Coordination of Care Upon Release From Incarceration: A NACo Opioid Solutions Strategy Brief

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“By improving care and coordination prior to release from the justice system, we can help build a bridge back to the community and enhance individual and collective public health and public safety outcomes.”

– Chiquita Brooks-LaSure, Administrator, U.S. Centers for Medicare & Medicaid Services, 2021–20241

What is coordination of care upon release from incarceration?

Overdose is the leading cause of death among formerly incarcerated people,2 particularly within the first two weeks of release.3 With approximately 6 in 10 incarcerated people meeting criteria for substance use disorder,4,5 and more than 600,000 people released from state and federal prisons each year,6 coordination of care is critical to protecting the health and wellbeing of persons returning to the community.

Coordination of care upon release is the deliberate organization and sharing of information between correctional and community-based service providers to ensure the most effective care for each person returning to the community.7 During incarceration, effective care for opioid use disorder (OUD) includes screening and treatment with medications for OUD (MOUD).8,9 Upon release, effective care for individuals with OUD involves linking people to evidence-based care in the community, including:

HEALTH SERVICES

  • Assisting with enrollment in Medicaid or other health insurance,
  • Connecting with a community-based MOUD provider,
  • Ensuring that the costs of treatment and medications are covered and
  • Training and equipping all incarcerated persons with naloxone upon release.

Click here to read NACo’s Strategy Brief on effective treatment for opioid use disorder for incarcerated populations.

HUMAN SERVICES

  • Providing permanent supportive housing for people with unmet health needs who are at high risk of overdose, homelessness or re-arrest;10
  • Engaging peer support specialists to assist individuals with pre-release planning and engagement with health care, social services and the community post-release;11
  • Offering temporary guaranteed income, which reduces recidivism and increases the likelihood of finding long-term employment, to formerly incarcerated people living with OUD or at high risk of overdose.12

What evidence supports coordination of care upon release from incarceration?

Treatment with methadone or buprenorphine is an evidence-based overdose prevention strategy13 that reduces the risk of overdose in persons with OUD by as much as 50%.14,15 When Rhode Island began providing universal access to MOUD during incarceration and linkage to community-based treatment with MOUD upon release, the state observed a 60% reduction in mortality among recently incarcerated persons. This is equivalent to one fatal overdose prevented for every 10 persons connected with evidence-based care.16

The FDA has approved three MOUD: buprenorphine, methadone and naltrexone. However, programs that facilitate linkage to treatment solely with naltrexone, and not with methadone or buprenorphine, are in violation of the standards set by the American Society for Addiction Medicine and the National Commission for Correctional Health Care8,9 and may violate the Americans with Disabilities Act.17 Studies have shown that naltrexone is associated with increased risk of overdose among recently incarcerated persons.18,19

Connection with peer-led mutual aid and support programs, including recovery support groups and well-managed recovery housing, are associated with long-term recovery.20–22 Evidence-based peer recovery coaching also increases rates of housing and employment among people living with SUD, including formerly incarcerated people.23 Temporary guaranteed income programs support re-entry across all of these domains by increasing long-term employment, improving mental health and reducing risk taking among recently incarcerated persons.12

Are there risks to my community if we don’t coordinate care for individuals with OUD upon release from incarceration?

Yes.

A key step in coordinating care prior to release from incarceration is securing health care coverage ahead of re-entry. People who do not obtain health care coverage after release have higher rates of recidivism.24

Programs that support treatment and recovery upon release are also cost-effective. Over the course of a lifetime, the total health care and criminal justice cost savings of treatment with MOUD ranges from $40,000 per person (naltrexone) to $100,000 per person (methadone).25 Likewise, formerly incarcerated persons tend to represent greater health care needs and public health care costs due to higher rates of illness and financial precarity than the general population. Without early investment in the recovery and reentry success of formerly incarcerated persons, counties may experience more of these harmful and costly outcomes.

What are best practices for coordinating care for individuals with OUD upon release from incarceration?

  • Plan for linkage to care upon release during intake and discharge processes by:
    • Completing Medicaid or other health care coverage enrollment procedures26,27
    • Scheduling first appointments with community treatment providers, and
    • Arranging in-person or telehealth meetings with community treatment providers to initiate this relationship.28
  • Work with state and county officials to accelerate the Medicaid enrollment process for formerly incarcerated persons.29 Consider using the Medicaid 1115 wavier to speed-up this processes and/or provide transitional care services.30,31
  • Contract with a behavioral health care provider or create a referral network for linkage to MOUD upon release. Seek connections with providers that offer and encourage, but do not mandate, psychotherapy alongside MOUD treatment.28
  • Assist formerly incarcerated persons with overcoming practical challenges to employment, such as obtaining a driver’s license, identification card and other documentation of employment eligibility.32
  • Consider county-wide “fair chance employment” and “ban the box” initiatives to reduce employment barriers among formerly incarcerated persons. Through these initiatives, counties can encourage employers to hire people who are formerly incarcerated and/or in successful recovery from substance use disorder and protect them from discrimination and exclusion in the job market.33,34
  • Hire or partner with peer recovery coaches to provide social support, recovery support and assistance navigating health care and social services to formerly incarcerated people prior to and following release.35

What are some examples of successful coordination of care upon release programs?

Orange County, Calif., has been operating a coordinated care upon reentry program since 2014. The program has been proven to effectively reduce rearrest among persons with mild-to-moderate behavioral health disorders by more than 50%. The program provides intensive case management and linkages to evidence-based treatment, housing services, behavioral health services and community support. Many of these services are offered by community-based providers in direct collaboration with county corrections and health authorities.36 

Several jurisdictions, including Stockton, Calif., Durham, N.C., and Alachua County, Fla., have piloted temporary guaranteed income programs that provide unconditional cash payments of $500-600 to formerly incarcerated persons. These programs help persons in finding long-time employment by removing the barriers caused by the financial precarity and uncertainty that many experience after release.12,37,38 

In 2013, under a Section 1115 Medicaid waiver, the Cook County, Ill. Department of Corrections began screening incarcerated persons for Medicaid eligibility at intake. The screening process takes about 10 minutes and resulted in more than 10,000 successful Medicaid enrollments in the first two years of implementation.39

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Author

Jennifer J. Carroll, PhD, MPH

Dr. Carroll is a medical anthropologist, research scientist and subject matter expert on substance use and public health. She is currently an Assistant Professor of Anthropology at North Carolina State University.

Additional Resources

Best practices for linkage to treatment and services after release

Guidance on ways to improve linkage to care through Medicaid

Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP)

COSSAP is a program of the U.S. Bureau of Justice Administration that provides training and technical assistance to COSSAP grantees and to other local, state, and tribal authorities seeking to implement evidence-based responses to substance use within the criminal justice system. COSSAP accepts direct requests for technical assistance and provides such assistance through several partner agencies.

Opioid Response Network (ORN)

The ORN is a technical assistance collaboration between the American Academy of Addiction Psychiatry and the Addiction Technology Transfer Center at Columbia University. The ORN has local consultants in all 50 states and 9 U.S. territories to provide communities with technical assistance and education on the prevention and treatment of OUD.

Opioid and Stimulant Implementation Support Training and Technical Assistance (OASIS-TTA)

OASIS-TTA, hosted by the University of California, Los Angeles, is on online repository of resources and toolkits for establishing MOUD services in a variety of health and social service settings. OASIS-TTA also accepts direct requests for technical assistance.

Rural Communities Opioid Response Program – Technical Assistance (RCORP-TA)

RCORP-TA is a multi-year initiative by the Health Resources and Services Administration (HRSA) that offers numerous online technical assistance resources related to linkage to care at re-entry. 

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