Lifespan Transitions Clinic

The Lifespan Transitions Clinic (LTC) is an interdisciplinary, primary care-based program serving individuals recently released from incarceration in Rhode Island. Located at the Rhode Island Hospital Center for Primary Care, the LTC provides medical care and peer-driven reentry support to formerly incarcerated patients with chronic medical conditions. The LTC is a partnership of the Center for Health and Justice Transformation, the Rhode Island Hospital Center for Primary Care, and the Lifespan Community Health Institute.

CHJT employs a Medical Discharge Planner, based at the RI Department of Corrections, who can refer patients to the program while they are still incarcerated, and develops safe release plans for patients with terminal and serious illnesses. Transitions Clinic patients are seen for their first appointment within two weeks of their release, at which point they establish with a primary care provider and with a community health worker (CHW). All Transitions Clinic CHWs also have a history of incarceration and work one-one-with patients to help them navigate the healthcare and social service systems while also providing peer support and mentorship.

The LTC serves some of Rhode Island’s most high-risk citizens: incarcerated Rhode Islanders are more likely than their non-incarcerated peers to have chronic and infectious diseases, and in the weeks after their release from prison they have significantly increased mortality and hospitalization rates. More than 50% of LTC patients are homeless or unstably housed upon intake. Sixty percent have a substance use disorder and 66% have a diagnosed mental health disorder.

Launched in January 2018, the Transitions Clinic is still evaluating its long-term impact on patient health outcomes and health care system utilization. Early data from the program’s first year shows that patients are highly engaged in their care: patients who came to clinic at least once had an 88% show rate and were seen at clinic 4.6 times in the first year on average; 89% of patients were still engaged after 6 months in care. Small but significant decreases in emergency department utilization show promise for the program’s ability to decrease health system costs. Thirty of the program’s first 56 patients had only previously interacted with the Lifespan health system via the emergency department, highlighting the program’s ability to bring patients into ambulatory care.

CHW Spotlight: Transitions Clinic CHWs provide comprehensive support to their clients, helping to address numerous reentry needs and allowing the program team to take a true “social determinants” approach to health care. The CHWs meet with clients prior to their release from prison in order to promote trust and facilitate connections to the clinic. Post-release, the CHWs can assist clients with accessing housing, finding employment, enrolling in public assistance programs, replacing vital documents, and securing basic needs like food, clothing, and transportation to appointments. Transitions Clinic CHWs routinely coordinate care with other service providers and partner particularly closely with substance use treatment providers to respond quickly to relapse and encourage long-term recovery. 

The CHWs respond to alerts that their clients are in the hospital and act as patient advocates with the hospital physicians, social workers, and discharge planning teams. Because of the relationships they form with their clients, CHWs often end up working with patients’ family members, facilitating connections often broken by incarceration and providing guidance on how to best support their formerly incarcerated loved ones. Finally, Transitions Clinic CHWs serve as advocates within the criminal legal system, coordinating with clients’ probation and parole officers as necessary and assisting clients in dealing with outstanding legal issues like court fines and fees.

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