Models for Pre-Release Services
Develop strategies and models for providing required Medicaid OUD services efficiently while accommodating short stays, long stays, and unpredictable release dates
2.1 Short Stays
Why is this important?
In this context, jails often have limited time to deliver pre-release services. This situation is complicated by the fact that release dates are unpredictable for people being held pre-trial.
Strategy
- Within 24 hours, 48 hours, 72 hours, and 96 hours
- Between 96 hours and 2 weeks
- Within 30 days, 60, and 90 days
- Implement a rapid assessment and linkage model that begins on the first day of detention, connects individuals to MOUD, and establishes linkages to community post-release services during the first week of the individual’s jail stay.
- Use the National Association of Boards of Pharmacy (NABP) PMP Interconnect® to verify an individual’s community medication.
NABP PMP InterConnect®
This national network of prescription drug monitoring programs (PDMPs) enables the sharing of PDMP data across state lines. All states except Missouri have a statewide PDMP. Missouri has not yet adopted a statewide program but does have localized initiatives that cover most of the state and are counted as a state PDMP. Learn more from PDMPWorks.
Example #1: Short stay MAT initiation model
The following example describes how to initiate MAT and connect an individual to case management during a typical short stay of 7 days.
- Screens for OUD and withdrawal
- Obtains the necessary consent to disclose personal information
- If the individual is receiving an MOUD, arranges for the facility’s U.S. Drug Enforcement Administration (DEA)-registered practitioner to continue the individual’s medication
- Conducts a MAT assessment and initiates MOUD on the same day, if the individual wants to begin medication
- Provides a supply of naloxone at this time and either trains the individual on how to use it or provides instructions
- Meets with the individual to help them choose a community MAT provider
- Provides an electronic referral to the community MAT provider through an electronic health record (EHR)
- Identify the specific post-release care manager
- If possible, arrange a telephonic or telehealth warm handoff
In the short stay model, the pre-release case manager is responsible for monitoring the process as a whole. This includes projecting a targeted release date, if possible, and adjusting activities if the length of stay is shorter than expected, like by arranging for the correctional facility navigator to continue working with the individual after release.
Example #2: Philadelphia, Pennsylvania
The Philadelphia Department of Prisons uses NABP PMP InterConnect® to verify individuals’ community medications. They’ve also developed a network of community providers for post-release case management and MAT. Each provider signs a memorandum of understanding (MOU) committing to offering 1-day intakes and accepting walk-ins. Each provider also designates a point of contact to facilitate appointments and manage coordination of care. Prison staff meet with individuals shortly after intake to help them choose a post-release community provider. Staff then send a secure, electronic secure referral to that provider and a complete discharge summary at the time of the individual’s release8.Example #3: California
California has developed both required and recommended timelines for a short stay model that provides pre-release services within 30 days.
Example #4: Massachusetts
To mitigate short stay challenges, Massachusetts’ MassHealth intends to provide clinical guidance that requires facilities to conduct clinical assessments and implement plans for needed medications (including MAT) within a short timeframe from the date of incarceration. This will ensure that all MassHealth members have a plan for medications early in their incarceration period. The clinical guidance will also set timeframes for when care management and other pre-release services need to be offered.
Browse: Reentry Demonstration Initiative Implementation Plan, pages 17–20
Example #5: Washington
Washington has developed a short stay model that requires:
- Medicaid eligibility and/or application and health screening on Day 1
- Continuation of existing medications and evaluation and initiation of new medications on Day 2
- Case management assignment on Day 3
- Health assessment on Day 4
- Reentry care plan and coordination on Day 5
In this model, warm handoff can occur at any point before release and no later than 7 days post-release. For individuals’ whose incarceration lasts 2 days or longer, reentry medication occurs at release.
Browse: Reentry Initiative Policy and Operations Guide, pages 26, 27, and 45
2.2 Unpredictable Release Dates
Why is this important?
As discussed for short stays, most individuals in jails have an unpredictable release date.
An unknown percentage of individuals incarcerated in prisons also have unpredictable release dates. This unpredictability is caused by a variety of factors, including:
- Indeterminate sentencing
Parole boards’ ability to decide release dates - The potential for “good time” credits to shorten a sentence
In this context, correctional facilities must quickly initiate pre-release services for individuals whose release dates aren’t known until shortly before release.
Strategy
Correctional facilities can:
- Activate the rapid assessment and linkage model described for short stays when an individual has been identified as having an unpredictable release date
- Consider creating a methodology to proactively predict release dates for individuals expected to be released within 6 months
2.3 Long Stays
Why is this important?
Centers for Medicare & Medicaid Services (CMS) guidance requires that MAT, case management, and connection to post-release case management be provided within the 90-day pre-release period. It also requires that medications be provided to individuals at release.
Strategy
Correctional facilities must adopt a long stay model that begins 90 days before release.
Example #1: Washington
Washington has developed a long stay model that requires:
- Medicaid eligibility and application, health screening, care manager assignment, reentry health assessment, and reentry care plan and coordination during Days 61 to 90
- Continuity of medication and evaluation for and initiation of new MOUD on Day 90
- Warm handoff 14 days before release and no later than 7 days post-release
- Medication provision at release
Access: Reentry Initiative Policy and Operations Guide, page 25
Access: Reentry Initiative Policy and Operations Guide, page 25
References
6 Jail inmates in 2023–Statistical tables. U.S. Department of Justice, Office of Justice Programs.
7 Small but growing group incarcerated for a month or more has kept jail populations high. Pew.
8 B.Herdman (personal communication, February 18, 2025)