Program Profile: Primary Care-Based Complex Care Management (San Francisco, Calif.)

This program is designed to provide a lower cost alternative to emergency medical treatment for chronically ill individuals who have been recently released from prison. The program is rated Ineffective. Treatment group participants had statistically significantly lower rates of emergency room use, compared with the control group. However, there was no impact on recidivism and primary care utilization.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Ineffective rating implies that implementing the program is unlikely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

The Primary Care–based Complex Care Management program is designed to address the overuse of emergency room care for chronically ill individuals who have been recently released from prison. The use of the emergency room for primary care can create a backlog of patients and result in high costs of treatment. The program offers an alternative to accessible primary care for those patients who need primary care, but are routinely seen in emergency rooms. The goal of the program is to provide primary care for chronically ill individuals recently released from prison and ensure this population receives needed health care post-incarceration. Additional program goals are to address the low rates of primary care engagement and the high rates of emergency room use and death among prisoners returning to the community.

Target Population/Eligibility

The target population includes formerly incarcerated individuals (i.e., released from prison within 2 weeks) who have been diagnosed with a chronic health condition.

Services Provided

The program offers an alternative to accessible primary care, called Transitions Clinic (TC), which consists of a primary care physician who has experience working with formerly incarcerated individuals and a community health worker (CHW), who has a personal history of incarceration and provides care management. Patients initially enrolled in TC receive an expedited primary care appointment, but future appointments are made at the discretion of the TC provider. However, patients can call the provider for urgent medical issues.

Ongoing care at TC consists of basic case management, chronic disease self-management support, health care navigation, and patient panel management. The CHW provides 1) referrals to community-based housing and education and employment support; 2) medical and social navigation, including accompanying patients to pharmacies, social services, and medical or behavioral appointments; and 3) chronic disease self-management support, including home visits and medication adherence support. Follow up includes refilling medications and addressing urgent medical issues.

Study

Wang and colleagues (2012) conducted a randomized controlled trial to study the effect of primary care–based, complex care management as an alternative to expedited emergency primary care for chronically ill individuals who were released from prison within the past 2 weeks. The study was in San Francisco, Calif.  

The treatment group was offered an alternative to accessible primary care, called Transitions Clinic (TC). Participants who initially enrolled received an expedited primary care appointment, but future appointments were made at the discretion of the TC provider. However, patients could call the provider for urgent medical issues. The comparison group received an expedited primary care appointment within 4 weeks with a primary care–clinic provider who did not have formal training for previous prisoner populations. The comparison group also had access to the same services, but was not assisted by a community health worker.  

To be eligible for the study, individuals had to 1) be English speaking; 2) be 50 years or older; 3) have at least one chronic illness, including mental health conditions or addiction; and 4) not have a primary care provider in San Francisco. The treatment group participants (n=98) had an average age of 42.9 years, Of this group, 23.5 percent were married, and 91.8 percent were male. The race/ethnicity of the treatment group was 63.4 percent Black, 20.8 percent white, 10.4 percent Hispanic, and 5.4 percent Asian. One third of the group was insured, 13 were covered by Medicaid, 4 were covered by Medicare, and 4 were covered by Healthy San Francisco. The comparison group participants (n=102) had an average age of 43.6, 13.7 percent were married, and 96.5 percent were male. The race/ethnicity of the comparison group was 65 percent Black, 17 percent white, 14 percent Hispanic, and 3 percent Asian. Four percent were employed, while 29.4 percent were insured, 11 were covered by Medicaid, 4 were covered by Medicare, and 3 were covered by Healthy San Francisco. There was a statistical adjustment for time incarcerated and deaths; however, the rest of the baseline data was determined to be statistically equivalent. 

The baseline data was collected on a participant questionnaire. Participants self-rated health questions and diagnoses, past health care while incarcerated and before incarceration, case worker interaction, and past hospitalization history. Information on age, gender, race, and ethnicity was collected from the electronic data repository. The two primary health care outcomes that were assessed were 1) two or more visits to the study-assigned, primary care clinic; and 2) visits to the medical or psychiatric emergency room that did not result in hospitalization. Two secondary health care outcomes, rate of emergency room use and of any hospitalization, were also assessed. Finally, two incarceration outcomes were also assessed: 1) first-time incarceration, and 2) time to first incarceration, which included short stays not resulting in conviction and longer, stays resulting in transfer to the state prison system.

An intent-to-treat analysis was conducted, using a chi-square test to compare primary care, emergency room use, hospitalizations, and incarceration. The Wilcoxon rank sum test was used to compare emergency room visits, and applied Poisson regression was used to compare the rates of emergency room utilization and hospitalization. The Poisson regression adjusted for the time incarcerated and death. The follow-up period was 12 months.

Primary health care providers were trained in the aspects of the prison population and the certified community health worker had a personal history of incarceration.  

The community health worker (CHW) completed a 6-month certificate program at a community college and on-the-job training to learn how to navigate the local health care and social service delivery system. The CHW applies skilled learned from training as well as skills learned through their own experience with incarceration, homelessness, and addiction. 

The program staff started initially with one part-time provider and one full-time case management worker; however, in July 2008, the staff increased to two part-time providers and two full-time case workers.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Wang, Emily A., Clemens S. Hong, Liz Samuels, Shira Shavit, Ronald Sanders, and Margot Kushel. 2010. “Transitions Clinic: Creating a Community-Based Model of Health Care for Recently Released California Prisoners.” Public Health Reports 125:171–7.