Imagine you are an HIV-positive ex-offender. You have no job, no car, and you are estranged from your family and friends. You now have to find your way in a bad economy and you must do all of this while trying to take care of your health in a sprawling, mostly rural state, relying only on public transportation and the occasional favor of strangers.
"Florida is a very diverse, primarily rural state. A lot of people don't recognize that," said Priya Rajkumar, director of Case Management Programs at Metro in the Tampa Bay area in Florida. "There are pockets of cities like the Tampa Bay area, Orlando area, South Florida; but everything else in between is a lot of swamp land and just a lot of nothing."
Rajkumar spoke at the Office of Minority Health's (OMH) conference on In-service Training, HIV/AIDS Health Improvement for Re-Entering Ex-Offenders Initiative (HIRE) during World AIDS Day, on December 1, 2011.
She has worked in the field of HIV/AIDS for more than 12 years in areas ranging from medical case management to HIV testing and prevention education and has been the Project Director for HIRE since the beginning.
Metropolitan Charities was formed in 1984 to provide a variety of much needed services to the HIV/AIDS community of Tampa Bay. Today, Metro is the largest provider of HIV/AIDS services in West Central Florida and among the largest in the state, serving approximately 3,000 clients at any one time.
According to Rajkumar, Florida is ranked third in the nation in the number of AIDS cases and, because of the large number of HIV-positive ex-offenders, Metro has created a model of care that allows clients to access most services at one central location where they receive case management, mental health counseling, and substance abuse services. The centralized location is effective and helps decrease recidivism while easing the burden a lot of the charity's clients endure as they try to reintegrate into society.
"We found that if everything is right there in one location, we have a higher success rate," she said. "It's very difficult to get around town. A bus trip from our office to one of the clinics could be easily a half-a-day trip...nd in the hot Florida sun, waiting for the bus, it's not really good for our clients who have compromised immune systems."
The Office of Minority Health in the U.S. Department of Health and Human Services awarded nearly $2 million to eight organizations that support the HIRE initiative. The program assists individuals living with HIV/AIDS who have been released from state or federal prison and links clients to services targeted at health improvement in the communities they live in after they are released.
"Our Project HIRE program has really fallen right in with the mission of our agency," Rajkumar said, adding that METRO received $250,000. "It originally started out with just linkage case management and then from that we started expanding as more and more folks started coming to us with additional needs." Since then, she noted, Metro has added prevention education and collaborative networking components to the program.
Because of Project HIRE, Metro, with its linkage management program, was the first organization to have a point of access within the Florida Department of Corrections. This has enabled any HIV-positive Floridian who is released from any state prison to be immediately referred to the charity in the Tampa Bay area. Before this, individuals who had no resources to access proper care and lacked community support were more likely to reoffend, Rajkumar said.
"Referral to our linkage case manager happens before our client is released," Rajkumar said. "We schedule an appointment ahead of time for primary care."
In Florida, every individual who is HIV-positive must get an eligibility determination in order to obtain primary care and 'Ryan White' services. With the thousands of applicants seeking help, there is often not enough staff to push the required paperwork through the system and the process to get Ryan White services can take anywhere from six to eight weeks, with another 30 days to obtain primary care.
Metro's link case managers, who are trained eligibility specialists through Project HIRE, are able to start the process prior to an inmate's release, so that upon release the ex-offender is already certified to obtain Ryan White services and has a primary care appointment scheduled.
Metro is also working on a prevention education portion of the program included in this partnership with the Department of Corrections.
"We found that there was a component that's part of their pre-release planning that requires our folks to go through prevention education. However there was no one going into the prisons to provide the education," Rajkumar said. "So after a lengthy process we've been able to kind of get into the state prisons. We are close to finalizing collaboration with federal prisons as well."
She said Metro currently does provide prevention education to places in the community, including halfway houses, and that educating probation officers has been very important. "We find that as we are educating our clients there, we are also educating the staff too. Many of them just don't want to deal with HIV. They don't want to acknowledge it."
But before Metro can even broach the topic of prevention and primary care with clients, Rajkumar said they have to learn about their clients' personal priorities.
"The first thing coming out of prison that we see with our clients is not a matter of care. It's not medications; it's housing, employment. It's a little bit of money to get by; it's finding family. It's everything, except medical care," said Rajkumar. "We have to be very cognizant of that. Our linkage case manager does prioritize by individual what their needs are. We're working with the primary care aspect and the social and supportive needs all at the same time."
The comprehensive support that Metro offers includes a program that deals primarily with family members of ex-offenders, which is also funded through OMH. This program works specifically with ex-offenders who already have an existing family. Another program, funded through the Office on Women's Health, is for women whose partner is or was incarcerated.
"Many times the men coming out of prison … have a girlfriend or someone who needs services, but because she doesn't quite fit in in any of the other categories, she's not able to go anywhere, so we are able to provide intervention through our program," Rajkumar said.
Another of Metro's services is a medical adherence program that works in unison with Project HIRE. Through that program, Metro is able to utilize peer advocates, including those bilingual in Spanish, and medical educators to transport clients coming in through the HIRE program to their medical appointment. This same, service-oriented approach applies to the group's HIV testing initiative. "We call it non-traditional outreach," she said of the 3,500 HIV tests Metro conducts per year. "We look at all the areas in the community where no one else is servicing so we go to those places. We're out there, beating at the door, trying to get in…that's how we end up getting a lot of folks that have never been in care that may have been positive for many, many years" or that were unsure of their HIV status.
Rajkumar said Metro has become a defacto hub for serving HIV-positive ex-offenders because it has reached out to the community in a comprehensive and collaborative way.
"The services were very fragmented; there was no sort of connection anywhere for the ex-offender. And if it's hard enough for me to make appointments and take care of the stuff that I have to, much more so for someone who is trying to come back to society after being completely removed for 10, 15, 20 years."
So far, Metro has developed more than 90 community partners as part of that network.
"Folks can be very protective of their own organizations and their own clients so we've really had to do a lot of community capacity building in order to really tie that all together. Our network also expanded beyond the Tampa Bay area and we are now serving a lot of the rural counties."
"Our agency started out 17 years ago. We're actually still with our original executive director. She started out of the trunk of her car in a parking lot of a church and started giving out prevention materials, giving out condoms, and just trying to get the message out to anyone that would listen to us. Since then we have truly grown and expanded our services to be able to look at the entire picture of what HIV is, beyond just prevention."
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