Edward Johnson, 59, served 27 years in a Louisiana prison for bank robbery. “Prison is a brutal experience, and you have to find yourself and your path to maintain your sanity,” he says.
Released in 2016, Johnson has been trying hard to contribute to society, hoping to use the psychology degree he received in 2020. “I believe in transformation, a complete reversal, a process that gives you different values and principles,” he says.
But when he left prison, Johnson walked out bearing physical and mental health problems.
“One of the major things that’s needed [when leaving prison] is adequate medical attention. In prison, they give you enough to just get by,” says Johnson.
Johnson now gets care from the Formerly Incarcerated Transitions (FIT) Clinic in New Orleans run by the Tulane School of Medicine, which has provided or arranged for an array of medical services.
“They are patient and thorough. If I’m going through a mental health crisis, they will get me help urgently,” says Johnson. “Whatever they can do to assist me, they do it.”
Johnson is one of an estimated 9.6 million people who are released from U.S. jails and prisons each year. Often, they arrive home awash in health problems.
Incarcerated individuals are 1.5 times more likely to report a history of diabetes, asthma, or high blood pressure than those who have not been incarcerated. They are 10 times more likely to have hepatitis C, which can be deadly, and up to 5 times as likely to meet the threshold for serious psychological distress.
One statistic is particularly telling: The risk of dying within two weeks of release from prison is nearly 13 times higher than that faced by other individuals even after adjusting for age, race, and sex.
“To some people, we are our crimes. But the clinic wraps its arms around us.”
Transitions Clinic, San Francisco
Experts also note that people often leave prison with no health insurance and little connection to care.
What’s more, they often return with few skills necessary to navigate the health care system and little faith that it will work for them. Frequently, they struggle to obtain the basics necessary for a healthy, productive return, such as jobs and housing.
Programs like FIT, many run by teaching hospitals, work to provide returning individuals with medical care, essential social services — and a much-needed sense of hope.
“To some people, we are our crimes,” says Sharon Fennix, a former patient at the Transitions Clinic in San Francisco. “But the clinic wraps its arms around us.”
Interest in such post-incarceration programs has been increasing significantly, says Shira Shavit, MD, a national leader in incarceration-related health and the University of California, San Francisco (UCSF) clinical professor who runs the Transitions Clinic.
“There is increased awareness of social determinants of health, health equity for Black and Brown communities, and criminal justice reform,” says Shavit. “There also is greater recognition of the need to treat mental health and substance use disorders in primary care. All of this has helped raise up our work.”
“More people realize that when we look at mass incarceration, it’s not just about having locked up more people and for longer periods,” she says. “It’s also about what happens when people leave those systems and return to their communities.”
Massive medical needs
A long list of problems can conspire to undermine the health of people leaving jails and prisons.
For one, connection to care upon release often is meager. Released individuals don’t necessarily receive medications, referrals, or their electronic health records, notes a 2022 Aspen Institute report.
Also, years in prison can erode basic health-related skills. “Even something as simple as getting medications from a pharmacy can be challenging because they don’t know how to do it,” says Shavit.
Perhaps most problematic, incarcerated individuals may deeply distrust medical care. “There’s a lot of trauma around health care while incarcerated. Staff often may not believe you when you say you have a problem, for example,” says Anjali Niyogi, MD, MPH, director of FIT in New Orleans and an assistant professor of pediatrics at the Tulane University School of Medicine.
The most effective post-incarceration programs aim to address all these issues. To do so, they usually hire special employees: community health workers (CHWs) who have been incarcerated themselves.
“When I tell potential patients that I am formerly incarcerated too, their shoulders let down, and you see a sliver of relief cross their faces. The whole dynamic changes,” says Tommy Green, a CHW at the North Carolina Formerly Incarcerated Transition (NC FIT) Program that the UNC School of Medicine runs in six counties.
Post-incarceration health programs take somewhat different approaches, but 48 in more than a dozen states use the Transitions Clinic model that UCSF physicians created in San Francisco. Those institutions collaborate via the Transitions Clinic Network (TCN), which provides trainings and other resources to spearhead systemic changes.
Usually, the first step is for CHWs to visit with people inside jails and prisons — or soon after their release — to explain a program’s provided services, says Shavit, who also serves as TCN executive director. Then they help a patient navigate the entire medical process, from appointment scheduling to insurance enrollment, and work to ensure ongoing connection to care.
CHWs accompany patients to their medical appointments to help with potential obstacles like completing paperwork. And they partner with physicians to craft an appropriate care plan. “A CHW can say whether a proposed treatment is realistic given how the patient is living, such as if they don’t have housing,” says Evan Ashkin, MD, director of NC FIT.
“When I tell potential patients that I am formerly incarcerated too, their shoulders let down, and you see a sliver of relief cross their faces. The whole dynamic changes.”
Community Health Worker, North Carolina Formerly Incarcerated Transition Program
In Pittsburgh, the Rethinking Incarceration and Empowering Recovery (RIvER) clinic of Allegheny Health Network takes a somewhat different approach, though it also relies on CHWs. Often, RIvER provides care via a mobile medical van and does outreach in places like parks and soup kitchens. “We want to bring services directly to the people who need them, so we park outside the jail and in neighborhoods with high incarceration rates,” explains clinic co-coordinator Divya Venkat, MD.
Like other post-carceral health programs, Venkat emphasizes treatment for substance use disorders (SUDs). That’s partly because the risk of an opioid overdose is 40 times higher in the two weeks post-release compared with that faced by the general population.
“Our goal is to get medication to prevent an overdose into the hands of everyone who wants it,” she says.
One program, run with the support of the Worcester-based UMass Chan Medical School, focuses exclusively on individuals with SUDs and mental health needs. Among other services, it offers daily contact initially plus ongoing 24/7 on-call support for crises. Launched in 2019, it has reached more than 2,600 people in 14 Massachusetts counties.
Adrianna LeBlanc, 37, is grateful for the treatment she’s received for her substance use disorder — as well as for attention-deficit/hyperactivity disorder and migraines — from NC FIT. Among the program’s many features is funding that subsidizes her medications. “With seven kids and a grandbaby, it’s a struggle financially,” says the roofing company employee, “but the clinic has my back no matter what.”
Making health seem possible
When a person is released from prison, their first thoughts rarely turn to health care, experts say. “People think about all the other stuff that makes health care seem impossible,” says Venkat.
“I go into the jail with a printout,” says Carol Bibbens, a CHW at Allegheny’s RIvER clinic. “I ask, ‘Do you need help with food, transportation, literacy. … Did you lose your family, your housing, your children?’”
Often, an immediate focus is a place to stay. Formerly incarcerated individuals are nearly 10 times more likely to face homelessness than the general public, research shows. Housing obstacles are numerous, including laws that bar individuals with certain convictions from public housing.
“One of our patients was released from prison to a home with mental and physical abuse. He really tried to stay out of trouble, but got reincarcerated,” says Venkat. “Now he’s expected to be released in the cold of the winter, and he’ll be discharged to the streets. We’re trying everything we can to figure out housing for him.”
Another high priority is employment, which can be key to avoiding recidivism. The FIT program in New Orleans helped Johnson get his first post-release position, working for a justice-related nonprofit, but a criminal record can often make finding work difficult. “Formerly incarcerated people must be creative and work hard to live with dignity financially,” he says.
Programs also help arrange numerous daily-life basics, such as getting an ID card to replace a long-expired driver’s license. “We had one man who went into prison at 17 and came out at 80. It’s like coming in from another country,” says Niyogi.
Whatever obstacles patients face, CHWs say they are committed to providing consistent support and acceptance. “I never look down on anybody no matter what,” says Bibbens.
Bibbens describes one patient she’s followed for years. The young woman was a victim of sex traffickers who got her hooked on drugs, and she wound up pregnant. Repeatedly, the woman tiptoed up to the idea of entering rehab and then slid back. But Bibbens stuck with her, and eventually helped her get into recovery.
“We thought that baby wouldn’t make it. He’s two now, and we got her into her own place. It’s amazing,” she says. “I love this job. This job is my passion.”
Will the clinics continue?
Research suggests that efforts to help people regain health post-incarceration work well.
The TCN approach has reduced post-release emergency department use and preventable hospitalizations by half during a 12-month period, for example. It also cut average reincarceration days during that time by nearly a month.
But maintaining these programs requires adequate funding, experts say. While some clinics benefit from state funding, many rely on grants that don’t always continue.
Meanwhile, those involved see hope in possible Medicaid changes. A few states have requested federal permission to turn on Medicaid benefits — which are usually suspended during incarceration — 90 days prior to a person’s release. Such benefits would enable greater prison in-reach efforts as well as smoother transitions to community-based care, experts say.
California is the first state to request this waiver, and Shavit expects approval from the Centers for Medicare and Medicaid Services soon. “This could be a huge change in how carceral systems and health systems can work together,” she says.
Of course, money alone isn’t enough: Post-incarceration health efforts also need physicians interested in doing the work.
“This issue needs to be on the radar of our future health workforce,” says David Acosta, MD, AAMC chief diversity and inclusion officer. “Our medical education leaders need to make this a priority as I’m sure many students have no idea that this issue even exists and that they would want to know.”
NC FIT’s Ashkin sees signs of such interest. “I get emails several times a week from medical students or residents interested in learning more about this work,” he says.
“The patients I work with are highly motivated to take charge of their bodies and health, and they are so resilient. They are amazing, remarkable people.”
Anjali Niyogi, MD, MPH
Director, Formerly Incarcerated Transitions in New Orleans
Even if trainees don’t wind up focusing on post-incarceration care, exposure to the field is crucial, Ashkin adds.
“When they see someone coming from a correctional setting in their practices in the future, they’ll understand them better.” That greater understanding can help mitigate stigma and improve care, he says.
Fennix, who eventually shifted from being a patient at San Francisco’s Transitions Clinic to working as the TCN’s hotline coordinator, also emphasizes the need to reduce bias.
“We are someone’s mother, sister, father, uncle,” she says. “We are looking to be part of a community. … We are not necessarily who we were when we went into prison.”
For her part, Niyogi hopes the field will flourish. “This gives me some of the most joy I get as a doctor,” she says. “The patients I work with are highly motivated to take charge of their bodies and health, and they are so resilient. They are amazing, remarkable people.”