Project Name: Planning Community Health Care Coordination for Youth in the Juvenile Justice System in Savannah, Georgia

Project Overview: The Georgia Primary Care Association (GPCA) is a 34-member organization supporting 225 community health center sites covering 123 counties in the state of Georgia, and serving over 400,000 patients. Together with Curtis V. Cooper Primary Health Care (CVCPHC) its oldest member agency servicing Georgia’s second-largest population center in Savannah, Chatham County, GPCA will build upon an existing collaboration with the Chatham County Juvenile Court to develop a new pilot focused on coordinating primary care referrals for vulnerable youth to CVCPHC.

Juvenile incarceration is associated with adverse health outcomes in later adulthood, but for many vulnerable youth, the problems start much earlier. Lack of access to consistent, comprehensive primary, oral, and mental health care is not only detrimental to long-term health, but impedes early development and exacerbates other social and economic stressors. GPCA has been funded by the Centers for Disease Control and Prevention (CDC) to develop collaborative efforts between CVCPHC and the Court that address the referral of juveniles for family planning needs only. GPCA intends to build upon the CDC effort, expanding beyond family planning to comprehensive primary care, targeting under-utilization of primary care services by youth involved with the juvenile justice system.

The planning grant phase will set the stage for the full-scale intervention, aimed at engaging youth referrals in a medical home with screening and primary care treatment, including behavioral health and oral health, and improving health and social outcomes for underserved teens.

Planning project objectives are to:

  • Enhance collaboration among the community partners including the Court and CVCPHC;
  • Enhance systems of referral/tracking and focus on quality of care through Improvement Teams;
  • Increase staff capacity at the Court through trainings, reciprocal site visits, use of training materials for staff and clients and their families; and
  • Increase the number of vulnerable youth referred by the Court (from 800 by 10%).
2018-2019 Project Activities:


2018-2019 Project Outcomes:

  • Building on an earlier collaboration, established foundation for primary-care focused referral program;
  • Delivered initial training for court personnel addressing procedures for screening and referral, site visits, and adolescent health topics;
  • Identified cohort of 15 adolescents and their families as a trial group to test program concepts, engagement, and satisfaction of the participants and stakeholders; and
  • Completed initial assessment of the screening and referral procedures of primary health care with identification of possible changes in forms, procedures, and staff needs.

2019-2020 Expected Project Activities:

Year two will focus on bringing the pilot to scale in preparation for implementation of the program model in 2020-2021.

  • Use Year One learned concept of process mapping to improve processes for: intake and screening, needs assessment and referrals, and development of judges’ orders;
  • Partner with Work Readiness Enrichment Program (WREP) to test screening and referral processes, systems and processes for involvement of Court staff, teens and their parents and adolescents, and evaluation approach;
  • Develop adolescent health training materials for judges and court personnel to enhance direct referrals;
  • Identify consumer – oriented materials on adolescent health topics, access to health insurance, and information about CHC providers for distribution to teens and families involved with juvenile court; and
  • Develop and pilot teen health screening instruments.

Project Partners: Curtis V. Cooper Primary Health Care, Chatham County Juvenile Court.

About the Grantee

The Georgia Primary Care Association (GPCA) is a member service organization representing community health centers in Georgia through the provision of training, technical assistance and the development and implementation of strategies to expand and strengthen the CHC system. Additionally, GPCA is involved in the development and implementation of additional programs and services that will enhance the CHC health care delivery system. For more information, visit: http://georgiapca.org/.