Linking Former Inmates to Primary Care
Transitions Clinic Network: Linking High-Risk Medicaid Patients From Prison to Community Primary Care
研究概览
详细说明
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.
研究类型
注册 (实际的)
联系人和位置
学习地点
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Caguas、波多黎各、00725
- Corporacion SANOS
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Alabama
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Birmingham、Alabama、美国、25294-4410
- University of Alabama
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California
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Martinez、California、美国、94553
- Contra Costa Health Services (East and West Contra Costa)
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San Francisco、California、美国、94103
- Southeast Health Center
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San Jose、California、美国、95128
- Santa Clara Health Center
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Connecticut
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New Haven、Connecticut、美国、06520
- Yale Primary Care Center
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Maryland
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Baltimore、Maryland、美国、21287
- East Baltimore Medical Center
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Massachusetts
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Boston、Massachusetts、美国、02118
- Boston Healthcare for the Homeless Program
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New York
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New York、New York、美国、10025
- Morningside Clinic
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New York、New York、美国、10467
- Montefiore Transition Clinic
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Rochester、New York、美国、14642
- Medicine in Psychiatry Service clinic of the University of Rochester Medical Center
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参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
取样方法
研究人群
描述
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
学习计划
研究是如何设计的?
设计细节
队列和干预
团体/队列 |
干预/治疗 |
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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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研究衡量的是什么?
主要结果指标
结果测量 |
措施说明 |
大体时间 |
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Health outcomes
大体时间: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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次要结果测量
结果测量 |
措施说明 |
大体时间 |
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Cost savings to the Centers for Medicare & Medicaid Services
大体时间: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
大体时间: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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合作者和调查者
调查人员
- 首席研究员:Emily A Wang, MD, MAS、Yale University
出版物和有用的链接
研究记录日期
研究主要日期
学习开始
初级完成 (实际的)
研究完成 (实际的)
研究注册日期
首次提交
首先提交符合 QC 标准的
首次发布 (估计)
研究记录更新
最后更新发布 (实际的)
上次提交的符合 QC 标准的更新
最后验证
更多信息
此信息直接从 clinicaltrials.gov 网站检索,没有任何更改。如果您有任何更改、删除或更新研究详细信息的请求,请联系 register@clinicaltrials.gov. clinicaltrials.gov 上实施更改,我们的网站上也会自动更新.
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