People returning from incarceration face a myriad of health inequities, including increased emergency department utilization, hospitalization and death. In the first 2 weeks post release, people are 12 times more likely to die than their community counterparts from health conditions that could be treated in the primary care setting (including SUD, cardiovascular disease, mental illness and cancer).

Transitions Clinic Network has 21 affiliated FQHCs in 14 counties across California that have special programs to care for people returning from incarceration. However, no organized system of care coordination exists between state prisons and primary care systems. This CHIP project aimed to leverage the TCN network and existing relationships with the California Department of Corrections and Rehabilitation (CDCR) to create an organized system of continuity of care between state prison and community health systems.

By late spring 2020, COVID-19 was spreading like wildfire across state prisons due to congregate housing and cramped conditions. By fall of 2020, incarcerated people were 5 times more likely to contract COVID. Under community pressure, California state prison officials sought to release tens of thousands of people early to slow the spread of COVID-19 necessitating the immediate creation of care coordination systems.