Wednesday, February 5, 2025
2/5/2025
Address: 405 Belcher Street, Centreville, AL 35042-2946 Project Director Name: John B. Waits, MD Email Address: John.waits@cahabamedicalcare.com Contact Phone Numbers (Voice): 205-312-8080 (Fax): (205) 316-7675 Website Address: www.cahabamedicalcare.com HCP Grant Number: H80CS24177 Summary: Cahaba Medical Care Foundation (CMC) seeks funding through the HRSA Fiscal Year (FY) 2025 Quality Improvement Fund – Transitions in Care for Justice-Involved Populations (QIF-TJI) to enhance and expand its services aimed at facilitating the transition of justice-involved individuals reentering the community (JI-R). This initiative focuses on improving access to community-based, high-quality primary care services within 90 days of release from incarceration, addressing this vulnerable population's critical and complex healthcare needs. Partnering with the Bibb County Court system and the Bibb County Correctional Facility, CMC aims to implement a comprehensive care transition program to mitigate health disparities for those released from prison. Justice-involved individuals often have acute healthcare needs and face challenges such as a lack of education on their medications and diagnosed conditions, frequent misdiagnoses, and inconsistent treatment regimens. By integrating evidence-based models and piloting innovative approaches, CMC will connect or reconnect JI-R individuals to our Federally Qualified Health Centers (FQHCs) and other local healthcare facilities. The core of this program will leverage CMC’s robust behavioral health and social services departments to ensure a seamless transition for JI-R individuals. Our multidisciplinary team will provide personalized care coordination, health education, and social support services to address the unique needs of each individual by: Conducting thorough comprehensive health assessments, SDOH screenings, and medical, behavioral health, and substance use screenings pre-release to identify and document existing health conditions, medication needs, and any immediate health concerns at the jail. Developing personalized care plans that outline post-release healthcare management, medication adherence strategies, and necessary follow-up appointments with primary care providers at CMC where they will be seen within 2-4 weeks depending on their personalized risk assessment and medical acuity. Offering behavioral health support, including counseling and therapy, to address the high prevalence of mental health issues and substance use disorders among JI-R individuals through CMC’s behavioral health team with appointments scheduled within 2 weeks of discharge. Assisting with access to essential social services such as housing, food, employment, and transportation through the CMC Community Center that are critical for the holistic well-being and successful reintegration of JI-R individuals. Offering each patient, at the time of release, an opportunity to meet with a CHW and provider to discuss their medications, diagnoses, and care plan in a health-literate way. By addressing both healthcare and social determinants of health, CMC’s program aims to reduce recidivism and promote long-term health and stability for JI-R individuals. The program will employ a rigorous evaluation framework to assess its impact, including healthcare utilization rates, adherence to care plans, and overall health outcomes. CMC’s initiative aligns with HRSA’s mission to improve health outcomes for underserved populations by ensuring that justice-involved individuals receive the necessary support to transition smoothly back into society. With HRSA’s QIF-TJI funding, CMC will build upon its existing infrastructure to pilot this innovative program of an integrated transition plan for medical and behavioral health within a rural court system, ultimately creating a scalable model that can be replicated in other communities facing similar challenges.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).