CHC Highlight: How Health Centers Assist with Reentry After Incarceration

Each year, over 600,000 individuals return to their communities after incarceration, bringing with them significant health care needs such as chronic conditions, mental illness, and substance use disorders, all while facing higher risks of overdose and recurrence of legal system involvement (cdc.gov). Community Health Centers, with their accessible and community-oriented model, are uniquely equipped to serve this population and help close gaps in care.

Recently, in November 2024, HRSA announced $52 million in new funding to 54 health centers aimed specifically at supporting patients within 90 days prior to release. These resources support services such as chronic disease management, behavioral health care, and substance use treatment, critical interventions, as individuals are significantly more likely to experience overdose shortly after release.

HRSA also formalized these services through Policy Information Notice (PIN 2024‑05), allowing care to be provided to individuals “reentering the community” for up to 90 days pre-release. States like California and Washington have implemented Medicaid 1115 waivers to further fund this care.
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Fantastic work in Region X has been done, and while this is not an exclusive list, we would like to highlight some of our membership’s programs.

JAMHI Health & Wellness in Juneau AK operates a 9-month reentry program beginning three months before release and extending six months post-release. Guided by Risk–Need–Responsivity principles, a reentry case manager collaborates with the Juneau Reentry Coalition to assess criminogenic needs, such as substance use, employment, mental health, and tailor support accordingly. Participants receive integrated primary and behavioral health care, case management for housing and employment, medication assistance, and supportive housing coordination. The emphasis on early engagement inside custody and strong coalition partnerships help ensure individuals connect to insurance and evidence-based services, reducing recidivism and promoting community stability.
 
Outside In, operates a comprehensive service model that directly supports individuals transitioning from incarceration. In addition to its primary care and mental health services, the center includes a syringe exchange and fentanyl testing program with support structures that play a critical role in reducing overdose risk and facilitating connection to healthcare right when people reenter the community. In 2023, Outside In served nearly 5,600 individuals through medical, mental health, and substance use services, with over 900 youth receiving integrated support for housing, employment, and education.

Seattle Roots Community Health Center’s Reentry Clinic, supports individuals returning from incarceration by providing comprehensive follow-up care. The clinic connects patients to primary medical services, behavioral health, and chronic disease management, alongside light case coordination to address housing, transportation, food, and clothing needs. It also facilitates referrals to in-house specialty programs like HIV care, addiction services, gender health, and hepatitis treatment, ensuring continuity through warm handoffs to community partners focused on legal, employment, and family reunification support

Multnomah County Health Department is a community health center embedded in the county system, which situates them well for a comprehensive reentry program. Their ARC Transition Services brings together in-custody assessments, pre-release planning, and post-release support to smooth the path back to community life. A Health Assessment Team (HAT), a team of medical, mental health, and developmental specialists, works alongside corrections counselors to gather vital information before release, including chronic conditions and medication needs. They help enroll individuals in health insurance, provide on-site consultations, referrals, and coordinate housing and transportation. ARC also offers immediate transitional housing through contracted agencies, averaging 323 beds in 2023.

CHCs are trusted community anchors positioned to support people reentering society after incarceration. By investing in early outreach, integrated care, and community partnerships, health centers can play a vital role in promoting well-being and reducing disparities for individuals navigating complex transitions.

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