Program Implementation

Funding

This section provides potential funding opportunities and modalities to cover the costs of MOUD (also referred to as MAT) for pregnant patients in jail – things like where to find funding to run a program, what will impact costs, and resources to support estimating and acquiring funding. While MOMCARE is geared toward serving pregnant patients with OUD, many of these funding considerations apply to non-pregnant patients in custody as well. 

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Funding

HOW

  • Determine what model of MOUD delivery best suits your jail’s needs.
    • Engage in conversations with your contracted healthcare provider to assess whether MOUD can be included in your contract.
    • Contact your local health department (or other community MOUD providers) if an alternative option is needed.
  • Estimate the cost of MOUD for pregnant patients. Include items like medication costs, staff time (assessment, dosing, transport), and behavioral health services.
  • Determine what funding mechanisms your jail is eligible for. Some include:


WHY

  • Jails need funding to provide and sustain sufficient evidence-based MOUD care to pregnant patients.
  • Jails should offer both methadone and buprenorphine, but some may be more readily available in the community.


KEEP IN MIND

  • Consultation with a perinatal care provider may be an additional cost if your healthcare provider does not have pregnancy expertise
  • Since pregnant patients need more frequent dose adjustments, it may mean more off-site transports or visits to medical within the facility
  • Breastmilk expression and storage are important (g. equipment, coordination, etc.)
  • Most pregnant individuals without private insurance are eligible for Medicaid in every state, and it should include MOUD coverage. MOUD services after release can be paid through Medicaid. Reentry staff should ensure the pregnant patient is signed up for Medicaid upon release so they can access MOUD and prenatal care at little to no cost.

HOW

Action Items 

  1. Consult with your contracted health provider (if applicable) to discuss MOUD being in the request for proposals (RFP) and having at least buprenorphine on the formulary. See sample contractual language used for incorporating MOUD services into medical provider RFPs.
  2. Contact your local health department for possible funding and collaboration opportunities for MOUD. Find out if your state has received opioid abatement funds from pharmaceutical company settlements to be used towards overdose reduction programs.
  3. Determine what MOUD delivery model is best for your facility. The model will directly impact There are pros and cons to each.
  4. Assess what medications are available in the surrounding community (accessible to your facility and the public). Evidence-based MOUD involves making multiple forms of medication available and promotes shared decision-making between the patient and provider.
  5. Find out whether your state has been awarded opioid response grants, and if so, what they are. This can help fund MOUD treatment and training for staff in corrections settings.


Estimating costs 

Each jail must first determine what MOUD delivery model is feasible and appropriate for their setting. Administrators should consider the following when determining the delivery model: staffing capacity to get daily MOUD doses to patients, staffing expertise in OUD and pregnancy care, health care delivery models and contracts, and community infrastructure. The type of medications your jail makes available will impact cost, as each formulation and delivery method vary. We recommend making both methadone and buprenorphine available. Methadone is often the least expensive. Extended-release injectables like naltrexone and Sublocade are often the most expensive, but these are not recommended in pregnancy. 

Please see the Implementation – MOUD delivery –  Delivery models for information describing the different modalities of delivering MOUD to people in jail custody. 


Tools to help you estimate what the costs will be for your jail to have MOUD: 


Identifying funding opportunities 

Jails fund MOUD in many different ways ranging from local, state, and federal grants and support. We first suggest finding out whether your state has applied and been approved for a Medicaid Reentry Section 1115 Demonstration Waiver to cover health care costs, including MOUD, for services provided in custody between 30-90 days pre-release. Then, you should look at whether your state has been awarded opioid response grants and what they are. Jails may be able to get discounted rates on MOUD through state block grants, Federally Qualified Health Centers (FQHCs), or subsidized medication programs. Use the table below to learn more details on possible funding options.

Name of Funding (with link)

Description

Medicaid Section 1115 Waivers

BJA webinar: Navigating the New Medicaid Section 1115 Demonstration Opportunity

Medicaid will not pay for ongoing health services for people in custody, but states can apply for a Section 1115 Waiver that will allow Medicaid to pay for health care costs, potentially including MOUD, for people in jail 30-90 days pre-release. The waiver is dually beneficial since it offsets some costs from the jail and ensures the patient has coverage at reentry.

If your state has applied and been approved for a waiver, then you can enroll patients in Medicaid while they are in jail, and it will cover health care costs for them! This website can tell you if your state has an approved 1115 Waiver that covers incarcerated people. 

SAMHSA State Targeted Response to the Opioid Crisis Grants (STR)

Intended to close the treatment gap between those who seek treatment and those who receive it. At least 80% of the award must fund treatment services and may be used for services in corrections settings and for reentry.1

SAMHSA State Opioid Response Grants (SOR)

$1 billion grant program with 15% set aside for the states with the highest rates of drug overdose deaths. Grants can be used for services including treatment and training for staff in corrections settings and for reentry. 1

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

The COSSAP grant program is awarded to state, local, and tribal entities to support responses to the opioid epidemic to reduce overdose deaths, promote public safety, and support access to treatment and recovery services in the criminal justice system, including in correctional facilities. 1

DOJ, BJA Residential Substance Abuse Treatment (RSAT)

The RSAT for State Prisoners Program assists states, local, and tribal governments in the development and implementation of substance abuse treatment programs in state, local, and tribal correctional and detention facilities. Funds are also available to create and maintain community reintegration services for individuals after they are released from incarceration. 1

SAMHSA Block Grants

SAMHSA funds states and territories through the following grants:

Block grants are used to supplement Medicaid, Medicare, and private insurance to provide access to prevention, treatment, recovery supports, and other services. Grant funds are awarded to the state behavioral health authority, substance abuse authority, and/or mental health authority, depending on how the state agencies are arranged.1

340B Drug Discount Program

Allows certain entities that serve large uninsured patients to obtain drugs from pharmaceutical supplies at the same discounted rates that Medicaid pays (i.e. 25-50% less).2

Federally Qualified Health Centers (FQHCs)

FQHCs are located in inner cities and rural areas and serve uninsured and low-income individuals. Many offer Buprenorphine based on discounted fees. 2

1 Expanding Access to Medications for Opioid Use Disorder in Corrections and Community Settings: A Roadmap for States to Reduce Opioid Use Disorder for People in the Justice System. (Washington, D.C.: National Governors Association and American Correctional Association, January 2021).

2 Jail-based Medication-Assisted Treatment: Promising Practices, Guidelines, and Resources for the Field. (National Sheriff’s Association and National Commission on Correctional Health Care, October 2018)


WHY

A successful and comprehensive MOUD program for pregnant individuals is dependent on being able to pay for the medications, staffing, and training required to run it. Addressing funding will help you plan for your program’s capacity, scope, and sustainability. 

Policies and Procedures 🤰

Policies and Procedures 🤰

This section highlights the importance of having an official jail policy and protocol for pregnant and postpartum patients at your jail, including those who use opioids. This section describes key things that the policy should include. 

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HOW

  • Use the MOMCARE Preparing a Model Jail Pregnancy Policy Checklist to assess your jail’s current pregnancy policy
  • Create a plan of how to address items flagged as ‘insufficient, missing, and unsure.’ This may include adding more details to the policy or developing new procedures.
  • Once the policy is revised, disseminate it to all staff and bring special attention to newly added or updated content. Consider reviewing the policy reviewing the policy during in-service training or designated team meetings to ensure all staff are informed.
  • When a pregnant patient enters custody, reorient medical and custody staff to your policy, including when to transport a pregnant patient to the hospital.  Host weekly multidisciplinary meetings with staff from medical, custody, behavioral health, etc., to discuss updates on pregnant and postpartum patients custody. 
  • If policies and protocols are not being followed, leadership should discuss options for reinforcement (g. post visual 1-pagers, individual check-in meetings, etc.)
  • Update (and announce/educate) the policy as needed, including addressing any identified gaps, changes in services, and contact persons listed. Policies should be reviewed at least every 6 months.


WHY

  • A comprehensive jail policy for pregnant patients with OUD serves as a guidebook and reference for staff, increases accountability, and fosters thoughtful and coordinated care.
  • A robust policy also decreases the chances of non-standard care and thus prevents possible litigation.


KEEP IN MIND

  • The policy should explicitly state practices that are illegal and/or not recommended for pregnant patients in custody due to the risk of harm to the fetus and pregnant patient. These include forced withdrawal, discontinuing MOUD (also referred to as MAT) postpartum, custody restraints, segregated housing (special housing unit), top bunk assignments, and male officers present for pelvic/breast exams or delivery.
  • The policy should direct staff on what to do if a pregnant patient goes into labor while in custody or has other urgent maternal warning signs.
  • The policy should be updated (and disseminated) if there are any changes including those made to treatment protocols, community partnerships, and contact persons.
  • All care should be documented in the patient’s chart
  • The contact information (address, telephone, specific person) should be documented for all community partners and providers, including the nearest labor and delivery unit.

HOW


Action Items 

  1. Use the MOMCARE Preparing a Model Jail Pregnancy Policy Checklist to assess your jail’s current pregnancy policy
  2. Create a plan of how to address items flagged as ‘insufficient, missing, and unsure.’ This may include adding more details to the policy or developing new procedures.
  3. Once the policy is revised, disseminate it to all staff and bring special attention to newly added or updated content. Consider reviewing the policy reviewing the policy during in-service training or designated team meetings to ensure all staff are informed.
  4. When a pregnant patient enters custody, reorient medical and custody staff to your policy including when to transport a pregnant patient to the hospital.   Host weekly multidisciplinary meetings with staff from medical, custody, behavioral health, etc., to discuss updates on pregnant and postpartum patients in custody. 
  5. If policies and protocols are not being followed, leadership should discuss options for reinforcement (g. post visual 1-pagers, individual check-in meetings, etc.)
  6. Update (and announce/educate) the policy as needed including addressing any identified gaps, changes in services, and contact persons listed. Policies should be reviewed at least every 6 months.

Policies and protocols should be detailed and thorough. They direct staff what to do, when to do it, who is involved, and where to go (or who to contact) for additional services and support. Including information on outside entities (e.g. local hospital, opioid treatment provider, and prenatal care provider) in your protocols will also help foster relationships between the jail and the community, making it easier to coordinate care. 

Your jail’s policy for pregnant and postpartum individuals in custody should be informed by national guidelines and standards on perinatal care, correctional health, and substance use disorder treatment. Organizations that publish such national guidance include (but are not limited to) the American College of Obstetricians and Gynecologists (ACOG), the National Commission on Correctional Healthcare (NCCHC), the American Correctional Association (ACA), the American Society of Addiction Medicine (ASAM), and Substance Abuse and Mental Health Administration (SAMHSA). 

Use the MOMCARE Preparing a Model Jail Pregnancy Policy Checklist to get a better understanding of what a robust, comprehensive policy for pregnant and postpartum individuals with OUD should entail and to assess your jail’s current policy.

All procedures in the policy should follow the SMART principles: 

Specific Does the directive clearly state what needs to be done to address the issue and/or provide care?
Measurable How should jail staff document that the procedure was performed?
Achievable Do jail staff have the support and resources they need to accomplish the procedures?
Relevant Do the procedures align with the national standards, the needs of the patients, and the values of the jail?
Time-bound Does the procedure indicate when (and how often) it should be completed/performed?

WHY

Having an official jail policy for pregnant and postpartum patients in custody, including those with OUD, promotes a standardized approach to treatment and suggests readiness to provide care. The policy can serve as a reference and resource for medical and custody staff on what to do when a pregnant or postpartum individual with OUD enters and leaves custody and will keep staff accountable. Creating or enhancing your jail’s policy for pregnant patients with OUD will also foster a thoughtful approach and coordinated care if challenges arise when caring for this population. From a risk management perspective, a detailed policy can help protect the health of your pregnant patients and decrease the chances of non-standard care, which can prevent possible litigation. 

Memorandum of Understanding (MOU)

This section introduces the importance of using a memorandum of understanding (MOU) when forming partnerships between the jail and other entities that provide services to pregnant and postpartum patients and those with OUD. 

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Memorandum of Understanding (MOU)

HOW

  • Identify the organization, a point person, and the services provided to your facility/incarcerated persons.
  • Request a meeting with the point person to discuss using an MOU to outline your arrangement, goals, responsibilities, and terms of your agreement.
  • Draft and review the MOU so that both parties are satisfied with the terms. Revise as necessary. See example MOUs on the resources tab.
  • Consult each organization’s legal team (if applicable) for final review before signing.

 

WHY

  • Providing MOUD (also referred to as MAT) in a jail setting sometimes requires partnerships with community providers.
  • A MOU ensures that all parties agree on the terms of their arrangement.

KEEP IN MIND

  • A confidentiality clause in a MOU means that all parties intend to keep designated information confidential when sharing information between parties during the partnership.
  • A conflict resolution clause may be used in the event of a dispute, controversy or disagreement related to the MOU including a breach of agreement or termination. It outlines a process for raising issues and/or questions and how to resolve them

HOW

If you are working with an outside entity to provide care to pregnant (and other) patients in custody, consider implementing an MOU. 


Action Items 

  1. Identify the organization, a point person, and the services provided to your facility/incarcerated persons.
  2. Request a meeting with the point person to discuss using an MOU to outline your arrangement, goals, responsibilities, and terms of your agreement.
  3. Draft and review the MOU so that both parties are satisfied with the terms. Revise as necessary. See example MOUs on the resources tab.
  4. Consult each organization’s legal team (if applicable) for final review before signing.


There are some key elements that every MOU should encompass: 

  • Title
  • Names of the organizations involved
  • Timeline and length of the agreement
  • Context and purpose of the agreement
  • Scope and objectives
  • Terms of agreement and responsibilities of each involved party
  • Confidentiality clause
  • Conflict resolution clause
  • When and how involved parties can end the agreement
  • Signatures of all parties involved


WHY

A memorandum of understanding (MOU) is an agreement between two or more parties that clearly defines how the entities will work together and outlines shared expectations and responsibilities. It is used to achieve mutual understanding of the partnership and shared goals that each party feels confident about. Some benefits of using a MOU include establishing a common intention, formulating clear objectives, reducing uncertainty in who does what, ease of dissolving the partnership, and leaving a paper trail on record. Unlike a contract or memorandum of agreement (MOA), a MOU is not legally binding but should be taken as a serious declaration and you may want the jail’s legal team to review it. 


For pregnant patients with OUD in custody, some partnerships may include the vendor used to provide MOUD like a community opioid treatment provider (OTP), or a community-based prenatal care provider.