Quality improvement fund - justice involved - hrsa H80 grant number: H80CS00529 family first health proposes to provide medical care and assistance with navigation of social determinants of health…

Quality improvement fund - justice involved - hrsa H80 grant number: H80CS00529 family first health proposes to provide medical care and assistance with navigation of social determinants of health to those within 90-days of reentry into the community from york county prison in york, pennsylvania. This project will connect individuals to care at FFH's sites in the service area for the delivery of medical (including behavioral health and substance use services), dental, optometry, and podiatry services upon their release from york county prison. Needs to be addressed FFH's project will support several needs of the individuals scheduled for reentry into the community within 90 days. These needs include prevention, screening, diagnosis, and treatment of hepatitis C and HIV, as well as other infectious diseases. We will also address the needs of reducing the risk of drug overdose and addressing mental health and substance use disorder treatment. The team will support individuals participating in this program with health-related social needs including housing insecurity, food insecurity, financial strain, and lack of transportation or access to public transportation. Proposed services an FFH clinical provider and clinical care team member will provide services onsite at the prison which include clinical assessment and screening for individuals pending release within 90 days. The focus will be on chronic health condition identification and coordination of management with prime care (the onsite carceral medical provider); prevention, screening, diagnosis and treatment connections for hepatitis C, HIV, and other infectious diseases; screening for substance use concerns and providing bridge medications and warm hand-offs to mat treatment at FFH or other local community providers; connection to primary medical, dental, optometry, and podiatry care in the community upon release; assessing and providing bridge support and services for behavioral health concerns; and providing accessible pharmacy opti ONS for individuals pending release. Additionally, working in coordination with other local community organizations such as the york county reentry opportunity center, an FFH community health worker will provide support for individuals with social determinants of health challenges and barriers, addressing needs in transportation, housing, financial stability, and food access. Population groups to be served we will pilot the program by targeting individuals on work release and minimum risk incarcerated individuals at the prison. Our second priority will be individuals with known sentence lengths and planned releases to the community. As the project progresses, we hope to be able to provide services for those with non-predictable releases, or those with time served.