Care Coordination for Prisoners

(Call2Care Trial)

Overseen By Maggie Chilsen

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: University of Wisconsin, Madison

Disqualifiers: Ineligible for WI Medicaid, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

488 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial aims to determine if a short program can help people leaving prison connect with healthcare services. It will compare the frequency of non-emergency outpatient clinic visits between two groups: one receiving calls and texts, and another receiving additional support from a Nurse Case Manager (NCM). This trial may suit individuals planning to enroll in Wisconsin Medicaid, who have a history of substance use, and live with or have a history of a chronic medical or psychiatric condition. Participants must be able to read, understand, and speak English.

As an unphased trial, this study provides a unique opportunity to contribute to research that could improve healthcare access for others in similar situations.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It seems likely that you can continue them, especially since the trial involves people with chronic conditions who are currently taking prescription medications.

What prior data suggests that this program is safe for participants?

In a previous study, researchers examined programs that assist individuals leaving prison in connecting to healthcare. These programs typically involve phone calls and organizational support, sometimes with a Nurse Case Manager (NCM). Research has shown that these programs are safe, as they focus on improving access to healthcare without involving medicine or medical procedures.

No reports of major safety issues or negative experiences have emerged from similar programs. Participants generally find these programs helpful and manageable. The goal is to ensure individuals receive necessary healthcare after leaving prison, and studies suggest this can be achieved safely through phone and text communication. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about these treatments because they offer a personalized approach to helping prisoners transition back into the community. Unlike traditional options, which might focus on general support services, these treatments provide targeted care through phone calls and texts, with one group even having the added benefit of working with a nurse case manager. This method aims to improve re-entry success by offering continuous and personalized support, potentially reducing recidivism and enhancing overall well-being for former inmates.

What evidence suggests that this program is effective for increasing non-emergency outpatient clinic visits?

Research has shown that helping people transition from prison to community life can be effective. In this trial, participants will join one of two groups: the Phone Group, which will receive phone calls and texts, or the Phone + Nurse Case Manager (NCM) Group, which will work with a nurse case manager who will call and text. Studies have found that support programs, such as having a Nurse Case Manager (NCM), can facilitate access to medical care. Reports highlight that when individuals receive health care assistance after leaving prison, they are more likely to attend regular medical appointments. Previous programs have also linked better access to health care with improved outcomes, such as securing jobs and stable housing. These findings suggest that a program with phone calls and NCM support could increase visits to non-emergency clinics for those reentering society. ^{1 2 3 5 6}

Who Is on the Research Team?

Marguerite Burns

Principal Investigator

University of Wisconsin, Madison

Are You a Good Fit for This Trial?

This trial is for individuals recently released from prison who have Aviator's Disease, Substance Use Disorder, chronic illnesses, or mental illness. They should not be currently enrolled in similar programs and must be willing to complete surveys and engage with the study team.

Inclusion Criteria

Eligibility for WI Medicaid and intention to enroll before release

Substance use history (i.e., 'have you ever considered your alcohol or drug use to be a problem?')

I have a chronic medical or psychiatric condition.

Exclusion Criteria

No substance use history

Ineligible for WI Medicaid

I do not have any long-term medical or mental health conditions.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

6 months

Pre-release Preparation

Participants are enrolled and prepared for the transitional care program before release from prison

6 months

Transitional Care Intervention

Participants receive weekly phone calls and texts for up to 60 days post-release to connect them to primary care

8 weeks

Weekly phone calls

Follow-up

Participants are monitored for the number of emergency and non-emergency clinic visits

2 months

What Are the Treatments Tested in This Trial?

Interventions

• Calls and Coordination for Transitions of Care At Re-entry

Trial Overview The study tests if a program involving in-person visits and phone calls/texts with a Nurse Case Manager (NCM) increases outpatient clinic visits compared to enhanced usual care after release from prison. Participants will either interact frequently with an NCM or receive standard follow-ups.

How Is the Trial Designed?

Group I: Phone Group Experimental Treatment 2 Interventions

Participants will receive phone calls and texts.

Group II: Phone + Nurse Case Manager (NCM) Group Experimental Treatment 2 Interventions

Participants will work with a nurse case manager, who will call and text.

Who Is Running the Clinical Trial?

University of Wisconsin, Madison

Lead Sponsor

Trials

1,249

Recruited

3,255,000+

National Institute on Drug Abuse (NIDA)

Collaborator

Trials

2,658

Recruited

3,409,000+

Published Research Related to This Trial

A randomized controlled trial involving 200 recently released prisoners showed that both Transitions Clinic and expedited primary care had similar rates of primary care engagement, with 37.7% and 47.1% respectively.

However, participants in the Transitions Clinic experienced significantly lower emergency department visits (25.5%) compared to those receiving expedited primary care (39.2%), indicating that a tailored care management program can effectively reduce acute care utilization.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Engaging individuals recently released from prison into primary care: a randomized trial. Wang, EA., Hong, CS., Shavit, S., et al.[2021]

The Transitions Clinic Network (TCN) successfully linked the California Department of Corrections and Rehabilitation with 21 primary care clinics, facilitating 8420 referrals for health care services to individuals released from prison between April 2020 and August 2022.

This initiative highlights the importance of care continuity and coordination, including data sharing and pre-release planning, as a model for improving health outcomes for formerly incarcerated individuals, especially in light of new policies like the Medicaid Reentry Act.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Reentry Health Care Hub: Creating a California-Based Referral System to Link Chronically Ill People Leaving Prison to Primary Care. Divakaran, B., Bloch, N., Sinha, M., et al.[2023]

Citations

1. withpower.com withpower.com/trial/phase-disease-1-2025-70dfe

Care Coordination for Prisoners (Call2Care Trial) The goal of this clinical trial is to learn if a short program for people being released from prison can help connect them to medical care.

2. aspe.hhs.gov aspe.hhs.gov/sites/default/files/documents/d48e8a9fdd499029542f0a30aa78bfd1/health-care-reentry-transitions.pdf

Health Care Transitions for Individuals Returning to the ... This report identifies promising practices for health care transitions for individuals returning to the community from a public institution, as ...

3. pmc.ncbi.nlm.nih.gov pmc.ncbi.nlm.nih.gov/articles/PMC4580511/

A Strengths-Based Approach to Prisoner Reentry: The Fresh ... The present paper highlights a strengths-based prisoner reentry program that provided services to men both pre- and post-release from prison to the community ...

4. csgjusticecenter.org csgjusticecenter.org/publications/beyond-recidivism-redefining-reentry-data-health-housing-employment/

Beyond Recidivism: Redefining Measures to Understand ... Reentry success measures include: recidivism progression, employment and financial stability, housing security, health and wellbeing, and ...

5. justice.gov justice.gov/archives/opa/press-release/file/1497911/dl

Coordination to Reduce Barriers to Reentry Moreover, better health and access to health care during reentry can improve employment, housing, and family support outcomes.29 ... re-entry- ...

6. reporter.nih.gov reporter.nih.gov/search/14E9CE024F8FC5D27598B8961CAA4A01A2FFCEB861BF/project-details/11097268

Project Details - NIH RePORTER Prior research demonstrates that formerly incarcerated adults under-utilize routine, outpatient health care during the transition from prison to community ...