Quality improvement fund - justice involved - cumberland family medical center, INC. (CFMC) is a federally qualified health center (FQHC) serving 32 rural counties in south-central and north-central…

Quality improvement fund - justice involved - cumberland family medical center, INC. (CFMC) is a federally qualified health center (FQHC) serving 32 rural counties in south-central and north-central kentucky. Pulaski county, the state's third largest county by area and the 14TH largest by population (65,795 residents), is part of our federally designated service area. In this county, we provide dental, OB/GYN, pediatrics, behavioral health, primary care, substance use disorder (SUD) services, and medically-assisted treatment (mat) across five clinic locations in the county seat of somerset. With a mission to provide affordable, accessible, high quality health care to all patients regardless of income or ability to pay, we are applying for the "quality improvement fund - transitions in care for justice-involved population" (QIF-TJI) grant. If funded, CFMC will partner with the pulaski county detention center to strengthen the transition in care for individuals who are within 90-days of release, or scheduled release, from incarceration, by increasing their access to community-based primary care services within the detention center and prior to release. With a large inmate population of approximately 320 at the time of this application, pulaski county houses one of the largest numbers of county level detainees in our service area with space for detainees from both pulaski and lincoln counties - both within our CFMC service area. To implement this project and meet transitional needs in care, we will build upon existing evidence-based models to pilot and evaluate innovative approaches that connect justice-involved individuals reentering the community to in-scope health center services that address their unique critical health and health related social needs. To accomplish this goal, we will use grant funding to hire designated medical and support staff to partner with the county jail and other local social support groups in pulaski county. By creating a bridge between the detention setting and RE-entry into the community, we can ensure that no gaps in health services are created, and social determinants of health are met for both the detainees returning to the community and their families who are also affected by their incarceration. Those receiving care for chronic conditions (i.e., diabetes, heart disease) as well as those requiring assistance with addictive and/or behavioral disorders, will be provided a continuity of care through health center services provided pre-release and then continued post-release through the clinical options available to them through CFMC locations in pulaski county including our promise community health center that focuses on the integration of primary care and behavior health for those recovering and in recovery from addictive issues or who may benefit from individual or family therapy. Our project will be unique in that IT is a pilot project for this area and will not supplant or duplicate any funding for health services currently provided as required by the county or state for detainees. Our additional partnerships with local social service agencies will ensure that our patients in this project will also have appropriate assistance ascertaining employment, health insurance, education, housing, and transportation needs as they transition back into the community. Located in one of the most impoverished US congressional districts in the nation in a state that ranks 46TH out of 50 for being the least healthy, pulaski county ranks 75 out of 120 kentucky counties for quality of life. This project will bring much needed attention and services to a demographic of people that are currently among the least healthy and the most under-served. IT is our goal to change that.