Name
Supporting People with Serious Mental Illness Upon Release from Incarceration with Co-Located Psychiatric and Primary Care and Community Health Worker Engagement
Description

We will review mass incarceration in the U.S. along with the burden of chronic physical and psychiatric illness in carceral settings. We will then discuss health outcomes and the challenges of community reentry for the millions of people releasing from incarceration each year. Community health workers will discuss the heightened difficulty people with serious mental illness experience after leaving incarceration. We will spend the bulk of the session discussing the Formerly Incarcerated Transition (FIT) Wellness model, which embeds community health workers, people with lived experience of incarceration, into a primary care clinic with co-located psychiatric care. Preliminary data from the first 3.5 years of program implementation will be reviewed.

Co-Authors
Evan Ashkin, MD; Elena DiRosa, MPH
Content Level
Intermediate
Tags
Innovations, Psychiatry, Underserved populations such as LGBTQ+
Session Type
Concurrent
Objective 1
Describe the physical and mental health burden of people who experience incarceration.
Objective 2
Discuss the challenges people face upon community reentry.
Objective 3
Identify components of the FIT Wellness model and how to support people with serious mental illness returning from incarceration.
Content Reference 1

Zarzar TR, Rosen DL, Ashkin EA. Supporting People With Serious Mental Illness After Prison Release: The FIT Wellness Model. Psychiatr Serv. 2024;75(4):395. doi:10.1176/appi.ps.20230513

Content Reference 2

Rosen DL, Zarzar TR, Baker A, Ashkin EA. Serious Mental Illness‐Associated Socio‐Medical Needs and Imprisonment Risk in Reentry Clients. Psychiatr Res Clin Pract. Epub ahead of print. 13 Jan 2026. doi:10.1176/appi.prcp.20250046

Content Reference 3

Aminawung JA, Harvey TD, Smart J, et al. Formerly Incarcerated Community Health Workers Engaging Individuals Returning From Incarceration Into Primary Care: Results From the Transition Clinic Network. Front Public Health. 2021;9:681128. Published 2021 Aug 5. doi:10.3389/fpubh.2021.681128

Content Reference 4

Applegarth DM, Abrams LS, Farabee DJ. Exploring Reentry Concerns of Incarcerated Individuals with Severe Mental Illness. Community Ment Health J. 2025;61(4):704-715. doi:10.1007/s10597-024-01389-x

Content Reference 5

Favril L, Rich JD, Hard J, Fazel S. Mental and physical health morbidity among people in prisons: an umbrella review. Lancet Public Health. 2024;9(4):e250-e260. doi:10.1016/S2468-2667(24)00023-9