Calls and Coordination for Transitions of Care at Re-entry

Health Systems Innovations for Supporting Transitions of Care for Incarcerated People Living With Substance Use Disorders

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

The objective of this clinical trial is to test the effectiveness of a transitional care program adapted to meet the healthcare needs of adults after release from prison. The goal of the transitional care intervention being tested is to help the study participants connect to primary care within 60 days of release through weekly check-in calls. Participants in this study are enrolled approximately 6 months before their anticipated release. One group will receive weekly phone calls for up to 60 days post-release. Additionally, novel, linked administrative datasets will be leveraged to enhance, contextualize, and clarify policy implications of the clinical trial results.

Inclusion Criteria:

• age 18 or older
• 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?"), and
• living with, or history of, a chronic medical or psychiatric condition other than substance use disorder. This is defined as ever having been diagnosed with a medical or psychiatric chronic condition, or currently taking prescription medications for a chronic condition.
• able to read, understand, and speak English.

Exclusion Criteria:

• ineligible for WI Medicaid
• no substance use history
• not living with, or no history of, chronic medical or psychiatric condition