Transitions Clinic Network
367 Cedar St.
New Haven CT 06510
Contact Information
Address 367 Cedar St.
New Haven, CT 06510-
Telephone (203) 737-7475 x
Fax 203-737-3306
E-mail s.greenberg@yale.edu
Web and Social Media
Mission

In Connecticut and across the country, there is a decades-old health crisis for those coming home from prison. In New Haven 1,200 individuals are released from incarceration to the community each year and 80-85% have chronic health problems. These individuals, like their counterparts across the country, are often acutely vulnerable. In the first two weeks following release, an individual coming home from state prison is 12 times more likely to die than an average person from the same state.

To address these severe inequities, Transitions Clinic–New Haven provides patient-centered, transitional and primary care services to individuals with chronic diseases returning home to New Haven from prison. Embedded within the Yale Primary Care Center and Cornell Scott Hill Health Center care systems, the program creates a unique medical home for patients and their families. Our mission is to provide timely medical care for individuals upon release from prison in order to promote healthy reintegration into their communities. Transitional care includes visits with a primary care provider, medication refills, and a referral to specialty services, while also addressing any urgent medical issues.
 
Patients who receive primary care at Transitions Clinic–New Haven receive specific services geared toward the reentry population: (1) primary medical care by healthcare providers who are culturally competent in working with incarcerated or previously incarcerated individuals, (2) case management and chronic disease self-management support by a trained community health worker (CHW) with a history of previous incarceration, and (3) partnerships with community organizations providing services to recently released individuals. Input from focus groups of individuals with a history of incarceration and ongoing advice from a community advisory board with majority representation of formerly incarcerated individuals informed the design for this model of healthcare.
At A Glance
Year of Incorporation 1988
Organization's type of tax exempt status Public Supported Charity
Organization received a competitive grant from the community foundation in the past five years Yes
Leadership
CEO/Executive Director Dr. Emily Wang
Board Chair Robyn Frye
Board Chair Company Affiliation Workday
Financial Summary
Revenue vs Expenses Bar Graph - All Years
Statements
Mission

In Connecticut and across the country, there is a decades-old health crisis for those coming home from prison. In New Haven 1,200 individuals are released from incarceration to the community each year and 80-85% have chronic health problems. These individuals, like their counterparts across the country, are often acutely vulnerable. In the first two weeks following release, an individual coming home from state prison is 12 times more likely to die than an average person from the same state.

To address these severe inequities, Transitions Clinic–New Haven provides patient-centered, transitional and primary care services to individuals with chronic diseases returning home to New Haven from prison. Embedded within the Yale Primary Care Center and Cornell Scott Hill Health Center care systems, the program creates a unique medical home for patients and their families. Our mission is to provide timely medical care for individuals upon release from prison in order to promote healthy reintegration into their communities. Transitional care includes visits with a primary care provider, medication refills, and a referral to specialty services, while also addressing any urgent medical issues.
 
Patients who receive primary care at Transitions Clinic–New Haven receive specific services geared toward the reentry population: (1) primary medical care by healthcare providers who are culturally competent in working with incarcerated or previously incarcerated individuals, (2) case management and chronic disease self-management support by a trained community health worker (CHW) with a history of previous incarceration, and (3) partnerships with community organizations providing services to recently released individuals. Input from focus groups of individuals with a history of incarceration and ongoing advice from a community advisory board with majority representation of formerly incarcerated individuals informed the design for this model of healthcare.
Background

Transitions Clinic-New Haven is part of a national network of 13 primary care programs focused on improving the health of those returning from incarceration in 6 states and Puerto Rico. 

 

In Connecticut, since its inception, Transitions Clinic-New Haven has served approximately 480 recently-released individuals. These patients benefit tremendously. With the help of CHWs, 55% of new patients referred to clinic showed up for their first appointment, and 77% of patients remained in care at six months—rates significantly higher than those in the clinic’s general population. 

 

Transitions Clinic-New Haven core care team is made up of three providers (two internal medicine physicians and an advanced practice registered nurse), formerly-incarcerated community health workers, and a panel manager. Each clinician has extensive experience providing primary care to underserved populations in the New Haven community.
 
The community health workers use their own lived experience and college-level training on the health impacts of incarceration to connect with patients in prison and immediately following release to help navigate them through the complexities of the social service and healthcare system. They accompany patients to other medical appointments, provide chronic-disease self-management support, and place referrals to employment, education and housing services. Community health workers are available twenty-four-seven by phone to assist patients and act as a tightly knit support network for patients.
 

In addition to the core care team, each patient has access to the services of a medical-legal partnership between Transitions Clinic and Yale Law School. Two law student volunteers work directly with the team at the clinic sites to address patients’ potentially health-harming legal needs, such as employment discrimination and access. Moreover, patients seen at Cornell Scott Hill Health Center have access to wrap-around primary care, dental services, and mental health treatment.


Impact
In a city so heavily affected by incarceration and chronic illness—particularly asthma, diabetes and hypertension—Transitions Clinic-New Haven strives each year to expand its reach, in terms of patient population and breadth of programming. In New Haven 1,200 individuals are released to the community each year, of which 80-85% have chronic health problems.
 
1) From 2015-2016, a Community Foundation for Greater New Haven grant allowed us to serve 110 new patients recently-released from incarceration and have 599 patient-doctor visits, a 10% increase from the previous year.
 
2) In the last year Transitions Clinic-New Haven was awarded a number of other grants, including a:
 
-U.S. Department of Health and Human Services grant to provide trauma-informed care to women coming home from incarceration with substance use disorders. The grant's primary aims are to reduce sexual and drug risk behaviors, reduce Intimate Partner Violence, and link women to HIV treatment programs.
 
-Tow Foundation grant to open Transitions Clinic-Bridgeport, Connecticut. This clinic will provide patient-centered, transitional and primary care services to individuals with chronic diseases returning home from prison to Bridgeport. 
 
- A three-year Substance Abuse and Mental Health Services Administration grant to use trauma-informed and evidence-based treatments to support the successful transition of 300 substance-using adults back to their communities and families.
 
3) Decades-long over-incarceration has fractured the social contract in the United States, perpetuating intergenerational poverty and political marginalization. To address this, our program works to engage formerly incarcerated individuals in forms of democratic life such as community organizing and policy reform. For example, in 2016 we launched a voter registration campaign; our research from previous campaigns shows that formerly incarcerated individuals are as likely to vote as new voters without criminal records.
Needs In the wake of the 2016 election, with its implications for mass incarceration and public health, Transitions Clinic-New Haven continues to push its model forward. In the last year our outfit was awarded a number of grants, including a U.S. Department of Health and Human Services grant to provide trauma-informed care to women coming home from incarceration with substance use disorders. Though these are achievements, none of them can fund our community health worker. Without a community health worker, Transitions Clinic-New Haven would cease operating for some time. As we build our programs, our core operating support—our lead community health worker—is critical: for training, implementation and operations. As we continue to expand in these uncertain times, maintaining the pillar of the Transitions model is more critical than ever.
CEO Statement Transitional health care is a critical safeguard for individuals coming home from prison, especially given communities most impacted by mass incarceration are medically underserved. Transitions Clinic–New Haven works with three primary outcomes in mind: 1) Improving patient health and quality of life, which includes addressing chronic medical conditions and assisting with family unification, connections to employment, housing and legal services; 2) Improving health care utilization among formerly incarcerated individuals by improving access and engagement with primary care and decreasing preventable emergency department utilization and hospitalizations; and (3) reducing rates of rearrest, reconviction, and reincarceration.  - Emily Wang, MD, MAS
Board Chair Statement

Since 2004, the San Francisco Public Health Foundation has been pleased to be the fiscal sponsor for the Transitions Clinic Network, both  in California and in New Haven.  The successes of the Transitions Clinic-New Haven program are detailed elsewhere in this profile, and we are especially proud of its good work. I volunteer for the San Francisco Public Health Foundation to ensure that programs like Transitions Clinic-New Haven can continue to make our communities fairer, happier, and healthier. I am honored to be affiliated with them. - Robyn Frye

Service Categories
Primary Organization Category Health Care / Public Health
Areas Served
Ansonia
Bethany
Branford
Cheshire
Derby
East Haven
Guilford
Hamden
Lower Naugatuck Valley
Madison
Milford
New Haven
North Branford
North Haven
Orange
Oxford
Seymour
Shelton
Shoreline
State wide
Wallingford
West Haven
Woodbridge
Programs
Description Connecting the formerly incarcerated to primary care.
Population Served Minorities / Poor,Economically Disadvantaged,Indigent / At-Risk Populations
Program is linked to organization’s mission and strategy Yes
Program is frequently assessed based on predetermined program goals Yes
Short Term SuccessHelpOrganizations describe near term achievement(s) or improvement(s) that will result from this program. This may represent immediate outcomes occurring as a result of the end of a session or service. On the individual level, we will decrease ED and hospitalization utilization for ambulatory sensitive care conditions, increase enrollment in health insurance, and improve access post-release to primary care and behavioral health and substance use treatment. On the community level, we plan to actively focus on increasing civic engagement of returning community members. We want to simultaneously attend to first-order needs of the formerly incarcerated and the systematic social-civic disenfranchisement of communities by facilitating community advocacy and organizing, voter registration and outreach.
Long Term SuccessHelpOrganizations describe the ultimate change(s) that will result from this program. This may be far into the future and represent an ideal state. On a systems level, we will continue to expand in Connecticut and work with State government to develop a mechanism for sustainability that would fund community health workers through State Medicaid. 
Program Success Monitored ByHelpOrganizations describe the tools used to measure or track program impact.
Transitions Clinic-New Haven is committed to quality improvement of care through the collection of patient-centered data. For individuals engaged in care, we administer a survey at the first appointment that captures baseline demographic information, social needs (housing, employment, etc.) and healthcare concerns; we also capture the participants’ referral source, time from release engaged in primary care, and medical records at baseline. For those who consent to further data collection, we collect a more detailed array of data on socio-demographics, medical and behavioral health history, past health care utilization, and incarceration history. We also collect data at 3-month intervals on health care utilization through participant self-report and data abstraction from electronic medical records, and recidivism through self-report, direct communication with the local department of correction, or publicly available criminal justice data portals.   
Examples of Program SuccessHelpOrganization's site specific examples of changes in clients' behaviors or testimonies of client's changes to demonstrate program success.

At the jump, Transitions Clinic-New Haven was the progeny of rigorous evaluation, backed by the success of previous transitional clinics in the Transitions Clinic Network (TCN). In a randomized controlled trial in San Francisco, participants receiving TCN care demonstrated a 50% reduction in emergency department visits over the first 12 months compared to participants receiving non-TCN care (Wang, 2012). In addition, certain health outcomes, especially HIV-related, were improved in specific Transitions Clinic sites (Fox, 2014). Furthermore, with the help of community health workers, 55% of new patients referred to clinic showed up for their first appointment, and 77% of patients remained in care at six months—rates significantly higher than those in the clinic’s general population (Wang, 2010). 

Since its inception, the Transitions Clinic-New Haven team has served approximately 480 recently-released individuals.

CEO/Executive Director
Dr. Emily Wang
Term Start Jan 2012
Email emily.wang@yale.edu
Co-CEO
Experience Dr. Emily Wang, MD, MAS, is an Associate Professor at the Yale School of Medicine and Co-Founder of the Transitions Clinic Network. Dr. Wang’s research focuses on promoting health equity for vulnerable populations, especially individuals with a history of incarceration, through both prison and community based interventions. She has developed expertise in training former prisoners to become community health workers and researchers through community based participatory research methods. She is Co-Founder of the Transitions Clinic Network, a consortium of 15 community health centers nationwide dedicated to caring for recently released prisoners and defining best practices for the health care of individuals leaving prison. In 2012, the Transitions Clinic Network was awarded the Centers for Medicare & Medicaid Innovation Award to provide care to over 2,000 high-risk, high-cost patients returning from prison and to train and employ former prisoners as community health workers. Dr. Wang is the principal investigator on a number of NIH and institute-funded research projects, including a NHLBI-funded project to improve cardiovascular outcomes in patients with a history of incarceration. She was a member of the Institute of Medicine’s Health and Incarceration Workshop (2012) and Means of Violence Workshop (2014). Dr. Wang has a BA from Harvard University, an MD from Duke University, and a MAS from the University of California, San Francisco.
Staff
Number of Full Time Staff 4
Number of Part Time Staff 1
Number of Volunteers 7
Staff Retention Rate 100%
Staff Demographics - Ethnicity
African American/Black 2
Asian American/Pacific Islander 1
Caucasian 2
Hispanic/Latino 0
Native American/American Indian 0
Other 0 0
Staff Demographics - Gender
Male 3
Female 2
Unspecified 0
Formal Evaluations
CEO Formal Evaluation Yes
CEO/Executive Formal Evaluation Frequency Annually
Senior Management Formal Evaluation Yes
Senior Management Formal Evaluation Frequency Annually
Non Management Formal Evaluation Yes
Non Management Formal Evaluation Frequency Annually
Collaborations
Transitions Clinic-New Haven works with many organizations in the city, state and country. This includes the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration, the City of New Haven, the Connecticut Department of Correction, Easter Seals Goodwill Industries, and Project Fresh Start.
We are also part of a national network of 13 community health centers in 6 states and Puerto Rico. The TCN’s work is guided by local Community Advisory Boards whose membership is made up of a majority of individuals with a history of incarceration, and a National Advisory Board, which includes expertise and leadership from civil rights and advocacy organizations for formerly incarcerated individuals, like All of Us or None and JUSTUSA.
Board Chair
Robyn Frye
Company Affiliation Workday
Term July 2016 to June 2017
Board of Directors
NameAffiliation
Colleen Chawla SF Dept. of Public Health
Nicole Falk Ernst & Young
Elizabeth Ferber Kaiser Permanente
Rachel Fernandez Genentech
Sarah Fine UCSF
James Loyce Community Volunteer
Tim McDowell Cypress Point Capital Management
Margine Sako St. Mary's Medical Center Foundation
Gayle Uchida Synergy Home Care
Alice Villagomez Community Volunteer
Board Demographics - Ethnicity
African American/Black 1
Asian American/Pacific Islander 2
Caucasian 7
Hispanic/Latino 1
Native American/American Indian 0
Other 0 0
Board Demographics - Gender
Male 2
Female 9
 
 
Financials
Fiscal Year Start July 01 2016
Fiscal Year End June 30 2017
Projected Revenue $350,000.00
Projected Expenses $300,000.00
Spending Policy N/A
Credit Line No
Reserve Fund Yes
Documents
Form 990s
Form 9902016
Form 9902015
Form 9902014
Audit Documents
SFPHF Audit2016
SFPHF Audit2015
SFPHF Audit2014
IRS Letter of Exemption
SFPHF Affirmation Letter 2014
Detailed Financials
Prior Three Years Revenue Sources ChartHelpThe financial analysis involves a comparison of the IRS Form 990 and the audit report (when available) and revenue sources may not sum to total based on reconciliation differences. Revenue from foundations and corporations may include individual contributions when not itemized separately.
Fiscal Year201620152014
Foundation and
Corporation Contributions
$4,872$21,680$30,263
Government Contributions$0$0$0
Federal------
State------
Local------
Unspecified------
Individual Contributions------
------
$358,403$1,016,574$1,267,628
Investment Income, Net of Losses$12,352$7,510$11,732
Membership Dues------
Special Events------
Revenue In-Kind------
Other----$10,444
Prior Three Years Expense Allocations Chart
Fiscal Year201620152014
Program Expense$148,738$865,132$1,118,708
Administration Expense$83,239$82,373$69,617
Fundraising Expense------
Payments to Affiliates------
Total Revenue/Total Expenses1.621.101.11
Program Expense/Total Expenses64%91%94%
Fundraising Expense/Contributed Revenue0%0%0%
Prior Three Years Assets and Liabilities Chart
Fiscal Year201620152014
Total Assets$4,521,332$3,027,701$2,402,896
Current Assets$4,521,332$3,027,701$2,402,896
Long-Term Liabilities$4,112,404$2,568,367$2,053,066
Current Liabilities$18,745$15,711$4,778
Total Net Assets$390,183$443,623$345,052
Prior Three Years Top Three Funding Sources
Fiscal Year201620152014
Top Funding Source & Dollar Amount -- -- --
Second Highest Funding Source & Dollar Amount -- -- --
Third Highest Funding Source & Dollar Amount -- -- --
Solvency
Short Term Solvency
Fiscal Year201620152014
Current Ratio: Current Assets/Current Liabilities241.20192.71502.91
Long Term Solvency
Fiscal Year201620152014
Long-Term Liabilities/Total Assets91%85%85%
Capitial Campaign
Currently in a Capital Campaign? No
Comments
Foundation Staff Comments
The Transitions Clinic Network operates under the 501c3 of the San Francisco Public Health Foundation. The 990s and audits contained in this profile are those for the San Francisco Public Health Foundation. The previous three years of financial information in the profile is specific to the San Francisco Public Health Foundation.
 

This profile, including the financial summaries prepared and submitted by the organization based on its own independent and/or internal audit processes and regulatory submissions, has been read by the Foundation. Financial information is inputted by Foundation staff directly from the organization’s IRS Form 990, audited financial statements or other financial documents approved by the nonprofit’s board. The Foundation has not audited the organization’s financial statements or tax filings, and makes no representations or warranties thereon. The Community Foundation is continuing to receive information submitted by the organization and may periodically update the organization’s profile to reflect the most current financial and other information available. The organization has completed the fields required by The Community Foundation and updated their profile in the last year. To see if the organization has received a competitive grant from The Community Foundation in the last five years, please go to the General Information Tab of the profile. 

Address 367 Cedar St.
New Haven, CT 06510
Primary Phone 203 737-7475
Contact Email s.greenberg@yale.edu
CEO/Executive Director Dr. Emily Wang
Board Chair Robyn Frye
Board Chair Company Affiliation Workday

 

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