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Linking Former Inmates to Primary Care

23. oktober 2017 opdateret af: Yale University

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.

Studieoversigt

Status

Afsluttet

Betingelser

Intervention / Behandling

Detaljeret beskrivelse

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.

Undersøgelsestype

Observationel

Tilmelding (Faktiske)

816

Kontakter og lokationer

Dette afsnit indeholder kontaktoplysninger for dem, der udfører undersøgelsen, og oplysninger om, hvor denne undersøgelse udføres.

Studiesteder

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

Deltagelseskriterier

Forskere leder efter personer, der passer til en bestemt beskrivelse, kaldet berettigelseskriterier. Nogle eksempler på disse kriterier er en persons generelle helbredstilstand eller tidligere behandlinger.

Berettigelseskriterier

Aldre berettiget til at studere

18 år og ældre (Voksen, Ældre voksen)

Tager imod sunde frivillige

Ingen

Køn, der er berettiget til at studere

Alle

Prøveudtagningsmetode

Ikke-sandsynlighedsprøve

Studiebefolkning

Former inmates; released from state or federal prisons.

Beskrivelse

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

Studieplan

Dette afsnit indeholder detaljer om studieplanen, herunder hvordan undersøgelsen er designet, og hvad undersøgelsen måler.

Hvordan er undersøgelsen tilrettelagt?

Design detaljer

Kohorter og interventioner

Gruppe / kohorte
Intervention / Behandling
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.
Andet: Primary care redesign
Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).

Hvad måler undersøgelsen?

Primære resultatmål

Resultatmål
Foranstaltningsbeskrivelse
Tidsramme
Health outcomes
Tidsramme: One year
Patient health outcomes and quality of life, including self reported health, depression severity, hypertension, and relapse to alcohol and substance use.
One year

Sekundære resultatmål

Resultatmål
Foranstaltningsbeskrivelse
Tidsramme
Cost savings to the Centers for Medicare & Medicaid Services
Tidsramme: 3 years
Cost savings from prevented emergency department visits and hospitalizations, as well as improved health and decreased recidivism
3 years
Health care utilization
Tidsramme: One year
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

Samarbejdspartnere og efterforskere

Det er her, du vil finde personer og organisationer, der er involveret i denne undersøgelse.

Sponsor

Yale University

Efterforskere

  • Ledende efterforsker: Emily A Wang, MD, MAS, Yale University

Publikationer og nyttige links

Den person, der er ansvarlig for at indtaste oplysninger om undersøgelsen, leverer frivilligt disse publikationer. Disse kan handle om alt relateret til undersøgelsen.

Generelle publikationer

Datoer for undersøgelser

Disse datoer sporer fremskridtene for indsendelser af undersøgelsesrekord og resumeresultater til ClinicalTrials.gov. Studieregistreringer og rapporterede resultater gennemgås af National Library of Medicine (NLM) for at sikre, at de opfylder specifikke kvalitetskontrolstandarder, før de offentliggøres på den offentlige hjemmeside.

Studer store datoer

Studiestart

1. maj 2013

Primær færdiggørelse (Faktiske)

1. maj 2016

Studieafslutning (Faktiske)

1. maj 2016

Datoer for studieregistrering

Først indsendt

22. maj 2013

Først indsendt, der opfyldte QC-kriterier

22. maj 2013

Først opslået (Skøn)

27. maj 2013

Opdateringer af undersøgelsesjournaler

Sidste opdatering sendt (Faktiske)

25. oktober 2017

Sidste opdatering indsendt, der opfyldte kvalitetskontrolkriterier

23. oktober 2017

Sidst verificeret

1. oktober 2017

Mere information

Begreber relateret til denne undersøgelse

Nøgleord

Yderligere relevante MeSH-vilkår

Andre undersøgelses-id-numre

  • 1301011280

Disse oplysninger blev hentet direkte fra webstedet clinicaltrials.gov uden ændringer. Hvis du har nogen anmodninger om at ændre, fjerne eller opdatere dine undersøgelsesoplysninger, bedes du kontakte register@clinicaltrials.gov. Så snart en ændring er implementeret på clinicaltrials.gov, vil denne også blive opdateret automatisk på vores hjemmeside .

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Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

CROs by country

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Betingelser

Sjældne sygdomme

Narkotikainterventioner

Kosttilskud

Sponsor / samarbejdspartnere

Placeringer

Abonner