Community Health Worker

Transitions Clinic network program

A Transitions Clinic Network (TCN) program provides health care and wrap-around support for formerly incarcerated people who are transitioning into the community. A TCN program treats patients for chronic health conditions including mental health and substance use disorders; provides linkages to inpatient or outpatient treatment programs; and for patients with opioid use disorder can prescribe medications for opioid use disorder (MOUD). A TCN program provides culturally informed care and seeks to reduce the stigma formerly incarcerated patients may face. Through the work of a Community Health Worker who has lived experience, it connects with patients before release, ensures coordination of care, and helps patients navigate resources in the community.

The Transitions Clinic Network supports TCN programs across the country, providing support and implementation assistance. TCN is a national nonprofit organization that works in collaboration with primary care health systems to transform care for chronically ill people returning from incarceration. As of 2021, 48 health systems in 14 states and Puerto Rico have implemented and adapted the TCN evidence-based model in their communities. TCN programs all employ Community Health Workers with lived experience of incarceration on healthcare teams.

Provide preventive and treatment services to high-risk enrolled patients to address the needs of individuals recently released from incarceration. Supplement primary care with services to reduce substance use and mental health disorders as well as trauma that impact health and access to health care. Provide services to enrolled patients directed at identifying and prioritizing patient concerns/problems impacting the quality of their lives. Promote and support patients' engagement in services that address their concerns.

The role and activities of the Community Health Worker are tailored to meet the unique needs of the community they serve. The role also depends on factors such as education, training, lived experience, and experience working with specific populations.

The Community Health Worker has lived experience with incarceration. Varied work experience may be considered, including care of a relative at home, health education of others while incarcerated, or community volunteering.

Clinical Services and Other Duties

1. Meet with enrolled participants in a group or individual setting to conduct interventions that focus on facilitating access to health and social/community services and prevention/treatment of chronic health care conditions, in the context of re-entry from incarceration or other recent justice involvement. The employee will be trained in and utilize evidence-based approaches to assist patients in identifying and prioritizing problems that impact their well-being.

2. Create working relationships with primary care providers, an interdisciplinary team, and community-based programs to provide coordinated care strategies to engage patients in identifying problems that impact them and assist them in addressing these problems.

3. Assist patients in formulating health action plans addressing problems according to their choices, in line with Transitions Clinic practices.

4. Document activities in the electronic medical record and team tracking materials.

An extended (such as 1-year) period in sobriety, and justice involvement. The employee must demonstrate promptness, dependability, responsibility, good interpersonal skills, verbal and written communication skills, strong organizational skills, self-motivation, empathy, acceptance of and interest in a diverse client population, ability to respond supportively and with persistence to the patients/participants, understanding of the community (including resources), and ability to maintain project records. The ability to work well and flexibly with a variety of individuals is needed. Willingness to represent the program and collaborate with community agencies is required. Must have a valid driver’s license (to operate company car) and/or own/lease a car (mileage reimbursed), and be willing to seek out participants in various community locations, including home, transitional housing, jail, or court if needed. Computer skills with Word are required and must know or be willing to learn how to manage Outlook for scheduling and email, as well as Excel.

Professional and personal experience are valued over formal education. No specific educational requirement. Community Health Workers are not licensed, but employers may set continuing education requirements.

Individuals may qualify for loan repayment, forgiveness, or assistance depending on their particular circumstances. For more information, please see the National Health Service Corps’ webpage (https://nhsc.hrsa.gov/). This includes those working with special populations (opioid use disorder) and in specific regions (rural communities).

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