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Re-entry High Risk

Overview:
The Whole Person Care Reentry program aims to enroll 1,000 LA County jail inmates per month who are eligible for Medi-Cal, are high utilizers of health or behavioral health services, and are at high risk due to chronic medical conditions, mental illness, substance use disorders, homelessness, or pregnancy.  An additional 400 individuals per month recently released from custody will be enrolled from the community, via referrals from Probation, California Department of Corrections and Rehabilitation, and community-based reentry services agencies.

Pre-release:

Services provided (within the jail setting):

  • In-person meetings with identified inmates within the first 3 days in custody, to conduct a comprehensive psychosocial assessment and develop a re-entry care plan in collaboration with the participant;
  • Increased Medi-Cal enrollment efforts, with enrollment starting at jail intake for activation after release;
  • Referrals to Homeless Initiative programs, including the Supplemental Security Income (SSI) advocacy program;
    Provision of a discharge medical or behavioral health visit when feasible;
  • Provision of a 30-day supply of prescription medication at release for participants with chronic health or mental health conditions;
  • Generation of a Continuity of Care Document for transmittal to the participant’s health care provider in the community;
  • Establishment of a Whole Person Care release desk to arrange transportation, shelter or other services for those being released with little notice; and
  • An in-person or video-conference visit with the Community Health Worker (CHW) to be assigned to the participant in the community, where feasible, to facilitate a warm handoff upon release.

Post-release:

The WPC Reentry post-release program connects participants to Community Health Workers with a prior personal history of incarceration.  CHWs assist participants to effectively engage with community-based health, behavioral health, and social service providers as they return to the community. 

Services Provided:

  • Mentorship and social support;
  • Health and social service navigation;
  • Linkage to housing, employment, education, legal assistance and social supports;
  • Accompaniment to key health and behavioral health appointments;
  • Assistance with adherence to appointments, treatments and medications; and
  • Connection to transportation. 

Length of Service:
The average length of service for the Re-entry program is 3 months, with a subset of participants receiving 9 months of services.

Inclusion Criteria (for both programs):

  • Involvement with the justice system (pre-booking, probation, or incarceration) within the last 3 months; and
  • 1 Emergency Department visit in the past 6 months; or 1 hospital visit in the past 12 months; and
  • At least one of the following:
    • Chronic medical condition;
    • Serious mental illness;
    • Substance Use Disorder;
    • Homelessness; or
    • Pregnant