referrals, such as
assessment, treatment planning, advocacy, and generalized drug counseling. Given the
importance of sessions devoted to issues of motivation and support, other programs might
consider how to document those areas of case manager attention, perhaps by asking case
managers to record topic areas such as self-esteem, social relationships, and motivational
obstacles to seeking help.

The project identified the need for a protocol to guide new staff as they joined the
projects and the use of interim findings to offer valuable feedback for the site coordinators,
clinical supervisors, and case managers. Barriers to implementing the model that were not
apparent when it was designed might have become evident, such as the absence of adequate
HIV prevention interventions in the community. These observations also would have called
attention to the need to document and possibly expand the services that were proving
particularly useful to clients, such as motivational counseling or help with resume writing.

DISSEMINATION OF THE PROJECT CONCEPT

To make wider audiences aware of the videotape developed for this project, a
descriptive account of its production was published in the Journal of Drug Education. The
National Institute of Justice has reprinted that article and has distributed it to a 400-member
mailing list of criminal justice officials in the National Criminal Justice Reference Service
(NCJRS) database, which includes administrators of drug treatment programs, jail
administrators, and sheriffs who run jails. Copies of the videotape in either English or
Spanish version may be ordered through NCJRS at (800) 851-3420.

60
Major findings on the impact of case management were reported during an oral
presentation at the November 1994 annual meeting of the American Public Health
Association. With cosponsorship by the National Institute on Drug Abuse, the National
Institute of Justice plans to publish an issue of its "Research in Brief" series describing the
design and results of the project. In addition, the NIJ Journal, with a circulation of 60,000,
will include in a future issue a one-page summary of the project and the videotape. These
publications will reference the availability through NCJRS of both the videotape and, once
approved, the final report of the National Institute of Justice on the project. Upon approval
of the final report, one or more papers will be prepared and submitted to peer-reviewed
journals.

NOTES

1. The statistics appearing in Table 3 are from scales based on participants’
responses to the baseline interview. Some scales are simple indications of unmet needs, but
most are based on factor analysis, latent variable construction, or extant instruments. (See M
Gross, W Rhodes, C Conly, M Mason, L Truitt, T Enos, P Scheiman, and S Langenbahn:
AIDS/HIV Education in Lockups and Booking Facilities, report submitted to the National
Institute of Justice and the National Institute on Drug Abuse, May 13, 1994.) The scale cut-
off, on which table 3 is based, is subjective; other cut-off criteria would show participants to
be somewhat more or less "needy." It is doubtful, however, that any reasonable cut-off
criterion would fail to show that these arrestees have high latent service demands.

2. Candidates were informed that the project sought volunteers for a study of people
with substance abuse problems, and that the candidates would be compensated for their
participation in three interviews designed to understand their life circumstances and to
determine how to help others like them. They were also informed that they would be
randomly assigned to one of the three research groups. (Arrestees in both sites were
compensated for their participation in the baseline, 90-day, and 180-day interviews. In
Washington, D.C., participants received $20 for each interview; in Portland, they received
$15 for the baseline and 90-day interviews and $30 for the 180-day interview.)

Candidates were reassured that their participation was completely voluntary and would
have no effect, helpful or harmful, on their pending court cases. To support that claim, a
certificate of confidentiality and court orders from each jurisdiction protected from subpoena
project-related information about participants. After giving informed consent to participate,
newly enrolled subjects answered questions that would help project staff locate them.
[Recruits provided information on the following: name, nickname, sex, race, age, date of
birth, court identification number (later confirmed using court records), social security
number, lawyer’s name and phone number, home address and phone number, work address
and phone number, alternate address and phone number, and other important contacts and
their phone numbers.] Those who agreed to participate were scheduled for a baseline
interview, after which they received their intervention assignment.

61
3. It is, of course, entirely possible that various forms of intervention were
considered to be treatment. The interview distinguished between treatment and self-help or
12-step programs. However, communities typically have a diversity of agencies and
individuals who provide services they define as drug treatment. The public treatment data
corroborate that study. Participants who report increased drug treatment are not referring to
the case-management services provided by this project (in which case managers did counsel
their clients about substance abuse to varying degrees in the context of referrals to
treatment).

4. These figures are based on the operating budgets for the two sites. They include
labor and other direct and indirect costs for case management. Arbitrarily, half of the cost
of program administration was attributed to case management operations, the other half to
research-related administration. All social service and clinical supervision and nonresearch-
related training expenses were attributed to case management. Occupancy was allocated by
the fraction of total personnel costs associated with case management relative to total
personnel. Direct costs for case management included half of all duplication costs and all
expenses for refreshments and transportation assistance, but none of the costs for interview
stipends (paid in three increments over a period of 6 months to all research participants).
The difference in costs for case management in Washington, D.C., and Portland is almost
directly proportional to differences in the average annual salaries of case managers in the two
cities. In addition, occupancy and indirect costs were lower in Portland (while research-
related costs for recruitment and arrestee tracking were higher).

5. According to the Drug Services Research Survey (Batten et al. 1991, Table 38),
drug treatment costs an average of $2,640 per client ($790 per client for outpatient drug-free
treatment). The report’s authors warn that these are charge data for clients who were billed
the full amount for services, not cost data, and they may differ from cost data. Thus, the
costs of case management are in the same range as the costs for substance abuse treatment,
although case management is somewhat more expensive than outpatient drug-free treatment.
Also, the costs of formal drug treatment must be added to the costs of case management for
case management arrestees who entered substance abuse treatment. Thus, estimates of case
management costs understate the true costs of "treating" drug users.

6. Suppose that 20 percent of case management participants report heavy drug use
during the followup , while 25 percent of the other participants report heavy drug use during
the same time. The apparent effectiveness of case management is 5 percentage points.
However, if only half of all participants tell the truth about heavy drug use, the difference
would be 10 percent rather than 5 percent. The effectiveness of case management is greater
than it appears.

7. AIDS Outreach to Pregnant Women and Their Children (Gross et al. 1992) in two
sites, AIDS Outreach to Female Prostitutes and Sexual Partners of Injection Drug Users
(Hammett et al. 1992) in three sites, and Evaluation of an AIDS Outreach and Prevention

Program for Injection Drug Users not in Treatment and Their Sexual Partners (Finn et al.
1992).

62
REFERENCES

Anthony, WA, M Cohen, B Cohen, M Farkas (1988). Clinical Care Update: The
Chronically Mentally Ill: Case Management— More Than a Response to a Dysfunctional
System. Community Mental Health Journal 24(3): 219-227.

Applebaum, R, C Austin (1990). Long-Term Care Case Management: Design and
Evaluation. New York: Springer.

Ashery, RS (1992). Case Management Community Advocacy for Substance Abuse Clients.
Progress and Issues in Case Management. Rockville, MD: National Institute on Drug Abuse
Research Monograph 127.

Batten, HL, CM Horgan, JM Prottas, LJ Simon, MD Larsoon, EA Elliot, ML Bowden
(1991). Drug Services Research Survey: Provisional Report Phase II. Waltham, MA: Bigel
Institute for Health Policy, The Heller School, Brandeis University.

Brown, BS, GM Beschner, National AIDS Research Consortium (1993). Handbook on Risk
of AIDS: Injection Drug Users and Sexual Partners. Westport, CT: Greenwood Press.

Centers for Disease Control and Prevention (1993). HIV Prevention Through Case
Management for HIV-Infected Persons: Selected Sites, United States, 1989-1992. Morbidity
and Mortality Weekly Report 42(23): 448-456.

Finn, P, C Smith, W Rhodes, L Harrold, P Cole, S Teitelbaum, et al. (1992). Evaluation of
an AIDS Outreach and Prevention Program for Injection Drug Users Not in Treatment and
Their Sexual Partners: The Patterson (New Jersey) Health Behavior Project. Cambridge,

MA: Abt Associates, Inc.

Gross, M, DE Hunt, P Cole, L Harrold, M Mason, W Rhodes, C Smith (1992). AIDS
Outreach to Pregnant Women and Their Children: Final Report to the National Institute on
Drug Abuse. Cambridge, MA: Abt Associates, Inc.

Hammett, T, D Hunt, W Rhodes, C Smith, S Sifre (1991). AIDS Outreach to Female
Prostitutes and Sexual Partners of Injection Drug Users: Final Report to National Institute on
Drug Abuse. Cambridge, MA: Abt Associates, Inc.

Martin, SS, FR Scarpitti (1993). An Intensive Case Management Approach for Paroled IV
Drug Users. Journal of Drug Issues 23(1): 43-59.

McLellan, AT, 10 Arndt, DS Metzger, GE Woody, CP O’Brien (1993). The Effects of

Psychosocial Services in Substance Abuse Treatment. Journal of the American Medical
Association 269: 1953-1959.

63
NOVA Research Company (1992). Documentation for NADR Principal Investigator Tape.
Prepared for the National Institute on Drug Abuse. Bethesda, MD.

Rothman, D (1971). Conscience and Convenience: The Asylum and Its Alternatives in
Progressive America. Boston, MA: Little, Brown.

Rothman, J (1991). A Model of Case Management: Toward Empirically Based Practice.
Social Work 36(6): 520-528.

Weil, M, JM Karls, et al. (1985). Case Management in Human Service Practice. San
Francisco, CA: Jossey-Bass.

Wish, ED, J O'Neil, V Baldau (1990). Lost Opportunity to Combat AIDS: Drug Abusers in
the Criminal Justice System. In AIDS and Intravenous Drug use: Future Directions for
Community-Based Prevention, edited by CJ Leukefeld, RJ Battjes, A Amsel. Rockville,
MD: National Institute on Drug Abuse Research Monograph 93.

AUTHORS

Michael Gross, Ph.D.
Senior Analyst

Abt Associates

4800 Montgomery Lane
Suite 600

Bethesda, Maryland 20814

William Rhodes, Ph.D.
Senior Scientist

Catherine Conly
Tammy Enos
Theresa Mason
Linda Truitt

Abt Associates

55 Wheeler Street
Cambridge, Massachusetts 02138

64
APPENDIX

Drugs and AIDS — Reaching for Help:
A Health Promotion Videotape for Criminal Justice Populations

This 27-minute videotape* uses a drama-based approach to influence behaviors of
inmates in jails, lockups, and booking facilities. The videotape depicts both criminal
sanctions for illicit drug use and the results of advanced HIV disease. Its real emphasis,
however, is to encourage viewers to link with resources in their own communities.

The videotape presents three stories about people whose lives have been seriously
affected by drug abuse, who have experienced multiple brushes with the law, and who have
in some way been affected personally by AIDS or HIV infection. The stories emphasize the
complementary roles of formal treatment and informal support from self-help programs,
friends, and family in dealing with addiction and HIV prevention. Personal stories portray
abandoning a criminal lifestyle as a positive step, one that restores physical and spiritual
well-being, builds self-esteem, reinforces positive connections with family members, and sets
the stage for further life-enhancing opportunities. Consistent with the emphasis on seeking
help from others, the videotape concludes with a list of resources for finding assistance in
one’s own community.

After an initial script was written and recorded, edited audiotaped segments were
synchronized with appropriate images and transferred to videotape for a pretest version. For
this pretest, 14 focus groups, with an average of 12 participants per group, were conducted
in Chicago, IL, Phoenix, AZ, and Prince George’s County, MD. Focus groups suggested
that the final version of the videotape place greater emphasis on the importance of condom
use, the impact of HIV status on life, and the difficulty of finding effective drug treatment
and persisting at it.

The videotape integrates the message that incarceration is a constant threat in the lives
of many addicts. Each story also addresses susceptibility to HIV through sexual exposure.
Especially important are the vivid and emotional renderings of the treatment process,
particularly group meetings and self-help sessions. Although the videotape is frank about the
difficulties to be encountered in trying to free oneself of addiction, it emphasizes throughout
that social support can be found and that success can be achieved.

 

“The videotape can be ordered from the National Institute of Justice/National
Criminal Justice Reference Service, Box 6000, Rockville, MD 20850, phone (800) 851-
3420. Other videotapes developed on AIDS prevention used a drama-based approach to
promote risk reduction, such as "Olga’s Story" and "Alicia" (both distributed by Modern
Learning Aids, St. Petersburg, FL) but productions using this approach had not been
designed for persons under the supervision of the criminal justice system.

65
The videotape also acknowledges obstacles, for example, treatment failures occur,
effective treatment may be difficult to find, and staying with a treatment program requires
hard work. Conditions that maximize the chances of success, such as strong social support,
are accentuated. Participation in groups and meetings and recreational activities with drug-
free friends are depicted as a part of the fabric of a rewarding, drug-free life. Presenting
characters similar to the viewers themselves supports the belief that success in treatment is
within reach with sufficient motivation and social support.

Drug treatment specialists and people in recovery have endorsed the approach in the
videotape, noting that it is essential to convey positive reasons for embracing a drug-free
lifestyle and to give people the conviction that when they reach for help, recovery will be
within their grasp. Many jail and prison officials have reacted favorably to the videotape.
However, some officials who viewed the pretest videotape discounted its approach because it
did not depict graphic portrayals of people suffering withdrawal symptoms in jail and hard-
headed, no-nonsense messages that AIDS is a "death sentence" for illegal drug use.

Criminal justice officials who are suspicious of this "nonpunitive" approach might reconsider:
promoting health behaviors emphasizes what people will gain, not just what they might lose.

Several factors suggest that training and stable clinical supervision of service delivery
staff need to be taken very seriously. Problems attributable to inadequate training and
supervision include unevenness in the delivery of services and episodes of dysfunctional staff
behavior (e.g., bickering, hostility, and inappropriate personal relationships between staff and
clients). To provide effective HIV prevention counseling, less experienced staff require
substantial training on routes of HIV transmission, techniques of HIV prevention education
and counseling, and strategies for counseling clients with HIV infection substantial training
on clinical issues in the client-case manager relationship.

66
The Rhode Island Prison Release Program

Timothy P. Flanigan, Denise Bury-Maynard, Kevin Vigilante

Joseph Burzynski, Gary Bubly, Joo Kim, Josiah D. Rich
Sally Zierler, Mary Lou DeCiantis, Lenore Normandy
Mary Snead, Ann DeGroot, Paul Lobert, and Barbara A. DeBuono

Rhode Island, with a population of about one million people, has an inmate population
of approximately 2,500 men and women in its only prison facility, the Adult Correctional
Institute (ACI). Of these inmates, 4 percent of the men and 12 percent of the women test
positive for HIV at any given time (Dixon et al. 1993), a rate highly disproportionate to the
2 percent HIV-seropositivity rate for the State. Each year from 1989 through 1993,
approximately one-third of individuals in Rhode Island who tested positive for HIV were
tested at the ACI.

To meet the health care needs of inmates living with HIV, the ACI, in conjunction
with the Rhode Island Department of Health and the Miriam Hospital, have operated an
AIDS/HIV clinic on site since 1989. Initially the clinic did not provide linkages to
community services. Medical, psychosocial, and substance abuse treatment ended for an
inmate upon release from prison. Not surprisingly, this lack of resources for the former
inmate now in the community led to rapid relapse in drug use, high-risk behavior, and
reincarceration. Of the 160 inmates seen at the clinic in 1990, 27 percent were lost to
medical followup upon release. It was not unusual for individuals to be in and out of prison
six times a year.

In December 1991, the Rhode Island Department of Health, in cooperation with the
Department of Corrections and the Miriam Hospital, Brown University AIDS Program,
instituted a practical, low-cost program, the Prison Release Program, to help bridge the gap
in services between release from prison and enrollment in community-based support
programs. The Prison Release Program initiates discharge planning and medical followup.

It provides comprehensive case management with referrals for substance abuse treatment,
housing, and other resources to reduce the recidivism rate. This program has been supported
as one of the Special Projects of National Significance (SPNS) through Title II of the Ryan
White Care Act.

67
PROJECT DESCRIPTION
Goal and Objectives

The goal of the Prison Release Program is to link inmates with agencies that can
either provide them with or assist them in obtaining appropriate medical care, psychosocial
support, and substance abuse treatment. The objectives are to extend supportive counseling,
medical care, and substance abuse treatment for inmates while still in prison and to facilitate
linkages to appropriate resources upon discharge. The measure of success of the program is
the extent to which inmates are linked with community resources after release. Upon
release, appointments are scheduled for medical care and counseling regarding appropriate
treatment (including use of antiretroviral medications and prophylaxis treatments to prevent
opportunistic infections); followup is conducted to assess whether inmates keep their
appointments. In addition, appointments are scheduled for individuals to obtain further
financial assistance, referrals to community housing agencies, and followup sessions with
substance abuse treatment agencies.

Profile of the Client Population

From July 1992 through August 1993, a total of 115 inmates participated in the
Prison Release Program. Of these 115 inmates, 74 were men and 41 were women. Sixty-
four percent of all eligible men with HIV participated in the program and 75 percent of all
eligible women with HIV participated. The mean age at the time of testing was 34 years.
Approximately half of the inmates were Caucasian, a third African-American, and a sixth
Hispanic/Latino.

Women. Of the 41 women participating, 90 percent spent less than 12 months in
prison, 2 percent spent between 12 and 30 months in prison, and 2 percent spent more than
30 months in prison (Figure 1). Criminal charges for the women were distributed as
follows: 20 percent for drug-related crimes, 34 percent for prostitution, 41 percent for both,
and 2 percent for other charges.

Men. Men spent more time in prison than women. Of the 74 men participating, 46
percent spent more than 12 months in prison. Criminal charges for the men were distributed
as follows: 59 percent for drug-related crimes and 41 percent for other charges such as
breaking and entering, robbery, sexual assault, homicide, larceny, and fraud.

Nature of the Intervention
Although this paper focuses on discharge planning and postrelease intervention, these

services are only part of the continuum of HIV care provided to the inmates (also including
HIV testing, counseling, and education; medical management; and discharge planning).

68
Testing, Counseling, and Education. All persons processed at the ACI Intake
Service Center are given a physical examination, tuberculin skin test, and a VDRL blood
test. These blood samples are used for the HIV test, with the signed consent of the
individual. Persons who refuse the HIV test but are subsequently convicted of a crime are
required by State law to be tested for HIV. Since 1990, between 9,000 and 10,000 inmates
were tested each year. A total of 242, 142, and 141 tested positive in 1990, 1991, and 1992,
respectively.

 

46% .
50% A (I on

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90% © i Ns d+ 8. Sa FF 0 EEE

20% 4 PR

 

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< 8 Months 6 - 12 Months 12 = 90 Monthe > 90 Months
Time in Prison

B Men 123) Women

Figure 1. Distribution of Time Spent in Prison by Gender of Client

All individuals who test seropositive receive one-on-one counseling with a trained
counselor. A full-time psychologist and a nurse provide backup and support to the counselor
as needed. During the posttest counseling sessions, the counselor explains the services
available within the prison and asks the inmates if they want to be followed by the HIV
medical management team. Inmates are scheduled for HIV medical clinic visits at their
request.

HIV posttest counseling includes an explanation of the voluntary notification program.
In this program, a person is offered two choices: 1) partner referral, through which the tested
person agrees to notify all contacts; or 2) provider referral, through which a trained
Department of Health outreach counselor will attempt to notify all contacts named as possibly
exposed to HIV. (Contacts are made anonymously and are offered counseling.) A full-time
employee of the Department of Health provides outreach to all areas of the community for

69
provider referral. Approximately 20-30 percent of inmates with HIV choose to use the
provider referral system.

All inmates and correctional personnel have access to general, ongoing AIDS
education. Emphasis is directed to the importance of risk avoidance and prevention. In
addition, a peer counseling service that allows inmates knowledgeable about HIV to educate
others was developed. Many of these peer counselors are living with HIV. The AIDS
educational programs are initiated while the patient is in prison and continue upon release.
There are support programs for referrals, group discussions, stress reduction, and HIV
education for individuals and their families.

Medical Management. The majority of inmates with HIV are asymptomatic. For
many, the period of incarceration is the first opportunity to begin antiretroviral therapy and
prophylactic medications; in fact, for many inmates, this is the first experience with any
system that provides continuing health care. The HIV management team uses the same
medical facilities as the prison medical staff but operates as a specialized consultation
service. All inmates living with HIV are referred to the team for initial evaluation and
counseling, but they are entitled to request evaluation at any time. This initial evaluation
includes a baseline blood analysis and physician recommendations concerning medical
regimens. During the first clinic visit, an initial needs assessment is performed and a more
comprehensive assessment is scheduled.

Inmates diagnosed as HIV-asymptomatic are scheduled for periodic medical evaluation
at intervals no greater than 3 months. The evaluation includes a medical history, a physical
examination, complete blood cell counts, and CD4 lymphocyte counts. Those with more
advanced disease or with cytopenias are evaluated more frequently, as are inmates recently
discharged from the hospital. Standard recommendations for the initiation of antiretroviral
agents are followed. All approved antiretroviral and prophylactic medications are available.
No experimental therapies are allowed.

Medical management of women with HIV is similar to that for men with the
exception of special attention to the gynecological manifestations of HIV. All women receive
a comprehensive gynecological examination and a Pap smear with cultures for gonorrhea and
chlamydia, regardless of symptoms.

Discharge Planning. The newly developed HIV discharge planning program
evaluates all inmates living with HIV prior to their release from prison. Discharge planning
includes an evaluation of inmates’ needs for medical followup, financial assistance, housing,
family support, care of children, and employment. Nurse case managers work with inmates
with HIV while they are in prison, maintain contact with former inmates, attempt to continue
their service plans, and coordinate their postrelease progress. During the first year, the
program evaluated 115 inmates: 104 required medical appointments, 100 required financial
assistance, 90 needed drug treatment referrals, and 47 needed housing referrals. All

70
individuals sign consent forms to verify followup with the referrals. All former inmate files
are kept open until stable community life is achieved.

Referrals. Five hospitals collaborate with the Department of Corrections and the
Department of Health to deliver care to incarcerated individuals. These facilities have
specialty HIV clinics. An in-house drug rehabilitation program extends residential treatment
after the patient is released from prison. Four other residential drug programs in Rhode
Island and one in nearby Massachusetts provide beds for former inmates. In addition, four
outpatient drug counseling facilities, three of which offer methadone maintenance, are
contacted for referrals. Agency co-affiliation agreements, implemented between community-
based agencies and the Prison Release Program, were made to monitor inmates’ progress of
reintegration into community life and long-term compliance with the case management plan.

The Prison Release Program also has developed an innovative relationship with
Sunrise House, which provides comprehensive long-term housing and support for individuals
with AIDS who have nowhere else to turn. This facility serves the needs of individuals who
cannot be cared for by family members or significant others or who do not have the
resources to provide comprehensive home care. Sunrise House is not a substance abuse
treatment program and therefore is not appropriate for people who need residential drug
rehabilitation services. The program does reimburse individual and group counseling at
CODAC, a drug treatment facility in Rhode Island.

Staff

Case Managers. The Prison Release Program component is coordinated by two
prison-based nurse case managers, each sharing HIV clinic and case management
responsibilities. Originally, the program included one full-time nurse case manager. Given
that the Prison Release Program dovetails with the HIV clinic program, it was determined
that the goal of continuity of care could be improved by hiring an additional nurse case
manager and assigning each person responsibility for half-time service to each program.

The case managers are registered nurses and report to the project director for
monitoring and evaluation. They carry a combined caseload of 100 to 200 inmates and
families. They coordinate referrals, make follow-up contacts to track progress, and work
closely with the Partner Notification Specialist to assure continuity of care. They are part of
the overall prison HIV Service Network, the "A-Team." With the substance abuse treatment
facilities in the state, the nurses develop contacts that facilitate their obtaining a slot or a bed
and following the progress of their clients.

Partner Notification Specialist. The partner notification specialist, a full-time
employee with the Rhode Island Department of Health, is responsible for interviewing
inmates living with HIV who agree to participate in the program. This specialist is
responsible for the Prison Release Program field work, which includes referring contacts to
counseling and HIV testing sites and locating inmates released to the community prior to

71
receiving notification of their serostatus. With an office at the ACI, the Partner Notification
Specialist communicates regularly with the staff of the prison, the nurse case managers, and
the Rhode Island Department of Health.

Medical Management Team. The HIV management team includes two attending
physicians, an infectious disease fellow, and a registered nurse who serves as the on-site
coordinator. The team evaluates patients at the ACI 4 half days a week on a regular
schedule. The physicians are trained in internal medicine and infectious diseases as well as
HIV-related diseases. Both physicians are full-time faculty members of the Brown
University-affiliated Miriam Hospital. The team uses the same medical facilities as the
prison medical staff but operates as a specialized consulting service.

Program Administration Staff. The Rhode Island Department of Health provides
overall direction of the project, project evaluation, progress monitoring, administrative
oversight, computer assistance with data collection and reporting, and information
dissemination and report writing. Staff meet with the Prison Release Program personnel on a
regular basis to discuss data generated from client intake and information forms.

A psychologist at the Department of Corrections provides 10 percent time for on-site
supervision and support to the "A-Team." As on-site supervisor, this individual leads
interdisciplinary case conferences, facilitates meetings, and acts as an on-site administrator.

Social Worker. A clinical social worker (1 full-time equivalent) and evening
supervisory staff (.75-time equivalent) are located at the Sunrise House, a comprehensive,
long-term residential housing program for adult men and women with symptomatic HIV.
The social worker is responsible for developing and maintaining a supportive, permanent
housing program; coordinating prerelease counseling and admission planning with ACI
personnel; providing crisis intervention and on-call services; and constructing and monitoring
counseling and support during the extended postrelease adjustment period.

Funding

The Rhode Island Prison Release Program component initially received funding from
Title II of the Ryan White Care Act, Special Projects of National Significance (SPNS). It
was supported also by a grant from the Centers for Disease Control and Prevention and by
the Rhode Island Department of Health. The Prison Release Program is now funded by the
Department of Corrections and the Department of Health. The testing and counseling and
the medical management program components are also funded by these two departments.

PROJECT SUCCESSES
From July 1992 through August 1993, a total of 115 inmates participated in the

postrelease program. Sixty-four percent of all eligible men living with HIV and 75 percent
of eligible women participated. The principal outcome measures of interest were successful

72
referrals for housing, financial assistance, medical assistance, drug rehabilitation; reunion
with families; and psychosocial services (i.e., linkage of the community service with the
inmate at least 3 months after release). A secondary measure of success was the change in
the rate of recidivism for women who received referrals.

Referral Followup

During the first year of the program, 74 men and 41 women received discharge
planning. Over 75 percent of former inmates followed up with medical appointments and
substance abuse treatment. For women, the most common referral was for medical followup
(88 percent, or 36 women); 78 percent received the service. The second most common
referral was for financial assistance (85 percent, or 35 women); 80 percent had a successful
referral. The third most common need was for drug rehabilitation (76 percent, or 31
women); 65 percent followed up on these referrals. The fourth and final category was
housing; 34 percent (14) of the women were referred, and 57 percent of them received the
service.

The most common referral for men was medical followup (92 percent, or 68 men
were referred) 71 percent of those referred followed up with appointments and treatment.
The second most common need was for financial assistance (88 percent or 65 men); 89
percent of these referrals were successful. Drug rehabilitation referrals were the third most
common category (80 percent or 59 men); 61 percent attended treatment. The fourth and
final category was housing; 44 percent (33) of the men needed this service, and 61 percent
secured housing during the analysis period.

Through the Prison Release Program discharge planning process, 68 percent of the
inmates living with HIV were evaluated in the first year. Most of the remaining 32 percent
remained at the ACI less than 2 weeks. The nurse case managers observed that clients who
actively participated in their discharge planning were more successful than those who
expected the nurse to develop plans for them. They predicted that the involvement of the
inmate in developing their individualized referral process would be the major determinant for
successful reintegration into the community.

Reduction in Recidivism

The Prison Release Program’s discharge planning significantly reduced recidivism
rates for women: that is, fewer women in the program returned to prison, even for minor
charges such as failure to pay a fine. In the first year of the program, 41 women received
prerelease counseling and appropriate referrals. These women were followed for 12 months.
The outcomes of three groups of women were compared: 1) women who participated in the
program between June 30, 1993 and July 1, 1993 and returned to prison; 2) women who
tested positive for HIV in 1991 and were never in the program; and 3) women with matching
release dates and charges irrespective of HIV status. The results for these three groups are
presented in Table 1. Even though these numbers are small, the decrease in recidivism for

73
those participating in the Prison Release Program is impressive. Over 17 percent of the
women in the Prison Release Program returned to prison within 12 months, compared with at
least 39 percent in the comparison groups.

Case Studies

Two case studies also illustrate the effectiveness of the Prison Release Program.
These individuals have been released from prison for approximately 1 year and have
successfully reintegrated themselves into the community.

"Al." Al is a white man, 38 years old, with a long history of drug abuse. To
support this habit, he committed crimes such as larceny, assault, and breaking and entering.
He spent 4 years in prisons. He earned his Graduation Equivalency Diploma and five

 

Table 1. Distribution of Recidivism for Women by Group

 

Returned within 6 months Returned within 12 months

Number of
Group Description Women Number Percent Number Percent
Prison Release Program 41 5 12 7 17
HIV-Positive in 1991 and 41 11 27 16 39
not in program
Matching release dates 41 9 22 15 41

and charges

 

 

 

college credits while incarcerated. In addition, he participated in drug addiction classes and
addressed his own history of addiction. Taking advantage of the community services
available, Al applied and was accepted to the Salvation Army Drug Rehabilitation Program.
When he completed this program, he established a home for himself and reunited with his
mother. He received an educational grant to continue his college education. The family
services agency that continues his case management maintains contact with him. He
maintains ongoing communication with the prison outreach nurse and schedules followup
medical visits. By actively participating in his discharge planning and by accessing
community-based services, Al has ensured continuity in achieving his case management
goals.

"Irene." Irene is a young African-American woman, 34 years old, with a long

history of injection drug use. She committed crimes to obtain money to support her drug
habit. She was incarcerated and served 2.5 years of a 4-year sentence while her mother

74
cared for her child. During incarceration, Irene became aware of the services available to
her and participated in the discharge planning process. Since her release, she has complied

~ with all medical appointments and is an active participant in the prevention program for high-
risk women. She is counseling peers in alternatives to drug use and attends college on a
part-time basis to earn a degree in social work. Irene’s family issues have been successfully
addressed. Her relationship with her mother is greatly improved and they are raising the
child together.

BARRIERS ENCOUNTERED AND RECOMMENDATIONS
Lack of Housing Facilities

The major barrier faced by the Prison Release Program was locating housing services
in the community. Inmates with criminal histories are disqualified from most housing
facilities. Housing is a crucial issue for many people with HIV. Hospice services and home
care depend on the resolution of housing issues; homeless shelters are not necessarily the
most practical solution for this population. Frequently, released prisoners return to their old
neighborhoods and are offered cocaine, heroine, and opportunities to exchange sex for
money or housing. For many inmates, the first step in breaking the cycle of violence,
substance abuse, and homelessness is a new, safe environment. One suggestion for
overcoming this barrier is to recommend that housing authorities waive the 1-year waiting
period for recently released inmates in the Prison Release Program. The Sunrise House has
an agreement with the Rhode Island Department of Health, with SPNS funds, to provide
services to a specified number of released inmates requiring a residence and ongoing case
management. Prior to release, each inmate referred to Sunrise House receives a
psychological evaluation conducted by a trained credentialed consultant. These evaluations
assess the inmates’ potential for admission to the residence.

After the first medical visit, a registered nurse records the patient’s history of
substance abuse, previous substance abuse treatment, and future treatment options. The most
difficult but important part of the program is the link with an active substance abuse
treatment program upon release. Occasionally, there are problems placing inmates into
residential drug treatment programs. Residential programs often are full, and methadone
maintenance programs often have a wait of 2-6 weeks. During this waiting time, former
inmates might relapse to drug use in their old neighborhoods. Outpatient drug treatment is
an option, but the lack of family housing, particularly for women with children, presents a
problem. The family was often not available to care for children while the woman was
enrolled in a halfway house program. Halfway houses able to accommodate children and
provide child care for the recovering parent would help overcome this barrier.

Communication Difficulties

Program staff encountered numerous problems communicating with the inmates.
Literacy and foreign language barriers increased the difficulty of communicating information

ag) 75
to inmates. Interpreters were not available at the prisons. In addition, inmates were not
always ready or willing to process the information and outreach prior to release.

MAINSTREAM ISSUES

Prisoners infected with HIV represent a major health care challenge, particularly
because they account for a relatively large proportion of the HIV-seropositive population and
because many have had limited access to HIV-related education, counseling, and health care
services. In addition, as discussed above, the placement of inmates in residential treatment
programs and the availability of safe housing for patients with HIV and AIDS are critical
problems not only in Rhode Island but in most of the country.

As stated by the Presidential Commission on the HIV Epidemic, effective programs to
provide "care and treatment to HIV-infected inmates—equal to that available to HIV-infected
individuals in the general community—are necessary" (Presidential Commission on the HIV
Epidemic, 1988). A subsequent report of the National Commission on AIDS addressed HIV
disease in correctional facilities and recommended that "given the dearth of anecdotal and
research information on incarcerated women, incarcerated youth, and children born in
custody, federal and state correctional officials should immediately assess and address
conditions of confinement, adequacy of health care delivery systems, HIV education
programs, and the availability of HIV testing and counseling, for these populations”
(National Commission on AIDS, 1991).

Incarceration may be the first time an inmate has access to HIV testing, counseling,
specialized medical care, and support; thus, prisons play a central role in the identification
and treatment of HIV infection in our community. A program such as the Prison Release
Program in Rhode Island combined with medical management during incarceration can have
a strong, long-lasting impact on the well-being of individuals with HIV infection, can assist
in decreasing high-risk behaviors, and can slow the further spread of the infection.

EVALUATION METHODS

The evaluation of the Prison Release Program focused primarily on determining if
individuals have succeeded in linking up with the appropriate community resources to which
they had been referred, thereby meeting their needs for medical care, substance abuse
treatment, financial support, housing, counseling, and spiritual support. After being released
from prison, individuals are followed for at least 3 months. Community agencies and service
providers are contacted to confirm participation of the former inmates. In addition to service
linkages, the program assessed recidivism rates for women within 6 months and 12 months
of prison release.

76
DISSEMINATION OF THE PROJECT CONCEPT

The Prison Release Program model has been presented locally in talks and in an
article published by the Centers for Disease Control (HIV/AIDS Prevention, Winter 1995, pp.
4-5). Program staff have also presented the merits of the program to State agencies; in fact,
funding for continuation of the program has been "mainstreamed" by the Department of
Corrections and the Department of Health. Plans for future projects, if funding can be
obtained, include extending the Prison Release Program to inmates testing negative for HIV
who are substance abusers. The extension of the program to this population would be critical
in preventing continued high-risk behaviors among these individuals.

REFERENCES

Cu-Uvin, S, TP Flanigan, CCJ Carpenter. (1993). Routine Gynecologic Monitoring of HIV
Seropositive Women: Research and Recommendations, The AIDS Reader, July/August: 133-
140.

Dixon, PS, TP Flanigan, BA DeBuno, JJ Laurie, ML DeCiantis, J] Hoy, M Stein, HD Scott,
CCJ Carpenter. (1993). Infection with the Human Immunodeficiency Virus in Prisoners:
Meeting the Health Care Challenge, The American Journal of Medicine 95: 629-634.

National Commission on Acquired Immune Deficiency Syndrome. (1991). HIV
Disease in Correctional Facilities, Report Number 4, March.

Presidential Commission on the Human Immunodeficiency Virus Epidemic. (1988). Report,
June 24: 134-126.

Zierler, S, L Feingold, D Laufer, P Velentaga. (1991). Adult Survivors of Sexual Abuse
and Subsequent Risk of HIV Infection, American Journal of Public Health 81 (5): 572-575.

AUTHORS

Timothy P. Flanigan, M.D.
Kevin Vigilante, M.D.

Joseph Burzynski, M.D.

Gary Bubly, M.D.

Joo Kim

Josiah D. Rich, M.D., M.P.H.
Ann DeGroot, M.D.

The Miriam Hospital

164 Summit Avenue
Providence, Rhode Island 02906

77
Denise Bury-Maynard, M.P.H.
Mary Lou DeCiantis, Ph.D.
Paul Loberti, M.P.H.

Barbara A. DeBuono, M.D.

Rhode Island Department of Health
Providence, Rhode Island

Sally Zierler, Ph.D., M.D.
Brown University

Department of Community Health
Providence, Rhode Island

Lenore Normandy, R.N.
Mary Snead, R.N.

Rhode Island Department of Corrections
Adult Corrections Institute

Post Office Box 8274

Cranston, Rhode Island 02920

ACKNOWLEDGEMENTS

The authors express appreciation to Ellen Enderson, Cindy Drake, and Theresa Foley
for their tireless efforts in support of the inmates. We thank Finian Murphy, Joe Marocco,
and Jeff Laurie of the Department of Corrections for their support; Charles J. Carpenter for
manuscript review and unending support; and Connie Arvanites, Pat Schreiber, and Heidi
Felice for editorial assistance.

78
Specialized Medical and Social Service Interventions
for Inmates with HIV in Maryland

Newton Kendig, Barbara A. Boyle, and Leslie H. Kummer

The Maryland Division of Correction (DOC) is a State agency whose purpose is to
protect the public safety of Maryland by incarcerating men and women committed by the
court to the custody of the Commissioner of Correction. The DOC currently houses
approximately 19,000 male and 1,000 female offenders in 23 institutions ranging from
maximum to prerelease security and spread over four geographic regions of the State.
Seroprevalence testing of these inmates for human immunodeficiency virus (HIV) has
revealed a nearly constant HIV-positive rate of approximately 8 percent for men and 15
percent for women.

Maryland DOC inmates who are living with HIV have complex medical needs,
including primary health care, substance abuse treatment, mental health care, and extensive
social support. Furthermore, because many inmates with HIV have not accessed health care
prior to incarceration, they encounter barriers to care in the community when they are
released. Access to medical services in the community may be impeded by sociological,
financial, or logistical obstacles that can compromise the continuation of medical therapies
initiated during incarceration. The Maryland DOC has developed a program that provides
medical and social services to inmates with HIV and that maintains continuity of care in the
community after release or during parole. The program emphasizes medical case
management, expeditious medical parole, and clinical trial participation for targeted inmates.
It is supported as one of the Special Projects of National Significance (SPNS) through Title II
of the Ryan White Care Act.

PROJECT DESCRIPTION
Goals and Objectives

The goals of the Maryland DOC program of specialized medical and social services
are to expand medical treatment options for inmates with HIV and to maintain continuity of

those services in the community for released inmates. The program goals are accomplished
through the following objectives:

79
¢ To provide medical case management for all inmates with HIV before they are
released;

¢ To establish community linkages for implementing an aftercare plan for each
inmate in the case management program; and

¢ To expedite medical parole for inmates with endstage AIDS.
Profile of Client Population

An average of 51 percent of men and 61 percent of women entering prison participate
in voluntary HIV seroprevalence testing. Of those inmates tested in 1994, approximately
1,600 tested HIV positive. Among inmates with HIV, about 90 percent were African-
American men with a median age of 36 years. Over 90 percent of inmates with HIV
identified injection drug use (IDU) as their primary risk factor for acquiring HIV infection.
During the 1990s, the population with HIV became more symptomatic and more were
diagnosed with AIDS; since many inmates were first infected with HIV during the mid- to
late 1980s, they are only now developing late-stage complications of their infection. A 1992
survey indicated that 50 percent of Maryland inmates with HIV infection were candidates for
antiretroviral therapy and 17 percent were severely immunocompromised with CD4 cell
counts of less than 200 cells per mm. During 1994, HIV was the leading cause of deaths
among Maryland inmates; 26 inmates died from AIDS, accounting for 39 percent of all
inmate deaths. An additional 40 inmates with AIDS were released from DOC to the
community through medical parole. Table 1 reflects the characteristics of a sample of
inmates living with HIV who are targeted for case management services.

Nature of the Intervention

Seroprevalence Testing. All inmates, at admission to prison, attend a mandatory
education session on HIV infection and its prevention. Subsequently, HIV testing is offered
to all inmates. Additionally, many inmates receive HIV testing as a component of clinical
evaluations. All testing is conducted by staff social workers or nurses trained by the
Maryland Department of Health and Mental Hygiene. Testing is voluntary and anonymous
and is accompanied by individual pre- and posttest counseling. Inmates are referred to
psychologists for trauma counseling if they are very distressed by their HIV-positive status.

Case Management. As soon as an inmate is diagnosed with HIV, case management
services at the DOC’s social work department begin. Through a confidential infectious
disease database, the Maryland DOC Observational Correctional Information System,
regional social work supervisors track inmates living with HIV to anticipate release dates and
assign them by geographic regions to medical case managers. Case management services
become intensive 3-6 months before an inmate’s anticipated release, with contact at least
every 2-3 weeks and the development of an aftercare plan about 3 months before anticipated
release. At release, this plan ensures referral for ongoing health care, financial support,

80
substance abuse treatment, mental health treatment and counseling, housing, legal aid, and
other services as needed. An interagency agreement between the Maryland Department of
Human Resources and the DOC has facilitated the submission of entitlement applications
prior to release, which expedites financial support for inmates when they are released to the
community. Networking with community agencies has resulted in formal and informal
interagency agreements that facilitate referrals to primary health care providers, substance
abuse treatment centers, home health care, institutional care, and hospice services. Case
management staff have also facilitated prison access for hospice volunteers to meet with
inmates who are terminally ill with AIDS and are either awaiting medical parole or have
been denied parole.

 

 

Table 1. Characteristics of DOC Inmates for Case Management
(n=255 inmates)
Gender CDC Classification
Men 242 II 15
Women 13 III 98
IV 20
Race
African American 234 * AIR 5
Caucasian 21 * A2R 17
A3 36
Age Bl 3
18-30 64 B2 11
31-40 130 B3 14
40+ 61 Ci 1
C2 4
Risk C3 20
Injection Drug Use 190
Other 41 Reportable/
Unknown 24 Class. pending 11
CD4 Count
<200 105
200-500 80
> 500 66
Unknown 4
* AIR/A2R = Previously reportable new system Al or A2.

 

 

 

Medical Parole. An ancillary goal of effective medical case management is to
expedite medical parole for inmates who have endstage HIV disease if their condition
precludes their compromising public safety. The DOC has developed a medical parole

81
procedure for this purpose with defined timeframes.* A physician initiates the procedure by
completing a medical evaluation for inmates who have been identified as medical parole
candidates (i.e., diagnosed with illnesses that have impaired the inmate so that release to the
community would not compromise public safety). The medical evaluation is forwarded to
the social work and correctional case management departments. A security case management
specialist makes a recommendation based solely on public safety considerations. The
medical case manager develops an aftercare plan encompassing all the standard case
management services; in addition, arrangements are made for special needs such as formal
psychological evaluation and clinical treatment and for dealing with anticipated barriers. The
medical evaluation, security case management review, and the aftercare plan are collectively
forwarded to the warden of the facility for review and approval or disapproval of medical
parole. The warden’s recommendation is subsequently forwarded to the DOC medical
director. The medical director, in consultation with the Director of Social Work and
Addiction Services, submits to the Commissioner a recommendation and rationale for or
against medical parole approval. If approved by the commissioner, the case is forwarded to
the parole commission for a final decision. Once final approval is granted, the medical case
manager completes the aftercare plan and ensures its implementation after the inmate is
paroled to the community.

Medical Monitoring. Inmates living with HIV are medically monitored in accordance
with a DOC medical protocol that is based on recommendations from the medical literature
and public health guidelines. Inmates living with HIV are referred for a series of baseline
evaluations, including a physical examination by a physician, laboratory studies, and referral
for psychosocial assessments when indicated. Followup care for inmates is provided in
chronic care clinics at 6-month intervals. The frequency of care depends on the stage of
illness. Individuals with later stages of disease are given priority over asymptomatic
inmates. Acute medical care is provided to inmates by prison-based infirmaries and by
community and university hospitals. The care provided to the population of inmates living
with HIV is tracked by regional infection control nurses through a confidential infectious
disease database.

Clinical Trials. Additional treatment options have been made available to inmates
with HIV through access to federally funded clinical trials. Through a collaborative
arrangement with The Johns Hopkins University, university nursing staff enroll inmates in
clinical trials, thereby enabling inmates to be treated with experimental drugs for AIDS and
related conditions. All clinical trials are approved by The Johns Hopkins University
institutional review board, which includes an inmate advocate. Only nonplacebo clinical
trials approved by the National Institutes of Health for prisons are considered. None of the
clinical trials, however, is exclusive to prisons; that is, the same clinical trial is offered in
the community. A benefit of this inclusion of the community is that continuity of care is not

 

*State of Maryland Department of Public Safety and Correctional Services, Division of Correction. "Section
190 - Medical Parole," DCD 130-100: Primary/Specialty Medical Services. June 9, 1994.

82
compromised when the inmate is released. University nursing staff administer the clinical
trials onsite in Maryland prisons.

Staff

Providing case management and clinical services is labor intensive, requiring staff
dedicated to meeting the complex needs of inmates living with HIV. The core staff is
composed of two licensed clinical social workers who serve as case managers; a fulltime
nurse consultant who reviews clinical records and identifies candidates for case management,
medical parole, and clinical trials; and a data manager who collects data from the case
managers, processes them, and forwards them to a statewide information system for merging
with other HIV-related health and vital statistics.

Funding

A SPNS grant to the Maryland DOC in 1991 provided 3-year funding to develop the
case management component of this service delivery system. Additional services are
contributed by the agency; these include consultation and supervision from the Directors of
Medical Services and Social Work and Addiction Services and the Administrator of Infection
Control.

PROJECT SUCCESSES
Case Management and Referrals

It is estimated that 320 inmates (66 percent) have been provided case management
services prior to release. The medical case managers have established commitments with a
number of agencies to provide services to inmates living with HIV after their release, as
shown in the following examples:

* The Chase-Brexton Clinic agreed to provide for primary care needs in the
Baltimore area and for mental health needs under Ryan White Title II funding
provisions;

¢ The Chesapeake AIDS Foundation provided financial assistance and creative

approaches to case management challenges;

¢ The Health Education Resource Organization (HERO) agreed to accept 15
referrals for case management services;

* The Prince George's County Health Department agreed to provide

comprehensive treatment and support services to inmates who would, after
release, reside in Prince George's County;

83
* The Stella Maris Hospice Care Program agreed to accept DOC referrals for
inpatient hospice care, based on available beds; and

¢ The Maryland Department of Human Resources agreed to permit application
of entitlements prior to inmate release.

Medical Parole

Medical parole procedures with definitive timeframes have facilitated medical parole
for Maryland inmates. The number of inmates receiving medical parole increased from 8 in
1991 to 42 in 1994. The increase in the number of medically paroled inmates has resulted
not only from the structured medical parole procedure but also from increased inmate
morbidity, primarily from AIDS. A survey of inmates medically paroled through 1994
indicated that the median time for processing a medical parole was 44 days. Through the
end of 1994, none of the inmates medically paroled from Maryland prisons has been
reincarcerated in Maryland for violent crimes.

Participation in Clinical Trials

The population of inmates living with HIV has enthusiastically endorsed the clinical
trials program. The program has been personnel intensive and has required a strong bilateral
commitment from both the Maryland DOC and The Johns Hopkins University. Through
1994, six different clinical trials have been offered to inmates and 53 inmates have been
enrolled. Continued participation in clinical trials upon release from prison has been
excellent.

BARRIERS ENCOUNTERED AND RECOMMENDATIONS
Service Gaps

The most significant barriers to effective medical case management reflect gaps in
available services. Some of those gaps can be addressed by training the medical staff in
custody and security issues as they relate to the performance of clinical duties, training social
workers in substance abuse counseling, and training correctional health care providers in
palliative care and the provision of hospice services.

Participation in Clinical Trials

Specific barriers must be addressed regarding the enrollment of inmates in HIV
clinical trials. The Johns Hopkins University AIDS Clinical Trials Unit (ACTU), funded by
the National Institutes of Health, has successfully performed four multicenter clinical trials
within the DOC since May 1991. Still, four broad categories of barriers were identified as
warranting special attention: accommodation to correctional administrative procedures,

84
implementation of studies within the correctional health care delivery system, retention, and
ethical concerns.

Program administration requires a strong bilateral commitment from the DOC and
The Johns Hopkins University because of the cost and labor intensity of implementing
satellite trials. A dedicated research team from The Johns Hopkins University provides
onsite screening, enrollment, and followup. DOC personnel assist with screening,
phlebotomy, and transitional activities associated with release. Also, drug dispensation
protocol requires an adaptation of The Johns Hopkins University labeling policies and
procedural changes in the DOC that do not compromise security.

Conducting studies within the correctional system also encompasses challenges. For
example, additional onsite visits are required to provide ongoing DOC staff education and to
assess the clinical condition of study participants. DOC protocols for transporting specimens
may be limited because of special processing requirements.

Barriers to retention have been addressed in a variety of ways. Study participants
have been retained partially through the 24-hour availability of Johns Hopkins staff.
Telephone contact with family members is also available. Newsletters about HIV, greeting
cards, and home visits after release are other strategies employed to increase retention.
Another service provided is that Johns Hopkins staff facilitate referrals for medical and social
services and for substance abuse treatment.

Ethical considerations include study subject confidentiality; involvement of a prisoner
advocate on institutional review boards; the use of a database to facilitate identification of
inmates as potential clinical trial candidates; and consent forms that clearly state that
participation is voluntary, without incentives, and does not affect eligibility for parole.

MAINSTREAM ISSUES
Housing Shortage

At least 60 percent of DOC releases and paroles are to the Baltimore area, which is
beset with severe housing shortages for low-income persons. The Federal Government has
recently earmarked a large block of funds to help, but the problem is still present; nearly
7,000 persons are on waiting lists for public housing and nearly 8,000 on lists for Section 8
subsidies.

Dearth of Mental Health and Substance Abuse Treatment Services
Of the 77 inmates granted medical paroles from 1991 to 1993, only 5 returned to
prison. However, these inmates were not convicted of violent offenses but for activities

related to substance abuse and mental health problems for which there were no available
services at the time of release. Access to mental health and substance abuse treatment is

85
problematic in part because of long waiting lists. By the time the substance abuse treatment
appointment approaches, the former inmate has relapsed. The mentally ill need more than a
once-a-month clinic appointment. Their condition is exacerbated by their physical problems,
and they need a level of support across the treatment community that does not exist.
Baltimore has no agency whose mission is case management support to exoffenders.

The DOC participates on task forces, planning groups, and interagency meetings.
Slowly needs are being addressed but the level of cooperation needed to bring real change
has not yet been reached.

EVALUATION METHODS

A key element of the Maryland DOC model is program evaluation. The model is
unique in that continuity of care for former inmates will be critically evaluated through the
Maryland Department of Health and Mental Hygiene HIV Information System (HIVIS) and
using the data collected by the DOC. Outcomes for each kind of intervention—case
management, medical parole, and treatment in clinical trials—will be compared to the
outcomes of individuals who did not receive an intervention or who participated in clinical
trials but were recruited from the community rather than from the prison population.
Monthly reports of all inmates with HIV involved in specialized case management are
submitted by the clinical social workers to the Director of Social Work and Addiction
Services and to the Medical Director. The information tracked is listed in Table 2.
Demographic and laboratory data on inmates with reportable disease are also forwarded to
the HIVIS, which links information from the Maryland AIDS registry with data extracted
from health care claims, institutional records, and death certificates. The data elements that
are entered into the HIVIS are listed in Table 2.

By establishing linkage with the HIVIS, the DOC will track the accessibility,
utilization, and effectiveness of therapeutic and support services targeted for inmates released
into the community. Periodic reports from the Maryland Department of Health and Mental
Hygiene will allow the DOC to ascertain whether critical components of health care have
been used by released or paroled inmates. Vital statistics will also be monitored to enable
the Division to determine if former inmates had access to medical and social services at the
time of their deaths. These endpoints will be measured against other data elements such as
race, age, DOC institution, address on release, and agencies involved to determine factors
that may have compromised continuity of care.

The program for expedited medical parole will be evaluated internally by the nurse
consultant by tracking each inmate with HIV who is evaluated for parole and monitoring the
data listed in Table 2. The Maryland Parole Commission will provide data on inmates in
this program who are returned to the custody of the DOC for violation of parole. As a result
of these evaluations, the procedures and criteria for medical parole of inmates with HIV will
be refined.

86
 

Table 2. Data Elements Collected for Evaluation

 

Monthly Reports on Inmates
In Case Management

Name
Date of birth
DOC number
Social security number
Institution
Date of diagnosis of HIV
seropositivity
Date of medical evaluation
Date of initial case-
management intervention
Estimated release date
Completion date
Completion date of
entitlement application
Date of release
(if applicable)
Community referrals

 

 

Data Entered
In the HIVIS

Name

Gender

Race

Date of birth

DOC number

Social security number

Institution

Date of diagnosis of
HIV seropositivity
(if known)

CDC classification

Date of AIDS diagnosis

Antiretroviral therapy

Pneumocystis carinii
pneumonia (PCP)
prophylaxis

AIDS-related illnesses

Address upon release

 

Data Monitored
For Medical Parole

Name

Race

Gender

Date of birth

DOC number

Institution

Offense

Sentence length

Time served

Date of diagnosis of
HIV seropositivity

Date of change in clinical
condition prompting
parole consideration

CD4 + count

AZT usage

AIDS-related diagnoses

Karnofsky score (measure
of functionality)

Date of referral for
classification review
for medical parole
eligibility

Date aftercare plan is
completed

Date parole request is
approved or denied

Anticipated disposition

Community referrals

Hospitalization and
hospice utilization

Date of death

 

The DOC will also use an assessment tool to measure the validity of its program and
identify any barriers that have limited inmate access to community therapeutic and support
services. The medical, social, or resource issues that can compromise continuity of care will
also be applicable to other State and Federal correctional systems, as replicating this model
in other systems will depend on such variables as the availability of qualified staff,

interagency communication, and quality community resources.

87

 
Data concerning the aforementioned variables for 1992 through 1994 have been
forwarded to the Maryland Department of Health and Mental Hygiene. Data analysis will be
completed in mid-1995.

DISSEMINATION OF THE PROJECT CONCEPT

Information gained from the described model will be disseminated internally within
the Maryland DOC and more broadly through local and national conferences and through
publication in appropriate journals and information bulletins. The DOC has shared and will
further share instructive lessons gained from developing and pursuing the goals and
objectives of this model with other correctional systems to enhance the quality of health care
for all inmates with HIV infection. For example, the DOC has shared its model for
participation in experimental drug trials for inmates with HIV with the New Jersey
Department of Corrections through participation in a formal workshop, "Forum on Prisoner
Access to Clinical Trials," sponsored by the North Jersey Community Research Initiative.
Additionally, the Maryland models for medical parole and clinical trials were presented at the
First National AIDS/HIV in Prison Roundtable in San Francisco, California, in October
1993. Informal discussions about establishing a clinical trials program in a State correctional
system have been convened with North Carolina and Massachusetts. It is the intention of the
Maryland DOC to continue the positions created with the SPNS grants at the end of the
funding period in recognition of the project’s many successes.

AUTHORS

Newton Kendig, M.D.
Chief Medical Officer

Barbara A. Boyle, L.C.S.W.
Director of Social Work and Addiction Services

Leslie H. Kummer, R.N.
Infection Control Administrator

Maryland Department of Public Safety and Correctional Services

6776 Reistertown Road, Suite 309
Baltimore, Maryland 21215-2342

88
Cermak Health Services:
Linking Pretrial Detainees
With HIV/AIDS to Community Services

Tara Howleit and Katie Stauffer

Cermak Health Services provides comprehensive medical, dental, psychiatric, and
substance abuse services to the approximately 9,000 detainees at Illinois Cook County
Department of Corrections (CCDOC), the largest single-site jail complex in the Nation. Of
the approximately 80,000 admissions to the Cook County jail system in 1993, the majority
were pretrial detainees.* Detainees experience an average stay of 3-4 months in this facility
that has a capacity of 8,661 beds and a recent history of overcrowding.

The prison population is at extremely high risk for acquiring HIV infection; therefore,
Cermak’s intention is to link individuals who are infected with HIV with health services as
early as possible after arrival. In 1994, 3,551 detainees and 12 employees were tested for
HIV/AIDS; of these, 227 (6.4 percent) tested HIV-positive. Among those who tested HIV-
positive, 32 were confirmed as having AIDS, and 10 were HIV-symptomatic. Through its
Health Education and HIV Supportive Services Program, Cermak introduces individuals
living with HIV and AIDS to a responsive and caring system of continuing health care and
supportive services that emphasizes case management. Staff has an opportunity to begin a
comprehensive course of treatment for a clientele that under other circumstances might
receive few, if any, services. The HIV program has funding support from Title II and Title
[Ib of the Ryan White CARE Act as well as the Cook County Bureau of Health.

PROJECT DESCRIPTION
Goals

Cermak has two goals. The first is to provide the following types of services to
detainees and to the health care and correctional staff:

¢ Educational information about HIV infection and AIDS and other chronic illnesses
such as hypertension, lupus, tuberculosis, cancer, and hepatitis;

 

*Detainees are persons unable to pay bail bonds set by the courts and those whose offenses or criminal records
mandate that they be held without bond.

89
¢ Training in risk-reduction and behavior-modification techniques, such as safer sex
and needle use practices, for the population at risk;

¢ HIV counseling and testing of individuals living with HIV/AIDS;

¢ Referrals to case managers for an initial interview and intake to assess the needs of
each client testing positive for HIV/AIDS;

¢ Advocacy services on behalf of detainees living with HIV;
¢ Discharge planning services for detainees living with HIV;

¢ Individual mental health counseling services and support groups for detainees
living with HIV; and

¢ Assistance to detainees living with HIV in accessing primary medical services.

The second goal is to help clients meet their needs for ongoing treatment after discharge by
directing individuals to appropriate community services and enabling those individuals to
continue care in the community.

Profile of the Client Population

Cermak serves an incarcerated adult population of all ages, drawn from communities
within Chicago and suburban Cook County. According to the CCDOC’s annual statistical
data, the average age of adults in the facility is 23 years. The racial breakdown is 75
percent African-American, 15 percent Hispanic, and 10 percent Caucasian. Ninety-five
percent of the detainees are men, and 5 percent are women. More than half of the
population have less than a high school education with an average reading level of grade six.
A majority of persons are unemployed. Their living arrangements vary, but 25 percent of
detainees are homeless and 55 percent live with other adults without children.

Client intakes were conducted for 203 of the 221 detainees receiving case
management services in 1994. The statistics for the client population vary slightly from the
total incarcerated population. Eighty-eight percent of the clients were men, and 12 percent
were women. The racial breakdown was 73 percent African-American, 11 percent Hispanic,
and 15 percent Caucasian (Figure 1). Most (59 percent) had been living with adults before
incarceration, and 19 percent were homeless (Figure 2). The highest risk factor for HIV
infection was injection drug use (51 percent), followed by heterosexual transmission (29
percent) (Figure 3). AIDS was confirmed in 16 percent, and 56 percent were HIV-
asymptomatic (Figure 4).

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Figure 1. Racial/Ethnic Background of Client Population
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Figure 2. Distribution of Living Arrangements for Client Population

91

 
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Figure 3. Distribution of Client Population by Health Status

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Figure 4. Distribution of Client Population by Risk Behavior

92
Nature of the Intervention

Enrollment. Client participation in case management services is voluntary and
available to all detainees living with HIV throughout their incarceration period. Case
management clients can be referred to case managers by health educators or any other
clinical staff (doctors, physicians’ assistants, nurses, etc.) working throughout the jail
complex. Occasionally, case managers receive referrals from outside HIV-related
community service agencies. In attempting to locate clients who have missed appointments
or who have stopped coming for services, these agencies discover a number of their "lost"
clients in the jail system, with ongoing continuity of care requirements.

This program attempts to reach as many detainees as possible by conducting education
outreach in the sick call areas, housing tiers, and classrooms. It also provides pre- and
posttest counseling for HIV antibody testing. The health educator of each CCDOC unit or
division receives requests for HIV testing from detainees themselves, who may volunteer for
testing during the education outreach process. The health educator also receives referrals for
testing from the doctors, the sexually transmitted disease clinic, the tuberculosis clinic, and
the court system (court order for testing). All HIV testing is voluntary, including referrals
made for diagnostic reasons.

The Cermak approach is to conduct an initial interview with every detainee diagnosed
at or admitted to the CCDOC with a history of HIV infection. The purpose of the initial
interview is to provide empathetic support to those individuals who are newly diagnosed and
offer supportive services to all detainees living with HIV. Cermak then attempts to engage
all of these clients in case management services to link them with necessary services should
they be released to the community. For some clients, Cermak is the first experience with
any system that provides continuing health care and case management services. Jail provides
a continuum of basic services (e.g., food, housing, medical care) that some detainees lack in
the community .

Needs Assessment and Treatment Planning. Clients who are interested in case
management services are screened to assess their needs and to gather pertinent data. Clients
are strongly encouraged to take part in the resolution of their problems; one of Cermak’s
objectives is to empower clients to better manage their lives, as well as their HIV disease.

At this stage, clients are engaged in identifying stress areas to gain an understanding of the
client’s perception of problem areas. Working with a Cermak case manager, clients develop
an informal contract to help the client assess their needs. These needs range from getting out
of jail to obtaining adequate health care.

Then, with the support of a case manager, clients set a realistic treatment plan based
on the perceived need for change and the existence of services. For example, it is unrealistic
to suggest that drug-addicted individuals make drug treatment a priority if they do not feel
that the addiction is a problem. Although case managers continue to encourage these clients

93
to look at the potential hazards of drug use, as well as problematic behavior patterns, some
of these clients may give priority to another aspect of their current living situation.

Often it is important to help clients separate the issues they face, because they are
often interrelated and overwhelming. Incarcerated individuals who test positive for HIV
experience a heightened sense of powerlessness. The case managers work to help their
clients recognize the things they can change and to accept those things that are beyond their
control. This assessment process is ongoing; therefore the plans can change as priorities
change.

Ongoing Support. All case management services are provided on site at CCDOC.
After initial screening and treatment planning, clients are seen bimonthly, or more frequently
if needed.

Some clients are released from the jail before receiving their HIV antibody test
results. The Cermak case manager attempts to locate those clients who test positive by
letter. Once located, a meeting is arranged between the health educator, case manager, and
client for posttest counseling, and the client is referred to a medical facility in the
community. Public transportation tokens are also available for those in need.

On occasion, clients are released from jail prior to a followup visit. In these cases,
case managers attempt to locate the clients by telephone and to link them with resources in
the community. The case managers act as advocates and liaisons; they interact on behalf of
the clients with community agencies, the court system, family members, and internal (jail)
systems involved in the clients’ overall care. The case manager refers these clients to those
services that are available in an appropriate catchment area to meet their individual needs.

Referrals to Community Service Providers. Linkages in the community for Cermak
clients and their families include medical centers throughout the Chicago and suburban areas,
social service agencies that provide case management and other support, testing sites for
partners of clients (Board of Health clinics in the county and city), and substance abuse
facilities.

At discharge, most of Cermak’s clients are referred to community facilities with case
managers, who then become responsible for further followup or for linkages to services.
Most of the larger HIV provider agencies have case management services should the need
arise. Some clients do not desire case management services in the community, as they are
able to access services without the help of an outside provider.

Relevant clinical information about clients is sent to the medical provider with
permission. For those clients requiring zidovudine (AZT), Cermak Health Services has a
grant that provides a 2-week supply of this anti-retroviral drug so there is no gap in the
provision of medication. Those requiring other medications are referred to the Cook County
Hospital outpatient clinic, which provides medications free of charge.

94
Often, Cermak case managers provide clients with the phone number and location of
their local social security and public aid offices. Clients are encouraged to seek these
services as well as Medicaid. Cermak’s clients include patients with advanced AIDS who
require acute care or skilled care hospitalization; these clients are sent to Cook County
Hospital or Oak Forest Hospital for inpatient care.

Referrals to Prison Alternatives. When appropriate, Cermak case managers work
with the court system through the client’s attorney to initiate referrals to substance abuse
rehabilitation services such as Treatment Alternatives for Special Clients (TASC). A client
with a history of substance abuse may qualify for a presentence alternative that permits
receipt of the treatment instead of a prison sentence.

TASC is not an option for some. Violent offenders and those who do not
demonstrate to the TASC interviewer a serious desire for treatment are denied access.
However, if a "violent" offender has a significant need for drug treatment and demonstrates a
seriousness about changing his or her behavior, the Cermak case managers and TASC
representatives work with the detainee’s attorney or public defender to persuade the court to
reduce the charge.

Clients accepted to the TASC program go directly from jail into a inpatient treatment
program for 3-6 months . The counselors at the drug treatment program become the ongoing
support and referral sources for clients.

Linkages to Prison Clients. Pretrial detainees who go to prison before receiving HIV
test results are followed by a case manager via a confidential letter to an established referral
source in the receiving prison. These clients are then referred to posttest counseling.

Among the Cermak clients who have gone to prison, some have reported a lack of
adequate linkage services as they prepare to leave prison. After release from prison, some
individuals call Cermak’s case managers for referrals in their communities. Case managers
provide these linkages in much the same way as they do for detainees when they are being
released from the jail facility.

Linkages to Family and Partners. Cermak does not have a formal policy about
notifying partners. Officially, case managers do not notify the partners of clients; however,
Cermak is establishing a linkage with the Chicago Department of Health to conduct such
notifications. Currently, the case managers work with the clients to help them notify family
members and partners. In addition, Cermak case managers provide linkages to community
services and emotional support for family members and partners of clients living with HIV.

Linkages to family and partners are usually initiated by the clients. Clients may
either ask the case manager to call their partners or may ask these individuals to call the case
manager. A consent form for release of confidential information is signed by the client prior
to discussing or disclosing any information regarding HIV status. Clients are strongly

95
encouraged to notify as many possible partners they can reach or feel comfortable in telling.
Once they disclose their status to their partners, the case manager may provide them with
support and information about community services.

Staff

The health education and HIV supportive services team comprises 17 people who
bring to Cermak a wide range of backgrounds and experiences. Each has, at a minimum, a
bachelor’s degree and extensive knowledge about HIV. The positions and their basic duties
are as follows:

4 1 program director, who administers the program;

# 11 health educators, who provide health education and information and receive
requests for HIV testing, and provide pretest and posttest counseling;

# 3 case managers, who provide individuals living with HIV with linkages to care
services and give supportive counseling for behavioral changes;

¢ | medical (HIV) information specialist, who discusses medical care with
individuals living with HIV;

# | physician’s assistant, who facilitates provision of medical care to individuals
living with HIV;

¢ | mental health specialist, who provides one-on-one mental health counseling and
facilitates in-house support groups;

¢ | support group coordinator (part-time), who coordinates in-house support groups;
and

# 1 consulting psychologist, who provides psychological services on an as-needed
basis.

All of the above positions are funded through various grants, including funding from Title
[IIb and Title II of the Ryan White CARE Act, with the exception of the program director
and seven health educators, who are funded by the Cook County Bureau of Health.

PROJECT SUCCESSES

Project success is defined as the delivery of appropriate HIV support services and the
establishment of contact by the client to community resources. It includes, ultimately, the
achievement of positive behavioral changes, including improvements in safe sex practices and
reductions in criminal activity and substance abuse behavior.

96
Delivery of HIV Support Services

HIV Testing. In 1994, 3,551 inmates and 12 employees were tested for the presence
of antibodies to HIV, an increase of 12.5 percent over the total testing in 1993. In an effort
to provide HIV testing for all individuals at greatest risk, Cermak established a collaborative
agreement with the Chicago Department of Health health workers who are currently assigned
to the sexually transmitted disease clinic. In June of 1993, the Department of Health
workers, during interview sessions, began offering the HIV antibody test routinely to all
patients who tested positive for syphilis. This arrangement allowed Cermak to offer the test
to a number of patients who might have been missed otherwise. In 1994, 326 detainees
chose to be tested through this arrangement; of those, 16 tested positive (5 percent).

Educational and Counseling Sessions. Health education services are offered to every
detainee and employee who requests them. By merging the Health Education Program and
the HIV Related Services Program, Cermak was able to eliminate a number of service gaps;
1994 was the first full year in which the two programs operated as a combined effort,
providing comprehensive services. Many clients have no idea what to expect from their
disease. The addition of an HIV information specialist has filled the void between the point
of diagnosis and medical followup. Additionally, the mental health specialist is providing
much needed support for clients during this difficult time in their lives. During 1994,
23,574 sessions of health education were delivered; a 5.5-percent increase over 1993. The
1994 breakdown for these encounters is listed in Table 1.

Case Management Services. Once a referral is made, the case manager conducts an
initial interview, completes the intake, helps each detainee assess his or her needs, completes
followup services, and links the client with an agency that will provide a continuum of care
upon release into the community. During the 2 1/2 years since the inception of case
management services at CCDOC, the program has been well received by the detainee
population seeking help in coping with HIV and with the stress of incarceration. Various
community providers and the detainees themselves express their gratitude for the support
provided at CCDOC. In 1993, 182 out of 224 clients diagnosed with HIV received case
management services at CCDOC; in 1994, 221 of 227 received case management services.
Of these 221 clients, 88 percent were men and 12 percent were women.

Data from a random sample of 47 clients interviewed in the first 4 months of 1994
showed the following:

# 37 chose to receive services during the first interview and went through the intake
process;

# 7 refused services during the initial interview;

® 2 were repeat clients (received case management services, left jail, and returned to
jail, then reconnected with case management services); and

07
¢ 1 asked for time to think about services and scheduled a return visit the following
month.

The primary reason for refusal of service was the "fear of others finding out.” A few
clients reported that they were already linked to services in the community and would rather
not focus on HIV while dealing with stresses related to incarceration and their legal cases.
For those refusing services during the initial interview, case management services remained
an option throughout the period of incarceration.

 

Table 1. Services Provided in 1994

 

Case-management services
75 Initial client interview sessions
949 Follow-up sessions
18 Repeat client sessions
4 Group sessions with participation from 30 HIV-positive detainees
Educational services
4,261 One-on-one educational/prevention sessions (for detainees)
598 Follow-up sessions
3,431 Pre-test counseling sessions
2,488  Post-test counseling sessions
180  Post-discharge notification sessions
780 Group sessions with participation from 11,861 inmates
101 Staff one-on-one educational/prevention sessions
28 Staff group sessions with participation from 654 employees
Mental health services
898 One-on-one counseling sessions

88 Group sessions with participation from 68 HIV-positive detainees. These 68 individuals
attended an average of 7 sessions each, resulting in a total of 468 units of service.

 

 

 

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Mental Health/Support Groups. The first full year in which supportive counseling
and HIV support groups were made available for all detainees living with HIV who were in
need of such services was 1994. During 1994, a total of 1,366 units of mental
health/support group services were provided. Approximately 31 percent of the individuals
referred by case managers participated in the HIV support groups. The breakdown for these
encounters is listed in Table 1.

Linkage with Community Resources

Initially, the community hesitated to serve those coming out of CCDOC because of
their criminal label; however, over time Cermak has established a network of community
agencies willing to work with the clients. Some of the agencies belong to a cooperative of
agencies under the direction of the AIDS Foundation of Chicago. Cermak invites outside
providers to its offices and meets with them in the community to discuss the program.
Cermak’s staff have attended community meetings and participated in community-based
groups and organizations in an effort to establish working relationships with outside
providers, as well as to educate others about the program. Cermak continues to establish
linkages with outside agencies in order to increase awareness about its services and to
encourage other service providers to accept its clients.

In addition, Cermak has been successful in locating clients who have failed to show
up for scheduled appointments with outside providers. Community providers call the jail to
see if their clients have been incarcerated. The case manager becomes the liaison between
client and provider, as well as a resource for meeting the client’s needs while he or she is
incarcerated. Once the client is released, the provider is notified. This system has enabled
Cermak to establish a mutual working relationship with the community providers.

Behavioral Changes

Through program records and interviews with key personnel, as well as with
detainees, Cermak has found that many of the program participants have achieved behavioral
changes. The current rate of recidivism for the CCDOC is approximately 30 percent. *

The recidivism rate for clients receiving case management services is 8 percent. The
primary reasons clients state for returning to jail are related to substance abuse and the
inability to secure financial stability. Clients have difficulty securing employment because
they lack job skills and work histories or because they are "felons." Of course, some clients
lack the motivation or desire to seek employment. It is also difficult to get into drug
treatment facilities. Waiting lists are long and by the time they can be placed, clients often
have become heavily reinvolved in their drug use and are no longer living in the location
they indicated on the discharge forms.

 

*"Recidivism" at CCDOC denotes individuals who have entered the correctional system previously and have
returned to the jail, either by committing another crime or by failing to appear in court after having been
released on bond.

99
The health education staff conduct a followup session with clients to ask whether or
not any behavioral changes have been made as a result of the education provided.
Additionally, the program director conducts informal interviews with randomly selected
clients. These followup sessions and interviews indicate (a) clients’ intention to use condoms
more frequently, (b) their reduced use of injection drugs, and (c) their intention to avoid the
sharing of needles. Many of these behavioral changes may be temporary and due partly to
incarceration; however, self-reported changes are viewed as a start to long-term behavior
modification and self-empowerment.

Followup

It is difficult to gauge the success of intervention at this early stage. However, given
the positive reception clients have received from the community HIV service providers,
Cermak is optimistic. Acceptance of clients plays a major role in the overall success of this
component of the program. Some clients maintain contact with case managers by calling
from time to time to keep them informed or to ask for further assistance. Cermak has
established a collaborative effort with some of the outside providers to work toward keeping
the client engaged in services. In addition, Cermak staff asks clients questions about the
quality of services, the effectiveness of the services, and whether or not the services are
adequate.

BARRIERS ENCOUNTERED AND RECOMMENDATIONS
Discharge Planning
Due to the uncertain outcome of court cases and the potential for clients to be
released unexpectedly on bond, effective discharge planning becomes a unique struggle for
case managers working in the jail system. Pretrial detainees are not assigned release dates.
The average length of stay for detainees in the HIV program is 4-5 months, but a few have
stayed 1-2 years. Furthermore, once detainees are discharged from the Cook County jail,
they go to one of numerous locations. Following is a breakdown of the destinations of the
221 detainees who received case management services during 1994:
108 (56 percent) went to prison;
61 (32 percent) went to the community;
16 (8 percent) went to TASC;
2 (1 percent) went to the Dept. of Mental Health;
3 (1.5 percent) died while in jail; and

2 (1 percent) terminated services.

100
The primary goal of case managers is to link clients with services. Case managers
advocate on behalf of clients living with HIV to reduce the waiting time for ancillary
services. Cermak refers clients to a significant number of agencies for services, but
resources of these agencies are often overwhelmed by the needs they encounter. Long
waiting lists, limited placements, and increasing demand for services make it difficult for
case managers to establish linkages. In addition, the lack of a definite release date poses
problems for scheduling services and for getting financial aid for detainees at release.

Staff Issues

Presently, two case managers staff ten Cermak divisions. Caseloads fluctuate
between 30 and 60 clients for each case manager. To prevent staff burnout from these
extremely high caseloads, case managers work with the client’s family members who may
become resources to both them and the client whenever possible. Case managers usually
contact family members by telephone, but they do meet with them on occasion.
Unfortunately, the lifestyle choices of some clients have alienated them from family members
who might otherwise be important sources of support.

A large number of people living with HIV/AIDS pass through jails and prisons. In
the beginning of Cermak’s program, there was considerable opposition on the part of the
security personnel to working with this population. An educational in-service training
program was established to lower the anxieties of security personnel. The need for ongoing
education is vital as efforts continue to maintain a cohesive working relationship and to
respond to the rapidly changing face of HIV/AIDS in corrections.

MAINSTREAM ISSUES
Special Needs of Women

Cermak’s staff have found that the needs of their women living with HIV are often
greater than those of the men. Two factors for women are involvement with the Department
of Children and Family Services (DCFS) and the availability of fewer facility beds for
substance abusers. Residential, coed substance abuse facilities are often unable to address
the special needs of women that relate to their drug use, including issues of sexuality and
victimization. Residential programs specifically designed for women have inadequate
numbers of treatment slots.

Women are often the primary caretakers of their children. The involvement of DCFS
usually means that the women have to appear in juvenile court as well as criminal court.
The stress of "fighting" two cases can be overwhelming. These women have a heightened
sense of helplessness as they struggle with the potential loss of children in addition to the
possibility of losing their own freedom. Add to this the diagnosis of a potentially life-
threatening illness, and the burden facing these women can be enormous.

101
Limited Community Resources

Other factors influencing outcomes include the clients’ inability to access public aid
and social security benefits while incarcerated; the staff’s inability to place clients in housing
on the day of discharge (18 percent of clients are homeless); waiting lists for chemical
dependency treatment, mental illness treatment, and HIV treatment; and for some clients, a
lack of internal resources and skills necessary to make lifestyle and behavioral changes (e.g.,
self-esteem, education, and employment). Recognizing that some issues are external to the
program, Cermak staff have learned to accept certain limitations and do their best with the
available resources.

EVALUATION METHODS

Currently, Cermak is developing a followup questionnaire to assess progress
towards its goals of establishing linkages between prisoners living with HIV and community
services to address their multiple needs, and to determine whether and how clients are
implementing lifestyle and behavioral changes. Behavioral changes of interest are those
necessary to deter clients from reentering the CCDOC system, to better manage their medical
needs, to address their substance abuse issues, and to make more informed choices about
their lives.

Recently, Cermak began tracking the length of jail stay for its clients, the number of
referrals that are made to community HIV service providers, and the rate and reason for
return to the jail. In addition, Cermak is working with the City of Chicago to establish a
referral and tracking system that will help gauge the success of community linkages made for
clients. A formal linkage with the City of Chicago was incorporated into the objectives of
one of Cermak’s recent grants. When Cermak refers clients to city clinics, the clinics
respond in writing within a month to indicate whether a referral was successful (the client
made the appointment) or whether there was a problem. Cermak and the city work together
to reengage the client in services if the initial attempt at linkage proves unsuccessful.

Cermak anticipates revising its statistical reporting format to make better use of the
information it is gathering. It expects to conduct a more thorough analysis of services
needed or received, risk factors of clients, the effectiveness of the services, client breakdown
in terms of testing patterns (i.e., voluntary, diagnostic, court orders, referrals related to
sexually transmitted disease, tuberculosis-related referrals, and body fluid exposures), and
what happens to clients once they are linked with case management services.

These analyses will be based on followup interviews that are expected to occur at 1-,
3-, and 6-month-intervals after discharge. The 1-month followup interview will be a
telephone contact from the Cermak case manager to the former client. The 3-month
followup will be a letter sent from the Cermak case manager to the current provider to
ensure that the client is receiving services from the agency to which he or she was referred.
If the client is no longer receiving services from the referred agency, Cermak will inform the

102
provider of the reason. The 6-month follow-up will be a letter to the former client to inquire
whether the case management services were beneficial, to what degree the linkages were
helpful, and whether the linkages were appropriate.

Additionally, Cermak plans to inquire about any suggestions for improvement in the
delivery of services. Given the nature of the population, a high response rate is unlikely.
However, Cermak is considering an incentive to motivate former clients to respond. The
addition of two case managers will reduce the caseload of the current staff to more
manageable levels. It will be the responsibility of each case manager to followup on the
discharge data for each client after 1, 3, and 6 months. Given that the primary function of
Cermak case managers is to provide services to those currently incarcerated, postdischarge
tracking methods may be restricted to telephone and mail.

DISSEMINATION OF THE PROJECT CONCEPT

Cermak produces several ongoing publications, including a quarterly newsletter,
Health Watch, which provides pertinent medical and programmatic information to the
detainees and staff at CCDOC. Pamphlets describe the program, available services, and
information about contacts for prospective clients and other interested parties. Handouts and
videos are available for distribution. Ongoing tours of the facility and interactions with the
community increase the network of providers and keep the public informed about activities.
Several health educators provided cross-educational coverage for the Healthy Start program.

Cermak’s staff has presented its program and results to many organizations, including
the AIDS Public Policy and Advocacy Workshop (February 1994, Champaign, Illinois), the
Seventh International Conference on AIDS Education (November 1993), the 17th National
Conference on Correctional Health Care (September 1993), and the 16th National Conference
of Correctional Health Care (September 1992). Several staff members presented workshops
at the 18th National Conference on Correctional Health Care: "Diverse Approaches to the
Management of HIV in a Correctional Setting," and "Health Education in Corrections: What
Works, What Doesn’t, and Why?"

AUTHORS

Tara Howleit
Case Manager

Katie Stauffer
Nurse Case Manager

Cermak Health Services

2800 South California Street
Chicago, IL 60600

103
The Philadelphia Linkage Program

Alicia Beatty and Mary Hale Meyer

By 1991, it was obvious that HIV/AIDS was prevalent and increasing among prison
inmates in Philadelphia, Pennsylvania. Studies conducted by the prisons showed a steady
increase in the seropositive rates of inmates entering prison; by 1989 7 percent were
seropositive, by 1990 10 percent were seropositive, and by the first quarter of 1991 12.8
percent were seropositive. Although individuals living with HIV in Philadelphia received
medical care, treatment for drug and alcohol abuse, and mental health counseling through
Philadelphia’s AIDS Activities Coordinating Office’s (AACO) Prison Project, these services
stopped at the prison walls. After release there was little if any followup to ensure that a
former inmate received either case management or clinical services. Furthermore, the
existing prison-based programs did not include either case management or services for the
inmates’ families.

The Philadelphia Linkage Program was first funded in October 1991 by the Special
Projects of National Significance (SPNS) under Title II of the Ryan White CARE Act as the
"Inmates and AIDS Intervention Project"; the name was later changed to the Family Linkage
Program and then to the Philadelphia Linkage Program. The program was a project of The
Circle of Care, a pediatric, adolescent, and family AIDS demonstration project in
Philadelphia. The Circle, a program of the Family Planning Council (FPC) of Southeastern
Pennsylvania, is funded under Title IV of the Ryan White Care Act and provides family-
centered primary and HIV-specific medical care and comprehensive social services in three
clinical sites.

The Philadelphia Linkage Program was based on two assumptions: 1) that
incarcerated individuals with HIV will be lost to the AIDS service system unless they are
linked to appropriate community services prior to their release, and 2) that the inmates’
families must also be linked to appropriate services prior to the inmates’s release or they too
will be lost to the service system.

Based on these assumptions, the Philadelphia Linkage Program sought to demonstrate
that a prerelease intervention would ensure that both the inmate and the inmate’s family
would receive appropriate care and that this intervention would reduce stress on the inmates,
increase their involvement with their families, and reduce the risk of their recidivism.
Presumably, through the case management intervention, a case manager could ease the
family stress that prison elicits; thus, the earlier the intervention, the greater the opportunity
to keep the family intact. Inmates and all their family members were to be linked to The
Circle of Care’s clinical care, case management, and social services; those without families

104
were to be linked to community-based clinical services funded by Title I and to case
management funded by Title II of the Ryan White Care Act.

PROJECT DESCRIPTION
Goals
The Philadelphia Linkage Program began with two initial goals:

4 To link inmates living with HIV to community case management and clinical
services before their release, with postrelease followup; and

¢ For the inmates with families, to link the families to The Circle of Care.

Subsequently, the Philadelphia Linkage Program modified the first goal and made it
the primary focus of the program:

# To link incarcerated individuals to community services though case management
both before and after their release from prison.

The project proposed to provide these linkages for 480 inmates over a 3-year period.
In addition to providing these linkages, the project had an objective of increasing the
inmates’ involvement with their families through at least one combined health care visit.

Profile of the Client Population

The Philadelphia prison system comprises five short-term institutions. Operated by
the city, these institutions confine persons who are 18 years or older. Many persons detained
in these prisons are not serving sentences but are awaiting trial or transfer to a State or
Federal prison. Those serving sentences are typically confined for less than 2 years.
Currently, the total population of the Philadelphia prison system is approximately 5,000:
4,650 men and 350 women. The inmates are predominately young and nonwhite,
characterized by low incomes, poor educational background, and poor employability.! An
overwhelming majority of inmates in Philadelphia prisons use or abuse drugs. In 1989, of
men arrested in Philadelphia, 84 percent tested positive for any drug and 76 percent tested
positive for cocaine; of women, 79 percent tested positive for any drug and 64 percent for
cocaine.” HIV seroprevalence data reveal that the seropositivity rate among women equaled
that of men: 12.8 percent.

Client data of the Philadelphia Linkage Program mirror those of the larger prison
population: of 40 HIV-positive prison inmates enrolled in the program in mid-1994:

¢ 80 percent (32) were men and 20 percent (8) were women;

105
¢ 50 percent were African American, 23 percent were white, and 28 percent
Latino/Hispanic;

¢ 75 percent were 30 to 39 years old; and
¢ 60 percent acquired HIV by injection drug use.
Nature of the Intervention

The Philadelphia Linkage Program was designed as a collaboration among several
Philadelphia-based AIDS service organizations, including 1) The Circle of Care and its
parent organization, The Family Planning Council, which developed and implemented the
research design; 2) the Philadelphia Health Management Corporation (PHMC), a regional
health planning agency, whose staff had considerable experience working with women in
prisons; 3) ActionAIDS, the case management agency, which was to coordinate the services
to inmates and their families; and 4) the AACO Prison AIDS Project, which was to be the
primary source of referrals. The collaborating organizations decided that The Circle would
be the lead agency for the linkage program because of its focus on the family. However,
because of inmates’ reluctance to divulge names of family members, the focus shifted to
individual case management, with referrals to medical facilities funded by Title I of the Ryan
White CARE Act.

The Circle of Care is a coalition of 13 agencies and institutions formed with both
public and private support in 1990 to provide clinical care and supportive services to
families, children, and adolescents affected by HIV/AIDS. Programs help prevent the spread
of HIV/AIDS through outreach and prevention education. The Circle provides
comprehensive, coordinated, family-centered primary medical care and social services to
families and children affected by HIV in three family clinics. Two of the clinics are based in
Philadelphia’s two pediatric hospitals, the Children’s Hospital of Philadelphia and St.
Christopher’s Hospital for Children. The third clinic (which had not opened when the
Philadelphia Linkage Program first began), Care Plus, is located in a community-based city-
funded health center. Entry into The Circle is available to infants and children with HIV.
The children’s parents with HIV and uninfected siblings receive health care and a broad
array of social services at the same place and at the same time.

Each family has a clinic-based social worker. Approximately 70 families with the
most intensive social service needs have an ActionAIDS case manager/homeworker team.
ActionAIDS is the largest case management agency in Philadelphia. It was founded in 1986
as an all-volunteer agency that offered a buddy-system program; later, the agency became
more structured. ActionAIDS provides services to those affected by HIV; its primary service
is case management for adults who are symptomatic, but it also provides case management
when a mother or child has HIV and is psychosocially dysfunctional. ActionAIDS began its
Family Program in 1989 to provide culturally competent and linguistically appropriate case
management to HIV-affected families. Presently, there are two community-based Family

106
Program sites, one in north Philadelphia near St. Christopher’s Hospital for Children, the
other in west Philadelphia near the Children’s Hospital of Philadelphia. The program has a
staff of 16, including 8 homeworkers. The case manager/homeworker teams provide
counseling and support for domestic care, medical compliance, and liaisons with physicians
to the clients, their families, friends, and caregivers. In 1994 the program had a capacity of
90 families.

In addition to the services provided by The Circle of Care, the Philadelphia Linkage
Program provided discharge planning for inmates living with HIV and their families by a
team of case manager, nurse, and, for families, a lay homeworker. Prior to release from
prison, each inmate with HIV was referred to the Philadelphia Linkage Program case
manager and nurse by the AACO Prison AIDS Project. AACO had a staff of eight at the
House of Corrections and conducted HIV testing and AIDS education for all incoming
prisoners. The Philadelphia Linkage Program case manager and nurse 1) arranged for
medical care for the inmate while he or she was still in prison and 2) planned for medical
and case management services to be available immediately after release from prison.
Referrals were to the closest health facility with Ryan White funds. If for any reason the
inmates were denied services—e.g., if they wanted AZT and were not getting it, the team
advocated on behalf of them with prison staff. If an inmate had a family, the team sought
the inmate’s permission to contact them and to enroll them in The Circle of Care prior to the
inmate’s release. The PHMC had initially planned to conduct an orientation and education
program for women inmates, but there were too few women inmates with HIV; instead, the
PHMC conducted a needs assessment of a population of women in a residential drug
rehabilitation program.

After release from prison, inmates and their families were followed by the case
manager for 3-6 months to ensure that they accessed services. The families received the
assistance of a homeworker to provide in-home services, to ensure that the families kept
clinic appointments, and to give them emotional as well as practical support.

As of August 1994, the Philadelphia Linkage Program had received a cumulative total
of 107 referrals; the case load was 40, with 6 pending referrals. The caseload characteristics
are shown in Table 1.

The case manager has established relationships with a number of in-prison resources.
In addition to AACO’s Prison Project and the social workers and drug counselors mentioned
above, the case manager receives referrals from the Defenders’ Association social workers,
the AIDS Law Project, and the prisons’ mental health social workers. Each prison has a 10-
bed psychiatric unit linked to Hahnemann University Hospital and mental health social
workers. Referrals are also received from the prison chaplin. Some prisoners have self-
referred. In the 8 months that the current case manager has been with the program, only two
people have refused the services: one was mentally disturbed, the other felt he did not need
social supports because he had a strong family support system.

107
The case manager meets with the inmates while they are still incarcerated (usually
within two weeks of release) and links them to appropriate social services, including drug
rehabilitation. The case manager talks with the admissions person at the referral health
facility. The nurse provides medical assessments, makes sure that the prisoners receive
adequate medicines, and facilitates care for the inmates when they are sick. The services do
not end with the inmate’s release. For inmates, transitional planning and support are critical
to ensure that they receive needed medical and social services; this is particularly true of
substance abusers, who are the clear majority of those served by the Philadelphia Linkage
Program. If a connection is not made before release, staff find it difficult to reconnect with
the client. In the case management approach, the case manager typically works with her
clients for 3 months after release. The case manager provides linkages to financial
assistance, other case management and medical services, housing assistance, nursing home
placement, HIV education, and general emotional and practical support.

 

 

Table 1. Philadelphia Linkage Program: Case Load Characteristics
(n=40)
Characteristic Percent
Race
African American 50
Latino 28
White 23
Sex
Men 80
Women 20
Mode of Transmission
IV Drug 60
Heterosexual 25
Homosexual/Bisexual Men 8
Transfusion 7

 

 

 

Staff

Three kinds of staff were underwritten by the project: direct service, evaluation, and
administrative. Staff of the AACO Prison Project referred inmates to the Philadelphia
Linkage Program but were not funded by it. The direct service staff included the family
program coordinator, case manager and nurse; the research associate and assistant designed
and conducted the evaluation; and the project director and program coordinator administered
the project. Table 2 summarizes the roles and responsibilities of the project staff.

108
 

Table 2. Project Staffing of the Philadelphia Linkage Program

 

Counseling & Testing
Staff

# Conducted training
and orientation of case
manage-ment staff re:
environment,
procedures, and jargon
of prison.

Case Manager

4 Responsible for
discharge planning; lead
contact with inmates

Nurse

# Performed health
assessments of each
inmate in the discharge
planning process;
worked with health
services system of the
prison; helped inmates
understand their health
care plan and how to
follow through

Homeworker

# Provided in-home
services

#4 Chaired steering
committee; responsible
for program implementa-
tion

Direct Service

Referrals (ActionAIDS Evaluation Administration Needs Assessment

(AACO)* Family Program) (FPC) (The Circle) (PHMC)
Prison Project Family Program Research Associate | Project Director Principal Investigator

Supervisor Coordinator & Assistant
4 Oversaw project; 4 Conducted women’s

# A pivotal member of ¢ Member of steering 4 Managed interacted with executives | needs assessment
the steering committee; committee; coordinated database; designed of collaborating agencies
performed liaison and activities with the and conducted
gained entry to the prison; worked closely research Program Coordinator
prison with AACO.

 

 

 

 

* AACO staff was not funded with SPNS funds.

 

 

 

Funding

The Circle of Care, which is under the fiduciary responsibility of the Family Planning
Council of Southeastern Pennsylvania, is one of 42 national pediatric AIDS demonstration
projects. Major funding for The Circle services come from public and private sources,
including Ryan White Titles II, III, and IV; Rhone-Poulenc Rorer; and The Pew Charitable
Trusts. The only funding for the Philadelphia Linkage Program was $180,848 annually in
Federal SPNS funds to support both research and service delivery.

PROJECT SUCCESSES

Although The Philadelphia Linkage Program was beset with barriers, it had a number
of successes.

109
Steering Committee

An important administrative success was the project’s steering committee, established
by The Circle of Care’s project director in the program’s second year. The committee was
composed of representatives of all the collaborating organizations, as outlined in Table 3.
Initially, all executives. and direct service staff were members of the steering committee;
later, only direct service staff were members.

 

Table 3. Steering Committee Composition of the Philadelphia Linkage Program

 

AACO ActionAIDS Research TCOC PHMC
Supervisor ~~ Family Program Research Associate Project Director Principal Investigator
Assistant Director
Counselor Research Assistant Program Coordinator
Program
Coordinator

Case Manager

 

 

 

The steering committee which met monthly, ensured that all the players were partners
in program planning and implementation. At committee meetings, the members identified
problems and brainstormed possible solutions. The steering committee was dissolved when
the grant terminated.

Working Relationship with Prison and Staff

Although it took a long time, the Philadelphia Linkage Program staff developed a
good relationship with the Philadelphia prison system staff. Part of the credit for the
cooperative relationship belongs to the prison system’s director of inmate services; part goes
to efforts of the program staff to meet with prison staff and develop cooperative relationships
with them. For example, at the end of the first year, Philadelphia Linkage Program staff
conducted an orientation for prison social workers, which helped them understand that the
program staff were not threats to their jobs. Resistance to the program by prison staff
diminished when they realized the benefits of discharge planning and continuity of care. At
present, Philadelphia Linkage Program received referrals from a number of sources within
the prison, including in-prison social workers and drug counselors.

Referral Agreements

Because the Philadelphia Linkage Program had only a few families in its client base,
it could not refer clients into The Circle of Care and had to develop referral agreements with

110
agencies funded by Title I and Title II. The program developed formal agreements with a
number of agencies serving Philadelphia’s HIV community, including The Circle of Care
provider agencies, BEBASHI (Blacks Educating Blacks About Sexual Health Issues) and
Congreso de Latinos Unidos.

The Value of the Case Management Approach

Throughout the project, it became clear that once the initial resistance of the prison
staff to outsiders was overcome, having outsiders as the intervention team was very
important. Their status as outsiders increases their credibility with inmates and helps the
team establish trust. Moreover, because they are not part of the system, nonprison staff can
advocate more effectively. For instance, both nurse and case manager advocate for inmates
to get appropriate medical care in the prison; the nurse has additional credibility because she
is medically trained. The lay homeworker is indigenous to the community and is able to
move in and out of family homes, often presented as a relative or friend.

BARRIERS ENCOUNTERED AND RECOMMENDATIONS

Before developing this paper, The Circle of Care circulated a questionnaire to project
staff. Questions were asked about proposal development, project implementation, project
administration, and program evaluation. Most of the responses concerned the first two areas.
Eleven people responded to the survey. Of these, seven felt they had been involved in the
program long enough to answer the survey in depth. The following discussion of barriers
draws heavily on both the questionnaires and on the project’s periodic progress reports.

Project Planning

Many of the issues encountered in implementing the Philadelphia Linkage Program
began with the project planning process. Table 4 summarizes what the survey respondents
indicated to be the greatest obstacles during the planning process.

One concern was that the people who developed the project plan did not interact with
The Circle of Care’s own Board of Directors, which had great difficulty understanding how
this project would fit with The Circle’s mission. Many board members declined to write
support letters for the project.

Problems with the prison system can be avoided by making the appropriate contacts
during project planning and early implementation. When the Philadelphia Linkage Program
contacted the director of the prison system for assistance, the program director referred to
the director of inmate services, whose job it was to ease the way for outside groups to work
within the prison system. His assistance was invaluable in helping the Philadelphia Linkage

111
Program staff learn the prison system and cut through the red tape. Responding to the lack

of inclusion of the prison staff in the planning, one survey respondent said:

"If [the prison staff] had been brought into the program, it could
have eliminated turf and culture issues.. They would have offered
a broader perspective [and] advocated for the program rather than
be threatened by it."

 

Table 4. Obstacles to the Success of the Planning Process

 

Key players not involved in planning
¢ Prison staff and administration

# Other agencies doing prison work (Defenders Association., Hahnemann Mental
Health Unit)

# ActionAIDS direct service staff
Lack of information about prisons
4 AACO withheld information
4 Little understanding of how difficult it was to retain staff in this setting

¢ Limited knowledge of relationship of many inmates to their families; thus eligibility
criteria for program too narrow

Other
# Proposal objectives stretched to fit The Circle’s mission

4 Planning rushed because of proposal deadline

 

 

Number of
Respondents
(n=11)

5

2

|S)

 

The director of inmate services also was instrumental in expanding the program’s
referral base by convening a meeting of the special service staff of all the prisons. Ata
meeting of 60 prison employees, the Philadelphia Linkage Program staff presented its
program and secured cooperation from the social service staff, drug and alcohol programs,

the mental health unit, the social work staff, and others.

112

 
Project Implementation

The limitations in the planning process revealed themselves during project
implementation. A key barrier was the project staff’s lack of knowledge about the prison
system and about the difficulties in working with an inmate population. Additional obstacles
to implementation included an insufficient number of client referrals, insufficient time to
build trust, the changing name of the project, and high turnover of case management staff.

Mistrust of the Program. The prison’s internal social work staff was suspicious of
the program and its staff and feared the Philadelphia Linkage Project staff would replace
them, particularly in the face of a municipal workers’ strike. Distrust of the Philadelphia
Linkage Program staff by the prison staff was intensified by the city’s budget crisis and the
city administration’s threats to privatize city services to save money.

Some project staff and prison social workers may not have had an adequate
understanding of the project’s goals and criteria. The lack of knowledge about the prison
system hampered the startup in practical ways as well; case managers did not have clearance
to enter the prison, staff did not have identification badges, and there was no confidential
work space or telephone.

In addition, the initial budget funneled all funds to direct services and evaluation, with
no funds available for coordination. During the first 2 years of the project, as elements
clearly were not going well, there was an undercurrent of distrust and blame among the
project staff. Finally, all staff met with the coordinator of client services at ActionAIDS and
the director of Philadelphia’s AIDS Activities Coordinating Office to clarify roles and
responsibilities.

Insufficient Number of Clients. Too few clients was an ongoing problem. Because
the project developers lacked knowledge of the prison system, they relied on the AACO
Prison Project for guidance and for referrals. Consequently, the Philadelphia Linkage
Program did not reach inmates who had been tested prior to incarceration or inmates who
were tested by a provider other than AACO. Also, most client referrals were not family
connected possibly because inmates were not willing to admit to children that they would not
be reuniting with their families or because they feared facing a child support detainer upon
release. The steering committee and staff studied the low number of referrals and decided to
implement two suggestions: 1) seek referrals from prison social workers and health services
staff: and 2) encourage the case manager to spend more time with each inmate. At the
request of the steering committee, a meeting of project participants provided an opportunity
for networking and information exchange among the project participants.

Insufficient Time to Build Trust. The original program plan called for the case
management team to meet once with an inmate prior to release from prison. Planners
assumed that the nurse and case manager could build trust with a client in one meeting.
When it was realized that trust takes more time, the program timetable was revised to include

113
more than one in-prison visit. However, because prison terms are usually short and release
dates unpredictable, keeping to the timetable proved difficult.

The Project Name and Focus. The project’s names were a major barrier to inmate
enrollment in the program. Its original name, "Inmates and AIDS Intervention Program,"
deterred prisoners from self-referring because of the word "AIDS." A woman inmate who
missed several appointments with her case manager said that such a meeting might let other
inmates know that she was living with HIV and she feared being ostracized.

Distributing flyers with the project’s name as a form of outreach proved to be
counterproductive as well because of the AIDS identification. Inmates would not take these
flyers to their cell blocks for fear of stigma. Subsequently, focus group results revealed the
extent to which the prisoners feared exposure and knew, better than did the program
planners, how little confidentiality there is in a prison. In the second year, therefore, The
Circle of Care changed the project’s name to "The Family Linkage Program."

This name better fitted the original purpose to link inmates and their families with
appropriate services, and it better reflected the mission of The Circle of Care. However, the
new name proved to be a barrier to referrals. Although many of the inmates have children
and families, contact with their families is sporadic. Two focus groups conducted by the
Family Planning Council Research Department probed family relationships. When asked
about their relationships with their families since incarceration, the majority of the men said
that their relationships have been strained since their sentencing. Only one man reported
regular contact with his family; most have older children "out on their own" who do not visit
often. While ten of the women in the focus group reported having children and having been
responsible for the children’s health care prior to incarceration, these women were unsure
what would happen when they were released. Some barely knew their children; others
expected that the State would take custody.

As the program evolved it also became clear that few of the inmates living with HIV
who were in contact with their families had disclosed their HIV status. Like many people
with HIV, inmates fear the consequences of disclosure. Disclosure to family members might
have even more devastating consequences for people in prison than for people "outside."
Families are an inmate’s link with the world; they bring money, cigarettes, and other gifts.
Disclosure might break that link.

Finally, The Circle of Care renamed the program to "The Philadelphia Linkage
Program." This name and the revised goal of working with inmates living with HIV whether
or not they wished to identify families greatly increased the program’s chances of success. It
also helped to increase the number of participating clients.

Turnover in Case Management Staff. Undoubtedly, the greatest obstacle to the

ability of the program to meet its goals was the high turnover in case management staff (five
case managers in 2.5 years). Each resignation or firing resulted from issues of personality

114
conflicts and private quarrels. The turnover impeded progress and affected the program’s
ability to develop relationships with inmates and to provide meaningful followup after
discharge. Furthermore, the instability of the staff affected relationships among
organizations cooperating on the project. As a representative of AACO wrote in his survey:

"The staff turnover and [subsequent] lack of coverage and continuity made
it difficult for [our] staff to see the case manager as more than a drain on
services and not a support to existing services."

The position of case manager was a demanding one and was vital to the success of the
project. It required a professional with flexibility, resourcefulness, empathy, compassion,
persistence, enthusiasm, and the ability to work with all parties. The case management staff
stabilized in the winter of 1994; thereafter, the program began to move forward.

MAINSTREAM ISSUES
Understanding the System

A mainstream issue for any program providing service linkages to prisoners is
cooperation from the prison system. Perhaps no one connected with the project with the
possible exception of AACO staff understood the difficulty an outside organization
encounters in becoming accepted by inmates and staff of a prison system.

Events in the prison system also interfered with program implementation. Often,
there was an inordinate period between the time an inmate was called to be interviewed and
the time the inmate actually arrived. There were many reasons for this delay, including a
lock down and a prison count. Frequently, inmates did not hear their call because they were
asleep, in the yard, at meals, or in the infirmary and no one bothered to find them.

Understanding the Population

A clear understanding of the characteristics of the clients to be served is critical to the
success of a program like the Philadelphia Linkage Program. HIV disease may not be an
inmate’s greatest concern; in fact, practical needs at the time of release most likely
overshadow, if not overwhelm, the client’s ability to seek HIV-related services. The ideal
approach would be to gather data and profile the population to be served by the intervention.

The Philadelphia Linkage Program was not able to survey the Philadelphia prison
population, but observations from a study of 66 women in a voluntary residential drug
rehabilitation program in Philadelphia assisted in program planning.> The findings from the
study must be interpreted conservatively for several reasons: the small sample size, the
potential bias of sampling only women in a drug treatment program, and the limitations of a
self-administered questionnaire. However, the characteristics and life situations of the study
participants were similar to those of the larger population in Philadelphia prisons (Table 5).

115
 

Table 5. Characteristics of Women in Voluntary Drug Rehabilitation Program Study

(n=66)

 

 

Age
Mean in years
(Range)

Race/Ethnicity
African American
White
Latino
Other

Marital status
Single
Divorced/Separated
Married
Widowed

Children
Yes
No

Lived with children before incarceration?
Yes
No

Education
Did not complete high school
Completed high school

Ever homeless?
Never
At some time

Ever worked?
Yes
No

Drug use
Alcohol
Cocaine

HIV status (n=65)
Positive
Don’t know/not sure
Negative

30.8
(18-64)
(18-64)

61
23
15

73
12

82

18

32
68

73
27

58
42

75
25

83
80

77
20

 

116

 
A majority of the women did not complete high school, and 42 percent had been
homeless. The majority of women (77 percent) were living with HIV. The high percentages
of women using alcohol and cocaine indicate that most women used both substances. A high
percentage (68 percent) of women had not lived with their children prior to incarceration,
even though 82 percent of the women had children. The study reported that many women
had few close relationships, although one-third reported having a close relationship with a
grandmother and one-fourth reported regular visits from a parent; one-fourth reported no
visits.

The women reported emotional and physical distances that were rooted in many
issues, including drug addiction. Drug addiction was termed "one of the toughest
challenges" facing a provider working with incarcerated women. Often, women in prison
are drug free for the first time in many months, or even years. The majority of the study
participants... identified drug addiction as the number one issue they needed help with,
presently and in the future, when they leave prison. Programs such as the Philadelphia
Linkage Program must place a strong emphasis on linking women in the prison system to
intensive drug rehabilitation programs. Otherwise, the impact of the program will be
limited, if not lost.

The study underscores what providers need to know about women living with HIV
and women affected by HIV, i.e., that such women have multiple needs that must be met in
a coordinated fashion within a fragmented system. Furthermore, the study notes that since it
is easy to lose track of women once they are released from prison, a program like the
Philadelphia Linkage Program which builds a trusting relationship with women is "key to
maintaining a relationship following [these women’s] release into the community."

EVALUATION METHODS

The program’s evaluation was designed 1) to provide an ongoing assessment of
project components to monitor the implementation of project activities and 2) to assess the
project’s effectiveness in meeting its goals. The evaluation instruments included:

® Focus groups with men and women to probe their issues, attitudes, perceptions,
and feelings so that the needs of inmates living with HIV and their families could
be better addressed once the prisoners are released.

® A longitudinal survey to assess the program’s effectiveness in providing support to
clients. The survey was to be administered before an inmate’s release and at 3
months after release.

® Comparison group of families enrolled in The Circle of Care to compare the
service needs of referrals, the use of services, and aggregate demographics of
individuals with HIV and HIV-affected families with and without a history of
incarceration.

117
Focus Groups

Family Planning Council Research Department staff conducted two focus groups in
the Philadelphia prison system, one with 11 men and one with 14 women, on May 11, 1992,
and October 28, 1992, respectively. The participants were not necessarily living with HIV.
Table 6 lists the characteristics of these inmates. Although participants in both focus groups
showed a general lack of knowledge about the transmission of AIDS, the men were much
more reluctant than the women to talk about AIDS and other sexually transmitted diseases.
Among the men there was a high degree of homophobia. Of the two groups, women had
closer ties with their families than men, although it was unclear how many would regain
custody of their children after being released. Men and women wanted separate facilities for
inmates with HIV, but for different reasons: the men wanted separate facilities to prevent
transmission while the women wanted a place where they could express their feelings openly
in support groups. In addition, participants said they preferred the staff to be people from
outside the prison system.

Longitudinal Survey

The longitudinal survey was designed to measure the following:

¢ Inmates’ perceived medical and social service needs (both HIV- and non-HIV-
related) during and after incarceration;

# Perceived medical and social service needs (both HIV- and non-HIV-related) of the
inmates’ families; and

¢ Inmates’ sexual risk behaviors, condom use, and injection drug use before and
after incarceration.

In addition, the evaluation team planned a "linkage monitoring system"—an
instrument designed to track individuals and families for 3 months after the inmates’ release
to document the number and demographics of Philadelphia Linkage Program clients, their
needs, referrals made for them, and their use of services. The linkage monitoring system
was designed to gather the following information:

¢ Communication by inmates to prison staff, Philadelphia Linkage Program staff,
and families regarding HIV/AIDS and prison issues;

# Pregnancy status, birth control history, and intentions to give birth of women
inmates living with HIV;

118
4 Emotional well-being and stress levels of inmates; and

4 Demographic characteristics of inmates living with HIV.

 

Table 6. Characteristics of Focus Group Participants

 

 

Total Men Women
(n=25) (n=11) (n=14)

Race/Ethnicity
African American
Latino
White
Other

ooo an B
v=
1
ono wv
ad
wo = 2

Marital Status
Single
Married
Separated
Divorced
Widowed

57
14
14

hoo S
—_ NN Wo
OO = OO
—_—— NN 00

Age
Mean in Years 29 28 30
(Range) (18-46) (18-46) (21-42)

Education
Mean in Years 10.0 10.0 10.0
(Range) (5-12) (6-12) (5-12)

Number of Children
Mean 1.5 1.0 2.0

(Range) (0-9) (0-6) (0-9)

Number of Jail Terms
Mean in Months 2.5 3.0 2.0
(Range) (1-10) (1-10) (1-10)

Length of Current Sentence
Mean in Months 8.2 6.5 10.0
(Range) (.5-24) (2-12) (.5-24)

 

119

 
Unfortunately, the database never became operational because of the turnover in case
management staff.

While the study was designed to compare inmates’ needs during incarceration and
after release, as of September 1994 only two inmates were eligible for the followup survey;
therefore, the study was limited to a cross-sectional description of the prison population.
Surveys were obtained between March and June of 1994 from a convenience sample of 13
inmates in the Philadelphia Linkage Program. The demographics of those surveyed were
similar to those of the prison population and of participants in the program. Eleven were
men and two were women; five were African American, three Hispanic, three white, and
two "other." They ranged in age from 23 to 50. Eight were single, two were widowed, two
had long-term relationships with a partner, and one was divorced.

The survey covered a number of issues. One of the most positive findings was the
inmates’ response to the questions regarding to whom, inside and outside of prison, they
could talk about their concerns about HIV and the prison. All the respondents said they
could talk to their case manager or nurse about HIV and all but one said they could talk to
the case manager or nurse about the prison. In contrast, only 39 percent said they could talk
to the prison social worker about HIV; 46 percent said they could talk to the social worker
about prison issues.

Comparison Group

A component of the comparison group analysis was the stress scale, designed to
measure how inmates were functioning, in general and with regard to their HIV status. The
results of the scale were compared to the results of a similar survey with family caretakers
living with HIV enrolled in The Circle of Care. The results show that inmates living with
HIV experienced a greater degree of stress than did the families affected by HIV enrolled in
The Circle of Care. These results were statistically significant (p < .05). The original aim
of the comparison group analysis was to compare the levels of stress of the inmate before
and after incarceration, to see if case management support alleviated the stress and to see
how this compared with families enrolled in The Circle of Care. To date, the staff have not
been able to interview inmates released from prison.

DISSEMINATION OF THE PROJECT CONCEPT

Staff felt that the program, including the obstacles it faced and overcame, provides
valuable lessons for other organizations seeking to provide case management and related
services to incarcerated men and women. Findings from the survey, the numbers currently
reported by the case management staff, and the insights from the "Women in Prison" study
suggest that The Philadelphia Linkage Program is on the right track. Prerelease case
management for incarcerated men and women with HIV is crucial if these individuals are to
be linked to medical care and social services upon their release. The program, in a limited
form (without a nurse or homeworker), will continue for at least another year with funding

120
for case management supplied by the Philadelphia Department of Public Health’s AIDS
Activities Coordinating Office.

The Philadelphia Linkage program has been disseminated in a number of forums.
The program was presented at the 1993 American Public Health Association meeting; at the
African American Summit in Gabon, Africa; and at the SPNS Annual Meeting.

NOTES

1. The Philadelphia Regional Comprehensive Plan. This is the planning document of
The Philadelphia AIDS Consortium (TPAC), the Ryan White Planning Council for the
Philadelphia EMA.

2. National Institute of Drug Abuse Forecasting System.

3. Women, AIDS and Prison: Findings from a 1993 Survey of Women in Prison in
Philadelphia, by Lisa Bond. Philadelphia Health Management Corporation, 1993.

AUTHORS

Alicia Beatty
Director

Mary Hale Meyer, M.A., M.Ed.
Coordinator of Program Planning and Development

Circle of Care

260 Broad Street

Suite 1510

Philadelphia, Pennsylvania 19102

121
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