Tracy Macdonald Mendez, Pacific Health Consulting Group
The Transitions Clinic model is an evidence-based program designed to serve people with chronic diseases who have recently been released from incarceration. Operated by health centers located in communities with high rates of incarceration, Transitions Clinic Network (TCN) programs assist people in this vulnerable population with reintegration into their neighborhoods and lives. TCN sites have served thousands of patients in California and other states.
Founded on the idea that people with lived experience are best able to support people returning to their communities, each clinic that adopts the TCN model employs a community health worker (CHW) as a vital member of its clinical team. CHWs meet with all patients one-on-one, connecting them with health and social services through outreach, assessment, education, counseling, follow-up, and advocacy. They act as liaisons that help ensure that clients receive culturally relevant health services, and they build a unique trust with them that sees their clients using emergency departments and being hospitalized less, and using primary care more.
Health Homes Program: Health Home Program funding is designed to serve Medi-Cal beneficiaries with multiple specified chronic health, mental health, and/or substance use disorders. As it specifically targets care coordination, referrals, case management, and transitional care, it is an ideal funding source for the CHW role.
Whole Person Care: California’s Whole Person Care pilots aim to increase integration and improve coordination for vulnerable Medi-Cal beneficiaries who are frequent users of multiple health care systems. These pilots can pay for care coordination and an array of social services.
Medi-Cal Administrative Services: Several aspects of the CHW role in a Transitions Clinic are eligible activities under Medi-Cal Administrative Activities, including making referrals, coordinating client health care needs with other health care providers, and arranging transportation.
The paper details several more funding sources, all of which come with their own pros and cons. Download the paper and read the full analysis in Related Materials.