Case · 89
Individuals Transitioning from Incarceration
Housed in the highest-risk window after release
Member
Rosa
Service line
Individuals Transitioning from Incarceration
Location
Fresno County, CA
Duration
60-day intensive post-release
01 —
The outcome
Two weeks after release from county jail — the window when returning to homelessness sends most people back inside — Rosa had a recuperative care bed, a Lifeline phone, and a Community Health Worker who answered every call.
Housed by Day 5
Headline result for Rosa.
Day 5
Move-in date
From release to a signed transitional lease.
0
Nights unsheltered
Across the 60-day post-release window.
8/8
Parole check-ins attended
Full compliance across the supervision period.
100%
PCP appointment adherence
First primary care relationship of her adult life.
02 —
Background
Where the member started.
Rosa, 31, was releasing after a 90-day jail stay with no confirmed address, a suspended Medi-Cal, and prior release cycles that ended with a return to the streets within 72 hours.
In their words —
“Every time I got out before, I was back on the block by nightfall. This time they handed me a key instead of a bus pass.”
— Rosa, Reentry Member
03 —
The challenge
What stood in the way.
- 01
Direct-to-street risk with no housing plan on file at release.
- 02
Medi-Cal suspended during incarceration and not yet reactivated.
- 03
No phone, no ID, and no active bank account to complete housing paperwork.
- 04
Prior enrollment attempts at community services failed at the transportation step.
04 —
Our approach
How we built the plan.
Move 01
Pre-release in-reach 30 days before the gate to build a housing and benefits plan.
Move 02
Community Supports Housing Deposit and Recuperative Care reserved before release.
Move 03
Community Health Worker + Lifeline phone handed off at the gate for daily contact.
05 —
The solution
Step by step, what we actually did.
- 01
Day −30 — Pre-release engagement
Reentry Care Manager met Rosa weekly inside the facility, completed the ECM assessment, and locked in a Housing Deposit authorization with her Medi-Cal plan.
- 02
Day 0 — Warm handoff
Medical transportation from the gate, Lifeline phone activated in her hand, and a same-day PCP visit before her recuperative care intake.
- 03
Day 5 — Housing move-in
Community Supports Housing Deposit applied to a transitional unit; Tenancy Sustaining Services scheduled twice weekly.
- 04
Days 14–60 — Continuity
Community Health Worker visits twice weekly, care plan coordinated with parole so appointment adherence counted toward supervision compliance.
06 —
Services involved
The full network on this case.
- 01
Darnell · Individuals Transitioning from Incarceration
From the gate to a clinic chair in 24 hours
0 days without meds
- 02
Marcus (17) · Youth Transitioning from Incarceration
Diversion instead of detention
Charges dismissed
- 03
Aaliyah (15) · Youth Transitioning from Incarceration
A dual-status youth, one coordinated team
1 placement in 12 months