Linking Former Inmates to Primary Care
Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
Descripción general del estudio
Estado
Condiciones
Intervención / Tratamiento
Descripción detallada
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.
Tipo de estudio
Inscripción (Actual)
Contactos y Ubicaciones
Ubicaciones de estudio
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Alabama
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Birmingham, Alabama, Estados Unidos, 25294-4410
- University of Alabama
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California
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Martinez, California, Estados Unidos, 94553
- Contra Costa Health Services (East and West Contra Costa)
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San Francisco, California, Estados Unidos, 94103
- Southeast Health Center
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San Jose, California, Estados Unidos, 95128
- Santa Clara Health Center
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Connecticut
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New Haven, Connecticut, Estados Unidos, 06520
- Yale Primary Care Center
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Maryland
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Baltimore, Maryland, Estados Unidos, 21287
- East Baltimore Medical Center
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Massachusetts
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Boston, Massachusetts, Estados Unidos, 02118
- Boston Healthcare for the Homeless Program
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New York
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New York, New York, Estados Unidos, 10025
- Morningside Clinic
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New York, New York, Estados Unidos, 10467
- Montefiore Transition Clinic
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Rochester, New York, Estados Unidos, 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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Criterios de participación
Criterio de elegibilidad
Edades elegibles para estudiar
Acepta Voluntarios Saludables
Géneros elegibles para el estudio
Método de muestreo
Población de estudio
Descripción
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
Plan de estudios
¿Cómo está diseñado el estudio?
Detalles de diseño
Cohortes e Intervenciones
Grupo / Cohorte |
Intervención / Tratamiento |
|---|---|
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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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¿Qué mide el estudio?
Medidas de resultado primarias
Medida de resultado |
Medida Descripción |
Periodo de tiempo |
|---|---|---|
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Health outcomes
Periodo de tiempo: 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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Medidas de resultado secundarias
Medida de resultado |
Medida Descripción |
Periodo de tiempo |
|---|---|---|
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Cost savings to the Centers for Medicare & Medicaid Services
Periodo de tiempo: 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
Periodo de tiempo: 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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Colaboradores e Investigadores
Patrocinador
Investigadores
- Investigador principal: Emily A Wang, MD, MAS, Yale University
Publicaciones y enlaces útiles
Fechas de registro del estudio
Fechas importantes del estudio
Inicio del estudio
Finalización primaria (Actual)
Finalización del estudio (Actual)
Fechas de registro del estudio
Enviado por primera vez
Primero enviado que cumplió con los criterios de control de calidad
Publicado por primera vez (Estimar)
Actualizaciones de registros de estudio
Última actualización publicada (Actual)
Última actualización enviada que cumplió con los criterios de control de calidad
Última verificación
Más información
Términos relacionados con este estudio
Palabras clave
Términos MeSH relevantes adicionales
Otros números de identificación del estudio
- 1301011280
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