Linking Former Inmates to Primary Care
Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
調査の概要
詳細な説明
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.
研究の種類
入学 (実際)
連絡先と場所
研究場所
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Alabama
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Birmingham、Alabama、アメリカ、25294-4410
- University of Alabama
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California
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Martinez、California、アメリカ、94553
- Contra Costa Health Services (East and West Contra Costa)
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San Francisco、California、アメリカ、94103
- Southeast Health Center
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San Jose、California、アメリカ、95128
- Santa Clara Health Center
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Connecticut
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New Haven、Connecticut、アメリカ、06520
- Yale Primary Care Center
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Maryland
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Baltimore、Maryland、アメリカ、21287
- East Baltimore Medical Center
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Massachusetts
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Boston、Massachusetts、アメリカ、02118
- Boston Healthcare for the Homeless Program
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New York
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New York、New York、アメリカ、10025
- Morningside Clinic
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New York、New York、アメリカ、10467
- Montefiore Transition Clinic
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Rochester、New York、アメリカ、14642
- Medicine in Psychiatry Service clinic of the University of Rochester Medical Center
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Caguas、プエルトリコ、00725
- Corporacion SANOS
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参加基準
適格基準
就学可能な年齢
健康ボランティアの受け入れ
受講資格のある性別
サンプリング方法
調査対象母集団
説明
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
研究計画
研究はどのように設計されていますか？
デザインの詳細
コホートと介入
グループ/コホート |
介入・治療 |
|---|---|
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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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この研究は何を測定していますか？
主要な結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
|
Health outcomes
時間枠：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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二次結果の測定
結果測定 |
メジャーの説明 |
時間枠 |
|---|---|---|
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Cost savings to the Centers for Medicare & Medicaid Services
時間枠：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
時間枠：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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協力者と研究者
スポンサー
捜査官
- 主任研究者：Emily A Wang, MD, MAS、Yale University
出版物と役立つリンク
研究記録日
主要日程の研究
研究開始
一次修了 (実際)
研究の完了 (実際)
試験登録日
最初に提出
QC基準を満たした最初の提出物
最初の投稿 (見積もり)
学習記録の更新
投稿された最後の更新 (実際)
QC基準を満たした最後の更新が送信されました
最終確認日
詳しくは
この情報は、Web サイト clinicaltrials.gov から変更なしで直接取得したものです。研究の詳細を変更、削除、または更新するリクエストがある場合は、register@clinicaltrials.gov。 までご連絡ください。 clinicaltrials.gov に変更が加えられるとすぐに、ウェブサイトでも自動的に更新されます。