Linking Former Inmates to Primary Care

Completed

• Conditions: Substance Abuse; Asthma; Hypertension; Depression
• Interventions: Other: Primary care redesign

• Registration Number: NCT01863290
• Lead Sponsor: Yale University

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.

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 Timeline

• Study Start: 2013-05
• Study First Submitted: 2013-05-22
• Study First Submitted QC: 2013-05-22
• Study First Posted: 2013-05-27
• Primary Completion: 2016-05
• Study Completion: 2016-05
• Status Verified: 2017-10
• Last Update Submitted: 2017-10-23
• Last Update Posted: 2017-10-25

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 816

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

Read More

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

Read More

Study & Design

• Study Type: OBSERVATIONAL
• Study Design: Not specified

Arm && Interventions

Group	Intervention	Description
Former inmates	Primary care redesign	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.

Primary Outcome Measures

Name	Time	Method
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

Name	Time	Method
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.
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

Trial Locations

Locations (11)

University of Alabama; 🇺🇸 Birmingham, Alabama, United States

Contra Costa Health Services (East and West Contra Costa); 🇺🇸 Martinez, California, United States

Southeast Health Center; 🇺🇸 San Francisco, California, United States

Santa Clara Health Center; 🇺🇸 San Jose, California, United States

East Baltimore Medical Center; 🇺🇸 Baltimore, Maryland, United States

Morningside Clinic; 🇺🇸 New York, New York, United States

Corporacion SANOS; 🇵🇷 Caguas, Puerto Rico

Boston Healthcare for the Homeless Program; 🇺🇸 Boston, Massachusetts, United States

Yale Primary Care Center; 🇺🇸 New Haven, Connecticut, United States

Montefiore Transition Clinic; 🇺🇸 New York, New York, United States

Medicine in Psychiatry Service clinic of the University of Rochester Medical Center; 🇺🇸 Rochester, New York, United States