Dr. Robert Moore, MD, MPH, MBA, Chief Medical Officer

“To be 95% confident that a large-scale implementation will be successful, look for at least four independent small-scale tests all showing a significant benefit.”

– Summary from The Science of Using Science: Towards an Understanding of the Threats to Scaling Experiments (Al-Ubaydli, List, & Suskind, 2019).

The transition of integrating back into the community after being incarcerated marks one of the most dangerous periods in a person’s life. Overdose is the leading cause of death for people recently released from incarceration, with rates more than three times the national average for incarcerated populations. Building on a 2006 pilot in San Francisco that Partnership helped expand starting in 2012, California is now poised for state-wide implementation of an approach that transforms this vulnerable transition period from a health crisis into an opportunity for healing through comprehensive, coordinated care that begins before the prison gates open.

Justice-involved individuals typically face a constellation of health challenges. In California, approximately 35,000 people are released yearly from state prisons, while most of the 350,000 people booked into county jails are released within weeks. 66% have moderate or high need for substance use disorder treatment, while incarcerated individuals with active mental health cases rose by 63% over the last decade.

The racial disparities are stark: nearly 29% of incarcerated men in California are Black, while Black men comprise only 5.6% of the state’s population. This means health care interventions for justice-involved individuals must intersect with critical racial equity initiatives.

Origins: The Transitions Clinic Network

In 2006, the pilot project at a San Francisco community health center, partnering with San Quentin State Prison, launched what became the Transitions Clinic model. This evidence-based program included innovative components like community health workers (CHWs) with lived experience of incarceration as integral health care team members.

The model proved successful and expanded rapidly. By 2024, the Transitions Clinic Network (TCN) linked 48 clinics in 14 states and Puerto Rico, including 21 in California. Research demonstrates that the TCN model cut emergency department visits and hospitalizations in half.

Partnership HealthPlan of California recognized the potential early, embracing the pilot version with strategic use of reserves more than a decade ago. The organization ultimately funded three different sites, adding two locations to the original pilot in Vallejo, demonstrating how managed care organizations could collaborate effectively to serve justice-involved populations.

Based on the proven success of multiple pilot sites in the years that followed, the Transitions Clinic and Partnership discussed expanding this model state-wide with the California Department of Corrections, even before CalAIM existed.

California Builds a Statewide Model Using Medi-Cal

Fast forward to 2023, when California became the first state to receive federal approval to use Medicaid funds for services provided to people leaving jail or prison. This breakthrough came through a federal Medicaid 1115 demonstration waiver, representing a fundamental shift in approaching health care for incarcerated populations.

The Justice-Involved Initiative is part of California’s broader CalAIM transformation. When Medicaid was created in 1965, federal law barred the use of federal funds for services for incarcerated people. California’s waiver effectively bridges this gap, allowing continuity of care that was previously impossible.

Eligible individuals can receive targeted Medi-Cal services for up to 90 days prior to release, including:

• Reentry care management services
• Physical and behavioral health clinical consultations
• Laboratory and radiology services
• Medications and medication-assisted therapy
• Services from CHWs with lived experience

Most importantly, qualifying members receive prescribed medications and medical equipment upon release, addressing the critical “medication cliff” that often leads to rapid health deterioration.

Justice-Involved Implementation and Early Success

The rollout began strategically with three pilot counties—Inyo, Santa Clara, and Yuba—on October 1, 2024. By July 1, 2025, 17 counties plus the state prison system will have launched services. For Partnership, three counties—Yuba, Sutter and Siskiyou—are included in this initial wave. Nevada County is tentatively scheduled for September 1.

Partnership’s Justice-Involved team is now seeing a steadily increasing stream of referrals coming in from ECM providers within the state prison system.

An example of how coordination of implementation is as follows: An incarcerated person with specific mental health needs and nearing release qualifies for 90-day pre-release services. They are assigned a pre-release care manager who develops a reentry plan. Before release, the individual is connected to a community psychiatrist through a “warm handoff” meeting. Upon release, the individual receives Enhanced Care Management (ECM) and subsequently gets a supply of medication to take with them.

ECM provides intensive care coordination for high-risk individuals, creating continuity that spans institutional and community settings. ECM providers address not just health care needs but social determinants of health including housing, employment, and transportation. Community Supports (CS) services complement ECM and address fundamental barriers to stability, including housing transition navigation, security deposits, and other services that promote community integration. Housing is perhaps most critical – homelessness rates among those being released from incarceration are extremely high, and unstable housing is associated with increased recidivism and poor health outcomes.

All counties must launch services by September 30, 2026. The initiative’s sustainability depends on demonstrating positive outcomes and cost-effectiveness. Success metrics include health care outcomes, community integration measures, and quality of life indicators for participants. Meanwhile, success in each county depends on local engagement activities and leadership commitment.

What Primary Care Providers Can Do

The initiative’s success ultimately depends on primary care providers’ willingness to serve justice-involved individuals effectively. Most importantly, providers must ensure that requests for initial appointments are addressed quickly. Discharged individuals typically receive only 30 days of medication and face complex medical and mental health issues. They’re at high risk of death after discharge, making rapid access to care a critical public health need.

Case managers from correctional facilities will reach out to schedule pre-release appointments. While members won’t be assigned to specific health plans while incarcerated, DHCS will make assignments retroactive to release dates. Providers should schedule these appointments immediately when requested—this transition period carries much higher mortality and recidivism rates without appropriate services.

Beyond rapid access, providers should anticipate that patients with complex needs will require comprehensive, coordinated care. This includes working collaboratively with ECM providers and community health workers, approaching patients without judgment, managing medication transitions carefully, and connecting patients to specialty care and community resources supporting long-term stability.

California’s Justice-Involved Initiative represents a fundamental shift in approaching the intersection of criminal justice and compassionate health care. Building on years of successful pilots, the state has created a model with a high likelihood of successfully spreading state-wide, which will help to transform outcomes for one of our most vulnerable populations.