Quality Improvement Fund - Justice Involved - Funding Opportunity: Project Abstract for Fiscal Year 2025 Quality Improvement Fund—Transitions in Care for Justice-Involved Populations (QIF-TJI) Community Health Centers of Benton and Linn Counties P.O. Box, 530 NW 27th Street, Corvallis, OR 97339-0579 Lacey Mollel, Interim Executive Director, lacey.mollel@bentoncountyor.gov Project Title: Pathways to Care for Justice-Involved Community Reentry This proposal will improve the care and support for individuals reentering the community after being involved with the justice system (JI-R). Our goal is to create patient-centered, scalable models that address the unique needs of this population. We focus on providing quicker access to primary care, managing medications, treating chronic diseases, supporting opioid use recovery, educating about substance use, and reconnecting individuals to insurance and social support systems. Our project will use proven and innovative methods to tackle the health issues and social needs faced by JI-R individuals. These include managing chronic conditions, preventing and treating infectious diseases like HCV and HIV, reducing overdose risks, and providing mental health and substance use disorder treatments. By focusing on the specific needs of JI-R individuals, we can improve health outcomes, reduce recidivism, and promote successful reintegration into the community. We will engage a network of healthcare providers, social service organizations, and community partners to ensure smoother transitions from incarceration to community care. A key part of this effort is to create immediate access to primary care, following re-entry, to overcome long wait times (usually 9-16 months), increasing meaningful engagement with primary-care. We aim to ensure continuity of medication, especially for chronic diseases and substance use disorders, through collaboration with correctional facilities and community pharmacies. The project will include targeted interventions to manage chronic health conditions. We will also expand access to medications for opioid use disorder (MOUD), along with other comprehensive substance use treatments. Education and scaffolding of services will provide JI-R individuals with resources to support substance use recovery, aiming to reduce short-term relapse risk and encourage long-term success. The project will connect JI-R individuals with insurance benefits. It will also focus on housing, food, clothing, social supports, identification, and more, to address overall health needs. Through this project, we aim to expand our reach and understanding of the resources and supports needed for successful reentry. Collaboration with our local correctional authorities, healthcare providers, and community organizations will ensure a holistic approach to care. Collaboration includes work with the CHC, Linn County Sheriff's Office, Benton County Sheriff's Office, Communities Helping Addicts Negotiate Change Effectively (CHANCE), Family Tree Relief Nursery, Linn County Public Health Department, Benton County Public Health Department, and the Western Restorative Criminal Justice Research Center at Western Oregon University. Together, we can test, evaluate, and support a seamless, integrated care system that meets the complex needs of JI-R individuals and supports their long-term health and well-being.