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RCORP - Rural Center of Excellence on SUD Prevention

Transitions Clinic Network Programs: Engagement Plan

When implementing a Transitions Clinic Network (TCN) program, consider creating an engagement plan that addresses barriers while developing relationships with rural community stakeholders. A community health worker (CHW) with lived experience of incarceration is a core component of the TCN program and is vital to the overall success of this engagement plan in rural communities.



Lack of awareness of TCN programs

  • Develop promotional plan utilizing websites, social media, flyers.
  • CHW and/or primary care provider (PCP) goes on local radio/television stations; speaks at community locations (e.g., libraries); attends health fairs (with attention to privacy concerns).
  • Build relationships with community-based organizations, criminal justice partners (such as parole and probation), faith-based organizations, and other healthcare providers such as emergency departments and behavioral health providers.
  • CHW and PCP share the value of medications for opioid use disorder (MOUD) and its impact on individuals returning to the community and their loved ones to address concerns and stigma. 
  • CHW meets regularly with community agencies and prison/jail systems to build partnerships.


  • CHW attends re-entry programs and connects with representatives from transitional housing; courts, including drug treatment courts; and inpatient and outpatient substance use treatment programs.
  • CHW connects with organizations addressing health disparities by race, income, and other demographic factors.
  • These relationships lead to word of mouth and patient and CHW referrals.

Patients experience financial limitations or social/cultural barriers or are unaware of services available

  • CHW engages patients before jail/prison release to assess needs and coordinate services for warm handoffs.
  • CHW helps with navigating health department services and Supplemental Security Income (SSI)/Social Security and Disability Insurance (SSDI).
  • CHW connects with organizations addressing health disparities by race, income, intimate partner violence, and other social determinants of health and is knowledgeable about resources.


  • CHWs with lived experience of incarceration act as cultural interpreters and advocates between patients and healthcare providers to mitigate stigma.
  • CHWs engage patients in care and help overcome mistrust of medical systems.
  • UR Medicine Recovery Center of Excellence has developed community-focused stigma tools and workshops for both providers and community members. See our resource page on reducing stigma.


Partnerships can strengthen referrals, provide training and guidance, and help in securing funding. Potential partners include:

  • Substance use disorder treatment programs
  • Community service organizations
  • Faith-based organizations
  • Foundations
  • Government organizations
  • Health and dental plans
  • Local hospitals
  • Multicultural alliances and associations
  • Public health organizations
  • State and local health departments
  • Universities and colleges
  • Volunteer groups

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