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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.

Interested in Learning More? Contact Us!

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: Quanesha Archer | | (919) 560-7098

Contact: Tina Clayton| | (919)-560-7214

Contact: Sean Blue| | (919)-560-7212

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: Dana Crews| |
Contact: Tommy Green | | (919) 339-2410

Visit their website here

The FIT Program of Wake County

Partners: UNC Department of Psychiatry, UNC Healthcare at UNC REACH, Advance Community Health Center, Wake County Local Reentry Council
Contact: Jennifer Wade | | Office: (984) 974-4818 | Cell: (919) 322-8185
Contact: Dwight Walker | | (984)-974-4818

Contact: Sheila Bonilla (FIT Wellness)|

Contact: Shawn Baker (FIT Wellness)| | (984)-974-4857

The FIT Program of Mecklenburg County

Partners: The Center for Community Transitions, Charlotte Community Health Clinic, Re-entry Partners of Mecklenburg

Contact: Deborah Rose | | Office: (704)-374-0762 ext: 3711

Contact: Rishod Dendy | | Office: (704) 374-0762 ext. 3712

Visit their website here

The FIT Program of Guilford County

Partners: Triad Adult Pediatric Medicine, Guilford County Health Department
Contact: Eugene Wilson | | (336) 279-4259

Contact: Pamela Faulkner | | (336)-840-9257

Visit their website here

The FIT Program of New Hanover County

Partners: MedNorth Health Center, Leading Into New Communities (LINC), Inc.

Contact: Michelle Gunn| | (910)-332-1134

Contact: Demond Wells | | (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.

North Carolina Technical Assistance Center

The North Carolina Technical Assistance Center (NC TAC) is a partnership between the NC FIT Program, The NC Harm Reduction Coalition, and the Duke Harm Reduction Research Collaboratory. With the support of the NC Department of Health and Human Services in the Division of Mental Health, the collaborative works together supporting grantees from 22 different communities in North Carolina. Their work support centers on three 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

Prison Reentry Services. More crisis care beds. Better pay for health care workers. Where $835 million in new mental health money is being spent.
NC Health News, 4/3/2024

FIT Wellness receives grant to help formerly incarcerated people
The Daily Tar Heel, 2/22/2024

NCDDHS Expands Investment in Reentry Services for People Involves in the Justice System
NCDHHS, 2/12/2024

Out of prison, but struggling to stay healthy
AAMC, 1/10/23

Meeting Health Needs at Reentry: North Carolina’s FIT Program
Policy Research Associates, 2/10/21

Health Care Half Hour: Successful reentry- Health issues facing people leaving incarceration
NC Health News, 11/18/21

Increasing MAT use in carceral facilities could save lives, but faces barriers
NC Health News, 12/21/21

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

Academic Publications

We Must Do Better: Addressing High Mortality After Release from Incarceration
Baker A, Ashkin E, Rosen D North Carolina Medical Journal Sep 2022, 83 (5) 342-345; DOI: 10.18043/ncm.83.5.342

Spotlight on the Safety Net: Connecting People Released from Incarceration to Essential Health Services: The North Carolina Formerly Incarcerated Transition (FIT) Program
Clark E, Ashkin E. North Carolina Medical Journal November-December 2019 80:377-379; doi:10.18043/ncm.80.6.377

Prison And Jail Reentry And Health
“Prison And Jail Reentry And Health”, Health Affairs Health Policy Brief, October 28, 2021. DOI: 10.1377/hpb20210928.343531

Overwhelming Need, Insufficient Health Care for Justice-involved North Carolinians.
Rosen D, Gifford E, Ashkin E. North Carolina Medical Journal November-December 2019 80:339-343; doi:10.18043/ncm.80.6.339

The Transitions Clinic Network: Post Incarceration Addiction Treatment, Healthcare, and Social Support (TCN-PATHS): A hybrid type-1 effectiveness trial of enhanced primary care to improve opioid use disorder treatment outcomes following release from jail
Howell BA, Puglisi L, Clark K, Albizu-Garica C, Ashkin E, Booth T, Brinkley-Rubinstein L, Fiellin D, Fox A, Maurer KF, Lin H McCollister K, Murphy S, Morse D, Shavit S, Wang K, Winkelman T, Wang EA. J Subst Abuse Treat. 2021 Jan 29:108315. doi: 10.1016/j.jsat.2021.108315. Epub ahead of print. PMID: 33583610.