How Community Health Centers Support Transitions Out of Incarceration

As the healthcare industry continues to eye better transitions of care for patients who are recently incarcerated, community health centers agree they are poised to fill the gap, according to a new assessment from The Commonwealth Fund.

However, to make that happen, CHCs will need additional supports and resources to overcome current limitations, like staffing and financial issues.

The issue of healthcare reentry for recently incarcerated people has been central for healthcare stakeholders, spurred on by the reality that poor health is linked to recidivism and high taxpayer costs and a push for the industry to focus on health equity.

“Recognizing the complex health risks experienced by incarcerated people, the health challenges they face following release from jail or prison, and the clear association between health status and recidivism, federal and state policymakers have been reforming Medicaid's role in covering health services for this population,” the researchers explained in the study’s introduction.

For example, a lapse in substance use disorder (SUD) treatment has been linked to reincarceration, relapse, and overdose, the researchers said.

Medicaid is working to ease the transition of care from incarceration to the general population via 1115 waivers called Reentry Demonstrations. Two states have waivers approved (California and Washington), and another 17 have waivers that are pending.

CHCs will likely be instrumental in ensuring these Reentry Demonstrations work, the researchers said, mostly because of their existing focus on medically underserved populations.

“CHCs are poised to play a key role in improving health care for people reentering their communities after incarceration, potentially serving as a ‘turnkey’ source of care,” the researchers said. “CHCs are required by statute to serve medically underserved communities, and they have extensive experience in providing comprehensive physical and behavioral health care to populations facing high risks, including poverty and health disparities.”

Additionally, many previously incarcerated people received care at a CHC prior to incarceration, the researchers pointed out, making CHCs poised to lead continuity of care for these populations. CHCs already serve one in six Medicaid beneficiaries and are instrumental in Medicaid managed care organization networks.

CHCs likewise see themselves as critical in supporting Reentry Demonstrations and easing transitions of care for previously incarcerated people, a qualitative study of 21 CHC leaders showed.

In fact, CHCs already spearhead a number of different reentry activities, including:

• Providing care inside correctional facilities
• Coordinating ongoing treatment, including medication-assisted treatment for SUD
• Integrating community health workers with experience of incarceration
• Offering pre- and post-release case management
• Orchestrating referrals and connections

To that end, CHCs have even identified key principles for supporting reentry programs successfully, including:

• Building trust, including strong patient-provider relationships
• Creating and maintaining partnerships with correctional facilities, law enforcement, medical, public health, behavioral health agencies, and other community-based organizations like reentry service providers
• Leveraging interdisciplinary care teams, stressing coordination between physical, mental, and substance use care
• Employing community health workers with lived experiences with incarceration
• Initiate a pre-release patient-provider relationship wherever possible
• Using trauma-informed care practices
• Training providers in cultural responsiveness
• Identifying shared goals across healthcare, correctional, and other service organizations
• Establishing the CHC has the hub for other social services, including housing, food, and employment
• Including people and communities impacted by incarceration in designing of these systems and processes

Respondents noted that CHCs are already experienced with many of these principles. For example, CHCs have extensive federal reporting requirements, which gives them experience in data capture and reporting that could serve them well in designing care transition plans.

Additionally, CHCs already serve as a hub for social determinants of health referrals, giving them the foundation needed to enable these services for a population of recently incarcerated patients.

Still, despite this existing knowledge base, the 21 CHC leaders noted that there are still some challenges associated with easing the care transition. For example, CHCs need clear federal guidance about their role in permissible reentry activities.

CHCs receive federal funding to facilitate certain activities within the practice, and these funds come with guidelines. The organizations need to know what activities are permissible under those funding guidelines and which activities would need to be self-funded.

“Alongside this clarification, the Health Resources and Services Administration (HRSA) could provide dedicated training and technical assistance resources to build CHC capacity in this area, including through implementation of models of care tailored to meet the needs of the formerly incarcerated population,” the researchers reported.

There’s also the workforce and service capacity to consider, the interviewees said. Workforce woes at CHCs are similar to those at other provider offices, but supporting a reentry program could exacerbate the issue by introducing a new set of specialized skills. There are also licensing and permitting concerns for employing community health workers with prior incarceration.

Next, there’s the question of payment. Currently, community health centers operate under a federally qualified health center (FQHC) payment system that generates a payment rate based on the CHC’s scope of project.

Integrating reentry programming would require a new payment model, the interviewees told researchers.

“An alternative payment model focused on reentry care would entail a change in scope with increased allowable costs, which can translate into advance payments for the cost of implementing a new type of care, selecting the performance measures that will guide payment, and then supporting care over time,” the researchers explained. “While such a model has numerous precedents, technical experts could translate a CHC-based reentry initiative into an FQHC alternative payment model enhancement.”

Finally, there’s the perennial issue of data infrastructure and data exchange that could stymie efforts. Although CHCs are well-versed in capturing and reporting data due to their federal reporting obligations, they will need further capital to invest in more data-sharing capacity.

These limitations should not discourage CHC-led reentry programs for recently incarcerated individuals. Rather, the Commonwealth Fund researchers said more supports need to be put in place to support this programming.

“Achieving these goals means addressing the financing, workforce, data-sharing, and operational challenges that inevitably arise in any initiative to improve health outcomes and health care equity,” the researchers concluded. “Because CHCs are experienced in care innovation and offer a unique payment approach through Medicaid, these goals, while challenging, are achievable over time.”