Tuesday, April 29, 2025
4/29/2025
Quality Improvement Fund - Justice Involved - In operation since 1976, Optimus Health Care, Inc. (Optimus) is a patient centered Federally Qualified Health Center that continuously grows its network throughout medically underserved and health professional shortage areas in Fairfield and New Haven Counties, Connecticut (CT). For the past 8 years, Optimus has been part of the Transitions Clinic Network (TCN), a national organization dedicated to eliminating racial health and economic disparities caused by mass incarceration. Optimus’ Transition Clinic annually serves about 50 justice-involved individuals reentering (JI-R) the community after incarceration. The State of Reentry 2024 report, examining the CT Dept of Correction (DOC) Census as of June 1, 2023, highlights mental health, substance dependency, and housing challenges faced by returning citizens. Among those with sentences ending within 6 months: 93% reportedly had a substance use problem (48% serious or extremely serious); 37% had a moderate to severe mental health disorder; 74% were assessed as needing some level of nursing care. Black/African Americans and Hispanic/Latinx are overrepresented within CT’s prisons. The CT prison population was 42% Black, 29% White and 28% Hispanic, with men comprising 88% and women 2%. This project will demonstrate innovative collaboration with CT’s criminal justice system to enhance the continuity of care for JI-R individuals. The project will be supported by TCN to promote existing evidence-based interventions and strengthen pre-release planning and cross-sector collaboration. The model of care is designed to CT’s prison landscape. As a small state, CT is comparable in size to many state counties. Consequently, its prisons operate based on functionality rather than geographic location. For example, within Optimus’ HRSA approved service area, the Bridgeport Correctional Center holds many pre-trial individuals who would not be the subject of this opportunity. Optimus’ carceral partner includes Bridgeport Correctional Center and is negotiating with DOC to identify JI-R individuals across CT returning to Optimus service area. A special emphasis is on addressing the healthcare needs of JI-R women given the lack of services in the greater Bridgeport area for this population. The project will enhance partnerships with current community organizations that include Career Resources Inc. (CRI), a statewide leader in re-entry programs and employment with strong ties to DOC. CRI will collaborate with discharge planners, court administrators, and probation departments, and conduct outreach within correctional facilities to compile lists of patients scheduled for release within 90 days. CRI will also identify individuals transitioning to DOC halfway houses for follow-up. Within 30 days of release, a case manager will meet the JI-R individual in the carceral or community supervised setting to assess social determinants of health, including intimate partner violence screening, health insurance status, food assistance, housing, transportation, employment, and other referrals. The case manager, paired with a nurse, will perform clinical assessments, rapid HIV and HCV testing if needed. The nurse will coordinate appointments with Optimus medical providers and mental health professionals via telehealth. Patients with substance use disorders will be referred to Recovery Network of Programs, a substance use treatment center in operation for 50 years. Sacred Heart University's College of Health Professions will support the project by providing an Advanced Practice Registered Nurse for 8 hours per week and supervising Doctor of Nursing Practice or Family Nurse Practitioner students for added capacity. Upon release, the patient will be established as a patient at Optimus or be provided a warm hand off to a health center located where the JI-R individual will reside. Project costs include staffing (case manager, nurse, program director) outreach services (CRI), technical assistance (TCN), and technology.
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).