- ICH GCP
- US Clinical Trials Registry
- Klinisk forsøg NCT01863290
Linking Former Inmates to Primary Care
Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
Studieoversigt
Status
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
Tilmelding (Faktiske)
Kontakter og lokationer
Studiesteder
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Alabama
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Birmingham, Alabama, Forenede Stater, 25294-4410
- University of Alabama
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California
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Martinez, California, Forenede Stater, 94553
- Contra Costa Health Services (East and West Contra Costa)
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San Francisco, California, Forenede Stater, 94103
- Southeast Health Center
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San Jose, California, Forenede Stater, 95128
- Santa Clara Health Center
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Connecticut
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New Haven, Connecticut, Forenede Stater, 06520
- Yale Primary Care Center
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Maryland
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Baltimore, Maryland, Forenede Stater, 21287
- East Baltimore Medical Center
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Massachusetts
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Boston, Massachusetts, Forenede Stater, 02118
- Boston Healthcare for the Homeless Program
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New York
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New York, New York, Forenede Stater, 10025
- Morningside Clinic
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New York, New York, Forenede Stater, 10467
- Montefiore Transition Clinic
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Rochester, New York, Forenede Stater, 14642
- Medicine in Psychiatry Service clinic of the University of Rochester Medical Center
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Caguas, Puerto Rico, 00725
- Corporacion SANOS
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Deltagelseskriterier
Berettigelseskriterier
Aldre berettiget til at studere
Tager imod sunde frivillige
Køn, der er berettiget til at studere
Prøveudtagningsmetode
Studiebefolkning
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
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.
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Connect individuals released from prison to primary care using trained, culturally competent primary care providers and community health workers (CHWs).
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Hvad måler undersøgelsen?
Primære resultatmål
Resultatmål |
Foranstaltningsbeskrivelse |
Tidsramme |
---|---|---|
Health outcomes
Tidsramme: One year
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Patient health outcomes and quality of life, including self reported health, depression severity, hypertension, and relapse to alcohol and substance use.
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One year
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Sekundære resultatmål
Resultatmål |
Foranstaltningsbeskrivelse |
Tidsramme |
---|---|---|
Cost savings to the Centers for Medicare & Medicaid Services
Tidsramme: 3 years
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Cost savings from prevented emergency department visits and hospitalizations, as well as improved health and decreased recidivism
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3 years
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Health care utilization
Tidsramme: One year
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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.
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One year
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Samarbejdspartnere og efterforskere
Sponsor
Efterforskere
- Ledende efterforsker: Emily A Wang, MD, MAS, Yale University
Publikationer og nyttige links
Datoer for undersøgelser
Studer store datoer
Studiestart
Primær færdiggørelse (Faktiske)
Studieafslutning (Faktiske)
Datoer for studieregistrering
Først indsendt
Først indsendt, der opfyldte QC-kriterier
Først opslået (Skøn)
Opdateringer af undersøgelsesjournaler
Sidste opdatering sendt (Faktiske)
Sidste opdatering indsendt, der opfyldte kvalitetskontrolkriterier
Sidst verificeret
Mere information
Begreber relateret til denne undersøgelse
Nøgleord
Yderligere relevante MeSH-vilkår
Andre undersøgelses-id-numre
- 1301011280
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