Individuals returning from incarceration face a variety of challenges, including homelessness, substance use disorders, and mental health issues. These risk factors increase the likelihood of adverse outcomes, including overdose, premature death, and increased rates of emergency department visits.
UC Davis Health has devised a solution to help this vulnerable population succeed.
The Department of Psychiatry and Behavioral Sciences and the Digital Collaborative have partnered to create a digital support program for people with mental illnesses and substance use disorders who have been released from prison, which will provide them with a free smartphone, automated SMS text message check-ins, and a web-based community resource guide.
“Those recently released from prison are some of the most vulnerable members of society.” —Helen C. Cales
“People recently released from prison are some of the most vulnerable people in society,” said Helen C. Cales, M.D., chair of the Department of Psychiatry and Behavioral Sciences at the University of California, Davis School of Health. “Rearrest is so common that it’s known as the revolving door. This vicious cycle places a huge burden not only on the individual but also on the community.”
The new program is called Digital SAFE-T. It is an extension of the SAFE-T (Subacute Facilitated Engagement and Transition) program that was launched more than two years ago. SAFE-T is built on a partnership between Psychiatry and Behavioral Sciences and WellSpace Health, Sacramento’s largest Federally Qualified Health Center (FQHC). The program provides individualized case management for individuals recently released from prison.
The SAFE-T team connects participants to available benefits and services, including Social Security Insurgency (SSI) benefits, Medi-Cal (California’s Medicaid health care program), housing assistance, access to mental health providers, bus passes, and many other supports.
The pilot SAFE-T program had a significant impact during its first year. Rearrest rates for participants in the program dropped to 17% compared to the normal rate of 70%. Emergency room visits were just 3% compared to the normal rate of about 30%.
Funding for this new program was made possible through the efforts of Congresswoman Doris Matsui, who helped include Digital SAFE-T in the Fiscal Year 2023 omnibus appropriations bill and provided a $1.5 million congressional grant from the Substance Abuse and Mental Health Services Administration (SAMHSA).
“Partnerships between the federal government and local leaders like UC Davis Health and WellSpace Health are essential to developing new, innovative tools to reach people in need,” Matsui said. “From virtual care coordination to comprehensive resources at people’s fingertips, the digital SAFE-T program builds on the success of the SAFE-T program to further remove structural barriers people recently released from incarceration face as they transition back into society. This investment underscores the importance of federal support to our region’s mission to enable and empower all of our neighbors to maximize their health.”
How does the Digital SAFE-T program work?
The UC Davis Health Digital CoLab developed the Digital SAFE-T program with input, collaboration and feedback from Psychiatry and Behavioral Sciences, WellSpace Health and the community.
We provide individuals enrolled in the SAFE-T program with technology tools, including a comprehensive digital “street sheet” of local, social, medical and community resources that can be easily accessed on a phone or tablet with text-to-speech and one-click GPS navigation, providing directions to where you want to go.

The digital SAFE-T program also provides automated text messages from WellSpace Health and Sacramento County with important reminders, check-ins and customized resources to help patients stay informed and connected about their health care and other services.
Additionally, the program facilitates communication with WellSpace Health caseworkers who coordinate the individual’s care. Caseworkers connect individuals to relevant services and help overcome barriers to resource utilization, outreach, and crisis intervention. Such coordination has been proven to effectively improve multiple outcomes for at-risk individuals recently incarcerated.
“We are proud to have developed the Digital SAFE-T program to help incarcerated and released people access resources and critical care in the palm of their hand,” said Ashish Atreja, CIO and chief digital health officer at UC Davis Health. “By rethinking how we can support this vulnerable patient population, we are looking beyond the walls of our hospital to deliver care through technology.”
The digital SAFE-T program goes beyond the original SAFE-T program by providing greater convenience, especially for mobile and vulnerable populations who are unhoused and difficult for health care providers to keep in touch with.
Enrolled participants will access the digital SAFE-T program on a free smartphone provided by UC Davis Health in partnership with Verizon Business. Addressing equity and inclusion in digital healthIn addition to smartphones, the program also provides tablets and hotspots to help patients access telehealth and social services.
“Our goal is to minimize friction in accessing the care and resources our most vulnerable patients need.”—Keisuke Nakagawa
“Our goal is to minimize the gap in access to the care and resources our most vulnerable patients need,” said Keisuke Nakagawa, innovation director for the Health Digital Collaborative at UC Davis. “This is a great example of how we’re investing in the social and digital determinants of health to provide more complete, holistic care. By combining a human touch with just the right amount of technology, we’re building trust and supporting these patients at a critical time as they leave prison and transition back into their communities.”
The Need for the SAFE-T Program
People released from prison are at increased risk of poor health and death due to pre-existing behaviors and health conditions, as well as the adverse effects of prison itself. Compounding these issues are barriers to health care and fundamental social determinants of health, such as housing, food and employment.
A recent study found that the risk of these people dying within two weeks of being released from prison is almost 13 times higher than the risk faced by other people.
Psychiatrists at UC Davis Health have seen these challenges up close: For nearly 40 years, they’ve provided mental health services to people incarcerated in the Sacramento County Jail, and they also treat former inmates who arrive in emergency rooms experiencing mental health crises.
“Release from prison impacts an individual’s ability to secure basic needs such as health, housing and employment,” Cales explains. “Further compounding these barriers is the issue of returning to impoverished areas and accessing resources.”
This new program is another avenue for UC Davis to advance health equity in the Sacramento region.
“We are excited about the work we’ve done with the SAFE-T program and look forward to further improving the lives of some of the most vulnerable members of our Sacramento community,” Cales added. “We also hope that this program can provide a model for other communities across the country to support people recently released from prison.”