Behavioral Health Services: Recovery and Reintegration

Project Description
Fort Bend County has been approved to develop a continuum of care that is founded on evidence-based practices for this target group (persons with severe mental illness and / or mental illness and physical health conditions) identified as high risk for recidivism due to homelessness/ lack of stable housing, prior history of non-compliance, lack of access to services, complex trauma, lack of family supports and /or lack of integrated care to address complex needs. The target population will be the Medicaid and uninsured population. Evidence-based interventions will be developed based on identified patients and family needs. The goal of this project is to reduce recidivism rates and to promote recovery. The focus is to develop a system to support reintegration into the community, stability in living environment, and improved functioning. Evidence-based interventions such as short and long term residential supports, peer supports; specialized therapies, personal assistance, intensive case management and access to health (physical and behavioral health) will be developed. This project will focus on persons with high clinical needs and low criminogenic risk factors. The diversion of this population from ongoing incarceration is critical to preventing further deterioration in health as well as further involvement in the criminal justice system.

In the criminal justice system the number of persons diagnosed with mental illness is significantly greater than that in the general population. Many jails are now de facto mental health hospitals. It is estimated that almost 15% of men and 31% of women recently booked in jail have a serious mental illness. Many have co-occurring disorders of substance abuse. The Fort Bend County (FBC) Recovery &Reintegration program will focus on the development of specialized interventions and a service delivery system to address the complex health and social needs of persons at risk of incarceration. This project will interface other FBC-DSRIP projects, including the Behavioral Health Crisis and Response system.

The FBC Recovery & Reintegration program will work collaboratively with public and private behavioral health providers, FBC’s Health & Human Services, physical health providers, Mental Health America (MHA), National Alliance on Mental Illness (NAMI), and behavioral health providers and organizations in the community to provide the necessary array of services to divert adults from incarceration and provide the necessary array of services to improve functional outcomes and support recovery in the community.

Goals and Relationship to Regional Goals
Develop and deliver evidence-based practices for persons with severe mental illness and or mental illness and physical health conditions identified as high risk for recidivism due to untenable living conditions / environment.

This project meets the following regional goals:

  • Develop a regional approach to health care delivery that leverages and improves on existing programs and infrastructure that is responsive to patient needs throughout the entire region, and improves health care outcomes and patient satisfaction; and
  • Increase access to primary and specialty care services, with a focus on underserved populations, to ensure patients receive the most appropriate care for their condition, regardless of where they live or their ability to pay.

5-year Expected Outcome for Provider and Patients

  • Reduce recidivism rates for adults with complex behavioral health problems (person with severe mental illness and/ or combination of behavioral health and physical health).
  • Promote recovery in the community (reduce risks factors and needs and increase strengths / protective factors).

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