Presbyterian Medical Services

Quality Improvement Fund - Justice Involved - Presbyterian Medical Services (PMS), a New Mexico Based 501(C)(3) Nonprofit Corporation Serving the Safety Net Primary Care and Enabling Service Needs of New Mexicans for 55 Years Is a 330 (e)(h)(i) Grantee Over 50 Clinic Sites Serving 17 Counties Across the State. Building on This Experience, PMS Has Formed a Collaboration With the Santa Fe County Jail, Life Link, and Santa Fe Rides to Take a Critical Step Forward to Address the Comprehensive Health and Health Related Social Needs of Justice Involved-re-entry (ji-r) Populations During Their Transition From Incarceration to Release to Community-based Health Services by Creating a Support System That Connects This Vulnerable and Under Resourced Target Population to Community Resources That Promote Well-being. the Importance of Connecting Ji-r Populations to Health Care and Human Service Support Is Evident From the High Levels of Physical and Behavioral Health Issues They Experience. an Estimated 80% of Individuals Returning to the Community After Incarceration Have Chronic Medical, Psychiatric, And/or Substance Use Conditions. People in Jails Tend to Have 10 Times the Rate of Hepatitis C Found in the General Population, Half of Incarcerated Individuals Report Having a Chronic Medical Condition, and More Than One Third Report a History of a Mental Health Condition. in Addition, Syphilis Cases Have Increased 80 Percent in the Past Five Years, With Disproportionate Impacts on Racial and Ethnic Minorities Who Are More Likely to Be Incarcerated. Nearly Half of Individuals Entering Incarceration Meet the Criteria for Having a Substance Use Disorder (sud). Many Ji-r Individuals Are at High Risk of Overdose Death Upon Release as They Struggle to Access and Afford Medication-assisted and Other Substance Use Treatments. PMS Will Utilize Grant Funds to Apply the Best Practices of the Patient Centered Medical Home (PCMH) Model for Service Access, Care Coordination, and Integration to the Ji-r Transition Process and Pilot/evaluate Strategies That Connect Ji-r Target Populations With PMS’ Community-based Santa Fe Family Health Center (sffhc). This Clinic Has the Capability of Providing the Target Population With a Quality and Affordable Medical Home Offering Medical, Mental Health, Sud, and Oral Health Services as Well as Care Coordination/case Management, Translation, and Enabling Services. This Pathway to Community-based Care Will Be Accomplished by Creating Two Transition Teams Composed of a Community Health Worker (medical Care Coordinator) and a Certified Peer Support Worker (case Manager) With Lived Experience in Confinement. Teams Will Begin Engagement With the Detainee Prior to Release to Make Transitions to Community Support More Personnel and Provide Stability. Transition Services Will Focus on Conversational Screens to Help the Detainee Identify Their Experiences and Needs for Services Following Release. the Intent of This Process Is to Craft a Non-institutional Coming Along Side of the Person to Ensure Their Transition to Civilian Life Is Supported and Empowering. Transition Groups Will Be Used to Address Psychoeducational Needs and Best Practice Tools Associated With Core, Seeking Safety and PSR Strategies Will Be Available. Referrals and Coordination With Primary Care, Behavioral Health, And/or Psychiatric Providers Will Be Facilitated and Entry Into Behavioral Health Services Will Be Available via Rapid Access/treat First. Other Services Related to Personal Identification; Benefit Status; Medication Transition; Employment; Housing; and Transportation Will Be Offered. Post-release Transition Services Will Include Ongoing Outreach to Nurture Engagement in Community-based Services, Re Assessments of Needs, Support for Attachment to Other Health and Human Service Programs Identified After Release, and Ongoing Assessments of Effectiveness of Referrals/services Will Be Provided.