Case management as a bridge from incarceration to the community

The Philadelphia Linkage Program is a foundation element of what has been built over a number of years between the Philadelphia Prison System and social-service providers in the community. It has been called a “best practice” in correctional-medicine care for HIV-positive patients.

As background, following CDC “opt-out” testing recommendations, the Philadelphia Prison System increased testing of citizens incarcerated at PPS from 6-95 percent. PPS will treat nearly 1,000 individuals for HIV this year.

The majority of HIV-positive inmates arrive with controlled viral loads, i.e., had been receiving appropriate care in the community prior to incarceration. At the time of release from PPS, these patients are referred back to their community providers, and these providers are sent detailed discharge summaries, if the patient permits.

However, one-third of HIV-positive patients at the PPS report not having seen an HIV provider routinely in the community, or not having one at all. Here is where linkage services make a big difference.

ActionAIDS has been in the Philadelphia county jails since 1991, when there was one case manager to help clients navigate myriad challenges awaiting them upon release from jail. Over the years, other community providers such as Philadelphia FIGHT have joined efforts to continue the continuity of care for clients while incarcerated and prepare them for discharge. Linkage staff visits these patients at PPS — given the patient’s permission — regularly until release, and makes arrangements for care after release. Issues such as continuity of medical care, housing, drug and alcohol and mental-health treatment are explored. More than 80 percent of these patients make it to their first linkage appointments after release, which is a commendable rate of continuity of care.

Linkage services and PPS continue to work to shorten the time between diagnosis and initial linkage staff visits with patients on campus. AIDS Activities Coordinating Office, ActionAIDS, Philadelphia FIGHT and other advocacy groups have been wonderfully supportive of PPS to assure timely testing, treatment and continuity of care upon release. 

Newsletter Sign-up