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About the Team

The Maine team seeks to create tailored transitional services to support whole person care (behavioral, social, and physical health) to patients with a history of incarceration and/or complex health needs.

The Maine team is made up of:

Identifying and Diagnosing the Problem

The Maine team is exploring models to improve transitional care assistance and intensive case management to support whole person care when adults are released/discharged from institutional settings (i.e. inpatient facilities, jails, or prisons). The team is working with the Department of Human Services and HealthInfoNet (the statewide health information exchange in Maine) with the goal to share data with the Department of Corrections. The team is also exploring provider organization and member financial incentives.

Creating Cultures of Equity

Simultaneously, the Department of Human Services (DHS) is developing a DEI strategy for each department within DHS, including MaineCare. The DEI initiatives include a broad range of activities including strategies to improve the quality of data to better analyze disparities; activities to better understand member needs and improve member outreach; sustainable models for meaningful community engagement; and the development of a community health worker model.

Lessons Learned


Getting feedback along the way from any stakeholder who interacts with the system you seek to change is critical. The Maine team was intentional from the start with members impacted by the incarceration system. They also asked for feedback on their program and strategy from DOC, leaders across their partnering organizations, and other groups to apply many different perspectives and expertise to their plans.