Authors: Robyn Haas, Michelle Clark, Melissa Walter, Sharon Bailey
Twenty relevant references were identified regarding the models of care have been used to support integrated health care service delivery for incarcerated adults transitioning back into the community setting.
The majority of the studies identified were conducted in the US with additional studies conducted in Canada, Ireland, the UK, and New Zealand.
People who are reintegrating into the community after incarceration often have unmet physical and psychological health needs.1,2 Common conditions that these individuals live with may include mental illness, substance use disorders, HIV, hepatitis C, and diabetes, among others. These health needs are not unique to people who have been incarcerated; however, they can face a difficult transition in accessing health care from incarceration to the community. In addition to heightened health needs, this population is also faced with challenges surrounding employment, education, and housing. Addressing these health and human service needs can be challenging because there is often a lack of support and connection within the community, which could otherwise help them access resources. Despite these difficulties, timely access to health services for people re-entering the community after incarceration is critical. Previous research has shown that this population is at a greater risk of death following their release from prison compared with the general population, and that the first 2 weeks following release are a particularly vulnerable period.3
It is difficult to provide continuity of care from prison to the community, but it is an important factor in ensuring that people can successfully re-enter the community and avoid adverse outcomes.4 Models of care, or re-entry programs, for people who are transitioning out of incarceration can play a key role in meeting this need. Re-entry models may take various forms but will often begin treatment in the prison setting and then continue to provide support for a period after an individual’s release. The type of services provided can include treatment for substance use, mental illness, cognitive behavioural issues, as well as the provision of support for education, accessing primary health care, housing, employment, and general life skills. Some care models are targeted toward specific subgroups of people, such as women, people with specific health needs, and sexual or violent offenders. Care models can also range in their format, whether they be voluntary or mandatory, individual- or group-focused, and unimodal or multimodal. Finally, the setting and location of the programs can vary (e.g., based in a correctional facility before community release, in the community, in a halfway house, and so on). Regardless of the specifics of each care model, the overall goal of these programs is to help participants successfully transition back into the community, meet their health care needs, and reduce recidivism.
Interventions for successful re-entry and reintegration into the community may be of particular importance for populations who are disproportionately represented in the carceral system in Canada, such as those who identify as First Nations, Inuit, and Métis.5-7 Both the Calls to Action from the Truth and Reconciliation Commission7 and the Calls for Justice from the National Inquiry into Missing and Murdered Indigenous Women and Girls8 call for both the health and justice systems to recognize and the health and wellness, rehabilitation, and safety needs of Indigenous people in Canada. This includes removing barriers to Indigenous healing practices and increasing access to transitional services. These should be done in culturally appropriate, trauma-informed ways and be designed and led by Indigenous people.7,8
What are the models of care that have been used to support integrated health care service delivery for incarcerated adults transitioning back into the community setting?
The purpose of this report is to provide an annotated list of integrated models that have been implemented to increase the continuity of care for previously incarcerated people who are re-entering the community. contains additional references of interest that did not meet the inclusion criteria for the main report. is an additional reference list including information regarding models of care for people with mental health or substance use disorders.
Two limited literature searches were conducted by information specialists on key resources including MEDLINE, PsycInfo, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategies comprised both controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts for the first search were models of care and transition from prison. The main search concepts for the second search were mental health or substance use care and transition from prison. No filters were applied to limit the retrieval by study type. The searches were completed on June 9, 2022, and were limited to English-language documents. The first search was limited to documents published since January 1, 2012, and the second search was limited to documents published since January 1, 2017.
Citations were included if they described an integrated model of care, including health care and other supporting resources, for people who were re-entering the community following incarceration. Studies of models of care that did not include a health care component or only included 1 supporting intervention were excluded. Studies were also excluded if they took place only before a person’s release from jail or prison.
Twenty relevant references were identified for this report. Systematic reviews, randomized controlled trials, non-randomized studies, program evaluations, and qualitative studies were identified. The majority of the studies identified were conducted in the US, and most focused on re-entry of male prisoners. Integrated models of care identified included:
Access to Recovery initiative
Breaking Free Online
Collaborative chronic care model
Comprehensive Anti-Gang Initiative
Critical Time Intervention model
Delaware County Transition Program
Fresh Start Prisoner Reentry Program community re-entry initiative
Forensic assertive community treatment
High-Risk Revocation Reduction program
Jail Inreach Project
Minnesota Comprehensive Offender Reentry Plan
Multimodal Community-Based Reentry Program
Pathway Total Reintegration Programme
Pre-release Planning Program
Redemption Reintegration Services program
Saint Leonard’s Ministries’ Grace House Program
Serious Offender Accountability Restoration project
Sober Network Interpersonal Psychotherapy
Solid Start program
State parole board programs
Transitions Clinical Network
Women's Initiative Supporting Health-Transitions Clinic
Aminawung JA, Harvey TD, Smart J, et al. Formerly incarcerated community health workers engaging individuals returning from incarceration into primary care: results from the Transition Clinic Network. Front Public Health. 2021;9:681128.
This is a non-comparative observational study of the Transitions Clinic Network. The services provided include assistance with health care visits and addressing other social determinants of health, most commonly housing, insurance, transportation, government benefits, food access, and legal issues. The program is run through community clinics across the US for anyone re-entering the community after incarceration.
Angell B, Matthews E, Barrenger S, Watson AC, Draine J. Engagement processes in model programs for community reentry from prison for people with serious mental illness. Int J Law Psychiatry. 2014 Sep-Oct;37(5):490-500.
This is an evaluation of 2 programs: Forensic Assertive Community Treatment (FACT) and Critical Time Intervention (CTI). The FACT program involves a multi-disciplinary team that provides tailored support for people with mental illness with a focus on preventing reincarceration. CTI involves 9 months of case management services focused on creating connections with treatment programs (e.g., psychiatrists, therapists, housing programs, day treatments) and community (e.g., family relationships, landlords, and social networks). These evaluations included participant interviews. Participants in the programs were identified as people in the US who were re-entering the community following incarceration and had special mental health needs.
Beausoleil V, Renner C, Dunn J, et al. The effect and expense of redemption reintegration services versus usual reintegration care for young African Canadians discharged from incarceration. Health Soc Care Community. 2017 03;25(2):590-601.
This is a randomized controlled trial of the clinical and cost-effectiveness of the Redemption Reintegration Services program, which is a culturally specific, multi-level intervention for young people in Canada of African descent The program uses traditional African practices to provide culturally relevant services. Services provided are individualized and gender-specific and may include education, employment, ethnic racial and cultural identity, mentorship, housing, mental health, legal, recreation and familial relationships. The study included young African Canadians in Southern Ontario who were previously incarcerated.
This is a qualitative study including interviews of users of the Comprehensive Anti-Gang Initiative and their experience with, and perceptions of, the program. The initiative includes provision of transitional housing, job readiness, and placement assistance, and substance use and mental health treatment. The study included high-risk offenders in multiple US states who were re-entering the community following incarceration.
This is a systematic review of randomized controlled trials of 9 interventions (5 unimodal and 4 multimodal) reporting outcomes of recidivism and reintegration. The multimodal interventions included were the High-Risk Revocation Reduction Program, Minnesota Comprehensive Offender Reentry Plan, Multimodal Community-Based Reentry Program, and Serious Offender Accountability Restoration project. The programs included multiple phases focused on continuity of care, including housing, subsidized employment, mentoring, drug treatment, and so on. The included studies were conducted in a mix of correctional, community, and combined settings in the US, and included predominantly non-White males.
Clark VA. Making the most of second chances: An evaluation of Minnesota's high-risk revocation reduction reentry program. J Exp Criminol. 2015 Jun;11(2):193-215.
This study is a randomized controlled trial of the High-Risk Revocation Reduction program for high-risk adult male offenders leaving Minnesota state prisons. The types of care services provided include supplemental case planning, housing, employment, mentoring, cognitive behavioural programming, and transportation assistance.
Colibaba A, Skinner MW, Balfour G, Byrne D, Dieleman C. Community reintegration of previously incarcerated older adults: exploratory insights from a Canadian community residential facility program. J Aging Soc Policy. 2022 Feb 02:1-21.
This is an exploratory interview-based case study of experiences at Hayley House, a Correctional Services Canada–contracted community residential facility that provides specialized support for previously incarcerated older men who are facing serious chronic mental or physical health issues or are nearing the end of their life. The facility, located in Ontario, provides health and medical support to older men using a dignity-centred model.
Cossyleon JE, Reichert J. Women and reentry: evaluation of the St. Leonard's Ministries' Grace House Program. Chicago (IL): Illinois Criminal Justice Information Authority; 2015: . Accessed 2022 Jul 4
This is a program evaluation of the Saint Leonard’s Ministries’ Grace House Program, which is a residential program for women in Illinois. The types of services provided include housing support, substance use treatment, psychological services, life skills mentoring, and educational and vocational services.
Grommon E, Davidson Ii WS, Bynum TS. A randomized trial of a multimodal community-based prisoner reentry program emphasizing substance abuse treatment. Journal of Offender Rehabilitation. 2013 May;52(4):287-309.
This is a randomized controlled trial of a multimodal, community-based prisoner re-entry program with an emphasis on substance use treatment. The program included 2 phases of release from incarceration. The first focused on housing, employment, life skills training, initiating contact with family members, and outpatient substance use treatment. The second phase included more frequent substance use treatment interventions and random drug testing. The study population was at-risk males with substance use issues in the US who are returning to the community under 24-month supervision.
Held ML, Brown CA, Frost LE, Hickey J, Buck DS. Integrated primary and behavioral health care in patient-centered medical homes for jail releasees with mental illness. Criminal Justice and Behavior. 2012 Apr;39(4):533-551.
This is an evaluation of the Jail Inreach Project for adults leaving jails in Houston, Texas. As part of this program, case managers can accompany participants from their jail release to the facility and connect them immediately with primary care. Additional services provided vary based on the participant but can include counselling, psychiatry (including telepsychiatry), treatment for substance use, dental care, housing, employment, and help navigating applications for government benefits and identification.
Hunter BA, Lanza AS, Lawlor M, Dyson W, Gordon DM. A strengths-based approach to prisoner reentry: the Fresh Start Prisoner Reentry Program. Int J Offender Ther Comp Criminol. 2016 Aug;60(11):1298-1314.
This study is a program overview and qualitative study of participant experience with the Fresh Start Prisoner Reentry Program. The program facilitates increased access to substance use treatment, behavioural health services, employment, housing, community connections, and health care. The study included men re-entering the community from correctional facilities in Connecticut.
Kendall S, Redshaw S, Ward S, Wayland S, Sullivan E. Systematic review of qualitative evaluations of reentry programs addressing problematic drug use and mental health disorders amongst people transitioning from prison to communities. Health Justice. 2018 Mar 02;6(1):4.
This systematic review of reentry program evaluations included information regarding 8 programs: Critical Time Intervention and Forensic Assertive Community Treatment, Breaking Free Online, Pathway Total Reintegration Programme, Fresh Start Prisoner Reentry Program Community Reentry Initiative, Sober Network Interpersonal Psychotherapy, Delaware County Transition Program, Solid Start Program, and a state parole board program. The programs included housing and employment supports, support with reconnecting with family, links to services and resources, peer support, and psychological and substance use health services. The studies included adults re-entering the community in the US, UK, and New Zealand.
Kim B, Bolton RE, Hyde J, et al. Coordinating across correctional, community, and VA systems: applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders. Health Justice. 2019 Dec 12;7(1):18.
This is a qualitative study using the collaborative chronic care model. The services provided include patient self-management support, health care provider decision support, and linkages to community supports. This model provides services to veterans in Massachusetts, US, with mental health disorders and substance use disorders.
McNeeley S. A long-term follow-up evaluation of the Minnesota High Risk Revocation Reduction reentry program. J Exp Criminol. 2018 Dec;14(4):439-461.
This is a randomized controlled trial of the Minnesota High-Risk Revocation Reduction re-entry program. The program provides services to assist with housing, transportation, employment, and family relationships, and is targeted to offenders incarcerated for violating the conditions of their supervised release.
Miller J, Miller HV, Barnes J. Treating co-occurring disorders in jails: Outcome findings from a second chance act offender reentry program. Crime Delinq. 2019 May;65(5):583-605.
This is a quasi-experimental study of the Delaware County Transition Program. It provides coordinated mental health, medical, and drug treatment; delivers cognitive behavioural therapy; and links participants to community resources before their release. The program was examined in dually diagnosed offenders in Ohio, US, and was set in correctional facilities during the pre-release phase and in the community in the post-release phase.
This is an observational study of the Access to Recovery initiative for adults with substance use issues who were released from prison in Indiana. As part of this initiative, clients are empowered to choose which elements of service they think they need to be successful. The available interventions include a range of social resources and benefits, economic and tangible resources, and knowledge and connection with other available resources.
This is a randomized controlled trial using the Critical Time Intervention model. The care needs addressed by this model include mental health, social care, and resettlement. This study takes places across 8 prisons in the UK and incudes adult male prisoners with a diagnosis of severe mental illness.
This is a non-randomized study (prospective observational cohort study) of the Pre-Release Planning program. The program aims to improve continuity of mental health care and improve the level of mental health support and the security and quality of housing following release from prison. This program is delivered in prisons in Ireland; only adult males with mental health disorders were included in this study.
This is a qualitative study of the Women’s Initiative Supporting Health-Transitions Clinic, a primary care model. It facilitates access to substance use disorder, medical, and mental health treatment for women. This study is set in a medical clinic in New York, US.
Zortman JS, Powers T, Hiester M, Klunk FR, Antonio ME. Evaluating reentry programming in Pennsylvania's Board of Probation & Parole: An assessment of offenders' perceptions and recidivism outcomes. Journal of Offender Rehabilitation. 2016 Aug;55(6):419-442.
This is a qualitative study of a re-entry program designed by Pennsylvania’s Board of Probation and Parole. No specific name or title is given. The types of care services provided include those for substance use, mental health, employment assistance, educational services, and family reunification. This program is targeted toward any paroled or reparoled state-sentenced offender.
6.Government of Canada Office of the Correctional Investigator. Indigenous People in Federal Custody Surpasses 30% - Correctional Investigator Issues Statement and Challenge. 2020; . Accessed 2022 Jul 13.
8.Reclaiming power and place: the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. Calls for justice. [Ottawa (ON)]: National Inquiry into Missing and Murdered Indigenous Women and Girls; 2019: . Accessed 2022 Jul 13.
This appendix provides additional references identified for this report that may be of interest but did not provide sufficient information to be included in the main results. References include program descriptions, toolkits, and review articles.
Melton AP. Considerations for developing a program of reentry in tribal communities. Washington (DC): U.S. Department of Justice, Bureau of Justice Assistance, Community Corrections Institute; 2013: . Accessed 2022 Jul 4.
Pettus-Davis C, Renn T, Veeh CA, Eikenberry J. Intervention development study of the five-key model for reentry: An evidence-driven prisoner reentry intervention. Journal of Offender Rehabilitation. 2019 Oct;58(7):614-643. Accessed 2022 Jul 4.
National inventory of mental health and substance use services and supports for people transitioning out of the criminal justice system: final report. Ottawa (ON): Mental Health Commission of Canada; 2021: . Accessed 2022 Jul 4.
Berry KR, Gilmour M, Kennedy SC, Tripodi SJ. Coming home: Challenges and opportunities to enhance reentry success. In: Church WT II, Springer DW, editors. Serving the stigmatized: Working within the incarcerated environment. New York (NY): Oxford University Press; 2018. p. 287-306.
Reentry Health Policy Project: meeting the serious health and behavioral needs of prison and jail inmates returning to the community. Oakland (CA): California Health Care Foundation; 2018: . Accessed 2022 Jul 4.
Patel K, Boutwell A, Brockmann BW, Rich JD. Integrating correctional and community health care for formerly incarcerated people who are eligible for Medicaid. Health Aff (Millwood). 2014 Mar;33(3):468-473.
This appendix includes a reference list of articles related to the transition of people with mental health or substance use disorders from correctional services to community care and is a supplement to the main report.
One systematic review, 5 non-randomized studies, and 5 qualitative studies regarding interventions at the transition from prison to the community for people with mental illness or substance use disorders were identified.
What is the evidence regarding interventions at the transition from prison to the community for people with mental illness or substance use disorders?
People in transition from correctional services care to community care who have mental illness, substance use disorders or require mental health services
Mental Health Services; Mental Health Transitional Care; (could be described as person-centred or recovery-oriented mental health care); Services aimed at providing transitional support those with mental health or substance use service needs
Standard of care, no support
Recidivism, employment, substance use, and so on
Health technology assessments, systematic reviews, randomized controlled trials, non-randomized studies, evidence-based guidelines
Eleven relevant references were identified for this appendix. One systematic review, 5 non-randomized studies, and 5 qualitative studies were identified regarding interventions at the transition from prison to the community for people with mental illness or substance use disorders
Fontanarosa J, Uhl S, Oyesanmi O, Schoelles KM. Interventions for adult offenders with serious mental illness. (Comparative Effectiveness Review No. 121). Rockville (MD): Agency for Healthcare Research and Quality; August 2013: . Accessed 2022 Jul 4.
Cigrang JA, Fedynich AL, Nichting EM, Frederick SA, Schumm JA, Auguste CB. Brief motivational interview-based intervention for women in jail with history of drug addiction and sex-trading. Professional Psychology: Research and Practice. 2020 Feb;51(1):25-33.
Bellamy C, Kimmel J, Costa MN, et al. Peer support on the “inside and outside”: Building lives and reducing recidivism for people with mental illness returning from jail. Journal of Public Mental health. 2019;18(3):188-198.
Janssen PA, Korchinski M, Desmarais SL, et al. Factors that support successful transition to the community among women leaving prison in British Columbia: a prospective cohort study using participatory action research. CMAJ Open. 2017 Sep 13;5(3):E717-E723.
Hancock N, Smith-Merry J, McKenzie K. Facilitating people living with severe and persistent mental illness to transition from prison to community: a qualitative exploration of staff experiences. Int J Ment Health Syst. 2018;12:45.
Watson TM, Benassi PV, Agic B, Maharaj A, Sockalingam S. Addressing the complex substance use and mental health needs of people leaving prison: Insights from developing a national inventory of services in Canada. Int J Drug Policy. 2022 02;100:103523.
Chaudhri S, Zweig KC, Hebbar P, Angell S, Vasan A. Trauma-informed care: a strategy to improve primary healthcare engagement for persons with criminal justice system involvement. J Gen Intern Med. 2019 06;34(6):1048-1052.
Armstrong ER, Winters DE, Jaggers JW. Mental health in prison populations: Policy, practice, and challenges. In: Church WT II, Springer DW, editors. Serving the stigmatized: Working within the incarcerated environment. New York (NY): Oxford University Press; 2018. p.1-16.
Kiss M, Del Principel S, Taxman FS. Chapter 43: Traditional and innovative reentry approaches and interventions. In: Polaschek DLL, Day A, Hollin CR, editors. The Wiley international handbook of correctional psychology. Hoboken (NJ): Wiley Blackwell; 2019. p. 689-705.
Smith-Merry J, Mellifont D, McKenzie K, Clenaghan P. A narrative review of mental health support for people during transition from incarceration to community: the grass can be greener on the other side of the fence. J Ment Health. 2019 Apr;28(2):189-197.
Cite As: Models of Care for People Re-Entering the Community After Incarceration. (CADTH Reference List: Summary of Abstracts). Ottawa: CADTH; 2022 Jul.
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