Thursday, March 13, 2025
3/13/2025
Family Health Centers of San Diego, Inc. (FHCSD) (H80CS00224) will increase the number of justice-involved individuals reentering the community (JI-R) who are accessing in-scope health center services that address critical health and health-related social needs by implementing a multifaceted, innovative program. FHCSD’s Reentry Support Services will engage a minimum of 1,000 JI-R in partnership with the San Diego County Sheriff’s Department during the 2-year project period of performance. Needs: Justice-involved individuals (JII) have a higher risk for injury and death than the general public, prompting California to become the first state in the nation to offer Medicaid services specifically targeting eligible youth and adults in state prisons, county jails, and youth correctional facilities for up to 90 days prior to their release. After release, JII face a higher burden of multiple physical and mental health conditions, including substance use disorder (SUD), as well as higher rates of uninsurance, poverty, and use of emergency department services than the general population (Hawks et al, 2020). Navigating the healthcare system is already challenging for most people, but JII often have a harder time due to incomplete/missing documents, low health literacy, and other competing life priorities (e.g., financial instability, housing instability and food insecurity). Over 100,000 of the approximately 1 million uninsured Californians who are eligible for financial assistance reside in San Diego County. Even after successful outreach and enrollment efforts, JII find themselves unable to access the services they need. A pilot project involving JII who were FHCSD patients from 2017-2021 found that at enrollment only about half had health insurance coverage, one third were seeking care at a clinic, one third had an unmet health need, one third were employed, and 85% remained unstably housed. Proposed Services: FHCSD’s Reentry Support Services will build upon existing evidence-based practices from the Transitions Clinic Network (TCN) and offer wraparound services to connect or reconnect JI-R to in-scope health center services that address their unique critical health and health-related social needs. The multidisciplinary care team will include Community Health Workers (CHW) with lived experiences with incarceration and a Clinical Case Manager with expertise in value-based care quality outcomes who together with FHCSD’s larger system of care, will assess, inform, refer, and assist JII in accessing comprehensive services in a culturally responsive manner. The CHWs and Clinical Case Manager will support JI-R with pre-release transitional care management to address both socially and clinically complex needs that require full wraparound coordination of care. The multidisciplinary care team will work with the JI-R clients on individualized care plans and help them navigate services immediately upon release, including but not limited to: connecting them to health insurance coverage, establishing a medical home, and arranging transportation to their first medical appointment. FHCSD will identify at least one Provider Champion who will see patients and also support organization-wide efforts to enhance care for JII clients. FHCSD will also partner with San Diego Second Chance to offer clients with access to supportive resources (e.g., job and housing readiness) that aim to reduce recidivism and break the cycle of incarceration in the community. Populations to be served: FHCSD’s Reentry Support Services will engage a minimum of 1,000 JI-R adults with chronic conditions and/or an unmet behavioral health need within the San Diego County Sheriff’s Department’s system. The population of focus will consist of racially and ethnically diverse, low-income individuals who are primarily residents of or originally have ties to San Diego County.
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).