Reentry and Transitions of Care

HOW 

Comprehensive reentry planning can be difficult for individuals who have very short jail stays, multiple healthcare and resources needs, and unexpected releases. Pregnant and postpartum individuals in jail with OUD may fall into this category. Ensuring that pregnant and postpartum individuals with OUD have or can get their next dose of MOUD after release is the most important reentry step to prevent overdose death. These action items can assist you with building robust reentry services and protocols.

Action Items

1. Reentry staff must be familiar with resources in your community, the needs of pregnant and postpartum patients with OUD, and how they align.
   • See the list below of possible resource needs for pregnant and postpartum patients with OUD leaving jail.
   • See MOMCARE Working with Community Partners on steps to building relationships with community-based organizations. Keep a list of resources and contact information for the services available. Update regularly.
2. Reentry staff should assess the individual’s reentry needs at intake for planning and preparation. Use the MOMCARE Preparing for Reentry Checklist for Pregnant and Postpartum Patients to assess the individual’s needs as soon as possible.
3. Based on the needs identified in the checklist, link pregnant and postpartum patients with OUD to the needed services. Getting their next dose of MOUD is most important to avoid overdose death upon release. There are two types of reentry handoffs:

“Warm handoff” – planned release involving the transition of care management responsibility (individualized planning, linking, monitoring, and coordinating) from jail to community that is intentional with the accepted transition of responsibility

• • The next MOUD and prenatal appointments are set up in the community
  • The incarcerated individual is aware and possibly even able to communicate with the community providers ahead of time.
  • Logistics on how to get to the appointment and when are discussed before release.

“Hot handoff”– sudden or unplanned releases involving urgent and emergent processes that must be done at the moment to ensure essential continuity of MOUD.

• • Jail staff call the methadone/buprenorphine provider in the community to let them know you referred a discharged pregnant patient to them. Jail staff give the provider’s information to the individual leaving custody.

4. Throughout someone’s stay, reentry staff should gather information on community resources and place it in the individual’s property in preparation for release. (See the list below of what should be placed in their property upon release)
   • Include a methadone or buprenorphine take-home dose if appropriate and feasible.
   • Include harm reduction supplies like naloxone (Narcan) and fentanyl test strips. Consider giving harm reduction supplies to the family/friends of people being released if possible.
5. Establish a mechanism for sharing patient records (with permission) with community-based medical providers for continuity of care and care coordination. This is especially true for methadone/buprenorphine dose information. Patients should be informed of this practice and asked to sign a release of information (ROI) form.

Jails should consider using a patient navigator who can assist individuals transitioning out of custody with understanding system processes to successfully navigate systems and receive services. Patient navigators often have lived experience of substance use or justice involvement and can help facilitate a smooth transition back into the community, sometimes by meeting with people in custody before release. Patient navigators may be employed by the jail and follow people for a set period once they leave custody.

🤰 Reentry needs for pregnant and postpartum patients with OUD may include:

• MOUD continuation – identify a methadone program in your community that accepts pregnant patients & identify a champion there
• Harm reduction (e.g. naloxone, fentanyl test strips) – purchase/obtain
• Prenatal care
• Medicaid enrollment
• Behavioral health and peer support
• Social needs (e.g. housing, transportation, employment, food assistance, etc.)
• Domestic Violence Shelters
• Sexual assault and abuse resources – RAINN National Sexual Assault Hotline

Ideally, appointments should be made in the community before release and all documentation should be given to the individual when discharging from the facility. Provide each person with a bag for medications and a folder with written information about:

• Upcoming appointments
• Local resource list, including prenatal care provider
• Patient’s jail medical record
• Handout with pregnancy warning signs to look out for – urgent maternal warning signs
• Information, referrals, medical records, etc.

See MOMCARE Reentry Planning for more details.

• MOMCARE Preparing for Reentry Checklist for Pregnant and Postpartum Patients– A checklist that can be used to guide reentry planning for pregnant and postpartum people with OUD.
• See MOMCARE Reentry Planning for more details
• BJA Guidelines for Managing Substance Withdrawal in Jails
  • Reentry and recommendations (p.19+ and 53)
  • Newly developed toolkit on substance withdrawal management instructions and care guidance (including opioids) for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
• After Incarceration: A Guide to Helping Women Reenter the Community (SAMHSA)

This guidebook is for people who provide or coordinate reentry services for women involved in the criminal legal system. It provides guidance on identifying and addressing their needs, including substance use disorders and reproductive health care. 

• Partnering with Jails to Improve Reentry: A Guidebook for Community-based Organizations (Urban Institute)
  • Developing and sustaining a relationship with the local jail (p.9)
  • Examples of strong partnerships between CBOs and jails (p. 27)

This guidebook is for community-based organizations regarding partnering with jails, however, it provides useful information on developing and sustaining a relationship as well as examples of strong partnerships between community-based organizations and jails.

• Innovation efforts to distribute naloxone to justice-involved populations (BJA COSSUP)

This webinar describes an effort to distribute naloxone (Narcan) through a vending machine to people released from jail, including strategies for implementation.

• Reducing the risk of opioid overdoses: MAT reentry programs (BJA COSSUP, 2018)

This webinar shares information about how the Middlesex Sheriff’s Office implemented reentry for people who were on MOUD and leaving custody. It discusses the