Linking Former Inmates to Primary Care

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

Study Overview

• Status: Completed
• Conditions: Depression; Hypertension; Asthma; Substance Abuse
• Intervention / Treatment: Other: Primary care redesign

Detailed 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.

• Study Type: Observational
• Enrollment (Actual): 816

Contacts and Locations

Study Locations

• Puerto Rico
  • Caguas, Puerto Rico, 00725
    • Corporacion SANOS
• United States
  • Alabama
    • Birmingham, Alabama, United States, 25294-4410
      • University of Alabama
  • California
    • Martinez, California, United States, 94553
      • Contra Costa Health Services (East and West Contra Costa)
    • San Francisco, California, United States, 94103
      • Southeast Health Center
    • San Jose, California, United States, 95128
      • Santa Clara Health Center
  • Connecticut
    • New Haven, Connecticut, United States, 06520
      • Yale Primary Care Center
  • Maryland
    • Baltimore, Maryland, United States, 21287
      • East Baltimore Medical Center
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Boston Healthcare for the Homeless Program
  • New York
    • New York, New York, United States, 10025
      • Morningside Clinic
    • New York, New York, United States, 10467
      • Montefiore Transition Clinic
    • Rochester, New York, United States, 14642
      • Medicine in Psychiatry Service clinic of the University of Rochester Medical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Former inmates; released from state or federal prisons.

Description

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 Plan

How is the study designed?

Number of groups / cohorts

1

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
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.	Other: Primary care redesign; Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
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 Outcome Measures

Outcome Measure	Measure Description	Time Frame
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
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

Collaborators and Investigators

• Sponsor: Yale University
• Investigators: Principal Investigator: Emily A Wang, MD, MAS, Yale University

Publications and helpful links

General Publications

• 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.

Study record dates

Study Major Dates

• Study Start: May 1, 2013
• Primary Completion (Actual): May 1, 2016
• Study Completion (Actual): May 1, 2016

Study Registration Dates

• First Submitted: May 22, 2013
• First Submitted That Met QC Criteria: May 22, 2013
• First Posted (Estimate): May 27, 2013

Study Record Updates

• Last Update Posted (Actual): October 25, 2017
• Last Update Submitted That Met QC Criteria: October 23, 2017
• Last Verified: October 1, 2017

More Information

Terms related to this study

• Keywords: health care utilization; prison; reentry
• Additional Relevant MeSH Terms: Mental Disorders; Chemically-Induced Disorders; Substance-Related Disorders
• Other Study ID Numbers: 1301011280