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Community Health Worker (CHW) colleagues on-site in Charlotte

 

21,893 people were released from North Carolina prisons in 2020. Upon release, individuals are frequently without housing, employment, health insurance, or access to healthcare services. The North Carolina Formerly Incarcerated Transition (NC FIT) Program, sponsored by UNC Family Medicine, connects formerly incarcerated individuals who have a chronic disease, mental illness and/or substance use disorder with appropriate healthcare services and other reentry resources. These efforts are orchestrated by our Community Health Workers (CHWs).

What is NC FIT?

CHW health navigation appointment

The NC FIT Program is a partnership between:

  • UNC Family Medicine
  • The North Carolina Department of Public Safety (which administers the state prisons)
  • The North Carolina Community Health Center Association,
  • Federally Qualified Health Centers
  • County Departments of Public Health,
  • Community-based reentry organizations
  • local reentry councils.

The NC FIT Program employs Community Health Workers (CHWs) with a personal history of incarceration. CHWs connect recently released people with chronic disease, mental illness and/or substance use disorder to appropriate health care services and helps put together a comprehensive reentry plan working with local reentry partners.

The NC FIT Program is based on the Transitions Clinic Network model that has shown improved outcomes for participants. The NC FIT Program is a member of this nationwide network of 25 clinical sites.

NC FIT Program Sites and Partners

The FIT Program of Durham County

Partners: Durham County Department of Public Health, Lincoln Community Health Center, The Durham Local Reentry Council
Contact: Dorel Clayton | dclayton@dconc.gov | (919) 672-8929
Visit their website here 

The FIT Program of Orange County

Partners: Orange County Department of Public Health, Piedmont Health Services, Inc., Orange County Reentry Council
Contact: Tommy Green | hgreen@orangecountync.gov | (919) 339-2410

Contact: Jeremy McKoy | jmckpy@orangecountync.gov | (919) 627-8385
Visit their website here

The FIT Program of Wake County

Partners: UNC Department of Psychiatry, UNC Healthcare at Wakebrook, Advance Community Health Center, Wake County Local Reentry Council
Contact: Jennifer Wade | jennifer_wade@med.unc.edu | Office: (984) 974-4818
Cell: (919) 322-8185
Contact: Asiyah James | asiyah_james@med.unc.edu | (919) 964-5920

The FIT Program of Mecklenburg County

Partners: The Center for Community Transitions, Charlotte Community Health Clinic, Re-entry Partners of Mecklenburg
Contact: Deborah Rose | drose@centerforcommunitytransitions.org | Office: (704)-374-0762 ext: 3711
Visit their website here

The FIT Program of Guilford County

Partners: Triad Adult Pediatric Medicine, Guilford County Health Department
Contact: Eugene Wilson | ewilson@tapmedicine.com | (336) 279-4259
Greg Liggs | gliggs@tapmedicine.com | (336) 840-9621
Visit their website here

The FIT Program of New Hanover County

Partners: MedNorth Health Center, Leading Into New Communities (LINC), Inc.
Contact: Demond Wells | dwells@lincnc.org | (910) 332-1132
Visit their website here

 

NC FIT Programs

FIT Recovery

FIT Recovery is a program to identify people in the state prison system that suffer from opioid use disorder and to initiate treatment and medication for opioid use disorder prior to release. This is a collaboration between the prison system, the Mountain Area Health Education Center (MAHEC), and the FIT Program. The program is in the pilot phase, working with 3 prisons that include the North Carolina Correctional Institution for Women in Raleigh, Wake, and Orange Correctional Centers. People in the program are started on Suboxone prior to their release and then given an injection of the same medication that lasts 30 days. The FIT Program coordinates care for people upon release if they will be living in any of the 6 FIT counties, and FIT has partnered with organizations in 12 counties to expand eligibility for people to be treated.

FIT Wellness

FIT Wellness is a unique program in our Wake County FIT Program that focuses on people with severe mental illness (SMI). Funded by a grant from the NC Department of Mental Health, FIT is able to offer continuity Psychiatric care for people with SMI released from state prisons and coming to Wake County. Participants work with a FIT Community Health Worker dedicated to this effort that assists them in a comprehensive reentry plan and coordinates their care at UNC Wakebrook, a behavioral health and primary care facility. At Wakebrook, they see a Psychiatrist that also works in the prison system, and they become established with a primary care provider for medical needs.

Justice Technical Assistance Team

The Justice TA Team is a partnership between the NC FIT Program, The NC Harm Reduction Coalition, and the Duke Opioid Collaboratory. The collaborative works together supporting grantees from 22 different communities in North Carolina. Their work support centers on 3 areas to address the opioid epidemic:

  • Firstly, all grantees are supported in harm reduction. This may include education, distribution of Narcan rescue kits, supporting syringe services programs, and other life-saving efforts.
  • The Team then works with communities in developing strategies with law enforcement and prosecutors, to get people into treatment instead of incarceration when picked up for low-level drug crime, like possession of small amounts for their own use.
  • A third area of assistance is centered on identifying people in county jails that have opioid use disorder and working to connect them to evidence-based treatment upon release, and in some cases, to start medication for opioid use disorder prior to release.

How is the NC FIT Program Funded?

Funding to support our Community Health Workers (CHWs) in Durham and Orange is a combination of a grant from The Duke Endowment and support by the Durham and Orange County Departments of Public Health. Initial seed funding for the program in Durham came from the NC Division of Public Health. A contract with the NC Department of Public Safety is allowing us to expand the NC FIT Program to Wake and Mecklenburg Counties.

A significant barrier to health care services for our clients is a lack of insurance. Most formerly incarcerated people do not qualify for Medicaid and have no health insurance. The NC FIT Program provides vouchers to cover the office visits and medication costs for uninsured patients. Office visits at Community Health Centers are $20-$30 and medications cost between $4-$20 per month per medication.

We are working with our community partners and foundations to obtain long term funding for the CHWs.

Make a Gift to the
UNC Family Medicine
NC FIT Program

Please consider making a donation. Formerly incarcerated people face multiple barriers to care and this program can really make a difference in their lives.

Thank you for your support!

News and Media

Out of Prison and Trying to Build a New, Healthy Life
Washington Post, 12/23/19

They’re Out of Prison, Can They Stay Out of The Hospital?
New York Times, 5/29/18

UNC-led FIT Program helps former prisoners take on chronic illnesses
UNC Health Care News 8/2017

FIT Program Provides Critical Support for Former Inmates
WUNC — The State of Things, June 13th