Formerly incarcerated community health workers engaging individuals returning from incarceration into primary care: Results from the transition clinic network

Over half a million individuals return from United States prisons and millions more from jails every year, many of whom with complex health and social needs. Community health workers (CHWs) perform diverse roles to improve health outcomes in disadvantaged communities, but no studies have assessed their role as integrated members of a primary care team serving individuals returning from incarceration. Using data from participants who received primary care through the Transitions Clinic Network, a model of care that integrates CHWs with a lived experienced of incarceration into primary care teams, we characterized how CHWs address participant health and social needs during interactions outside of clinic visits for 6 months after participants established primary care. Among the 751 participants, 79% had one or more CHW interactions outside of the clinic documented. Participants with more comorbid conditions, longer stays during their most recent incarceration, and released with a prescription had more interactions with CHWs compared to those with fewer comorbidities, shorter stays, and no prescription at release. Median number of interactions was 4 (interquartile range, IQR 2–8) and 56% were in person. The most common issues addressed (34%) were social determinants of health, with the most common being housing (35%). CHWs working in interdisciplinary primary care teams caring for people with histories of incarceration perform a variety of functions for clients outside of scheduled primary care visits. To improve health outcomes among disadvantaged populations, CHWs should be able to work across multiple systems, with supervision and support for CHW activities both in the primary care clinic and within the community.