Linking Former Inmates to Primary Care


The Transitions Clinic Network (TCN)aims to connect former inmates to primary care using trained, culturally competent primary care providers and community health workers (CHWs). The purpose of this project is to support ongoing quality improvement at the 11 participating sites by training culturally competent CHWs and measuring the health, health care utilization, and the costs of caring for former inmates.

Study Start Date

May 2013

Estimated Completion Date

May 2016


  • Other: Primary care redesign


  • Internal Medicine: Preventive Medicine
  • Family Medicine: Preventive/Nutrition
  • Hospital Administration: Managed Care

MeSH Terms

  • Depressive Disorder
  • Hypertension
  • Inmate
  • Substance-Related Disorders

Study ID

Yale University -- 1C1CMS331071



Trial ID


Study Type


Trial Phase


Enrollment Quota



Yale University

Inclusion Criteria

  • Recently-released from prison (within one month)
  • Has >=1 chronic disease condition , and/or age >=50 years
  • Plans to live in the TCN area for the duration of the study
  • Understands English or Spanish and able to provide consent

Exclusion Criteria

  • Does not plan to live in the TCN area for the duration of the study
  • Does not understand English or Spanish, or unable to provide consent
  • Does not plan to receive healthcare through a TCN clinic




18 Years and older

Accepts Healthy Volunteers


Study Locations and Contact Information (9)

Study Location Distance Name Phone Email
Yale Primary Care Center - New Haven, Connecticut 18.1 miles Emily Wang MD 203-737-6317
Montefiore Transition Clinic - New York, New York 40.3 miles Aaron Fox MD 718-944-3854
Comprehensive Health Care Center - New York, New York 44.6 miles Aaron Fox MD 718-944-3854
Boston Healthcare for the Homeless Program - Boston, Massachusetts 137.1 miles Jessie Gaeta MD 857-654-1784
East Baltimore Medical Center - Baltimore, Maryland 219.6 miles Rosalyn Stewart MD MS MBA None
Medicine in Psychiatry Service clinic of the University of Rochester Medical Center - Rochester, New York 260.4 miles Daine Morse MD 585-275-6484
Contra Costa Health Services East and West Contra Costa - Martinez, California 2,585.7 miles Tiombe Mashama HEd MPA 925-957-5553
Santa Clara Health Center - San Jose, California 2,590.7 miles Buu Thai 408-535-4277
Southeast Health Center - San Francisco, California 2,603.7 miles Shira Shavit MD 415-476-2148 provides clinical trial listings in an easy to view format. All clinical trial information is pulled directly from This website does not guarantee acceptance into any clinical trial, and is not responsible for adverse events that may be incurred from a clinical trial.