<i class="fa fa-balance-scale"> </i> Jails

Transitional Care Coordination

From Jail Intake to Community HIV Primary Care


This intervention has been informed and adapted from the best practice findings of a past SPNS initiative. It is currently being implemented and evaluated across each of the 4 interventions developed, at a total of 12 funded sites. Based on the findings of this current implementation, a final evidence-informed toolkit will be designed and available at the end of 2021. Contact information provided is required in order to download these materials for review and/or implementation; however, all information is protected and any follow-up will be limited to collecting information on your impressions and experiences related to the materials and any implementation you may have done of the interventions covered therein.

Intervention Summary

HIV Continuum of Care: Linkage to Care

Collaborations between public health agencies, community-based organizations, and jail health services have implications for public health and safety efforts and have been proven to facilitate linkage to care after incarceration.1 Medical screenings that happen for all inmates through the jail intake process offer an opportunity to implement such interventions, as do booking processes and intervention intake.2, 3, 4 Jordan et al., introduce the concept of "Warm Transitions" as an integral part of implementing the HIV Continuum of Care Model by "applying social work tenets to public health activities for those with chronic health conditions, including HIV-infection."5 Absent "a caring and supportive warm transition approach," pre-existing barriers to care and other stressors that come with the experience of incarceration and cycling in and out of correctional facilities will continue or be exacerbated after incarceration.6 Without transition assistance, people living with HIV who are released from jails are at risk of unstable housing; lack of access to health insurance and medication; overdose due to period of detoxification; exacerbation of mental health conditions due to increased stress; and lack of social supports, when exposed to the same high risk communities from which they were incarcerated.7

Professional Literature

Figure showing the increase in people in jails and prisons and the decrease of people in psychiatric hospitals from 1930 to 2000

Figure 1: De-Institutionalization?

The United States has the highest incarceration rates of any industrialized country in the world.8,9 Approximately 1 out of every 100 people in the United States is incarcerated10; and, if rates persist, 1 in 15 Americans will have been incarcerated at some point in their lives.11

The U.S. Criminal Justice System includes Law Enforcement (police, sheriff, highway patrol, FBI, and others), Adjudication (courts), and Corrections (jails, prisons, probation, and parole).12 Most incarcerated individuals (85%) pass solely through jails. Yet most corrections spending is in state prisons, rather than in jails, which are dependent on local funding.13,14

Jails are often the de facto health provider of last resort where people with low income, mental illness, unstable housing, substance use issues, and a range of social and health problems are concentrated.15,16 Further, while historic arrest rates tend to mirror the racial and ethnic demographics of the local community, the incarcerated population is predominantly men of color.17,18

Theoretical Basis

A behavioral change theory is a combination of, "interrelated concepts, definitions, and propositions that present a systematic view of events or situations by specifying relations amount variables, in order to explain or predict the events or situations."39 By grounding an intervention in theory, the component parts are intentionally sequenced to build off of one another to facilitate a change in health behavior.

Intervention Components and Activities

The central aim of the Care Transitional Coordination intervention is to facilitate the linkage of a client living with HIV to community-based care and treatment services after incarceration. Intervention activities include identifying and engaging people living with HIV during the jail stay, identifying "right fit" community resources, developing a client plan for their time during and post-incarceration, and coordinating activities needed to facilitate linkage to care after incarceration. These activities need to occur quickly because jail stays are often brief and the uncertainty around discharge dates presents a shorter window of opportunity to reach people leaving jail settings.41

Staffing Requirements

The following staff positions need to be developed and filled in order to successfully implement the intervention.

Programmatic Requirements

The following are programmatic requirements that need to be addressed prior to implementation (prior to enrollment of clients in the jails) in order to facilitate a successful implementation:


The SPNS Jail Linkages projects were deemed cost-effective from a societal perspective42 with an average cost per client at $4,219. In an analysis of nine sites, the mean cost to sustain linkage to care post-incarceration for 6 months was $4,670.43 Health outcomes impacting costs (reductions in ED use and self reported unstable housing and hunger when compared to themselves at baseline and at 6 Month follow up) were found under the Transitional Care Coordination intervention including a reduction in emergency department use and homeless shelter stays.13,14



The following source documents were cited in the Intervention document: