POF 01
CalAIM Population of Focus
Justice-Involved Reentry. Ninety days can decide the next ten years.
About this POF
Under CalAIM's Justice-Involved (JI) initiative and PATH Reentry framework, Atlas partners with county jails, state prisons, probation, parole, and juvenile justice to bridge the pre-release-to-community gap. Our Reentry Care Team activates 90 days before release and stays with members for at least 12 months after.
Who qualifies
- Adults 18+ enrolled or eligible for Medi-Cal, releasing from a county jail, state prison, or ICE facility within 90 days
- Transitional-age youth (16–26) releasing from DJJ or county juvenile detention
- Members on probation or parole with unmet behavioral or physical health needs
- Individuals flagged for high risk of overdose, self-harm, or ED recidivism in the first 30 days post-release
What we do
The full CalAIM toolkit — pointed at one population.
- 01
Pre-release in-reach (90 / 45 / 15 days)
Care managers meet members inside the facility to build a reentry care plan, confirm Medi-Cal enrollment, and schedule the first community appointment before the gate opens.
- 02
Day-of-release warm handoff
Transportation from the facility, a 30-day medication supply for MAT and psychiatric prescriptions, and a same-day visit with a PCP or behavioral health provider.
- 03
Housing & basic-needs navigation
Recuperative care, transitional housing, sober living, and Community Supports to prevent the direct-to-street outcome that drives 30-day recidivism.
- 04
MAT & behavioral health continuity
Uninterrupted buprenorphine, methadone, and naltrexone, plus co-occurring SUD/mental health treatment — because the two weeks after release are the highest-overdose window in a person's life.
- 05
Probation & court alignment
Documented care plans, appointment adherence letters, and coordinated communication with POs, drug courts, and Behavioral Health Courts.
The stakes
Why concentrating care here matters.
- 40K+
- Californians released from state prison each year
- 12.7×
- Higher overdose death risk in the 2 weeks after release
- 90 days
- CalAIM pre-release in-reach window
Source · CDCR Offender Data Points
Source · NEJM / BJS reentry mortality studies
Source · DHCS PATH Reentry Policy Guide
Refer a member
Correctional partners can submit warm handoffs at any point in the 90-day pre-release window. We accept referrals from jails, prisons, PDs, probation, parole, drug courts, defense counsel, and family members.
For members & families
Enroll yourself or a loved one — we'll walk you through every step, in your language, at your pace.
Other populations of focus