Improving Health Outcomes and Program Effectiveness for Justice-Involved Populations

March 31, 2025

A platform-based approach using data and analytics to drive measurable impact

People lose their Medicaid coverage when they are incarcerated. They have to reapply after release just as they are working to successfully transition back to community life. This population faces challenges such as housing instability, establishing employment, and management of complex conditions. The reapplication process and determination of eligibility can be burdensome, resulting in delays in accessing clinical care, medications, and support services. These impacts not only compromise members’ health outcomes but also contribute to higher healthcare costs and increased risks of recidivism.

For the state Medicaid agencies coordinating services for justice-involved individuals, leveraging analytics and insights can improve health outcomes while optimizing the cost of care and improving program effectiveness.

Justice-Involved Programs: Data and Analytics are Key

Most incarcerated individuals are eligible for Medicaid post release—and many have complicating health issues.

Justice-involved individuals are at disproportionately high risk for poor health outcomes. In addition to having chronic diseases, many report mental health concerns, and substance use disorders are common. For people leaving incarceration, these health concerns are in addition to pressing needs such as housing, employment, education, and transportation. Limited access to healthcare can worsen health and influence higher rates of recidivism. This is why justice-involved programs are essential to improving health outcomes while containing costs.

Data, analytics, and interconnectivity underpin effective justice-involved programs. This powerful trio is also critical to overcoming common barriers, which include identifying and enrolling individuals and enabling care managers, community-based-organizations, and others to provide the necessary help.

When creating a justice-involved program, a primary goal should be reducing costs without sacrificing quality. It is critical to co-develop a holistic vision with the broader community, build a common, secure data backbone, integrate closely with existing systems, and ensure that the platform can support the full justice-involved journey.

These best practices help to expand access for individuals transitioning from incarceration by supporting continuity of care, reducing coverage gaps, and supporting successful reintegration. At the same time, states have the data insights they need to reduce avoidable expenses, assess program effectiveness, and support value-based care models.

Addressing the Needs of Justice-Involved Individuals

CMS and States are Taking Action

Governments and states are increasingly taking proactive measures to support justice-involved populations. For example, Congress recently passed bipartisan legislation that includes several changes to Medicaid policy for justice-involved populations. These provisions include suspending rather than terminating Medicaid coverage during incarceration, using state grants to build operational capacity. Taken together, these changes could help improve incarceration transition and the overall health of justice-involved populations.

The Incarceration Transition Healthcare Journey

There are three primary phases to the incarceration transition healthcare journey — pre-release, transition, and post-release. A successful justice-involved program includes a highly targeted set of capabilities for each phase.

1. Pre-Release Phase

Identify and Enroll in/Activate Medicaid

To-be-released individuals are identified, and their Medicaid (and other program) eligibility is assessed. If eligible, they are enrolled (or activated if suspended). At time of incarceration, a determination is made about whether Medicaid enrollment should be suspended, based on Medicaid regulations.

Key Challenges

Securely accessing and integrating key datasets, such as correctional facility release schedule, eligibility and enrollment, and Medicaid information

Seamlessly enrolling/activating Medicaid and if it is not already in place, suspending Medicaid as appropriate upon incarceration

2. Transition Phase

Support People Through Their Transition

The first step of the transition phase is to assign a care manager or case manager to coordinate medical and supporting services for the transition. The care manager conducts a comprehensive assessment to identify members’ specific needs and determine the required care and services. Based on this assessment, the care manager develops a care and transition plan that covers events like discharge, post-discharge primary care visit, and other necessary medical or behavioral health appointments. Additionally, the care manager helps coordinate the facility discharge process, including ensuring prescription fulfillment and connecting members with essential support services.

To enable integrated care, states need a secure and connected data platform that allows care coordination and information sharing. This includes care planning information, analytics to assess service needs and coverage, and solutions to identify appropriate, cost-effective care and support options. A well-designed platform facilitates seamless collaboration among healthcare providers, community-based organizations, correctional facilities, and other key stakeholders involved in the transition process.

Key Challenges

Addressing workforce-related issues

Collaborating on care plans across multiple organizations

Finding providers and community-support organizations to support people post release due to a lack of closed-loop referrals

3. Post-Release Phase

Helping People Navigate the System

Navigating the healthcare system is hard, especially for post-release individuals who have challenges and adjustments to manage during and immediately after leaving incarceration. They can also have a higher prevalence of healthcare, behavioral health, and substance-abuse conditions.

To help people during this critical time, states need robust care management strategies. Whether through managed care organizations, health homes, contracted partners, or state-led initiatives, it’s essential to identify the appropriate providers and community-based organizations, coordinate scheduling, and ensure closed-loop referrals to deliver the required services.

Key Challenges

The post-release phase is unique, and the underlying platform can make or break the success of post-release care. The platform should support:

Collaborative development of individualized care plans

Identification and scheduling of appointments (with closed-loop referrals) with providers and community-based organizations

Secure access to relevant patient information to maximize the impact of care delivered

Beyond the platform and data, successful programs focus extensively on engaging stakeholders — such as correctional facilities, community-based organizations, state agencies, and providers — to ensure that the platform and overall program is tailored to the community’s needs.

Community Information Exchanges (CIEs) play an important role in post-release care, helping members connect with key services such as healthcare, behavioral health, housing, and social support. When looking for a partner in this area, find one that engages with leading CIE solutions providers. Together, they can develop integrated solutions that combine both core CIE services, such as service matching with foundational capabilities including data interoperability, longitudinal patient records, and collaborative care planning.

Justice-Involved Platform Components

A number of organizations have conducted research and developed best practices to inform justice-involved programs. The Commonwealth Fund developed a potential care model that, when enabled with an underlying platform, can support people after release.

The Fundamentals

Implementing a Justice-Involved Platform

This is a unique population with unique needs. While every state has nuanced issues to address, these fundamentals apply broadly.

Cast a Wide Net for Support:Successfully developing a justice-involved program requires support from many stakeholders across the healthcare and social support sectors. These programs engage a broad set of stakeholders in setting the vision, design, and deployment, then tightly integrating this engagement with platform design.

Set the Vision, Build Toward It: Setting a clear vision inspires people and provides direction to all organizations required to make the program successful. Implementing the full vision will take time. Effective implementation planning can demonstrate impact, achieve success, and sustain momentum for the broader program and vision.

Prepare for Sharing Data: Helping justice-involved members receive the necessary care and support requires reliable access to medical, behavioral, and community services. Accurately updating the members’ healthcare records and status ensures continuity of care. Doing this requires a secure, interoperable, broad, and readily accessible data layer to support multiple data types.

Expect a Ripple Effect of Change: Significant changes will be required to Medicaid and other state systems and process. It will be important to deeply integrate with or build upon existing systems and operational infrastructure to get the desired results.

Avoid False Tradeoffs:State leaders often think they must choose between innovation and experience – that they either must work with small technology companies that provide point solutions or large companies that work with states on large-scale implementations. This can be a false tradeoff. States have experienced significant success working with established partners that deliver integrated solutions including best-in-class point solutions that help states do more with less.

Gainwell offers the experience, capabilities, and understanding to support states in launching and scaling justice-involved health programs through Gainwell Whole Health^TM solutions.

To effectively support justice-involved individuals, states can collaborate with trusted, experienced partners on tailored solutions while strengthening data and analytics – ensuring better outcomes while maximizing resources.