The Transitions Clinic Network (TCN) is a national network of medical homes for individuals with chronic diseases recently released from incarceration. The TCN is founded on the concept that the people closest to the problem are also closest to the solution. Thus, each clinic that adopts the Transitions Clinic Program employs a Community Health Worker (CHW) with a history of incarceration as part of the clinical team. In Fall 2019, the TCN with support from the California Health Care Foundation (CHCF), launched an initiative to expand the TCN program to up to 25 primary care sites throughout California.

CommuniCare Health Centers, Inc. (CCHC) is one of the 25 TCN programs in California. In November 2019, CCHC was notified that they had been accepted into the TCN program. HHSA Public Health Branch (formerly Community Health Branch) partnered with CCHC on the program, as its goal is to address and improve disparities in health outcomes for formerly incarcerated populations.  

On May 5, 2020 the County entered into an Agreement with CCHC which funded a 1.0 FTE CHW Worker (CCHC CHW Worker) to support the TCN program pilot at CCHC through fiscal year (FY) 2022-23.  The CCHC CHW Worker operates in a supportive role within an interdisciplinary health care team utilizing an integrated care and treatment model; provide outreach, case management and navigational service to recently released prisoners with chronic medical, psychiatric, and substance use conditions; and collaborate with primary care and behavioral health providers in the clinic to provide health and behavioral interventions that will maximize patient health outcomes. 

HHSA plans to transition this project to the self-sustaining Enhanced Care Management (ECM) model utilizing “re-entry" scope funding.  The ECM funding/scope was originally scheduled to launch in January 2023, however it has now been delayed to FY23-24.  Thus, HHSA requests the approval of this amendment which adds an additional $16,539.50 in Realignment funding and extends the term of the Agreement through September 30, 2023. This requested extension to September 30, 2023 will allow several months to secure the funding and launch the transition to the ECM model. This funding will continue to fund the CCHC CHW Worker position so that services can continue through the ECM transition. 

Performance Measures included in this Agreement are as follows:
The Performance Measures were included in the underlying Agreement and are not being revised at this time. They are attached here as (Att. B. Performance Measures). HHSA confirms CCHC has performed satisfactorily under this agreement.

A Community Health Worker (CHW) is critical and necessary to the work of the Transitions of Care Team, providing social support, intensive case management, and advocacy services for those recently released from prison who have been diagnosed with a chronic physical or mental health condition, including those affected by substance use. A CHW helps individuals who accept services navigate the local medical, mental health system resource systems to obtain services that support stability and wellness. A CHW has lived experience and has personally experienced incarceration in a federal and/or state prison facility.

As a TCN program site CCHC has become members of TCN’s national network of healthcare professionals, dedicated to amplifying the voice of individuals impacted by mass incarceration to create systematic change. TCN membership has provided CCHC with an opportunity to share best practices and collaborate with colleagues from programs across the nation. Members participate in monthly meetings that are CHW specific called “Firesides”. California site specific meetings have afforded CCHC a network where they can troubleshoot challenges, share best practices, and gain a deeper understanding of significant policies impacting current and prospective patients, and engage in advocacy. CCHC has been able to collaborate in a creative process as they learn from the experiences of their patients, identify gaps in services, and build their skills and networks to fill those gaps. Additionally, there are also annual conferences, ongoing webinars; and the team has access to the online cultural humility manual and toolkit.

The performance measure information provided is from the time period of July 1, 2020 through June 30, 2021.  During this period the funded CCHC CHW Worker completed seven hundred twenty-six (726) visits, including eighty-five (85) unique patients. The number of new patients that were linked to and accessed services are as follows: fifty-three (53) new patients accessed mental health services; thirty-six (36) new patients accessed substance use disorder treatment; and sixty-one (61) new patients accessed physical healthcare with a primary care provider. The primary goal of Transitions of Care and the CCHC CHW Worker position is to provide patient linkage to resources. However, the support needed and provided often goes beyond basic linkage. The CCHC CHW Worker assists patients with accessing the following services, resources, and supports: enrollment in health coverage or other benefits (Cal Fresh/SSI/SSDI/establishing payee), healthcare navigation (primary/specialty care, therapy, psychiatry), accessing vital documents (birth certificates, driver’s licenses, identification), basic human dignity essentials (food, hygiene, laundry), transportation, employment search or job training/education, and peer support. The CCHC CHW Worker position was vacant from December 2021 to November 2022 due to workforce/hiring challenges brought on by the Covid-19 public health emergency.