Each year in the U.S., more than nine million people return home after being released from local jails, and another 600,000 leave state and federal prisons. A disproportionate number of these individuals have chronic medical or behavioral health conditions. Care coordination between correctional facilities and community-based health and social service providers, however, is often limited or nonexistent. Without comprehensive reentry planning, this population faces high rates of emergency department visits, hospital admissions, substance use, reincarceration, and significantly elevated risk of death from cardiovascular disease, drug overdose, homicide, and suicide.

The Point of Reentry and Transition (PORT) program addresses these challenges by linking adults discharged from New York City’s Rikers Island jail complex to comprehensive care upon return to the community. Through the voluntary PORT program individuals released from incarceration receive comprehensive, trauma-informed, patient-centered primary care and other health and social services, guided by a multidisciplinary team that includes community health workers with lived experience of the criminal legal system.

This profile features the PORT program and how it seeks to address the barriers individuals face when being discharged from jail. The profile is part of the Better Care Playbook’s ongoing series, In the Field: Spotlight on Complex Care Interventions, that highlights how organizations are implementing evidence-based and promising innovations to improve care for people with complex health and social needs.