The Georgia Health Policy Center recently spoke to Rita Torres, the CEO of Health Care Partners Foundation, about efforts to build a comprehensive suite of tools to enhance continuity of care and transitions following the release of incarcerated individuals back into the community. 

To date, what has been the biggest accomplishment or an early win in your Rural Health Care Services Outreach grant program?

One of the early wins was developing user-friendly, electronic tools to really assess comprehensively an individual for their well-being needs. In addition to medical and mental health, it was also looking at housing, transportation, socio-economic needs, and how we could capture that information very quickly. The development of the electronic tools was significant because we had to consider the provider, who deals with a lot of electronic medical record systems that are not very user-friendly. We also recognize that within a correctional setting, there is not too much time with each patient. 

In the final year of the grant, we are going to team up with the data exchange companies so that we can start integrating data into our systems, which will help the community provider group, as well. That kind of information is key. We also are going to look at medication consistency and reporting and to make sure that these individuals are getting their appropriate medication in a timely fashion. We are very excited about adding to what we already have to make it even more comprehensive with even better care coordination in the community. 

What is a tip or early learning you would share with an organization launching a similar program?

For anyone that is trying to do a transitional program, the most important thing is to understand the individuals are going back into the community. So, to do this type of program, you really have to appreciate the individual’s overall sense of worth. We are working in a jail setting, but we come from the perspective of we are going to help you as an individual to go be a part of your community instead of you are an inmate, and you are going to go back into the community. That understanding is very important in order to really have them buy-in to our program. 

How does your Federal Office of Rural Health Policy grant fit into your broader health improvement efforts?  

The way we see this fitting into the broader community efforts is really identifying high-risk individuals, and it does not have to be within a jail setting. What we’re finding is as we work with this high-risk group, there is a family connected to them. And they are also part of the high-risk group. So, by thinking of this entire system and starting with a high-risk population, you are really able to get into the community and touch a lot more groups that are associated with them. That is very important for us as we move forward and what we are now targeting to demonstrate within the communities. 

What will your organization be doing more of or differently to emerge stronger from the pandemic? 

The COVID-19 experience will change all programs going forward, including ours. We started with telehealth and telepsychiatry back in 2011 and what COVID has done on the positive side for us is to bring more exposure to the benefits of telehealth in terms of improving access to care. We have found a way to make patients comfortable with the telehealth systems, especially for telecounseling, because we have a counselor that gets very engaged with the patient. A benefit out of COVID was bringing more exposure to what we wanted to do on a larger level, and that is going back into the community and building safety nets with the telehealth systems.  

For more information on Health Care Partners Foundation, read a piece Rita authored in the magazine of the National Commission on Correctional Health Care. See page 12

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