Quality improvement fund - justice involved - justice-involved populations face significant barriers to healthcare access upon RE-entry into the community, including navigating resources and health…

Quality improvement fund - justice involved - justice-involved populations face significant barriers to healthcare access upon RE-entry into the community, including navigating resources and health insurance access, interrupted care, mental health and substance use disorders, chronic condition management, transportation and housing instability, and stigma and discrimination. Common conditions upon release include hypertension, obesity, diabetes, latent tuberculosis, hepatitis c, hepatitis b, HIV, syphilis, and drug dependency. To strengthen transitions to health care and address these barriers for justice-involved populations, we will create the valleywise health justice collaborative building upon our innovative partnership between a hospital-based healthcare system, maricopa county carceral authorities, and community-based peer organizations. For almost 150 years, maricopa county special health care district, DBA valleywise health (VH) has been arizona's only safety-net health care system serving predominantly low-income populations. Our long-standing relationships with carceral authorities in the phoenix metropolitan area have allowed VH to care for almost 30,000 justice-involved individuals to date. VH provides comprehensive primary care and specialized chronic disease management, including STI treatment, rapid start antiretroviral treatment, and prep. Our integrated behavioral health services for both mental health and substance use include adult and child psychiatry and individual and family therapy. VH supports the entire family, with bilingual libraries and social support services offered at our eight family resource centers. To support justice-involved individuals, VH engages the center for health and recovery (CHR), hope lives, and hope INC. To provide health education, screening for health-related social needs, and referrals to both medical care and social services. Partner in-reach services are staffed by forensic peer support specialists who have lived experience and have received specialized training on the risk-need-responsivity principles and evidence-based practices. The VH justice collaborative will target individuals who are within 90 days of release from prison in maricopa county. The goals of this collaborative model are to increase the number of justice-involved individuals and their families who establish in primary care services, including integrated behavioral health and medication-assisted treatment, through increased engagement in care prior to and upon release. This program will provide a medical home for patients and include intensive patient navigation, links to support services prior to and following release from incarceration, and enhancing access to appointments for primary care, behavioral health, dental, and other specialty care. Following release, individuals will be connected to primary and integrated behavioral health services at our network of 11 federally qualified health centers (fqhcs), located throughout the phoenix metropolitan area. Strategies of this initiative are to 1) hire a justice liaison to coordinate with the carceral authorities and ensure patients transition to VH; 2) support our partner peer run organizations who conduct in-reach services within prisons; 3) streamline patient file transfer to ensure continuity and reduce delays in care; 4) use the VH mobile health unit at post-release orientations hosted by the arizona department of corrections, at which patients will be screened for medical and social needs and initial primary care appointments will be scheduled, and; 5) evaluate the impact of these activities on engagement in care. By addressing the unique health and social needs of justice-involved populations in our community, VH aims to significantly increase their engagement with primary care services and other needed social supports, ultimately improving health outcomes and reducing recidivism.