Calls and coordination to connect people to care after prison release
Health Systems Innovations for Supporting Transitions of Care for Incarcerated People Living With Substance Use Disorders
This program will test whether short weekly phone check-ins with a Nurse Case Manager help people leaving prison who have substance use history and chronic medical or psychiatric conditions get more non-emergency outpatient clinic visits.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 488 (estimated) |
| Ages | 18 Years and up |
| Sex | All |
| Sponsor | University of Wisconsin, Madison Academic / other |
| Locations | 1 site (Madison, Wisconsin) |
| Trial ID | NCT06794983 on ClinicalTrials.gov |
What this trial studies
The trial enrolls adults about six months before their expected release and randomizes participants to enhanced usual care or to a transitional care program that adds a Nurse Case Manager. All participants complete surveys and have 2–3 contacts with a study team member, while those in the NCM arm receive additional weekly calls or texts for up to 60 days post-release (approximately 6–11 contacts). The primary outcome is the number of non-emergency outpatient clinic visits within 60 days of release, and researchers will link trial data with administrative datasets to clarify policy implications. The intervention is tailored to address substance use history and co-occurring chronic medical or psychiatric conditions to improve connections to primary care.
Who should consider this trial
Good fit: Ideal candidates are adults eligible for Wisconsin Medicaid who are enrolled before release, have a history of substance use, and have a current or prior chronic medical or psychiatric condition and can read and speak English.
Not a fit: People who are ineligible for Wisconsin Medicaid, have no history of substance use, or have no chronic medical or psychiatric condition would not meet inclusion criteria and are unlikely to benefit from this intervention.
Why it matters
Potential benefit: If successful, the program could increase timely primary care visits after release and reduce reliance on emergency services for people with substance use history and chronic conditions.
How similar studies have performed: Similar transitional-care and case-management interventions for people leaving incarceration have shown mixed but promising results in improving outpatient follow-up, though evidence remains limited.
Eligibility criteria
Show full inclusion / exclusion criteria
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
Where this trial is running
Madison, Wisconsin
- University of Wisconsin — Madison, Wisconsin, United States (Recruiting)
Study contacts
- Principal investigator: Marguerite Burns — University of Wisconsin, Madison
- Study coordinator: Maggie Chilsen
- Email: mchilsen@wisc.edu
- Phone: 608-263-2704
How to participate
- Review the eligibility criteria above with your treating physician.
- Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
- Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.