The transition from incarceration back to the community is a crucial time for individuals living with HIV/AIDS, and effective transitional planning is essential to ensure that they connect to medical care after their release. Access to safe and stable housing, transportation assistance, employment opportunities and health education are all key factors in ensuring people with HIV/AIDS connect with and maintain medical treatment after release.   

However, without effective discharge planning, only 30% of people maintain HIV medical care after six months in the community.   

The Fortune Society’s Health Services team aims to address this concern. They provide individuals living with, or at risk of developing, HIV and AIDS with discharge planning, case management, connection to community-based treatment and HIV prevention education. This holistic and integrated approach to serving formerly incarcerated individuals living with HIV/AIDS helps ensure their safe and healthy transition back into the community. 

Community Health Workers Offer Critical Support

Michael joined the Health Services team, or the Drop-In Center, about ten years ago as a Community Health Worker (CHW) before becoming a Transition Specialist Coordinator. He works directly with participants from their time on Rikers Island up to 90 days after their release. During that time, CHWs aim to connect participants with medical care within the first 30 days of their release. 

Michael noted some barriers to getting participants connected to a medical provider within 30 days, including losing contact with individuals upon release. CHWs and Transitions Coordinators help them develop transition and care plans for their release to address this.  

“We establish our care on Rikers, so if they don’t have a medical provider, we can refer them,” Michael explained. “When they get released, they have their first appointments set up, and we also have a list of pharmacies we can refer them to. We also make sure to transport them from Rikers when they’re released, which helps establish trust with them during the vulnerable transitional period.” 

The Value of a Transition Plan and Wraparound Services 

Individuals receiving health services at Fortune also gain access to wraparound services, including case management and housing assistance. While on Rikers Island and upon immediate release, staff at the Drop-In Center work with participants to establish their specific needs and prepare a care plan.

Michael emphasized the importance of allowing participants access to Fortune’s services, including the convenience of finding services in one location. The staff at the Drop-In Center can make referrals, offer critical resources, and there is a staff of Entitlement Specialists who work on-site, as well.   

“Having everything here, and with us being here to call and make referrals or find the services they need, they can just come to us and get access to many things that they need,” Michael said. “It’s convenient, because a lot of our clients are from this area or the Bronx, so it can be easier to get here than to some other places. Or, if they need to go to Long Island City for something, we can give them a ride.” 

As Health Services aims to address the barriers individuals with HIV/AIDS face connecting to medical care after incarceration, they also seek to help participants navigate their reentry journeys as a whole. Michael shared that he, and the rest of the Health Services staff, are sure to establish trust with participants and continue to approach them with dignity and respect.