Quality Improvement Fund - Justice Involved - Project Title: Transition: Justice Involvement to Community Integration Contact Phone Number: 865-765-0304 Contact Email Address: Parinda.Khatri@cherokeehealth.com Health Center Program Grant Number: H80CS00309 Website: https://www.cherokeehealth.com Address: 2018 Western Ave City & State: Knoxville, TN 37921-5718 The mission of Cherokee Health Systems (CHS) is to enhance the health and well-being of East Tennessee residents by providing high-quality, integrated, comprehensive, equitable, and person- centered care for all. CHS has 19 brick and mortar clinics, a mobile clinic, and 18 school-based sites. As a Federally Qualified Health Center (FQHC), CHS offers family practice, OB-GYN, pediatrics, dental, vision, pharmaceutical services, optometry, cardiology, dermatology, psychiatry and a variety of behavioral health services to all patients regardless of the ability to pay. In 2023, CHS served 65,960 unduplicated patients. As a leader among community health centers, CHS recognizes the multifaceted challenges facing justice-involved individuals reentering the community (JI-R) from the carceral system in Knox County, Tennessee and is committed to strengthening transitions into care for this population. CHS will address post-release Critical Health Needs, including managing chronic conditions, reducing risk for drug overdose, addressing mental health and substance use disorder treatment needs, and screening, diagnosis and treatment of HCV, HIV, and other infectious diseases. CHS will also offer intensive care navigation, as indicated, for the first 120 days after release to provide individually tailored support to assure successful reintegration into the community. These intensive navigation services will include collaboration with a number of community partners to address Health Related Social Needs, including housing insecurity, food insecurity, financial strain, lack of transportation, and intimate partner violence. CHS will partner with the Knox County Sheriff’s Office, a community mental health center’s Criminal Justice Liaison (CJL) program, and the local public defender’s office to coordinate transitions in care with healthcare providers as justice-involved individuals prepare for and reenter the community. CHS will also partner with these community-based organizations to meet JI-R social needs: Vocational Rehabilitation, Knoxville Family Justice Center, and Legal Aid of East Tennessee. Other program activities will include the provision of: - Health evaluation(s) to identify acute and chronic physical health, behavioral health, or oral health needs and care coordination. - Primary health services including diagnosis, treatment, and medication management. - Immunizations. - Behavioral health services and peer recovery support, along with MAT/MOUD. - Screening and treatment for infectious diseases such as HIV, HCV and STIs. - Case management services connecting J-IR individuals with federal, state and local benefits programs to address critical health and health-related needs. - Obstetrical and gynecological care, including prenatal and postpartum care. - Voluntary family planning. - Pharmaceutical services including medication management. Through HRSA QIF-TJI funding, CHS will increase the number of JI-R individuals who: - Receive wraparound support from CHS and community organizations post-incarceration. - Receive in-scope health center services post-incarceration. - Are enrolled in eligible local, state, and federal benefits programs post-incarceration.