Clinical trial NCT01863290: Linking Former Inmates to Primary Care
Official title: Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
Study type: OBSERVATIONAL
Overall status: COMPLETED
Conditions: Hypertension
Substance Abuse
Asthma
Depression
Keywords: prison
reentry
health care utilization
Lead sponsor: Yale University
Sponsor class: OTHER
First posted: 2013-05-27
Enrollment: 816
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Observational model: COHORT
Time perspective: PROSPECTIVE
Sampling method: NON_PROBABILITY_SAMPLE
Study population: Former inmates; released from state or federal prisons.

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.

Eligibility criteria: 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

Primary outcomes:
measure: Health outcomes
timeFrame: One year
Secondary outcomes:
measure: Cost savings to the Centers for Medicare & Medicaid Services
timeFrame: 3 years
measure: Health care utilization
timeFrame: One year
Other outcomes:
Locations:
city: Birmingham
country: United States
facility: University of Alabama
state: Alabama
city: Martinez
country: United States
facility: Contra Costa Health Services (East and West Contra Costa)
state: California
city: San Francisco
country: United States
facility: Southeast Health Center
state: California
city: San Jose
country: United States
facility: Santa Clara Health Center
state: California
city: New Haven
country: United States
facility: Yale Primary Care Center
state: Connecticut
city: Baltimore
country: United States
facility: East Baltimore Medical Center
state: Maryland
city: Boston
country: United States
facility: Boston Healthcare for the Homeless Program
state: Massachusetts
city: New York
country: United States
facility: Morningside Clinic
state: New York
city: New York
country: United States
facility: Montefiore Transition Clinic
state: New York
city: Rochester
country: United States
facility: Medicine in Psychiatry Service clinic of the University of Rochester Medical Center
state: New York
city: Caguas
country: Puerto Rico
facility: Corporacion SANOS
Study officials:
affiliation: Yale University
name: Emily A Wang, MD, MAS
role: PRINCIPAL_INVESTIGATOR
References:
citation: Redmond N, Aminawung JA, Morse DS, Zaller N, Shavit S, Wang EA. Perceived Discrimination Based on Criminal Record in Healthcare Settings and Self-Reported Health Status among Formerly Incarcerated Individuals. J Urban Health. 2020 Feb;97(1):105-111. doi: 10.1007/s11524-019-00382-0.