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The Case For Expansion
<br />Transitions Clinic Network cofounders
<br />Shavit,thenetwork’sexecutivedirector,
<br />andEmilyWang,itsevaluationdirector,
<br />have worked to build the case forexpan-
<br />sion by conducting regular evaluations
<br />that document the program’s effec-
<br />tiveness.
<br />An early evaluation found that recent-
<br />ly released inmates who got care from
<br />the Transitions Clinic in San Francisco
<br />made fewer emergency department vis-
<br />its than those who were offered care in a
<br />standard primary care clinic, resulting
<br />in an estimated savings of $912 per
<br />patient.4
<br />A more recent study, published this
<br />year in BMJ, looked at outcomes at the
<br />Transitions Clinic in New Haven, Con-
<br />necticut.5 The authors found that in the
<br />twelve months after they were released
<br />from prison, patients who were getting
<br />cared for by the program were neither
<br />morenorlesslikelytoberearrestedthan
<br />another group of former inmates who
<br />were not part of the program. The big
<br />difference: When they were rearrested,
<br />Transitions Clinicpatients spent 45 per-
<br />cent fewer days locked up in jail or
<br />prison. Wang and her colleagues wrote
<br />that the ninety-four people in the
<br />control group would have spent 2,300
<br />fewer days incarcerated if they’d been
<br />clients of the Transitions Clinic. The
<br />authors also found that the clinic’s pa-
<br />tients were less likely to be hospitalized
<br />for preventable conditions and spent
<br />60percentlesstimeinthehospitalwhen
<br />they were admitted. While the authors
<br />couldn’tsaypreciselywhyclinicpatients
<br />spent less time imprisoned, they specu-
<br />lated that being part of the clinic helped
<br />patients get into drug treatment more
<br />quicklyorgavethemaccesstoadvocates
<br />who helped them bail out sooner.
<br />Green helps his clients in these ways
<br />and more. He once convinced a magis-
<br />trate to drop charges against one of his
<br />clients and often talks to parole officers
<br />on his clients’behalf. He works out of
<br />three offices scattered around the coun-
<br />ty to be accessible to his clients, but he
<br />spends most of his time in his mobile
<br />office:thecounty-ownedHondaCiviche
<br />usestogotoclients’homesorferrythem
<br />tocourtdatesordoctor’sappointments.
<br />Green manages a caseload of almost
<br />thirty-five former inmates and gives pri-
<br />ority to those he calls his high-touch
<br />patients,peopleheconsidersvulnerable
<br />and wants to connect with at least once
<br />a week. He drives with a Bluetooth ear-
<br />piece in one ear and makes me slightly
<br />nervous as he engages in animated
<br />phone conversations while making fre-
<br />quent U-turns. He logs about a hundred
<br />miles in a week, he says, while visiting
<br />up to fifteen clients.
<br />I’m pleased when he actually pulls
<br />over to call one client, Pete Jacobs, be-
<br />fore driving to his mobile home on a
<br />country road in Hillsborough. Jacobs
<br />isabigmanwho’sbeingtreatedforhigh
<br />blood pressure and heart problems, as
<br />wellas a leghematoma hesufferedin an
<br />auto accident. Before the accident, he
<br />did roadwork and landscaping. Now,
<br />he says, he’s unemployed and broke.
<br />Jacobs spent five years in prison on
<br />drugcharges,andwhilehewasthere,he
<br />was diagnosed with heart failure.When
<br />he got out, he went a few weeks without
<br />medication until his probation officer
<br />told him about the FIT Program and
<br />gave him Green’s phone number.
<br />Green checks in with Jacobs about
<br />how he’s doing as he drives Jacobs to an
<br />appointment at a county social services
<br />office and then to a local food pantry.
<br />Jacobs is hungry and has no money for
<br />food. Under North Carolina law, he’s
<br />ineligible for benefits from the Supple-
<br />mental Nutrition Assistance Program
<br />(formerly known as food stamps) be-
<br />cause of his drug conviction. At the food
<br />pantry, run by a local United Way affili-
<br />ate, he gets a few bags of groceries.
<br />Green helps him load the food in the
<br />car and then drives Jacobs back home.
<br />WithouttheFITProgram,Jacobssays,
<br />he doesn’t know how he’d get the food,
<br />health care, or medications he needs:
<br />“I don’t get Medicaid. I don’t get food
<br />stamps. I don’t get no check every
<br />month.”
<br />Still, he says, he’s doing a lot better.
<br />He’s taking fewer medications and no
<br />longerneedsdiuretics.“Myhealthisdo-
<br />ing good,”he says.“I take my medicine
<br />everyday.IgotDr.Ashkin.IgotTommy.
<br />And I made it through my probation.”
<br />Green’s next call is to Jeffrey
<br />Fradsham, who at that moment is at
<br />a construction site applying for a job.
<br />Green wants him to meet Marcus
<br />Pollard—a job placement specialist with
<br />the Reentry Council, a local agency
<br />that assists released inmates. We drive
<br />around looking for Fradsham and final-
<br />lypullovertothesideoftheroadtopick
<br />him up. He is covered in tattoos.
<br />Fradsham tells me he’s been in and
<br />out of prison since he was seventeen
<br />and learned to do tattooing there be-
<br />cause “the only thing to do in prison is
<br />fight or tattoo yourself.”He’s nothing if
<br />not ingenious: In prison he made tattoo
<br />needles out of the springs in ballpoint
<br />pens and used the motor of an old CD-
<br />ROM player to drive the needles. Out-
<br />side prison, he has worked as a profes-
<br />sional tattoo artist, so when we get to
<br />Pollard’sofficeinChapelHill,Fradsham
<br />tells him he’d like to go back to that line
<br />of work. He says he’s been offered a seat
<br />in a local tattoo parlorbut needs around
<br />$400 to buy a tattooing machine. If the
<br />offerfromtheparlorisreal,Pollardtells
<br />him,hecanprobablygethimthemoney.
<br />Fradsham has struggled with heroin
<br />addiction but says he quit cold turkey
<br />during his last stint in prison. He’s
<br />been out for ten months and struggles
<br />with posttraumatic stress disorder from
<br />the violence he experienced. He once
<br />watched a man get stabbed thirty-seven
<br />times “over nothing”with a shiv made
<br />from a light fixture. It’s difficult to be
<br />back outside, he says:“People move out
<br />of the way when I walk down the street.”
<br />Green drops Fradsham at his house,
<br />and we head to Hillsborough and the
<br />Orange County Jail, where Alison
<br />Zirkel, a social worker with the county’s
<br />Criminal Justice Resource Department,
<br />is about to meet with an inmate. She’s
<br />sitting at a card table in a small meeting
<br />room, near a bank of phones and a sign:
<br />“Inmates, pick up your phone first.”
<br />Inajailwithacapacityof120inmates,
<br />Zirkel typically works with 20–30 at
<br />any one time who have mental health
<br />orsubstanceabuseproblems—frequent-
<br />ly both—and little or no access to medi-
<br />cal care outside of custody. For many,
<br />the combination of being homeless
<br />andabusingsubstanceshasledtopublic
<br />intoxication, assaults, and fights.
<br />Without the FIT Program,
<br />Jacobs says, he doesn’t
<br />know how he’dgetthe
<br />food, health care, or
<br />medications he needs.
<br />October 2019 38:10 Health Affairs 1619
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