Talbert House successfully achieved its goals and is implementing the principles discovered in this planning grant.  Talbert House distributed the guidebook to appropriate schools and agencies.  All funds have been spent and reported to the Foundation. I recommend that this grant be closed.

Seven part-time medical clinics were established at five Talbert House sites in Hamilton County and two sites in Warren County, serving a total of ten residential programs.  The clinical model uses primary care nurse practitioners who are supervised by a primary care physician, as well as an adult and child psychiatrist.  Service delivery began in January of 2003, and by April 2003 all staff positions were filled.  During the first 14 months of operation (4/1/03 – 7/30/04), a total of 2,631 clients were served which represented 6,591 patient visits.  Services performed were health screenings, physical exams, sick visits, and modest pharmacological management for mental health clients.  By the end of the grant period, the number of patients served was approximately 5600.

Offsite medical visits decreased from 737 prior to implementation to 437 after 18 months of operation, a reduction of 40.7%.   During the same period, Talbert House’s cost of transporting clients for off-site medical visits decreased from $10,394.60 to $2,388.37, a reduction of 77%.

Talbert House selected Neighborhood Health Care (NHC), a Federally Qualified Health Center, as a potential partner in shared services, with Talbert House’s residential sites designated as satellite offices of NHC. The model chosen would integrate all services at the corporate level.  NHC is seeking HRSA approval before entering into a services agreement with Talbert House, as they are very cautious about their FQHC status and liability under the Federal Tort Claims Act. Billing for services will not commence until an agreement is reached. Talbert House is exploring shared services partnerships with other providers, including Crossroads and Cincinnati Health Network.  It has also applied for a grant with Winton Hills Medical Center to help fund services for primary and behavioral health care.

Outcomes from this grant:

• Missed behavioral health treatment at the residential sites was reduced by 457 hours, or 126.5%, by having on-site primary care.
• Of 90 referrals to a primary care physician upon discharge, 30 resulted in an actual connection, indicating a follow-through rate of 33.3%.   This is well below the 90% target.  However, not all clients referred remained in Hamilton County and the rate of connection is probably higher than the data indicates.
• The grant project was presented at the International Community Corrections Association Conference in 2003 and 2004.  An articles was published, Corrections Today, October 2004.
• A staff survey indicated that 85% “highly agree” that the project had helped to enhance the healthcare of their clients.

The case manager has identified 25 high-risk female clients who are receiving Shelter Plus Care housing support and has started providing intensive case management services to these clients. Clients usually meet with the case manager every two weeks, or more often, if needed. The case manager provides referral information about community services, helps the client access these needed services, and serves as an advocate for the client when necessary.

Talbert House initiated an electronic clinical documentation system this past year, and the case manager uses it to document assessment needs and client strengths, to develop an individual service plan with each client, and to document client progress in achieving case management service goals.

The case manager has begun to identify clients who will benefit from the more structured living environment provided by the Josephine House. Tom Geiger House will operate the Josephine House, and Talbert House will provide case management services to the women living there.

A needs assessment was conducted which included focus groups with ex-offenders, reviewing Adult Parole Authority records, obtaining criminal justice statistics and conducting a provider survey.  The results were published in “Rebuilding Lives: Planning for Reentry,” which was distributed to collaborative members and the HFGC.

An extensive literature review was conducted.  The project manager attended the inaugural meeting of the International Association of Reentry.

The model selected was Assessment, Planning, Identifying and Coordinating (APIC).  This model provides case management services for re-entering ex-offenders at a local level until they are engaged in community based treatment.  It was developed by the National GAINS Center and is a set of critical elements that, if implemented, are likely to improve outcomes for individuals released from incarceration.

A business plan for implementation of a reentry program was submitted as a grant application to the HFGC for implementation of the Warren County Reentry Project.