Tuesday, May 20, 2025
5/20/2025
Quality Improvement Fund - Justice Involved - Treasure Coast Community Health (TCCH) requests $1M through the Fiscal Year (FY) 2025 Quality Improvement Fund – Transitions in Care for Justice-Involved Populations (QIF-TJI) to implement a pilot program utilizing a combined MAT/Case Management approach to provide support to incarcerated individuals who are within 90 days of release from the Indian River County (IRC) Jail, located in Vero Beach, FL. The goal of this program is to strengthen transitions in care for these individuals by increasing their access to community based, high quality, primary care services. Specifically, this program will increase the number of JI-R (Justice-Involved individuals Reentering the community) who receive in-scope health center and wrap-around services in order to facilitate successful continuity of care while improving overall health outcomes. TCCH currently provides 24/7 health care services, along with comprehensive intake assessments for all inmates under the supervision of the Indian River County Sheriff’s Office (IRCSO) Department of Corrections (DOC). All 5,800 individuals incarcerated annually have access to TCCH services. As those individuals transition from incarceration, the Public Defender’s (PD’s) Office provides voluntary re-entry support to assist eligible inmates in identifying community resources to assist in reintegrating as a productive member of society. These services, however, are limited, as the PD’s Office serves a three county-area, resulting in the ability to meet with just four individuals weekly at the IRC Jail. Additionally, there is no post-release follow-up provided to inmates, reducing the effectiveness of such services. As up to 50% of incarcerated individuals meet the criteria for substance use disorder (SUD), leaving them at high risk for overdose and death upon release, TCCH will focus its transitional care pilot program on this population. There currently exists no formal, established MAT program at the IRC Jail. JI-R individuals will be assessed for eligibility for MAT within 90 days of their scheduled release. Treatment plans will be developed for those determined to benefit from MAT, using a Risk-Needs-Responsivity (RNR) tool; for while SUD is one of the 'Big 8' risk/need factors associated with criminogenic outcomes, the impact of other factors count (i.e. history of antisocial behavior, antisocial personality pattern, antisocial/procriminal attitudes, antisocial associates, problematic circumstances at home or work, few/no prosocial recreational activities). These treatment plans will carry them forward until they have established ongoing care at one of TCCH’s eight health centers throughout IRC. Concurrently, JI-R individuals will be assigned a case manager who will utilize TCCH’s strong network of health-related social needs partners to guide them and their families in accessing enabling services, including care coordination, eligibility assistance, housing, food insecurity, employment and education. The program, which will be tailored to meet the specific needs of the JI-R individuals under the supervision of the IRCSO DOC, will be modeled on evidence-based models of care, such as California’s Transitions Clinic Network, the South Carolina ReConnect US Program/Seamless Transitions, and the New York Community Justice Reentry Network. In addition to increasing access and engagement with TCCH health center services, this program will also address inequities in the justice system, where people of color (POC) are overrepresented in jails and prisons. While Black/African Americans represent 9.2% of the general population in IRC, they represent 33% of the IRC inmate population. TCCH’s diverse workforce/peers will provide cultural support. TCCH will conduct ongoing evaluation in order to identify any barriers that might inhibit successful outcomes. Upon completion of the period of performance, a comprehensive assessment will be done to strengthen the program and scale it for larger populations.
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).