People leaving incarceration are disadvantaged in many ways, not the least of which is finding health care for chronic conditions, including mental and substance use disorders. Evan Ashkin, M.D., discovered this when he began running a family medicine residency track that worked with underserved individuals at a community health center in Caswell County, in rural North Carolina. “I mistakenly thought that when you’re released from prison, if you have chronic medical conditions, including mental illnesses and substance use disorders, you would be referred for follow-up care, and that’s just not true, not only in North Carolina, but around the country,” Dr. Ashkin explains. He is a professor of family medicine at the University of North Carolina, Chapel Hill, and director of the North Carolina Formerly Incarcerated Transition (FIT) program.

His community health center treats many people with barriers to care, but among those, one recurrence was notable: incarceration kept leading to large gaps in accessing even basic, essential medical services. That was in 2014. The next year, Dr. Ashkin found the California-based Transitions Clinic Network, a national network of medical homes for individuals with chronic health conditions recently released from incarceration. The Transitions Clinic model was developed to focus on insufficient continuity of care between prison or jail and community services, as well as on mental illnesses, substance use disorders, and trauma histories that may not be addressed adequately in traditional primary care.

By 2017, Dr. Ashkin had founded the FIT program in North Carolina, with one site in Durham County. With funding from the North Carolina Department of Health, which he funneled into the Durham Health Department, the North Carolina FIT program recruited its first community health worker. The FIT Program hires people with histories of incarceration and trains them as community health workers, who are the backbone of the Transitions Clinic model. These community health workers reach out to jails, prisons, and local reentry partners to find people recently released and help connect them to the health care, housing, and employment services they need to establish or reestablish a life in the community.

With some foundation funding and a contract with the North Carolina Department of Public Safety, the FIT program is now operational in 5 counties across the state, with 10 community health workers serving roughly 400 individuals. The majority are Black men over the age of 35 whose chronic illnesses include diabetes and high blood pressure, as well as behavioral health conditions.

The primary focus is on health care, so the FIT programs work with local community health centers; about 75 percent of their clients regularly access primary care services, compared to 25 percent of the comparable population nationally, Dr. Ashkin says. Because North Carolina did not expand Medicaid, most FIT clients are uninsured. This means it’s extremely difficult to connect them to specialty care, or even to fund their primary care. “A vast majority of our people have no medical coverage when they come out, and they cannot afford even the low co-pays at the Federally Qualified Health Centers (FQHCs),” Dr. Ashkin says. The FIT program raises private funds to cover these costs. Though FQHCs do include some behavioral health services, there are limited dollars for uninsured people to see a psychiatrist, he notes.

Soon, some of the program’s work helping individuals manage substance use disorders will begin during their incarceration. Currently, in North Carolina, the only people who have access to medication-assisted treatment (MAT) in prison are pregnant women. However, the FIT Program is working closely with both the Orange and Durham County Detention Centers (jail) to expand that availability and continue lifesaving MAT for people incarcerated with opioid use disorder (OUD). With the aid of a NIDA grant, in Durham they will be starting MAT prior to release for people with OUD that have never before been treated, and they are working on a pilot project in three state prisons—including the women’s prison—to initiate treatment for OUD.

The FIT program community health workers also currently develop a comprehensive reentry plan for each individual in their program and try to connect them with necessary services. In Charlotte, the community health workers are employed by The Center for Community Transitions (CCT), which runs the LifeWorks! employment and training program, so FIT program participants are able to address this important reentry need as well, notes Patrice Funderburg, executive director of CCT.  “At CCT, our 2-year recidivism rate is 16 percent, compared to the 3-year rate in North Carolina of about 40 percent,” Funderburg says. She notes that the average cost of incarceration in her state is a little over $37,000 a year.

“We’re saving our communities, and we’re equipping individuals with tools and resources to help them reestablish themselves in the community,” she remarks. While the potential for reduced spending might help underline the value of the program’s work, the human element is just as important as any impact on the community’s bottom line. Says Funderburg, “When you compound chronic health and behavioral health problems, on top of the stigma of being justice involved, it requires a more relational approach that centers on the individual and not necessarily a transactional approach that there’s a savings to the community.”

Where dollars and cents are at the forefront of the discussion is in health care, according to Dr. Ashkin. He finds it unconscionable that people without insurance are left to get sicker and eventually require more expensive treatment. “The fact that economically we let it be this way is just another example of how much bias and prejudice there is in this system, that we don’t connect people to basic care,” Dr. Ashkin says.

Since the COVID-19 pandemic caused North Carolina prison officials to release some people with chronic conditions to serve out their terms in home confinement, the FIT program has begun FIT Connect, making an attempt to connect individuals even in communities without FIT programs to a primary medical home. They have received some 500 referrals and have been successful about half of the time, according to Dr. Ashkin.

With 25,000 individuals released from North Carolina prisons each year, Dr. Ashkin calls his program “a drop in the bucket,” though vitally important for the individuals it serves. For those who wish to replicate it, he has some recommendations. The first is to inventory your returning citizens’ needs and identify the gaps in meeting them: talk to the people who are providing reentry services. Next is to find “a good medical partner that really believes in the mission and understands the reentry community,” Dr. Ashkin says.

In addition, you need to determine how you are going to fund the community health worker positions in a sustainable way; these positions are one way to help formerly incarcerated people find employment, Dr. Ashkin notes. He also recommends reaching out to the Transitions Clinic Network at for technical assistance in establishing a similar program.  

Finally, Dr. Ashkin calls for a more comprehensive approach to this problem. “We chase enough grants to try to keep this program afloat, but what we really need is a broad public health investment to do the right thing for this very marginalized population,” he concludes.

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