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Service Delivery Innovation Profile

Community-Based Clinic Enhances Access to Medical Care and Reduces Emergency Department Visits for Chronically Ill Recently Released Prisoners


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Snapshot

Summary

The Transitions Clinic Program reaches out to individuals who have recently been released from prison who suffer from chronic health conditions, providing them with transitional and primary health care and case management services, including referrals to needed social services. Open four half-days a week, the clinic is staffed by trained community health workers who have experienced incarceration and by medical staff who show compassion and treat patients with dignity and respect. The program has increased access to medical care for recently released prisoners, as evidenced by increases in the number seeking medical care and by above-average attendance at their initial and followup appointments. It also has decreased emergency department visits as documented in a randomized controlled trial of emergency department use. Eleven community health centers nationally have adopted the Transitions Clinic Program to care for recently released prisoners, forming The Transitions Clinic Network.

Evidence Rating (What is this?)

Strong: Evidence for care-seeking behavior and a reduction in ED visits resulted from a randomized controlled trial (RCT) of 200 individuals, half assigned to the Transitions Clinic and half assigned to another safety net clinic that did not provide case management services. Additional evidence consists of post-implementation data on the number of newly released individuals seeking care at the clinic and attendance rates for initial and followup clinic appointments (as compared to attendance rates for other, similar patients seen at the large health center in which the clinic operates).
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Developing Organizations

San Francisco, CA
For the Transitions Clinic Network, developers include: Richmond, CA; Birmingham, AL; Boston, MA; New Haven, CT; Rochester, NY; New York, NY; Bronx, NY; Baltimore, MD; Washington, DC; San Juan, PR.end do

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Prisonersend pp

Problem Addressed

The majority of individuals released from prison have chronic medical and mental health problems and receive little, if any, assistance accessing community services to address them. As a result, they tend to rely on the emergency department (ED) to manage acute episodes and face increased risk of death.
  • Many chronically ill ex-prisoners: More than 70 percent of the approximately 700,000 people released from U.S. Federal and State prisons each year have chronic medical, substance abuse, and other mental health problems. The need for treatment often competes with other important issues, such as finding housing, obtaining employment, and reuniting with their families.1
  • Little support in accessing needed services: Few prison systems release individuals with medications, health insurance, or referrals to needed services, such as primary care.1 In most instances, recently released prisoners are left on their own to find much-needed medical and social services.
  • Leading to increased use of ED, higher risk of death: Individuals recently released from prison use the ED more frequently and face higher risk of death than do members of the general population.1 For example, in California those released from prison have higher rates of death during the first 2 weeks after release, with deaths most often being attributed to a drug overdose. Other causes include heart disease, homicide, and suicide.

What They Did

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Description of the Innovative Activity

The Transitions Clinic Program reaches out to individuals suffering from chronic illness who have been recently released from prison, providing them with transitional and primary health care and case management services, including referrals to needed social services. Open 4 half-days a week, the clinic is staffed by trained community health workers who have experienced incarceration and by medical staff who show compassion and treat patients with dignity and respect. Key program elements are described below:
  • Continuous outreach to target population: The clinic uses several strategies to connect with the target population, with a strong focus on reaching individuals while they are still in prison and shortly after their release. Specific outreach strategies include the following:
    • Prison-based outreach: Transitions Clinic medical staff conduct a weekly clinic for inmates at San Quentin prison, during which they educate prisoners on how to access care at the clinic after release. A trained community health worker who has previously experienced incarceration conducts a monthly session that teaches soon-to-be-released prisoners how to do the same.
    • Community-based outreach: Community health workers attend parole meetings each week (which are mandatory for recently released individuals), during which they introduce the program and schedule appointments. Typically, these meetings result in 6 to 8 parolees (out of 20 to 30 who attend) making a clinic appointment.
    • Regular contact with community-based organizations: As part of their case management activities, community health workers are in regular contact with a variety of community-based organizations that serve the target population, including urgent care clinics, substance abuse programs, courts, homeless shelters, single room occupancy hotels, and the San Francisco General Hospital and Trauma Center ED. As a result, these service providers also act as referral sources for the program.
  • Clinic logistics: A community health worker helps every new patient register for services. If patients do not have medical insurance, the worker helps them apply for it. As part of the registration process, patients sign a consent form that allows the community health worker to participate in health care visits, which patients often find reassuring.
  • Quick access to primary and followup care: The clinic, which operates out of designated space at the Southeast Health Center (a San Francisco Department of Public Health facility), provides services 4 days a week (for 4 hours each day). The clinic generally offers appointments within 2 weeks of release to anyone with a chronic illness (including substance abuse) and anyone over the age of 50. Staffed by a physician who treats recently released prisoners with dignity and respect, the clinic offers initial appointments to address immediate needs and ongoing followup care, as outlined below:
    • First visit to address immediate needs: At the first visit, the physician addresses urgent medical issues, screens for infectious diseases, refills medications, and refers patients to specialty care as necessary. At the end of the examination, the community health worker participates in a review of findings and next steps, and then helps the patient address all identified issues, such as obtaining medications and making additional appointments.
    • Followup care: If the patient has an existing relationship with a primary care provider, the community health worker helps to reestablish care with that provider for future followup visits, thus ensuring continuity of care. If not, the community health worker helps establish ongoing care at the clinic or, if requested, with another provider at a San Francisco Department of Public Health clinic.
  • Comprehensive case management, including assistance with social services: The community health worker provides ongoing case management services, including counseling, assistance in navigating the health care system, chronic disease self-management support, and referrals to substance abuse and mental health services. As part of this process, they remind patients about appointments and visit them if they are hospitalized. They also assist with non–health care needs, such as housing, transportation, child care, employment, and legal aid (including assistance in making required court appearances).

Context of the Innovation

In 2005, Dr. Emily Wang and Dr. Clemens Hong, cofounders of the Transitions Clinic, convened a meeting of formerly incarcerated individuals and community organizations to discuss starting a program to address the transitional and primary health care needs of recently released individuals returning to San Francisco from California State prisons. The impetus for the meeting was their past work as internal medicine interns at University of California San Francisco–San Francisco General Hospital where they witnessed high numbers of previously incarcerated individuals receiving treatment in the ED and being hospitalized. In January 2006, with community input and support, they established the Transitions Clinic in collaboration with leaders at Southeast Health Center, a San Francisco Department of Public Health community health center. In 2007, with funding from private foundation grants, they hired their first community health worker.

Did It Work?

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Results

The Transitions Clinic Program has enhanced access to medical care for those recently released from prison, as evidenced by increases in the number of individuals seeking medical care at the clinic and above-average attendance at initial and followup appointments. It also reduced ED visits and generated positive feedback from patients.
  • More recently released prisoners seeking care: Since the program began, the clinic has served over 700 patients. After hiring the community health worker, the average number of new patients seen each month rose by 36 percent (from 7 to 11). Without access to the Transitions Clinic, many of these individuals likely would have sought care in the ED for their chronic illnesses.
  • Above-average attendance at appointments: Transitions Clinic patients show up for their appointments more frequently than do other patients seen at the Southeast Health Center (which serves the neighborhood with the largest number of formerly incarcerated individuals in San Francisco). More than half of clinic patients (55 percent) attend their initial appointment and more than three-quarters (77 percent) attend their 6-month followup appointment, well above the 40 and 46 percent attendance rates for other Southeast Health Center patients.
  • Reductions in ED use: Transitions Clinic patients had significantly fewer ED visits than recently released prisoners who had access to care but did not receive case management services.
  • Positive patient feedback: Many patients have expressed high levels of satisfaction with the Transitions Clinic physician, noting that they are pleased to have this individual as their doctor (suggesting that the patients perceive the clinic as their "medical home").

Evidence Rating (What is this?)

Strong: Evidence for care-seeking behavior and a reduction in ED visits resulted from a randomized controlled trial (RCT) of 200 individuals, half assigned to the Transitions Clinic and half assigned to another safety net clinic that did not provide case management services. Additional evidence consists of post-implementation data on the number of newly released individuals seeking care at the clinic and attendance rates for initial and followup clinic appointments (as compared to attendance rates for other, similar patients seen at the large health center in which the clinic operates).

How They Did It

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Planning and Development Process

Key steps included the following:
  • Engaging political and policy leaders: Dr. Wang and Dr. Hong recognized the need to obtain support from public officials and political leaders (including those working in the Department of Public Health and the Prison System) who understood the political, financial, and social benefits of addressing the health care and social service needs of recently released prisoners. With support from these influential individuals, they obtained buy-in to the program from leaders of community organizations already serving this population.
  • Establishing and eliciting input from advisory board: The two physicians established an advisory board comprised of previously incarcerated individuals and community leaders serving the target population. They conducted focus groups with board members to gain insight into how best to offer program services. The focus groups identified a need for including someone who had previously been incarcerated on the program staff; choosing an easily accessible location for the clinic, close to where the target population lives and preferably within an existing facility; and providing near-immediate access to health care after release.
  • Identifying clinic site: Based on this input, Dr. Wang and Dr. Hong began looking for a health center already serving people who had been incarcerated. They knew the medical director at the Southeast Health Center, who was well aware of how parolees overuse EDs and often require hospitalization. After hearing about their plans, the director readily agreed to designate an examination room within the center to house the clinic.
  • Developing evaluation plan: Dr. Wang and Dr. Hong had previously reviewed ED usage and hospitalization rates among recently released prisoners as a way to document the magnitude of the problem. As part of the development process, they created an evaluation plan designed to document the program's impact on various process measures, such as outreach activities, appointments scheduled, and attendance rates at initial and followup appointments. They also planned to measure the effect of the program on ED usage rates once they had enough patients to capture this type of information. (As mentioned in the evidence rating, they conducted an RCT that looked at care-seeking behavior and ED use.)
  • Securing funding: The doctors received initial funding from the San Francisco Department of Public Health. However, they quickly realized they would need additional funds to pay the salaries of the community health workers. As noted, private foundations provided this funding roughly a year after the clinic opened.
  • Facilitating program expansion: From the beginning, Dr. Wang and Dr. Hong sought to create a model program that others would adopt. Transitions Clinic staff are now providing training and evaluation support to others interested in establishing similar clinics.

Resources Used and Skills Needed

  • Staffing: Program staff include two full-time community health workers, a physician and nurse practitioner who both work 2 half-days a week, and a half-time administrative assistant who maintains contact with prisons. Each community health worker handles a caseload of 30 to 40 patients.
  • Costs: Program costs total roughly $200,000 a year; this figure does not include salary and benefits for the nurse practitioner, which is covered by the Southeast Health Center.
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Funding Sources

Centers for Medicare and Medicaid Services; Robert Wood Johnson Foundation; University of California, San Francisco; Catholic Healthcare West; California Endowment; California Wellness Foundation; San Francisco Department of Public Health; San Francisco Foundation; Newman Foundation; California Policy Research Foundation; African American Disparities Project; Langeloth Foundation
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Adoption Considerations

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Getting Started with This Innovation

  • Research program need: To obtain support from various stakeholders, would-be implementers must be prepared to document the need for transitional and primary health services among chronically ill individuals who have been recently released from prison, along with the potential cost savings associated with providing such services (e.g., fewer ED visits and inpatient admissions).
  • Network with other community-based organizations: High-quality case management services require good relationships with other organizations serving this population. In addition to providing support services to the target population, these organizations can refer patients to the clinic.
  • Hire community health workers who have been in prison: Building trust with those who have been incarcerated can be quite difficult. Community health workers who have previously been in prison have a much greater chance of successfully engaging parolees.

Sustaining This Innovation

  • Remind physicians to be sensitive to patient demeanor: During initial visits, patients may exhibit significant anxiety about how they will be treated. Medical staff must be prepared to address signs of anxiety, mistrust, and general discomfort that may arise.
  • Maintain advisory board: Hold regular meetings with the community advisory board, as members can provide valuable guidance on effective outreach strategies, needed changes to public policy, and methods for disseminating outcomes.
  • Identify sources of long-term funding: Demand for this type of program will likely grow over time. To maintain program viability, would-be developers need to identify public and private sector sources of funding and in-kind support.

More Information

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Contact the Innovator

Shira Shavit, MD
Executive Director, Transitions Clinic Network
2401 Keith Street
San Francisco, CA 94124
Phone: (415) 476-2148
Email: info@transitionsclinic.org

Innovator Disclosures

In addition to the organizations that have financially supported this program that are listed in the Funding Sources section, Dr. Shavit reported receiving monetary payments that are directly or indirectly related to this program from various organizations, as outlined below:
  • Consulting fees and honoraria from the San Francisco Public Health Foundation and the City College of San Francisco for curriculum development and continuing medical education
  • Payment from the University of California, San Francisco for continuing medical education lectures for family physicians
  • Reimbursement of travel expenses from the National Institute of Justice and the Langeloth Foundation for presentations and network expansion activities
  • Receipt of monetary award (the Community Health Leaders Award) from the Robert Wood Johnson Foundation
  • Funding from the California Department of Corrections for activities that are indirectly related to the Transitions Clinic Program

References/Related Articles

An article describing the program is available at: http://www.nytimes.com/2010/02/05/us/05sfprison.html.

An article about one of the program's community health workers is available at: http://articles.sfgate.com/2008-03-30/living/17169128_1_parolees-cell-phone-southeast-health-clinic.

Footnotes

1 Wang EA, Hong CS, Samuels L, et al. Transitions clinic: creating a community-based model of health care for recently released California prisoners. Public Health Rep. 2010 Mar-Apr;125(2):171-7. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 22, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 27, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 23, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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