Addressing Social Determinants of Health: Community Health Workers for Legal Advocacy and Navigation

Low-income patients have many unaddressed legal needs due to a lack of financial resources or unfamiliarity with their rights leading to detrimental consequences for their health and welfare. Recently released prisoners make up an especially vulnerable subset of underserved communities struggling with social determinants of health when reintegrating into society. They are frequently denied social security applications, confront housing discrimination, contend with child custody disputes, and face parole violations.. The outcome of these legal interactions has great implications on their health impacting food security, family reunification and stable housing. Former prisoners face additional barriers when navigating the legal system. They may feel mistrustful or intimidated by the courts and lack resources to obtain adequate legal counsel. The Transitions Clinic is an innovative primary care medical home that provides services to chronically-ill recently released prisoners utilizing a team of community health workers (CHWs). The CHWs, who have histories of incarceration, aid the patients in navigating the complexities of the legal system They inform patients of their rights, determine eligibility for services, refer them to legal counsel and act as a support system when patients become frustrated and disillusioned. While the clinic is primarily focused on returning prisoners, strategies utilized for legal advocacy and navigation can be implemented to provide comprehensive services for any vulnerable population. Utilizing CHWs for legal system navigation is a model for addressing the social determinants of health of vulnerable, chronically-ill populations improves the health of communities beyond the healthcare system.