Empowering Transitions from Jail to Community Health: The Point of Reentry and Transition Program

More than nine million people return home after being released from local jails in the U.S. each year and another 600,000 leave prisons. Most are men of color. A disproportionate number of people in jails and prisons have chronic medical or behavioral health conditions, which include mental illnesses or substance use disorders (SUDs), as well as criminalized social problems, such as poverty or homelessness. But care coordination between correctional facilities and community-based health and social service providers is typically limited or nonexistent. Without comprehensive re-entry planning, these individuals face high rates of emergency department visits, hospital admissions, substance use, re-arrest and return to incarceration, and significantly elevated risk of death from drug overdose, cardiovascular disease, homicide, and suicide.

Background

The Point of Reentry and Transition (PORT) program was established in 2019 by NYC Health + Hospitals through a partnership with NYC Health + Hospitals/Correctional Health Services (CHS) and NYC Health + Hospitals Department of Ambulatory Care. CHS is responsible for delivering health care in New York City’s jails, primarily at the Rikers Island jail complex that has a daily population of over 6,000 people in custody.

Discharge from jail can be difficult to plan for. Unlike people being discharged from state prisons — where people are serving their sentence and have scheduled release dates well in advance — people in jails are predominately in custody awaiting trial or disposition of their cases. Being released from jail can happen at any time, including during a court appearance. Also, in New York City, there are a variety of different reentry programs that people may qualify for depending on their specific circumstances or mental health diagnosis.

“The priority of people leaving jail is getting back to their communities, to address all the needs they had to put on hold during the time they were in custody,” said Amanda Johnson, MD, MBA, Senior Assistant Vice President for Care Models at NYC Health + Hospitals and a primary care doctor. CHS wanted to develop a low-barrier, community-based health care and social services program that was simple to communicate to all people being released under these often chaotic and unpredictable circumstances.

CHS and the Department of Ambulatory Care partnered with two H+H hospitals — NYC Health + Hospitals/Bellevue in Manhattan and NYC Health + Hospitals/Kings County in Brooklyn — to create primary care clinics dedicated to supporting people being released from jail. The PORT practices also serve people returning home to the city from New York State prisons.

In launching the new program, the team immediately identified CHWs as a critical component to support the reentry population. Employing CHWs with a personal history of incarceration is an evidence-based approach for increasing access to primary health care services and reducing recidivism among people with complex health and social needs, as demonstrated by pioneering models like Transitions Clinic Network, where this approach has been employed since 2006. The PORT program integrated CHWs with lived experience of criminal legal system involvement throughout the PORT primary care practices. The original group of CHWs hired for the program also provided leadership in envisioning the program and establishing program policy and procedures.

“Having CHWs who have experience with the criminal legal system themselves and who have struggled with mental illness or addiction — that’s absolutely necessary and helpful,” said William Vail, MD, Deputy Chief of Medicine at CHS, who sees PORT patients once a week at Bellevue. “There’s lots of stigma around people coming out of jail and prison, and finding a place where people accept you is incredibly powerful to patients when they come in.”

The PORT program can connect people after they leave the jail system, and during pre-release planning. However, the federal government recognizes the need to improve transitional care for the reentry population. In 2023, the Centers for Medicare & Medicaid Services (CMS) released guidance encouraging states to apply for a new Medicaid Section 1115 demonstration waiver opportunity to test transition-related strategies to support community reentry for people released from incarceration. This includes providing Medicaid reimbursement for case management, medications for addiction treatment (MAT), and prescription drugs during the pre-release period and requiring states to activate Medicaid coverage for individuals before release. As of fall 2024, CMS has approved Section 1115 reentry waiver requests from 11 states, with waiver requests pending from 14 other states and Washington D.C. New York is one of the states with a pending request.

Intervention

A person leaving Rikers Island might first learn about PORT from a CHS primary care doctor or discharge planner based at the jail, or at the CHS Reentry Center located right outside the jail, where people can get a MetroCard and place a phone call, among other supports.

CHS operates a hotline called the PORTline, staffed by CHWs, who greet callers and can get them scheduled at one of the PORT primary care practices. They make a warm hand off to the hospital based CHWs. These hospital-based CHWs become the patients’ primary point of contact and are available in-person and by text and cell phone.

“People who have been released or are just leaving Rikers Island might have a whole host of needs that they’re bringing up on these phone calls or they just need to talk to someone,” said Johnson. PORTline CHWs typically arrange for people to be seen at a PORT practice within a week and ensure they have contact information to make future attempts for outreach. The PORTline also takes calls from social service providers and corrections staff to receive referrals of individuals leaving incarceration.

At the hospital-based PORT practices, patients are greeted by a CHW who aims to put the individual at ease and build rapport. Patients are seen by a primary care physician, and together with the CHW, the care team focuses on understanding the patient’s stated needs and goals. “Patient choice is really important to us,” said Callie Janoff, PORT Project Manager. “We want to emphasize their freedom. We want them to get the health care that they want and have outcomes they want.”

CHWs are skillful in handling these patient-centered planning and goal-setting discussions in collaboration with physicians. “The CHWs are so important for connecting with the patients and lowering the emotional valence of coming to the hospital,” Johnson said. CHWs are also skilled in engagement, offering to call with appointment reminders or just to check in, as patients tend to be scheduled to return frequently for a certain time period.

Specialty health care services are also available, either on-site at the PORT practice or via low-barrier and timely referrals to other NYC Health + Hospitals practices. For example, Johnson said she and the PORT staff have worked hard to embed behavioral health care into PORT practices but have not yet been able to fully integrate this approach. For MAT, the PORT clinics may prescribe buprenorphine or Suboxone, Vail said. The PORT providers have to arrange for other providers to prescribe methadone, a medication that can only be dispensed at opioid treatment programs, as well as long-acting injectable anti-psychotic medications.

Additionally, PORT’s CHWs explore how they can support program participants in overcoming a range of barriers to successful reentry: re-activating Medicaid, helping to replace lost identification documents, obtaining transportation benefits, etc. They can also help with connecting re-entering individuals to prescriptions through the hospital pharmacy, supporting their search for employment, or anything else that program participants bring up as a challenge to reentry.

In addition to these program components, Johnson said another key aim of the program is to address “the existential and psychological trauma of reentry.” Some individuals will have calls with their CHWs multiple times a week, talking about everything from recovering from solitary confinement to how to use a smartphone. Recognizing that space was needed for program participants to help and empower one another, the Kings County PORT practice started a mutual support group facilitated by a chaplain. Janoff said, “It’s a space where they can connect with each other and gain understanding and support that that’s unlike anything else they might have gotten.”

Implementation

PORT does not currently have any dedicated funding, and instead uses staff from CHS, other departments and the hospitals. Since launching in 2019, the program has increased the number of hospital-based CHWs to five, as well as two supervisors (one at each hospital), in addition to the three PORTline CHWs. This has allowed the program to take on more patients. The patients are also provided with small “tokens of engagement,” such as such as food and gift cards which can be used to put participants at ease and facilitate non-clinical interactions with the care team.

The PORT practices use the time of NYC Health + Hospitals medical staff, including physicians, nurses, and medical assistants. There are eight H+H primary care physicians who dedicate a session to the PORT clinics, in addition to their main practices based out of Bellevue, Kings County, or Rikers Island. Most of the physicians are board-certified in addiction medicine and have a passion for working in correctional and reentry settings. All have volunteered to join PORT as part of their work at NYC Health + Hospitals. And although they bring the clinical expertise, Johnson explained there is a lot of on-the-job training and education they receive from the CHWs. She said, “The CHWs help the physicians understand how institutions affect someone. The physicians take cues from the CHWs on engaging patients and incorporating that into their practice.”

“I’ve had CHWs sit in with me, and if I’m not communicating with patients because of a personal or cultural divide, they help me,” Vail said. “They have so much more experiential knowledge than I do. And a lot of the heavy lifting of checking in with patients falls on their shoulders.”

There is also participation from the CHS physicians who work at Rikers Island. The Rikers-based CHS physicians often facilitate referrals to PORT, and some continue to see the patients as their PORT primary care physician. The advantage of having these physicians on the team at the PORT clinic is that program participants appreciate the continuity of seeing the same physician after their release, eliminating the time and hassle of re-explaining their physical and behavioral health issues, Johnson said.

A highly unique continuity-of-care feature of the PORT program is a special arrangement that allows PORT physicians to access the jail-based medical records of program participants, which is separate from the hospital medical record. For example, emergency department staff might encounter patients who recently left Rikers Island and are seeking to continue their prescriptions for MAT. After being alerted, Janoff explained, a PORT CHW can bring the person over to the PORT physician, who can see what medication and dose the person was on in the jail medical record and re-prescribe it.

Impact

Over the past year, PORT practices have worked with 300 unique program participants and recorded 1,350 total patient visits. Of these individuals, 62 percent have at least one chronic condition, and 72 percent have a behavioral health diagnosis. Most are single adult men of color. The majority of patients have been incarcerated in New York City jails, usually attending their first PORT appointment within three months of release.

The conversion rate of referrals to people attending their first appointment is similar to the rate for the rest of NYC Health + Hospitals primary care. Janoff noted how this was exceptional data for this population, given the complexities of the daily lives of people returning home from incarceration. She believes the CHWs’ outreach work is part of the reason for this success.

To better track and analyze data going forward, the team has incorporated a care planning and task management tool called Compass Rose that is part of NYC Health + Hospitals Epic medical record. The team uses the tool to collect data on program participant goals — how and how often these goals are met — and to track levels of case acuity and thereby stratify caseloads. It has also become an important tool for facilitating case conferencing with the physician-CHW teams.

While some days are frustrating, said Douglas Duncan, a CHW at the Bellevue PORT clinic, “almost every day you get some type of win.” He proudly described how he helped one PORT participant go through many hoops to obtain a state identification card and then use that card to make appointments for a psychiatric evaluation and apply for transitional housing. Now that individual is about to receive permanent housing and get needed physical therapy.

“That’s what we do as CHWs — put the agencies together and make the system work seamlessly, so the patients can focus on [their health needs, like] keeping their blood sugar level down,” he said. “It’s a daunting task.”

There is published evidence that care provided by other clinics around the country using similar models for people leaving jails and prisons results in reductions in emergency department use, preventable hospital admissions, criminal legal system costs, and Medicaid costs:

• People leaving incarceration who participated in a Transitions Care Network (TCN) program in San Francisco, with support from a CHW, had a 51 percent reduction in overall ED use after one year compared with returning individuals receiving standard primary care, according to a study published in the American Journal of Public Health in 2012.
• TCN participants in New Haven, Connecticut had lower criminal legal system costs after one year compared with returning individuals who received standard care, with a return to the state of $2.55 for each dollar invested, according to a study published in BMC Health Services Research in 2022.
• In another study from New Haven published in BMJ Open in 2019, participants in a transitions clinic spent 45 percent fewer days incarcerated in a correctional facility in the 12 months following release compared with a matched comparison group not enrolled in the clinic.

Insights

• Health care providers should examine their own stigmatizing attitudes and prioritize services for people returning from incarceration. “I hope that young physicians and physicians-in-training think about starting these transitional models,” Vail said. “And hospital systems need to think about providing this as specialty care, like they do with clinics for refugees, victims of torture, and people with unstable housing.”
• Making access easy for returning community members and getting them in often for appointments is key. “I can’t emphasize how nice it is as a provider to say, ‘I can see you every week for the next month,’” Vail said. “Then I can deal with one or two serious problems, taking tiny bits, until things are under control and I can transition them to the regular primary care practice.”
• Individuals may have other priorities when they are released from incarceration, but a strong relationship with the CHW can help focus them on their health. “Individuals coming home are pulled in a thousand ways, with girlfriends and so many things they want to catch up on,” Duncan said. “Going to the clinic appointment may not seem sexy. But we play advocate and treat them as individuals, and that’s what makes us effective at what we do.”
• Staff deserve strong support to continue their valuable work and assist others effectively. “The people who are drawn to this work are mission driven. It’s important they know they are valued for the hard work that they do. We also really try to support their well-being and support good boundaries,” said Callie.

Acknowledgements

Thank you to Dr. Amanda Johnson, Douglas Duncan, Dr. William Vail, and Callie Janoff for helping to inform this blog post.

*Author Harris Meyer is a freelance journalist who has been writing about health care policy and delivery since 1986.