Health Center State Policy, Social Determinants of Health

Removing Barriers to Care for Those Who Served Behind Bars

By Alisha Reginal, NACHC Intern

Community Healthcare Network (CHN) is a Community Health Center with eleven sites that serve over 80,000 patients in Brooklyn, the Bronx, Queens, and Manhattan. Over 5,000 of CHN’s patients are enrolled in New York’s Health Homes program.  Created as part of the Affordable Care Act, the Section 2703 Health Homes program (now in operation in 20 states and the District of Columbia) aims to create new opportunities through Medicaid to boost health services to beneficiaries, especially people who suffer from complex health care needs (such as mental health, substance abuse, asthma, diabetes and heart disease). To be eligible, Medicaid beneficiaries must have or be at risk for two or more chronic conditions (including poor mental health).

In connection with the state’s Health Homes program, New York formed six pilot programs focused on connecting people to critical health services upon release from jail or prison and reduce costly ER usage and hospital admissions. CHN saw a need for such services among their patients who were recently released from incarceration — not only were the patients at higher risk for mental illness and substance abuse, they were also more likely to develop chronic health conditions than the general population. The health center joined one of the pilot programs and partnered with The Fortune Society, a care management agency that has extensive expertise in working with people who have had some involvement with the justice system and are in transition. The Fortune Society provides housing, employment, education, behavioral health, health, and other services to patients in need.

This pilot program has been beneficial on even the most seemingly basic levels. For example, upon release from a state facility, many people are discharged to a shelter in New York City and may receive funds to use the metro to get to their parole office, to medical appointments, or to various other service providers, such as the Human Resources Administration (to activate their Medicaid) or to their specified care management agency. But what if someone who been incarcerated for over twenty years doesn’t know how to purchase a MetroCard or use the metro system? That is where care managers come in. CHN’s care managers help the clients navigate through those critical first days, helping them prioritize their appointments and initiating a plan of care that will guide them in their reentry. They also conduct a brief needs assessment for things such as obtaining (or reactivating) insurance, identifying a primary care physician, scheduling an initial medical appointment, making necessary referrals for mental health services, and ensuring that the client prescriptions are filled. Once the emergency needs are tended to, the care management team works in tandem with the client to address key social determinants, such as granting emergency funds to access food or a coat. In addition to care managers, The Fortune Society also provides liaisons who foster relationships with state and county facilities to help expedite social service appointments for justice-involved individuals.

CHN plans to expand the pilot past its 14-month pilot time frame with the expectation that this model will become a best practice to help former inmates stabilize their health and lives as they transition back into the community. After all, healthy people make healthy communities and CHN’s efforts on this front not only make people healthy, it ultimately may help in preventing recidivism back into incarceration.

A special thank you to Dorothy Farley and Alyssa Lord of Community Healthcare Network.