Nilda Ricard, Director and Drop-In Center employee at The Fortune Society

Why Transitional Planning For PLWHAs Is So Important At The Department Of Corrections

Monday, November 30, 2015

Our correctional facilities are filled with people diagnosed with mental illness, chronic substance abuse, people who are living with HIV/AIDS (PLWHAs), and with chronically homeless people.

On any given day, however, there are clients who are enrolled in The Fortune Society’s Drop-In Center who experience all of these issues simultaneously — a quadruple whammy. How do we address an individual with so many needs who, in all likelihood, will be released back into the community with just a MetroCard and a referral to Bellevue Men’s Shelter?

The answer is that the Health and Hospital Corp.’s (HHC) Transitional Health Care Consortium (THCC) partnered with The Fortune Society’s Drop-In Center (DIC) and with the Department of Corrections (DOC) to create a model where individuals who are diagnosed with HIV/AIDS and who suffer from the above co-occurring issues are identified as soon as they enter the correctional system. Clients are assessed by THCC staff and referred to the DIC. A DIC staff member is then assigned and they coordinate a jail visit with THCC staff along with a DOC officer who will assist in escorting the client to a private and safe area to begin a discussion centered around the client’s needs.

It’s important to note that the DOC officer is not dressed in uniform but in civilian attire. This helps the officer identify with the client in a non-threatening manner.

Both THCC and Fortune’s DIC staff will develop a discharge plan to address not only the crucial needs of connecting a client to medical care but also addressing clients’ housing needs, substance use, mental health, and other ancillary needs.

Many of the individuals we serve will look at their medical and mental health needs as the bottom of “their totem pole.” If you don’t have a safe place to live, thinking about going to a doctor or a mental health provider may not be a realistic priority.

The focus of this work is to stabilize our clients as soon as they are released from custody — which is the most crucial time. Fortune’s DIC staff will pick up the client the day of release in the Fortune van and take them to breakfast. From there, we will escort them to their first appointment of the day. This could be for housing, a medical appointment, applying for benefits, placement in a skilled nursing facility, and so on. Fortune’s DIC staff will work with clients closely for the first 90 days to ensure that all of their immediate needs are met. Clients will then be referred to other Fortune programs for longer-term assistance in other areas of their lives.

This transitional planning model has shown that PLWHAs in custody who receive this type of support have a better chance of living a healthier life and avoiding criminal justice system involvement. Transitional planning with continuity of care has proven to be effective – and this model should be adopted nationwide.

Categories: Community

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