Quality Improvement Fund - Justice Involved - AccessHealth serves as a 501(c)(3) Federally Qualified Health Center and primary safety net clinic system for Texans regardless of income or health insurance coverage. We are partnering with Fort Bend County Sheriff’s Office Jail to strengthen transitions in care for justice-involved populations during the community re-entry process and provide essential health care services. In 2022, Fort Bend County Jail saw 1,749 arrests, and the top 3 offenses were simple assault (481), drug abuse violations (332), and driving under the influence (241). With 60% of arrests falling into these categories, it becomes clear that this population shows higher rates for a substance use disorder (SUD), other mental health issues, or co-occurring disorders. Fort Bend County Health & Human Services estimates that almost 15% of men and 31% of women recently booked in jail have a serious mental illness, and that many have co-occurring disorders of substance abuse. A significant number of incarcerated individuals also experience chronic health conditions. The Texas Department of Criminal Justice (TDCJ) reported that 30.06% of incarcerated individuals in 2019 were diagnosed with hypertension, and other frequently seen conditions such as asthma (7.34%), diabetes (6.91%), and hepatitis C (8.91%) require costly, specialized treatment. A recent Johns Hopkins study suggests that chronic and mental illness may be greatly undertreated in U.S. jail and prison systems. While carceral healthcare is lacking in many areas, for some, it is the closest thing to proper care they’ve received. For incarcerated individuals who will soon be released, they face the uncertainty of their continued care. Texas being a state which terminates Medicaid coverage upon incarceration causes delays for re-entering individuals to receive healthcare services. Since these vulnerable populations cannot afford costly prescriptions to manage their health, they become highly susceptible to worsening health conditions or relapsing, increasing the chances of recidivism. It is important for this transient population to be guided into a medical home rather than slipping through systematic cracks, especially if they have a chronic disease or mental health condition. AccessHealth is in a unique position to help end this cycle of unmanaged conditions and connect released individuals to community resources and social support. We will accomplish this by hiring a reentry Community Health Worker (CHW) who has lived experience with justice-involved populations, and they will serve as the bridge between AccessHealth and Fort Bend County Jail. The biggest barriers to care for reentering individuals are lacking the necessities required to sign up for assistance, such as a home address or government ID. The reentry CHW will work with them in-person within the 90-day release period to begin collecting information to streamline the process and connect them via telehealth services with a primary care provider to foster the provider-patient relationship. Upon release, individuals will be enrolled into an AccessHealth facility and take a reentry screening for integrated care to determine their SDOH needs. There, they can access primary care, OB, dental, etc., to ensure continuity of care. If needed, they can be connected to AccessHealth’s behavioral health team. For basic needs, we have internal program referrals for our partner organizations (Houston Food Bank, Texas Workforce Solutions, United Way), and the CHW will initiate these applications. The success of our project will be defined by helping re-entry individuals manage chronic conditions, addressing mental health and substance use disorder treatment needs, and working with community partners to meet our target population’s health-related social needs. AccessHealth's collaboration with Fort Bend County Jail will strive to enhance transitional care for justice-involved individuals to facilitate successful community reintegration.
