Shira Shavit, MD


Transitions Clinic Network (TCN) is a UCSF FCM based program that supports health systems to implement an evidenced based model of care for people with chronic conditions returning to the community from incarceration.  The TCN program, developed in San Francisco in 2006, has since been implemented at 40 clinics in 14 states and Puerto Rico.  All TCN partner clinics employ community health workers (CHW) with histories of incarceration as an integral part of the primary care team.

TCN programs work with patients who are older, sicker and have complex social needs. These patients are at increased risk of contracting and experiencing negative consequences due to COVID-19.

In response to COVID-19, TCN:

  • Hosted multiple weekly COVID response calls with national TCN program partners to share programmatic and policy updates;
  • Created an online referral system to facilitate continuity of healthcare services from the 35 California state prisons to community health systems;
  • Launched a toll-free reentry hotline staffed by TCN CHWs, 844-TCN-WELL, to assist individuals returning or recently released from incarceration in California with accessing community health services;
  • Collaborated with local, state and national reentry organizations to advocate for mass release of individuals from all incarceration settings to prevent rampant spread of COVID-19 across correctional facilities.

We continue to facilitate conversations around re-defining best practices in connecting to and engaging with people coming home from incarceration during COVID-19. We also are trying to explore ways to assure that some of the responses related to decarceration and expansion of telehealth services and access are sustained post pandemic.