Navigating reentry: a qualitative analysis of health system engagement among adults with chronic health conditions after release from prison

Abstract

Transitioning from prison to the community is accompanied by multiple challenges which limit individuals’ ability to access health care after release. To address this gap, we developed and pilot-tested a nurse-delivered, transitional case management intervention in two state prisons in the Midwestern U.S. The goal of this analysis was to understand how the intervention, named Call2Care, supported recently-released men and women to attend a primary care appointment after release from prison. We conducted semi-structured interviews with formerly incarcerated men and women after their participation in Call2Care. Interviews were analyzed using an experiential approach to thematic analysis. Major themes identified were Aligning Priorities and Resources, Teaching and Rehearsing Logistics of Health System Use, Impact of Context, and Gaining Trust. All of these themes occur within the context of Feeling Overwhelmed during release and reentry. The complex challenges faced by people returning to the community after prison oftentimes negatively affect their ability to access health are services after release, requiring strategic efforts to support access to care after incarceration. Call2Care is a strategy to support people to access primary care services after release from prison, while also providing additional supports and resources which are not explicitly health-related.

Background

Over 600,000 people are released annually from state and federal prisons in the United States (NASEM, 2022). Research has increasingly focused on the transition from prison to the community, identifying strategies to improve post-release healthcare access. Emerging strategies include initiating Medicaid enrollment prior to release, providing peer support, and establishing designated transition clinics (Burns, Cook, Brown, Hernandez, et al., 2021; Shavit et al., 2017). Additionally, research has found that people returning to the community after incarceration report that establishing community health care appointments prior to release is helpful in accessing health care after release (Lincoln et al., 2006). Strategies supporting adults releasing from incarceration have also found that warm handoffs, support that begins while the individual is still incarcerated and continues in the community, and care teams located in both the setting of incarceration (e.g., prison or jail) as well as the community support individuals in accessing health care after release (Jacob Arriola et al., 2007; Lincoln et al., 2006; Shavit et al., 2017).

While interventions evaluating the impact of case-management of varying intensity before and after release have had varying levels of impact (Kinner et al., 2016; Wohl et al., 2011), barriers persist which limit individuals’ abilities to access health care after release, including challenges with insurance, limited health literacy, and difficulty navigating the health care system (Agbaria et al., 2024; Eisenstein et al., 2020; Hadden et al., 2018). This is of particular concern considering that following release, individuals face high rates of premature death from causes including suicide, drug overdose, and other health conditions (Binswanger et al., 2013; Hartung et al., 2023).

Incarcerated individuals have higher rates of physical and mental illness compared to the general population, which persist after their release into the community (Binswanger et al., 2009; Maruschak et al., 2021). Since most incarcerated individuals will eventually return to the community, there is a critical need for care during and after reentry. While many chronic conditions can be successfully managed by primary care providers (PCPs), formerly incarcerated individuals continue to face barriers accessing primary care after release from prison. There are important differences between men and women when considering post-release health care experiences. Women are more likely than men to have multiple comorbid conditions compared to men (Calais-Ferreira et al., 2022).

Methods

The Call2Care intervention

This paper describes a qualitative analysis of exit interviews conducted among formerly incarcerated individuals who participated in a health-focused transitional care pilot intervention. The intervention protocol was adapted from an evidence-based transitional care intervention for hospitalized older adults known as Coordinated Transitional Care (C-TraC) (Kind et al., 2012). Our research team engaged prison-based health care staff, people with a history of incarceration, and other stakeholders to adapt the intervention protocol for the prison setting, ultimately naming the new intervention “Call2Care.” Call2Care employed a nurse case manager (NCM) to support formerly incarcerated persons to access primary care after release from prison. To do this, the NCM met individually with participants while still incarcerated to assess health literacy, motivation, and socioeconomic barriers to care during the period after participants were released from a state prison system. As part of standard protocol of the prison system, the process of enrolling participants in Medicaid was initiated prior to release (Burns, Cook, Brown, Tyska, et al., 2021). The primary outcome of interest was participants’ rates of attendance at a primary care appointment after release from prison. To facilitate this, participants had a scheduled primary care appointment at their time of release. Prior to release, participants met with the NCM for at least two meetings. The first meeting introduced the project, informed consent, and focused on assessing the participant’s specific needs. Subsequent meetings included a range of topics, such as identification of “red flags,” or other challenges that may interfere with the ability to remain engaged in health care after release. This included addressing other demands, such as location of food pantries for those who were food insecure, as well as challenges such as transportation. Additionally, to build rapport further and to help elicit hope, the NCM engaged in discussions about the future and exploration of long-term goals.

When enrolled, all participants were given a cell phone and 3 months of service post-release. Each participant was able to work one-on-one with the NCM to practice using the cell phone before release, including using the phone to schedule health care appointments, adding contacts (e.g., clinic contact information, NMC contact information), and using the calendar function. In some cases, the NCM also supported individuals to identify relevant bus routes and transportation. All study-provided cell phones were smart phones, unless the participant was prohibited from using a smartphone as a condition of release (e.g., registered on the sex offender registry), in which case they were given a flip phone without internet connectivity.

After release from prison, the NCM communicated with Call2Care participants via phone (text or call), until either they attended a health care appointment or three months had passed. Calls were not recorded. These conversations were used to remind the participants of upcoming appointments, check in on how they were doing, ask about new challenges or difficulties they were facing, and to answer questions.

This study included exit interviews conducted after participants completed the intervention to evaluate the impact of the Call2Care intervention. The purpose of this analysis was to learn how Call2Care contributed to successfully attending a first primary care provider appointment after release from prison, as well as to investigate the larger implications of the Call2Care intervention, and where potential changes in the intervention were implicated. Our second research question investigated differences in experiences with release and health care engagement between men and women.

Analysis

All participants in the current analysis were participants in the Call2Care study. Eligibility criteria for Call2Care included adults 18 years of age or older, able to understand and speak in English, intention to reside in the state of the study after release, eligibility for Medicaid, willingness enroll in the program prior to release, and meeting one of the following criteria: current HIV infection, current or past HCV infection, and/or identified substance use. This analysis did not apply additional eligibility criteria. All study procedures were reviewed and approved by the university Institutional Review Board (IRB 2022-0398) as well as the department of corrections.

Question guide development

The semi-structured interview question guide was generated inductively by the research team to understand the experiences of people after release from prison. By expanding the scope beyond Call2Care evaluation, participants had greater latitude to describe their experiences following release, supporting an inductive approach to data analysis. The question guide included both directive and non-directive open ended questions. Directive questions are generally more specific, directing the participant to a certain topic, and generally addressed topics directly related to Call2Care evaluation (“How prepared did you feel to access healthcare?”). Directive questions in this study focused on health system engagement, as this was the primary focus of the parent study. In contrast, the non-directive questions were more open, allowing participants to identify salient topics or concerns (“Think back to when you were released from prison and tell me what the first month was like”). Non-directive questions facilitated a broader exploration of issues relevant to participants, regardless of their relevance to health systems engagement. Therefore, the analysis went beyond health systems engagement to consider the broader context of reentry experiences, including but not limited to factors affecting health decisions and actions. This thematic analysis relies heavily on responses from non-directive questions.

Sampling and data collection

Participants were purposively recruited from participants of the larger Call2Care study who had been released from two state prisons (one prison for men, one prison for women). Participants were recruited by using the electronic medical record and list of anticipated releases to identify individuals who had eligible diagnoses (HIV, Hepatitis C, substance use disorder), cross referenced with a list of individuals anticipated to release within 6 months. Additionally, flyers with study information were hung in common areas for potential participants to self-identify. Participants were invited to interview based on characteristics of their reentry experience, such as release location (e.g., rurality, sober living program), additional supports (e.g., family, access to another case manager), and registration as a sex offender. These categories were iteratively generated from the ongoing analysis. For example, when a participant described residing in urban community with resources available to support formerly incarcerated individuals, we purposively sought someone released to a rural area with fewer such resources. Recruitment efforts also aimed to ensure comparability between the male and female participants based on these characteristics. Two researchers (KM, BB) conducted all interviews. Interviews lasted 32–91 minutes (average: 58 minutes). One interview was not recorded due to technical difficulties.

Data analysis

Interview data were analyzed using an experiential approach to thematic analysis (TA) (Braun & Clarke, 2022, 2023), which investigates participants’ experiences within their unique context (Braun & Clarke, 2022). As such, this analysis sought to understand the post-release experience and the contextual factors that impacted these experiences. This included both aspects related to the intervention (e.g., the nurse case manager), as well as other factors (e.g., family connections, location of release). This analysis followed the six-step process as described by Braun and Clarke (2006): familiarization, coding, generating initial themes, reviewing themes, refining and naming, and reporting the themes. These steps are described in more detail below.

Each interview was transcribed verbatim and reviewed by the researchers for accuracy prior to beginning analysis. The researchers familiarized themselves with the interviews by engaging in transcript review, reading, and discussing the transcripts. Following familiarization, data were inductively coded, and broad concepts were developed. For example, when a participant described obstacles preventing them from attending a health care appointment after release, these obstacles were initially coded as “barriers to attending appointment.” These codes generally used language similar to the language used by participants. Following initial coding, the concepts were organized and refined, where related concepts were grouped into themes. Concepts represent smaller, less conceptual meaning units as compared to themes, which are patterns of meaning present across interviews. Conversely, concepts are more likely to be summaries or purely descriptive of the participants’ experience. Furthermore, aligned with the constructivist approach to thematic analysis (Braun & Clarke, 2022), concepts related to participants’ descriptions of their experiences immediately after release were grouped into themes. This phase of analysis also included generation of sub-themes, or those themes which fall within the purview of larger, broader themes. For example, “Cell Phone and Internet” was a subtheme of Impact of Context.

Throughout each phase of analysis, the researchers met regularly to discuss and compare concepts and sub-concepts. The ongoing analysis was also presented to the larger intervention research team, including the nurse case manager, for feedback. The organization and generation of sub-concepts was not informed by any a priori decisions or theoretical frameworks, consistent with inductive analyses.

Consistent with the overall goals of the Call2Care program, the primary purpose of the post-incarceration interviews was to learn whether/how the Call2Care program contributed to successfully attending a first primary care provider appointment within 30 days following release from incarceration.

Results

In total, 30 individuals (15 men and 15 women) participated in interviews between April 2023 and December 2024 (Table 1).

Table 1.

Participant demographics.

	Men (n = 15)	Women (n = 15)	Total (N = 30)
Mean age at time of release (min – max)	43.0 (24–63)	47.1 (32–71)	45.1 (24–71)
Race and Ethnicity*
White, not Hispanic or Latino	6	8	14
Black or African American	7	2	9
Hispanic or Latino	1	4	5
American Indian	–	3	3
Other	–	1	1
Mean length of time incarcerated in months (min – max)	69.5 (9–292)	28 (4–90)	49.4 (4–292)
Released to a rural community	6	11	17
Health Insurance Prior to Incarceration
Medicaid	9	11	20
Private	2	–	2
None	4	2	6
Unknown	–	2	2
Registered Sex Offender	6	1	7

^*Participants could select more than one response.

Major themes identified were Feeling Overwhelmed, Aligning Priorities and Resources, Teaching and Rehearsing Logistics of Health System Use, Impact of Context, and Gaining Trust. Importantly, all of these themes occur within the context of Feeling Overwhelmed during release and reentry.

Feeling overwhelmed

Use of the term “overwhelming” to describe the immediate post release period was pervasive. All but 2 participants used this term spontaneously when describing the first few weeks or months post release. Most participants suggested that having the appointment scheduled for them prior to release was crucial and that having the appointment scheduled prior to release facilitated earlier engagement with their PCP.

Getting out, being overwhelmed with stuff, new situations new people. I think it would of took me a lot longer for myself to actually call and make that appointment versus already having that appointment there when I got out. (Participant 1105).

Many participants described that given how overwhelmed they felt with other priorities such as housing, employment, acquiring a driver’s license, transportation support, and repairing relationships, they likely would not have accessed health care without the NCM’s support: “I wouldn’t have been thinking about trying to get my health in order and get no personal doctor and … you know, checking on my mental health and all of that, that probably would have never happened” (Participant 1056).

Feeling Overwhelmed consisted of two subthemes: Social Connections and Society and Life Outside.

Social connections and society

Participants consistently described how reengaging with social connections and society in general contributed to their feeling overwhelmed after release. Many participants described how avoiding certain people or groups was a strategy to avoid reverting to their life before prison: “when I’m walking down certain blocks and I see certain people, or if I see a certain crowd or whatever, …, I just take a detour and go a whole another way” (Participant 1004).

Interactions with previous friends or acquaintances could be further complicated if the person was committing to a changed lifestyle after prison, particularly for participants recovering from substance use disorder who were trying to maintain their sobriety after incarceration:

when I, like the first day I got out someone tried to offer me some coke, and I was like, well I don’t do all that. And they’re like really? Out of everybody, you? And I’m like yeah you can’t do that if you wanna have a good life. (pt 1128).

Additionally, participants described how their offense, or the reason for their incarceration, could contribute to feeling wary or uncomfortable in society:

My personal case was very public. … Going into Walmart was really overwhelming for me, because- or going to the grocery store where, you know, you’re going to run into- I live in a small town, you know, you’re going to run into people you’re going to see people that, you know, and how are they going to react (Participant 2005).

Life outside

Life outside of prison and societal changes that occurred while incarcerated also contributed to feeling overwhelmed after release. In the words of one participant, life on the outside was “sensory overload” (Participant 1047). In particular, the pace of life, the lack of structure or routine, and the number of decisions that had to be made were overwhelming. “But everything is moving quickly now. It’s not like it was in prison, where everything is just routine” (Participant 1014).

Many participants described how they felt prepared for release and reentry until they were actually going through it, expressing that they were not as prepared as they had thought they were. Even seemingly “simple” tasks were difficult.

I thought that I would be able to jump out and get right back on my feet and, you know, kind of pick up, you know, pick up life easy and it was it was very overwhelming and … I had a really high anxiety, like, going to the grocery store was, was very difficult. (Participant 2022)

Anxiety over the pace of life and the pervasive shift from in person to online communication was particularly notable for participants with sentences longer than 5 years. In addition to broader challenges of feeling overwhelmed during release, this feeling of being overwhelmed also contributed to challenges with health system navigation and accessing health care services.

Aligning priorities and resources

Identifying potential health resources that were in a convenient location for the participant was widely described as supportive for them being able to attend their appointments after release from prison, as transportation was a challenge for many. Several participants described receiving health care services at a location that was geographically convenient, such as being close to where they were living, being on a bus line, or being in a place where they could access services. Identifying providers who were geographically located in a convenient place was described as extremely helpful because it eased the challenges of co-navigating the health and transportation systems. For example, one participant described how the NCM helped him identify potential apartments and then identified clinics that were nearby: “he looked at some apartments for me to rent … Just to where I was moving at. Because that’s where the doctor was” (Participant 1045).

Because the primary focus of Call2Care was successfully accessing primary care, other health-related appointments, such as mental health, dentistry, and specialists were generally not made prior to release. Because of this, participants were largely responsible for scheduling these appointments on their own, often finding it difficult to access these specialty services. These appointments were therefore much less likely to occur or to be significantly delayed. Dental appointments were widely described as a priority for those with dental issues, particularly when pain was a prominent symptom. Dental health appointments were particularly difficult to schedule as it was challenging to find a provider who accepted Medicaid, the health insurance most participants relied on, and long wait lists. Participants generally considered these other appointments, particularly dentistry and mental health, as priorities, just as or even more important than primary care, suggesting that scheduling these prior to release may have been helpful.

I wish I would have been able to find a dentist appointment when we were setting up the initial health care appointment for when I got it. (Participant 1105).

Teaching and rehearsing logistics of health system

Participants with minimal experience using primary care prior to their incarceration described the NCM teaching them how to navigate the health system. Many participants, particularly male participants, who had been incarcerated for a long period of time, and had limited involvement with the health system other than emergency rooms prior to their incarceration. Some were uncertain about how to cancel, schedule or reschedule appointments even being unaware that missed appointments could be rescheduled. The NCM rehearsed scheduling and rescheduling appointments with these individuals prior to release. The NCM guided these participants through calls to the PCP’s office or engaged them in role-playing how this could be done.

The NCM also rehearsed different scenarios with the participants, which were described as helpful when they encountered similar scenarios on the outside. Scenarios included potential triggers, stressful situations, or challenging situations they may face on the outside:

And each day, we try to go for, at least like, 3 different scenarios instead of just one because after that, cause you know, just in case one idea don’t work. Still, have more you could fall back on so. (Participant 1037).

Participants described how the NCM taught them logistics of accessing the health care system, such as finding transportation, principally bus routes, that would allow them to attend their health care appointments. Particularly for individuals who released to urban areas, the NCM used the study-provided cell phone to teach participants how to access the maps feature, allowing them to search for bus routes to take them to scheduled appointments. Participants were also able to rehearse this skill, identifying different origins and mapping routes to health care clinics. These skills were described by participants as extremely helpful, likely influencing their ability to make scheduled appointments.

He [the NCM] showed me on Google Maps how to, uh, where it was at. He asked me where I was staying at, …, he found a place around by where I was staying at. And he kind of showed me on Google Maps, where it was at, … He was like, “it’s kind of real close by where you at. You can, uh, catch the bus there or you can walk there” (Participant 1014)

Impact of context

Impact of Context considers a wide array of important contextual factors that influenced a person’s release experience. This theme includes three subthemes: Rurality, Phone and Internet, and Offense-Specific Considerations.

Rurality

Post-release access to health services (e.g., dental and mental health) and non-health services (e.g., public transportation and temporary housing) was much more challenging in rural than in urban areas. Participants identifying as Black or African American or Latino largely released to urban areas, while white and Native American participants largely released to rural areas. Participants in rural areas described having access to resources like public transportation, multiple types of clinicians (e.g., pulmonologist, psychiatrist), and social resources such as friends and family in close proximity. In rural areas, transportation and wait lists were major contributors to challenges with accessing care. Several rural participants expressed need for more information and assistance with post-release transportation services. One participant released to a rural community described how the lack of public transportation impeded her ability to make it to appointments with her parole officer, leading to additional challenges. When describing challenges with transportation, she described how rural living makes it difficult to access services: “I live out kind of like in the country. So, a bus isn’t going to do me any good” (Participant 2033).

Phone and internet

The study-provided cell phone, which participants had in their possession when they were released from prison, was routinely referred to as a “lifeline”: “My cell phone became my lifeline when I got out” (Participant 2005). While a few participants had friends and family who were helpful reintegrating into life outside prison, the smartphone was described by all but one participant as vital for maintaining connections, locating resources, applying for jobs, connecting with parole officers, scheduling and rescheduling health care appointments, and maintaining emotional equilibrium. The study-provided cell phone was used for a multitude of purposes related to health system engagement, family connection, and other needs. “I used it for my PO [parole officer] too. … medical appointments, getting a hold of family, … chatting with my daughter … social media … music, music is a big thing for me” (Participant 1047). Importantly, in addition to these uses, the study-provided phone was also used as a tool to manage anxiety:

Job interviews, job searching, um, social media, connections, use it for the physical health, physical health, in terms of like, my stats, things to help me with my anxiety-music to help me with my anxiety. Um, yeah, my banking. Oh, boy, I use a chime account from a banking. (Participant 1037).

Some participants described how the study-provided phone was the only means for reconnecting with family members. Use of the phone to contact friends and family members to request transportation made it possible for participants to make appointments, access food pantries, and get to work sites.

Using the internet to complete job applications was unfamiliar and challenging for many participants. Several commented that they were only able to apply for jobs through their cell phone as most employers would not accept in-person applications. Several also described the use of their cell phone to successfully manage mental health and substance use. For example, anxiety was successfully managed by several participants through online resources designed to decrease anxiety and improve stress management skills. Some participants found podcasts and online games very useful and effective distractions when struggling with cravings. Notably, these resources were not necessarily identified by the NCM for the participants.

Those who had completed longer incarcerations, greater than 4–5 years, often had limited familiarity or comfort with cell phones, particularly the study-provided smartphone. These participants described how the NCM had provided opportunities for them to watch and then rehearse use of the cell phone, beyond just scheduling health appointments and health system engagement. “And then the third visit, uh, he just kind of like talked to me a little bit, showed me the phone, helped me set it up, and then wished me good luck, which was nice” (Participant 1047). One participant received the phone as she left prison and was unable to work with the NCM on the phone prior to release. After release, she described her great difficulty in learning to use the phone, almost giving it up.

Offense-specific considerations

Offense-specific considerations was a third subtheme of Understanding Context. For example, the one person who was required to register as a sex offender faced challenges such as limitations on where he could seek employment and where he could live. The difficulty he faced was substantially increased by his release to a small rural town. Persons who were incarcerated for a DUI faced limitations on being able to secure a driver’s license after release, hindering their ability to secure employment:

When I got out, I couldn’t get a driver’s license. … Cause I, I got in trouble for drinking and driving. … if you get two drinking and driving within a five year period, you lose your driver’s license for ten years … It’s horrible because I got interviews and I got stuff going on and I’m just trying to figure out (Participant 1001).

Being unable to secure a driver’s license and secure transportation also impacted participants’ access to health services, “I missed one doctor’s appointment because of that too” (Participant 1001). Participants described how it is essential to consider these offense-specific factors when considering post-release planning because these factors tended to have wide-reaching and profound impacts on their ability to access and utilize different services.

Gaining trust

Participants described the necessity of trusting the NCM in order to engage in conversations about health and health care. They described several actions engaged in by the NCM that led to the development of trust including shaking his hand, introducing himself with his first name and asking what name the participant preferred to be called. This was described by many as reflecting respect, seeing the participant as “a person not just a number” (Participant 1086). Importantly these actions generally occurred early on when the NCM initially met the participant, and continued throughout their engagement.

Um, well, he addressed me by my 1st name. … he would actually talk with me … like, how was your day you know, … he was professional, but he wasn’t cold, I guess would be the way to say it. You can tell that he had a heart about what he was doing and, you know he cares (Participant 2022).

The development of trust relied heavily on the belief that the NCM was genuinely interested in helping them and cared how they did after release, not just “checking a box.” This was facilitated by inquiring about their short- and long-term goals and listening carefully to what participants chose to share. Participants noted that sharing their long-term goals—even those unrelated to health or healthcare—reflected the NCM’s genuine interest in them and recognition of their priorities. This suggested to participants that the NCM was not “just doing their job,” that he “actually cared” about the participant as a person. Additionally, participants described how sharing even superficial personal details (e.g., sharing a passion for fishing and engaging in a discussion of fishing rods) helped them feel more connected and seen by the NCM.

Additionally, trust in the NCM was strengthened by his independence from the Department of Corrections (DOC). While some participants acknowledged supportive correctional staff and parole officers, many saw the NCM’s non-affiliation with the DOC as a key reason for their willingness to trust and share:

most prison staff do not care about the inmates, they don’t give a s*** what you do beyond getting out, they have no interest in doing anything helpful, but that’s the prison staff itself. So, um, I never necessarily looked at [the NCM] like that because he’s not a DOC employee. (Participant 2039).

Trust and engagement were also promoted by the NCM offering participants choices, following through on promises, doing more than was necessary, and seeming knowledgeable and honest. “He was knowledgeable in his feedback and he was honest about it” (Participant 2082). Examples of doing more than necessary or “going beyond” was reflected in checking up on someone who had missed an appointment, traveling to a different prison after the participant had been transferred, spending time rehearsing how to use the cellphone, giving choices, and listening attentively. An example of giving choices was asking whether the participant preferred the NCM to make the primary care appointment, do it themselves, or do it together. Feeling that the NCM was working collaboratively facilitated developing trust because participants felt involved in the process:

he would show us what he was doing … he let us be a part of it too, like, how does this sound or, … Instead of just saying this is where you’re going to go, you know, he let us also be a part of that (Participant 2022).

Finally, gaining trust was facilitated by following through on promises, which was often described as providing information at follow up visits that the participant had requested or making a “check in” call following release. The continuation of communication with the NCM after release also facilitated trust and made the participants feel that the NCM was sincere and invested in their success:

[after release] he’ll still text me and be like, “hey how are you doing what you’re doing? Well, let me know if there’s anything that I can help you with,” “are you know, are you getting to your doctor’s appointments” he’s still is in contact with me. … helped a lot with a lot of things and it is, you know, it’s another one of those things that, you know that he cares. (Participant 2022).

Gender differences

During analysis, important gender differences were identified. Women were more likely to have familiarity and experience with the health care system prior to incarceration, oftentimes due to having children for whom they had sought health care. Women were also more likely to report having support from family and friends, often including housing and transportation. Relatedly, women generally expressed less urgency with finding a job compared to men, because they were in safe, supportive surroundings.

Discussion

This analysis sought to learn how the Call2Care program contributed to successfully attending a first primary care provider appointment including mechanisms that supported individuals following release from prison, as well as to explore differences between men and women who returned to the community after incarceration in prison. While the goal of Call2Care was to connect participants with primary care after release, the implications were much broader, including facilitating skills in broader health care navigation, connectedness to friends, family, and other resources, and developing transferrable skills that could be used in aspects of life outside of health care. Importantly, participants gaining trust in the NCM was essential to the entire process. Despite the support and resources provided as part of Call2Care participation, participants consistently described release and reentry as overwhelming due to the complexity of navigating society and adjusting to a changed world.

It is well established that transitions from prison to the community often disrupt continuity of care. This study illustrates how the context and the experience of being overwhelmed may take priority over seeking health care. Prison health care functions as a unique system that is largely isolated from the general, community-based health care system. During the transition from prison to community, individuals are faced with a new care team, different approaches to appointment scheduling and communicating with the health care team, health insurance, and logistical barriers that are often absent in the prison setting (e.g., securing your own transportation to health appointments). Many people who have experienced prison have limited experience with the community health care system before they were incarcerated. Evidence also suggests that a history of incarceration is associated with being less likely to access preventative care, screenings, and routine health care (Zhao et al., 2024). There has been limited, but growing, attention paid to supporting individuals reentering the community after release from prison to primary care services. Provision of Medicaid alone may be inadequate to support individuals releasing from prison in accessing the quantity and quality of care needed to address their health needs (Calais-Ferreira et al., 2022). Other strategies, such as varying levels of case management before and after release and utilizing patient navigators, individuals who help support individuals to accessing primary care, have been identified as successful strategies to support connection between patients and primary care clinics (Kinner et al., 2016; Shavit et al., 2017; Wohl et al., 2011). Together, this echoes calls for collaborative calls to engage in policy and practice changes which will address challenges experienced by incarcerated persons (Merss & Bowers, 2023). Researchers, community health care teams, community organizations, and policy makers should consider integrating existing strategies, such as securing Medicaid enrollment prior to release, as well as novel strategies, such integrating an NCM, into standard care for individuals releasing from prison. Additionally, special attention should be paid to high-risk populations, such as older adults. Prison systems could consider standardizing support with Medicare enrollment to all eligible individuals who are returning to the community after releasing from prison.

This study also found that receiving a cellphone at release, as well as training on how to use the cell phone, supported individuals’ release experiences by providing access to resources, both in the community, as well as supports for mental health and communicating with friends and family. Previous research has demonstrated that providing a written resource at the time of release, which included information on reentry tasks (e.g., housing and employment), health information, and community services, coupled with case management by phone supported individuals in accessing health services after release (Kinner et al., 2016). Through the Call2Care-provided cell phone, participants had access to much of the same information, but the cell phone extended access to information and resources beyond a fixed paper document. Previous literature has also identified that, specifically for incarcerated older adults, technology can be useful but challenging after release and reentry, and that older adults can struggle with the technology changes that occur in the community during their incarceration (Merss et al., 2025). Strategies to provide cell phones and support in using the cell phone should be investigated for all adults returning to the community.

Discharge planning, or preparing for transition from one setting to another, is widely studied in other health care settings such as hospital-to-home transitions. However, the same level of attention has not been paid to prison-to-home transitions, despite the fact that infectious diseases such as HIV and hepatitis C disproportionately affect prison populations compared to the community, in addition to a higher burden of other illness (Binswanger et al., 2009; Massoglia, 2008; Varan et al., 2014; Westergaard et al., 2013). Furthermore, insufficient treatment for these conditions while a person is in prison can contribute to a higher risk to the community after their release (Chandler et al., 2009; Springer et al., 2011; Stasi et al., 2020). Differences in prevalence and access to treatment for HIV, Hepatitis C, and substance use disorder have been identified by race (Bradley et al., 2020; Evans et al., 2017; Silverberg et al., 2009). These disparities, coupled with the racial disparities seen in prison contexts (Kaiksow et al., 2021) highlight the need for effective interventions which support individuals’ access to health care services after release from prison. This study found that discharge planning in the form of scheduling PCP appointments prior to release from prison was helpful to individuals and supports their access to PCP services. Future research investigating prison-to-community transitions should integrate individual characteristics and goals into the release preparation process, particularly addressing potential triggers or things that may contribute to reincarceration or relapse (e.g., homelessness, difficulty securing employment, challenging family dynamics). Prison systems and policy makers should identify resources that can be provided to support individuals who are returning to the community after prison, including peer support and clinical support that begins while still incarcerated and continues after release.

Additionally, this study found that it can be beneficial to provide resources and support (e.g., the NCM) for transition using staff who are not employed by the prison system. While participants acknowledged that prison staff can be supportive, it was overwhelmingly described how the NCM’s independence from the prison system fostered trust and willingness to engage with the NCM. Distrust of staff was identified in other studies as a barrier to accessing health care services in the incarcerated population (Buck et al., 2006). Future research should consider strategies to improve feelings of trust between incarcerated persons and corrections staff, including health care staff, as well as the role of non-corrections staff to support transitional care during release and reentry.

Limitations of this study include the small sample size of men and women who participated. Specifically, the shorter average length of incarceration for participants may not represent the experiences of persons who are incarcerated for multiple years or decades. As these experiences of release and reentry are likely unique, future research should emphasize people with longer experiences of incarceration. All participants were recruited from one state Department of Corrections and were incarcerated in minimum security facilities, so findings may not be transferrable to other security levels in other states. Future research should explore the unique characteristics of multiple prison security levels (e.g., maximum security). Additionally, we were unable to analyze comorbidities in this analysis. Comorbidities can increase the complexity of a person’s health and health care needs, and may play an important role in influencing someone to access primary care after release from prison. Future research should investigate the role of comorbidities in accessing primary care services after release, and strategies to support incarcerated persons with multiple comorbidities in accessing primary care services. This study also had a limited ability to analyze race-specific conditions influencing engagement with the NCM, release, and access to primary care after release. A more robust examination of race and the role of race in release and reentry experiences, particularly in accessing primary care, is warranted. Future research should investigate the experiences of historically marginalized racial groups’ during release and reentry, and how these experiences influence access to health care services after incarceration. Finally, all participants in this study had an existing health condition (HIV, hepatitis C, and/or substance use disorder), and so as a result generally had at least some level of interaction with the prison health care system while incarcerated, which may not be true for incarcerated persons not living with these conditions. Furthermore, these conditions often encouraged participants to engage in health care after release, and often had systems in place to support engagement in health care after release (e.g., unique care pathways for individuals living with HIV/AIDS). Future research should explore factors influencing access to primary care in broader populations, such as persons not impacted by a chronic condition.

In all, this study provides important insight into factors of a NCM in a men’s and women’s prison that are helpful to better support persons impacted by incarceration to accessing primary care after release from prison. This study highlighted how the impact of the NCM can extend well beyond the primary care access after incarceration by helping recently-released adults with navigating the community health care system, and general life outside of prison. The improved understanding of experiences of release and health system engagement is important to designing effective interventions to improve the health and wellbeing of justice-involved populations after they return to the community.