The Returning Citizens Program: Evaluating a Program to Connect Formerly Incarcerated Adults to Health Services in Milwaukee, Wisconsin, 2022-2025

When a person leaves prison, they step back into a world that often feels foreign and hostile. The years spent inside have frequently interrupted their access to regular medical care, while the stress of incarceration and the conditions of confinement have often worsened existing health problems or created new ones. Many people returning to their communities face a perfect storm of challenges: they need to find housing, secure a job, and navigate complex legal supervision, all while managing chronic conditions like high blood pressure, diabetes, or mental health disorders. For too long, the moment of release has been a point where medical care simply stops, leaving a dangerous gap between the prison system and the community. To bridge this divide, health experts have developed a model that places community health workers—individuals who have themselves experienced incarceration—directly into primary care clinics. These workers act as trusted guides, using their shared life experience to build relationships, help navigate the healthcare system, and connect people to the doctors and resources they need.

In Milwaukee, Wisconsin, a team of researchers and healthcare providers put this model to the test in a real-world setting, moving it out of a controlled research lab and into the daily rhythm of a large hospital system. They launched the Returning Citizens Program, designed to help adults re-entering society after prison get connected to primary care. The team wanted to see how this program actually worked when it was not part of a special research study with perfect data collection, but rather a routine part of a busy hospital's operations. They tracked the journey of 207 individuals who signed up for the program between February 2022 and August 2025, looking at who they were, what health issues they faced, and whether the program successfully helped them see a doctor.

The people who joined the program were predominantly men, with nearly 90 percent of participants being male, and the majority were Black, non-Hispanic adults. The typical participant was 38 years old, though the group ranged from their early thirties to their late forties. When the researchers looked at the medical records of those who had visited a clinic, they found a heavy burden of health challenges. More than a third of the participants had documented mental health disorders, and nearly a third had injuries that required medical attention. High blood pressure affected over a quarter of the group, while substance use disorders and tobacco use were each present in about one-fifth of the participants. Diabetes or pre-diabetes was also common, affecting nearly one in five people. These were not minor issues; they were substantial, ongoing health needs that required consistent medical attention.

The program relied heavily on community health workers who had lived experience with the prison system. These workers reached out to people as they were preparing to leave prison or shortly after their release, helping them fill out intake forms, identifying their medical and social needs, and making appointments for them. The researchers found that this approach worked to get people through the door. Of the 207 people who completed an intake appointment, 157 went on to have at least one visit with a healthcare provider. About 121 of those individuals saw a primary care doctor, and 90 visited one of the four specific clinics dedicated to the program. However, the path was not a straight line. Many participants also used the emergency department, with about two-thirds of those who saw a doctor also visiting the emergency room at some point. This suggests that while the program was successful in connecting people to regular care, many were still turning to emergency rooms for immediate needs, often while simultaneously trying to establish a relationship with a primary care physician.

The researchers also discovered that the way the program was set up created both opportunities and obstacles. The lived experience of the health workers was a powerful tool for building trust, and partnerships with local prisons and community groups helped identify people who needed help. However, the system itself was not always ready to capture the full story. The hospital's electronic medical records did not have a simple, standard place to mark that a patient was part of this program or to record their release date from prison. This made it difficult for the researchers to count exactly how many people the health workers reached out to or to track the precise timing of care. In some cases, the health workers did a great deal of work outside the clinic—helping with housing or navigating social services—but this vital support was not always written down in the medical record in a way that could be easily counted. The team also faced challenges with access to the prison facility, which sometimes limited their ability to meet people before they were released.

Despite these hurdles, the evaluation showed that the program reached a population with significant health needs and provided a pathway to care that would otherwise have been difficult to access. The study did not prove that the program eliminated health disparities or stopped people from returning to prison, as it was a descriptive look at how the program operated rather than a controlled experiment. Instead, it offered a clear picture of the reality of implementing such a program in a busy hospital. The researchers concluded that for other hospitals wanting to adopt this model, the key to success lies in setting up the right tools from the very beginning. They recommended that health systems create simple, standard ways to record incarceration history and program participation in their medical records, ensuring that the hard work of community health workers is visible and that the people they serve can be tracked effectively over time. By fixing these logistical details, hospitals can better support the transition from prison to community, ensuring that the people who need care the most can actually receive it.