Experience delivering an integrated service model to people with criminal justice system involvement and housing insecurity.

BACKGROUND: People returning to communities from prison or jail face stressors related to securing housing, including discrimination, restrictions based on prior felony convictions, and limited economic and social resources. Existing housing programs can effectively reduce housing instability but often do not fully address the needs of people involved in the criminal justice system experiencing homelessness who often have co-occurring chronic medical issues, and psychiatric and substance use disorders. METHODS: Project CHANGE is an ongoing program to deliver person-centered, integrated care and services to individuals involved with the criminal justice system and experiencing homelessness. Applying a Screening, Brief Intervention, (Referral to) Treatment framework, a comprehensive needs assessment is followed by delivery of intensive housing and vocational case management; and psychiatric, substance use, and medical services in a single location by an interdisciplinary team. Participants are followed with study interviews for 12 months. The current analysis was designed to assess the baseline characteristics and needs of the sample population, and the intensity of contact required for integrated service delivery. RESULTS: Between November 2019 and September 2021, 86 participants were enrolled, of whom 64% had been released from prison/jail in the past 6 months; the remainder were on parole, probation, or intensive pretrial supervision. Participants were unstably housed (64%) or residing outdoors (26.7%) or in a shelter (24.4%). Most participants had high medical need and frequent healthcare engagement through outpatient and emergency department visits. Most participants were at-risk for clinical depression, and half were diagnosed with anxiety, dissociative, stress-related, somatoform, and other non-psychotic psychiatric disorders. Over 12-month follow-up, the interdisciplinary team made over 500 contact encounters, over half of which resulted in direct services provided, including obtaining vital documents for homelessness verification, housing applications, and employment coaching. CONCLUSION: Navigation of services can be particularly challenging for individuals experiencing criminal justice involvement, homelessness, and co-occurring medical, psychiatric, and substance use issues, which can be addressed holistically in an integrated service model. Integrated service delivery was time-, resource-, and staffing-intensive, and challenged by the COVID-19 pandemic, requiring innovative solutions to sustain participant engagement.

Overlapping needs for sexual and reproductive health and HIV prevention in women with substance use disorders.

OBJECTIVES: Women with substance use disorders have high unmet needs for HIV prevention and drug treatment and face challenges accessing care for other unique health issues, including their sexual and reproductive health. METHODS: We did a cross-sectional evaluation of sexual and reproductive health behaviors and outcomes among women with substance use disorders, who were enrolled in one of two concurrent clinical trials of pre-exposure prophylaxis for HIV prevention. Descriptive analyses and bivariate logistic regression were used to assess factors driving contraceptive use, and other essential sexual and reproductive health services utilization and outcomes. RESULTS: Among 226 women, 173 (76.5%) were of reproductive age. Most women had histories of unintended pregnancy (79.2%) or miscarriage (45.1%) and high HIV risk behaviors (53.5%). Most (61%) participants did not use any form of contraception at the time of assessment, although few (15%) reported pregnancy intentions. In bivariate models, ongoing criminal justice involvement was associated with 2.22 higher odds of not using contraception (95% confidence interval = 1.09-4.53; p = 0.03) and hazardous drinking was protective against not using contraception (odds ratio = 0.33, 95% confidence interval = 0.13-0.81; p = 0.02). Contraception use was not significantly associated with any other individual characteristics or need factors. CONCLUSIONS: This is the first study that identifies the unmet sexual and reproductive health needs of women with substance use disorders who are engaging with pre-exposure prophylaxis. We found that women accessed some health services but not in a way that holistically addresses the full scope of their needs. Integrated sexual and reproductive care should align women's expressed sexual and reproductive health intentions with their behaviors and outcomes, by addressing social determinants of health.