Wednesday, March 12, 2025
3/12/2025
Release from prison is characterized by discontinuity of care and poor health outcomes, including an increase in mortality. Research consistently demonstrates that the top two causes of death after release from prison are fatal overdose and cardiovascular disease. Public and community-based initiatives struggle to keep up with the diverse needs and barriers faced by people released from prison. The critical gap is that this vulnerable population does not receive health care at the right time or place following release. In Denver, Colorado, only 1 in 10 people released from prison access primary care within 30 days of release (Frank et al, Health & Justice, 2023). Expedited access to primary care is paramount to the health of people released from prison. Primary Care After Incarceration Reentry Planning and Navigation (P-CAIRN) will establish a partnership between Denver Health (DH), community-based reentry programs, and the Colorado Department of Corrections, specifically at its two carceral facilities in DH's Service Area: Denver Women's Correctional Facility and Denver Reception & Diagnostic Center. P-CAIRN will (1) ensure people scheduled for release from prison in less than 90 days receive person-centered and trauma-informed care prior to and after release, resulting in expedited access to two evidence-based models of primary care, the integrated behavioral health and transitions clinic models, both already established at DH. Primary care services will include screening, diagnosis, and treatment for chronic medical conditions, infectious diseases like HIV, hepatitis C, and sexually transmitted infections; medication for addiction treatment; counseling for substance use disorders (SUDs); and diagnosis, therapy, and psychiatry referral for mental health conditions. Furthermore, P-CAIRN will (2) provide intensive case management services to address health-related social needs (HRSN) such as housing, food, transportation, and personal safety; (3) hire peer specialists with a personal history of successful reentry who will leverage their unique experience and training to build relationships and encourage positive health behaviors; (4) support the operations of an innovative DH mobile health program that acts as a bridge to primary care at four community corrections housing sites in Denver; and (5) distribute harm reduction kits with fentanyl and xylazine test strips and naloxone. DH will scale and sustain these interventions after the funding period to other carceral facilities and reentry organizations with the assistance of telehealth and the anticipated authorization of Colorado's Medicaid 1115 Reentry Waiver submitted to CMS. P-CAIRN aims to serve 250 adults annually over a 2-year period (500 individuals total). The key outcomes of the program are primary care utilization and retention, referral to community-based organizations for HRSN after release, and the number of pre- and post-release case management and peer specialist encounters, behavioral health and SUD visits, and harm reduction kits distributed. The program will accomplish these goals by hiring the necessary clinical supervision, case management, and peer specialist staff, which will be integrated into existing DH clinical workflows and complemented by the DH integrated healthcare delivery system. Additional funds will be used to expand mobile health operations at Denver community corrections housing programs where participants reside after release; obtain training for peer specialists; consult on program implementation with the Transitions Clinic Network; purchase transportation assistance; and establish a community advisory panel comprised of individuals whose lives, families, and communities have been affected by incarceration. The long-term goal of P-CAIRN is to strengthen our DH infrastructure, partnerships, and program delivery to ensure timely, equitable, and accessible primary care to foster health among per sons with criminal-legal system involvement.
HHS’ Tracking Accountability in Government Grants System (TAGGS) website provides access to detailed descriptions of grants, loans, aggregated direct payments and other types of financial assistance awarded by the HHS Operating Divisions (OPDIVs) and the Office of the Secretary Staff Divisions (STAFFDIVs).