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Essential Connections: Community Health Centers’ Role in Facilitating Healthy Transitions Out of Incarceration

Black man and woman embrace in an outdoor fair welcoming formerly incarcerated community members

Stephen Pina, left, hugs Stacey Borden, executive director of New Beginnings Reentry Services. After being wrongfully convicted, Pina served 28 years in prison. Community health centers are a key care access point for people returning to their communities following incarceration. Photo by John Tlumacki/Boston Globe via Getty Images

Stephen Pina, left, hugs Stacey Borden, executive director of New Beginnings Reentry Services. After being wrongfully convicted, Pina served 28 years in prison. Community health centers are a key care access point for people returning to their communities following incarceration. Photo by John Tlumacki/Boston Globe via Getty Images

  • Community health centers are poised to play an important role in delivering care to formerly incarcerated people as they return to their communities

  • Expanding community health centers’ involvement in reentry care may require additional training on the health needs of people leaving incarceration and the tailoring of service delivery approaches

  • Community health centers are poised to play an important role in delivering care to formerly incarcerated people as they return to their communities

  • Expanding community health centers’ involvement in reentry care may require additional training on the health needs of people leaving incarceration and the tailoring of service delivery approaches


Issue: Recent Medicaid policy changes to improve health care continuity and access for people during incarceration and following release will require health care providers to facilitate care transitions to improve long-term outcomes. Community health centers (CHCs) are poised to play an important role in delivering care to people as they return to their communities.

Goals: Understand the current activities of CHCs serving currently and formerly incarcerated populations; assess the barriers facing CHCs in delivering reentry care; and provide recommendations to better support CHCs and to integrate them into efforts to strengthen continuity of care for people leaving incarceration.

Methods: Twelve interviews with 21 stakeholders representing CHCs and other providers, national training and assistance organizations, and correctional officials; policy review and legal analysis.

Key Findings and Conclusions: CHCs are a key health care access point for people returning to their communities following incarceration. As Medicaid policy changes to improve health care access and continuity go into effect, CHCs face operational and policy barriers to scaling their work. They can effectively navigate these challenges by expanding their reentry care with support from local, state, and federal partners. Enhanced policy guidance, funding, and research could bolster the role and impact of CHCs in caring for people after incarceration.


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. Research shows a clear association between health status and recidivism: continual access to substance use disorder treatment reduces the likelihood of reincarceration, relapse, and overdose.1 Box 1 shows how certain states are using Medicaid waivers to undertake reentry demonstrations, and how Congress has changed Medicaid’s role in caring for incarcerated youth.


Community health centers (CHCs) are community-based providers of integrated primary care and related services that focus on medically underserved patients and communities (see Box 2 for CHC reach, structure, and characteristics). 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. 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. As a result, CHCs are a major source of care for many people before incarceration — care that is disrupted while patients are in jail or prison. As Medicaid plays a larger role in coverage for incarcerated populations, it is important to note that CHCs already serve one in six Medicaid beneficiaries, and often act as the primary care backbone of the Medicaid managed care organization networks that most beneficiaries must enroll in to receive services.2

To gain greater insight into the current and potential role of CHCs in pre- and post-release care delivery, we interviewed 21 stakeholders, including CHC leaders involved in reentry care, clinical and program staff, patients, correctional officials, policy leaders, and organizations active in reentry work. Through these interviews, we learned about current CHC activities and the types of policy and practice changes that could facilitate a larger role for CHCs in the care of people leaving incarceration.


Community Health Centers, Medicaid, and Reentry Care

CHCs have unique features that make them a potentially strong partner in carrying out new Medicaid reentry policies. As a major source of primary care for Medicaid beneficiaries, both directly and through managed care plans, CHCs may be more ready than other providers to operationalize care delivery throughout, and beyond, the transition from incarceration to community. Because CHCs have historically implemented a social and community-based approach to health care delivery, they are accustomed to engaging with agencies and programs involved in health and social supports, including organizations that focus on housing, nutrition, and employment.3 However, CHCs may need additional competencies such as training on the health needs of people leaving incarceration and tailoring of service delivery approaches, including trauma-informed approaches, to strengthen their capacity to meet the needs of returning community members.

As CHCs build capacity for offering tailored reentry services, Medicaid’s unique payment model for CHCs offers potential benefits. Known as the federally qualified health center (FQHC) prospective payment system, it ensures that Medicaid covers the costs of efficiently operated health centers, thus preserving grant funding for uncovered populations and services.4 The payment system also allows states, managed care organizations, and CHCs to negotiate alternative payment models that enhance financing tied to performance goals for targeted services and populations. In recent years, a small number of FQHCs and states have been using these payment models to implement value-based arrangements focused on improving overall population health. This flexibility presents an additional opportunity for financing directed approaches to reentry care.5

Current Community Health Center Involvement in Reentry Care

Our discussions with CHC executives, as well as with clinical and program directors, staff, and patients, revealed a range of ongoing activities to support people leaving incarceration, as well as a shared understanding of what effective reentry health programs need to look like. Respondents noted that health care is not typically the top priority for people returning to communities; housing, food, employment, transportation, and/or family reunification may take precedence.6 As one clinical provider described it, during reentry, people’s “social determinants of health are all up in the air at one time, and all of those feed into their health care needs.” Also common are the extended periods CHCs can go without having any contact with incarcerated patients. Upon those patients’ return, clinicians often have little information about their health conditions or what care has been provided during incarceration.


Some CHCs emphasized that improving care for currently incarcerated people or those reentering the community is an organizational focus. As discussed below, what emerged was a spectrum of involvement, from accepting referrals for services to providing corrections-based care.

Referrals and connections. At the less intensive end, CHCs accept referrals for health care services made by other organizations, including correctional institutions and reentry service organizations, as people leave prison and jail. For some respondents, this involved multiple planning meetings prior to release, as well as, in certain cases, staff meeting people at discharge to connect them directly to the CHC for needed care. Respondents reported that this “warm handoff” approach, where transfers of care between providers are made in person and with the patient present, is especially effective.

In-reach and case management, pre- and post-release. Respondents also described “in-reach” efforts, which typically focus on establishing a connection with people before their expected release to ensure that they will be able to access services in the community. In-reach can be conducted by the CHC itself to establish successful connections to post-release health care and other needed services. This function is a precursor to the more robust case management requirement that CMS established in its Medicaid reentry demonstration guidance. The CMS guidance sets forth detailed case management requirements, including needs assessment, care planning, warm handoffs between pre-release and post-release case managers, connections to services in the community, ongoing monitoring, and follow-up activities. CHCs are well-positioned to work with state Medicaid programs and local correctional facilities to offer these services.

Integrating community health workers with experience of incarceration. A commonly identified, evidence-based element of successful reentry care is the integration of community health workers (CHWs) with lived experience of incarceration as part of CHC care teams. Transitions Clinic Network is a national organization that has worked with 48 CHCs in 14 states to redesign their overall service delivery approach to caring for returning individuals with chronic illness. This has included embedding a CHW-focused model, which resulted in improved health and reentry outcomes.7 As part of the Transitions model, CHWs are hired to be integrated into the primary care system, engaging and supporting returning patients and serving as liaisons to navigate health and social services. People leaving incarceration commonly mistrust the health care system. By hiring workers who have experienced incarceration, CHCs can mitigate patients’ skepticism that might undermine their care. The CMS Medicaid reentry demonstration guidance specifically highlights the Transitions Clinics model and lists “services provided by community health workers with lived experience” as an additional service that may be covered.8

Coordination of ongoing treatment, including medication-assisted treatment. In 2022, nearly all CHCs provided behavioral health care, including medication-assisted treatment (MAT) for more than 205,000 patients with opioid use disorders.9 As prisons and jails have expanded their capacity to furnish pre-release MAT, both clinical and correctional leaders have identified the continuity of MAT as one of the most effective partnerships between correctional settings and CHCs.10 In Massachusetts, the Middlesex Jail and House of Correction operates an MAT program while people are incarcerated and coordinates post-release treatment transitions with the Lowell Community Health Center. The need for these types of dedicated care transitions will likely grow as more states launch Medicaid 1115 reentry demonstrations, which require medication-assisted treatment as one of three pre-release services that prisons and jails must offer.11

Care provided inside the carceral setting. Some CHCs contract with jails and prisons either to provide discrete services or to serve specific groups of patients during incarceration. A small number play an even larger role through contracts with local jails to offer in-facility care. This type of approach, which is more extensive and far-reaching than providing in-reach or post-release connections to services, can promote post-release continuity of care and develop CHC expertise in the needs of the incarcerated population as they reenter communities. Interviewees were divided on the question of whether contracting to provide services inside carceral systems was ultimately helpful, or harmful, to CHCs’ ability to build trust with patients once they have returned to communities.

10 Principles for Successfully Meeting People’s Health Needs at Reentry

Interviewees identified 10 key principles for CHCs and partners — including jails and prisons, managed care organizations, and reentry service providers — for the provision of more effective, holistic care during the reentry into communities:

  1. Build trust from the beginning of the provider–patient relationship by creating meaningful and direct connections between patients, health professionals, and CHCs.
  2. Create and maintain partnerships across corrections, legal/law enforcement, medical, public health, and behavioral health agencies, managed care organizations, and other community-based organizations such as reentry service providers.
  3. Use interdisciplinary care teams, integrating physical and mental health care, care for substance use disorders, and other professionals where appropriate.
  4. Incorporate community health workers who have lived experience of incarceration into care teams.
  5. Initiate a pre-release patient–provider relationship wherever possible.
  6. Employ trauma-informed care approaches that take into account the trauma resulting from, or intensified by, incarceration itself.
  7. Train providers to understand the culture of incarceration and people’s needs upon release.
  8. Work at an organizational level to identify shared goals across community health providers, correctional entities, and other service organizations.
  9. Establish the CHC as a hub for connections to other services, including housing, food, employment, and other social supports.
  10. Include people and communities impacted by incarceration in the development of organizational policies, programs, implementation plans, and evaluation strategies.

These recommendations align closely with the stakeholder-informed guiding principles and reentry care model by HARP in Redesigning Reentry (2022), published with support from the Commonwealth Fund.

Advancing Community Health Center Involvement in Reentry Care

Expanding CHC involvement in reentry care has its challenges. Addressing these challenges is crucial to the success of reentry efforts, including the new Medicaid reentry initiatives now underway.

Need for clear federal guidance on CHCs and permissible reentry activities. While Medicaid is only just beginning to cover medical care provided while an individual is incarcerated, CHCs have been heavily involved in a range of pre-release and post-release reentry activities as described above, supported by state and local funds and CHCs’ non-Medicaid revenue. Yet as this capacity among CHCs grows, including in response to new Medicaid policies, there is a need for federal guidance on when, and to what degree, the costs of developing and operationalizing dedicated reentry approaches can be drawn from CHCs’ federal operational grant funding. All CHCs operate within a federally approved scope, including guidelines covering their services, providers, service delivery sites, service area, and target population. These guidelines determine the kinds of activities covered by grant funds and federally provided medical malpractice insurance. CHCs can undertake programs outside this scope, but such programs must operate without federal funding, presenting a major operational barrier to most CHCs. In playing a larger role in reentry-related activities, CHCs would benefit from additional clarity regarding what types of reentry-related services and activities are permissible, as well as the settings in which such services can be furnished. 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. 

Workforce and service capacity. A leading barrier to more fully meeting people’s health needs at reentry, identified by nearly all respondents, was building and maintaining the care workforce. Workforce recruitment and retention are broad challenges for CHCs, but they are magnified when it comes to workers with special skills and knowledge.12 One issue is that funding for CHWs who were formerly incarcerated can be difficult to sustain. CHWs who have been incarcerated can also find it particularly difficult to get licensed as other types of health providers because of past convictions. Correctional leaders echoed concerns over staff shortages and the need for training for both clinical and correctional staff.

Aligning a new service model with payment. As noted, the FQHC payment system enables state Medicaid programs, managed care organizations, and CHCs to negotiate alternative payment models. Currently, each health center’s FQHC payment rate is derived from the cost of providing care under its scope of project. 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. While such a model has numerous precedents, technical experts could translate a CHC-based reentry initiative into an FQHC alternative payment model enhancement.13

Building CHCs’ role as a service “hub” in a reentry context. CHCs in most communities represent not only an access point for primary care and other health services, but also a connection point between patients and other social service organizations and resources, including those related to housing, nutrition, transportation, and employment. These connections are especially critical for people returning to communities from incarceration because they often face multiple overlapping needs, and health care access may not be a top priority. Given these connections, CHCs are well-positioned to act as a hub for needed services and should build on partnerships with local reentry service providers (in addition to the types of organizations referenced above) to work toward a seamless, “no wrong door” approach to accessing needed services.

Data infrastructure and data-sharing. Any community reentry project requires sharing data across community and institutional settings. CHCs are especially experienced in capturing and reporting data because of their federal patient, service, expenditure, and performance reporting obligations. This experience is an asset to correctional and CHC collaborations. To support this work, future data-sharing capacity investments should prioritize the integration of CHCs and other community providers.


Through statutory changes to Medicaid policies and through Medicaid’s 1115 reentry demonstration, Congress and the Biden administration have signaled the importance of strengthening reentry support and innovation. Additional proposals to enhance Medicaid’s role in this area have been introduced in Congress and are under active consideration. Yet fully realizing the aims of the new Medicaid policies will require a care delivery system capable of operationalizing these reforms.

Community health centers could be important partners for state Medicaid programs and other system leaders working to strengthen reentry care. By both statute and mission, CHCs already serve many of the lower-income, underserved people and communities most affected by incarceration. They also aim to deliver accessible, equitable, integrated care, to have a large role in Medicaid-financed care generally, and to have considerable experience in reentry care.

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. Because CHCs are experienced in care innovation and offer a unique payment approach through Medicaid, these goals, while challenging, are achievable over time. These efforts may be strengthened through investment in the dissemination and financing of evidenced-based programs, through additional study of how CHCs currently serve formerly incarcerated patients, and through evaluation of innovative care and payment models, including through Medicaid reentry demonstrations. Progress will depend, in part, on efforts to align CHC policy with the new models of health care needed to advance the national goal of enhanced reentry care and better outcomes for people and communities.


For this qualitative, stakeholder-informed analysis, authors conducted 12 interviews with 21 individuals between May and July of 2023. Interview participants included: community health center leaders, clinicians and program staff; representatives of national organizations that provide technical assistance and training to CHCs, including both clinical leaders and attorneys; community health workers who have been both incarcerated and CHC patients; correctional officials with strong existing relationships with community providers; federal health care officials; and staff of a local consortium of health and social service providers. Interviewees were asked questions on current activities, opportunities, barriers, keys to success, and advice they would give to practitioners and providers beginning this work.

The results of these interviews were synthesized and paired with a review of the current public policy landscape, including recently enacted and approved changes to Medicaid policy, and a legal analysis of potential, actual, and perceived statutory and regulatory barriers facing CHCs. Drafts of the issue brief were reviewed by interviewees representing backgrounds in both health care delivery and corrections.


The authors would like to thank representatives from the following organizations which contributed their time and expertise to this report: Community Clinic Association of Los Angeles County; Feldesman, Tucker, Leifer, Fidell; JWCH Institute; Middlesex County (Mass.) Jail and House of Correction; National Association of Community Health Centers; National Council on Mental Wellbeing; National Health Care for the Homeless Council; Northwest Regional Primary Care Association; Open Door Family Medical Center (N.Y.); St. Johns RISE Program; Saint Louis Integrated Health Network; Transitions Clinic Network; Unity Health Care.

Special thanks to staff of Transitions Clinic Network and the Middlesex County Jail, who reviewed drafts of the report and provided valuable feedback.

  1. John M. Nally et al., “Post-Release Recidivism and Employment Among Different Types of Released Offenders: A 5-Year Follow-Up Study in the United States," International Journal of Criminal Justice Sciences 9, no. 1 (Jan.–June 2014): 16–34; and Substance Abuse and Mental Health Services Administration (SAMHSA), Use of Medication Assisted Treatment for Opioid Use Disorder in Criminal Justice Settings, HHS Publication #PEP19- MATUSECJS (SAMHSA, National Mental Health and Substance Use Policy Laboratory, 2019).
  2. National Association of Community Health Centers (NACHC), Community Health Center Chartbook 2023 (NACHC, July 25, 2023).
  3. Sara Rosenbaum et al., Medicaid and Safety-Net Providers: An Essential Health Equity Partnership (Commonwealth Fund, Apr. 2022).
  4. Similar payment models also apply to two other types of Medicaid providers: Rural Health Clinics (RHCs), which furnish health care in rural underserved communities, and Certified Community Behavioral Health Clinics (CCBHCs), which focus on providing comprehensive mental health and substance abuse services. CHCs may be dually designated as RHCs and/or CCBHCs.
  5. Martha Hostetler and Sarah Klein, “The Perils and Payoffs of Alternative Payment Models for Community Health Centers,” feature article, Commonwealth Fund, Jan. 19, 2022.
  6. Ebony N. Russ et al., “Supplemental Exhibit 1: Social Determinants of Health and Barriers to Successful Reentry,” in Prison and Jail Reentry and Health (Health Affairs Policy Brief, Oct. 28, 2021).
  7. Transitions Clinic, “Transitions Clinic Network Model,” Transitions Clinic, 2014; and Emily A. Wang et al., “Propensity-Matched Study of Enhanced Primary Care on Contact with the Criminal Justice System Among Individuals Recently Released from Prison to New Haven,BMJ Open 9, no. 5 (May 2, 2019): e028097.
  8. Centers for Medicare and Medicaid Services, “Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who Are Incarcerated,” letter from Daniel Tsai, CMS Deputy Administrator and Director, to State Medicaid Directors, Apr. 17, 2023.
  9. In 2021, 1,338 CHC grantee organizations reported offering these services, representing 97.5% of all CHCs. National Association of Community Health Centers, “Health Center Service Expansion,” NACHC, 2023; National Association of Community Health Centers, “America’s Health Centers,” NACHC, Aug. 2023; and Health Resources and Services Administration, “National Health Center Program Uniform Data System (UDS) Awardee Data,” HRSA, 2023.
  10. Shannon Mace et al., Medication-Assisted Treatment for Opioid Use Disorder in Jails and Prisons: A Planning and Implementation Toolkit (Vital Strategies and National Council for Behavioral Health, Jan. 2020).
  11. The demonstration also requires that eligible patient receive a 30-day supply of prescription medications and case management for physical and behavioral health needs.
  12. National Association of Community Health Centers, “Current State of the Health Center Workforce: Pandemic Challenges and Policy Solutions to Strengthen the Workforce of the Future,” NACHC, Mar. 2022.
  13. Because Rural Health Clinics and Certified Community Behavioral Health Clinics are paid according to similar principles, payment innovations developed for CHCs also could be extended to these facilities.

Publication Details



John Sawyer, Senior Advisor, Waxman Strategies


John Sawyer et al., Essential Connections: Community Health Centers’ Role in Facilitating Healthy Transitions Out of Incarceration (Commonwealth Fund, Feb. 2024).