Linking Former Inmates to Primary Care
Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
Studieöversikt
Status
Betingelser
Intervention / Behandling
Detaljerad beskrivning
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.
Studietyp
Inskrivning (Faktisk)
Kontakter och platser
Studieorter
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Alabama
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Birmingham, Alabama, Förenta staterna, 25294-4410
- University of Alabama
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California
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Martinez, California, Förenta staterna, 94553
- Contra Costa Health Services (East and West Contra Costa)
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San Francisco, California, Förenta staterna, 94103
- Southeast Health Center
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San Jose, California, Förenta staterna, 95128
- Santa Clara Health Center
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Connecticut
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New Haven, Connecticut, Förenta staterna, 06520
- Yale Primary Care Center
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Maryland
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Baltimore, Maryland, Förenta staterna, 21287
- East Baltimore Medical Center
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Massachusetts
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Boston, Massachusetts, Förenta staterna, 02118
- Boston Healthcare for the Homeless Program
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New York
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New York, New York, Förenta staterna, 10025
- Morningside Clinic
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New York, New York, Förenta staterna, 10467
- Montefiore Transition Clinic
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Rochester, New York, Förenta staterna, 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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Deltagandekriterier
Urvalskriterier
Åldrar som är berättigade till studier
Tar emot friska volontärer
Kön som är behöriga för studier
Testmetod
Studera befolkning
Beskrivning
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
Hur är studien utformad?
Designdetaljer
Kohorter och interventioner
Grupp / Kohort |
Intervention / Behandling |
|---|---|
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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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Vad mäter studien?
Primära resultatmått
Resultatmått |
Åtgärdsbeskrivning |
Tidsram |
|---|---|---|
|
Health outcomes
Tidsram: 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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Sekundära resultatmått
Resultatmått |
Åtgärdsbeskrivning |
Tidsram |
|---|---|---|
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Cost savings to the Centers for Medicare & Medicaid Services
Tidsram: 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
Tidsram: 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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Samarbetspartners och utredare
Sponsor
Utredare
- Huvudutredare: Emily A Wang, MD, MAS, Yale University
Publikationer och användbara länkar
Studieavstämningsdatum
Studera stora datum
Studiestart
Primärt slutförande (Faktisk)
Avslutad studie (Faktisk)
Studieregistreringsdatum
Först inskickad
Först inskickad som uppfyllde QC-kriterierna
Första postat (Uppskatta)
Uppdateringar av studier
Senaste uppdatering publicerad (Faktisk)
Senaste inskickade uppdateringen som uppfyllde QC-kriterierna
Senast verifierad
Mer information
Termer relaterade till denna studie
Nyckelord
Ytterligare relevanta MeSH-villkor
Andra studie-ID-nummer
- 1301011280
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