Checklist for Adding a Transitional Care in a Carceral Setting Site to Scop

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Checklist for Adding a Transitional Care in a Carceral Setting Site to Scope
Transitional Care in Carceral Setting (TCCS) Site Criteria 
    • The carceral setting is a prison, jail, correctional facility, juvenile justice facility, or other facility where a justice-involved individual reentering the community (JI-R) is incarcerated or detained by a state or local government. 
    • The carceral authority is a local or state government that is responsible for the care and custody of the JI-R individual. 
    • Health center services will not be provided to JI-R individuals in the care and custody of the Federal Government, even if they are in the same carceral setting as those in the care and custody of a state or local government.
    • The physical address for the carceral setting is located in your health center’s HRSA-approved service area or an adjacent area.

Notes: Areas adjacent to a health center’s service area are: 
    • The local jurisdiction (county, township, borough, parish, city, or equivalent type of minor civil division) adjacent to the area covered in whole or in part by the ZIP Code Tabulation Areas (ZCTAs) for each approved service site, as identified by your health center on its Form 5B: Sites; and 
    • Any ZCTAs not identified on your health center’s Form 5B but that are within such local jurisdictions covered in part by the service area ZCTAs.

You will not be able to add ZIP Codes to your health center’s service area through this Transitional Care in Carceral Setting (TCCS) Change in Scope (CIS) request.
Background
Your change in scope (CIS) request will not become part of your health center’s HRSA-approved Health Center Program scope of project until all the following steps have been completed: 
    1. HRSA sends your health center the Notice of Award (NoA) or Notice of Look-Alike Designation (NLD) approving the CIS request; 
    2. Next, your health center submits a scope verification task that confirms your health center has implemented the change. HRSA will allow up to 120 days for your health center to submit the scope verification task; and 
    3. Finally, HRSA sends your health center a NoA or NLD documenting that the change is included in your health center’s scope of project. 
For more information, refer to the Scope of Project Resources. 

    1. Has your health center recently submitted or is it in the process of submitting any other CIS requests related to this site or related to any attachments within this CIS request?
For example, contracts or agreements within this CIS request are referenced within other CIS requests or your health center previously submitted a CIS request to add this site that HRSA disapproved.
    • Yes 
    • No 
 
        1.1 If YES: Provide the CIS tracking numbers and describe the connection to this CIS request. 
For example, the same contract, same school-based agreement, same sub-recipient agreement, adding a new service at the proposed site, why you are submitting another CIS request for this site that HRSA previously disapproved.

    2. Is this CIS request a scope correction in preparation for or resulting from one or more site visits?
    • Yes 
    • No 

        2.1 If YES: Identify the related site visits.

        2.2 If YES: Explain. 

    3. Within the last five years, has your health center received Health Center Program supplemental funding related to this site?  
    • Yes 
    • No 

If YES: 
        3.1 Which Health Center Program supplemental awards are related to this site?  
        3.2 Explain how each supplemental award relates to this CIS request.
        3.3 If there are any related Prior Approval tracking numbers or Project Change Form tracking numbers, provide them here.

Description and Rationale
    4. Identify what type of carceral authority operates the carceral setting where your health center will provide in-scope transitional care services. 
    • State government
    • Local government

    5. ZIP Codes
5.1 All Current Service Area ZIP Codes
These are the current service area ZIP Codes for all of your health center’s in-scope sites, based on your health center’s Form 5B: Sites: 
        5.2  Proposed TCCS Site’s Physical Address ZIP Code
This is the ZIP Code of the physical address of the proposed TCCS site at the carceral setting : 
        5.3  Confirm that the ZIP Code for the physical address of the proposed TCCS site is one of your health center’s current service area ZIP Codes. 
        ◦ Yes
        ◦ No

5.3.1 If NO: Confirm that the ZIP Code for the physical address of the proposed TCCS site is in an area adjacent to at least one of your health center’s current service area ZIP Codes. 
        ◦ Yes
        ◦ No

    6. Attach Service Area Map: Select the “Service Area Competition” application map/table type in Health Center Program GeoCare Navigator. The purpose of this map is to document that the proposed TCCS site’s physical address is in one of your health center’s current service area ZIP Codes or is in an area adjacent to at least one of your health center’s current service area ZIP Codes. Make sure your map shows your health center’s:
        ◦ Current service area ZIP Codes 
        ◦ Current in-scope sites 
        ◦ Proposed TCCS site

Notes: Areas adjacent to a health center’s service area are: 
    • The local jurisdiction (county, township, borough, parish, city, or equivalent type of minor civil division) adjacent to the area covered in whole or in part by the ZIP Code Tabulation Areas (ZCTAs) for each approved service site, as identified by your health center on its Form 5B: Sites; and 
    • Any ZCTAs not identified on your health center’s Form 5B but that are within such local jurisdictions covered in part by the service area ZCTAs.

    7. Discuss how your health center will ensure that it will only provide transitional care services to JI-R individuals: 
    • During the 90-day period prior to their scheduled or expected release, and/or 
    • Without an official expected or scheduled release date for a period no longer than 90 days, where your health center has a reasonable understanding that the individual will likely be released within 90 days. This includes individuals in pretrial detention during a 90-day time period, notwithstanding the absence of an official expected or scheduled release date.
Note: A health center may not provide in-scope health center services to JI-R individuals in the care and custody of the Federal Government, even if they are in the same carceral setting as those in the care and custody of a state or local government.
		
    8. Discuss how providing transitional care in a carceral setting will benefit your health center’s target population.
		
    9. Discuss how your health center’s governing board has approved the site and the services that your health center will offer to JI-R individuals in a carceral setting. Specifically address how your health center’s governing board: 
    • Retains authority over the provision of all health center services at the site where in-scope transitional care services will be provided to JI-R individuals; and 
    • Determines which services will be provided at the carceral setting (services must be within the list of allowable services in PIN 2024-05: Section VII. Allowable In-Scope Services to Support Transitions to Care for Justice-Involved Individuals Reentering the Community). 

    • Attach board minutes to support your response. 

    10. Select the services that will be provided in the carceral setting from the list of allowable services [placeholder for link].
		
Select all that apply:
    • Care coordination to facilitate continuity of care (including documentation of a reasonable effort to provide access to relevant health data, as well as exchange of transfer and discharge information) from the carceral setting to your health center;
    • Health evaluation(s) to identify physical health, behavioral health, or oral health issues and associated needs;
    • Screening and treatment for communicable diseases, such as HIV, Hepatitis C (HCV), and sexually transmitted infections (STIs); 
    • Primary health services to begin or continue treatment of conditions and associated health needs identified by your health center provider through the health evaluation, including diagnosing conditions, developing treatment plans, prescribing and providing access to medications, and performing minor procedures of the kind ordinarily conducted in a primary care outpatient setting;
    • Immunizations; 
    • Behavioral health (mental health services and substance use disorder services), including initiating and continuing medication-assisted treatment (MAT), and peer recovery support;
    • Recommendations or referrals for post-release care. This may include referrals for substance use disorder treatment and, when medically indicated, specialty services;
    • Obstetrical and gynecological care (including prenatal and postpartum care) of the kind ordinarily conducted in a primary care outpatient setting. This does not include labor and delivery services;
    • Voluntary family planning services;
    • Optometry services;
    • Preventive dental services, including screenings and recommendations or referrals for post-release dental care;
    • Pharmaceutical services, including: 
    • Medication management plan development and therapeutic monitoring; and 
    • To the extent authorized by law, and as appropriate and feasible in coordination with the carceral authority, a supply of medications for use post-release, including pre-exposure prophylaxis (PrEP), such as long-acting injectable PrEP; and naloxone and MATs for opioid use disorder (MOUD), such as buprenorphine or methadone. For example, a health center may provide a JI-R individual scheduled for release with a 30-day supply of medication for opioid use disorder to prevent relapse during the individual's transition back into the community; 
    • Case management services, including:
            ▪ Connecting JI-R individuals with Federal, State, and local programs that provide or financially support the provision of housing services; 
            ▪ Assisting JI-R individuals with preparing prescription drug vouchers; 
            ▪ Assisting JI-R individuals with navigation of and enrollment for benefits, such as Medicaid, Medicare, Supplemental Nutrition Assistance Program, Supplemental Security Income, Social Security Disability Insurance, and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); and 
            ▪ Assisting JI-R individuals with access to education enrollment, legal services and aid, job training, and employment assistance; 
    • Translation services to support access to Health Center Program in-scope services and medical adherence;
    • To the extent authorized by law, and as appropriate and feasible in coordination with the carceral setting, providing transportation (including transportation vouchers) for use post-release to support JI-R individuals to access health center services;
    • Establishing new or strengthening existing partnerships with justice system stakeholders (such as police and probation departments, discharge planners, and other community partners) to inform them about and promote the availability of health center services; 
    • Promoting awareness among JI-R individuals of your health center’s services and supporting entry into care post-release, including by staff such as community health workers or peer navigators with lived experience of incarceration; or
    • Other health education (for example, education regarding the availability and appropriate use of health center services or targeted education on health-promoting behaviors). Explain: 

Note: If your health center plans to add any new services as part of providing transitional care in carceral settings, your health center must submit a separate CIS request to add these new services to your health center’s scope of project (as documented on Form 5A: Services). All services provided to JI-R individuals must also be available to all residents of your health center’s service area.

    11. Will your health center staff directly deliver (Form 5A: Services Provided, Column I) in-scope transitional care services at the carceral setting?
    • Yes
    • No

        11.1  If YES: Discuss how the services will be directly delivered by health center staff.
		
    12. Will your health center provide in-scope transitional care services at the carceral setting through one or more contracts (Form 5A: Services Provided, Column II)? 
    • Yes
    • No

        12.1  If YES: 
    • Discuss how services will be delivered at the carceral setting; and
    • Confirm that your health center’s governing board approved these contracts to provide services at the carceral setting.
		

        12.2  If YES: Attach the contracts. 
The attachments must contain the complete (including any additional documentation, such as appendices or addenda) and fully-executed (signed by all parties and dated) contracts.
		

    13. Will your health center provide in-scope transitional care services at the carceral setting through one or more cooperative arrangements with other organizations (Form 5A: Services Provided, Column III)? 
    • Yes
    • No

        13.1  If YES:
    • Discuss how services will be delivered at the carceral setting; and
    • Confirm that your health center’s governing board approved these cooperative arrangements to provide services at the carceral setting.
	

        13.2   If YES: Attach the cooperative arrangements. 

The attachments must contain the complete (including any additional documentation, such as appendices or addenda) and fully-executed (signed by all parties and dated) cooperative arrangements.
		

    14. Describe how your health center will assess each individual for income and family size.
	
		
    15. Will your health center apply its board-approved sliding fee discount scale to individuals served in this carceral setting?
    • Yes
    • No

        15.1 If YES or NO: Explain. 

    16. Does your health center have a board-approved policy for waiving charges that will be applied to individuals served in this carceral setting?
    • Yes
    • No

        16.1 If YES or NO: Explain.  

Note: It is acceptable for a health center’s patient fee and payment waiver policy to include, as a specific circumstance for waiving fees, those patients who are JI-R individuals. Refer to PIN 2024-05 for the definition of JI-R individuals. 

    17. Discuss how your health center will seek reimbursement from third-party payors (such as Medicaid or private insurance) when such reimbursement is available. 
Refer to Health Center Program Compliance Manual Chapter 16: Billing and Collections.


    18. Describe how your health center will establish and maintain its own health records related to the in-scope transitional care services provided to JI-R individuals served at the carceral setting. 
		

    19. Discuss how your health center will ensure that the JI-R individuals it serves in the carceral setting will have access to all of your health center’s in-scope services upon release and for as long as the individuals continue to reside in the community served by your health center.
		

    20. Discuss how your health center will connect JI-R individuals who will not reside in your health center’s service area after their release to a health center or other primary care provider in the community where the individuals will reside.
		

MOA/MOU Documentation
    21. Attach your health center’s MOA or MOU with the carceral authority. 

The attachments must contain the complete (including any additional documentation, such as appendices or addenda) and fully-executed (signed by all parties and dated) agreements. You may attach additional documentation that supports this CIS request.

Within the attached MOA or MOU for your health center’s proposed TCCS site, clearly mark or highlight the proposed TCCS site address and the language that demonstrates compliance with the requirements below. 

For each of the requirements below, provide the citation (for example, page numbers) for where the requirement is addressed in the attached MOA or MOU, as required by PIN 2024-05. You may provide additional narrative if necessary.


        21.1  Identification of the carceral authority
Citation within the attached (for example, page numbers): 
Brief Narrative: 

        21.2  Identification of the carceral setting’s address
Citation within the attached (for example, page numbers): 
Brief Narrative: 

        21.3  The transitional care timeframe for services
Citation within the attached (for example, page numbers): 
Brief Narrative: 

        21.4  The specific services that will be provided by your health center in the carceral setting to JI-R individuals
Citation within the attached (for example, page numbers): 
Brief Narrative: 

        21.5  How your health center will maintain its own health records for JI-R individuals served in the carceral setting.
Citation within the attached (for example, page numbers): 
Brief Narrative: 

21.6 The exchange of appropriate patient medical information with the carceral authority to ensure continuity of care. 
Citation within the attached (for example, page numbers): 
Brief Narrative: 

        21.7  Patient care coordination between your health center and the carceral authority (for example, mechanisms for distribution of health center-prescribed medications during hours in which your health center provider is not on site at the carceral setting).
Citation within the attached (for example, page numbers): 
Brief Narrative: 


Reminder: If any information in this CIS request is incomplete, HRSA may disapprove this CIS request.

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until 06/30/2029. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.