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

Trial Summary

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 data supports the effectiveness of the treatment Calls and Coordination for Transitions of Care At Re-entry?

Research shows that coordinated care programs, like the Transitions Clinic Network, help people leaving prison connect with healthcare services, improving their health outcomes. These programs use community health workers and data sharing to ensure continuous care, which is crucial for managing chronic conditions and reducing emergency care visits. ^{1 2 3 4 5}

Is the care coordination program for prisoners safe for humans?

The research articles do not provide specific safety data for the care coordination program for prisoners, but they emphasize the importance of continuity of care and coordination between prison and community health services to improve health outcomes for released prisoners. ^{2 3 4 5 6}

How does the treatment in the Care Coordination for Prisoners trial differ from other treatments for this condition?

This treatment is unique because it focuses on improving care coordination for prisoners transitioning back into the community, addressing the gap in healthcare continuity that often leads to poor health outcomes. Unlike standard treatments that may focus solely on medical interventions, this approach emphasizes collaboration between correctional facilities and community healthcare systems to ensure a seamless transition and ongoing support for released individuals. ^{3 4 5 7 8}

What is the purpose of this 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. The main question it aims to answer is: * Will there be more non-emergency, outpatient clinic visits? Researchers will compare the number of clinic visits between people who use a Nurse Case Manager (NCM) to people in enhanced usual care. Participants will: * Complete surveys * Talk to a study team member 2-3 times, or talk to a study team member 2-3 times and talk to an NCM 6-11 times

Research Team

Marguerite Burns

Principal Investigator

University of Wisconsin, Madison

Eligibility Criteria

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

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

Treatment Details

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.

Participant Groups

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+

Findings from Research

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]

References

1. United States pubmed.ncbi.nlm.nih.gov

Engaging individuals recently released from prison into primary care: a randomized trial. [2021]

2. United States pubmed.ncbi.nlm.nih.gov

Integrating correctional and community health care for formerly incarcerated people who are eligible for Medicaid. [2021]

3. United States pubmed.ncbi.nlm.nih.gov

Transitions to Care in the Community for Prison Releasees with HIV: a Qualitative Study of Facilitators and Challenges in Two States. [2018]

4. England pubmed.ncbi.nlm.nih.gov

No health without access: using a retrospective cohort to model a care continuum for people released from prison at an urban, safety net health system. [2023]

5. Switzerland 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. [2023]

6. Australia pubmed.ncbi.nlm.nih.gov

Supporting continuity of care between prison and the community for women in prison: a medical record review. [2017]

7. United States pubmed.ncbi.nlm.nih.gov

Communication Over Incarceration: Improving Care Coordination Between Correctional and Community Mental Health Services. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Transitional care coordination in New York City jails: facilitating linkages to care for people with HIV returning home from Rikers Island. [2015]