Believed to be the only one of its kind in rural America.

According to the Substance Abuse and Mental Health Services Administration, one in five adults in the U.S. have a behavioral health diagnosis or substance use disorder (American Medical Association, 2022). The number is even higher for the justice-involved population.

These individuals have been isolated from society for a period of time and making their own decisions has become a foreign concept. Without adequate support, individuals have a greater risk for engaging in behaviors that lead to overall health implications, as well as reincarceration.

When Jillian Rafter joined the practices at Valley Regional Hospital (VRH) as a Primary Care Nurse Practitioner, she identified the justice-involved population as underserved. Upon re-entry into society these individuals often delayed seeking primary care; she discovered that many did not know how to seek care, found accessing care difficult, felt ashamed, or the general process of establishing care overwhelming and stressful. Due to the various reasons, the delay in seeking care led to a delay in treatment for chronic conditions ranging from depression and anxiety to high blood pressure and diabetes. The public health implications of untreated infectious disease and chronic medical conditions often put a great strain on emergency and behavioral health related services.

Determined to make a difference, Jillian met with licensed social worker, Krista Lafont-Leamey, to close the gap and identify how to best care for this underserved population. Together they researched current practices and programs, as well as developed relationships with various community organizations and correctional facilities to create Valley Regional Hospital’s own Post-Sentencing Integrated Care (PSIC) program. Though common in urban settings, they have not been able to find a similar program in rural United States.

The PSIC program is set up to work with correction facilities prior to release to create a plan of care, so individuals are more likely to receive ongoing medical care after re-entry into the community. In addition, VRH has been able to obtain additional funding through a grant focused on the care of this population. It has enabled them to expand the behavioral health team as well as their PSIC support services, allowing our organization to better coordinate care for all clients with behavioral health needs. The behavioral health team now includes primary care providers, a Psychiatric Nurse Practitioner, a Substance Use Disorder and Behavioral Health Nurse, two community health navigators, pharmacy services, and two licensed social workers.

The PSIC program has been active for one year, and has supported approximately thirty patients on their journey as they work towards maintaining a successful re-entry into society.

“It is our goal to decrease stigma, provide integrated care, improve access, and support each individual in their success throughout the reintegration process. With improved access to care individuals will have the supports they need to thrive. We’ve been able to develop a relationship and build trust while supporting individuals through reintegration and management of medical and behavioral health needs. We are not the only group in the community interested in caring for this population, we are developing relationships with other professionals to further support these individuals and their families”. Jillian Rafter, MSN, FNP-BC, APRN

Every patient deserves an equal opportunity for care, regardless of their past. If you are among the many professionals interested in supporting this population, please contact Rebecca Stickney, our Community Health Navigator, to learn more about this program at [email protected].

If you or someone you love are interested in establishing care at Valley Regional Hospital and accessing these support services, please contact Valley Primary Care at (603) 542-6700.

For all other press inquiries, please reach out to Savannah Tyrrell, [email protected].



American Medical Association. (August 22, 2022). What is behavioral health?. American Medical Association.

Jillian Rafter

Jillian Rafter, MSN, FNP-BC, APRN

Krista Lafont-Leamey, LICSW Valley Regional Hospital in Claremont NH

Krista Lafont-Leamey, LICSW

Rebecca Stickney Valley Regional Hospital in Claremont NH

Rebecca Stickney
Community Health Navigator