st. louis integrated health network (ihn) · pdf filethe hssn agreed on several charges and...

St. Louis Integrated Health Network (IHN)Re-Entry Community Linkages (RE-LINK)

Evidence-based CHW systems navigation in St. Louis to link recently incarcerated young adults to community resources: Addressing improved provider care continuity, reduction in health disparities, and

reduction in recidivism post-Ferguson

Mikel Whittier, MHA – Program ManagerAtara Estes – Certified Community Health Worker

Phillip Brooks – Certified Community Health Worker

The St. Louis Integrated Health Network, through collaboration and partnership, will strive for quality, accessible and affordable

healthcare services for all residents of Metropolitan St. Louis, with an emphasis on the medically underserved.

St. Louis Integrated Health Network

ABOUT IHN

A non-profit membership health intermediary organization that collaborates with community health centers, public health departments, hospital systems, academic medical institutions and other safety net organizations to advance its mission.

The IHN acts as a convener and facilitates partnerships across the safety-net system toward the common goal of advancing health equity by increasing healthcare access and quality for the medically under-served.

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IHN Board Network

Community Health Centers

HospitalSystems

Public Health Departments

Academic Institutions

Other Safety-Net Orgs

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A Regional Crisis

Ferguson Commission (2015) noted:

“for thousands of St. Louisans, the status quo is killing them. The status quo means living in a food desert, with no grocery stores for miles around. The status quo means sending your children to underperforming schools that get fewer resources but dole out more punishments. The status quo means driving in fear of a court system that will put you in jail for failure to pay a traffic ticket” (p. 21).

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Photograph by J. B. Forbes AP Photo/St. Louis Post-Dispatch.

Regional PrioritiesAccording to Ferguson Commission (2015), regional priorities should include:

• Justice for All

• Youth

• Economic Opportunity

• Safe Space for Conversation for Process Improvement

These priorities should be considered in regards to racial equity, tangible change, and health equity supported by research to be transformational, urgent, and unflinching.

Ferguson Commission. Forward through Ferguson: a path toward racial equality. 2015. Available at: http:// forwardthroughferguson.org

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A divided region

Many social issues including race and access to resources can be illustrated with the Delmar Divide

Purnell J, Camberos G, Fields R. For the sake of all: a report on the health and well-being of African Americans in St. Louis and why it matters for everyone. 2014. p. 29. Available at: https://forthesakeofall. files.wordpress.com/2014/05/for-thesake-of-all-report.pdf

FULL FOR SAKE OF ALL REPORT: https://forthesakeofall.org/wp-content/uploads/2016/06/FSOA_report_2.pdf6

https://forthesakeofall.org/wp-content/uploads/2016/06/FSOA_report_2.pdf

Ferguson Commission. Forward through Ferguson: a path toward racial equality. 2015. Available at: http:// forwardthroughferguson.org

FULL FERGUSION COMMISSION REPORT: http://3680or2khmk3bzkp33juiea1.wpengine.netdna-cdn.com/wp-content/uploads/2015/09/101415_FergusonCommissionReport.pdf

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http://3680or2khmk3bzkp33juiea1.wpengine.netdna-cdn.com/wp-content/uploads/2015/09/101415_FergusonCommissionReport.pdf


Addressing Health Disparities

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Addressing Health Disparities

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Health Access Best Practice➢ Healthy People 2020 has featured the IHN’s Community Referral

Coordinator (CRC) Program in their sharing library of "Who's Leading the Leading Health Indicators?“ as a national best practice.

➢ The CRC program is working towards Healthy People's goal of improving access to comprehensive, quality health care services.

➢ The CRC (1) meets non-emergent and/or admitted Hospital patients to provide education regarding availability of primary, specialty, behavioral health and urgent care services; (2) offer patients a choice of primary care homes; and (3) assist with scheduling follow-up appointments and arranging transportation/support services as needed.

➢ This same approach has been utilized in addressing crime prevention in the Re-Entry Community Linkages (RE-LINK) and Community Health Worker (CHW) model

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CRIME IS A HEALTH AND WELLNESS CRISIS

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Criminogenic Risk Factors = Social Determinants of Health

Crime Density in St. Louis

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CRIME IN ST. LOUIS

CURRENTLY • Over the past 6 months, St.

Louis has experienced

roughly 4900 violent crimes

within the city limits City of St. Louis Metropolitan Police Department. (n.d.). Crime Mapping.

Retrieved July 7, 2017, from http://www.slmpd.org/crime_mapping.shtml

HOW CRIME COSTS HEALTHCARE. . . .

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ASSAULT-RELATED GUNSHOT INJURIES LEVEL OF CARE AND COST

Number of Injuries Cost

2012

Emergency Department 188 $1,440,783

Inpatient Hospitalization 139 $9,844,379

2013



2014



Total 989 $41,341,382

MODHSS (Missouri Department of Health and Senior Services). MICA. In Injury MICA. Retrieved January, 2017, from

http://health.mo.gov/data/mica/InjuryMICA/


Metropolitan St. Louis population. . .

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Yet. . .


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RE-LINK Objectives

AIM

• To demonstrate the effectiveness of multiple stakeholders

• Specifically, public health system and community support system working

• Implement a model transition process from jail

• minority and/or economically or environmentally disadvantaged re-entrants ages 18-

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• “Link” community reentrants to community-based organizations and

resources

• healthcare providers, health care coverage, behavioral health, and social service

supports.

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RE-LINK Strategic Planning

IHN’s goals were to align regional priorities including health and racial equity for:

• Improved transitions of care

• Improved access

• Improved health and social service network interoperability

• Improved sharing of data for translation into informational and evidence

Photograph by J. B. Forbes AP Photo/St. Louis Post-Dispatch.

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Demographics SnapshotAssault-Related Gunshot Injuries St. Louis 2012-2014

Age Groups 2012 2013 2014 Total % of Total

Under 15 7 8 9 24 2%

15-24 164 152 175 491 49.6%

25-44 126 122 134 382 38.6%

45+ 30 25 37 92 9.3%

Total 327 307 355 989

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MODHSS (Missouri Department of Health and Senior Services). MICA. In Injury MICA. Retrieved January, 2017, from http://health.mo.gov/data/mica/InjuryMICA/

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Health Centers, Health Providers, &

Health Intermediaries

Government Agencies

Housing

Employment Services

Multi-dimensional Social Service

Providers

Academic Partners

Community Health Worker

St. Louis City Jails

The RE-LINK model

Health & Social Services Network

Utilization of a Health & Social Services Network (HSSN) for Reentry

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GOALS/CHARGES

• Improve collaboration and communication

• Promote the sustainability of resources

• Enhance the RE-LINK CHW model

• If program is effective at reducing recidivism

• pursue sustainability and expansion of the model

• Identify and address policy gaps and systemic barriers to successful reentry to the community

Health and Social Services Network (HSSN)The HSSN agreed on several charges and deliverables to ensure the network is working efficiently and effectively yet also to ensure reproducibility and sustainability

2017 Deliverables

Policy and Systems Change

• Develop a shared policy platform across the network

• Offer training and open houses to HSSN member organizations (e.g. policy engagement, tour of the jails, health equity, CLAS, trauma-informed care, etc.)

Communication and Coordination among Providers

• Identify common language to use across the network

• Documented processes and protocol for referral network communication and coordination between the jails, probation and parole, community reentrants, social service providers, and healthcare providers

Access and Care Continuity for Reentrants

• Quarterly review of program data to identify trends, barriers, and areas to improve access

• Identify and prioritize target populations to be impacted by efforts and measurable outcomes that will indicate progress

• Strategic plan for communication of HSSN efforts to providers, government, public health, and broader community

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Defining policy for sustainable change

Building… • A shared vision of perpetual improvements that builds consensus and informs all

stakeholders

In order to Develop… • A course of action or guiding principles to achieve enduring community wellbeing

That is Implemented through…

• A law, regulation, procedure, administrative action, incentive, or voluntary practice being adopted by individuals, organizations, systems, and/or government.

Policy is. . .

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RELINK Health and Social Service Network (HSSN)Backward Plan for Implementation of Policy Reform

Today

Sep Nov 2017 Mar May Jul Sep Nov 2018

First Health and Social Service Network Convening

9/1/2016

Develop HSSN Charge and Deliverables -Charge to build a Policy Platform

10/18/2016

Key Stakeholder Interviews to inform Policy Reform Ideas

11/1/2016

Policy Mapping Sessions

12/9/2016

HSSN Partners identify Policy Recommendations

1/12/2017

Identify HSSN Policy Prioritizations

3/9/2017

Finalize Policy Actions

3/31/2017

Implementation (update on ongoing progress)

5/11/2017

Complete Actions for 2017

11/9/2017 Revisit Plan and Prioritize for 20181/11/2018

BUILD DEVELOP IMPLEMENT BUILD

25

26

67%

31%

2%

Male Female Transgender

20

24

4

1

Age 18-21

Age 22-25

Age 26 Age 27*

84%

10%

4% 2%

Black/African American

White/Caucasian

Mixed/Multi-Racial

Unknown94% are Single

31% are Parents *One participant turned 27 shortly before Intake

Top 5 Most Common Charges

Unlawful Use of Weapon

Burglary

Probation Violation

Possession of Controlled Substance

Assault

Pending Charges

Other

Probation Violation

Revocation/Technical Violation

Pre-Trial

Parole Violation

Already Sentences

Reason for Confinement

DEMOGRAPHICS

78% have at least one prior arrest

Preliminary Data – Not for Distribution

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39%indicated that for 15

or more of the last

30 days their mental

health* was not good

41%have at least 1

chronic health

condition

88%have a history of

substance use

30

17

2

No Insurance Public Insurance Insurance throughfamily member

Insurance Coverage Before Jail

1

2

3

5

16

Don't Know

Urgent Care

Doctor's Office

Hospital Emergency Room

Clinic or Health Center

Usual Source of Care

51% indicated they had a regular source

of care prior to jail

Most Common Chronic Conditions

Mental Health

Asthma

Substance Use

Hepatitis C

Chronic Pain

Seizures

Diabetes

*Including stress, depression, and problems with emotions

64%

21%

12%

2%

Frequency of Substance Use

Daily2-3/weekLess than once/month

35% of substance users indicated

stress was their main trigger

MEDICAL


Preliminary Data – Not for Distribution 28

SOCIAL DETERMINANTS OF HEALTH

Mode of Transportation

6

25

97

2

8th GradeCompleted

Up to 12thGrade, Nodiploma

GED High SchoolGraduate

Some College, Nodegree

Educational Attainment

33

10

41 1

Staying withFriends/Family

Own/rent houseor Apt

Homeless - OnStreet or in Car

Staying inShelter

Hotel

Housing Before Jail

20

17

8

13

Working for payat a job

Not working andlooking for work

Not working andnot looking for

work

Working but notfor pay at family-owned business

Unknown

Employment Status Before Jail

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49 participants completed the intake process

25in pre-release

status

13released &

active in

program

9released &

currently

missing

2unenrolled*

from

program

*Reasons for disenrollment: 1) Death due to overdose 2) Moving out of state

22 referrals issued

10 unique individuals

Applications Completed

Gateway to Better Health (11)

Medicaid (7)

SNAP (3)

SSI/SSDI (3)

Types of Referrals

Substance Use (6)

Mental Health/Behavioral Health (4)

Job Training (4)

Housing Services (3)

Education (3)

Medical (2)

Others (5)

58%appointment

kept rate

REFERRALS

Averages 2.7

referrals per

person

5 RELINK

participants were

previously served by

CRC Program

LOCATION OF REFERRALS

Employment Connections

Places for People

Myrtle Hilliard Davis

Mission St. Louis

People Ready

Community Action Agency


Calls to action for preventing crime1. Like community health, crime prevention requires taking a holistic

approach addressing various aspects of one’s life that influences criminal behavior

2. Promote system accountability for sustained community wellbeing

3. Do not assume community members understand how to create and sustain health and wellness

a. Health literacy entails an individual’s ability to:

i. (1) read, (2) understand, and (3) communicate important health needs and the information necessary for addressing these needs

4. Sustainability. . . .

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QUESTIONS

The St. Louis Integrated Health Network, through collaboration and partnership, will strive for quality, accessible and affordable

healthcare services for all residents of Metropolitan St. Louis, with an emphasis on the medically underserved.

APPENDIX

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Health and Social Services Network (HSSN)

Government Agencies

• City of St. Louis

• City of St. Louis Mayor’s Office

• Senator Claire McCaskill’s Office

• Missouri Board of Probation and Parole

• City of St. Louis Department of Health

• Department of Corrections/St. Louis City Justice Center including Corizon and SLU OT program

Health Centers and Health Service Providers

• Myrtle Hilliard Davis Comprehensive Health Centers

• Family Care Health Centers

• Betty Jean Kerr People’s Health Centers

• Affinia Healthcare

• Preferred Family Healthcare/Bridgeway Behavioral Health

• People’s Community Action Corporation

• Places for People 34

Health and Social Services Network (HSSN)

Health Intermediaries

• Behavioral Health Network of Greater St. Louis

• Saint Louis Mental Health Board

Housing

• Criminal Justice Ministry

Employment Services

• Connections to Success

• Employment Connection

Multi-dimensional Social Service Providers

• Fathers’ Support Center

• The SPOT

• Mission St. Louis

• Center for Women in Transition

Academic Partners

• Washington University Evaluation Center

• SMART Decarceration Initiative

• St. Louis Alliance for Reentry

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What does the referral process look like?

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Pick 3 Policy Reform Recommendations

Coordinate and standardize the intake and discharge process within the jails. This could include:• Develop a formal method in the jails to track all inmates in need of services apart from those on the sentencing list

• Develop a standardized discharge planning process

• Develop a process to triage patients, but especially behavioral health patientsSuspend Medicaid upon incarceration rather than terminate coverage so that Medicaid can be immediately reinstated upon release from jails

Develop a digital regional platform for referral network resources for the public defenders (to help coordinate the overloaded public defender program)

Develop a centralized record system for the reentry population at the provider organizations

Create a system to get IDs without having to use community provider voucher programs

Enhance programming within the jails. This could include:• Develop more reentry related programming within the jails

• Design programs within the jails that are fun and engaging (e.g. art opportunities, t-shirt or game design, etc.)

• Reentry programming needs to start as soon as an individual comes into the jails

• Continue to expand the work of Agency Forward, to bring external programs into the jails to inform others of their servicesCreate a mental health court that for pre-charge diversion programming

Require formal accreditation standards for health services provided in the jails

Coordination of care after release. This could include:

• For provider capacity, work with service providers to track and coordinate when there are open spots for care

• Pilot a standardized process for communication between service providers (e.g. between health and social service providers coordinating shared

clients, etc.)

• Identify a strategy for a reentrant to keep a CM/assigned support to stay with you despite the services you receive or where you move to (e.g. Atara

Estes, RELINK CHW)

Provide support for training and workforce development/culture change. This could include:• Provide training to provider HSSN partners on topics such as cognitive thinking, equity and racial bias, strengths-based approaches, correctional

workforce training, and others as identified

• Create a trauma-informed culture at the jails and with all supporting partnersCreate opportunities for people who have been through the system to share their story and inform policy

Build a singular database like HMIS/Systems of Care to track participant success/engagement

Reform for charges and misdemeanors. This can include:• Issue misdemeanors as a citation only – no threat of incarceration for misdemeanors

• Remove incarceration as a sanction for probation and parole violations

• Advocate for policy to ban the box – focus on skills and abilities instead of convictions

• Work with judges to reconsider how to open up more pro bono legal services for misdemeanor cases

Develop a system to coordinate court dates. This can include:• Easy access to potential pending court dates

• Develop a system to attach the inmate roster

• Clarify the process for release datesRedesign/modify the building environment within the jails to support better health and decrease deprivation (e.g. color on the walls, lighting, sound)

Align funding for reentry to support identified priorities. This could include:• Funding strategy that supports organizational capacity of providers to adequately serve reentrants referred to programming

• Funding is coordinated to align with priorities set by the HSSN (e.g. need substance abuse treatment, behavioral health, housing, etc.)

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Template Action PlanPolicy Reform Priority Action(s)

List actions your organization can take to support the

identified policy reform – include key steps needed to

take action

By When?

Day/Month/Year

By Whom?

Name key authorizing

leadership and

stakeholders within

your organization

How will success be

measured?

Identify key metrics,

outcomes, infrastructure,

and processes that will be

built as a result of the

action

1.

2.

3.

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RE-LINK’s Comprehensive Staff

Bethany Johnson-Javois, CEO

Jessica Holmes, Principal Strategist –Alignment, Innovation, Growth

Amanda Stoermer, Outcomes and Information Manager

Casey Peetz, HR & Office Manager

Sagar Mehta, Health Equity Fellow

Mikel Whittier, RE-LINK Program Manager

Atara Estes, Community Health Worker

Phillip Brooks, Community Health Worker

Nancy Mueller, Network Evaluation Lead

Carrie Pettus-Davis, Co-Lead

Bobbi Carothers, Senior Data Analyst

Sarah Bobmeyer, Evaluator

Mackenzie Staub, Project Coordinator

Annie Grier, Content Consultant

Washington University in St. Louis

(Evaluation Team)

St. Louis Integrated Health Network

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RE-LINK’s Jail Partners

Robin Edwards, Program Director

Jennifer Davis, Reentry Case Manager

Markeisha Franklin, Reentry Case Manager

Michelle Wayman, Corizon Discharge Planner

Brittany Conners, SLU Occupational Therapist

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