Linking Former Inmates to Primary Care

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.

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