Problem
Problematic Behavior Or Activity
More than 200,000 Oregonians spend time in a correctional facility every year, many of whom suffer from untreated chronic illness, disease, mental health, and/or substance abuse disorders. Between 70% and 90% of justice-involved adults were uninsured before the implementation of the Affordable Care Act (ACA).
Although these individuals are now eligible for health insurance, many still face complex barriers to health insurance enrollment and access to care. Low levels of health literacy, the tendency to utilize emergency room services over a primary care provider (PCP), and delays in coverage due to confusion upon release from coverage results in a lack of adequate health care.
Solution
Program Description
The Health Assessment and Treatment (HAT) team is a coordinated effort between the Department of Community Justice (DCJ) and the Multnomah County Health Department aimed at improving access to health care by connecting adults involved in the criminal justice system with community based support services and providers.
The team consists of a Community Health Nurse, Community Health Worker, Corrections Counselors, Parole Officers, and Dual Diagnosis Evaluators. Each position plays an integral role in targeting formerly incarcerated individuals who have a chronic disease or mental health issues and assisting them with successfully transitioning back into the community. This is done by providing services such as Oregon Health Plan enrollment, finding a PCP, dentist, pharmacist, or therapist, and securing other basic necessities.
The nurse, health worker, corrections counselor, and parole/probation officer establish a care plan with the client. This care plan includes enrolling with a PCP, finding a pharmacist and getting prescriptions filled, educating the client about chronic disease management, assisting in obtaining vital records, and connecting to safety nets like SNAP (Supplemental Nutrition Assistance Program). Additionally, the team engages in advocacy for other needed supports, such as housing and transportation, to increase client engagement, stabilization, and successful transition into the community.
The care plan is intended to set clients up for long-term success by teaching them how to navigate the system and advocate for themselves, while creating a shared understanding between the health care and community corrections communities.
Funding
The first year of the HAT team was paid for by a grant from Health Share of Oregon. Going forward the HAT team will be funded by the DCJ and the Health Department’s general funds. The Health Department funds the Community Health Nurse and the Community Health Worker.
Outcome
Program Impact
Since its inception, the HAT team has enrolled more than 200 individuals in the Oregon Health Plan. More than 500 individual drug and alcohol evaluations have been completed, and 44 individuals have been connected with primary care physicians and other care providers.
Having access to a PCP results in the reduction of emergency-service utilization because clients may get the health care and medications they need before an issue spirals out of control. Additionally, there has been a positive correlation with a reduction in jail-bed usage and the HAT team’s efforts.