The Transitions Clinic Network (TCN) transforms both lives and health systems. Individuals released from incarceration receive support that helps them thrive in the community. In addition, primary care clinics improve their services for people returning from incarceration who often experience challenges accessing health care. The key to this success? The power of lived experience.
The Model
In 2006, Dr. Clemens Hong and Dr. Emily Wang developed the TCN model in San Francisco, California. It was created in collaboration with community partners and community members with lived experience of incarceration. The model features community health workers (CHWs) who have a history of incarceration. Outreach to community partners, such as emergency departments, reentry halfway houses, and homeless encampments, is an inherent part of the CHW position. Their job involves assisting individuals returning to the community with accessing and navigating local health systems, as well as connecting them with the reentry service provider network.
“One of the things that makes our model unique is hiring people who have lived experience with incarceration,” explains Dr. Shira Shavit, Executive Director of TCN. “But, even more uniquely, we embed these CHWs within the primary care team. In addition to the system navigation CHWs do with the clients, they work alongside doctors, nurses, and mental health providers as cultural interpreters. They help build patients’ trust in the medical system and help providers better understand the clients and their needs. It is a very dynamic relationship.”
When possible, CHWs connect with individuals prior to release. For example, a TCN member site in California holds in-jail support groups, through which CHWs help prepare individuals for release. Another TCN member site does not have the same pre-release access, so it stations a bus outside of the jail. Individuals can get to where they need to go, but as importantly, CHWs have an opportunity to connect with them during the ride home.
“[Transitions clinic staff] don’t judge you. They treat you like a human being, like you’re still a person. That’s something that prison takes away from you, and when you get out, society takes that away from you. I think that’s what makes Transitions clinic so successful.”—Transitions clinic patient
Evolution
Helping communities build partnerships is a significant piece of the services TCN now provides. As interest in the model started to increase, the need for in-depth technical assistance and training became apparent. Once sites hire CHWs and become part of the network, they can participate in CHW training, ongoing policy forums, supervisory calls, continuing education, and an annual multi-day convening.
“Through collaboration, we created the core model. We then learned, again through collaboration, how to adapt it to local communities and their resources,” reflects Shavit. “We recognize the range of what is possible, depending on resources, capacity, and relationships with carceral settings. To date, we have worked with over 50 sites, both rural and urban, in 15 states around the country and in Puerto Rico,” including the North Carolina Formerly Incarcerated Transition (NC FIT) Program and the Bronx Transition Clinic in New York.
A Silver Lining
One of the most profound, yet unexpected developments in TCN’s evolution was prompted by the COVID-19 pandemic. When the virus started infiltrating California’s state prison system, authorities adopted a policy of early release for individuals scheduled to be released from custody within the next year. At the same time, many primary care clinics were shut down due to the pandemic, so people leaving custody did not have access to healthcare services.
CHWs across the state created a reentry hotline for people to use within the facility and after release, and a formal referral process between the state prison and clinics. This process shared information about who was leaving, when they were leaving, and their COVID status. The referrals served a two-fold purpose: supporting the health needs of people during reentry and mitigating the spread of COVID.
The robust relationship between clinics and corrections that formed over time led to a greater investment in formal discharge planning, including linking people to post-release care. Pre-release initiation of medication for opioid use disorder was also made possible due to collaborations with community providers, ensuring continuity of care.
Building on Success
TCN is leveraging its lessons learned from the pandemic to advance California’s 1115 Reentry Demonstration Waiver, which seeks to improve healthcare for vulnerable populations, such as those leaving incarceration who are eligible for Medicaid. This includes training providers on enhanced care management through the Justice-Involved Reentry Initiative.
In the Centers for Medicare & Medicaid Services’ guidance on designing Section 1115 reentry demonstration projects, TCN is acknowledged for promoting “high quality, equitable health care and cultural responsiveness in clinics that serve reentering individuals in the neighborhoods most impacted by incarceration.” Studies demonstrate that TCN participants have fewer emergency department visits, days in jail, and parole/probation violations after release than those who did not participate in TCN.
The greatest success of all, however, may be the sense of pride that CHWs have in helping their peers. “Every day, CHWs across TCN show us what transformation looks like,” observes CHW Dorel Clayton. “You are not just part of a system; you are changing systems. You make healing possible and justice tangible.”