The NCCHC Reentry Toolkit

Scalable Strategies for Successful Reentry Nationwide

Introduction

If you’ve seen one jail reentry program, you’ve seen one jail reentry program. Each facility operates within its own constraints, resources, staffing realities, and community landscape. Yet across jurisdictions, one truth remains constant: successful reentry does not happen by chance. Instead, it requires dedicated champions and program staff, intentional planning, strong partnerships, and a sustained commitment to making community reentry more manageable for those being released.

A Call for Persistence: The NCCHC Reentry Toolkit is designed to meet correctional leaders where they are. Whether you are building a program from the ground up or strengthening existing reentry activities, this toolkit translates evidence-informed practices into clear, actionable steps that can be adapted to your facility.

Our main takeaway is this: systemic change is needed to adequately serve all who are reentering the community. We encourage you to persist in making the impact, however small and incremental, that you have the power to make. Additionally, the greatest resources are our people, from incomparably dedicated staff to those reentering, who are so often sorely in need of support.

Toolkit Development

NCCHC convened a working group of four professionals working in jail reentry to develop this toolkit, with the objective of providing evidence-informed, accessible recommendations for jail administrators and staff seeking to implement or expand jail reentry programming.

Special recognition is due to the working group who graciously contributed their expertise and time to this publication: Alison O. Jordan, Matt Pate, Annie Ritsick, and Debra Scarlett.

• Alison O. Jordan, LCSW-SIFI, CCHP, is a partner at ACOJA Consulting LLC, represents the American Public Health Association (APHA) on the Board of the National Commission on Correctional Health Care, and serves as a mentor for APHA and NCCHC Foundation.
• Matt Pate, LMSW, CCHP-MH, is the Deputy Director of Detainee & Crisis Systems in Pima County, Arizona.
• Annie Ritsick, BS, CAS-AC, is the MAT Clinical Coordinator for PrimeCare Medical at Baltimore County Detention Center.
• Debra Scarlett, MS, CCHP, is the Vice President of Community Support Services for Centurion Health.

Claire Wolfe, MPH, MA, CCHP, Senior Program Manager for NCCHC Resources, Inc., the consulting arm of the National Commission on Correctional Health Care, supported this project by coordinating the working group and conceptualizing, drafting, and editing the publication. Julie Haugland, NCCHC Foundation Director, provided executive support. Kelli Hancock, PA-C, MPAS, provided editorial support.

Once a draft was completed, external reviewers from the NCCHC Foundation Reentry Committee provided feedback on the content and structure, which was incorporated into the final product. Augie Ghilarducci, MBA; Whitney Kraemer, LMHC, CCHP; and Marianne Clear, MSW, LICSW, CCHP-MH served as external reviewers. We appreciate their valuable input.

How to Use This Toolkit

Recognizing the demands on today’s correctional professionals, this toolkit is intentionally structured to be modular and easy to use. Key concepts are broken down into discrete steps, supported by tools and key takeaways. In practice, steps may overlap and be worked on concurrently. Previous steps may need to be revisited and deliverables edited as the team progresses in planning. This is not a one-size-fits-all model. Instead, it is a flexible, scalable guide designed to help jurisdictions start small, learn quickly, and build programs that are responsive to their unique populations and resources. The goal is not perfection, but progress.

Throughout this toolkit, you’ll see colored boxes. The blue boxes are excerpts taken directly from the full case studies which demonstrate how a certain facility is utilizing the concept being discussed. An example is provided below:

The case study from which the excerpt was taken is referenced for further review. The full case studies are included in the toolkit in an appendix at the end.

There are also green boxes which provide practical tips for putting a concept into practice. An example is provided below.

A useful framework to help conceptualize the advice in this document is the Plan-Do-Study-Act (PDSA) cycle. The framework consists of four steps:

The process is repeated, as needed, as part of continuous quality improvement and expansion efforts.

Foundational Concepts of Reentry

While reentry programs vary across the country, seven foundational concepts emerged while developing this publication:

1. Reentry is not a single point in time; rather, it’s a process during which staff identify an individual’s reentry needs, provide appropriate health care and mental health care during incarceration, and act to ensure continuity of care and access to services upon and following release.
2. Reentry programming must be intentional — separate from existing job responsibilities, sustainably funded, and integrated into operations.
3. Identify a champion for the program (i.e., a staff member with the interest and appropriate qualifications) to ensure that it is planned, implemented, and run effectively.
4. Start reentry programming with the population that makes sense (e.g., those with a history of opioid use, those with serious mental illness) based on funding, court mandates, disease prevalence in the facility, community resources, or other factors. Begin small and expand over time.
5. Integrate reentry screening and assessment policies and procedures to identify individual health, social, and/or criminogenic needs following an initial appearance in court.
6. Identify, cultivate, and maintain formal and informal partnerships with community-based organizations. Community-based partners are crucial to this work.
7. Maintain continuous communication and collaboration across disciplines with internal staff and leadership.

The Five Steps to Launch Your Program

Wondering where to start? The five simplified steps to launching your program are:

1. Define your goal and target population.
2. Build your Advisory and Implementation teams.
3. Conduct a gap analysis.
4. Design your program.
5. Implement: start small and scale.

Read on for more detailed guidance.

Build Your Program

Step 1: Identify baseline data to determine target population

Collect and/or review current data to better understand the recidivism and health picture of different populations and provide justification for the program goal. Baseline data may include metrics around cost, including jail booking costs, daily jail housing costs, court costs, and/or supervision costs for those who recidivate. While looking at these datapoints, it’s also important not to lose sight of the human costs of recidivism (e.g., loss of family connection/job, children being raised while their parents are detained). Demographic data may also be useful in determining the target population if an association between demographic characteristics, health and social needs, and recidivism risk is identified.

A solid baseline measure allows for comparison when evaluating program impact in the future. It is prudent to partner with an independent evaluator early in program planning. Be aware that data sharing agreements may be needed to facilitate this work.

Review your baseline data to determine the target population for the program. It may be necessary to begin with a pilot project that focuses on a specific population based on the funding source or disproportionate recidivism rates (e.g., those with a substance use disorder or other chronic conditions). Provide a justification for focusing on a particular population. It is important, while in the planning process, to be mindful of later expansion and what methods will be used to identify future program participants.

Step 2: Identify the overall goal of the program

Identifying a concrete goal for the program will help guide activities and allow stakeholders to measure success. A goal should be a broad, overarching statement detailing what the project will achieve and is aspirational in nature. For example, a reentry goal may be, “To ensure those in the target population leave custody with the resources, connections, and support needed to maintain their health and access ongoing care in the community.”

Many different objectives (explored in more detail in Step 5 below) will aid in working toward the program’s overall, aspirational goal.

Step 3: Establish your program team

• A program champion leads the program to ensure that it moves forward and is evaluated, improved, and sustained on an ongoing basis. This person, or their designee, is responsible for coordinating the entire program team. This may be a current employee who is moved into this role or a new hire.

An Advisory Committee is a group of executive-level leaders from organizations that interact with reentering individuals and who can make actionable, strategic decisions on behalf of their organizations. Key characteristics of the Advisory Committee include:

• The committee may be comprised of members who represent pretrial services, adult probation, public housing, local and state government (e.g., the health department), mayoral and county executive offices, social services, community nonprofits, local law enforcement, and local faith-based organizations.
• Strive to include formerly incarcerated individuals who have become leaders and role models in the community or those who have successfully navigated system gaps.
• Initial tasks for the committee may include:
  • Identify key data sets.
  • Implement necessary data sharing agreements.
  • Engage an independent evaluator.
  • Identify key performance indicators (KPIs) for each entity.
  • Determine the target population of the program.
  • Define recidivism for the purpose of program evaluation.
  • Develop a sustainability plan.
  • Develop a staff educational curriculum and framework for personal and professional support.
• The committee meets every 3–6 months to review progress and assist in troubleshooting system-level challenges. They should be kept aware of program health through a standardized monthly performance report distributed by the individual championing the program.

An Implementation Team is a group of ground-level staff from key stakeholders who can execute the program within their organizations. Include individuals who will be engaged at any point in the reentry continuum, including during arrest, court, incarceration, discharge, and after return to the community. One approach is to have those on the Advisory Committee appoint someone within their organization to the Implementation Team. Characteristics of the Implementation Team include:

• Team cohesion is essential amongst this group. The individual coordinating this group is responsible for promoting active communication, collaboration, and respect.
• Initial tasks for this team may include:
  • Conduct a literature review
  • Create a logic model
  • Develop a service delivery and intervention model
  • Identify relevant resources and map referral pathways
  • Develop a collaborative case planning process
  • Work directly with the evaluator to develop an evaluation plan
  • Determine baseline data points in collaboration with the Advisory Committee

This team meets as frequently as needed to develop the reentry program during the planning phase. Some members will only be needed for planning, while others will assist with implementation. When the program is in the planning stage, begin with a small group of passionate, dedicated, and knowledgeable individuals and expand involvement to additional individuals as planning and implementation progress.

Establish these groups thoughtfully to ensure inclusion of those who may be needed to garner buy-in among staff, community organizations and members, and incarcerated people. When done well, a reentry program is well-coordinated among trained corrections staff, the corrections transportation unit, and dedicated correctional health service team members (medical, mental health, and substance use disorder treatment). The ideal is for reentry staff to collaborate and coordinate with court health liaisons, legal services, parole and probation units, employment and housing services, and community reentry service programs. Information sharing sessions and community-wide collaboration will be needed for the implementation team to overcome challenges.

Step 4: Conduct a gap analysis

Once the goal is determined, a gap analysis is needed. A gap analysis is a strategic process used to compare an organization’s actual, current performance or state with its desired, future state. This process will help stakeholders understand what preexisting processes are in place that can be utilized to support the program and what improvements and associated resources are needed. The gap analysis tool in this publication is designed to help visualize and organize data (see the Gap Analysis Worksheet).

In summary:

• Review policies and procedures
• Interview staff and those in custody
• Map community resources
• Identify barriers to community health care and social services
• Analyze current workflows from intake to release (see the Member Journey Reentry Mapping Template)

Collect data to inform the gap analysis through:

• A review of policies and procedures that directly or indirectly impact reentry (e.g., receiving screening, initial health assessment, continuous quality improvement, health records, staffing, among others. See the 2026 NCCHC Standards for other relevant areas).
• Semi-structured interviews with staff working on the reentry continuum (e.g., police, court staff, jail staff, community health organizations, local and state government staff, community corrections). The general purpose of these interviews is to both start defining what success looks like and to determine the commitment level of major stakeholders.
• Semi-structured interviews with incarcerated individuals.
• A community asset map that identifies resources and strengths in the community with a set cadence for future review to ensure the information remains current.
• Review of historical continuous quality improvement measures that directly or indirectly impact reentry.
• Observations of processes that directly or indirectly impact reentry.
• Documenting barriers that reduce access to community resources. For example, do participants need identification (ID)? Are services covered by Medicaid? Then start determining how many of these requirements are going to negatively impact access to care. For example, many people entering jail do not have IDs, Social Security cards, and/or birth certificates. This is problematic when they leave because, without these, they often cannot access community care.
• Mapping of existing in-custody processes from jail booking to release to identify feasible intervention points.

Step 5: Identify the objectives of the program

Objectives describe the intended short- and medium-term impacts that will contribute to achieving the goal. They measure progress toward achieving the goal and must be thoughtfully developed to be useful. A useful objective should be Specific, Measurable, Attainable, Relevant, and Time-Bound (SMART) (Figure 1). Multiple objectives will be needed to achieve the goal in its entirety.

Reducing recidivism is a common objective for reentry programs. Using this as an example, start by clearly defining the concept. Determine if you will measure rearrest, reconviction, or reincarceration and whether technical violations or only new offenses will serve as inclusion criteria. Plan a uniform period of time for collecting recidivism data, typically up to 3 years and not under 1 year.

Using the SMART guidelines, an example objective for recidivism could be, “Among patients released from the facility on MAT, the rate of reincarceration for new offenses dropped from 80% to 50% in the first year after reentry.” This objective is specific (individuals released on MAT, reincarceration for new offenses), measurable (compliance rate drop from 80% to 50%), attainable (it was deemed unrealistic to expect a drop from 80% to 0%, but a drop from 80% to 50% was deemed realistic in this facility for this population), relevant (aligns with the program goal of helping individuals successfully reenter the community), and time-bound (the third quarter of 2027, in the first year).

While reducing recidivism and improving public safety are important in this work, it is equally important to consider the role that health, social, and related factors play in achieving such goals. By intervening to improve physical and mental health, reduce substance use, teach prosocial skills, help build a prosocial identity, and enhance prosocial recreation and leisure activities, targeted reentry programs with goals unrelated to recidivism can increase the likelihood that the proverbial revolving door stops. Recidivism is just one aspect of reintegration; it does not capture other aspects such as an individual’s well-being or the social complexities of reintegration. Consider health-related, continuity of care objectives, such as community health care appointment attendance, health insurance coverage status at time of release, or access to medications at release. Below is an example:

In this example, the objective is specific (among those in the target population, 2-week bridge dose of prescribed medications and/or prescriptions), measurable (compliance rate of 95%, a 2-week bridge dose), attainable (a 95% rate is attainable, while a 100% rate was deemed unattainable in all situations over an extended period of time), relevant (aligns with the facility and program’s overall goal of helping individuals reenter the community with the tools needed to maintain good health), and time-bound (between January 1, 2026 and March 31, 2026).

Step 6: Determine program design

Step 8 in this section includes information about creating an implementation plan, a document that outlines step-by-step tasks, timelines, assigned responsibility, and deliverables. Before creating an implementation plan, the following is required to determine program design:

• A literature review of evidence-based practices to understand the association between criminogenic risks and needs, programming, and recidivism. Your program should be based on existing evidence.
• Development of a robust logic model to lay out program design.
• An evaluation plan, based on the logic model, to assist in developing a structured process for evaluation and quality improvement efforts. Evaluation and associated performance measures are informed by goals and objectives.

Some changes can happen quickly and others will take time. This process should be conducted thoughtfully to ensure efforts are aligned with the goal and resources are used efficiently. Identify “easy wins,” cost savings within the system, and impacts across the jurisdiction, and begin with useful, manageable interventions that can be built upon. Evaluate and continually improve the program to build support among stakeholders.

If contracting for correctional health care services, ensure that reentry needs are included in the request for proposal (RFP). For example, consider adding terms for the provision of an appropriate supply of discharge medications that is aligned with the community’s ability to initiate care. If intakes to community providers take 2 weeks to schedule, then an adequate supply of medication and/or prescriptions is needed to ensure treatment adherence and reduce emergency room utilization. Other needs may include discharge planner positions and patient access to medications for opioid use disorder (MOUD).

Evidence-Based Programming

Programming that is offered should be based on previously evaluated methodology that has been demonstrated to bring a positive impact and help achieve the goals of the facility and partners. For example, if peer support professionals are part of the program, there may be a preferred length of time that the individual has not been incarcerated. Further, volunteers and other nonemployees may be subject to requirements. The Risk-Need-Responsivity Model may be used to develop interventions. The foundational principles of this model are (a) reduce recidivism by matching the intensity of services to an individual’s risk of committing future crimes; (b) target individual attributes that have been shown to be correlated with criminal behavior; (c) tailor cognitive-behavioral and social learning interventions to individuals’ personal attributes.

• Risk principle: Match the intensity of services and supervision to an individual’s risk of reoffending. Higher-risk individuals generally benefit from more intensive interventions, while low-risk individuals may be harmed by unnecessary intensive programming.
• Need principle: Target criminogenic needs, i.e., the dynamic factors that are associated with criminal behavior and that can be changed through intervention. Criminogenic needs include:
  • Antisocial attitudes and beliefs
  • Antisocial peers
  • Behavioral characteristics (e.g., problem solving, coping skills, anger management)
  • Criminal history
  • Family or marital status
  • Education/employment
  • Recreation and leisurely hobbies
  • Substance use
• Responsivity principle: Interventions are delivered based on an individual’s learning style, level of motivation, abilities, strengths, age, gender, and culture.

There are existing curricula/communication methods that target criminogenic thinking, decision making, and problem-solving skills that use evidence-based cognitive behavioral, substance use disorder recovery, and community reintegration approaches (see Table 1 for a list of examples).

Educate staff on the curriculum(s) that will be provided, the logistics of how behavioral programs work, and who will be involved and why. Take these steps to help staff understand that they are an important part of the program, advise on ways they may contribute to the program, and to address any concerns. Consider reciprocal education with member organizations of the Advisory Committee and Implementation Team.

Group or Individual Programming

It is often logistically more feasible to conduct group over one-on-one programming. When designing groups, it should be assumed that people may not start at the beginning of a group curriculum or finish the full course. A plan for mitigating these issues and maintaining fidelity to the chosen curriculum(s) is needed. Do not mix groups in different risk and classification levels.

Programming needs strong leadership — individuals who are engaging, knowledgeable on stages of change, and who possess high-quality relationship skills. Programming can be transformative and can humanize custody and correctional health staff when they are active participants within appropriate professional boundaries. Asking custody staff for their input in groups helps the detained population to see the people behind the badges. However, care must be taken to maintain appropriate professional boundaries, especially among young correctional staff.

Develop a Logic Model

A logic model is a tool that enables the program team to visualize the relationships between the resources for the program, the activities that are planned, and the changes the program is designed to achieve. A logic model template and sample logic model are included in this toolkit. While creating a logic model takes time on the front end of program development, the time and effort that goes into it benefits the organization on the backend because, when developed collaboratively, logic model development provides an opportunity to talk through assumptions, anticipate challenges, build a shared understanding of expectations for how the program will be run, and also helps to translate desired impact into evaluation questions.

The components of a logic model are illustrated in Figure 3. Note that outputs are related to what activities are conducted for the program and who it reaches. Outcomes, on the other hand, are related to the impact on the target population in the short- (within 1 year), medium- (between 1–3 years), and long-term (over 3 years).

Review logic models on a regular basis to understand whether objectives are being met and to identify unanticipated challenges in the implementation process.

Step 7: Take action early to garner buy-in

The implementation of a successful reentry program requires buy-in. Culture change may be needed in order to successfully implement a reentry program. This must come both from the top down and from the bottom up. Begin by asking staff, “What are the top three reasons for recidivism?” This will help to begin a conversation on the “why,” the goals, and the methods of the program. Similarly, leaders must act as stewards of culture change by modeling persistence and dedication to the goal.

There must be joint buy-in from custody, health, and staff from community organizations. Strategies to obtain support include:

• Early on, provide education on the curriculum, the benefits of reentry programming, and the important role that each staff member/entity plays. Programming, when done well, can improve the day-to-day experience of all. In pitching this programming to custody, it is worth mentioning that jails who have bought into this type of programming have seen ancillary benefits like reduced overdoses, reduced hospital send-outs, reduced suicides/attempts, fewer disruptions, and improved milieu.
• Engage in discussions about curriculum to determine the staff’s comfort level with the programming content. Forensic peer support has proven to be a successful intervention, but not all jail leadership is comfortable with this concept.
• Open communication, earnest listening, and feedback can help to foster an inclusive, rehabilitative culture. Leadership is ultimately responsible for ensuring that staff abide by reentry programming policies and procedures.
• Showcase reentry work. Ensure that positive results are disseminated through press releases and other communication channels. Engage with community stakeholders, including policymakers, community health providers and related organizations, and media to spread the word.
• Encourage discussion with peers to alleviate concerns and provide an opportunity to hear about successful programming in other jurisdictions.

Custody staff are agents of change and must be able to have a prosocial influence on the incarcerated to keep the facility safe and secure. Evidence-based programs can often be seen as “soft”; however, it has been demonstrated repeatedly that punishment does not rehabilitate the individual. This is why the facility needs to identify “ambassadors,” those who are invested in the program and can help to garner additional buy-in. For those who are apprehensive or defiant, consider facilitating a discussion with other jail leaders who have embraced this approach. Concerns might be mitigated by hearing about the experience of their peers.

Support Staff Wellness

This work is challenging and requires coordination and collaboration across disciplines and jurisdictions. Providing the above professional development and training opportunities can equip staff with the knowledge and skills to adequately serve this population and implement the reentry program as it is designed.

Address moral injury head on. Develop processes to monitor staff well-being and enable a timely, adequate response. This work requires strong boundaries to prevent burnout. Develop ways to assist staff with “turning off.” Strategies include:

• Education on burnout, compassion fatigue, and moral injury
• Opportunities to connect with other professionals doing similar work, for example, through NCCHC conferences
• Employer-provided mental health resources, such as an Employee Assistance Program (EAP)
• Flexible scheduling
• Structured mentorship
• A leadership culture that condones taking a sick day for mental health

Step 8: Create an implementation plan

The previous steps lay the foundation for implementation; however, they do not provide a roadmap to go from ideation to action. An implementation plan is the roadmap to action. An implementation plan includes concrete tasks that transform input from the advisory committee, work of the implementation team, program goals and objectives from the logic model, and the data from the gap analysis, into a functioning program.

An implementation plan may include the following components:

• Actionable tasks
• Responsible staff member(s)
• Timeline for task completion
• Resources needed for each task

Examples of tasks during this step include development of policies and procedures, creating a process and repository for data collection, and formalizing key community partnerships. For example, a staff member may be assigned to draft policies and procedures for screening and assessment for the reentry program, with the task due in one month and a team meeting scheduled at that point for collaborative discussion and finalization. In this example, resources needed may include Microsoft Word and Adobe PDF (if not previously available).

The implementation plan may include a pilot period during which the program can be refined before full implementation. Section 2 of this toolkit includes further guidance on implementation and important factors to consider. Once the implementation plan is finalized, the plan is executed and the program begins.

Step 9: Identify funding opportunities for program sustainability

A sustainability plan ensures that efforts, and therefore resources, are not wasted. A robust sustainability plan demonstrates how implementation, operations, and development will be continued if the initial funding stream is time-limited. There are several funding pathways for reentry programming, including foundation grants, state and federal health and justice funds, and local fund allocations. Each comes with its own advantages and challenges.

Grants are blocks of funding typically awarded through a competitive application process. They are time- and dollar-specific. Grant awards are usually made by state or federal governments or private foundations, which set overarching goals and reporting requirements. Grants are useful for funding innovative, proof-of-concept programming when well-aligned with the grant’s objectives and local priorities. Grant funding will likely require a minimum funding commitment from the applicant (also known as “matching funds”), along with in-kind contributions, or non-cash donations of goods, services, or resources, such as equipment, professional expertise, or free facility usage, to demonstrate buy-in and the likelihood of sustainability once the grant ends. Funders often require a sustainability plan be developed concurrently with program implementation. Local libraries are a resource for grant prospecting.

State and federal health and justice funds. Many people admitted to jails have Medicaid health insurance, which is suspended upon booking. However, there are opportunities to access Medicaid and other federal funds for reentry services. Consider the following: Is your state a Medicaid expansion state? Does your state have a Medicaid section 1115 waiver for reentry? Are your patients living with HIV? Does your jurisdiction have Health Resources & Services Administration (HRSA)-funded health centers? If so, your jurisdiction may be able to leverage health services funding to support continuity of care after incarceration. If not, consider reaching out to local elected officials or joining ongoing lobbying efforts for these and other supportive measures. For more information on 1115 waivers, visit www.medicaid.gov.

General Operating Fund allocations from your local or state government are the most sustainable source of dedicated reentry program funding.

It is best to consider a blended funding model with three or more identified funding sources. Blended funding models are more resilient as funding sources’ priorities change. With such funding, contracts with community-based service providers can help to ensure greater accountability and consistency.

The Reentry Spectrum: From Intake to Discharge

Step 1: Develop policies and procedures to screen for reentry needs

Targeted intervention, made possible through screening by a qualified health care professional or health-trained custody staff member, will enhance the effectiveness of services. “Reentry begins at intake” is a common saying. Standardized screening during the intake process is essential to gain a baseline understanding of the security level, physical health, mental health, and substance use history of all individuals booked into the facility. Screening results should alert the appropriate staff to conduct a more detailed assessment if appropriate. It is not necessary to rework any existing processes that are effective. Use existing tools and processes to identify individuals who meet your eligibility criteria. Examples include:

• Medical screening questionnaire: This includes assessment of existing or current physical health conditions, allergies, medications, recent illnesses or injuries, infectious diseases, and chronic care conditions, among other items.
• Mental health questionnaire: A standardized tool (e.g., Brief Jail Mental Health Screener [BJMHS]) is used to identify risks such as suicide ideations, mental health conditions, cognitive impairments, education level, and history of psychiatric treatment, among other items.
• Substance use questionnaire: This is used to screen for withdrawal and verify current prescriptions via urine drug screen, prescription drug monitoring programs (PDMP), or pharmacy confirmation. Standardized tools (e.g., Texas Christian University [TCU] Drug Screen 5; Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS] tool) document the individual’s history of substance use, including route of administration, frequency, and last use.

Classification: Using standardized tools (e.g., Level of Service Inventory-Revised [LSI-R], Ohio Risk Assessment System [ORAS]), individuals are classified after their security screening, medical screening, substance use screening, and criminal history review. Once classified, individuals will be housed according to their needs and risk level.

While the processes in place can be built upon, policies and procedures related to how this information will be used for the reentry program will need to be updated or developed. During the screening process, explain the reentry process/program and ask the individual to sign Release of Information forms related to continuity of services. These forms may include:

• Reentry program informed consent
• Release of information for the reentry program
• Additional releases of information (e.g., for public defender, community treatment providers, housing providers, adult probation, correctional health, pretrial services, family)
• Consent documents (as required by an Institutional Review Board [IRB] for conducting research)

Step 2: Develop policies and procedures for reentry assessment

Those individuals who may be eligible for the reentry program based on their screening should be referred for a more in-depth and holistic reentry assessment. Each facility should develop policies and procedures that clearly define this referral process and the transfer of pertinent information. While these processes may differ between facilities, they should remain consistent within each facility.

The aim of a reentry assessment is to examine various domains of health and well-being to better understand the whole individual and their unique reentry needs. The facility should decide which tool(s) to use based on their reentry program goals and objectives (see Section 1, Steps 2 and 5 above), the facility’s resources, and the resources available in the surrounding community. See Table 2 for a sample list of existing questionnaires that assess well-being.

Step 3: Prepare for planned and unplanned releases

The nature of jail is that many individuals stay for short periods of time and have unplanned releases. The reentry program must take this reality into account. Discharge planning staff should receive training on accessing court calendars and understanding the different court hearing types. Understanding when a jail release decision is likely to occur can be extremely beneficial to better care coordination and planning. Some courts livestream their proceedings, which can also be useful for discharge planners.

Strategies to address reentry planning in the event of unplanned releases include:

• Begin reentry assessment and planning after the individual’s initial appearance in court when there is a better understanding of the detainee’s anticipated length of stay.
• Train staff to treat each court date as a potential release date.
• Ask the individual if they are planning on posting bond.
• Post information about community-based services in the screening area.
• Coordinate with custody staff to provide a reentry resource guide upon discharge from the facility.

For short-term, pretrial detainees, assessments and discharge planning may need to occur in one sitting. Under these circumstances, the goal of reentry planning will be to gain an understanding of urgent needs and current health status to provide information on community resources and to make referrals to appropriate people and agencies in the community.

Those with planned releases should be prioritized for job readiness programming like resume building, identifying employers who are hiring, and assisting with connection to community employment programs. Soft skills training, including practicing interviews, telling their story, and how and when to share their incarceration history, is essential. Local workforce development boards (WDBs) may be available to partner with the jail on reentry and job training. (See the Partnership Tracking Spreadsheet.)

Planned releases require:

• In-custody engagement
• Incarcerated individual buy-in
• Collaboration with the incarcerated individual to develop a reentry plan
• Collaboration with the individual’s defense attorney and communication of the reentry plan with the courts and prosecution
• If placed on supervised release, coordination to ensure the reentry plan aligns with their judicial requirements
• Transportation from jail to treatment/housing, as applicable

Family reintegration is not typical upon jail release, especially if there is a domestic violence situation or when there is an active custody case. However, family reunification is often a stated goal and can form the basis of discharge planning. It is best to not characterize decisions as “good” or “bad” but rather as “helpful” or “unhelpful” toward family reunification if that has been a stated goal.

Consistency is key. Programming for results demands consistency. In order to develop rapport with program participants, a consistent approach is needed. After you have identified your target population or housing unit, meet with the custody staff managing the population or housing unit to talk logistics and scheduling so that programming won’t conflict with other operations, and develop an engagement strategy with your target population or housing unit.

Step 4: Approach discharge planning as a critical, collaborative process

Discharge planning facilitates community reintegration by connecting patients who have social and health needs to appropriate community-based services. It also provides medications and prescriptions in adequate supply to give the patient enough time to engage in follow-up care in the community.

Medical discharge planning for incarcerated individuals is complex. Competing compelling priorities external to medical needs must also be addressed and mitigated in order to develop a realistic and achievable post-release plan. Discharge planning must consider:

• Legal system requirements (e.g., location of housing, parole/probation requirements)
• Health insurance/Medicaid status
• Chronic care management
• Acute care management and related emergency department limitations
• Medication management
• Nursing home eligibility and barriers
• Substance use disorder treatment continuity
• Veterans Affairs (VA) domiciliary and nursing homes can be helpful for those with military service

Discharge planning out of jails is one of the most challenging transfer-of-care environments in all of health care. In most settings, a change in health care needs or improved symptom management prompts discharge; this is not the case in jails, where judicial decisions trump traditional health care discharge logic. This reality forces jail-based discharge planners to be proactive and targeted (see the Discharge Planning Worksheet and the Discharge Plan Development Tool). The ultimate goal of discharge planning is adherence to pre-aligned community treatment.

Components of a Discharge Plan

Discharge planning supports a patient’s health and social needs to help them reintegrate confidently into the community.

Discharge planning is documented in the health record and may include:

• A current community resource guide.
• Assistance with health insurance application or Medicaid enrollment/re-enrollment. People booked into jail have a range of insurance designations, including private coverage, suspended Medicaid coverage, expired coverage, or no insurance. Understanding who is the responsible payor for community treatment will help guide your discharge planning decisions. If a significant portion of your detained population does not have community-based insurance, consider adding corrections assistors to your discharge planning process.
• Leverage pharmacy benefit cards and bridge medications to fill insurance gaps.
• Connect individuals with benefits counselors in the community.
• A warm handoff to community-based providers for health care and substance use treatment (ensure that medications for opioid use disorder are provided by community-based organizations so the patient does not undergo undesired withdrawal). (See the Partnership Tracking Spreadsheet.)
• Patient education on appropriate follow-up and aftercare.
• A warm handoff to social service agencies and nonprofits that address social determinants of health.
• An adequate supply of medications and prescriptions, as indicated, to ensure continuity until the patient is able to engage with a community-based provider.
• An appointment with a community-based provider (coordination with probation to remind the patient of their appointment can help reduce missed appointments).
• Copies of correctional medical records and contact information for obtaining additional copies.
• Transportation assistance (if available).
• Help obtaining identification documents (i.e., birth certificate, social security card, state ID).
• Social safety net applications (i.e., TANF, SNAP, WIC).

Partnerships

When developing discharge planning policies and procedures, staff must be familiar with the communities to which patients typically return, the availability and accessibility of community-based services, and applicable state and federal resources. Strategies for cultivating relationships with community partners include:

• Determine who will be responsible for the care of the population leaving jail. Many released from jail are on some form of pretrial supervision or are placed on probation. Talk to these professionals and determine if there are ways for jail release planners to support their efforts.
• Utilize your Advisory Committee and Implementation Team to develop a data use agreement for jail-based discharge planning. A data exchange can help facilitate better coordination of care when people enter or exit the jail.
• Develop accountability measures for partners. Accountability will help your community determine who the “preferred providers” of care are for those leaving jail. It is better to have one dedicated provider than a patchwork of providers who are not truly committed to this population.
• Develop clear expectations. For agencies the facility will work with on a regular basis, a formal memorandum of understanding (MOU) may be needed to align expectations and ensure continuity in the event of personnel and leadership changes.

Evaluation

Meaningful data collection and evaluation methodologies are essential to assess the impact of reentry programming. Partnering with a university or other research-oriented organization is a good way to embed the evaluation process into the program from the start and ensure that methods are sound. Any staff or partners who are handling personally identifiable information should be trained on confidentiality and compliance with HIPAA and 42 CFR Part 2, which imposes restrictions on the use and disclosure of personal information.

Evaluation Plan

Evaluation and quality improvement efforts should work in tandem and be managed by the same individual or team. The evaluation plan should detail how the reach and impact of the program is going to be measured (see the Evaluation Plan Template).

The logic model created earlier is a starting point for evaluation. As part of that process, intended outputs (i.e., the activities and participants) and outcomes were documented. The evaluation process will help the team determine if the intended outputs and outcomes are achieved. The “Outputs” and “Outcomes” on the logic model will inform the development of performance metrics (i.e., process and outcome measures, respectively). While measuring outputs is useful in quantifying activities conducted and participants reached, measuring outcomes is the best way to demonstrate the value of a program.

Use the columns “Participants,” “Initial impact,” and “Intermediate impact” to develop performance measures. Each listed participant to be reached, short-term impact, and medium-term impact should have one or more associated performance measure(s), either process or outcome. Performance measures should be created in a SMART format (see Figure 1). If there is no supporting baseline data, begin generally (e.g., reduce, increase) and refine performance measures as more data is collected.

When developing performance measures, be sure to answer the following questions:

• Why? Include an evidence-based rationale.
• What? Include a detailed explanation of the data element.
• Who? Indicate inclusion and exclusion criteria based on the intent of the performance measure.
• Where? Indicate where the data will be collected. Examples include electronic health records, medication administration records, Prescription Drug Monitoring Programs (PDMPs), interviews, and surveys.
• When? Determine the frequency at which audits will occur.

In order for data to be consistent across audits, the evaluation team must detail definitions, data sources, and any analysis conducted.

Reporting

Evaluation is not only important for understanding the program’s impact on the target population but also for demonstrating that impact to stakeholders, including staff, community partners, government officials, and outside funders. In other words, evaluation is an opportunity for learning, improving, and storytelling. Be sure that your evaluation results are appropriately communicated internally and externally.

Develop a reporting template to be used on an ongoing basis, with a specific reporting cadence that aligns with audits (e.g., monthly) and relevant meetings. Results may be reported in various forms depending on the audience and purpose. Case studies and qualitative results can be powerful and effective. Descriptive statistics allow for presentation of a larger sample and insights into variables of interest. There may be inherent limitations in the data, and it’s important to be transparent about them when reporting.

Continuous Quality Improvement

During the evaluation process, if specific performance measures do not meet internal thresholds, brainstorm to understand why this may be and determine what changes can be made that may improve future performance. For example, if the evaluation results suggest that discharge planners are frequently unable to make appointments with a specific community partner, corrective action may include formalizing the partnership with an MOU or making other efforts to strengthen the partnership. Once the change is implemented, the performance measure is restudied to see if improvement has been made.

Appendix A: Additional Reentry Resources

• National Reentry Resource Center — Operated with support from the Bureau of Justice Assistance, it provides information, tools, training, and guidance on reentry and Second Chance Act implementation.
• Bureau of Justice Assistance (BJA) — Publishes webinars, toolkits, and resources, including guidance on the Section 5121 Medicaid and CHIP requirements for jails and prisons.
• Office of Justice Programs (OJP) — Hosts research, program models, and information on Second Chance Act grantees providing transition services for people leaving jails and prisons.
• Health and Reentry Project (HARP) — Provides policy analysis, helping governments implement policies to drive collective progress.
• Crime and Justice Institute (CJI) — Produces toolkits, reentry directories, and policy reports for corrections practitioners, policymakers, and service providers.
• SAMHSA Reentry Resources — Behavioral health treatment locators and resources for substance use and mental health continuity post-release.
• Ryan White HIV/AIDS Program — Supports continuity of HIV care for people leaving incarceration.

Appendix B: Case Studies

Armstrong County, Pennsylvania

Medium-sized, rural jail · capacity ~150

Jail leadership developed an early medications for opioid use disorder (MOUD) program, having identified opioid use as a prevalent health issue in the facility. With state grant funding, an on-site drug and alcohol counselor, collaboration with local faith-based organizations and neighboring counties, and a partnership for program evaluation with a local university, facility leadership aimed to continuously improve substance use treatment and provide warm handoffs upon release.

Informed by her extensive correctional experience, the warden initiated a dog training program, solely for those who qualify for the facility’s work-release program, in collaboration with a local animal shelter. Other programming includes art classes provided via in-reach by local community partners. Tablets are also provided for individuals to engage in educational opportunities and reentry planning.

Lessons Learned

• Leadership support is crucial and culture change may be needed. The warden serves as a key champion for all reentry-related efforts, with consistent visibility including regular walkthroughs and direct engagement with incarcerated individuals and staff. When implementing the dog-training program, policies were specifically designed to minimize additional responsibilities for staff.
• Reentry coordination and community health care partnerships must be strong. A reentry coordinator developed strong relationships with local physicians and treatment providers to ensure individuals could continue MOUD after release. The facility also collaborates with neighboring county jails to share information and best practices.
• Programming should be reflective of facility and community strengths. What works in one facility may not work in another. Programs such as dog training and art classes help create constructive outlets and improve relationships between staff and those in custody.
• Community partnerships expand capacity. Due to the rural location, faith-based groups and volunteers fill transportation gaps upon release, and local businesses have donated toward the dog training program. Public events, such as art shows in the jail lobby, have built public awareness and support.
• Persistence is necessary. Securing approvals from oversight bodies, county-level stakeholders, and probation/parole partners required sustained advocacy over several years.

Charleston County, South Carolina

Large, urban detention center in North Charleston · capacity 2,000+

The reentry program begins with screening and assessment using a risk-needs assessment module accessed through the jail management system. Those identified as medium and high risk are targeted for programming during their stay, and dedicated reentry staff work to connect those individuals with community-based organizations prior to release.

Lessons Learned

• Leadership buy-in is essential. Strong support from the Sheriff’s Office was critical to launching and expanding the program, aligning operational policies with reentry and securing funding and staff buy-in.
• Reentry staff must be embedded in operations. Successful implementation requires reentry staff to integrate with daily jail operations rather than function as a separate program. Offering professional development that incorporates reentry concepts (trauma-informed communication, motivational interviewing, de-escalation) strengthens buy-in among nonprogrammatic staff.
• Hire the right people. Staff with experience in behavioral health, case management, and corrections are key. Staff diversity in languages, cultural background, and lived experiences helps build effective relationships with clients.
• Shorter, modular programming works best in jails. Shorter, flexible curricula are better suited to the large pre-sentenced population and unpredictable releases. Tablets are useful for educational and reentry planning resources individuals can use in their own time.
• Funding shapes strategy. Programs must adapt to available funding streams while maintaining focus on broader reentry needs.
• Regional collaboration is critical. Working with neighboring counties strengthens referral networks and expands service capacity.

Clark County Detention Center (CCDC)

Large, urban jail in Las Vegas, Nevada · capacity ~4,100

Individuals returning to the community face significant barriers, including difficulty securing employment, stable housing, health care, and rebuilding family relationships. CCDC provides a range of reentry and transition-of-care services aimed at reducing recidivism and supporting successful reintegration, including warm handoffs, embedded support from the local social service agency, and resource fairs for sentenced individuals within 90 days of release.

Lessons Learned

• Identifying a target population helps to focus resources. Programming is focused on those with substance use and mental health disorders, taught by community partners who volunteer their time.
• Start with dedicated champions. The program is a result of early championship by a now-retired corrections officer whose advocacy was critical to development and sustainability.
• Leverage community partnerships for clinical and nonclinical services. A resource fair connects those releasing within 90 days to Medicaid and SNAP enrollment, DMV identification, harm reduction tools, and employment resources.
• Address core needs prior to release. Post-release support includes free bus passes, documentation of incarceration, and basic needs supplies (food, water, hygiene products) in a backpack.
• Promote a rehabilitative culture. Viewing incarceration as a chance for change, and treating those in custody with an open mind, is key to how staff approach reentry.
• Persistence is necessary. Flexibility and creativity in where and how programming is offered has helped overcome space, technology, and funding constraints.

Pima County Adult Detention Complex (PCADC)

Large, urban jail in Tucson, Arizona · capacity ~2,000

PCADC operates a comprehensive, health care-driven reentry program through the Detainee and Crisis Systems Department in partnership with the health services vendor. Reentry staff prioritize individuals with complex medical, mental health, and substance use needs. The facility also runs INVEST, which targets individuals with co-occurring substance use and mental health conditions identified as high criminogenic risk, offering individualized assessments, case management, court-system navigation, benefits enrollment, and coordinated transitions to community care through “hot handoffs.”

Lessons Learned

• Strong partnerships are foundational. Early in program design, engage community providers to set expectations and procedures for handoffs.
• Facility staff buy-in and support is critical. Take time to understand misgivings around reentry, and find and embrace those who believe in and support this work as messengers.
• Pre-release planning drives success. Addressing systems-level barriers — identification, insurance activation, appointment scheduling — prior to release improves engagement in community-based services.
• Flexibility is critical within structured systems. Standardized processes support efficiency, but programs must remain adaptable to the varied, complex needs of individuals.
• System limitations must be anticipated. Housing shortages, inaccessible treatment, and economic constraints are persistent; start small and expand thoughtfully.
• Data and evaluation strengthen impact. INVEST partnered with a third-party evaluator using a randomized controlled trial for an independent perspective and consistent methodology.
• Leadership and champions matter. Dedicated leadership and cross-system collaboration are key to sustaining initiatives.
• Reentry success is complex and nonlinear. Effective programs define success in nuanced ways beyond traditional metrics.

Santa Fe County Adult Correctional Facility

Large, mixed-setting jail in Santa Fe, New Mexico · capacity ~600

Reentry is approached as a continuous process that begins at intake and extends through release. Despite short lengths of stay and unpredictable release timelines, the facility has developed a proactive, relationship-driven model focused on individualized planning, strong community partnerships, and hands-on support.

Lessons Learned

• Make reentry a core, resourced function informed by local context. Reentry staff positions were established in 2019 and maintained via direct county employment. Dedicated staff coordinate appointments and transportation, going beyond passive referral.
• Effective reentry work begins early in incarceration. The short average length of stay (12 days) is met with a program focused on continuous engagement, including individualized planning initiated early, in-house behavioral health services, Medicaid verification and re-enrollment, appointment coordination, and transportation assistance.
• Reentry coordination and community health care partnerships must be strong. Quarterly reentry fairs bring community providers into the facility, and a key partnership with a local health and social services organization provides access to medical, mental health, substance use, psychiatric, and dental care after release.

PSIMED, Inc., West Virginia

Integrated statewide system, in collaboration with the mental health services vendor

Jails and prisons in the integrated West Virginia system have implemented reentry programming focused on those with acute behavioral health needs, heavily involving discharge planning and community partnerships. Leadership and staff have worked to integrate reentry as a core component of operations.

Lessons Learned

• Make reentry a core, resourced function informed by local context. Reentry must be intentional and supported by dedicated staff integrated into daily operations — for example, dedicated reentry positions included in the vendor contract.
• Strong leadership and culture are drivers of success. Ongoing support and mentorship from leaders helps maintain staff well-being. Personal relationships, transparency, and a culture of continuous quality improvement are key; when a process fails, an openness to explore “why?” has been instrumental.
• Collaboration and communication are foundational. Early partner engagement and formal planning — with transparent information sharing and a formalized communication structure — was foundational. Consolidated resource systems include county-level family resource network guides, reentry workbooks for individuals in custody, and shared “reentry drives” accessible to justice system stakeholders.
• Use technology and collect data to support reentry. A reentry questionnaire embedded in the electronic health record helps identify individual needs early, and tablets provide self-directed reentry planning resources.
• Plan for time, persistence, and continuous improvement. Building reentry infrastructure takes time; ongoing evaluation, flexibility, and quality improvement processes are necessary for long-term success.