Linking Former Inmates to Primary Care

NCT ID: NCT01863290

Last Updated: 2017-10-25

Study Results

Results pending

The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.

Basic Information

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Recruitment Status

COMPLETED

Total Enrollment

816 participants

Study Classification

OBSERVATIONAL

Study Start Date

2013-05-31

Study Completion Date

2016-05-31

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.

Conditions

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Hypertension Substance Abuse Asthma Depression

Keywords

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prison reentry health care utilization

Study Design

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Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

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Former inmates

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 care redesign

Intervention Type OTHER

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

Interventions

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Primary care redesign

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

Intervention Type OTHER

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
Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No

Sponsors

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Yale University

OTHER

Sponsor Role lead

Responsible Party

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Responsibility Role SPONSOR

Principal Investigators

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Emily A Wang, MD, MAS

Role: PRINCIPAL_INVESTIGATOR

Yale University

Locations

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University of Alabama

Birmingham, Alabama, United States

Site Status

Contra Costa Health Services (East and West Contra Costa)

Martinez, California, United States

Site Status

Southeast Health Center

San Francisco, California, United States

Site Status

Santa Clara Health Center

San Jose, California, United States

Site Status

Yale Primary Care Center

New Haven, Connecticut, United States

Site Status

East Baltimore Medical Center

Baltimore, Maryland, United States

Site Status

Boston Healthcare for the Homeless Program

Boston, Massachusetts, United States

Site Status

Morningside Clinic

New York, New York, United States

Site Status

Montefiore Transition Clinic

New York, New York, United States

Site Status

Medicine in Psychiatry Service clinic of the University of Rochester Medical Center

Rochester, New York, United States

Site Status

Corporacion SANOS

Caguas, , Puerto Rico

Site Status

Countries

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United States Puerto Rico

References

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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.

Reference Type DERIVED
PMID: 31628588 (View on PubMed)

Other Identifiers

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1301011280

Identifier Type: -

Identifier Source: org_study_id