From Incarceration to Community: Reintroducing the Importance of ECM in Reentry

Justice-involved individuals reentering the community often face serious challenges after release. Many are managing chronic health conditions, mental health needs, substance use disorders, unstable housing, limited employment opportunities, and difficulty trusting or navigating care systems.

The first days and weeks after release are especially critical. Without coordinated support, individuals may lose access to medications, miss follow-up care, struggle with transportation or housing, and experience worsening health outcomes. These gaps can increase the risk of emergency department visits, hospitalization, overdose, and reincarceration.

Enhanced Care Management, or ECM, helps address these challenges through a coordinated, person-centered approach. Under California’s CalAIM initiative, ECM supports Medi-Cal members with complex needs by connecting medical care, behavioral health services, housing support, benefits assistance, transportation, and community-based resources.

The Health Risks of Reentry

People who have experienced incarceration are more likely than the general population to live with serious health needs, including:

• Chronic conditions such as asthma, diabetes, and heart disease

• Infectious diseases such as hepatitis B, hepatitis C, and HIV

• Mental health conditions

• Substance use disorders

• Co-occurring behavioral health and physical health needs

Reentry is also a high-risk period. Studies show that people leaving incarceration are significantly more likely to die within the first two weeks after release compared to the general population. Overdose, suicide, heart disease, cancer, and violence are among the major risks during this time.

This makes early care coordination essential. Without a direct connection to community-based care, individuals may struggle to access medications, primary care, mental health treatment, substance use support, housing, and other stabilizing services.

Why ECM Matters for Justice-Involved Individuals

Under CalAIM, justice-involved individuals are recognized as a Population of Focus for ECM. Eligible individuals may include adults who were released from a correctional facility within the past 12 months or who are transitioning from incarceration and have qualifying health or social needs.

These needs may include:

• Serious mental illness

• Substance use disorder

• Chronic or significant health conditions

• Intellectual or developmental disability

• Traumatic brain injury

• HIV/AIDS

• Pregnancy or postpartum needs

Youth transitioning from youth correctional facilities may also be eligible.

ECM is especially important because many people leave incarceration without a clear connection to care. Medications may be discontinued, treatment plans may be interrupted, and individuals may not have appointments, transportation, housing, or active benefits in place. ECM helps close these gaps by coordinating care across medical, behavioral health, and social support systems.

How ECM Supports Reentry

Successful reentry requires more than a referral. It requires early planning, hands-on support, and continued follow-up. ECM can support justice-involved individuals through three key phases:

Pre-Release Assessment and Planning

Whenever possible, care coordination should begin before release. Care managers can assess immediate needs and help plan for:

• Identification documents

• Medi-Cal or benefits enrollment

• Medication continuity

• Transportation

• Housing referrals

• Follow-up medical and behavioral health appointments

Warm Handoffs

Warm handoffs help ensure individuals are directly connected to care after release. Instead of simply receiving a list of resources, individuals are connected to clinics, behavioral health providers, housing programs, social services, and community-based organizations.

This support is especially important during the first few days after release, when individuals are at greater risk of falling through the cracks.

Long-Term Navigation

Reentry is an ongoing process. ECM provides continued support through regular check-ins and care coordination. This may include help with:

• Chronic condition management

• Mental health treatment

• Substance use recovery

• Parole or probation requirements

• Employment goals

• Benefits renewal

• Stable housing

Practical Strategies That Improve Outcomes

Effective ECM programs for justice-involved individuals are built on trust, consistency, and community connection. Strategies that can improve outcomes include:

• Using peer support: Peer mentors with lived experience can build trust and help individuals feel understood.

• Starting early: Pre-release engagement creates continuity and reduces the chance of a disconnected transition.

• Meeting urgent needs first: Food, clothing, transportation, phones, medication, and housing support can help stabilize individuals immediately.

• Hiring community-based teams: Staff who understand local neighborhoods, cultures, and resources can better connect with members.

• Supporting technology access: Many individuals need help using smartphones, apps, benefits portals, and digital forms.

• Building strong partnerships: ECM is more effective when care teams coordinate with parole, probation, housing agencies, clinics, behavioral health providers, and employment programs.

• Using trauma-informed care: Many justice-involved individuals have experienced trauma. Care teams should lead with empathy, patience, and flexibility.

The Benefits of ECM During Reentry

When implemented effectively, ECM can help improve reentry outcomes by addressing the root causes of instability.

Key benefits include:

• Reduced recidivism: ECM can help address untreated mental health needs, substance use disorders, housing instability, unemployment, and lack of care access.

• Continuity of care: Individuals can maintain access to medications, treatment, and primary care after release.

• Improved health outcomes: Coordinated care can reduce preventable emergency department visits and hospitalizations.

• Holistic support: ECM connects individuals to food assistance, transportation, housing, employment services, benefits, and community resources.

• Greater long-term stability: Ongoing navigation helps individuals stay engaged in care and move toward independence.

A More Coordinated Path Forward

Justice-involved individuals are not defined by incarceration. They are parents, workers, neighbors, and community members rebuilding their lives. Many return home with complex needs, but the right support can help make reentry safer and more stable.

Enhanced Care Management offers a more coordinated and compassionate approach. By addressing medical care, behavioral health, housing, transportation, benefits, and social support together, ECM helps individuals navigate reentry with greater stability and dignity.

Improving reentry outcomes requires early engagement, warm handoffs, peer support, trauma-informed care, local partnerships, and long-term navigation. Through ECM, California has an opportunity to help justice-involved individuals move from fragmented systems toward coordinated care and healthier futures.