Medication-Assisted Treatment DISCHARGE PLANNING Fred Meyer, MA, CJM, CCHP and Claire Wolfe, MPH, MA, CCHP
One of the essential components of a jail-based medication-assisted treatment (MAT) program is discharge planning to ensure continuity of care following release from incarceration. The risk of overdose in the two weeks following release is extremely high. One study found the risk to be 40 times as high as the risk of overdose in the community (Ranapurwala et al., 2018). In 2021, it is estimated that more than 80,000 individuals in the U.S. died from an opioid-involved overdose (Centers for Disease Control and Prevention, 2022) and more than 500,000 individuals in the U.S. have died from an opioid-involved overdose since 2000, the world’s highest number of opioid-involved deaths per capita (Congressional Budget Office, 2022). Access to MAT during incarceration has been demonstrated to substantially reduce the risk of overdose one month following release (Lim et al., 2023).
This is an area of public health where jails play a crucial role. Discharge planning continues the impact of a well-run MAT program following release and can ease the difficulties associated with reentry and lead to healthier individuals, safer communities, and less pressure on government budgets. Failing to provide adequate discharge planning services results in missed opportunities for communities because high-risk individuals are not identified, supported, and adequately prepared for release.
Access to Community-Based Treatment
Discharge planning must begin at intake and should be addressed throughout incarceration to avoid any interruption of treatment upon reentry. At a minimum, facilities should ensure that released individuals have an appointment with a community-based opioid treatment program (OTP) or provider and/or a warm handoff, depending on how the community organization functions. To avoid any gaps in care, a prescription and/or bridge dose of medication should be provided. The process of continuing treatment will vary based on community resources and specific partners, for example, whether an appointment is needed or if an individual can walk in following release. If possible, having a patient go directly from the correctional facility to community-based treatment is ideal and improves outcomes. To ensure that a warm handoff is coordinated, jail staff may be able to complete intake information for individuals during incarceration that meets the criteria for the community organization. Co-occurring substance use and mental health disorders should be addressed through adequate screening during incarceration and through appointments for primary and psychiatric care as needed upon re-entry. However, not everyone on MAT will be ready for long-term recovery upon release. A harm reduction model that provides education on overdose risks and access to and education on using naloxone will save lives.
Efforts to ensure that individuals are covered by Medicaid or another form of health insurance upon release will enable them to access essential treatment services in a timely manner. This requires designated resources to help with the preparation, application, and follow-up process and will vary by state. As is an ongoing theme in this series, the importance of leadership support and institutional buy-in cannot be understated. It takes time, funding, and dedication to ensure this work is done in a thoughtful and effective way. If funding is available, consider a dedicated discharge planner. These individuals will be able to gain an understanding of patients to create a more in-depth and tailored transition into the community. All individuals will not require the same level of services. Understanding the needs of the population helps to create a more effective and efficient strategy with limited resources.
If you are unsure what resources exist in the community, consider conducting an inventory of community-based services and organizations to understand what is available. This may include informal discussions, or a survey sent out to organizations that will allow for the collection of necessary information to help individuals access the services upon release. The goal is to ensure that services are evidence-based and to understand eligibility requirements, including making sure the program is available to the jail re-entry population.
Relationships are crucial. It is extremely important to minimize any gaps in care that may occur between release and continued access to treatment. This requires thoughtful collaboration across systems, including correctional facilities, community health care organizations, probation and parole, and social service providers. One strategy to strengthen relationships and trust between patients and community organizations is to provide in-reach services, where staff come to the facility or video call to meet patients prior to release. This strategy can help to garner trust and allows for patient education.
Perhaps the biggest challenge to continuity of care is that, for many individuals, their discharge date will be unknown, and release can occur with little notice. This reality underlies the importance of beginning discharge planning at intake.
Reintegration
The concept of continuity of care is not limited to medical care but includes other factors that impact an individual’s well-being and behavior, including employment, education, and housing. A framework for understanding these factors is the Social Determinants of Health (SDOH), or the nonmedical factors that impact health outcomes. There are several ways that correctional facilities can work with patients to improve access to the SDOH. For some facilities, this may be difficult due to lack of funding and community resources, however, starting on a small level and building up these initiatives over time is a strategy that can help strengthen support and obtain funding. It is important to remember that sustainability is key and ongoing funding needs to be secured. Aiding individuals in obtaining an ID and aiding with transportation through ride sharing vouchers or bus tickets are a good start, but larger-scale programs offered during incarceration may include skills training, community college classes, and partnerships with external organizations for employment assistance. It is important that any programs offered provide true value to incarcerated individuals upon release.
It is hard to imagine building a self-directed life without safe and stable housing, however, formerly incarcerated individuals face higher rates of homelessness than the general population (Couloute, 2018). Facilities can provide referrals for residential treatment facilities or sober living in the community. To ensure that housing placement does not interfere with the continuation of MAT, care should be coordinated and supported by community corrections officers.
Electronic Health Record
It’s imperative that agencies utilize an electronic health record (EHR) system to provide effective medical and mental health care. There are still facilities working with paper custody and medical records, which causes a large gap in operations. Antiquated record systems impair timely access to relevant information and may lead to adverse events in your jail. Without an effective electronic health care record system and jail management system, it’s extraordinarily difficult to have internal and external communication and continuity of care upon release.
There should be consideration of implementing a “dashboard‚ of critical areas that can be quickly evaluated by custody and medical leadership to help keep the ship on course. Daily population count, emergency room send-outs, suicide watch numbers and attempts, inmates on withdrawal protocols, gaps in suicide watch rounds, etc. are a few categories that leadership should be monitoring to reduce risk.
As agencies move forward, it’s critical to consider your needs when evaluating both jail management and EHR systems. When considering vendors and/or systems, there needs to be thought given to data sharing and reporting capabilities. The more data is available to the interdisciplinary leadership team (custody and health administration), the better. The systems should be able to communicate and generate reports so proper performance auditing and oversight of operations can be accomplished. Understanding your population and the overall disease burden is crucial to ensuring appropriate continuity of care and reentry services are prioritized and provided.
The use of an electronic health record will aid in the development of policies and practices to share information across organizations for greater awareness of health status. Strive to provide patients with health records or instructions to access health records when released so that interaction with health care providers in the community does not require starting from scratch. This may interrupt continuity of care, lead to duplicate efforts, and can lead to frustration for the patient and provide
Continuous Quality Improvement (CQI)
Designing and implementing an evaluation process for discharge planning efforts is crucial. Metrics of interest should be clearly defined and aligned with the goals of the program. Evaluation may be difficult for many, given the resource-intensive nature of the process and the difficulty in data sharing and collection, however, it is important that we begin to move the field in this direction, using data to understand the
impact of programs and conducting CQI efforts. Consider exploring an external partnership with a research or nonprofit organization to fill any gaps in expertise and time. When choosing an EHR or jail management system, keep in mind the goals of program evaluation and what tools are needed to effectively and efficiently conduct CQI studies. The SDOH, including employment status and housing stability post-release, should be considered in discharge planning evaluation in situations where this information can be obtained. This process may be challenging but will provide valuable insights into how we can improve outcomes post-release, including reduced recidivism, and it is what we need to work toward.
Addressing Lack of Resources in the Community
The community is a better place to address substance use and mental health issues than jail. Given that deinstitutionalization and the criminalization of substance use has brought society to a place where many of individuals with mental health and substance abuse issues are instead routed to the criminal justice system, there is a distinct need for advocacy to address the lack of treatment resources in many communities in this country. As individuals who work in this environment each day, there is no one better than you to seek funding and educate policymakers on the importance of community resources in reducing recidivism, improving public safety, and enabling individuals to lead self-directed lives. Education and stigma reduction will continue to be key in serving these populations, and there is much work to be done. The National Commission on Correctional Health Care and the American Jail Association support and appreciate the work you are doing.
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Fred W. Meyer, MA, CJM, CCHP, is managing director of NCCHC Resources, Inc., the consulting arm of the National Commission on Correctional Health Care. A retired deputy chief, he has more than 25 years of experience in corrections and is a graduate of the National Jail Leadership Command Academy and Jail Executive Development Program. He holds a master’s degree in criminal justice from the University of Nevada, Las Vegas. He can be reached at fredmeyer@ncchcresources.org
Claire Wolfe, MPH, MA, CCHP, is a program manager at NCCHC Resources, Inc. She holds a Master of Public Health in Epidemiology and has focused her research on opioid use disorder treatment in jails. Previously, she worked for the philanthropic arm of a multi-national IT consulting company and as the chief of staff for a New Jersey State Assemblyman. She can be reached at clairewolfe@ncchcresources.org.
Thank you to Holly Witt RN, BSN, CAS, CCHP, nurse program manager, Behavioral Health & Substance Use, Denver Health˛Denver Sheriff Health Services, for your invaluable input.
References
Centers for Disease Control and Prevention (2022, May 11). U.S. Overdose Deaths In 2021 Increased Half as Much as in 2020˛But Are Still Up 15% [Press Release]. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm
Congressional Budget Office. (2022). The opioid crisis and recent federal policy responses. https://www.cbo.gov/system/files/2022-09/58221-opioid-crisis.pdf
Couloute, L. (2018). Nowhere to Go: Homelessness among formerly incarcerated people. Prison Policy Initiative. Retrieved May 23, 2023 from https://www.prisonpolicy.org/reports/housing.html.
County Health Rankings Model. (n.d.). University of Wisconsin Population Health Institute. Retrieved May 23, 2023 from https://www.countyhealthrankings.org/explore-health-rankings/county-health-rankings-model.
Lim, S., Cherian, T., Katyal, M., Goldfeld, K. S., McDonald, R., Wiewel, E., Khan, M., Krawczyk, N., Braunstein, S., Murphy, S. M., Jalali, A., Jeng, P. J., MacDonald, R., & Lee, J. D. (2023). Association between jail-based methadone or buprenorphine treatment for opioid use disorder and overdose mortality after release from New York City jails 2011-17. Addiction. 118(3), 459fi467. https://doi.org/10.1111/add.16071
Ranapurwala, S.I., Shanahan, M.E., Alexandridis, A.A., Proescholdbell, S.K., Nauman, R.B., Edwards, D., Marshall, S.W. (2018). Opioid overdose mortality among former North Carolina inmates: 2000fi2015. American Journal of Public Health. 108, 1207-1213. https://doi.org/10.2105/AJPH.2018.304514