Community-based transitional care from prison to the community: A new role for community health workers

The period immediately after release from prison is one of the most vulnerable for people with chronic illnesses. The Post-Release Wellness Project is an innovative model designed to promote the health and well being of newly released prisoners in which Community Health Workers (CHWs) are at the heart of its success. This model has been developed through a partnership of three organizations. Transitions Clinic is the first patient-centered clinic serving San Francisco's recent parolees who have chronic health conditions by providing primary health care, substance abuse counseling and mental health services. The clinic's CHW plays a pivotal role in providing culturally appropriate care through outreach, case management, and linkages to a range of health, social and educational services within two weeks upon release. City College of San Francisco provides the educational foundation for this model through the development of a specialty certificate for CHWs who want to serve people with a history of incarceration. Courses expose students to the particular health concerns facing formerly incarcerated people and prepare them to support patients' successful reentry to their communities. Legal Services for Prisoners with Children, through its links to the community, conducts formative research for this project and leads its policy and advocacy component by challenging systemic barriers to successful re-entry. This unique model utilizes the expertise of CHWs with the collaboration of community organizations to successfully promote the health and well being of recently released patients with chronic disease.