| Abstract: | Objectives. Individuals released from prison have high rates of chronic conditions but minimal engagement in primary care. We compared 2 interventions designed to improve primary care engagement and reduce acute care utilization: Transitions Clinic, a primary care–based care management program with a community health worker, versus expedited primary care.Methods. We performed a randomized controlled trial from 2007 to 2009 among 200 recently released prisoners who had a chronic medical condition or were older than 50 years. We abstracted 12-month outcomes from an electronic repository available from the safety-net health care system. Main outcomes were (1) primary care utilization (2 or more visits to the assigned primary care clinic) and (2) emergency department (ED) utilization (the proportion of participants making any ED visit).Results. Both groups had similar rates of primary care utilization (37.7% vs 47.1%; P = .18). Transitions Clinic participants had lower rates of ED utilization (25.5% vs 39.2%; P = .04).Conclusions. Chronically ill patients leaving prison will engage in primary care if provided early access. The addition of a primary care–based care management program tailored for returning prisoners reduces ED utilization over expedited primary care.In the United States, 700 000 individuals are behind prison bars at any point in time; this represents the highest incarceration rate in the world.1 In the past 20 years, states’ correctional costs have risen by 315% to $44 billion annually, constituting the fastest-expanding area of government spending after Medicaid.2 Ninety-five percent of prisoners will eventually be released to the community; more than 500 000 prisoners are released annually.3 There is pressure to release more prisoners because of prison overcrowding, growing correctional health expenditures, and constrained legislative budgets.1,4,5 In October 2011, California began releasing more than 30 000 inmates from its prison system to comply with a Supreme Court ruling citing an unhealthy level of overcrowding.6 Correctional health care systems are constitutionally responsible for health care while patients are incarcerated, but not upon release.Recently released prisoners have low educational attainment; high rates of poverty, unemployment, and homelessness; and high risk of poor health outcomes, including death, upon release.7,8 Eighty percent of released individuals have chronic medical, psychiatric, or substance abuse problems, yet only 15% to 25% report visiting a physician outside of the emergency department (ED) in the first year postrelease.8,9 Most released individuals state that they use the ED as their regular source of care.10 There is little care coordination between prison and community health systems. Few individuals are released with a sufficient supply of chronic medications, primary care follow-up, or health insurance.11,12 There is limited evidence to guide how to provide effective health care to this population after release. More primary care practices are tailoring care to high-risk populations using primary care–based, complex care management (PC-CCM) programs.13 These PC-CCM programs are designed to assist patients in managing medical problems and related psychosocial problems, in an effort to improve care and health system engagement, and to reduce costs.14–16 However, the effectiveness of these PC-CCM programs for recently released prisoners has not been demonstrated.In 2007, we designed and compared 2 interventions to engage recently released prisoners into primary care. We offered individuals returning to San Francisco postincarceration an initial transitional care visit. After this initial visit, we randomly assigned participants to receive (1) ongoing care at Transitions Clinic (TC), a PC-CCM program for formerly incarcerated individuals consisting of primary care from a provider with experience working with this population and care management from a community health worker (CHW) with a personal history of incarceration,17 or (2) an expedited primary care (EPC) appointment at another safety-net clinic. Care management from a CHW included basic case management, as well as chronic disease self-management support, health care navigation, and patient panel management. We compared the effectiveness of TC versus EPC in increasing primary care and reducing acute care utilization. We hypothesized that individuals randomized to TC would have more primary care and fewer ED visits compared with those randomized to EPC. |
