TI-18-003 Individual Grant Awards

The Augusta Area Comprehensive Offender Reentry Program (AACORP) will expand substance use disorder (SUD) treatment and related recovery/reentry services to adult male and female offenders transitioning into communities within Georgia's East Central Public Health District. Administratively housed within the Institute of Public and Preventive Health (IPPH) at Augusta University, AACORP will develop and implement a coordinated, comprehensive, evidence-based, patient-centered approach to offender reentry through partnerships with corrections facilities (Augusta Transitional Center, the Department of Community Supervision - Augusta Office), community treatment providers (Hope House, Serenity Behavioral Health Systems), and peer recovery support specialists (Certified Addiction Recovery Empowerment Specialists [CARES]). The improved coordination and expansion of services for transitioning offenders with SUDs will be accomplished by meeting 4 objectives: 1) Within 30 days of award, establish an AACORP advisory board to meet regularly, review program performance, and make improvements to processes; 2) Within 45 days of award, implement staffing and coordinate services with local correctional facilities and community supervision agencies; 3) Within 90 days of award, implement treatment service expansion (medical assisted treatment and motivational interviewing) and systems linkages to achieve a fully operational case management model delivered by an interdisciplinary team addressing offenders' long-term needs; 4) Within 30 days of award, design and implement system of data collection and performance measurement to facilitate ongoing program improvement and to promote sustainability. By meeting these objectives, AACORP will expand and improve existing services, providing SUD treatment and recovery support services to 80 additional unduplicated individuals per year (5 male and 30 female) or 400 individuals over the 5-year project period. All SUD services delivered through this project will meet the American Society of Addiction Medicine criteria for outpatient or intensive outpatient. The goal and objectives of AACORP fits perfectly with IPPH's mission to ""improve health, reduce health disparities, and prevent injury and illness in Georgia through research, service, leadership and training"".

The Reintegration for Life Program (RLP) will promote successful community reintegration for adults returning to Syracuse/Onondaga County, New York from Onondaga County Correctional Facility (OCCF), the local jail that houses people sentenced to up to one year of incarceration. The program is a partnership among the Center for Community Alternatives (CCA); Crouse Chemical Dependency Treatment services (CCDTS), a licensed treatment program provider, OCCF, and a new housing program, Freedom Commons, developed jointly by CCA and the Syracuse Housing Authority. The housing component, the first partnership in the country between a recovery/reentry-focused housing program and a Housing Authority, offers affordable, supportive housing and emergency shelter beds that will help prevent relapse and recidivism associated with homelessness. The program will address substance abuse and other factors associated with recidivism through a seamless array of pre-release and post-release services. CCDTS will expand its SUD services, and out-station a credentialed counselor to deliver individual and group counseling at CCA. Participants in need of more intensive treatment will be referred to CCDTS inpatient or intensive outpatient programs. Participants will also participate in CCA?s ?CUSE? Recovery Center, either for treatment readiness or recovery support. Treatment and recovery will be delivered as a single nexus of services operating under recovery-oriented system of care (ROSC) principles. The program will be guided by CCA?s Reintegration Services Advisory Committee, which will significantly enhance system linkages within the local community, in particular through the integration of new housing services. The population of focus?people incarcerated in OCCF for at least 4 months and parole violators?will be prominently people of color from very low income neighborhoods, male, and age 18-30. They will be assessed using the George Mason Risk, Needs, and Responsivity Simulation Tool. Services will include assessment, discharge planning, treatment readiness, substance use treatment, recovery support, work readiness/ employment services, housing assistance and civic restoration. The services will use evidence-based practices including the Transtheoretical Model, Motivational Interviewing, Moral Reconation Therapy, and others based on need. Participants will be connected to CCA?s employment services funded through federal and state sources. They will access legal services that address collateral consequences of incarceration that serve as barriers to employment, housing, and reintegration. The program will serve 50 people per year or 250 over the life of the program. As outcome objectives, 75% of participants engaged in the community will remain in treatment/recovery for at least 3 months, 80% will report abstinence or reduce substance use, and their 1-year recidivism rate will be less than 20% compared to a baseline of 55%. Eighteen individuals per year will be placed in employment, and 10 or more will receive shelter housing, preventing homelessness.

Fortune Society?s Health, Wellness and Success (HWS) program will engage 180 incarcerated adults within 4 months of release in discharge planning pre-release and enroll 150 (over a 5-year period, 30 people annually) released adults with a substance use disorder (SUD) or co-occurring disorder (COD) into treatment and other reentry services in the community post-release. The population of focus is sentenced adults (18+) being released from NYS Department of Correction & Community Supervision (DOCCS) Correctional Hubs/Facilities: (1) New York City Hub: Edgecombe, Lincoln, Queensboro; (2) Green Haven Hub: Fishkill, Downstate, Green Haven, Taconic, Bedford Hills, Sing Sing; and, (3) Oneida Hub: Mohawk, Mid-state, and Marcy. We will also serve individuals from NYC Department of Corrections (DOC) Correctional Facilities (Rikers Island). We will use evidence-based interventions, including Moral Reconation Therapy (MRT), Motivational Interviewing (MI) & Seeking Safety. Our goals include: (1) In collaboration with correctional staff, parole staff, and CBOs, effectively transition individuals, in need of substance use disorder (SUD) treatment and related recovery and reentry services, from the correctional to the community setting; (2) Stabilize participants in recovery from substance abuse and/or co-occurring disorders; (3) Assist participants to become fully functioning parents, employees and citizens; and, (4) Strengthen partnerships and systems of care for the reentry population. Key outcomes include: 65% of clients enrolled in the program will successfully complete Moral Reconation Therapy (MRT) and/or Seeking Safety; 100% of clients will receive individual case management sessions, utilizing Motivational Interviewing (MI), at least twice a month; 65% of clients will achieve at least 90 days sobriety; 65% of clients interviewed will self-report no or reduced use of alcohol or illegal substances over the past 30 days at 6 month follow up; 100% of clients needing such services will be referred to health services, including HIV and Hepatitis testing; 100% of clients who test positive for HIV or Hepatitis will be referred to medical services; 100% of clients in need of mental health services will be referred to Fortune?s Better Living Center, or other mental health treatment provider; 100% of clients for whom such referral is appropriate will be referred to education and/or employment services and family services; at point of discharge: 80% of clients completing treatment who needed housing assistance will self-report living in an improved housing situation; 65% of clients completing treatment will be employed, attending school, in a job training program, or otherwise engaged in regular constructive activity; 100% of clients in need of housing, and unable to be housed in one of Fortune?s housing programs, will be referred to our partner organizations specializing in this; and, 65% of clients completing treatment and on parole/probation will be in compliance with criminal justice supervision. It should also be noted that we will provide 3 dedicated beds annually to HSW participants, as well as make available an additional 2 beds in-kind for women HWS participants.

Mountain Comprehensive Care Center (MCCC), in partnership with the Big Sandy Regional Detention Center (BSRDC), is applying for the Big Sandy Offender Reentry Program to provide culturally and gender-competent evidence-based outpatient substance abuse treatment with integrated trauma-informed approaches, mental health care, case management, wraparound recovery/reentry supports and aftercare to meet the underserved needs of the population of focus in Floyd, Johnson, Lawrence, Magoffin, Martin, Morgan and Pike Counties in eastern KY. Population: The population of focus is sentenced adult offenders/ex-offenders ages 18 or older; assessed or diagnosed as having a SUD and/or COD; sentenced to and serving at least 3 months in the BSRDC or have violated parole and serving at least 1 month; and are within 4 months of release to receive jail-based services. The population will be medium to high risk and have similar characteristics to the overall rural, homogenous population including high rates of poverty, unemployment, low educational attainment, and no insurance. Of the population, 80% are men, 20% women, and less than 1% LGBT with 90% having been arrested on alcohol and/or drug-related charges and 40% with a COD. Opioid use is most prevalent. Interventions: In tandem with the BSRDC, all clients will be assessed for SUD and/or COD and criminogenic needs per the RNR. MCCC will incorporate the evidence-based practices of Motivational Interviewing, Matrix Model for Criminal Justice Populations, Seeking Safety, and Living in Balance as conducted through a trauma-informed care approach. MCCC will also provide and/or link participants to hepatitis B/C and HIV testing and primary health care, case management, peer supports, wraparound recovery and reentry services, enrollment in public benefits/insurance and other needs per their Individual Transition Plan, and offered aftercare. Goals & Objectives: MCCC will serve 45 eligible participants in Year 1 and 70 annually in Years 2-5 for a total of 325 served. By the end of the 5-year grant period, participants of the targeted population of focus will meet the following objectives: 1) 60% will improve their SUD or COD functioning; 2) 35% engaged in tobacco cessation services will reduce their past 30-day tobacco use; 3) 100% who have agreed to testing will receive viral hepatitis (B and C) and HIV testing, and linkages to treatment as needed; 4) 60% will improve their housing stability; 5) 50% will improve their employment status and/or access to disability benefits; 6) 70% will access eligible benefits; and 7) 70% will participate in peer recovery services. Also, MCCC will submit the Behavioral Health Disparities Impact Statement within 60 days of award; achieve a six-month follow-up rate of at least 80%; and conduct a minimum of quarterly Project Management Team meetings with partners for project oversight and coordinated systems linkages. Morehead State University will conduct the performance assessment which will focus on GPRA measures; implementation; achievement of project goals, objectives, and outcomes; fidelity to treatment models and cultural competence; assessment of client satisfaction; and CQI.

Ridgeview Behavioral Health Services, Inc. (Ridgeview) is a 501c(3) not-for-profit community behavioral health agency located in East Tennessee and is applying to the Substance Abuse and Mental Health Services Administration for a grant in support of the RIDGEVIEW REENTRY PROGRAM, an Offender Reentry Program designed to introduce substance use disorder (SUD) treatment and recovery and reentry services to sentenced adult offenders with co-occurring substance use and mental health disorders. The goal of RIDGEVIEW REENTRY PROGRAM is to reduce recidivism and increase successful adult offender reentry by introducing access to SUD treatment in the jail setting and linkage to employment and housing support services pre/post release. RIDGEVIEW REENTRY PROGRAM envisions a three-phase modified Integrated Dual Disorders Treatment (IDDT) model in partnership with Anderson, Morgan, and Roane County Jails to offer direct outpatient substance abuse treatment within and outside the jail and to utilize a collaborative team approach to develop system linkages related to reentry services that connect eligible individuals to housing and employment supports. Using the Criminogenic Risk and Behavioral Health Needs Framework, individuals 18 and older meeting the Medium/High risk criteria will be eligible for RIDGEVIEW REENTRY PROGRAM. The framework addresses the complex treatment needs of diverse groups of individuals with co-occurring disorders and helps coordinate treatment and supervision approaches to promote individual recovery while improving public safety outcomes. The modified ACT strategy used by RIDGEVIEW REENTRY PROGRAM will include the use of the following Evidence-Based Practices: Cognitive Behavioral Therapy (CBT); Co-Occurring Educational Group using Hazelden EBP Curriculum; Motivational Interviewing; Trans-theoretical Stages of Change; the use of Compass-EZ Tool for the collective learning experience for the program and translating that learning into an improvement plan; and finally, linkage to Medication Assisted Treatment (MAT), where clinically indicated. RIDGEVIEW REENTRY PROGRAM anticipates serving 60 individuals per year with a total of 300 matriculating through the five year grant cycle. Objectives are for individuals to abstain from substance use; achieve stable housing; obtain employment; increase social connectedness; retention in outpatient substance use treatment; reduction in criminal justice involvement; and determine eligibility (and enrollment if possible) for health coverage. RIDGEVIEW REENTRY PROGRAM will be further strengthened by partnering with the Social Work Office of Research and Public Service at the University of Tennessee (TN-SWORPS) to assist with data collection, data analysis, performance measurement, and

Serving Children and Adults in Need Inc. (SCAN), is proposing to implement the Border Reentry and Community Integration Program which will serve adult males and females 18 years of age and older from Webb County, Texas returning to the community following incarceration in state and local facilities and who meet the criteria for a substance use disorder and/or co-occurring substance use and mental health disorders. The project proposes to serve 350 unduplicated participants for the five years of the project (70 per year). The project will expand and enhance substance use disorder treatment and recovery and reentry services for sentenced adult offenders and ex-offenders with a substance use disorder and/or co-occurring substance use and mental health disorders. Webb County residents have greater substance abuse treatment needs than other populations in Texas and are exposed to adverse environmental factors that place them at higher risk of criminal behaviors and incarceration. The proposed project will address existing service gaps in Webb County that will provide the support needed for participants to successfully reenter their communities and families. Treatment services available will include outpatient, intensive outpatient and intensive and supportive residential treatment services that will be delivered according to the participants? unique substance use and criminogenic needs. The project will provide outreach, pre-treatment, continuing and recovery components to ensure ongoing engagement and linkages to community peer support after successful discharge. SCAN envisions a project that meets the unique needs of each participant, utilizing evidence-based practices and infrastructure development activities. The evidence based practices selected are: Acceptance and Commitment Therapy (ACT), Motivational Interviewing (MI), Seeking Safety, and the Matrix Model for Criminal Justice Settings. These interventions will address concurrently the participants? substance use, mental health, criminogenic and trauma needs, while case management and wrap around activities will address the participant?s comprehensive needs through community linkages. The project will include COPSD (Co-occurring Psychiatric and Substance Use Disorder) case management services to closely link participants with co-occurring disorders to psychiatric assessment and treatment. The project will foster services coordination and integration for reentry individuals by creating a stakeholder group composed of institutional and community corrections, treatment providers and community agencies. The project will also help reentry individuals access employment and stable housing. The project will also meet the cultural and linguistic needs of participants by ensuring that clinical intervention and services are sensitive to needs of the population by making cultural adaptations providing services in Spanish. The project will engage families and significant others by developing family component that will focus on strengthening the participant?s recovery and successful reintegration to families and communities.

ABSTRACT Time for Change Foundation (TFCF)'s Positive Futures program will enroll 220 program eligible females (44 per year). An estimated 90% (200 program graduates, 40 per year) will receive program services upon release into the targeted area from the CDCR system. Demographics: The service area is San Bernardino County and includes the cities of San Bernardino, Rialto, Redlands, Victorville, and Colton and covers 234.45 square miles. The target area demographics reflect a total population of 567,818. Clinical Characteristics: All ex-offenders enrolled in Positive Futures II program will be screened for substance abuse and/or co-occurring disorders. It is estimated that 100% of ex-offenders will need substance abuse treatment, 70% will need some mental health treatment. Strategies/Interventions: strategies include use of evidence-based practices and models: Strengths-Based Case Management, 12-Step facilitation therapy, Seeking Safety, and collaborative behavioral management that reduces health disparities. Intervention services include treatment that includes Inter-Personal Therapy, Cognitive-Behavioral Therapy, and, medication assisted treatment. Implementation starts in prison and thru the 6 month follow up. Goals: 1-Engaging experienced and appropriately credentialed agencies and community-based partners that commit to using their experience, working with ex-offenders to carry out Positive Futures Program services and support networks; 2- Expanding treatment services and a continuum of wrap around recovery support services to assist with reentry; 3-Addressing the gaps in treatment services identified in the program service area, San Bernardino County with a focus in targeted cities by providing comprehensive substance abuse treatment and mental health services to the targeted offenders; and 4- Reducing substance abuse related crime among Positive Futures Program clients, thus reducing the likelihood that program participants will be re-offend Measurable Objectives: The Positive Futures program will: Phase 1- solidify all partnerships, system linkages, referral processes, and pre-release institutional (on-site) wrap around support services via MOU's and engage 44 program eligible adult offenders into the program. Phase 2- Increase access and availability of treatment and wrap-around services to 90% (44) program engaged parolees; use evidence-based practices, reducing recidivism below established baseline rate, and provide substance abuse and/or mental health treatment and mentoring. Phase 3- Demonstrate lasting impact based on measurable behavioral changes in 90% of the program participants; demonstrate program improvement based on independent evaluation; secure additional funding, to sustain program efforts.

Baystate Medical Center (BMC), the Hampden County Sheriff’s Department (HCSD), Providence Behavioral Health Hospital, Mercy Medical Center and the Center for Addiction Recovery will collaborate to provide BRIDGE II to adult ex-offenders with substance use and mental health disorders, who are returning to their community in the catchment area of Hampden County, in western Massachusetts. BRIDGE II’s primary goal is to improve the health of our population by providing a comprehensive network of substance use and mental health treatment and recovery support services that will reduce the likelihood of relapse and recidivism among formerly incarcerated adults. BRIDGE II will serve a total of 350 former inmates over the 5-year period. Additional goals include: 1) reducing the negative impact of behavioral health problems; 2) increasing access to and retention in treatment for co-morbid behavioral health and medical health conditions; 3) preventing new HIV and viral Hepatitis infections and overdoses. Our re-entering releasees are at high risk for relapse, drug overdose, and recidivism; many are also challenged by the need for bilingual and bicultural health care providers and services. We will deliver an intensive case management and service coordination model before and after release from jail. Under BRIDGE II, we will deliver the Thinking for a Change (T4C) curriculum, to be provided prior to the participants’ release from jail. Thinking for a Change (T4C) is a cognitive-behavioral curriculum that concentrates on changing the criminogenic thinking of offenders. T4C stresses interpersonal communication skills development and confronts thought patterns that can lead to problematic behaviors. Another significant health care need that we intend to address in our program implementation is that of overdose prevention. We recognize that the risks of overdose are most salient when clients leave incarceration or after a period of intensive, in-patient detox or substance use treatment; at discharge, they are abstinent and without physiologic tolerance. We will link patients to in-house and external resources for bio-medical prevention and harm reduction services, provide overdose education services prior to release, and provide Naloxone at the time of release. Once in the community, case managers will continue to provide services to ex-offenders that will enable them to meaningfully continue their engagement in SUD treatment, educational and job training programs, recovery housing searches, social supports, resource benefits, and other community services. The BRIDGE II team will include SUD treatment professionals in and outside of the jail, help with enrollment and maintenance into Medicaid and health insurance, and linkage to community-based primary care to support long-term recovery. Stable housing and adequate physical and mental health are essential for seeking and maintaining employment; BRIDGE II will more intentionally knit supports for post-incarceration housing stability and employment into this project.

The Orange County Bridge Portal will serve adult men and women that have been identified through evidence based screening to have substance use disorder (SUD) and/or co-occurring substance use and mental health disorders (MHD) and other reentry needs who are returning to families and communities in and around Orange County, Florida from incarceration in state and local facilities. Without targeted reentry services many of the can expect to recidivate at the current rate of 48.8%. The Orange County Bridge Portal is expected to serve 100 individuals in the first year of operation and 150 in each subsequent year for a total of 700 individuals serve. In addition to this number the portal will provide behavioral health services to approximately 500 participants family members and significant others as well (this cost will not be charged to this award). The total number serve is expected to be approximately 1,200. All services will be based on a trauma informed approach. Services will include Substance Use Disorder and/or Mental Health Disorder services; Employability programming; Education/Vocation services; Evidence Based Life Skills to include Crimenogenics; Medication Assisted Treatment (Vivitrol); access to healthcare and other public benefits; family reunification and community reintegration services; and system linkages. The goals are as follows: : 1-Decreased Recidivism and re-offending; 2- Increase the capacity for formerly incarcerated adults to become productive, tax paying, and law abiding citizens; 3 ? Decrease substance use that contribute to criminality and other high risk behaviors; and 4 ? Increase family and social support systems.

Coastal Horizons Center, Inc. proposes to expand the treatment & recovery support services provided by its ReEntry Systems for Effective Treatment (RESET) program to individuals with substance use disorders (SUD) or co-occurring disorders (COD) transitioning to the community from incarceration in local facilities. This project will be carried out in partnership with the New Hanover County Detention Center (NHCDC), North Carolina Department of Public Safety (NCDPS), Oxford House, Journeymen Recovery Homes, Seeking Serenity, Leading into New Communities (LINC), & Phoenix Hometown Hires. RESET was first implemented in 2015 to provide SUD & COD services to women returning to New Hanover County after a period of incarceration. The proposed project, through the RESET program, will continue to serve women & expand to include men. The population of focus for the proposed expansion project consists of men & women 18 years & older transitioning from incarceration in the NHCDC to NHC. To participate in the proposed project, adult individuals must have been incarcerated for at least three months; or served at least one month in NHCDC for a probation/post-release violation; must have been diagnosed with SUD or COD; & are within four months of scheduled release to the community. RESET will provide pre-release treatment services including screening, assessment, transitional planning (including referrals to wraparound/recovery support services) & Moral Reconation Therapy (MRT). Post-release treatment services include evidenced-based practices such as: Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Acceptance Commitment Therapy, MRT, Motivational Interviewing, Seeking Safety, Matrix Model, & Parenting Inside Out. The proposed project has five goals: 1) reduce the health, social, & economic costs of SUD & COD by increasing the number of individuals served & providing the services that will meet the needs of the population of focus; 2) enhance the ability of all participants to improve their quality of life by providing them with the opportunity to develop to their fullest potential the four dimensions of recovery; 3) reduce recidivism among project participants by decreasing alcohol/drug use & thus increase the safety of the community; 4) expand & enhance SUD & COD treatment & recovery support services among agencies serving the population of focus to strengthen system linkages among correctional agencies & the community-based applicant organization in the County; & (5) evaluate the project. The proposed project will serve 50 individuals in Year 1, 100 annually in Years 2 through 4, & 50 in Year 5. Thus, a total of 400 adults will be served with grant funds during the 5-year project period.

Plymouth County MISSION Re-entry Program provides coordinated and integrated services utilizing the MISSION-CJ EBP for incarcerated adults at the Plymouth County Correctional Facility with at least 3 month sentences, assessed with SUD, DOD and high criminogenic factor, and are returning to the Greater Brockton/Plymouth communities, in Plymouth County, MA. Population of focus: The population of focus is men housed in the Plymouth County Correctional Facility (PCCF) and their families (post-release) with at least 3 month sentences who are assessed with SUD, DOD and high criminogenic factors, who are within 4 months of and returning to Greater Brockton/ Plymouth communities, in Plymouth County, MA. The impact of untreated substance abuse/dependence and/or dual diagnosis bears a large health and social cost to public safety through related crime and violence, increased unemployment, housing and family instability, and a costly cycle of criminal justice involvement. Interventions: 1) Utilize the MISSION-CJ model which integrates Critical Time Intervention (CTI), and Dual-Recovery Treatment (DRT) EBP?s and a wrap-around team approach (clinician, case manager and peer) to increase access to treatment, community linkages, recovery, and positive family/community connections. 2) Provide a full array of community linkages including: MH/SA, MAT, medical, dental, infectious disease treatment, vocational & employment placement, and Sober Housing 3) Provide Peace From Within (PFW) curriculum provided by the Louis D. Brown Peace Institute, a Mindfulness and Peacebuilding class promotes a process of healing from a multi-cultural perspective 4) Recovery Support Services provided through the CM/PSS team which provides transportation, a vocational unit and linkages, wraparound case management that includes linkages to benefits, money management, relapse prevention, life skills and SA education curricula. Project Goals: Goal 1: Expand access to structured post-release MH/SA/MAT, health, recovery and community services, to sentenced adult offenders w/ SUD and/or COD returning to the community to increase housing and economic stability, reduce substance, crime and violence & prevent recidivism. Goal 2: Deliver comprehensive re-entry services based on the MISSION CJ model, including; Clinical supervision, wraparound CM/PSS staff team, DRT Curriculum, 11-session Peer Support modules, and requirements through all pre-enrollment and CTI phases. Goal 3: Build & track coordinated linkages to treatment and recovery services and jurisdiction capacity to achieve a fully integrated Re-Entry model that promotes recovery stability and reduces Recidivism. Number to be Served: 260 individuals will be enrolled across the 5 years: Y1=40 Y2-4 = 60 each year, and Y5 =40 for ramp down.

Project name, Population to be served, Number to be served over life of project: PFH?s proposed SHOW ME HOPE project will focus on assistance to 543 reentering offenders incrementally over a period of 60 months, in St. Louis and Franklin Counties in Missouri. The targeted participants are adults aged 18-65, who are within three months/90 days of release from the St. Louis County Justice Center or Franklin County Adult Detention Facility, primarily returning to these two jurisdictions or within the greater St. Louis metropolitan region. Strategies/interventions: Participants will be assessed as high-risk, using the Addiction Severity Index, and exhibiting high need for treatment and case management, including intensive transition planning and supports in all domains: mental/behavioral health; substance use disorder (SUD) treatment; peer relationships; family functioning; education, vocational training and employment; legal assistance; transportation; clothing and food; primary and oral health; community/spiritual support; and healthy housing. Overarching Project Goals with measurable objectives: Goal 1 HOPE will increase the number of reentering offenders served in St. Louis and Franklin County Goal 2 HOPE will provide wraparound treatment and community support for 543 participants over 60 months. Goal 3: HOPE will incorporate IPS employment service model for at 100% participants Goal 4: HOPE will provide appropriate SUD interventions for 100% participants Goal 5: HOPE treatment professionals will collaborate with community supervisors to increase outcomes for 100% participants Goal 6: Risk, Needs, Responsivity (RNR) tool will be fully implemented in the initial quarter of the project Each goal has quantified, specific, outcome based, measurable, and outcome based objectives that will be measured with standardized and relevant tools. The program will be monitored for quality assurance by a strong stakeholder team comprised of providers, with ongoing input from participants, and with process and outcome evaluation integrally embedded into the program approach. Each of the seven (7) SAMHSA domains, including Abstinence from alcohol and drug use; Increased employment status and/or education; Decreased involvement in criminal justice system; Increased stabilization in family-living conditions; Increased retention in treatment; Increased social supports and connectedness; and Increased access to services will be individually addressed through a robust treatment, case management and resource coordination system with stakeholders and service providers in order to to incentivize and improve quality of overall healthy, community integration, and decrease relapse and recidivism into incarceration and addiction. Participants will remain engaged in reentry services for 98 days post-release, at which time each will receive a warm hand off/transition into aftercare, or be discharged with culturally appropriate and relevant, supportive, community connections. Facilitated, Peer Alumni opportunities to continue community connections and positive retention with post-care support will be emphasized.

10 Project Abstract Summary Rock Valley Community Programs, Inc. (RVCP), if awarded these funds, proposes to serve to 250 offenders (50/annually), with post-release services through Project Transitional Recovery Services to Empower and Transcend (Project TREAT). RVCP will assist adult offenders, returning to Rock County assessed with substance use disorder (SUD), with transitional planning, including expanded access to SUD treatment and other wrap-around reentry services. RVCP, founded in 1971, and provides services based on accountability, safety and treatment that enhance the community. RVCP develops and administers programs through partnerships with local, state and federal agencies to serve residents in southern WI and northern Illinois with public safety the constant. RVCP programs provide the opportunity for education, treatment, and guidance in the areas of community service, substance use and mental health disorders, including co-occurring disorders, cognitive behavioral restructuring, employment, transitional and permanent housing, and supportive services. RVCP will provide pre-release services, including assessments and transitional planning, promote social, economic and housing independence of program participants by offering expanded access to post-release evidenced based treatment and referrals to wrap-around reentry services, establish a multidisciplinary steering committee to identify and promote best practice system and service protocol improvements for offenders needing substance use disorder treatment, and identify, treat, and prevent the infectious diseases through education and risk reduction. Offenders will be screened and assessed, pre-release, for substance use/co-occurring disorders, and engage in transitional planning with their assigned Case Manager. Post-release assessments will be administered to offenders, and the appropriate referrals for substance use disorder treatment, including Residential, Medication Assisted Treatment, and Outpatient, will be made. Additionally, referrals to appropriate wrap around reentry services will be made. Hepatitis B and C and HIV testing will be completed on at-risk offenders, and referral to treatment, educational resources, and prevention services will be made. Project TREAT will provide annually, a) pre-release SUD assessment to a minimum of 115 offenders in the Rock County Jail; b) provide intensive/outpatient, including Medication Assisted Treatment, to a minimum of 50 offenders annually; c) provide inpatient/residential services to a minimum of 10 offenders annually, and d) case management services to a minimum of 50 offenders annually. The proposed project is expected to support Rock County WI of reducing recidivism by expanding access to SUD treatment and wrap around reentry services.

With W-RISE (Women's Reentry with Integrated Services, Engagement, Empowerment) Program, St. John's Well Child and Family Center proposes to provide 360 (72 annually) sentenced adult cisfemale & transfemale offenders (Reentry Women = RW) and 720 of their partners and/or children with access to comprehensive substance use disorder (SUD) and SUD with co-occurring mental health disorder (co-SUD/MHD) treatment and wraparound recovery support services. St. John's will also initiate SLARRP (South LA Reentry Recovery Partnership), which will be a coalition of reentry serving organizational stakeholders that will address infrastructure gaps in local reentry services, develop a system for seamless linkage among partner agencies, conduct advocacy and provide cross-training. Overrepresented in the justice system, the African American and Latina women to be served by W-RISE will be from South LA, an area highly impacted by poverty, crime, homelessness and housing instability, low education levels, and low degree of social cohesion. For South LA RW these issues are often compounded by HIV, HCV, pregnancy, and co-SUD/MHD, including PTSD, which greatly affects recidivism rates (49% for women in LA County). 1,080 unique individuals will be served over the life of the project. Through expert culturally competent delivery of evidence-based practices, and provision of integrated comprehensive and support services for co-SUD/MHD that are well coordinated with partner agencies, W-RISE aims to improve the health, functioning and stability of trans- and cisgendered reentry women and their families, while also decreasing rates of recidivism of previously incarcerated women in South LA. St. John's will hire transgender or trans-affirming women with lived experience to provide co-SUD/MHD treatment and case management, and will execute gender-responsive trainings to increase the capacity of SLARRP agencies to serve women. W-RISE/SLARRP's goals are: (1) To improve infrastructure and system linkages for reentry individuals, particularly women, developing capacity for a better coordinated, community-driven response to reduce health and social costs of co-SUD/MHD in South LA. (2) To improve health and wellness and enhance stability, including reducing recidivism, among RW and their families in South LA Measurable objectives include: 1.1) By Month 1, launch monthly SLARRP community meetings with local providers and representatives from correctional facilities to continue throughout grant period. 1.2) By Month 3, conduct a needs assessment to identify behavioral health, recovery support services and related service coordination/infrastructure gaps and establish a 2-year SLARRP Strategic Plan to address (revisited annually). 1.3) By Month 2 of each program year, assess for SLAARP training needs; coordinate and implement at least 2 trainings that address gender-informed strategies/approaches. 1.4) By Month 4, St. John's EMR system will be updated to include all assessments & reports needed to successfully implement W-RISE. 2.1) Within 2 weeks of initial DHS referral, Reentry Recovery Specialist will visit 100% of W-RISE-eligible clients; 85% will receive SBIRT, comprehensive assessment, and initial treatment planning. 2.2) Of those provided the above, 60% will access ongoing individual/group/family counseling and/or psychiatric care; of those who initiate services, 60% will complete treatment. 2.3) Within 30 days from initial contact, W-RISE staff will develop individualized recovery support plans with 95% of clients to address recovery support service needs. 2.4) 80% will be linked to St John's for primary care visit within 30 days of release. 2.5) Annually, provide MAT to at least 10 patients exiting jail system. 2.6) By the end of project period, ensure that 95% of W-RISE clients learn their HIV, HBV/HCV status and are linked to appropriate prevention or treatment services at St. John's. 2.7) Reduce risk of recidivism for 75% of St. John's RW clients.

SUMMARY: WestCare Tennessee's Breaking the Cycle program will provide evidence-based behavioral health treatment and recovery support services to help citizens reintegrate into the community post-incarceration. PROJECT NAME: Breaking the Cycle POPULATION: The proposed program will serve adult (men and women 18+) offenders & ex-offenders who are returning to the community from incarceration in Morgan County Jail or Roane County Jail in Tennessee. Participants must: 1) be assessed or diagnosed as having a moderate to severe substance use disorder (SUD) and/or co-occurring mental health disorder (COD); 2) have been sentenced to & serving at least 3 months in jail, or have violated parole & serving at least 1 month in jail; & 3) be within 4 months of scheduled release. INTERVENTIONS: The program will provide direct treatment services & systems linkages through an interconnected network of direct service provider partners. As the lead applicant, WC-TN will provide direct SUD and/or COD outpatient and intensive outpatient treatment services, as well as recovery support services (employment services, case management, relapse prevention, referrals & assistance in locating housing, life skills, education, parent education & child development, & substance use education). The program will also link participants to direct service provider partners for other recovery support services, including primary medical care, HIV testing, Hepatitis testing, & transportation to and from services. GOALS & OBJECTIVES: Goal 1-Foster a stable & manageable transition from incarceration to community-based living for reentering citizens. Objective 1.1-Strengthen & expand the existing partnership between WC-TN & Morgan & Roane County Jails. Objective 1.2-Provide pre- & post-release reentry services to 45 participants annually (225 over 5-years). Objective 1.2.1-100% of participants will have a transition plan. Objective 1.3-90% of participants who received medical testing will effectively manage their own health. Goal 2-Avert relapse & support sustained recovery. Objective 2.1-Provide SUD treatment to 45 participants annually (225 over 5-years). Objective 2.1.1-75% of persons enrolled in treatment will successfully complete the program. Objective 2.2-Conduct random urinalysis for 100% of participants. Objective 2.2.1-70% of participants will be substance free for 6 months post intake & remainder will reduce use. Objective 2.3-90% of participants completing Seeking Safety will report reduced trauma symptoms at discharge and 6 months post intake. Goal 3-Promote community and family safety through the prevention of criminal recidivism, and enhance social, mental health, and behavioral health functioning among participants reintegrating into the community. Objective 3.1-Provide case management services to 45 participants annually (225 over 5-years). Objective 3.1.1-100% of participants identified as needing housing support will receive targeted case management. Objective 3.1.2-At least 80% of completers will have improved relationships at discharge and at 6 months post intake. Objective 3.2.1-80% of completers will not engage in new criminal activity at discharge, and 70% will not recidivate at 6 months post intake. Objective 3.3- Provide vocational/employment services to 100% of participants identified as needing this service. Objective 3.3.1-80% of completers will be in an educational/vocational program, seeking employment, or employed at discharge, and 70% at 6 months post-intake. Objective 3.4-100% of completers will complete an anger management class. Objective 3.5-80% of completers who are parents will complete a parenting class.

Community Partners in Action (CPA), established in 1875, seeks to expand its Resettlement Program by serving an additional 275 citizens (55 annually) returning to the Hartford/Greater Hartford, CT area. The Resettlement Program will provide Recovery Support Services that assist individuals to recover from alcohol and drug addiction and partner with InterCommunity, Inc. to provide the Substance Abuse and/or Co-occurring Treatment and Recovery Services. The population of focus will be men and women 18 years of age and older who: have been assessed/diagnosed as having a Substance Use Disorder (SUD) and/or co-occurring substance use and mental disorder; have been sentenced to and serving at least three months in prison or have violated parole and serving at least one month in prison; be within four months of release to the community; and upon immediate release from prison be connected to treatment. Evidence-Based Practices (EBP) will be integrated throughout service delivery and the program will implement coordinated transition planning in correctional institutions. This planning will include the screening and assessment of substance use and/or co-occurring mental disorders and coordination of continued care from institution to community which will include community-based treatment, recovery, and reentry services. The goals and objectives for this project include, but are not limited to: Goal 1: To increase access to and utilization of treatment for 275 returning citizens with SUD and/or co-occurring substance use and mental disorders. Objective: To coordinate pre- and post-release service provision with the CT Department of Correction and InterCommunity for 55 individuals annually. Goal 2: To enhance and strengthen treatment for SUD/co-occurring disorders for returning citizens to increase abstinence. Objective: To decrease hospitalization for participants with SUD/co-occurring disorders by 70% and obtain an 80% successful treatment completion rate. Goal 3: To augment recovery/wraparound support services through peer to peer case management to enhance and strengthen treatment and decrease recidivism. Objective: To keep the recidivism rate of program participants under 22%. Goal 4: To expand ability to implement Evidence Based Practices (EBP) for SUD/co-occurring disorders and recov/wraparound support services. Objective: To support continued improvement and efficacy of EBP implementation and sustainability throughout the project’s duration. Goal 5: To ensure project implementation and evaluation adhere to goals and objectives and facilitate Continuous Quality Improvement (CQI). Objective: To identify monthly practices that are working and those in need of attention and determine the enhancements essential to support improvement for quality service provision.

Casa Esperanza Inc.?s proposed ?Transcend: Empowerment, Recovery, and Reentry? program will aim to reduce relapse and recidivism among Latino reentering citizens living with co-occurring substance abuse and mental health disorders (CODs) by expanding access to substance use disorder treatment and related recovery and reentry services. Over 5 years, Transcend will serve 240 individuals. Transcend?s goals are: 1) Support successful transition from incarceration to integrated substance abuse and mental health treatment to increase retention of, and improve long-term outcomes for, individuals reentering the community; 2) Provide treatment services that educate and empower participants to develop skills to identify risky behaviors for relapse and recidivism; solve problems and navigate complex systems through the development of self-efficacy and social skills; and identify resources to overcome barriers to reintegration; 3) Grow our Latino Reentry Network to expand access to an integrated recovery and reentry-oriented continuum of care focused on the unique needs of multiply-diagnosed Latino reentering citizens; and 4) Create and deliver culturally-focused Peer Leadership Development program to develop returning citizens into emerging Latino recovery leaders who promote healthy attachment and culturally relevant, trauma-informed, and recovery-oriented values in the community. Transcend will be anchored in the evidence-based practice of Integrated Dual Disorder Treatment (IDDT). IDDT is a framework that incorporates a powerful combination of individual, group and family evidence-based interventions within it. IDDT has a strong evidence base as an effective treatment for individuals with co-occurring substance use and mental health disorders; and is beginning to be tested with specific reentry populations, with promising results, especially for increased utilization of mental health services and reduced hospitalizations.

First Call respectfully requests $425,000/year SAMHSA funding in support of the ME After Reentry Program to expand and enhance substance use disorder (SUD) treatment and related recovery and reentry services for adults transitioning out of incarceration from the Kansas City, Missouri Regional Corrections Center (RCC). The purpose of the ME After Reentry program is to reduce recidivism and sustain recovery from substance use disorder after release from jail. Wrap-around services are offered to drug court participants post-release but utilization rates are low; this ME First Reentry program will increase number of individuals served; increase abstinence from substance use; increase employment, and decrease recidivism for 50 clients annually and 330 clients in total over the 5 year grant period. The ME After Reentry program?s target population is Kansas City Municipal Drug Court (KCMDC) adult defendants diagnosed with a substance use disorder as their primary condition, as well as adult defendants who have co-occurring substance use and mental health disorders and trauma treatment needs. First Call and the Kansas City Municipal Drug Court (KCMDC) developed a key stakeholder partnership in 2002 and have worked together to provide treatment and recovery-related services to drug court participants ever since. KCMDC participants are 64% male, 36% female. The inmate population is 73% Black; 24% Caucasian; 4% American Indian. Just over 5% of the target population identifies as Hispanic/Latino. With an age range of 17-63, the average participant age is 39. The primary strategy for this program is to engage each participant with a clinically-trained First Call recovery advocate before their release and during the participant?s transition back into their community. As participants navigate an increasingly complex network of SUD treatment and wrap-around support services, the advocate role becomes critically important. First Call is the current provider of evidence-based substance use disorder treatment services (Sober ME) for KCMDC clients while incarcerated. The ME After program will build on Sober ME by providing an aftercare group and one-on-one client support provided by First Call recovery advocates. Grant funds will also be used for urinalysis administered by ARCPoint Labs, trauma services administered through Truman Medical Center and Medication Assisted Treatment (MAT)/outpatient treatment administered by ReDiscover. Employment support will be offered through the Warehouseman Training, Inc.

The Honolulu County Offender Reentry Program (HCORP) at Hina Mauka proposes a public-private partnership that focuses on fully implementing a collaborative criminal justice system (CJS) and behavioral health system (BHS) response to the criminogenic risks and needs (i.e., RNR) of offender transitioning out of correctional institutions and into community corrections settings with untreated substance use disorders (SUD). Data from the Hawaii State Judiciary (JUD) and Department of Public Safety (PSD) has pointed out a need to reduce felony probationer recidivism and correctional facility overcrowding both in the City and County of Honolulu and statewide. Here, our focus is on addressing the issue of limited substance abuse treatment program (SATP) and wrap-around recovery support service (WRSS) availability and accessibility for adult sentenced felony probationers (SFP) serving bifurcated jail and probation sentences, with maximum 18-month and 5-year terms, respectively. Recent PSD and JUD reports have indicated that SFPs represent nearly 40% of the local jail population, with over 55% re-incarcerated within 3-years after release from a PSD correctional facility. Over 80% of SFP report a history of SUD, with almost 20% presenting acute co-occurring disorders (COD) at the time of JUD?s presentence investigation. The SFP population is an important gap group, because probationers serving jail sentences under JUD jurisdiction do not have the same access to SUD treatments and services as do parolees and prisoners while held in PSD facilities. The HCORP at Hina Mauka proposes to strategically plan and phase-in structurally sustainable expansions and enhancements to our existing SATP and WRSS continuum of care over the next 5 years. This involves systematically increasing the number of SFP clients currently receiving coordinated CJS and BHS reentry services from a base-rate of 52 per year to 120 per year. We propose to serve a minimum of 542 unduplicated clients during the proposed 5-year project period. Our implementation plan is guided by three interrelated goals and objectives that are specific, measurable, achievable, realistic, and time-bound (SMART). Our goals and objectives are designed to progressively build the capacity to: provide SFP with access to a continuum of publicly-funded SATP and WRSS immediately upon (re)entry into the community (Goal 1); utilize and coordinate RNR model best practices (BP) and evidence-based practices (EBP) with fidelity (Goal 2); collaborate with CJS and BHS agencies, stakeholders and partners (Goal 3). To accomplish these goals and objectives, we plan to implement innovative project-level and client-level activities that adhere to BPs and EBPs in: HOPE-court supervision; collaborative RNR assessment with facility-based reentry planning; cognitive-behavioral and medication-assisted treatment with fidelity monitoring, training and coaching; community-based case management, forensic peer support, supported education, employment, and housing; and performance data collection, outcome evaluation, and continuous quality improvement. Total 5-year project costs are estimated at $425 thousand per year; $3,921 per client per year; and $11 per client per day.

Abstract Title: Puerto Rico Offender Reentry Project In response to SAMHSA?s Offender Reentry Program RFA (No. TI-18-003), Guara Bi, Inc. a subsidiary of WestCare Foundation, Inc. (Guara Bi) proposes to provide additional reentry services in Puerto Rico. Services are located in, but not limited to, the geographic catchment areas of Caguas, Comerio, and Vega Baja, Puerto Rico. Guara Bi proposes to provide outpatient substance use treatment, mental health treatment, case management, and other reentry services for adult (ages 18 and over) offenders (men and women) reentering the community following incarceration at four correctional facilities under the jurisdiction of the Puerto Rico Department of Corrections and Rehabilitation. All clients will have a DSM 5 diagnosis of substance use disorder (moderate to severe) or mental health disorder. Guara Bi, Inc. will provide re-entry services to 40 unduplicated adult offenders in year 1 and 45 adult offenders each for years 2-5 (220 across the five-year funding period). The proposed program will: 1) offer evidence-based, gender responsive and trauma-informed substance use, mental health and co-occurring treatment; 2) employ a Risk-Needs-Responsivity (RNR) model using George Mason University?s Center for Advancing Correctional Excellence RNR Simulation Model; 3) provide each client with an individual reentry plan before release; 4) provide offenders with substance use and mental health assessment before release 5) expand Guara Bi staff to better serve offenders; 6) implement an additional evidence based practice; 7) provide Onsite Rapid HIV Antibody testing and HIV Case Management Services; and 8) provide Viral Hepatitis Testing. Guara Bi will utilized evidence based practices including 1) Brief Strengths Based Case Management for Substance Use, a case management practice designed to assist substance users; 2) Moral Reconation Therapy, a cognitive behavioral therapy proven effective for substance use in the correction population; 3) Motivational Interviewing, a brief psychotherapeutic intervention for helping people change addictive behavior; 4) Seeking Safety, a present-focused therapy to help people attain safety from trauma/Post Traumatic Stress Disorder and substance use; and 5) Cognitive Behavioral Therapy which offers effective and time-limited treatments for limited anger control skills often experienced by our clients. Using a number of evidence-based programs and practices rooted in Cognitive Behavioral Therapy and Motivational Interviewing, Guara Bi will combine the case management with effective treatment services to break the cycle of criminal behavior, violence and trauma, alcohol and/or drug use, and incarceration or other penalties. The program also intends to address disparities and gaps in the continuum of treatment. Anticipated outcomes include: increased number of individuals served, increased abstinence from substance use, decreased recidivism rates, decreased criminal justice involvement, improved individual and family functioning and well-being, improved treatment retention, increased social connectedness, and decreased risky behaviors.

BRiDGES is seeking funding through the SAMHSA Offender Reentry Program (ORP) grant in support of expanding Re-entry services in Rockland County, NY for 500 individuals returning to the community from local County Jails and State Prisons. Services are provided through a Conflict-Free Case Conferencing model designed to ensure treatment for Substance Use Disorder (SUD) and/or Co-Occurring Disorders (COD) as indicated. Historically, more than 80% of individuals returning to Rockland County from incarceration are known to have an SUD/COD. BRiDGES coordinates Re-entry for the Rockland County Re-entry Task Force (RCRTF). RCRTF has identified various social determinants that contribute to an increased likelihood of successful Re-entry, including: timely and comprehensive treatment for SUD/COD and supportive services available through Re-entry of benefits advisement, information & referral, advocacy, and access to affordable housing, education, transportation, and employment. Additional social factors may lead to an increased likelihood of recidivism, including: insufficient treatment and supportive services as well as factors that may contribute to the SUD/COD related to trauma from military service or other life experience. BRiDGES, through the RCRTF, utilizes a Conflict-Free Case Conferencing (CFCC) model that separates functions of financial and policy oversight from service planning and delivery. Each person in Re-entry receives an Intake assessment. Bi-weekly Case Conferences are coordinated through BRiDGES. Each conference involves the person served and local County departments and community based service providers to develop, monitor, and implement person-centered treatment plans. Re-entry services through BRiDGES include the use of Evidence-Based programs that include Positive Behavior Interventions & Supports (PBIS), Thinking for a Change (T4C), and Ready-Set-Work! (RSW!). SUD/COD services are provided by local community based organizations as determined through the CFCC. RCRTF currently provides Re-entry services to individuals returning to the community from State Prison who are determined to be at High or Medium Risk with a COMPAS score of ""1,"" ""2,"" or ""3."" This project will expand those services annually to 40 individuals with SUD/COD who are determined to be at Low risk with a COMPAS score of ""4."" In addition, this project will expand Re-entry services annually to 60 individuals with SUD/COD who are returning to Rockland County from County Jails from Rockland and neighboring Counties, including Bergen, NJ as well as Westchester, Dutchess, Orange, Ulster, and Putnam Counties in New York. Goals for the program include expanding Re-entry services for 100 people annually / 500 people over five (5) years in order to improve likelihood of successful return to family and communities and reduce recidivism; ensure treatment services for individuals with SUD/COD to increase abstinence and reduce recidivism related to SUD/COD; and to ensure supportive services are provided to increase housing stability, employment, and social connectivity.

Project ROAR will expand its current partnership with Bristol County House of Correction and Jail (BCHOC) and collaborate with the Barnstable County Correctional Facility (BCC) to provide enhanced and expanded treatment and recovery support services to 440 adult male and female offenders/ex-offenders in Southeastern MA who have been diagnosed with a substance use disorder (SUD) or co-occurring mental health disorder (COD) over a five-year period. ROAR will also prioritize pregnant women and those with histories of or at high risk for opioid dependency. To increase engagement in treatment among our population of focus, Steppingstone?s (SS) Parole Re-entry Navigator, based in the MA Region 8 Parole office, will collaborate with ROAR and correctional staff to provide a unified approach that supports individual treatment and reentry goals. Project ROAR staff includes a Project Director, Licensed Substance Abuse and Mental Health professionals, Psychiatrist, Clinical Nurse, integrated care facilitators, peer specialist/recovery coaches and Administrative Assistant. Services will begin in the correctional setting within four months prior to release, including brief screening and assessments for SUD/CODs, recidivism risk assessments (LS/CMI, George Mason Univ. RNR tool), case management, and transition planning, as well as various groups. Other EBPs include Seeking Safety, Motivational Interviewing and Cognitive Behavioral Therapy. During this period, staff strive to build rapport and trust with individuals. Once participants are released into the community, the intensity of case management is increased to facilitate engagement in substance abuse and mental health treatment and recovery support services, such as family counseling, education and job training programs, social supports, mainstream resource benefits, faith based services, and other community services. ROAR will follow the RNR Model, with Integrated Care Facilitators performing ongoing evaluation to ensure the intensity and timeliness of planned treatments and support services are appropriately staged for each individual. SS is a provider of outpatient and residential treatment services and works with other SUD/MHD providers to connect ROAR participants to treatment which is best suited to their individual needs. SS also operates over 100 units of supportive housing for persons with SUD/CODs or HIV/AIDS. SS has formal written agreements in place with an array of local providers to provide access to Medication Assisted Treatment (MAT), HIV and Hepatitis B and C testing, and all necessary wrap-around services. To address the opioid overdose epidemic, ROAR offers an opioid overdose prevention program and works closely with parole, probation, drug courts and other providers to efficiently identify and respond to high-risk situations. Measurable outcomes include: decreased substance use, recidivism, criminal justice involvement, and risky behaviors; and increased employment, housing stability, social connectedness, and improved functioning and well-being.

Our successful Living-Free reentry program integrates evidence-based addiction and mental health treatment, physical health care, and peer mentorship to provide a system of care for women and men returning to the New Haven CT area following release from incarceration. This collaborative care model is supported by an ongoing partnership between the State of Connecticut Department of Correction, the State of Connecticut Department of Mental Health and Addiction Services, and Yale School of Medicine. Results from our Living-Free program demonstrate that we have engaged 94% in outpatient treatment, 79% have successfully completed treatment and are substance-free, and 6-month recidivism rates are 4.6% for new arrest and 0% for incarceration based on new arrest. For this application, we are proposing an expansion of our Living-Free program to deliver outpatient addiction services provided by our FORDD Clinic to an additional 400 substance-using adult men and women reentering the New Haven CT community (for a total of 650 unduplicated persons treated). The New Haven community is the 4th poorest city for its size in the United States and addiction-focused reentry services are lacking. The primary aims are to 1) identify, engage, and support the successful transition of substance using adults back to their communities and families (treat an additional 94 per year over 4.5 years) and 2) to increase access to our reentry program by expanding recruitment from the prison population to also include jail and violation of parole populations. To support our aims, we plan to provide significant in-reach services prior to discharge including pre-release escorted visits to our FORDD clinic for assessment and treatment planning. A motivational enhancement approach will be utilized during the in-reach phase to increase engagement in treatment post-release. Addiction and mental health treatment involves individualized treatment plans with individualized lengths of treatment (min of 3 months and max of 12 months), and focus on the delivery of trauma-informed evidence-based behavioral (e.g., Motivational Enhancement Therapy, Cognitive-Behavioral Therapy) and pharmacological treatments. Peer mentors with prior addiction/incarceration experiences will be utilized to assist with wrap-around case management services focused on housing stability, employment, and education. We have a long-standing successful model of utilizing peers to provide these supportive services, improving both treatment retention and outcomes. All clients will be seen at the Transitions Clinic (a Centers of Medicare & Medicaid Innovation-funded program designed to treat a reentry population) to provide culturally competent timely primary health care and HIV/HCV screening. The program evaluation will assess our primary goals of expansion, access, increased abstinence from substances, improved physical health, improved community engagement and social connectedness, increased rates of housing/employment/education, and decreased recidivism with assessments occurring up to 1 year post-discharge to assess the durability of effects.