Transitions in Care
Ensure strategies exist for transitioning individuals between facilities and community OUD MAT providers
Why is this important?
Effective transitions are key to successful reentry initiatives, but they can present challenges that aren’t encountered in typical health care transitions. For example, individuals being released from correctional facilities have high behavioral and medical needs and have often lost connection to their communities and families. As a result, communication and connection are even more important when bridging from correctional facilities to communities.
Strategy
Transitions in care must be carefully managed by a designated individual or team. An effective transition begins with a personal, in-person (including telehealth) meeting that includes the individual whose care is being transitioned. The transition process should ensure timely access to services through same-day, walk-in appointments or telephone/telehealth visits.25
The easiest way to minimize disruptions during care transitions is to have the same providers work with an individual both pre- and post-release. Nationally, 11% of all county health departments play a role in providing correctional health care through a dually based model — in which providers in the jail also serve patients in the community, thereby easing transitions in care when individuals are released.
Referral system considerations
SMAs can consider developing a technology-enabled closed loop referral system — similar to North Carolina’s NCCARE360 — for health-related social needs demonstrations for providers to:- Refer individuals to behavioral health and social service organizations
- Receive confirmation that the individual was successfully connected to care26
Example #1: Franklin County, Ohio
The Rapid Resource Center, launched in 2021, plays a key role in linking individuals leaving incarceration to a variety of services and treatment. With hours that span morning, afternoon, and evening, individuals can, upon release, meet in person with staff members to learn about their options, including linkage to MOUD. Individuals can also contact the center later, after their initial consultation, to learn more about their options and opportunities.
Learn more: Supporting Incarcerated People’s Recovery: Linkage to Care Policies for People Entering and Exiting Incarceration with Substance Use Disorder, page 5
Example #2: Camden County, New Jersey
The Camden County Jail’s MOUD program includes navigators who provide face-to-face coordination post-release, assisting with connections to community treatment providers, pharmacies, and other supports.
Check out: Evaluating the Camden County Correctional Facility’s Medications for Opioid Use Disorder Program, page 7
Example #3: Multnomah County, Oregon and Hampden County, Massachusetts
These counties’ dually based models allow community providers to access (with the individual’s permission) health records from during and before incarceration.
Download: Jails: Inadvertent Health Care Providers, pages 5 and 15
Example #4: New York City, New York
NYC Health + Hospitals operates the Point of Reentry and Transition (PORT) program, an initiative of the city’s Correctional Health Services. PORT practices are located at 2 public hospitals (Bellevue and Kings County) and are staffed by primary care providers who usually work in city jails, alongside practitioners who work in the 2 community hospitals. Community health workers within the 2 hospitals serve as bridges to services. This model creates opportunities for individuals released from jail to see the same providers who treated them during their incarceration.
Example #5: Rhode Island
The Rhode Island Department of Corrections established 12 community-based Centers of Excellence (COEs) in MOUD to ensure continuity of care and treatment post-release. To create these COEs, the state repurposed existing outpatient facilities located throughout Rhode Island. Individuals choose the center for their treatment.
Learn more: Health Care Transitions for Individuals Returning to the Community from a Public Institution: Promising Practices Identified by the Medicaid Reentry Stakeholder Group, page 20
Example #6: Franklin County, Massachusetts
Franklin County changed their post-release programming to provide telehealth options, such as recovery management checkups, a peer-recovery telehealth group, and a mobile texting application (Textedly) to “connect with, educate and motivate individuals to access community treatment and resources.”
In addition, the major behavioral health provider in Franklin County (Behavioral Health Network) has an embedded staff person who works at the jail, collaborating with the reentry team on identifying treatment options, making electronic referrals, and scheduling first community appointments.
Example #7: Massachusetts
Massachusetts provides reentry support for individuals receiving MAT by matching individuals preparing for release with Recovery Support Navigators, who are trained to provide non-clinical peer support services. These navigators ensure that individuals connect with an outpatient treatment program within 24 hours of release and maintain contact for a year to provide ongoing support.
Read: Connecting the Justice-Involved Population to Medicaid Coverage and Care: Findings from Three States, page 8
Example #8: Washington
Health engagement hubs serve as all-in-one locations where people in Washington can access a range of medical and social services. The Washington State Health Care Authority, in collaboration with the Department of Health, oversees this effort to ensure efforts align with cross-agency goals around expansion of services and resources through public health and behavioral health systems.
Explore: Health Engagement Hub
6.1 MAT with Buprenorphine and Naltrexone
Why is this important?
While buprenorphine is the most frequently prescribed MOUD, there is still insufficient provider supply to meet the need, and adding the justice-involved population to the existing population requiring treatment will widen the access gap. In addition, like methadone, buprenorphine is significantly less available in rural areas than in more densely populated communities.
Providers must use innovative, person-centered practices to engage and retain individuals who are released from correctional facilities — consistent with the needs of others receiving MOUD.
Strategy
With the exception of Vermont, most counties and states have far fewer DEA-registered providers than the number required to meet existing need. SMAs, SSAs, and Medicaid Health Plans will need to consider developing plans and approaches to increase access to both buprenorphine and methadone.
As recommended for pre-release MAT, post-release MAT must maximize telehealth use to increase engagement and retention in treatment. In fact, research has shown that starting buprenorphine through telehealth is associated with an increased likelihood of staying in treatment longer compared to starting in a non-telehealth setting.27
Correctional facilities can establish relationships with agencies offering telehealth buprenorphine bridge programs, so that post-release MAT is rapidly available as a connection to long-term treatment if there are time or geographic gaps in access.
SMAs and/or their correctional partners can encourage MCOs to
- Designate providers who offer telehealth for MOUD as preferred providers to facilitate increased access to treatment
- Increase retention in treatment by identifying MAT providers using mobile digital technology to support individuals during treatment and after providing access to crisis alerts, e-therapy for recovery skill development, clinical support, and connection to peer specialists
Example #1: Washington, New York, New Jersey, and Pennsylvania
Modelled after hospital bridge clinics, organizations in several states are offering rapid linkages to buprenorphine telehealth providers or directly providing rapid initiation of buprenorphine. Examples of these organizations include Telebup in Washington and the MATTERS (Medication for Addiction Treatment and Electronic Referrals) Network, which covers New York, New Jersey and Pennsylvania.
Explore:
Example #2: Pennsylvania and Illinois
The University of Pittsburgh Medical Center Telemedicine Bridge Clinic and Penn Medicine’s Care Connect in Pennsylvania and Medication Assisted Recovery (MAR) in Illinois:
- Facilitate rapid engagement of individuals with OUD
- Initiate MOUD
- Refer them to appropriate health and recovery programs
All three programs provide telephonic prescriptions and buprenorphine induction.
Learn more:
Example #3: Niagara and Dutchess Counties, New York
Jails in these counties have partnered with the MATTERS Network, whose referral network connects community providers and correctional facilities to treat individuals via telemedicine. Individuals can select the location and time for follow-up MOUD care that work best for them.
Access: Medication for Opioid Use Disorder (MOUD): Correctional Health Implementation Toolkit, page 38
Example #4: Middlesex, Massachusetts
The Middlesex Jail and House of Correction operates an in-facility MAT program and coordinates post-release treatment transitions with the Lowell Community Health Center.
6.2 MAT with Methadone
Why is this important?
The same regulatory restrictions that create barriers to pre-release methadone provision apply to post-release access. These barriers include regulatory restrictions on who can deliver methadone and the presence of fentanyl in the drug supply. In this context, it’s crucial that methadone be available to individuals who are incarcerated as soon as possible
Strategy
States must employ similar strategies for creating access to treatment post-release as for MAT with methadone pre-release, in terms of both:
- The delivery models used, like medication units
- The adoption of the 2024 regulatory flexibilities, especially take-home dosing
Notably, directly observed therapy with methadone has been shown to be safe and effective in increasing retention in treatment and take-home dosing privileges while reducing barriers related to daily in-clinic dosing. Directly observed therapy can combine video-observed dosing and an electronically controlled pill dispenser for administering and monitoring methadone.28
SMAs can encourage MCOs to identify OTPs that offer telehealth for MOUD and greater use of take-home dosing, which could drive increased patient acceptance and lower treatment burden.
Example #1: Illinois
MAR NOW, a telehealth buprenorphine provider, offers same- or next-day appointments for methadone treatment at 14 OTPs throughout Illinois.
Learn more: Medication Assisted Recovery (MAR) Expansion
Learn more: Medication Assisted Recovery (MAR) Expansion