Quality Improvement Fund - Justice Involved - Project Title: Fiscal Year 2025 Quality Improvement Fund - Transitions in Care for Justice-Involved Populations Applicant Name: University Muslim Medical Association, Inc. Community Clinic Health Center Program Grant Number: H80CS10609 Applicant Address: 711 West Florence Ave., Los Angeles, CA 90044 Project Director Name: Adel Syed, Ed.D, Chief Executive Officer Contact Phone Number (Phone/Fax): (323) 406-5800 ext. 1010 / (323) 233-2685 Email Address: asyed@ummaclinic.org Web Site: https://www.ummaclinic.org/ List all grant program funds requested in the application: $1,000,000 UMMA Community Clinic (UMMA) is part of a larger network of institutions addressing the health and well-being of underserved and indigent populations in Los Angeles County (LAC), California. UMMA serves communities in South Los Angeles, an area located in the southern portion of LAC, mostly within the Los Angeles city limits, south of Downtown Los Angeles (LA). Our service area is a densely populated urban core with a significant unmet need related to primary care, mental health, and oral health services as demonstrated by a shortage of healthcare providers. Our Health Professional Shortage Area (HPSA) scores are 19 for primary care, 25 for dental health, and 19 for mental health. The most recent available quarterly report (January - March 2024) shows that the Average Daily Inmate Population (ADIP) in the LA County jail system was 12,408. According to researchers, an estimated 18% of the U.S. prison population may be infected with Hepatitis C virus (HCV). This suggests that the number of people living with the virus in Los Angeles County’s jail system is likely in the thousands. Incarcerated populations tend to also be disproportionately affected by HIV and sexually transmitted infections (STIs). Moreover, the number of people with mental illness and addiction issues in LA County jails has surged 20% since 2020, with more than 5,000 people with mental health needs, according to the LA County Sheriff’s Department. UMMA’s strategy is to conduct in-reach and outreach to justice-involved (JI) populations reentering our community to enhance health outcomes and reduce recidivism. Using a model of harm reduction, UMMA offers culturally sensitive, trauma-informed, holistic care in a community that is known to have complex social and medical needs. We strive to provide this in all four lines of service: medical, dental, and behavioral health, and case management. UMMA plans to focus on the following critical health needs of the re-entry population: prevention, screening, diagnosis and treatment of HCV, HIV, and other infectious disease. The following social needs will be addressed: housing insecurity. UMMA already offers medication-assisted treatment (MAT) for substance use disorders, Hepatitis C treatment, and bridge therapy to long-term HIV care. We have robust food, housing, and wellness programming, as well as related community partnerships, which enable us to address various social determinants of health. The availability of these additional medical and social services position us to provide comprehensive care to the JI population. For this project, UMMA is proposing to implement an innovative adaptation of the evidence-based Navigator Case Management intervention which was found to significantly increase linkage to and engagement in HIV care for reentry HIV-positive individuals. The project also incorporates contingency management to incentivize patients’ access to treatment and will utilize peer navigators with lived experience as JI individuals and case managers trained in motivational interviewing. UMMA has established communication with the Los Angeles County Department of Health Services’ Correctional Health Services (CHS). This communication, especially with CHS has introduced UMMA as a central prospective partner for care plan transitions and continuity of care and treatment of JI individuals reentering the community.