Initiate Transitions Clinic Network Pilot(s)

Lead agency: Health and Human Services Agency, Medical Care Services (MCS)  

Population of focus: People transitioning from jail with high need for ongoing healthcare and other supports

SIM intercept: 3-4-5

Summary of planned action: 

Pilot up to two Transitions Clinics, which leverage individuals with lived justice experience to connect individuals leaving jails to a primary care doctor and clinic they can identify as their “medical home.” The Transitions Clinic Network (TCN) is a national program model with the goal of addressing health inequities faced by individuals transitioning out of incarceration.   Community Health Workers engage with and support individuals returning from incarceration, serving as liaisons to help navigate health and social services.

Actions taken:

  • Medical Care Services (MCS) worked closely with key partners such as the TCN national office, the Sheriff’s Office, the Office of Evaluation, Performance and Analytics (OEPA) and a County-employed Community Health Worker with experience working with justice-involved individuals to develop the solicitation documents. The resulting RFP was released in July 2024 and MCS executed a contract in March 2025.  

  • MCS worked collaboratively with the contracted provider and the Sheriff’s Office throughout the program implementation period. Prior to the start of services, the contracted provider was invited to provide a program presentation to the Reentry Counselors from all County Jails, orienting them on the services Transitions Clinic offers and the referral process. The contractor also created program flyers to promote service to potential program participants. 

  • Transitions Clinic is now providing services to individuals referred by the Sheriff’s Office Reentry team. The first referral was received September 5, 2025.  

Next steps: 

  • Transitions Clinic will continue to receive referrals, work closely with the Sheriff’s Office and provide services to program participants. The contractor will continue to track key data such as but not limited to:  

  • Number of clients enrolled in Transitions Clinic Services  

  • Number of clients Community Health Workers met with in jail prior to intake  

  • Percentage of clients in need of primary care services with a scheduled clinical appointment made within one month of intake  

  • Percentage of clients with identified social care service needs linked to needed services within one month of intake