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RRP 10-182 – HSR&D Study

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RRP 10-182
Qualitative Assessment of Re-Entry Care for Previously Incarcerated HIV/HCV-Infected Veterans
Henry Anaya PhD
VA Greater Los Angeles Healthcare System, West Los Angeles, CA
West Los Angeles, CA
Funding Period: June 2011 - May 2012

BACKGROUND/RATIONALE:
VA Outreach Specialist Program in the Los Angeles County Jail System
Since 1997, as part of the VA's extensive outreach to homeless Veterans through the Healthcare for Homeless Veterans, the Greater Los Angeles Healthcare System (GLAHS) has hosted a Community Care Re-entry Program that sends VA Outreach Specialists (VAOS) into the Los Angeles County Jails. The program's staff includes outreach specialists, social workers, and eligibility clerks. The program provides anticipatory assistance to over 400 incarcerated Veterans per month in preparation for the challenges of community reentry.

When an inmate enters the jail system, the Los Angeles Sheriff's Department staff asks each inmate about his/her Veteran status. A list of self-reported Veterans is passed on daily to the Community Care Re-entry Program clerks who perform an eligibility assessment of these veterans. The clerk then passes on a list of eligible Veterans (usually more than 80% are eligible for VA services) to the VAOS who go to the different jail sites that day to meet with the veterans. The VAOS perform thorough pre-release assessments to identify the medical and non-medical needs of the incarcerated veterans and work with other program staff to make the necessary referrals and facilitates linkages to medical, psychiatric, and social services, including substance abuse treatment programs, employment services, and housing.

Hepatitis C Care
Hepatitis C has been well recognized as a public health problem of particular importance to the VHA. The prevalence estimates of HCV among Veterans range between 5 to 22%, and inmates have a prevalence of 15%. A quarter of HCV infected Veterans may be co-infected with HIV, which greatly increases the morbidity from each disease. Thus, access to care for HCV-infected Veterans is critical so that they can receive needed medical care in line with quality indicators such as assessment of disease severity through confirmation of viremia and HCV genotype testing, hepatitis A and B vaccination, and evaluation by a specialist for possible antiviral treatment. Treatment is potentially curative, with the current interferon and ribovarin success rates ranging from 50 to 85% depending on genotype. While many patients and their physicians now choose to forego care when balancing such success rates and interferon side effects, new regimens expected next year will double effectiveness, making outreach programs all the more critical.

HIV Care
One of the VHA's HIV priorities is improving access to care for HIV-infected Veterans. In the modern era of effective antiretroviral therapy, HIV has transformed from a uniformly fatal to a treatable, chronic disease. However, late entry into medical care, gaps in care, and non-adherence to pharmaceutical regimens continues to be a problem, particularly for African and Latino men, who make up the majority of the jail population in Los Angeles County. Given that the prevalence of HIV among inmates of the Los Angeles County Jail was last estimated at 1.5%, jails offer a location to identify HIV-infected Veterans who are either not in care at all or receiving care elsewhere in the community. Linking an HIV-infected Veteran to the VHA would not only open the door for that individual to the outstanding HIV care and comprehensive services offered by the VHA, but would also free up community services for non-Veteran clients.



OBJECTIVE(S):
Correctional institutions offer an opportunity to identify Veterans with Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV), and for the US Department of Veterans Affairs - Veterans Health Administration (VHA) to then link them into medical care upon release. To inform a tailored intervention to reach out to this vulnerable Veteran population, we propose a formative evaluation with the following specific aims:

1.Evaluate the barriers, facilitators, and gaps in care that exist regarding linkage to VHA medical services for recently incarcerated HIV and/or HCV infected veterans from the perspective of clinical and social service providers, as well as newly released Veterans themselves.

2.Use the results of this formative needs assessment as the basis of future interventions to:

-Strengthen the currently existing linkage-to-care networks between local and federal (VA) systems nationwide;

-If none exist, provide a foundation for stakeholders to use in designing effective linkage networks between local and federal government.


METHODS:
This study is qualitative in nature and involved two cohorts. Data was collected via semi-structured interviews. The first cohort (C1) included VA employees, including clinical staff and outreach specialists, as well as transitional case managers at the jail who provided re-entry planning for many HIV-positive persons. We expected to identify and recruit approximately 20 participants. Initially, participants were identified by their position (i.e. VA outreach specialists in the jail, practicing physician or nurse practitioner in the Homeless Screening Clinic at West LA and Downtown VA Clinic, practicing physicians at the Infectious Disease clinics, HIV transitional case managers at the jail). We utilized modified snow-ball techniques to identify additional participants. This technique consists of asking initial identified participants to identify other individuals who have regular contact with previously incarcerated veterans with Hepatitis C or HIV. We called potential participants to request a meeting to discuss the study, obtain verbal consent to participate in the research study, and scheduled the interview.



FINDINGS/RESULTS:
Both Veterans and outreach staff characterized linkage to care (LTC) in largely positive terms. Some Veterans explained that they were contacted by outreach staff either while still incarcerated or upon being released from jail, and some outreach staff noted that they receive from jails the names of prisoners who are Veterans and then meet with them to inform them of VA services.
Veterans identified some shortcomings of the LTC, including the need for more outreach staff in the jails, never having been contacted by an outreach worker, and insufficient outreach to female Veterans. Outreach staff also identified some challenges, noting a shortage of outreach staff, not receiving the names of all incarcerated Veterans, and Veterans' difficulties obtaining reliable transportation to care.
Veterans and outreach staff offered many of the same suggestions for improving linkage to care. These include: posting flyers about LTC in jails, having the Sheriff's office screen all new prisoners for veteran status, and establishing a "hotline" Veterans could call to learn about VA services.

IMPACT:
We anticipate our findings will contribute to interventions to make LTC a stronger, more effective program, with the distinct possibility more recently released Veterans will be linked to HIV and/or HCV care.

PUBLICATIONS:

Journal Articles

  1. Anaya H, Solomon J, Saifu H. An Evaluation of Post-Incarceration Linkage to Care for HIV and/or Hepatitis-C Infected Veterans in Los Angeles County. Journal of AIDS & clinical research. 2015 Jun 8; 6(8:493):1-5.


DRA: Health Systems, Infectious Diseases
DRE: Technology Development and Assessment
Keywords: QUERI Implementation
MeSH Terms: none

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