Transitions Clinic Network: Challenges And Lessons In Primary Care For People Released From Prison

Low-income and minority communities are disproportionately affected by incarceration, which exacerbates health disparities. Through enhanced primary care, the Transitions Clinic Network (TCN) seeks to improve the health of people with chronic conditions who return to their communities from prison. Using TCN data, we assessed the impact of early engagement in primary care and referral from correctional systems to TCN on the use of acute care (emergency department visits and hospitalizations) and recidivism. Of 751 patients, 29.8 percent were referred by correctional partners, and 52.7 percent were engaged in TCN care within one month after release. In the twelve months after release, patients referred by correctional partners had fewer acute care visits, compared to those referred by community-based partners, while early engagement was associated with more acute care visits. Neither referral by correctional partners nor early engagement was significantly associated with recidivism. Our findings suggest that health equity for this vulnerable population could be achieved through improved coordination between correctional and community health care systems.