The St. Luke's-Roosevelt Hospital Center's Coming Home Program (CHP) located in the Morningside Clinic at St. Luke's Hospital in Harlem, New York City, aims to reduce health disparities by providing primary healthcare, mental health, evidence-based interventions and social services to New York City's formerly incarcerated adult populations, primarily African American and Latino, who are re-entering the community upon release from NYC/NYS jails and prisons. The CHP will screen and treat for HIV, HBV/HCV, substance use and/or co-occurring mental disorders (SUD/COD). The CHP will partner with community-based organizations to refer CHP patients for needed support services such as housing, employment training, education support, legal services and family reunification services. The CHP will provide services to 300 formerly incarcerated individuals over a 5-year project period, or 60 formerly incarcerated individuals annually. The majority of NYC's justice-involved population are people of color, with 53.2% being African American and 33.1% being Hispanic. Among NYC's jail inmates, roughly 48% self-report substance abuse upon admission, and 43% need mental health treatment. New York State has the largest percentage of prisoners who have HIV (3.5%) in their custody population, and third largest total number of inmates (1,820) who are HIV positive. It is further estimated that 33% of all people with Hepatitis C pass through the correctional system. The goals and main objectives of the CHP are: Goal 1: Increase the number of formerly incarcerated adults in NYC who receive substance use and mental health treatment and recovery services, by engaging with 60 new formerly incarcerated patients annually in SUD/COD treatment; Goal 2: Enhance the quality/intensity of treatment for patients with substance abuse disorders with/without co-occurring mental health disorders by providing evidence-based treatment interventions to 80% of clients screening positive for SUD and/or COD, including SBIRT, Motivational Interviewing (MI), Cognitive Behavioral Therapy (CBT), Mindfulness-Based Relapse Prevention (MBRP), Seeking Safety, and/or Medication Assisted Treatment (MAT); Goal 3: Enhance and expand screening referral and treatment for HIV and Hepatitis B/C infection among formerly incarcerated adults in NYC by implementing universal HIV/HBV/HCV screening for 100% formerly incarcerated patients and linking patients who test positive to medical care within the Morningside Clinic; and Goal 4: Enhance case management services to address barriers to care, facilitate linkages to follow-up care, and increase access to critical wraparound support services for formerly incarcerated individuals. The CHP will provide case management to 100% of clients enrolled in the CHP, including those patients who are HIV+ or at risk for HIV; the social workers will assist clients with getting health insurance, facilitating internal referrals for medical, mental health and other support services and link them with community partners for other wraparound services.