Headline
Primary care-based community health worker (CHW) program reduced emergency department (ED) use among people recently released from prison.
Context
Individuals with criminal legal system involvement experience high rates of chronic physical and behavioral health conditions, as well as often encounter barriers to accessing primary and specialty outpatient care. The Transitions Clinic Network (TCN) is a primary care-based program designed to provide patient-centered and integrated physical and behavioral health care to this population. TCN programs incorporate CHWs with histories of incarceration to support patients through case management, health and social service navigation, and chronic disease self-management support.
This study assesses differences in primary and acute care use between individuals who accessed a community health center-based TCN program within four weeks following release from prison and a control group who received traditional primary care services from a safety-net provider within a similar time frame.
Findings
Individuals recently released from prison were randomly assigned to either program or control groups, with TCN program participants 15% less likely than the control group to report an ED visit in the 12 months after program enrollment. The authors found no significant differences in rates of primary care visits, hospitalizations, or returns to jail between the two groups.
Takeaways
This study demonstrates the efficacy of the TCN model in reducing ED use among recently incarcerated individuals. By using an integrated care approach that incorporates peers with similar lived experience, the TCN model mirrors other interventions that have been shown to effectively serve other populations with complex health and social needs. Health care organizations can look to the TCN model as an evidence-based approach to improving primary care for people with criminal legal system involvement.