Special Projects Fund

Project Title

Replicating an Integrated Care Model for Justice System-Involved Youth

Grant Amount


Priority Area

Special Projects Fund

Date Awarded

December 12, 2022




In Progress



Individuals with mental illness and substance use disorder are disproportionately represented in the criminal justice system and encounter barriers to behavioral and primary care services after returning to their communities.

Resulting delays in care can trigger a cascade of devastating events, including uncontrolled chronic illnesses and mental health crises. With State and NYHealth support, the Center for Alternative Sentencing and Employment Services (CASES) launched its Nathaniel Clinic in Central Harlem in 2014 for individuals with mental illness who have involvement with the justice system. CASES offers integrated mental health, primary care, substance use, peer and case management, and mobile crisis outreach services all at one site. The demand for services is high, and individuals travel long distances for care. As of 2021, one-quarter of patients traveled from the Bronx, a borough with disproportionately high rates of incarceration, chronic illness, and hospitalization, to the Central Harlem site. In 2022, NYHealth awarded CASES a grant to replicate the integrated care model and provide primary care services in the Bronx for justice system-involved youth.

Under this grant, CASES will recruit and train staff on the clinic’s integrated systems, screening protocols, and service coordination model to ensure a seamless patient experience. CASES will implement workflow protocols and referral processes for all co-located programs. It will conduct outreach among youth programs, make referrals, and conduct health screenings and assessments to monitor substance use risk. It will also assist with medication management, implement rapid response for mental health crises, connect patients to specialty care and counseling, and provide group education on health and wellness.