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Completed

NCT Number: NCT01863290

Linking Former Inmates to Primary Care

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.

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Key information

Conditions

Hypertension Asthma Behavior Behavioral Symptoms Bronchial Diseases Cardiovascular Diseases Chemically-Induced Disorders Depression Health Behavior Hypersensitivity Hypersensitivity, Immediate Immune System Diseases Lung Diseases Lung Diseases, Obstructive Mental Disorders Patient Acceptance of Health Care Respiratory Hypersensitivity Respiratory Tract Diseases Substance Abuse Substance-Related Disorders Treatment Adherence and Compliance Vascular Diseases

Age range

18 year and older

Sex eligibility

All sexes

Study type

Observational

Primary location

Corporacion SANOS, Caguas, Puerto Rico

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About this study

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.

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

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

Treatment and study plan

Primary care redesign

Other

Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).

Primary outcomes

  1. Health outcomes

    Time frame: One year

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

Secondary outcomes

  1. Cost savings to the Centers for Medicare & Medicaid Services

    Time frame: 3 years

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

  2. Health care utilization

    Time frame: 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.

Sponsors and collaborators

Lead sponsor

Yale University

Other

Registry information

Official study title

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

Important dates

Study start
2013
Primary completion
2016
Study completion
2016
First posted
May 27, 2013
Registry last updated
Oct 25, 2017

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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