The NYC Health Justice Network: Supporting Health and Reentry Success
By Aimee McPhail, Research Associate, and Pavithra Nagarajan, Senior Research Associate
The New York City Health Justice Network (NYC HJN) is supporting people returning home from incarceration by pairing them with Community Health Workers (CHWs). CHWs link them to trauma-informed primary care and integrated health services to address their health and other needs as they reenter local communities.
In New York City, thousands of people return home from incarceration each year.[1] People who have been incarcerated often have complex needs across several domains—including education, employment, and housing—which can undermine successful reentry into the community.[2] These individuals also often have significant health needs that require accessing primary care, obtaining medication, and receiving mental or behavioral health care. The experience of incarceration itself can create new or exacerbate existing needs due to the stress stemming from a loss of freedom and removal from one’s family and community. Even further, people reentering the community encounter the collateral consequences of incarceration (e.g., stigmatization and restrictions with regard to housing and employment) that can interfere with their ability to meet their basic needs. [3]
Having supports in place to guide and ease folks with their reentry back into the community can make all the difference in whether they’re able to safely reintegrate and get on the path to success. The reentry process can be overwhelming, and individuals are often focused on needs related to housing and employment, leaving health needs potentially unaddressed. To address key gaps in the city’s reentry landscape, the Manhattan District Attorney’s Office (DANY) funded the NYC Department of Health and Mental Hygiene[4] launch and operate the Health Justice Network (NYC HJN) in Northern Manhattan. Funded through the Criminal Justice Investment Initiative (CJII), a partnership between DANY and CUNY ISLG, the NYC HJN embeds community health workers (CHWs) in primary care and community-based organization (CBO) sites to connect previously incarcerated individuals to health care services (e.g., primary care, dental care, substance abuse treatment). CHWs also connect participants to other wraparound services (i.e., employment and housing services) to ensure that other, vital needs are being met. Individuals are eligible for the HJN if they are 18 years of age or older and have been released within 3 years of enrollment. From March 2019 through August 2023, NYC HJN supported 1,188 people recently released from incarceration—more than half of whom enrolled in the program within three months of being released.
Through CJII funding, NYU-CUNY Prevention Research Center (PRC) conducted an interim evaluation report on the program. The findings highlight the spectrum of service needs indicated by NYC HJN clients and the role of CHWs in helping these individuals navigate the reentry process, address critical needs, and avoid future criminal legal system involvement.
NYC HJN Uses a Multi-pronged Outreach and Recruitment Strategy
HJN recruits potential participants via three-pronged strategy. First, it embeds CHWs in six primary care/CBO sites to conduct outreach and identify potential clients with unaddressed healthcare and reentry support needs who could benefit from help navigating these systems. Second, NYC HJN partners with CBOs that have an established presence on Rikers Island and state prisons, and these CBOs share NYC HJN recruitment materials (e.g., flyers, brochures) with eligible, potential clients interested in receiving services upon their release. Finally, CHWs raise awareness of NYC HJN’s program offerings by developing referral relationships with CBOs and halfway houses, liaising with community leaders and local merchants, as well as participating in community-wide events to recruit potential clients who have recently been released. Once eligible clients are identified, their information is reviewed and, if accepted, they are assigned to a CHW at one of the six sites depending on their most immediate needs (including whether they are health-related, or not), client preferences, and CHW caseload. For example, if a client indicates several healthcare-related needs, they are assigned a CHW embedded at a primary care site.
Community Health Workers Help Clients Navigate the Reentry Process
NYC HJN’s CHWs have prior criminal legal system involvement and, therefore, have lived experience in common with potential clients. This shared experience is paramount to CHWs’ ability to build and maintain trust with their clients and fully support them through the reentry process. CHWs take a strengths-based approach to working with their clients. CHWs receive training on social reliance,[5] trauma-informed care,[6] and the value of having and using shared language (i.e., healthcare and criminal legal system terms) to ensure clients feel supported by others who are familiar with the challenges of reentering after incarceration and the various needs one may have when doing so.
CHWs receive training on social reliance, trauma-informed care, and the value of having and using shared language (i.e., healthcare and criminal legal system terms) to ensure clients feel supported by others who are familiar with the challenges of reentering after incarceration and the various needs one may have when doing so.
The NYC HJN program includes practices to engage with and retain clients in health and reentry support services to ensure quality, effective coordinated care and treatment. Once a client is assigned a CHW, the CHW and client work together to determine which health and reentry support needs to prioritize in order to create an individualized care plan. Based on this plan, each CHW coordinates referrals to services to meet the needs and priorities identified by the client, which include but are not limited to assistance with employment and housing as well as connections to primary care and other healthcare services. CHWs support clients by showing them how to make appointments, even assisting them with scheduling such that clients are able to receive care earlier; accompanying them to appointments when needed; conducting home visits; and by making ongoing, frequent contact. The integration of CHWs at each of the program sites establishes linkages between primary care clinics and CBOs—creating a more efficient and streamlined process for clients in navigating services.
NYC HJN Clients Present with Many Needs
Two thirds of the clients who enrolled in NYC HJN as part of PRC’s study were between the ages of 36 and 61 (62 percent). Nearly all were male (92.7 percent), and most identified as Black (52.1 percent) or Latine (27.3 percent), broadly reflecting the New York State incarcerated population.[7] Upon enrolling, nearly half of clients had only a high school diploma or equivalent or less (39.4 percent), and the vast majority were unemployed (80.3 percent). One-third were staying in transitional homes (17.1 percent) or halfway houses (15.7 percent).
Program clients reported healthcare-related and non-healthcare-related needs. Examples of healthcare needs included primary care, dental care, health promotion/education (e.g., engaging with care providers, educating clients about health risks, navigation to health insurance enrollment), and mental health or emotional support. Regarding non-healthcare services, clients reported needs related to employment, obtaining vital documents, peer support, and housing support.
About the Program and Evaluation
NYC HJN continues to provide individuals returning from incarceration with the necessary supports and services to ensure the process of reentering the community is made less challenging.
This blog accompanies NYU-CUNY PRC’s interim evaluation report of NYC HJN, drawing from descriptive findings. PRC is currently concluding its additional data collection for the outcome evaluation of the program, which will be shared in 2024 in a final report and which will focus on the NYC HJN’s impact on clients’ recidivism outcomes (i.e., arrest, case disposition, conviction, and reincarceration).
About the Criminal Justice Investment Initiative
The Manhattan District Attorney’s Criminal Justice Investment Initiative (CJII) focuses on three investment areas—crime prevention, diversion and reentry, and supports for survivors of crime. HJN is part of the CJII’s investments in diversion and reentry.
The CUNY Institute for State and Local Governance manages and provides technical assistance to CJII contractors, and conducts oversight and performance measurement throughout the lifetime of the initiative.
[1] NYC Open Data. Inmate Discharges. Updated June 1, 2023. Accessed June 2, 2023. https://data.cityofnewyork.us/Public-Safety/Inmate-Discharges/94ri-3ium.
[2] Phillips, L. A., & Spencer, W. M. (2013). The challenges of reentry from prison to society. Journal of Current Issues in Crime, Law & Law Enforcement, 6(2).
[3] Feingold, Z. R. (2021). The stigma of incarceration experience: A systematic review. Psychology, Public Policy, and Law, 27(4), 550–569.
[4] With the Fund for Public Health in New York City as the fiscal conduit
[5] An approach to individual self-regulation, health and resilience that trains and empowers providers to deploy tangible self-regulation and behavioral modification skills in response to the specific physical and emotional symptoms triggered by trauma and stress.
[6] Trauma-informed care refers to an approach that aims to engage people with histories of trauma, recognize the presence of trauma symptoms, and acknowledge the role that trauma has played in their lives.
[7] Profile of Under Custody Population as of January 1, 2021. NYS Corrections and Community Supervision.
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