Housed in the highest-risk window after release
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.
Member
Rosa
Who we help
Justice Involved (JI)
Location
Fresno County, CA
Timeframe
60-day intensive post-release
What changed
The outcome 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.
Where things started
The situation.
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.
“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.”
The hard part
What stood in the way.
- 1
Direct-to-street risk with no housing plan on file at release.
- 2
Medi-Cal suspended during incarceration and not yet reactivated.
- 3
No phone, no ID, and no active bank account to complete housing paperwork.
- 4
Prior enrollment attempts at community services failed at the transportation step.
Our approach
How we built the plan.
Step 1
Pre-release in-reach 30 days before the gate to build a housing and benefits plan.
Step 2
Community Supports Housing Deposit and Recuperative Care reserved before release.
Step 3
Community Health Worker + Lifeline phone handed off at the gate for daily contact.
The support
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.
Behind the scenes
The team and services on this case.
You could be next
Tell us what's going on — we'll take it from there.
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