Using Primary Care-Based Community Health Workers to Support Individuals with a History of Incarceration: Transitions Clinic Network

Kelsey Brykman, Center for Health Care Strategies

Across the U.S., more than 600,000 people are released from prison and nine million return to their communities from jails each year. Structural racism, in the form of discriminatory policies and inequitable socio-economic conditions, has led to significant racial and ethnic disparities in incarceration. Individuals released from incarceration face a greater burden of physical and behavioral health conditions and are at heightened risk of death, due to causes such as overdosesuicide, and cardiovascular disease, compared to the general population. This population also faces many barriers to health care access such as discrimination, challenges accessing insurance coverage, and low health literacy. Social barriers such as heightened risk of homelessness, frequent lack of social supports, and barriers to employment are further challenges to community reentry.


Program Snapshot

  • Program: Transitions Clinic Network (TCN), a national network of primary care clinics that transformed their systems and collaborate with communities to provide patient-centered medical homes for individuals after incarceration.
  • Populations: Chronically ill individuals recently released from incarceration.
  • Goal: Provide holistic health care and social support to facilitate wellbeing, reentry into communities, and advance health equity.
  • Key Features/Results: The model integrates community health workers with a history of incarceration into primary care settings. Research indicates the TCN model can result in cost savings for criminal legal systems, reduce emergency department use and preventable hospitalizations, and reduce parole and probation violations as well as length of time re-incarcerated.

The Transitions Clinic Network’s (TCN) first program launched in 2006 at the San Francisco Department of Public Health’s Southeast Family Health Center. Today, TCN is a national network of 45 primary care clinics across 14 states and Puerto Rico that provide comprehensive, patient-centered primary care services and social supports to individuals recently released from incarceration. The TCN model grew out of the recognition that the health system was not meeting the needs of individuals returning to the community from incarceration for example, returning community members were being hospitalized because they could not get connected with primary care in a timely manner. Recognizing these gaps in care, a group of health care providers from the University of California San Francisco, community-based organizations, and City College of San Francisco held community focus groups with directly impacted populations to collaboratively develop TCN’s approach. With the recent CMS approval of a waiver allowing Medicaid coverage of pre-release services in California, there is enhanced opportunity for practices and policymakers to implement this type of model to meet the needs of the reentry population.


The TCN model is embedded within primary care clinics and supports primary care transformation to include integrated behavioral health as well as social supports, with the goal of improving health outcomes, supporting reentry into communities, and, ultimately, breaking the cycle of unemployment, poverty, poor health, and incarceration. While many reentry programs are based in the criminal legal system, the primary care setting of TCN allows for implementation of a more supportive and patient-centered intervention. Sites that implement the TCN model engage in a year-long training program, with the clinic assessing and shifting policies, practices, and processes to provide culturally humble, trauma-informed care to the reentry population.

A key component of the TCN model is integrating community health workers (CHWs) with a history of incarceration into primary care programs to help engage patients in care, provide emotional support, and connect patients to community resources to address social needs. Clinics support this work by building cross-sector collaborations within their communities, such as with employment, housing, harm reduction, food support, and family reunification services. Care teams also build relationships with criminal legal system probation and parole, using CHWs to advocate for patient health care needs.

In addition to providing better care, an important goal of the TCN model is to develop employment pathways for returning community members through the CHW role. Hiring CHWs with a history of incarceration is a concrete way that health systems can break down barriers to reentry and help reverse the harms of mass incarceration and systemic racism to strengthen communities. Because people of color are disproportionately incarcerated, hiring CHWs with a history of incarceration also supports a more diverse workforce.

Community Health Worker Role

Within the TCN model, CHWs are a critical liaison between the health system and communities, leveraging their shared history to help build patient trust, support relationships, and connect people to primary care services. When possible, CHWs perform in-reach to jails and prisons to begin working with clients prior to their release from incarceration. CHWs also work to meet patients where they are after release from incarceration, including at halfway houses, emergency departments, churches, and parks. CHWs remind patients about appointments, let them know what to expect from the care team, help them prepare for visits, and arrange transportation for them to get there. CHWs use techniques such as motivational interviewing to help returning community members develop a health and reentry plan — this can include both health and social goals, such as family reunification.

CHWs regularly collaborate with primary care teams to discuss patient goals and needs. Through their role, CHWs are uniquely positioned to advocate for process changes to make care more patient-centered and responsive to patients’ barriers and needs. For example, while traditional clinics often cancel visits if a patient is 15 minutes late, TCN clinics avoid such policies so as not to unintentionally replicate the punitive culture of the criminal legal system in health care settings. CHWs with lived experience understand that punitive policies can feel too much like the criminal legal system and can be a barrier to care access and building trusting relationships with patients.

As another example, since patients often face food insecurity, some TCN programs provide snacks for patients and offer food pantries onsite. CHWs with a history of incarceration understand these challenges and recognize that being genuinely attentive to patient needs is often critical to keeping patients engaged in care.

Additionally, CHWs provide ongoing support to help patients manage their health and address social needs. CHWs often accompany returning community members to appointments, assist with care coordination, provide health coaching, and help individuals access and understand medications. CHWs also support individuals to address issues such as housing and transportation access, securing health insurance, and enrolling in government benefits. CHWs provide critical mentorship and emotional support, with many important interactions occurring between formal appointments. As Joe Calderon, TCN’s lead CHW, explained, he has supported returning community members as they navigate many experiences. He recalls a time when a returning community member saw him using Facebook while waiting for an appointment in a Social Security office and asked what it was. This was an opening that led Joe to help the person use social media to find and reunify with their family.

Financing and Sustainability

TCN sites use a variety of strategies to fund the model, often depending on what resources are available locally and what health insurance policies cover in their state. One key factor for sustainability of the TCN model is whether states have implemented Medicaid expansion, since this makes it more likely that individuals have insurance coverage upon release from incarceration. Covering pre-release services through Medicaid, as California has made possible through a recent 1115 waiver, can further help engage returning community members in care. If patients have health insurance, most primary care and behavioral health services are covered and, in some states, Medicaid also covers CHW services. A key strategy for providing patient-centered care and sustaining the model is implementing the TCN model within existing primary care practices versus creating separate TCN clinics. This addresses returning community members’ preferences of not wanting to be treated differently than other patients, while also making the TCN model more financially viable, as clinics can leverage existing health system resources. The majority of TCN costs are related to hiring, training, and providing ongoing funding for CHWs.

Medicaid policies that support enhanced primary care can potentially ease TCN model implementation. For example, there is increasing national recognition of the need to fund comprehensive, person-centered primary care, such as through enhanced investment or alternative payment models. Medicaid benefits that support enhanced care management, such as health homes, can also be helpful for supporting community-based models for at-risk patient populations. Additionally, states have new opportunities to use Medicaid 1115 waivers to help fund housing and nutrition supports and related case management, potentially enhancing primary care’s capacity to connect returning community members with social services.

For services and costs that are not adequately covered by insurance benefits, TCN model sites use a mix of other government funding, private grants, or self-funding through their health system. For example, some sites have leveraged Substance Abuse and Mental Health Services Administration grants to support behavioral health integration and substance use disorder services. Other sites have received grants from local foundations or entered into an arrangement in which health plans support start-up costs to get TCN models off the ground. Some states are also seeking to reinvest money from the criminal legal system into communities and reentry programs may quality for such funds. For example, the California Community Reinvestment Grants Program is funded by cannabis excise and cultivation taxes and provides grants to community-based organizations to fund health and social service programs for communities disproportionately affected by past drug policies.


Research on the TCN model suggests that the model can result in cost savings for criminal legal systems, reduce emergency department use and preventable hospitalizations, and have positive impacts on criminal legal system involvement.

  • A propensity-matched study used Connecticut government data to examine the TCN model’s impact on Medicaid and criminal legal system costs over a 12-month period. The study compared chronically ill and older individuals released from incarceration who participated in a TCN program to similar individuals who did not receive care through a TCN site. The results showed that average monthly criminal legal system costs were lower for TCN participants than non-participants ($733 versus $1,276 a month) at a statistically significant level. Based on differences in total Medicaid and criminal legal system costs between groups, the study estimated a return on investment of $2.55 for each dollar invested.
  • Another propensity-matched study, also using Connecticut data, explored the TCN model’s impact on further involvement with the criminal legal system and health care utilization. The results showed no significant differences in re-incarceration rates between individuals receiving care at TCN sites and those receiving care elsewhere. However, TCN participants spent fewer average days re-incarcerated and were less likely to be re-incarcerated for a parole or probation violation than non-participants. Results also showed that individuals in TCN programs who had been hospitalized had reduced preventable hospitalizations and shorter length of stays.
  • A randomized controlled trial examined the impact of the TCN model on health care utilization 12 months after incarceration for two primary care interventions in California: (1) the TCN model which included an expedited primary care appointment and support from a CHW with a history of incarceration; and (2) an expedited primary care appointment at a safety net organization without a CHW. Individuals receiving care at a TCN site had statistically significant reductions in emergency department utilization compared to the non-TCN clinic.
  • A randomized controlled trial is currently underway to assess the impact of the TCN model on improving opioid use disorder treatment. The study will also investigate cost-effectiveness and facilitators to implementation.


Supporting returning community members requires health system advocacy

TCN’s mission is about more than changing primary care practices — it is also about encouraging health systems and staff to be advocates for broader policy change to support individuals with a history of incarceration. Historically, most health care organizations have taken a relatively passive role addressing the harms of mass incarceration. TCN encourages systems to recognize the influential role they can play in addressing health disparities and take action at health system and policy levels. 

Hiring CHWs with a history of incarceration often requires systemic change

A key barrier to TCN model implementation is health system or state policies that prohibit the hiring of individuals with a history of incarceration as health workers. Implementing this model requires health care staff to commit to addressing biases and breaking down discriminatory employment policies. Having a health system leader who champions the model is helpful to spurring change.

Prioritizing community engagement and learning from individuals with lived experience is essential

Health care staff and researchers often have blind spots and biases toward doing things the way they’ve always been done. In developing a TCN program, co-designing the model with community members is essential to shifting the status quo. It is also important to avoid “shortcuts” that undermine the community and relationship-building focus of model. For example, there is no substitute for lived experience of incarceration. Providers that have tried to substitute other staff for CHWs with a history of incarceration have found such arrangements were not as effective in developing patient trust and supporting patient-centered approaches to care.


Thank you to the following individuals who helped inform this profile: Joseph Calderon, Lead Community Health Worker; Morgan Gliedman, Communications Manager; and Shira Shavit, Executive Director, Transitions Clinic Network.

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