Wednesday, February 5, 2025
2/5/2025
Brockton Neighborhood Health Center (BNHC) will implement the Brockton Reentry Care Collaborative (BRCC) in partnership with Plymouth County Correctional Facility (PCCF) to address the health and social needs of justice-involved individuals. The population of focus will be adults with 90 days of release and returning to the Greater Brockton area. An evaluation of needs for the BRCC program revealed substantial health disparities related to chronic conditions and behavioral health, including substance use in Brockton and surrounding areas. Residents are disproportionately impacted by diabetes, cardiovascular disease, overdose, and health-related social needs, as well as disrupted access to medical care due to unforeseen health care ecosystem changes. Current justice-involved patients and carceral partners at PCCF described the need for access to reentry-centered primary care, inreach, and integrated behavioral health. They described barriers related to lack of transportation, housing insecurity, and insufficient social support and community connections. Existing programs provide evidence-based strategies for meeting the needs of the justice-involved population. The Transitions Clinic in California attributes dedicated programming for returning individuals, staff training, and the role of a Reentry Community Health Worker (CHW) with lived experience with carceral-system involvement to its success in engaging recently-released patients.14-16 Rhode Island’s Project Bridge promoted follow up among returning individuals living with HIV by conducting inreach within the correctional facility.17,18 BNHC will integrate these lessons into its program. BRCC will be intentionally designed to meet the needs of returning individuals. Program staff members will undergo training to understand the unique needs of justice-involved patients. BNHC and PCCF will collaborate on logistical planning, identifying eligible participants, insurance enrollment, sharing health records with patient consent, and coordinating reentry plans. The treatment team will consist of a provider, Behavioral Health Clinician, and Reentry CHW who will conduct inreach at PCCF. The provider will collect medical histories and medication lists and create individualized treatment plans. Patients may initiate counseling and complete intakes for psychiatric referrals, if desired. The Reentry CHW will execute referrals to community agencies to address participants’ social needs. Prior to release, participants will have scheduled medical appointments at BNHC. Transportation will be arranged to facilitate attendance of same-day appointments when possible. Walk-in appointments will also be offered to ensure low-threshold availability in BNHC’s Adult Medicine Special Populations Pod, designed to integrate primary care, infectious disease, SUD, and behavioral health services for highest risk patients. The CHW will facilitate referrals to partnering health centers for patients returning to locations outside of BNHC’s service area. BRCC appointments will be offered for all justice-involved patients, not only those released from PCCF, as well as adult family members of participants. Pediatric appointments will be scheduled for participants’ children, which is a need identified from patient and community partner interviews. Partnerships with Father Bill’s and MainSpring shelter, Brockton Comprehensive Treatment Center, and Old Colony YMCA will help BNHC address health-related social needs by addressing housing insecurity, SUD treatment, and the desire for community support and connection. BNHC maintains prior experience in the scope of this project. From 2018 until 2020, the RIZE Foundation enabled BNHC to station a Reentry Coordinator at PCCF to facilitate referrals to substance use treatment upon release. The Reentry Coordinator reached 298 unique individuals. BNHC expects that previous inreach efforts will contribute to the future success of the BRCC.
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).