Post Discharge: Reconnecting to Health and Society by Joey DelFerro

When discharged from a correctional institution, one faces a laundry list of things that must be accomplished, ranging from self-made to court stipulated goals. This seemingly endless list of tasks often detracts from an individual’s ability to reconnect with their community and to achieve “good health”. Through my service at Action Wellness, I am able to help individuals navigate various systems in order to obtain quality medical care and to combat the social determinants of health that often restrict their ability to lead a healthy lifestyle.

By having an NHC member at Action Wellness, my team is able to extend more individualized services to clients. For example, I can meet with clients to provide resources on navigating various systems, help them with Medical Assistance and SNAP enrollment, and escort them to various medical and social service appointments. By providing this individualized care, clients are able to learn these complicated systems with the support of a team of social workers, rather than on their own. I am also responsible for training eligible clients in overdose prevention and Narcan administration. These trainings allow clients to not only protect themselves from a fatal overdose, but to share this information across their communities. Throughout my service term, I have provided this training to over 30 individuals and have been able to provide them with Narcan so that they can actively help in an overdose situation. 

At Action Wellness, the majority of clients are people living with HIV. Many of these individuals have only recently been diagnosed during their medical screening upon incarceration. For most of these recently diagnosed clients, the list of medical appointments and medications becomes daunting, as many have no previous exposure to the healthcare system. By escorting clients to their medical appointments, I am able to provide support for them during this stressful time and to better ensure their engagement in their medical care. By coordinating medical appointments, I can make sure that clients obtain the medical care they need in a timely manner. In addition to medical appointments, I provide clients with food resources, housing resources, and mental health referrals to allow them to achieve a healthier lifestyle. Throughout my service term, I have followed individuals from diagnosis, to obtaining insurance, to their first infectious disease appointment, to the point where they come to Action Wellness with all of their medical appointments already made. The success of my role and the organization as a whole relies on this achievement. The purpose of my role is not to walk clients to their appointments for the rest of their lives. The goal is to help clients understand the complicated healthcare network and become independent in their ability to lead healthy lives. During the past months, I have achieved this goal and have seen clients grow and even share resources with me that I can pass on to other clients. This client-focused progression towards “good health” is what makes my role at Action Wellness through NHC effective, fulfilling, and unique.