Critical Path Network: Community CM program targets prison population

Continuum of care maintained for 18 months

An award-winning hospital-based program for prisoners with HIV/AIDS has achieved an incredible 85% completion rate.

The program, called Project Bridge, is sponsored by The Miriam Health Care System in Providence, RI, and recently received the Russell E. Brady Award for Innovative Services Delivery from the U.S. Department of Health & Human Services’ Health Resources and Services Administration (HRSA).

What makes Project Bridge so unique — and so successful? "The length of our follow-up, the intensity of the program, and the professional staff," says Leah Holmes, MSW, program director and principal investigator for Project Bridge.

"The program is community-based. This means that [post-release], we meet the clients in the clients’ environment — home, treatment centers, wherever," Holmes explains.

"We see them at least weekly for the first three months, and then monthly thereafter, and go with them to all their medical appointments to act as facilitators — patient advocates. This helps the patients overcome barriers to adherence with their meds and medical plans," she says.

Project Bridge social workers go into the prison and meet with prospective clients within 90 days of their release date. They formulate a discharge plan, then conduct intensive social work case management for a period of 18 months following discharge. "To my knowledge, this is the only program that follows people with that intensity," Holmes says. "Other programs follow clients for six months at most, and many follow them for only three."

The Miriam, a 247-bed acute-care hospital, is part of the Lifespan health system and has a 76-year history of serving patients with chronic illnesses. "Our specialties include cancer care and cardiac care, as well as AIDS research and prevention," she says.

The foundation for Project Bridge was laid in 1996, when Miriam applied for a "Special Projects of National Significance" grant, or SPNS, which is part of the Ryan White Care Act, funded by HRSA. "They were looking for programs to provide innovative services to under- or unserved populations," Holmes recalls. "Our immunology center has for many years provided HIV specialty care at the state’s prisons."

When Rhode Island passed a law requiring HIV testing of all sentenced inmates, Miriam physicians noted that it would be unethical to test without providing good medical care. "Consequently, the state prison system contracted with them to provide that care," she says.

In the early days, the treatment involved "a couple of nurses who worked for the prison who tried some preliminary discharge planning," she notes. "It provided information on referrals with no community-based follow-up."

In the winter of 1996, Project Bridge officials met with potential collaborative agencies, created job descriptions, and began interviewing. In spring 1997, the first case manager and outreach worker were hired and program enrollment began. A referral protocol was created, and the case manager and outreach worker received training at the prison on protocols. As the program grew, client satisfaction surveys were created, technology enhanced, newer, larger facilities were found, and the staff evolved.

In the summer of 1998, terminations were begun for the first clients to have completed the program. 

Today, Project Bridge has two teams of two people each — a professional social worker and a paraprofessional — and it has served more than 100 patients.

How effective has the program been? "Of our 100-plus patients, 85% completed the entire 18 months; only three were lost to follow-up — the rest was natural attrition, deaths, moving out of state, or being reincarcerated," she notes. "That, in itself, is excellent for any population."

Through chart review, Project Bridge researchers went back after clients completed the program to see how many had been seen for viral load, and 90% had labs drawn. "That’s kind of phenomenal," Holmes points out.

At baseline, 60% of the clients had no health insurance. "At the point of program completion, 75% had obtained health insurance, so it pays for itself," she asserts.

Other preliminary outcomes include:

  • CD4 counts increased from 423 at baseline to 477 at 24 months.
  • There was a drop in viral loads.
  • There was an increase in mental health services use by clients who indicated they needed the services.
  • There was an increase in the resolution of substance abuse problems by clients who accessed services.
  • Clients report decreased difficulty in finding housing.

[For more information, contact:

  • Leah Holmes, MSW, Program Director, Project Bridge, 369 Broad St., Providence, RI 02907. Telephone: (401) 455-6879. Fax: (401) 455-6893.]