Re-Entry High Risk

header-title-decorationRe-Entry High Risk

The Whole Person Care Reentry program targets LA County jail inmates with anticipated release in 90 days who are eligible for Medi-Cal. They are also 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.  Individuals released from state prison or county jail within the last 180 days can be enrolled from the community, via referrals from Probation, California Department of Corrections and Rehabilitation, and community-based reentry services agencies.

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
  • Increased Medi-Cal enrollment efforts by starting at jail intakes 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
  • 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 handoff upon release

The WPC-LA Re-Entry Post-Release program connects participants to Community Health Workers (CHW) 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
  • 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 service.

Inclusion Criteria (for both programs):

  • Involvement with the justice system (pre-booking, probation, or incarceration) within the last 3 months; and
    • One 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
        • Pregnant

How to Refer: Call the WPC-LA Helpline (844) 804-5200