The Bronx Transitions Clinic (BTC) is an innovative model for primary care linking former inmates to medical care promptly after release from jail or prison. Chronic health conditions, including infectious diseases, substance use disorders, and mental illness, are overrepresented among jail and prison inmates and may go untreated during incarceration. Following release from jail or prison, former inmates face barriers to care, such as costs, long waits, and discrimination in medical settings. The BTC is a collaboration between Montefiore Medical Center and the Osborne Association, a community-based organization serving former inmates, and it seeks to address these barriers to care. The BTC provides a medical home with open access scheduling at a Federally Qualified Health Center (FQHC), uses a community health worker (CHW) to provide patient navigation, and is staffed by clinicians with experience caring for former inmates. Our goal is to link former inmates with chronic health conditions to primary care within two weeks of release from jail or prison and to retain them in medical care. In this model of primary care delivery, the CHW, who was formerly incarcerated, is a key member of the medical team, and intervention begins within correctional facilities. The Osborne Association provides health education and discharge planning at New York State prisons, so they are ideally positioned to refer inmates with chronic health conditions to the BTC. All referrals are received by the CHW, who meets former inmates following their release, educates them about the BTC, and builds rapport. The CHW is fluent in English and Spanish, trained in health education, evidence-based recidivism prevention, and communication skills, and committed to this population. Prior to the initial BTC visit, the CHW assists new patients in completing clinic registration forms, applying for Medicaid, and accessing other social services. The CHW also calls former inmates with reminders about their appointment and provides transportation assistance. The clinical services available at the BTC include comprehensive primary care, HIV, substance abuse, and mental health treatment. The BTC is integrated into the FQHC's normal work flow and provides care two half-days per week with a voluntary physician. One session is open access, and in the other, care is provided by a medical resident. Medical students often accompany physicians during clinical encounters. All other services offered at the FQHC, including social work, Medicaid enrollment, and pharmacy services, are also available to BTC patients. Following their initial visit, BTC patients may follow-up at the open access session or they are integrated into the treating physician's patient panel. The BTC was established in 2009. The location of care at a FQHC and collaboration between an academic medical center and community based organization has contributed to sustainability. All medical care is paid for by health insurance or on a sliding-scale for patients without insurance. The CHW and discharge planning are supported with grant funding from New York State. Building on the resources already available at an FQHC and in the community, the BTC has delivered patient-centered care to over 300 former inmates.
KeywordsPrimary Care, Health Equity Research, Medical Home, Chronic Disease, Community Health, Transitions Clinic, Community Health Worker
Aaron D. Fox, MD, MS, Albert Einstein College of Medicine of Yeshiva University
Matthew R. Anderson, MD, MS, MPH, Albert Einstein College of Medicine of Yeshiva University
John Valverde, Osborne Association
Chinazo O. Cunningham, MD, MS, Albert Einstein College of Medicine of Yeshiva University
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