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Formerly Incarcerated Transitions

The North Carolina Formerly Incarcerated Transition (or FIT) Program is establishing patient-centered primary care medical homes for returning inmates with chronic medical conditions, mental illness and/or substance use disorder.

Nearly 25,000 people were released from NC prisons in 2017 and previously there has been no system providing linkages to healthcare during the critical transition from incarceration to the community. Best estimates tell us that 30-40% suffer from chronic disease including Diabetes, Hypertension, Kidney problems and Lung disease. Up to 20% have significant mental illness and 50% likely suffer from substance use disorder. Only prisoners with HIV/AIDS are regularly liked to healthcare. An additional barrier is lack of health insurance for the majority of this population. We also know that recently released prisoners are 74 times more likely than the general population to die of a heroin overdose in the first 2 weeks post-release.

The NC FIT Program builds on investments being made by the NC Department of Public Safety (DPS) to remission the state prison system to improve reentry. In coordination with DPS the FIT Program extends the work of local reentry councils and community-based organizations to link recently released prisoners with essential healthcare services. The North Carolina Community Health Center Association has been an important partner in establishing partnerships with Federally Qualified Health Centers that are uniquely positioned to care for these complex patients addressing physical and mental health as well as treatment for addiction. The NC FIT Program utilizes specially trained community health workers (CHWs) with a personal history of incarceration, to establish rapport and trust and act as peer navigators in all aspects of reentry.  Currently there are FIT Programs in Orange and Durham Counties, and expanding into Wake and Mecklenburg in August 2018.  The NC FIT Program is based on the Transitions Clinic Network model that is being successfully implemented in 24 clinics in ten states.

The FIT Program emphasizes:

  • Strong linkages with the Department of Public Safety (DPS) to coordinate warm handoffs of care from incarceration to needed healthcare services in the community.
  • A peer navigator model that works with local reentry councils and community-based organizations to create comprehensive reentry plans including healthcare.
  • Culturally competent, patient-centered medical services capable of addressing the complex needs of people returning to their communities that suffer from multiple comorbidities.
  • Close partnerships with key stakeholders in North Carolina that include DPS, County Jails, County and State Departments of Public Health, local reentry councils, community mental health, community substance use disorder treatment and the North Carolina Community Health Center Association.

The FIT program is currently being operated in collaboration with the state’s Department of Public Safety, the UNC Medical School’s Department of Family Medicine, the NC Community Health Center Association, the Orange and Durham County Health Departments, Piedmont Health Services, Inc. and the Lincoln Community Health Center. New partners are the Charlotte Community Health Clinic and the Center for Community Transitions in Mecklenburg County, and Advance Community Health Center and UNC Wakebrook Primary Care in Wake County.  NCCHCA is a promoting partner in this expanding initiative.


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