Quality Improvement Fund - Justice Involved - SSTAR will partner with the Bristol County Jail and House of Correction, the City of Fall River, and community partners to implement Revive, Re-enter, Restart (RRR): Reconnecting and Wellness project. The project’s overarching goal is to demonstrate reduced rates of recidivism for justice involved-returning (JI-R) individuals by ensuring they have access to tools and resources to help them manage primary and chronic health conditions, prevent/screen/diagnose/treat HCV, HIV, and other infectious diseases, reduce drug overdose risk, address mental health and SUD treatment needs, and linkages to other basic needs that correlate to health outcomes including food, housing, and transportation. RRR will utilize the Critical Time Intervention (CTI) evidence-based model to plan and implement a range of services that strengthen transitions in care for individuals being released from incarceration including increasing their access to high-quality primary care services. CTI facilitates community integration and continuity of care by ensuring that re-returning justice involved populations (JI-R) have ties to their community and systems of support during the critical re-entry period. To ensure fidelity to the CTI model, the project will operate through a phased-based approach including a Pre-phase, Phase 1 (Transition), Phase 2 (Try-out) and Phase 3 (Transfer of Care). During the Pre-phase we will work with the Bristol County Jail and House of Correction to provide in-reach activities and build trust with patients. During Phase 1 we will connect patients to SSTAR clinicians and other key staff who will assume primary roles of support for each patient’s CTI duration; in Phase 2 we will monitor and strengthen the support network and patient’s skills, while mediating conflicts between patients and providers; in Phase 3 we will ensure the patient and their identified supports can function safely and in-place, and will hold final meetings with patients and support providers to transfer care. (https://www.criticaltime.org/cti-model/cti-implementation-faqs/) The project will focus on the following critical health needs for JI-R individuals: managing chronic conditions, preventing, screening, diagnosis and treatment of HCV, HIV, and other infectious diseases, reducing drug overdose risk, and addressing mental health and substance use disorder treatment needs. In addition, we will provide case management and services specific to lack of transportation, access to transportation, food insecurity and housing insecurity. Across RRR, qualitative and quantitative evaluative measures such as interviews, focus groups, and surveys will be used to measure impact. Throughout the project, we will strive to develop and maintain trusting relationships with each client, validating their experiences, and listening to their needs. SSTAR will take a community-based participatory approach, working with all stakeholders on all aspects of the project including collecting data, analyzing results, and disseminating findings. In addition, SSTAR will utilize Culturally and Linguistically Appropriate Services (CLAS) standards, a set of 15 guidelines established by the US Department of Health and Human Services, (HHS) to bridge the gap in healthcare access and quality for people from various cultural and linguistic backgrounds by ensuring respectful and responsive service delivery.
