Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island

AIDS Behav. 2013 Oct;17 Suppl 2:S212-9. doi: 10.1007/s10461-012-0352-5.


New York City (NYC) jails are the epicenter of an epidemic that overwhelmingly affects Black and Hispanic men and offer a significant opportunity for public health intervention. The NYC Department of Health and Mental Hygiene instituted population based approaches to identify the HIV-infected, initiate discharge planning at jail admission, and facilitate post-release linkages to primary care. Using a caring and supportive 'warm transitions' approach, transitional care services are integral to continuity of care. Since 2010, over three-quarters of known HIV-infected inmates admitted to jails received discharge plans; 74 % of those released were linked to primary care. The EnhanceLink initiative's new Health Liaison, a lynchpin role, facilitated 250 court-led placements in medical alternatives to incarceration. Transitional care coordination programs are critical to facilitate continuity of care for people with chronic health conditions including the HIV-infected returning home from jail and for the public health of the communities to which they return.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Case Management
  • Continuity of Patient Care / organization & administration*
  • Delivery of Health Care / organization & administration*
  • Female
  • HIV Infections / diagnosis
  • HIV Infections / therapy*
  • Humans
  • Male
  • Middle Aged
  • New York
  • Patient Discharge
  • Prisoners / statistics & numerical data*
  • Prisons
  • Program Development
  • Surveys and Questionnaires
  • Young Adult