To connect those who are Health Home eligible, being released from jail or prison or who have been in jail or prison before, to needed medical, mental health, substance use and/or other community support services. With the help of Correctional Health Services, for those being released from Rikers Island, their discharge planners will talk with them about the choice to sign up for the Health Home Program. If the person agrees, the discharge planner will work with our Criminal Justice Manager and connect them to a care management agency (CMA). The CMA will help them sign up for the Health Home program and access to the needed services and re-engagement into the community.