Every year, more than one million people are admitted to and released from California jails and prisons. This reentry population — people returning to the community following incarceration — have acute health needs but often have difficulty accessing timely, appropriate care.

People involved with the justice system experience high rates of physical and mental health problems within complicated social contexts, including trauma, unemployment, and poverty. Many have complex health conditions: An estimated 60% of California prison inmates have substance use disorders, one quarter have a serious mental illness, and many also have multiple physical health conditions including hypertension, infectious diseases, and asthma.

The Transitions Clinic model is an evidence-based program designed to serve the needs of people recently released from incarceration. It started in 2006 with a pilot project at a San Francisco community health center. The model spread, and now the Transitions Clinic Network (TCN) links together 48 clinics in 14 states and Puerto Rico, including 21 in California.

TCN provides training and technical assistance to its member sites. Studies have shown that the TCN model cut emergency department visits and hospitalizations in half. An innovative component of the model is including a community health worker (CHW) with a history of incarceration as part of the health care team. CHWs connect patients to health and social services through outreach, educational, and advocacy efforts.