Criminal Justice Coordinated Transitional Care (CJC-TraC)

Health Systems Innovations for Supporting Transitions of Care for Incarcerated People Living With HIV, Hepatitis C, and Substance Use Disorder

This project aims to enroll 220 incarcerated individuals living with HIV, Hepatitis C (HCV), or history of substance misuse preparing for release into a pilot implementation study to test the feasibility and acceptability of an adapted Coordinated Transitional Care intervention in a Criminal Justice setting (CJC-TraC). Participants can expect to be on study for up to 6 months.

This protocol describes the second, implementation phase of a 5-year NIH-funded research project designed to evaluate post-incarceration health care utilization and outcomes for underserved people living with HIV, HCV and substance use disorder. In the first study phase, conducted from 2020-21, the investigators analyzed Wisconsin Medicaid data to characterize the baseline level of outpatient care utilization for adults during their first 6 months after release from prison, and conducted formative research necessary to adapt an existing transitional care intervention, called C-TraC, to support individuals leaving prison. The current project aims to enroll participants in a pilot implementation study to test the feasibility and acceptability of the adapted intervention in a criminal justice setting, which has been given the name "CJC-TraC." Participants will be enrolled from one of two institutions: men from Oakhill Correctional Institute (OCI) women from the Wisconsin Women's Correctional System (WWCS) Primary Objectives: To evaluate the feasibility and acceptability of CJC-TraC when implemented in a state prison system. Secondary Objectives: To gather preliminary evidence describing the effectiveness of CJC-TraC for improving the rate of outpatient care utilization.

Incarcerated individuals with HIV, hepatitis C, or substance use disorder readying for release will enroll in the CJC-TraC intervention intended to assist in transitioning their health care.

CJC-TraC utilizes a nurse case manager (NCM) to coordinate the participant's transitional care through release from a correctional facility. The NCM will visit either in person or via telehealth with the participant up to 4 times while incarcerated, and up to 4 times after release.

Feasibility Outcome: Number of participants who are enrolled and complete the baseline study assessment per month

The investigators aim to enroll about 9 people per month over a 2 year study period. Results will be reported in total and per institution.

Feasibility Outcome: Number of pre-release CJC-TraC intervention sessions completed with the nurse case manager for each participant

The investigators plan for 3 pre-release sessions with additional sessions as needed. The results will be reported in total and for each institution.

Feasibility Outcome: Number of post-release telephone contacts between the CJC-TraC nurse case manager and study participants

Feasibility Outcome: Proportion of study participants who are retained in follow-up for three months and complete the end-of-study assessment

Acceptability measured by the Proportion of study participants who rated specific aspects of the intervention useful and encounter volumes appropriate

Of participants who enroll and complete a follow up assessment, percentage of participants who responded to questions soliciting their perspectives about the intervention usefulness

Participant responses to qualitative interview questions will be analyzed for themes, responses to questions regarding helpful and liked parts of the intervention and work with the nurse case manager will be particularly meaningful for acceptability

Acceptability measured by the Proportion of Department of Corrections (DOC) staff who rated the intervention acceptable, useful, or appropriate

Inclusion Criteria: Able to understand and speak in English Plans to reside in Wisconsin after release Eligible for Wisconsin Medicaid and willing to enroll prior to release Has a history of one or more of the following: current HIV infection, current or past HCV infection, identified need for substance use related services based on Correctional Offender Management Profiling for Alternative Sanctions (COMPAS) assessment Anticipated release date (must be within 6 months of review) Exclusion Criteria: Unable to provide informed consent form or impaired ability to make decisions Planned discharge to another correctional facility or other carceral setting (e.g. release to jail or immigration detention center)