Navigator Case Management

  • Priority Population
    People with HIV, who are currently incarcerated and are leaving jail
  • Setting
    Jail
  • Location
    San Francisco, CA
  • Intervention Focus
    Linkage, Re-engagement, and Retention
  • Study Period
    2010-2013

Summary

This patient navigation-enhanced case management intervention improved linkage and retention in HIV care among people with HIV who were leaving jail to return to the community.

Download the Implementation Guide

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Download the Intervention Summary

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Intervention Outcomes

Clients were twice as likely to be linked to care within 30 days of being released from jail.
Clients were almost twice as likely to be retained in care during the intervention period.

Intervention Components

  1. Secure Stakeholder Buy-in
  2. Assess Gaps and Resources and Hire Staff
  3. Conduct Pre-Release Planning Activities
  4. Monitor Legal Status of Clients
  5. Conduct Post-Release Care Plan Activities
  6. Implement the Care Plan
  7. Follow-up and Monitor Client Progress
  8. Graduate Clients

Cost Analysis

The Navigator Case Management intervention cost analysis is not currently available. However, you can use the CIE Cost Calculator to create an estimate of the cost of implementing the intervention at your organization.

Challenges & Solutions

Challenge: Implementing a peer-based model
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Solution:

Involve people with peer-based intervention experience to troubleshoot potential issues. Research examples of peer-based interventions.

Challenge: Funding
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Solution:

Secure diverse funding to help facilitate best practices for client retention. Work with a local university, foundation or national substance use or research organizations to assess resources that are available for program services or evaluation.

Challenge: Geographically distant navigators and clients
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Solution:

Offer flexible office hours to allow for more convenient scheduling and travel time. Provide transportation assistance.

Challenge: Commitment to social justice among all involved
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Solution:

Convene all parties before implementation to discuss intervention planning and execution through a social justice lens. Discuss interrelated social justice issues (e.g., mass incarceration of Black and Latinx people, the criminalization of people who use drugs) and explore solutions.

Publications

A Randomized Controlled Study of Intervention to Improve Continuity Care Engagement Among HIV-Infected Persons After Release From Jails
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Resources

Tips for Working with People with HIV who have been Incarcerated
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Tips for Working with People Who Use Drugs—in the Pandemic Era and Beyond
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Engaging Latinx Community in RW Program Fact Sheet
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Engaging Black Men in RW Program Fact Sheet
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Trauma-Informed Approaches Toolkit
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NASTAD Brief: The Intersection of Hepatitis, HIV and the Opioid Crisis: The Need for a Comprehensive Response
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Needs Assessment Form
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Risk Assessment Form
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Transition Plan Form
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Authorization to Release Client Information Form
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Navigator Note Guide
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NASTAD Webinar: Addressing Stigma Surrounding People Who Use Drugs
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National Harm Reduction Coalition: Principles of Harm Reduction
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Trainings

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Videos

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