Quality improvement fund - justice involved - caring health center, INC. (CHC) proposes creating expedited healthcare access points for post-release justice-involved individuals, offering integrated…

Quality improvement fund - justice involved - caring health center, INC. (CHC) proposes creating expedited healthcare access points for post-release justice-involved individuals, offering integrated medical, behavioral (including mat/moud), and social care with a focus on serving low-income, black, indigenous, people of color (BIPOC), hispanic, lgbtqia+, and immigrant/refugee individuals. The hampden county sheriff's 2022 data highlights the urgent need for this initiative: 27% of incarcerated individuals have serious mental illnesses, and 65% have substance use disorders. Black and latino/a individuals are incarcerated at more than twice the rate of their white counterparts, indicating significant racial disparities (hampden county sheriff's department, april 2022). Additionally, 21% of the incarcerated population is 55 or older, often suffering from chronic conditions like hypertension, diabetes, and arthritis (public health institute of western massachusetts, 2022). Lgbtq+ individuals are also significantly overrepresented in the criminal justice system, being incarcerated at three times the rate of the general population, with 124,000 adults identifying as lesbian, GAY, or bisexual, and over 6,000 identifying as transgender (the sentencing project, 2022). The project's objectives are to: (1) drive system change by integrating CHC into the post-release care network, creating referral pathways to ensure seamless, expedited access to services upon release; (2) deliver care coordination through CHC's peer justice-involved (JI) chws starting 90 days before release, ensuring a seamless transition that prioritizes individual health needs and preferences; (3) provide culturally responsive, patient-centered health services addressing chronic conditions, infectious diseases, overdose risk, mental health and substance use disorders, reproductive health, and primary care through in-person and virtual care services; and (4) conduct a local evaluation using fqhc best practices to improve project implementation and assess impacts on health disparities, access, engagement, retention, substance use, mental health, housing, and food security. Building on the preliminary findings of CHC's 2018-2021 samhsa-funded "safe haven" project, which focused on the integration of mat/obat services, several key activities include: work with the hampden county sheriff's office to strengthen partnerships, streamline care processes, and refine referral workflows, hiring a TJI project manager to oversee these tasks; hire two justice-involved (JI) peer community health workers (CHW) and one peer recovery coach to provide services exclusively to justice-involved individuals scheduled to release within 90 days through the hcso, ensuring coordinated, comprehensive health care for pre-trial and sentenced individuals; develop team-based personalized reentry plans with incarcerated individuals, focusing on their individualized health and social needs; provide an expedited medical intake process for justice-involved individuals returning to the community, requiring clear coordination with CHC's front operations/scheduling team and revising existing workflows for faster access; and include integrated primary care enrollment, continuation of mat and BH services, and social risk assessment with referrals to peer (JI) chws in the intake process. The project aims to enroll approximately 250 new clients/patients into CHC primary care and behavioral health services over the two-year performance period.