Multnomah County

Quality Improvement Fund - Justice Involved - Brief Description of the Proposed Project - Multnomah County Community Health Centers (MCCHC) Will Work With Fellow Multnomah County Health Department (MCHD) Division Corrections Health (CH) to Strengthen Transitions Into Primary Health Care for Individuals Soon to Be Released From Multnomah County Jails. Mcchc and CH Will Develop New and Formalized Workflows to Allow Mcchc Case Managers and Nurse Case Managers to Provide Linkage Support Within the Jail Up to 90 Days Before Individuals Are Released. Case Managers Will Use This Engagement to Establish Relationships Pre-release and Work Toward Streamlined Access to Primary Medical Care Through Mcchc Upon Individuals’ Release. the Project Will Focus on Transition to Care for Individuals With Mental Health and Substance Use Disorder Treatment Needs, Especially Those Receiving or Looking to Initiate Medication for Opioid Use Disorder (MOUD) and Those With Severe and Persistent Mental Illness, Which Often Requires Complex Medication Management Including Long-term Injectable Medications. Mcchc Will Work With Community Partners to Support Clients Around Health-related Social Needs, Especially Housing and Nutrition Security. Needs to Be Addressed - People Released From Multnomah County Jails Experience Numerous Barriers to Accessing Primary Care Upon Reentry to the Community, Including Competing Needs for Survival, Stabilization, and Self-sufficiency, as Well as Challenges Around Mental Health and Substance Use Disorder. However, the Latter Underscores the Importance of Establishing a Medical Home. Approximately 80% or People Housed in Multnomah County Jails Struggle With Substance Use, 65% Have a Mental Health Diagnosis, and 45% Are Dually Diagnosed for Mental Health and Substance Use Issues. Despite Strong Transition Planning Services and Existing Collaboration Between Mcchc and CH, MCHD Is Confident That Formalized Workflows and Integration of Evidence-based Practices Into These Processes Will Increase Linkage to Care for Released Individuals to Primary Care With Mcchc. Proposed Services - Mcchc Will Provide Care Coordination and Case Management Through a Registered Nurse Case Manager, Behavioral Health Case Manager, and Peer Support Specialist in Multnomah County Jail Settings Within 90 Days of Individuals’ Release. the Transition of Care Will Include Health Assessment and Goal Planning; Medication Reconciliation, Management, and Arrangement for Community-based Continuity; Eligibility Screening/insurance Enrollment; Pre-release Registration and First Appointment Scheduling With Mcchc; Navigation for Additional Mental Health and Substance Use Treatment Services; and Peer Navigation to Follow Through With and Support Access to All Medical, Psychosocial, and Other Resources. Evidence-based Practices Will Include Pre- and Post-release Moud, Jail In-reach Case Management, Peer Support Services, Shared Erm for Health Information Exchange, and Patient Centered Medical Home and Accountable Care Organization Models. Two Housing and Food Security-focused Community-based Organizations Have Provided Letters of Commitment to Coordinate Referrals. Mcchc Will Collect Ongoing Patient Input Through Client Surveys and Will Refer Clients to and Engage Community for Input Through a Local Leadership Group for People With Lived Experience of Incarceration. Population Group(s) to Be Served - Mcchc’s Transitions in Care Project Will Serve Adults to Be Released From Multnomah County Jails, With a Focus on Those With Mental Health and Substance Use Disorder Treatment Needs.