{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T23:51:18Z","timestamp":1788911478193,"version":"build-2803163510"},"reference-count":49,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2023,5,12]],"date-time":"2023-05-12T00:00:00Z","timestamp":1683849600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["IJERPH"],"abstract":"<jats:p>People released from prison experience high health needs and face barriers to health care in the community. During the COVID-19 pandemic, people released early from California state prisons to under-resourced communities. Historically, there has been minimal care coordination between prisons and community primary care. The Transitions Clinic Network (TCN), a community-based non-profit organization, supports a network of California primary care clinics in adopting an evidence-based model of care for returning community members. In 2020, TCN linked the California Department of Corrections and Rehabilitation (CDCR) and 21 TCN-affiliated clinics to create the Reentry Health Care Hub, supporting patient linkages to care post-release. From April 2020\u2013August 2022, the Hub received 8420 referrals from CDCR to facilitate linkages to clinics offering medical, behavioral health, and substance use disorder services, as well as community health workers with histories of incarceration. This program description identifies care continuity components critical for reentry, including data sharing between carceral and community health systems, time and patient access for pre-release care planning, and investments in primary care resources. This collaboration is a model for other states, especially after the Medicaid Reentry Act and amid initiatives to improve care continuity for returning community members, like California\u2018s Medicaid waiver (CalAIM).<\/jats:p>","DOI":"10.3390\/ijerph20105806","type":"journal-article","created":{"date-parts":[[2023,5,12]],"date-time":"2023-05-12T09:56:18Z","timestamp":1683885378000},"page":"5806","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":9,"title":["The Reentry Health Care Hub: Creating a California-Based Referral System to Link Chronically Ill People Leaving Prison to Primary Care"],"prefix":"10.3390","volume":"20","author":[{"given":"Bethany","family":"Divakaran","sequence":"first","affiliation":[{"name":"San Francisco Public Health Foundation Project, Transitions Clinic Network, San Francisco, CA 94102, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Natania","family":"Bloch","sequence":"additional","affiliation":[{"name":"San Francisco Public Health Foundation Project, Transitions Clinic Network, San Francisco, CA 94102, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahima","family":"Sinha","sequence":"additional","affiliation":[{"name":"School of Public Health, University of California-Berkeley, Berkeley, CA 94704, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anna","family":"Steiner","sequence":"additional","affiliation":[{"name":"San Francisco Public Health Foundation Project, Transitions Clinic Network, San Francisco, CA 94102, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shira","family":"Shavit","sequence":"additional","affiliation":[{"name":"San Francisco Public Health Foundation Project, Transitions Clinic Network, San Francisco, CA 94102, USA"},{"name":"School of Community Family Medicine, University of California-San Francisco, San Francisco, CA 94103, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,5,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"912","DOI":"10.1136\/jech.2009.090662","article-title":"Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population","volume":"63","author":"Binswanger","year":"2009","journal-title":"J. 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