An individual returning to their community after incarceration is often met with a host of challenges. This population already experiences higher than normal rates of mental health and substance abuse issues, chronic physical health conditions and other social barriers. Read below to learn how the ACG^® System is helping one organization ensure proper post-release health care for this population, or click here to download the full case study.

The Challenge

When people are released from incarceration, they often return to their communities with very little support. While incarcerated, the facility takes care of their health care needs, including maintaining health insurance, scheduling doctor’s appointments and keeping up with medications. After release, these responsibilities fall to the individual.

As a result, most returning citizens are likely to use the emergency department for primary care once they re-enter their community. These patients, many with chronic conditions such as high blood pressure, diabetes, heart or kidney problems and compounded with mental health challenges and unique social needs, often become an inpatient admission, leading to unnecessary costs and a lack of focus on preventative care.

The Solution

Patient Sortal^® is a health care data management system, management service organization and primary care/internal medicine practice that ensures returning citizens have necessary health care, care management and medical coverage as they re-enter their community. They provide care specifically focused on this group’s unique needs while reducing costs associated with continuity of care during community reintegration. How do they do this?

Patient Sortal created a data-driven care model — leveraging data analytics from Johns Hopkins ACG System — to group patients into one of four risk tiers. This risk score was correlated to a resource utilization band (RUB) to predict the intensity of future care management needs. By understanding current and future risk factors, Patient Sortal was better equipped to care for this population through their re-integration.

Historically, care and case management has focused on managing individuals with complex medical conditions and high medical needs. Patient Sortal’s predictive model — powered by the ACG System — goes a step further to evaluate possible future risk. Patient Sortal combines this predictive data with case managers who have years of experience managing complex disease states and a passion for working with justice-involved individuals. The result? Patient Sortal’s providers have a better understanding of the returning citizen population and the risks they encounter upon release. Returning citizens are managed more effectively, with a reduction in emergency department visits, inpatient admissions and negative outcomes.

Click here to read our full case study about the Patient Sortal’s impact on the health of these returning citizens. For more information about the ACG System, email acginfo@jh.edu. If you are an ACG System user, contact your account manager.