Linking Former Inmates to Primary Care

Yale University

Status: Completed

Conditions: Hypertension; Asthma; Depression; Substance Abuse

Treatments: Other: Primary care redesign

Study type: Observational

Funder types: Other

Identifiers

NCT01863290

1301011280

Details and patient eligibility

About

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.

Full 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.

Enrollment: 816 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

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

Trial design

816 participants in 1 patient group

Former inmates

Description:

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.

Treatment:

Other: Primary care redesign