Linking Former Inmates to Primary Care

• Sponsor: Yale University (Other)
• Overall Status: Completed
• CT.gov ID: NCT01863290
• Collaborator: (none)
• Enrollment: 816
• Locations: 11
• Duration (Months): 36
• Patients Per Site: 74.2
• Patients Per Site Per Month: 2.1

Study Details

Study Description

Brief Summary

The Transitions Clinic Network (TCN)aims to connect former inmates to primary care using trained, culturally competent primary care providers and community health workers (CHWs). The purpose of this project is to support ongoing quality improvement at the 13 participating sites by training culturally competent CHWs and measuring the health, health care utilization, and the costs of caring for former inmates.

Condition or Disease	Intervention/Treatment	Phase
Hypertension; Substance Abuse; Asthma; Depression	Other: Primary care redesign

Detailed Description

The Transitions Clinic Network (TCN) is a network of 13 community-based transitional healthcare programs, which aim to improve health, improve health care, and lower costs for vulnerable, high-risk Medicaid patients returning from prison across the United States. The TCN aims to connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs). The providers and CHWs, help patients obtain timely healthcare; promote healthy reintegration into their communities; provide care coordination and chronic disease management; and prevent unnecessary emergency department utilization and hospitalizations.

The project supports ongoing quality improvement at each of the 13 clinical sites by measuring the health, health care utilization, and the costs of caring for recently released patients. We will prospectively examine the rates of primary care engagement, acute care utilization, substance abuse and reported health, and recidivism in a cohort of 2000 patients recently released from prison receiving primary care at the 13 TCN programs. We will compare these rates of utilization at 6, 12, 18, 24, 30, 36 months to patient self-reported utilization prior to incarceration and historical controls.

Additionally, we aim to describe the implementation of, fidelity to, and sustainability of the TCN model in each of these clinical programs. Specifically, we aim to capture assets and barriers to starting and sustaining primary care programs targeting returning prisoners.

Study Design

• Study Type: Observational
• Actual Enrollment: 816 participants
• Observational Model: Cohort
• Time Perspective: Prospective
• Official Title: Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
• Study Start Date: May 1, 2013
• Actual Primary Completion Date: May 1, 2016
• Actual Study Completion Date: May 1, 2016

Arms and Interventions

Arm	Intervention/Treatment
Former inmates Former inmates with a chronic disease condition or aged 50 years and above engaged into primary care through an innovative primary care redesign model of the Transitions Clinic Network.	Other: Primary care redesign; Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).

Outcome Measures

Primary Outcome Measures

1. Health outcomes [One year]

   Patient health outcomes and quality of life, including self reported health, depression severity, hypertension, and relapse to alcohol and substance use.

Secondary Outcome Measures

1. Cost savings to the Centers for Medicare & Medicaid Services [3 years]

   Cost savings from prevented emergency department visits and hospitalizations, as well as improved health and decreased recidivism

2. Health care utilization [One year]

   Rates of engagement with primary care, all cause emergency department utilization and hospitalization rates, emergency department utilization and hospitalization rates for ambulatory care sensitive conditions.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 18 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Recently-released from prison (within one month)

• Has >=1 chronic disease condition , and/or age >=50 years

• Plans to live in the TCN area for the duration of the study

• Understands English or Spanish and able to provide consent

Exclusion Criteria:

• Does not plan to live in the TCN area for the duration of the study

• Does not understand English or Spanish, or unable to provide consent

• Does not plan to receive healthcare through a TCN clinic

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of Alabama	Birmingham	Alabama	United States	25294-4410
2	Contra Costa Health Services (East and West Contra Costa)	Martinez	California	United States	94553
3	Southeast Health Center	San Francisco	California	United States	94103
4	Santa Clara Health Center	San Jose	California	United States	95128
5	Yale Primary Care Center	New Haven	Connecticut	United States	06520
6	East Baltimore Medical Center	Baltimore	Maryland	United States	21287
7	Boston Healthcare for the Homeless Program	Boston	Massachusetts	United States	02118
8	Morningside Clinic	New York	New York	United States	10025
9	Montefiore Transition Clinic	New York	New York	United States	10467
10	Medicine in Psychiatry Service clinic of the University of Rochester Medical Center	Rochester	New York	United States	14642
11	Corporacion SANOS	Caguas		Puerto Rico	00725

Sponsors and Collaborators

• Yale University

Investigators

• Principal Investigator: Emily A Wang, MD, MAS, Yale University

Study Documents (Full-Text)

None provided.

More Information

Publications

None provided.

• Responsible Party: Yale University
• ClinicalTrials.gov Identifier: NCT01863290
• Other Study ID Numbers: 1301011280
• First Posted: May 27, 2013
• Last Update Posted: Oct 25, 2017
• Last Verified: Oct 1, 2017

• Keywords provided by Yale University: prison; reentry; health care utilization
• Additional relevant MeSH terms: Substance-Related Disorders

Study Results

No Results Posted as of Oct 25, 2017