Quality improvement fund - justice involved - medlink georgia, INC

Proposes the thrive "reentry to wellness initiative," a comprehensive, patient-centered project designed to enhance transitions in care for adult individuals scheduled to be released from incarceration within 90 days. This initiative will ensure a seamless continuum of care, beginning 30 days prior to release and extending through their reintegration into the community, providing access to high-quality comprehensive healthcare such as primary care, chronic care management, behavioral health, medication-assisted recovery, and case management support to address both health and health-related social needs. The transition from incarceration to community life is a critical period, often marked by significant health challenges and social instability. Justice-involved individuals (JI-r) face heightened risks for chronic conditions, infectious diseases, substance use disorders, and mental health issues. Additionally, they encounter barriers such as housing and food insecurity and financial strain. By addressing these needs, the proposed project aligns with medlink georgia's mission to support wellness through compassionate, quality healthcare, aiming to reduce health disparities in rural and medically underserved areas. Building on existing evidence-based models, our initiative will pilot innovative approaches to connect JI-r individuals with our comprehensive health center services. Leveraging established partnerships with local correctional facilities, community organizations, and specialty healthcare providers, we will create a coordinated care network. This network will ensure individuals receive pre-release care coordination starting 30 days prior to release, including comprehensive health assessments, chronic disease management plans, and mental health evaluations. Additionally, we will provide a combination of in-person and telehealth consultations to manage chronic conditions, screen for and treat infectious DIS eases (such as HCV and HIV), and address mental health and substance use disorders. Furthermore, case management services will connect individuals with housing, food, transportation, and financial resources, utilizing partnerships with local housing agencies, food banks, and public transportation services to address social determinants of health. With this grant, we can provide critical services to underserved populations in our area, improving health outcomes and quality of life. Our project aims to reduce the incidence of chronic disease complications and infectious disease transmission, decrease the risk of drug overdose and relapse, improve engagement in mental health and substance use disorder treatment, and enhance social stability by addressing housing, food, and transportation needs. By addressing these critical factors, we also aim to lower recidivism rates by promoting stable and healthy reintegration into the community. To inform project development and evaluation, we will gather input from health center patients, staff, and community partners, including individuals with lived experience of incarceration. Success will be measured by health outcomes, patient engagement, social stability metrics, and recidivism rates, with continuous feedback loops to adapt and improve the initiative.