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Transforming the Health Care System in Partnership with Formerly Incarcerated Individuals

Monday, September 17, 2018   (0 Comments)
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  By Anna Steiner, MSW, MPH, Program Manager and Rand Hale, Program Assistant, Transitions Clinic Network


Anna Steiner & Shira Shavit from Transitions Clinic Network, and Laura Morgan from Country Doctor Community Clinic will be presenting at the 2018 Fall Primary Care Conference


The Transitions Clinic Network (TCN) is a non-profit that supports the transformation of health systems to better serve individuals with chronic physical and behavioral health conditions returning to the community from incarceration. Founded on the idea that the people closest to the problem are also closest to the solution, TCN programs integrate community health workers (CHWs) with histories of incarceration into the primary care team. Teams are specially trained in cultural humility; best practices in promoting healthy reintegration into the community; complex care coordination; chronic disease management; and preventing unnecessary emergency department utilization and hospitalizations. TCN programs are bolstered by strong relationships with correctional partners and community organizations that address the social determinants of health.


Since the program’s inception in 2006, TCN has worked with clinics in 11 states and Puerto Rico, including Country Doctor Community Health Center in Seattle, WA, a NWRPCA member, to implement the TCN program and serve over 5,000 patients recently released from incarceration. 

A randomized control trial found the TCN program significantly reduced emergency department utilization. TCN program patients also have fewer and shorter preventable hospitalizations, and fewer parole and probation violations (preliminary results). TCN programs are leading efforts in data collection, linkages and analysis to inform national efforts on best practices for caring for the millions of individuals who return home from incarceration.

While correctional systems are constitutionally mandated to provide health care services to inmates, that legal responsibility ends upon release. When individuals transition from an institutionalized and controlled healthcare environment to a highly fragmented community health system, health care needs frequently go unmet. The first two weeks after release are particularly risky. A seminal study found individuals returning from incarceration to be 12 times more likely to die as compared to a matched cohort in the community within the two weeks following release. The majority of these deaths were from preventable causes that could be addressed within the primary care system. 

In addition to barriers related to accessing care and juggling multiple priorities, many formerly incarcerated individuals have experienced mistreatment, discrimination and stigma within the community health system and may not willingly seek out care. 


People coming home have many health needs. They need food, a place to stay and a job, yet many face discrimination in housing and employment. They may have also lost connections with family and community. A health care system that wants to engage this population must be able to address this big picture within the clinic. CHWs make this possible. 

TCN program CHWs are trained in core competencies, how to work as part of a clinical team and best address the complex needs of individuals returning from incarceration. Their passion, dedication and credibility with their patients, however, cannot be taught. In addition to working with patients within the clinic, TCN CHW’s hit the streets, assist patients in meeting patient-determined health and reentry milestones, act as mentors, cultural liaisons between providers and the patient and perhaps most importantly, as advocates to patients within the health, social and correctional systems. 


While it is easy to blame the correctional system for mistreating these patients and keeping them from seeking services, the community health system has been complicit in neglecting the needs of these patients. By implementing a TCN program and hiring individuals historically excluded from health care employment as essential members of the primary care team, health systems demonstrate a commitment to mitigating some of the harms done to individuals and communities most impacted by mass incarceration. They also commit to improving patients’ health and reentry outcomes while saving the health care system money. And, perhaps most importantly, they commit to doing the right thing.   


If you want to know more about TCN’s work or how to implement a TCN program, visit http://www.transitionsclinic.org/, email info@transitionsclinic.org or come to our presentation at NWRPCA’s annual conference in Denver on Sunday October 21st at 8:30a!




NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

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