Linking Former Inmates to Primary Care

Study Overview
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Brief Summary
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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
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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.

Official Title
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Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care

Conditions
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Hypertension, Substance Abuse, Asthma, Depression

Intervention / Treatment
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* Other: Primary care redesign


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Former inmates<br>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<br>* Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Health outcomes | Patient health outcomes and quality of life, including self reported health, depression severity, hypertension, and relapse to alcohol and substance use. | One year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cost savings to the Centers for Medicare & Medicaid Services | Cost savings from prevented emergency department visits and hospitalizations, as well as improved health and decreased recidivism | 3 years | 
| Health care utilization | 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. | One year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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prison, reentry, health care utilization