The current reentry program for follow-up primary care of newly released inmates from a local correctional facility is inadequate in providing continuity of post-release healthcare. A process improvement project, based on the components of Dr. Mary Naylor’s Transitional Care Model (TCM), was designed to improve inmates’ transition from correctional facility to community healthcare. Using the TCM provides structure to develop comprehensive discharge plans, follow-up care, improve coordination of care, and improve quality outcomes. Naylor has successfully shown the TCM enhances patient satisfaction, reduces hospital readmissions, and reduces healthcare costs.
The development of a discharge protocol and referral process to establish a community-based health clinic network will potentially result in fewer inmates being lost to follow-up care and will increase positive outcomes in inmates’ health. Data analysis of this process improvement will be both quantitative and qualitative. Summary of data will support that by implementing a discharge protocol and referral process for released inmates, the transition from correctional to community healthcare (CaTCH Protocol) will improve and will provide better management of inmate’s chronic health conditions.