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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT01863290
Other study ID # 1301011280
Secondary ID
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
Health authority
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

Study Design


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
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