Linking Former Inmates to Primary Care

Hypertension Clinical Trial

Official title:

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

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT01863290
• Other study ID #: 1301011280
• Status: Completed
• Phase: N/A
• First received: May 22, 2013
• Last updated: October 23, 2017
• Start date: May 2013
• Est. completion date: May 2016

Study information

• Verified date: October 2017
• Source: Yale University
• Contact: n/a
• Is FDA regulated: No
• Study type: Observational

Clinical Trial 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.

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.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 816
• Est. completion date: May 2016
• Est. primary completion date: May 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

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

Related Conditions & MeSH terms

• Asthma
• Depression
• Hypertension
• Substance Abuse
• Substance-Related Disorders

Intervention

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

Locations

Country	Name	City	State
Puerto Rico	Corporacion SANOS	Caguas
United States	East Baltimore Medical Center	Baltimore	Maryland
United States	University of Alabama	Birmingham	Alabama
United States	Boston Healthcare for the Homeless Program	Boston	Massachusetts
United States	Contra Costa Health Services (East and West Contra Costa)	Martinez	California
United States	Yale Primary Care Center	New Haven	Connecticut
United States	Montefiore Transition Clinic	New York	New York
United States	Morningside Clinic	New York	New York
United States	Medicine in Psychiatry Service clinic of the University of Rochester Medical Center	Rochester	New York
United States	Southeast Health Center	San Francisco	California
United States	Santa Clara Health Center	San Jose	California

Sponsors (1)

Lead Sponsor	Collaborator
Yale University

Countries where clinical trial is conducted

United States,  Puerto Rico, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	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	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
Secondary	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