Transitions Clinic Network: Shifting Paradigms in Care for Individuals with a History of Incarceration

Health-related Reentry Challenges • Continuity of care: No discharge planning, health records and short supply of medications1 • Access: No health insurance/lapse in Medicaid and Medicare B2 • Collateral Consequences of incarceration: Individuals returning from incarceration face high needs and additional barriers related to SDoH3 • Discrimination: Individuals with histories of incarceration were. [...] 2014 Mar 25;2:6 Shifting the Paradigm of Health Care Image Courtesy of Ray Chavez and CA Prison Health Care Receivership 8 Transitions Clinic Program Strategies to Successful Engagement Post-Release • Include individuals and communities impacted by criminal justice system in design, implementation and evaluation of programs • Broad Definition of health & well-being • Adapt systems to be patient-ce. [...] Parole Medication Home assistance Jail/prison Health insurance Hospital Specialty Treatment appointments facilities Pharmacy, lab, The streets radiology CHWs with homeless Transitions Patient Role of the Community Health Worker Referrals & Advocacy: Emotional Support & Housing ,employment, job training , Mentorship education and other social services. [...] CHW with TCN patient Outreach Health System Navigation Health Education and Self Management Support Social Service Navigation and Advocacy Emotional Support and Mentorship TCN Results: Acute Care Utilization TCN program reduces ED visits for patients in the TCN program¹. [...] doi: 10.1136/bmjopen-2018-028097 Transitions Clinic Network Transitions Clinic Network 39 programs, 13 states and Puerto Rico California: 21 sites, 13 counties Transitions Clinic Network Consulting Services: Implementation Facilitation • Hiring, supervision, integration & training of CHW • Reentry & Criminal Justice Partnerships • Development of patient-centered services • System redesign • Patien.