Yale Faculty Receive Grant Funding To Help Ensure Health Care for Incarcerated People Upon Release Into the Community

It’s estimated that at least 80% of incarcerated people have chronic health problems, including hypertension, HIV, hepatitis C, and mental health and substance use disorders. This population is overwhelmingly Black and Latinx and often lives in underserved areas of the state.

Chronic health problems tend to worsen, often severely, once individuals are released from prison. This is due in part to a lack of integrated health care delivery between the carceral health system and the community health system, as well as the extensive competing needs people face when returning to the community, said Lisa Puglisi, MD, associate professor of medicine (general medicine) and director of the Transitions Clinic-New Haven (TC-NH), a multidisciplinary clinic that is part of a national network of programs focused on care of those who are returning to the community from incarceration.

The current system represents a disconnect, with two entirely different systems of health care coverage inside and outside.

“The Connecticut Department of Correction (DOC) provides health care for people during incarceration, and we work closely with them to try to coordinate care transitions for people returning to New Haven, Bridgeport, and Hartford, where we have Transitions Clinics. We serve a fraction of the population returning to Connecticut communities each year. For most people, this transition is fraught with discontinuity with medications, therapy, and other care plans,” Puglisi said.

Puglisi and her team at the SEICHE Center for Health and Justice sought grant funding to create a central hub called TC-HUB to fix the gaps in the system. Over the past few months in 2024, they received $1 million from The Tow Foundation and The Connecticut Project to create an infrastructure that would make for a more seamless transition for people with chronic health issues leaving the prison system, including a nurse care coordinator and community health workers who have themselves been previously incarcerated.

The funding is especially timely, as it provides an opportunity to take advantage of the Centers for Medicare & Medicaid Services' recent 1115 Justice-Involved Demonstration Waiver to improve care transitions for people being released from carceral facilities.

“The TC-HUB aligns with our longstanding commitment to helping communities across Connecticut thrive,” said Emily Tow, president of The Tow Foundation. “By addressing the health care gaps faced by people reentering their communities after incarceration, we move closer to a more just and compassionate health care system.”

"Formerly incarcerated people are people, and every person should have access to the quality health care they need. The Transition Clinic’s peer-led model is a unique and critical program that makes our whole state better, and we are proud to support it,” said Mirellise Vazquez, vice president of investment for The Connecticut Project.

The funding will cover hiring and training a nurse care coordinator to coordinate community referrals; hiring community health workers with a history of incarceration to help people leaving incarceration navigate the health care system and address health-related social needs such as housing, food, and employment; and training existing health centers and medical providers on how to best care for this population.

“We have the unprecedented opportunity to improve care transitions for arguably the most high-risk people in the community, those who are transitioning from carceral spaces back to our communities,” Puglisi said. “It also presents a novel opportunity for innovation and improvement of population health and health equity on a large scale, given mass incarceration’s disproportionate impact on minoritized populations.”

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