Transitions Clinic Network: Integrating Community Health Workers into Primary Care to Support the Reentry Population

April 2023

Each year, millions of individuals in the U.S. return to their communities from jails or prisons. People with a history of incarceration face health disparities across a wide range of physical and behavioral health conditions, compared to the general population, and also have higher risk of death, due to causes such as overdose, suicide, and cardiovascular disease. Supporting the health and wellbeing of this population is also essential to advancing racial health equity since structural racism has caused significant racial and ethnic disparities in incarceration rates in the U.S. CMS’ recent approval of California’s waiver allowing Medicaid coverage of pre-release services signals enhanced opportunities for health care organizations and policymakers to support care delivery approaches to better meet the needs of the reentry population.

The Transitions Clinic Network (TCN), a national network of primary care clinics, provides patient-centered and culturally appropriate care for people with a history of incarceration and supports reentry into communities. A key feature of the TCN model is integrating community health workers (CHWs) with a history of incarceration into primary care settings to help provide holistic care and social support. The model offers demonstrated evidence, including cost savings for criminal legal systems, reduced avoidable acute health care utilization, and positive impacts on criminal legal system involvement.

This interactive webinar, made possible through the Seven Foundation Collaborative, featured presenters with on-the-ground experience implementing the TCN model. It focused on:

  • TCN program elements including roles, training, and workflows;
  • Lessons for achieving model buy-in and transforming primary care to advance health equity;
  • How to integrate CHWs with a history of incarceration into primary care teams; and
  • Approaches for engaging and building trust with returning community members.

Presenters included:

  • Tommy Green, Formerly Incarcerated Transition (F.I.T) Program, Lead Community Health Worker, North Carolina Peer Support Specialist, Orange County Health Department, North Carolina;
  • James Mackey, MA, MSW Transitions Clinic Network Program Manager and Coordinator of Case Management, Community Medical Centers, Stockton, California;
  • Lisa Puglisi, MD, Assistant Professor of General Medicine, Yale School of Medicine and Director, New Haven Transitions Clinic Network; and
  • Shira Shavit, MD, Professor of Family and Community Medicine, University of California San Francisco and Executive Director, Transitions Clinic Network.

This webinar is part of the Better Care Playbook Implementation Lab series. These sessions explore implementation strategies for specific models or tools with demonstrated evidence. Ample opportunities are provided for participants to ask questions to help further their understanding of moving evidence to practice.  

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